Urology Flashcards
URINARY TRACT INFECTION
• Common in Women; Uncommon in Men and Children and require further investigation
• Recurrent infection causes considerable morbidity; Complicated UTI may even lead to severe
Renal Disease E.g. Pyelonephritis and ESRF; Common source of Gram Negative Septicaemia
• Most infection from Bowel Flora; Symptomatic infection associated with virulence of
organism (e.g. Presence of Adhesins); Inflammation and Injury due to host response
• Urine Osmolality >800mOsm/kg or low/high pH can reduce bacterial survival; IgA production
plays a role in defence against UTI; Commensal organisms (e.g. Lactobacilli, Corynebacterium)
• Urine flow and Micturition wash out bacterial; Stasis promotes UTI
Natural History of Urinary Tract Infection
90% are Single/Isolated attacks; Recurrence due to Relapse or Reinfection
Relapse
• Recurrence of Bacteriuria with same
organism within 7 days of completing
antibiotics; Failure to eradicate infection
• Occurs in Stone disease, Fibrosis, PKD
Reinfection
• Bacteriuria is absent after infection for
>14 days followed by recurrence;
Reinvasion of susceptible tract
Uncomplicated UTI
Functionally Normal Urinary Tracts – Persistent or Recurrent infection seldom results in
serious kidney injury
Complicated UTI
Stone disease, Diabetes etc might be made worse with infection = Complicated UTI; UTI with
Proteus predisposes to Stone formation
o Combination of Infection and Obstruction results in Obstructive Pyonephrosis; Major
cause of Gram-Negative Septicaemia
Acute Pyelonephritis
Fever, Loin pain and Tenderness,
Bacteraemia implies infection of the Kidney; Small Renal
Cortical Abscesses and Streaks of Pus in Renal Medulla
o Focal infiltration by Polymorphonuclear cells,
many in Tubular lumen
Reflux Nephropathy (Chronic Pyelonephritis)
Vesicoureteric Reflux and Infection acquired in Infancy
or Early Childhood; Ascending infection and incomplete
Bladder emptying; Papillary damage, Tubulointerstitial
nephritis and Cortical scarring in areas adjacent to
“Clubbed Calyces”
o Usually ceases at Puberty following growth of
the Bladder base; Progressive Renal Fibrosis
might follow even in absence of infection
o Chronic Reflux Nephropathy – Predisposes to
HTN, relatively common cause of ESRD in the
young; Detection, Treatment of infection can
prevent disease incidence
o ? Place in therapy of Ureteral Reimplantation
Presentation of Urinary Tract Infection
• Lower Urinary Tract – Polyuria, Nocturia, Dysuria, Suprapubic pain and Tenderness,
Haematuria, Smelly Urine; Upper Tract Involvement – Loin pain, Tenderness, Fever
• UTI can also present asymptomatically, or with atypical symptoms; Abdominal Pain, Fever or
Haematuria without Frequency or Dysuria
• In the Elderly, can be non-specific symptoms including Confusion, Malaise, Restlessness, Falls
Diagnosis of Urinary Tract Infection
• Quantitative Culture of Clean Catch
Midstream Urine (MSU); Most Gram-negative
organisms reduce Nitrates to produce Nitrites
• Complicated UTI – Ultrasound KUB, CT with
Contrast, MRI if unable to tolerate
Treatment of Isolated Urinary Tract Infection
• Pre-treatment Urine Culture is desirable for
Antibiotic sensitivity
• Antibiotics for 3-5 days e.g. Amoxicillin,
Nitrofurantoin, Trimethoprim, Cephalosporins
o Resistant organisms – Co-Amoxiclav or Ciprofloxacin (Fluoroquinolone)
• Single IM Amoxicillin or Co-Trimoxazole for Acute Cystitis without previous UTI history
• High Fluid Intake encouraged during treatment and subsequent weeks; Urine Culture
repeated 5 days after treatment
• IV antibiotics if patient is Acutely ill e.g. Cefuroxime, Gentamicin; Oral switch after 7 days; IV
fluids may be required to achieve Urine Output
o First-time presentation with Upper tract signs need to undergo urgent Ultrasound to
exclude Obstructed Pyonephrosis; Drained by Percutaneous Nephrostomy
Treatment for Recurrent Infections
• Urine Cultures to determine Relapse or Recurrence; Search for cause in Relapse, IV Antibiotics
required; Failure to treat requires long term Antibiotic use
• Reinfection – Contraceptive practice reviewed, Atrophic Vaginitis (due to Oestrogen
deficiency causing dryness); All patients require high fluid intake, voiding at 2-3-hour
intervals, Voiding before bed and after intercourse, Low-dose Antibiotics Prophylaxis
o ? Cranberry Juice said to reduce risk by 12-20%
Urinary Tract Infection due to Catheterisation
• Colonisation common after Catheterisation due to Bacterial Biofilm formation; Antibiotic
treatment not useful while catheter in-situ
• Antibiotics used if symptomatic/evidence of infection followed by replacement of catheter
o Single injection of Gentamicin while changing catheters
• Infection with Candida is a frequent complication of prolonged Catheterisation; Treat if
evidence of invasive infection or in Immunosuppressed patients
o In severe Candida infections, Bladder irrigation with Amphotericin
Schistosomiasis (Snail Fever)
– Parasitic flatworms which
might infect Urinary Tract and Intestines, leading to
Abdominal Pain, Diarrhoea, Bloody Stool or Haematouria
o Fresh water contaminated with parasites, from
Freshwater snails; Common in developing countries
amongst Children, Farmers, Fishermen etc
o Serological diagnosis, or ova within stool or urine;
Treated with Praziquantel
o Associated with Squamous Bladder Carcinoma
Urinary Tuberculosis
Cystitis unresponsive to typical antibiotics, Urinary Frequency, Dysuria,
Loin discomfort, Malaise and other Generalised TB symptoms
o Often asymptomatic and insidious over long time; ‘Sterile’ Pyuria and Haematuria
o May cause strictures, which may heal after infection treated
Fourier’s Gangrene
• Rapidly progressive Necrotising Fasciitis of the Deep Fascia (Group-A Streptococci is major
cause, but often multiple organisms); Localisation to Scrotum and Perineum
• Radical Debridement, IV Antibiotics (Benzylpenicillin, Clindamycin)
TESTICULAR TORSION
• Torsion must be dealt with immediately to preserve Testicular function; Commonest cause of
referral for Acute Testicular Pain
• Peak Age of Incidence 12-18yrs; Occurs more commonly in Anatomical Variants e.g. Bell
Clapper Testicular which allows Rotation within the Tunica Vaginalis
• Torsion causes Venous obstruction initially but increased Venous Pressure leads to Arterial
Compression and Development of Ischaemia and Necrosis
• Testicular Salvage depends on Degree of Torsion; Torsion >360o
for more than 24hrs leads to
complete or very severe atrophy
o Spermatogenic cells more susceptible to Ischaemic than Leydig cells; Subfertility
might occur even if Macroscopically normal after treatment
Presentation of Acute Testicular Pain
• Testicular Torsion – Sudden Onset Moderate-Severe Constant Unilateral Scrotal Pain often
with Nausea, Vomiting and Abdominal Pain
o Testes globally Tender, Sitting High in Scrotum, might have Transverse Axis and may
be slightly Enlarged; If Infarcted, Scrotal Wall Oedema and Tenderness
o Absence of Ipsilateral Cremasteric Reflex is most reliable sign
• Testicular Appendage Torsion – Torsion of Hydatid of Morgagni or Epididymal Appendages;
Presents similarly to Testicular Torsion, but Testes and Epididymis might be non-tender;
Cremasteric Reflex should be preserved
o Blue Dot Sign – Cyanosis of affected Testicular Appendage
• Acute Epididymo-orchitis – Peak incidence 35yrs and >55yrs; In young, Chlamydia or
Gonorrhoea more common; 1/3 of Male Adolescents with Mumps develop Orchitis
o E coli, Proteus occur in Chronic Bladder Outflow Obstruction or Instrumentation
Emergency Management of Testicular Torsion
• Analgesia – E.g. Morphine 5-10mg IV
• Immediate Surgical Exploration for all cases where Diagnosis is possible and History is short (If
Viability is still at issue); Otherwise Colour Duplex Ultrasound
• MSU, Urethral Swab and Chlamydia Serology if suspected infection
• Surgery – Viable Testicle Detorted and Fixed; Non-Viable Testicle is Excised; Opposite Testicle
is fixed (Orchidopexy) to prevent opposite site from torsion in future
Hydrocoele
Accumulation of Serous fluid, secreted by remnant peritoneum, within the
Tunica Vaginalis; If no hernia present, will resolve spontaneously if <1yr age
o Soft, non-tender swelling, with non-palpable testis; Unless communicating
Hydrocoele, unable to ‘get above the mass’; Large hydrocoeles might cause Atrophy
due to compression or obstruction to vascular supply
o Surgery; typically, general anaesthetic as local anaesthetic might not provide
sufficient analgesia due to Spermatic cord traction
Varicocoele
Abnormal enlargement of Pampiniform Plexus; typically, on Left due to
drainage of Testicular vein into Renal vein (Possible venous congestion and poor drainage)
o Surgery – Laparoscopic or Percutaneous Embolisation
Circumcision
• Normal for baby’s foreskin to be retractable in first few years of life; Around 2yrs should be
able to separate naturally, Full separation in most by 5yrs
• Medical reasons (Phimosis or Recurrent Balanitis in most cases), or religious/cultural reasons
(Jewish and Islamic communities, and other cultures)
URETHRAL STRICTURE
• Different Aetiology – E.g. Post-inflammatory/Infective, Traumatic (Fractures, Instrumentation)
• Graded according to Length and Degree of Fibrosis of Corpus Spongiosum
• Annular Narrowing by Scar Tissue of dense Collagen and Fibroblasts that might extend into
Corpus Spongiosum causing Spongiofibrosis
• Often with background of Urethritis, Trauma or previous Instrumentation
• Presents as LUTS, Haematuria (Initial or Terminal), UTI (Often Recurrent), Acute/Chronic
Urinary Retention and Overflow Incontinence
• Complications of Bladder Outflow Obstruction include Stone Disease, Infection (UTI,
Prostatitis, Epididymitis and rarely Fournier’s Necrotising Fasciitis); Reflux/Obstructive
Nephropathy if chronic
