Urology Flashcards
Severe, sudden testicular pain w/o fever, pyuria or hx of recent mumps
-Testicular torsion
What are the characteristics of testicular torsion?
- Swollen testis, exquisitely tender
- “High riding” and with “horizontal lie”
- Cord is not tender
How is testicular torsion treated?
- Urological emergency
- Immediate surgical intervention
- Orchiopexy done after the testis is untwisted
- Some surgeons fix both testicles
What condition is commonly confused with testicular torsion?
-Acute epididymitis
How does Acute epididymitis present?
-In young men old enough to be sexually active
-Severe, sudden testicular pain
-Has fever and pyuria
-Testis is swollen and tender, but in the right position
-Cord is very tender
-
How is Acute epididymitis treated?
- r/o testicular torsion
- antibiotics
What are the two main urologic emergency?
- Testicular torsion
- Combination of obstruction and infection of the urinary tract
What is the most dire consequence of having both obstruction and infection of the urinary tract?
-Destruction of the kidney within hours and potential death from sepsis
How is the Combination of obstruction and infection of the urinary tract managed?
- IV antibiotics
- Immediate decompression of urinary tract above the obstruction using the quickest and simplest means
Urinary frequency, painful urination with small volumes of cloudy and malodorous urine:
Urinary tract infection (UTI; cystitis)
In which patient are UTI’s most common?
- Women of reproductive age
- Does not require elaborate workup
How are UTI’s managed?
-empiric antimicrobial therapy
What does an urologic workup consist of?
- Sonogram to look for dilation/obstruction
- CT used for renal tumors
- Cystoscopy is the only way to look at the bladder mucosa in detail (to detect early cancers)
- Intravenous Pyelogram (IVP) which is the gold standard, but only used when safer, cheaper tests have been done
What is an IVP? What is it good for? What are its limitations?
- Intravenous Pyelogram
- Good to view the kidney, collecting ducts, ureters and some of the bladder (does not detect early bladder cancer)
- Provides good idea of function of the kidney, ureters and bladder
- Limited by potential dye allergy, contraindications in patients with limited renal function (Cr>2)
A patients with chills, high fever, nausea and vomiting, and flank pain, most likely has:
-Pyelonephritis
How is pyelonephritis treated?
- Hospitalization
- IV antibiotics guided by cultures
- Urologic workup
An elder male patient with chills, fever, dysuria, urinary frequency, diffused low back pain, and exquisitely tender prostate on rectal exam, most like has:
-Acute bacterial prostatitis
How is acute bacterial prostatitis treated?
- IV antibiotics
- NO more rectal exams bc continuous prostatic massage can lead to septic shock
What is the most common reason for a new-born boy to NOT urinate during the first day of life?
-Posterior urethral valves (congenital)
How are posterior urethral valves managed?
- r/o meatal stenosis
- Catheterization to empty the bladder
- Dx w voiding cystourethrogram
- Tx w endoscopic fulguration/resection
In what patients should circumcision never be done? Why?
- Patients with hypospadias (congenital)
- Urethral opening in on dorsal side of the penis, between the tip and the base of the shaft.
- The skin of the prepuce will be needed for the plastic reconstruction that will eventually be done
When should urologic workup always be done?
-In the case of UTIs in children since they may be caused by vesicouretereal reflux, or another congenital abnormality
A child having burning with urination, urinary frequency, low abdominal and perineal pain, flank pain, and fever and chills, most like has:
-Vesicoureteral reflux and infection
How is a vesicoureteral reflux and infection in a child managed?
- Tx infection with antibiotics (empiric, then culture guided)
- Do IVP and voiding cystogram to look for reflux
- Long term abx are used until the child “grows out of the problem”
How does low implantation of the ureter present in little boys? Little girls?
- It is usually asymptomatic in little boys
- In little girls there is normal void at appropriate intervals, but the girls is wet with urine all the time bc of urine that drips into the vagina
How is a low implanted ureter managed in a little girl?
- IVP is used for dx
- Corrective surgery is done
An adolescent that goes on a beer-drinking binge for the first time and develops colicky flank pain, most likely las?
-Ureteropelvic junction (UPJ) obstruction
What is the cause of the sx in a UPJ obstruction?
-The UPJ allows normal urine output to flow without difficulty, but when a larger diuresis occurs, the narrow area cannot handle it and causes backup
What is the most common cause of hematuria?
-Most cases are caused by benign disease
What is the most common presentation for cancers of the kidney , ureter, or bladder?
- Hematuria
- although mostly benign, all patients with hematuria (excepts after urologic trauma) need to have cancer workup
What si the workup for hematuria?
- CT scan first
- Cystoscopy (only reliable way to r/o bladder cancer)
A patients that presents with hematuria, flank pain, and flank mass, most likely has:
-Renal cell carcinoma
What other sx can be seen in Renal Cell Carcinoma?
-Hypercalcemia, erythrocytosis, elevated liver enzymes
What is the best imaging method for Renal Cell carcinoma? How does it look like?
- CT scan
- Heterogenic solid tumor (w potential growth into the renal vein and vena cava
What is the treatment of Renal Cell carcinoma?
-Surgery is the only effective therapy
Which is the most common type of bladder cancer?
-Transitional cell cancer
What is the usual presentation of bladder cancer?
- Hematuria
- Sometimes w irritative void sx that may lead to tx w antibiotic for a UTI (despite negative cultures and no fever)
Which is the best way to diagnose bladder cancer?
-Cystoscopy (But CT should be done first)
How is bladder cancer treated?
- Surgery
- Intravesical Bacillus Calmette-Guerin (BCG) therapy
- Close f/u d/t high rate of recurrence
What are the sx of prostate cancer?
-Mostly asymptomatic
What is the relationship between prostate cancer and age?
-Incidence increases with age
How is prostate cancer diagnosed?
- Rectal exam showing a rock-hard discrete nodule
- Elevated prostatic specific antigen (PSA) for age group
- Transrectal needle biopsy
- CT helps assess extent and choose therapy
How is prostate cancer treated?
- Surgery and/or radiation
- Widespread bone metastasis responds to androgen ablation (orchiectomy, LH-releasing hormone agonist or antiandrogens like flutamide)
How does testicular cancer present?
-Painless testicular mass in young men
How is testicular cancer managed?
- Bc testicular tumors are most likely malignant a biopsy is done w a radical orchiectomy by the inguinal route
- Pre-op and post-op levels of AFP and bHCG are used for f/u
- Further lymph node dissection may be done int he future
How is advanced, metastatic testicular cancer managed?
–Platinum-based chemotherapy may be used since most testicular cancers are very sensitive to radiation and chemo
Which urologic cancer is most strongly associated with smoking?
-Bladder cancer (even more so than lung cancer)
In which patients is acute urinary retention most commonly seen?
- Men with significant symptoms of BPH
- Often precipitated during a cold by the use of antihistamines and nasal drops and abundant intake of fluids
What are the sx of acute urinary retention?
-Patients wants to void but can’t and the huge distended bladder is palpable
How is acute urinary retention managed?
- Indwelling bladder catheter placed and left for at least 3 days
- Long temp tx w alpha-blockers
- 5-alpha-reductase inhibitors are used for very large glands (>40g)
- Transurethral resection of the prostate (TURP) is rarely done
What is post-op urinary retention? How is it managed?
- Very common
- masquerades as incontinence
- Patient does not feel the need to void bc of post-op pain, medication, etc.
- There are involuntary release of small amounts of urine from time to time
- A huge distended bladder is palpable (overflow incontinence from retention)
- An indwelling bladder catheter is needed
In which patients is stress incontinence most commonly seen
-Middle-age women who have had many pregnancies and vaginal deliveries
How does stress incontinence present?
- Leakage of small amounts of urine after increases in intraabdominal pressure such as sneezing, laughing, standing up, lifting or coughing
- No incontinence during the night
- Weak pelvic floor with prolapsed bladder neck outside the “high pressure” abdominal area
-How is stress incontinence managed?
- Surgical repair of pelvic floor in cases with large cystoceles
- Pelvic floor exercises may be sufficient for early cases
What causes colicky flank pain w irradiation to the inner thigh and labia/scrotum, sometimes accompanied by nausea and vomiting?
-Passage of ureteral stones
Most stones are visible in which type of imaging?
-CT
How are small (<3mm) stones at ureterovesical junction managed?
- 70% chances of passing spontaneously
- Analgesics, fluids and watchful waiting
How are large (>7mm) stone at the ureteropelvic junction managed?
- 5% chances of passing spontaneously
- Extracorporeal shock-wave lithotripsy (ESWL)
- Basket extraction, sonic proves, laser beams and open surgery may be done in patients in which ESWL is contraindicated (pregnant, bleeding diathesis, stones several centimeters large)
What are the most common causes of pneumaturia?
- Most commonly d/t fistula between bladder and GI tract, especially the sigmoid colon d/t diverticulitis
- Cancer of the sigmoid colon
- Cancer of the bladder (distant 3rd)
What is the workup for pneumaturia? How is it managed?
- CT first to look for diverticulitis
- Sigmoidoscopy to r/o cancer
- Surgical therapy is required
What are the 2 types of impotence?
- Organic
- Psychogenic
What are the characteristic of psychogenic impotence?
- Sudden onset
- Partner/situation specific
- Does not interfere with nocturnal erections
- Effectively tx with psychotherapy only if done promptly
What are the characteristic of organic impotence?
- Sudden onset if caused by trauma (pelvic surgery, arterial disruption)
- Gradual onset if caused by chronic disease (atherosclerosis, diabetes): from erection not lasting long enough to being poor quality, to not happening at all
- Includes absence of nocturnal erections
- First choices for tx are Sildenafil, tadalafil, vardenafil
- Vascular surgery, suction devices and prosthetic implants are also available as therapy
What is a varicocele? What causes it?…physical exam maneuver to make it bigger?
Tortuous dilation of pampinifotm plexus of veins surrounding spermatic cord and testis in scrotum…caused by incompetent valves of testicular veins….valsalva makes it bigger
