Urology Flashcards
UTI
^E.coli, F>M
Upper
= fever, loin pain, renal angle tenderness, haematuria, systemically unwell
-> admit? 7-10d broad Abx (cephalosporin/ quinolone)
Lower
= dysuria, frequency, urgency, incontinence, confusion, suprapubic pain
-> 3d trimethoprim or nitrofurantoin (7d if M/ catheter - only treat if symptoms)
Inv - urine dip (nitrates, leukocytes), culture if >65/ M/ preg/ catheter
Pregnancy; nitro (not in T3, use amox)
Bacterial Prostatitis
Cause - E.coli
RF - UTI, urogenital instrumentation, catheterisation
= fever, pain (perineum, back or penis), tender boggy prostate, obstructive voiding, myalgia, sepsis
-> 14d quinolone, STI testing
Balanitis
Inflammation of the glans penis
Candidiasis = after sex, itching, white discharge
-> topical clotrimazole
Dermatitis = Hx elsewhere, very itchy, painful, clear non-urethral discharge (contact/ allergic) or none (eczema/ psoriasis)
-> steroids
Bacterial = pain, itchy, yellow discharge (^staph)
-> PO fluxloxacillin
Anaerobic = itchy, offensive yellow non-urethral discharge
-> saline washing
Lichen Planus= itchy, Wickham’s striae, violaceous papules
Lichen sclerosis (balanitis xerotica obliterans) = itchy, white plaques, scarring, can cause phimosis
-> high-dose steroids e.g., clobetasol
Circinate Balanitis = painless erosions, link to reactive arthritis
-> steroids
Circumcision
Use - phimosis, recurrent balanitis, balanitis xerotica obliterans, paraphimosis, ^Jewish/ muslim
*reduces penile cancer, UTI, STI
NOT if hypospadias
Epididymal Cyst
Most common cause of scrotal swellings in primary care
RF - PCKD, CF, vHL
= separate from body of teste, posterior to testicle
Inv - US
Epididymo-orchitis
Infection of the epididymis +/- testis
Cause - chlamydia, N gonorrheae, E.coli
= unilateral teste pain and swelling, urethral discharge (^STI), dragging sensation
Inv - STI screen, urine MSU
-> refer to sexual health, IM ceftriaxone + 10-14d doxy, 14d quinolone if E.coli
Erectile Dysfunction
Persistent inability to attain and maintain an erection that permits satisfactory sexual performance
RF - CVD, alcohol, beta blockers, SSRIs
Organic = gradual onset, normal libido, no erection
Psychological = sudden onset, low libido, can get one on own, premature ejaculation
Inv - free testosterone 9-11am, if abnormal do FSH/ LH/ prolactin
-> PDE-5 inhibitor
Hydrocele
Collection of fluid in the tunica vaginalis, communicating (patent processus vaginalis) or non-communicating (excessive fluid production)
Cause - can be second to infection of testes/ epididymis, torsion or tumour
= soft, non-tender swelling, anterior and below the teste, can get above it, transilluminates
-> reassure newborn and repair if not gone by age 1-2, fix adults + US to excl tumour
Varicocele
Abnormal enlargement of the testicular veins
= bag of worms, ^left (?RCC, esp if doesn’t disappear lying), infertility due to ^temp
Inv - US with doppler, 2ww RCC
-> surgery if pain, testicular atrophy or fertility issues
Testicular Cancer
Most common cancer in men in 20s, met to lymph, lung, liver and brain
Germ cell (95%): seminomas, non-seminomas (yolk, teratoma, choriocarcinoma)
Non-germ cell: leydig, sarcoma
RF - infertility, cryptorchidism, FHx, Klinefelter’s, mumps orchitis
= painless lump, +/- pain, hydrocele, gynaecomastia (^oes:androgen)
Inv - hCG (80% non, 20% sem), AFP (80% non), LDH (40% both), US
-> orchidectomy, chemo/ radio
Renal Stones
= abdo pain + blood + leucocytes
Renal Stones - Types
Calcium Oxalate (radio-opaque)
- RF: ^Ca, ^oxalate, v citrate
Calcium phosphate (radio-opaque)
- RF: RTA T1/3, ^urine pH
Uric acid (radiolucent)
- RF: v urine pH, malignancy, inborn errors of metabolism
Cysteine (radiodense)
- RF: inherited disorder of cysteine transport (AR)
Struvite (radio-opaque)
- Mg, ammonium, phosphate
- RF: urease-producing bacteria in chronic infections
XR - C’s you can see (cysteine - semi) and others can’t.
Renal Stones - RF
Dehydration
PCKD
Gout
Ileostomy - loss of bicarb so ^acidity of urine
Loop diuretic, steroids, acetazolamide and theophylline (^calcium in urine)
*Thiazides protective
Renal Stones - Management
Inv - non-contrast CT KUB <24hrs of admission, US if pregnant/ children
-> NSAID (diclofenac) or paracetamol
Renal
< 5mm and asymptomatic = wait
5-10mm = shockwave lithotripsy
10-20mm = lithotripsy or ureteroscopy
>20mm/ staghorn/ complex = PC nephrolithotomy
Ureteric
<10mm = lithotripsy +/- a-blockers
10-20mm = ureteroscopy
If obstruction + infection need decompression (nephrostomy tube or catheters)
Chronic Retention
= painless and insidious
High pressure - impaired renal function + bilateral hydronephrosis
Low pressure - normal renal function + no hydro
Comp - decompression hematuria (no treatment)
Acute Retention
Cause - BPH, strictures, calculi, constipation, anticholinergics, TCA, antihistamines, opioids
= pain, confusion, palpable distended bladder, tenderness
Inv - abdo, PR and neuro exam, US (>300ccc confirms)
-> catheter
Comp - post-obstructive diuresis, AKI
Hydronephrosis
Unilateral - PACT
Pelvic ureteric obstruction
Aberrant renal vessels
Calculi
Tumours
Bilateral - SUPER
Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
Acute obstruction -> nephrostomy
Chronic -> stent or pyeloplasty
Vasectomy
Under LA
Inv - semen analysis to ensure azoospermia at 16 and 20wks
Comp - reversal works in 55% of cases <10yrs, drops to 25% after this
Transitional Cell Carcinoma
Cancer of the urothelium - ureters or bladder
BPH
^transitional zone, hyperplasia
RF - age, black ethnicity
= voiding and storage issues, UTI, retention, obstructive uropathy
Inv - urine dip, PSA, IPSS score (20-35 severe, 8-19 mod)
-> alpha 1 blocker (tamsulosin) in moderate, + 5 alpha reductase (finasteride) if sig enlargement or risk of progression (6m to work), may add tolterodine/ darifenacin if void + storage, TURP if fails
Torsion
Spermatic cord twists around its own blood supply.
RF - 10-30yrs
= severe pain, n+v, lose cremasteric reflex, phren’s signs (elevation does not help pain)
-> bilateral orchidopexy
Bell-clapper deformity: teste not fixed to the tuniva vaginalis, bilateral
False Positive PSA
Ejaculation / vigorous exercise last 48 hours
BPH
Instrumentation
Prostatitis / UTI last month
Retention
LUTS
Hesitancy - difficulty starting or maintaining flow
Weak flow
uregency
Frequency
Straining
Terminal Dribbling
Nocturia
Chronic Prostatitis
> 3 months, chronic pelvic pain syndrome (no infection) or bacterial
= pelvic pain, LUTS, sexual issues, tender prostate, painful poo
-> alpha blockers, analgesia, psychosocial treatment i.e., CBT
Prostate Cancer
Most common cancer in men, 95% adenocarcinoma, ^peripheral zone, slow growing, met to bones or lymph nodes
RF - age, FH, black, tall, anabolic steroids
= BOO, hematuria/ hematospermia, back/ perineal pain, hard nodular prostate, loss of median sulcus
Inv - multiparametric MRI + biopsy, prev via TRUS, Likert scale, PSA
-> radical prostatectomy, radio, met use Goserelin (GnRH agonist) + bicalutamide (ant.) or cyproterone acetate (anti-androgen) to prevent tumour flare
Gleason score
Prognosis in prostate cancer, based on Histology
Two numbers (out of 5) added together;
First is the grade of the most prevalent pattern
Second is grade of second most prevalent pattern
8+ is high risk
Interstitial Cystitis
Chronic inflammation of the bladder, combination of dysfunction of blood vessels, nerves, immune system and epithelium, ^F
= suprapubic pain, frequency, urgency, >6wks
Inv - cystoscopy (Hunner red inflamed lesions with small blood vessels)
-> analgesia, antihistamines, bladder instillations
Bladder Cancer
90% TCC, 5% SCC, 2% adeno
RF - smoking, M 50-80yrs, amine dye (printing/ textiles), rubber, schistosomiasis
= painless haematuria
2WW:
45+ unexplained macroscopic blood
66+ with microscopic blood + dysuria or ^WCC
Inv - cystoscopy, pelvic MRI, CT
-> TURBT / Intravescial chemo / cystectomy (need urostomy via ileal conduit after)
Renal Stones: Prevention
^Fluid, fresh lemon juice (citric acid reduces stone formation)
v Salt, spinach/ rhubarb (oxalates), liver/ sardines (purines, uric)
Thiazides, potassium citrate
Renal Cell Carcinoma
Adenocarcinoma arising from renal tubules, ^clear cell
RF - M, smoking, obesity, HTN, TS, VHL, rubber/ textiles (TCC)
= haematuria, loin pain, mass, fever, polycythaemia (secrete EPO), ^Ca (PTHrp), paraneoplastic hepatic dysfunction, left varicocele, Stauffer (cholestasis, organomegaly), HTN (renin)
Spread - via renal vein and IVC to lungs (cannon ball mets)
-> partial or radical nephrectomy, interferon a/ TK inhibitors
Priapism
Persistent painful erection
Cause - idiopathic or 2nd to ED drugs, trauma or sickle cell
Ischemic: impaired vasorelaxation, ^CO2, vO2, v PH
-> if >4 hours then aspirate blood, vasoconstriction agent (phenylephrine) if fails, surgery
Non-ischemic: high arterial inflow, normally 2nd to fistula formation
-> observe first line
Inv - cavernosal blood gas analysis, US
Lower Genitourinary Tract Trauma
Bladder Injury
= blunt trauma, 85% pelvic fracture, can’t wee
Urethral Injury
= ^bulbar (retain, perineal hematoma, bloody meatus) or membranous (2nd to fracture, prostate displaced up so exam is hard)
-> suprapubic catheter
