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Surgery Clerkship > Urology > Flashcards

Urology Flashcards

1
Q

What are the four cardinal signs/symptoms of testicular torsion?

A

N/V
Testicular pain < 24 hours
Superiorly displaced testicle
Absent cremasteric reflex

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2
Q

What is needed to prompt intervention for testicular torsion?

A

High clinical suspicion

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3
Q

What is Prehn’s sign?

A

+ when patients report pain relief with elevation of scrotal contents
- when it does not relieve pain

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4
Q

What is the blue-dot sign?

A
  • Palpation of testes reveals small firm tender nodule near the head of the epididymis: appears to have blue discoloration
  • Pathognomonic for testicular or epidermal appendage
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5
Q

Is the cremasteric reflex present with appendix testes torsion?

A

Yes

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6
Q

Is the cremasteric reflex present with testicular torsion?

A

No: absent

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7
Q

What is a condition that predisposes to testicular torsion?

A

Bell-clapper deformity: congenital defect of processus vaginalis can lead to failure of the testes to attach to inner lining of scrotum

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8
Q

If clinical suspicion is low for torsion, what is the next step?

A

UA to r/o UTI or epidymo-orchitis

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9
Q

What is the best imaging test for testicular torsion and what does it show?

A

Absence of arterial blood flow in affected testicle

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10
Q

In the trauma setting, what do we look for in suspicion for testicular torsion?

A

Violation of the tunica albuginea because it would warrant surgical repair

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11
Q

If testicular torsion presents < 6 hours, what is the next step?

A

Attempt manual detorsion followed by elective orchiopexy

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12
Q

If testicular torsion presents > 6 hours, what is the next step?

A

Patient directly to OR for surgical detorsion

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13
Q

When is an orchiectomy performed for testicular torsion?

A

Necrotic testicle

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14
Q

What type of testicular trauma is most common?

A

Blunt (85%)

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15
Q

How does the cremasteric reflex work?

A

Stroke medial thigh: sensory fibers from femoral branch of genitofemoral nerve (L1-L2) stimulated: contracts cremasteric muscle to cause ipsilateral elevation of testis

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16
Q

What can cause absent cremasteric reflex?

A
  • UMN/LMN disorders
  • Spinal cord injury at L1-L2
  • In patients with testicular torsion
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17
Q

What are other risk factors for tesicular torsion besides bell-clapper deformity?

A

Age 12-18

History of prior torsion

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18
Q

What should be done following surgical reduction of torsion?

A

Affected side untwisted and orchiopexy should be performed to prevent recurrence

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19
Q

What key attributes in a case make you think of testicular cancer?

A

Males
Age 20-40
Non tender testicular mass

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20
Q

What is the most common type of testicular tumor?

A

Seminoma

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21
Q

What is one big risk factor for testicular cancer? In which testicle?

A

Cryptorchidism increases risk of testicular cancer in both testicles, even the normally descended one

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22
Q

What is the imaging test used to evaluate for testicular cancer?

A

Ultrasound

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23
Q

What imaging is used for staging of testicular cancer?

A

CT abdomen pelvis

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24
Q

Do we biopsy testicular cancer? why or why not?

A

No: it may seed cancerous cells

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25
Q

What is the treatment for highly suspicious testicular cancer?

A

Radical orchiectomy

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26
Q

What other treatment, besides surgery, is indicated for testicular cancer?

A

Radiation (seminoma)
Chemo (most types)
RPLND (mostly non seminomas)

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27
Q

What are causes of scrotal masses found involving the skin?

A

Epidermoid or pilar cysts

Squamous cell carcinoma

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28
Q

What is the differential of scrotal masses involving the spermatic cord?

A

Indirect inguinal hernia
Hydrocele
Varicocele

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29
Q

What is differential diagnosis of scrotal masses involving the epididymis?

A

Epididymitis
Spermatocele
Torsion of testicular epididymal appendage (appendix testis)

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30
Q

What is the differential of scrotal masses found involving the testes?

A

Orchitis
Testicular torsion
Testicular cancer

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31
Q

What do constitutional symptoms in the setting of painless testicular mass imply?

A

Metastatic testicular cancer: symptoms match location of mets

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32
Q

What risk factors for testicular cancer should be obtained on history?

A
  • Cryptorchidism
  • Personal or family hx of testicular cancer
  • Klinefelter’s
  • White race
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33
Q

What features on PE for testicular mass suggest non-malignant etiology?

A 
Extratesticular
Bilateral
Painful
Mobile
Fluid filled
Transillumination
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34
Q

What are the main diagnoses to consider in presence of very painful scrotal mass?

A
  • Epididymitis/ Orchitis

- Puberty: torsion of testes or appendix testes

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35
Q

What benign processes in the testicle are typically painless?

A

Spermatocele
Varicocele
Hydrocele
* Usually separate from testicle itself

36
Q

What PE maneuver can help identify a varicocele?

A

Mass disappears on lying down, reappears on standing up. Feels like a spongy bag of worms

37
Q

What are most likely organisms causing epidiymitis in young adult < 35?

A

Chlamydia

Neisseria

38
Q

What are most likely organisms causing epidiymitis in adult > 35?

A

E. coli

Pseudomonas

39
Q

What causes gynecomastia in patients with testicular cancers?

A

Choriocarcinoma: hCG

40
Q

What are differences between epididymitis and spermatocele?

A

Epididymitis: infection, often with dysuria and tenderness
Spermatoceles: result of retention cyst at head of epididymis: often asx, but transilluminate

41
Q

Why does a varicocele form? What side does it usually form on and why?

A

Impaired venous drainage: L side due to less optimal as the L testicular vein enters L renal vein a right angle

42
Q

Why does varicocele affect fertility?

A

Venous stasis increases testicular temperature, increases seminal oxidative stress and damages sperm DNA

43
Q

Sudden onset of a L sided varicocele may be caused by?

A

Thrombosis of L renal vein due to RCC

44
Q

What is pathophysiology of a hydrocele?

A

Due to lack of separation of tunica vaginalis from processes vaginalis: fluid communication or persistent sac in testes.
* Transilluminate!

45
Q

What are key imaging modalities in workup for testicular cancer?

A

US: look for solid mass
CT abdomen pelvis: look for retroperitoneal lymph node mets
CXR: look for pulmonary mets
CT/MRI of brain if neuro symptoms

46
Q

What relevant blood tests should be obtained in a patient with testicular cancer?

A

Beta-hCG
AFP
LDH
* Useful for staging, establishing prognosis and following response

47
Q

Why is testicular cancer removal inguinally vs. through scrotum?

A

Due to higher rate of recurrence via trans-scrotal

48
Q

What should be recommended for patients about to undergo orchiectomy and/or chemo?

A

Cryopreservation of sperm to ensure future fertility

49
Q

Does orchiectomy lead to impotence?

A

No: but RPLND can injure nerves that affect erectile function

50
Q

What does pain with hematuria suggest?

A

UTI or urinary obstruction

51
Q

What does painless gross hematuria suggest?

A

suspicion for malignancy

52
Q

What is pseudohematuria?

A

Red urine without RBCs due to certain food, drugs or metabolic disorders

53
Q

How is renal carcinoma usually found?

A

Incidentally, usually asymptomatic

54
Q

How does bladder cancer usually present?

A

Painless gross hematuria

55
Q

How is prostate cancer usually discovered?

A

PSA and prostate biopsy

56
Q

How do we find microscopic hematuria?

A

Urine dipstick for blood, protein

57
Q

What findings on urinalysis suggest glomerular cause?

A

Dysmorphic RBCs or RBCs casts

58
Q

What is the first step in evaluating a suspected kidney stone?

A

Non contrast CT

59
Q

What is the first step in evaluating a suspected kidney stone in a female of childbearing age or kids?

A

US

60
Q

Which kidney stone is not radiopaque?

A

Uric acid

61
Q

If a patient presents with true gross hematuria, what is the next step?

A

Malignancy workup:

  • CT urogram
  • Urine cytology
  • Cystourethroscopy
62
Q

How do we manage a kidney stone < 5mm?

A

Likely will pass spontaneously

63
Q

How do we manage a kidney stone 5-9 mm?

A

Individual management depending on patient

64
Q

How do we manage a kidney stone >10 mm?

A

Extracorporeal shock wave lithotripsy
Percutaneous nephrostomy
Ureteroscopy
Rarely nephrolithotomy

65
Q

What is the treatment for Renal cancer?

A

Partial or radical nephrectomy

66
Q

What is the treatment for bladder cancer?

A

Transurethral resection
Infusion of mitomycin of BCG
Radical cystectomy

67
Q

What is the treatment for prostate cancer?

A 
External beam radiation
Brachytherapy
Androgen deprivation therapy
Radical prostatectomy
Active surveillance
68
Q

What is the most likely cause of acute hematuria (<2 weeks) in patient under 20?

A

UTI
Foley trauma
exercise

69
Q

What is the most likely cause of chronic hematuria (>2 weeks) in patient under 20?

A

IgA nephropathy

70
Q

What is the most likely cause of chronic hematuria (>2 weeks) in patient 20-50?

A

PKD

Cancer: bladder, kidney or prostate cancer

71
Q

What is the most likely cause of chronic hematuria (>2 weeks) in patient 50+?

A

BPH
PKD
Cancer: bladder, kidney or prostate

72
Q

What is the most likely cause of acute hematuria (<2 weeks) in patient 20+?

A

UTI, foley trauma, nephrolithiasis

73
Q

What does pain + hematuria suggest?

A

Infection or urinary obstruction

74
Q

How to differentiate nephrolithiasis vs. peritonitis?

A

Nephrolithiasis: tend to move around
Peritonitis: prefer to remain rigid

75
Q

What is the most common presentation for bladder cancer?

A

Painless gross hematuria

76
Q

What is the most common location for RCC metastasis?

A

Lung

77
Q

What genetic syndromes are associated with RCC?

A

von Hippel-Lindau
Tuberous sclerosis
Birt-Hogg-Dube

78
Q

What paraneoplastic syndromes are associated with RCC?

A 
Polycythemia
Hypercalcemia
Hypertension
Cushing's: high cortisol
Stauffer's: reversible liver dysfunction
79
Q

If a patient presents with gross hematuria, what is the next step?

A

Urinalysis to confirm there are RBCs in urine:

1) Positive dipstick
2) microscopic urinalysis: number of types of cells

80
Q

What additional labs should be ordered during the hematuria workup?

A 
CBC
Metabolic panel
PT/PTT/INR
PSA
Urine culture
Urine cytology
81
Q

Does negative urine cytology rule out a malignancy?

A

No: not a very sensitive test

82
Q

What drug can be given to help pass ureteral stones? How does it work?

A

Alpha-blockers: tamsulosin: relax ureteral wall

83
Q

What are emergent surgical indications for renal stones?

A

Obstructive stones that lead to urosepsis, intractable pain, progressive renal damage or solitary kidney

84
Q

What is a radical nephrectomy?

A

Removal of kidney, perinephric fat, Gerota’s fascia, ureter, lymph nodes, possibly ipsilateral adrenal gland

85
Q

In the setting of gross hematuria, what should be done to manage bleeding?

A

Place a Foley catheter to improve urine flow and pass the blood clots

86
Q

Do we place a foley in the setting of trauma and blood at the urethral meatus?

A

No: potential urethral injury

Surgery Clerkship (16 decks)

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