Urology Flashcards
Treatment of renal colic (oral opioids of choice, expulsion therapy)
1) Tapentadol 50mg IR or Tramadol 50-100mg PO
Expulsion therapy = tamsulosin if >5mm stone/distal segment
Causes of haematuria (DDx), 5 broad categories
1) Transient (exercise induced, trauma, sexual intercourse, vaginal atrophy)
2) Malignancy (urothelial, renal cell, prostate)
3) Infectious (pyelonephritis, radiation cystitis, UTI)
4) Renal disease (IgA nephroopathy, interstitial nephritis)
5) Obstructive (Kidney stone, BPH)
Investigation - gold standard for haematuria (and others to consider)
CT IVP gold standard
Urine MCS
Bloods - FBE, UEC, coags
Renal tract uSS - if <50 or renal impairment
Urine cytology - low sensitivity for low grade tumours (3 mid morning specs on 3 consecutive days)
Investigation - gold standard for haematuria (and others to consider)
CT IVP gold standard
Urine MCS
Bloods - FBE, UEC, coags
Renal tract uSS - if <50 or renal impairment
Urine cytology - low sensitivity for low grade tumours (3 mid morning specs on 3 consecutive days)
Management of low risk microscopic haematura
Risk stratification first
Repeat urine microscopy in 6/12
-Could monitor annually if persistent
Antibiotic prophylaxis doses for recurrent UTIs (3)
-Trimethoprim 150mg nocte
-Cefalexin 250mg nocte
-Nitrofurantoin 50mg nocte
Post-coital option - single dose above within 2 hours post-intercourse
Management of recurrent UTIs (non-Abx)
Topical oestrogen
Methenamine hippurate (Hipprex) 1g BD
Epididymo-orchitis Rx
(presumed STI)
(urinary tract pathogen)
-Ceftriaxone 500mg in 2ml 1% lignocaine IM + Doxycycline 100mg BD 14 days OR Azithro 1g PO stat & repeated in a week
-Trimethoprim 300mg 7 days OR ceflex 500mg BD 7 days
Erectile dysfunction risk factors (7)
-Age
-Antidepressant use
-Antihypertensive use
-BPH/obstructive LUTS
-CVS disease/diabetes/dyslipidaemia/obesity
-Smoking
-Pelvic surgery/trauma
Erectile dysfunction baseline bloods
Essentially CV bloods (FBE, UEC, HbA1c, lipids, fasting BSL) plus early AM testosterone
Erectile dysfunction aetiology (categories) (6)
Vasculogenic (CVS disease, diabetes etc.)
Neurogenic (MS, Parkinsons, stroke etc.)
Psychogenic (anxiety/depression/situational)
Anatomical (Peyronies, phimosis, micropenis)
Endocrinological (hypogonadism, prolactinaemia, thyroid)
Traumatic (?post-prostatectomy) [erectile function can return as neuropraxia subsides 6-18 months, Rx w/ penile rehab - early PDE5 inhibitor]
PDE5 inhibitor contraindications (5)
Recent AMI/stroke within last 6 months
Resting hypotension/severe hypertension
Unstable angina
Severe CCF
Nitrate use
Undescended testes - when to refer? (expect descent?)
3 months - (beyond 3mths, spontaneous descent rare)
If no testes palpable at birth - need karyotype, USS, electrolytes (?female w/ CAH)
Retractile testis monitoring frequency
Annual exam
If does not remain in scrotum –> refer. Half improve w/ age but half develop UDT
Investigations for male urinary incontinence (5)
-Urinalysis
-Bladder diary
-Bladder scan for PVR
-eGFR/PSA
-USS renal tract
Urinary incontinence management aspects
Reduce bladder irritants (caffeine/alcohol)
Smoking cessation, weight loss
Pelvic floor physio
Bladder re-training
Antimuscarinic/cholinergics - oxybutynin, solifenacin
Beta3 adrenoceptor agonist - Mirabegron
Botox, electrical stimulation
Haematospermia aetiology (5 categories)
-Idiopathic (most cases! benign/self-limiting)
-Infectious - prostatitis/urethritis/epididymo-orchitis (STI source)
-Iatrogenic (procedures incl. vasectomy, orchidectomy, transrectal biopsy)
-Malignancy (prostate)
-Trauma (coital)
Haematospermia red flags for referral
Age >40 y.o
Persistent/recurrent
Prostate Ca suspicion/risk
Concurrent haematuria
Pain on ejaculation = highly suggestive of (1 condition)
Prostatitis
Haematospermia Ix
Urine MCS/cytology
STI screen
FBE, coags
PSA (if >40 y.o)
Male infertility history questions (10+ categories)
-Age of pt and partner
-Reproductive hx (amt of time trying, previous offspring, previous Ix)
-Sexual practices - frequency, timing w/ ovulation
-Sexual function - libido/erection, ejaculation
-Paeds history - cryptorchidism (empty scrotum), hypospadias (malpositioned urethral opening), testicular torsion
-Previous genital/adbo surgery
-STI history
-Smoking/alcohol, drugs
-FHx of infertility
-Occupational exposures (heat/vibration/pesticides)
Male infertility GP initial investigations (6)
-FSH
-LH
-Testosterone (if low, repeat AM + free levels)
-Prolactin
-Semen analysis (repeat analysis if abnormal, 1-3 months if mild abnormality)
-Scrotal USS (?RFs for testicular Ca)
Nocturia underlying causes (6)
-Bladder (OAB)
-Kidney (water/salt diuresis)
-Hormones (menopause, andropause)
-Sleep (OSA, restless legs)
-Cardiovascular (HTN, heart failure, obesity)
-Intake (polydipsia, salt intake)
PSA elevation - other causes (apart from Prostate Ca) (5)
○ Transiently after sex/ejaculation
○ Heavy exercise (avoid for previous 48 hours prior to testing)
○ Recent UTI
○ BPH
○ Catheterisation/Biopsy (avoid in previous 6 weeks prior to testing)
BPH - Obstructive symptoms (4) vs. storage symptoms (4)
Obstructive
-Hesitancy
-Straining
-Poor stream
-Terminal dribbling
Storage
-Frequency
-Urgency
-Incontinence
-Nocturia
BPH Investigations (4)
-Urine dip/MCS –> urine cytology if haematuria
-UEC
-PSA (if suspicion for Ca)
-Renal imaging (USS/CT) if haematuria
BPH Management (non pharm and pharm), surg
Non-pharm: Lifestyle modification, pelvic floor physio/bladder retraining
Pharm: alpha-blockers (e.g tamsulosin) 1st-line - smooth muscle relaxation in prostate & bladder neck
A/e’s - dizziness, nasal congestion, anejaculation/retrograde ejaculation, hypotension
5a-reductase inhibitors (e.g dutasteride) can be added on - reduction of prostate volume over 6-12 mths
A/e’s - gynaecomastia, loss of libido, erectile dysfunction
Surg - TURP/green light laser
Restless leg syndrome 2ndary causes
-Iron deficiency
-Renal failure
-Peripheral neuropathy
-Pregnancy
-MS/Parkinson’s disease
-Medications - sedating antihistamines, dopamine antagonists (metoclopramide), mirtaza/venlafaxine
Urinary incontinence non-pharm Rx aspects (5)
-Avoid excessive amt of fluid
-Avoid bladder irritants e.g caffeine/alcohol
-Bladder training - timed voiding/established voiding interval
-Pelvic floor muscle exercise/physio
-Maintaining soft regular bowel motions
Urinary incontinence - pharm Rx options (5)
-Non-selective antimuscarinic - oxybutynin 5mg TDS
-M3 selective antimuscarinic - solifenacin
-Vaginal oestrogen = vagifem pessary 10mcg weekly
-Beta-adrenergic agonists - Mirabegron 25mg daily
-Botox into bladder wall
RFs for urological malignancy (5)
Ix for microscopic haematuria and RFs present
-Male
-Age >40
-Smoking
-Pelvic irradiation
-Exposure to occupational chemical dyes/cyclophosphamide
Urine cytology x3
Urinary tract USS
Refer urologist for consideration of cystoscopy
Frank haematuria Mx option:
-With visible blood clots
-Without visible blood clots
-Imaging of KUB + urgent urology referral for cystoscopy
-?Imaging, refer to renal if a/w AKI or glomerular bleeding
Calcium renal stones lifestyle/dietary prevention aspects
-Adequate hydration to ensure clear urine
-Reduce sodium
-Reduce protein
-Reduce oxalate
-Normal calcium intake
UTI women (non-pregnant) resistant pathogen Abx optins (3)
- Amoxicillin 500mg TDS 5/7
- Bactrim 160/800 BD 3 days
- Augmentin 500/125 BD for 5 days
Ureteric colic acute + long-term management aspects (6)
-Analgesia (paracetamol, NSAIDs)
-Tamsulosin 400mcg daily
-Strain urine to catch stone
-GP r/v in 4 weeks for rpt CTKUB (esp. if no stone caught)
-Diet - hydration, low salt/protein/oxalate diet
-Safety net - return if fever etc,
