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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
What is the treatment for highly suspicious testicular cancer?
Radical orchiectomy
26
What other treatment, besides surgery, is indicated for testicular cancer?
Radiation (seminoma) Chemo (most types) RPLND (mostly non seminomas)
27
What are causes of scrotal masses found involving the skin?
Epidermoid or pilar cysts | Squamous cell carcinoma
28
What is the differential of scrotal masses involving the spermatic cord?
Indirect inguinal hernia Hydrocele Varicocele
29
What is differential diagnosis of scrotal masses involving the epididymis?
Epididymitis Spermatocele Torsion of testicular epididymal appendage (appendix testis)
30
What is the differential of scrotal masses found involving the testes?
Orchitis Testicular torsion Testicular cancer
31
What do constitutional symptoms in the setting of painless testicular mass imply?
Metastatic testicular cancer: symptoms match location of mets
32
What risk factors for testicular cancer should be obtained on history?
- Cryptorchidism - Personal or family hx of testicular cancer - Klinefelter's - White race
33
What features on PE for testicular mass suggest non-malignant etiology?
``` Extratesticular Bilateral Painful Mobile Fluid filled Transillumination ```
34
What are the main diagnoses to consider in presence of very painful scrotal mass?
- Epididymitis/ Orchitis | - Puberty: torsion of testes or appendix testes
35
What benign processes in the testicle are typically painless?
Spermatocele Varicocele Hydrocele * Usually separate from testicle itself
36
What PE maneuver can help identify a varicocele?
Mass disappears on lying down, reappears on standing up. Feels like a spongy bag of worms
37
What are most likely organisms causing epidiymitis in young adult < 35?
Chlamydia | Neisseria
38
What are most likely organisms causing epidiymitis in adult > 35?
E. coli | Pseudomonas
39
What causes gynecomastia in patients with testicular cancers?
Choriocarcinoma: hCG
40
What are differences between epididymitis and spermatocele?
Epididymitis: infection, often with dysuria and tenderness Spermatoceles: result of retention cyst at head of epididymis: often asx, but transilluminate
41
Why does a varicocele form? What side does it usually form on and why?
Impaired venous drainage: L side due to less optimal as the L testicular vein enters L renal vein a right angle
42
Why does varicocele affect fertility?
Venous stasis increases testicular temperature, increases seminal oxidative stress and damages sperm DNA
43
Sudden onset of a L sided varicocele may be caused by?
Thrombosis of L renal vein due to RCC
44
What is pathophysiology of a hydrocele?
Due to lack of separation of tunica vaginalis from processes vaginalis: fluid communication or persistent sac in testes. * Transilluminate!
45
What are key imaging modalities in workup for testicular cancer?
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
What relevant blood tests should be obtained in a patient with testicular cancer?
Beta-hCG AFP LDH * Useful for staging, establishing prognosis and following response
47
Why is testicular cancer removal inguinally vs. through scrotum?
Due to higher rate of recurrence via trans-scrotal
48
What should be recommended for patients about to undergo orchiectomy and/or chemo?
Cryopreservation of sperm to ensure future fertility
49
Does orchiectomy lead to impotence?
No: but RPLND can injure nerves that affect erectile function
50
What does pain with hematuria suggest?
UTI or urinary obstruction
51
What does painless gross hematuria suggest?
suspicion for malignancy
52
What is pseudohematuria?
Red urine without RBCs due to certain food, drugs or metabolic disorders
53
How is renal carcinoma usually found?
Incidentally, usually asymptomatic
54
How does bladder cancer usually present?
Painless gross hematuria
55
How is prostate cancer usually discovered?
PSA and prostate biopsy
56
How do we find microscopic hematuria?
Urine dipstick for blood, protein
57
What findings on urinalysis suggest glomerular cause?
Dysmorphic RBCs or RBCs casts
58
What is the first step in evaluating a suspected kidney stone?
Non contrast CT
59
What is the first step in evaluating a suspected kidney stone in a female of childbearing age or kids?
US
60
Which kidney stone is not radiopaque?
Uric acid
61
If a patient presents with true gross hematuria, what is the next step?
Malignancy workup: - CT urogram - Urine cytology - Cystourethroscopy
62
How do we manage a kidney stone < 5mm?
Likely will pass spontaneously
63
How do we manage a kidney stone 5-9 mm?
Individual management depending on patient
64
How do we manage a kidney stone >10 mm?
Extracorporeal shock wave lithotripsy Percutaneous nephrostomy Ureteroscopy Rarely nephrolithotomy
65
What is the treatment for Renal cancer?
Partial or radical nephrectomy
66
What is the treatment for bladder cancer?
Transurethral resection Infusion of mitomycin of BCG Radical cystectomy
67
What is the treatment for prostate cancer?
``` External beam radiation Brachytherapy Androgen deprivation therapy Radical prostatectomy Active surveillance ```
68
What is the most likely cause of acute hematuria (<2 weeks) in patient under 20?
UTI Foley trauma exercise
69
What is the most likely cause of chronic hematuria (>2 weeks) in patient under 20?
IgA nephropathy
70
What is the most likely cause of chronic hematuria (>2 weeks) in patient 20-50?
PKD | Cancer: bladder, kidney or prostate cancer
71
What is the most likely cause of chronic hematuria (>2 weeks) in patient 50+?
BPH PKD Cancer: bladder, kidney or prostate
72
What is the most likely cause of acute hematuria (<2 weeks) in patient 20+?
UTI, foley trauma, nephrolithiasis
73
What does pain + hematuria suggest?
Infection or urinary obstruction
74
How to differentiate nephrolithiasis vs. peritonitis?
Nephrolithiasis: tend to move around Peritonitis: prefer to remain rigid
75
What is the most common presentation for bladder cancer?
Painless gross hematuria
76
What is the most common location for RCC metastasis?
Lung
77
What genetic syndromes are associated with RCC?
von Hippel-Lindau Tuberous sclerosis Birt-Hogg-Dube
78
What paraneoplastic syndromes are associated with RCC?
``` Polycythemia Hypercalcemia Hypertension Cushing's: high cortisol Stauffer's: reversible liver dysfunction ```
79
If a patient presents with gross hematuria, what is the next step?
Urinalysis to confirm there are RBCs in urine: 1) Positive dipstick 2) microscopic urinalysis: number of types of cells
80
What additional labs should be ordered during the hematuria workup?
``` CBC Metabolic panel PT/PTT/INR PSA Urine culture Urine cytology ```
81
Does negative urine cytology rule out a malignancy?
No: not a very sensitive test
82
What drug can be given to help pass ureteral stones? How does it work?
Alpha-blockers: tamsulosin: relax ureteral wall
83
What are emergent surgical indications for renal stones?
Obstructive stones that lead to urosepsis, intractable pain, progressive renal damage or solitary kidney
84
What is a radical nephrectomy?
Removal of kidney, perinephric fat, Gerota's fascia, ureter, lymph nodes, possibly ipsilateral adrenal gland
85
In the setting of gross hematuria, what should be done to manage bleeding?
Place a Foley catheter to improve urine flow and pass the blood clots
86
Do we place a foley in the setting of trauma and blood at the urethral meatus?
No: potential urethral injury

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