Urology Flashcards
What are the common causes of haematuria?
Nephritic syndrome
Renal, ureteric or bladder or prostate cancer
Trauma
Renal and ureteric and bladder stones
TB
Pyleonephritis
Schistosomiasis
Urethritis
Strictures
BPH
Epidymitis
Menses
What are the risk factors for haematuria?
Above 60
Smoking
Worked with paint, dyes, metals or petroleum
Recurrent UTI
FHx of bladder cancer
Schistosomiasis prevalent
How might you examine a patient with haematuria?
Abdo - tenderness or masses, urinary retention
DRE - prostate
What are the primary Investigations for haematuria?
Blood tests, urinalysis, midstream urine sample for culture, upper tract imaging and flexible cystoscopy
What other symptoms should be assessed with haematuria?
Rigours
Fever
lethargy
What results in renal colic?
Acute ureteric obstruction - usually calculus or blood clots
What can acute ureteric obstruction lead to?
Acute renal failure or pyonephrosis
What type of pain Is renal colic?
From loin to groin
Peristalytic movement
How do you respond to pyonephrosis.
Urological emergency. Decompress
What is the common presentation of renal colic!
Sweat, pale, restLess, N+V
How is upper urinary tract obstruction diagnosed?
CT or USS
Diuretic renography (MAG3)
How is an upper urinary tract drained?
Nephrostomy
JJ stent
Anagelesia
High fluid intake
ESWL
PCNL
What are the causes of stress UI?
Weakness in pelvic floor muscle - post partum, constipation, obesity, post menopausal, pelvic surgery
What are the causes of urge UI?
Neurogenic caused - infection, malignancy or idiopathic, medication - cholinesterase inhibitors
Mixed UI
Stress and urge
What are the causes of overflow UI!
Prostatic hyperplasia, spinal cord injury or congenital defects
What are the causes of continuous UI?
Ectopic ureter or bladder fistula
What investigations should be performed for incontinence?
Bladder diaries
Midstream urine dipstick - infection or haematuria
Post void bladder scans
Urodynamics assessment
Cytoscopy
What is the conservative management of UI?
Stress: Pelvic floor muscle training and Duloxetine (ssri)
Urge - anti muscularis drugs and bladder training
What is the surgical management of UI?
Urge - botulinum toxin A injection, percutaneous sacral nerve stimulation, augmentation cystoplasty (whereby a detubularised segment of bowel is inserted into the bladder wall to increase bladder capacity), or urinary diversion via ileal conduit.
Stress - tension free vaginal tape, open colposuspension (involving elevation of the bladder neck and urethra through a lower abdominal incision), intramural bulking agents, or an artificial urinary sphincter
How should a testicular lump be inspected?
the Site, Size, Shape, Symmetry, Skin changes, and any Scars present.
Obstructive uropathy
How should you palpate a testicular lump?
Tenderness, Temperature, Transillumination, Consistency, Attachments, Mobility, Pulsation, Fluctuation, Irreducibility, Regional lymph nodes, and the Edge.
What investigations should be taken for a scrotal lump?
USS, blood tests (tumour markers - LDH, AFP, beta -hCG)
What are the possible causes of testicular lump?
Extra testicular - hydrocoele (fluid between layers of tunica vaginalis, transilluminate), varicoele (abnormal dilation of pampnifork plexus, bag of worms), epididymal cysts (fluid filled sacs from epididymis), epididymitis(usually STI), inguinal hernia (into scrotum via external inguinal ring entering inguinal canal or hesselbach)
Testicular - cancer - painless lumps, does not transillumiate, irregular, testicular torsion (twisting of testis on spermatic cord, bell clapped deformity - high attachment of tunica vaginalis, orchitis
What is a medical emergency!
Testicular torsion
What is the treatment for testicular cancer?
radical inguinal orchidectomy
what parts of a history are important for scrotal lumps?
time of onset
associated sx
previous episodes
how should a scrotal lump be inspected?
Site
Size
Shape
Symmetry
Skin changes
Scars
how should a scrotal lump be palpated?
1) Palpate testis, epidiymis and vas deferens
2) Tenderness, temperature and transillumination
3) CAMPFIRE - Consistency, Attachments, Mobility, Pulsation, Fluctuation, Irreducibility, Regional lymph nodes and Edge
what is the first line investigation for a scrotal lump?
USS of scrotum
which investigations are required if testicular cancer is suspected?
NO BIOPSY - risk of seeding cancer
on other factors and histopathology of testis following orchidectomy
LDH and AFP and beta-hCG can be used
what are the differentials for scrotal lump?
extra testicular - hydrocoele, varicocoele, epidiymal cysts, epididymitis, inguinal hernia
testicular - tumour, torsion, benign lesions, orchitis
hydrocoele - definition, management
abnormal collection of peritoneal fluid between the visceral and parietal parts of tunica vaginalis
- painless fluctuant swellings, transilluminate..can get painful and require surgery
- can be congential requiring ligation
- or idiopathic or secondary to trauma, infection or malignancy..USS
varicoele - definition, management, red flag signs
abnormal dilation of the pampiniform venous plexus within spermatic cord..bag of worms, disappear lying flat
found on left side usually - spermatic veins drain into left renal vein (smaller) compared to IVC on right
- can result in infertility, testicular atrophy…semen analysis
red flag signs = acute, R sided, remain lying flat - embolisation and ligation of veins, but if asymptomatic - no treatment
epidiymal cysts
benign fluid filled sacs arising from epididymis, will transilluminate
no tx
epididymitis
inflammation of the epididymis
unilateral acute onset pain, swelling, erythematous, fever, dysuria, haematuria, urethral discharge
pain relieved on elevation of testis - prehn’s sign
STI or enteric organisms - oral abx and analgesia
inguinal hernia
passes into scrotum via external inguinal ring(through inguinal or hesslebach’s first)..run alongside spermatic cord
cannot palpate its superior surface and cough may exacerbate swelling
testicular tumour
painless lumps in tesis
firm, irregular mass, do not transilluminate
USS, tumour markers, radical inguinal orchidectomy + chemo
testicular torsion
twisting of testis on spermatic cord occludes testicular and cremasteric arteries..ischaemia and testicular infarction
acute, unilateral, N+V
may be associated with bell clapper deformity - high attachment of tunica vaginalis resulting in rotation
tender, swollen, loss of cremasteric reflex
EMERGENCY - surgical exploration..untwisted and return of vascularity then orchidectomy if infarcted
give 4 examples of benign testicular lesions
benign leydig cells tumours, sertoli cell tumours, lipomas, fibromas
orchitis
inflammation of testis
main causes - viral (mumps)
rest and analgesia
which investigations are required for acute scrotal pain
urine dipstick - and requires microscopy culture sensitivity
urethral swab - STI
blood test - FBC, U and E, CRP
USS of scrotum
what are some causes of referred scrotal pain?
branches of genitofemoral and ilioinguinal nerve - anterior and pudendal and posterior femoral cutaneous nerve - posteriot
…ureteric stones
what is the biggest complication of acute-on chronic urinary retention?
post obstructive diuresis
what are some causes of urinary retention?
BPH, urethral strictures, prostate cancer, UTI, constipation (compress urethra), anti-muscarinics or spinal/epidural, peripheral neuropathy, MS or parkinsons (Upper motor neurone diseases)
what are the clinical features of urinary retention?
acute suprapubic pain
unable to micturate
palpable, distended bladder
PR exam - prostate
associated fevers or lethargy - infective
which investigations are required for acute urinary retention?
post void bladder scan - volume of retained urine
FBC, CRP, UE
after catheterisation - a catheterised specimen of urine assessed for infection
USS - hydronephrosis
hydronephrosis
as intravesicular pressure increases and becomes too high, counteracts the anti reflux mechanism of bladder and ureter —> hydroureter and hydronephrosis…deranged renal function, renal scarring, CKD
how is BPH treated?
tamsulosin - alpha receptor antagonist, relaxes smooth muscle at bladder neck and within prostate
what is the most common cause of chronic urinary retention in men?
BPH, or urethral strictures or prostate cancer
what are the most common causes of chronic urinary retention in women?
pelvic prolapse - cystoele, rectocele or uterine prolpase, pevlic masses such as large fibroids
what is the management of chronic urinary retension?
high post void volumes - post obstructive diuresis monitoring
long term catheter
treat underlying cause
what is the most common complication of chronic urinary retention?
UTI due to urinary stasis, or CKD
what is the difference between visible and non visible haematuria?
visible - naked eye
non visible - urine dipstick or urine microscopy
what are some differentials for haematuria?
UTI,renal cancer, renal calculi, prostate cancer, BPH
how is the degree of haematuria quantified?
pink v dark red
presence of clots or not
timing in the stream - if terminal (at end), then bladder irritation but if total - bladder or Upper tract
what are important questions in the history for haematuria?
associated sx - LUTS, fever, rigor, suprapubic or flank pain, weight loss, recent trauma
smoking - urological malignancies, industrial work - bladder cancer, or recent travel (schistosomiasis)
which examinations are required for haematuria?
DRE, abdo, external genitalia
which initial investigations are required for haematuria?
urinalysis - presence of nitites and leukocytes - infection
FBC, UE, clotting
PSA
urinary protein levels and referral to nephrology
what are the nice guidlines for urgent referral to urological service for haematuria?
> 45
unexplained visible without UTI or visible that persists are successful treatment of UTI
> 65
unexplained non visible haematuria, dysuria, raised WCC
what is the gold standard investigation for assessing lower urinary tract?
flexible cystoscopy, with local anaesthetic for further assement or follow up for proven malignancy
waht is the management of haematuria?
treat underlying cause
require insertion of three way catheter for wash out and irrigation and evacuation of clots
what are the differentials for LUTS and some exacerbating factors to ask in hx?
men - BPH,
female - UTI,
others - bladder cancer, prostate cancer, destusor muscle weakness, pelvic floor dysfunction, chronic prosatitis, urethral strictures, external compression from pelvic tumours
exacerbated - fluids at night, alcobol, caffeine
what are the sx of voiding and storage luts?
voiding - hesistancy or straining in micruturion, poor flow, terminal dribble, feeling of incomplete emptying
storage - increased frequency, nocturia, increased sense of urgency to urinate, urge incontinence
what are the clinical features of LUTS?
hx - voiding or storage
associated sx - visible haematuria, suprapubic discomfort, colicky pain
medication hx - anticholinergics, antihistamines and bronchodilaters - exacerbate
examinations - DRE, external genitalia
score - international prostate symptom score - impact of luts on QoL in men
what investigations are required for LUTS?
post void bladder scan and flow rate
bladder diary
urinalysis then culture
FBC, UE, PSA
specialist - urodynamic studies, cytoscopy (recurrent infections or haematuria), upper uri imaging via uss or ct
what is the conservative management of LUTS?
regulate fluid intake and avoid exacerbating factors
voiding sx - urethral milking technique (manually emptying bulbar urethra of residual urine) or double voiding (passing urine and waiting before passing urine again)
pelvic floor exercises
bladder training techniques
what is the pharmacological treatment of LUTS?
anticholinergics (oxybutynin) - for overactive bladder..relax bladder muscle by opposing parasympathetic control of contraction or Beta-3 adrenergic agonist(mirabegron) as this causes relaxation of detrusor muscle
alpha blockers (tamsulosin) or 5 alpha reductase inhibitors (finasteride) for BPH, relaxes prostatic muscle
loop diuretics (furosemide) - prevent nocturia
what are the complications of untreated LUTS?
infection, renal and bladder caliculi - stagnation of urine
bladder wall distension - overflow incontinence
renal failure, vilateral hydronephrosis
define renal cysts
simple - well defined outline, homogenous features
complex - thick walls, septations, calcification, risk of malignancy
what are the risk factors for renal cysts?
age
smoking
hypertension
male
define polycystic kidney disease
mutation in PKD1 OR 2 - multiple renal cysts forming in affected individuals
what are the clinical features of renal cysts?
usually asymptomatic, but may have flank pain
diagnosed through CT/MRI
bosniak scoring
serum u and e check
what is the management of renal cysts?
if symptomatic and simple - analgesia and maybe aspiration
if symptomatic and cmplex - staging, surveillance and possible surgical intervention - nephrectomy
…can lead to infection, haemorrahge and rupture
what are the types of renal stones?
renal or ureteric stones
made of calcium oxalate, calcium phosphate or mixed oxalate and phosphate, urate and cystine stones as well
what is the pathophysiology of renal tract calculi?
over saturation of urine
urate - high levels of purine (from diet - red meats or blood disorders)—urate formation and crystallisation of urine
cystine - homocystinuria, meaning less citrate…prediposes to stone formation
where are renal stones likely to lodge?
-pelviureteric junction
- where iliac vessels travel across ureter in pelvis
- vesicoureteric jjunction
what are the clinical features of renal caliculi?
ureteric colic pain (increased peristalysis from around site of obstruction), sudden onset and severe and radiating from flank to pelvis, N+V, haematuria, fever
- tenderness in affected flank
give 3 differentials for renal caliculi
pyelonephritis, ruptured AAA, bowel obstruction
how is renal caliculi diagnosed?
urine dip - haematuria, infection
FBC, CRP, UE, urate and calcium levels, retrieval of stone
gold standard - non contrast CT scan of renal tract
how are renal caliculi managed?
adequate fluid resuscitation
stones can pass spontaneously
sufficient analgesia - opiate, NSAID per rectum
IV abx if infection
may require stent insertion or nephrostomy(place stent within ureter distal to proximal via cystoscopy)
ESWL (shock waves), percutaneous nephrolithotomy, flexible uretero-renoscopy
what are bladder stones?
chronic urinary retention - stasis, or from infections
drained through cystoscopy
can predispose to development of bladder cancer
define pyelonephritis and the pathophysiology
inflammation of the kidney parenchyma and renal pelvis - usually due to bacteria
either from ascending lower UTI, or directly from blood stream - sepsis or infective endocarditis…usually E.coli
what are the risk factors for pyelonephritis?
antegrade flow of urine - BPH, spinal cord injury
retrograde ascent of bacteria - female, indwelling catheter, structural renal abnormalities
factors predisposing/immunocompromised - DM, HIV, corticosteroid use
bacterial colonisation - renal caliculi, sex, menopause (oestrogen depletion)
what are the clinical features of pyelonephritis?
fever, unilateral loin pain, N +V, lower UTI sx, haematuria, pyrexia, costovertebral angle tenderness
…should be checked for potentially ruptured AAA
which investigations are required for pyelonephritis?
urinalysis - nitrites, leukocytes, urinary beta hCG
FBC, CRP, UE
renal USS for suspected obstruction…then non contrast CT
possible flexible cystoscopy
how is pyelonephritis managed?
ABX
Fluid
analgesia
anti emetics
possible catheterisation
what are the types of renal cancer?
renal cell carcinoma
transitional cell carcinoma
nephroblastoma
squamous cell carcinoma
define renal cell carcinoma
adenocarcinoma of renal cortex…from PCT
-direct spread into tissues
- lymphatics
- haematogenous spread
what are the risk factors for renal cell carcinoma?
smoking
industrial exposure
dialysis
hypertension
obesity
anatomical abnormalities - polycystic and horseshoe
what are the clinical features of renal cell carcinoma?
haematuria
flank pain and mass
lethargy
weight loss
mass may be able to be palpated in flank, left sided masses with left varicoele due to compression of left testicular vein as joins renal
paraneoplastic syndromes - ectopic secretion of hromones
what is the first line investigation for RCC?
CT scanning of abdomen-pelvis pre and post IV contrast
how is RCC staged?
american joint committee on cancer staging classification based on size
what is the management of RCC?
if smaller - partial nephrectomy or radical if larger (kidney, perinephric fat, local lymph nodes, adrenal glands)
if not able to undergo surgery - percutaneous radiofrequency ablation or cryotherapy + surveillance + immunotherapy (not chemo)
what are the types of bladder cancer?
transitional cell carcinoma, squamous cell carcinoma, adenocarcinoma, sarcoma
further subdivided - non muscle invasive, muscle invasive and metastatic
give 4 layers of the bladder wall
inner - urothelium
second - lamina propria
third - muscular propria
fourth - connective tissue
give the risk factors for bladder cancer
smoking
age
industrial dyes or rubber
schistosomiasis
previous radiation
what are the clinical features of bladder cancer?
painless haematuria, recurrent UTI, LUTS, pelvic pain, weight loss
how is bladder cancer investigated?
flexible cystoscopy
tumour - biopsy and transuretheral resection
CT staging
how is bladder cancer managed?
non muscle invasive - resected, intravesical therapy, radial cystectomy possible
muscle invase - radical cystectomy and neoadjuvant chemo
…can have bladder reconstruction
metastatic - chemo
give 5 types of urinary incontinence
stress
urge
mixed
overflow
continuous
stress UI
intra abdominal pressure exceeds urethral pressure…due to usually weakness in pelvic floor muscles
urge UI
overactive bladder - destrusor hyperactivity - rise in intravesicular pressure…neurogenic,infectious or malignancy cause
mixed ui
stress + urge
overflow UI
complication of chronic UI - progressive stretching of bladder wall leads to damage…prostatic hyperplasia or spinal cord injury
continious UI
constant leakage..anatomical abnormality such as ectopic ureter or fistula
which investigations are required for UI?
midstream urine dipstick
post void bladder scans
urodynamic assessment- destrosumer muscle pressure calculated
outflow dynnamics = detrusor muscle activity against urine flow rate
how is UI managed conservatively?
weight loss, reduce caffeine intake, avoid drinking excess, smoking cessation
pelvic floor muscle training, duloxetine (SSRI) = stress
anti muscarinics such as oxybutynin, bladder training = urge
what is the surgical management of UI?
urge - botulinum toxin A injections, sacral nerve stimulation
stress - tension free vaginal tape, intramural bulking agents or artificial urinary sphincter
define prostatitis
inflammation of prostate gland
can be acute or chronic (becomes chronic when not treated)
usually caused by ascending urethral infection- e.coli but can also be STI’s
what are the risk factors for acute bacterial prostatitis?
indwelling catheter, phimosis, recent surgery, immunocompromised
for chronic - intraprostatic ductal reflex, dysfunctional bladder
what are the clinical features of prostatitis?
LUTS, pyrexia, perineal or suprapubic pain
DRE - tedner prostate
how is prostatitis investigated?
uirne culture
STI screen
bloods - fbc, crp, u and e, psa
if fail to respond to tx - prostate abscess suspscted so tranrectal prostatic USS
how is prostatitis treated?
prolonged abx - usually quinolone
analgesia
alpha blockers - tamsulosin
possible urology referral and chronic pain specialist
what are the risk factors for BPH?
age
family history
black african or caribbean
obesity
what are the clinical features of BPH?
LUTS - voiding sx
haematuria
haemtospermia
DRE - firm, smooth, symmetrical prostate
international prostate symptom score
how is BPH investigated?
urinary frequency and volume chart
bedside urinalysis
post void bladder scan
PSA test
USS of renal tract - volume of prostate
urodynamic studies
how is BPH treated?
reassurance, sx diary, medication review
alpha adrenoreceptors antagonist - tamsulosin
5 alpha reductase inhibitors - finasteride
analgesia
surgical - if high pressure retention - transurethral resection of prostate
what are the two types of prostate cancer?
acinar adenocarcinoma
ductal adenocarcinoma
what are the risk factors of prostate cancer?
age
men of black african or caribbean
family history
BRCA1/2 gene
obesity
smoking
what are the clinical features and investigations of prostate cancer?
LUTS
haematuria, dysuria, incontinence, haemtospermia, suprapubic pain,loin pain, rectal tenesmus, lethargy, unexplained weight loss
DRE - posterior peripheal zone - evidence of asymmetry, nodularity or fixed irregular mass
mp-MRI and then a targeted biopsy
what is the reason for raised PSA
prostate cancer, BPH, prostatits, UTI, recent surgery, urinary retention
how is prostate cancer graded?
gleason
how is prostate cancer managed?
low risk - surveillance
intermeidate - mostly surveillance
metastatic - chemo and anti hormonal agents
surgical - radial prostatectomy…can cause erectile dysfunction
radiotherapy
anti androgen therapy and chemo
define urethritis
inflammation of the urethra…gonococcal or non gonococcal (usually chamydia trachomatis or trichomonas vaginalis)
what are the clinical features of urethritis?
dysuria, penile irritation, discharge
give 2 complications of urethritis
epididymitis or reactive arthritis
define balanitis
inflammation of the glans penis, presents with pruritis, erythema and discharge between foreskin and glans..older patients
how is urethritis diagnosed?
first void urine sent for nucleic acid amplification test
urethral gram stain under microscopy from urethral swabs
mid stream urine dipstick
how is urethritis managed?
gonococcal - cefraxione IM single dose + azithroymycin PO single dose
non gonococcal - doxycyline PO BD + azithromycin PO single dose
no sexual activity for 7 days after abx have finished
condom use
notify sexual partners
what is the most common cancer in males aged 20-40?
testicular cancer
what are the types of testicular cancer?
germ cell tumour and non germ cell tumours
germ cell - seminomas and non seminomatous (yolk sac, choriocarcinoma, embryonal carcinomas, teratoma) - worse prognosis
non germ cell - leydig cell or sertoli cell - better prognosis
what are the risk factors for testicular cancer?
cryptochordism - germ cell tumours
previous testicular malignancy
family history
caucasian ethnicity
kleinfelter’s syndrom
what are the clinical features of testicular cancer?
unilateral painless lump
mass is ireegular, firm, fixed and not transilluminate
weight loss
back pain from retroperitoneal metastases
dypnoea from lung metastases
what are the investigations for testicular cancer?
beta-hcg
AFP
LDH
scrotal USS and then staged via CT with contrast
staged via royal marsden classification
how is testicular cancer managed?
surgery - inguinal radical orchidectomy
radiotherapy, chemo
pre treatment fertility assessment
define epididymitis and age range
inflammation of epidiymis, bimodal age distribution
what is the pathophysiology of epidiymitis?
local extension of infection from lower urinary tract - UTI OR STI
what are the clinical features of epidiymitis?
unilateral scrotal pain and swelling with fever
dysuria, storage LUTS, urethral discharge
tender on palpation
cremasteric reflex not intact and positive prehn’s sign
which investigations are required for epidiymitis?
urine dipstick, first void urine for NAAT, routine bloods
USS of testes via doppler
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
how is epididymtiis managed?
abx and analgesia
bed rest and scrotal support
abstain from sex
condoms
can result in reactive hydrocoele formation
define testicular torsion
spermatic cord twists WITHIN TUNICA VAGINALIS
which investigations are required for testicular torsion?
clinical diagnosis
dopper can be used to see compromised blood flow
urine dipstick - rule out
what is the management of testicular torsion?
within 4-6 hrs - bilateral orchidopexy or orchiodectomy if non viable testes
analgesia
anti emetics
maintenance fluids
how is the diagnosis made for the cause of epidymitis?
Investigations for suspected epididymo-orchitis are guided by age:
sexually active younger adults: NAAT for STIs
older adults with a low-risk sexual history: MSSU
how is epididymitis treated?
Single dose ceftriaxone and 10-14 days of doxycycline
what are the sx requiring a radical nephrectomy?
Painless flank mass, haematuria, and paraneoplastic features including hypertension, polycythaemia, hypercalcaemia, and Cushing’s syndrome.
