Urology Flashcards
Geniturinary tract pain could be due to
- Obstruction: stone/retention
- Inflammation
Parenchymatous organ inflammation (pyelonephritis, epididmitis) produces_____ Pain, while inflammation of the mucosa of a hollow viscous, such as bladder produces________
Severe, discomfort
Site of renal pain is
At the costovertebral angle just lateral to sacro-spinalis muscle, beneath 12th rib
Where does renal pain radiate to?
Flank anteriorly towards upper abdomen and umbilicus, and might be to the testis/labium
Describe the character of renal pain?
Inflammatory: steady dull aching
Obstruction: fluctuating colicky
Justify: obstructive renal pain is associated with GI symptoms
Due to reflex stimulation of the celiac ganglion
Lower urinary tract symptoms divides into:
- Voiding (obstructice) symptoms
- Storage (irritative) symptoms
Mention bladder irritative symptoms
Frequency
Urgency
Nocturia
Mention LUT obstructive symptoms
Hesitancy
Intermittency
Abdominal straining
Weak stream(bifid)
Post voiding dribbling
Sense of incomplete evacuation
Define hematuria
Presence of blood in urine > 3 RBC’s per high power microscopic field
Initial hematuria indicates
Indicates problem of urethra or prostate
Terminal hematuria
Bladder or prostate
Total hematuria
Kidney, ureter or bladder
Define infertility
Couple failing to conceive after 1 yr of regular unprotected intercourse
Normal Urine pH
5.5-6.5
Highly acidic urine is found in
Hyperuricosuria
Normal WBCs in urine microscopy
Male: up to 2/ HPF
Females: up to 5/HPF
Chemical dipsticks screen for:
Glucose, pH, protein, hemoglobin, ketones
Normal serum creatinine
Adults: 0.8-1.2mg/dl
Infants: 0.1-0.4 mg/dl
Why is BUN much less accurate than creatinine in indicating GFR
As its influenced by many factors such as: dietary protein and hydration
Normal BUN/Creatinine ratio
10/1 to 20/1
High: dehydration, renal ds, bleeding
Low: pregnancy, low prtn diet and hepatic ds
PSA
Prostatic specific antigen < 4 ng/ml
4-10 grey zone
>10 malignancy?
If PSA > 10, perform:
TRUS guided biopsy check for malignancy
If PSA is in grey area what do we do next?
Grey zone 4-10 ng/ml
Get a PSA Free/ total ratio
TRUS
Transrectal ultrasound scan: prostate viewing
Most used screening imaging study in urology
Ultrasound
Disadvantage of U/S
No functional data
Poor anatomical imaging of ureter
To detect mass and torsion in testis use
Scrotal Doppler U/S
Advantages of IVU
Anatomical and functional data of urinary tract
Disadvantage of IVU
Contract allergy and adverse effects
Radiation exposure
Phases of IVU imaging
Immediate film
Nephrogram phase (5-15min)
Ureterogram phase (30min)
Cystogram phase (45 min)
Post voiding film
Cobra head appearance on IVU
Ureterocele
Key hole sign
Posterior uretheral valve anomaly
Uses of CT in urology
- Radiolucent/radio-opaque stone detection
- Tumor detection & staging
- Urinary tract trauma
Varicocele commonest side
Left side
Uses of MRI in urology
Replacing CT when contraindicated
Renal/ adrenal tumors
Vascular invasion
Renal isotope scan uses
- Need for surgery: onstructive or nonobstructive hydronephrosis
- Evaluate split renal function
- Monitor effect of therapy
MAG3 isotope
Evaluate Renal function and plasma flow as it is cleared by tubular secretion & no glomerular filtration
DPTA
Evaluate obstruction and renal function as it is cleared by glomerular filtration
DMSA isotope
Cleared by filtration and secretion
Used to evaluate renal scarring (renal cortical image)
Most common type of kidney injury?
Blunt retroperitoneal
Meteorism
Abdominal distention, nausea and vomiting within 24-48 hr due to retroperitoneal hematoma involving splanchnic nerves
Kidney injury grading
Grade 1: subcapsular hematoma only
Grade 2: perirenal hematoma and <1cm cortical laceration; without urinary extravasation
Grade 3: grade 2+ > 1cm cortical laceration
Grade 4: laceration thru corticomedullary junction with urinary extravasation + segmental vessel injury contained hematoma
Grade 5: shattered kidney, pedicle injury, avulsion
Early complications of kidney injury
1- anuria
2- clot retention
3. Paralytic ileus
4- perinephric abscess
5- urinary fistula
6. Pseudohematohydronephrosis
7. Intraperitoneal hem + peritonitis
Late complications of kidney injury
- Hydronephrosis: periureteral fibrosis
- Nephroptosis: tear of supporting tissue
- Hypertension: fibrosis of kidney
- Aneurysm of renal artery
Gold standard investigation for kidney injury
CT contrast
Initial evaluation test for kidney injury
Ultrasound
Lack of parenchymal contrast enhancement using CT contrast suggests
Arterial injury
Why is ultrasound not a gold standard test in renal injury?
It only identifies retroperitoneal hematoma, but does not clearly delneate lacerations or vascular or collecting injuries
When is intravenous pyelography indicated in renal injury
“Single shot’’ intra-operative IVP in haemodynamically unstable patients is better instead of CT (no time)
Indications of nephrectomy
In extensive renal injuries or unstable, patient in a normal contralateral kidney
In an unstable patient with low body temperature and coagulopathy in a normal contralateral kidney
The treatment of choice for the majority of renal injuries is
Non-operative management
Indications for surgical management of kidney injury
- Haemodynamically instability
- Exploration for associated injuries
- Grade 4 and 5 injury
- Expanding or pulsatile peirenal haematoma
- Pre-existing renal pathology requiring surgery
- Vascular injuries after failed and angiographic treatment.
The two most common signs and symptoms of major bladder injuries are
Gross haematuria and abdominal tenderness
The standards of care in urethral injury is
Suprapubic cystostomy
Eggplant deformity
Trauma of penis: Swelling and ecchymosis of the penis due to rupture of Tunica Albina the cover the corporal cover no
Tear in tunica albugenia is investigated by
Penile duplex
Flame shaped collection of contrast in the pelvis
Extra-peritoneal injury
Most extraperitonial bladder rupture heal within____ days
10 days
Blunt extra peritoneal bladder rupture is managed by?
Foley catheter drainage
What is the most common cause of urethral stricture?
Endoscopic / catheter trauma
What are the management steps upon suspected testicular torsion?
- scrotal duplex to confirm diagnosis
- Immediate surgical exploration and don’t wait for laboratory studies.
Clot retention is confirmed by?
Cystoscopy
During distal radio-cephalic AV fistula care must be taken not to injure
Dorsal branch of radial nerve.
Care must be taken not to injure_____ during brachio-cephalic or brachio-basilic fistula
Median nerve at cubital fossa
Autogenous access needs _______weeks for proper vein maturation
6-8 weeks
Advantages of autogenous AV access over prosthetic AV graft?
- Resist infection
- Longer estimated usage time
Prothetic arteriovenous graft needs_______weeks to start using it
1-2 weeks
Define a cyst
A sac containing fluid lined by epithelium or endothelium
In dermoid or branchial cyst the contents are like ____
Tooth paste
The wall of a false cyst is lined by
Fibrous or granulation tissue
Examples of a pseudo cyst
- Pseudo cyst of the pancreas(encysted collection of fluid in the lesser sac)
- Tumor Cystic degeneration
Complications of cysts
- Infection
- Hemorrhage
- Torsion
- Calcification
Cock’s peculiar tumor
Infection complicating sebaceous cyst on the scalp by forming an ulcer
Type or shape of the incision to treat sebaceous cyst
Elliptical incision to avoid recurrence
Complications of sebaceous cyst
Infection
cock’s peculiar tumor: ulceration
sebaceous horn
Mention 4 types of dermoid cyst
Sequestration dermoid
Tubulodermoid
Teratomatous dermoid
Implantation dermoid
Common side of sebaceous cyst
Face, scalp and scrotum, but never palms and soles
XRay or CT must be performed before excision of a head dermoid cyst. Why
Exclude communication with intracranial dermoid
Describe a sequestration dermoid cyst
Cystic, smooth, rounded, not attached to skin, but maybe adherent to underling structures, there may be indentation of underlying bone. It is lined by epidermis and contain a paste like desquamated material.
Mucus cyst more common in
Female
Middle age
Dorsal DIP Joint
Immobile and ill-defined swelling at friction points (bone&skin)
Bursitis
Hallmark symptom of bursitis is
Localized swelling at the joint
Semimembranous bursitis is located on
Medial side of popliteal fossa
Semimembranousus TTT
Primary type: excision
Secondary type: treat cause
Midline popliteal fossa’s swelling
Baker’s cyst
Baker’s cyst happens mostly secondary to:
Osteoarthritis
Hallus valgus
Bunion
Example for an adventitious bursae
Bunion
Preferred type of biopsy in soft tissue tumours
True cut needle biopsy
Common site for diffuse lipoma is
Neck
Lipoma can occur anywhere in the body except
The cranium
The line of cleavage in lipoma facilitates
Enucleation of the tumour
The line of cleavage encapsulated lipoma occurs between
True capsule (fibrous capsule )
false capsule (surrounding tissue)
Lipoma is classified according to
Capsule
Structure:
Site
What is the commonest type of lipoma? And it’s favourable site.
Subcutaneous lipoma; back, shoulder buttocks, forehead and limbs
Pathognomonic signs of subcutaneous lipoma
A well defined slippery edge and Dimpling of skin on displacement of the swelling (lobulation)
Dercum’s disease (adiposis dolorosa)
Tender deposit of fat, specially on the trunk and is an associated condition with multiple lipomatosis
Subsynovial lipoma can be mistaken for?
Baker’s cyst
Retroperitoneal lipoma may grow into ______size
Enormous
Most dangerous lipoma is:
Sub-mucous lipoma:
Larynx: respiratory obstruction
Intestine: intussusception
Treatment of lipoma
Surgical excision indicated if a lipoma is causing trouble on account of its site, size, appearance, or the presence of pain
Neurofibroma origin
Connective tissue of nerve sheet . In relation to cranial 5&8 or a peripheral nerve
Describe neurofibroma
Arise from any nerve usually in subcutaneous tissue, firm, tender, well defined slowly growing swelling that can be moved across, but not along the nerve from which it arises.
Von Recklinghausen’s disease
Generalized neurofibromatosis (AD)
Types of neurofibroma
- Solitary neurofibroma
- Generalized neurofibromatosis
- Acoustic neuroma
- Plexiform neurofibomatosis
- Elephentiasis neurofibromatosa
Gamma knife radio-surgery
Acoustic neuroma
Pachydermatocele
Plexiform neurofibromatosis
Types of neuroma
Tumors in sympathetic system
1. Gangiloneuroma
2. Neuroblastoma
3. Myelinic neuroma
Neuroblastoma resembles_______ and disseminate by________ and is treated by_______
Round cell sarcoma, blood , surgery +/- chemo
Common sites of Gangileoneuroma
Connection with sympathetic plexus so:
In the neck, thorax or retroperitoneal tissue
Myelinic neuroma consists of_______only and arises in connection with ________ or ______
Nerve fibers, spinal cord or pia matter
A lobulated encapsulated, soft, whitish swelling that displace the nerve from which it rises
Schwanoma (neurilemmoma)
Varieties of fibroma
- Soft subcutaneous nodule (fibroma mole)
- Pedunculate lesion of oral mucosa ( fibroma durum)
- Pleomorphic fibroma
Aggressive fibromatosis
Desmoid tumor
Example of intermediate tumor (locally invasive)
Desmoid tumor
Histology of desmoid tumor
Uncapsulated, composed of fibrous tissue containing multinucleated giant cells
Soft tissue tumours that can be treated by chemo
Desmoid tumor and neuroblastoma
Commonest site of desmoid tumor
Anterior abd wall and shoulder girdle
Urine will pass to _______ in an interior bulbar urethra injury (fall astride)
Connective tissue of scrotum
Pelvic fracture with highly displaced prostate (non palpable on PR) and a perineal oedema is suggestive of
Membranous urethral rupture
What is the normal intra-vesical pressure at the beginning of micturition?
30 cm of water
Mention some features seen in bladder compensation to BPH
Detrusor muscle hypertrophy
Trabiculation
Cellules
Diverticula
Describe trabiculations of the bladder
muscle bundle with deposit of interstitial collagen fibers, becomes taut, and give an interwoven appearance to the mucosa)
Score used to ttt BPH
IPSS International prostate symptom score
0-7 mild
8-19 moderate
20-35 severe
If BPH is associated with hematuria then _________ is mandatory to rule out other bladder pathology
Cystoscopy
DD and what to exclude when making a diagnosis of BPH
Urethral stricture (cystoscopy)
Bladder neck contracture (cystoscopy)
Trauma (history)
Bladder stone (pain and hematuria)
UTI (urinalysis and culture)
Cancer prostate (DRE and high PSA)
Neurogenic bladder DM
Adverse effects of alpha blockers
Asthenia
First dose phenomenon
Dizziness
Postural hypotension
Retrograde ejaculation
Finastride is a competitive injibitor of type ___ 5alpha reductase enzyme while dutasteride is a competitive inhibitor for type ______
Maximum volume suppression of BPH achieved after ______
2 (prostate only)
1&2 (1 in prostate, liver and skin)
6 months
Relative surgery indication in BPH
- Hematuria
- Recurrent lower UTI
- Bladder stone
- Moderate symptoms (moderate IPSS)
- Bad compliance
Absolute indication of surgery in BPH
- Severe symptoms (severe IPSS)
- Recurrent acute retention
- Upper urinary tract affection
- Uraemia
- Failure of medical treatment
