Urology Flashcards
What are the causes of acute urinary retention?
- benign prostatic hyperplasia
- urethral strictures/calculi
What is the presentation of acute urinary retention?
- inability to pass urine
- lower abdominal discomfort
- pain
- confusion in elderly patients
What are the signs of acute urinary retention?
- palpable distended bladder
- lower abdominal tenderness
Investigation for acute urinary retention
- bladder scan >300cc
- urine dip and culture
- UEs
- creatinine
- FBC
- CRP
What is the management of acute urinary retention?
- urinary catheterisation (measure the urine drained in 15 minutes >400cc confirms retnetion, <200 excludes)
What is a complication of acute urinary retention?
Post obstructive diuresis - worsening of AKI and volume depletion
What is the cause of chronic urinary retention?
High pressure retention: impaired renal function and bilateral hydronephrosis, typically due to bladder outflow obstruction
What are the transient causes of haematuria?
- UTI
- menstruation
- vigorous exercise
- sexual intercourse
What are the causes of non visible haematuria?
- cancer
- stones
- BPH
- prostatits
- urethritis
- renal causes e.g. IgA nephropathy
What are the causes of visible haematuria?
- prostate/bladder cancer
- Stones
- BPH
- UTI/acute pyelonephritis
- trauma
Investigations for haematuria
- urinalysis
- U+Es
- Albumin: protein (ACR) or protein: creatinine ratio (PCR)
- blood pressure
Explain referral to urology
Urgent referral
- If age >45: unexplained haematuria without UTI, or persists/recurs after treatment for UTI
- If age>60: unexplained non-visible haematuria and dysuria or increased WCC
Non urgent
- Age>60 with recurrent or persistent UTI
What are the types of testicular cancer?
- 95% are germ cell tumours = seminomas and non seminomas
- Non seminomas = teratotmas, yolk sac, embryological and choriocarcinoma)
- non germ cell: leydig tumours and sarcomas
What are the risk factors for testicular cancer?
- infertility
- cryptorchidism
- family history
- klinefelter’s
- mumps orchitis
What is the peak incidence for teratomas?
25
What is the peak incidence for seminomas?
35
What is the presentation of testicular cancer?
- painless lump
- pain
- hydrocele
- gynaecomastia (in germ cell and leydig)
Investigations testicular cancer
- ultrasound scan
- tumour markers: alpha fetoprotein (teratoma); beta hCG (teratoma and seminoma); LDH (non specific)
- staging CT scan
Explain the royal marsden staging system
- stage 1: isolated to the testicle
- stage 2: retroperitoneal lymph node spread
- stage 3: spread to lymph nodes above the diaphragm
- stage 4: metastasised to other organs
What is the most common metastasis from testicular cancer?
- lymphatics
- lung
- liver
- brain
What is the management of testicular cancer?
- radical orchidectomy
- chemotherapy/radiotherapy
- sperm banking
What is testicular torsion?
Urological emergency caused by twisting of the testicle on the spermatic cord causing constriction of the vascular supply
What is the presentation of testicular torsion?
- sudden onset testicular pain
- nausea and vomiting
- negative prehn’s sign
- absent cremasteric reflex
- swollen testes, retracted upwards
What is prehn’s sign?
No pain relief on elevation of the scrotum
What is the management of testicular torsion?
- emergency scrotal exploration
- morphine and ondasetron
What are the causes of testicualr torsion?
- trauma
- bell clapper testis
What are the complications of testicular torsion?
Testicular damage/loss leading to infertility and cosmetic deformity
What is the presentation of BPH?
- Storage symptoms: urgency, frequency, urgency incontinence, nocturia
- voiding symptoms: weak flow, straining, hesitancy, terminal dribbling, incomplete emptying
What are the storage symptoms?
- urgency
- frequency
- urgency incontinence
- nocturia
What are the voiding symptoms?
- weak flow
- straining
- hesitancy
- terminal dribbling
- incomplete emptying
Investigations for BPH
- urinalysis (should be normal if uncomplicated)
- prostate specific antigen
- IPSS -mild 0-7, moderate 8-19, severe 20-35
- volume charting for at least 3 days
What is the management of BPH?
- behavioural management programme
- alpha blocker: terazosin
- 5-alpha-reductase inhibitor: finasteride (indicated if large prostate and high risk of progression)
- anti-cholinergic: tolterodine
What are the complications of BPH?
- UTI
- renal insufficiency
- bladder stones
- haematuria
- sexual dysfunction
What is the presentation of renal stones?
- renal colic: unilateral loin to groin pain
- haematuria
- nausea and vomiting
- decreased urine output
Investigations for stones
- Non-contrast helical CT scan/renal USS if CT is contraindicated
- urinalysis
- FBC: increased WCC may suggest infection
- UEs - any hypercalcaemia? or hyperuricaemia?
What is the management of renal stones?
- NSAID, anti-emetics (metoclopramide), antibiotics, tamsulosin
- watch and wait if <5mm it is likely to pass without intervention
- surgery if large stone, infection or renal abnormality
What is the urgent management of renal stones?
- decompression
- ureteric stent or percutaneous nephrostomy tube
Surgery if renal stone <10mm
Shock wave lithotripsy
Surgery if renal stone 10-20mm
Shock wave lithotripsy or ureteroscopy
Surgery if renal stone >20mm or staghorn
Pecutaneous nephrolithotomy
Management of recurrent renal stones
- increase oral intake (2.5-3L a day)
- add fresh lemon juice to water
- avoid carbonated drinks
- reduce dietary salt
- maintain normal calcium intake
- thiazide (if calcium stones) or potassium citrate (calcium oxalate stones)
What are the types of renal stone?
- Calcium oxalate
- cysteine
- uric acid
- calcium phosphate
- struvite
Which of the renal stones are visible on x ray?
- calcium oxalate
- cysteine
- calcium phosphate
- struvite
Which type of renal stone can form a staghorn shape?
Struvite
Which drugs increase the risk of calcium renal stones?
- loop diuretics
- acetazolamide
- theophylline
- steroids
Which stones are more likely with a high urinary pH?
Calcium phosphate
Which stones are more likely with a low urinary pH?
uric acid
What is the management of hydronephrosis?
If an upper obstruction:
- acute: percutaneous nephrostomy tube
- Chronic: ureteric stent
If lower obstruction:
- urinary or suprapubic catheter
What are the risk factors for bladder cancer?
- Smoking
- age
- aromatic amines
- schistosomiasis (squamous cell)
What are the types of bladder cancer?
- transition cell
- squamous cell
- adenocarcinoma
What is the presentation of bladder cancer?
Painless haematuria
What is the investigation for bladder cancer?
- Cystoscopy: flexible or rigid
T staging of bladder cancer
- T0: no evidence of tumour
- Ta: non-invasive papillary carcinoma
- T1: invades the sub epithelial connective tissue
- T2: a: superficial/b: deep invasion of muscularis propria
- T3: perivesical fat
- T4a: prostatic stroma, seminal vesicle, uterus, vagina
- T4b: pelvic sidewall/abdominal sidewall
N staging of bladder cancer
- N0: no nodal disease
- N1: single regional lymph node
- N2: Multiple regional lymph nodes
- N3: common iliac lymph nodes
M staging of bladder cancer
- M0: no distant mets
- M1: distant mets
What is the management of bladder cancer?
- Transurethral resection of bladder tumour (TURBT): if non muscle invasive
- Intravesicle chemotherapy
- Intravesicle BCG
- Radical cystectomy
What is the presentation of prostate cancer?
- asymptomatic
- lower UTI symptoms
- Haematuria
- erectile dysfunction
- symptoms of advanced disease or metastasis (weight loss, bone pain, cauda equina)
What are the causes of a mildly raised PSA?
- prostate cancer
- BPH
- prostatitis
- UTI
- vigorous exercise
- Recent ejaculation or prostate stimulation
What should a prostate normally feel like?
- smooth
- symmetrical
- slightly soft
- central sulcus
What should an infected prostate feel like?
- enlarged
- tender
- warm
What should a cancerous prostate feel like?
- firm/hard
- asymmetrical
- craggy/irregular
- loss of central sulcus
Investigation for prostate cancer
- multiparametric MRI
- prostate biopsy (transrectal ultrasound guided biopsy)
- isotope bone scan
What are the investigations that should be carried out in someone presenting with erectile dysfunction?
- free testosterone (measured between 9 and 11am)
- lipid and fasting glucose levels to calculate 10 year cardiovascular risk
What are the features of renal cell carcinoma?
Classical triad:
- Haematuria
- loin pain
- abdominal mass
Plus:
- fever of unknown origin
- varicocele (due to tumour compressing veins)
-
What are the features of epididymo-orchitis?
- unilateral testicular pain and swelling
- urethral discharge
Investigation for epidiymo-orchitis
- STI (Chlamydia trachomatis and Neisseria gonorrhoeae)
- MSU microscopy and culture (E.coli)
What are the causes of scrotal swelling?
- inguinal hernia
- testicular tumour: discrete testicular nodule
- acute epididymo-orchitis: tender swelling, phren’s sign may be positive
- epididymal cysts: painless, can ge behind cysts
- hydrocele: transilluminate
- testicular torsion: severe onset testicular pain
- varicocele: typically on the left
