Urology Flashcards
What is a hydrocele and what are the 3 types?
Fluid collection within tunica vaginalis around the scrotum or spermatic cord
1. communicating (congenital) - patent processus vaginalis
2. non-communicating - patent processus vaginalis but no flow of peritoneal fluid from abdominal cavity occurs; due to excessive production fo fluid within tunica vaginalis
3. hydrocele of the cord - defective closure of tunica of vaginalis
What are 8 causes of hydroceles in adults?
- orchitis
- epididymitis
- tuberculosis
- torsion
- trauma
- testicular tumour
- post renal transplant
- post radiation treatment
What is the presentation of hydrocele?
swelling superior and anterior to testicle; painless; dragging sensation
What is the location of spermatoceles?
superior and posterior to testis
Which side is more commonly affected by testicular torsion?
Left side
What are the 2 most common causative organisms of epididymo-orchitis in men >35y?
E. coli, Pseudomonas (non-sexually transmitted)
What is Prehn’s sign?
elevation of testicle relieves pain in epididymo-orchitis (not in torsion)
What are the 3 treatments that may be given in epididymo-orchitis?
- if gonococcal: ciprofloxacin
- chlamydia, or non-specific genital infection, non-gonococcal urethritis: doxycycline or azithromycin
- if urine dip +ve and most likely enteric organisms: trimethoprim
What are 2 medical treatments for BPH?
- alpha-adrenergic antagonists e.g. tamsulosin (relaxation of prostate + bladder neck)
- 5-alpha reductase inhibitors e.g. finasteride (reduces production of dihydrotestosterone which enlarges prostate)
What are 2 options for treatment of BPH that are minimally invasive?
- TUMT - transurethral microwave thermotherapy
- TUNA - transurethral needle ablation
What is the gold standard surgical management of BPH?
TURP
What may be the signs on examination of urethral injuries?
blood at external urethral meatus, perineal bruising, DRE: high riding prostate/inability to palpate prostate
What are 4 conditions that must be met for PSA blood test to be performed?
- no active urine infection or prostatitis (treatment completed 1 month ago)
- not ejaculated last 48h
- non vigorous exercise last 48h
- no prostate biopsy last 6 weeks
What proportion of children with a UTI have vesicoureteric reflux?
30%
What is the pathophysiology of vesicoureteric reflux?
Ureters enter the bladder more perpendicular rather than at an angle therefore shorter intramural course of ureters; therefore vesicoureteric junction can’t function properly
What are 5 drugs which may cause urinary retention?
- Tricyclic antidepressants e.g. amitriptyline
- Anticholinergics e.g. antipsychotics, antihistamines
- Opioids
- NSAIDs
- disopyramide (antiarrhythmic)
What are 4 risk factors that define complicated UTI?
- abnormal urinary tract e.g. calculus, obstruction, indwelling catheter, VUR
- virulent organism e.g. Staph aureus
- immunosuppression
- impaired renal function
What is the definition of recurrent UTI?
- 2 or more UTI in 6 months
- 3 or more UTIs in 12 months
What are 8 situations to send urine for MCS in suspected UTI?
- pregnant
- > 65 years
- persistent symptoms that don’t resolve with abx
- recurrent UTI
- urinary catheter or recent catheterisation
- risk factors for resistance/complicated UTI
- atypical symptoms
- visible or non-visible haematuria
How should the management approach to UTI be taken in men?
confirm diagnosis with urine culture before starting empirical drug treatment (don’t use urine dipstick or microscopy)
What are 2 situations when nitrofurantoin should be avoided?
- G6PD deficiency
- Acute porphyria
What are 3 situations to avoid / exercise caution with trimethoprim?
- caution - folate deficiency
- renal impairment (use half dose)
- blood dyscrasias
What is the antibiotic treatment for UTI in pregnancy?
nitrofurantoin (but avoid at term); 2nd choice amoxicillin (only if susceptible) or cefalexin
for 7 days
avoid trimethoprim
What are the 7 commonest organisms that can cause acute UTI?
- E coli
- Proteus
- Klebsiella
- Eneterobacter
- Candida
- Enterococci
- Staphylococci saprophyticus
In which patient group is Staph saprophyticus a common organism for causing UTI?
young, sexually active women
What are 2 organisms causing UTI which may be seen in abnormalities of the urinary tract?
- Pseudomonas aeruginosa
- Staphylococcus epidermidis
What is penile fracture?
traumatic rupture of the corpus cavernosum - urologic emergency. 30% occur during sexual intercourse
What is the presentation of penile fracture?
- snapping sound with immediate detumescence; pain varies depending on injury severity. normal external penile appearance obliterated - swelling, eccymosis (eggplant deformity)
- if urethra injured - blood present at meatus +- haematuria, dysuria, retention
What are 3 investigations that are considered for penile fracture?
- if urethral injury suspected - retrograde urethrography
- carvernosography
- MRI
What is the management of penile fracture?
mainstay is surgical therapy including evacuating haematoma, correcting defect in tunica albuginea + repairing urethral injury
What is the commonest cause of renal stones (/composition)?
calcium oxalate (75%)
What are 4 situations when surgery is indicated for renal tract calculi?
- persistent / severe pain
- renal failure
- renal infection
- if stone fails to pass/move for 30 days
What are 5 different types of renal stones and their respective incidence?
- calcium oxalate (75%)
- magnesium ammonium phosphate aka struvite (10%)
- urate (5%)
- hydroxyapatite (5%)
- cystine (1%)
What is the gold standard investigation for renal stones?
non-contrast CT-KUB
What proportion of renal stones are visible on plain x-rays?
80%
What are 4 surgical options for renal tract stones?
- extracorporeal shock wave lithotripsy - before enters ureter
- laser - ureteroscopic fragmentation
- pneumatic / shock wave fragmentation of larger stones
- percutaneous nephrolithotomy (PCNL) - large/complicated stones
What is advised with regards to dietary calcium in renal tract calculi?
normal calcium intake (low calcium diets increase oxalate excretion)
What are 8 foods patients should have less of to reduce oxalate intake if at risk of renal stones?
- tea
- chocolate
- nuts
- strawberries
- rhubarb
- spinach
- beans
- beetroot
What is the normal value for urine output?
0.5ml / kg / hour (35ml / hr in 70kg patient)
What is the failure rate of male sterilisation (vasectomy)?
1 in 2000
When can men have unprotected intercourse after a vasectomy?
semen analysis needs to be performed twice afterwards before can have UPSI - usually at 12 weeks
What are 5 complications of vasectomy?
- bruising
- haematoma
- infection
- sperm granuloma
- chronic testicular pain (5-30%)
What is the success rate of vasectomy REVERSAL?
up to 55% if done within 10 years (25% after 10)
What is the management of bilateral hydroceles in the newborn?
Reassure - most are communicating (patent processus vaginalis) and self resolve within a few months
What should be done if a hydrocele in an infant persists beyond 1 year of age?
Routine referral to urology for consideration of repair
What is the clinical importance of varicoceles?
Associated with infertility
What is the investigation to diagnose varicocele?
US with Doppler studies
What is the management of varicocele?
Conservative usually - surgery if troubled by pain
What is the commonest type of penile cancer?
Squamous cell cancer
What are 8 risk factors for penile cancer?
- HIV
- HPV
- Genital warts
- Phimosis
- Paraphimosis
- Balanitis
- Poor hygiene
- Age >50y
What are 4 risk factors for prostate cancer?
- Increasing age
- Obesity
- Afro-Caribbean ethnicity
- Family history
What is the management of testicular torsion?
urgent surgical exploration - if torted testis identified, both testes should be fixed (As bell clapper testis is often bilateral)
note likely to be non viable after 6h of symptoms - orchiectomy
What is the first line treatment of lower UTI in pregnancy not at term (including duration)?
nitrofurantoin PO 7 days
What type of cancer causes the majority of testicular cancers?
95% are germ cell tumours
What are 2 types of germ cells tumours?
- seminomas
- non-seminomas (embryonal, yolk sac, teratoma and choriocarcinoma)
What are 2 types of non-germ cell testicular tumours?
- Leydig cell tumours
- sarcomas
What are 5 risk factors for testicular cancer?
- infertility
- cryptorchidism (undescended testicle)
- family history
- Klinefelter’s syndrome
- mumps orchitis
What is the commonest presenting symptom of testicular cancer?
painless lump
What are 4 possible presenting features of testicular cancer?
- painless lump
- pain in a minority
- hydrocele
- gynaecomastia
Why does gynaecomastia sometimes occur in testicular cancer?
- increased oestrogen: androgren ratio
- germ-cell tumours - hCG - Leydig cell dysfunction - increase in both oestradiol and testosterone production, rise in oestradiol relatively greater than testosterone
Which tumour marker may be elevated in testicular seminomas?
hCG
in 20%
Which 2 tumour markers may be elevated in non-seminoma testicular cancer?
AFP and/or beta-hCG in 85% (LDH in 40%)
What is the first line investigation for suspected testicular cancer?
ultrasound testes
What is the management of testicular cancer?
- depends on whether tumour is seminoma or non-seminoma
- orchidectomy
- chemotherapy and radiotherapy - depending on staging and tumour type
What is the recommended antibiotic therapy for acute prostatitis?
quinolone (e.g. cipro) or trimethoprim
What is the first line treatment abx for acute pyelonephritis?
broad-spectrum cephalosporin or quinolone
What are 5 risk factors for urinary incontinence?
- advancing age
- previous pregnancy and childbirth
- high BMI
- hysterectomy
- family history
What investigations should be performed for all causes of urinary incontinence? Give 4
- bladder diary - minimum 3 days
- vaginal exam - exclude pelvic organ prolapse + ability to voluntarily contract pelvic floor muscles
- urine dipstick + culture
- urodynamic studies
What is the first line management of stress urinary incontinence?
bladder retraining - minimum 6 weeks
What drugs may be offered second line in urge urinary incontinence?
- antimuscarinics first line: oxybutynin, tolterodine, darifenacin
- mirabegron (beta-3 agonist) if elderly
What is the first line maangement of stress incontinence?
pelvic floor muscle training - 8 contractions TDS minimum 3 months
In addition to PFME what are 2 other options for the management of stress incontinence?
- surgical: retropubic mid-urethral tape
- medical: duloxetine if decline surgical
What is the mechanism of action of duloxetine to treat stress urinary incontinence?
- a combined noradrenaline and serotonin reuptake inhibitor
- increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction
How may hypospadias present if missed during newborn baby check?
abnormal urine stream
What are 4 characteristics of hypospadias?
- ventral urethral meatus
- hooded prepuce
- chordee (ventral curvature of penis) if severe
- urethral meatus open more proximally in severe variants; 75% distally located
What are 2 conditions that rarely accompany hypospadias?
- cryptorchidism
- inguinal hernia
What is the management of hypospadias?
- referral to specialist services
- corrective surgery age 12 months
- must NOT be circumcised prior - may be used in corrective procedure
- if very distal - may not require treatment
At what age does corrective surgery for hypospadias usually occur?
12 months
What is the most important counselling to give to parents of children with hypospadias?
must not be circumcised prior to surgery - foreskin may be used in corrective procedure
What is the classic presentation of bladder cancer?
painless, visible haematuria (e.g. transitinoal cell carcinoma)
What is the triad of renal cell carcinoma presentation?
- haematuria
- loin pain
- abdominal mass
What are 2 drugs that can cause red/orange urine?
- rifampicin
- doxorubicin
What are the NICE guidelines for 2ww referral for haematuria?
- age 45 years and over AND unexplained visible haematuria without UTI
- age 45 years and over AND visible haematuria that persists or recurs after successful UTI treatment
- age 60 years and older AND non-visible haematuria AND dysuria OR raised WCC
What are NICE guideslines for non-urgent referral for haematuria?
Aged 60 years and over with recurrent or persistent unexplained UTI
What do NICE advise for the management of non-visible haematuria in someone <40 years?
if normal renal function, no proteinuria and normotensive do not need referral
When do NICE recommend alpha blockers (E.g. tamsulosin) are used for renal stones?
distal ureteric stones <10mm in size
How quickly should non-contrast CT KUB be performed for suspected renal stones?
- within 24h of admission for all patients
- immediately if fever, solitary kidney or diagnosis uncertain (exclude ruptured AAA)
What diagnostic imaging should be used in pregnant women and children for suspected renal stones?
US
What are the NICE first-line guidance for renal stones?
- <5mm and asymptomatic: watchful waiting
- 5-10mm: shockwave lithotripsy
- 10-20mm shockwave lithotripsy or ureteroscopy
- > 20mm percutaneous nephrolithotomy
What are the options for managing ureteric stones?
- <10mm: shockwave lithotripsy +- alpha blockers
- 10-20mm ureteroscopy
What are the options for treating ureteric calculi causing obstruction and infection?
- nephrostomy tube placement
- insertion of ureteric catheters
- ureteric stent placement
When is ureteroscopy indicated over shockwave lithotripsy for renal calculi?
- pregnant females / other CIs for lithotripsy
- complex stone diesase
What is usually done after ureteroscopy for renal calculi?
stent left in situ for 4 weeks afterwards
What are 6 ways of prevention calcium renal stones?
- high fluid intake
- add lemon juice to drinking water
- avoid carbonated drinks
- limit salt intake
- potassium citrate
- thiazide diuretics (increase distal tubular calcium resorption)
What are 2 ways of avoiding oxalate renal stones?
- cholestyramine - reduces urinary oxalate secretion
- pyridoxine - reduces urinary oxalate section
What are 2 ways to prevent uric acid stones?
- allopurinol
- urinary alkalinisation e.g. oral bicarbonate
What are 4 key parts of the assessment of suspected BPH?
- dipstick urine
- U+Es, PSA
- urinary frequency-volume chart - at least 3 days
- IPSS
What are the 3 categories for IPSS?
- 20-35: severely symptomatic
- 8-19: moderately symptomatic
- 0-7: mildly symptomatic
What is first line for moderate-severe voiding symptoms in BPH?
alpha-1 antagonists (tamsulosin, alfuzosin)
What is the mechanism of action of alpha-1 antagonists for BPH?
decrease smooth muscle tone of prostate and bladder
What is the mechanism of action of 5-alpha reductase inhibitors for BPH?
block conversion of testosterone to dihydrotestosterone (DHT) - reduces prostate volume and may slow disease progression (can take 6 months)
When are 5-alpha reductase inhibitors indicated in BPH?
significantly enlarged prostate considered at high risk of progression
What are 4 adverse effects of 5 alpha reductase inhibitors?
- erectile dysfunction
- reduced libido
- ejaculation problems
- gynaecomastia
When is combined treatment for BPH with alpha-1 antagonists and 5 alpha-reductase inhibitor recommended?
if man has bothersome moderate-to-severe voiding symptoms and prostatic enlargement
What drug can be tried for BPH with mixture of storage and voiding symptoms that persistent after alpha-blocker alone?
antimuscarinic e.g. tolterodine or darifenacin
What is the most significant risk factor for transitional cell carcinoma of the bladder?
smoking
What are 4 risk factors for transitional cell carcinoma of the bladder?
- smoking
- exposure to aniline dyes - 2-naphthylamine, benzidine (printing/textiles)
- rubber manufacture
- cyclophosphamide
What are 2 risk factors for squamous cell carcinoma of the bladder?
- schistosomiasis
- smoking
What are 3 associations with epididymal cysts?
- polycystic kidney disease
- cystic fibrosis
- von Hippel-Lindau syndrome
What is the management of epididymal cysts?
usually supportive; surgical removal or sclerotherapy may be attempted for large / symptomatic cysts
How long should you wait to perform PSA in someone who has had a UTI or prostatitis?
1 month
What is the first-line investigation for priapism?
Cavernosal blood gas analysis (identify whether ischaemic or non-ischaemic priapism)
What is a second-line investigation for priapism if cavernosal blood gas analysis is not possible?
doppler or duplex ultrasonography
What is the management of ischaemic priapism?
- if >4 hours: aspiration of blood from cavernosa + saline flush
- 2nd line: intracavernosal injection of vasoconstrictive agent e.g. phenylephrine, repeated every 5 minutes
- if fails - surgery
What is the management of non-ischaemic priapism?
usually suitable for observation first-line
What is phimosis?
inability ot retract the foreskin because of a narrow preputial ring
What complication can develop from phimosis?
inability to clean under foreskin associated with stones in the preputial sac + Development of cancer of the penis
What problems with intercourse can phimosis cause?
pain during intercourse
What are the 2 types of phimosis?
- primary: without scarring (rarely congenital)
- secondary: scarring from conditions such as recurrent balanitis, traumatic retraction of foreskin, balanitis xerotica et obliterans
What is the management pf physiological vs pathological phimosis?
- physiological: conservative (becomes retractable with time), topical steriods can help
- pathological: circumcision, short course of topical steroids
What is meant by asthenozoospermia?
reduced sperm motility
What is the term used to refer to poor sperm morphology?
teratospermia
What is the cause of most paediatric hydroceles?
congenital
