Urology Flashcards
1
Q
In new onset erectile dysfunction, check for?
A
DM
CAD RFs
2
Q
The most common etiology of gross hematuria in 0-20 yr
A
UTI > GN
3
Q
The most common etiology of gross hematuria in 20-40 yr
A
UTI > stones
4
Q
The most common etiology of gross hematuria in 40-60
A
M: bladder tumor > stone
F: UTI > stoned
5
Q
The most common etiology of gross hematuria in > 60
A
M: BPH > bladder tumor
F: bladder tumor > UTI
6
Q
Initial gross hematuria
A
Anterior urethra
7
Q
Terminal hematuria
A
Bladder neck and prostatic urethra
8
Q
Total gross hematuria
A
Bladder and above
9
Q
Inv for gross hematuria
A
CBC Lytes Cr, BUN INR/PTT U/A, urine S&C, cytology CT contrast U/S (alone may not be sufficient) Cystoscopy, retrograde pyelogram
10
Q
Test of choice for renal parenchyma, calculi, infection?
A
CT urography
11
Q
Renal U/S is superior to IVP in?
A
Evaluation of renal parenchyma, renal cyst
Insufficient for upper tract imaging.
Limited sensitivity for UCC and small renal masses
12
Q
Acute Mx of severe bladder hemorrhage
A
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
13
Q
Definition of microscopic hematuria
A
2 or more RBC/HPF in at least 2 separate samples
14
Q
1st step in microscopic hematuria
A
R/O benign reversible causes:
Mense Heavy exercise Meds Urethral trauma Infection
And retest after underlying cause resolved
15
Q
Indications of referal to nephrology
A
Evidence of glomerular disease: Raised Cr Dysmorphic RBC RBC cast Proteinuria
16
Q
If no benign/reversible condition identified and no indication for referral, what’s the next step?
A
Renal U/S
Urine cytology
17
Q
Indications for referral to urology for cystoscopy
A
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
18
Q
If negative for benign/reversible conditions and U/S and urine cytology in low-risk pts
A
Urinalysis, urine cytology, BP
At: 6, 12, 24 and 36 mo
19
Q
Contraindications to CT contrast
A
Renal failure
Pregnancy
Allergy
20
Q
Type of urinary incontinence caused by hypoestrogenemia
A
Stress incontinence (interinsic sphincter deficiency)
21
Q
Types of stress incontinence
A
Urethral hypermobility: Childbirth Pelvic surgery Aging Levator muscle weakness Obesity
Intrinsic sphincter deficiency: Pelvic surgery Neurologic problem Aging Hypoestrogen state
22
Q
Dx of urge incontinence
A
Hx
Urodynamic studies
23
Q
Tx of urge incontinence
A
Lifestyle changes:
Fluid alterations
Diet
Bladder habit retraining
Anticholinergics
B-3-agonists
Botulinum toxin A
Neuromodulation
24
Q
Dx of stress incontinence
A
Hx
Stress test (cough, valsalva)
Urodynamics
25
Tx of stress incontinence
Wt loss
Kegel exercise
Bulking agents
Surgery
26
Dx of mixed incontinence
Hx
Urodynamics
Stress test
27
Tx of mixed incontinence
Combination of stress and urge incontinence managements
28
Meds causing urinary retention
```
Anticholinergics
Narcotics
Antihypertensives (ganglionic blocker, methyldopa)
Ephedrine/pseudoephedrine
Antihistamines
Ecstasy
```
29
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
30
Investigations for urinary retention
```
CBC
Lytes
BUN, Cr
U/A, Urine S/C
U/S
Cystoscopy
Urodynamic studies
PVR
```
31
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
32
Mx of post operative urinary retrntion
Encourage ambulation
a-blockers to relax bladder neck outlet
May need cath
Definitive treatment depends on etiology
33
BPH inv
```
U/A
Cr
Renal U/S
PSA
Uroflowmetry
PVR
+/- cystoscopy, bladder U/S, Bx
```
34
Tx of BPH
| Asymptomatic pt or symptomatic without bother
Watchful waiting
50% improve spontaneously
35
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
36
Indications for surgical BPH Tx
Significant symptom burden
Acute urinary retention
Refractory hematuria
Recurrent infections
37
Pt with BPH who wishes to avoid surgery
Microwave therapy
TUNA
Stent
38
Med contraindicated in men with BPH who plan to undergo cataract surgery
a-adrenergic antagonist
| Floppy iris syndrome during surgery
39
Absolute indications for BPH surgery
Renal failure with obstructive uropathy
Refractory urinary retention
40
Relative indications for BPH surgery
Recurrent UTIs
Recurrent refractory hematuria
Renal insufficiency
Bladder stone
41
Inv for urethral stricture
Uroflowmetry
(Flow rate < 10 ml/s)
U/A (pyuria)
RUG
VCUG
Cystoscopy
42
Tx of urethral stricture
Urethral dilatation (high recurrence rate)
Visual internal urethrotomy (high recurrence rate)
Open surgical reconstruction
43
Nerve roots for bladder function
Sympathetic: T10-L2
Somatic (pudendal): S2-4
Parasympathetic: S2-4
44
Pontine micturition center
Activated by information from stretch receptors in bladder wall
Activates parasympathetic neurons
Inhibits sympathetic and somatic neurons
45
Neurogenic detrusor overactivity, location of lesion
Above PMC
Intact pathway inferior to PMC
Coordination of bladder and sphincter maintained
46
Location of lesion in detrusor sphincter dyssynergia
Suprasacral lesion of spinal cord
Loss of coordination between detrusor and sphincter
Detrusor overactivity
47
Detrusor atony/areflexia location of lesion
Sacral cord or peripheral efferents
Flaccid bladder
May progress to poorly compliant bladder with high pressures
48
Deficient bladder sensation
Increasing residual urine, leading to decompensation
49
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)
```
50
Goal of treatment of neurogenic bladder
Prevention of renal damage, infection
Achieve social continence
51
Tx of neurogenic bladder
Bladder hyperactivity:
Anticholinergics
If refractory: botulinum toxin injection,augmentation cystoplasty
Urinary diversion
Flaccid bladder:
CIC
52
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
53
Med causing hydronephrosis
a-adrenergic agonist
54
Inv for hydronephrosis
```
CBC
Lytes
BUN, Cr
U/A, S&C
U/S
MAG3 diuretic renogram
```
55
Goal of Tx of hydronephrosis
Improving symptoms
Treating infections
Improving renal function
May require percutaneous nephrostomy tube, ureteral stenting
56
Post-obstructive diuresis definition
>3 L/24h
Or
>200 cc/h over each of 2 comsecutive hours
57
Physiologic POD course
Resolves within 48h with PO fluids
May persist
58
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
59
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
60
Definition of frequency and nocturia
Frequency: voiding 8 or more times/24 h
Nocturia: awakening One or more times at night to void
61
Overactive bladder definition
Urgency+ frequency + nocturia
62
Inv for overactive bladder
U/A
+/- PVR
Cystoscopy
Urodynamics
63
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
64
Anti-muscarinics
Oxybutynin
Tolterodine
Solifenacin
Fesoterodine
Trospium
65
Complicated UTI
Structural or functional abnormality
Male
ImmComp
DM
Iatrogenic complication
Pregnancy
Pyelonephritis
Catheter-associated
66
Uncomplicated pyelonephritis with enterococcus infection, Tx?
Ampicillin
67
Typical UTI organisms
KEEPS
```
Klebsiella
E.Coli
Enterococcu
Proteus
Pseudomonas
S. Saprophyticus
```
68
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
69
UTI inv
U/A, urine S&C
Investigations if indicated: U/S, CT
70
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
```
71
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
72
Inv for recurrent cystitis
Assess predisposing factors
+/- cystoscopy, U/S, CT
73
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
74
Indications for treatment if asymptomatic bacteriuria
Pregnancy
Pt undergoing urinary tract instrumentation
75
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
76
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
77
Inv for interstitial cystitis
U/A, microscopy, C&S, cytology
78
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
79
Dysuria in pyelonephritis
Concurrent cystitis
80
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
81
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
82
Most common urological Dx in men < 50
Prostatitis/ prostatodynia
83
Acute bacterial prostatitis, the most common pathogen?
E-coli
84
Associations of Acute bacterial prostatitis
Often associated with:
Outlet obstruction
Recent cystoscopy
Prostatic Bx
85
Inv for Acute bacterial prostatitis
U/A
Blood CBC, C&S
If non-resolving: TRUS
If suspect abscess: TRUS
86
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
87
Chronic bacterial prostatitis etiology
Recurrent exacerbations of acute prostatitis-like signs and symptoms
Recurrent UTI with same organism
88
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
89
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
90
Tx of chronic bacterial prostatitis
ABx (cipro 4-6 wk)
| +/- BB
91
Chronic pelvic pain syndrome (abacterial) subtypes
Inflammatory
Non-inflammatory
Etiology:
Intraprostatic urine reflux +/- urethral hypertonia
Multifactorial
92
Chronic pelvic pain syndrome Sx
Pelvic pain
Storage LUTS
Ejaculatory pain
Post-ejaculatory pain
93
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
94
Chronic pelvic pain syndrome Tx
Supportive
AB trial if newly diagnosed
+/- BB, anti-inflammatories, phytotherapy (quercetin, cernilton)
95
Etiology of epididymitis and orchitis
<35:
N. Gonorrhea
C. Trachomatic
```
>35:
GI organisms (E.coli)
```
MSM:
GI organisms
96
Med causing epididymitis
Amiodarone
97
RFs of epididymitis and orchitis
UTI
Unprotected sexual contact
Instrumentation
Catheterization
Increased pressure in prostatic urethra (sterile epididymitis)
ImmComp
98
Inv for epididymitis and orchitis
U/A, S&C
Urethral discharge: gram stain, culture
If uncertain: Doppler U/S to R/O torsion
99
epididymitis and orchitis Tx
Scrotal support
Bed rest
Ice
Analgesia
if <35:
Ceftriaxone 1 dose + Doxy (10d)
If > 35:
Ofloxacin 10 d
100
If unsure between epididymitis and torsion
Go to OR
101
Prehn sign
Elevation of testicles
Relieves pain in epididymitis
No change in torsion
102
Discharge of gonococcal urethritis
Thick, profuse, yellow-gray, purulent
103
Inv for urethritis
Gram stain:
GN diplococci (gono)
Or
>4 PMN (non-gono)
Urine PCR
Urethral specimen culture
104
Urethral discharge in non-gonococcal infection
Mucoid, whitis, purulent
105
Urethritis with negative culture and unresponsive to Tx
Ureaplasma urealyticum
Mycoplasma genitalium
Trichomonas vaginalis
HSV
adenovirus
106
Life style factors precipitating stone formation
Minimal fluid intake
```
Excess:
Vit C
Oxalate
Purines
Ca
```
107
Hereditary RFs of renal stones
RTA
G6PD deficiency
Cystinuria
Xanthinuria
Oxaluria
108
Meds predisposing to renal stone
Loop diuretics
Acetazolamide
Topiramate
Zonisamide
Indinavir
Acyclovir
Sulfadiazine
Triamterene
109
Medical conditions predisposing to renal stone
```
UTI
Myeloproliferative disorders
IBD
Gout
DM
Hypercalcemia
Obesity (BMI>30)
```
110
Which BMI increases the risk of renal stone?
30
111
Which UTI organisms can cause stone?
```
Urea-splitting organisms:
Proteus
Pseudomonas
Providencia
Klebsiella
Mycoplasma
Serratia
S.aureus
```
112
Bladder stone hematuria
Terminal hematurua
113
Stone inhibitory factors
Citrate
Pyrophosphate
Mg
Tamm-Horsfall gb
114
Radiolucent stones, visualized on CT but not on KUB
Uric acid
115
Radiopaque stones
Calcium
Struvite
Cystine
Uric acid (only CT)
116
Radiolucent stones
Uric acid
Indinavir
Atazanavir
117
First step in diagnosis of renal stone
Helical CT abdomen/pelvis
If negative consider other diagnoses
If positive proceed to KUB x-ray
118
Indications of urgent intervention for kidney stone
Solitary kidney
Bilateral stones
Intractable pain or vomiting
Acute renal failure
Septic stone
119
Urgent intervention for uric acid stones
Dissolution therapy
120
Urgent intervention for non-uric acid stones
ESWL
Ureteroscopy
PCNL
Stent/nephrostomy
121
Urgent intervention for septic stone
Ureteric stent
Percutaneous nephrostomy
Definitive treatment of the stone should be delayed until the sepsis has cleared
122
Management of stone with no indication of urgent therapy
If high likelihood of stone passage:
Observation
If low likelihood of stone passage:
Intervention
123
Indications for PCNL
>2 cm
Staghorn
UPJ obstruction with correction of obstruction
Calyceal diverticulum
Cystine stones, staghorn
Anatomical abnormalities
Failure of less invasive modalities
124
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)
125
Extra Inv for recurrent stones or pediatric cases
24 h urine x 2 (volume, Cr, Ca, Mg, P, Na, citrate, oxalate, cystine)
126
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
127
Indications for admission
Intractable pain
Intractable vomiting
Fever
Compromised renal function
PregnNcy
128
Indications for detailed metabolic studies
Recurrent stone
Pregnancy
Pediatrics
Strong FHx
Underlying kidney or systemic disease
129
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
130
Interventional Tx for kidney stone
Stone < 2 cm, ESWL
Stone > 2cm, PCNL
+/- stent prior to ESWL if 1.5-2.5 cm
131
Interventional Tx for ureteral stone
If > 10mm
ESWL or URS
2nd line: PCNL
Laparscopic, open removal
132
Interventional Tx for bladder stone
Transurethral stone removal
| Cystolitholapaxy
133
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)
134
F/U for stone formers
Periodic imaging:
Yr 1
Then q2-4 yr
135
The most common type of stones
Calcium
136
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
137
Specific Tx for Ca stones
Cellulose phosphate
Orthophosphate
Ca-oxalate:
Thizides
K-citrate
Allopurinol
Ca-struvite:
ABx (stone must be removed)
138
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)
139
Urine in uric acid stones
Acidic urine
pH < 5.5
Urinary uric acid not necessarily elevated
140
Specific treatment for uric acid stones
Alkalinization of urine to pH 6.5-7
(Bicarbonate, K-citrate)
Allopurinol
141
RF for struvite stones
Alkaline urinary pH
Infection with urea-splitting organisms
E.coli: not culprit
M>F
142
Constituents of struvite stones
Mg
PO4
NH4
143
Special Tx for struvite stones
Stone and all foreign bodies must be removed
ABx for 6 wk
Regular F/U cultures
144
Cystine stone etiology
AR
Defect in small bowel and renal absorption of dibasic aminoacids
```
COLA in urine:
Cystine
Ornithine
Lysine
Arginine
```
145
Cystine stone features
Children and young adults
Recurrent
FHx
Staghorn
Faintly radiopaque
Positive urine Sodium nitroprusside test
Urine chromatography for cystine
146
Specific Tx for cystine stone
Alkalinize urine
Penicillamine
a-MPG or Captopril (form complex with cystine)
ESWL not effective
147
Cyst on renal ultrasound. Next step?
Nothing if:
Hypoechoic
No calcification
Thin wall
CT with contrast (+/- aspiration, Bx)if:
Dense
Calcified
Septated
148
If solid mass on U/S, next step?
CT (exclude angiomyolipoma)
Large mass> 4cm:
Surgery
Small mass <4 cm:
Possible surveilence
149
Renal mass in TS
Angiomyolipoma
Multiple, bilateral
150
Cysts requiring resection on CT
Complex
Thick, irregular walls
Measurable enhancement
Or
Enhancing soft tissue components
151
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
152
Cysts not requiring F/U on CT
Round,
No septation or a few thin septa
No true enhancement
No solid component
Well marginated
< 3cm
153
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
154
Tx of angiomyolipoma
If symptomatic, risk of bleeding (pregnancy):
Surgical resection, embolization
mTOR inh if unresectable, mets
Otherwise, F/U with U/S
155
Renal oncocytoma features
Benign
M>F
Spherical
Capsulated
Central scar
Bx: eosinophilic cells, originating from intercalated cells of collecting ducts
156
Tx of oncocytoma
Treat as RCC
Partial/radical nephrectomy if large
HIFU or RFA for smaller masses
157
Renal adenoma features
Most common benign
M>F
<1cm
Cortical
Benign
158
Tx of renal adenoma
If > 3 cm (likely not benign):
Partial/radical nephrectomy
159
RFs for RCC
Smoking
HTN
obesity
Horseshoe
Acquired renal cystic disease
160
Poor prognostic factors for RCC
Wt loss
Weakness
Anemia
Bone pain
161
Inv for RCC
CBC, ESR, LFT, extended lytes
U/A
Renal U/S
Contrast-enhanced CT
MRI (vascular extension)
Renal Bx
162
Staging w/u for RCC
CXR
CT
LFT
Liver enzymes
Bone/head imaging
163
RCC staging
T1: < 7cm
T2: > 7cm
T3: extension into major veins, perinephric
T4: extension into Gerota, adrenal
164
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
```
165
RF for carcinoma of renal pelvis and ureter (UCC)
Smoking
Chemical/dietary exposure (industrial dyes and solvents):aristolochic acid, aniline
Analgesic abuse
Balkan nephropathy
166
DDx of filling defect
Urothelial carcinoma
Uric acid stones
Blood clot
Pyelitis cystica
Papillary necrosis
Fungus ball
Gas bubble (gas producing organism)
167
Inv for UCC
IVP/CT urogram
Cystoscopy
Retrograde pyelogram
168
Tx for UCC
Radical nephrectomy with excision of ipsilateral bladder cuff
Distal ureterectomy for distal ureter tumors
Laser ablation for low grade disease
169
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
170
Features of bladder cancer
M>F
Whites
Mean age: 65
UCC: > 90%
Poorer prognosis if muscle invasion
High recurrence if non-invasive
Usually multifocal
171
Key symptom of bladdercancer
Hematuria
172
Inv for bladder cancer
U/A, C&S, cytology
U/S
CT with contrast
Cystoscopy and Bx
Tumor markers: NMP-22, BTA, Immunocyt, FDP
173
Gold std of Dx of bladder cancer
Cystoscopy and Bx (initial procedure of choice)
174
Inv for staging of bladder cancer
CT/MRI
CXR
LFT
Extended lytes
175
Most important prognostic factor for bladder cancer
Tumor grade
176
Intravesical Tx for prevention of bladder cancer progression
BCG
177
Staging of bladder cancer
T0: insitu
T1: subepithelial connective tissue
T2: muscularis propria
T2a: superficial
T2b: deep
T3:
Perivesical tissue/fat
T4:
Adjacent organs
178
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
179
RFs for prostate cancer
> 50yr
African
High dietary fat
FHx
BRCA mutation
180
Leading causes of male cancer death
Lung > colon > prostate
181
Inv for prostate cancer
```
DRE
PSA
TRUS-guided needle Bx
Bone scan (omitted if PSA<10)
CT
```
182
Staging of prostate cancer
T1: clinically undetectable
T2: palpable. Confined to prostate
T3: extends through prostate capsule
T4: invades adjacent structures
183
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
184
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
185
Indication for radical prostatectomy
Young: < 75y
| High riskdisease
186
PSA determinants for prostate cancer Dx
Increased risk of cancer if:
Decreased free/total PSA
Elevated PSA velocity
Elevated PSA density
187
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
188
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)
189
RFs for testicular tumor
```
Cryptorchidism
Atrophy
Sex hormones
HIV
Infertility
Family Hx
PHx of testicular cancer
```
190
Acute hydrocoele in young pt
R/O testicular cancer
191
Testicular cancer is more common in which testis?
Rt
192
The most common type of testis tumor
Germ cell tumors (95%)
| Among which seminoma is the most common
193
Inv for testicular cancer
Dx: radical inguinal orchidectomy
B-hCG, AFP, LDH
Testicular U/S
194
Significance of tumor markers
Return to normal after operation (provided there’s no mets)
195
Markers for seminoma
AFP: never increased
B-hCG: 7%
196
Non-seminoma markers
B-hCG
| AFP
197
Significance of testicular microlithiasis
Nothing
198
Staging evaluations for testicular cancer
CXR
Markers
CT abdomen/pelvis
199
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
200
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.
201
Orchiopexy and risk of malignancy, infertility, torsion
Risk of malignancy: no reduction (may reduce)
Risk of infertility: reduced
Risk of torsion: reduced
202
RFs of malignant penile cancers
Chronic inflammatory disease
STI
Phimosis
Uncircumcised penis
203
Tx of penile malignancy
Wide excision
+/- lymphadenectomy
Cryo, laser... for CIS
204
Torsion of testes features
Pain
Diffuse tenderness
Horizontal lie
Absent cremaster reflex
Negative Prehn’s sign
205
Features of epididymitis
Pain
Epididymal tenderness
Present cremaster reflex
Positive Prehn
206
Features of orchitis
Pain
Diffuse tenderness
Present cremaster reflex
Positive Prehn
207
Hematocele features
Pain
Diffuse tendernesd
No transillumination
Hx of trauma
208
Hydrocele
No pain
Testis not separable from hydrocele
Cord palpable
Transillumination
Hx of trauma
209
Spermatocele
No pain
Testis separable from spermatocele
Cord palpable
Transillumination
210
Varicocele
Bag of worms
No transillumination
Increase in size with valsalva
Decrease in size if supine
211
Indirect inguinal hernia
Cord not palpable
Testis separable from hernia
No transillumination
212
Generalized dependent edema (scrotom)
Diffuse swelling
Post-operative or immobilized
Liver dysfunction should be checked
213
Varicocele happens on which side?
90% Lt
214
Inv for varicocele
PEx
215
Tx of varicocele
Conservative
Surgical ligation
Repair improves sperm count/motility
216
Inv for spermatocele
P/E
U\S
217
Tx of spermatocele
Conservative
Excise if symptomatic
NO NEEDLE ASPIRATION
218
Types of hydrocele
Communicating( children)
Changes size during day
Non-communicating (adults)
219
Inv for hydrocele
U/S
220
Tx if hydrocele
Conservative
Needle aspiration
Surgery
221
Predisposing factors for testicular torsion
Trauma
Cryptorchidism
Bell clapper deformity
50% during sleep
222
Time of necrosis in testicular torsion
5-6 h
223
Inv for testicular torsion
U/S doppler
Decreased uptake on scintillation scan (doughnut sign)
224
Tx of testicular torsion
Emergency surgical exploration
Bilateral orchiopexy
Orchiectomy if poor prognosis
225
When to suspect retroperitoneal problem in pt with varicocele?
Acute onset
Rt sided
Palpable abdominal mass
Does not reduce while supine
226
Indications for Tx of varicocele
Impaired sperm quality/quantity
Pain/ache affecting QOL
Affected testis fails to grow in adolescence
Cosmetic indications
227
Torsion of testicular appendix
Similar Sx to testicular torsion
vertical lie
Preserved cremaster reflex
Blue dot sign (children)
228
Tx of testicular appendix torsion
Analgesia
Resolves over 5-7 d
Surgical exploration and excision if refractory pain
229
Hematocele Dx
U/S to exclude testis fx
230
Tx of hematocele
Ice pack
Analgesics
Surgical repair
231
Site of pathology in Peyronie’s plaque
Fibrous thickening of tunica albuginea
232
Etiology of Peyronie’s plaque
Unknown
Trauma
Repeated inflammation
FHx
Associations:
DM
Vascular disease
AI
Dupuytren’s contracture
Erectile dysfunctiin
Urethral instrumentation
233
Tx of Peyronie’s plaque
Watchful waiting
Verapamil (IL, topical)
Incision/excision of plaque
Shortening of less affected side
Penile prosthesis
234
Priapism definition
Erection > 4 h, in the absence of sexual excitement/desire
+/- pain
+/- signs of necrosis
235
Etiology of priapism
50% idiopathic
Ischemic:
Thromboembolic (SCA)
Non-ischemic:
Trauma
Medication
Neurologic
236
Priapism inv
Cavernal blood gas analysis
Doppler U/S of penis
237
Tx of priapism
Underlying
High flow:
Self-limited
Arterial embolization
Low flow:
Needle aspiration for decompression
Phenylephrine intracorporeal injection
Surgical shunt
238
Phimosis etiology
Congenital
Poor hygiene
Balanitis
239
Tx of phimosis
Proper hygiene
Topical CS
Dorsal slit
Circumcision
240
Paraphimosis etiology
Iatrogenic (post cleaning/ instrumentation)
Trauma
Infectious (balanitis, balanopsthitis)
241
Tx of paraphymosis
Manual pressure (with analgesia)
Dorsal slit
Circumcision (urgent/electively to prevent recurrence)
242
Inv for premature ejaculation
Testosterone levels if in conjunction with impotence
243
Mx of premature ejaculation
R/O medical conditions
Address psychiatric concerns
Counseling
SSRI
Clomipramine
Topical lidocaine-prilocaine
244
Erection is the function of which nerve?
Parasympathetic
245
Emission is the function of
Sensory afferents from glands
Secretion from prostate, seminal vesicle, ejaculatory ducts, enter prostatic urethra (Sympathetic)
246
Ejaculation is the function of
Bladder neck closure (sympathetic)
Spasmodic contraction of bulbo-cavernous and pelvic floor musculature (somatic)
247
Detumescence is the function of
Sympathetic nerve
248
Psychogenic erectile dysfunction characteristic
10%
Sudden onset
On and off
Variation with partner and circumstance
Younger age
No organic RF
Nocturnal/AM erection present
249
Organic erectile dysfunction features
90%
Gradual onset
All circumstances
No variation with partner or circumstance
Older age
Vascular RFs present
No nocturnal/AM erection
250
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)
251
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
252
When to refer ED pt
Failed medical therapy
Penile anatomic abnormality
Pelvic/perineal trauma
Psychogenic cause
Endocrinopathy
Vascular/neurologic assessment
253
Classification of renal trauma severity
Minor:
Contusion
Hematoma
Superficial laceration
Major:
Laceration extending into medulla and collecting system
Major renal vascular injury
Shattered kidney
254
Inv for renal trauma
U/A:
Hematuria requires W/U
CT (contrast, triphasic) if pt stable
255
When to send home pt with renal trauma
Microscopic hematuria + isolated well-staged minor injuries
256
Wham to admit pt with renal trauma
If gross hematuria
+ contision/minor laceration
Tx: hospitalize, bed rest, repeat CT if bleeding continues
257
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
```
258
Inv for bladder injury
U/A (90% gross hematuria)
CT cystogram and post drainage films for extravasation
259
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
260
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
261
Inv for urethra trauma
Always R/O bladder rupture
RUG or Cystoscopy prior to cath
262
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
263
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)
264
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
265
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
266
Male reproductive system abnormalities in CF
Congenital bilateral absence of vas deferens and epididymal cysts
267
Tracks causing male infertility
Alcohol
Tobacco
Cocaine
Marijuana
268
If azospermia, next step?
FSH
If high/normal: testis Bx (if normal = obstruction)
If low: hypogonadotropic hypogonadism
269
If absent/low volume ejaculation, next step?
R/O short abstinence, incomplete collection.
If non of the above:
Post ejaculatory U/A
270
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
271
Course of antenatal hydronephrosis
Most resolve during pregnancy or within the first year of life
(1-5% of fetal U/S)
272
Education for antenatal in utero intervention bored Antenatal hydronephrosis
If there is evidence of lower urinary tract obstruction with oligohydramnios
273
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
274
Tx of PUV
Immediate cath (relieve obstruction)
Cystoscopic resection of PUV when baby stable
Vesicostomy if resection not possible
275
The most common congenital defect of ureter
UPJ obstruction
M>F
40% bilateral
276
Dx of UPJ obstruction
Mostly asymptomatic finding on Antenatal U/S
Renal scan +/- furosemide
277
Tx of UPJ obstruction
Surgical correction
Nephrectomy if < 15% differential renal function
278
RFs for VUR
White race
F>M
Age < 2y
Genetic predisposition
279
Inv for VUR
BP
UTI: U/A, C&S
RF: serum Cr
Growth parameters: Ht, Wt
Renal U/S
DMSA renal scan
+/- sibling screening
280
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
281
Indications for surgical treatment of VUR
Failure of medical management
Renal scarring (renal insufficiency, HTN)
Breakthrough UTIs
Persistent high-grade reflux (stage 4,5)
282
Tx of hypospadiasis
Optimal time of repair < 2yr
DO NOT CIRCUMCISE
283
Associations of hypospadiasis
White race
Cryptorchidism
Inguinal hernia
Disorders of sexual differentiation
Ventral Penile curvature
Distal > proximal
284
Tx of epispadias
Surgical correction at birth
285
Wilm’s tumor
Average age: 3y
Congenital malformation: in 10%
Bilateral: 5%
286
Inv for Wilm’s tumor
Investigate other kidney, and renal vein
287
Tx of Wilm’s
Unilateral:
Radical nephrectomy
+/- RT/Chemo
Bilateral:
Nephron-sparing surgery + adjuvant chemo
288
Most common site of testis in cryptorchidism
Denis Brown pouch ( between external oblique and Scarpa fascia)
External inguinal ring > inguinal canal > abdomen
289
Fertility rate in treated cryptorchidism
Bilateral: 53%
Unilateral: 90%
Normal men: 93%
290
Palpable gonads in Disorder of sexual differentiation
= chromosomal male
291
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
292
Tx of sexual differentiation disorder
Steroid supplementation as indicated
Sex assignment
Reconstruction of external genitalia (6-12 mo)
Long-term psychological guidance and support
293
Male phenotype newborn with no palpable testes
Bilateral cryptorchidism
Or
Female with salt wasting CAH
294
Catheter for BPH
Coudé
295
Cath for urethral disruption/obstruction
Filiform
296
Cath in pelvic fx
Contraindicated
297
HIV and circumcision
Male circumcision reduces risk of HIV acquisition in heterosexual men
Not enough evidence in MSM
298
Medical indications for circumcision
Phymosis
Recurrent paraphymosis
Recurrent UTI esp in infants
Balanitis xerotica obliterans
Other chronic inflammatory conditions
299
Contraindications to circumcision
Unstable/sick infant
Congenital genital abnormalities
FHx of bleeding disorders (investigate first)
300
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
301
Indications for cystoscopy
Gross hematuria
LUTS
Urethral and bladder neck stricture
Bladder stones
Bladder tumor surveillance
Evaluation of upper tracts with retrograde pyelography
302
AB for cystoscopy?
Recommended prophylactically
303
The part of prostate that is removed in TURP
Periurethral portion and transition zone
304
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
305
Contraindications for ESWL
UTI
Obstruction distal to stone
Coagulopathy/ bleeding diathesis
Pregnancy
306
Contraindications to PDE5 inh (sildenafil)
With nitrates
Hx of priapism
```
Conditions predisposing to priapism:
Leukemia
Myelofibrosis
Polycythemia
SCD
```
307
Med useful for both stress and urge incontinence
Imipramine
| Sympathomimetic effect
