Urology Flashcards
What is the surgical treatment for renal stones?
Nephoscopy, to remove stones
Define Acute Urinary retention?
- painful inability to void
- followed by relief of pain on catherization: may be an alternative cause to the pain if it isn’t relieved from this
- <1L of urine in the bladder (acute)
- May be a bladder outflow obstruction (BOO) or contractility problem?
What may cause Bladder outflow obstruction?
- BPH
- Prostate cancer
- Stricture
- urethral stone
- Clot retention
- pelvic organ prolapse
- UTI/abscess
What would cause a contractility problem in the bladder?
- Drugs
- antimuscarinics and benzodiazepine opiates
- Pain
- Cord compression
- MS
- cord compression effecting bladder control
- Diabetes
- Post-op
- UTI
What Initial assessments would be carried out when presenting with Acute urinary retention?
what would you expect to see?
- History
- Clinical examination (abdo, neuro, DRE)
- Temperature
- Urinalysis
- Bladder scan
- IV access?
- FBC / UEs
What is the treatment for acute urinary retention?
- Insert catheter
- Urethral
- suprapubic
- Record residual volume
- Midstream urine cultures (MSU)/ blood cultures +/- antibiotics
- Admit if pain is severe or if there is renal impairment
Define Chronic Urinary Retention
- Painless inability to void
- May present with ‘acute on chronic retention’
- May present with nocturnal incontinence alone
- high pressure
- > 1L urine in bladder
- Two types; high pressure or low pressure
Explain what Haematuria is and it’s causes
- Blood in the urine - microscopic or macroscopic
- non-visible and visible → associated with more sinister pathologies than non-visible
- Usually not an emergency
- only when a significant amount of blood is released enough to cause clots where the patient goes into clot retention
- clots can block the urethra causing patient to go back into urinary retention
- Urine dip detects haem, myoglobin, porphyrins – microscopy is needed
- non-visible
- Causes of bleeding
- Tumour (24% in macro, <5% in microscopic)
- Infection
- cystitis (Lower UTI) , pylo nephritis (Upper UTI)
- Trauma
- Stones
What are important features to pick out in a history that involves haematuria
- Where in the stream is the blood
- malignant cause/ systemic cause/nephrological cause/ infective cause
- Associated urinary symptoms
- History of Trauma?
- Employment/ Social history
- barber sprays in 80’s (bladder cancer), textiles, rubber manufacturing
- smoking history (cause not risk factor) - cause of bladder cancer
What investigations would you carry out to investigate haematuria?
- Bloods – FBC / UEs / PSA? / Coag? / G+S
- Urine – dip / m,c&s / cytology
- Imaging – US+KUB / CT Urogram
- Cystoscopy
- camera through the urethra into the bladder
What imaging modality is this and what does it show?
Bladder cancer - CT
What imaging modality is this and what does it show?
Bladder cancer - cystoscopy
Which haematuria patients would be admitted to the hospital vs investigated as an outpatient?
Outpatient investigation
- Microscopic and voiding
- Macroscopic and voiding
Admit
- Macroscopic and anaemia
- Macroscopic and clot retention
- Haemodynamically compromised
What is the Etiology of Renal trauma?
- Occurs in 8-10% of abdominal trauma
- Blunt 90% - crushes kidney against ribcage
- Penetrating 10%
- 80% associated with other abdominal visceral injury
- 95% of isolated renal injuries are minor
What signs would indicate Renal Trauma?
- Loin or abdominal bruising
- Cullen’s sign (rare)
- Loin tenderness
- Loss of loin contour
- Loin mass
- Macroscopic haematuria / clots
What is the management for Renal Trauma?
- ABCDEs
- Resuscitate the patient
- Other associated injuries may prove fatal first
- Imaging - defines the extent of the injury
- triple phase CT (pre-contrast, venous, arterial)
- Graded from (least sever) I-V(most severe)
- Mainly conservative - bed rest, 5/7 antibiotics
- More sever grades require intervention
- Surgical: nephrectomy
- Radiological: arterial embolisation
Explain what Torsion is?
- Tunica Vaginalis layer moves proximally far into the posterior aspect of the testicle : Bell clapper deformity
- This makes the testicles more likely to spin in the horizontal axis
- causes spermatic cords and vas deferens where vessels are to coil up, causing ischaemia
What are differentials for scrotal pain?
- Testicular Torsion
- Torsion of the Hydatid of Morgagni/testicular appendix
- Epididymitis
- Orchitis
How does Testicular Torsion Present?
- Twisting of spermatic cord and thus testicular artery; ischaemic pain
- Acute onset of painful testicle
- Nausea / vomiting
- Lower abdo pain
- Horizontal lie of testicle on examination
- and high lying in scrotum
- may be red and inflamed initially
What is the management of testicular torsion?
- Testicle may die within 4-6 hours
- Scrotum to be explored as soon as possible surgically
- Assess the severity of the twist and if the testicle is viable
- untwist and see if it perfuses (pale white) - but it back inside scrotum otherwise must be removed
- The other testes must be fixed, Bell clapper deformity likely to be on the opposite side
What is the sign/presentation of Hydatid of Morgagni?
What is the management?
- Blue dot sign
- Excise lesion as soon as possible
- when presenting would still take to theatres to rule out testicular torsion otherwise can be treated conservatively with
- Anti-inflammatory’s
- Painkillers
- Antibiotics (rarely)
What is the presentation of Epididymo-orchitis?
What is the treatment?
- Treat with antibiotics
- <35 y/o - more concerned for STI
- > 35 y/o - more concerned for for UTI
- may have a history of repeat infections
- may need to be explored, if diagnosis is unsure (TT?)
- if patient is more than 35 less likely to be testicular torsion as most torsion happens in those will bell Clapper and would have likely caught it before the age of 35.
Explain what Phimosis and what is the management for it?
-
Phimosis: the inability to retract the foreskin
- by the age of 16 only 1% of population expected to have a tight foreskin
- means foreskin is tight enough that it cannot be retracted behind the glans → the ability to retract allows for ejaculation during intercourse
- can be caused by Balanitis xerotica obliterans: chronic disease can also cause urethral stenosis
- Both managed with circumcision
What is Paraphimosis and what’s the mangement?
-
Paraphimosis: when a tight foreskin retracts behinds the glands and gets stuck
- this is an emergency
- longer it remains there it tightens around the penile shaft obstructing venous return and eventually arterial flow → necrosis of the gland
- common in catheterised patients; when foreskin not repositioned
- Managed by: reducing it
- Gentle manual retraction, place thumbs on the glans and hold the ring → perform a traction-counter traction maneuver (most common way to relieve a paraphimosis)
- Dundee method -local anesthetic, no adrenaline (no collateral blood supply as they are end digit terminal arteries)
- Surgical release if the above fails
What are key epidemiological points in the population presenting with renal stones?
- Prevalence
- Developed western populations 5-20%
- Age
- Peaks 20-40 yrs
- Sex M>F 3:1
- becoming closer (2 & a bit to 1)
- 35,000 vs 16,000 completed episodes
- HES data 2005/6
- Less urinary oxalate Oestrogen protects vs Test promotes
- Ethnicity
- White>Hispanic>Asian>African American
What are the risk factors for developing renal stones?
Intrinsic
- Age
- Sex
- Genetics
Extrinsic
- Geography
- Diet + Fluid (salt)
- Climate
- Occupation
What are the familial and genetic links with renal stones?
- 25% of patients have a FHx
- Hypercalciuric patients have up to a 65% FHx
- Poly/monogenic mutations: SAC, VDR, CaSR, CLCN5
- Cystinuria -Autosomal Recessive disorder
- very dramatic presentation in hospital
- Xanthine & dihydroxyadenine
What is the composition of renal stones? (5)
Calcium Oxalate 60%
Calcium Phosphate 20%
Urate 10%
Struvite 8%
Cystine 1 %
What is the first line treatment for managing renal colic?
- the BAUS recommend an NSAID as the analgesia of choice for renal colic
- whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing
- the CKS guidelines suggest for patients who require admission: ‘Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain’
How does Renal Stones present?
Renal colicky pain
Haematuria (visible, non-visible)
Urinary tract infection
Incidental
How do you asses for renal stones?
- Bloods (renal function)
- Creatinine & eGFR (high)
- Ca2+ (raised)
- urate
- K+
- +/- PTH (sequels of primary hyperthyroidism)
- Urine
- Dip → infection & pH
- blood and positive for nitrates and leukocytes
- Spot test cystine- sodium cyanide nitroprusside
- Culture + sensitivity
- Microscopy
- Dip → infection & pH
- Stone Analysis
- Imaging to confirm
- plain abdominal X-ray (KUB)
- Intravenous Urogram
- Non-contrast Ct scan (occasionally US)
- Isotope renography
What imaging modality is this and what is the pathology?
Non-contrast CT showing a Staghorn calculus
What are the managements options for renal stones?
In acute presentations you may have to decompress the kidney → nephrostomy tube or a stent to bypass the stone to get to the bladder then you deal with the renal stones
- Conservative
- Medical
- Medical Expulsive Therapy (MET)
- uses Tamsulosin which is an alpha-blocker to relax the ureteric walls
- Chemolysis - Uric acid stones
- alkalise the urine → prevents uric acid stones (dissolves stones better for long term management, not very effective in chronic setting)
- Medical Expulsive Therapy (MET)
- Shock Wave Lithotripsy - ESWL
- Ureteroscopy & Ureterorenoscopy
- Percutaneous Surgery - PCNL
- Laparoscopic Surgery
- Open Surgery
What is the medical and pharmacological treatment for renal colic?
In an acute painful episode, give analgesia, radiological imaging, relieve the obstruction (preserve renal function) and treat the infection)
-
NSAIDS
- Diclofenac via PR or suppository
- Analgesics
- Opiates
- Antiemetics
When should intervention be introduced in renal cholic?
- Pain – Uncontrolled & Persisting
- Infection
- Deteriorating renal function
- Solitary Kidney
- Failure to progress
- Degree of obstruction, Time, Stone size, Stone position
- Patient circumstances or preference
What are potential complications of ESWL Lithiotripsy
- Steinstrasse 2-10%
- Residual fragment re-growth 21-59%
- Fragment colic 2-4%
- Sepsis 1-2%
- Macro haematuria majority Renal haematoma Symptomaic <1%
- Renal haematoma Asymptomatic 4%
- Bowel perforation - rare
- Liver & splenic haematoma - rare
What is Lithiotripsy (ESWL)?
- These are shockwaves that can be
- Electroconductive
- Electromagnetic
- Piezoelectric waves
- Waves are focused on the stone which is localized using either ultrasound or fluoroscopy
- This breaks the stone up into small fragments that can be more easily passed
- 2 or 3 attempts are used before alternative modality is used
What is Ureteroscopy?
- Camera is passed through the ureter up to the kidney
- The stone can be gather using a basket on the end which captures it and pulls the stone out of the body
- A laser can also be used to break the stone up (Lasertripsy)
- a flexible ureterscope can also be used which allows the camera to go into the kidney
Compare the use of ESWL and Ureteroscopy for treating renal stones
Ureteroscopy has an increased clearance at as single sitting but an increased risk of complications
Explain Percutaneous nephrolithotomy
Entering the kidney through the back to either troll, laser larger stones in the kidney or upper ureter.
This is usually used for larger stones >2cm or for complex stones or in difficult anatomical regions
Gallstones vs renal stones
80% of renal stones are radiopaque
20% of gallstones are radiopaque
What are ways to prevent getting renal stones?
- Urine dilution
- 2.5l/day throughout the day
- Tap water not sugary water
- Optimise body weight
- Fruit, veg & fiber
- citrate
- Low salt <6g/day & lower animal protein intake
- Avoid excess sugar
- Some dairy products
- Plant fat instead of animal fat
Give the epidemiology of Bladder Cancer
- 7th most commonest cancer in men
- 11th most commonest cancer in both genders
- 75% confined to mucosa/ submucosa (pT1/pTa)
What is the aetiology of bladder cancer?
- Tobacco Smoke commonest cause. 50% of cases (for both transitional cell and squamous)
for Transitional cell carcinoma
- Occupational Exposure e.g in prining and textile industry
- paints
- Aniline dyes: 2-napthyalmine, benzidine
- petroleum.
- Chlorination/arsenic in drinking water
- Cyclophosphamide
- Egypt and middle east
- Schistosomiasis (for squamous cell carcinoma of the bladder)
What is the staging for bladder cancer?
- divided between muscle invasive (T2 onwards) and non-muscle invasive (Ta-T1) bladder cancer
- Tis (carcinoma in situ) → T4a (advanced into the prostate gland)
Explain the pathology of the metastatic spread of bladder cancer and how this is related to this image
- Lining of the bladder is urothelium (transitional cell) and is continuous from the distal urethra in the penis to the collecting system in the kidney
- The image shows a dark spot in the collecting system of the kidney’s which is a filling defect which is indicative of a tumor invading the kidney and the ureter
- hence if you have a tumor in the bladder you can have a cancer anywhere along that tract
- These are called upper tract transitional cell carcinomas
How are non-muscle invading bladder cancers managed?
Follow -up guidance?
- Transurethral resection of bladder tumour
- single shot intravesical chemotherapy immediately post op
- Follow up based on risk assessment
- grade of tumour (G1-G3, how aggressive a tumour is) / age/ smoking cessation/ presence of VH
- multifocal
- recurrences can occur quickly
Where does prostate cancer anatomically present in the prostate?
- Peripheral zone - 70% of cancers
- more aggressive - tends to invade the peri-prostatic tissues
- when examining that’s why you feel posteriorly
- far away from the prostatic urethra hence unlikely to cause any compression
- Transitional Zone - 20%
- relatively non-aggressive
- Benign prostatic hyperplasia (BPH) more likely to occur here, hence causing LUTS
What is the staging for renal cancer?
TNM
- pT1
- pT2
- pT3
- pT4
Stage I-IV
What Investigations would you do to confirm Renal cancer?
- Ultrasound
- CT - triple phase/ renal/ abdomen & pelvis with contrast
- characterize the size and morphology
- CT chest for staging - Pulmonary Mets/ Cannon Ball lesions
- common in Renal cell cancer
Review this image and identify key structures
What is this an image of?
Torsion of the Testis
