Urology Flashcards
Acute bacterial prostatitis causes
gram - bacteria entering prostate gland via urethra
E coli - most commonly isolated pathogen
RFs: recent UTI, urogenital instrumentation, intermittent bladder catheterisation and recent prostate biopsy.
Mx of acute bacterial prostatitis
14 day course of quinolone
consider STI screening
Causes of ATN
ischaemia
- shock
- sepsis
nephrotoxins
- aminoglycosides
- myoglobin secondary to rhabdomyolysis
- radiocontrast agents
- lead
Medication that can cause acute urinary retention
anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines
(affect nerve signals to bladder)
Ix & Mx acute urinary retention
- bladder USS - vol > 300 cc confirms dx, but can be lower if symptoms
- urine catheterisation & sample for urinalysis
- find & tx cause
Look out for complication: post-obstruction diuresis (mx: IV fluids to prevent AKI)
Balanitis tx
- conservative: gentle saline washes, ensuring to wash properly under the foreskin
- more severe irritation and discomfort :1% hydrocortisone
treat cause if infective
tool for classifying the severity of lower urinary tract symptoms in BPH?
International Prostate Symptom Score (IPSS)
Mx of BPH
Watchful waiting
1st line: Alpha 1 antagonists - tamsulosin, alfuzosin
5 alpha-reductase inhibitors - finasteride
- if the patient has a significantly enlarged prostate and is considered to be at high risk of progression
- takes 6mo to work
combination of both works well - if moderate-severe voiding symptoms & prostatic enlargement
antimuscarinic ( tolterodine or darifenacin ) - storage & voiding symptoms not responsive to a-blockers
transurethral resection of prostate (TURP)
RFs for bladder ca
urothelial (transitional cell) carcinoma of the bladder
- smoking
- aniline dyes (2-naphthylamine and benzidine) in printing & textile industry
- rubber manufacture
- cyclophosphamide
SCC
- Schistosomiasis
- smoking
Medical indications for circumcision
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
( exclude hypospadias prior to circumcision as foreskin used for repair )
Epididymal cysts associated conditions
polycystic kidney disease
cystic fibrosis
von Hippel-Lindau syndrome
Epididymo-orchitis Ix & mx
Ix (depends on age)
younger - assess for STI
Older w low risk STI - send mid-stream urine (MSU) for microscopy and culture
Mx
- STI -> refer to sexual health clinic. If organism unknown: : ceftriaxone 500mg IM single dose, plus doxycycline 100mg by mouth BD for 10-14 days
- If enteric organisms -> empirically w oral quinolone for 2 weeks whilst awaiting MSU
RFs for erectile dysfunction
increasing age
CVS disease
Alcohol use
SSRIs, Beta blockers
Ix for erectile dysfunction
10 yr CVS risk calculated - measuring lipid & fasting glucose
Free testosterone between 9-11am - if low/borderline, repeat w FSH, LH & prolactin - if low, refer to endo
Mx for erectile dysfunction
PDE-5 inhibitors (sildenafil ‘viagra’)
If Ci to above - vacuum erection devices
young man who has always had difficulty achieving an erection -> referral to urology
Stop cycling >3hrs a week if ED
communicating vs non communicating hydroceles
accumulation of fluid w/in the tunica vaginalis
communicating: latency of processus vaginalis. so peritoneal fluid drains into scrutum. Common in newborn males & resolve in few mos
non-communicating: excessing fluid production w/in tunica vaginalis
can occur secondary to: epididymis-orchitis, testicular torsion, testicular tumours
Hydrocele ix & mx
ix - clinical but USS used if any doubt about dx if underlying testis cannot be palpated
Mx
- infantile hydroceles repaired if no spontaneous resolution by age 1-2yrs
- adults - conservative approach depending on severity. Uss to rule out underlying cause- e.g. tumour
Ix of hydronephrosis
1st line: USS - presence of hydronephrosis & can assess kidneys
intravenous urogram (IVU) - position of obstruction
Antegrade or retrograde pyelography- allows treatment
if potential real colic - CT scan
Mx of hydronephrosis
remove obstruction & drain urine
acute upper urinary tract obstruction: nephrostomy tube
Chronic: ureteric stent or pyeloplasty
types of urethral injury and features
Bulbar rupture
- most common
- straddle type injury (bicycles)
- triad: urinary retention, perineal haematoma, blood at meatus
Membranous rupture
- can be extra or intraperitoneal
- mostly due to pelvic fracture
- penile or perineal/ heamatoma
- PR prostate displaced upwards
urethral injury ix & mx
ascending urethrogram
suprapubic catheter (surgically placed, not percutaneously)
Bladder injury px, ix, mx
px
- haematuria or suprapubic pain
- pelvic fracture & inability to void!!
- inability to retrieve all fluid after irrigation through Foley
Ix
- IVU or cyst-gram
Mx
- laparotomy if intraperitoneal, conservative if extraperitoneal
Voiding vs store vs post micturition LUTS
Voiding
- hesitancy, poor stream, straining, incomplete emptying, terminal dribbling
Storage (FUNI)
- Frequency, Urgency, Nocturne, Incontinence
Post-micturition
- post-micturition dribbling
- sensation of incomplete emptying
Lower urinary tract symptoms ix
Ix
- urinalysis
- DRE
- PSA test
- urinary frequency-volume chart
- International Prostate Symptom Score (IPSS): classifies severity
predominantly Voiding LUTS symptoms
pelvic floor muscle training, bladder training, prudent fluid intake and containment products
tx as BPH
Predominately overactive bladder
conservative - moderating fluid intake
bladder retraining
antimuscarinic drugs : oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron - if first-line drugs fail
Nocturne mx
moderating fluid intake at night
furosemide 40mg in late afternoon
desmopressin
Post prostatectomy syndrome/ complications
haemorrhage, urosepsis, retrograde ejaculation and electrolyte disturbances from the irrigation fluids used during surgery.
Causes of priapism
ischemic - impaired vasorelaxation -> reduced vascular outflow -> congestion and trapping of de-oxygenated blood within the corpus cavernosa
Non-ischaemic priapism -> high arterial inflow (due to fistula formation <- congenital or traumatic mechanisms)
(more likely to be non-painful & not fully rigid)
idiopathic, sickle cell disease, haemoglobinopathies, medication (esp Erectile dysfunction meds), recreational ( cocaine, cannabis and ecstasy), trauma
Ischaemic priapism ix & mx
ix
- Cavernosal blood gas analysis (Po2 & pH reduced, increased pCO2)
- Doppler or duplex ultrasonography
- FBC & toxicology
- Dx: mostly clinical, Ix helps classify into 2 types
Mx
Ischemic:
- a medical emergency! otherwise, long term ED
- >4hrs- aspirate blood from cavernous & Inject saline flush.
- if failed -> intracavernosal injection of a vasoconstrictive agent (phenylephrine), repeated at 5 min intervals
- -> surgical options
non-ischemia priapism- not emergency & suitable for observation
prostate ca ix
DIgital recital examination -> asymmetrical, hard, nodular enlargement with loss of median sulcus
prostate specific antigen measurement (age dependent but >3 in 50-69, or >5 if older)
Multiparametric MRI - 1st line ix for ppl w people with suspected clinically localised prostate cancer (due to biopsy complications)
Trans rectal USS (+/- biopsy)
MRI/ CT & bone scan for staging
Graded using Gleason grading system - based on histology (95% adenocarcinoma)
First lympathics that prostatic ca spreads to?
& first place of distant spread?
Lymphatic spread - obturator nodes
local extra prostatic speed to seminal vesicles
Prostatic ca tx
Watch & wait - elderly, lots of co-morbities, low Gleason score
<- NICE recommend active surveillance for low risk men! (T1/2) - need at least 10 biopsy & one re-biopsy.
If evidence of disease progression (T3/4) -> medical treatment !!
Radiotherapy - either External or Internal (brachytherapy)
(SE: proctitis, bladder/colon/rectal ca)
Surgery - radical prostatectomy & obturator node removal (usually robotic)
Hormonal therapy - 95% of ca is testosterone dependent. so injections/ bilateral orchidectomy- rapid reduction/ GNRH agonists (goserelin) & anti androgens to cover initial T rise/ bicalutamide (non-steroidal anti-androgen. Blocks androgen receptor)
Chemotherapy - docetaxel
Prostate ca RFs
increasing age
obesity
Afro-Caribbean ethnicity
family history
PSA levels rise due to
prostate ca (poor specificity & sensitivity)
BPH
prostatitis & UTI (postpone till 1mo after tx)
ejaculation (last 48hrs)
vigorous exercise (last 48hrs)
urinary retention
instrumentation of urinary tract
Renal cell carcinoma pathology
a.k.a hypernephroma
85% of renal neoplasms
arises from proximal renal tubular epithelium
most common histological subtype-> clear cell carcinoma (75-85%)
haematogenous metastasis
renal cell carcinoma associations
middle-aged men
smoking
von Hippel-Lindau syndrome
Tuberous sclerosis
ADPKD (only slight increase)
Px of renal cell carcinoma
triad: haematuria, loin pain, abdo mass
pyrexia of unknown origin
endocrine effects (epo-> polycythemia, parathyroid related protein-> hypercalcaemia, renin, ACTH, hypertension)
Stauffer sundrome - paraneoplastic hepatic dysfunction syndrome - cholestasis & hepatosplenomegaly
left sided varicocele (compression of the renal vein between AA & SMA - nutcracker angle)
Tumour staging for RCC
T1 - =<7cm & confined to kidney
T2 - >7cm & only kidney
T3 - extending into major veins/ perinephric tissue. But not T4
T4 - beyond Gerota’s fascia, ipsilateral adrenal gland
RCC mx
confined disease - partial or total nephrectomy
T1 (<7cm) - offered partial nephrectomy
alpha-interferon, interleukin-2, receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) -> reduce tumour size
Nephroblastom vs Neuroblastoma
nephro- most common genitourinary malignancies in under 15
Neuro - neural crest origin- 50% in adrenal gland. mostly under 4yrs. most common extra cranial tumour of childhood.
Transitional cell carcinoma mx
Radical nephroureterectomy
Angiomyolipoma?
benign kidney tumour
hamartoma type lesion
- composed of blood vessels, smooth muscle and fat
80% sporadically, 20% w tuberous sclerosis
types of renal stones?
calcium oxalate - most common, radio-opaque
Cystine- inherited recessive disorder of transmembrane cystine transport, radio-opaque
uric acid - radiolucent, low urinary pH (acid), diseases w increased tissue breakdown- malignancy, children with inborn errors of metabolism
Calcium phosphate - renal tubular acidosis 1 & 3, normal/high urinary pH, radio-opaque
struvite - magnesium, ammonium and phosphate, urease producing bacteria, chronic infections, high urine pH (alk), Slightly radio-opaque
Renal & ureteric stone mx
Pain mx
- NSAID: IM diclofenac (careful of increased risk of CV events) –> IV paracetamol
Renal stone
- <5mm & asymptomatic - watchful waiting. will pass in 4 weeks.
- 5-10mm - shockwave lithotripsy
- 10-20mm shockwave lithotripsy OR ureteroscopy
- > 20mm percutaneous nephrolithotomy
Ureteric stones
- < 10mm - shockwave lithotripsy +/- alpha blockers
- 10-20 mm ureteroscopy
obstructive urinary calculi & signs of infection -> urgent renal decompression (nephrology time/ureteric catheter/ ureteric stent) & IV antibiotics
if pregnant -> lithotripsy is contraindicated, rather ureteroscope
Prevention of renal stones
Calcium stones (likely due to hypercalciuria)
- high fluid intake
- add lemon juice to drinking water
- avoid carbonated drinks
- potassium citrate
- thiazide diuretics (increase distal tubular calcium resorption)
Oxalate stones
- cholestyramine reduces urinary oxalate secretion
- pyridoxine reduces urinary oxalate secretion
Uric acid stones
- allopurinol for gout
- urinary alkalinization e.g. oral bicarbonate
types of testicular ca
95% are germ-cell tumours which are divided into:
seminomas
non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
Non-germ cell tumours include Leydig cell tumours and sarcomas.
Testicular tumor markers
seminomas: beta-HCG elevated in 20%, AFP normal
non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
(non seminoma = embryonal, yolk sac, teratoma and choriocarcinoma)
testicular ca ix & mx
Dx
- USS is first line
- tumor markers
Mx
- depends on if tumor is seminoma or non-seminoma
- orchidectomy
- chemotherapy and radiotherapy
Risk factors for testicular cancer
Cryptorchidism
Infertility
Family history
Klinefelter’s syndrome
Mumps orchitis
