Urology Flashcards
Causes of haematuria
Tumours - frank/microscopic, usually painless, carcinoma in situ of bladder usually causes micturition symptoms
Irritation from infection/stones - usually + dysuria
Prostatic enlargement - straining at micturition may dilate bladder neck veins
Trauma
Haemoglobinuria - red from Hb not blood, in young people excess exercise
Renal parenchymal inflammation
Micro-emboli in kidneys from AF, infective endocarditis§
What are the micturition symptoms?
Dysuria - pain/discomfort on micturition, often a/w difficulty voiding and burning/scalding pain. due to urethral irritation usually UTI, recent instrumentation or catheterisation
Frequency - frequently pass small volumes but normal overall daily volume. E.g. bladder irritation, incomplete emptying in BPH/MS, detrusor overactivity, fibrosed bladder e.g. schistosomiasis
Nocturia - HF, old age, drugs
Urgency - e.g. UTI, BPH
Hesitancy - BPH (not enough urine into proximal urethra to relax sphincter)
Poor stream - urethral compression or stricture
Post-micturition dribbling - weak bulbospongiosus, abnormal sphincter, pelvic floor weakness
Acute urinary retention?
Medical emergency: abrupt inability to PU over a period of hours. Usually painful
Causes:
- infection/inflammatory: e.g. BPH (often acute on chronic picture), proctitis, vulvovaginitis, lichen planus, schistosomiasis, cystitis, primary HSVV, peri-urethral abscess
- drug-related: anticholinergics, opioids, anaesthetic drugs, alpha agonists, BZDs, NSAIDs, detrusor relaxants, CCBs, antihistamines, alcohol
- neurological (more often chronic tbh): autonomic/peripheral nerve (DM, GBS, pernicious anaemia, poliomyelitis), brain (CVD, MS, neoplasm, NPH, PD), SC (meningomyelocele, MS, SC haematoma, cauda equina)
- post-op: common, due to pain, traumatic instrumentation, bladder overdistension, drugs
- other: e..g penile #, postpartum complications, pelvic trauma
Ix: urinalysis, US bladder scan to see post-void residual volume, US KUB for hydronephrosis, CT AP to see bladder neck compression, cystoscopy
M: catheterise, treat cause, alpha blocker (Tamsulosin or alfuzosin), 5-alpha reductase inhibitors (finasteride), TWOC, if fails TURP
Comps: post-obstructive diuresis (causes electrolyte issues), post-retention haematuria, AKI, UTI
Chronic urinary retention?
Gradually develop inability to completely empty bladder causing residual volume >1L/distented bladder
Often painless. High pressure causes renal impairment. May get overflow voiding. If long term can get bladder diverticula-back pressure on kidneys-uraemia. At an point may get acute on chronic retention
Causes: structural/functional abnormalities of bladder muscle/sphincter, persistent urethral obstruction (e.g. BPH), lower spinal neuro problems
Management: intermittent catheter - then long term indwelling catheter, TURP if fit, drugs for BPH
*urethral catheterisation best, record residual volume, re-examine to ensure mass disappeared
Normal bladder capacity?
300-500ml
Micturition ?
Filling - detrusor muscle relaxes so pressure doesn’t rise until bladder near full
Detrusor contracts to void (both mediated by spinal reflex at S2-4)
Cortical conscious inhibitory control to delay voiding
What are the causes of urinary incontinence?
- Loss of cortical inhibitory control e.g. dementia, supra-sacral SC issue (e.g. MS, traumatic paraplegia)
- Abnormal sacral reflex: sacral neurogenic bladder (damaged reflex arc so large residual volume e.g. diabetic neuropathy, pelvic tumours, low trauma), overactive bladder (hypersensitive so get voiding reflex below capacity, urge incontinence, treat with antimuscarinics e.g. oxybutinin), infection, hypotonic bladder (from BPH persistent obstruction causing stretching)
- Detrusor/sphincter abnormalities: stress incontinence (weak sphincter pelvic floor damage), post-prostatectomy, tumour, urethral trauma, TB, radiotherapy, congenital e.g. epispadiasis
What may cause pneumaturia?
Fistulae - from diverticular disease, pericolic abscess in Crohns, colon/bladder cancer
– abnormal communication between bowel + UT
Renal trauma?
Minor trauma common to get microscopic haematuria
Major trauma, or when kidneys more susceptible to damage e.g. PKD, hydronephrosis
Grade from I to V, from contusion up to laceration + shattered kidney
Most conservative treatment, if penetrating renal trauma need exploration and control vascular, debride, remove haematoma + mattress suture over absorbable material
Ureteric injury?
Iatrogenic, blunt abdo/pelvic trauma, penetrating usually gunshot, deceleration (PUJ shear), obstruction, fistula formation, ischaemic strictures post-hysterectomy
Cause pain, infection, functional issues
Repair includes debridement of necrotic tissue, mucosa-mucosa anastomosis, drains
Bladder trauma?
Blunt/penetrating, iatrogenic (TURBT), extra or intra-peritoneal
May see bruising, visible wounds, abdo distention, peritoneum, anuria, raised urea + creatinine
Extra-peritoneal - conservative, catheter drainage; intraperitoneal - open repair, AB, catheter
Urethral trauma?
Usually male.
Anterior - bulbar/penile urethra, mobile, injury by direct or penetrating trauma
Posterior - membranous/prostatic urethra, find by puboprostatic ligament
Symptoms - difficulty voiding, high riding prostate. butterfly bruise if Buck’s fascia ruptures
Risk of incontinence, strictures and impotence
Suprapubic catheterisation
Penile trauma?
Penile # - strong bending force on erect penis, sudden pain tearing + detumescence. Due to tear in tunica of corporal body, need surgery obv
Avulsion/degloving
Ischaemia
Amputation - assault, psychiatric illness
Scrotal trauma?
Penetrating, blunt, avulsion
Pain, oedema, may not be able to palpate (?rupture)
What are the complications of urinary obstruction?
- Proximal distention of UT - bladder dilatation + hypertrophy + diverticulae, in ureter - megaureter + hydronephrosis
- Pain
- Reduced renal function - back pressure causing tubular atrophy, glomerular hyalinisation + fibrosis
- Urinary stasis - UTI, sepsis, stones
What are the commonest sites of urinary obstruction?
Pelvi-Ureteric junction (ureters cross brim at level of iliac vessels)
Vesico-ureteric junction (where joins bladder)
Causes of urinary obstruction?
- Within lumen - clot, calculi, sloughed papillae, tumour of renal pelvis/ureter
- Within wall - strictures of ureter/urethra, congenital megaureter, bladder neck obstruction, neurogenic bladder
- Pressure from outside: PUJ compression, prostate cancer/BPH, retroperitoneal fibrosis, pancreatitis, Crohn’s disease, chronic granulomatous disease, phimosis
How may urinary obstruction present?
- Acute UT obstruction - flank pain, radiates to IF/inguinal/genital/back, provoked by alcohol/high fluid/diuretics, occasionally enlarged kidney, symptoms of UTI/sepsis, N&V, anuria
- Chronic UT obstruction - pain, CKD, polyuria
- Acute LT obstruction - severe suprapubic pain (but absent in acute on chronic/neuropathy), abdo distention, suprapubic dullness
- Chronic LT obstruction - urinary symptoms, signs f prostate issues
- Idiopathic retroperitoneal fibrosis - uncommon, non-specific dull ado-low back pain, 50% have HTN, anaemia, raised CRP/ESR. Around half due to metastasised cancer, causes hydronephrosis, IVCO. Steroids + stents
Complications of urinary obstruction?
Infection - cystitis, pyelonephritis, abscess, sepsis Urinary extravasation AKI Fistula CKD Bladder dysfunction Pain
Ureteric colic?
C-calculi, clot, PUJ obstruction
CF-sudden onset colicky pain, radiation to IF/genitals, u/l, N&V, may have rigors/tachycardia/hypotensive (sepsis), non-visible haematuria
M-analgesia, anti-emetic, fluids if dehydrated, many pass spontaneously, IV ABs if have infection (gentamicin + co-amox/tazocin), drainage of abscess, surgical removal of stone
Acute pyelonephritis
Causes: E coli, Proteus miribalis (forms stag horn calculi by urinary alkalisation due to urease), Pseudomonas, Klebsiella …
CF: pain may be more gradual onset, not colicky, radiates, often preceding UTI, systemically unwell, pyrexial, tender flank/suprapubic, dysuria, strong smelling cloudy urine, haematuria, pyrexia, tachycardia, urine dip often blood leucocytes + nitrates
M: medical, analgesia, anti-emetic
C: pyonephrosis, perinephric abscess (gets into fat, slowly expanding loin mass, need drainage usually), sepsis
What part of the prostate is palpable on DRE?
Posterior part, feel median groove which divides the two lateral lobes
What is benign prostatic hyperplasia?
Transition zone undergoes nodular hyperplasia - symmetrical enlargement - can cause bladder outflow obstruction, back pressure, overflow incontinence, urinary sx
How is BPH managed?
- Cystoscopy for assessment
- Finasteride/dutaseride - 5 alpha reductase blockers. Reduce conversion of testosterone to dihydrotestosterone so reduce hyperplasia, takes 6m to work, s/e are erectile dysfunction, reduced libido, gynaecomastia
- Alpha A1 blockers e.g. tamsulosin, alfuzosin - allow prostatic urethra to open more readily, s/e are postural hypotension, dry mouth, depression
- TURP - remove most of prostate in strip. Comps-retrograde ejaculation, impotence, urethral strictures, clot retention from secondary haemorrhage (infection or cancer)
- Long-term catheterisation - small proportion. Intermittent self-catheterisation best as reduces infection
Prostate cancer presentation?
- Starts peripherally so urinary symptoms usually a later feature - often asymptomatic. Other symptoms include oedema of legs/genitals from nodal involvement, backache, pathological #.
- Most adenocarcinomas and well-differentiated.
- Highest prevalence in Afro-Caribbean men
- Metastasise to pelvic and obturator LN, seminal vesicles, bone (esp via sub scapular venous plexus into spinal veins)
- Most secrete prostate specific antigen - but this also raised in BPH, prostatitis
Prostate cancer grading
TRUS biopsies, serum PSA, XR for bone pain (typically sclerotic [osteoblastic, dense, white] rather than lytic lesions)
Gleason score
Get grade 1-5 for most dominant and second most dominant, add the two scores together so out of 10
Lowest Gleason score indicating malignancy is 6/10.
Management of prostate cancer
Early: prostatectomy, +/- radiotherapy often curative, or active monitoring if low grade + impalpable
Hormonal treatments - most tumours androgen dependent . E.g. goserelin (LHRH agonist so stimulates LH release from AP, increases testicular testosterone initially then this feeds back to inhibit LH release)
Also give anti-androgen treatment e.g. cyproterone acetate or flutamide initially due to risk of tumour flare from initial stimulation of testosterone + LH (which causes symptoms)
Locally-advanced-neoadjuvant radiotherapy + surgery
Metastatic: control sx,reduce progression
TURP syndrome?
Rare serious complication of prostate surgery, caused by venous destruction + absorption of the irrigation fluid.
RF: surgery >1h, large amount of fluid used, poorly controlled CCF, large blood loss, perforation
Prostatitis
- Usually coliforms, Chlamydia or Gonorrhoea or Neisseria
- Acute: perineal pain, fever, swelling, obstruction, tender prostate. IV AB to reduce fever then PO for 6w
- Chronic: low grade suprapubic/perineal pain, vague symptoms, ABs and NSAID
When should you not do PSA test within due to risk of increased result? (NICE)
6 weeks of a prostate biopsy 4 weeks following a proven urinary infection 1 week of digital rectal examination 48 hours of vigorous exercise 48 hours of ejaculation
Urological tumours?
Renal cell adenocarcinoma - mostly sporadic but ass w von Hippel-Lindau syndrome, smoking. Involves large clear cells, can invade para-aortic LN, renal vein, IVC, lung (cannonball mets), liver, bone. CF-haematuria, mass, flank pain, often incidental. Less common-iron def anaemia, polycythaemia (EPO), HTN (renin), hypercalcaemia (PTHrP), PUO, varicocele on L from obstruction of LTV. M-nephrectomy, isolated pulmonary met removal may cure
Nephroblastoma - Wilms’ tumours. Developmental, mass + haematuria, pyrexia, often met early to lung
Benign renal tumours - oncocytoma, adenoma, angiomyolipoma (ass w tuberous sclerosis)
Transitional cell carcinoma - anywhere in UT but mostly bladder, 4x more common than RCC, RF-smoking, industrial carcinogens (long incubation) Carcinoma in situ-frequency + dysuria. CF-painless haematuria, v occasionally clots causing UT obstruction, hydronephrosis if near ureteric orifice. M-single dose intravesical chemotherapy, TURBT, cystectomy with urinary diversion via ideal conduit
Squamous cell carcinoma - ass w stones/schistosomiasis
Adenocarcinoma of bladder - v rare, remnants of urachus
Pathophysiology of renal stones
Supersaturation when concentration of minerals exceed their solubility in urine. Most include calcium with the commonest being calcium-oxalate
Calcium-containing usually idiopathic or hypercalcaemia
Excess urinary excretion of main component can cause- hyperparathyroidism (calcium), hyperoxaluria (oxalate), gout/chemotherapy (uric acid), cysteinuria (metabolic disorders), struvite stone (infection-alkaline urine from urease-producing enzymes)
