Urology Flashcards
Treatment of bladder hyperactivity (neurogenic bladder)?
Bladder hyperactivity - antimuscarinic medications to relax bladder
When should you refer to a urologist for LUTS?
o Failure of medical therapy
o UTIs
o Hematuria, Retention, Renal Compromise
o Concerns re: elevated PSA, abN DRE
o Any consecutive rise in PSA while on 5ARi
What are the side effects of vacuum erection devices?
Side effects of petechiae, numbing, trapped ejaculation.
What are the side effects of intracavernosal injections?
Priapism
Which disorders to organic causes for ED usually stem from?
Atherosclerosis or diabetes
Common causes of urinary retention in men?
Prostate abnormalities or urethral strictures causing outlet obstruction
Treatment of bladder hyperactivity if refractory to antimuscarinic medications?
o Botulinum toxin injections into bladder wall (detrusor muscle)
o Occasionally augmentation cystoplasty (enlarging bladder volume and improving compliance by grafting section of detubularized bowel onto the bladder)
o Occasionally urinary diversion (ileal conduit or continent diversion) in severe cases if bladder management unsuccessful
What should be done on physical exam for scrotal pain?
- Abdomen: tenderness and masses (including bladder distention). Flanks are percussed for costovertebral angle tenderness.
- Inguinal and genital examination should be done with the patient standing.
- Inguinal area is inspected and palpated for adenopathy, swelling, or erythema.
- Scrotal examination: asymmetry, swelling, erythema or discoloration, and positioning of the testes (horizontal vs vertical, high vs low).
- Cremasteric reflex should be tested bilaterally.
- The testes, epididymides, and spermatic cords should be palpated for swelling and tenderness.
MOA of α1-adrenoceptor-blocking agents
Hyperplasia of the prostate is primarily a phenomenon of the stromal rather than epithelial tissue in the majority of men. The smooth muscle of the stroma receives adrenergic innervation. For this reason, the selective α1-blockers may be useful for relaxing the smooth muscle of the prostate and the bladder neck.
Which medications can cause ED?
Antihypertensives, antidepressants (SSRIs – not bupriopion), dopaminergic, alcohol
What is the conservative management for BPH?
Watchful waiting (mild to moderate symptoms)
Lifestyle modification (i.e. caffeine intake, exercise)
Modification of current medications (i.e. diuretics)
What should be asked on history for scrotal pain?
o Location (unilateral or bilateral), onset (acute or subacute), and duration of pain o Important associated symptoms include fever, dysuria, penile discharge, and presence of scrotal mass o Injury, straining or lifting, and sexual contact.
Contraindications to PDE5 inhibitors
Nitrates (drops your BP too much), active MI, LV outflow obstruction.
Typical investigations for scrotal pain?
o Urinalysis and culture (all patients)
o STD testing (all patients with positive urinalysis, discharge, or dysuria)
o Color Doppler ultrasonography to rule out torsion (no clear-cut alternate cause)
Side effects of surgical penile prosthesis?
S/E: infection, perforation, urethral injury, malfunction, erosion
What do you need to r/o for priapism?
Rule out leukemia and sickle cell anemia
Two general categories of etiology for ED?
Psychologic and organic
Examples of 5 alpha reductase inhibitors?
Finasteride – type II, dutasteride – type I & II
3rd line treatment for ED?
- Surgical penile prosthesis - Need to take out cavernosal tissue so if this thing fails – no other therapy allowed!
What are the emptying symptoms of LUTS?
(WISE): Weak Stream, Intermittency, Straining, Sense of Incomplete Emptying
What are the mandatory investigations for BPH?
Mandatory: Hx including LUTS, surgery, trauma, medications (OTC and phytotherapeutic agents), impact of QOL, P/E including DRE, U/A to exclude UTI
What should be preformed on physical exam for a patient with LUTS?
o Abdominal exam – palpable masses, suprapubic tenderness
o External genitalia – obstruction, scrotal pathology
o DRE – size, texture and nodules
o Neurological Exam – walk to the bed
Treatment options for priapism?
Corporal irrigation, intracavernosal injection alpha adrenergic agonists or surgical shunt
1st line treatment for ED?
Phosphodiesterase inhibitor (sildenafil/viagra, tadalafil/cialis)
How do 5 alpha reductase inhibitors work?
Slow the rate of prostate enlargement - block conversion of testosterone to DHT
Clinical presentation of orchitis?
- Abrupt onset of testicular pain
- Nausea, fever
- Unilateral or bilateral swelling, erythema and tenderness of scrotum
Clinical presentation of strangulated inguinal hernia
o Long history of painless swelling (often known diagnosis of hernia) with acute or subacute pain
o Scrotal mass, usually large, compressible, possibly with audible bowel sounds
o Not reducible
What is priapism?
Prolonged, painful, unwanted erection >4h, emergency
Bilateral scrotal pain suggests _____
Suggests infection (eg, orchitis, particularly if accompanied by fever and viral symptoms) or a referred cause.
What referred pain could cause scrotal pain?
Abdominal aortic aneurysm, urolithiasis, lower lumbar or sacral nerve root impingement, retrocecal appendicitis, retroperitoneal tumor, postherniorrhaphy pain
2nd line treatment for ED?
- Vacuum erection devices - uses VENOUS Blood (unnatural)
- Intracavernosal injections – inject prostaglandin into cavernosa – leads to involuntary erection.
- Constriction rings
Investigations to be done for a patient with LUTS?
o Uroflow/PVR
o Urinalysis +/- culture
o Creatinine + lytes
o PSA
Indications for surgery for BPH?
Bothersome symptoms despite maximal medical treatment
Inability to tolerate medical therapy
BPH-related complications: Urinary Retention (inability to void), Bladder calculi, Recurrent UTI, Recurrent hematuria from the prostate, Upper tract dysfunction (hydronephrosis, renal dysfunction)
In females, LUTS are most commonly presents in those over 40 years old and commonly associated with a
Lower urinary tract infection
What are the investigations and their findings of urethral stricture?
- Laboratory findings - flow rates <10 mL/s (normal >15 mL/s) on uroflowmetry
- Radiologic findings - RUG and VCUG will demonstrate location
Men with psychogenic ED usually have _____ nocturnal erections and erections upon awakening
Normal
What is defined as erectile dysfunction?
Consistent (>3 mo duration) or recurrent inability to obtain +/or maintain an erection sufficient for satisfactory sexual activity
What are the side effects of alpha blockers
Orthostatic hypotension, asthenia, dizziness, abnormal ejaculation, nasal congestion, headache.
Treatment of chronic urinary retention?
Chronic retention - intermittent catheterization by patient may be used; definitive treatment depends on etiology
In older men, LUTS are commonly caused b
BPH
Clinical presentation of testicular torsion?
Sudden onset unilateral scrotal pain with nausea
Gold standard surgical technique for BPH?
TURP – Gold standard if prostate moderate size
Appendiceal torsion tx?
Treat conservative + NSAIDs. Surgical exploration and excision if refractory pain
Treatment of post-operative patients with retention?
- Encourage ambulation
- α-blockers to relax bladder neck/outlet (men only)
- May need catheterization
Examples of selective α1-adrenoceptor-blocking agents
Alfuzosin, Tamsulosin
What are the optional investigations for BPH?
Optional: Cr, urine cytology, uroflowmetry, PVR, voiding diary, sexual function questionnaire, renal U/S to assess for hydronephrosis
Common causes of urinary retention in both sex?
Retention may be due to drugs (particularly those with anticholinergic effects, including many over-the-counter drugs), severe fecal impaction (which increases pressure on the bladder trigone), or neurogenic bladder in patients with diabetes, multiple sclerosis, Parkinson disease, or prior pelvic surgery resulting in bladder denervation
What is Detrusor sphincter dyssynergia (DSD) and its causes?
- Suprasacral lesion of spinal cord (e.g. trauma, MS, arteriovenous malformation, transverse myelitis)
- Loss of coordination between detrusor and sphincter (detrusor contracts on closed sphincter and vice versa)
What is a urethral stricture?
Decrease in urethral calibre due to scar formation in urethra
First steps in treating ED (including lifestyle)?
- Underlying organic disorders (eg, diabetes , prolactin-secreting pituitary adenoma , hypogonadism , Peyronie disease ) require appropriate treatment
- Drugs that are temporally related to onset of erectile dysfunction (ED) should be stopped or replaced.
- Depression may require treatment or counselling
- Lifestyle stuff: stop smoking, exercise, eat right, ↓alcohol, sleep, modify meds (e.g. aniHTN, SSRIs, antiandrogens).
Examples of the non-selective alpha blockers?
Doxazosin, terazosin
Tx of testicular torsion?
Treat with surgery in <6hrs (up to 24) - bilateral orchiopexy
What do you need to do with taking PDE5?
Need sexual stimulation to activate the NO pathway! Won’t work without it. Onset 15-30min, can last for 6-24 hrs. Cialis lasts longer – helps erectile function, but does not cause erection
Clinical features of urinary retention?
Suprapubic pain (with acute retention), incomplete emptying, weak stream
Possible purulent/bloody meatal discharge (with UTI)
Increased size of prostate or reduced anal sphincter tone on DRE
Neurological: presence of abnormal or absent deep tendon reflexes, reduced “anal wink”, saddle anesthesia
Severe, sudden onset of scrotal pain suggests _____ or ______
Testicular torsion or renal calculus.
What is the pathophysiology behind OSA resulting in nocturnal polyuria?
o Increased airway resistance - Hypoxia
o Pulmonary Vasoconstriction
o Increased Right Atrial Pressure = Atrial Naturetic Peptide = Na and H2O excretion
S/E of 5 alpha reductase inhibitors?
S/E – decreased libido, ED, ejaculatory dysfunction, gynecomastia
Clinical presentation of epididymitis?
o Acute or subacute onset of pain in the epididymis and sometimes also the testis
o Possibly urinary frequency, dysuria, recent lifting or straining
o Cremasteric reflex present
o Often scrotal induration, swelling, erythema
o Sometimes penile discharge
Ddx of LUTS in men?
Prostate: BPH, prostate cancer, prostatitis
Bladder: cystitis, bladder tumour, bladder or ureteric stone, overactive bladder
Urethra: urethral stricture, urethritis (STI), meatal stenosis, phimosis, foreign body
Neurologic: Neurogenic bladder: Parkinson’s disease, stroke, Alzheimer’s disease, spinal cord disease
Other: Obstructive sleep apnea, medication side effect (anticholinergics, opioids), dietary irritant, external compression from pelvic mass or constipation, polydipsia, congestive heart failure, DM
What is the neuro-urologic evaluation for neurogenic bladder?
- Hx and P/E (urologic and general neurologic)
- Voiding diary
- Catheterization volumes in patients with CIC
- U/A, renal profile
- Imaging - U/S to rule out hydronephrosis and stones; occasionally CT scanning with or without contrast
- Cystoscopy
- Urodynamic studies
Risk factors for ED?
Risk factors for ED are basically the same as that of CV disease – they are related! Include: HTN, obesity/sedentary, smoking, heart disease, diabetes, hyperlipidemia, BPH, vascular disease
A vesicular nonpedunculated structure attached to the cephalic pole of the testis
Appendix testis
Investigations for epididymitis?
Urinalysis and culture – likely to be abnormal, Nucleic acid amplification tests for Neisseria gonorrhoeae and Chlamydia trachomatis
o Severe pain, fever, toxic appearance, erythema, blistering or necrotic lesions
o Sometimes palpable subcutaneous gas
o Sometimes history of recent abdominal surgery
o More common in older men with diabetes, peripheral vascular disease, or both
Fournier gangrene
Name two other potential causes of ED (other than meds, organic or psychological)?
Pelvic radiation and testosterone deficiency
Clinical findings + signs of testicular torsion?
o Asymmetric, transversely oriented, high-riding testis on affected side
o Cremasteric reflex absent
Deficient bladder sensation - Increasing residual urine - decompensation (e.g. DM, neurosyphilis, herpes zoster)
Peripheral autonomic neuropathy
What risk can alpha blockers pose for cataract surgery
Intraoperative floppy iris syndrome
Treatment for epididymitis?
Treatment: ceftriaxone (200 mg IM) AND doxycycline (100 mg PO bid) x14d, bedrest, scrotal support, and NSAIDs.
Important things to ask about on history for ED?
- History of drug (including prescription drugs and herbal products) and alcohol use, pelvic surgery and trauma, smoking, diabetes, hypertension, and atherosclerosis and symptoms of vascular, hormonal, neurologic, and psychologic disorders.
- Satisfaction with sexual relationships
Psychologic causes of ED?
Include guilt, fear of intimacy, depression, or anxiety. In secondary ED, causes may relate to performance anxiety, stress, or depression. Psychogenic ED may be situational, involving a particular place, time, or partner.
When should open prostatectomy be considered for BPH?
Gland Size > 80cc, Urethral Stricture, Hip contractures, Need for concomitant bladder surgery (diverticulum, big stones)
Treatment of neurogenic bladder
- Clean intermittent catheterization (CIC) (if there is associated inability to void)
- Bethanechol is a parasympathomimetic choline carbamate that selectively stimulates muscarinic receptors without any effect on nicotinic receptors.
What are the clinical features of urethral stricture?
- Voiding and storage symptoms
- Urinary retention
- Hydronephrosis
- Related infections: recurrent UTI, secondary prostatitis/epididymitis
What are the storage symptoms of LUTS?
(FUUND): frequency, urgency, urgency incontinence, nocturia and dysuria
_____ can be a useful tool for assessing and monitoring the impact of LUTS on quality of life in men
International Prostate Symptom Score
Fournier gangrene treatment
Treatment: Immediate debridement and broad-spectrum antibiotics, with hemodynamic support
What are the recommended investigations for BPH?
Recommended: symptom inventory (IPSS), PSA if >10yr life expectancy or if it changes management of voiding symptoms
On ROS for scrotal pain what information should you gather?
Review of systems should seek symptoms of causative disorders, including purpuric rash, abdominal pain, and arthralgias (immunoglobulin A–associated vasculitis [Henoch-Schönlein purpura]); intermittent scrotal masses, groin swelling, or both (inguinal hernia); fever and parotid gland swelling (mumps orchitis); and flank pain or hematuria (renal calculus).
What is Detrusor atony/areflexia?
- Lesion of sacral cord or peripheral efferents (e.g. trauma, DM, disc herniation, MS, congenital spinal cord abnormality, post abdominoperineal resection)
- Flaccid bladder which fails to contract
o Subacute onset of pain over several days
o Pain in the upper pole of testis
o Cremasteric reflex present
o Typically occurs in boys aged 7–14 years
Appendiceal torsion
Organic causes of ED?
Neurologic:
- Include stroke, partial complex seizures, multiple sclerosis, peripheral and autonomic neuropathies, and spinal cord injuries. Diabetic neuropathy and surgical injury are particularly common causes.
Vascular:
- The most common vascular cause is atherosclerosis of cavernous arteries of the penis (decreases capacity to dilate), often caused by smoking, endothelial dysfunction, and diabetes.
Treatment for urethral stricture?
Urethral dilatation - temporarily increases lumen size by breaking up scar tissue
Visual internal urethrotomy (VIU) - endoscopically incise stricture
Open surgical reconstruction (urethroplasty) - complete stricture excision with anastomosis depending on location and size of stricture
What are the causes behind urethral stricture?
- Congenital - failure of normal canalization (i.e. posterior urethral valves)
- Trauma - instrumentation/catheterization (most common), external trauma (e.g. burns, straddle injury)
- Infection - long-term indwelling catheter, STI (gonococcal or chlamydial disease)
- Inflammation - balanitis xerotica obliterans (BXO; lichen sclerosus or chronic progressive sclerosing dermatosis of the male genitalia) causing meatal and urethral stenosis, radiation
- Malignancy (urothelial carcinoma) - most urethral cancers in men are squamous
What typically causes epididymitis?
- UTI – E.coli, pseudomonas – Most common cause among older men and children
- STI – chlamydia, gonorrhoeae
For best results what should you start men with BPH on?
Usually start men on combo of alpha block and 5ARI
What is neurogenic detrusor overactivity?
- Lesion above PMC (e.g. stroke, tumour, MS, Parkinson’s disease)
- Loss of voluntary inhibition of voiding
- Intact pathway inferior to PMC maintains coordination of bladder and sphincter
Investigations for ED?
- Morning testosterone level; if the level is low or low-normal, prolactin and luteinizing hormone (LH) should be measured.
- DIABETES (Hb1Ac or urinalysis for glucose). TSH, lipid panel if indicated
Treatment of acute urinary retention?
Acute retention - immediate catheterization to relieve retention; leave Foley in to drain bladder; follow-up to determine cause; closely monitor fluid status and electrolytes (risk of POD)
Conservative management options for a patient with LUTS?
- Regulating fluid intake
- Urethral milking techniques* (manually emptying the bulbar urethra of residual urine) or double voiding (passing urine and then remaining for a short time before passing urine again)
- Pelvic floor exercises to strengthen the pelvic floor are useful in cases of stress incontinence or post-micturition dribble.
- Bladder training techniques, which aim to increase the duration between the urge to void and micturition, when done properly (under supervision) these may be useful in overactive bladder.
What should you ask on history for LUTS?
o Whether symptoms are mostly voiding or storage (FUUND / WISE)
o Associated symptoms - visible hematuria, suprapubic discomfort, or colicky pain, and their medication history (anticholinergics, antihistamines and bronchodilators)
o Previous urologic or pelvic surgery
o Family history of prostate cancer
Does the size of gland (prostate) correlate with degree of symptoms (LUTS)?
No
Pharmacological management options for a patient with LUTS?
- Anticholinergics (e.g. oxybutynin, tolterodine) for overactive bladder, helping to relax bladder muscle by opposing parasympathetic cholinergic control of contraction
- Alpha blockers (e.g. alfuzosin, tamsulosin) and / or 5alpha-reductase inhibitors (e.g. finasteride) for BPH can help in reducing prostate size by relaxing prostatic muscle
- Loop diuretics (e.g. furosemide, bumetanide), may be taken mid-afternoon to prevent nocturia
BPH treatment done on smaller prostates and when the primary obstruction occurs at the bladder neck
TUIP
What is the neurophysiology of micturition?
Stretch receptors in the bladder wall relay information to PMC and activate micturition reflex (normally inhibited by cortical input)
Micturition (voiding):
• Stimulation of parasympathetic neurons (bladder contraction)
• Inhibition of sympathetic and somatic neurons (internal and external sphincter relaxation, respectively)
• Voluntary relaxation of the pelvic floor and striated urethral sphincter
What is the definition of cystitis?
Symptoms suggestive of UTI + evidence of pyuria and bacteriuria on U/A or urine C&S