Urology Flashcards
Define Balanitis
Inflammation of the glans penis and the prepuce
What are the causes of Balanitis?
Infective:
- Bacterial = streps and staphs
- Candidiasis
- Viral = HPV, HSV
Non-infective:
- Derm = psoriasis, lichen planus, lichen sclerosis
- Chemical irritants
- Poor hygiene
- Phimosis
Balanitis features
- Redness and discomfort of the plans penis and prepuce
- Itching
- Foul-smelling discharge
- Phimosis
Balanitis investigaion
Swab for culture to guide treatment
Balanitis management
Abx based on swap
Hygiene advice
Define BPH
Non-cancerous enlargement of the prostate, particularly the transitional zone
Leads to compression of the urethra and subsequent LUTS
BPH features
- Hesitancy
- Weak stream
- Frequency
- Urgency
- Nocturia
- Incomplete voiding
BPH investigations
International Prostate symptoms score (IPSS):
- 20-35 = severely symptomatic
- 8-19 = moderate
- 0-7 = mild
DRE:
- Assess size, consistency and the presence of nodules
PSA:
- To rule out prostate cancer
What are the 2 week wait criteria for prostate cancer?
Refer if prostate feels cancerous on DRE or PSA levels are above age range
Consider a PSA or DRE in men with:
- LUTS
- ED
- Visible haematuria
BPH management
Conservative:
- Watchful waiting in older pts w/ mild symptoms
- Lifestyle modifications = avoidance of caffeine and alcohol, timed voiding
Medical:
- Alpha blockers (tamsulosin) for dynamic obstruction
- 5-alpha reductase inhibitors (finasteride) to reduce prostate size - this can take up to 6 months to show effects
- IPSS score of 8 or more = give tamsulosin
- If pt has moderate-severe voiding symptoms, then add in finasteride
Minimally invasive:
- Transurethral resection of the prostate (TURP)
- Laser prostatectomy
Surgery:
- For resistant cases
What are the risk factors for bladder cancer?
Transitional cell (90%):
- Smoking
- Exposure to aromatic amines (rubber, dyes, chemical industry)
- Use of cyclophosphamide
SCC:
- Schistosomiasis
- Long term catherization (> 10 yrs)
Adenocarcinoma:
- Local bowel cancer
Bladder cancer features
- Painless haematuria
- Recurrent UTIs
- Hydronephrosis
- WL and NS
- Neuropathic pain on the medial thigh due to compression of the obturator nerve
Bladder cancer investigations
- Urinalysis and MC&S to confirm haematuria
- CT urogram = identifies filling defects indicating a tumour
- Flexible cystoscopy = allows for visualisation and biopsy
- Staging CT/MRI
What are the 2WW criteria for Bladder cancer?
Aged 45 and over and have:
- Unexplained visible haematuria w/out an UTI
- Visible haematuria that persists or recurs after successful UTI treatment
Aged 60 and over with unexplained non-visible haematuria and either:
- Dysuria
- Raised WCC
Consider in pts 60 and over w/ recurrent UTIs
How is Bladder cancer staged?
TNM system:
- Tis = non-invasive, in situ
- Ta = non-invasive
- T1 = invades inner lining and connective tissue
- T2 = invades muscle
- T3 = invades perivesical fat and LN
- T4 = mets
Bladder cancer management
Non-muscle invasive (Tis-T1):
- Transuretheral resection of the bladder tumour (TURBT) is gold standard
- Chemo = fill bladder w/ drugs e.g. Mitomycin C
- Immunotherapy = fill bladder w/ BCG
Muscle invasive (T2+)
- Radical cystectomy w/ urinary diversion (ileal conduit, neo-bladder or Mitrofanoff procedure) = gold standard
- Radio/Chemo
Define Post-obstructive diuresis
When urinary obstruction is resolved there is a pathological response to the retained sodium, water and urea = to produce large volumes of urine
Diuresis occurs when there is >200ml/hr for 2 consecutive hours
Need to check the urine osmolarity = if hypo-osmolar, then replace fluids in pt
What are the causes of Epididymo-orchitis?
- Young and sexually active w/ multiple partners = chlamydia the gonorrhoea
- Older or w/ single sexual partner = E.coli UTI
Less common:
- Mumps
- TB
Epididymo-orchitis features
- Acute scrotal pain and swelling
- Fever
- Dysuria
- Urethral discharge
- Prehn’s positive = lifting the testicle relives the pain
- Cremasteric reflex intact
Epididymo-orchitis management
- Analgesia, scrotal elevation and rest
- If due to STI = single dose IM ceftriaxone (cover gonorrhoea) plus 10-14 days of oral doxycycline (cover chlamydia)
- If E.coli related = treat w/ levofloxacin 10 days or ofloxacin 14 days
What are the causes of ED?
- Vascular = atherosclerosis can lead to impaired blood flow to the penis
- Autonomic neuropathy = in DM or excessive alcohol intake
- Medications = anti-HTNs
- Psychological = anxiety, depression, other factors
- Endocrine = prolactinoma, hypogonadism
- Pelvic surgery = can damage the nerves and blood vessels
- Anatomical abnormalities = Peyronie’s disease (fibrous scar tissue inside the penis)
What signs point to organic vs psychological causes of ED?
Organic:
- Lack of tumescence (swelling with blood)
- Slow-onset
- Normal libido
Psychological:
- Situational
- High levels of stress
- Still having morning erections
ED management
- Psychosexual therapy
- Oral phosphodiesterase inhibitors (e.g. Sildenafil) enhance the effects of nitric oxide to increase blood flow to the penis - can cause flushing, headaches and blue tinge to vision
- Vacuum erection devices to draw blood into the penis by applying negative pressure
- Intra-cavernosal injections to directly increase blood flow
- Penile prostheses for resistant cases
What are the causes of a Hydrocele?
Primary (congenital):
- Incomplete obliteration of the processus vaginalis
- This allows fluid from the abdomen to gradually accumulate in the scrotum
Secondary:
- Occurs when there is excessive fluid production w/in the tunica vaginalis
- Due to malignancy trauma or infection
Hydrocele investigations
- Testicular exam = transilluminates and you can get above the swelling to feel the cord
- Can do an USS (usually just a clinical diagnosis)
Hydrocele management
Primary:
- Observe as most will spontaneously resolve by 12 months of age
- If it persists past 12 months, or its causing discomfort then refer to surgery
Secondary:
- Conservatively - most self resolve
- If not, then can refer to surgery
What are the Lower urinary tract symptoms (LUTS)?
Voiding:
- Weak stream
- Straining
- Hesitancy
- Terminal dribbling
- Incomplete emptying
Storage:
- Urgency
- Frequency
- Urgency incontinence
- Nocturia
Define Phimosis
When the foreskin is too tight to be retracted over the glans of the penis
Is considered normal in infants and young children, but should resolve with time
Phimosis in adults may be indicative of an underlying pathology
Define Paraphimosis
Inability/forgetting to replace the foreskin to its original position after it has been retracted, leading to venous congestion and potentially causing ischaemia and oedema of the glans penis
Usually due to iatrogenic mistakes when catheterising pts
What are the causes of Phimosis in adults?
- STIs
- Eczema
- Psoriasis
- Lichen planus/sclerosis
- Balanitis
Phimosis management
Topical steroid creams to reduce inflammation and encourage stretching of the foreskin
Circumcision can be used in refractory cases
Paraphimosis management
Reducing the oedema of the glans by applying manual pressure over a period of time
If that fails, a dorsal slit procedure is done where by the foreskin is cut to relieve the constriction
Define Priapism
A prolonged, typically painful erection lasting more than 2 hours, beyond sexual activity or unrelated to sexual stimulation
This is a urological emergency due to the risk of irreversible damage to the penis (ischaemia leading to ED)
What are the causes of Priapism?
Ischaemic (low flow):
- Most common type
- Caused by a lack of venous drainage from the corpora cavernosa
- Is related to haematological disorders (SCA), malignancies and certain drugs
Non-ischaemic (high flow):
- Due to unregulated cavernous arterial flow
- Often a result of trauma
Priapism management
- 1st line = aspiration of the blood w/in the corpus cavernosa and irrigation w/ normal saline - always do a blood gas of the aspirted blood
- 2nd line = intracavernosal injections of alpha agonists e.g. adrenaline
- 3rd line = surgical shunt
What type of cancer is Prostate cancer?
Usually adenocarcinomas - typically affect the peripheral prostate
Prostate cancer features
- LUTS
- Haematospermia (blood in semen)
- Pelvic discomfort
- Bone pain = mets
- ED
Prostate cancer investigations
- DRE = asymmetrical, hard/craggy/nodular prostate w/ loss of median sulcus
- PSA
- Multiparametric MRI = gold standard imaging
Prostate cancer management
- Cancer not visible/palpable = watchful waiting/active surveillance
- Cancer confined to the prostate = radical prostatectomy =/- external beam therapy (EBT)
- Cancer beyond the prostate but not invasive = hormonal therapy (GnRH analogues, androgen antagonists, GnRH antagonists), EBT
- Metastatic = Hormonal, chemo (docetacel, cabazitaxel), immunotherapy
What are the risk factors for Prostatitis?
Usually due to bacterial infection and can be acute or chronic:
- Pre-existing UTI
- Epididymitis
- Catheter use
- Previous urethral surgery
- Presence of prostate stones
- Radiotherapy
Prostatitis features
- Perineal or prostatic pain
- LUTS
- Systemic symptoms = fever, myalgia
- Boggy prostate on PR exam
Prostatitis management
- Abx tailored to cause = usually fluoroquinolones for 2 wks
- Analgesia
- Management of urinary retention if present
What are the types of Testicular cancer?
Germ cell (95%):
- Seminoma = 55%
- Teratoma = 33%
- Mixed = 12%
Non-germ cell:
- Leydig tumour
- Sarcomas
Testicular cancer features
- Painless lump in the scrotum
- Germ cell tumours may be hormone producing and can increase the oestrogen:androgen ratio resulting in gynecomastia
- Spread via paraaortic lymph nodes, then chest and neck lymph nodes
Testicular cancer investigations
- Scrotal USS
- Tumour markers = AFP, hCG and LDH
Testicular cancer management
- Radical orchidectomy
- Radiotherapy = esp good for seminomas which are highly sensitive to radiation
- Chemo = adjuvant in advanced disease (cisplatin)
What are the risk factors for Testicular torsion?
- Bell-Clapper deformity = an anomaly where the testis is inadequately fixed allowing it to rotate freely
- Undescended testes
- Trauma
- Prior intermittent torsion
- Testicular tumour
What are the risk factors for Testicular cancer?
- Age < 45
- Caucasian
- Previous Hx
- Cryptorchidism
- HIV
- Previous mumps orchitis
- Klinefelter’s
Stress incontinence management
Conservative:
- Avoid caffeine, fizzy drinks, limit fluid intake
- Pelvic floor exercises
Medical:
- Duloxetine
Surgical:
- Incontinence pessaries
- Bulking agents injected into bladder neck
- Fascial slings
- Mid-urrtheral slings = gold standard
Urge incontinence management
Conservative:
- Avoid caffeine, fizzy drinks and limit fluid intake
- Bladder training
Medical:
- Anticholinergics = oxybutynin, solifenacin
- Mirabegron (beta 3 receptor agonist)
Surgical:
- Injection of botox into detrusor muscle to paralyse it
- Sacral nerve stimulation (only in tertiary centres)
Define Overflow incontinence
When a small amount of urine leaks with no warning
This occurs when the pressures within the bladder overcome the pressures of the outlet structures due to:
- Detrusor muscle damage
- Constipation= increases pressure in the bladder by extrinsic pressure
Cryptorchidism management
Treatment is surgical = orchidopexy, done around 12 months of age
For bilateral undescended testes at birth:
- Urgent referral to senior paediatrician w/in 24hrs to rule out congenital adrenal hyperplasia
- If ruled out, and the testes haven’t descended by 3 month then refer to the surgeons by 6 months
For unilateral undescended testes at birth:
- Review at 6-8 weeks, if still undescended then review at 4-5 months
- If still undescended then refer to surgeons by 6 months of age
UTI management
Women = nitrofurantoin or trimethoprim for 3 days
Men = nitrofurantoin or trimethoprim for 7 days
Pregnancy = nitrofurantoin for 7 days till3rd trimester, then give trimethoprim instead
