Urology Flashcards
What are the possible differentials for acute urinary retention?
prostatic obstruction e.g. BPH, tumour urethral stricture constipation neurological e.g. cauda equina alcohol infection (UTI) post op
How should acute urinary retention be assessed?
- abdominal exam
- DRE
- test for perineal sensation (cauda equina)
- MSU, PSA
- lower limb neurological exam - weakness
How should acute urinary retention be managed initially?
- encourage voiding e.g. to sound of running water, standing when voiding
- analgesia
- privacy on the ward
If your initial conservative treatment is unsuccessful, how should acute urinary retention be managed?
catheterisation (drain <1.5L)
alpha blocker e.g. tamulosin
List the differentials for obstruction of the urinary tract
IN THE LUMEN - stone, blood clot, foreign body, congenital valve
IN THE WALL - tumour, stricture, BPH, trauma
PRESSURE FROM OUTSIDE - fibroids, pregnancy, constipation , diverticulitis , crohns, tumour
Where does BPH occur in the prostate and how?
in the INNER (TRANSITIONAL) zone
= benign proliferation of the connective tissue and glandular layers of the prostate with failure of apoptosis
List the lower urinary tract symptoms
STORAGE SYMPTOMS - urgency, increased frequency, nocturia, urinary incontinence
VOIDING SYMPTOMS- hesitancy, weak stream, terminal dribbling, incomplete emptying
POST MICTURITION SYMPTOMS - post void dribble, incomplete emptying
How is BPH investigated?
- assess how affecting QOL with the “international prostate scoring system”
- PR exam - enlarged smooth prostate
- MSU - may show infection indicating prostatitis
- complete a “urinary frequency volume” chart
List the differentials for LUTS in men?
BPH infection diabetic neuropathy dementia drugs e.g. diuretics, anti muscarinics
How is BPH managed conservatively, medically and surgically?
CONSERVATIVE dietary advice (avoid alcohol, caffeine, spicy foods), avoid constipation, voiding routine (void twice in row, relax), bladder retraining (try holding on, pelvic floor exercises)
MEDICAL
1st line = alpha adrenergic receptors e.g. tamsulosin, doxazosin
2nd line = 5 alpha reductase inhibitors e.g. finasteride
SURGICAL
Transurethral resection of prostate (TURP)
Transurethral incision of prostate (TUIP)
Describe mechanism and SE of alpha 1 adrenergic blockers?
e.g. tamsulosin, doxazosin
block alpha adrenergic receptors in the prostate and bladder -> relax the smooth muscle -> increase flow of urine
SE: drowsiness, dizziness, reduce BP, dry mouth, weight gain
Describe the mechanism and SE of 5 alpha reductase inhibitors?
e.g. finasteride
decrease testosterone conversion to dihydrotestosterone so shrink the size of the prostate
SE: decrease libido, impotence, take 4-6 months for effect
What are the complications of TURP?
general: bleeding, infection
at risk: sexual dysfunction, urinary continence
complications of surgery: TURP syndrome (glycine irrigation fluid enters intravascular space and expands causing fluid overload and hyponatraemia -> seizures, SOB), retrograde ejaculation, retention, clotting
What are the causes and risk factors of prostatitis?
S. faecalis, E.coli, chlamydia
RF: STI, UTI, indwelling catheter, post procedures, diabetics
What are the symptoms/ signs of prostatitis?
UTI
retention
haematospermia
swollen/boggy prostate on DRE
How is prostatitis treated?
analgesia
admit to hospital
levofloxacin for 28 days
What type of prostate cancer is the most common and where?
adenocarcinoma 95% in the peripheral zone of the prostate
How does prostate cancer present?
asymptomatic and found with elevated PSA
LUTS - retention, increased urgency, frequency, haematuria, weak stream
weight loss , fatigue, fever
How might locally advanced prostate cancer present?
impotence - due to infiltration of neuromuscular bundle
haematospermia
bone mets - pain, fracture, spinal cord compression , malignancy hypercalcaemia
How would you investigate possible prostatic cancer?
- DRE - hard craggy irregular NODULAR prostate
- serum PSA >4mg/L -> indicates a biopsy
- transrectal ultrasound and biopsy (4 core biopsies from each lobe)
- MRI - to stage
How is prostate cancer graded?
GLEASON SCALE
6 = low grade cancers = slow growing, confined to prostate 8-10 = high grade cancers = fast growing, invade through prostate capsule
How is prostate cancer treated?
- watch and wait/ active surveillance = regularly monitor PSA to assess if disease progressed
- surgery (prostatectomy) and radiotherapy - if localised or local spread
- if metastatic- hormonal treatments = GnRH agonists e.g. goserelin (-ve feedback to anterior pituitary to stop testosterone), LH antagonists
How can haematuria be classified?
- Visible - frank, macroscopic
2. non visible - found on dipstick or microscopy
What is the most sensitive test for blood in the urine?
** urine dipstick **
MSU has a high false -ve rate
List the differentials for haematuria?
Transient - UTI, trauma, vigorous exercise, menstruation
Bladder cancer - urgent 2 week referral
infection
stones
drugs e.g. anti coagulants, furosemide, ACE-I, cephalosporins
TITS: Trauma, Infection, Tumour, Stones
List the risk factors for an UTI
female catheter sexual intercourse urinary tract obstruction e.g. stones pregnancy recurrent UTIs menopause catheter
Define recurrent UTIs
= >2 UTI in the past 6 months
What are the main pathogens causing UTIs
E.COLI (gram -ve bacillus)****
+ klebsiella, proteus, staphylococcus saprophyticus
Describe the symptoms of a lower urinary tract infection
dysuria increased frequency, urgency fever haematuria suprapubic pain foul smelling urine delirium *
How should a possible UTI be investigated?
- urine dipstick - positive leukocytes or nitrates (treat whilst waiting for MCandS)
- Mid stream urine for MCandS - > 10^5 organisms per ml is diagnostic - mandatory if complicated UTI
How should you investigate if possible Urosepsis?
FBC UandE blood cultures CRP monitor urine output and urinanalysis ABG - lactate
what is defined as a complicated UTI? how is the management different?
if children, men, fail to respond to abx, recurrent UTI, impaired renal function, abnormal organism , pregnancy
need to do imaging e.g. CT KUB, cystoscopy or urodynamics
How is an uncomplicated UTI treated?
conservative - plenty of fluids, analgesia, void often, void after intercourse
trimethoprim or nitrofurantoin (if pregnancy = nitrofurantoin) for 3 days
What are the possible complications of a UTI?
recurrent UTI Urosepsis impaired renal function pyelonephritis pre term pregnancy or small birthweight
How are renal stones formed?
stones form in the collecting duct from urine due to high concentration of the particular precipitate in the urine
What are the most common composite of renal stones?
- CALCIUM OXALATE** (75%) or calcium phosphate
- struvate
- uric acid
Where do ureteric stones often get stuck if >5mm?
- pelvi-ureteric junction
- pelvic brim
- vesico-ureteric junction
List the predisposing factors for renal/ ureteric stones?
diet - high in nuts, chocolate, spinach dehydration obesity men 40-65 y/o drugs e.g. calcium and vitamins D supplements, diuretics, corticosteroids, allopurinolol recurrent UTIs metabolic conditions e.g. hypercalcaemia, hyperparathyroidism, Addisons, bushings catheters
How do ureteric stones present?
asymptomatic renal colic ** (pain referred as visceral nerve supply to ureter and kidney follows similar course to somatic nerve supply to gonads and flanks) \+ nausea and vomiting haematuria \+/- UTI
Describe renal colic
excruciating “worst ever” pain from loin to groin
associated with nausea and vomiting
lasts for mins-hours
occurs in spasms - with no pain or dull ache in between (pain comes in waves as peristalsis pushes on obstruction and causes ischaemia)
associated with nausea and vomiting
How are renal stones investigated?
- urine dipstick - for blood or signs of infection
- urine microscopy and culture
- KUB x-ray
- non contrast CT KUB **- best for visualising stones
How are renal stones managed conservatively?
- analgesia (NSAIDs - IM diclofenac ) + anti -emetic
- encourage lots of fluids, IV fluids and admit if dehydrated/ can’t keep fluids down
- most pass spontaneously (if <5mm) within 4 weeks
- calcium channel blocker (nimodipine)
What are the possible differentials for renal stones?
RENAL- pyelonephritis, acute renal infarction
GYNAE- ectopic, endometriosis, ovarian cyst, PID
GI- appendicitis, diverticulitis, biliary colid
CARDIO- ruptured aortic aneurysm
how are renal stones managed surgically?
1st line = extracorporeal shock wave lithotripsy
SE: HTN, diabetes, haematuria, steinstrasse
2nd line = uteroscope (laser)
3rd line = percutaneous nephrolithotomy (large stones)
if hydronephrosis/ obstruction = percutaneous nephrostomy
List the risk factors for bladder cancer (transitional cell carcinoma)?
smoking **
occupational exposure e.g. aromatic amines in rubber and dye industry, gas works, textile printing, sewage works
schistosomiasis (causes squamous cell ca)
pelvic radiotherapy
How does bladder cancer present?
painless frank haematuria
irritative bladder symptoms e.g. frequency, dysuria , recurrent UTIs
How should non/visible haematuria in >60 y/o be managed?
2 week referral wait!!!
cystoscopy and biopsy
How are bladder tumours managed?
superficial tumours/ carcinoma in situ: transurethral resection of superficial lesions
Invasive tumours into muscle: radical cystectomy or radical radiotherapy
what is a hydrocele?
excess fluid within the tunica vaginalis
How is a hydrocele caused?
PRIMARY- in <1 y/o with a patent vaginalis
SECONDARY - to trauma, tumour or infection
How is a hydrocele treated?
- aspirated
2. surgery (lords repair)
What are the possible causes of epididymo-orchitis?
Chlamydia ** (<35 y/o)
Gonorrhoea
E.coli
Mumps
How does epididymo orchitis present?
sudden onset of a tender swelling dysuria fever/ sweats urethral discharge Prehns sign - lifting testis relieves pain
How should epididymo- orchitis be investigated?
- first catch urine sample
- STI screen - NAAT for chlamydia/ gonorrhoea
- sexual history
How is epididymo- orchitis treated?
- antibiotics - doxycycline for chlamydia, ceftriaxone if gonorrhoea, ciprofloxacin if >35 y/o
- analgesia (NSAIDs)
- contact tracing
- supportive underwear
What is testicular torsion?
when the spermatic cord to a testicle twists and cuts off the blood supply to the testis which causes testicular ischaemia and necrosis
What is contained within the spermatic cord?
testicular artery, cremasteric artery
cremasteric nerve, sympathetic nerve
pampinform plexus of veins, vas deferens, lymphatic drainage
starts at deep inguinal ring and enters scrotum at the superficial inguinal ring
List the RF for testicular torsion
<30 y/o bell clapper deformity (free floating in testis in the scrotum) undescended testis large size testis most common in neonate or adolescents
How does testicular torsion present?
unilateral sudden onset pain, tender (can radiate to groin and abdomen)
nausea and vomiting
acute swelling, redness, erythema
What are the signs of testicular torsion on examination?
testis lying transverse and high
tender, hot, swollen testis
loss of cremasteric reflex
List the differentials of a swollen, inflamed testis
epididymo orchitis - prehn sign +ve (-ve in testicular torsion) testicular torsion tumour trauma acute hydrocele idiopathic scrotal oedema
How is testicular torsion managed?
clinical diagnosis and requires surgery within 6 hours (orchidectomy and bilateral fixation) - do both sides to ensure doesn’t happen to other testis
complications: psychological impact, decreased fertility, tissue loss
** doppler USS diagnoses**
list possible causes of testicular cancer?
undescended testis (10%) FH klinefelters sydnrome previous testicular cancer mumps orchitis infertility
What are the most common types of testicular cancer?
95% are germ cell in origin which can be divided into:
- seminoma - peak incidence 30-40 y/o
- non seminoma/ teratoma - peak incidence 20-30 y/o (tumour markers)
- mixed germ cell
Where does testicular tumours commonly spread to?
lymph nodes: para aortic and supra diaphragmatic lymph nodes
lumbar bone
lung mets
(25% of seminomas and 50% of non seminomas metastasised at presentation)
How does testicular cancer present?
hard painless testicular lump (warrants 2 week referral) +/- dragging sensation, abdominal pain
+ gynaecomastia (due to high levels of HCG), secondary hydrocele, haemospermia, abdo mass
How is testicular cancer diagnosed?
1st line = ultrasound of both testes
2nd = tumour markers (alpha fetoprotein and human chorionic gonadotropin)
+ CT/ PET + CXR for staging
how is testicular cancer managed?
- low dose radiotherapy
- radical orchidectomy - good prognosis!
+ chemo if mets/widespread
List sites where transitional cell carcinoma can occur?
bladder
urethra
ureter
renal pelvis
List lymph nodes that drain the bladder
obturator
external and internal iliac
common iliac
Where does the blood supply to the bladder come from?
vesical arteries (branch of the internal iliac arteries)
what are the complications of BPH?
urinary retention
urinary tract infection
obstructive uropathy
what is the gold standard investigation to diagnose testicular torsion?
doppler ultrasound !!
*but usually clinical diagnosis as do not delay surgical exploration
which drugs increase the risk of renal stones?
loop diuretics calcium and vit D supplements steroids theophylline acetalozomide
what are the risk factors for urate kidney stones?
gout
hyperuricaemia
myeloproliferative disorders
ileostomy patients
where is testosterone produced?
in the leydig cells by LH
where is sperm produced?
Sertoli cells
list examples of non germ cell tumours?
lymphoma
leydig cell tumours
sarcoma
What are the complications of prostate cancer?
spread to OBTURATOR lymph nodes
spinal cord compression
hypercalcaemia
bone mets - fracture, pain
when does PSA increase?
prostate cancer BPH vigorous exercise ejaculation - wait 48hrs after to do test prostatitis, UTI
where do bladder cancers spread to?
para aortic and common / external/ iliac lymph nodes
pelvic structures locally
via blood: lungs, bone, liver
how are renal stones and obstruction / signs of sepsis managed?
- urgent decompression via ureteric stent or nephrostomy
2. IV abx
how is hydronephrosis diagnosed?
USS = dilatation of renal pelvis
can be caused by renal obstruction
what is the difference between acute and chronic urinary retention?
acute = painful, <1.5L retention chronic = painless, >1.5L drained
what are the risks with acute urinary retention?
post obstructive diuresis - ensure hourly UO monitoring and replace with IV fluids
how can you tell O/E if there is a renal mass?
mass palpable on bimanual palpation
moves up and down with respiration
able to get above mass
what are the causes of urethral strictures?
long term catheter
pelvic truama
foreign bodies
lichen sclerosis
what are the complications of urethral strictures?
calculus
prostatitis
how are urethral strictures managed?
internal uthrostomy
