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MCC Part 1 > Urology > Flashcards

Urology Flashcards

1
Q

Define dysuria

A
  • pain or discomfort with micturiation
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2
Q

Define urinary frequency

A
  • micturition at short intervals that is bothersome
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3
Q

Define urgency

A
  • sudden, compelling urge to urinate that is difficult to avoid
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4
Q

Define pyuria

A 
men = presence of >2 leukocytes/HPF
women = presence of >5 leukocytes/HPF
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5
Q

Define cystitis

A
  • dysuria, urinary frequency and urgency, sometimes with suprapubic pain and often in presence of pyuria
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6
Q

What are protective factors for men re: UTI?

A
  • long male urethra

- bactericidal properties of prostate secretions

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7
Q

Classify UTI re: anatomic

A
  • upper: pylonephritis, ureteritis

- lower: cystitis, prostatitis, orchiepididymitis, epididymo-orchitis

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8
Q

Classify UTI re: clinical

A
  • uncomplicated: structurally normal urinary tract who respond to short course of abx (mostly female)
  • complicated: abnormal GU tract, male, pregnant, children, elderly, DM, immunocompromised, urolithiasis, recent instrumentation, nocosomial
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9
Q

Classify UTI re: clinical/ chronologic

A
  • isolated (sporadic) - first infection or remotely occurring infection; most common
  • unresolved bacteriuria - urine not sterilized by abx (bacterial resistance, azotemia, pt noncompliance, rapid reinfection, papillary necrosis, infected calculi, tumor, foreign object)
  • recurrent - repeated infection after tx interrupted by periods of sterile urine (often predisposing condition) -> relapse (within 2wk, same bacteria), reinfection (>2wk post treatment)
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10
Q

UTI risk factors

A

<5yr old: anatomic anomalies (UPJ, VUR), uncircumcised in male

6-15yr: functional anomalies (dysfunctional voiding)

16-35 yr: female - sexual intercourse, spermicidal use

36+: female= gyne surgery, genital prolapse; male= obstruction

50+ yr: female = postmenopausal

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11
Q

Etiology UTI re:

  • non-infectious
  • infection
  • external to lower urinary tract
A

Non-infectious urinary tract inflammation

  • trauma
  • interstitial cystitis
  • bladder cancer
  • bladder stones
  • ureteral stones
  • urethral stricture

Infection of urinary tract

  • urethritis
  • prostatitis
  • cystitis
  • pyelonephritis

External to lower urinary tract
- vulvovaginitis

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12
Q

Pyelonephritis complications and predisposing factors

A

complications

  • bacteremia and septic shock
  • renal parenchymal damage - pyonephrosis, emphysematous pyelonephritis, renal abscess
  • papillary necrosis

predisposing

  • VUR
  • nephrolithiasis
  • cystitis
  • UPJ
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13
Q

Cystitis complications and predisposing factors

A

complications

  • evolution to pyelonephritis
  • relapse of infection
  • bacterial persistence

predisposing

  • female
  • obstruction
  • indwelling catheter
  • sexual intercourse
  • urolithiasis
  • foreign bodies
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14
Q

What is next step investigation for suspected upper and lower tract UTI, male UTI, febrile UTI, complicated UTI?

A

urine culture

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15
Q

What can VCUG detect?

A

VUR

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16
Q

What can 99mTc-DMSA detect?

A

Acute pyelonephritis or renal scarring

Evaluate function of each kidney separately

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17
Q

What components indicate UTI in dipstick urinalysis

A
  • nitrites

- leukocyte esterase

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18
Q

Pathogens causing UTIs

A 
E coli
Klebsiella spp.
Proteus mirabilis
S. aureus
Psudomonas aeruginosa
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19
Q

Empiric abx UTI tx

A

Uncomplicated

acute cystitis = TMP-SMX (or Ciprofloxacin) PO x 3d

acute pyelonephritis:

  • mild: Ciprofloxacin PO x7-14d
  • severe: Ciprofloxacin + 3rd gen cephalosporin IV
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20
Q

Abx tx gram + uncomplicated UTI

A

Assume enterococci - amoxicillin+/- clavulante PO

- if severe = amoxil + clav + gentamicin IV

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21
Q

Empiric abx tx complicated UTI

A

Cystitis or pyelonephritis
- 3rd gen cephalosporin or ciprofloxacin IV

if gram + stain (assume enterococci) = ampicillin + gentamicin

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22
Q

When do you treat asx bacteruria?

A
  • pregnancy
  • urologic procedure
  • GU tract obstruction
  • kids with vesicoureteral reflux
  • Proteus and Pseudomonas species
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23
Q

Erectile dysfunction definition

A
  • persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3mo (>75% of time)
    80% primary organic cause
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24
Q

Pathophys erection

A

Stimulation -> neural discharge and response -> release NO -> increase intracellular cGMP -> hemodynamic changes = intracavernousal arteriolar dilation

neural d/c and response:

  • parasymp S2-S4: pelvic n
  • symp T12-L2: hypogastric n
  • somatic S2-S4: pudendal n
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25
Q

Mechanism of testosterone in erection?

A
  • maintains intrapenile levels of NO synthase
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26
Q

Site of action of drugs for ED?

A

Sildenafil
Tadalafil
Vardenafil

-> inhibit PDE-5
PDE-5 inactivates cGMP which causes intracavernousal arteriolar dilation

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27
Q

Cause conditions of ED? (IMPOTENCE)

A

Inflammatory - prostatitis, urethritis, stricture
Mechanical - cord, Peyronie disease, phimosis
Occlusive - arteriogenic
Traumatic - pelvic #, urethral rupture
Endurance - CVD
Neurologic - neuropathy, temporal lobe epilepsy, MS
Chemical - EtOH, cannabis, rx drugs (SSRI, b-blocker, thiazide, hormone modulator, 5-alpha reductase inhibitors)
Endocrine - testicular failure, pituitary failure, hyperprolactinemia, DM

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28
Q

Important questions re: psychogenic ED?

A
  • incidence of involuntary erections (morning erections)
  • performance with manual stimulation (masturbation)
  • perceived acute situational ED or associated performance anxiety
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29
Q

Physical exam for ED?

A
  • BP
  • neurologic exam, including bulbocavernous reflex
  • GU exam - anatomical survey and testicular exam for hypogonadism
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30
Q

Investigations for ED?

A
  • cbc, urinalysis, serum prolactin, FSH, LH, TSH
  • testosterone
  • fasting glucose, HBA1C, lipids
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31
Q

Medical tx ED?

A
  • PDE-5 inhibitors: sildenafil, tadalafil, vardenafil (1st line)
  • intracavernous injections: smooth muscle relaxants and vasodilators
  • MUSE intraurethral suppository
  • androgen replacement (IF androgen deficiency)
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32
Q

CI PDE-5 inhibitors?

A

absolute: nitrate use (notroglycerine) or allergy
relative: baseline hypoTN, liver or renal insufficiency, use of pharmacologic agents that inhibit cytochrome P450 (olanzapine), CHF NYHA >=2, MI/stroke in last 6mo

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33
Q

What is hematuria?

A
  • gross (visible)

- microscopic (>=3 RBC/HPF on 2 UA)

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34
Q

What filters blood molecules based on size and electrical charge?

A
  • glomerular capillaries
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35
Q

Is basement membrane positively or negatively charged? How does this affect filtration of molecules?

A

Negatively charged proteoglycans

- repels molecules with negative electrical charge (e.g. albumin)

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36
Q

How can immune system alter renal filtration at basement membrane?

A
  • humoral and cellular immunity pathways and complement system alters BM properties -> albumin and RBCs can be filtered and reach Bowman’s capsule = proteinuria and hematuria
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37
Q

Causes of non-RBC red urine (heme + and heme -)

A

heme +

  • hemoglobinuria: dialysis, hemolysis
  • myoglobinuria: rhabdomyolysis, rifampin, trauma

heme -

  • drugs: sulfa, nitrofurantoin, salicylate, phenytoin
  • foods: beets, food colouring
  • metabolites
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38
Q

Common causes hematuria age 0-20?

A

glomerulonephritis
UTI
congenital anomalies

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39
Q

Common causes hematuria age 20-40?

A

UTI

calculi

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40
Q

Common causes hematuria age 40-60?

A

female: UTI> calculi > bladder tumor
male: bladder tumor> calculi, UTI

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41
Q

Common causes hematuria age >60?

A

female: bladder tumor > UTI
male: BPH > bladder tumor > UTI

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42
Q

RF for bladder cancer?

A
  • cyclophosphamide
  • occupational exposure to chemicals (benzenes or aromatic amines)
  • blackfoot disease
  • radiation to pelvis
  • A. fangchi
  • smoking
  • chronic UTI
  • analgesia abuse
  • renal transplant recipient
  • Schistosomiasis hematobium
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43
Q

Classic triad for renal cell carcinoma?

A
  • flank pain
  • palpable flank mass
  • hematuria
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44
Q

Workup microscopic hematuria for pt high risk or >40 yrs?

A
  • UA
  • urine culture
  • urine cytology
  • upper tract imaging (US of kidneys, bladder)
  • cystoscopy for lower tract
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45
Q

Workup microscopic hematuria for pt low risk?

A
  • repeat UA

- if repeat UA + then same eval as high risk pt excluding cystoscopy

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46
Q

Workup asx gross hematuria?

A
  • urine cytology
  • UA
  • upper tract imaging (CT-IVP)
  • cystoscopy
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47
Q

Indications for nephrology referral?

A
  • proteinuria
  • red cell casts
  • dysmorphic red blood cells
  • elevated Cr
  • > suggestive of glomerular cause of hematuria
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48
Q

Follow up for hematuria?

A
  • Fam physician fup with UA, urine cytology and BP checks at 6, 12, 24, 36 mo
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49
Q

What is involuntary loss of urine?

A

Urinary incontinence

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50
Q

Causes of urgency incontinence?

A

overactive bladder (detrusor contraction overcomes sphincter inhibition)

  • irritation of bladder mucosa
  • neurogenic
  • iatrogenic
  • idiopathic
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51
Q

Causes of stress incontinence?

A

insufficient outlet pressure

  • lack of pelvic floor support
  • iatrogenic
52
Q

Causes of overflow incontinence?

A

bladder underactive (detrusor atony)

  • neurologic lesion (trauma/ other) -> sacral region (S2- S5) or peripheral nerves (pudendal or pelvic n)
  • congenital defect (spina bifida)

outlet obstruction (mechanical hindrance to flow)

  • extrinsic obstruction
  • intrinsic obstruction
53
Q

Ddx neurogenic bladder?

A
  • MS
  • Spinal trauma (including iatrogenic)
  • stroke
  • DM
54
Q

Transient causes of incontinence in elderly (DIAPPERS)?

A
  • delirium
  • infection
  • atrophic urethritis or vaginitis
  • pharmaceuticals
  • psychogenic
  • excessive urine output
  • restricted mobility
  • stool impaction
55
Q

Dx and pathophys
- involuntary loss of urine with efforts that cause increased intra-abdominal pressure (coughing, sneezing, laughing, lifting)

A

Stress incontinence

- increase abdo pressure = transmitted to bladder and due to reduced pelvic support allows leakage of urine

56
Q

Dx and pathophys

- involuntary urine leakage accompanied by need to urinate

A

Urge incontinence
- uninhibited bladder contractions cause increased intravesical pressure, which, when higher than urethral resistance causes leakage

57
Q

What investigations if incontinence likely from BPH?

A
  • uroflowmetry

- post void residual assessment

58
Q

Investigations of incontinence with concurrent lower urinary tract sx and hematuria?

A
  • cystourethroscopy
59
Q

What is the indication for urodynamic study?

A
  • dx uncertain after history and physical
  • failed medical tx
  • history suggests incontinence with mixed etiology
60
Q

Dx incontinence

A

R/O UTI!! (urinalysis and culture)

based on history re: stress vs. urge incontinence

61
Q

Tx urge incontinence

A
  • anticholinergics, lifestyle
62
Q

Tx stress incontinence

A
  • Kegel exercises
  • pelvic floor physiotherapy
  • pessaries/ endovaginal cone
  • surgical procedures (urethral sling or artificial urinary sphincter)
63
Q

What is enuresis?

A
  • repeated voiding of urine into child’s clothes or bed after the developmental (not necessarily chronological) age of 5yr
  • at least 2x/wk over 3mo OR cause significant distress and impairment
64
Q

Classification of enuresis

A
  • diurnal or nocturnal

- primary (never been consistently dry at night) or secondary (resumes wetting after 6mo of continence/ dryness)

65
Q

Is increase or decrease ADH associated with nocturesis?

A
  • less secretion or blunted response to nocturnal ADH
66
Q

What is needed for child’s readiness to toilet train?

A
  1. child’s interest (20-30mo), dependent on culture
  2. physiologic readiness: voluntary coordination of sphincter control; myelination of pyramidal tracts (12-18mo), acquiring larger bladder capacity
  3. behavioural readiness: ambulation to toilet, communication with parents
67
Q

Investigations enuresis?

A 
Urinalysis
- UTI
- renal disease
- DM
Voiding diary
Renal US in older kids or not responding to tx
68
Q

Tx enuresis?

A

conditioning therapy

  • enuresis alarms
  • conditioned awakening and timed voiding

reward system
- bladder stretching by having child progressively refrain from urinating for increasing periods of time coupled with reward

pharmacotherapy

  • DDAVP
  • oxybutynin
69
Q

Define infertility

A
  • inability to conceive after 1 yr of intercourse without contraception
  • > investigate both partners
70
Q

Why are testes outside the body?

A
  • spermatogenesis occurs at lower temperatures than core temperature
  • > increased temp affects spermatogenesis
71
Q

What is a varicocele? Can it affect fertility?

A
  • dilated veins of pam-uniform complex

= increase in temperature of scrotal content and reflux of toxins from body -> result is poorer spermatogenesis

72
Q

Pathophys spermatogenesis

A
  • GnRH -> anterior pituitary
    -> LH acts on Leydig cells -> activin and testosterone negative feedback to anterior pituitary and hypothalamus
    AND testosterone from testicle -> sertoli cells
    -> FSH acts on Sertoli cells -> inhibin negatively feedback to pituitary
    and prolactin released from pituitary -> negative feedback to hypothalamus
73
Q

Ddx male infertility

A

Pretesticular

  • hypothalamic disease (e.g. Kallmann syndrome = gonadotropin deficiency)
  • pituitary disease

Testicular

  • chromosomal
  • cryptochidism
  • testicular trauma
  • viral orchitis
  • varicocele
  • radiation
  • drugs (ROH, lithium, alpha blockers, TCAs, CCB, steroids)
  • idiopathic

Posttesticular

  • obstruction
  • sperm motility or function
  • disorders of coitus
74
Q

Investigations male infertility

A

semen analysis x2

  • ejaculate volume (>1.5mL)
  • pH (>7.2)
  • sperm concentration
  • total sperm count
  • motility
  • morphology
  • WBC

other investigations

  • karyotype
  • FSH, LH
  • testosterone
  • scrotal/ prostatic US
75
Q

Intercourse timing with ovulation?

A

2d before ovulation x5d

76
Q

Abnormal sperm analysis?

A
  • oligospermia (small number spermatozoids)
  • low volume
  • low mobility
  • teratospermia (structural defects)
  • combination -> oligoteratospermia (OAT) = most commonly associated with varicocele
77
Q

Embryology of male gonads and anatomy re: clinical entities

A
  • gonads arise in retroperitoneum near kidneys and descent into scrotum by pushing into peritoneum and out through abdominal wall
  • left gonadal vein drains into left renal vein (varicocele)
  • liquid accumulating in tunica vaginalis, which originates from peritoneum (hydrocele)
  • weakness of abdo wall at internal inguinal ring (inguinal hernia)
  • spread of testicular cancer through lymphatics directly into retroperitoneum
78
Q

Ddx scrotal mass

A
  • testicular cancer
  • hydrocele
  • hematocele
  • communicating hydrocele
  • spermatocele/ epididymal cyst
  • varicocele
  • infectious (orchitis/ epididymitis)
79
Q

Definition and aetiologies of testicular cancer

A
  • 95% germ cell tumors
  • seminomas
  • nonseminomas

etiology - RF

  • cryptorchidism (up to 14-fold)
  • testicular atrophy
  • testicular dysgenesis
  • HIV
80
Q

Definition and aetiologies of hydrocele

A

collection of fluid within tunica vaginalis, surrounding the testicle

  • idiopathic
  • tumor
  • epididmytis/ orchitis
  • trauma
  • torsion (reactive)
81
Q

Definition and aetiologies of hematocele

A
  • collection of blood within tunica vaginalis
  • mass not separated from testicle
  • trauma
  • post-up complication
82
Q

Definition and aetiologies of communicating hydrocele

A
  • incomplete obliteration of process vaginalis, allowing peritoneal fluid to pass into scrotum
  • congenital
83
Q

Definition and aetiologies of spermatocele/ epididymal cyst

A

sperm filled collection of epididymus, resulting in cyst-like structure superior to testicle

  • idiopathic
  • associated with von Hippel-Lindaw disease
84
Q

Definition and aetiologies of varicocele

A

dilated and tortuous veins of pam-uniform plexus of spermatic cord

  • L>R
  • right sided may be due to intra-abdominal pathology
85
Q

Definition and aetiologies of infectious orchitis/ epididymitis

A

scrotal pain and swelling, associative tenderness and erythema

  • <35 = gonorrhoea, chlamydia
  • > 35 = E coli
86
Q

What is often left sided and disappears when supine?

A

varicocele -> bag of worms

87
Q

Likely dx if painless firm enlargement of testicle?

A

testicular cancer

88
Q

Imaging for scrotal mass?

A

Scrotal US

  • cystic vs. solid
  • doppler US for vascularization
89
Q

Do you do a transscrotal biopsy of intratesticular mass?

A

NO - risk of cancer dissemination

90
Q

Investigations for testicular cancer?

A
  • serum tumor markers - b-hCG, AFP, LDH
  • abdominal and pelvic CT
  • CXR
91
Q

Treatment testicular cancer?

A
  • radical inguinal orchidectomy + adjuvant therapy if indicated
92
Q

Tx varicocele?

A
  • surgical ligation of testicular vein
93
Q

Are hydroceles, and spermatoceles treated medically or surgically?

A

Surgical excision

94
Q

Define bell clapper deformity

A
  • congenital malformation in which the testis is inadequately affixed to scrotum (40% men bilaterally and 17% unilaterally)
  • absence of properly formed gubernaculum testis (scrotal ligament) allows the testis to move freely on its axis, rendering it susceptible to torsion
95
Q

Define testicular torsion

A
  • spermatic cord twists on itself causing acute testicular torsion, irreversible ischemic injury to tests can begin 4h after occlusion of cord, often 6h window of preservation
96
Q

Ddx acute scrotal pain

A
  • testis - orchitis, testicular hemorrhage into tumor, testicular #/rupture
  • testicular appendix - torsion
  • epididymis - acute epididymitis
  • spermatic cord - testicular torsion
  • tunica vaginalis - hematocele
  • inguinal - incarcerated/ strangulated inguinal hernia
  • distal ureter - referred pain from distal ureteric calculus
97
Q

Dx

  • no cremasteric reflex (elevation of ipsilateral testicle by scratching inner superior aspect of thigh)
  • no relief with elevation of testicle (negative Prehn sign)
  • testicle may be high riding or horizontal lie
A

Testicular torsion

98
Q

Dx

  • cremasteric reflex present
  • Pregn sign (pain relieved with teste elevation)
  • epididymal swelling and focal point of pain
A

acute epididymitis

99
Q

Dx

- blue dot sign

A

torsion of appendix testis

100
Q

Is dx testicular torsion clinical or based on investigations?

A
  • clinical dx

- can do doppler US to assess testicular blood flow

101
Q

How do you attempt to detort a testicular torsion?

A

open book

- lateral detorsion

102
Q

Is testicular detorsion definitive treatment?

A

No

- pt needs urgent surgical evaluation for definitive testicular affixation (orchiopexy)

103
Q

Is the patient at increased risk of torsion in other testicle?

A

Yes - often bilateral orchiopexy is performed

104
Q

Treatment acute epididymitis

A 
ceftriaxone 250mg IM x1
tetracycline 500 mg QID x10d
doxycycline 100mg BID x10d
evaluate partner
counsel re: safe sex practices
105
Q

Sx renal trauma

A
  • flank bruising, palpable mass, pain, tenderness

- hematuria (gross or microscopic)

106
Q

Sx ureteral trauma

A
  • iatrogenic cause often dx postop

- flank pain, fever, sepsis, urinoma, prolonged ileus, acute kidney injury

107
Q

Sx bladder injury

A
  • 95% have gross hematuria

- suprapubic pain, bruising, pelvic mass, urinary retention, peritonitis

108
Q

Sx urethral injury

A
  • often pelvic #
  • blood at tip of meatus, hematuria, perineal or scrotal bruising (butterfly hematoma), high-riding prostate, urinary retention, penile swelling
109
Q

Investigations renal and ureteral injuries

A

CT

  • renal = CT-IVP
  • ureteral = contrast CT with delayed imaging to assess leakage retrograde pyelography
110
Q

Investigations bladder injury

A
  • cystogram
111
Q

Investigations urtheral injury

A
  • retrograde urethrogram
112
Q

Is intraperitoneal or extraperitoneal bladder rupture treated with surgery?

A
  • intraperitoneal = surgery

- extraperitoneal = Foley

113
Q

Classification of urinary obstruction?

A
  • acute vs. chronic
  • complete vs. partial
  • unilateral (usually upper tract) vs. bilateral (usually lower tract)
114
Q

Etiology of HTN in unilateral vs. bilateral urinary tract obstruction

A

unilateral- vasoconstriction from RAAS

bilateral - volume expansion

115
Q

Sx lower tract - voiding LUTS and physical exam

A
  • hesitancy
  • weak stream
  • post void dribbling
  • frequency, nocturne, urgency
  • inability to empty bladder
  • hematuria +/- clots

HTN
palpable bladder
palpable urethral stricture
enlarged prostate

116
Q

Sx upper tract obstruction and physical exam

A
  • flank pain +/- radiation to groin or RLQ or LLQ
  • hematuria
  • GI sx (n/v)

HTN
CVA tenderness

117
Q

Management of patient with urinary obstruction and fever and chills?

A
  • urologic emergency

- restore urine flow -> insert nephrostomy tube or ureteric stent with IV abx

118
Q

Dx location of renal colic

- renal colic with flank pain

A

Ureteropelvic junction

119
Q

Dx location of renal colic

- RLQ or LLQ pain; may mimic appendicitis, diverticulitis, ectopic pregnancy

A

pelvic brim (as ureter crosses iliacs)

120
Q

Dx location of renal colic

- renal colic with irritative (urgency, dysuria, frequency) lower urinary tract sx and radiation to ipsilateral testicle

A

ureterovesical junction

121
Q

Investigations of LUTS of obstruction

A
  • UA, urine culture
    +/- cbc, Cr, BUN, lytes, glucose, PSA

others

  • bladder scan/ urinary catheter re: post void residual
  • cystoscopy
  • uroflow
  • us/CT scan
  • transrectal US guided prostate biopsy to r/o prostate cancer
122
Q

Investigations of upper tract obstruction

A
  • UA, urine culture, serum Cr, lytes
  • US - assess hydronephrosis and bladder residual volume
  • CT - without contrast to see stones; contrast for lesions other than stones causing hydronephrosis
  • renal scintigraphy (DTPA, MAG-3 with furosemide) - functional evaluation of kidneys

other:

  • cystoscopy
  • retrograde pyelography
  • ureteroscopy
123
Q

Medical and surgical treatment of benign prostatic obstruction?

A

medical

  • alpha blockers (sx tx)
  • 5 alpha reductase inhibitors (shrinks volume of prostate)

surgical

  • TURP
  • laser photo-vaporization
  • open simple prostatectomy
124
Q

Conservative tx kidney stones

A
  • calculus <5mm (90% pass spontaneously)
  • alpha blockers
  • analgesics
  • hydration (>2L/d)
125
Q

Where is hyperplasia located in BPH?

A
  • transitional zone
126
Q

Most common type of prostate cancer?

A

adenocarcinoma

- peripheral zone > transitional zone > central zone

MCC Part 1 (22 decks)

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