Urology Flashcards
1
Q
What is a common complication of radiotherapy for testicular cancer?
A
Proctitis
2
Q
What are patients at increased risk of following radiotherapy for prostate cancer?
A
Bladder, colon and rectal cancer
3
Q
What is the management of hard, irregular prostate felt on DRE?
A
2 week wait referral to urology alongside measuring PSA
4
Q
What is important to exclude before circumcision can take place?
A
Hypospadias
5
Q
What are the side effects of tamsulosin?
A
- dizziness
- postural hypotension
- dry mouth
- depression
6
Q
Ongoing loin pain, haematuria, pyrexia of unknown origin suggests what?
A
Renal cancer
7
Q
What does circumcision help to reduce?
A
Rates of HIV transmission
8
Q
What is the first line investigation for prostate cancer?
A
Multiparametric MRI: results reported using a 5-point Likert scale and if >=3 then biopsy.
9
Q
What is the investigation of choice for renal stones?
A
Non contrast CT KUB
10
Q
What is the most common form of prostate cancer?
A
Adenocarcinoma
11
Q
What is the referral criteria for bladder cancer?
A
A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test
12
Q
What is the analgesia of choice in renal colic?
A
IM Diclofenac
13
Q
What is the mode of action of tamsulosin?
A
Alpha-1 antagonists which promote relaxation of the smooth muscle of the prostate and the bladder
14
Q
schistosomiasis is a major risk factor for what?
A
Squamous cell carcinoma of the bladder
15
Q
What is the treatment of choice for renal stones in pregnant women?
A
Ureteroscopy
16
Q
Adult patients with hydroceles should have what?
A
Ultrasound scan
17
Q
How are infantile hydroceles managed?
A
Surgical repair if not resolved spontaneously by ages 1-2
18
Q
What is the management of epipidimo-orchitis with no known organism?
A
ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days
19
Q
What are the investigations of choice for epipdidimo-orchitis?
A
Younger adults with sexual history - NAAT
Older adults - MSSU
20
Q
What should be sent for all women with suspected UTI and haematuria?
A
MSU
21
Q
Acute vs chronic urinary retention
A
Chronic will have much larger volumes (1.5L) and be painless
22
Q
What is a complication of losing too much fluid following catheterisation?
A
Post-obstructive diuresis: monitor urine output + replace fluids
23
Q
How do Tamsulosin and finasteride work?
A
Tamsulosin - alpha blocker - relaxes smooth muscle
Finasteride - 5-alpha reductase inhibitor - inhibits conversion of testosterone to dihydrotestosterone
24
Q
What are risk factors for bladder cancer?
A
- Smoking
- Aromatic amines (paint and dye workers)
- Schistosomiasis
- Men 50-8-yrs
25
Types of bladder cancer?
- Urothelial (transitional cell) cancinoma (>90%)
- SCC
- Adenocarcinoma
26
Characteristics of transitional cell carcinomas of the bladder?
papillary growth pattern; superficial and better prognosis than others (SSC and A more prone to local invasion).
27
CP of bladder cancer?
painless macroscopic haematuria
28
Bladder cancer Ix?
TURBT or cystoscopy and biopsy: histological diagnosis.
Spread: pelvic MRI and distant disease CT
29
What is treatment for TCC of bladder?
TURBT
30
Bladder ca Mx if recurrences or higher grade/risk?
intravesical chemotherapy
31
Bladder ca Mx if T2 (invades supperfical or deep muscularis propria- 60% prog)?
Surgery- radical cystectomy and ileal conduit or radical radiotherapy
32
Where can bladder tumours metastasize to?
- Uterus, rectum, iliac lymph nods, liver, lungs, bone
33
Management of ureteric stone + signs of infection?
Surgical decompression + IV Abx
34
What do you call a hernia which cannot be reduced and is painless?
Incarcerated
35
What can a left sided varicocele be a complication of?
Renal cell carcinoma due to venous congestion of the left testicle
36
What is the scoring system used to assess prostate cancer severity?
Gleason
37
What is the management options for prostate cancer?
Low grade - active surveillance
Radical prostatectomy - robotic in younger/fitter patients
Open prostatectomy
38
What are causes of urinary retention?
- Stones
- BPH, Prostate cancer
- UTIs
- Post surgery
- Constipation in elderly
- Medications such as anticholinergics, benzos
39
Management of urinary retention
- Bladder scan/renal US
- Post void residual volume
- Catheterisation
- Treat cause
40
What scoring system can be used to assess prostate symptoms?
International Prostate Symptom Score
41
How should bladder cancer be investigated?
Flexible cystoscopy with biopsy
CT urogram for staging
42
Bladder cancer Mx?
superficial lesions= TURBT
higher grade/risk= intravesical chemo
T2 disease= radical radiotherapy or surgery (radical cystectomy and ileal conduit)
43
TNM staging: T?
T0= No evidence of tumour
Ta= Non invasive papillary carcinoma
T1= Tumour invades sub epithelial connective tissue
T2a= Tumor invades superficial muscularis propria (inner half)
T2b= Tumor invades deep muscularis propria (outer half)
T3= Tumour extends to perivesical fat
T4= Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
T4a= Invasion of uterus, prostate or bowel
T4b= Invasion of pelvic sidewall or abdominal wall
44
TNM staging: N?
N0= No nodal disease
N1= Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
N2= Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
N3= Lymph node metastasis to the common iliac lymph nodes
45
TNM staging: M?
M0= No distant metastasis
M1= Distant disease
46
What are causes of epididymo-orchitis
STI - Chlamydia/Gonorrhoea
UTI - E coli in older adults
47
What are signs of epididymo-orchitis?
- Acute scrotal pain/swelling
- Fever
- Dysuria
- Prehn's positive: lifting up testicle relieves pain
- Present cremasteric reflex
48
Management of epidiymo-orchitis
- Analgesia
- Scrotal elevation
- Abx to treat underlying cause (Ceftriaxone + Doxy if any STI, Doxy if chlamydia)
49
Erectile dysfunction?
Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
50
What are some causes of erectile dysfunction?
- vascular (HTN, PAD, smoking, obesity)
- neuronal (MS, Parkinsons, stroke)
- neurogenic (DM, CKD, liver disease)
- anatomical (prostate ca)
- psychogenic (relationship issues, stress, depression, disorders of arousal)
- drugs
51
Drugs that may cause erectile dysfunction?
antihypertensives, diuretics, antidepressants, hormonal treatments, recreational drugs
52
Cx of erectile dysfunction?
performance anxiety, reduced confidence, depression, increased risk of CVD and stroke, relationship difficulties
53
Ix for erectile dysfunction
- lifestyle? relationships, mental health, sexual desire, arousal, onset, duration and quality of erections
- HbA1c, lipid profile and fasting morning total testosterone levels in all men
54
What is the management of erectile dysfunction?
- Lifestyle: weight loss, smoking cessation
- Psychosexual therapy
- PDE-5 inhibitor: Sildenafil 50mg /Tadalafil which increase blood flow to penis (can cause blue vision)
- Injections
55
What drugs class is sildenafil 50mg or tadalafil?
Phosphodieasterase-5 inhibitor (PDE-5)
56
When should pts with erectile dysfunction be followed up?
after 6-8w
57
When should pt with erectile dysfunction be admitted to hospital urgently?
if priapism (painful prolonged erection for >4hrs)
58
When should pt be referred with erectile dysfunction?
lifeling symptoms, young, not responding to max dose of at least 2 PDE-5 inhibitors; suspected test def or hypogonadism; cardiac risk; psychogenic cause
59
What is the referral criteria for haematuria?
Bladder/Renal
- >45 with unexplained haematuria/haematuria which persists after UTI treatment
- >60 with haematuria + dysuria/raised WCC
60
What causes a hydrocele?
Processes vaginalis does not obliterate complete during foetal development causing abdominal fluid to accumulate in scrotum
61
Phimosis vs paraphimosis
Phimosis - foreskin too tight to be retracted over the glans of the penis
Paraphimosis - inability to replace foreskin to its original position
62
What is the management of phimosis vs paraphimosis?
Phimosis - steroid creams/surgery
Paraphimosis - manual pressure/dorsal slits
63
What is priapism?
Painful erection which continues over 2 hours after sexual activity
64
What causes priapism?
Ischaemic - lack of venous drainage
Non-ischaemic - often due to trauma
65
What is management of priapism?
Aspiration of blood within corpus cavernosa and fluid irrigation
Adrenaline injections
66
What causes prostatitis?
Acute - often due to bacterial infection
Chronic - recurrent/persistent prostatitis usually caused by E coli
67
How will prostatitis present on DRE?
Tender, warm, swollen prostate
68
How is prostatitis managed?
2 weeks of ciprofloxacin
69
What are the 2 types of renal cancer?
- Clear cell carcinoma
- TCC
70
What the 2 most common types of testicular cancer?
Germ-cell tumours:
- Seminomas
- Teratoma (non-seminomas)
71
Example of non-germ cell tumours?
Leydig cell tumours and sarcomas
72
What are risk factors for testicular cancer?
- Younger age (25-35yrs)
- HIV
- Undescended testes (cryptochidism)
- infertility
- FHx
73
Testicular cancer CP?
- painless lump mostly (pain may be present)
- hydrocele
- gynaecomastia
74
Why do pts get gynaecomastia in testicular cancer?
due to increased oestrogen:androgen ratio
germ cell tumoure -> hCG -> Leydig cell dysfunction -? increases in both oestradiol and testosterone production but more oestradiol
75
Germ cell tumour markers: what may be elevated in around 20% of seminomas?
hCG
76
Germ cell tumour markers: what may be elevated in around 80% of non-seminomas?
AFP and/or beta-hCG
77
Germ cell tumour markers: what may be elevated in around 40% of of germ cell tumours?
LDH
78
Ix for testicular cancer
1st line & diagnostic= scrotal USS
- Tumour markers: hCG, AFP, LDH
79
What is the management of testicular cancer?
- Radical orchidectomy (+ radio/chemo)
80
What is testicular torsion?
Twisting of the testicle around the spermatic cord -> obstruction of blood flow to testicle
81
How does testicular torsion present?
- Sudden onset severe pain
- Absent cremasteric
- Negative Prehns
- Following trauma
82
What is the management of torsion?
- Surgical exploration
- Bilateral orchidopexy: fix both testicles
83
What is the management of undescended testes?
Bilateral: refer to paeds to rule out genetic causes then surgery at 6 months
Unilateral: review at 6-8 weeks with referal at 3 months
84
What are causes of raised PSA?
- UTI
- BPH
- Prostate cancer
- Retention
- Catheterisation
85
Why are Abx given following prostate biopsy?
Minimise risk of infection where bowel flora can move into the prostate
86
Indications that a mass is renal
Moves up and down with respiration, mass palpable on bimanual
palpation, able to get above mass
87
Why does ureteric obstruction cause pain?
Ureteric spasm arises from peristalsis attempting to push the stone and relieve obstruction. This causes local ischaemia and hence pain
88
What are common sites for ureteric stones?
- Renal pelvis
- Pelvic-ureteric junction
- Vesico-ureteric junction
89
What immediate test should be done with painless scrotal swellings?
Trans-illumination: illumination suggests hydrocele
90
Where are prostate cancers likely to originate?
Peripheral zone
91
Which drugs can cause priapism?
Trazadone
92
What are the most common causes of pyelonephritis?
- E coli: gram negative pink rod shaped bacteria
- Klebsiella
- Proteus
- Enterococcus
93
What are the common components of renal stones?
- Calcium oxalate (most common)
- Calcium phosphate
94
Patients with signs of chronic retention should not have what?
TWOC - this can exacerbate renal impairment so they need a long term catheter
95
Lifestyle interventions for stress incontinence
- Stop smoking
- Lose weight
- Avoid alcohol/caffeine
- Avoid drinking at nightime
96
Causes of recurrent UTI in men
- Bladder outflow obstruction
- Urinary tract surgery
- Immunosuppression
97
Common organisms which cause UTI
- Escherichia coli
- Klebsiella
- Enterococcus
- Proteus sp
98
What are causes of urethral strictures?
- Pelvic trauma
- Perineal trauma
- Urethral instrumentation
- Long term catheter
99
Investigations for urethral strictures
- Cystoscopy
- U+E
- Urinalysis
- Urodynamic testing
100
What are complications of urethral strictures?
- Calculus formation in the urinary tract
- Chronic infection
- Bladder diverticula
101
What causes bladder diverticula?
- Chronic increase in intravesical pressure causing mucousa to push through the muscle layer -> risk of chronic infection
102
What is the management of urethral strictures?
- Internal urethrotomy
- Urethroplasty
- Graft reconstruction
103
Men with erectile dysfunction should have what tests
Glucose, lipid profile, testosterone
104
What is the most common testicular tumour in younger men?
Non-seminomatous germ cell tumours
105
What is a Wilms tumour?
Nephroblastoma
106
What is the most common organic cause of erectile dysfunction?
DM
107
Where are staghorn calculi found?
Renal pelvis
108
What are the 2 broad classes of testicular cancers?
Seminomas and non-seminomatous germ cell tumours
109
How do testicular cancers metastasize?
Para aortic lymph nodes
110
How to classify LUTS?
Storage: frequency, urgency, nocturia, dysuria
Voiding: hesitancy, poor stream, dribbling
111
What is a common complication of radical prostatectomy?
Erectile dysfunction
112
How long can finasteride treatment take?
6 months
113
Risk factors for testicular cancer?
- Infertility
- FH
- Cryptorchidism
114
What usually precedes development of a urethral stricture?
Urethral inflammation often due to infection
115
Tumour containing different types of tissue e.g. cartilage?
Teratoma
116
What is the management of neuropathic bladder?
Intermittent self catheterisation
117
Management of mixed colonisation of urinary catheters?
No changes needed - mixed growth bacteria is very common and does not cause symptoms usually
118
Cystocele vs Rectocele
Cystocele - prolapse of anterior vaginal wall containing bladder
Rectocele - Prolapse of posterior vaginal wall containing rectum
119
What are lifestyle modifications for urge incontinence?
Avoid caffeine
Pelvic floor excercises
Bladder retraining
Avoid alcohol/smoking
Weight loss
120
Abx of choice for prostatitis?
Ciprofloxacin
121
What is sometimes on present on standing?
Varicocele
122
What is an epidydimal cyst?
Painless nodule at the head of the epididymis adjacent to inferior pole of testis
123
Gynaecomastia can be a presenting feature of what?
Testicular cancer
124
terminal, painful haematuria
Think bladder calculi
125
What can present with recurrent balanitis and ballooning around the penis?
Phimosis
126
Bell clapper deformity (testis is not fixed) increases the risk of what?
Testicular torsion
127
What is an electrolyte complication of TURP?
Hyponatraemia
128
What marker is associated with testicular seminomas?
hCG
129
Benign prostatic hyperplasia RFs?
- older age
- only in men
- black > white > Asian
130
What do pts with BPH typically present with?
LUTS (lower urinary tract symptoms):
1) voiding symptoms (obstructive)
2) storage symptoms (irritative)
3) post-micturition
131
Voiding symptoms in BPH?
weak/intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
132
Storage symptoms of BPH?
urgency, frequency, urgency incontinence, nocturia
133
Post-micturition symptoms of BPH?
dribbling
134
Cx of BPH?
UTI, retention, obstructive uropathy
135
Ix for BPH?
- urine dip
- PSA
- U&Es
- urinary frequency volume chart >3days
- International Prostate Symptom Score (IPSS)
136
What is the International Prostate Symptom Score (IPSS)?
tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life
Score 20-35: severely symptomatic
Score 8-19: moderately symptomatic
Score 0-7: mildly symptomatic
137
Mx for BPH?
- watch and wait, advice on fluid intake
- alpha-1 antagonists eg. tamsulosin= if mod-severe LUTS eg. voiding symptoms
-5 alpha-reductase inhibitor eg. finasteride= if prostate >30g or PSA >1.4 and high risk for progression eg. older men
- combination therapy: if both
- 4th= antimuscarinic (anticholinergic) eg. tolterodine + alpha blocker= if still have storage symptoms after alpha Mx
- Surgery: transurethral resection of prostate (TURP)
138
Example of alpha-1 antagonist?
Tamsulosin
139
When is alpha-1antagonist eg. tamsulosin indicated?
BPH if f mod-severe LUTS, esp. voiding symptoms
140
alpha-1antagonist eg. tamsulosin adverse effects?
dizziness, postural hypotension, dry mouth, depression
141
Alpha-1antagonist eg. tamsulosin mechanism of action?
decrease smooth muscle tone of the prostate and bladder
142
Example of a 5 alpha-reductase inhibitor?
Finasteride
143
When is a 5 alpha-reductase inhibitor eg. finasteride indicated?
BPH if if prostate >30g or PSA >1.4 and high risk for progression eg. older men
144
Mechanism of action for 5 alpha-reductase inhibitor eg. finasteride?
Block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH. May decrease PSA. May cause reduction in prostate vol (unlike alpha-1 antagonist) so may slow progression but takes up to 6m.
145
5 alpha-reductase inhibitor eg. finasteride adverse effects?
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
146
What is TURP syndrome?
rare and life-threatening Cx of transurethral resection of prostate surgery
147
What is TURP syndrome caused by?
Irrigation with large vols of glycine (hypo-osmolar) and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. Results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
148
What does TURP syndrome present with?
CNS, resp and systemic symptoms
149
RFs for developing TURP syndrome?
surgical time > 1 hr
height of bag > 70cm
resected > 60g
large blood loss
perforation
large amount of fluid used
poorly controlled CHF
150
Epididymo-orchitis?
Infection of epididymis +/- testes resulting in pain and swelling
151
Causes of epididymo-orchitis?
local spread of infections from genital tract eg. Chlamydia trachomatis and Neisseria gonorrhoeae or the bladder eg. E.coli
152
CP of epididymo-orchitis?
- unilateral testicular pain and swelling
- urethritis often asymptomatic but urethral discharge may be present
- factors suggesting testicular torsion eg. <20yrs, severe acute pain
153
What is the most important differential diagnosis of epididymo-orchitis?
Testicular torsion- exclude urgently
154
Ix for epididymo-orchitis?
- young pt= STI assessment
- older= mid-stream urine (MSU) for microscopy and culture
155
Mx for epididymo-orchitis?
- STI most likely= urgent referral to specialist sexual health clinic
- enteric organism most likley= MSU then empirical Mx with oral quinolone for 2w eg. ofloxacin
156
Mx of epididymo-orchitis if STI cause and referred to sexual health clinic?
if organism unknown= ceftriaxone 500mg IM single dose + doxycycline 100mg oral twice daily for 10-14 days
157
95% of prostate cancers are...
adenocarcinomas
158
Prostate cancer is multifocal, what does this mean?
the different foci may be caused by different genetic mutations, which can differ greatly in growth rate and ability to metastasise
159
Characteristics of most prostate cancers?
indolent and grow slowly, minority are aggressive and invade local structures or metastasise to remote tissuesi
160
Localised prostate cancer develops where?
Outer zone of prostate where it seldom causes symptoms
161
Locally advanced prostate cancer is where?
extends beyond the capsule of the prostate and is often asymptomatic
162
Metastatic prostate cancer most frequently affects what?
Bones- causes pain and fragility fractures.
163
RFs for prostate cancer
Age, black ethnicity, FHx
164
Prostate cancer should be suspected in people with any of what symptoms that are unexplained?
lower back or bone pain
lethargy
erectile dysfunction
haematuria
anorexia/weight loss
LUTS eg. frequency, urgency, hesitancy, terminal dribbling and/or overactive bladder
165
Ix for prostate cancer
- digital rectal exam (DRE)
- prostate-specific antigen (PSA) test
166
When should urgent referral to urological cancer specialist be arranged?
- prostate is hard and nodular on DRE or benign enlargement (smooth, firm, enlarged gland)
or
- PSA level high for their age eg. >4.5 for 60-69yrs
167
Prostate cancer Mx
- watch and wait
- active surveillance
- radical treatments eg. prostatectomy or radiotherapy (external beam and brachytherapy)
- adjunctive and palliative treatments eg. hormonal or chemotherapy with docetaxel
168
Example of hormonal therapy for prostate cancer?
GnRH agonists eg. Goserelin (anti-androgen therapy)
169
Prostate-specific antigen (PSA)?
Protein produced by prostate gland. Secreted by prostate epithelium into prostatic fluid, it liquefies semen. Small amounts present in blood.
170
Why is blood PSA inaccurate marker for prostate cancer?
PSA can be increased by: prostate cancer, BPH, prostatitis, UTI, age.
Cancer can be present without increased PSA.
171
Most men will have a PSA level less than 3. 3 in 4 men with raised PSA level will...
not have cancer. 15% men with normal PSA do have cancer
172
What should people not do before PSA test?
have active UTI/previous 6w; ejaculated in past 48hrs; vigorous exercise in past 48hrs; had urological intervention eg. prostate biopsy in previous 6w.
173
What should you do before PSA testing?
Give info to pt to make informed choice
174
Benefits of PSA testing?
- early detection
- early treatment
175
Limitations of PSA testing
- false -ves = 15% with normal PSA have ca
- false +ves = 75% with raised PSA 3+ will have -ve prostate biopsy
- unnecessary Ix eg. biopsy- adverse effects (bleeding, infection)
- unnecessary Mx: slow growing tumours common, may not cause symptoms or shorten life.
176
Is there screening for prostate cancer in UK?
No
177
Mx for erectile dysfunction?
Phosphodiesterase-5 inhibitor eg. sildenafil
178
What is the Gleason score?
Estimates the grade of prostate cancer according to its architectural differentiation.
179
RFs for urinary incontinence?
- age
- female
- previous pregnancy and childbirth
- high BMI
- FHx
- hysterectomy
180
Types/classification of urinary incontinence
- urge incontinence (overactive bladder)
- stress
- mixed (urge and stress)
- overflow
- functional
181
Urge incontinence (overactive bladder) CP?
urge to urinate quickly followed by uncontrollable leakage (few drops-complete emptying) due to detrusor overactivity
182
what type of incontinence is due to detrusor overactivity?
urge
183
Stress incontinence?
leaking small amounts when coughing or laughing
184
Mixed incontinence?
Both stress and urge
185
Overflow incontinence?
due to bladder outlet obstruction eg. due to prostate enlargement
186
What type of incontinence may be due to prostate enlargement?
Overflow
187
Functional incontinence?
Comorbid physical conditions impair the pts ability to get to bathroom in time
188
Causes of functional incontinence?
dementia, sedating meds, injury/illness resulting in decreased ambulation
189
Ix for urinary incontinence?
- urine dip
- vaginal exam= weak pelvic muscles, pelvic organ prolapse or pelvic mass
190
When to do urgent 2ww referral for suspected bladder cancer if pt presents with urinary incontinence?
>=45yrs with unexplained visible haematuria without UTI or recurrent
- >=60yrs with unexplained non-visible haematuria and dysuria or raised WCC
191
Mx for stress incontinence?
- 1st: 3m supervised pelvic floor muscle training
- 2nd: + duloxetine= STRESS
- 3rd: surgery eg. retropubic mid-urethral tape
192
Mx for urge incontinence?
- 1st: bladder retraining
- 2nd: + antimuscarinic
- 3rd: injection or botulinum toxin type A into bladder wall, percutaneous sacral nerve stim, augmentation cystoplasty and urinary diversion
193
Examples of antimuscarinics eg. for urge incontinence?
oxybutynin, tolterodine (both immediate release)
194
Who should oxybutynin be avoided in?
frail old women (anticholinergic S/Es) so could use mirabegron (beta-3agonist)
195
Mechanism of action for duloxetine?
noradrenaline and serotonin reuptake inhibitor
increase synaptic conc of N and S within pudendal nerve -> increase stimulation of urethral striated muscles within the sphincter -> enhanced
196
Causes of transient or spurious non-visible haematuria?
urinary tract infection
menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse
197
Causes of persistent non-visible haematuria
cancer (bladder, renal, prostate)
stones
benign prostatic hyperplasia
prostatitis
urethritis e.g. Chlamydia
renal causes: IgA nephropathy, thin basement membrane disease
Causes of persistent non-visible haematuria
198
Haematuria spurious causes - red/orange urine, where blood is not present on dipstick?
foods: beetroot, rhubarb
drugs: rifampicin, doxorubicin
199
Haematuria Ix
- urine dip
- renal dunction: albumin:creatinine ratio and BP
- urine microscopy (time to analyse affects no of RBCs detected
200
Blood being present in 2 out of 3 urine dip samples tested 2-3w apart is the definition for what?
Peristent non-visible haematuria
201
Haematuria non-urgent referral criteria?
>=60yrs with recurrent or persistent unexplained UTI
202
What pts with haematuria can be managed in primary care and don't need referral?
<40yrs, normal renal function, no proteinuria and normotensive
203
UTI (lower) in adults clinical features?
dysuria, urinary frequency, urgency, lower abdo pain, cloudy/offensive smelling urine, fever (low-grade), malaise, acute confusion in elderly
204
What is a common feature in elderly pts with lower UTI?
acute confusion
205
Urine dip can be used to aid diagnosis in who?
Women <65yrs.
NOT in >65yrs, men or catheterised pts
206
Urine dipsticks results +ve and -ve for UTI
- +ve nitrite or leukocyte and RBC= likely
- -ve nitrite, +ve leukocyte= likely or other diagnosis
- -ve for all three= unlikely
207
Urine culture for ?UTI for what pts?
women >65yrs, recurrent UTI, pregnant, men, visible or non-visible haematuria
208
Definition of recurrent UTI?
2 episodes in 6m or 3 in 12m
209
Lower UTI definition?
infection of bladder (cystitis) caused by bacteria from GI tract entering urethra
210
'uncomplicated UTI'?
WOMEN, caused by typical uropathogens, non-pregnant, no anatomical or functional abnorm of urinary tract and no predisposing cormorbidies
211
How long to recover from uncomplicated UTI?
usually self-limiting and resolves within few days
212
'catheter-associated' UTI?
UTI in women who is catheterised or has had a catheter within 48hrs
213
Most common causative uropathogen of lower UTI?
E.coli
214
Cx of lower UTI?
pyelonephritis (upper UTI), renal abscess, acute kideny injury, urosepsis
215
Lower UTI in women Ix?
- pregnancy test
- urine dip and/or urine culture (MSU for C&S)
216
When to refer to specialist if female pt with lower UTI?
recurrent or persistent unexaplained UTI, serious underlying cause eg. urogynaecological malignancy
217
Mx of lower UTI in women?
- self-care measures in mild-moderate eg. paracetamol, hydration
- Empirical: Nitrofurantoin (100mg tds 3 days) or Trimethoprime (200mg tds 3d)
218
Advise women with lower UTI to seek urgent medical review when?
if symptoms rapidly worsen or don't improve within 48hrs of starting Abx
219
Mx for lower UTI in pregnant women?
urine sample for culture and sensitivities BEFORE starting Abx:
cefalexin (3 times a day for 7d)
or amoxicillin (same)
or nitrofurantoin (avoid in 3rd T)
or trimethoprim (avoid 1st T)
220
What if group B strep identified on urine culture on pregnant women with lower UTI?
IV intrapartum Abx prophylaxis in labour
221
What should you consider prescribing in postmenopausal women with recurrent UTI?
topical vaginal oestrogen
222
When should you consider prescribing single dose or low dose daily Abx prophylaxis for women?
recurrent UTI, follow up within 6m
223
When to avoid nitrofuranoin in pregnant women?
3rd trimester
224
When to avoid trimethoprim in pregnant women?
1st trimester
225
Cx of lower UTI in men?
renal function impairment, prostatitis, pylenephritis, sepsis, urinary stones
226
Ix for lower UTI in men?
MSU for culture and sensitivites BEFORE starting empirical treatment
- don't use dip or microscopy to diagnose UTI in men
227
Mx for lower UTI in men
Trimethoprim
or
nitrofurantoin (not if prostate invl)
228
Pyelonephritis should be suspected in all children with what?
unexplained fever >=38 or loin pain/tenderness
229
UTI CP in children 3m and over?
fever, frequency, dysuria, abdo pain, V, poor feeding, dysfunctional voiding, changes to continence
230
All children aged what with suspected UTI should be urgently referred to paeds for Mx with parenteral ABx and urine sample sent for MCS?
3m and over
231
What Ix if UTI suspected in child 3m or over?
dip
232
When should Abx be started in children with suspected UTI?
- L & N +ve start Abx
- If L +ve and N -ve then send urine for culture. If <3yrs then start Abx, if >3yrs start Abx only if good clinical judgement.
- If L -ve and N +ve then start Abx
233
Abx treatment for children aged 3m or over with cystitis/lower UTI?
Oral trimethoprim or nitrofurantoin (if GFR >=45).
2nd: N or amoxicillin/cefalexin
234
What should be considered for children >3m with recurrent UTI?
daily Abx prophylaxis
235
Mx for upper UTI/pyleonephritis in children 3m or older?
oral cefalexin
236
Phosphodiesterase-5 inhibitors (eg. sildenafil) mechanism of action?
cause vasodilation through increase in cGMP leading to smooth muscle relaxation in blood vessels supplying corpus cavernosum
237
Contraindications to PDE-5 inhibitors?
hypotension; recent stroke/MI (wait 6m) or taking nitrates and related drugs eg. nicorandil
238
Sidenafil (blue pill- viagra) causes what...
blue discolouration of vision
239
Side effects of PDE-5 inhibitors?
visual disturbances (blue discolouration); nasal congestion; flushing; GI s/es; headache; priapism
240
Visible haematuria?
Macroscopic haematuria
241
Non-visible haematuria?
microscopic or dipstick +ve haematuria
242
Causes of transient non-visible haematuria?
UTI, menstruation, vigorous exercise, sex
243
Causes of persistent non-visible haematura?
cancer (bladder, renal, prostate), stones, BPH, prostatitis, urethritis (chlamydia); renal (IgA neph, thin BM disease)
244
Spurious causes (red/orange urine) where blood is not present on dip?
foods eg. beetroot, rhubarb or drugs (rifampicin, doxorubicin)
245
Trauma causes of haematuria?
injury to renal tract; renal trauma (blunt injury); ureter trauma (iatrogenic) or bladder trauma (RTA or pelvic fractures)
246
Infective causes of haematuria?
TB
247
Malignant causes of haematuria?
renal; urothelial; SCC and adenocarcinoma (rare bladder tumours); prostate; penile (SCC)
248
Renal disease that can cause haematuria?
glomerulonephritis or stones
249
Structural causes of haematuria?
BPH, PKD, vasucular malformations, renal vein thrombosis due to renal cell carcinoma
250
Iatrogenic causes of haematuria?
catheter, radiotherapy, cystitis, severe haemorrhage, bladder necrosis
251
Benign causes of haematuria?
Vigorous exercise (normally settles after around 3d)
252
Haematuria that may be drug related?
- cause tubular necrosis or intersitial nephritis= aminoglycosides, chemo
- intersitial nephritis= penicillin, NSAIDs, sulphonamides
- anticoag
253
Differential diagnoses in child with acute scrotal problem?
- testicular torsion (around puberty)
- irreducible inguinal hernia (<2yrs)
- epididymitis (rare in prepubescent)
254
Most common cause of scrotal swelling seen in primary care?
epididymal cyst
255
Scrotal swelling that is separate to the body of the testicle and found posterior to the testicle?
Epididymal cyst
256
Epidiymal cysts associated conditions
PKD, CF, von Hippel-Lindau syndrome
257
Diagnosis of epididymal cyst confirmed by?
USS
258
Mx of epididymal cyst?
supportive but if larger or symptomatic: surgical removal or sclerotherapy
259
Hydrocele?
accumulation of fluid within the tunica vaginalis
260
Types of hydrocele?
- communicating: common in newborns, usually resolve in 1st few months; caused buy ppatency of processus vaginalis allowing peritoneal fluid to drain down into scrotum
- non-communicating: caused by XS fluid production within tunica vaginalis
261
Hydroceles may develop secondary to what?
- epididymo-orchitis
- testicular torsion
- testicular tumours
262
CP of hydrocele
- transilluminates with pen torch
- soft, non-tender swelling of hemi-scrotum
- usually anterior and below testicle
- swelling confined to scrotum- you can get above the mass on exam
- testis may difficult to palpate if hydrocele large
263
Diagnosis of hydrocele?
clinical but USS if any doubt or underlying testis can't be palpated
264
Mx of hydrocele?
- infantile hydroceles repaired (paeds surgeon referral) if don't spontaneously resolve by 1-2yrs
- adults: conservative depending on severity; USS warranted to exclude underlying cause eg. tumour
265
Varicocele?
abnormal enlargement of testicular veins- usually asymptomatic but important as associated with infertility
266
Typical left sided (80%) scrotal swelling, classically described as 'bag of worms' and associated with subfertility?
Varicocele
267
Diagnosis of varicocele?
USS with Doppler studies
268
Mx of varicocele?
- usually conservative
- surgery if pain
269
Scrotal swelling: Can't get above swelling on examination, cough impulse may be present, may be reducible?
Inguinal hernia (inguinoscrotal swelling)
270
Scrotal swelling: Often discrete testicular nodule (may have associated hydrocele); symptoms of metastatic disease may be present; USS scrotum and serum AFP and β HCG required?
Testicular tumours
271
Scrotal swelling: Often history of dysuria and urethral discharge; swelling may be tender and eased by elevating testis; most cases due to Chlamydia; Infections with other gram negative organisms may be associated with underlying structural abnormality?
Acute epididymo-orchitis
272
Scrotal swellings: Single or multiple cysts; may contain clear or opalescent fluid (spermatoceles); usually occur over 40 years of age; painless; lie above and behind testis; it is usually possible to 'get above the lump' on examination?
Epidiymal cysts
273
Scrotal swellings: Non painful, soft fluctuant swelling; 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?
Hydrocele
274
Scrotal swelling: Severe, sudden onset testicular pain; RFs 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?
Testicular torsion
275
Scrotal swelling: Varicosities of the pampiniform plexus; g
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?
Varicocele
276
What scrotal swelling can the pain be eased by elevating the testis and which is not eased by elevating?
- eased by elevating= acute epididymo-orchitis
- non-eased by elevating= testicular torsion
277
What scrotal swelling is easy to 'get above it' on examination and which is not?
- can get above= hydrocele, epididiymal cyst
- can't get above= inguinal hernia
278
What scrotal swelling might the cough impulse be present on?
Ingunial hernia
279
Testicular malignany Mx
Always Mx with orchidectomy via inguinal approach (allows high ligation of testicular vessels and avoids exposure of another lymphatic field to the tumour)
280
What condition is the cremasteric reflex lost in?
Testicular torsion
281
Testicular torsion?
Twist of spermatic cord resulting in testicular ischaemia and necrosis
282
CP of testicular torsion
- common 13-15yrs
- pain severe and acute
- cremasteric reflex lost and elevation of testis doesn't ease pain
283
Mx of testicular torsion?
Prompt surgical exploration and testicular fiaxtion- both testis should be fixed (condition of bell clapper testis often bilateral). Using sutures or by placement of testis in a Dartos pouch.
284
USS would show what in testicular torsion? (confirms diagnosis but if delays pt going to theatre then not recommended)
Whirlpool sign
285
How quick should pt with testicular torsion have surgery?
- within 4hrs of onset of symptoms (90% chance)
- after 12hrs only 50% chance saving testis
- >24hrs then 10%
286
Torsion of appendix testis or appendix epididymis?
related but distinct from testicular torsion; occurs in boys 8-11yrs
287
What is the appendix testis?
small structure on anterosuperior aspect of testis (embryologic remnant of Mullerian duct)
288
What is the appendix epididymis?
small remnant of Wolffian duct located at head of epididymis
289
Features of torsion of appendix testis or appendix epidiymis?
- similar but less severe to testicular torsion eg. acute testicular pain
- testicular body non-tender but there is a tender mass palpable
- blue dot sign may be seen through scrotum
290
Diagnosis of torsion of appendix testis or appendix epididymis?
Clinical, Doppler USS helpful
291
Mx of torsion of appendix testis or appendix epididymis?
conservative Mx possible but many will have exploratory operation to exclude torsion
292
