Urology Flashcards
What is testicular torsion?
surgical emergency and describes the twisting of the spermatic cord and its contents
What is the most common age group for testicular torsion?
between the ages of 10-30 (peak in 13-15)
How would someone with testicular torsion present?
- severe sudden onset pain in scrotum
- referred to lower abdo
- N&V
- unable to walk or sit, fidgeting
How would testicular torsion appear on examination?
- swollen, tender testis retracted upwards
- long axis orientated transversely due to shortening of spermatic cord
- erythema
- loss of cremasteric reflex
- Prehn’s sign - elevation of testis does not ease pain
What is the management for testicular torsion?
urgent surgical exploration - within 6 hours
- incision made in midline of testes, untwist cord and see if colour returns (will appear blue/black)
- soak in warm saline and hyper-oxygenate the patient for 5-10 mins
- 3 point fixation of testicle - albuginea to dartos
list some ddx for testicular torsion
- epididymo-orchitis
- tumour
- trauma
- acute hydrocele
what is epidiymitis and in what populations does it present?
inflammation of the epididymis
young (<35) due to STIs - chlamydia and gonorrhoea
older (>35) due to gram -ve bacteria (e.coli and pseudomonas) - associated with UTIs and BPH
How does epidiymitis present?
acute onset scrotal pain - tenderness and swelling of posterior testicle
fever
chills
myalgia or muscle pain
What is epidiymo-orchitis and how does it present?
epidiymitis that has spread to the testicle
acute onset scrotal pain
fever
N&V
what are the specific exam findings for epidiymo-orchitis?
testicular swelling and tenderness
positive phrehn sign - pain relived when elevating testicle
intact cremasteric reflex
what is cryptorchidism?
congenital undescended testis is one that has failed to reach the bottom of the scrotum (can affect one or both)
usually occurs in premature babies
testis usually gets stuck in the inguinal canal
what is the treatment for cryptorchidism?
if not descended by 2 years - orchidopexy
usually not required as testes will complete descent by 6 months
what is variocele?
abnormal enlargement of the testicular veins
dilatation of the pampinifrom plexus due to increased venous pressure
they are usually asymptomatic but may be important as they are associated with infertility
which side of the testes does varicocele more commonly effect?
left testis
left testicular vein drains into left renal vein forming perpendicular angle before draining into IVC = increases resistance to blood flow
unlikely to occur on right as the right testicular vein drains directly into the IVC therefore shorter route and less resistance
if a patient presents with right sided varicocele what should we suspect?
retroperitoneal tumour - renal cell carcinoma
how does varicocele present?
soft scrotal mass feeling of pressure or dull achy scrotal pain feels like a bag of worms mass distends/gets bigger when cough does not transilluminate
what is the treatment for varicocele?
conservative
surgical ligation or embolisation of dilated pampiniform plexus
what is hydrocele and what are the 2 types?
accumulation of fluid within the tunica vaginalis - between the visceral and parietal layer
congenital = communicating
- failure of processus vaginalis to close up, allows peritoneal fluid to drain into scrotum
- usually resolves within 1st few months of life
acquired = non-communicating
- due to underlying condition - excessive fluid production within tunica vaginalis
- trauma
- infections - roundworm
how does a hydrocele present on examination?
soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
transilluminates with a pen torch
the testis may be difficult to palpate if the hydrocele is large
how to confirm the diagnosis of hydrocele?
US
management of hydrocele?
infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
in adults conservative - resolve on their own
what are neohrolithiasis and why do they form?
renal stones
form due to solute in the urine precipitating out and crystallising
what are the 6 different types of renal stones and which is the most common?
- calcium oxalate (most common)
- calcium phosphate
- uric acid
- struvite (Mg, ammonia, P)
- cysteine
- xanthine
what are the 3 most common places for renal stones to get stuck?
- uretero-pelvic junction
- vesico-ureteric junction
- location where ureters cross sacroiliac joint
what are the risk factors for renal stones?
- age - middle aged
- M>F
- Caucasian
- Diet - excess animal protein
- Chronic dehydration, low urine output
- Obesity
- FHx
- PMHx - anatomical abnormalities, diabetes, gout, hyperparathyroidism, PKD
how would renal stones present in a patient?
- renal colic (loin to groin)
- N&V
- haematuria
- dysuria and straining
- restless, unable to lie still
- fever and sweating (if co-current UTI)
describe the feature of renal colic in renal stones
sudden onset unilateral abdo pain lasts mins-hours spasms loin to groin
a patient presents with renal stones, what investigations would you organise?
urine dip - blood present
urine culture - MC&S
bloods - U&Es (check urine function), FBC and CRP (infection), clotting (if intervention planned)
blood culture - if pyrexial or signs of sepsis
imaging - non contrast CT KUB within 14 hours
what colour do renal stones show up on non contrast CT KUB and why?
white - due to containing calcium
what pain relief is given to a patient with renal stones?
NSAID - paraenteral analgesia (IM diclofenac for rapid pain relief)
what is the management for a stone <5mm?
conservative
generally pass spontaneously
if causing obstruction or infection - requires urgent surgery
what is the management for a stone >5mm with pain?
pain relief
estracorporeal shockwave lithotripsy (ESWL)
what is the management for a large, multiple or complex renal stone?
percutaenous nephrolithotomy - access gained directly through the skin
what is the management for a renal stone presenting with infection and obstruction?
percutaneous nephrostomy or ureteric stent (rigid cystoscopy)
what is BPH?
condition where a biopsy of the prostate shows histological signs of hyperplastic changes (abnormalities at the cellular level)
what LUTS is most common in men with BPH?
voiding sx
how are LUTS classified?
- Voiding sx (obstructive)
- weak/intermittent flow, straining, hesitancy, terminal dribbling
- Storage sx (irritative)
- urgency, frequency, urge incontinence, nocturia
- Post-micturition
- dribbling
- Complications
- UTI, retention, obstructive uropathy
what are risk factors for BPH?
- Age - 50% of 50 year old men will have BPH (30% experience sx), 80% of 80 year old men will have BPH
- Ethnicity (black and white - less in Asian)
- FHx of BPH
- Cigarette smoking
- Male pattern baldness
- Metabolic syndrome
how would someone with BPH present?
- Presence of risk factors
- Storage sx - frequency, urgency, nocturia
- Voiding sx - weak stream, hesitancy, post-void dribbling, incomplete emptying
what are the investigations for a man presenting with LUTS?
urine dip
U&Es (if chronic retention suspected)
PSA (if sx obstructive and patient worried about PCa)
urinary freq volume chart
internation prostate symptom score (IPSS) 0-35
what is the management for a patient with suspected BPH?
watchful waiting, medication, surgery
what drugs are given to those with moderate-severe voiding sx from BPH?
what are the SE?
tamsulosin, alfuzosin (alpha 1 antagonists)
SE: dizziness, postural hypotension, dry mouth, depression
what drugs are given to those with a significantly enlarged prostate and high risk of progression?
what are the SE?
finasteride (5 alpha reductase inhibitors)
blocks conversion of T-> DHT therefore reduces prostate volume
SE: erectile dysfunction, ejaculation problems, gynaecomastia
what drug is given to a patient with moderate/severe voiding AND prostatic enlargement?
combination therapy - (alpha-1 antagonist + 5-alpha reductase inhibitor)
you have given a patient with BPH an alpha-blocker but their storage and voiding sx still persist, what will you prescribe?
anti-muscarinic (tolterodine, darifenacin)
what type of surgery is offered to men with BPH?
transurethral resection of the prostate (TURP)
which zone of the prostate does BPH occur in?
transitional zone
what happens to the bladder detrusor muscle in response to BPH?
needs to generate more pressure to eject urine
therefore it undergoes compensatory hypertrophy
can see trabeculations on the detrusor muscle
what are the complications of BPH?
bilateral hydronephrosis
bilateral hydroureter
increased infection
loss of renal function
what is a primary care test used to assess the prostate gland?
PSA
what is a TRUS?
trans rectal ultrasound guided biopsy of prostate
12 biopsies taken from prostate
what type of cancers are prostate cancers usually?
adenocarcinomas
what scoring system is used to grade prostate cancer
Gleason score
what is prostatic intraepithelial neoplasia?
precancer of prostatic adenocarcinoma
asymptomatic and has the ability to progress to cancer but not inevitable
which zone of the prostate gland does prostate cancer usually arise in?
peripheral zone
where does prostate cancer usually metastasise to?
bones (spine)
they appear to be osteoscleorotic (calcifications and bony lesions)
can impinge nerves
what other cancers metastasise to the bone?
breast
kidney
thyroid
lung
osteolytic mets (destroys bone)
what type of tumour is most common in testicular cancers
seminomas (germ cell tumours)
arise from seminiferous tubules
what is the classification for testicular cancer
seminoma and non-seminomatous germ cell tumour
which testicular cancer behaves most aggressively
NSGCTs
risk factors for testicular cancers
- age - 30-40
- infertility
- cryptorchidism
- fhx
- klinefelter syndrome
- mumps orchitis
clinical features of seminoma
- painless lump
- hydrocele
- gynaecomastia
where do seminomas spread
via lymphatics to para-aortic nodes
testicular cancer investigations
- US of testes
- serum tumour markers - raised hCG
- staging with CT TAP (TNM)
management of testicular cancer
- radical orchidectomy
- radiotherapy to retroperitoneal nodes
