Urology Flashcards
Key differentials for scrotal swelling?
Inguinal hernia
Hydrocoele
Varicocoele
Acute epididymo-orchitis
Epididymal cyst
Testicular torsion
Testicular tumour
Key features of inguinal hernias?
If inguinoscrotal swelling; cannot ‘get above it’ on examination
Cough impulse may be present
May be reducible
Key features of testicular tumours?
Investigations?
Management?
Painless or acute scrotal pain due to internal haemorrhage
Often discrete testicular nodule (may have associated hydrocele)
May present with gynaecomastia
Symptoms of metastatic disease
USS scrotum and serum AFP and β HCG required
radical inguinal orchidectomy +/- adjuvant chemo
Key features of acute epididymo-orchitis?
Often hx of dysuria and urethral discharge
Tender swelling eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be associated with underlying structural abnormality
Can also present as acute pain and swelling after urological intervention (pyrexia and +ve urine dipstick can differentiate from torsion)
Key features of epididymal cysts?
How can they be treated?
May contain clear or opalescent fluid (spermatoceles)
Lie above and posterior to testis
Separate from the body of the testicle
It is usually possible to ‘get above the lump’ on examination
Usually occur over 40 years of age
Tx: excision using a scrotal approach
Key features of hydrocoele?
Non painful, soft fluctuant swelling
Usually anterior to and below the testicle
Often possible to ‘get above it’ on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
Key features of testicular torsion?
Severe, sudden onset testicular pain
Can be spontaneous or precipitated by minor trauma
Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Urgent surgery is indicated, the contra lateral testis should also be fixed
Key features of varicocoele?
Varicosities of the pampiniform plexus
Typically occur on left (because testicular vein drains into renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles may affect fertility
How is testicular malignancy treated?
orchidectomy via an inguinal approach
allows high ligation of testicular vessels and avoids exposure of another lymphatic field to the tumour
How is testicular torsion managed?
prompt surgical exploration and testicular fixation
sutures or placement of the testis in a Dartos pouch
How can hydrocoele be managed?
in children where the underlying pathology is a patent processus vaginalis : inguinal approach is used so that the processus can be ligated
In adults: scrotal approach is preferred and the hydrocele sac excised or plicated
How do high pressure and low pressure urinary retention present differently?
High pressure retention:
impaired renal function and bilateral hydronephrosis
typically due to bladder outflow obstruction
Low pressure retention:
normal renal function and no hydronephrosis
After inserting a catheter for chronic urinary retention, decompression haematuria can result due to the rapid decrease in the pressure in the bladder. How should it be managed?
does not require further management if the patient is haemodynamically stable
A hydrocele describes the accumulation of fluid within the tunica vaginalis. What are the 2 different types?
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum
common in newborn males (5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis
Transurethral prostatectomy is a common and popular treatment for benign prostatic hyperplasia. What are the possible complications?
TURP
T urp syndrome *
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
- TURP syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are:
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity
Risk factors for TCC of the bladder?
Smoking
- most important risk factor in western countries
Exposure to aniline dyes
- printing and textile industry
- examples are 2-naphthylamine and benzidine
Rubber manufacture
Cyclophosphamide
Risk factors for SCC of the bladder?
Schistosomiasis
Smoking
Surgical causes of haematuria?
Common:
UTI
renal cancer, bladder cancer, prostate cancer
renal calculi
BPH
Less common:
trauma
radiation cystitis
parasitic infection (most commonly schistosomiasis)
Medical causes of haematuria?
glomerulonephritis ( IgA nephropathy or post-infectious)
thin basement membrane disease
HUS
multi-system diseases (e.g. Henoch-Schönlein Purpura or Goodpasteur’s disease)
What is pseudohaematuria? Causes?
red or brown urine that is not secondary to the presence of haemoglobin
Causes:
medication (such as rifampicin or methyldopa)
hyperbilirubinuria, myoglobinuria
certain foods ( beetroot or rhubarb)
Hx and examination for haematuria?
Hx:
- degree of haematuria (pink v dark red) and presence of clots
- timing in stream (total haematuria suggests as a bladder or upper tract source, whilst terminal haematuria suggests potential severe bladder irritation)
- associated symptoms :LUTS, fevers or rigors, suprapubic pain, flank pain, weight loss, or recent trauma
- smoking status and exposure to carcinogens
- recent travel
Examination:
Abdo exam and DRE
external genitalia if indicated
Investigations for haematuria?
Urinalysis
Baseline bloods - FBC, U&Es, and clotting
PSA if prostatic cause suspected (after counselling pt)
Albumin:creatinine ratio if suspected nephrotic cause
What is the Urological Referral Criteria for Haematuria?
urgent referral to an adult urological service for the following:
Aged ≥45yrs with either:
Unexplained visible haematuria without UTI
Visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged 60yrs with unexplained non‑visible haematuria and either dysuria or a raised WCC
What specialist investigations are available for haematuria?
Low urinary tract imaging:
Flexible cystoscopy is the gold standard investigation - often under local at one stop uro clinic
Upper urinary tract imaging:
USS of renal tracts (non-visible haematuria)
CT urogram (visible haematuria)
Urine cytology
Management of haematuria?
tx of underlying pathology
anticoagulation reviewed, underlying clotting disorders corrected, blood transfusions performed as required
significant haematuria / clot retention:
inpatient admission under Urology
three-way catheter for ongoing washout and irrigation +/- evacuation of clots
refractory visible haematuria:
rigid cystoscopy
Renal tract stones (urolithiasis) are a common condition, particularly in men. They can form as both renal stones (within the kidney) or ureteric stones (within the ureter).
What can the calculi be composed of?
80%: calcium
(as either calcium oxalate (35%), calcium phosphate, or mixed oxalate and phosphate)
Remaining stones:
struvite stones (magnesium ammonium phosphate)
urate stones (radiolucent)
cystine stones (familial disorders affecting cystine metabolism)
What is the most common cause of “staghorn calculi” (stone fills the renal pelvis) ?
Struvite stones - large soft stones
Pathophysiology of urinary tract stone formation?
Oversaturation of urine
urate stones : high levels of purine in the blood, from diet (e.g. red meats) or haematological disorders (such as myeloproliferative disease)
cystine stones : homocystinuria
Where do renal tract stones become impacted?
Pelviureteric Junction (PUJ), where the renal pelvis becomes the ureter
Crossing the pelvic brim, where the iliac vessels travel across the ureter in the pelvis
Vesicoureteric Junction (VUJ), where the ureter enters the bladder
How do ureteric stones present?
ureteric colic:
due to increased peristalsis from around the site of obstruction
sudden onset, severe
radiating from flank to pelvis (“loin to groin”)
associated with N+V
Haematuria (90% cases) : typically non-visible
Differentials for flank pain (renal colic)?
pyelonephritis
ruptured AAA
biliary pathology
bowel obstruction
lower lobe pneumonia
musculoskeletal related pain
Investigations and imaging for renal tract stones?
Investigations:
Urine dip
Bloods - FBC, U&Es, CRP
Urate and calcium levels
Imaging :
Gold standard: non contrast CT KUB
USS : assess for hydronephrosis
Initial management of renal tract stones?
fluid resuscitation
majority of cases will pass spontaneously without further intervention, especially if in the lower ureter or <5mm in diameter : provide opiate analgesia and NSAIDs per rectum
evidence of significant infection or sepsis: IV abx and refer to uro team
Criteria for inpatient admission for renal stones?
Post-obstructive acute kidney injury
Uncontrollable pain from simple analgesics
Evidence of an infected stone(s)
Large stones (>5mm)
How can you manage patients with stones and evidence of obstructive nephropathy?
obstruction must be immediately relieved to avoid renal damage
temporary methods before definitive tx:
Retrograde stent insertion :placement of a stent in the ureter, (distal to proximal) via cystoscopy
A nephrostomy: tube placed directly into the renal pelvis and collecting system
Definitive treatment of retained renal or ureteric stones?
Extracorporeal Shock Wave Lithotripsy (ESWL):
- targeted sonic waves to break up the stone
- used for small stones (<2cm), performed via radiological guidance ( X-ray or USS)
- Contra-indications include pregnancy or stone positioned over a bony landmark (e.g. pelvis)
Percutaneous nephrolithotomy (PCNL) :
- renal stones only
- preferred method for large renal stones (including staghorn calculi)
- nephroscope passed into the renal pelvis, stones can then be fragmented using various forms of lithotripsy.
Flexible uretero-renoscopy (URS):
- passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser lithotripsy
Complications that can occur from ureteric stones?
Infection and post renal AKI
Renal scarring and loss of function if persistent
How can you manage recurrent stone formers?
Advise all patients to stay hydrated
Specific management options depend on the underlying stone composition:
Oxalate: avoid high purine foods and high oxalate foods (such as nuts, rhubarb, and sesame)
Calcium : PTH levels checked to exclude any primary hyperparathyroidism and avoid excess salt
Urate: avoid high purine foods (such as red meat and shellfish) and may need to be considered for urate-lowering medication (e.g. allopurinol)
Cystine: genetic testing for underlying familial disease
Bladder stones typically form from urine stasis within the bladder, so are commonly seen in cases of chronic urinary retention.
How do they present?
Management?
What are they a risk for?
LUTS
cystoscopy and then allowing the stones to drain or breaking up through lithotripsy
chronic irritation of the bladder epithelium can predispose to the development of SCC bladder cancer
Pyelonephritis is defined by inflammation of the kidney parenchyma and the renal pelvis, typically due to bacterial infection. Can occur in all ages but more common in women ages 15-29.
How does it present?
Presentation:
fever, unilateral loin pain (or rarely bilateral), and nausea & vomiting
OE: pyrexial, unilateral or bilateral costovertebral angle tenderness
Risk factors for pyelonephritis?
Factors reducing antegrade flow of urine:
obstructed urinary tract , spinal cord injury
Factors promoting retrograde ascent of bacteria:
female gender, indwelling catheter or ureteric stents / nephrostomy tubes in-situ, structural renal abnormalities such as vesico-ureteric reflux
Factors predisposing to infection or immunocompromise:
Diabetes corticosteroid use, HIV infection
Factors promoting bacterial colonisation:
Renal calculi, intercourse, oestrogen depletion (menopause)
What imaging should be performed for patients with pyelonephritis?
renal USS for evidence of obstruction (infected obstructed system is a urological emergency)
If obstruction is suspected :non-contrast CT KUB
What should you do if pyelonephritis is unresponsive to antibiotics?
imaging should be performed to rule out pyonephrosis and perinephric abscess which require drainage
Complications of pyelonephritis?
severe sepsis and multi-organ failure
renal scarring leading to CKD
pyonephrosis
preterm labour in pregnant women
What is emphysematous pyelonephritis?
Presentation?
Patient group?
rare and severe form of acute pyelonephritis, caused by gas-forming bacteria, and is associated with a high-mortality rate
will fail to respond to empirical IV antibiotics, CT imaging will show evidence of gas within and around the kidney
More common in diabetics
Give broad spectrum abx, collections may require drainage
Outline the Cremasteric Reflex and Prehn’s Sign
The cremasteric reflex is elicited by stroking the proximal and medial aspect of thigh; a normal response is retraction of testes upwards on the ipsilateral side.
Absence of the cremasteric reflex = potential testicular torsion
Prehn’s sign is the alleviation of scrotal pain by lifting of the testicle = suggestive of acute epididymitis
Acute scrotal pain commonly presents unilaterally.
What are the main differentials?
Urological:
Testicular Torsion / Torsion of Testicular and Epididymal Appendages
Epididymitis
Testicular cancer
Referred pain:
luminal ureteric stones
strangulated inguinal hernia
Non-urological:
Henoch-Schoenlein Purpura (HSP)
Viral Orchitis
What is testicular torsion?
What is the surgical management?
twisting of the spermatic cord with occlusion of the testicular and cremasteric arteries. This leads to ischaemia and subsequent testicular infarction
bilateral orchidopexy - moves testes into scrotum
orchidectomy (removal of testicle) is indicated if the testicle is infarcted and the contralateral testis is fixed
What are the testicular appendix ( hydatid of Morgagni) and epidydimal appendix?
Associated pathology?
Finding on examination?
Tx?
remnants of embryological development
can twist and result in torsion - often with normal testicular lie and present cremasteric reflex
‘blue dot sign’ - found in the upper half of the hemi-scrotum sign, occurs due to infarction of the appendices
analgesia or surgical exploration if uncertain diagnosis
What causes epididymitis?
in males aged <35 years old, the most likely mechanism is sexual transmission
in males aged >35 years old, an enteric organism from a UTI is more likely
Most common cause of viral orchitis?
Tx?
Mumps
scrotal swelling and pain develop around 4 to 8 days after the initial parotitis
Treat with analgesia but swelling may persist for 6 weeks
Acute urinary retention is defined as a new onset inability to pass urine, which subsequently leads to pain and discomfort, with significant residual volumes.
What is the most common cause in men?
What are the other causes?
BPH most common
Prostate cancer
Urethral strictures
UTIs- sphincter closure
Constipation - compression of urethra
Severe pain
Medications: anti-muscarinics or spinal or epidural anaesthesia
Neurological causes: peripheral neuropathy, iatrogenic nerve damage, upper MND
Investigations for acute urinary retention?
post-void bedside bladder scan
bloods - FBC, U&Es, CRP
CSU (Catheterised Specimen of Urine)
If there is a large volume of urine drained on catheterisation (>1000ml), then high pressure chronic retention (HPCR) should be ruled out- USS for hydronephrosis
Management of acute urinary retention?
immediate urethral catheterisation and measure vol drained
underlying causes should then be treated
Patients who have a large retention volume (>1000ml) probably have a chronic element to their retention. What should they be monitored for post catheterisation?
post-obstructive diuresis
What is TWOC?
When should this occur in people with BPH?
Trial WithOut Catheter (TWOC) - catheter is removed after treatment of the cause
> 72hrs after starting alpha-1 adrenoreceptor antagonist (e.g. tamsulosin)
Chronic urinary retention is the painless inability to pass urine. Why is it painless?
What associated symptoms may patients present with?
long standing retention = significant bladder distension = bladder desensitisation
Associated voiding LUTS, such as weak stream and hesitancy, with a reduced functional capacity
Overflow incontinence may also be present ( intra-vesical pressures rise greater than those of the urinary sphincter) typically worse at night when the sphincter tone is reduced
Causes of chronic retention in women?
pelvic prolapse:
cystocele, rectocele, or uterine prolapse
pelvic masses:
e.g. large fibroids
What is High Pressure Urinary Retention?
Complications?
when the urinary retention causes such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract leading to hydroureter and hydronephrosis
scarring and CKD
How should patients with chronic urinary retention and very high post-void volumes (>1L) or evidence of high pressure retention be managed?
catheterised with a long-term catheter
urine output monitored for post-obstructive diuresis
What is post-obstructive diuresis?
How can you manage risk of AKI?
Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to loss of medullary concentration gradient
Can lead to worsening AKI
Patients producing >200ml/hr urine output should have around 50% of their urine output replaced with intravenous fluids to avoid any worsening AKI
What is Intermittent Self Catheterisation (ISC)?
Why is it not suitable for all patients?
Patients are taught how to catheterise themselves at regular intervals (e.g. every 4-6hrs)
requires good manual dexterity and patient compliance
Complications of chronic urinary retention?
urinary tract infections and bladder calculi
CKD
Subtypes of urinary incontinence?
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
Continuous incontinence
Risk factors for stress UI?
post-partum- damage to the pelvic floor muscles
post-menopausal
constipation - recurrent straining
obesity
pelvic surgery (e.g. TURP, resulting in external sphincter damage)
Causes of urge UI?
overactive bladder (detrusor hyperactivity) causes rise in intravesical pressure and leakage of urine
neurogenic causes (such as a previous stroke)
infection
malignancy
idiopathic
medication, e.g. cholinesterase inhibitors
Most common cause of overflow incontinence?
BPH
What causes continuous UI?
anatomical abnormality (such as ectopic ureter) or bladder fistulae (e.g. vesicovaginal fistula)
What can aid in quantifying impact of incontinence?
bladder diaries
QoL questionnaires (such as ICIQ, BFLUTS, I‑QOL)
What can be done for those with unclear aetiology of UI?
urodynamic assessment - Intravesicular and intra-abdominal pressures are measured
Surgical management options for stress and urge UI?
Stress:
tension-free vaginal tape, open colposuspension , intramural bulking agents, or an artificial urinary sphincter
Urge:
botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty
Most cases of bladder cancer present with a painless haematuria. What investigation should be done for all cases of painless haematuria?
cystoscopy
Most common type of bladder cancer?
TCC
Risk factors for developing BPH?
Age
family history (first degree relatives)
black African or Caribbean ethnicity
obesity
Presenting symptoms of BPH?
Finding on DRE?
voiding symptoms:
hesitancy, weak stream, terminal dribbling, or incomplete emptying
storage symptoms:
frequency, nocturia, urge incontinence
less common symptoms:
haematuria and haematospermia
DRE: firm, smooth, symmetrical prostate (unlike cancer)
greater than 2 fingers width = potential enlargement
What is the International Prostate Symptom Score?
validated screening tool used in the evaluation and quantification of LUTS
0-7 are mild, 8-19 moderate and 20+ severe.
All men over the age of 50yrs (40yrs in black African or Caribbean men) presenting with LUTS for the first time should receive what?
Counselling for a PSA test
Tx option for patients with BPH who remain symptomatic despite α-adrenoreceptor antagonists?
α-reductase inhibitors, such as Finasteride
in patients with erectile dysfunction, PDE5 inhibitors can be trialled
in patients with severe storage symptoms can try anti-cholinergic
Complications of BPH?
High pressure retention
UTI
significant haematuria
The majority of prostate cancers (>95%) are adenocarcinomas. Where do they arise?
75% arise from the peripheral zone
20% in the transitional zone
5% in the central zone
Prostate adenocarcinomas can be categorised into two types:
Acinar adenocarcinoma – most common form of prostate cancer
Ductal adenocarcinoma – originates in the cells that line the ducts of the prostate gland
- grow and metastasise faster than acinar
In men thought to be at risk of prostate cancer, such as with a raised PSA or abnormal DRE, what investigation is indicated?
multi-parametric MRI scan of the prostate (mp-MRI)
Abnormal areas can be biopsied :
Transperineal biopsy
TransRectal UltraSound-guided (TRUS) biopsy
scoring system by which prostate cancers are graded?
The Gleason grading system - based on histiological appearance
higher score = worse prognosis
Basic outline of mainstay of management for prostate cancer?
Radical prostatectomy, external-beam radiotherapy, and brachytherapy are the mainstay treatments of localised or locally advanced prostate cancer
Anti-androgen therapy is effective in metastatic disease
A 4-year-old girl presents with symptoms of right sided loin pain, lethargy and haematuria. OE she is pyrexial and has a large mass in the right upper quadrant.
The most likely underlying diagnosis is:
Nephroblastoma (Wilm’s tumour)
Usually present in first 4 years of life
Often present as a mass + haematuria
Often metastasise early (usually lung)
Tx = nephrectomy
Classical triad of RCC?
What other features may it present with?
haematuria
loin pain
abdominal mass
PUO
varicocoele
25% have metastases at presentation (stage 4)
What is Stauffer syndrome?
paraneoplastic disorder associated with RCC
typically presents as cholestasis/hepatosplenomegaly
secondary to increased levels of IL-6
Voiding symptoms (weak flow, terminal dribbling, and incomplete emptying) in patients that are not the typical age for prostate problems (generally 65 years or older) could be due to what?
Urethral stricture due to STI (e.g. gonorrhea)
Define Functional urinary incontinence
urinary incontinence where the urinary system is intact, but other barriers cause the patient to become incontinent e.g. poor mobility, sedation, and injuries leading to decreased ambulation
The peak incidence for teratomas is 25 years and seminomas is 35 years. Risk factors include:
infertility (increases risk by a factor of 3)
cryptorchidism
family history
Klinefelter’s syndrome
mumps orchitis
Tumour markers for non-seminomas and seminomas?
non-seminomas: AFP / beta-hCG elevated in 80-85%
seminomas: hCG may be elevated in 20%
What is a Grawitz tumour?
eponymous name for Renal Adenocarcinoma
Management of renal colic?
NSAID is analgesia of choice
IM diclofenac in patients requiring admission
What can be used for pregnant women in whom lithrotripsy is contraindicated for removal of calculi?
Uteroscopy
What is tumour flare?
What management step can reduce risk of this?
goserelin (GnRH agonist) management of prostate cancer = initial increase in testosterone levels before subsequent suppression of testosterone
bone pain, bladder obstruction and other symptoms
Prescribe cyproterone acetate- prevent paradoxical increase in symptoms with GnRH agonists
Prostatitis tx?
14-day course of a quinolone e.g. ciprofloxacin
What is the tx of suspected epididymo-orchitis with an unknown organism?
ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days
Associations of epididymal cysts?
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
What conditions should be met before performing a PSA test?
testing should not be done within at least:
6 weeks of a prostate biopsy
4 weeks following a proven UTI
1 week of DRE
48 hours of vigorous exercise / ejaculation
pelvic fracture and lower abdominal peritonism =
suspected bladder rupture!
What are the 2 main types of urethral injury?
Bulbar rupture
most common
straddle type injury e.g. bicycles
triad signs: urinary retention, perineal haematoma, blood at the meatus
Membranous rupture
commonly due to pelvic fracture
Penile or perineal oedema/ hematoma
PR: prostate displaced upwards
investigate with ascending urethrogram
What post-void volumes are considered physiological?
Post-void volumes of <50 ml are considered physiological in patients aged < 65 years old.
Post-void volumes of < 100ml are considered physiological in patients aged > 65 years old.
Define obstructive uropathy.
Which imaging technique is helpful in diagnosing obstructive uropathy?
Mx?
a blockage preventing urine flow through the ureters, bladder and urethra
USS KUB
removing or bypassing the obstruction
what is the renal angle?
the angle formed by the 12th rib and vertebral column at the back
what is idiopathic hydronephrosis a result of?
narrowing at the pelviureteric junction
tx is pyleoplasty
