Urology Flashcards
Define dysuria
- pain or discomfort with micturiation
Define urinary frequency
- micturition at short intervals that is bothersome
Define urgency
- sudden, compelling urge to urinate that is difficult to avoid
Define pyuria
men = presence of >2 leukocytes/HPF women = presence of >5 leukocytes/HPF
Define cystitis
- dysuria, urinary frequency and urgency, sometimes with suprapubic pain and often in presence of pyuria
What are protective factors for men re: UTI?
- long male urethra
- bactericidal properties of prostate secretions
Classify UTI re: anatomic
- upper: pylonephritis, ureteritis
- lower: cystitis, prostatitis, orchiepididymitis, epididymo-orchitis
Classify UTI re: clinical
- 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
Classify UTI re: clinical/ chronologic
- 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)
UTI risk factors
<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
Etiology UTI re:
- non-infectious
- infection
- external to lower urinary tract
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
Pyelonephritis complications and predisposing factors
complications
- bacteremia and septic shock
- renal parenchymal damage - pyonephrosis, emphysematous pyelonephritis, renal abscess
- papillary necrosis
predisposing
- VUR
- nephrolithiasis
- cystitis
- UPJ
Cystitis complications and predisposing factors
complications
- evolution to pyelonephritis
- relapse of infection
- bacterial persistence
predisposing
- female
- obstruction
- indwelling catheter
- sexual intercourse
- urolithiasis
- foreign bodies
What is next step investigation for suspected upper and lower tract UTI, male UTI, febrile UTI, complicated UTI?
urine culture
What can VCUG detect?
VUR
What can 99mTc-DMSA detect?
Acute pyelonephritis or renal scarring
Evaluate function of each kidney separately
What components indicate UTI in dipstick urinalysis
- nitrites
- leukocyte esterase
Pathogens causing UTIs
E coli Klebsiella spp. Proteus mirabilis S. aureus Psudomonas aeruginosa
Empiric abx UTI tx
Uncomplicated
acute cystitis = TMP-SMX (or Ciprofloxacin) PO x 3d
acute pyelonephritis:
- mild: Ciprofloxacin PO x7-14d
- severe: Ciprofloxacin + 3rd gen cephalosporin IV
Abx tx gram + uncomplicated UTI
Assume enterococci - amoxicillin+/- clavulante PO
- if severe = amoxil + clav + gentamicin IV
Empiric abx tx complicated UTI
Cystitis or pyelonephritis
- 3rd gen cephalosporin or ciprofloxacin IV
if gram + stain (assume enterococci) = ampicillin + gentamicin
When do you treat asx bacteruria?
- pregnancy
- urologic procedure
- GU tract obstruction
- kids with vesicoureteral reflux
- Proteus and Pseudomonas species
Erectile dysfunction definition
- 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
Pathophys erection
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
Mechanism of testosterone in erection?
- maintains intrapenile levels of NO synthase
Site of action of drugs for ED?
Sildenafil
Tadalafil
Vardenafil
-> inhibit PDE-5
PDE-5 inactivates cGMP which causes intracavernousal arteriolar dilation
Cause conditions of ED? (IMPOTENCE)
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
Important questions re: psychogenic ED?
- incidence of involuntary erections (morning erections)
- performance with manual stimulation (masturbation)
- perceived acute situational ED or associated performance anxiety
Physical exam for ED?
- BP
- neurologic exam, including bulbocavernous reflex
- GU exam - anatomical survey and testicular exam for hypogonadism
Investigations for ED?
- cbc, urinalysis, serum prolactin, FSH, LH, TSH
- testosterone
- fasting glucose, HBA1C, lipids
Medical tx ED?
- PDE-5 inhibitors: sildenafil, tadalafil, vardenafil (1st line)
- intracavernous injections: smooth muscle relaxants and vasodilators
- MUSE intraurethral suppository
- androgen replacement (IF androgen deficiency)
CI PDE-5 inhibitors?
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
What is hematuria?
- gross (visible)
- microscopic (>=3 RBC/HPF on 2 UA)
What filters blood molecules based on size and electrical charge?
- glomerular capillaries
Is basement membrane positively or negatively charged? How does this affect filtration of molecules?
Negatively charged proteoglycans
- repels molecules with negative electrical charge (e.g. albumin)
How can immune system alter renal filtration at basement membrane?
- 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
Causes of non-RBC red urine (heme + and heme -)
heme +
- hemoglobinuria: dialysis, hemolysis
- myoglobinuria: rhabdomyolysis, rifampin, trauma
heme -
- drugs: sulfa, nitrofurantoin, salicylate, phenytoin
- foods: beets, food colouring
- metabolites
Common causes hematuria age 0-20?
glomerulonephritis
UTI
congenital anomalies
Common causes hematuria age 20-40?
UTI
calculi
Common causes hematuria age 40-60?
female: UTI> calculi > bladder tumor
male: bladder tumor> calculi, UTI
Common causes hematuria age >60?
female: bladder tumor > UTI
male: BPH > bladder tumor > UTI
RF for bladder cancer?
- 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
Classic triad for renal cell carcinoma?
- flank pain
- palpable flank mass
- hematuria
Workup microscopic hematuria for pt high risk or >40 yrs?
- UA
- urine culture
- urine cytology
- upper tract imaging (US of kidneys, bladder)
- cystoscopy for lower tract
Workup microscopic hematuria for pt low risk?
- repeat UA
- if repeat UA + then same eval as high risk pt excluding cystoscopy
Workup asx gross hematuria?
- urine cytology
- UA
- upper tract imaging (CT-IVP)
- cystoscopy
Indications for nephrology referral?
- proteinuria
- red cell casts
- dysmorphic red blood cells
- elevated Cr
- > suggestive of glomerular cause of hematuria
Follow up for hematuria?
- Fam physician fup with UA, urine cytology and BP checks at 6, 12, 24, 36 mo
What is involuntary loss of urine?
Urinary incontinence
Causes of urgency incontinence?
overactive bladder (detrusor contraction overcomes sphincter inhibition)
- irritation of bladder mucosa
- neurogenic
- iatrogenic
- idiopathic
Causes of stress incontinence?
insufficient outlet pressure
- lack of pelvic floor support
- iatrogenic
Causes of overflow incontinence?
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
Ddx neurogenic bladder?
- MS
- Spinal trauma (including iatrogenic)
- stroke
- DM
Transient causes of incontinence in elderly (DIAPPERS)?
- delirium
- infection
- atrophic urethritis or vaginitis
- pharmaceuticals
- psychogenic
- excessive urine output
- restricted mobility
- stool impaction
Dx and pathophys
- involuntary loss of urine with efforts that cause increased intra-abdominal pressure (coughing, sneezing, laughing, lifting)
Stress incontinence
- increase abdo pressure = transmitted to bladder and due to reduced pelvic support allows leakage of urine
Dx and pathophys
- involuntary urine leakage accompanied by need to urinate
Urge incontinence
- uninhibited bladder contractions cause increased intravesical pressure, which, when higher than urethral resistance causes leakage
What investigations if incontinence likely from BPH?
- uroflowmetry
- post void residual assessment
Investigations of incontinence with concurrent lower urinary tract sx and hematuria?
- cystourethroscopy
What is the indication for urodynamic study?
- dx uncertain after history and physical
- failed medical tx
- history suggests incontinence with mixed etiology
Dx incontinence
R/O UTI!! (urinalysis and culture)
based on history re: stress vs. urge incontinence
Tx urge incontinence
- anticholinergics, lifestyle
Tx stress incontinence
- Kegel exercises
- pelvic floor physiotherapy
- pessaries/ endovaginal cone
- surgical procedures (urethral sling or artificial urinary sphincter)
What is enuresis?
- 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
Classification of enuresis
- diurnal or nocturnal
- primary (never been consistently dry at night) or secondary (resumes wetting after 6mo of continence/ dryness)
Is increase or decrease ADH associated with nocturesis?
- less secretion or blunted response to nocturnal ADH
What is needed for child’s readiness to toilet train?
- child’s interest (20-30mo), dependent on culture
- physiologic readiness: voluntary coordination of sphincter control; myelination of pyramidal tracts (12-18mo), acquiring larger bladder capacity
- behavioural readiness: ambulation to toilet, communication with parents
Investigations enuresis?
Urinalysis - UTI - renal disease - DM Voiding diary Renal US in older kids or not responding to tx
Tx enuresis?
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
Define infertility
- inability to conceive after 1 yr of intercourse without contraception
- > investigate both partners
Why are testes outside the body?
- spermatogenesis occurs at lower temperatures than core temperature
- > increased temp affects spermatogenesis
What is a varicocele? Can it affect fertility?
- dilated veins of pam-uniform complex
= increase in temperature of scrotal content and reflux of toxins from body -> result is poorer spermatogenesis
Pathophys spermatogenesis
- 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
Ddx male infertility
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
Investigations male infertility
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
Intercourse timing with ovulation?
2d before ovulation x5d
Abnormal sperm analysis?
- oligospermia (small number spermatozoids)
- low volume
- low mobility
- teratospermia (structural defects)
- combination -> oligoteratospermia (OAT) = most commonly associated with varicocele
Embryology of male gonads and anatomy re: clinical entities
- 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
Ddx scrotal mass
- testicular cancer
- hydrocele
- hematocele
- communicating hydrocele
- spermatocele/ epididymal cyst
- varicocele
- infectious (orchitis/ epididymitis)
Definition and aetiologies of testicular cancer
- 95% germ cell tumors
- seminomas
- nonseminomas
etiology - RF
- cryptorchidism (up to 14-fold)
- testicular atrophy
- testicular dysgenesis
- HIV
Definition and aetiologies of hydrocele
collection of fluid within tunica vaginalis, surrounding the testicle
- idiopathic
- tumor
- epididmytis/ orchitis
- trauma
- torsion (reactive)
Definition and aetiologies of hematocele
- collection of blood within tunica vaginalis
- mass not separated from testicle
- trauma
- post-up complication
Definition and aetiologies of communicating hydrocele
- incomplete obliteration of process vaginalis, allowing peritoneal fluid to pass into scrotum
- congenital
Definition and aetiologies of spermatocele/ epididymal cyst
sperm filled collection of epididymus, resulting in cyst-like structure superior to testicle
- idiopathic
- associated with von Hippel-Lindaw disease
Definition and aetiologies of varicocele
dilated and tortuous veins of pam-uniform plexus of spermatic cord
- L>R
- right sided may be due to intra-abdominal pathology
Definition and aetiologies of infectious orchitis/ epididymitis
scrotal pain and swelling, associative tenderness and erythema
- <35 = gonorrhoea, chlamydia
- > 35 = E coli
What is often left sided and disappears when supine?
varicocele -> bag of worms
Likely dx if painless firm enlargement of testicle?
testicular cancer
Imaging for scrotal mass?
Scrotal US
- cystic vs. solid
- doppler US for vascularization
Do you do a transscrotal biopsy of intratesticular mass?
NO - risk of cancer dissemination
Investigations for testicular cancer?
- serum tumor markers - b-hCG, AFP, LDH
- abdominal and pelvic CT
- CXR
Treatment testicular cancer?
- radical inguinal orchidectomy + adjuvant therapy if indicated
Tx varicocele?
- surgical ligation of testicular vein
Are hydroceles, and spermatoceles treated medically or surgically?
Surgical excision
Define bell clapper deformity
- 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
Define testicular torsion
- 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
Ddx acute scrotal pain
- 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
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
Testicular torsion
Dx
- cremasteric reflex present
- Pregn sign (pain relieved with teste elevation)
- epididymal swelling and focal point of pain
acute epididymitis
Dx
- blue dot sign
torsion of appendix testis
Is dx testicular torsion clinical or based on investigations?
- clinical dx
- can do doppler US to assess testicular blood flow
How do you attempt to detort a testicular torsion?
open book
- lateral detorsion
Is testicular detorsion definitive treatment?
No
- pt needs urgent surgical evaluation for definitive testicular affixation (orchiopexy)
Is the patient at increased risk of torsion in other testicle?
Yes - often bilateral orchiopexy is performed
Treatment acute epididymitis
ceftriaxone 250mg IM x1 tetracycline 500 mg QID x10d doxycycline 100mg BID x10d evaluate partner counsel re: safe sex practices
Sx renal trauma
- flank bruising, palpable mass, pain, tenderness
- hematuria (gross or microscopic)
Sx ureteral trauma
- iatrogenic cause often dx postop
- flank pain, fever, sepsis, urinoma, prolonged ileus, acute kidney injury
Sx bladder injury
- 95% have gross hematuria
- suprapubic pain, bruising, pelvic mass, urinary retention, peritonitis
Sx urethral injury
- often pelvic #
- blood at tip of meatus, hematuria, perineal or scrotal bruising (butterfly hematoma), high-riding prostate, urinary retention, penile swelling
Investigations renal and ureteral injuries
CT
- renal = CT-IVP
- ureteral = contrast CT with delayed imaging to assess leakage retrograde pyelography
Investigations bladder injury
- cystogram
Investigations urtheral injury
- retrograde urethrogram
Is intraperitoneal or extraperitoneal bladder rupture treated with surgery?
- intraperitoneal = surgery
- extraperitoneal = Foley
Classification of urinary obstruction?
- acute vs. chronic
- complete vs. partial
- unilateral (usually upper tract) vs. bilateral (usually lower tract)
Etiology of HTN in unilateral vs. bilateral urinary tract obstruction
unilateral- vasoconstriction from RAAS
bilateral - volume expansion
Sx lower tract - voiding LUTS and physical exam
- hesitancy
- weak stream
- post void dribbling
- frequency, nocturne, urgency
- inability to empty bladder
- hematuria +/- clots
HTN
palpable bladder
palpable urethral stricture
enlarged prostate
Sx upper tract obstruction and physical exam
- flank pain +/- radiation to groin or RLQ or LLQ
- hematuria
- GI sx (n/v)
HTN
CVA tenderness
Management of patient with urinary obstruction and fever and chills?
- urologic emergency
- restore urine flow -> insert nephrostomy tube or ureteric stent with IV abx
Dx location of renal colic
- renal colic with flank pain
Ureteropelvic junction
Dx location of renal colic
- RLQ or LLQ pain; may mimic appendicitis, diverticulitis, ectopic pregnancy
pelvic brim (as ureter crosses iliacs)
Dx location of renal colic
- renal colic with irritative (urgency, dysuria, frequency) lower urinary tract sx and radiation to ipsilateral testicle
ureterovesical junction
Investigations of LUTS of obstruction
- 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
Investigations of upper tract obstruction
- 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
Medical and surgical treatment of benign prostatic obstruction?
medical
- alpha blockers (sx tx)
- 5 alpha reductase inhibitors (shrinks volume of prostate)
surgical
- TURP
- laser photo-vaporization
- open simple prostatectomy
Conservative tx kidney stones
- calculus <5mm (90% pass spontaneously)
- alpha blockers
- analgesics
- hydration (>2L/d)
Where is hyperplasia located in BPH?
- transitional zone
Most common type of prostate cancer?
adenocarcinoma
- peripheral zone > transitional zone > central zone
