Urology Flashcards
Benign prostate enlargement
Pathology (3 components)
Features
Hyperplasia of epithelial and stromal prostatic components due to age-related hormonal changes (androgen/oestrogen imbalance)
Static component due to increased epithelial tissue in transitional zone
Dynamic component due to increased stromal smooth muscle tone (prostatic capsule) which has high number alpha-1a receptors
Storage symptoms
-FUN - frequency, urgency, nocturia
Voiding symptoms
-HIIPP - hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling
Ix for BPH
DRE
TRUSS ± biopsy
PSA - increased may indicate prostate cancer or prostatitis
Urinalysis
MSU/urine dip to rule out pyuria and complicated UTI
Scoring system
IPSS - International Prostate Symptom Score (0-35) also includes quality of life
Volume chart
USS KUB
Management for BPH
For all
Mild with symptoms
Abnormal DRE/PSA
For all = behavioural management
-Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids
Mild - FIRST LINE: Alpha blocker (tamsulosin or doxazosin - Relax smooth muscle) or 5-alpha reductase (finasteride - Reduce conversion of testosterone) or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)
Abnormal DRE or elevated PSA
- Surgical referral
- Prostate < 80g - TURP or TUVP (transurethral resection/vaporisation)
- Prostate > 80g - Open prostatectomy
TURP syndrome
What
Features
Management
Consequence of absorption of irrigating fluids into prostatic venous sinuses
Fluid overload, disturbed electrolyte balance, hyponatraemia and hypothermia (bladder source of heat loss) i.e. hypertension + reflex bradycardia, restless, headache, N + V, confusion
MGMT: is supportive, 100% O2 non-rebreather, monitor BP with arterial line, correct hyponatraemia
Causes of Acute urinary retention Men Women Infection M/F Drugs Neuro
Men - BPH (by far most common of all) , prostate cancer, meatal stenosis
Women - Prolapse (cystocele, rectocele, uterine), pelvic mass (uterine fibroid, ovarian cyst, gynae malig)
Both - Bladder/urethral calculi, bladder cancer, faecal impaction
Infectious/inflammatory
M: balanitis, prostatitis, F: vulvovaginitis, B: bilharzia (schisto), cystitis
Drug-related - ANTICHOLINERGICS (antipsych, antidep, antichol resp agents), ALCOHOL, opioids, alpha agonists
Neurological - Autonomic neuropathy (DM), spinal cord damage (disc disease, MS, spinal stenosis, cauda equina, cord compression), pelvic surgery
Prostate cancer
What
Spead
Risk factors
Malignant neoplasm of glandular origin (adenocarcinoma) arising in the peripheral prostate
Local - through capsule to seminal vesicles, bladder, rectum
Lymphatic - pelvic LNs
Haematogenous - *bone sclerotic (90%), lung (50%) and liver
+ve family history (x2 for one relative)Increased testosterone
Genetic: BRCA and HPC-1 (hereditary prostate cancer)
Prostate cancer
Presentation
>50years LUTS: fill and void Haematuria Weight loss/anorexia/lethargy (advanced metastatic) Bone pain (advanced metastatic) Palpable LNs (advanced metastatic)
Ix for prostate cancer
PSA (protease responsible for liquefaction of semen - prostate specific not prostate cancer specific)
(Normal = 0-4 ng/ml)
DRE - hard and irregular prostate
TRUSS + biopsy (infection 1pc serious, bleed, retention, fp)
Abnormal cells in 2 different samples
MRI + CT for staging
Isotope bone scan for metastasis (If PSA > *20)
Testosterone (baseline if considering androgen deprivation)
FBC/LFT - normal
Metastatic prostate cancer
80% are androgen sensitive -> castration leads to remission
Androgen deprivation therapy/chemical castration
-Goserelin + tamoxifen + flutamide
Surgical castration - risk of impotence if cut cavernous nerve of penis
Bladder cancer
Types
Risk factors (4)
Transitional cell carcinoma (90% of west) may also occur at ureter or renal pelvis
Squamous cell carcinoma in schistosomiasis
Smoking (50%)
Occupational - rubber + dye, aluminum and coal
Age, 70% > 65
Pelvic radiation (prostate Ca)
Men > Women
HNPCC for upper tract urothelial cancers
Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma
Bladder cancer
Presentation
Ix (4)
Painless haematuria (frank or microscopic), dysuria, abdominal mass, RFs, systemic weight loss + bone pain
Urine dip
Haematuria (80% of patients) ± pyuria
Urine MC + S - cancers may cause sterile pyuria
KUB USS
*Flexible cystoscopy with biopsy TURBT
CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour or obstruction
Urinary cytology - abnormal cells
FBC - mild anaemia
CXR, isotope bone scan, alkaline phosphatase etc…
Bladder complications (4)
Hydronephrosis Upper tract TCC Prostatic urethral TCC Urinary retention Recurrence
Causes of discoloured urine
Other causes of discoloured urine are myoglobinuria (rhabdomyolysis or muscle destruction), haemoglobinuria (haemolytic anaemias), beeturia (beetroot), rifampicin = pseudohematuria
Causes of haematuria
Medical
Surgical
UTI Warfarin/clopidogrel etc Coagulopathies Menstruation contamination (pseudohaematuria) Acute pyelonephritis Trauma/instrumentation
Stones
Urological malignancy - renal, bladder, ureter, prostate
BPH
Ix for haematuria (4)
Urine dip - protein implies renal Culture - infection DRE - prostate Bloods -FBC: Hb/pt -Clotting/coagulation studies/INR -WCC (infx) -PSA -Nephrological - eGFR, Cr
Catheters
SPC vs urethral
Complications (3)
SPC more comfortable, more convenient change, better self-image, better sexual function
SPC increased risk cellulitis, leakage, prolapse through urethra
Failure e.g. phimosis, BPH (try a larger catheter)
Create false passages
Urethral strictures/perforation/bleeding
Infection (E.coli) bacteriuria is inevitable
UTIs
When complicated (5)
Management
Male, pregnant, children, recurrent (≥2 in 6 months, ≥3 in 12 months), immunocompromised, decreasing renal function, abnormal renal tract/obstruction, catheter in situ
Trimethoprim 3 days (in uncomplicated)
Nitrofurantoin 7 days (in pregnancy as trimethoprim is teratogenic)
Men/Resistant -> ciprofloxacin (500mg orally BD for 1-2 days)
Outpatient + pregnant - nitrofurantoin or cephalexin
Requiring hospitalisation + not pregnant - IV gentamicin
DDx of UTI
Overactive bladder (-ve dipstick)
Urothelial Ca (positive urine cytology)
Non-infectious urethritis (dysuria in absence of UTI)
STI (discharge) - -ve urine dipstick, analysis and MC+S
Interstitial cystitis - painful bladder syndrome, pain associated with bladder filling + urgency and frequency in absence of UTI
Prophylactic abx in catheter change
May consider prophylactic antibiotics when changing catheter (amoxicillin 2g oral, 1 hour before procedure)
Acute prostatits features
Lower abdominal, ejaculatory, rectal and perineal pain
Evidence of recent or ongoing infection (acute LUTS + fever, chills, malaise)
Prostatitis
Ix
Treatment
Urinalysis (microscopy - leukocytes, bacteria), urine culture (MSU, MC+S)
Culture of prostatic secretions (by massage)
Blood cultures (important in acute + febrile)
Serum PSA (may be elevated)
STI screen
TRUSS (?prostatic abscess)
No sepsis - fluoroquinolone oral for 2-4 weeks (ciprofloxacin 500mg PO BD) + NSAID + relief of obstruction + drainage of abscess
Chronic - 4/6 weeks ciprofloxacin ± alpha blocker ± NSAID
Causes of Urethritis
Complications
N.gonorrhoeae, C.trachomatis - Cause discharge
Untreated gonococcal urethritis may disseminate -> reactive arthritis, meningitis, endocarditis
Non-gonococcal urethritis -> reactive arthritis or infertility
Acute epididymo-orchitis
Presentation
Cause in <35/>35/Elderly
Unilateral pain and swelling (developing over days): may be associated with LUTS, discharge and fever -> must rule out a torsion
STI: c.trachomatis, n.gonorrhoeae (?viral - mumps orchitis)
UTI: enteric pathogens (e.coli, enterococcus) + association with bladder outlet obstruction, instrumentation of urinary tract
Catheter
Acute epididymo-orchitis
Ix
Treatement
First catch urine or NAAT for chlam/gon
Gram stain urethral secretions - intracellular gram neg diplocococci
Urine dip - +ve leucocyte esterase
Urine microscopy (first void) - > 10 WBC per high power field
Urine culture
Colour duplex USS - enlarged hyperaemic epididymis
Surgical exploration (torsion)
Likely STI: single dose ceftriaxone IM (250mg) + doxycycline (100mg PO 14D) Likely UTI (enteric): levofloxacin (500mg PO 10D)
Nephrolithiasis
Presentation
DDx (5)
Acute severe flank pain: renal colic = loin to groin, unilateral, nausea/vomiting+ worse on fluids+ microscopic haematuria+ symptoms depending on site
Acute appendicitis - -ve urine and CT
Ectopic pregnancy: preg test +ve and raised HCG
Ovarian cyst: AUSS - cystic adnexal lesions
Diverticular disease - NCCT shows absence of renal stones
*AAA or UTI - USS/CT abdomen shows presence of AAA - Consider this for 50+ until proven otherwise
Nephrolithiasis
Ix
*NCCT (Gold-standard) - 99% sensitive - stones (white) in collecting system, ureter ± hydropehrosis
Urinalysis - urine dip and MC+S
Microhaematuria, ± leukocytes, nitrates
FBC - raised WCC -> infection
U+E+Cr- hypercalcaemia (PTH), hyperuricaemia (gout)
Management
Acute
Stone with no obstruction <10mm/>10mm
Stone with obstruction
Hydration, pain control (IV ketorolac/morphine), anti-emetics (ondansetron) or RECTAL DICLOFENAC
< 10mm
Medical expulsive therapy - alpha blocker (tamsulosin) or CCB (nifedipine)
>10mm
Surgical: ESWL (extracorporeal shock wave lithotripsy) + ureteroscopy/Percutaneous ureteroscopy if > 15mm/Percutaneous nephrostolithotomy if >20mm
Scrotal swelling 2 Rules DDx if: Separate and cystic Separate and solid Testicular and cystic Testicular and solid Can’t get above
A testicular lump is cancer until proven otherwise
Acute, tender enlargement is torsion until proven otherwise
Epididymal cyst
Epididymitis or varicocele
Hydrocoele
Tumour/orchitis
Inguinal hernia
Epididymal cycst What When Presentation Ix
Smooth extratesticular + spherical cyst in head of epididymis
Common and benign and require no Rx. Present around puberty
Small painless cysts, bilateral. Will transilluminate. Testes is palpable as separate
USS for confirmation, aspiration (milky fluid = spermatocele)
Varicocele
What
Presentation
Abnormal dilatation of internal spermatic veins and pampiniform plexus due to increased hydrostatic pressure in left renal
90% left sided, 10% bilateral - Painless scrotal mass.
Dull ache & Feels like bag of worms
Nb. More pronounced on valsalva manoeuvre
Hydrocele
What
Types
Causes infant/adult
Collection of serous fluid between layers of the tunica vaginalis or along the spermatic cord
Communicating and non-communicating
Infant -> primary, common, most are congenital and resolve in the first year of life
Adult -> secondary to minor trauma, infection, torsion, tumour, varicocele operation
Presentation of hydrocele
Scrotal mass either restricted to scrotum or extending to inguinal canal (communicating).
Testicular and cystic
Transilluminated by light
Enlargement post activity (increased intra-abdominal pressure)
Testicular torsion
What
Presentation
Testicular torsion is a urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of vascular supply and time-sensitive ischaemia of testicle
TENDER, SWOLLEN, HOT, HIGH AND TRANSVERSE + LIE
Absent cremasteric reflex
Nausea and vomiting, Abdominal pain
Testicular cancer
Presentation
Diagnosis & Blood tests (3)
Types
Hard painless testicular nodule, haemospermia, secondary hydrocele + extratesticular manifestations: bone pain (skeletal mets), gynaecomastia (B-HCG), lower extremity swelling (venous occlusion), back pain (seminoma - para-aortic nodes)
USS of testicle is 90-95% accurate in diagnosis
Alpha-fetoprotein (AFP) - teratocarcinoma
Beta human chorionic gonadotropin (hCG) - choriocarcinoma
Lactate dehydrogenase (LDH),
Germ cell (90%) - Teratoma/Seminoma - 30-65 year olds Non germ cell - Leydig/stromal etc - 20-30 year olds
Functions of testosterone (4)
Skin - hair growth
Brain - libido
Bone - closure of epiphysis and growth
Muscle - strength
Risk factors for erectile dysfunction (5)
Age
Pain
Vascular - HTN, CHD, diabetes, smoking, obesity
Neurological - MS, spinal cord injury
Hormonal - Decreased androgens, increased prolactin, hypothyroidism
Psychological - Anxiety, depression, substance misuse
Surgical - Prostate
Drugs - SSRI, beta-blockers, alcohol, all psych drugs
ED Ix
Nocturnal rigiscan Penile doppler USS Testosterone Prolactin Cholesterol BP
ED management
PDE5 inhibitor (sildenafil) - headache, facial flushing, CI: hypotension
Alprostadil (PGE1) intracavernosal injx (SE: fibrosis) or intraurethral
Vacuum pump
Constriction ring
Penile implant
Psychosexual therapy
1) CBT (cog/beh) - dysfunctional belief - here and now
Sensate focus (couples), personal sexual self growth programme
2) Psychodynamic therapy - relate early behavious + current problem
3) Systemic therapy - focus on processes and context
4) Integrative (MIST)
Bladder control
Detrusor contraction
Urethral contraction + inhibit detrusor
Somatic
PSNS (cholinergic) S2,3,4: pelvic splanchnic
SNS, T11 - L2: hypogastric
S2,3,4: voluntary, external urethral sphincter
Stress incontinence Mx
F: pelvic floor, physio, surgery, sling (TVT, TOT)
M: artificial sphincter, male sling
Urge incontinence Mx
Behavioural: F/V chart, caffeine, alcohol
Drugs: anticholinergics (oxybutinin), B3 agonists (mirabegron), botulinum toxin
Bladder augmentation: detrusor myectomy/*cystoplasty (small bowel)
Neurogenic bladder
What
Types
Bladder dysfunction that is either flaccid or spastic and is caused by neurological damage. The main symptom is overflow incontinence
Flaccid (hypotonic) neurogenic bladder
Bladder volume is large, pressure is low, contractions are absent
Peripheral nerve or spinal nerve damage at S2-4
High residual volume predisposes to infection and overflow
Spastic bladder
Volume is normal or small, involuntary contractions are present
Brain damage or spinal cord damage above T12
Detrusor-sphincter dyssynergia (unco-ordinated)
Involuntary urination/defecation
Neurogenic bladder presentation
Overflow incontinence (both flaccid and spastic) due to retained urine and dribbling Erectile dysfunction (men) Spastic: FUN (frequency, urgency, nocturia)
