Urology Flashcards
Renal Colic Present to ANE (most appropriate investigation)
Non-contrast CT scan of KUB
NOT X-ray - cannot find Radio Lucent stone
Renal Colic Investigation :
Adults (18+) : low dose non-contrast CT KUB
Pregnant women(HCG +) : USG 1st line (CT will be risky for fetus)
Children & young people (>12 but less than 18) : USG 1st line,
2nd line : CT KUB non-enhancing if USG fails to detect stones
For all : give analgesic for pain relief (1st : NSAID any route)
if NSAID contraindicated/not tolerated/pain still there : IV Paracetamol
If still pain :weak Opoids –> Tramadol
DO NOT GIVE ANTI-SPASMODIC IN RENAL COLIC! Source : NICE 2020
Testicular Tumors and Markers
Testicular cancer:
Seminoma: - Commonest subtype (50%).
His of Undescended testis = best serum marker is LDH
Painless lump
Present at early age (mean 30-35)
growing 6 months within THE BODY OF THE TESTIS
Firm , NON TENDER LUMP
Left Testis is 3 times the size of the right testis
Average age at diagnosis= 40 years. Tumour markers: LDH elevated in 20% (b) HCG elevated in 10% (c) AFP usually NORMAL.
Non seminomatous germ cell tumours (42%):
Teratoma, yolk sac tumour, choriocarcinoma, mixed germ cell tumours (10%).
Younger age at 20 to 30 years.
Tumour markers
(a) AFP elevated in up to 70%
(b) HCG elevated in up to 40%
(c) Other markers rarely helpful.
Tumor Markers
TUMOUR MARKERS:
- CA 125 - Ovarian CA, Peritoneal Mets
- CA 15-3 - Breast CA
- CA 19-9 - Pancreatic CA
- AFP - Liver , Non-Seminomatous testicular CAs
- LDH - Seminoma Testes, Lymphomas
- CEA - Colorectal CAs, GI tumours
- Beta HCG - Choriocarcinoma of Ovaries or Testes
- Calcitonin - Medullary CA Thyroid
- ALP - elevated in Bone or Liver Mets
Renal Stone Tx
Please Read Carefully the stone size in Exam
(mm or cm )
(Percutaneous NephroSTOMY or NephroLITHOTOMY)
No specific Tx (Younger pt , bigger stone , more symptoms»_space; more inclined to Tx)
Stone size:
less than 5mm — Drink Fluids & likely to pass spontaneously
0.5cm and 1cm are on the border of if treatment are necessary (50% will pass spontaneously)
>5mm but <2 cm — ECSWL(extra corporal shock wave lithotripsy ) or Ureteroscopy with dormia basket (rarely used in UK)
2cm and above — Percutaneous nephroLITHOTOMY(PCNL)
IN ANY CASE if evidence of hydronephrosis present (obstructive uropathy) –> PERCUTANEOUS nephroSTOMY regardless of stone size
(PCNL) is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound (up to about 1 cm) through the skin. It is most suitable to remove stones of more than 2 cm in size and which are present near the pelvic region.
Prostatic Cancer
RISK FACTORS
Increasing age(most important risk factor)
Africo-Caribean
Family Hx.
Presentation:
Lower Urinary Tract symptoms (NOT specific as it is common in old age) .
RAISED PSA ***
UTI .
(Local invasion) Hematuria, Hematospermia
Obstruction of the ureter
Anuria(AKI or chronic KD)
Bone Metastasis (back and hip pain)
Spinal Cord compression lead to paraplegia ***,
Sciatica
wt. loss and lethargy
Ca prostate cases:
S/S= An old / African Caribbean man. Difficulty passing urine, Blood in urine with no pain, Nocturea frequency Weak stream, terminal dribbling, Unable to completely empty the bladder. Wt loss (cachexia) Thirst (in case of B. metastasis & hi Ca level).
O/E
Large, irregular, hard, asymmetric prostate gl.
Ix
1.Hi PSA (N=0-4) –> Pt shd. not ejaculate before test,
PSA –> will detect localized prostate Ca & good 4 F/U.
2. U/S= To detect hydronephrosis.
3. Low RBC
4. Hi CRP
5. Hi Ca
6. Non-urgent isotope bone scan–> for B. metastasis.
7. Urgent (within 24 hr’s ) MRI scan–> for spinal cord compression.
Metastasis= > common to B & LN’s
Rx=
For prostate Ca–> GnRH antagonist
For B pain–> Radio Rx– 1st line
Bisphosphonate & NSAID … 2nd line.
Cx=
- B metastasis –> Back pain/ B pain (dull)
- Pathological #
- UTI–> suprapubic pain.
- Spinal cord compression –> Neurological symp. as paraplegia
- Urinary obstructive symptoms.
Testicular torsion Vs Epididymo-orchitis
(In exam they will give mixed symptoms )
similar pain in the past few weeks (partial torsion)
now pain for 4 hours
cannot examine because of pain (testicular torsion) surgical tx
Rotation of tetstes through the spermatic cord , occluding testicular blood vessels
Sudden and severe pain (<6 hours)
Happens during sports or activity (trauma)
Lifting the testes does not relieve the pain
Absent Cremasteric Reflex
Inv
Colour Doppler USG to look for blood flow
MGx
Emergency surgery and testicular detorsion followed by bilateral orchidopexy
If epididymo-orchitis is suspected >Antibiotics (UTI / Fever/ Pain relived by elevation)
If given a mixed picture (i.e you are not sure if this is epididymo-orchitis or testicular torsion) >Perform urgent exploratory surgery as saving the testicle becomes the number one priority if there are doubts if this is testicular torsion
Patient >40 years with Microscopic Haematuria ( prostatic or bladder CA)
Cystoscopy (bladder cancer:TCC ) (biopsy are taken for suspicious lesions)
CTU - CT urogram with contrast (for renal or ureteric cancer)
Urine cytology (in case we pick up cancerous cells)
Renal biopsy after imaging suspects cancer
First step of any URINE DIPSTICK to rule out UTI
CT KUB - CT without contrast (for renal stones )
BPH (most common cause of urinary retention in Male)
Common in elderly men
DRE - smooth enlarged prostate
(Hard nodular - cancer)
Investigations
PSA(slight increase)
Post void residual bladder volume(elevated)
Tx
Selective Alpha1a blocker Tamsulosin (most common )
Less selective Alpha blocker Terazosin(not effective as selective, consider when↑BP)
(preferred in hypertension)
5Alpha reductase inhibitor Finasteride (↓bph size but requires 6mth to work)
(only after 1st Alpha reducase given , large prostate , raised PSA )
TURP (if medical management fails) - transurethral resection of prostate
Side Effects- **severe Hypo natremia*
HAEMATURIA
Bladder cancer - Smoker
Asymptomatic haematuria
Urinary Stones - Renal Colic
Possible fever
Prostate Cancer - Enlarged prostate
High PSA
Renal Cancer - Loin pain / Loin Mass
Schistomiasis - Africa(Egypt) and Middle East
Urology Scans and Cameras
CT KUB - Renal stones , Hydronephrosis
Urogram (CT+iv contrast) - Renal and ureteric cancers
Cystoscopy - Bladder cancer
Cystogram(Bladder dye) - VUR(vesicoureteral reflux)
IVU - largely susepneded by CT urography
DMSA scan - Renal scarring (radioactive isotope)
MAG3 scan - PUJ obstruction (radioactive isotope)
Epididymo-Orchitis
Presentation
● Unilateral scrotal pain and swelling
● Urethral discharge (Leucocytes and Nitrates positive)
● Tenderness to palpation of epididymis
● Fever
● History of UTI
● Pain relieved by elevation of the testes
● <35 years old sexually transmitted organisms:
○ Chlamydia & Gonorrhoea
● >35 years old UTI causing organisms:
○ E. coli & Pseudomonas. spp
Investigation
● Urethral swab and smear
● Microscopy and culture of mid-stream urine
Treatment
● Sexually transmitted pathogen:
○ Ceftriaxone 1 gm IM Stat PLUS ○ Doxycycline 100 mg BD for 10-14 days
● Enteric organisms:
○ Ofloxacin 200 mg BD for 14 days OR ○ Levofloxacin 500 mg BD for 10 days
Scrotal Swelling Ddx
Inguinal Hernia ● Inguinoscrotal swelling ● Not able to get above the swelling ● Cough impulse + ● Reducible
Hydrocoele ● Soft fluctuant swelling ● Painless and non-tender ● Able to get above the swelling ● Transillumination + ● Below and in front of the testes
Epididymal Cyst ● Single or multiple slow growing cysts ● Painless and non-tender ● Lies above and behind the testes **** ● Able to get above the swelling
Acute Epididymo-orchitis ● Dysuria ******* ● Urethral discharge ● Fever ● Red and tender scrotal skin ● Pain reduce on elevation of the testis******
Testicular tumour ● Discrete testicular nodule ● Firm to hard in consistency ● USG scrotum ● Raised serum AFP and β-HCG
Varicocele ● Dilation of the pampiniform plexus ● Common in the left side ***** ● Dull aching or dragging pain ****** ● Swelling ↑ on standing ● Swelling ↓ on lying down ● Bag of worm appearance ● Scrotal doppler ● Associated with renal cell carcinoma
Testicular Torsion
● Acute, severe testicular pain **** (so severe that dr cannot do examination)
● Common in adolescent and young
● Pain does not reduce by elevation of the testis
● Urgent exploratory surgery with Orchidopexy
Types of Incontinence
Stress incontinence - incompetent sphincter:
Leakage of urine during activities which ↑ intraabdominal pressure such as sneezing, coughing or laughing
Cause: Multiple vaginal delivery (pelvic floor muscles become weak)
Treatment:
Pelvic floor exercises (first-line)
Surgical - open colposuspension
Urge incontinence - detrusor overactivity:
Difficulty in controlling the desire to urinate
Wetting before making it to the bathroom
Treatment:
First → Bladder training - gradually ↑ the period between voiding
Second → Anticholinergic drugs: e.g.oxybutynin (only after trying bladder training)
Overflow incontinence - bladder outlet obstruction:
Continuous overflow and difficulty in completely emptying the bladder
Causes
○ BPH
○ Prostate cancer
Treatment
○ Specific for BPH or prostate cancer
○ Intermittent catheterisation
Ureteric Injuries
Flank pain , abdomen distended with tenderness in suprapubic area
Urine leak form the ureter (peritonitis, sepsis , ↓BP, ↑RR )
Ureter(divided / ligated / damaged by diathermy / angulated by suture )
After Pelvic or Abdominal Surgery (CS , hysterectomy , colectomy )
Please note: paralytic iliac and absent bowel sound are common in post operation (24 hours)
Renal Stone
Renal stones: S/S= Pt has intermittent(colicky) pain & he is writhing in pain.
Pain is radiated from loin to groin.
There might be micro or macroscopic hematuria.
If the stone was in the lower ureter –> renal colic.
If with infection–> fever & rigor.
If with gouty arthritis–> Uric-acid stones.
O/E
Loin or renal angle tenderness.
If stone was in the lower ureter–> iliac fossa tenderness.
Ix
- Non-contrast spiral CT–> Gold standard
- Renal U/S–> Hydronephrosis
- IVU–> Locate stones & show obstruction.
- Labs–>Hi WBC & CPR.
- If Pt was child baring female–> Preg. test
Risk factors
- Dehydration
- Sarcoidosis»_space; Hi Vit D ( there will be HyperCalcaemia)
- PolyCysticKidney disease (USG)
- Gout» Hi uric acid (urate stone)
- loop diuretics
Mx
small stones–> <0.5cm–> increase fluid intake & stone might pass spontaneously.
0.5-2cm–>ESWL or dormia basket.
>2cm–> Percutaneous nephron lithotomy (stone might be in renal pelvis)
