Urology Flashcards
How would you manage a >60 year old male with unexplained non visible haematuria?
Urgent Referral to Urology via the cancer route
Raised WCC and or Dysuria also raise need for urgency.
Signs of Epididimo-Orchitis
Acute Pain and swelling
Pyrexia and Positive dipstick differentiates from torsion
What is orchitis often linked to?
Preceding viral infection
Antibiotic of choice used in a catheterised patient presenting with a UTI.
Usual organism is Pseudomonas. Gentamicin is first line.
Periureteric fat stranding is a sign of what?
Recent stone passage.
If symptoms of an enlarged prostate alongside an overactive bladder arent controlled by Alpha blocker and 5 Alpha Reductase Inhibitors. What can be done?
Add an Anticholinergic
Oxybutinin
Tolterodine
What are the two types of urethral trauma and what is the commonest?
Bulbar #
Membranous
Urinary retention + perineal haematoma +Blood at meatus
Bulbar rupture
Usually located to trauma to that area i.e straddle injuries
Prostate displaced upwards
Penile or perineal oedema
History of pelvic fracture
Membranous rupture
How are urethral injuries investigated and managed?
In a suspected urethral injury with urinary retention a suprapubic catheter is used.
An ascending urethrogram is used to check patency.
Painless smooth lump indistinguishable testicle
Transilluminates
Can cause discomfort but not pain
Hydrocoele
Single or multiple cysts
Painless
>40 years
Can get above and behind the lump
Ependidymal cyst
First line in prostate cancer treatment
Goserelin - synthetic GnRH agonist
initial worsening of symptoms
Overstimulates causing suppression of LH and FSH after a few weeks
What can be used to help reduce the flare up of symptoms post Goserelin induction?
Flutamide
A non steroidal anti androgen
Bicalutamide
A patient undergoing a Trans Urethral Resection of the Prostate suddenly develops Hyponatrameia hyper ammonia headaches and visual disturbances.
TURP syndrome
Glycine is hypotonic. It is used in irrigation. This draws out Na+ from the venous plexus during resection. It is also absorbed and broken down in the liver to form ammonia.
Hyponatraemia and Hyperammonia are caused.
Urothelial Cancers
Transitional cell - 90% cancers - strong smoking link
Squamous Cell - 8% - increased in areas with endemic schistosomiasis
Adenocarcinoma
Management of epidiymoorchitis of unknown cause.
IM ceftriaxone + Oral doxycycline for 10 days
30 % of children presenting with a UTI will have what?
Vesicoureteric reflex due to laterally displaced ureters
Recurrent UTIs and reflux nephropathy
How should recurrent UTIs in children be investigated?
Micturating Cystourethrogram
Dilated ureter, pelvic and calyces, ureteric tortuousity
What is the commonest line of testicular cancers?
Germ Cell tumours
Seminoma and Non seminoma
List some Non-Seminoma germ cell tumours
Embryonic
Yolk sac
Teratome
Choriocarcinoma
What are the other type of rarer testicular tumours
Leydig cell
Sarcoma
Commonest testicular tumour before the age of 25
Teratoma
Non Seminoma - bHCG and AFP
Commonest testicular tumour over 35 years old
Seminoma
What are some generic symptoms of a testicular tumour
Painless lump, indiscernible from the testicle, Hydroceole, gynaecomastia
Increased oestrogen : androgen ratio
increased hCG in 20% of testicular tumours
Seminoma
Increased AFP bhCG in 80% of these testicular tumours
Non seminoma
Increased LDH in 40% of these testicular tumours
Germ cell
How are testicular cancers diagnosed and managed?
USS is first line - if suspicious testicle is removed surgically. Then specific type of cancer can be diagnosed.
Testicular Appendage Torsion
Cremasteric reflex still present
Severe pain
Torsion of the spermatic chord
Cremasteric reflex is absent
How do you differentiate high from low pressure chronic urinary hypertension?
High pressure - Impaired renal function + bilateral hydronephrosis
Low-pressure - no impaired renal function or hydronephrosis
Frank haematuria post catheterisation in a patient with chronic urinary retention.
Decompression haematuria
No intervention is required.
What is used to treat schistosomiasis and when?
Praziquantel
Even asymptomatic
List three of the drugs that should be used ( individually) alongside goserelin for the first three weeks of treatment to help reduce the tumour flair.
Bicalutamide
Cyproterone Acetata
Abirateron
What should you be wary of post catheterisation in someone who had urinary retention?
Physiological Diuresis - up to 24 hours
Pathological Diuresis - over 48 hours
Loss of large volumes of salt and water - may require fluid replacement
What is diagnostic of acute urinary retention?
300ml on USS
Can be less than this is signs and symptoms suggest
What can the volume of urine removed within the first 15 minutes of catheterisation tell us?
<200ml = no urinary retention >400ml = catheter should stay in place
What is the physiological post voiding volume remaining in the bladder?
<65 = <50ml is normal >65 = <100ml is normal
How is prostate confined adenocarcinoma managed?
T1/2
Active watch and wait
Radical prostatectomy
Radiotherapy
Post radiotherapy for prostate cancer what other cancers are they now at risk of?
Bladder
Colon
Rectal
Antibiotic management of Pyelonephritis
IV Amoxicillin + Gentamicin 7 or 10 days
Co-Trimoxazole + Gentamicin in pen allergic
Step down - Co Trimoxazole or sensitivities
Diagnosis of prostate cancer
PSA + Prostate exam -> multi parametric MRI
If >3 points on linkert scale -> TRUS biopsy
If <3 points on linkert scale -> patient given choice of having TRUS biopsy
Priapism key investigation
Cavernous Blood gas - determine in ischaemic or not
How is an ischaemic priapism managed?
Aspirate + Irrigate with saline
Phenylephrine repeated every 5 mins
Surgery
How is non ischaemic priapism managed?
Observe
Pain on intercourse
A hard lump on the penis
Penis is developing a bend
Peyronies disease
Inflammatory scar tissue causes bending
Surgery
Management of erectile dysfunction
Check BMI BP, lipid profile and glucose/Hb1AC
9am testosterone levels -> if low test free unbound testosterone FSH and LH
Varicocele affect on fertility?
Reduces it
Research whether surgery increases fertility
Vesicoureteric reflux - diagnosis
Micturating cystourethrogram is diagnostic
DMSA scan to look for renal scarring
Vesicoureteric reflex can cause
Recurrent UTI
Hydronephrosis
Reflux Nephropathy ( chronic pyelonephritis)
Renal scar can cause increased renin release and hypertension
Grading vesicoureteric reflux
Grade I = reflux into ureter only
Grade II = reflux up to renal pelvises + no dilatation
Grade III = Reflux up to calyces + mild dilatation
Grade IV = Dilated up to calyces + moderate ureteral tortuosity
Grade V = Gross dilation and severe ureteral tortuosity
Management of resolved testicular torsion?
Emergency surgery as very likely to reoccur
Whats the strongest risk factor for testicular cancer?
infertility
Timescale of PSA studies
> 6 weeks post biopsy
4 weeks post UTI
48 hours post ejaculation or vigorous exercise
When is TURP used?
If someone presents with acute urinary retention despite being on both Alpha blocker a 5 Alpha Reductase inhibitors.
How can regular UTIs post sexual intercourse be managed?
Post coital antibiotic prophylaxis
Management of testicular torsion - surgery
Even if only unilateral symptoms both sides are fixed
Management of vescioureteric reflux
All require prophylactic antibiotics.
Grade 1-3 will usually self-resolve
Grade 3-5 will require surgery
Management of Bladder cancer
Superficial - transurethral resection = T1
T2 and over = Radical cystectomy
