Urology Flashcards
How do renal stones present
severe loin to groin pain
nausea and vomiting
urinary urgency, frequency, retention
haematuria
what are most common types of renal stones
Calcium oxalate (85%)
calcium phosphate
Struvite (from proteus mirabilis)
Uric acid, xanthine (radio-lucent)
what is a risk factor for calcium oxalate stones
Metabolic (hypercalciuria, hyperurcaema, hypercysturia)
Low fluid intake
Structural abnormality
What are ssx of kidney stones
NOT peritonitic
Loi to groin tenderness
What is main differential ddx for kidney stones
Ruptured AAA
What basic bedside and blood ix do you need for kidney stones
Urine dip + MCS
Blood (FBC, CRP, UE; calcium, urate, phosphate)
What is the definitive ix for kidney stones
and what are the findings
CT-KUB (non contrast)
stone or peri-ureteric fat stranding
what clinical pictures can kidney stones present as
Renal colic
Pyelonephrosis (EMERGENCY)
When should you admit kidney stones
pain not controlled
impaired renal function
single kidney
pysexia / sepsis
stone >5mm
How should you manage a renal colic prior to referral to UROLOGY
Mx sepsis (sepsis &)
Mx pain (PR/IM diclofenac or diamorphine + antiemetic)
Check UE
Get CT KUB to confirm stone (Urology otherwise will not accept - could be a AAA)
How do urology manage renal stones (renal colic - not emergency)
<5mm = will likely pass spontaneously. Treat expectantily, consider alpha blocker (tamlosulin) or CCB
<2cm = lithotrypsy (Extracorporeal Shockwave Lithotripsy
Complex stone e.g. staghorne = NEPHROLIITHOTOMY
How do you manage hydronephrosis / pyelonephrosis ( infection
aggressive fluid resus
broad spec abx
urgent de-obstruction with PERCUTANEOUS NEPHROSTOMY
What do you do for renal colic patient who is discharged home (i.e. pt is well, pain is mild and well controlled)
outpatient visit in 4 weeks with CT-KUB (may need lithotripsy or surgical removal)
safety net
encourage high fluid intake
how common is BPH
very common, 70% of men over 70 years old
although only about half have sx
Sx of BPH
Frequency
Urgency
Urge incontinence
Nocturia
Hesistancy
Incomplete voiding
Poor stream
Examination findings BPH
on DRE: prostate is smoothly enlarged with palpable midline groove
Ix BPH
urine dip and MCS
Bloods: UE, PSA
Bladder scan (if retention)
Management of BPH
- Watchful waiting
- Medical:
- Alpha 1 ANTAGONIST (tamlosulin)
- 5alpha reductase inhibitor (finasteride) - Surgical - TURP
how does tamlosulin work
decreases smoooth muscle tone of prostate and bladder
How does finasteride work
blocks conversion of testosterone to dihydrotestosterone
causes reduction of prostate volume, but takes time to work (approx 6months)
what are risks with TURP
OVER-IRRIGATION, causing leakage into circulation
this causes hyponatraemia, fluid overloading, glycine toxic ity (confusion, coma)
Prostate cancer ix
- PSA testing
- Multi-parametric MRI (if +ve PSA + high index clin suspition)
- TRUS guided biopsy
When should you NOT do a PSA
48 hours of vigorous exercise / ejaculation
1 week of DRE
4 weeks of proven UTI / prostatitis
if 6 weeks from prostate biopsy
how do you manage prostate cancer
radical prostatectomy
radiotherapy
hormonal therapy if appropriate
what is the most common malignant cause of abdominal mass in children 2-5 years old
Wilms tumour
differentials for haematuria
Cancer:
- renal cancer
- bladder cancer
- prostate cancer
Urinary tract calcili
Renal calculi
Radiation cystitis
Trauma
Infection: UTI, infection, schistosomiasis, TB
what is the MAJOR CAUSE of PAINLESS VISIBLE HAEMATURIA
BLADDER CANCER
how do you investigate visible haematuria
urine dip, MSU
FBC, CRP
if suspecting bladder cancer:
Refer to urology for Flexible cystoscopy + CT urogram (to look at upper urinary tract)
how do urology investigate non-visible haematuria
Flex cystoscopy + US KUB (instead of CT urogram)
How do you manage bladder cancer
Trans urethral resection of bladder tumour
3 way catheter, keep in overnight
Risk factors for bladder cancer (based on histology)
TCC:
- smoking
- dyes (aromatic amines)
- cyclophosphamides
SCC:
- long term catheterisation
- smoking
- schistosomiasis
Testicular cancers types
SEMINOMA (around 40yo)
NON-SEMINOMA (teratoma, yolk sac)
what age group do teratomas occur in
20-35
What age group do Yolk sac tumours occur iin
10 year old
RF for testicular cancer
cryptorchidism (failed descent of testis in scrotum)
orchidopexy as chld
mumps orchitis
infertility
S/S testicular cancer
painless lump
rapidly growing, feels craggy and irrecular
gynaecomastia
tumour markers for testicular cancer
AFP == elevated in NON SEMINOMA
hCG = elevated in both
LDH = elevated in SEMNOMA
what are tumour markers very useful for in testicular cancer? especially which one and why
useful for monitoring response to treaatment
LDH is especially useful as t measures level of tumour necrosis
Ix for testicular cancer
urine dip, MCS (exclude infection)
USS + tumour markers (AFP, hCG, LDH)
Consider CT
Mx testicular cancer
orchidectomy + chemotherapy (BEP) +- radiotherapy
offer sperm banking
what approach do you need to take for orchidectomy
INGUINAL APPROACH (as this follows the lymphatic drainage of testes»_space; it avoids risk of spread)
How is epididymitis different to testicular cancer on exaMINATION
epididimytis is posterior, feels separate from testis
What is testicular torsion
twisting of spermatic cord > venous outflow obstruction > arterial occlusion > testicilar infarct
RF testicular tosion
trauma
imperfectly descended testes
bell clapper deformitiy
sx testicular torsion
sudden severe hemiscrotal pain
no pain relief on scrotal elevation (-ve Prehn sign)
abdo pain and vomiting
Which TWO SIGNS Occur in testicular torsion
Prehn sign NEGATIVE (no pain relief on scrotal elevation )
Cremasteriic reflex ABSENT (stroking innner part of thigh fails to pull scrotum ipsilaterallhy=
How do you clinically differentiate testic torsion from hydradid of Morgani
hydradid of Morgani:
- superior pole pain
- cremasteric reflex +ve
How do you ix testic torsion
Doppler USS (only if it doesnt delay tx)
mx testic torsion
surgical exploration + bilateral orchidopexy within 6 hours!!!!!
What are organic (not psychological) differentials for ED
atherosclerosis (do QRisk score, which includes CV risk factors)
abnormla endocrine picture (check testosterone )
manageement of ED
Sildenafil
second line: vacuum devices
what is a vasectomy
cutting of vas deferens
better contraception than female (failure rate only 1 in 2000)
how invasive is a vasectomy – how soon can you go home
under LA
Go home wiithin hours
when does a vasectomy start working
NOT immedate
semen analysis needs to be done at 16 weeks and 20 weeks before unprotected sex
what is vasectomy reversal success rate
55% within 10 years
Abx for uncomplicated UTI in women
Trimethoprim or nitrofurantoin
3 days
Abx for UTI in pregnancy
Nitrofurantoin 7 days (aboid at term)
OR
Amoxiicilliin 7 days
Abx for UTI in men or catheterised patients
Trimethoprim or nitrofurantoin 7 days
what is a Hydrocoele
collection of fluid in the tunnica vaginalis, in the testis
sx of hydrocoele
asymptomatic scrotal swelling
scrotum larger in evening or after exercise (due to change in abdominal pressures)
transilluminates
cannot be separated from testcles
ix of hydrocoele
urine dip, MSU (exclude infection)
USS testis (exclude lump)
TRANSILLUMINATES
Management hydrocoele
watchful waiting
Aspiration for symptomatic relief
Surgical repair
2 possible causes of hydrocoele
• Non-communicating hydrocele: tumour, infection, trauma, testicular torsion, epididimytis
• Communicating hydrocele: increased intra-abdo fluid/pressure (e.g. shunt, ascites)
what is varicocoele
scrotal swelling due to dilated veins in pampiniform plexus of spermatic cord, forming a scrotal mass
epidemiology of varcicoele
15 % male population, so very common
incidence highest after puberty
what is the biggest complication of varicocele
INFERTILITY
where is varicocele most likely to occur
on the LEFT
as the left testicular vein drains at 90 degree angle, is longer than the right, lacks terminal valve to prevent backflow
ix for varicocoele
doppler USS
presentation of varicocele
asymptomatic
bag of worms on palpation
dragging/ heavy sensation
dull ache
Examiination findings in varicocele
sidee with varicocele hangs low
swelling reduces with lying down
mx varicocele
generally conservative
ooccasional surgery
differential for scrotal mass (always split anatomically!)
SCROTAL SKIN: sebaceous cyst, melanoma
INTRA-VAGINAL (within processus vaginalis): hydrocele, epidydimal cyst, epididimits, torted hydratid
INTRA TESTICULAR: ooschitis, testicular abscess, testicular cancer, lymphoma
OTHER: inguinal hernia
what is the most common organism to cause prostatitis
E coli
RF prostatitis
recent UTI
urogenitaal instumentation
intermittent catheterisatiion
recent prostate biopsy
sx prostatitis
referred pain
obstructive voiding sx
fevers, rigors
Ix prostatitis
DRE: tender boggy prostate
mx prostatitis
Quinolone e.g. ciprofloxacin 14 days
which organisms are involved with the formation of staghorn calculi
Ureaplasma urealyticum and Proteus infections
what score do you use for prostate cancer and how does it work
Grade 1-5 for two worse slices
sum up the grades
how do you manage localised prostate cancer
conservative: active monitoring, watchful waiting (if low gleason score or elderly)
radical prostatectomy: surgical removal of prostate and obturator nodes
radiotherapy (external beam and brbachytherapy)
is circumcision available on NHS
NO
What are medical indications for circumcision on NHS
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
what must you exclude before circumcision
hypospadias
as foreskin would be needed for surgical repair
what is first line ix for testicular cancer?
USS
what must you NEVER do in testicular cancer
NEVER do a biopsy / FNA
because you risk spreading the cancer
what ix are necessary for all ED
lipids, glucose (Qrisk)
Free morning testosterone
what iix are necessary in ED if testosterone is low
do FSH, LH, prolactin
if these are low, then refer to endocrinology
what routes can you give diclofenac in for stones and why?
IM if very severe pain
PR/PO otherwise
when do you refer a man with uncomplicated UTI
at the SECOND UTI
when do you need to treat a cathheterised pt with UTI?
only if symptomatic!
do not treat if asymptomatic bacteriuria
what is stress incontinence due to
weakened or damaged muscles (pelvic floor / urethral sphincter) leading to small loss incontinence
what is urge incontinence due to
detrusor overactvity
what is functional incontinence due to
inability to get to the toilet in time (due to mobility)
ix for incontinence
speculum (if F - exclude pelvic organ prolapse)
Valsalva maneuvre to check for fluid leakage
Urine dip / MCS (exclude DM or UTI)
- Bladder diaries (min 3 days)
- Urodynamic testinig (if mixed - measures pressures inside bladder and urethra)
mx stress incontinence
Conservative:
- lifestyle
- WL (if BMI >30)
- pelvic floor exercisies
Medical/ surgical
- offer Burch colposuspension or SNRI duloxetiine
risk factors for stress incontinence
age
children
traumatic delivery
pelvic surgery
obesity
mx urge incontinence
COnservative:
- lifestyle advice (avoid fizzy drink)
- bladder training for 6 weeks (hold off going to toilet)
Mediical:
1
- antimuscarinic (oxybutinin, tolterodine)
- ADH analogue (desmopressin)
2.
- Mirabegron
- Surgical
- Botox injection, sacral nerve stimulation
commonest type of pancreatic cancer
adenocarcinoma
how does epididimo orchitis present
dysuria
urethral discharge
swelling (prehn p+ve)
what is the commonest cause of epididimo orchitis
chalmydia (esp <35)
what is MoA of Goserelin
GnRH agonist»_space; so it decreases LH levels by overstimulating the pituitary > decreases testosterone levels
What must you co-prescribe Goserelin with
3 week cover of anti androgen e.g. FLUTAMIDE; CYPROTERONE ACETATE
these prevent the initial rise in testosterone(due to initiial increased LH and FSH, due to GnRH agonisst»_space; which is later desensitised)
what is a complication of acute urinary retention
post-obstructive diuresis
- kidneys diuresis due to the loss of their medullary concentration gradient.
- it takes time re-equilibrate»_space; this can lead to volume depletion and worsening of any acute kidney injury
- may require IV fluids to correct this temporary over-diuresis
what is balanitis
inflammatino of the glans penis
cause of balanitis
STI
dermatitis
bacterial
fungaal infection (esp if immunocompromised or diabetes)
how do you manage recurrent balanitis
circumcision
how do you detect an inguinal hernia on examination in the testis
if you CANNOT GET ABOVE IT
+ separate to the testis
what does hydronephrosis mean in the context of ureteric stone
that the ureter is almosst completely occluded by the stone > very bad
what is the general cause of hydronephrosis
OBSTRUCTION of renal / ureteric tracts
so kidneys can no longer drain
how do you manage hydronephrosis
nephrostomy tube ( to relieve obstruction)
complications of radical prostatectomy
erectyle dysfunction
incontinence
key ix with hydronephrosis
renal USS
how do you manage RCC
nephrectomy
it is often non responsive to chemo or radiotherapy
how do you manage bladder cancer
- intravescicular immunotherapay
- radical cystectomy (if invasive) or transurethral resection of bladder tumour (if in situ)
how does urethritis cause urinary retention?
by causing urethral oedema
this may occur for instance with UTI /STI
