Urology Flashcards
What are the causes of lower urinary tract symptoms
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
What are the classifications of lower urinary tract symptoms
Storage symptoms: urgency, frequency, nocturia, urge incontinence
Voiding symptoms: bladder outflow obstruction, hesitancy, intermittency, straining, terminal dribbling, incomplete emptying
What additional symptoms should be asked about in a lower urinary tract symptoms history
Visible haematuria
Suprapubic discomfort
Colicky pain
Medications: anticholinergics, antihistamines, bronchodilators
What investigations are needed for lower urinary tract symptoms
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)
What is the management for lower urinary tract symptoms
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)
What is the urgent referral criteria for haematuria
> 45: unexplained visible haematuria without UTI/despite successful treatment of UTI
> 60: unexplained non-visible haematuria with dysuria/raised WCC
What are the causes of haematuria
UTI
Urothelial carcinoma
Stone disease
Adenocarcinoma of prostate
BPH
Infection (pyelonephritis, cystitis, prostatitis)
Malignancy
Renal calculli
Trauma
Recent surgery
Radiation cystitis
What investigations are needed for haematuria
Urinalysis
Bloods (routine + clotting + PSA)
Flexible cystoscopy
US KUB
CT urogram
What is acute urinary retention
New onset inability to pass urine
Leads to pain, discomfort, and significant residual volume
Most common in older males (BPH)
What are the causes of acute urinary retention
BPH
Urethral strictures
Prostate cancer
Urinary tract infection
Constipation
Severe pain
Anti-muscarinics
Peripheral neuropathy, iatrogenic nerve damage, upper motor neurone disease
How might acute urinary retention present
Acute suprapubic pain
Inability to micturate
Symptoms predisposing to retention: UTI, change in medication, LUTS
Palpable distended bladder
What investigations are needed for acute urinary retention
PR
Post-void bladder scan
Bloods
Catheterised specimen of urine
Ultrasound (hydronephrosis)
What is the management for acute urinary retention
Urethral catheterisation
Treat underlying cause
Antibiotics if have UTI
Medication review
What is chronic urinary retention
Painless inability to pass urine
Significant bladder distension
What are the causes of chronic urinary retention
BPH
Urethral strictures
Prostate cancer
Pelvic prolapse
Large fibroids
Peripheral neuropathies
Motor neurone disease
How might chronic urinary retention present
Painless urinary retention
Voiding LUTS
Reduced functional capacity
May have overflow incontinence
Palpable distended bladder
No/minimal tenderness
What investigations are needed for chronic urinary retention
DRE
Post-void bladder scan
Bloods
Ultrasound (if have high-pressure retention)
What is the management for chronic urinary retention
High volumes (>1 L): long-term catheterisation, monitor urine output
Do not TWOC (likely to get renal injury)
What investigations are needed for scrotal lumps
Ultrasound scrotum
Tumour markers for testicular cancer (LDH, AFP, beta-HCG)
Give an overview of hydrocele
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
Give an overview of varicocoele
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
Give an overview of epidermal cyst
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
Give an overview of epididymitis
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)
Give an overview of testicular tumours
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
Give an overview of testicular torsion
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
What are some benign testicular lesions
Leydig cell tumours
Sertoli cell tumours
Lipomas
Fibromas
Give an overview of orchitis
Inflammation of testis
Usually associated with mumps
Need rest and analgesia
If have intra-testicular abscess: drainage, may need orchidectomy
What are the 2 types of renal cysts
Simple: well-defined outline, homogenous features, common in elderly, develop from renal tubule epithelium
Complex: complicated structure (thick wall, septation, calcification), risk of malignancy
What are the risk factors for renal cysts
Increasing age
Smoking
Hypertension
M>F
Genetic conditions (polycystic kidney disease - autosomal dominant, PKD1/2)
How might renal cysts present
Usually incidental finding
Usually asymptomatic
Flank pain (if ruptured/infected)
Haematuria
In polycystic disease: uncontrolled HTN, flank mass
What investigations are needed for renal cysts
U&Es
CT/MRI
What is the Bosniak scoring system
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
What are renal tract calculi
Renal/ureteric stones
Males > 65
Mostly calcium (calcium oxalate, calcium phosphate, mixed)
Can be struvite or cystine
What is the criteria for admission in renal tract calculi
Post-obstructive AKI
Uncontrollable pain on simple analgesia
Evidence of infection
Large (>5cm)
What are the likely sites of impaction of renal tract calculi
Pelviureteric junction (PUJ)
Crossing pelvic brim
Vesicoureteric junction (VUJ)
How might renal tract calculi present
Sudden onset severe pain
Loin to groin
Ureteric colic
Nausea and vomiting
Haematuria
What investigations are needed for renal tract calculi
Urine dip
Bloods (+ urate + calcium)
Non-contrast CT (gold standard)
Ultrasound (for hydronephrosis)
What is the management for renal tract calculi
A to E
Most pass stones spontaneously
Analgesia
If infection, IV antibiotics
Stent insertion
Extracorporeal shock wave lithotripsy
Percutaneous nephrolithotomy
Flexible uretero-renoscopy
What is pyelonephritis
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
What are the common causative organisms of pyelonephritis
E coli
Klebsiella
Proteus
Staph aureus
Psuedomonas
What are the risk factors for pyelonephritis
Obstructed urinary tract
Spinal cord injury
F>M
Indwelling catheter
Ureteric stents
Structural renal abnormality
Diabetes, untreated HIV
Corticosteroid use
Renal calculi
Menopause
How might pyelonephritis present
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
What investigations are needed for pyelonephritis
Urinalysis
Bloods
Renal ultrasound
CT (if suspect obstruction)
What is the management for pyelonephritis
A to E
IV empirical antibiotics
Fluids
Analgesia
Antiemetics
Catheterisation
Consider HDU monitoring in severe cases
What are some types of renal cancer
Renal cell carcinoma (most common)
Transitional cell carcinoma
Wilm’s tumour
Squamous cell carcinoma
What are the risk factors for renal cancers
Smoking (major risk factor)
Industrial exposure to carcinogens
Dialysis
Hypertension
Obesity
Polycystic kidneys
Horseshoe kidneys
How might renal cancers present
Haematuria
Flank pain
Flank mass
Lethargy
Weight loss
Left varicocele
How might a paraneoplastic syndrome due to renal cell carcinoma present
Polycythaemia (abnormal EPO)
Hypercalcaemia (abnormal PTH)
Hypertension (abnormal renin)
Pyrexia of unknown origin
What are the subtypes of urinary incontinence
Stress
Urge
Mixed
Overflow
Continuous
Give an overview of stress incontinence
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
Give an overview of urge incontinence
Overactive bladder (detrusor hyperactivity)
Uninhibited bladder contractions - rise in intravesical pressure
Causes: neurological (stroke), infection, malignancy, idiopathic, medications (cholinesterase inhibitors)
Give an overview of mixed incontinence
Mixture of stress incontinence and urge incontinence
Give an overview of overflow incontinence
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
Give an overview of continuous incontinence
Anatomical abnormalities (ectopic ureter)
Bladder fistulae
Severe overflow incontinence
What investigations are needed for urinary incontinence
Midstream urine dipstick
Post-void bladder scan
Urodynamic assessment
Overflow urodynamics
Cystoscopy
IV urogram
Speculum
MRI
What is the conservative management for stress incontinence
Supervised pelvic floor muscle training (at least 3 months)
Duloxetine
What is the conservative management for urge incontinence
Bladder retraining (at least 6 weeks)
Antimuscarinics (oxybutynin, tolterodine)
What is the surgical management for stress incontinence
Tension-free vaginal tape
Open colposuspension (elevation of bladder neck and urethra)
Intramural bulking agents
Artificial urinary sphincter
What is the conservative management for urge incontinence
Botulinum toxin A injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion
What are the subtypes of bladder cancer
Transitional cell carcinoma (most common)
Squamous cell carcinoma
Adenocarcinoma
Sarcoma
What are the 4 layers of the bladder
Transitional epithelium (inner)
Lamina propria
Muscularis propria
Fatty connective tissue (outer)
What are the risk factors for bladder cancer
Smoking
Increasing age
Exposure to industrial carcinogens
Schistosomiasis
Previous radiation to pelvis
What are the risk factors for BPH
Age
Family history
Afro-Caribbean ethnicity
Obesity
How might BPH present
LUTS
Haematuria
Haematospermia
What investigations are needed for BPH
Urinary frequency and volume chart
Urinalysis
Post-void bladder scan
PSA
Ultrasound
Urodynamic studies
What is the management for BPH
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
What is TURP syndrome
Fluid overload and hyponatraemia during TURP procedure
Confusion, nausea, agitation, visual changes
What are the 2 common types of prostate cancer
Acinar adenocarcinoma (from glandular cells lining prostate)
Ductal adenocarcinoma (from cells that line ducts of prostate)
Which hormones influence the growth of prostate cancer
Testosterone
Dihydrotestosterone (DHT)
What are the causes of prostatitis
E coli
Enterobacter
Serratia
Pseudomonas
STIs
What are the risk factors for prostatitis
Acute bacterial: indwelling catheter, phimosis, urinary strictures, recent surgery, immunocompromised state
Chronic: all the above, intraprostatic ductal reflux, neuroendocrine dysfunction, dysfunctional bladder
How might prostatitis present
LUTS
Features of systemic infection
Perineal pain
Suprapubic pain
Urethral discharge
‘Boggy’ prostate
Inguinal lymphadenopathy
Lower back/rectum pain
What investigations are needed in prostatitis
Urine culture
STI screen
Bloods
PSA
Transrectal prostatic ultrasound/CT
What is the management for prostatitis
Prolonged antibiotics
Analgesia
Tamsulosin, finasteride
What are the risk factors for epididymitis
STIs
Instrumentation
Catheterisation
Bladder outflow obstruction
Immunocompromised state
How might epididymitis present
Unilateral scrotal pain
Swelling
Fever
Dysuria
LUTs
Urethral discharge
May have hydrocele
What are the special tests for epididymitis
Intact cremasteric reflex
Prehn’s sign (pain relieved by elevating scrotum)
What investigations are needed for epididymitis
Urine dipstick
Urine culture
STI screen
Bloods
Consider ultrasound
What is the management for epididymitis
Antibiotics
Analgesia
Bed rest
Scrotal support
What is testicular torsion
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
How might testicular torsion present
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)
What are the investigations for testicular torsion
Clinical diagnosis
Immediate scrotal exploration
If uncertain, doppler ultrasound
What is the management for testicular torsion
Emergency surgery (both testes fixed to scrotum)
Strong analgesia
Antiemetics
NBM
If testis not viable, orchidectomy
What are the types of testicular cancer
Germ cell: semonimas, non-seminomas
Non-germ cell: leydig cell, sertoli cell
What are the risk factors for testicular cancer
Undescended testes
Previous testicular malignancy
Family history
Kleinfelter’s syndrome
What are the tumour markers for testicular cancer
Beta-HCG
AFP
LDH
What is the staging system for testicular cancer
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
What are the common causes of urethritis
Gonococcal
Non-gonococcal (other STIs)
What are the risk factors for ureteritis
< 25
MSM
Previous STI
Recent new sexual partner
> 1 sexual partner in last year
How might ureteritis present
Dysuria
Penile irritation
Discharge from urethral meatus
What investigations are needed for ureteritis
Urethral swab gram stain
STI testing
Urine cultures
What is the management for ureteritis
Antibiotics
Normal STI advice
What is Fornier’s gangrene
Necrotising fasciitis of the perineum
Urological emergency
Due to: group A strep, C perfringens, E coli
Testes and epididymis not usually affected
What are the risk factors for Fornier’s gangrene
Diabetes
Alcohol
Poor nutritional state
Steroid use
Haematological malignancy
Recent trauma
How might Fornier’s gangrene present
Severe pain (out of proportion to clinical signs)
Pyrexia
Crepitus
Skin necrosis
Haemorrhagic bullae
Sensory loss over skin
Often go into septic shock
What is the scoring system for Fornier’s gangrene
Laboratory risk indicator for necrotising fasciitis
Based on: CRP, WCC, Hb, Na+, creat, glucose
What investigations are needed for Fornier’s gangrene
Clinical diagnosis
Routine bloods
Blood cultures
CT (fascial swelling, gas in soft tissue)
What is the management for Fornier’s gangrene
Urgent surgical debridement
Consider orchidectomy
Broad spectrum antibiotics
HDU
Close monitoring
Often need further surgical debridement
What is paraphimosis
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
What are the risk factors for paraphimosis
Phimosis
Indwelling catheter non-replaced foreskin)
Poor hygiene
Previous episode
How might paraphimosis present
Progressive pain
Swelling
Unable to pull foreskin over glans
May have repeat admissions
How is paraphimosis managed
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
What is a priapism
Unwanted painful erection
Not associated with sexual desire
> 4 hours
What are the 2 types of priapism
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
What are the causes of priapism
Idiopathic
Penile trauma
Perineal trauma
Spinal cord injury
Iatrogenic (drugs for impotence)
Sickle cell disease
Haematological disorders
Pelvic malignancy
How might priapism present
Ongoing unwanted erection
Ischaemic: painful, rigid penis
Non-ischaemic: painless, not fully rigid penis
What investigations are needed for priapism
Clinical diagnosis
Routine bloods
Corporeal blood gas (work out if it is ischaemic or non-ischaemic)
What is the management for priapism
Corporeal aspiration (large bore needle into lateral edge of one corpus cavernosum)
Intracavernoseal injection (sympathomimetic agent)
Surgical shunting between corpus cavernosum and glans
What are the risk factors for penile cancer
HPV (16, 18, 6)
Phimosis
Smoking
Lichen sclerosis
Untreated HIV
Previous psoriasis treatment
What is penile fracture
Traumatic rupture of corpus cavernosa
Usually on right side
Due to blunt trauma
Easy to fracture as tunica albuginea very thin during erection
How might penile fracture present
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)
What investigations are needed for penile fracture
Clinical diagnosis
Routine bloods
Cavernosography
Retrograde urethrography (if have symptoms of urethral injury)
What is the management for penile fracture
Analgesia
Antiemetics
Surgical exploration and repair
Abstinence from sexual activity for 6-8 weeks
