Urology Flashcards
What are epididymis cysts?
Epididymis cysts are the most common cause of scrotal swelling sein in primary care.
Features:
- Separate from body of testicle
- Found posterior to testicle
Associated with PCKD, Cystic Fibrosis and Von Hippel-Lindau syndrome.
Management is usually supportive, but can be surgical if large.
What is a hydrocoele?
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
- communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
- non-communicating: caused by excessive fluid production within the tunica vaginalis, e.g. 2° to epididimo-orchitis or testicular cancer.
Clinical features include:
- soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
- the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
- transilluminates with a pen torch
- the testis may be difficult to palpate if the hydrocele is large
What is a varicocoele?
A varicocoele is an abnormal enlargement of the testicular veins.
These are usually asymptomatic but may be important as they are associated with infertility.
What is the first line investigations in suspected prostate cancer?
The first line investigation for suspected prostate cancer is multiparametric MRI.
What do you need to counsel about that wants a vasectomy?
- doesn’t work immediately
- semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
- complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)
- the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
How long can it take for finasteride to benefit a patient with BPH?
This takes time and symptoms may not improve for 6 months.
What are the risk factors for BPH?
- Age: around 50% of men at 50 will have evidence of PBH. Around 80% of 80 year olds will have BPH
- Ethnicity: black > white > Asian
What are the symptoms of BPH?
BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into:
- voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying
- storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia
- post-micturition: dribbling
- complications: urinary tract infection, retention, obstructive uropathy
Summarise the management options for BPH.
Conservative:
- Watchful waiting. Advise on lifestyle:
- Avoid caffeine/tea/alcohol
- Don’t drink at night
Medical:
- Alpha-1-antagonists (e.g. tamsulosin, alfazuosin)
- Decrease smooth muscle tone of ureter/prostate
- First-line
- Side effect: postural hypotension, dry mouth, depression
- 5-alpha reductase inhibitors
- Block conversion of testosterone into di hydro testosterone
Surgical:
- TURP
- Uro-lift (see image - potentially better outcomes)
What is a normal post-void volume in <65 and >65 year old?
- <65: <50 mL
- >65: <100 mL
What is the definition of chronic urinary retention in terms of post-void volume?
Chronic urinary retention (CUR) is defined by the International Continence Society as ‘a non-painful bladder, which remains palpable or percussable after the patient has passed urine.`
Most commonly, a post-void residual volume of 300 mL is cited as diagnostic.
What are the most common causative organisms of epididymo-orchitis?
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia
trachomatis and Neisseria gonorrhoeae) or the bladder.
What is Prehn’s Sign, and what is its significance?
Elevation of the testis does not ease the pain (Prehn’s sign).
This indicates a testicular torsion.
What are the clinical features of epididimo-orchitis?
- Unilateral testicular pain and swelling
- Unilateral discharge may be present
- Absence of factors that would point towards torsion:
- Age < 20
- Severe pain
- Acute onset
What is the most effective analgesia in acute renal colic?
Diclofenac IM (usually 75 mg) is recommended first line.
What are the initial investigations you would like to perform in someon with a suspected renal stone?
- urine dipstick and culture
- serum creatinine and electrolytes: check renal function
- FBC / CRP: look for associated infection
- calcium/urate: look for underlying causes
- also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
Summarise the management of renal stones.
Conservative:
- Stones < 5mm will usually pass by themselves (within 4 weeks)
- Provide analgesia, and consider alpha blockers (although not recommended by BAUS)
Medical:
- As mentioned above, analgesia and alpha-blockers may be indicated
Surgical:
- In the non-emergency setting:
- extra-corporeal shock wave lithotripsy
- Percutaneous nephrolithiotimy
- Ureteroscopy
- Open surgery remains an option in some cases, especially if sever complications or failure of other methods
What can be done to prevent renal stones?
Calcium stones:
- High fluid intake
- Low animal protein, Low salt diet
- Thiazide diuretics (increase calcium reabsoption and therefore decrease urinary excretion)
Oxalate stones:
- Cholestyramine and pyridoxine reduces oxalate secretion
Urin acid stones:
- Allopurinol
- Alkalizing agents
What is the most common type of renal tumour?
Renal adenocarcinoma are the most common renal tumours.
They can be subdivided into:
- Clear Cell (75%)
- Papillary (10%)
- Chromophobe (5%)
Note: renal adenocarcinomas may produce cannon ball metastases in the lung, which can cause haemoptysis.
What are common causes of urethral strictures?
- Iatrogenic (e..g traumatic catheter insertion)
- Sexually transmitted infections
- Hypospadias
- Lichen Sclerosus
Summarised the management for STI related epididmo-orchitis.
BASHH guidelines:
- If organism unknown: ceftriaxone 500mg IM stat + Doxycycline 100 mg by mouth bd for 10-14 days
- Do futher investigations to rule out underlying structureal abnormalities
What organism are staghorn calculi associated with?
What is the likely composition of staghorn calculi?
Associated with Proteus infection.
Composition: struvate (ammonium magnesium phosphate, triple phosphate).
What is the MoA of goserelin?
Goserelin is a GnRH agonist, therefore leading to loss of the pulsatile stimulation of the pituitary required for sustained LH/FSH release. This causes chemical castration.
What medication should be co-prescribed when starting goserelin?
Goserelin is a GnRH agonist. As this initially leads to hyperstimulation of the axis before suppressing it, an anti-androgen has to be co-prescribed for the first 3 weeks of treatment.
What is testicular torsion?
Also summarise clinical features and management.
Testicular torsion is the twisting of the spermatic cord resulting in testicular ischaemia and necrosis (if not fixed quickly enough).
This is most common in males aged 10-30.
Features:
- Sudden onset severe testicular pain
- Pain refers to lower abdomen
- N&V may be present
- Testicle is swollen and reddended, and often retracted upwards.
- Cremasteric reflex is lost
- Elevation of testis does not ease pain
Management:
- Surgical exploration with detorsion and bilateral fixation of the testis as bell clapper testis is bilateral
What is bell clapper deformity of the testis?
The bell clapper deformity allows the testis to move more freely inside the scrotum.
The abnormality is an inappropriately high attachment of the tunica vaginalis, as well as abnormal fixation to the muscle and fascial coverings of the spermatic cord. This causes the testicle to be orientated transversly as opposed to cephalocaudally.
What is a varicocoele?
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Why are varcocoeles more common in the left testicle?
More than 80% of varicocoeles occur on the left side.
This is as the left gonadal vein drains into the left renal vein at a right angle, which can easier lead to backpressure (the right drains at a steeper angle directly into the IVC)
What are potential complications of AV fistulas?
- Infection
- Thrombosis (absence of bruit)
- Stenosis (acute limb pain)
- Steal syndrome
