Urology

Question 1

Epididymitis - pathophysiology + epidemiology

Answer 1

bacterial
ascending retrograde from urethra -> vas -> epididymis
rare before puberty (consider congenital abnormality of the wolffian duct)
usually e. coli in younger patients

Question 2

Epididymitis - קליניקה

Answer 2

acute scrotal pain, erythema, swelling

Question 3

Epididymitis - etiologies / ddx

Answer 3

E coli
Gonorrhea / chlamydia
familial mediterranean fever
enterovirus / adenovirus
HSP Henoch Scholein purpura -involves spermatic cord - systemic disease
Polyarteritis nodosa - isolate testicular vasculitis

Question 4

varicocele = epidemiology

Answer 4

10-15% of men
of those with varicocele - 10-15% are subfertile

Question 4

Varicocele - pathogenesis

Answer 4

congenital dilation of the papiniform plexus
due to valvular incompetence of the internal spermatic vein

Question 5

varicocele = presentation + grading

Answer 5

bag of worms
painless paratesticular mass (may be dull ache)
left sided predominantly (right side is rare)
2% cases are bilateral
present later on, after age 10 (with increased blood flow to testicles due to puberty)
be suspicious of abdo/peritoneal mass if varicocele right sided in under 10 year old
prominent when standing + valsalva maneuver
grade 1 = only palpable with valsalve
grade 2 = palpable but not visible
grade 3 = visible with inspection

Question 6

varicocele = management

Answer 6

grade 3 varicocele increases risk for testicular growth arrest - if left testis is significantly smaller than right testis - spermatogenesis is likely impacted
consider semen analysis if tanner stage V
varicocelectomy = goal to maximise future fertility
surgical indications:
- significant disparity in testicular size
- pain
- contralateral testis diseased or absent
- oligospermia on semen analysis
- consider if grade 3

Question 7

spermatocele

Answer 7

cystic lesion on upper pole of mature testis
incidental finding - painless
remove if enlarges, painful

Question 8

Hydrocele - facts הידרוצלה

Answer 8

fluid accumulation in the tunica vaginalis
1-2% neonates
mostly non-communicating + disappears before 1 yo
if persistent patent processus vaginalis - the hydrocele persists -> larger in day, smaller at night (risk of inguinal hernia)
rare variant = abdominoscrotal hydrocele
can appear in older males due to inflammatory scrotal condition

Question 9

hydrocele - diagnosis הידרוצלה

Answer 9

smooth + nontender
transilluminate
palpate testicle to rule out tumour
if testis nonpalpable - need US
if compression of the hydrocele completely reduces it = communicating / hernia

Question 10

hydrocele - management הידרוצלה

Answer 10

resolve by 12 m
surgical correction considered if hydrocele is large and tense (hernia?) or if persist beyond 12-18 m

Question 11

testicular microlithiasis

Answer 11

calcific deposition in the testis
finding in 2-3% of paediatric scrotal US
monitor for changes in testicular size / induration

Question 12

testicular tumour

Answer 12

35% of prepubertal testis tumours = malignant
mainly yolk sac tumours (also rhabdomyosarcoma + leukemia)
98% of adolescent testicular tumours = malignant
painless, hard mass - not transilluminate
serum tumour markers = alpha fetoprotein and Beta HCG
radical orchiectomy

Question 13

אשך טמיר

Answer 13

undescended testicle

Question 14

תסביב אשך

Answer 14

testicular torsion

Question 15

Ambiguous genitalia

Answer 15

most common cause = CAH
Hydroxylase 21 deficiency -> excessive hydroxy-progesterone 17 -> excessive androgens

Question 16

Normal voiding

Answer 16

coordinaed reflex voiding 15-20 / day as infant
children normal 4-7 / day
bladder capacity increases with age - calculate: age + 2 x 30 = ml bladder capacity

Question 17

toilet training - conditions

Answer 17

1. awareness of bladder filling
2. cortical inhibition of reflex bladder contractions
3. ability to tighten external sphincter
4. normal bladder growth
5. motivation to stay dry

Question 18

Diurnal Incontinence - causes

Answer 18

main 2 = overactive bladder (urge incontinence) and bladder-bowel dysfunction
other causes = voiding postponement, detruser-sphincter discoordination, nonneurogenic neurogenic bladder, giggle incontinence, cystitis, bladder outler obstruction, ectopic ureter and fistula, sphincter abnormality, neuropathic, overflow, trama, behavioural

Question 19

incontinence - history

Answer 19

pattern (keep diary) - including frequency day/night, volume of urine lost, association with urgency or giggling, occurs after voiding?, continuous?
strong urine stream?
sensation of incomplete bladder emptying?
UTI? vesicoureteral reflux? neuro disorders? FHx of renal duplications.
bowel habits?
sexual abuse? bullying?

Question 20

incontinence - physical exam

Answer 20

looking for signs of organic cause:
- shrot stature, htn, enlarged kidneys/bladder, constipation, labial adhesion, ureteral ectopy, spinal anomalies

Question 21

incontinence - assessment

Answer 21

urinalysis +/- culture
bladder diary
postvoid residual urine volume (bladder scan)
perform Dysfunctional voiding symptom score (females > 5 and males > 8 = problematic)
Bristol stool form score
Rome 3 diagnostic criteria for functional GI disorders: Children 4 yr of age or
older are diagnosed as being constipated if they fulfill two or more of the
following criteria over a period of 2 mo: two or fewer defecations in the toilet
per week, at least one episode of fecal incontinence per week, a history of
retentive posturing or excessive volitional stool retention, a history of painful or
hard bowel movements, the presence of a large fecal mass in the rectum, and a
history of large-diameter stools that obstruct the toilet

Question 22

overactive bladder (diurnal urge syndrome) - about

Answer 22

functionally smaller bladder,strong uninhibited contractions
association with recurrent UTI
voiding cystourethrography shows dilated urethra (spinning top deformity) and narrowed bladder neck with bladder wall hypertrophy. due to poor relaxation of external sphincter

Question 23

overactive bladder - treatment

Answer 23

• treat constipation
• timed voiding (1.5-2hr)
• treat UTI
• pelvic floor exercise - biofeedback
• med = anticholinergic = oxybutynin chloride (only fda approved in kids)
  if meds successful - taper periodically to assess need
  if no response -> urodynamic evaluation

Question 24

Hinman syndrome

Answer 24

Nonneurogenic neurogenic bladder
failure of external sphincter to relax during voiding
presentation = staccato stream, day and night wetting, recurrent UTIs, constipation, encopresis (fecal incontinence)
often there is = vesicoureteral reflux, a trabeculated bladder and decreased urinary flow rate intermittently . sometimes can develop hydronephrosis, renal insufficiency and ESRD
pathogenesis - ?? toilet training , learnt abnormal voiding habits

Question 25

infrequent voiding (underactive bladder)

Answer 25

behavioural disorder
associated with UTIs
void 2x day
usually females
bladder overdistension + prolonged retention of urine -> bacterial growth, recurrent UTIs
constipation
treatment = frequent voiding, complete emptying via double voiding

Question 26

Vaginal voiding

Answer 26

the urine runs backward into the vagina instead of forward and out. The urine then leaks from the vaginal area when she stands after voiding.
causes = labial adhesion (most common) - treat with estrogen cream or lysis
others = legs not seperated (overweight/ don’t pull underwear down to ankles) - teach to sit on seat backwards with legs spread

Question 27

Uretral ectopia

Answer 27

a ureter that drains outside the bladder,often into vagina or distal urethra.
constant urinary dribbling
associated with duplicated collecting system
the upper collecting system drained by the ectopic ureter usually has poor or delayed function
mri / ct or surgical exploration

Question 28

giggle incontinence

Answer 28

females 7-15 yo
incontinence occurs suddenly during giggling - entire bladder volume is lost
pathogenesis = sudden relaxation of urinary sphincter
methylphenidate low -dose = most expensive treatment

Question 29

daytime frequency syndrome of childhood (pollakiuria)

Answer 29

4-6 yo males
functional
usually stress or emotion related / changes
check for UTI and complete bladder emptying
assess for constipation. pinworms.