Urology Flashcards
What is a Vasectomy, what are the complications?
Male sterilisation, simple operation can be done as outpatient under LA or GA. The Vas deferens is identified at the top of the scout, and is ligated and excised or the lumen cauterised. Doesn’t work immediately takes up to 3 months for sperm stores to be used up. Semen analysis needs to be performed twice confirming negative sperm. Failure rate of procedure is 1/2000 and the success rate of reversal is 55% if done within 10years and around 25% after that.
Complications: Bruising, haematoma, infection, sperm granuloma, chronic testicular pain
Describe Erectile Dysfunction, it’s causes, investigations, and management.
Erections result from NO induced cyclic guanosine monophosphate (cGMP) build up. cGMP-dependent protein kinase activates large-conductance calcium activated potassium channels so hyper-polarising and relaxing vascular and trabecular smooth muscles cells allowing engorgement.
Causes: May be organic or psychogenic or a combination. Presence of morning erections is a good distinguishing factor. Organic causes are largely due to vascular disease e.g. smoking, alcohol and diabetes
- endocrine e.g. Hypogonadism, hyperthyroidism, hyperprolactinaemia.
- Neurological e.g. Cord lesions, MS, autonomic neuropathy
- pelvic surgery
- radiotherapy
- BPH
- drugs e.g. B-blockers, diuretics, digoxin, antipsychotics, antidepressants, narcotics.
Investigations: Sexual and psychological history, U+E, LFT, glucose, TFT, LH, FSH, lipids, testosterone, prolactin
Management:
- treat causes, lifestyle modifications weight loss, IHD
- oral phosphodiesterase inhibitors increase cGMP
- Sildenafil (Viagra)
- Vaccum AIDS,
- Transurethral pellets
- intracavernosal injections.
- inflatable prostheses
Describe PSA, it’s normal range, and causes of raised PSA.
Prostate Specific Antigen is a tumour marker that may be raised in a number of scenarios
Normal Range: 40-49yrs = 2.5, 50-59yrs = 3.5, 60-69yrs = 4.5, 70+yrs = 6.5
Causes of raised PSA:
- BPH (usually less than 10ng/mL)
- Prostate cancer (65% greater than 10ng/ml)
- BMI greater than 25
- Afro-carribeans
- Taller men
- Recent ejaculation
- Prostatitis
- Recent rectal examination
If PSA is greater than 10ng/mL think prostate cancer. Finasteride can half PSA so double for representative value of prostate
Describe Peyronie’s disease, symptoms, and management.
Penile angulation poorly understood but most commonly attributed to repetitive micro vascular trauma during sexual intercourse, resulting in penile curvature and painful erectile dysfunction.
Symptoms: associated with dupuytrens, ED, painful erections and penile curvature.
Management:
- penile traction, Vaccum devices
- verapamil, clostridial collagenase
- surgical, tunica plication and penile prostheses
Describe Haematuria, it’s causes, red flags, and investigations.
Defined as more than 3 RBCs found in centrifuged urine per high power field microscopy.
Causes:
- Pre-renal e.g. Bleeding diathesis, atrial fibrillation, infective endocarditis, scurvy, purpura, leukaemia, Thrombocytopenia, haemophilia.
- Renal e.g. IgA nephropathy, glomerulonephritis, polyarteritis nodosum, goodpastures syndrome, acute pyelonephritis, polycystic kidney disease, haemolytic uremic syndrome, alports syndrome. Malignancy, calculus, SLE,
- post-renal e.g. Calculus, carcinoma, schistosomiasis, bladder tumour, BPH, Prostatic cancer.
Red Flags:
Urgent referral required if frank haematuria, recurrent or persistent UTI in over 40, percent non-visible haematuria in adult over 50, abdominal mass identified. Non-urgent referral if persistent asymptomatic over 40 or any symptomatic.
Investigations: FBC, Urine ACR, ESR, U+Es, PSA, KUB, USS
Describe Undescended Testes and its management.
May be bilateral, be sure to exclude retractable testes, try milking testes from inguinal pouch. Retractile testes do not need surgery. Undescended testes lead to increased risk of testicular torsion and tumour.
Management:
- allow 6wks-6months for normal decent
- orchidoplexy if no decent by 1 year
What is the cremaster reflex?
Reflex is elicited by lightly stroking or poking the superior and medial inner part of the thigh. The normal response is an immediate contraction of the cremaster muscle that pulls up the testis ipsilaterally.
It may be absent with testicular torsion, upper and lower motor neuron disorders, as well as a lumbar spine injury. It can also occur if the ilioinguinal nerve has accidentally been cut during an hernia repair.
Describe Hydroceles, the cause, it’s features, and management.
Fluid within the tunic vaginalis.May be primary or secondary, primary are more common, larger and usually in younger men. Can resolve spontaneously. May be a presenting feature of testicular cancer in young men.
Causes:
Primary:associated with a patent processes vaginalis which typically resolves during the 1st year of life
Secondary: due to testis tumour/trauma/infection.
Features: non-painful, soft fluctuations swelling, often possible to get above it on examination, usually contain clear fluid and will often transilluminate.
Management:
- may resolve spontaneously
- may require aspiration or surgery.
- consider USS of testicle after aspiration.
Describe Varicoceles, it’s features, and management.
Varicosities of the pampiniform plexus. Most commonly occurs on left because testicular vein drains into renal vein. May be a presenting feature of renal cell carcinoma. Affected testis may be smaller and bilateral Varicoceles may affect fertility, repair has little effect on pregnancy rates.
Features: Distended scrotal vessels, feel like a bag of worms, patient may complain of dull ache. Associated with Subfertility.
Management:
- conservatively
- surgery or embolisation may be used if concerns about testicular function.
Describe Patent Processus Vaginalis, it’s complications
Failure of closure of the vaginal process leads to the propensity to develop a number of abnormalities. Persistent processus vaginalis is more common on the right than the left.
Complications: Peritoneal fluid can travel down a patent vaginal process leading to the formation of a Hydrocele. There is also potential for an indirect hernia to develop. Congenital malformation of the vaginal process is also the leading cause of testicular torsion, since lack of attachment to the inner lining of the scout rum leaves the testicles free to twist.
Describe Phimosis, it’s symptoms and management,
A condition of the penis where the foreskin cannot be fully retracted over the glans penis.
Symptoms: non-retractability, difficulty urinating, or sexual problems, can lead to paraphismosis.
Management:
- non surgical stretching of the foreskin
- steroid creams
- circumcision
Describe Paraphismosis and its management.
An uncommon medical condition in which the foreskin of an uncircumcised penis becomes trapped behind the glans penis and cannot be reduced. It this condition persists for several hours or there is any sign of lack of blood flow, it should be treated as a medical emergency.
Management:
- manual manipulation of the swollen foreskin under local anaesthetic with aid of lubricant and cold compression
- circumcision.
Describe Testicular Cancer, its risk factors, symptoms, investigations, and management.
Commonest malignancy in males aged 15-44, 10% occur in undescended testes even after orchidopexy. A contralateral tumour is found in 5%. Types include Seminoma 55%(30-65yrs), non-seminomatous germ cell 33% (20-30yrs), mixed germ cell tumour 12% and lymphoma.
Risk factors: Contralateral tumour, Undescended Testes, Infant hernia, infertility.
Symptoms: Painless testes lump, hydrocele, pain, dyspnoea (lung mets), abdominal mass, Gynaecomastia.
Investigations: USS, CT for staging, AFP and bHCG are markers for germ cell tumours, help monitor treatment.
Management:
- radical orchidectomy +/- implant
- Seminomas are radio sensitive.
- NSGCT can be cured even if mets by 3 cycles of Bleomycin, etoposide, cisplatin.
Describe Balanitis Xerotica Obliterans, its symptoms, and management
AKA Lichen Sclerosus, it’s is a chronic inflammatory dermatosis that effects the glans of the penis and foreskin.
Symptoms: White thickened plaque that progress to crinkle white patches like cigarette paper. Soreness from haemorrhagic blisters, dyspareunia, there may be poor urinary stream from meatal scarring.
Management:
- topical steroids
- circumcision.
Describe Penile Fracture, its symptoms and management.
Rupture of one or both of the tunica albuginea the fibrous coverings that envelop the penis corpora cavernousa. It is caused by rapid blunt force to a n erect penis usually during vaginal intercourse or aggressive masturbation.
Symptoms: A popping or cracking sound, significant pain, swelling (aubergine appearance) and immediate loss of erection.
Management:
-surgical repair of tunica albuginea.
