Urology Flashcards
What symptoms should you specifically ask about when taking a renal history?
Dyspnoea (ET, triggers, diurnal variation, orthopnea, PND, relieving factors)
Leg swelling (site, severity, time of onset, amount of fluid intake)
Nausea /& Vommiting
Upper airway symptoms
Constitutional symptoms (fever, joint pains, muscle aches, weight changes, lethargy, night sweats, puritis)
LUTs (dysuria, frequency, qunaitity of urine, colour of urine, frothieness, heamaturia)
Flank Pain (durayion, radiation, associated symptoms, intensity, aggravating/relieveing factors)
ENT symptoms (nasal secretions, sinusitis, epistaxis, haemoptysis, sore throat, visual disturbances, hearing loss)
What should you be sure to clarify in dialysis patients?
Mode of RRT (APD/CAPD/Asissted PD/UHD/HHM)
What access?
When was the last dialysis?
Relevant PMH and SHx in renal patients?
Previous AKI Requiring dialysis CKD stage Cause of CKD/ESRF CVD risk factors: DM, HTN, Hypercholestorolaemia UTIs CHildhood infections Surgery Cancer
What OTC drug is often associated with renal insult?
NSAIDs - ibuprofen
What family history should be specifically asked for in renal patients?
Renal disease Cardiac disease DM HTN Genetic conditions
Is chronic retention painful?
Not usually
What kind of retention is nocturnal enuresis suggestive of?
Chronic
What volume of urine to patients with chronic retention generally have in their bladders?
> 1L in bladders
What should you be suspicious of in painful haematuria in a patient over 65? What is the most common diagnosis?
Bladder cancer until proven otherwise
Transitional cell carcinoma is the most common type of bladder cancer
What may be seen on X-ray of a patient with metastatic prostate cancer?
Sclerotic lesions (bone mets)
How is testicular torsion managed?
Surgical exploration with orchiopexy fixation
What is the most commonly found renal stone composition?
Calcium oxolate
What type of kidney stone will not be seen on X-ray (raidoopaque)?
Uric acidic
What kind of renal stones cause acidic urine?
Uric acid
Struvite stones
What size renal stone can be managed conservatively?
<5mm
When would a JJ stent be used in renal stones?
Sepsis, renal failure
What might be used to prevent uric acid stones?
Allopurinol
Management options for renal stones?
Active surveillance
Lithotripsy
Uretoscopy
Percutatinoeus lithotomoy
Most common renal stone compositions?
Calcium oxolate
Uric acid
Struvite
Gold standard investigation for renal stones?
CT-KUB without contrast
What examination of the affected testi show in testicular torsion?
Transverse lie and no movement of the testis when the ipsilateral inner thigh is stroked
Whats Phren’s sign?
When will it be positive?
Elevation of the testicle reveals pain
Positive in epididymitis, negative in testicular torsion
Risk factor for Fournier’s gangrene?
DM
ETOH
Steroid therapy
Obesity
What is paraphimosis?
When the foreskin gets retracted behind the glans and can’t be put back
Occludes blood supply leading to ischemia
Put the foreskin back after catheterisation
What may be felt on DRE of a patient with prostate cancer?
Hard and craggy
What is used to score prostate cancer?
Gleason score
What makes up the gleason score?
most prodominent cell type + second most prodominent cell type
e.g. highest is 4+3
What is active survelance for prostate cancer?
Continue investigations to monitor disease with the aim of curative treatment
What are the most common complications of radical-prostectomy?
Erectile dysfunction
Cancer recurrence
Urinary incontinence
What should patients be advised about raised PSA levels?
Could be raised in BPH, prostatitis, UTI, recent medical procedure
Used as a marker for early prostate cancer detection and treatment
75% false positive as marker for prostate cancer (negative biopsy)
Gold standard investigation for prostate cancer?
Transrectal ultrasound prostate biopsy
USS guided biopsy takes 10-12 cores
Risk factors for prostate cancer?
Age BRACA1/BRACA2 genes Lynch syndromes/hereditery non-polyposis colorectal cancer Black african or carribean Obesity
How can GnRH receptor agonists such as leuprolide, bruserelin and goserelintreat prostate cancer?
GnRH receptor agonists decrease circulating androgens by negative feedback
Falters the cancer growth as prostate cancer is stimulated by androgens
Risk factors for bladder cancer?
Smoking Exposure to dyes/textiles/paints (aromatic amines) Chronic cystitis Intermittent self catheterisation Longterm catheterisation Schostosomiasis Radiotherapy to the pelvis
Triad of investigations for haematuria?
Urine cytology - abnormal cells in urine
USS KUB - anatomical changes
Flexible cytoscopy - visualise abnormal growths in bladder
What is the most common type of bladder cancer?
Transitonal cell carcinoma
What type of bladder cancer is associated with schistosomiasis?
Squamous cell carcinoma (rare)
What is the only curative option for T2 bladder cancer?
Radical cystectomy (+ illeal conduit)
When is TURBT a suitable curative treatment for bladder cancer?
T1 bladder cancers
Most common causative organism in UTI?
E coli
First line treament for pyelonephritis?
co-amoxiclav
How many UTIs a year warrent an US-KUB in a girl under 16?
3 or more
Voiding LUTS?
Haematuria+/- dysuria Hesitancy Poor flow Terminal dribbling Incomplete voiding
Storage LUTS?
Frequency Urgency Urge incontinence Noctura Bedwetting (due to high pressure chronic retention)
How is urinary retention diagnosed?
Post-void bladder scan
What complication should be monitored for post drainage of a patient with urinary retention?
AKI
Kidney had adapted to fluid overload
Massive diuresis
Kidney cannot compensate
Classifcations of haematuria?
Visable
Symptomatic non visable
Asymptomatic non visable
Pseudohaematuria (brown urine not secondary to the presence oof haemoglobin)
Causes of pseudohaematuria?
Rifampicin Methydopa Hyperbilirubinuria Myoglobinuria Foods such a beetroot or rhubarb
Most common cause of haematuria?
UTI Prostatitis Pyelnoephritis Urothelial carcinoma Stone disease Trauma or recent surgery Radiation cystitis Parasitic (schistosomiasis) Adneocarcinoma of the prostate BPH
What symptoms may be associated with haemturia?
Suprapubic pain Renal colic LUTs Fevers Rigors Weight loss
What does total haematuria suggest?
Bladder or upper tract source
What does terminal haematuria suggest?
Potential severe bladder irritation
Initial investigations when a patient presents with haematuria?
Urinalysis (true haematuria? nitrites + leukocytes = infection) Baseline bloods (FBC U&E clotting) PSA after appropriate counselling where prostatic pathology considered Urinary protein levels (albumin:creatinine or protein creatinine) if derranged renal function or suspected nephrological cause
What level of blood on dipstick constitutes haematuria?
1+ blood
NOT TRACE
What is the criteria for urgent referal in haematuria in a patient 45 or older?
Unexplained visible haematuria without UTI
Visible haematuria that persists or recurrs after sucsessful treatment or UTI
When should patients with asymptomatic haematuria be reffered for further investigations?
non-visable haematuria present on two out of three tests
When should a patient with haematuria who is over 60 be referred urgently to an adult urological service?
Unexplained non-visable haematuria and either dysuria or a raised WCC on blood test
What is the gold standar investigation for lUT?
Flexible cystoscopy
Performed under local anesthetic
What, more commonly used in follow up of patients with proven mallignancy, may be sent in an initial assement of haematuria?
Urine cytology
Upper urinary tract imaging that may be used in haematuria?
US KUB - non visable
CT urogram - visable
Which is more likely to be malignancy: non visable or visable haematuria?
Visable (20% of presenting patients vs 5%)
Most common urinary tract stones in order?
Calcium oxolate
Mixed calcium oxolate and phosphate
Calcium phosphate
Struvite, urate, cystine
Which stones are often large and soft, the most common cause of ‘‘staghorn calcuili’ whereby the stone will fil the renal pelvis?
Struvite stones (magnesium ammonium phosphate)
What is the only renal tract stone composition that is radiolucent?
Urate
Basis for formulation of urinary tract stones?
Over-saturation of urine
i.e. urate stones - high levels of purine in the blood, resulting in increas of urate formation and subsequent crystalisation in the urine
What causes urate stones?
High levels of purine in the blood from:
- Diet, red meats
- Haematological disorders such as myeloproliferative disease
What are cystine stones associated with and how are they formed?
Homocystinuria
Inherited defect that affects the absorption and transport of cystine in the bowel and kindeys,
As citrate is a stone inhibitor, hypocitrauria from the condition can predispose affected individuals to recurrent stone formation
Where are ureteric stones likely to impact?
Pelviureteric junction, where the renal pelvis becomes the ureter
Crossing the pelvic brim, where the illiac vessels travel across the ureter in the pelvis
Vesicoureteric junction, where the ureter enters the bladder
Most common presenting symptoms of ureteric stones?
Ureteric colic, associated with N&V
Haematuria
Tenderness in affected flank
Describe renal/ureteric colic and why it occurs?
Sudden onset
Severe
Radiated from flank to pelvis (loin to groin)
Occurs from increased peristalsis around site of obstruction
Differentials for flank pain?
Ureteric stones Pyelonephritis Ruptured AAA Billary patholgy Bowel obstruction Lower lobe pneumonia MSK pain
What is the gold standard for diagnosis of renal stones?
Non-contrast CT KUB
How might renal colic be investigated?
Urine dip (microscopic haemturia, evidence of infection) +/- urine culture
Routine bloods (FBC and CRP, evidence of infection, U&Es to asses renal function)
Urate and calcium levels (aid assesment of stone analysis)
Retrival of the stone to send for analysis
non contrast CT KUB
When might USS of the renal tract be used in renal colic?
Use concurrently in cases of known stone disease to assess for any hydronephrosis
What stones can USS KUB detect and which can they not?
Can detect renal stones
Cannot detect ureteric stones
What is hyrdronephrosis (also known as obstructive uropathy)
A condition of excess urine accumulation in the kidney causing welling of the kidney
Can cause pain during urination
Nausea
Vommiting
Initial management of renal stones?
Adequate fluid resussitation as required due to dehydration secondary to reduced oral intake and or vommiting
Sufficient anlgesia - opiate and NSAID
IVABx therapy and urgent referal to urology if evidence of signficiant infection or sepsis
Criteria for inpatient admission in renal stones?
Post-obstructive acute kidney injury
Uncontrollable pain from simple analgesia
Evidence of infected stone(s)
Large stones > 5mm
How does a retrograde stent insertion help treat renal stones?
Stent is placed in the ureter, approaching from distal to proximal via cystocopy, keeping the ureter patent and temporarily releiving the obstruction
How can a nephrostomy treat renal stones?
A nephrostomy is a tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally (Fig. 5). If required, an anterograde stent can subsequently be passed via the same tract made.
What is the definetive treatment of retained renal or ureteric stones that do not pass spontaneously, and what does each treatment involve?
Extracorporeal Shock Wave Lithotrispy (ESWL) involves targetd sonice waves to break up the stone, to then be passed sponatneously. Percutaneous nephrolithotomy (PCNL) involves percutaneous access to the kidney being performed, with a nephrocope passed into the renal pelvis. Stone are fragmented using various forms of lithrotripsy Flexible utero-renoscopy (URS) involved passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser lithotripsy.
What is extracorporeal show wave therapy (ESWL) reserved for?
Small stones <2cm, that are retained or do not pass spontaneously
What is percutaneous nephrolithotomy (PCNL) reserved for?
Large renal stones only, including staghorn calculi
Complications of ureteric stones?
Infection
Post-renal AKI
Complications of recurrent renal stones?
Renal scarring, loss of kidney function
How are recurrent stone formers managed?
Advised to stay hydrated
Ask patient to retrive any passed stones or check calcium and serum urate
Specific advice as per stone composition
How can oxalate stones be prevented?
Avoid high purine foods and oxalate foods, including:
Nuts
Rhubarb
Sesame
How can calcium stones be prevented?
Check PTH levels to exclude primary hyperparathyroidsim (and treat if present)
Avoid excess salt in diet
What should urate stone formers be advised?
Avoid high purine foods: red meat, shellfish
Consider urate-lowering medications: allopurinol
What should cystine stone formers be tested for?
Genetic testing for underlying familial disease (homocystinuria)
In what cases are bladder stones often seen?
Chronic urinary retention (cause urinary stasis)
Secondary to schistosomiasis
Passes ureteric stone
Defintive management of bladder stones?
Cystocopy, allowing the stones to drain for fragmenting them through lithotrispy if required
What can recurrent bladder stones predispose patients to?
Development of SCC bladder cancer due to chronic irritation of the bladder epithelium
How do bladder stones present?
LUTS
What is SUI?
Involuntary leakage of urine occuring when the inra-abdominal pressure exceeds the urethral pressure (laughing, coughing, sneezing), secondary to weakness of the pelvic floor muscles, impairing urethral support.
Risk factors for SUI?
Post-partam Consitpation (recurrent strainig) Obesity Postmenopause Pelvic surgery such as TURP, damaging the external sphincter
What is UUI?
Involuntary leakage of urine due to detrusor hyperactivity, leading to uninhibited bladder contraction, leading to a rise in intravesical pressure and subsequent leakage of urine.
What may cause UUI?
Neurogenic (previous stroke) Infection Malignancy Medications such as cholinesterase inhibitors (Donepezil) Idiopathic
What is Mixed UI?
Urge incontinence and stress incontinence
What is overflow UI?
Involuntary constant dribbeling of urine
Progressive stretching of the bladder wall (ie. chronic urinary retention),
damage to the efferent fibers of the sacral reflex and
loss of bladder sensation.
As the bladder fills with urine it becomes grossly distended
Intravesicular pressure builds
Causes of overflow UI?
BPH
Spinal cord injury
Congenital defects
What is Continuous UI?
Constant involuntary leakage or urine, typicall due to an anatomical abnormality such as an ectopic ureter or bladder fistulae (e.g. vesicovaginal fistula) however may also be due to severe overflow incontience.
What can aid diagnosis of the underlying cause of UI?
Bladder diarys
Enquiery about other symptoms (dysuria, haematuria), precipitating factors, PMHx, PSHx, DHx
Examination: enlarged prostate, prolapse, fistula openinig
What can be used to determine the severity of UI?
Qol questionaires such as
ICIQ
BFLUTS
I-QOL
How might a patient with incontinence be investigated?
Midstream urine dipstick performed (infection/haematuria)
Post-void bladder scans - especially for overflow UI
Urodynamic assessments’ (measure intravesicular and intra-abdominal pressures are measured, allowing detrusor muscle activity against urine flow rate)
Outflow urodynamics can then also be performed, to measure detrusor muscle activity against urine flow rate.
Cystoscopy/IV urogram/vaginal speculum investigation
When will urodynamic testing be performed in a patient with UI?
Considered in those weith suspected detrusor over-activity, symptoms suggestive of voiding dysfunction, or had previous surgery for stress UI
What does presence of high intra-vesicular pressure with poor urine flow on outflow urodynamic studies suggest?
Overflow UI
What would bladder wall hyperactivity on urodynamic assesment suggest?
Urge UI
Lifestyle advise regarding UI?
Weight loss Avoid excessive fluid Reducing caffeine intake Avoid drinking excessive fluid volumes each day Smoking cessation
Conservative management of stress or mixxed UI?
Pelvic floor muscle training (3 months)
Limited response, trial of duloxetine (works to cause stronger urethral contractions)
Conservative management of urge/mixed UI?
Anti-muscarinic drugs can be trialled such as oxybutynin or tolterodine, inhbiting detrusor contraction
Bladder training should be offered, ensure the patient continues this for a minimum of 6 weeks
Surgical options to treat urge UI?
Botulinum toxin A injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion via ileal conduit
Surgical options to treat stress UI?
Tension-free vaginal tape,
Open colposuspension (elevation of the bladder neck and urethra through a lower abdomincal incision)
Intramural bulking agents
An artificial urinary sphincter
What clinical features should be considered in the presentation of a scrotal lump?
Time of onset Associated symptoms - especially pain Previous episodes Inspection: (6 S's) Site Size Shame Symmetry Skin changes Scars Palpation: (TTT CAMPFIRE) Tenderness Temperature Transilumination Consistency Attachments Mobility Pulsation Fluctutation Irreducibility Regional lymph nodes Edge
Why isn’t biopsy used in the diagnosis of testicular cancer? How is it diagnosed?
Risk of seeding,
Diagnosis made purely on clinical features, USS, histopathological examination of testis following orchidectomy
Blood tests for tumour markers
What testicular tumour markers may be sent for in suspected testicular cancer?
Lactate dehydrogenase (LDH) Alpha-fetoprotein (AFP) Beta-human chorionic gonadotrophin (beta-hCG)
Extra-testicular causes of scrotal lump?
Hydrocele Varicocele Epididymal cysts Epdidymitis Inguinal hernia
Testicular causes of scrotal lumps?
Testicular tumour
Testicular torsion
Benign testicular lesions (include benign leydig cell tumours, sertoli cell tumours, lipomas, fibromas)
Orchitis
What is a hydrocoele?
Abnormal collection of peritoneal fluids between the parietal and visceral layers of the tunica vaginalis enveloping the testis.
How do hydrocoeles typically present?
Painless fluctuant swelling that will transilluminate,
Unilateral or bilateral,
Occasionally they can grow very large and cause discomfort when sitting and walking necessitating surgical management
By what point do congenital hydroceles, regress spontaneously?
By two years
If a patent processus vaginalis causes a hydrocele what treament may be needed?
Ligation to stop recurrence
How should patients presenting with a hydrocele between 20 and 40 years old be managed?
Urgent ultrasound scan?
What may cause hydroceles in an older male?
Primary (idiopathic)
Secondary due to trauma, infection, or malignancy.
Which testicular masses will transilluminate?
Hydrocele
Epididymal cyst
What is a varicocele?
Abnormal dilation of the pampinform venous plexus within the spermatic cord.
How might a varicocele present?
Testicular lump
Feel like a bag of worms/dragging sensation
Disappear on lying flat
Examine patient lying down, standing up and while performing a valsalva manouvere
Which side are varicocoeles typically found on and why?
Left side
Spermatic vein drains directly into the left renal vein, as opposed to the inferior vena cava on the right
What complications can variocoeles cause?
Increase in intra-scrotal temperature, leading to:
Infertility (if this is the case patient should undergo semen analysis with referal to urology if abnormal)
Testicular atrophy
Red flag signs with a varicocoele, that warrent urgent investigation?
Acute onset
Right sided
Remain when lying flat
What management may be offered in varicocele and when?
If symptomatic or with red flag signs (acute onset, remains on lying flat, right sided)
Embolization by an interventional radiologist
Ligation of the spermatic veins (open or laproscopic)
Why, in a patient with a varicocoele, should the abdomen always be examined?
Exclude renal tumour as the cause (although this is rare)
What is an epididymal cyst/spermatocele?
Benign fluid-filled sac arising from the epidiymis
How might an epididymal cyst present?
Smooth, fluctuant nodule,
found above and seperate from the testes
transilluminates
often multiple
Which patients are epididymal cysts most commonly seen in?
Middle-aged men
How are epididymal cysts managed?
Usually no treatment as no association to mallignancy, rarely cause symptoms
Can be surgically managed if large and painful but this can cause infertility
What is epididymitis?
Inflammation of the epididymis
One of the most common causes of scrotal pain in adults
How does epididymitis typicall present?
Unilateral acute onset scrotal pain \+/- associated swelling Erythematous underlying skin Systemic symptoms - fever Tender Pain may be relieved on elevation of the tesis - phren's sign
What bacteria typically cause epididymitis?
STI-related organisms - sexually active younger patients
Enteric ogranisims - older males
How is epididymitis managed?
Oral abx and analgesia
How will testicular tumours present?
Painless lump arising from the testis (5% painful)
Firm irregular mass
Do not transilluminate
How are testicular tumours managed?
Radical inguinal orchidectomy
Chemotherapy following this
What is testicular torsion?
Testicular torsion is a twisting of the testis on the spermatic cord, leading to ischemia, surgical emergency
How does testicular torsion present?
Sudden onset severe unilateral scrotal pain
Associate nausea vommiting
?’Bell clapper’ deformity (high attachment of tunica vaginalis allowing rotation)
Testis affected is extremely tender, raised and swollen
Loss of cremasteric reflex
How is testicular torsion managed and within what time frame?
Surgically: scrotal exploration and fixation of both testes, to prevent irreversable testicular damage
Salvage rates decline after 6 hours following the onset of pain
Examples of benign testicular lesions?
Leydig cell tumours
Sertoli cell tumours
Lipomas
Fibromas
What is orchitis?
Inflammation of the testis - rare in isolation
What is orchitis often proceeded by and why?
Main cause is mumps virus so preceded by a history of parotid swelling
What is the treatment of orchitis?
Rest, analgesia
If intra-testicular abscess may warrent surgical drainage and occasionally orchidectomy
What is urethritis and what causes it most commonly?
Inflammation of the urethra, most commonly due to infection.
How can urethritis be classified?
Gonococcal urethritis - caused by N. gonorrhoeae
Non-gonococcal urethritis - c. trachomatis, m. genitalium, t. vagininalis
Risk factors for urethritis?
<25 years MSM Previous STI Recent new sexual partner Multiple sexual partners in the last year
Symptoms of urethritis?
Dysuria
Penile irritation
Discharge from the urethral meatus
Complications of urethritis?
Epididymitis
Reactive arthritis
How is urethritis investigated?
Urethral swabs for urethral gram stain under microscopy (puss cells, gram negative diplococci)
First void urine for NAAT (gold standard) for N. gonorrhoeae, C. trachomatis, M. genitalium
MSU dipstick
Triple site testing for culture in the case of gonococcal infection
Further STI testing, HIV and syphillis serology
First line analgesia for renal colic?
IM diclofenac in the acute management of renal colic
What is the only cure for transitional cell muscle invasive bladder cancer?
Total cystectomy
Why is non-contrast spiral CT scan the best diagnostic investigation for renal colic?
Reveals radiolucent stones
Rules out important differentials such as AAA
What is the treatment for BPH with failed medical management, given the patient has normal detrouser activity?
TURP
Why might tamsulosin (alpha 1 blocker) cause dizziness?
Associated with pre-syncopal symptoms and postural hypotension
Urinary retention post-pelvic fracture suggests likely urethral injury, how should it be managed?
Suprapubic catheter - urethral catheter is contraindicated
What abx should be used in women with G6PD def for uti?
Cefalexin
Management of prostitis?
Prostatitis - quinolone for 14 days e.g. ciprofloxacin
