Urology Flashcards
List the common anatomical sites with urolithiasis occur
- Pelviureteric junction
- Pelvic brim
- Vesicoureteric junction
Types of stones that causes urolithiasis
- Calcium oxadate stones (spikey or smooth opaque stones)
- Struvite stones (staghorn stones, linked to infection)
- Urate stones (smooth brown stones)
- Cystine stones (yellow crystal stones)
Factors that predispose patients to developing stones
Dehydration Hypercalcaemia (1 PTH) Increased oxalate excretion UTIs Hyperuricaemia Anatomical abnormalities Drugs: furosomide
Presentation of urolithiasis
Acute severe flank pain Pt cannot lie still - renal colic - loin to groin - unilateral \+ n/v \+ worse on fluids \+ microscopic haematuria
Investigation for suspected urolithiasis
- Spiral non contrast CT of the kidneys , gold standard
- Urinalysis
- dip and Mc+s: microhaematuria, leukocytes, nitrates - Bloods
- FBC, raised WCC
- U+E, hypercalcaemia, gout - Pregnancy test
- KUB USS (hydronephrosis)
Watch out for signs of sepsis
Treatment of urolithiasis
ACUTE
- Hydration
- Pain control
- Anti-emetics
- Rectal diclofenac
Stone with no obstruction
- +bacteriuria (trimethoprim/nitrofurantoin)
- <10mm: medical explosion therapy (alpha blockers or CCB
- > 10mm : Extracorporeal shock wave lithotripsy + ureteroscopy
Stone with obstruction
- as above + surgical decompression
Define BPH and discuss why the lower urinary tract symptoms occur
Proliferation of musculofibrous and glandular layers
Enlargement of inner transition zone
LUTRS due to bladder outlet obstruction
- Static component: increase in the tissue bulk
- Dyanamic component: increase in the prostatic smooth muscle (alpha adrenergic receptors)
List the symptoms of BPH
Frequency Urgency Nocturia Hesitancy Intermittent emptying Poor flow Post voiding dribble
Investigations for BPH
- PR examination
- TRUSS +/- biopsy
- PSA
Urinalysis
- rule out UTI
Volume chart
Urodynamics
USS KUB
Treatment of BPH
MILD
- Watch and wait
MILD + symptomatic
- Alpha blocker (tamulosisn)
- 5 alpha reductase inhibitor (finasteride)
- NSAID
Abnormal DRE + elevated SA
- surgical referral
- Prostate <80g TURP/TUVP
- Prostate > 80g radical prostectomy
Complications of BPH
- Progression
- Sexual dysfunction
- Acute urinary retention
- TURP syndrome: absorption of irrigating fluids into prostatic venous sinuses
Causes of urinary retention
OBSTRUCTIVE - Mechanical BPH Clots Strictures Stone Constipation
- Dynamic
Drugs
Post operative pain
NEURO - Interruption of sensory or motor innervation Pelvic surgery MS DM
MYOGENIC
- Over distension of the bladder
High alcohol intakes
Clinical features of acute urinary retention
Suprapubic tendernes Palpable bladder - Dull to percussion Large prostate on PR <1L on catheterisation
Investigations in acute urinary retention
Blood
- FBC
- U&E
- PSA
Urine
- Mc&s
Imaging
- US bladder volume
- Hydronephrosis
- Pelvic XR
Management of acute urinary retention
Conservative
- Analgesia
- Walking
- Running water or bath
Catheterise - + stat gent cover - hourly UO - Tamulosin, decreased the risk of recatherterisation after retention - TWOC 24-72hr if failed TWOC will need TURP
Organisms that cause prostatitis
S.faecalis
E.coli
Chlamydia
Clinical features associated with prostatitis
UTI Pain - low backache - pain on ejaculation Haematospermia Fevers Rigors Retention Malaise
O/E
Pyrexia
Swollen/boggy/tender prostate on PR
Treatment of prostatitis
Sepsis
- IV taz
- IV gent
- NSAIDs
- SPC
No sepsis
- Fluoroquinolone oral 2-4 weeks
- Ciprofloxacin 500mg PO BD
Chronic
- 4/6 weeks of ciprofloxacin + alpha blocker + NSAIDS
Causes of false haematuria
Beetroot
Rifampicin
Porphyria
PV bleed
Outline the presentation of acute epididymo-orchitis
Unilateral pain and swelling (develops over days) Discharge Fever LUTS (must rule out torsion)
List the causes of epididymo-orchitis
<35
- STI
- N.Gonorrhoeae
> 35
- UTI
- Enteric pathogens (E.coli)
Retrograde ascent of urinary pathogens
A 24yr old male presents to A&E complain of pain and swelling in his testicles. It is sore and hot to touch.
On questioning further he mentions that he has had some LUTS symptoms in the last few days as well as some discharge.
What are you ddx?
What investigations would you perform?
How will you manage this patient?
A) Acute epididymo-orchits from a STI
B) Acute epididymo-orchitis from a UTI
Ix
- First catch urine or NAAT for STI check
- Gram stain of urethral secretions
- Urine dip +ve leucocyte esterase
- Urine culture
- Urine microscopy
- Colour duplex USS
- May require surgical exploration
Rx
- STI : Single dose of ceftriaxone (IM) + doxycycline (100mg)
- UTI levofloxacin 100mg
Presentation of testicular torsion
Surgical emergency
Tender, swollen, hot, high and transverse lie
Morel likely in bell clapper deformity
Treatment of testicular torsion
Ordidopexy (bilateral fixation)
Must also consent for an orchidectomy
Define erectile dysfunction
ED is difficulty in attaining, maintaining an erection or a marked decrease in rigidity
Importnat Q’s
- Early morning erection
- Foreplay
- Masturbation
List the causes of ED
Age Pain Vascular Neurological ( Spinal cord injury) Horomonal (increased prolactin, low androgens) Psychological (anxiety, depression) Surgical Drugs (SSRI, B-blockers)
Investigations for erectile dysfunction
Nocturnal rigiscan Penile doppler USS Testosterone Prolactin Cholesterol BP Fasting glucose HbA1c FSH/LH TSH
Outline the possible treatment options for men with erectile dysfunction
Rx underlying cause
- PDE5 inhibitor: sildenafil
- Alprostadil:
- Vacum pump
- Constriction ring
- Penile implant
- Psychosexual therapy
Outline the pathology of prostate cancer
Commonest male Ca
Adenocarcinoma
Peripheral zone of prostate
Clinical features of prostate cancer
Asymptomatic Urinary - Nocturia - Frequency - Hesitancy - Poor stream - Dribbling Weight loss Fatigue Bone pain from mets
Outline the types of spread expected in prostate cancer
Local: seminal vesicles, bladder, rectum
Lymph: para-aortic nodes
Haem: Sclerotic bony lesions
Investigations in suspected prostate cancer
Bloods
- PSA
- U&Es
- FBC
- ALP-
- Ca
Imaging
- XR chest and spine
- Transrectal USS guided biopsy
- Bone scan
- Staging MRI
Outline the issues in relation to PSA
Proteolytic enzyme that is not specific to prostate Ca
Increases with age, RP, TURP and prostatitis
Name the grading system used for prostate cancer
Gleason
Outline the treatment of prostate cancer
VERY LOW RISK
- Active surveillance
- +/- brachytherapy or external beam radiotherapy
- Check PSA/DRE/BIopsy
LOW RISK
- As above
HIGH RISK
- Radiacal prostectomy plus pelvic LN dissection
- External beam radiotherapy + androgen deprivation therapy
Outline the management of metastatic disease
80% are androgen sensitive: castration leads to remission
- Goserelin (GnRH analogue) may initially make things worse and will then improve.
- Tamoxifen
- Anti-androgen ( flutamide)
If castration resistant
- Bisphosphonates/ denosumab for bone pain and hypercalcaemia
- Palliative radiotherapy
Complications of prostate cancer
Erectile dysfunction
Hormone induced gynaecomastia
Hormone induced flush
Radiation induced LUTS
Define a varicocele
Abnormal dilatation of internal spermatic veins and paminiform plexus
Possible due to absent valves
Management of a varicocele
Reassurance and observation
High grade: surgical repair
Define a hydrocele
Collection of serous fluid between layers of the tunica vaginalis
Types: Communicating or non-communicating
Management of a hydrocele
May resolve spontaneously
Surgical repair
- Lord’s repair
Define neurogenic bladder
Bladder function that is either flaccid or spastic and is caused by neurological damage.
Main feature: OVERFLOW INCONTIENCE
Outline the innervation of the bladder
Detrusor contraction: PSNS (cholinergic) S2,3,4, pelvic splanchnic
Urethral Contraction and inhibition of the detrusor: SNS T11-L2 (hypogastric)
Somatic: S2,3,4 external sphincter muscle
Outline the causes of neurogenic bladder
CNS
- Spinal injury
- ALS
PNS
- Diabetes
- Alcohol
- VItB12 neuropathy
Mixed
- Parkinsons
- MS
- Syphillis
- Tumour
Classify the different types of neurogenic bladder
Flaccid (hypotonic)
- Areflexic bladder
- Bladder volume is large, press sure is low
- Absent contractions
Spastic bladder
- Brain or spinal cord damage
- Detrusor-sphincter dyssynergia
- Involuntary urination/defecation
Complications of neuropathic bladder
Reduced quality of life
Increased UTI and calculi
Hydronephrosis (problematic kidney damage)
Acute bladder distension
