Urology Flashcards
A man presents with Left Scrotal dull pain, dragging pain, after sports. PE: (+) cough impulse
Varicocele
Imaging of choice for varicocele
Scrotal Doppler
Why is varicocele more common in the left?
You have to remember that
- Left testicular vein drains into the left renal vein in a 90 degree manner
- Right testicular vein drains into the IVC in an oblique
The slanting of drainage has something to do with pressure and Left Testicular Vein has to drain blood at a much higher pressure
You have to remember that varicocele results from INCOMPETENT VALVES in the testicular vein leading to retrograde blood flow, vessel dilatation and tortuosity of the pampiniform plexus.
In which types of scrotal swelling will you be able to go above the swelling on physical examination?
Epididymal Cyst
Hydrocele
Acute, severe testicular pain
Common in adolescent and young
Pain does not reduce by elevation of testis
Testicular Torsion
Treatment for testicular torsion
Urgent explratory surgery with orchidopexy
Dysuria + urethral discharge + sexually active +M fever + red and tender scrotal skin + pain reduced on elevation of testis
Acute EO
Common causative agents of EO in a 35 year old sexually-active
Chlamydia
Gonorrhea
Common causative agents of EO in >35 y/o
E. coli
Pseudomonas
Investigation of choice for acute epididymo-orchitis
Urethral swab and smear
Microscopy and culture of mid-stream urine
Treatment of AEO in sexually-active <35 y/o
Cetriaxone 1g IM stat
PLUS
Doxycycline 100mg BD for 10=14 days
Acute EO in >35y/o
Ofloxacin 200mg BD x 14 days
OR
Levofloxacin 500mg BD for 10 days
Best management for stress incontinence
Pelvic floor exercises
Management of renal stones
For a healthy individual:
<0.5 cm - increase oral fluid intake
0.5-2cm - ESWL > Ureteroscopy with dormia basket
>2cm - PCNL
If patient has only ONE FUNCTIONING kidney:
Regardless of the size, Percutaneous nephrostomy
FEVER + AKI + STONE + HYDRONEPHROSIS
What does this suggest?
Management?
This suggests OBSTRUCTIVE UROPATHY
Regardless if patient presents with two or one kidney, management is PERCUTANEOUS NEPHROSTOMY to instantly decompress the renal collecting system regardless of the stone size.
***Remember that Percutaneous Nephrostomy is the BEST INITIAL STEP in an attempt to save the kidney. After draining the urine, you may proceed with the most appropriate management by applying the STONE SIZE RULE.
Also, if percutaneous nephrostomy is not available in the options, pick Uretering Stenting as this would function in decompressing the pelvicalyceal system.
When is STONE SIZE rule not applicable?
It is not applicable if patient presents with FEVER + ANURIA (AKI) + STONE + HYDRONEPHROSIS. Regardless if the patient has one or two healthy kidneys, patient is managed with percutaneous nephrostomy.
Unilateral loin pain + Positive HCG in urine
Suspect Ectopic pregnancy
Loin pain + negative HCG + pain radiates to groin
with or without elevated WBCs and CRP
with or without vomiting
Ureteric colic
Positive prehn’s signs
Pain relief by elevating the testis
Single or multiple cysts that develop slowly + contains clear or opalescent fluid + over 40 years of age + painless, non-tender scrotal swelling + lies above and behind the testis + on examination, usually possible to get above the lump
Diagnosis?
DIagnostic?
Epididymal Cyst
Ultrasound
Non-painful, soft, fluctuant scrotal swelling + on examination, possible to get above the lump + contains clear fluid + transilluminates
Hydrocele
Severe, sudden onset testicular pain + abnormal testicular lie + affects adolescents and young males + on examination: testicular pain and tenderness not eased by elevation
Testicular torsion
How does acute EO present?
Dysuria + urethral discharge + positive prehn’s sign + scrotal skin is red and tender + painful micturition
Scrotal swelling typically occurring in the left + dull-aching or dragging pain that is worse after exercise or at the end of the day + bag of worms + show impulse on cough
Management?
Varicocele
If painless - Reassure
If with concerns regarding fertility and if patient complains of persistently severe pain - Surgery
Management of testicular malignancy
Orchidectomy via an inguinal approach
Management of testicular torsion
URGENT surgical exploration and testicular fixation
Urinary urgency or frequency + Subrapubic pain worse on bladder filling and relieved after voiding
Diagnostics?
Management?
Urine (midstream) for culture to rule out UTI Bladder training (Avoid pelvic floor exercises as we need pelvic floor relaxation)
Leakage of small amount of clear fluid (usually with no distinct odor) into the vagina + history of gyne surgery or radiotherapy (for cervical cancer)
Diagnosis?
Diagnostic?
Vesicovaginal fistula
3 swab test (3 swabs on top of each other)
***In V-V fistula, you expect discoloration of the topmost or middle swab. Remember that bladder is filled with methylene blue. So if the topmost is wet but no discoloration, fistula must be coming above the bladder which is the ureter, thus, Ureterovaginal fistula should be entertained.
Leakage of urine during activity (sneezing, coughing or laughing)
Diagnosis?
Initial Management?
Stress incontinence
Pelvic floor exercises: 8PC TID x 3 mos.
If fails, vaginal tape. Duloxetine if not amenable for surgery
***Remember that in stress incontinence, you have weak pelvic floor muscles or bladder outlet that cannot counteract the increased abdominal pressure (during physical activity), hence, leakage of urine.
Leakage of urine when there is a sensation of need to void.
Diagnosis?
Management?
Urge incontinence (Detrusor overactivity) Bladder training (anti-M if bladder training fails)
When I feel the desire to pee, I have to go and pee.
Urge incontinence (Detrusor overactivity) Bladder training (anti-M if bladder training fails)
When I feel a desire to pee, sometimes I slightly wet myself before making it to the bathroom
Urge incontinence (Detrusor overactivity) Bladder training (anti-M if bladder training fails)
DRE finding of BPH
Firm, enlarged, smooth, NOT NODULAR prostate
First line treatment of BPH
(Watchful waiting)
Alpha1blocker - Tamsulosin
Side effects of Alpha1 Blockers
Postural Hypotension and drowsiness, Cough & dyspnea
Finasteride is first-line if patient presents with LUTS with prostate enlargement in addition to this PSA value
> 1.4
There is urinary flow obstruction that has been relieved after inserting Foley catheter, what should you do next?
Before jumping into surgery, you must PRESCRIBE TAMSULOSIN and REFER FOR TWOC*
*Trial without catheter
***Tamsulosin then TWOC to check if voiding will happen
Patient underwent TURP and presents with agitation and confusion.
Diagnosis?
TURP syndrome
***Think of dilutional hyponatremia as excessive irrigation might have triggered the dilutional hyponatremia. Excessive irrigation must be done for full visualization.
DRE finding of prostate cancer
Hard, asymmetrical, nodular, irregular enlargement with loss of median sulcus
HANI of prostate cancer
DRE findings: Hard, asymmetrical, nodular, irregular enlargement of the prostate with loss of median sulcus.
First-line investigation if you are presented with a patient who presents with hesitancy, hematuria, weight loss, pain (suprapubic, back, perineal or testicular) with DRE finding of HANI.
Most appropriate follow-up investigation?
First-line: Multiparametric MRI
Follow-up: Serum PSA
Basing on the PSA levels when do you suspect PSA?
40-49: >2.0
50-69: >3.0
>70: >5.0
A known case of prostate cancer presents with LOIN PAIN and ANURIA. RFT is impaired. Diagnostics?
Suspect occluded ureter
Do US of KUB
A known case of prostate cancer presents with groin/perianal numbness (saddle paresthesia) with back pain and no urge to void
Suspect cauda equina syndrome
URGENT MRI of the spine
***Remember SPINE is the most common site of bone metastasis
After abdominal surgery, patient presents with unilateral flank pain, anuria post-op. Initial investigation?
Renal ultrasound
Why is a patient with sarcoidosis prone in developing kidney stones?
Due to hypercalcemia
Most common malignancy in men aged 20-35 years old
Testicular cancer
Painless, non-tender lump within the testis + slowly growing + young man
Diagnosis?
INitial investigation?
Testicular cancer (90% is germ cell tumor) Ultrasound | LDH
Greatest RF for bladder cancer
Smoking
Commonest type of bladder cancer
Transitional cell CA
Above 40 years old + Frank hematuria
Diagnostics?
Flexible cystoscopy + CT urogram
Less than 40 years old with hematuria
Diagnostics?
CT KUB (less likely caused by malignancy
After successful treatment of UTI, non-smoker patient aged >45 presents with persistent hematuria. Next step?
Suspect bladder CA even if patient is non-smoker, thus, you should REFER patient for a 2-WEEK WAIT appointment with Uro or Nephro
Important disease associated with ADPKD
Intracranial aneurysm
Gold standard for Reflux nephropathy
MCUG
Diagnostic test of choice to check for renal scarring
Tc scan (DMSA)
What is recurrent UTI
2 in 6
OR
3 in 12
Description of varicocele with renal pain and hematuria
RCC
If a patient is to be requested for PSA, what advice should you give?
Avoid ejaculation or exercise 48 hours before serum PSA test.
Isolated frank hematuria in an elderly? Next step?
It is important to rule out bladder cancer, hence, CYSTOSCOPY
Prolonged IFC + urine dipstick (+1 protein, 1+ RBC, - nitrates)
Best investigation?
Urine culture
Investigation for scrotal swelling
Ultrasound
A patient presents with LUTS. DRE: large, symmetrical, soft prostate. He was given finasteride. What may be the cause for him being given finasteride?
MOA of finasteride?
Elevated PSA > 1.4
5-alpha reductase inhibitor
Initial investigation for UTI
Dipstick urinalysis
DRE finding of acute bacterial prostatitis?
Tender and boggy PG
Management for acute bacterial prostatitis?
Empiric antibiotic: Quinolones (ciprofloxacin, ofloxacin)
A 55-year old man presents complaining of LBP on urination over the past week. There is also increased urinary frequency. O/E: there is suprapubic tenderness. Per rectal examination detects tender prostate. Midstream urine is sent for culture and sensitivity. What should be done next?
What is the likely diagnosis?
Next step in management?
Prostatitis
Start on empirical antibiotics - quinolones (No need to wait for culture and sensitivity results)
Why do you do cystoscopy and CT urogram in a patient above 40 with hematuria while CT KUB in patients less than 40?
Above 40 with frank hematuria, you rule out bladder cancer through cystoscopy. You also look for ureteric and renal cancers through CT urogram. Since malignancy is not likely to be found in patients below 40, you request for CT-KUB as stone might be the plausible cause of hematuria.
Recurrent UTI in postmenopausal women with no other abnormalities?
Vaginal oestrogen
***because of the risk of antibacterial resistance
Recurrent UTI in premenopausal women with no other abnormalities
Long-term antibiotic prophylaxis
Two conditions where you would pick percutaneous nephrostomy or ureteric stenting
Obstructive uropathy PLUS fever
Obstructive uropathy PLUS AKI
Spina bifida with UTI
Urinary incontinence pad
Spina bifida with incontinent, no UTI
Self-catheterization
Spina bifida with advanced urinary disease
Augmentation cystoplasty and Mitrofanoff stoma
