Urology Flashcards
prostatitis
acute causes
caused by staphylococcus faecalis and E. coli, chlamydia and TB
prostatitis
acute features
UTIs
retention
haematospermia
swollen/ boggy prostate on DRE
prostatitis
actue treatment
analgesia
levofloxacin 500mg/day PO for 28/7
Prostatitis
Chronic
bacterial or non-bacterial
symptoms same as acute >3/12
Doesn’t respond to abx
anti-inflammatory drugs, alpha blockers and prostatic massage
Balantitis
acute inflammation of foreskin and glans
associated with strep and staph infections
more common in diabetics
often seen in children with tight foreskins
Rx - abx, circumcision, hygiene advice
Phimosis
foreskin occludes meatus
causes recurrent balantitis and ballooning
time and trials of retraction may prevent need for circumcision
in adults - painful intercourse, infection, ulceration and associated with balantitis xerotica obliterans
Paraphimosis
tight foreskin retracted and becomes irreplaceable
–> prevents venous return –> oedema and ischaemia of the glans
Rx –> ask pt to squeeze glans, glucose soaked swab, ice pack, lidocaine
–> may need aspiration, dorsal slit/ circumcision
Prostate Ca
commonest male cancer
increasing incidence with age
associated with positive family hx
mostly adenocarincoma arising in peripheral prostate
Symptoms of prostate Ca
asymptomatic nocturia hesitancy poor stream terminal dribbling obstruction weight loss +/- bone pain suggests mets
DRE of prostate in Ca
hard irregular prostate
Diagnosis of Prostate Ca
raised PSA transrectal USS & biopsy X-rays bone scan MRI/CT
Treatment of Prostate Ca
Disease confined to prostate
- radical prostatectomy
- radical radiotherapy +/- neoadjuvant & adjuvant hormonal therapy
- hormone therapy alone - delays disease progression
- active surveillance
Treatment of Prostate Ca
Metastatic Disease
- hormonal drugs - LHRH agonists goserelin stimulate and then inhibit pituitary gonadotrophin
Symptomatic treatment of Prostate Ca
analgesia
treat hypercalcaemia - fluids and allopurinol
radiotherapy for bone mets/ spinal cord compression
Penile Ca
rare in the UK - more common in Far East and Africa
very rare if circumcised
related to chronic irritation, viruses and smegma
Presentation: chronic, fungating ulcer, bloody/ purulent discharge - 50% spread to lymph at presentation
radiotherapy if early, amputation and lymph node dissection if late .
Benign Prostatic Hyperplasia
Pathology
benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate
inner (transitional) zone enlarges in contrast to peripheral layer (vice versa in prostate Ca)
Benign Prostatic Hyperplasia
Features
lower urinary tract symptoms
- nocturia, frequency, urgency, post-micturition dribbling, poor stream/ flow, hesitancy, overflow incontinence, haematuria, bladder stones, UTI
Benign Prostatic Hyperplasia
Tests
MSU U&E USS Rule out Ca- PSA Transrectal USS +/- biopsy
Benign Prostatic Hyperplasia
Lifestyle Management
Avoid caffine/ alcohol
relax when voiding
void twice in a row to aid emptying
control urgency by practicing distraction methods
train bladder by holding on to increase time between voids.
Benign Prostatic Hyperplasia
Drugs - alpha blockers
(tamulosin, alfuzosin, doxasosin, terazosin) decrease smooth muscle tone (prostate and bladder)
SE: drowsiness, depression, dizziness, low BP, dry mouth, ejaculatory failure, extra-pyrimidal signs, nasal congestio, increased weight
Benign Prostatic Hyperplasia
Drugs - 5alpha-reductase inhibitors
e.g. finasteride - decrease testosterone’s conversion to dihydrotestosterone
- excreted in semen so advice to use condoms, women should avoid handling
SE - impotence, low libido
Benign Prostatic Hyperplasia
Surgery
Transurethral resection of the prostate
Transurethral incision of the prostate- relieves pressure on urethra
Retropubic prostatectomy
Transurethral laser-induced prostatectomy
Acute Retention
Causes
Bladder usually tender (+600ml)
causes - prostatic obstruction, urethral strictures, anticholinergics, alcohol, constipation, post-op, infection, carcinoma, neurological
Acute Retention
MAnagement
- analgesia, privacy, running taps, hot bath
- alpha blocker
clot–> 3 way catheter and washout
catheter and then TWOC
Acute Retention
Prevention
Finasteride to decrease proste size and retention risk
tamulosin reduces risk of recatheterisation
Chronic Retention
Presentation
more insidious and maybe painless
Overflow incontinence
acute on chronic retention
lower abdo mass
UTI or renal failure
Chronic Retention
Causes
Prostatic enlargement Pelvic Malignancy Rectal Surgery DM CNS disease- transverse myelitis/MS
Chronic Retention
Management
Avoid catheterising unless pain/UTI or renal impairment
Institute definitive treatment promptly
Intermittent self-catheterisation may be needed
Epididymal Cysts
develop in adulthood
contain clear/milky fluid - spermatocele fluid
lie above and behind testis
remove if symptomatic
Hydrocele
fluid in the tunica vaginalis
primary- patent processus vaginalis–> common, larger, younger
secondary- trauma/ infection/ tumour
Rx - aspiration or surgery
Epididymo-orchitis
Causes
chlamydia e.coli mumps (EBV) n. gonorrhoea TB
Epididymo-orchitis
features
sudden onset tender swelling
dysuria
sweats/ fever
Epididymo-orchitis
investigations
1st catch urine sample
look for urethral discharge
consider STI screen
ward of possible infertility, symptoms may worsen before improving
Epididymo-orchitis
Management
<35 doxycycline (treat sexual partners) (if suspect gonorrhoea –> add ceftriaxone)
> 35 (non-STI) ciprofloxacin or ofloxacin
ALSO: analgesia, scrotal support, drainage of abscess
Varicocele
dilated veins of pampiniform plexus more commonly left-sided often visible as distended scrotal blood vessels that feel like a bag of worms Dull ache associated sub-fertility
Haematocele
blood in tunica vaginalis
follows trauma
may need drainage or excision
Testicular torsion
symptoms
sudden onset of pain in one testis
makes walking incomfortable
pain in abdomen
nausea and vomiting
Testicular torsion
signs
inflammation in one testis- tender, hot, swollen
may lie high and transversely
most common 11-30
Testicular torsion
Management
Analgesia- opioids
- consent for possible orchidectomy and bilateral fixation
Indirect inguinal hernia
pass though internal inguinal ring and then out through the external ring
direct inguinal hernias
pass directly through the posterior wall of the inguinal canal into a defect in the abdominal wall
Hesselback’s triangle - medial to inferior epigastric vessels, lateral to rectus abdominus
Predisposing factors for inguinal hernias
- males
- chronic cough
- constipation
- urinary obstruction
- heavy lifting
- ascites
- past abdominal surgery
deep (internal) ring
mid-point of the inguinal ligament
1.5cm above femoral pulse- crosses mid-inguinal point
superficial (external ring)
split into external oblique aponeurosis superior and medial to pubic tubercle
relation of the inguinal canal
floor
inguinal ligament and lacunar ligament medially
relation of the inguinal canal
roof
fibers of transversalis, internal oblique
relation of the inguinal canal
anterior
external oblique aponeurosis
+ internal oblique for lateral 1/3
relation of the inguinal canal
posterior
laterally - transversalis fascia
medially - conjoint tendon
Examination of inguinal hernia
-look for previous scars
- feel other side
- examine external genitalia
- is lump visible- can pt reproduce it?
ask pt to cough
- repeat standing
Male hypogandism
failure of testes to produce testosterone, sperm or both
- small testes, low libido, erectile dysfunction, loss of pubic hair, decreased muscle bulk, increase fat, gynaecomastia, osteoporosis, low mood
If prepubertal - low virilization, incomplete puberty, eunuchoid body, reduced secondary sex characteristics
Primary male hypogonadism
testicular failure - trauma/ torsion/chemo/radiation Post orchitis - mumps/HIV/ brucellosis/ leprosy Leydig cell toxicity - Renal failure/ liver cirrhosis or alcohol excess Chromosome abnormality - Kleinfelters syndrome (47XXY)
Secondary hypogonadism
low gonadotrophins- LH/FSH
- hypopituitarism
- prolactinoma
- Kallman’s syndrome- isolated gonadotrophin releasing homone deficiency with associated anosmia and colour blindness
- systemic illness e.g. COPD/HIV/DM
- Laurence-Moon-Beidl & Prader-Willi syndrome
Management of hypogonadism
testosterone dermal gel
CI if high calcium, polycythaemia, nephrosis, prostate/male breast/ or liver Ca
- monitor PSA
Clinical features
acute upper urinary tract obstruction
loin pain radiating to groin
- maybe superimposed infection +/- loin tenderness or an enlarged kidney
Clinical features
chronic upper urinary tract obstruction
flank pain, renal failure, superimposed infection
polyuria may occur due to impaired urinary concentration
Clinical features
acute lower urinary tract obstruction
acute urinary retention- severe suprapubic pain
preceded by symptoms of bladder outflow obstruction
clincically - distended, palpable bladder, dull to percussion
Clinical features
Chronic lower urinary tract obstruction
urinary frequency hesitancy poor stream terminal dribbling overflow incontinence Signs: distended, palpable bladder +/- large prostate on PR Complications: UTI, urinary retention
Luminal causes of urinary tract obstruction
stones
blood clots
sloughed papilla
tumour –> renal/ureteric/bladder
Mural causes of urinary tract obstruction
congenital/acquired stricture
neuromuscular dysfunction
schistosomiasis
Extra-mural causes of urinary tract obstruction
abdominal or pelvic mass/ tumour
retroperitoneal fibrosis
iatrogenic - post surgery
Urinary Obstruction tests
U&E, creatinine
MC&S
USS –> CT –> radionuclear MRI
Treatment of upper urinary tract obstruction
nephrostomy or ureteric stent
alpha-blockers for related pain
pyeloplasty
Treatment of lower urinary tract obstruction
urethral or supra-pubic catheter
treat underlying cause if possible
non-gonococcal urethritis
commoner than GC
- discharge is thinner and signs less acute
- women typically asymptomatic - cevicitis, urethritis,or salpingitis (pain/fever/infertility)
non-infective urethritis
trauma
chemicals
cancer
foreign body
Urothelial tumours
site
transitional cell carcinomas
- calyces
- renal pelvis
- ureter
- blader
- urethra
Urothelial tumours
demographics
men
over the age of 40
Urothelial tumours risk factors
- cigarette smoking
- exposure to industrial chemicals - benzidine
- exposure to drugs (phenacetin, cyclophosphamide, ketamine)
- chronic inflammation (schistosomiasis)
Urothelial tumours
clinical features
painless haematuria
LUTS (frequency, urgency, dysuria) in the absence of bacteriuria
- pain from locally advance or metastatic disease but may come from clot retention
TCC of kidney/ureters –> haematuria and flank pain
Urothelial tumours
Investigations
- plasma creatinine
- renal tract imaging and cystoscopy
Urothelial tumours
Management
Pelvic and ureteric tumours- nephrouretectomy
- treatment of bladder tumour: local diathermy, cystopic resection, bladder resection, radiotherapy and local/ systemic chemo
ureteral stones
urolithiasis
causes
calcium oxalate and/ or calcium phosphate
could also be uric acid, magnesium ammonium phosphate and cystine stones
Form when urine becomes super saturated and begins the formation of crystal formation + Calcium stones
hypercalciuria
causes
- hypercalcaemia (commonly primary hyperparathyroidism)
- excessive dietary intake of calcium
- excessive resorption of calcium from bone e.g. prolonged immobilisation
- idiopathic hypercalciuria (increased absorption from gut –> increased urinary excretion)
Primary renal disease –> alkaline urine –? calcium stones (precipitation of calcium phosphate)
Hyperoxaluria
increased oxalate excretion –> formation of calcium oxalate, even with normal calcium excretion
- dietary hyperoxaluria (spinach/rhubarb/tea) + low dietary calcium
- enteric hyperoxaluria - chronic intestinal malabsorption of any cause –> low intestinal calcium for oxalate binding (2ndary cause - dehydration due to fluid loss from gut)
- primary hyperoxaluria rare autosomal recessive enzyme deficiency resulting in high levels of endogenous oxalate production - widespread calcium oxalate deposition (CKD in teens/20s)
Uric acid stones
hyperuricaemia with or without clinical gout
pts with ileostomy at risk (loss of bicarb from GI secretions –> acid urine and reduced solubility of uric acid)
Infection induced stones
UTIs with urease producing organisms (proteus, klebsiella, pseudomonas) –> stones of ammonia, magnesium and calcium)
urease hydrolyses urea to ammonia increasing urinary pH
- large stones in pelvicalyceal system produce radiopaque staghorn calculus
Cystine stones
cystinuria (autosomal recessive condition affecting cystine and dibasic amino acid transport of epithelial cells of renal tubules and GI tract) –> excessive urinary excretion of cystine –> formation of crystals and calculi
Clinical features of urinary tract caliculi
- asymptomatic
- pain most commonly
- loin pain = staghorn renal caliculi
- ureteric stones = renal colic
Nausea, vomiting and sweating
Haematuria
urethral stones - bladder outflow obstruction = anuria and painful bladder distention
Management of stones
- strong analgesia
- extracorporeal shock wave lithotripsy
- endoscopy
Investigations of stones
MSU for culture and serum urea, electrolytes, creatinine and calcium
Plain KUB x-r
unenhanced helical CT
Prevention of stones
- normal calcium, avoid oxalate high foods
- meticulous control of bacteriuria
- xanthine oxidase inhibitor (allopurinol)
- high fluid intake
Normal urinary physiology
intravesical pressure remains low due to stretching of the bladder wall and the stability of bladder muscle (detrusor) which doesn’t contract involuntarily
- sphincter mechanisms of bladder neck and urethral muscles
- decreased sympathetic activity = sphincter relaxation and detrusor contraction
- overall control in cerebral cortex and the pons
stress incontinence
sphincter weakness
- iatrogenic (post prostatectomy)
- post child birth
- small leak of urine with increase in intra-abdominal pressure
urge incontinence
strong desire to void and inability to hold urine
- usual cause detrusor instability
- mild cases respond to bladder training
- anticholinergic agents –> oxybutynin –> decrease detrusor excitability
- may also be caused by bladder hypersensitivity from local pathology (UTI, bladder stones and tumours
Overflow incontinence
- prostatic hypertrophy causing outflow obstruction
- leakage of small amounts of urine
- distended bladder is palpable rising out the pelvis
