Urology Flashcards
What is testicular torsion
torsion/twisting of the spermatic cord. It causes occlusion of testicular blood vessels and, unless prompt action is taken, rapidly leads to ischaemia, resulting in loss of the testis
What age is testicular torsion most common
boys of any age - most commonly in teenagers
Px of testicular torsion
- Sudden onset pain, often so severe that causes vomiting. -> often triggered during sport or physical activity. (only 4-8% caused by trauma).
- testicle is tender
- redness and swelling are Late signs
- abdominal pain
Mx of testicular torsion
- urological emergency and all cases of acute testicular pain are torsion until proven otherwise.
- Surgery (orchiopexy).
What is hypospadias (congenital condition)
- males, where the urethral meatus (the opening of the urethra) is abnormally displaced to the ventral side (underside) of the penis, towards the scrotum.
- Can have chordee - tightening of tissue on underside of penis pulls penis down and it cannot straighten.
Mx of hypospadias
- Dont circumcise
- surgery to correct position of meatus and straighten penis
- palpate testes - undescended testis with hypospadias may suggest disorder of sexual development
Embryology of testes and inguinal canal
- Testicles develop near kidneys in abdomen. Inguinal canal is a pathway that allows testes to leave the abdomen and move into scrotum.
- inguinal canal has deep ring (connects to peritoneal cavity) and superficial ring (connects to scrotum)
- processus vaginalis is a pouch that extends through canal facilitating descent. After descent deep inguinal ring closes and processus vaginalis obliterates.
What can happen if processus vaginalis fails to regress and deep inguinal ring remains open
- indirect inguinal hernia -> peritoneal sac +/- loops of bowel enters inguinal canal.
- Hydrocele -> small amount of fluid can move into tunica vaginalis, around the testicle (communicating hydrocele).
What is a hydrocele and types?
- Abnormal collection of fluid within tunica vaginalis.
- simple hydrocele: fluid is trapped in the tunica vaginalis. Common in neonates.
- Communicating hydrocele: fluid travels (from peritoneal cavity) via processus vaginalis to tunica vaginalis.
Px of hydrocele
- soft, non tender swelling around testes.
- transilluminate with light
Mx of hydrocele
- simple: usually resolve in neonates within 2 years without having effects.
- Communicating: treated with surgery to remove processus vaginalis.
What is an inguinal hernia and types?
protrusion of abdominal contents through abdominal wall and inguinal ring.
- Indirect: protrusion through deep inguinal ring caused by failure of processus vaginalis to regress and inguinal canal to close properly.
- direct: hernia protrudes directly through a weakness in abdominal muscle (more common in elderly).
Inguinal hernia presentation and Tx?
- Swelling in groin that may appear with lifting and can be accompanied by sudden pain
- INDIRECT: pain in scrotum and dragging sensation.
- Tx = surgery
What are undescended testes
Testes develop in abdomen and migrate down, through the inguinal canal and into the scrotum. Normally reached scrotum prior to birth.
- in 5% not made it out of abdomen by birth.
Tx of undescended testes
Orchidopexy: surgical correction carried out between 6-12 months of age. If non-palpable, laparoscopic orchiopexy under GA
What does urinary tract infections include?
Includes urethra, bladder (cystitis), ureters and kidney infections
Px of UTI in infants
- Non-specific
- Fever may be only symptom
- Lethargy, Irritability, vomiting, poor feeding, urinary frequency
Px of UTI in children
More specific:
- Fever
- Abdo pain, particularly suprapubic pain
- Dysuria (painful urination)
- Urinary frequency, incontinence
Acute pyelonephritis
- Inflammation of kidneys
- fever, loin pain
What may a urine dipstick show to indicate UTI
- Nitrites: gram -ve bacteria (such as E.coli) break down nitrates->nitrites. Very likely indicate UTI
- Leukocytes: WBC’s. Rise can be a result of infection or other inflammation. May be present in UTI or negative.
- Nitrites better indication of infection than leukocytes.
- > both = UTI tx
- > Leuk only = not tx as UTI unless clinical evidence
- > Nitr only = UTI tx
- > either = MSU sample sent to microbiology lab.
Mx of UTI
- All children under 3 months with a fever = immediate IV Abx (e.g. ceftriaxone)
- > full septic screen, LP considered
- Children over 3 months = IV abx if feature of sepsis or pyelonephritis. IV abx considered if otherwise well
- follow local guidelines: typically trimethoprim, nitrofuranotin, cefalexin, amoxicillin
What type of cancer can cause a mass in the abdomen in children under 5 years of age
Wilms tumour - affecting the kidney of children
Px of Wilms tumour
- UNDER 5
- abdominal pain,
- haematuria,
- lethargy, weight loss
- fever
Dx of Wilms
- US of abdomen is initial investigation
- CT/MRI stages
- biopsy confirms diagnosis
Tx of Wilms tumour
- surgical removal along with affected kidney (nephrectomy)
- adjuvant chemo or radio
What is a neuroblastoma
a solid tumour that arises from the developing nervous system/neuroblasts (immature nerve tissue).
Px of neuroblastoma
- Most common before age of 5
- most children have abdominal mass (adrenal origin), but tumour can lie anywhere along sympathetic chain from neck to pelvis
- loss of appetite, weight loss, bone pain (bone metastasis), limping/bladder dysfunction (spinal cord compression from paraspinal sympathetic tumours)
Dx of neuroblastoma
- CT/MRI + raised urinary catecholamine levels
- biopsy = definitive diagnosis
What is nephrotic syndrome
- nePHROtic
a clinical syndrome showing Proteinuria, Hypoalbuminaemia, Hyperlipidemia, Renal dysfunction (frothy urine), Oedema - usually first diagnosed in children aged 2-5
Causes of nephrotic syndrome in children?
- Primary kidney disease:
Minimal change disease (most common in children). Congenital nephrotic syndrome = development of nephrotic syndrome within first 3 months of life. - 2ndary to underlying systemic illness:
Diabetes, infection, HSP
What is minimal change disease and how Dx + Tx
- most common cause of nephrotic syndrome in children. Not clear why it occurs
- Urinalysis will show small molecular weight proteins and hyaline casts. + Nephrotic syndrome characteristics.
- Tx = corticosteroids
What is nephritic syndrome
- clinical syndrome that occurs as a result of inflammation in the kidneys (nephritis)
- nePHRitis:
Proteinuria (slight), Haematuria, Renal dysfunction, Increased BP
2 most common causes of nephritic syndrome in children
- post-strep glomerulonephritis
- IgA nephropathy (Bergers disease)
Pathophysiology of post-strep glomerulonephritis
- beta haemolytic streptococcus infection e.g. tonsilitis caused by strep. pyogenes = classic
(beta haemolytic is grouped into A and B after) - 1-3 after, immune complexes get stuck in glomeruli of kidney and cause inflammation
Mx of post-strep glomerulonephritis
- Supportive and around 80% of patients will make a full recovery. In some cases patients can develop a progressive worsening of their renal function. They may need treatment with antihypertensive medications and diuretics if they develop complications such as hypertension and oedema.
What is Bergers disease
- IgA nephropathy
- related to Henoch Schonlein Purpura, which is an IgA vasculitis
- IgA deposits in nephrons causes inflammation
What is a posterior urethral valve
- tissue at the proximal end of the urethra (closest to the bladder) that causes obstruction of urine output. - It occurs in newborn boys. - The obstruction to the outflow of urine creates a back pressure into the bladder, ureters and up to the kidneys, causing hydronephrosis. A restriction in the outflow of urine prevents the bladder from fully emptying, leading to a reservoir of urine that increases the risk of urinary tract infections.
Px of mild posterior urethral valve
It can vary in severity. Mild cases may be asymptomatic or present with: Difficulty urinating Weak urinary stream Chronic urinary retention Palpable bladder Recurrent urinary tract infections Impaired kidney function
Px of severe posterior urethral valve
Severe cases can cause obstruction to urine outflow in the developing fetus resulting in bilateral hydronephrosis and oligohydramnios (low amniotic fluid volume). The oligohydramnios leads to underdeveloped fetal lungs (pulmonary hypoplasia) with respiratory failure shortly after birth.
Mx of posterior urethral valve
- Mild cases may simply be observed and monitored. A urinary catheter can be inserted to bypass the valve whilst awaiting definitive management.
- Definitive management is by ablation or removal of the extra urethral tissue, usually during cystoscopy.
What is the definition of enuresis, nocturnal enuresis?
- involuntary urination
- bedwetting
- most children get control of daytime urination by 2 years and nightime urination by 3-4 years
Causes of primary nocturnal enuresis
- child never managed to be consistently dry at night:
- variation on normal development (reassurance)
- overactive bladder
- fluid intake
- failure to wake (deep sleep)
- psychological distress
- secondary: constipation, UTI, learning disability
Mx of primary nocturnal enuresis
- Reassure parents of children under 5 years that it is likely to resolve without any treatment
- Lifestyle changes: reduced fluid intake in the evenings, pass urine before bed and ensure easy access to a toilet
- Encouragement and positive reinforcement. Avoid blame or shame. Punishment should very much be avoided.
- Treat any underlying causes or exacerbating factors, such as constipation
- Pharmacological: Desmopressin - reduces volume of urine produced by kidneys
Oxybutinin - anticholinergic reduces contractility of bladder
Imipramine is a TCA. May relax bladder.
What is the most common cause of haemolytic uraemic syndrome and what is the classic triad?
- shiga toxin produced by e.coli or Shigella.
- causes thrombosis within small blood vessels throughout the body
TRIAD: - Haemolytic anaemia - red blood cells being destroyed
- AKI - failure of kidneys to excrete waste products such as urea
- Thrombocytopenia - low platelet count
Px of haemolytic uraemic syndrome
- brief gastroenteritis (often bloody diarrhoea).
- may be followed by:
reduced urine output, haematuria, abdo pain, lethargy, confusion, oedema, HTN, bruising
Mx of haemolytic uraemic syndrome
- medical emergency
- self limiting and supportive management
- renal dialysis if required, antihypertensives if required
