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Surgery > Urology > Flashcards

Urology Flashcards

1
Q

What are the causes of lower urinary tract symptoms

A

BPH

UTI

Urological malignancy

Detrusor muscle weakness/instability

Chronic prostatitis

Urethral strictures

External compression

Neurological disease

Drinking fluids late at night

Alcohol excess

Excess caffeine intake

Polyuria

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2
Q

What are the classifications of lower urinary tract symptoms

A

Storage symptoms: urgency, frequency, nocturia, urge incontinence

Voiding symptoms: bladder outflow obstruction, hesitancy, intermittency, straining, terminal dribbling, incomplete emptying

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3
Q

What additional symptoms should be asked about in a lower urinary tract symptoms history

A

Visible haematuria

Suprapubic discomfort

Colicky pain

Medications: anticholinergics, antihistamines, bronchodilators

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4
Q

What investigations are needed for lower urinary tract symptoms

A

Post-void bladder scan

Flow rate

Urinalysis

Urine culture

Routine bloods (+ PSA)

Urodynamic studies (flow rate, detrusor pressure, storage capacity)

Cystoscopy (recent infection, haematuria)

Upper urinary tract imaging (chronic infections, recent infection, haematuria)

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5
Q

What is the management for lower urinary tract symptoms

A

Treat underlying cause

Regulate fluid intake

Urethral milking

Double voiding

Pelvic floor exercises (stress incontinence)

Bladder training (urge incontinence)

Anticholinergics (oxybutynin, for urge incontinence)

Alpha blockers (tamsulosin, for BPH)

Loop diuretics (take mid-afternoon to prevent nocturia)

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6
Q

What is the urgent referral criteria for haematuria

A

> 45: unexplained visible haematuria without UTI/despite successful treatment of UTI

> 60: unexplained non-visible haematuria with dysuria/raised WCC

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7
Q

What are the causes of haematuria

A

UTI

Urothelial carcinoma

Stone disease

Adenocarcinoma of prostate

BPH

Infection (pyelonephritis, cystitis, prostatitis)

Malignancy

Renal calculli

Trauma

Recent surgery

Radiation cystitis

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8
Q

What investigations are needed for haematuria

A

Urinalysis

Bloods (routine + clotting + PSA)

Flexible cystoscopy

US KUB

CT urogram

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9
Q

What is acute urinary retention

A

New onset inability to pass urine

Leads to pain, discomfort, and significant residual volume

Most common in older males (BPH)

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10
Q

What are the causes of acute urinary retention

A

BPH

Urethral strictures

Prostate cancer

Urinary tract infection

Constipation

Severe pain

Anti-muscarinics

Peripheral neuropathy, iatrogenic nerve damage, upper motor neurone disease

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11
Q

How might acute urinary retention present

A

Acute suprapubic pain

Inability to micturate

Symptoms predisposing to retention: UTI, change in medication, LUTS

Palpable distended bladder

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12
Q

What investigations are needed for acute urinary retention

A

PR

Post-void bladder scan

Bloods

Catheterised specimen of urine

Ultrasound (hydronephrosis)

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13
Q

What is the management for acute urinary retention

A

Urethral catheterisation

Treat underlying cause

Antibiotics if have UTI

Medication review

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14
Q

What is chronic urinary retention

A

Painless inability to pass urine

Significant bladder distension

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15
Q

What are the causes of chronic urinary retention

A

BPH

Urethral strictures

Prostate cancer

Pelvic prolapse

Large fibroids

Peripheral neuropathies

Motor neurone disease

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16
Q

How might chronic urinary retention present

A

Painless urinary retention

Voiding LUTS

Reduced functional capacity

May have overflow incontinence

Palpable distended bladder

No/minimal tenderness

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17
Q

What investigations are needed for chronic urinary retention

A

DRE

Post-void bladder scan

Bloods

Ultrasound (if have high-pressure retention)

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18
Q

What is the management for chronic urinary retention

A

High volumes (>1 L): long-term catheterisation, monitor urine output

Do not TWOC (likely to get renal injury)

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19
Q

What investigations are needed for scrotal lumps

A

Ultrasound scrotum

Tumour markers for testicular cancer (LDH, AFP, beta-HCG)

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20
Q

Give an overview of hydrocele

A

Abnormal collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis

Presentation: painless fluctuant swelling, transilluminates, unilateral/bilateral, discomfort on sitting/walking if very large

Neonates: regresses spontaneously within a couple of years

Infants: due to patent processus vaginalis, needs ligation

In 20-40s: need urgent ultrasound

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21
Q

Give an overview of varicocoele

A

Abnormal dilation of pampiniform venous plexus

Bag of worms

Disappears on lying flat

90% on left side (left spermatic vein drains directly into left renal vein)

Can cause infertility and testicular atrophy

Red flags: acute onset, right sided, remains when lying flat

If asymptomatic, no treatment needed

Surgery: embolisation, ligation of spermatic vein

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22
Q

Give an overview of epidermal cyst

A

Spermatocele

Benign, fluid-filled sac arising from epidermis

Presentation: smooth fluctuant nodule, above and separate to testis, transilluminates, common in middle aged men

Do not usually need treatment

Surgery if very large or painful

Avoid surgery in young men, causes infertility

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23
Q

Give an overview of epididymitis

A

Inflammation of epididymis

Presentation: unilateral acute onset scrotal pain, swelling, erythematous overlying skin, systemic symptoms, tender

Pain relieved by elevation of testis (Prehn’s sign)

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24
Q

Give an overview of testicular tumours

A

Painless lump in testis

Firm, irregular mass

Does not transilluminate

Most common malignancy in 20-40 men

Urgent ultrasound

Tumour markers

May need radical inguinal orchidectomy

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25
Q

Give an overview of testicular torsion

A

Twisting of testis on spermatic cord

Leads to ischaemia

Presentation: sudden onset severe unilateral scrotal pain, may have nausea and vomiting

Mostly in pubescent boys

Bell-clapper deformity: high attachment of tunica vaginalis allows for rotation

Examination: very tender, testis raised, swelling, loss of cremasteric reflex

Surgical emergency: surgical exploration and fixation of both testes

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26
Q

What are some benign testicular lesions

A

Leydig cell tumours

Sertoli cell tumours

Lipomas

Fibromas

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27
Q

Give an overview of orchitis

A

Inflammation of testis

Usually associated with mumps

Need rest and analgesia

If have intra-testicular abscess: drainage, may need orchidectomy

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28
Q

What are the 2 types of renal cysts

A

Simple: well-defined outline, homogenous features, common in elderly, develop from renal tubule epithelium

Complex: complicated structure (thick wall, septation, calcification), risk of malignancy

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29
Q

What are the risk factors for renal cysts

A

Increasing age

Smoking

Hypertension

M>F

Genetic conditions (polycystic kidney disease - autosomal dominant, PKD1/2)

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30
Q

How might renal cysts present

A

Usually incidental finding

Usually asymptomatic

Flank pain (if ruptured/infected)

Haematuria

In polycystic disease: uncontrolled HTN, flank mass

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31
Q

What investigations are needed for renal cysts

A

U&Es

CT/MRI

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32
Q

What is the Bosniak scoring system

A

For risk of renal cysts being malignant

Stage 1: simple, 1% malignancy, no follow up

Stage 2: complex, 3% malignancy, no follow up

Stage 2F: complex, 5% malignancy, CT scan at 3,6, 12 months

Stage 3: complex, 50-70% malignancy, surveillance or surgery

Stage 4: complex, 90-100% malignancy, surgery

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33
Q

What are renal tract calculi

A

Renal/ureteric stones

Males > 65

Mostly calcium (calcium oxalate, calcium phosphate, mixed)

Can be struvite or cystine

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34
Q

What is the criteria for admission in renal tract calculi

A

Post-obstructive AKI

Uncontrollable pain on simple analgesia

Evidence of infection

Large (>5cm)

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35
Q

What are the likely sites of impaction of renal tract calculi

A

Pelviureteric junction (PUJ)

Crossing pelvic brim

Vesicoureteric junction (VUJ)

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36
Q

How might renal tract calculi present

A

Sudden onset severe pain

Loin to groin

Ureteric colic

Nausea and vomiting

Haematuria

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37
Q

What investigations are needed for renal tract calculi

A

Urine dip

Bloods (+ urate + calcium)

Non-contrast CT (gold standard)

Ultrasound (for hydronephrosis)

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38
Q

What is the management for renal tract calculi

A

A to E

Most pass stones spontaneously

Analgesia

If infection, IV antibiotics

Stent insertion

Extracorporeal shock wave lithotripsy

Percutaneous nephrolithotomy

Flexible uretero-renoscopy

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39
Q

What is pyelonephritis

A

Inflammation of kidney parenchyma and renal pelvis

15 - 29s

Complicated: structurally and functionally normal urinary tract, non-immunocompromised

Complicated: structurally or functionally abnormal urinary tract, immunocompromised host

UTIs in males always complicated

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40
Q

What are the common causative organisms of pyelonephritis

A

E coli

Klebsiella

Proteus

Staph aureus

Psuedomonas

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41
Q

What are the risk factors for pyelonephritis

A

Obstructed urinary tract

Spinal cord injury

F>M

Indwelling catheter

Ureteric stents

Structural renal abnormality

Diabetes, untreated HIV

Corticosteroid use

Renal calculi

Menopause

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42
Q

How might pyelonephritis present

A

Classic triad: fever, unilateral loin pain, nausea and vomiting

Usually develops over 24-48 hrs

Symptoms of UTI

Haematuria

Pyrexia

Costovertebral angle tenderness

Suprapubic tenderness

Post-void residual volume

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43
Q

What investigations are needed for pyelonephritis

A

Urinalysis

Bloods

Renal ultrasound

CT (if suspect obstruction)

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44
Q

What is the management for pyelonephritis

A

A to E

IV empirical antibiotics

Fluids

Analgesia

Antiemetics

Catheterisation

Consider HDU monitoring in severe cases

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45
Q

What are some types of renal cancer

A

Renal cell carcinoma (most common)

Transitional cell carcinoma

Wilm’s tumour

Squamous cell carcinoma

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46
Q

What are the risk factors for renal cancers

A

Smoking (major risk factor)

Industrial exposure to carcinogens

Dialysis

Hypertension

Obesity

Polycystic kidneys

Horseshoe kidneys

47
Q

How might renal cancers present

A

Haematuria

Flank pain

Flank mass

Lethargy

Weight loss

Left varicocele

48
Q

How might a paraneoplastic syndrome due to renal cell carcinoma present

A

Polycythaemia (abnormal EPO)

Hypercalcaemia (abnormal PTH)

Hypertension (abnormal renin)

Pyrexia of unknown origin

49
Q

What are the subtypes of urinary incontinence

A

Stress

Urge

Mixed

Overflow

Continuous

50
Q

Give an overview of stress incontinence

A

Urine leakage when intra-abdominal pressure goes above urethral pressure

Coughing, straining, laughing, lifting

Common post-partum (damaged pelvic floor muscles, weakness of urethral sphincter)

Risk factors: constipation, obesity, post-menopausal, pelvic surgery

51
Q

Give an overview of urge incontinence

A

Overactive bladder (detrusor hyperactivity)

Uninhibited bladder contractions - rise in intravesical pressure

Causes: neurological (stroke), infection, malignancy, idiopathic, medications (cholinesterase inhibitors)

52
Q

Give an overview of mixed incontinence

A

Mixture of stress incontinence and urge incontinence

53
Q

Give an overview of overflow incontinence

A

Usually a complication of chronic urinary retention: progressive stretching of bladder wall, damage to efferent fibres of sacral reflex, loss of bladder sensation

Constant dribbling of urine

Causes: BPH, spinal cord injury, congenital defects

54
Q

Give an overview of continuous incontinence

A

Anatomical abnormalities (ectopic ureter)

Bladder fistulae

Severe overflow incontinence

55
Q

What investigations are needed for urinary incontinence

A

Midstream urine dipstick

Post-void bladder scan

Urodynamic assessment

Overflow urodynamics

Cystoscopy

IV urogram

Speculum

MRI

56
Q

What is the conservative management for stress incontinence

A

Supervised pelvic floor muscle training (at least 3 months)

Duloxetine

57
Q

What is the conservative management for urge incontinence

A

Bladder retraining (at least 6 weeks)

Antimuscarinics (oxybutynin, tolterodine)

58
Q

What is the surgical management for stress incontinence

A

Tension-free vaginal tape

Open colposuspension (elevation of bladder neck and urethra)

Intramural bulking agents

Artificial urinary sphincter

59
Q

What is the conservative management for urge incontinence

A

Botulinum toxin A injections

Percutaneous sacral nerve stimulation

Augmentation cystoplasty

Urinary diversion

60
Q

What are the subtypes of bladder cancer

A

Transitional cell carcinoma (most common)

Squamous cell carcinoma

Adenocarcinoma

Sarcoma

61
Q

What are the 4 layers of the bladder

A

Transitional epithelium (inner)

Lamina propria

Muscularis propria

Fatty connective tissue (outer)

62
Q

What are the risk factors for bladder cancer

A

Smoking

Increasing age

Exposure to industrial carcinogens

Schistosomiasis

Previous radiation to pelvis

63
Q

What are the risk factors for BPH

A

Age

Family history

Afro-Caribbean ethnicity

Obesity

64
Q

How might BPH present

A

LUTS

Haematuria

Haematospermia

65
Q

What investigations are needed for BPH

A

Urinary frequency and volume chart

Urinalysis

Post-void bladder scan

PSA

Ultrasound

Urodynamic studies

66
Q

What is the management for BPH

A

Alpha blocker (tamsulosin - relaxes prostatic smooth muscle)

5 alpha-reductase inhibitor (finasteride - prevents conversion of testosterone to DHT)

TURP (trans-urethral resection of prostate_

Laser enucleation of prostate

Photoselective vaporisation of prostate

67
Q

What is TURP syndrome

A

Fluid overload and hyponatraemia during TURP procedure

Confusion, nausea, agitation, visual changes

68
Q

What are the 2 common types of prostate cancer

A

Acinar adenocarcinoma (from glandular cells lining prostate)

Ductal adenocarcinoma (from cells that line ducts of prostate)

69
Q

Which hormones influence the growth of prostate cancer

A

Testosterone

Dihydrotestosterone (DHT)

70
Q

What are the causes of prostatitis

A

E coli

Enterobacter

Serratia

Pseudomonas

STIs

71
Q

What are the risk factors for prostatitis

A

Acute bacterial: indwelling catheter, phimosis, urinary strictures, recent surgery, immunocompromised state

Chronic: all the above, intraprostatic ductal reflux, neuroendocrine dysfunction, dysfunctional bladder

72
Q

How might prostatitis present

A

LUTS

Features of systemic infection

Perineal pain

Suprapubic pain

Urethral discharge

‘Boggy’ prostate

Inguinal lymphadenopathy

Lower back/rectum pain

73
Q

What investigations are needed in prostatitis

A

Urine culture

STI screen

Bloods
PSA

Transrectal prostatic ultrasound/CT

74
Q

What is the management for prostatitis

A

Prolonged antibiotics

Analgesia

Tamsulosin, finasteride

75
Q

What are the risk factors for epididymitis

A

STIs

Instrumentation

Catheterisation

Bladder outflow obstruction

Immunocompromised state

76
Q

How might epididymitis present

A

Unilateral scrotal pain

Swelling

Fever

Dysuria

LUTs

Urethral discharge

May have hydrocele

77
Q

What are the special tests for epididymitis

A

Intact cremasteric reflex

Prehn’s sign (pain relieved by elevating scrotum)

78
Q

What investigations are needed for epididymitis

A

Urine dipstick

Urine culture

STI screen

Bloods

Consider ultrasound

79
Q

What is the management for epididymitis

A

Antibiotics

Analgesia

Bed rest

Scrotal support

80
Q

What is testicular torsion

A

Spermatic cord twists within tunica vaginalis

Compromised blood supply to testis

Peaks in neonates and 12-25s

Associated with ‘bell-clapper’ deformity (horizontal lie to testis)

Risk higher if had undescended testis

81
Q

How might testicular torsion present

A

Sudden onset severe testicular pain

Unilateral

Nausea and vomiting

Referred abdominal pain

High, horizontal lie to testis

Swollen

Very tender

Absent cremasteric reflex

Pain persists when testis elevated (negative Prehn’s sign)

82
Q

What are the investigations for testicular torsion

A

Clinical diagnosis

Immediate scrotal exploration

If uncertain, doppler ultrasound

83
Q

What is the management for testicular torsion

A

Emergency surgery (both testes fixed to scrotum)

Strong analgesia

Antiemetics

NBM

If testis not viable, orchidectomy

84
Q

What are the types of testicular cancer

A

Germ cell: semonimas, non-seminomas

Non-germ cell: leydig cell, sertoli cell

85
Q

What are the risk factors for testicular cancer

A

Undescended testes

Previous testicular malignancy

Family history

Kleinfelter’s syndrome

86
Q

What are the tumour markers for testicular cancer

A

Beta-HCG

AFP

LDH

87
Q

What is the staging system for testicular cancer

A

Royal Marsden classification

Stage 1: confined to testes

Stage 2: infra-diaphragmatic lymph node involvement

Stage 3: supra and intradiaphragmatic lymph node involvement

Stage 4: extralymphatic metastatic spread

88
Q

What are the common causes of urethritis

A

Gonococcal

Non-gonococcal (other STIs)

89
Q

What are the risk factors for ureteritis

A

< 25

MSM

Previous STI

Recent new sexual partner

> 1 sexual partner in last year

90
Q

How might ureteritis present

A

Dysuria

Penile irritation

Discharge from urethral meatus

91
Q

What investigations are needed for ureteritis

A

Urethral swab gram stain

STI testing

Urine cultures

92
Q

What is the management for ureteritis

A

Antibiotics

Normal STI advice

93
Q

What is Fornier’s gangrene

A

Necrotising fasciitis of the perineum

Urological emergency

Due to: group A strep, C perfringens, E coli

Testes and epididymis not usually affected

94
Q

What are the risk factors for Fornier’s gangrene

A

Diabetes

Alcohol

Poor nutritional state

Steroid use

Haematological malignancy

Recent trauma

95
Q

How might Fornier’s gangrene present

A

Severe pain (out of proportion to clinical signs)

Pyrexia

Crepitus

Skin necrosis

Haemorrhagic bullae

Sensory loss over skin

Often go into septic shock

96
Q

What is the scoring system for Fornier’s gangrene

A

Laboratory risk indicator for necrotising fasciitis

Based on: CRP, WCC, Hb, Na+, creat, glucose

97
Q

What investigations are needed for Fornier’s gangrene

A

Clinical diagnosis

Routine bloods

Blood cultures

CT (fascial swelling, gas in soft tissue)

98
Q

What is the management for Fornier’s gangrene

A

Urgent surgical debridement

Consider orchidectomy

Broad spectrum antibiotics

HDU

Close monitoring

Often need further surgical debridement

99
Q

What is paraphimosis

A

Inability to pull forward a retracted foreskin

Mostly due to tight constricting band as part of foreskin

Glans becomes oedematous (vascular engorgement of distal penis, further oedema)

If untreated: penile ischaemia, Fornier’s gangrene

A urological emergency

100
Q

What are the risk factors for paraphimosis

A

Phimosis

Indwelling catheter non-replaced foreskin)

Poor hygiene

Previous episode

101
Q

How might paraphimosis present

A

Progressive pain

Swelling

Unable to pull foreskin over glans

May have repeat admissions

102
Q

How is paraphimosis managed

A

Analgesia

Penile block

Manual pressure: reduce glans oedema

Dextrose-soaked gauze: osmotic effect, reduces glans oedema

Dundee technique: puncture glans with needle, squeeze out oedematous fluid

Dorsal slit (incision of prepuce)

Consider circumcision

103
Q

What is a priapism

A

Unwanted painful erection

Not associated with sexual desire

> 4 hours

104
Q

What are the 2 types of priapism

A

High flow: non-ischaemic, unregulated cavernous arterial flow, arterial blood enters corpus cavernosum faster than it can be drained, associated with trauma/sexual stimulation

Low flow: ischaemic priapism, veno-occlusive

105
Q

What are the causes of priapism

A

Idiopathic

Penile trauma

Perineal trauma

Spinal cord injury

Iatrogenic (drugs for impotence)

Sickle cell disease

Haematological disorders

Pelvic malignancy

106
Q

How might priapism present

A

Ongoing unwanted erection

Ischaemic: painful, rigid penis

Non-ischaemic: painless, not fully rigid penis

107
Q

What investigations are needed for priapism

A

Clinical diagnosis

Routine bloods

Corporeal blood gas (work out if it is ischaemic or non-ischaemic)

108
Q

What is the management for priapism

A

Corporeal aspiration (large bore needle into lateral edge of one corpus cavernosum)

Intracavernoseal injection (sympathomimetic agent)

Surgical shunting between corpus cavernosum and glans

109
Q

What are the risk factors for penile cancer

A

HPV (16, 18, 6)

Phimosis

Smoking

Lichen sclerosis

Untreated HIV

Previous psoriasis treatment

110
Q

What is penile fracture

A

Traumatic rupture of corpus cavernosa

Usually on right side

Due to blunt trauma

Easy to fracture as tunica albuginea very thin during erection

111
Q

How might penile fracture present

A

Popping sensation

Hear a ‘snap’

Immediate pain

Swelling

Detumescence

Penile swelling

Discolouration (aubergine sign)

Deviation to opposite side of lesion

Firm, immobile haematoma in shaft (rolling sign)

Urethral injury (haematoma in perineum)

112
Q

What investigations are needed for penile fracture

A

Clinical diagnosis

Routine bloods

Cavernosography

Retrograde urethrography (if have symptoms of urethral injury)

113
Q

What is the management for penile fracture

A

Analgesia

Antiemetics

Surgical exploration and repair

Abstinence from sexual activity for 6-8 weeks

Surgery (7 decks)

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