Urology Flashcards
Risk factors for bladder cancer
- Smoking
- Occupation: aromatic amine, aniline dyes,polycyclic aromatic hydrocarbons,paint, hair dye, textilem rubber, motor , leather and pesticide industries
- drugs – phenacetin, cyclophosphamide
- pelvic irradiation
- Caucasian
- chronic urinary tract infection (squamous cell carcinoma)
*long term catherisation (squamous cell carcinoma) - Schistosomiasis in Middle East (squamous cell carcinoma)
Types of bladder cancer
- 90-95% are transitional cell carcinomas (TCC)
- 3-4% are squamous cell carcinomas ( in middle east, this one is more common)
- 1-2% are adenocarcinomas
Clinical presenation of bladder cancer
- haematuria
- irritative lower urinary tract symptoms (frequency, urgency)
- recurrent UTI (SCC)
- hydronephrosis
- pelvic pain
- lower limb/genital oedema from pelvic lymphadenopathy
2ww bladder cancer referral
if they are aged 45 and over and have:
Unexplained visible haematuria without urinary tract infection or
Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
or
if they are aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.
Ix bladder cancer
urine dip
CT urogram
Ultrasound and flexible cystoscopy
CT / MRI for staging
Tx Bladder cancer
transurethral resection of bladder tumour (“TURBT”)
Moderate/high grade non-muscle invasive (including carcinoma-in-situ) →Intravesical chemotherapy (Mitomycin C) or intravesical immunotherapy (BCG) + Cystoscopic surveillance
Muscle-invasive disease → Radical cystectomy with ileal conduit or radiotherapy ± neoadjuvant Cisplatin-based systemic chemotherapy
Epidemiology renal stones
M
40-60 years in males and late 20’s in females
Features of Calcium oxalate stones
85% of stones, radiopaque. Hypercalciuria is major risk factor.
Features of Calcium phosphate stones
10% of stones, radiopaque. Occurs in renal tubular acidosis type 1 & 3, where high urine pH increases supersaturation of urine with calcium and phosphate.
Features of Cystine stones
1% of stones. Semi opaque “ground glass” appearance. Inherited recessive inborn errors of metabolism. Leads to disruption of cystine transport and decreased absorption from renal tubule.stones at a younger age.
Features of uric acid stones
5-10% of stones. Radiolucent. Acid produced as product of purine metabolism. Precipitated with urinary pH is low. Can be caused by diseases which result in extensive tissue breakdown.high urinary concentration of uric acid. proportion of uric acid stones is higher in hot, dry climates
Features of Struvite stones
2-20% of stones. Radio opaque. Formed from magnesium, ammonium and phosphate. Occur as a result of urease producing bacteria, associated with chronic UTIs (ureaplasma, proteus). Tend to form staghorn calculi.
Management renal stones
NSAIDS
Antiemetic if nausea and vomiting (e.g. ondansetron or cyclizine)
Fluids
Abx if infection
Medical expulsive therapy – Tamsulosin,doxazocin ( alpha blocker)
Surgical Interventions in large stones or stones that do not pass
Extra corporeal shockwave lithotripsy (ESWL)
Ureteroscopy
Epidemiology UTI
more common in women where the urethra is much shorter
Duration of antibiotics in UTI
3 days for a simple lower urinary tract infection in women
5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter related UTIs
Hydroceles may develop secondary to
epididymo-orchitis, testicular torsion, testicular tumours
Features of hydrocele
soft, fluctuant and may be large non-tender swelling
Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
It is irreducible and has no bowel sounds
Scrotum Transilluminated by shining torch into the fluid
Hydrocele
collection of fluid around the testicle
Mx hydrocele
Most spontaneously resolve by 12 months
May indicate underlying testicular cancer
May require surgical intervention
there is a significantly increased risk of an indirect inguinal hernia
Varicocele
abnormal enlargement of the testicular veins
more common on the left side
associated with infertility
Swollen pampiniform venous plexus (testicular veins)
Can cause dragging or soreness
ultrasound with Doppler studies to diagnose
Usually harmless
Usually conservative, occasionally surgery if pain
Epididymal cyst/spermatocele
A cyst (sac of fluid)
Usually occur over 40 years of age
the most common cause of scrotal swellings seen in primary care.
often post to testicle
Usually harmless
Associated conditions: PCKD, CF, von hippel-lindau syndrome
Diagnosis confirmed by US
Epididymal cysts can be excised using a scrotal approach
Features of Epididymo-orchitis
gradual onset presents as acute scrotal pain often unilateral Dragging / heavy sensation Urethral discharge Swelling of testicle and epididymis Erythema to scrotum
Testicular torsion
occurs when the spermatic cord and its contents twists within the tunica vaginalis, compromising the blood supply to the testicle.
urgent surgical emergency
Testicular torsion epidemiology
peak incidence is in neonates and adolescents between the ages of 12-25yrs.
Testicular torsion presentation
Acute/sudden onset of unilateral testicular pain
Often triggered by activity (e.g. playing sports)
“6 hour window” after onset before damage from ischaemia is irreversible
nausea and vomiting secondary to pain
Cremasteric reflex
inner part of the thigh is stroked. This causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal.
in torsion the cremasteric reflex is absent and pain continues despite elevation of the testicle, termed a negative Prehn’s sign
Lower Urinary Tract Symptoms
Storage symptoms ( cant keep urine in the bladder) •Urgency •Daytime Frequency •Nocturia Voiding symptoms ( difficulty emptying bladder) •Poor flow • Straining to void •Incomplete emptying sensation •Hesitancy • Terminal dribbling
Ix for LUTS
Urine dipstick (exclude infection) PSA done prior to rectal examination Rectal exam to assess prostate size, shape and characteristics- smoothly enlarged IPSS - international prostate score Can image further if unsure with USS,MRI and biopsy to exclude malignancy
Treatment Benign prostatic hyperplasia
Conservative: Reassurance and monitoring if manageable symptoms
Medical:
Relax smooth muscle through alpha 1 selective blockers
Finasteride tablet 5a reductase inhibitors to reduce conversion of testosterone into dihydrotestosterone to reduce size of prostate
Surgical includes: Transurethral resection of the prostate (TURP),little bits and remove the bits
Prostatic artery embolisation,Open prostatectomy
Paraphimosis
typically caused by not replacing a retracted foreskin retracted foreskin can impair venous return to the glans penis, resulting in oedema. If left uncorrected, it may compromise the blood supply to the glans penis and lead to ischaemia.
Paraphimosis Mx
involves reducing the oedema to the glans by applying pressure over a period of time.
If conservative measures fail, a dorsal slit is used to cut the foreskin.
Phimosis
foreskin is tight and cannot be retracted over the glans.
It’s normal in babies and young children but over time it resolves.
In adults it may present with painful intercourse, recurrent infection and ulceration. In young males, recurrent balanitis and ballooning is common.
Phimosis Mx
Treatment involves steroid creams, or circumcision.
Balanoposthitis
inflammation of the glans penis and prepuce, most commonly caused by infection,
but can occur in dermatological conditions or pre-malignant/malignant conditions.
Take swab for culture, any infection tx with abx
avoid irritants such as soap, and keep the area clean. If doesn’t resolve, skin biopsy may be required for a diagnosis.
Priapism
prolonged and often painful erection which persists for more than 2 hours after sexual activity. Priapism carries a risk of permanent damage to the penis and requires prompt treatment. Sickle cell is a risk factor for ischaemic priapism.
Priapism mx
First line treatment is with aspiration of the blood within the corpus cavernosa and irrigation with normal saline. Intracavernosal alpha agonists such as Adrenaline or Phenylephrine may also be used.
Erectile dysfunction
•Oral therapy (PDE5is) eg viagra-sildenail
If this doesn’t work, can try vacuum pump , injectable devices
Peyronie’s Disease
Bend in penis
; age 18-80
Present with pain and deformity on erection, a palpable penile plaque, and, in many cases, erectile dysfunction
Associated with Dupuytren’s contracture and a history of penile trauma
Torsion of Hydatid of Morgagni
blue dot sign especially in caucasian patients
Causes of urinary retention
Neurological Obstructive Infectious Drugs - anticholinergic,alpha agonist.alcohol Post-operative
