Urology Flashcards
BPH
benign increase in size of prostate
inner (transitional) zone enlarges
BPH Px
LUTS
Storage
- frequency
- urgency, urgency incontinence
- nocturia
SHIPP
- straining
- hesitancy
- incomplete emptying
- poor / intermittent stream
- post-micturition dribbling
- also overflow incontinence
- enlarged bladder on abdo exam
- UTI sx, bladder stone
BPH Ix
- urine dip
- DRE - smooth, enlarged
- U/E
- urinary freq/vol chart
- transrectal US - not routine
- PSA
- International Prostate Symptom Score
- US / CT / cystoscopy
- post-void bladder scan
- urodynamic studies if dx unsure
BPH Mx
- avoid caffeine, alcohol
Medical
- tamsulosin
- finasteride
- consider tolterodine / darifenacin
Surgical
- transurethral resection of prostate (TURP)
- transurethral incision of prostate (TUIP)
- Transurethral electrovaporisation of prostate (TEVAP/TUVP)
- Holmium laser enucleation of prostate (HoLEP)
- Open prostatectomy
BPH indications for surgery
RUSHES
- Retention
- UTIs
- Stones
- Haematuria
- Elevated creatinine due to bladder outlet obstruction (BOO)
- Sx deterioration
LUTS Ix
- bladder diary
- post-void bladder scan
- urinalysis
- DRE
- urinary freq/vol chart
- IPSS
- bloods
- urodynamic studies
- cystoscopy / US / CT
LUTS Mx
Voiding sx
- pelvic flood muscle training, bladder training
- tamsulosin / finasteride
Overactive bladder
- bladder retraining
- oxybutynin, tolterodine, darifenacin
- mirabegron
Nocturia
- furosemide in late afternoon
- desmopressin may help
Prostatitis
inflammation of prostate
E coli most commonly
RFs
recent UTI, intermittent catheterisation, recent biopsy
Prostatitis Px
- pelvic pain, genital pain
- LUTS
- fever, rigors, N+V
- sexual dysfunction
- pain with bowel movts
- inguinal lymphadenopathy
Prostatitis Ix
- DRE - tender, boggy
- STI screen
- urine dip, MC+S
- FBC, blood cultures
- National Institute of Health Chronic Prostatitis Sx index
Prostatitis Mx
Acute
- 14d ciprofloxacin
- admit if unwell
Chronic
- tamsulosin, analgesia
Prostate cancer
growth of peripheral zone of prostate - adenocarcinoma
RFs
- older, FHx, black ethnicity, tall, anabolic steroids
Prostate cancer Px
- asym
- LUTS
- haematuria
- erectile dysfunction
- wt loss, bone pain, cauda equina
Prostrate cancer Ix
- PSA - 50-69yo refer if PSA >3 OR abnormal DRE
- DRE - firm, craggy, irregular
- multiparametric MRI
- Biopsy - transrectal / transperineal - Gleason Grading for severity
- isotope bone scan
- CT / MRI for mets
- TNM staging
Prostate cancer Mx
- surveillance / W+W
- external beam radiotherapy
- brachytherapy
Hormone therapy
- androgen-receptor blockers - bicalutamide
- GnRH agonists - goserelin, leuprorelin (Prostap)
- chemo
- radical prostatectomy
Bladder cancer - definition and RFx
cancer of urothelium of bladder (endothelium) - transitional cell carcinoma
RFs
- smoking
- hydrocarbon exposure - 2-naphthylamine
- Schistosomiasis causing chronic bladder inflammation
Bladder cancer Px
- painless, macroscopic haematuria
- LUTS
- wt loss, bone pain etc
Bladder cancer Ix
2ww if
- >45yo, unexplained visible haematuria
- >60yo, microscopic haematuria + dysuria / raised WCC
- non urgent referral if >60yo, recurrent unexplained UTIs
- cystoscopy, biopsy (flexible then rigid)
- CT / MRI / PET
Bladder cancer Mx
- TURBT - transurethral resection of bladder tumour
- intravesical chemo
- BCG vaccine
- radical cystectomy (+ urostomy + ileal conduit)
- chemo / radio
Renal cell carcinoma (& RFx)
- adenocarcinoma of kidney - from PCT, majority clear cell type
- Wilms tumour in paeds
Paraneoplastic
- polycythaemia - EPO
- hypercalcaemia - PTH mimic
- HTN - renin
- Stauffers syndrome
RFs
- smoking, obesity, HTN, ESRF, tuberous sclerosis, von Hippel-Lindau, industrial exposure, dialysis
RCC Px
- asym
- haematuria
- loin pain
- wt loss, fatigue, anorexia, night sweats
- renal mass
- PUO
- varicocele
RCC Ix
- FBC, U/E, LFTs, bone profile, PTH
- urinalysis, cytology
- US kidney
- CXR - cannonball mets
- CT chest, abdo, pelvis
- ?biopsy
RCC Mx
- nephrectomy - partial / radical
- arterial embolisation
- percutaneous cryotherapy
- radiofrequency ablation
- chemo / radio
- biological tx
Testicular cancer (& RFx)
commonly germ cells (produce gametes)
Mets to lymphatics, lungs, liver, brain
RFs
- undescended, infertility, FHx, taller
Testicular cancer Px
- lump +/- pain
- hard, irregular
- non-fluctuant
- no transillumination
- gynaecomastia - Leydig cell tumour
Testicular cancer Ix
- scrotal US
- Tumour markers - alpha-fetoprotein, bhCG, LDH
- staging CT
- Royal Marsden staging
Testicular cancer Mx
- radical orchidectomy
- chemo / radio
- sperm banking
Epididymo-orchitis (& causes)
infection of epididymis +/- testes
Causes
- genital tract - chlamydia, gonorrhoea
- bladder - E coli
- mumps
Epididymo- orchitis Px
- unilateral testicular pain + swelling
- dragging
- tender on palpation
- urethral discharge
- fever, LUTS
- Prehn’s positive - elevation of scrotum eases pain
Epididymo-orchitis Ix
- STI screen - first pass urine, charcoal swab of discharge
- MSU - dip + MC+S
- saliva swab / serum ABs - mumps
- ?US testes
Epididymo-orchitis Mx
- GUM referral
Organism unknown
- ceftriaxone 1g IM + doxycycline 100mg oral BD 10-14d
Enteric organism likely
- ofloxacin / co-amox
Testicular torsion (& RFx)
twisting of spermatic cord –> testicular ischaemia / necrosis in 4-6hrs
RFs
- FHx, undescended, age
- often sports related
Testicular torsion Px
- severe, sudden onset pain
- referred lower abdo pain
- N+V
- loss of cremasteric reflex
- Prehn’s sign negative
- horizontal testicular lie
- rotation - epididymis not in normal position
Testicular torsion Ix
- clinical dx
- USS - whirlpool sign
- urine dip - r/o infection
Testicular torsion Mx
- NBM
- analgesia
- surgical exploration - for dx
- orchidopexy
- orchidectomy - if necrosis
Hydrocele (& causes)
- collection of fluid within tunica vaginalis that surrounds testes
- communicating - patent processus vaginalis
- non-communicating - excessive fluid production
Causes
- idiopathic, cancer, torsion, epididymo-orchitis, trauma
Hydrocele Px
- painless
- soft scrotal swelling
- fluctuant
- testicle palpable within hydrocele
- irreducible, no bowel sounds
- transilluminates
Hydrocele Ix
- US
Hydrocele Mx
- conservative
- surgery / aspiration
Varicocele (& causes)
- swelling of veins in pampiniform plexus
Causes
- incompetent valves
- L>R - drains into L renal vein - higher resistance
- RCC - left
Varicocele Px
- throbbing, dull pain, worse standing
- dragging sensation
- sub/infertility
- bag of worms scrotal mass, worse standing
- red flags - acute onset, R side, remains whilst flat -> urology referral
Varicocele Ix
- US
- semen analysis - fertility
- hormone tests - FSH, test - if concern about function
Varicocele Mx
- conservative
- surgery / endovascular embolisation if painful / testicular atrophy / infertility
Epididymal cyst
- fluid filled cyst at head of epididymis
- PKD, CF, von Hippel Lindau associations
Epididymal cyst Px
- asym
- soft, round lump
- at top of testicle
- transilluminates
- can get above lump
Epididymal cyst Ix
US
Epididymal cyst Mx
- conservative
- surgical removal - if pain / discomfort
Scrotal lumps DDx
hydrocele
varicocele
epididymal cyst
testicular cancer
epididymo-orchitis
inguinal hernia
testicular torsion
Renal stones: definition and pathophysiology
stones form in renal pelvis, get stuck in ureters
obstruction -> AKI
infection -> obstructive pyelonephritis
get stuck at - PUJ, pelvic brim, VUJ
Types
- calcium oxalate
- Uric acid,
- Struvite
- Cystine
Risk factors for renal stones
- dehydration
- hypercalciuria, hyperparathyroidism, hypercalcaemia
- cystinuria
- high dietary oxalate
- renal tubular acidosis
- medullary sponge kidney, PKD
- gout
- drugs - loop diuretics, steroids, acetazolamide, theophylline
Renal stones Px
- renal colic - loin/groin pain
- haematuria
- dysuria
- N+V
- reduced UO
- sepsis sx
Renal stones Ix
- urine dip - blood +/- infection
- Bloods - FBC, U/E, Ca, CRP, coag
- NCCT KUB
- AXR
- US KUB - pregnancy / children
Renal stones Mx
- analgesia, antiemetics
- Abx if infection
- stones <5mm - W+W
- tamsulosin
admit if:
- AKI, uncontrollable pain, infected, large >5mm
stones >10mm
- extracorporeal shock wave lithotripsy (ESWL)
- ureteroscopy + laser lithotripsy
- percutaneous nephrolithotomy (PCNL)
- open surgery
infection / AKI
- stent / nephrostomy - decompress - prevent hydronephrosis
Tips for prevention of renal stones?
- increase fluids
- lemon juice, avoid carbonated drinks, reduce salt, normal Ca intake, reduce oxalate/purine rich foods, limit dietary protein
- potassium citrate / thiazide diuretics
Bladder stones (Px, Ix and Mx)
- from stasis of urine in bladder
- chronic urinary retention / schistosomiasis
Px
- LUTS
Ix
- as for renal stones
Mx
- cystoscopy, fragment with lithotripsy
Acute urinary retention
- acute inability to pass urine
Causes of acute urinary retention
- BPH
- urethral strictures, calculi, cystocele, constipation, masses
- meds - anticholinergics, TCAs, antihistamines, opioids, benzos
- neuro cause
- post-op, post-partum
Acute urinary retention Px
- no UO
- lower abdo discomfort, distension
- acutely confused
- pain, distress
Acute urinary retention Ix
- MSU for MC+S
- bloods - U/E, FBC, CRP
- DRE
- bladder scan - >300mls, also check post-void residual volume
Acute urinary retention Mx
- catheter
- if >1000mls - US kidneys to r/o high-pressure chronic retention / hydronephrosis
- Ix / Tx cause
- TWOC after tx cause
- IV fluids for post-obstructive diuresis
Chronic urinary retention
- chronic inability to pass urine
- bladder desensitised
- high-pressure - impaired renal function, bl hydronephrosis, bladder outflow obstruction
- low-pressure - normal renal function, no hydronephrosis
Causes of chronic urinary retention
- BPH
- pelvic prolapse
- pelvic masses - fibroids
- neuro - peripheral neuropathies, MS, Parkinson’s
Chronic urinary retention Px
- painless urinary retention
- LUTS - weak stream, hesitancy
- overflow incontinence
- palpable distended bladder
Chronic urinary retention Ix
- post-void bladder scan
- bloods - FBC, CRP, U/E
- USS urinary tract
Chronic urinary retention Mx
- catheter - long-term / intermittent self-catheterisation
Neurogenic bladder
Abnormal function of nerves innervating bladder / urethra
Causes
- MS, DM, stroke, Parkinson’s, brain / spinal cord injury, spina bifida
Results in
- urge incontinence
- increased bladder pressure
- obstructive uropathy
Hydronephrosis
Swelling of renal pelvis + calyces in kidney
Causes of hydronephrosis
Unilateral - PACT
- Pelvic-ureteric obstruction (congenital or acquired)
- Aberrant renal vessels
- Calculi
- Tumours of renal pelvis
Bilateral - SUPER
- Stenosis of the urethra
- Urethral valve
- Prostatic enlargement
- Extensive bladder tumour
- Retro-peritoneal fibrosis
Hydronephrosis Px
- vague renal angle tenderness
- mass
Hydronephrosis Ix
- USS
- CT
- IV urogram - XR with IV contrast in urinary tract
Hydronephrosis Mx
- tx cause
- nephrostomy
- antegrade ureteric stent
Lower UTI: uncomplicated?
infection of bladder (can spread to kidneys = pyelonephritis)
Uncomplicated
- normal renal tract structure / function
what is a complicated UTI?
increased likelihood of complications due to anatomical, functional or pharmacological factors predisposing to recurrence
e.g. stones, obstruction, DM, male
Causative organisms of lower UTI
KEEPS
- klebsiella
- e coli - most common
- enterococcus
- pseudomonas
- staph (coagulase negative
- candida
- catheters
what 4 things might make you suspect pyelonephritis?
Fever
Loin/back pain
Nausea/vomiting
Renal angle tenderness on examination
Lower UTI Px
- dysuria
- suprapubic pain / discomfort
- frequency, urgency, incontinence
- haematuria
- cloudy / foul-smelling urine
- confusion
Lower UTI Ix
Urine dip
- Nitrites / leucocytes, blood
- NB if only leukocytes then don’t treat as UTI unless other clinical reasons
MSU to MC+S
- if pregnant, recurrent, atypical sx, no resolution with abx, men, haematuria
Lower UTI Mx for males and non pregnant females? how longer would you treat for?
Non pregnant women - nitrofurantoin or trimethoprim for 3 days
Men - nitro or trimethoprim for 7 days
NB avoid nitro if eGFRv <45
lower UTI treatment for pregnant women? how long?
7 days of ABx
Nitrofurantoin (avoid in the third trimester)
Amoxicillin (only after sensitivities are known)
Cefalexin
Lower UTI: which ABx need to be avoided in which trimester?
nitro - avoid in 3rd trimester (risk of haemolysis)
trimethoprim - avoid in 1st trimester (folate antagonist - can cause congenital malformations)
What is pyelonephritis?
inflammation of the kidney resulting from bacterial infection - affects renal pelvis and parenchyma
Causes: same as lower UTI, typically e coli
risk factors for pyelonephritis?
Female sex
Structural urological abnormalities
Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
Diabetes
Pyelonephritis Px
key triad:
- fever
- loin/back pain
- n+v
other:
Lower UTI sx e.g. dysuria
Systemic illness
Loss of appetite
Haematuria
Renal angle tenderness
Pyelonephritis Ix
- Urine dip
- MSU for MC+S
- bloods - raised WCC and CRP
- USS / CT to exclude other pathology e.g. stones
Pyelonephritis Mx
- Cefalexin
- Co-amoxiclav (if culture results are available)
- Trimethoprim (if culture results are available)
- Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
patient is admitted with sepsis following pyelonephritis: what is the sepsis 6?
Three tests:
Blood lactate level
Blood cultures
Urine output
Three treatments:
Oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD)
Empirical broad-spectrum IV antibiotics (according to local guidelines)
IV fluids
what is chronic pyelonephritis?
- recurrent infections leading to scarring of parenchyma and CKD (possible ESRF)
- DMSA scan to assess damage
Interstitial cystitis
chronic inflammation of bladder
complex causes, various dysfunction
Interstitial cystitis Px
- LUTS
- suprapubic pain, worse with full bladder, relieved on emptying
- > 6wks
Interstitial cystitis Ix
- urinalysis - ?UTIs
- swabs - ?STIs
- cystoscopy - ?bladder Ca - may see Hunner lesions, granulations
- DRE - prostate
Interstitial cystitis Mx
- supportive
- meds
- surgery
Circumcision
- in Jewish and Islamic faiths
- reduces risk of penile cancer, UTI, HIV
Medical indications
- phimosis
- recurrent balanitis
- BXO
- paraphimosis
- exclude hypospadias first
Balanitis
- inflammation of glans penis
- various causes
Ix
- clinical dx
- swab if needed
- biopsy if doubt on cause / extensive skin change
Mx
- gentle saline washes
- 1% hydrocortisone - irritation / dermatitis
- topical clotrimazole - candida
- oral fluclox / clari - staph / strep infection
- metronidazole - anaerobic balanitis
- clobetasol / circumcision - lichen sclerosus
Erectile dysfunction ( + causes and RFx)
- inability to maintain erection sufficient for satisfactory sexual performance
Causes
Organic - gradual sx onset, normal libido
Psychogenic - sudden onset, decreased libido, good quality spontaneous erections, major life events, psych problems
Mixed
RFs
- older age, CVD (obesity, DM, lipids, HTN, smoking), alcohol, SSRIs, BBs
Erectile dysfunction Ix
- QRISK
- free testosterone level (9-11am) - if low, rpt with FSH, LH, prolactin
Erectile dysfunction Mx
- PDE-5 inhibitors - sildenafil
- if young and always had problem - refer to urology
- if pt cycles >3hrs/wk - stop
Urethral injury
- blood in meatus
- bulbar rupture - straddle injury, urinary retention, perineal haematoma
- membranous rupture - penile/perineal haematoma, prostate displaced upwards
Ix
- ascending urethrogram
Mx
- suprapubic catheter
Bladder injury
- haematuria, suprapubic pain, inability to void
Ix
- IVU / cystogram
Mx
- laparotomy / conservative
Penile fracture
- traumatic rupture of corpus cavernosa and tunica albuginea in erect penis
Px
- snap / popping
- immediate pain / swelling
- Aubergine sign
- firm immobile haematoma
Ix
- clinical dx
- US
- retrograde urethrography if ?urethral injury
Mx
- surgical repair
- no sex for 6-8wks
Urethral stricture
- narrowing of urethra
Causes
- iatrogenic (catheter)
- STIs - gonorrhoea
- penile fracture
- hypospadias
- lichen sclerosus
Px
- decreased stream, incomplete bladder emptying, spraying of stream, dysuria
Ix
- uroflowmetry
- US postvoid residual (PVR) measurement
Mx
- dilatation
- endoscopic urethrotomy
Vasectomy
- under LA
- semen analysis 2x post-op before sex
Cx
bruising, haematoma, infection, sperm granuloma, chronic testicular pain
Priapism
- persistent penile erection >4hrs, not associated with sexual stimulation
Patho
- ischaemic - due to impaired vasorelaxation, reduced outflow
- non-ischaemic - high arterial inflow - eg fistula formation
Causes
- sickle cell, sildenafil, drugs (anti-HTN, anticoagulants, antidepressants…), trauma
Priapism Px
- erection >4hrs
- pain in penis
- if not painful / fully rigid - more so non-ischaemic
Priapism Ix
- cavernosal blood gas - ischaemic pO2 / pH reduced, pCO2 increased
- doppler / duplex US
- FBC, tox screen
Priapism Ix
- cavernosal blood gas - ischaemic pO2 / pH reduced, pCO2 increased
- doppler / duplex US
- FBC, tox screen
Priapism Mx
- ischaemic - emergency
- aspirate blood
- inject phenylephrine, rpt 5 mins
- consider surgery - shunt
Haematuria
- blood in urine
- non/visible, a/symptomatic
Causes
- UTI, renal cancer, bladder cancer, renal calculi, prostate cancer, BPH, trauma, schistosomiasis, glomerulonephritis, HSP
- pseudo - eg rifampicin, beetroot, methyldopa
Haematuria Hx
- ask about urine colour, clots, timing in stream
- LUTS, fever, rigors, flank pain etc
- recent trauma
- smoking, occupational exposures
Haematuria Ix
- DRE, examine external genitalia
- urinalysis
- FBC, U/E, clotting, PSA
- flexible cystoscopy
- USS / CT urogram
Haematuria 2 WW
> 45yo with
- unexplained visible haematuria w/o UTI
- visible haematuria after UTI Ix
> 60yo
- unexplained non-visible haematuria + dysuria / raised WCC
Haematuria Mx
- Tx cause
- if clot retention - 3 way catheter - washout / irrigation
- to control bleed - rigid cystoscopy
Stress incontinence
- urine leakage with increased intra-abdo pressure - coughing / straining
- weakness of pelvic floor muscle
- post-partum, constipation, obesity, post-menopausal, pelvic surgery
Urge incontinence
- overactive bladder - detrusor hyperactivity
- eg stroke, infection, malignancy, cholinesterase inhibitors
Overflow incontinence
- from chronic urinary retention - stretching of bladder -> loss of bladder sensation, urine overflows
- BPH, spinal cord injury, congenital defects
Continuous incontinence
- constant leakage of urine
- anatomical abnormality - ectopic ureter, bladder fistulae
Urinary incontinence Px
- involuntary leakage of urine
- ask about other urinary sx
Urinary incontinence Ix
- bladder diaries
- QoL questionnaire
- examine prostate, prolapse, ?fistula
- urine dip
- post-void bladder scan
- urodynamic studies
- cystoscopy, IV urogram, MRI
Urinary incontinence Mx
- wt loss, reduce caffeine, stop smoking
Stress
- pelvic floor muscle training
- duloxetine
- surgery - tension-free vaginal tape….
Urge
- bladder retraining
- oxybutynin, tolterodine
- mirabegron
- botox injections, ….
Urethritis (& RFx)
- inflammation / infection of urethra
- gonococcal - N gonorrhoeae
- Non-gonococcal - chlamydia, mycoplasma genitalium…
RFs
- MSM
- <25yo
- previous STIs
- new sexual partner
- >1 partner in last yr
Urethritis Px
- dysuria
- penile irritation
- discharge
- sx of epididymitis / ReA
Urethritis Ix
- urethral swab / STI screen / first-void urine / MSU
Urethritis Mx
gonococcal
- ceftriaxone 1g IM + azithromycin 1g oral
Non-gonococcal
- oral doxy 7d / single dose oral azithromycin
contact tracing etc
Fourniers gangrene
- nec fasc that affects perineum
- eg GAS, e coli…
RFs
- DM, alcohol, poor nutrition, steroids, trauma…
Px
- severe pain, fever, unwel
- crepitus, skin necrosis, haemorrhagic bullae
Ix
- clinical dx
- FBC, U/E, CRP, LFT, coag, cultures
- CT
- tissue / pus to MC+S
Mx
- broad spec abx
- surgical debridement
- skin grafts
Paraphimosis
- inability to replace retracted foreskin -> glans swells, reduced venous return -> penile ischaemia, infection
RFs
- phimosis, catheter, poor hygiene, prior occurrence
Px
- pain, swelling
Mx
- analgesia
- manual pressure
- dextrose soaked gauze
- needle punctures into glans penis, drain swelling - Dundee technique
- dorsal slit / emergency circumcision
Penile cancer
- rare urological cancer - mostly SCC
- HPV 6,16,18 association
RFs
- HPV, phimosis, smoking, lichen sclerosis, untreated HIV
- circumcision protective
Px
- ulcerating lesion on glans
- +/- pain,
- discharge / bleeding
- inguinal lymphadenopathy
Ix
- penile biopsy
- CT TAP, PET
- TNM staging
Mx
- surgical removal
- radio / chemo
