Urology Flashcards
differentials of scrotal swelling?
inguinal hernia testicular tumour acute epididymo-orchitis epididymal cysts hydrocele testicular torsion
features of epididymal cyst?
lump found posterior and separate from the body of the testicle
associated condition of epididymal cysts?
polycystic kidney disease
CF
Von Hippel-Lindau syndrome
diagnosis of epididymal cysts?
USS
Mx of epididymal cysts?
supportive therapy
surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts
what is a hydrocele?
an abnormal collection of fluid between the 2 layers of the tunica vaginalis
causes of hydrocele?
- non-communicating or simple hydrocele- over production of fluid within the tunica vaginalis
- communicating hydrocele- the processus vaginalis fails to close allowing peritoneal fluid to communicate freely with the scrotal portion
- hydrocele of the cord- processus vaginalis closes segmentally, trapping fluid within the spermatic cord
presentation of hydrocele?
scrotal enlargement with a soft non-tender swelling
No pain
Will trans illuminate with pen torch
Can get above the mass on examination
Testis may be difficult to palpate if the hydrocele is large
Ix of hydrocele?
none required for simple hydrocele
USS if in doubt of diagnosis
suplex sonography
serum AFP and HCG levels to exclude malignant teratomas or other germ cell tumours
tx of hydrocele?
If in infancy, many resolve spontaneously
In adults, conservative approach may be taken depending on the severity of the presentation
Scrotal support
Therapeutic aspiration
Surgical removal in some cases
what is varicocele?
an abnormal dilatation of the testicular veins in the pampiniform venous plexus, caused by venous reflux
- usually asymptomatic, need to rule out RCC (due to compression of renal vein- swollen testicles can be a symptom)
- can be associated with infertility
- reflux
- valve incompetence
is a varicocele more common on the left or right?
LEFT as left testicle vein drains into the left renal vein which has more chance of compression
epidemiology of varicocele?
incidence increases after puberty
features of varicocele?
usually asymptomatic
scrotum feels like a ‘bag of worms’
scrotal heaviness
infertility
Ix of varicocele?
sperm count
USS colour doppler studies
Venography, thermography, CT
Serum FSH/LH/LHRH
tx of varicocele?
surgical repair where there is pain, infertility and testicular atrophy
what is testicular torsion?
twisting of the spermatic cord resulting in testicular ischaemia and necrosis
RFs for testicular torsion?
10-30 years, L sided more commonly affected
features of testicular torsion?
acute swelling of the scrotum pain-sudden and severe in one testicle testicle retracts upwards loss of cremasteric reflex lower abdo pain can come on during sport or physical activity reddening of the scrotal skin
Ix of testicular torsion?
mainly a clinical diagnosis
urinalysis to exclude infection and epididymitis
doppler ultrasound scan- GOLD STANDARD- shows reduced blood flow
tx of testicular torsion?
surgery within 6 hours to save testicle
what does the prostate secrete?
seminal fluid. it nourishes the sperm
stimulated by the dihydrotestosterone
features of BPH?
LUTS:
- voiding symptoms (obstructive) - weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
- storage symptoms (irritative) - urgency, frequency, urinary incontinence, nocturia
- post-micturition- dribbling
- complications- UTI, retention, obstructive uropathy
Ix of BPH?
DRE- enlarged prostate
serum electrolyte and renal USS
serum PSA
referral and biopsy if suspicious of malignancy
tx of BPH?
1) Alpha blockers- e.g. Tamsulosin, alfuzosin- a1 receptor antagonists
- relax smooth muscle in the bladder neck and prostate
- increase urinary flow rate and an improvement in obstructive symptoms
2) 5-alpha reductase inhibitors e.g. finasteride
- blocks conversion of testosterone to dihydrotestosterone (responsible for prostate growth)- may take 6 months before results are seen
- can slow progression
3) urethral or suprapubic catheterisation
4) prostatectomy/TURP or permanent catheter
SEs of alpha blockers
dizziness
postural hypotension
dry mouth
depression
SE of 5-alpha-reductase inhibitors
ED reduced libido ejaculation problems gynaecomastia (due to lack of testosterone)
complications of BPH?
Bladder obstruction-retention infections stones haematuria interactive obstructive uropathy
what are the majority of bladder cancers?
> 90% are transitional cell carcinomas
2nd type is SCC
incidence peaks in the 8th decade
RFs for transitional cell bladder cancer?
smoking aniline dyes rubber manufacture cyclophosphamide pelvic irritation
RFs for SCC bladder cancer?
schistosomiasis
BCG treatment
smoking
what is the grade of a cancer?
biological potential to invade and metastasise
what is the stage of a cancer?
how far it has spread
features of bladder cancer?
painless haematuria **red flag** recurrent UTIs voiding irritability LUTS dysuria **red flag** abdo pain weight loss/bone pain
Ix of bladder cancer?
urine dipstick-microscopic haematuria bloods- FBC, U&E, LEFTs flexible cystoscopy with biopsy is diagnostic urine- microscopy and cytology CT urogram MRI
tx of bladder cancer?
TURBT (resection) +/- intravesicle chemotherapy
2 main agents- mitomycin and BCG vaccine
If muscle invasive- radical surgery and radiotherapy
Chemotherapy
2 week wait for suspected urological malignancy?
> 45 years and unexplained macroscopic haematuria or persists after Tx for UTI
> 60 years and unexplained microscopic haematuria and either dysuria or increased ECC on testing
Consider non-urgent referral if >60 and recurrent or persistent UTI
what is the most common type of prostate cancer?
95% are adenocarcinomas
causes/RFs of prostate cancer?
age- disease of the elderly obesity afro-Caribbean ethnicity FH mutations in androgen receptor genes
features of prostate cancer?
localised disease- often asymptomatic LUTS pain- back, perineal or testicular mets to bone- hypercalcaemia B-symptoms Marrow replacement- purpura, anaemia, immune suppression
Ix of prostate cancer?
DRE- asymmetrical, hard, craggy, loss of median sulcus PSA screening tool PSMA in serum Urine test for PCA3 Multiparametric MRI TRUSS- transrectal USS Prostate biopsy CT
when should men be referred for further investigation?
men aged 50-69 should be referred if PSA .3 OR there is an abnormal DRE
causes of false positive PSA?
prostatis- wait 1 month UTI- wait 4 weeks Vigorous DRE- wait 1 week Vigorous exercise- wait 48 hours Ejaculation- wait 48 hours Urinary retention Surgery/instrument used BPH
what is the grading system for prostate cancer?
GLEASON GRADING SYSTEM
TX of prostate cancer?
radical prostatectomy and radiotherapy
focal therapy- high intensity USS
watchful waiting to see if the cancer progresses
active surveillance- follow up examination and PSA level monitoring
brachytherapy- radiotherapy beads
how to manage metastatic prostate cancer?
1) Androgen deprivation-
-surgical castration (removing testicles)
-medical castration-> GnRH analogues- buserelin, goserelin, LH antagonists, peripheral androgen receptor antagonists
(need to co-prescribe anti-androgen tx such as cryproterone acetate or flutamide- presents increase in symptoms)
Second line- hormone therapy (abiraterone), cytotoxic chemo, bisphosphonates, palliation of pain, ureteric obstruction, anaemia
what is a complication of TURP?
TURP syndrome
venous destruction and absorption of the irrigation fluid
causes restlessness, headache, tachypnoea, burning sensation in the face and hands
causes hyponatraemia, fluid overload, glycine toxicity
mx of TURP syndrome?
ABCDE and resuscitation and O2
fluid overload managed with furosemide
what produces testosterone and what produces sperm?
testosterone- Leydig cells
sperm- sertoli cells
cause of testicular cancer?
FH
genetic factors- abnormality in Chr 12, Klinefelter’s syndrome
Unknown- majority
RFs for testicular cancer?
25-35 years
cryptorchidism (undescended testis)
infertility
mumps
types of testicular cancer?
95% arise from germ cells- seminomas and teratomas
non germ-cell tumours- Leydig cells, Sertoli cells, sarcomas
features of testicular cancer?
painless lump testicular and/or abdominal pain dragging sensation in the testicles hydrocele gynaecomastia from B-HCG production Mets in lungs or para-aortic lymph nodes
Ix of testicular cancer?
USS
Tumour markers- AFP and Beta-HCG
CXR and CT of chest, abdomen and pelvis
tx of testicular cancer?
orchidectomy
radiotherapy- for seminomas with mets below the diaphragm
chemotherapy
sperm banking
what is epididymo-orchitis?
infection of the epididymis and/or testes resulting in pain and swelling
causes of epididymo-orchitis?
local spread of infections from genital tract or bladder
age <35= STI >UTI
age <35= UTI>STI
following urological intervention
in the elderly -> predominantly catheter related
features of epididymo-orchitis?
unilateral testicular pain and swelling
urethral discharge
rule out testicular torsion
Ix of epididymo-orchitis?
void urine and the perform CT +/- urethral swab
MSSU
USS to rule out abscesses
Sexual history
tx of epididymo-orchitis?
if STI suspected- refer to GUM
Abx- quinolone of >35 and not suspecting UTI
doxycycline +/- stat azithromycin if STI more likely
if organism unknown- IM ceftriaxone 500mg single dose plus doxycycline 100mg by mouth BD for 10-14 days
Supportive underwear
NSAIDS if required
what is hydronephrosis?
dilatation of the renal pelvis or calyces as a result of obstruction of the outflow of urine distal to the renal pelvis
causes of hydronephrosis?
SUPER (bilateral) PACT (unilateral) S- stenosis of the urethra U-urethral valve P-prostatic enlargement E- extensive bladder tumour R- retroperitoneal fibrosis
P- pelvic-ureteric obstruction (congenital or acquired)
A- abnormal renal pelvis
C-calculi
T-tumours of the renal pelvis
Ix of hydronephrosis?
USS
IV urogram
antegrade or retrograde pyelography
CT scan- if suspected renal colic
tx of hydronephrosis?
treat cause
catheter
nephrostomy tube- acute upper urinary tract obstruction
ureteric stent or pyeloplasty- chronic upper UT obstruction
what is obstructive uropathy?
functional or anatomical obstruction of urine flow at any level of the urinary tract can be supravesivle (above the bladder) or infravesicle (below the bladder)
renal causes of obstructive uropathy?
cysts (PKD)
Neoplastic- wilm’s tumour, RCC, TCC
Inflammatory- TB, echinococcosis infection
Metabolic- kidney stones
Miscellaneous- sloughed papillae, trauma, renal artery aneurysm
ureter causes of obstructive uropathy?
congenital- strictures, ectopic kidney
cancer- TCC of the ureter, mets
inflammatory- TB, schistosomiasis, endometriosis
misc- retroperitoneal fibrosis, AA, pelvic lipomatosis, pregnancy
kidney stones
bladder and urethra causes of obstructive uropathy?
congential- phimosis (narrow foreskin), abnormal opening of urethra
neoplastic- cancers
misc- BPH
what is post obstructive diuresis?
urine output increases to >200ml/hr
ends when normal levels have been achieved again
normal physiological resonse
features of obstruction of urinary tract?
dull ache in flank/loin
complete anuria
LUTS
Ix of obstruction of urinary tract?
imaging- CT, USS
serum creatinine- shows function of the affected kidney
bloods- FBC, U&E, coagulation, ABG
Urine- dipstick, MC&S to rule out infection as cause
tx of obstruction of urinary tract?
ABCDE fluids analgesia antibiotics catheter stents nephrostomies
what is acute urinary retention?
sudden (<6 hours) inability to voluntarily pass urine
PAINFUL
palpable distented bladder
causes of acute urinary retention?
BPH
urethral obstruction
meds- anticholinergics, TCAs, antihistamines, opioids, benzodiazepines
neurological- cauda equina, spinal cord compression
UTI
Postoperative
Postpartum
Ix of acute urinary retention?
DRE
neurological examination/ pelvic exam in women
urinalysis and culture
U&Es and creatinine
FBC and CRP
bladder USS to confirm diagnosis- volume >300cc
mx of acute urinary retention?
catheterisation
further Ix for underlying cause
features of chronic urinary retention?
PAINLESS incomplete bladder emptying frequency, urgency, hesitancy, dribbling nocturia incontinence
red flag causes of chronic urinary retention?
spinal cord injury pelvic/sacral fracture herniated disc infections MS myogenic failure due to chronic detrusor overdistension
Ix of chronic urinary retention?
urinalysis MSSU bloods (U&Es and creatinine) bladder diary imaging of urinary tract
mx of chronic urinary retention?
intermittent self-catheterisation indwelling catheter stop precipitating drugs tx for BPH lifestyle- reduce alcohol and caffeine, reduce evening alcohol, bladder training
complications of chronic urinary retention?
acute on chronic retention
hypertrophy of detrusor muscle and formation of bladder diverticula
hydronephrosis- leading to AKI or CKD
urinary incontinence due to overflow
indications for surgery in urinary problems?
RUSHES Retention UTIs Stones Haematuria Elevated creatinine due to bladder outlet obstruction Symptom deterioration
what causes erectile dysfunction?
erections are caused by inflow of blood to the corpora cavernosum (corpus spondiosum contains urethra)
->
trabecular smooth muscle relaxation and arteriolar dilatation (through nitric oxide mediator)
->
phosphodiesterase causes penis to return to flaccid state
what are the nerves responsible for an erection?
parasympathetic- S2,3,4- responsible for erections
sympathetic nerves T11-L2- responsible for ejaculation
RFs for ED?
lack of exercise obesity smoking hypercholesterolaemia hypertension metabolic syndrome DM
causes of ED?
- Vascular
- Central neurological
- Peripheral neurological
- Hormone
- low testosterone
- anatomical
- drug causes
- psychosexual- lack of arousability, situational
central neurological causes of ED?
Central neurological- PD, stroke, MS, tumours, traumatic brain injury, CVD, IV disc disease, spinal cord disease or injury
peripheral neurological causes of ED?
Peripheral neurological- polyneuropathy, DM, alcoholism, uraemia, surgery, peripheral neuropathy
hormonal causes of ED?
Hormone- hypogonadism, hyperprolactinaemia, cushings disease
low testosterone causes of ED?
Primary- pituitary, hypothalamus
Secondary- testes (tumour, injury, drugs), Klinefelter’s syndrome, Noonan’s
anatomical causes of ED?
Peyroine’s disease- penis bends over when it gets on erection to fibrous growth
drug causes of ED?
Beta-blockers anti-depressants e.g. SSRIs, TCAs anti-hypertensives recreational drugs H2 antagonists- ranitidine
Ix of ED?
physical exam and ED fasting glucose lipid profile morning testosterone if low testosterone-> perform prolactin, FSH and LH
tx of ED?
1st line- lifestyle modification
phosphodiesterase inhibitors- PDE5 inhibitors e.g. sildenafil (Viagra)- effective for 30 mins
Vacuum erection devices 1st line if can’t take PDE5 inhibitors
SEs of Viagra?
headache flushing dyspepsia nasal congestion dizziness visual disturbance
CI of Viagra?
nitrates (decrease BP) alpha blockers (decrease BP)
what is priapism?
prolonged erection
if lasts >4 hours there’s a risk of permanent ischaemic damage to the corpora
treat by aspirating the corpora with a 19 gauge needle or inject phenylephrine
what is persistent non-visible haematuria?
blood present in 2/3 samples tested 2-3 weeks apart
causes of persistent non-visible haematuria?
cancer stones BPH prostatis urethritis e.g. chlamydia renal causes e.g. IgA nephropathy
causes of transient or spurious non-visible haematuria?
UTI
menstruation
vigorous exercise
sexual intercourse
causes of red/orange urine without blood on dipstick?
beetroot, rhubarb
rifampicin, doxorubicin
Ix of haematuria?
urine dipstick
renal function, albumin:creatinine (ACR) ratio
BP check
urine microscopy
tx of haematuria?
urgent referral-
>45 years AND
-unexplained visible haematuria without UTI or
-visible haematuria that persists or recurs after successful treatment of UTI
organisms causing UTI?
Gram negative- E.coli, klebsiella, proteus, Enterobacter
Gram positive- enterococcus
RFs for UTI?
sexual intercourse female (shorter urethra) post-menopause (decrease oestrogen causes loss of protective vaginal flora) foley catheter DM infant boys with foreskin impaired bladder emptying urinary stasis
Ix of UTI?
Urinalysis- pyuria (leukocytes), nitrites
Urine culture
Renal USS
VCUG- voiding cystourethrogram- vesicoureteral reflux
Renal scintigraphy
what is sterile pyuria a sign of?
pyuria and urine culture (negative) suggests urethritis e.g. gonorrhoea or chlamydia
tx of UTI?
Abx- trimethoprim or nitrofurantoin for 3 days
fluids
CI of trimethoprim?
methotrexate, 1st trimester pregnancy
CI of nitrofurantoin?
breastfeeding
mx of pyelonephritis?
admit and broad-spectrum cephalosporin (cefotaxime, ciprofloxacin) or a quinolone for 10-14 days
features of pyelonephritis?
fever rigors loin pain vomiting white cell casts in urine
mx of overactive bladder?
moderate fluid intake
bladder training
antimuscarinics e.g. oxybutynin, tolterodine or darifenacin
signs of a bladder rupture?
pelvic fracture and lower abdo peritonism, free fluid in pelvis