Urology Flashcards
State the differences between upper and lower urinary obstructions in terms of:
- Presentation
- Management
Presentation:
- UO presents with ‘loin to groin’ pain, reduced urine output and non-specific symptoms e.g. vomiting
- Whereas LO presents with difficulty passing urine instead and urinary retention (swollen bladder)
- Both have impaired renal function on blood tests
Management:
- UO managed with a nephrostomy to bypass an upper blockage
- Whereas LO is managed with either a urethral or suprapubic catheter
Upper obstructive nephropathy - state the following:
- Pathology
- Presentation
- Common causes
- Management
- Complications if not treated
Pathology:
- Obstruction of the upper urinary tract (i.e. ureters)
Presentation:
- ‘Loin to groin’ pain
- Reduced urine output
- Non-specific symptoms e.g. vomiting
- Reduced renal function on blood tests
Common causes:
- Renal calculi
- Tumour pressing on ureters
- Ureteric strictures
- Retroperitoneal fibrosis
- Bladder cancer blocking entrance of ureters
- Uterocoele (congenital)
Management:
- Nephrostomy
- Involves inserting tube through skin, through kidney and into ureters to drain into catheter bag
Complications if not treated:
- Pain
- Post-renal AKI
- CKD
- Infection
- Hydronephrosis
- Urinary retention and bladder distension
- Overflow incontinence
Lower obstructive nephropathy - state the following:
- Pathology
- Presentation
- Common causes
- Management
- Complications if not treated
Pathology:
- Obstruction of the lower urinary tract (i.e. bladder or urethra)
Presentation:
- Difficulty passing urine
- Urinary retention and distended bladder
- Reduced renal function on blood tests
Common causes:
- BPH
- Prostate cancer
- Bladder cancer
- Urethral strictures
- Neuropathic bladder
Management:
- Urethral catheter
- Suprapubic catheter
Complications if not treated:
- Pain
- Post-renal AKI
- CKD
- Infection
- Hydronephrosis
- Urinary retention and bladder distension
- Overflow incontinence
Neuropathic bladder - state the following:
- Pathology
- Key causes
- Management
- Complications if not treated
Pathology:
- Abnormal functioning of the nerves innervating the bladder and urethra
- Can lead to either under/over activity of the urethral sphincter muscles or detrusor muscle of bladder
Key causes:
- Diabetes
- Spinal cord / brainstem injury
- Stroke
- Multiple sclerosis
- Parkinson’s disease
- Spina bidifa
Management:
- Depending on cause, manage as with upper/lower obstruction
Complications if not treated:
- Urge incontinence
- Distended bladder
- Obstructive uropathy (complications as seen in upper/lower obstruction)
Benign prostatic hyperplasia (BPH) - state the following:
- Pathophysiology and demographic it commonly affects
- Symptoms
- Assessment
- Management
Pathophysiology and demographic it commonly affects:
- Hyperplasia of the epithelial and stomal cells of the prostate
- Commonly affects men over the age of 50
Symptoms:
General lower urinary tract symptoms:
- Difficulty initiating urination
- Spitting or spraying of urine
- Urinary retention / incomplete bladder emptying
- Straining
- Increased urinary frequency
- Nocturia
- Urgency
Assessment:
- Digital rectal examination
- Abdominal examination
- PSA blood test
- Urinary frequency test
- Urine dipstick
Management:
Conservative
- Reduce oral fluid intake, reduce caffeine/alcohol intake
Medical
- Alpha receptor blockers e.g. Tamulosin
- 5-alpha reductase inhibitors e.g. Finesteride
Surgical
- TURP
- TEVAP
- HoLEP
- Open prostatectomy
Prostate specific antigen (PSA) - state common causes of raised PSA
- BPH / general enlarged prostate
- Prostatitis
- Urinary tract infection
- Vigorous exercise especially cycling
- Recent prostate stimulation / ejaculation
- Prostate cancer
List major complications of TURP (transurethral resection of prostate)
- Infection
- Bleeding
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation
- Urethral strictures
- Failure to resolve symptoms
Prostate cancer - state the following:
- Key risk factors
- Presentation
- Investigation (order of events)
- Management
Key risk factors:
- Increasing age
- Family history
- Black
- Tall stature
- Anabolic steroids
Presentation:
- May be asymptomatic
- Haematuria
- LUTS
- Erectile dysfunction
- Systemic cancer signs e.g. weight loss
Investigation (order of events):
- DRE / PSA blood test
- Multiparameteric MRI
- Biopsies (either transrectal or transperineal)
- Isotope bone scan
Management:
- Watchful waiting
- Radiotherapy
- Radical prostectomy
- Hormone therapy e.g. androgren-receptor blockers, GnRH agonists
Prostatitis - state the following:
- Pathophysiology
- General categories of prostatitis
- Presentation for the 2 main types
- Investigation
- Management
- Complications of acute prostatitis
Pathophysiology:
- Inflammation of the prostate, either acute and bacterial or chronic inflammation
General categories of prostatitis:
1. Acute bacterial
2. Chronic bacterial
3. Chronic non-bacterial
Presentation:
Chronic
- Pelvic pain
- LUTS
- Sexual dysfunction
- Pain on bowel movements
Acute bacterial is as above, but with these additional symptoms
- UTI symptoms
- Fever
- Nausea
- Fatigue
- Myalgia
Investigation:
- Urine dipstick
- Urine microscopy
- STI testing
Management:
Acute
- Antibiotics
- Analgesia
- Laxatives
Chronic
- Alpha blockers
- Analgesia
- Psychological therapy
- Antibiotics
- Laxatives
Outline some complications of acute prostatitis
- Sepsis
- Prostate abscess
- Acute urinary retention
- Chronic prostatitis
Epididymo-orchitis - state the following:
- Key causative organisms
- Presentation
- Investigation
- Management
- Long term complications
Key causative organisms:
- E Coli
- Chlamydia
- Gonorrhoea
- Mumps
Presentation:
Unilateral and gradual onset (mins to hrs)
- Scrotal swelling
- Testicular pain
- Dragging sensation
- Systemic infection symptoms e.g. fever
- Urethral discharge if STI cause suspected
Investigation:
- MC&S to elicit likely organism
- STI testing
- Ultrasound to rule out other causes
Management:
- Antibiotics to treat underlying infection
- May refer to GUM if STI cause
- Analgesia
- Reduce physical activity / sexual activity
Long term complications:
- Chronic testicular pain
- Chronic epididymitis
- Reduced fertility
- Scrotal abscess
Testicular torsion - state the following:
- Pathophysiology and demographic
- Presentation
- Examination findings / investigations
- Management
Pathophysiology:
- Twisting of the spermatic cord with rotation of the testicle
- Typically teenage boys, but can occur at any age
Presentation:
- Sudden onset of unilateral testicular pain
- May have associated abdominal pain and nausea/vomitting
Examination findings / investigations:
- Elevated testicle / horizontal testicle
- Firm testicular swelling
- Absent cremasteric reflex
Management:
- Analgesia
- Surgical exploration leading to orchidoplexy or orchidoectomy (depending on situation)
List some causes of scrotal lumps
- Hydrocoele
- Varicoele
- Epididymal cyst
- Inguinal hernia
- Epididymo-orchitis
- Testicular torsion
- Testicular cancer
Hydrocoele - state the following:
- Pathophysiology
- Presentation
- Examination findings / investigations
- Management
Pathophysiology:
- Collection of fluid within the tunica vaginalis that surrounds the testes
- Can be idiopathic or secondary to cancer, torsion etc.
Presentation:
- Scrotal lump
Examination findings / investigations:
- Soft, fluctuant swelling
- Can feel the testicle through
- Irreducible with no bowel sounds
- Transilluminates
Management:
- Exclude more serious causes
- Conservative if idiopathic
- Surgery / aspiration if large/symptomatic
Varicocele - state the following:
- Pathophysiology
- Presentation
- Examination findings
- Investigations
- Management
Pathophysiology:
- Swelling of the veins forming the pampiniform venous plexus
- Can result from either increased resistance in the testicular vein or incompetent valves
Presentation:
- Scrotal lump
- Dragging sensation
- Throbbing/dull pain
- Fertility issues
Examination findings:
- Bag of worms texture
- Worse on standing/disappears on sitting down
- Asymmetry in testicular size if atrophy has occurred
If doesn’t disappear on lying down, suspect more sinister cause
Investigation:
- Colour doppler ultrasound for diagnosis
- May do sperm analysis if fertility is a concern/issue
Management:
Reassurance if minimal
- Surgery
- Endovascular embolisation to prevent abnormal flow
Epididymal cyst - state the following:
- Pathophysiology and epidemiology
- Presentation
- Examination findings
- Investigations
- Management
Pathophysiology:
- Fluid filled swellings, most commonly in the head of the epididymis
- Commonly in men (up to 30% of men)
Presentation:
- Scrotal lump but this can be an incidental finding
- Mostly asymptomatic
Examination findings:
- Soft, round lump associated with the epididymis
- Separate from the testicle
- Transilluminates
Management:
- Mostly entirely harmless so may be left
- Removal may be considered if causing pain or discomfort
Testicular cancer - state the following:
- Pathophysiology including the 2 types
- Risk factors
- Presentation
- Examination findings
- Investigation
- Staging system for testicular cancer
- Management
- Prognosis
Pathophysiology:
- Most arise as germ cell tumours in the testes (from cells that produce sperm)
- Rarely can be non-germ cell or secondary mets
2 main types
1. Seminomas
2. Non-seminonas (mostly teratomas)
Risk factors:
- Undescended testes
- Male infertility
- Family history
- Previous testicular cancer
Presentation:
- Painless lump on the testicle
- May be testicular pain
Examination findings:
- Firm / craggy / irregular mass
- Non-tender
- Can’t separate from testicle
Investigation:
- Ultrasound
- Tumour markers (alpha-feta protein, beta-hCG, LDH)
- Can stage with CT scan
Staging system for testicular cancer:
- Royal Marsden staging system
- Classic TNM staging with focus on whether spread above or below the diaphragm
Management:
- Surgical to remove testicle
- Radiotherapy
- Chemotherapy
+ sperm banking
Patients require monitoring follow ups with imaging and tumour markers
Prognosis:
- Mostly good if early with 90% cure rate
- Metastatic can also be curative
Common sites for testicular cancer metastasis
LLLB
Lung
Lymphatics
Liver
Brain
List some side effects of testicular cancer management
- Sub-fertility or infertility
- Hypogonadism
- Hearing loss
- Peripheral neuropathy
- Lasting kidney/liver/heart damage
- Risk of cancer in the future
Lower UTI (cystitis) - state the following:
- Pathophysiology
- Risk factors
- Presentation including additional symptoms for pyelonephritis
- Investigation
- Management including medication duration
Pathophysiology:
- Tracking of bacteria from the anus to the urethral opening, then up to the bladder
- Most commonly of E Coli
Risk factors:
- Female
- Sexual activity (spreads it)
- Incontinence
- Poor hygiene
Presentation:
- Dysuria
- Increased frequency / nocturia
- Cloudy / foul smelling urine
- Suprapubic pain
- Haematuria
- Urgency
- Confusion in the elderly
ADDITIONAL SYMPTOMS FOR PYELONEPHRITIS
- Loin/groin pain
- Fever
- Nausea and vomiting
Investigations:
- Urine dipstick (likely show positive for nitrites and leukocytes)
- Midstream urine sample (in pregnancy, recurrent UTIs, atypical symptoms and if antibiotics are ineffective)
Management:
Give Nitrofurantoin or Trimethoprim
- Uncomplicated: 3 day course
- Complicated (e.g. immunocompromised or abnormal anatomy): 5 day course
- Men/pregnancy/catheter related: 7 day course
Upper UTI (pyelonephritis) - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management
Pathophysiology:
- Inflammation of the kidneys (parenchyma or renal pelvis)
- Results from tracking of bacteria from the anus to the urethral opening, then up to the bladder and further up to the kidneys
- Most commonly of E Coli
Risk factors:
- Female
- Pregnancy
- Diabetes
- Vesico-ureteric reflux
- Structural abnormalities (urological)
Presentation:
- Dysuria
- Increased frequency / nocturia
- Cloudy / foul smelling urine
- Suprapubic pain
- Haematuria
- Urgency
- Confusion in the elderly
PLUS
- Loin/groin pain
- Fever
- Nausea and vomiting
May also have
- Systemic illness
- Haematuria
- Loss of appetitie
- Renal angle tenderness
Investigations:
- Urine dipstick (likely show positive for nitrites and leukocytes)
- Midstream urine sample (in pregnancy, recurrent UTIs, atypical symptoms and if antibiotics are ineffective)
- Blood tests (looking for raised inflammatory markers or WBCs)
- Imaging (USS or CT) may help to investigate the cause
Management:
- Give Cefalexin 7 day course (also consider giving Co-Amoxiclav or Trimethoprim, if have culture results)
- Consider sepsis!
Explain how lower UTIs can affect pregnancy and how management changes in pregnancy
Lower UTIs in pregnancy can cause premature rupture of foetal membranes and pre-term labour
Management:
- 7 days of antibiotics (rather than the normal 3 days)
- Avoid Trimethoprim in the 1st semester as it’s a folate antagonist (risk of spina bifida)
- Avoid Nitrofurantoin in the 3rd trimester (risk of neonatal haemolysis)
Interstitial cystitis - state the following:
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology:
- Chronic condition causing inflammation of the bladder
- Results in LUTS symptoms and suprapubic pain
- Complex pathophysiology
Presentation:
- LUTS symptoms that persist for more than 6 weeks, specifically suprapubic pain, frequency and urgency
Investigations:
No diagnostic criteria - diagnosis of exclusion
- Urine dipstick
- Swabs (check STI)
- Cystoscopy (may see Hunner lesions or granulations)
- DRE in males
Management:
- Can be challenging, but options include
- Lifestyle changes
- CBT / pelvic floor exercise / TENS machine
- Medications (oral and intravesicle)
- Hydrodistension
- Surgical procedures
Bladder cancer - state the following:
- Pathophysiology
- Main types of bladder cancer
- Risk factors
- Presentation
- Diagnosis
- Key stages of bladder cancer
- Management
Pathophysiology:
- Cancer arising from the endothelial lining
- Majority of cancers at superficial at time of presentation
Main types of bladder cancer:
- Transitional cell carcinoma
- Squamous cell carcinoma
Risk factors:
- Age
- Smoking
- Aromatic amines (factory dye)
- Schistosomiasis
Presentation:
- Painless haematuria (important to remember!)
Diagnosis:
- Cystoscopy (rigid or flexible)
Key stages of bladder cancer:
- TNM staging
- Non-muscle invasive (in situ, Ta and T1)
- Muscle invasive (T2-T4)
Management:
- MDT management
Surgical options
- Transurethral resection of the bladder
- Intra-vesicle chemo or BCG
- Chemotherapy
- Radiotherapy
- Radical cystectomy (would need: urostomy which is most popular, continent urinary diversion, neobladder reconstruction)
Renal stones - state the following:
- Pathophysiology and main complications
- Composition of 2 main types of stone
- Risk factors (for calcium based)
- Presentation
- Investigations
- Management
Pathophysiology and main complications:
- Formation of hard stones in the renal pelvis
- Complications include obstruction (leading to AKI) and infection
Composition of 2 main types of stone:
- Calcium oxalate (more common)
- Calcium phosphate
Risk factors (for calcium based)
- Hypercalcaemia
- Low urine output
- Previous renal stones
Presentation:
- Generally only become symptomatic when they get stuck in the ureters (commonly at the vesico-ureteric junction)
- Unilateral loin to groin pain
- Colicky pain
- Restlessness (can’t get comfortable)
May also be
- Haematuria
- Nauseas/vomiting
- Reduced urine output
- Systemic infection symptoms
Investigations:
- Urine dipstick
- Blood tests
- Non-contrast CT (CT KUB)
- Ultrasound (more useful in pregnancy or children)
Management:
- Analgesia (IM or PR Diclofenac)
- Anti-emetics
- Antibiotics (if infection present)
- Watchful waiting?
- Tamsulosin
- Surgical intervention (shock wave lithotripsy, laser lithotripsy or nephrolithotomy)
Outline the management options for renal stones (based on their size)
All patients = PR diclofenac and strong opiates e.g. Codeine
Stones < 5mm with no signs of obstruction:
- Watchful waiting
If stones < 5 mm in the distal ureter:
- Medical expulsive therapy e.g. tamsulosin
If > 5mm
- Extracorporeal shock wave lithotripsy
- Ureteroscopy = treatment of choice for pregnant women
If > 20mm, signs of obstruction, infection or stones not spontaneously passing:
- Percutaneous nephrolithotomy (under GA)
- Open surgery
Outline lifestyle modifications for preventing recurrent kidney stones
- Increase oral fluid intake
- Add fresh lemon juice to water (citric acid binds calcium)
- Avoid carbonated drinks
- Reduce salt intake
- Maintain calcium intake
Calcium stones specifically - reduce oxalate-rich foods
Uric acid stones specifically - reduce purine-rich foods
Renal cell carcinoma - state the following:
- Pathophysiology
- Main types of renal cancer
- Risk factors
- Presentation and spread of metastasis
- Diagnosis
- Management
Pathophysiology:
- Adenocarcinoma of the renal tubules
Main types of renal cancer:
- Clear cell
- Papillary
- Chromophobe
- Wilm’s tumour (affects children <5 yrs)
Risk factors:
- Smoking
- Obesity
- Hypertension
- End-stage renal failure
Presentation and spread of metastasis:
- Triad of symptoms: haematuria, flank pain and palpable mass
- Non-specific cancer symptoms
- First presentation could be varicoceles
- Commonly spreads to surrounding fascia
- If spreads to lungs, forms cannonball metastasis (also comes from placenta cancer)
Diagnosis:
- CT
- TNM system
Management:
- Partial nephrectomy
- Radical nephrectomy
- Other less invasive procedures
- Chemotherapy or radiotherapy
Explain how a renal transplantation is done including post-transplant treatment
- Leave old kidney in-situ
- Hockey stick incision
- Place kidney anteriorly in the iliac fossa on affected side
- Anastomose donor kidney vessels to the pelvic vessels
- Anastomose donor ureter to bladder
Post-transplant:
- Requires life long immunosuppressants
- Tacrolimus
- Presnisolone
- Mycophenolate
State the different types of complications post-renal transplant (transplant complications and immunosuppressant complications)
Transplant complications:
- Transplant rejection
- Transplant failure
- Electrolyte disturbances
Immunosuppressant complications:
- Skin cancer
- T2DM
- Ischaemic heart disease
- Increased likelihood of infections, including atypical and rare infections
List investigations for a patient presenting with haematuria
Simple investigations:
Urinalysis - check for an infective cause of haematuria
Baseline bloods (FBC, U&Es, and clotting) - check general condition and kidney function
DRE and PSA testing - if prostate malignancy is suspected
Surgical investigations:
Lower urinary tract imaging - Flexible cystoscopy
Upper urinary tract imaging - CT urogram or USS
List common benign and malignant causes of haematuria
Urinary tract infection (UTI)
Renal stones
BPH
Cancer:
Renal cancer
Bladder cancer
Prostate cancer
Define a paraneoplastic syndrome
Distant systemic effects that are unrelated to symptoms
List the common paraneoplastic syndromes associated with RCC
Polycythaemia - secretion of unregulated EPO
Hypercalcaemia - secretion of hormone that mimics PTH
Hypertension - various factors including increased renin secretion, polycythaemia and physical compression
Stauffer’s syndrome - abdominal LFTs without liver metastasis
Upper Tract Transitional Cell Carcinoma - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Transitional Cell Carcinoma of the renal pelvis and ureter
Presentation:
- Haematuria
- Palpable pelvic mass
- Hydronephrosis
- Strangury
Investigations:
- Ureteroscopy
- CT urography
Management:
- Radical nephroureterectomy
State the difference between CT urogram and non-contrast CT KUB
Both used to investigate the kidneys, ureters and bladder
CT urogram - contrast technique
- Helps to illustrate the urinary tract
- Can be used to investigate upper tract tumours, strictures and kidney function
CT KUB - non-contrast technique
- First line investigation for renal calculi
State the significance between non-muscle and muscle invasive bladder cancer in terms of management
Non-muscle invasive bladder cancer:
- Requires local treatment only e.g. intravesicle BCG
- May require repetitive treatments due to high rate of recurrence
Muscle invasive bladder cancer:
- Requires multimodal treatment strategies e.g. radical cystectomy, chemotherapy (neoadjuvant and adjuvant), radiotherapy
State the risks and benefits of PSA screening for prostate cancer
Risks:
- False positive test results (man has an abnormal PSA test but does not have prostate cancer), can lead to unnecessary tests and anxiety
- Individual may never die from their prostate cancer
Benefits:
- Finding prostate cancers that may be at high risk of spreading, so that they can be treated earlier before they spread which may lower deaths
- Some men prefer to know if they have prostate cancer
Explain the Gleason scoring system for prostate cancer
- Pathologist looks at how the cancer cells are arranged in the prostate
- Assigns a score on a scale of 3 to 5 from 2 different locations
3 = cancer cells that look similar to healthy cells
5 = cancer cells that look more aggressive
Scores are added together (between 6 and 10)
6 = low-grade cancer
7 = medium-grade cancer
8-10 = high-grade cancer
Score helps to guide treatment
Explain the differences between active surveillance and watchful waiting for prostate cancer
Active surveillance: more aggressive
- Agreement not to treat cancer straight away
- Actively monitor to determine if the cancer is growing or getting more aggressive
- Monitor using PSA, DRE, imaging and biopsies
- Curative
- Best for men with small, low-risk tumours without symptoms
.
Watchful waiting: less aggressive for older/less medically fit patients
- No regular biopsies or other frequent testing
- Palliative
- Best for men with prostate cancer who do not want or cannot have treatment therapies
Explain how the hypothalamo-pituitary-gonadal axis of testosterone regulation is targeted in hormone therapy for advanced prostate cancer
- All hormone therapy treatments aim to reduce levels of testosterone that normally stimulate the cancer
- This can be done by suppressing the HPA axis at various points along the axis
Hormone treatments:
- GnRH agonists to suppress the HPA axis, leading to reduced testosterone production
- Androgen receptor blockers
- Rarely: bilateral orchidectomy to reduce endogenous testosterone production
List the testicular tumour markers and which type of testicular cancer they are most reflective of
AFP
- Protein secreted by the fetal yolk sac, liver and gastrointestinal tract
- Teratomas (NOT seminomas)
beta-HCG
- In germ cell tumours, cancerous cells can transform into syncytiotrophoblasts and secrete bHCG
- Teratomas and seminomas
Lactate dehydrogenase:
- Expressed on chromosome 12p, which is often amplified in testis cancer cells
- Non-specific
Describe the lymphatic drainage of the testis and how this influences the surgical treatment of testis cancer
- Lymphatics from the testes drain into the para-aortic lymph nodes
- Therefore during surgery, retroperitoneal lymph node removal is important
Describe the pattern of penile cancer metastasis
Penile cancer metastasises in a predictable pattern
- Sentinel lymph node (often superficial lymph nodes)
- Metastases to deep inguinal lymph nodes
- Metastases to pelvic lymph nodes
- Widespread metastasis to LLBB (lungs, liver, bones, brain)
List some differentials for acute flank pain
- Renal obstruction including stones and blood clots
- Pyelonephritis
- Gall bladder disease
- Liver disease
- Muscular pain
- Ectopic pregnancy
- Aortic dissection
Suggest pain management for renal colic
Start with NSAIDs: IM or PR Diclofenac
Escalation to IV Paracetamol
Escalation further to opioids
Explain what a JJ stent is
Internal system
- A thin, flexible plastic tube which is curled at both ends
- The ends are in the bladder and the affected side’s kidney
- Cystoscope through the bladder is used to guide the stent into the ureter opening (interventional radiologist)
- Stent must be changed every 3-6 months
Explain what a nephrostomy is
External system
- A thin plastic tube which is passed from the back through the skin and then through to the renal pelvis
- USS or x-ray guided
- Temporarily drains urine (allows the kidney to function)
- Can be removed once the because of the obstruction has been resolved
Explain the difference between UTI and asymptomatic bacteriuria, including how this affects management
UTI - symptomatic infection of the urinary tract with bacteria
- Requires treatment with antibiotics
Asymptomatic bacteriuria - colonisation of urinary tract WITHOUT symptoms
- Not appropriate to treat with antibiotics
- More common in elderly (over 65) and patients with catheters
How this affects management:
- Studies have found that prescribing antibiotics for people without UTI symptoms offers no benefits in women or men and increases risk of C.diff infection and antibiotic resistance
- Treat as soon as patient becomes symptomatic
Explain the importance of multi-drug resistant gram-negative bacteria and how they are managed
‘Multi-drug resistant Gram-negative bacteria’ are bacteria exhibiting resistance to multiple classes of antimicrobial agents,
- Includes E coli and others (doesn’t include MRSA)
- Most commonly detected in the urine, but can be present in respiratory tract or wounds
Management:
- Discussion with a Microbiologist to advise on appropriate therapy
- If catheter associated, remove catheter
Describe non-antibiotic based and antibiotic based strategies for managing recurrent UTIs in women
Non-antibiotic based:
- Advise about behavioural and personal hygiene measures
- Increase daily fluid in take
- Wipe from front to back
- Avoid long intervals between urination
- Urination after intercourse
- Suggest Cranberry products (evidence uncertain)
- Consider vaginal oestrogen in post-menopausal women
- D-mannose (non-pregnant women)
Antibiotic based:
- Consider single / daily dose antibiotic prophylaxis
- First line: Nitrofurantoin or Trimethoprim
- Second line: Amoxicillin or Cefalexin
Describe the clinical presentation of pyelonephritis and how it’s distinguished clinically from pyonephrosis (an infected, obstructed kidney)
Pyelonephritis:
- Inflammation of the kidney parenchyma and the renal pelvis
- Typically occurs due to bacterial infection
Presents with: fever, dysuria, abdominal pain and vomiting
Pyonephrosis:
- Infection of the kidneys’ collecting system, where pus collects in the renal pelvis which causes distension of the kidney
- Can occur as a complication of kidney stones (source of persisting infection), complication of hydronephrosis or pyelonephritis or spontaneously
Presents with: fever and chills, flank pain, with a previous history of infection, stones or surgery
Explain the difference between acute prostatitis and chronic prostatitis
Prostatitis is inflammation of the prostate gland
Acute bacterial prostatitis:
- Most cases are caused by ascending urethral infection or sometimes direct or lymphatic spread
- Presents with: LUTS, perineal or suprapubic pain, urethral discharge or features of systemic infection
- Management: prolonged antibiotic treatment
Chronic bacterial prostatitis:
- Infection of the prostate with or without prostatitis symptoms
- Thought to be the sequelae of inadequately treated acute prostatitis
- Presents with: pelvic pain or discomfort > 3 months alongside LUTS
- Management: can be difficult
Outline features that distinguish epididymo-orchitis from testicular torsion
Epididymo-orchitis:
- Testes in normal position
- Positive Prehn’s sign (pain relieved by lifting the testicle)
- Intact cremasteric reflex
Testicular torsion:
- Testes in high riding position and may be horizontal
- Negative Prehn’s sign (pain NOT relieved by lifting the testicle)
- Absent cremasteric reflex
- Occurs most commonly in younger males
Outline symptoms of bladder outflow obstruction and overactive bladder syndrome and how to distinguish between them clinically
Bladder outflow obstruction:
- A blockage at the base of the bladder, leading to reduced flow of urine into the urethra
Symptoms include
- Abdo pain
- Increased urinary frequency
- Feeling of a full bladder
- Urinary hesitancy
- Dysuria
- Straining / spraying urine
Overactive bladder syndrome:
- Combination of symptoms that may cause you to urinate more frequently with additional urgency
- Feel a sudden urge to urinate that’s difficult to control
- Urgency incontinence
- Increased urinary frequency
- Nocturia
Distinguish between:
- BOO is more of an obstructive pattern, whereas OAB is more of an urgency/frequency pattern
Discuss the causes of nocturia and how it can be managed
Causes of nocturia:
- Bladder pathology e.g. OAB, lower UTI, interstitial cystitis
- Prostate pathology e.g. BPH, prostate cancer
- Poor sleeping patterns e.g. sleep apnoea
- Excessive urine production e.g. diabetes, diabetes insipidus, diuretic medication, excessive fluid intake, excessive caffeine intake
Management:
- Correct the underlying because
Conservative: reduce fluid intake, reduce caffeine intake, increase general exercise
Medical: Anticholinergics, Desmopressin
Briefly explain how urodynamic study is performed
- Patient should attend with a full bladder and bladder diary (without any UTI symptoms)
- Explain that the tests are there to reproduce urinary symptoms and so not to be embbarrased about any leakage
Uroflowmetry:
- Patient voids into commode which measure urine volume and flow rate
FiIlling cystometry (storage capacity of bladder):
- Insert filling catheter and pressure sensor into bladder (at same time, pressure sensor in vagina or rectum to measure intra-abdominal pressure)
- Measure post-void residual volume
Voiding cystometry (mechanics of weeing):
- Patient voids normally
- Pressure and flow is measured, to give pressure-flow graph
- Can suggest a cause is fast/slow flow
List conservative, medical and surgical treatment options for bladder outflow obstruction
Conservative:
- Bladder retraining
- Alter drinking habits
- Manage weight
- Maintain bowel regularity
Medical:
- Anticholinergics
- Beta 3 agonists
Surgical:
- Botox injections
- Sacral nerve stimulation
- Augmentation cystoplasty
- Urinary diversion
Describe the difference between acute and chronic urinary retention
Acute retention:
Acute urinary retention is a medical emergency
- Characterised by a sudden inability to pass urine
- Painful / suprapubic tenderness
- High but not that high residual volume
- Palpable distended bladder
Chronic retention:
- Characterised by a gradual inability to empty the bladder completely
- Painless
- Very high residual volume
- Palpable distended bladder
List common causes of urinary retention
Obstructive:
- BPH or prostate cancer
- Bladder calculi
- Bladder cancer or compressive tumour
- Strictures
- Constipation
- Pelvic organ prolapse
Infectious and inflammatory:
- Prostatitis
- Cystitis
Other:
- Neurogenic bladder e.g. Guillain-Barré syndrome
- Iatrogenic / medications
- Fowler’s syndrome
- Trauma
Define residual volume and explain its importance
Residual volume: defined as the amount of urine left in the bladder at the end of micturition
Measured by catheterisation (gold standard) or non-invasively by ultrasonography (bladder scan)
< 50 mL = normal
> 200 mL = abnormal (urinary retention)
List the common treatments for acute urinary retention
Treatment depends on the underlying condition
- Catheterisation is used to relieve acute painful urinary retention or when no cause can be found
- Before the catheter is removed an alpha-adrenoceptor blocker should be given for 2 days
Need urine output monitored for post-obstructive diuresis - Surgical procedures or dilatation are often used to correct underlying mechanical outflow obstructions
Explain the distinction between low-pressure and high-pressure chronic retention
The terms “low” and “high” refer to the bladder pressure at the end of voiding
Low pressure chronic retention (LPCR):
- More common, less serious
- Upper renal tract unaffected due competent urethral valves or reduced detrusor muscle contractility / complete detrusor failure
- Normal kidney function and normal kidneys
High pressure chronic retention (HPCR)
- Less common, more serious
- High bladder pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract
- Leads to hydroureter and hydronephrosis (checked on USS and bloods)
Outline treatment options for chronic retention
What condition should you look out for once obstruction is relieved?
- A long term urethral or a suprapubic catheter
- Definitive management depends on underlying because
Beware of post-obstructive diuresis
Explain why Trial WithOut Catheter is not appropriate for high-pressure chronic retention
Should not undergo a TWOC due to concerns of repeat renal injury (risk of going back into high-pressure retention)
Erectile dynsfunction - state the following:
- Possible causes
- Importance of assessing cardiovascular risk in men with ED
- Common medications used in management
Possible causes:
- Psychological e.g. anxiety or stress
- Heart disease
- Atherosclerosis
- Hypercholesterolaemia
- Hypertension
- Diabetes
- Obesity
- Metabolic syndrome
- Parkinson’s disease
- Multiple sclerosis
- Medications
- Peyronie’s disease — development of scar tissue inside the penis
- Alcoholism / substance abuse
- Treatments for prostate cancer or enlarged prostate
- Surgeries or injuries that affect the pelvic area or spinal cord
- Low testosterone
Importance of assessing cardiovascular risk in men with ED:
- Many of the causes of erectile dysfunction are cardiovascular in nature such as hypercholesterolaemia or hypertension
- Further investigation is required to assess cardiovascular risk
Common medications used in management:
- Sildenafil
- Inhibits phosphodiesterase enzyme, which is normally responsible for degradation of cGMP
- By inhibiting degradation of cGMP, it enhances the effects of nitric oxide = smooth muscle relaxation and improves blood flow
- Requires an erection in the first place in order to work
Distinguish physiological from pathological/scarred phimosis
Phimosis is when the foreskin cannot be retracted
Physiological phimosis:
- Pliant and unscarred foreskin, occurs due to early developmental stage
- Common in male patients < 3 yrs, but often extends into older age groups
- At birth, there are adhesions between the prepuce (foreskin) and the glans of the penis
- Over time these gradually break down
True pathological phimosis:
- Secondary to distal scarring of the foreskin (often appears as a contracted white fibrous ring around orifice)
Define paraphimosis
- Inability to pull forward a retracted foreskin over the glans penis
- Often due to the presence of a tight constricting band
- If it continues, glans becomes increasingly oedematous due to reduced venous return, leading to vascular engorgement of the distal penis and further oedema
- If untreated this may lead to penile ischaemia and worsening infection
- Urological emergency and in worst case, can develop into Fournier’s Gangrene
Fournier’s Gangrene - state the following:
- Pathophysiology
- Risk factors
- Importance of prompt surgical debridement
Pathophysiology:
- A form of necrotising fasciitis that specifically affects the perineum
- Very high mortality rate 20-40%
Risk factors:
- Diabetes mellitus
- Excess alcohol intake
- Poor nutritional state
- Excess steroid use
- Haematological malignancies
- Recent trauma to region
Importance of prompt surgical debridement:
- Debridement should be urgent and is often extensive
- Requires adequate removal of all necrotic tissue is key
- Patient started on broad-spectrum antibiotics
Define Peyronie’s disease and its epidemiology
Peyronie’s Disease - condition characterised by an acquired curvature of the penis due to fibrosis of the tunica albuginea
- Acute inflammatory phase followed by a chronic stable phase.
- Most prevalent in middle aged men but can affect men of any age
- Generally a progressive condition
Describe the defining clinical features of:
- Indirect inguinoscrotal hernia
- Hydrocele
- Epididymal cyst
- Testicular cancer
- Varicocele
Indirect inguinoscrotal hernia (not incarcerated):
- Can’t get above lump
- Worse on coughing
- May disappear on lying flat
Hydrocele:
- Transilluminates
- Can’t feel testes through
Epididymal cyst:
- Smooth, fluctuant and round
- Transilluminates
Testicular cancer:
- Can’t separate from testicles
- Painless
Varicocele:
- Disappear on lying flat
- More common on left side
- Bag of worms
Outline common indications for catheters
- Urinary retention e.g. obstruction
- Neurogenic bladder
- Peri-operatively
- Close urine output monitoring e.g. in sepsis
- Bladder irrigation
- Chemotherapy administration
Outline which lymph nodes testicular cancer spreads to
Para-aortic lymph nodes
Outline which lymph nodes scrotal cancer spreads to
Superficial inguinal lymph nodes
Outline some potential complications of TURP surgery
- Erectile dysfunction
- Retrograde ejaculation
- Urethral strictures
- Dysuria / incontinence
- Electrolyte abnormalities e.g. hypernatraemia
- Failure to resolve symptoms
- Bleeding
- Infection
- Damage to local structures e.g. bladder neck
Outline some investigations that can be done for LUTS symptoms
- Urine dipstick
- Urine MC&S
- DRE
- Bladder scan
- USS KUB
- Bladder diary
- Urodynamics (best)
State how priapism is managed
- Aspiration of the blood within the corpus cavernosa
- Irrigation of the corpus cavernosa with saline water
- Intracavernosal alpha agonists can be used e.g. Adrenaline or Phenylephrine
