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
