Urology Flashcards
Suspect this in a pt w/ very severe testicular pain of sudden onset, but no fever, pyuria, or history of recent mumps. The testis is swollen, exquisitely tender, “high riding,” and with a “horizontal lie.” The cord is not tender.
Testicular torsion. Dire emergency
Consider this in young men old enough to be sexually active, who presents with severe testicular pain of sudden onset. There is fever and pyuria, and the testis although swollen and very tender is in the normal position. The cord is also very tender.
Acute Epididymitis.
What should you do for a person with Acute Epididymitis
Tx w/ Antibiotics. The possibility of missing a diagnosis of testicular torsion is so dreadful that sonogram is done to rule it out.
Suspect this in a pt who is being allowed to pass a ureteral stone spontaneously and who suddenly develops chills, fever spike (104° or 105° F), and flank pain
The urinary tract may be obstructed and infected. Dire emergency.
How do you treat an obstructed and infected urinary tract
IV antibiotics, immediate decompression of the urinary tract above the obstruction.
Treatment for pyelonephritis
Hospitalization, IV antibiotics (guided by cultures), and urologic workup (IVP or sonogram)
Suspect this in older men who have chills, fever, dysuria, urinary frequency, diffuse low back pain, and an exquisitely tender
prostate on rectal exam.
Acute bacterial prostatitis
Tx for acute bacterial prostatitis
IV antibiotics, and don’t do any more rectal exams. Prostatic massage could lead to septic shock.
Why not do circumcisions on kids with hypospadias
they need the foreskin for the plastic surgery to fix it
Tx for vesicoureteral reflux
long term antibiotics until he grows out of the problem
Suspect this in a little girl who voids normally but seems to always be wet with urine
low implantation of a ureter. correct with surgery.
First step in workup for hematuria suspicious for cancer
CT scan, then cystoscopy
suspect in pt w/ hematuria, flank
pain, and a flank mass. Also possibly produce hypercalcemia, erythrocytosis,
and elevated liver enzymes.
Renal cell carcinoma
Bladder Cancer has a super close assc w/ what
smoking
Presentation of prostate cancer
Most are asymptomatic and have to be sought by rectal exam (rock-hard discrete nodule) and prostatic specific antigen (PSA; elevated levels for age group).
Presentation of testicular cancer
painless testicular mass
Tx of testicular cancer
Because benign testicular tumors are virtually nonexistent, biopsy is done with a radical orchiectomy by the inguinal route. Blood samples are taken pre-op for serum markers (a-fetoprotein and b-HCG]), which will be useful for follow-up.
Workup for suspected prostate cancer
Transrectal needle biopsy (guided by sonogram when discovered by PSA) establishes diagnosis. CT helps assess extent and choose therapy. Surgery and/or radiation are choices
Short term therapy for urinary retention due to prostate hypertrophy? Long term?
Short term: indwelling catheter at least 3 days.
Long term: Alpha-blockers. Or 5-alpha-reductase inhibitors for very large glands..
Common kind of post-op urinary retention
Overflow incontinence
Suspect this in a middle-age multigravida woman who leaks small amounts of urine during sneezing, laughing, getting out of a chair, or lifting a heavy object. No incontinence at night. Examination shows a weak pelvic floor, with the prolapsed bladder neck outside of the “high-pressure” abdominal area.
Stress incontinence
Consider this in a pt w/ flank pain, with
irradiation to the inner thigh and labia or scrotum, and sometimes nausea and
vomiting.
Passing ureteral stones
If intervention is necessary for a kidney stone, what is most commonly done?
Extracorporeal shock-wave lithotripsy (ESWL). That, and abundant water intake is always indicated.
Most common cause of pneumaturia
Almost always caused by fistulization between the bladder and the GI tract, most commonly the sigmoid colon, and most commonly from diverticulitis
First steps when you have a pt w/ pneumaturia
Workup starts with CT scan, which will show the inflammatory diverticular mass. Sigmoidoscopy is needed later to rule out cancer. Surgical therapy is required.
How to tell the difference between organic and psychogenic impotence
Psychogenic does not interfere with nocturnal erections, organic does
Diagnosis when palpation of the testes reveals a small firm and tender nodule near the head of the epididymis that appears to have a blue discoloration
This is the blue dot sign, pathognomonic for testicular or appendix testes torsion
Four Cardinal Symptoms and Signs of Testicular Torsion?
Nausea/vomiting, testicular pain duration of less than 24 hours, a superiorly displaced testicle, and an absent cremasteric refl ex.
Gradual onset of testicular pain, most common cause of acute painful hemiscrotum in a child
Appendix testes torsion
Tx of testicular torsion
Presentation < 6 hours; attempt manual detorsion followed by elective orchiopexy.
>6 hours: surgical detorsion, followed by b/l orchiopexy
Tx of Appendix testes torsion
Nonsteroidal anti-inflammatory drugs, ice packs, and scrotal support; uncontrolled pain can be managed with surgical excision of the appendix testes
DDX of scrotal mass involving skin
Epidermal or pilar cysts; Squamous cell carcinoma
DDX of scrotal mass involving epididymis?
Epididymitis; Spermatocele; Appendix testes
DDX of scrotal mass involving testicle
Orchitis; Testicular torsion; Testicular cancer
Any painless mass in the testicle is what until proven otherwise
Cancer
PainFUL mass INSIDE testicle - what is it, and what caused it?
Orchitis; most often viral origin, think MUMPS
5 main diagnoses to consider in a painFUL scrotal mass
Epididymitis (outside testicle) and Orchitis (inside testicle). Testicular torsion and appendix testes torsion are up there too. Finally, incarcerated hernia can be super painful.
3 main benign diagnoses in a painLESS testicular mass
Spermatocele, hydrocele, varicocele. All separate from the testicle.
Think this diagnosis when a patient with a testicular mass, whose mass disappears when he lies down, and reappears when he stands back up.
Varicocele. P.S. Also, look for “feels like a bag of worms”. Also “associated with infertility”.
In a kid with an undescended testicle, what are they at higher risk for later?
Testicular cancer
Most common type of testicular cancer
Seminoma
4 bugs that cause epididymitis
Chlamydia trachomatis, Neisseria gonorrhea, E. coli, Pseudomonas
What causes gynecomastia in patients with testicular cancer?
Choriocarcinoma, a germ cell tumor, is associated with ectopic human chorionic gonadotropin (hCG) production. Elevated hCG can stimulate breast development, leading to gynecomastia.
Which side does a varicocele form more often?
Left side (left testicular vein drains into the left renal vein at a right angle, while the right testicular vein drains into the IVC at a better angle)
Blood markers useful when diagnosed with testicular cancer
Alpha-fetoprotein (AFP), beta-HCG, and LDH
Biopsy requirements for testicular cancer
Don’t do it you might seed the cancer
Tx for testicular cancer
Ochiectomy (via inguinal incision, not scrotal). Then possible chemo, radiation, and retroperitoneal lymph node dissection.
What to suspect when your patient has painless blood in the urine
Cancer (bladder), especially when they have risk factors
What to suspect when your patient has painful blood in the urine
Infection or obstruction, like UTI, pyelonephritis, or nephrolithiasis
Suspect this in a patient with acute colicky flank pain that may extend into the groin. The pain is described as colicky, with periods of severe pain during which the patient will not be able to stay still and will shift positions in an attempt to relieve their pain, followed by temporary resolution of the pain
Nephrolithiasis
Consider this in a patient with flank pain, abdominal mass, and hematuria
Kidney cancer; however, all 3 are only present in ~10-15% of cases
Most common type of renal stone
Calcium oxalate
Most likely places for a renal stone to get stuck
At points of narrowing in the GU tract: the ureteropelvic junction (UPJ), where the ureter crosses the iliac vessels, and the ureterovesical junction (UVJ)
Most common type of renal cancer
Renal Cell Carcinoma (RCC).
P.S. Of those, 70% are clear cell, 15% papillary, 5% chromophobe.
Most common location of renal cancer metastasis
Lung
Most common type of bladder cancer
Urothelial cell carcinoma
Most common type of prostate cancer
Prostatic adenocarcinoma
First step in management for a pt w/ hematuria
Urinalysis. Can also do a urine dipstick.
What, after urinalysis, is the next step in workup for a pt w/ hematuria?
Microscopic urinalysis
Best diagnostic test for urolithiasis
non-contrast helical CT-scan. For pregnant ladies, ultrasonography
What Is the Best Management for Nephrolithiasis? How Does the Size of the Stone Change Management?
Renal stones <5 mm pass on their own and should be managed with supportive therapy unless the patient is septic, has a solitary kidney, or has uncontrolled pain. Alpha-blockers such as tamsulosin may also be given to relax the ureteral wall. Stones between 5 and 9 mm should be managed using clinical judgment. Stones larger than 9 mm are unlikely
to pass spontaneously and will therefore require more invasive treatment.
What is a radical nephrectomy?
Removal of the kidney, perinephric fat, Gerota’s fascia, ureter, lymph nodes, and possibly the ipsilateral adrenal glands
Treatment of urothelial carcinoma of the bladder
Initially transurethral resection for diagnosis and staging. Small superficial tumors can be treated with complete transurethral resection and potentially intravesical chemotherapy (mitomycin) or immunotherapy (bacillus Calmette-Guérin infused via urinary catheter). UCC has a high recurrence rate, and patients need to be closely monitored. The standard of care for nonmetastatic tumors that invade the detrusor muscle is radical cystectomy with urinary diversion.
What is a radical cystectomy?
The removal of the entire bladder and pelvic lymph nodes. In a male, the prostate and seminal vesicles are also removed. In a female, the cervix, uterus, fallopian tubes, and part of the vagina are also removed
What Is a Radical Prostatectomy? Which Patients Are Appropriate Candidates for This Procedure?
Removal of the prostate and seminal vesicles. Patients with disease contained to the prostate and a life expectancy of at least 10 years are good candidates
What procedure should you do when you see blood at the meatus of the urethra/
Retrograde cystourethrogram
When you see a BUN/Creatinine ratio > 20 and history of hypovolemia or hypoperfusion, what should you suspect?
Prerenal AKI
Common nephrotoxic drugs
intravenous contrast agents, aminoglycosides (e.g. gentamicin), amphotericin, cisplatin, cyclosporine, and NSAIDs.
When you see a BUN/Creatinine >20 and evidence of hydronephrosis, what should you suspect?
postrenal AKI
Virchow’s triad
Stasis, epithelial injury, hypercoagulable state. Makes pts susceptible to venous thromboembolic events
If you suspect PE, what should you do first?
Start heparin right away. Then do a CT.
Suspect this in a patient who on DRE you feel a smooth rubbery prostate
Benign prostatic hypertrophy (BPH)
Treatment for benign prostatic hypertrophy, short term and long term
Short term: alpha blockers (terazosin, doxazosin, tamulosin, alfuzosin)
Long term: alpha-5-reductase inhibitors (finasteride)
Treatment for an organic cause of impotence, like atherosclerosis or diabetes
Phosphodiesterase inhibitors (sildenafil, verdanafil)
treatment for bacterial postatitis
fluoroquinolones
people with klinefelters syndrome (47, XXY) are at increased risk for what urologic cancer?
Germ cell tumors
