Urology Flashcards
If a 62 year old male presents with difficulty voiding with lower abdominal pain and fullness. He has not been able to urinate since yesterday. What is most concerning?
Acute Urinary Retention Most commonly due to: -- benign prostatic hyperplasia -- advanced age -- anticholinergic or sympathomimetic medications -- spinal cord injuries -- over-distention of bladder (can't contract) -- tumors
What is the immediate management of acute urinary retention?
- Attempt Foley placement (bladder catheterization) to decompress the bladder
- BPH drugs in men to prevent retention
- Surgery to resect prostate if needed
Where and who does benign prostate hyperplasia occur?
- Middle aged men increasing risk per year
- periurethral zone
- DOES NOT INCREASE RISK OF CANCER
How is a digital rectal exam different from BPH vs Prostate Cancer?
BPH – uniformly enlarged rubbery prostate
Prostate Cancer – non-uniform enlargement with nodules palpable
What are the steps that need to be taken to evaluate lower urinary symptoms including frequency, urgency, nocturia, and hesitancy?
- UA, look for infection or blood
- - PSA, BPH causes slight elevation typically, if above 10, then be concerned for prostate cancer
What are common complications associated with untreated BPH?
- bilateral hydronephrosis
- bladder diverticula due to increased wall tension and smooth muscle hypertrophy
- urine stasis = increased infections
- prostatic infarction (grows too big for blood supply)
What are the best ways to manage BPH in a middle aged male?
– Behavior modification (no liquids before bed, reduced caffeine and alcohol, etc)
– Alpha blocker (Tamsulosin / Terazosin)
– Alpha blocker + 5-Alpha Reductase inhibitor (Finasteride)
Prevents conversion of Testosterone to DHT, stopping the growth of the prostate
If a patient continues to experience symptoms of BPH despite maximal medical management and behavior modifications, what is the next step?
Transurethral Resection of the Prostate (TURP)
If patient not a surgical candidate, then transurethral needle ablation
What are commonly symptoms of low implantation of the ureter and how do you diagnose it?
Females Only – constant urine leakage from the vagina
– Diagnosed by intravenous pyelogram
What is posterior urethra valves and how do you diagnose it?
Most commonly in males, from an obstructing membrane covering the outlet to the urethra from the bladder, due to abnormal utero development.
– Diagnosed by voiding cystourethrogram (looking for the narrowing of the urethra at the bladder) or by cystoscopy by visualization.
What are the risks associated with vesicourethral reflex and what is it?
- valves on ureters are poor and there is retrograde flow from the bladder back up the ureters.
- *Increased risk of UTIs in children and progression to pyelonephritis (+failure to thrive)
When should you be suspicious of a child with vesicourethral reflex in a child?
When a child below the age of 2 who is diagnosed with a febrile symptomatic UTI.
– 1st time UTI in these children warrant a full work-up with an US of bladder and renal anatomy
What are the indications for performing a voiding cystourethrogram in a child?
- recurrent UTIs in child under the age of 2
- - positive renal US in a child on their eval after first UTI
What is the treatment of vesicourethral reflex in a child?
– low dose Abx for prophylaxis of UTIs (TMP-SMX)
VUR most commonly resolves over time spontaneously without surgical intervention, if there is evidence of kidney damage from back up of urine, surgery will be conducted
How might you evaluate a 26 year old male who states he has had intermittent episodes of colicky flank pain on and off for the last 8 years, almost exclusively on the weekends, otherwise he does not have any dysuria, hematuria, or abdominal pain.
- Renal Ultrasound – look for hydronephrosis
- Voiding cystourethrogram – rule out vesicourethral reflex
- Diuretic renogram – watch clearance at the ureteropelvic junction (most common cause of colicky flank pain after large volume intakes)
What is the best way to manage ureteropelvic junction obstruction (stenosis) in children?
Conservative treatment and monitoring kidney function making sure no recurrent hydronephrosis and kidney damage from back up
What is the cause of hypospadias and how is it managed?
Failure of the fusion of the urethral folds on ventral surface of the penis.
Surgical correction of the opening uses the prepuce for correction (Should not circumsized that tissue is needed)
If a child born with exstrophy of the bladder, what else should be looked for?
Epispadias – both conditions are caused by faulty positioning of the genital tubercle during development
A 63 year old female presents to the ED with flank pain and fever/chills. The patient has a long history of recurrent kidney stones and DM. Upon CT Abd/Pelvis imaging there appears to be air in the upper urinary tract at the kidney, what should be first step in management?
Rapid Administration of IV Abx
– Emphysematous Pyelitis
This is a complication from pyelonephritis and quickly lead to sepsis.
A 23 year old male presents to the office with left side scrotal pain and tenderness and says it feels better when he lifts them. He also has dysuria and admits to recent unprotected sex. What is the first step in management?
Testicular Ultrasound – Rule out testicular torsion (due to the acute testicular pain
UA – looking for WBCs (torsion will be negative WBCs)
If a patient who is suspected of having epididymitis culture grows gram negative rods, what is the management plan?
Ceftriaxone (Gonorrhea) + Azithromycin (Need to cover for Chalmydia too)
Ceftriaxone + Doxycycline – also treatment combo
If a patient is diagnosed with epididymitis and cultures are negative and no risk of exposure in his recent history only trauma, what’s the best management plan?
NSAIDS and Scrotal Support
– support the scrotum relieves tension on the spermatic cord and epididymitis
What is the best way to determine the type of erectile dysfunction a patient is experiencing?
Monitoring for noctural erections
– can determine if it is psychologic or mechnical cause
What are the most common mechanical (organic) causes of erectile dysfunction?
- Trauma
- Drug-induced
- Vascular Disease – DM, Atherosclerosis
What drugs most commonly cause erectile dysfunction?
- SSRIs
- Spironolactone
- Sympathetic Blockers – Clonidine
- Thiazide Diuretics
- Ketoconazole
- Cimetidine
If a patient describes developing erectile dysfunction suddenly one day where he was unable to achieve erection, but was the previous day, what is most likely?
- Trauma
- - Psychological
What is the evaluation you should perform when working up erectile dysfunction?
- Sexual History
- Physical Exam – looking for gynecomastia, PVD, testicular volume
- testosterone level
- nocturnal penile tumescence testing
What are the management options for erectile dysfunction?
- Treating the underlying cause of trauma or psychological distress FIRST
- Otherwise – Phosphodiesterase Inhibitors
- Sildenafil, Tadalafil (longest action)
What is contraindicated with patients taking PDE5 inhibitors?
The patients should not take Nitrates, will cause a dangerous hypotension
If you are seeing a 30 year old patient to evaluate a scrotal mass and the patient states it is painless, and the mass is seperate from the testis on palpation and has positive transillumination, what is likely diagnosis?
Spermatocele – a cystic structure containing sperm located within the epididymis
- painless swelling, does not cause infertility
- KEY – Transillumination, cancer does not
How can you determine the different between spermatocele vs testicular cancer?
Usually spermatocele is palpated seperate from the testicules and is transilluminated
– Ultrasound can determine if it is a cystic structure or solid (most worrisome for cancer)
If a male is being evaluated for 1 year of unable to conceive, he has noticed his scrotum has felt more full for an indeterminate amount of time, otherwise does not have any symptoms. What is the fundamental causation of the patient’s symptoms?
Increased venous pressure in the pampiniform plexus of veins in the LEFT spermatic vein flowing into the LEFT renal vein.
– can be for multitude of reasons there is congestion
