Urology Flashcards
217 This CT scan shows an abnormally positioned Kidney.
Q1. Where is the Kidney located?
Q2. What are the consequences of this abnormality?
Q3. How might the significance of this vary between men and women?
Q1. Horseshoe kidney = most common fused problem
Q2. UTI, obstruction, renal calculi, abdo pain, haematuria, fever, incontinence,
Q3. Mostly male > female, but equal in renal ectopia
263 How do you assess a middle aged patient who presents with an episode of microscopic haematuria?
Causes:
- Renal = benign/malignant mass, glomerular disease, pyelonephritis, structural disease, malignant HT, papillary necrosis
- Post-renal = ureter malignancy, stone, stricture, fistula
- Bladder = malignancy (urothelial, squamous), cystitis
- Post-bladder = BPH, prostate cancer, post-prostate procedure, urethritis
- Other = menstrual bleeding, exercise, endocarditis, medication
History:
- Recent urinary history: duration, dysuria, frequency, urgency, frank blood
- Risk factors for urinary tract malignancy: >35yo, smoker, occupational exposure, hx gross haematuria/chronic cystitis/pelvic radiation/cyclophosphamide/chronic IDC
- Other possible causes: exercise, intercourse, UTI, menstruation
Examination: (according to Dr Grant, of little value)
- Renal signs: elevated BP, petechiae, lymphadenopathy
- Abdomen
- External genitalia
- PR exam in males for prostate
Investigations:
- Urine MCS
- FBC
- Coags
- CRP/ESR
- Creatinine
- PSA
- USS
- Helical CT with IV contrast
- Cystoscopy
264 A 60 year old woman attends ED with a 3 week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for 1 month. There is nothing remarkable in the rest of her history. On exam, she is pale, pulse of 100bpm, BP 105/70mmHg, her Hb is 8.2g/dl with a pattern consistent with iron deficiency, rest of her blood work is normal. What is the important diagnosis to exclude and what investigations do you want to do?
Important diagnosis = URINARY MALIGNANCY
- Renal cell carcinoma (derived from renal tubular cells)
- Urothelial (transitional cell carcinoma, SCC, adenocarcinoma)
Haemodynamic instability due to blood loss is also an important immediate consideration
Investigations:
- Bloods: FBC (anaemia, leukocytosis), UEC (renal function), LFTs and coags (clotting factor production and function), ESR/CRP (inflammatory processes)
- Urine: dipstick, MCS (UTI)
- USS KUB
- Cystoscopy (assess urethra and bladder linings)
- Plain film AXR (calculi)
- CT urography (stones, haematoma, inflammation, neoplasms, urothelium of ureters and bladder)
265 You are asked to see a 75 year of age man in ED. He has not been able to urinate for 12 hours and is in acute pain. The ED doctor referring him has excluded all other conditions, but has had to attend a resus room case before considering his urinary tract, no imaging modality is available. What will you do to assess this man and how will you treat him?
Working diagnosis: acute urinary retention
Possible aetiologies:
- Obstruction: mechanical (narrowing of urethra), dynamic (increased muscle tone around sphincter)
- Medications
- Neurological impairment
- Infection
- Trauma
- Other: post-op, post-partum
History: urge to urinate, previous calculi, previous urinary tract malignancy, recent abdo/pelvic surgery, medications
Examination: vitals, abdo, rectal (masses, faecal impaction, perianal sensation, sphincter tone), pelvic (females), neuro
Investigations: urine dipstick and MCS, bloods (FBC, UEC), bladder USS (but not available in this instance)
Treatment = bladder decompression
1) IDC
2) In-out
3) Suprapubic - if failed urethral catheter, recent urological surgery, acute prostatitis, urethral stricture, severe BPH
>300mL drainage suggests urinary retention is the cause. Other causes should be considered if <200mL
Finally, call for urology consult/follow-up
266 An 81 yoa man presents to the ED complaining of difficulty passing urine. This has been a problem for 6 months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else. What is the diagnosis? Why is he complaining of bedwetting?
Diagnosis: BPH
International Prostate Symptom Score (I-PSS): incomplete void, frequency, intermittent flow, urgency, weak stream, straining to begin urination, nocturia
Other non-scored symptoms: hesitancy, terminal dribbling, pis-a-deux
Obstructive symptoms: weak stream, intermittent flow, hesitancy, terminal dribbling, incomplete voiding, straining to begin urination
Irritative symptoms: frequency, nocturia, urgency, pis-a-deux
Cause of bedwetting:
- Outflow obstruction results in chronic retention
- Bladder distension causes stretching and weakening of the detrusor and sphincter muscles
- This eventually results in an atonic bladder that has lost contractility and is therefore unable to empty completely
- As a result of bladder filling while sleeping, overflow incontinence results
267 An 81 yoa man presents to the ED complaining of difficulty passing urine. This has been a problem for 6 months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else. What is the diagnosis? What is the management?
Diagnosis: BPH
International Prostate Symptom Score (I-PSS): incomplete void, frequency, intermittent flow, urgency, weak stream, straining to begin urination, nocturia
Other non-scored symptoms: hesitancy, terminal dribbling, pis-a-deux
Obstructive symptoms: weak stream, intermittent flow, hesitancy, terminal dribbling, incomplete voiding, straining to begin urination
Irritative symptoms: frequency, nocturia, urgency, pis-a-deux
Medical management is guided by I-PSS scoring:
- Mild (0-7), no significant bother = watchful waiting, fluid restriction, bladder/pelvic floor training, constipation relief, medication review
- Mild (0-7) with significant bother = alpha-1a blockers (Tamsulosin) for smooth muscle relaxation, PDE-5 inhibitors (Sildenafil) for NO-induced penile vasodilation, NSAIDs (Celecoxib) to improve flow, selective M3 antimuscarinic agents (Solifenacin) where patient has irritative symptoms w/o elevated PVR
- Moderate to severe (8-35) = addition of 5-alpha reductase inhibitor (Finasteride) to reduce serum DHT and therefore prostate volume
Surgical management:
- Urethral stenting or catheterisation
- TURP
- Open prostatectomy
Complications of TURP: bleeding, post-prostatectomy syndrome (hyponatremia resulting from systemic absorption of hypotonic irrigating fluid), sexual dysfunction (ejaculatory, erectile), urethral stricture, urinary incontinence
Complications of open prostatectomy: impotence, urinary incontinence, urethral stricture, inguinal hernia
268 An 81 yoa man presents to the ED complaining of difficulty passing urine. This has been a problem for 6 months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else. What is the diagnosis? What features of the prostate, if found on examination, would make you concerned about prostate cancer?
Diagnosis: BPH
International Prostate Symptom Score (I-PSS): incomplete void, frequency, intermittent flow, urgency, weak stream, straining to begin urination, nocturia
Other non-scored symptoms: hesitancy, terminal dribbling, pis-a-deux
Obstructive symptoms: weak stream, intermittent flow, hesitancy, terminal dribbling, incomplete voiding, straining to begin urination
Irritative symptoms: frequency, nocturia, urgency, pis-a-deux
Examination features suggestive of prostate cancer:
- Nodular, asymmetrical surface
- Large, indurated, irregular gland with evidence of extension beyond capsule
- Tumour fixed to bone or adjacent pelvic organs
- Systemic features: fatigue, weight loss, night sweats, bone pain
- Risk factors: >50yo, fx, African ethnicity
269 What are the advantages of screening 55 year old man with a PSA test for prostate cancer?
Low risk
Easily conducted
Widely available
Rise in PSA can precede symptoms by 5-10 years
Increased benefit to high risk individuals (African-American, fx)
270 What are the disadvantages of screening 55 year old man with a PSA test for prostate cancer?
Screening is a test used in the general population to diagnose diseases before they become clinically detectable for the aim of improving mortality.
The Australian College or Urologists currently does not recommend the use of PSA as a screening tool. The disadvantages of this tool are both to the individual and the healthcare system
- *Individual**
- PSA is not a particularly sensitive or specific tool. That is, it is neither good at detecting or ruling out prostate cancer
- PSA increases the detection of prostate cancer, but does not significantly, if at all, prevent mortality as it detects cancers that would not have otherwise caused harm
- In increasing cancer diagnoses, PSA increases psychological distress without a morbidity or mortality benefit
- Biopsies following a positive PSA confer a time, financial and psychological burden to patients. They may also cause bleeding and infection
- Prostatectomies following a prostate cancer diagnosis confer a significant risk of incontinence and sexual dysfunction
- *Population**
- PSA and the investigations that follow a positive result confer a significant burden on the healthcare system without improving mortality
- These dollars may be better invested in areas with a proven mortality for dollar benefit
271 What are the classical symptoms and signs of renal cell carcinoma?
Classic triad of RCC presentation = frank haematuria + palpable abdominal mass + flank/loin pain
- Only present in max. 9% of patients BUT when present strongly suggests locally advanced disease
Common presentations:
- Microscopic haematuria, often discovered incidentally (VERY common occurrence)
- Incidental finding on imaging (CT or USS)
272 A 60 year old woman attends ED with a 3 week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for 1 month. The is nothing remarkable in the rest ofher history. On exam, she is pale, pulse of 100bpm, BP 105/70mmHg, her Hb is 8.2g/dl with a pattern consistent with iron deficiency, rest of her blood work is normal. What is the important diagnosis to exclude, what factors are relevant in taking a history in this case?
Diagnosis to exclude: urinary malignancy (likely bladder/lower renal tract)
Haemodynamic instability due to blood loss is also an immediate concern
Profile:
• Age >35 at higher risk, peak incidence of RCC is 50-70yo
• Gender - women tend to have more UTIs, men have a higher incidence of cancer
Presenting complaint:
• UTI symptoms - dysuria, frequency, urgency, nocturia
• Pain - indicative of inflammation or acute urinary obstruction
- Flank ⇒ pyelonephritis, renal nephrolithiasis
- Groin ⇒ stone
• Timing of blood in urine stream
- Initial/terminal ⇒ urethra, prostate, seminal vesicles, bladder neck
- Total haematuria ⇒ bladder, upper tract (kidney, ureter)
• Previous episodes
• Trigger - recent trauma, vigorous physical activity
• Risk factors for RCC - smoking, fx cancer
• Malignancy red flags - unexplained weight loss, fatigue, bone pain, night sweats
Past medical history:
• Recent urological or abdominal procedures
• Nephrolithiasis
• Past or present infections
• Chronic cystitis
• Gynaecological history
Medications:
• Chemotherapy (cyclophosphamide)
• Analgesic abuse
Social:
• Smoking
• Alcohol
• Occupation - printer, painter, chemical plant worker?
• Chemical exposures - benzenes, aromatic amines
• Recent travel
273 You are an ED intern. A 40 yoa woman presents to the emergency department. She has a fever of 39.4C, Blood pressure of 90/40mmHg, pulse 120 regular, respiratory rate of 24, she is drowsy and confused when answering questions. She initially complained of left sided abdominal pain, and the pain came in waves 3 - 10 minutes apart, with an urge to pass urine. She has a history of left sided renal calculi, and 48 hours before presentation she had lithotripsy (ESWL) to her left sided kidney stone. What is the likely diagnosis? What will you do?
Likely diagnosis = ureteric colic with uroseptic shock due to superimposed infection (likely a complication of ESWL)
Left-sided pain + colicky + urgency = ureteric colic
Fever + hypotensive + tachycardia + tachypnoeic + drowsy/confused = urosepsis
1) Sepsis 6
- Give: high flow O2 + fluid challenge + empirical antibiotics (gent + amoxy/ampicillin OR ceftriaxone)
- Take: blood cultures + lactate and bloods (esp. Cr) + hourly urine output measurement
2) Urine
- Dipstick
- MCS
- b-hCG
3) Other supportive measures
- Analgesia
- Anti-emetics
- Consider Tamsulosin (a1 adrenergic blocker) or Nifedipine (CCB) to promote smooth muscle relaxation of ureters
4) Imaging
- CT KUB (given temperature >38)
- USS KUB
5) Call for urgent urological consult
- Likely requires urgent decompression with ureteric stent OR drainage via percutaneous nephrostomy tube
274 A 30 year old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is seperate from the rest of the testis and epidisymis, is not tender and does not transilluminate. Abdominal and chest exam are normal. What is the likely diagnosis, what are the necessary investigations?
Likely diagnosis: testicular cancer (assume until proven otherwise)
Key features present: painless lump, smoker, doesn’t transilluminate, age 20-35 (peak incidence, 80% of cases)
Investigations:
1) Tumour markers: AFP, hCG, LDH
2) USS scrotum, abdomen
- Intra-testicular vs. extra-testicular, duplex Doppler of scrotal vasculature
- Renal masses or ascites in abdomen
3) CXR chest/abdo/pelvis for evidence of lymphadneopathy and mets
4) Histopathological confirmation following radical inguinal orchiectomy
275 A 30 year old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is seperate from the rest of the testis and epidisymis, is not tender and does not transilluminate. Abdominal and chest exam are normal. What is the likely diagnosis, how do you differentiate between different scrotal lumps on clinical examination?
Likely diagnosis: testicular cancer (assume until proven otherwise)
Key features present: painless lump, smoker, doesn’t transilluminate, age 20-34 (peak incidence, 80% of cases)
Risk factors:
- Cryptorchidism
- Gonadal dysgenesis
- Fx or personal hx
- Testicular atrophy
- Caucasian men
Differentiating scrotal lumps on examination:
1) Origin
2) Painful vs. painless (pain indicative of inflammation/infection or anatomical issue)
3) Intra-testicular vs. extra-testicular
Testis:
- Torsion = sudden onset, pain into abdomen, “Bell clapper testis” (opposite testis lies horizontal)
- Orchitis = inflammation of testis
- Testicular carcinoma = non-tender, does not transilluminate, chronically developing
- Hydrocele = excessive fluid within tunica vaginalis, non-tender, transilluminates, soft
Epididymis:
- Epididymitis = inflammation of scrotal contents usually secondary to urethral infection, acutely painful, diffusely swollen
- Spermatocele = cyst containing spermatozoa, nodular, stable in size
Spermatic cord:
- Indirect inguinal hernia = extension of swelling to inguinal ring, bowel obstruction signs
- Varicocele = dilation and tortuosity of the pampiniform plexus, “bag of worms”, L > R
- Hydrocele
Skin:
- Squamous cell carcinoma = irregular shape, enlarging, occupational/exposure risk
- Sebaceous cyst = smooth, cystic, stable in size
276 What are the indications for a person to be put on the kidney transplant waiting list?
3 inclusion criteria must be met:
1) NEED - ESRF requiring dialysis (Australia) or progressive CKD + GFR <15 (NZ)
2) SAFE - Anticipated low peri-operative mortality
3) WORTH - A reasonable post-operative graft survival (“an 80% likelihood of the transplant working for at least 5 years after transplantation”)
Exclusion criteria:
1) <80% chance of graft survival 5-years post transplant
2) Comorbidities having a significant impact on the life expectancy of the transplant recipient
- Cardiovascular (severe, non-correctable CVD would be an absolute exclusion)
- DM
- Infection (uncontrolled or chronic)
- Malignancy
- Inability to comply with complex medical therapy
- Age (not absolute, but <5% of ESRF patients >65yo end up being eligible)
Patients being considered for a second/subsequent kidney subject to same criteria
