Urology Flashcards by Afreen Salim

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)

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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

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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

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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.

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Ix bladder cancer

urine dip
CT urogram
Ultrasound and flexible cystoscopy
CT / MRI for staging

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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

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Epidemiology renal stones

M
40-60 years in males and late 20’s in females

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Features of Calcium oxalate stones

85% of stones, radiopaque. Hypercalciuria is major risk factor.

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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.

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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.

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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

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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.

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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

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Epidemiology UTI

more common in women where the urethra is much shorter

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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

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Hydroceles may develop secondary to

epididymo-orchitis, testicular torsion, testicular tumours

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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 ```