Urology Flashcards
What is acute urinary retention?
Sudden inability to pass urine
What is the most common cause of acute urinary retention?
BPH
Name three other causes of acute urinary retention in men.
Prostate cancer
Prostatitis
Balanitis
Name three causes of acute urinary retention in women.
Prolapse
Vulvovaginitis
Pelvic mass
Which conditions involving the bladder can cause acute urinary retention?
Bladder calculi
Bladder cancer
Urethral strictures
Cystitis
10% of acute urinary retention is caused by drugs, such as what?
Anti-cholinergics
Opioids and anaesthetics
Alcohol
Alpha-adrenoreceptor agonists
What neurological conditions can cause acute urinary retention?
Peripheral neuropathy MS Parkinsons' Cerebrovascular accident Cauda equina
What is found on abdominal examination in acute urinary retention?
Tender enlarged bladder with dullness to percussion above the symphysis pubis, almost to umbilicus.
What should be noted on DRE in acute urinary retention?
Anal tone
Prostatic size, nodules, and tenderness
What may be noted on examination of genitals in acute urinary retention?
Phimosis, discharge, inflammation, prolapse
How are prolapsed disc or cord compression checked on examination?
Lower limb power and reflexes
Perineal sensation
How is acute urinary retention diagnosed?
Routine bloods including PSA
Urinalysis for infection, haematuria, proteinuria, glycosuria
USS: post void residual volume and hydronephrosis
CT and MRI if indicated
How is acute urinary retention managed?
Immediate bladder decompression
Alpha blocker before removal of catheter
Define benign prostatic hyperplasia.
Increase in size of prostate gland without malignancy present
What is the pathophysiology of BPH?
Failure of apoptosis, hormone dependent
How does BPH present?
Urinary frequency Urgency Hesitancy Post micturition dribbling Incomplete bladder emptying
How is BPH diagnosed?
Check for palpable bladder DRE Urinanalysis and MSU for MC&S Routine bloods PSA
What should be noted on DRE for BPH?
Tone of anal sphincter
Size, texture, contour of prostate
Median sulcus clearly defined
Elevated ALP may suggest…
Bony metastases
What may a palpable bladder suggest?
Chronic outflow obstruction
Neurogenic bladder
If a BPH patient has moderate to severe voiding symptoms, what drugs can be offered?
Alpha blockers e.g. Tamsulosin
5-alpha reductase inhibitors (5-ARI) e.g. Finasteride
How do alpha blockers work?
Reduce the tone in the muscle of the neck of the bladder
When may doxazosin be described in patients with BPH?
It is less selective, so may be prescribed if patient also has hypertension.
What are the side effects of tamsulosin?
Rhinitis
Dizziness and headache
Intra-operative floppy iris syndrome
How do 5-ARIs work?
They block the synthesis of dihydrotestosterone from testosterone.
What is the main side effect of 5-ARIs?
Adverse effect on sexual performance which may continue after discontinuation.
What is the second line treatment of BPH?
When no response to monotherapy AND prostate>30g/PSA>1.4ng/mL
Combine alpha blocker and 5-ARI
What is the surgical management of BPH?
TURP - transurethral resection of the prostate
What are the risk factors for prostatitis?
HIV infection
BPH and prostate cancer
STI
Indwelling catheters
What are the causes of prostatitis?
Gram negative bacteria
STI
If non bacterial - elevated prostatic pressures
What are the four types of prostatitis?
Acute bacterial
Chronic bacterial
Chronic prostatitis
Asymptomatic inflammation
What are the symptoms of prostatitis?
Fever, malaise, arthralgia, myalgia
LUTS including nocturia and dysuria
Pain - lower back, abdo, perineal, urethral
Pain on ejaculation/premature ejaculation
Urethral discharge
What are the signs of prostatitis?
Pyrexia
Nodular/boggy/tender/hot or normal gland
Inguinal lymphadenopathy
How does the prostate gland feel in chronic prostatitis?
Hard from calcification
How is prostatitis diagnosed?
Urine culture and microscopy for WCC and bacterial count
Oval fat bodies and lipid laden macrophages
PSA may be elevated
What is the management of acute prostatitis?
Possibly admission
Analgesia
Ciprofloxacin 4 weeks
What is the management of chronic infective prostatitis?
Refer
Ciprofloxacin 4-6 weeks, repeated courses may be necessary
TURP may be required
What is the management of chronic abacterial prostatitis?
Analgesia
Alpha blocker plus antibiotic
What is neurogenic bladder?
Bladder dysfunction that may be either flaccid or spastic, which may co-exist with bladder outlet obstruction
What are the CNS causes of neurogenic bladder?
CVD
Spinal injury
ALS
What are the PNS causes of neurogenic bladder?
Diabetes
Alcohol
Vitamin B12 deficiency neuropathies
Disc damage
What are the mixed CNS and PNS causes of neurogenic bladder?
Parkinson’s
MS
Describe flaccid/hypotonic bladder.
Large bladder volume, pressure low, contractions absent
Damage at S2-S4
Describe the spastic bladder.
Normal/small volume, involuntary contractions occur
Damage above T12
Detrusor-sphincter dyssnergia
What is the main symptom of neurogenic bladder?
Overflow incontinence, retaining of urine
Spastic have LUTS too
How is neurogenic bladder monitored?
Renal function - serum creatinine
Hydronephrosis - Renal USS 1-2 yearly
Urodynamics if high risk
Large post-void residual volume
Patients with hydronephrosis or nephropathy undergo what?
Cystography
Cystoscopy
Cystometrography
What is the management of flaccid bladder?
Intermittent self catheterization
What is the management of spastic bladder?
Trigger voiding with suprapubic pressures and anti-cholinergics
Treat urge incontinence
What are prostate cancers and where do they arise?
Adenocarcinomas arising in the peripheral zone of the prostate gland
What are the risk factors for prostate cancer?
Increasing age
Afro-Caribbean
FH
How does prostate cancer present?
LUTS and raised PSA on screening
Locally invasive disease - haematuria, haematospermia, perineal and suprapubic pain, impotence
What are the signs of prostate cancer?
Irregular asymmetrical gland, induration, lack of median sulcus, lack of mobility - adhesion to surrounding tissue, palpable seminal vesicles.
What are the investigations for prostate cancer?
PSA PCA3 urine test Urinalysis Renal function tests Transrectal needle biopsy
What factors influence whether men should have a prostate biopsy?
PSA level
DRE findings
Comorbidities
Risk factors
What are the possible treatments of prostate cancer?
Watchful waiting
Radical prostatectomy
Curative radiotherapy
Brachytherapy
What is the most common androgen deprivation therapy?
GNRH agonists such as goserelin
What are the other forms of anti-androgen therapy?
Bilateral orchiectomy
Cytoproterone acetate
How do anti-androgens inhibit prostate cancer growth?
Inhibit androgen receptor signalling
What is flare phenomenon, an adverse effect of anti-androgen therapy?
What is the cause, and how can it be prevented against?
Bone pain, acute bladder outlet obstruction, obstructive AKI, spinal cord compression, fatal cardiovascular events due to hypercoagulation status
Caused by an initial increase in luteinizing hormone prior to receptor down regulation
Flutamide can pre-emptively attenuate the tumour flare.
What are the other adverse effects of anti-androgen therapy?
Hot flushes
Sexual dysfunction
Osteoporosis
Gynaecomastia
Define the acute scrotum.
Acute scrotal pain with or without oedema or erythema
What are the differentials for acute scrotum?
Torsion of the testes Epididymitis/orchitis Hydrocele Tumour Idiopathic scrotal oedema
What is bell-clapper testis and what is it a risk factor for?
Lack of normal fixation of posterior lateral aspect of testis to tunica vaginalis
Intravaginal testicular torsion
Which type of testicular torsion occurs in neonates?
Extravaginal - before the testis is fixed in the scrotum by the gubernaculum
What are the symptoms of testicular torsion?
Left>right
Sudden severe testicular pain, may be abdo
N+V
What are the signs of testicular torsion?
Swollen tender testis retracted upwards, erythema
Lifting testis up over symphysis increases pain
Absence of cremasteric reflex on affected side
Where does the cremasteric reflex originate?
L1/L2
How is testicular torsion diagnosed?
Colour Doppler USS
How is testicular torsion managed?
Attempt manual reduction by outwards rotation of testis
Bilateral orchiopexy
What are the complications of testicular torsion?
Infarction of testicle
Subfertility from ischaemia-reperfusion injury
What are the causes of epididymo-orchitis?
STI (chlam/gono)
UTI (gram neg)
Mumps
What are the risk factors for epididymo-orchitis?
STI/UTI
MSM
Catheters
What are the symptoms of EO?
Acute unilateral scrotal pain and swelling
What are the signs of EO?
Tenderness, palpable swelling of epididymitis
Secondary hydrocele, erythema, pyrexia
How is EO diagnosed?
Gram stained urethral smear, MC&S
NAAT urethral swab
Exclude TT
How is EO treated?
Doxycycline 100mg PO BD 10-14d
If STI, add IM 250mg ceftriaxone
If enteric: olfloxacin 200mg PO BD 14d
What is a hydrocele?
An abnormal collection of fluid within the remnants of the processus vaginalis
What are the main types of hydoceles?
Simple (usually congenital)
Communicating
Non-communicating
What are the causes of secondary hydrocele?
Epididymo-orchitis TB TT Tumours Trauma Generalised oedema
What are the features of a hydrocele?
Scrotal enlargement with a non-tender smooth swelling which transilluminates.
Lies anterior to and below the testis
Impalpable testis
What are important investigations to rule out a transilluminating teratomas?
Serum AFP and hCG
How is a hydrocele managed?
Infancy - resolve by 2 years
Large - therapeutic aspiration
Where do 95% testicular tumours arise and what are the subtypes?
Germ cells
Seminoma and non-seminomatous germ cell tumours (NSGCTs)
What are the risk factors for testicular cancer?
Cryptorchidism or testicular maldescent
FH
Klinefelter syndrome
Malignancy in contralateral testicle
What are the symptoms of testicular cancer?
Painless lump
Dragging sensation
Hydrocele
Gynaecomastia from bhCG
How is testicular cancer diagnosed?
Tumour marker assay
Bilateral testicular USS
Tissue histology
What is the treatment of testicular cancer?
Radical orchidectomy and prosthesis
What is the staging system of testicular cancer?
Royal Marsden
What elements produce AFP and bhCG?
AFP - yolk sac tumours
bHCG - trophoblastic elements - teratomas and seminomas
What are the three types of priapism?
Ischaemic (low flow)
Non-ischaemic (high flow)
Recurrent ischaemic (intermittent)
What is the most common cause of priapism?
Sickle cell disease
What are the consequences of priapism?
Ischaemic damage leading to erectile dysfunction, disfigurement, gangrene.
What does an ABG of the corpus cavernosum show in priapism?
Low pH: ischaemic
Normal pH: non-ischaemic
How is priapism diagnosed?
Doppler USS and ABG
What is the treatment of ischaemic priapism?
Aspiration of blood from corpus cavernosum, injection of normal saline
Injection of phenylephrine
What inotrope is used in sepsis?
Adrenaline increases cardiac output
Noradrenaline causes peripheral vasoconstriction
Why does sepsis result in hypovolaemia?
Massive vasodilation causes hypotension
What is the management of an ileus?
Drip and suck
NG tube inserted to decompress all the gas and allow a period of rest for the bowel
Bilious vomiting and an inguinal lump =
Obstructed hernia
What is the pathognomic sign of torsion of testicular appendage?
Blue dot sign
What is the treatment of torsion of testicular appendage?
Ibruprofen and conservative management
Exclude testicular torsion
What imaging modality is used to image urinary tract stones?
Non-contrast (stones are white)
In priapism, what is done before the penis is drained?
Dorsal nerve block
What are the PCRMP age adjusted upper limits for PSA (ng/ml)?
50-50 years: 3.0
60-69 years: 4.0
>70 years: 5.0
Name some complications of radical prostatectomy.
Incontinence
Erectile dysfunction
Retrograde ejaculation can occur after what?
Alpha-blocker therapy
TURP
What is the first line investigation of a testicular mass?
Ultrasound
Name a life threatening complication of a TURP.
TURP syndrome
Venous destruction and absorption of the irrigation fluid
What causes the symptoms of TURP syndrome?
Fluid overload
Hyponatraemia
What are the causes of unilateral hydronephrosis?
PACT Pelvic-ureteric obstruction Aberrant renal vessels Calculi Tumours of renal pelvis
What are the causes of bilateral hydronephrosis?
SUPER Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis
What are four medical indications for circumcision?
Phimosis
Paraphimosis
Recurrent balanitis
Balanitis xerotica obliterans
What are three causes of haematospermia?
Trauma
UTI especially prostatitis
STI
Exclude cancer with physical examination
