Urology Flashcards
In new onset erectile dysfunction, check for?
DM
CAD RFs
The most common etiology of gross hematuria in 0-20 yr
UTI > GN
The most common etiology of gross hematuria in 20-40 yr
UTI > stones
The most common etiology of gross hematuria in 40-60
M: bladder tumor > stone
F: UTI > stoned
The most common etiology of gross hematuria in > 60
M: BPH > bladder tumor
F: bladder tumor > UTI
Initial gross hematuria
Anterior urethra
Terminal hematuria
Bladder neck and prostatic urethra
Total gross hematuria
Bladder and above
Inv for gross hematuria
CBC Lytes Cr, BUN INR/PTT U/A, urine S&C, cytology CT contrast U/S (alone may not be sufficient) Cystoscopy, retrograde pyelogram
Test of choice for renal parenchyma, calculi, infection?
CT urography
Renal U/S is superior to IVP in?
Evaluation of renal parenchyma, renal cyst
Insufficient for upper tract imaging.
Limited sensitivity for UCC and small renal masses
Acute Mx of severe bladder hemorrhage
Manual irrigation via catheter with NS to remove clots
Continuous bladder irrigation
Cystoscopy if active bleeding (Dx, coagulation)
If refractory bleeding: Bilateral nephrostomy tube Hyperbaric oxygen Intravesical agents (Al-K-SO4, silver nitrate, formalin) Embolization, ligation (iliac branches) Cystectomy and diversion
Definition of microscopic hematuria
2 or more RBC/HPF in at least 2 separate samples
1st step in microscopic hematuria
R/O benign reversible causes:
Mense Heavy exercise Meds Urethral trauma Infection
And retest after underlying cause resolved
Indications of referal to nephrology
Evidence of glomerular disease: Raised Cr Dysmorphic RBC RBC cast Proteinuria
If no benign/reversible condition identified and no indication for referral, what’s the next step?
Renal U/S
Urine cytology
Indications for referral to urology for cystoscopy
Positive findings on U/S or urine cytology
High-risk pt: >40 Smoking Hx Occupational chemical exposure Gross hematuria Hx of storage/voiding symptoms Hx of recurrent UTIs Hx of urological disorders Pelvic radiation exposure
If negative for benign/reversible conditions and U/S and urine cytology in low-risk pts
Urinalysis, urine cytology, BP
At: 6, 12, 24 and 36 mo
Contraindications to CT contrast
Renal failure
Pregnancy
Allergy
Type of urinary incontinence caused by hypoestrogenemia
Stress incontinence (interinsic sphincter deficiency)
Types of stress incontinence
Urethral hypermobility: Childbirth Pelvic surgery Aging Levator muscle weakness Obesity
Intrinsic sphincter deficiency: Pelvic surgery Neurologic problem Aging Hypoestrogen state
Dx of urge incontinence
Hx
Urodynamic studies
Tx of urge incontinence
Lifestyle changes:
Fluid alterations
Diet
Bladder habit retraining
Anticholinergics
B-3-agonists
Botulinum toxin A
Neuromodulation
Dx of stress incontinence
Hx
Stress test (cough, valsalva)
Urodynamics
Tx of stress incontinence
Wt loss
Kegel exercise
Bulking agents
Surgery
Dx of mixed incontinence
Hx
Urodynamics
Stress test
Tx of mixed incontinence
Combination of stress and urge incontinence managements
Meds causing urinary retention
Anticholinergics Narcotics Antihypertensives (ganglionic blocker, methyldopa) Ephedrine/pseudoephedrine Antihistamines Ecstasy
Contraindications to urethral cath
Trauma pt unable to void
Trauma pt with blood at urethral meatus
Trauma pt with scrotal hematoma
Trauma pt with high riding prostate
Investigations for urinary retention
CBC Lytes BUN, Cr U/A, Urine S/C U/S Cystoscopy Urodynamic studies PVR
Tx of urinary retention
Underlying
Acute retension:
Immediate cath
Leave Foley in
Closely monitor fluid status/lytes
Chronic retention:
Intermittent cath by pt
Suprapubic cath if urethral not possible
Mx of post operative urinary retrntion
Encourage ambulation
a-blockers to relax bladder neck outlet
May need cath
Definitive treatment depends on etiology
BPH inv
U/A Cr Renal U/S PSA Uroflowmetry PVR \+/- cystoscopy, bladder U/S, Bx
Tx of BPH
Asymptomatic pt or symptomatic without bother
Watchful waiting
50% improve spontaneously
Tx of BPH
Mod-sev symptoms that are distressing for pt
LSM:
Evening fluid restriction
Planned voiding
a-adrenergic antagonist
5-a-reductase inh
Combination is synergistic
Anti-cholinergic/B3-agonist: if storage symptoms without elevated PVR
Indications for surgical BPH Tx
Significant symptom burden
Acute urinary retention
Refractory hematuria
Recurrent infections
Pt with BPH who wishes to avoid surgery
Microwave therapy
TUNA
Stent
Med contraindicated in men with BPH who plan to undergo cataract surgery
a-adrenergic antagonist
Floppy iris syndrome during surgery
Absolute indications for BPH surgery
Renal failure with obstructive uropathy
Refractory urinary retention
Relative indications for BPH surgery
Recurrent UTIs
Recurrent refractory hematuria
Renal insufficiency
Bladder stone
Inv for urethral stricture
Uroflowmetry
(Flow rate < 10 ml/s)
U/A (pyuria)
RUG
VCUG
Cystoscopy
Tx of urethral stricture
Urethral dilatation (high recurrence rate)
Visual internal urethrotomy (high recurrence rate)
Open surgical reconstruction
Nerve roots for bladder function
Sympathetic: T10-L2
Somatic (pudendal): S2-4
Parasympathetic: S2-4
Pontine micturition center
Activated by information from stretch receptors in bladder wall
Activates parasympathetic neurons
Inhibits sympathetic and somatic neurons
Neurogenic detrusor overactivity, location of lesion
Above PMC
Intact pathway inferior to PMC
Coordination of bladder and sphincter maintained
Location of lesion in detrusor sphincter dyssynergia
Suprasacral lesion of spinal cord
Loss of coordination between detrusor and sphincter
Detrusor overactivity
Detrusor atony/areflexia location of lesion
Sacral cord or peripheral efferents
Flaccid bladder
May progress to poorly compliant bladder with high pressures
Deficient bladder sensation
Increasing residual urine, leading to decompensation
Evaluation for neurogenic bladder
Hx, P/E
Voiding diary
Cath volumes if CIC
U/A
Renal profile
U/S
Cystoscopy
Urodynamic studies: Uroflowmetry (flow rate, flow pattern) Filling CMG (Capacity, compliance, detrusor overactivity) Voiding CMG (pressure flow study) Video study EMG and video (for Dx of DSD)
Goal of treatment of neurogenic bladder
Prevention of renal damage, infection
Achieve social continence
Tx of neurogenic bladder
Bladder hyperactivity:
Anticholinergics
If refractory: botulinum toxin injection,augmentation cystoplasty
Urinary diversion
Flaccid bladder:
CIC
Inv for disuria
Gonococcus/chlamydia testing of any discharge
Wet mount if vaginal discharge
U/A, urine C&S
+/- Empiric AB if suspect infection
+/- imaging of Urinary tract
Med causing hydronephrosis
a-adrenergic agonist
Inv for hydronephrosis
CBC Lytes BUN, Cr U/A, S&C U/S MAG3 diuretic renogram
Goal of Tx of hydronephrosis
Improving symptoms
Treating infections
Improving renal function
May require percutaneous nephrostomy tube, ureteral stenting
Post-obstructive diuresis definition
> 3 L/24h
Or
200 cc/h over each of 2 comsecutive hours
Physiologic POD course
Resolves within 48h with PO fluids
May persist
Pathologic POD
Na wasting nephropathy (impaired concentrating ability of renal tubules)
Etiologies:
Reduced reabsorption of NaCl in the thick ascending limb and urea in the collecting tubule
Increased medullary blood flow
Increased flow and solute concentration in the distal nephrons
Mx of POD
Admit
Closely monitor hemodynamic status and lytes
Na, K q6-12h
Cr, BUN (follow to baseline)
U/O q 2h
Ensure total intake < U/O (replace every 1 mL U/O with 0.5 mL 1/2 NS IV)
PO fluid if physiologic POD
Avoid glucose containing fluid
Definition of frequency and nocturia
Frequency: voiding 8 or more times/24 h
Nocturia: awakening One or more times at night to void
Overactive bladder definition
Urgency+ frequency + nocturia
Inv for overactive bladder
U/A
+/- PVR
Cystoscopy
Urodynamics
Tx of overactive bladder
Bladder training
Bladder control strategies
Pelvic floor muscle training
Fluid management
Avoidance of caffeine, alcohol
Anticholinergics
B3-adrenergics (mirabegron)
If refractory: botulinum toxin bladder injection
Neuromodulations
Anti-muscarinics
Oxybutynin
Tolterodine
Solifenacin
Fesoterodine
Trospium
Complicated UTI
Structural or functional abnormality
Male
ImmComp
DM
Iatrogenic complication
Pregnancy
Pyelonephritis
Catheter-associated
Uncomplicated pyelonephritis with enterococcus infection, Tx?
Ampicillin
Typical UTI organisms
KEEPS
Klebsiella E.Coli Enterococcu Proteus Pseudomonas S. Saprophyticus
Indications for investigation in UTI
Pyelonephritis
Persistence of pyuria/symptoms following adequate AB Tx
Severe infection with an increase in Cr
Recurrent/persistent infections
Atypical pathogens
Hx of structural abnormalities/decreased flow
UTI inv
U/A, urine S&C
Investigations if indicated: U/S, CT
Tx of UTI
If febrile, consider:
Admission, IV AB, R/O of obstruction
Simple uncomplicated UTI:
TMP-SMX, PO bid x3d
Or
Nitrofurantoin, PO bid x5d
If complicated: Cipro PO/IV x 2-3 wk Or Ampi/genta IV x 2-3 wk Or Ceftriaxon IV x 2-3 wk
Recurrent/chronic cystitis definition
3 or more/ yr
80% bacterial re-infection: with a different organism, OR the same organism cultured > 2 wk following therapy OR any organism with an intermittent sterile culture
20% bacterial persistence:
Same organism cultured within 2 wk of sensitivity-based therapy
Inv for recurrent cystitis
Assess predisposing factors
+/- cystoscopy, U/S, CT
Tx of recurrent cystitis
LSM:
Limit caffeine
Increase fluid/H2O intake
AB: continuous (6-12mo) or post-coital (within 2h)
TMP-SMX
Nitrofurantoin
Topical/systemic estrogen for post-menopause
If asymptomatic bacteriuria: NO Tx
Indications for treatment if asymptomatic bacteriuria
Pregnancy
Pt undergoing urinary tract instrumentation
Prevention of UTI
Good hydration
Cranberry juice
Wipe from front to back
Avoid feminine hygiene sprays and scented douches
Empty bladder immediately before and after intercourse
Interstitial cystitis Sx
Bladder pain (relief with emptying)
Urgency, frequency
Cystoscoy:
Glomerulation (submucosal petechia)
Hunner’s lesions (ulcer)
U/A, urine culture and smear, cytology: negative
Inv for interstitial cystitis
U/A, microscopy, C&S, cytology
Tx of interstitial cystitis
1st line: LSM, pain Mx: Diet Stress Lifestyle
2nd line: Pentosan polysulfate sodium Amitriptyline Cimetidine Hydroxyzine Intravesical DMSO, heparin, lidocaine
3rd line:
Cystoscopy with bladder hydrodistention under GA (traditionally diagnostic), treat huner’s lesion
Others:
Neuromodulation, cyclosporine A, intradetrusor botulinum
Surgery: augmentation cystoplasty
Dysuria in pyelonephritis
Concurrent cystitis
Inv for pyelonephritis
U/A, S&C
CBC, diff
Imaging (CT, U/S) if:
Suspect complicated pyelonephritis
No resolution of symptoms within 48-72 of Tx
DMSO: helps secure the Dx
If Nl: pyelonephritis excluded
Tx of pyelonephritis
Hemodynamically stable:
Outpatient
Oral AB (ciprofloxacin) x 7d
+/- single initial IV dose (ceftriaxone)
If severe/Non-resolving:
Admit
Hydrate
IV AB (Q, ampi+genta, extended cephalo, extended penicillin, carbapenem) x 14 d (total IV + oral)
Emphysematouse:
IV AB
nephrectomy when pt stabilized
Temporization with nephrostomy tube
If obstruction:
Emergent stenting
Or
Percutaneous nephrostomy
Most common urological Dx in men < 50
Prostatitis/ prostatodynia
Acute bacterial prostatitis, the most common pathogen?
E-coli
Associations of Acute bacterial prostatitis
Often associated with:
Outlet obstruction
Recent cystoscopy
Prostatic Bx
Inv for Acute bacterial prostatitis
U/A
Blood CBC, C&S
If non-resolving: TRUS
If suspect abscess: TRUS
Tx of prostatitis
Supportive
AB PO/IV:
Cipro 2-4 wk
TMP-SMX 4 wk
Ampi/genta IV 4 wk
Penicillin with Betalactamase inhibitor IV 4wk
3rd Generation cephalo IV 4wk
Q IV 4 wk
If severe obstructive symptoms or retention: Cath
Consider abscess
Chronic bacterial prostatitis etiology
Recurrent exacerbations of acute prostatitis-like signs and symptoms
Recurrent UTI with same organism
Acute vs Chronic bacterial prostatitis Sx
Acute: fever, chills, malaise. Rectal, lower back, perineal pain. Lower UTSx
Chronic: pelvic pain, storage LUTS. Ejaculatory pain. Post-ejaculatory pain
Inv for chronic prostatitis
U/A, urine C&S
(4-glass test: 1: initial stream, 2:modstream, 3: expressed prostatic secretion, 4: post-massage urine)
+ inv same as acute prostatitis
If colony count in 3 and 4 are more than 10 times greater than 1 and 2: prostatic source
Tx of chronic bacterial prostatitis
ABx (cipro 4-6 wk)
+/- BB
Chronic pelvic pain syndrome (abacterial) subtypes
Inflammatory
Non-inflammatory
Etiology:
Intraprostatic urine reflux +/- urethral hypertonia
Multifactorial
Chronic pelvic pain syndrome Sx
Pelvic pain
Storage LUTS
Ejaculatory pain
Post-ejaculatory pain
Chronic pelvic pain syndrome inv
U/A, urine C&S
(4-glass test: 1: initial stream, 2:modstream, 3: expressed prostatic secretion, 4: post-massage urine)
+ inv same as acute prostatitis
+ psychological assessment
Chronic pelvic pain syndrome Tx
Supportive
AB trial if newly diagnosed
+/- BB, anti-inflammatories, phytotherapy (quercetin, cernilton)
Etiology of epididymitis and orchitis
<35:
N. Gonorrhea
C. Trachomatic
>35: GI organisms (E.coli)
MSM:
GI organisms
Med causing epididymitis
Amiodarone
RFs of epididymitis and orchitis
UTI
Unprotected sexual contact
Instrumentation
Catheterization
Increased pressure in prostatic urethra (sterile epididymitis)
ImmComp
Inv for epididymitis and orchitis
U/A, S&C
Urethral discharge: gram stain, culture
If uncertain: Doppler U/S to R/O torsion
epididymitis and orchitis Tx
Scrotal support
Bed rest
Ice
Analgesia
if <35:
Ceftriaxone 1 dose + Doxy (10d)
If > 35:
Ofloxacin 10 d
If unsure between epididymitis and torsion
Go to OR
Prehn sign
Elevation of testicles
Relieves pain in epididymitis
No change in torsion
Discharge of gonococcal urethritis
Thick, profuse, yellow-gray, purulent
Inv for urethritis
Gram stain:
GN diplococci (gono)
Or
>4 PMN (non-gono)
Urine PCR
Urethral specimen culture
Urethral discharge in non-gonococcal infection
Mucoid, whitis, purulent
Urethritis with negative culture and unresponsive to Tx
Ureaplasma urealyticum
Mycoplasma genitalium
Trichomonas vaginalis
HSV
adenovirus
Life style factors precipitating stone formation
Minimal fluid intake
Excess: Vit C Oxalate Purines Ca
Hereditary RFs of renal stones
RTA
G6PD deficiency
Cystinuria
Xanthinuria
Oxaluria
Meds predisposing to renal stone
Loop diuretics
Acetazolamide
Topiramate
Zonisamide
Indinavir
Acyclovir
Sulfadiazine
Triamterene
Medical conditions predisposing to renal stone
UTI Myeloproliferative disorders IBD Gout DM Hypercalcemia Obesity (BMI>30)
Which BMI increases the risk of renal stone?
30
Which UTI organisms can cause stone?
Urea-splitting organisms: Proteus Pseudomonas Providencia Klebsiella Mycoplasma Serratia S.aureus
Bladder stone hematuria
Terminal hematurua
Stone inhibitory factors
Citrate
Pyrophosphate
Mg
Tamm-Horsfall gb
Radiolucent stones, visualized on CT but not on KUB
Uric acid
Radiopaque stones
Calcium
Struvite
Cystine
Uric acid (only CT)
Radiolucent stones
Uric acid
Indinavir
Atazanavir
First step in diagnosis of renal stone
Helical CT abdomen/pelvis
If negative consider other diagnoses
If positive proceed to KUB x-ray
Indications of urgent intervention for kidney stone
Solitary kidney
Bilateral stones
Intractable pain or vomiting
Acute renal failure
Septic stone
Urgent intervention for uric acid stones
Dissolution therapy
Urgent intervention for non-uric acid stones
ESWL
Ureteroscopy
PCNL
Stent/nephrostomy
Urgent intervention for septic stone
Ureteric stent
Percutaneous nephrostomy
Definitive treatment of the stone should be delayed until the sepsis has cleared
Management of stone with no indication of urgent therapy
If high likelihood of stone passage:
Observation
If low likelihood of stone passage:
Intervention
Indications for PCNL
> 2 cm
Staghorn
UPJ obstruction with correction of obstruction
Calyceal diverticulum
Cystine stones, staghorn
Anatomical abnormalities
Failure of less invasive modalities
Investigations for renal stone
CBC, U/A, Urine C&S (all)
CT (first episode of renal colic)
KUB (most of pts)
U/S (children, concern for obstruction)
Cystoscopy (if concerning for bladder stone)
Extra Inv for recurrent stones or pediatric cases
24 h urine x 2 (volume, Cr, Ca, Mg, P, Na, citrate, oxalate, cystine)
Acute Tx of renal stone
Analgesic (NSAID) Antiemetic Medical expulsion therapy (a-blocker) AB (if bacteriuria) IV fluid (if vomiting)
Surgical if sepsis, RF (obstruction endangering pt):
1st line: ureteric stent via cystoscopy
2nd: percutaneus nephrostomy
Admit if necessary
Indications for admission
Intractable pain
Intractable vomiting
Fever
Compromised renal function
PregnNcy
Indications for detailed metabolic studies
Recurrent stone
Pregnancy
Pediatrics
Strong FHx
Underlying kidney or systemic disease
Elective treatment of renal stone
Conservative if:
Renal stone < 5 mm
Ureteral stone < 10mm
+ no complication + Sx well controlled
PO fluid ( urine volume > 2 L/d, 3-4 L/d if cystine)
Medical expulsive therapy
Periodic imaging ( stone position, hydronephrosis)
Treatment specific to stone type
If Sx worsen or fail to improve, progress to interventional removal
Interventional Tx for kidney stone
Stone < 2 cm, ESWL
Stone > 2cm, PCNL
+/- stent prior to ESWL if 1.5-2.5 cm
Interventional Tx for ureteral stone
If > 10mm
ESWL or URS
2nd line: PCNL
Laparscopic, open removal
Interventional Tx for bladder stone
Transurethral stone removal
Cystolitholapaxy
Stone prevention
Fluid intake > 2 L/d
K intake
Reduce animal protein, oxalate, Na, sucrose, fructose intake
Avoid high dose Vit C supplements
Meds:
Thiazides (for hypercalciuria)
Allopurinol (for hyperuricosuria)
Potassium citrate (for hypocitraturia, hyperuricosuria)
F/U for stone formers
Periodic imaging:
Yr 1
Then q2-4 yr
The most common type of stones
Calcium
RFs for Ca stones
Hypercalciuria
Hyperuricosuria
Hyperoxaluria
Hypocitraturia
Hypomagnesemia (causes hypocitraturia and hyperoxaluria)
High dietary Na
Decreased urinary proteins
High urinary pH
Low urine volume
Hyperpara
Obesity
Gout
DM
Specific Tx for Ca stones
Cellulose phosphate
Orthophosphate
Ca-oxalate:
Thizides
K-citrate
Allopurinol
Ca-struvite:
ABx (stone must be removed)
RFs for uric acid stones
Low volume of urine
Acidic urine
Hyperuricosuria
ASA
Thiazides
Diet (purine-rich red meats)
Hyperuricosuria with hyperuricemia
Gout
High rate of cell turnover or cell death (leukemia, cytotoxic drugs)
Urine in uric acid stones
Acidic urine
pH < 5.5
Urinary uric acid not necessarily elevated
Specific treatment for uric acid stones
Alkalinization of urine to pH 6.5-7
(Bicarbonate, K-citrate)
Allopurinol
RF for struvite stones
Alkaline urinary pH
Infection with urea-splitting organisms
E.coli: not culprit
M>F
Constituents of struvite stones
Mg
PO4
NH4
Special Tx for struvite stones
Stone and all foreign bodies must be removed
ABx for 6 wk
Regular F/U cultures
Cystine stone etiology
AR
Defect in small bowel and renal absorption of dibasic aminoacids
COLA in urine: Cystine Ornithine Lysine Arginine
Cystine stone features
Children and young adults
Recurrent
FHx
Staghorn
Faintly radiopaque
Positive urine Sodium nitroprusside test
Urine chromatography for cystine
Specific Tx for cystine stone
Alkalinize urine
Penicillamine
a-MPG or Captopril (form complex with cystine)
ESWL not effective
Cyst on renal ultrasound. Next step?
Nothing if:
Hypoechoic
No calcification
Thin wall
CT with contrast (+/- aspiration, Bx)if:
Dense
Calcified
Septated
If solid mass on U/S, next step?
CT (exclude angiomyolipoma)
Large mass> 4cm:
Surgery
Small mass <4 cm:
Possible surveilence
Renal mass in TS
Angiomyolipoma
Multiple, bilateral
Cysts requiring resection on CT
Complex
Thick, irregular walls
Measurable enhancement
Or
Enhancing soft tissue components
Cysts requiring F/U on CT
Minimally complex
Well marginated
Non-enhancing
Multiple thin septa
Some thickening/calcification of septa/walls
> 3 cm
F/U: imaging q6-12 mo. If evolved: surgical resection
Cysts not requiring F/U on CT
Round,
No septation or a few thin septa
No true enhancement
No solid component
Well marginated
< 3cm
Angiomyolipoma features
F>M
20% associated with TS
Clonal, may extend to regional lymphatics and other organs
Negative attenuation on CT
Hematuria, flank pain, palpable mass
Tx of angiomyolipoma
If symptomatic, risk of bleeding (pregnancy):
Surgical resection, embolization
mTOR inh if unresectable, mets
Otherwise, F/U with U/S
Renal oncocytoma features
Benign
M>F
Spherical
Capsulated
Central scar
Bx: eosinophilic cells, originating from intercalated cells of collecting ducts
Tx of oncocytoma
Treat as RCC
Partial/radical nephrectomy if large
HIFU or RFA for smaller masses
Renal adenoma features
Most common benign
M>F
<1cm
Cortical
Benign
Tx of renal adenoma
If > 3 cm (likely not benign):
Partial/radical nephrectomy
RFs for RCC
Smoking
HTN
obesity
Horseshoe
Acquired renal cystic disease
Poor prognostic factors for RCC
Wt loss
Weakness
Anemia
Bone pain
Inv for RCC
CBC, ESR, LFT, extended lytes
U/A
Renal U/S
Contrast-enhanced CT
MRI (vascular extension)
Renal Bx
Staging w/u for RCC
CXR
CT
LFT
Liver enzymes
Bone/head imaging
RCC staging
T1: < 7cm
T2: > 7cm
T3: extension into major veins, perinephric
T4: extension into Gerota, adrenal
Tx of RCC
Radical nephrectomy
Partial nephrectomy if:
<4cm
Single kidney
Bilateral tumor
Metastasectomy (if solitary)
Palliative RT for painful bony lesions
Tx for advanced stage: tyrosine kinase inhibitors Anti-angiogenesis/anti-VEGF mTOR inh IL-2 IFN-a
RF for carcinoma of renal pelvis and ureter (UCC)
Smoking
Chemical/dietary exposure (industrial dyes and solvents):aristolochic acid, aniline
Analgesic abuse
Balkan nephropathy
DDx of filling defect
Urothelial carcinoma
Uric acid stones
Blood clot
Pyelitis cystica
Papillary necrosis
Fungus ball
Gas bubble (gas producing organism)
Inv for UCC
IVP/CT urogram
Cystoscopy
Retrograde pyelogram
Tx for UCC
Radical nephrectomy with excision of ipsilateral bladder cuff
Distal ureterectomy for distal ureter tumors
Laser ablation for low grade disease
RFs for bladder cancer
Smoking
Aromatic amines: naphthylamines, benzodine, tryptophan, phenacetine metabolites
Cyclophosphamide
Pelvis RT
Schistosoma hematobium (SCC)
Chronic irritation (SCC): Cystitis, chronic cath, bladder stones
Aristolochic acid
Chinese herbal
Features of bladder cancer
M>F
Whites
Mean age: 65
UCC: > 90%
Poorer prognosis if muscle invasion
High recurrence if non-invasive
Usually multifocal
Key symptom of bladdercancer
Hematuria
Inv for bladder cancer
U/A, C&S, cytology
U/S
CT with contrast
Cystoscopy and Bx
Tumor markers: NMP-22, BTA, Immunocyt, FDP
Gold std of Dx of bladder cancer
Cystoscopy and Bx (initial procedure of choice)
Inv for staging of bladder cancer
CT/MRI
CXR
LFT
Extended lytes
Most important prognostic factor for bladder cancer
Tumor grade
Intravesical Tx for prevention of bladder cancer progression
BCG
Staging of bladder cancer
T0: insitu
T1: subepithelial connective tissue
T2: muscularis propria
T2a: superficial
T2b: deep
T3:
Perivesical tissue/fat
T4:
Adjacent organs
Tx of bladder tumor
No muscle invasion: TURBT \+/- intravesical chemo (mitomycin), immunotherapy (BCG) \+/- repated TURBT F/U: cystoscopy, cytology
T2-T3: Radical cystectomy, lymphadenectomy Or TURBT + chemo/RT if small, non-obstructive Neoadjuvant chemo
Advanced disease: T4, mets:
Systemic chemo
+/- RT
+/- surgery
RFs for prostate cancer
> 50yr
African
High dietary fat
FHx
BRCA mutation
Leading causes of male cancer death
Lung > colon > prostate
Inv for prostate cancer
DRE PSA TRUS-guided needle Bx Bone scan (omitted if PSA<10) CT
Staging of prostate cancer
T1: clinically undetectable
T2: palpable. Confined to prostate
T3: extends through prostate capsule
T4: invades adjacent structures
Tx of prostate cancer
T1/2 (localized, low risk): If adequate life expectancy: Active surveillance Or Definitive local treatment
If short life expectancy or other comorbidities:
Watchful waiting + palliative Tx for symptoms
T1/2 ( intermediate-high risk):
Definitive therapy
T3/4: External beam radiation therapy \+ androgen deprivation OR RP + adjuvant EBRT
If node involvement or mets: Hormonal Tx Palliative RT Bilateral orchiectomy GnRH antagonist or agonist Estrogens Antiandrogens
If hormone-refractory:
Chemo
Watchful waiting vs active surveillance for treatment of prostate cancer
Watchful waiting for short life expectancy:
Non-curative hormonal therapy if progression
active surveillance:
More curative options if progression
Indication for radical prostatectomy
Young: < 75y
High riskdisease
PSA determinants for prostate cancer Dx
Increased risk of cancer if:
Decreased free/total PSA
Elevated PSA velocity
Elevated PSA density
Indications of PSA screening
Any man with > 10 yr life-expectancy and any of the following:
Suspicious finding on DRE
Mod-sev LUTS
High risk individuals
Investigating secondary carcinoma of unknown origin
Canadian guideline for prostate cancer screening
Offer to all men > 50 and > 10 yr life-expectancy
Offer to all men > 40 and > 10 yr life-expectancy and high risk factors (FHx, African)
Explain harms and benefits of screening
Established informed shared decision
Initial screen: PSA &DRE
Annual screening (q 2-4 yr is acceptable)
RFs for testicular tumor
Cryptorchidism Atrophy Sex hormones HIV Infertility Family Hx PHx of testicular cancer
Acute hydrocoele in young pt
R/O testicular cancer
Testicular cancer is more common in which testis?
Rt
The most common type of testis tumor
Germ cell tumors (95%)
Among which seminoma is the most common
Inv for testicular cancer
Dx: radical inguinal orchidectomy
B-hCG, AFP, LDH
Testicular U/S
Significance of tumor markers
Return to normal after operation (provided there’s no mets)
Markers for seminoma
AFP: never increased
B-hCG: 7%
Non-seminoma markers
B-hCG
AFP
Significance of testicular microlithiasis
Nothing
Staging evaluations for testicular cancer
CXR
Markers
CT abdomen/pelvis
Testicular cancer staging
State 1: disease limited to Testes, epididymis, or spermatic cord
Stage 2: Limited to retroperitoneal nodes
Stage 3: mets to supradiaphragmatic nodal or viceral sites
Mx of testicular cancer
Orchiectomy through inguinal ligament
Sperm banking
Testicular prosthesis
Adjuvant therapies
Adjuvant RT for:
Stage 2,3 seminoma.
Chemo:
Stage 2,3 seminoma, stage 2,3 non-seminoma.
RPLND:
For non-seminoma.
Orchiopexy and risk of malignancy, infertility, torsion
Risk of malignancy: no reduction (may reduce)
Risk of infertility: reduced
Risk of torsion: reduced
RFs of malignant penile cancers
Chronic inflammatory disease
STI
Phimosis
Uncircumcised penis
Tx of penile malignancy
Wide excision
+/- lymphadenectomy
Cryo, laser… for CIS
Torsion of testes features
Pain
Diffuse tenderness
Horizontal lie
Absent cremaster reflex
Negative Prehn’s sign
Features of epididymitis
Pain
Epididymal tenderness
Present cremaster reflex
Positive Prehn
Features of orchitis
Pain
Diffuse tenderness
Present cremaster reflex
Positive Prehn
Hematocele features
Pain
Diffuse tendernesd
No transillumination
Hx of trauma
Hydrocele
No pain
Testis not separable from hydrocele
Cord palpable
Transillumination
Hx of trauma
Spermatocele
No pain
Testis separable from spermatocele
Cord palpable
Transillumination
Varicocele
Bag of worms
No transillumination
Increase in size with valsalva
Decrease in size if supine
Indirect inguinal hernia
Cord not palpable
Testis separable from hernia
No transillumination
Generalized dependent edema (scrotom)
Diffuse swelling
Post-operative or immobilized
Liver dysfunction should be checked
Varicocele happens on which side?
90% Lt
Inv for varicocele
PEx
Tx of varicocele
Conservative
Surgical ligation
Repair improves sperm count/motility
Inv for spermatocele
P/E
U\S
Tx of spermatocele
Conservative
Excise if symptomatic
NO NEEDLE ASPIRATION
Types of hydrocele
Communicating( children)
Changes size during day
Non-communicating (adults)
Inv for hydrocele
U/S
Tx if hydrocele
Conservative
Needle aspiration
Surgery
Predisposing factors for testicular torsion
Trauma
Cryptorchidism
Bell clapper deformity
50% during sleep
Time of necrosis in testicular torsion
5-6 h
Inv for testicular torsion
U/S doppler
Decreased uptake on scintillation scan (doughnut sign)
Tx of testicular torsion
Emergency surgical exploration
Bilateral orchiopexy
Orchiectomy if poor prognosis
When to suspect retroperitoneal problem in pt with varicocele?
Acute onset
Rt sided
Palpable abdominal mass
Does not reduce while supine
Indications for Tx of varicocele
Impaired sperm quality/quantity
Pain/ache affecting QOL
Affected testis fails to grow in adolescence
Cosmetic indications
Torsion of testicular appendix
Similar Sx to testicular torsion
vertical lie
Preserved cremaster reflex
Blue dot sign (children)
Tx of testicular appendix torsion
Analgesia
Resolves over 5-7 d
Surgical exploration and excision if refractory pain
Hematocele Dx
U/S to exclude testis fx
Tx of hematocele
Ice pack
Analgesics
Surgical repair
Site of pathology in Peyronie’s plaque
Fibrous thickening of tunica albuginea
Etiology of Peyronie’s plaque
Unknown
Trauma
Repeated inflammation
FHx
Associations:
DM
Vascular disease
AI
Dupuytren’s contracture
Erectile dysfunctiin
Urethral instrumentation
Tx of Peyronie’s plaque
Watchful waiting
Verapamil (IL, topical)
Incision/excision of plaque
Shortening of less affected side
Penile prosthesis
Priapism definition
Erection > 4 h, in the absence of sexual excitement/desire
+/- pain
+/- signs of necrosis
Etiology of priapism
50% idiopathic
Ischemic:
Thromboembolic (SCA)
Non-ischemic:
Trauma
Medication
Neurologic
Priapism inv
Cavernal blood gas analysis
Doppler U/S of penis
Tx of priapism
Underlying
High flow:
Self-limited
Arterial embolization
Low flow:
Needle aspiration for decompression
Phenylephrine intracorporeal injection
Surgical shunt
Phimosis etiology
Congenital
Poor hygiene
Balanitis
Tx of phimosis
Proper hygiene
Topical CS
Dorsal slit
Circumcision
Paraphimosis etiology
Iatrogenic (post cleaning/ instrumentation)
Trauma
Infectious (balanitis, balanopsthitis)
Tx of paraphymosis
Manual pressure (with analgesia)
Dorsal slit
Circumcision (urgent/electively to prevent recurrence)
Inv for premature ejaculation
Testosterone levels if in conjunction with impotence
Mx of premature ejaculation
R/O medical conditions
Address psychiatric concerns
Counseling
SSRI
Clomipramine
Topical lidocaine-prilocaine
Erection is the function of which nerve?
Parasympathetic
Emission is the function of
Sensory afferents from glands
Secretion from prostate, seminal vesicle, ejaculatory ducts, enter prostatic urethra (Sympathetic)
Ejaculation is the function of
Bladder neck closure (sympathetic)
Spasmodic contraction of bulbo-cavernous and pelvic floor musculature (somatic)
Detumescence is the function of
Sympathetic nerve
Psychogenic erectile dysfunction characteristic
10%
Sudden onset
On and off
Variation with partner and circumstance
Younger age
No organic RF
Nocturnal/AM erection present
Organic erectile dysfunction features
90%
Gradual onset
All circumstances
No variation with partner or circumstance
Older age
Vascular RFs present
No nocturnal/AM erection
Inv for ED
Hx, P/E
Self administered questionnaires
lab (depending on clinic):
FBS, HbA1C, cholesterol profile
TSH, CBC, U/A, testosterone, PRL, LH
Specialized testing usually unnecessary
Evaluation of penile vasculature (if PHx of trauma)
Tx of ED
Non-invasive: LSM (smoking, alcohol cessation) Psychological (sexual counseling and education) Change precipitating meds Treat underlying cause
Minimally invasive:
Sildenafil, tadalafil (longer half-life, no cytopenia), vardenafil, avanafil
Vacuum devices
MUSE: men urethral suppository for erection
Invasive:
Intracavernous vasodilator injection
Surgical:
Penile implant
Penile artery reconstruction
When to refer ED pt
Failed medical therapy
Penile anatomic abnormality
Pelvic/perineal trauma
Psychogenic cause
Endocrinopathy
Vascular/neurologic assessment
Classification of renal trauma severity
Minor:
Contusion
Hematoma
Superficial laceration
Major:
Laceration extending into medulla and collecting system
Major renal vascular injury
Shattered kidney
Inv for renal trauma
U/A:
Hematuria requires W/U
CT (contrast, triphasic) if pt stable
When to send home pt with renal trauma
Microscopic hematuria + isolated well-staged minor injuries
Wham to admit pt with renal trauma
If gross hematuria
+ contision/minor laceration
Tx: hospitalize, bed rest, repeat CT if bleeding continues
Indications for intervention in renal trauma (surgical, embolization)
Absolute:
Hemorrhage and hemodynamic instability
Relative: Non-viable tissue and major laceration. Urinary extravasation. Vascular injury. Expanding or pulsatile perirenal mass Laparotomy for associated injury
Inv for bladder injury
U/A (90% gross hematuria)
CT cystogram and post drainage films for extravasation
Tx of bladder trauma
Penetrating trauma:
Surgery
Contusion:
Urethral cath until hematuria completely resolved
Extraperitoneal perforation: Foley. F/U with cystogram. Surgery if: Infected urine Rectal/vaginal perforation Bony spikes into bladder Laparotomy for concurrent injury Bladder neck involvement Persistent urine leak Failed conservative Mx
Intraperitoneal perforation:
Surgical repair + suprapubic cath
Urethra trauma mechanism
Posterior (at the junction of prostatic and membranous urethra):
Blunt trauma, shearing forces, pelvis fx, MVC
Anterior urethra:
Straddle injury
Other causes:
Penile fx, masturbation with urethral manipulation, iatrogenic
Inv for urethra trauma
Always R/O bladder rupture
RUG or Cystoscopy prior to cath
Tx of urethra rupture
Simple contusion:
No Tx
Partial urethral disruption:
Very gentle attempt at cath by urologist
If no resistance: Foley for 2-3 wk
If resistance: suprapubic cystostomy or urethral cath alignment
Periodic flow rates/ urethrograms
Complete disruption:
Immediate repair if pt stable
Suprapubic cath with delayed repair if unstable pt
Inv for infertility
Semen analysis:
At least 2 specimen, collected 1-2 wk apart
Hormonal evaluation:
Indicated with abnormal semen analysis.
Tests: testosterone, FSH (if abnormal, LH, PRL)
Genetic evaluation
Immunologic studies:
Anti-sperm ab (in ejaculate and blood)
Testicular Bx
Scrotal U/S
Vasography (patency of vas deferens)
Tx of male fertility
Assessment of partner
LSM:
Exercise
Healthy diet
Eliminate alcohol, tobacco, illicit drugs
Medical: Endocrine therapy Tx retrograde ejaculation D/C anti sympathomimetics \+/- a-adrenergic Tx underlying infection
Surgical:
Varicocelectomy
Vasovasostomy
Transulethral resection of blocked ejaculatory duct
Assissted reproductive technologies
Normal semen
Volume: 2-5 mL
Concentration: > 15 million/ml
Morphology: 30% normal forms
Motility: > 40% adequate forward
Liquefaction: complete in 20 min
pH: 7.2-7.8
WBC: < 10 HPF or <106/mL
Male reproductive system abnormalities in CF
Congenital bilateral absence of vas deferens and epididymal cysts
Tracks causing male infertility
Alcohol
Tobacco
Cocaine
Marijuana
If azospermia, next step?
FSH
If high/normal: testis Bx (if normal = obstruction)
If low: hypogonadotropic hypogonadism
If absent/low volume ejaculation, next step?
R/O short abstinence, incomplete collection.
If non of the above:
Post ejaculatory U/A
If liw/absent ejaculatory volume, and U/A negative for sperm, next step?
Transrectal U/S:
If abnormal anatomy: determine level of obstruction
If normal anatomy: emission failure
Course of antenatal hydronephrosis
Most resolve during pregnancy or within the first year of life
(1-5% of fetal U/S)
Education for antenatal in utero intervention bored Antenatal hydronephrosis
If there is evidence of lower urinary tract obstruction with oligohydramnios
Dx of PUV
Most commonly recognized on prenatal U/S:
Bilateral hydronephrosis
Thickened bladder
Dilated posterior urethra or keyhole sign
Oligohydramnios
VCUG:
Dilated and elongated posterior urethra, trabeculated bladder, VUR
Tx of PUV
Immediate cath (relieve obstruction)
Cystoscopic resection of PUV when baby stable
Vesicostomy if resection not possible
The most common congenital defect of ureter
UPJ obstruction
M>F
40% bilateral
Dx of UPJ obstruction
Mostly asymptomatic finding on Antenatal U/S
Renal scan +/- furosemide
Tx of UPJ obstruction
Surgical correction
Nephrectomy if < 15% differential renal function
RFs for VUR
White race
F>M
Age < 2y
Genetic predisposition
Inv for VUR
BP
UTI: U/A, C&S
RF: serum Cr
Growth parameters: Ht, Wt
Renal U/S
DMSA renal scan
+/- sibling screening
Course and Tx of VUR
Spontaneous resolution in 60% of primary cases
Goal of Tx in lower stages:
Prevention of UTI
Prevention of renal damage
Tx:
Daily AB (Px at half the treatment dose):
TMP/SMX, TMP, amoxicillin, nitrofurantoin
Indications for surgical treatment of VUR
Failure of medical management
Renal scarring (renal insufficiency, HTN)
Breakthrough UTIs
Persistent high-grade reflux (stage 4,5)
Tx of hypospadiasis
Optimal time of repair < 2yr
DO NOT CIRCUMCISE
Associations of hypospadiasis
White race
Cryptorchidism
Inguinal hernia
Disorders of sexual differentiation
Ventral Penile curvature
Distal > proximal
Tx of epispadias
Surgical correction at birth
Wilm’s tumor
Average age: 3y
Congenital malformation: in 10%
Bilateral: 5%
Inv for Wilm’s tumor
Investigate other kidney, and renal vein
Tx of Wilm’s
Unilateral:
Radical nephrectomy
+/- RT/Chemo
Bilateral:
Nephron-sparing surgery + adjuvant chemo
Most common site of testis in cryptorchidism
Denis Brown pouch ( between external oblique and Scarpa fascia)
External inguinal ring > inguinal canal > abdomen
Fertility rate in treated cryptorchidism
Bilateral: 53%
Unilateral: 90%
Normal men: 93%
Palpable gonads in Disorder of sexual differentiation
= chromosomal male
Lab tests for Disordered sexual differentiation
17-OH-prog
11-desoxycortisol
Basal adrenal steroid levels
Testosterone and DHT (pre- and post- hCB stimulation)
Lytes
Chromosomal evaluation
U/S of adrenal, gonads, uterus, fallopian tubes
Endoscopy, genitography of urogenital sinus
Tx of sexual differentiation disorder
Steroid supplementation as indicated
Sex assignment
Reconstruction of external genitalia (6-12 mo)
Long-term psychological guidance and support
Male phenotype newborn with no palpable testes
Bilateral cryptorchidism
Or
Female with salt wasting CAH
Catheter for BPH
Coudé
Cath for urethral disruption/obstruction
Filiform
Cath in pelvic fx
Contraindicated
HIV and circumcision
Male circumcision reduces risk of HIV acquisition in heterosexual men
Not enough evidence in MSM
Medical indications for circumcision
Phymosis
Recurrent paraphymosis
Recurrent UTI esp in infants
Balanitis xerotica obliterans
Other chronic inflammatory conditions
Contraindications to circumcision
Unstable/sick infant
Congenital genital abnormalities
FHx of bleeding disorders (investigate first)
Benefits of circumcision
Prevention of UTI
Prevention of penile cancer
Prevention of transmission of some STDs
benefits outweigh risks
Canadian pediatric society is opposed to routine circumcision
Indications for cystoscopy
Gross hematuria
LUTS
Urethral and bladder neck stricture
Bladder stones
Bladder tumor surveillance
Evaluation of upper tracts with retrograde pyelography
AB for cystoscopy?
Recommended prophylactically
The part of prostate that is removed in TURP
Periurethral portion and transition zone
Indications for TURP
Obstructive uropathy:
Large bladder diverticula
Renal insufficiency
Refractory urinary retention
Recurrent UTI
Recurrent gross hematuria
Bladder stones
Intolerance/failure of medical therapy
Contraindications for ESWL
UTI
Obstruction distal to stone
Coagulopathy/ bleeding diathesis
Pregnancy
Contraindications to PDE5 inh (sildenafil)
With nitrates
Hx of priapism
Conditions predisposing to priapism: Leukemia Myelofibrosis Polycythemia SCD
Med useful for both stress and urge incontinence
Imipramine
Sympathomimetic effect
