Urology Flashcards
Differentiate between the different types of hematuria
Pre-renal - coagulopathy - sickle cell disease - thromboembolism Renal - trauma - renal carcinoma - infection - glomerulonephritis Post-Renal (TITS) - Trauma: foreign body, catheritization, radiation - Infection - Tumour: bladder cancer, prostate hypertrophy - Stone: renal calculi
Differentiate between renal and post-renal hematuria
Renal - tea colored urine with no clots - high creatinine and BUN - dysmorphic RBC, RBC casts - proteinuria Post-Renal - red with some clots - normal creatinine - normal shaped RBC with no proteinuria
Discuss the presentation and management of renal cell carcinoma
Risk Factors - smoking - hypertension - obesity - kidney anomaly Presentation - asymptomatic with incidental finding on imaging - Triad of gross hematuria, flank pain, and palpable mass - paraneoplastic syndromes (hypercalcemia, anemia, erythrocytosis, hypertension) Investigation - CT - biopsy Management - partial or radical nephrectomy - radiotherapy - anti-angiogenesis factors, mTOR, IL-2 for advanced disease
Discuss the presentation and management of bladder cancer
- transitional cell carcinoma Risk Factors - smoking - chemical exposure - cyclophosphamide - radiation to pelvis - chronic bladder irritation Presentation - gross hematuria - pain - clot retention - FUNSHED Investigation - NMP-22, BTA, immunocyt and FDP are bladder tumour markers - cystoscopy with bladder washing Management - surperficial: transurethral resection of bladder tumour - invasive: cystectomy with chemo-radiation adjuvant (mitomycin)
Differentiate the different causes of failure to store
Urge Incontinence (detrusor overactivity or decreased compliance)
- detrusor overactivity from CNS lesion, inflammation, bladder neck obstruction
- decreased bladder compliance: fibrosis of bladder or non-functioning neck
Stress Incontinence (urethral hypermobility or instrinsic sphincter deficiency)
- urethral hypermobility: weakened pelvic floor from childbirth, pelvic surgery, age
- instrinsic sphincter weakness: aging, hypo-estrogen, pelvic surgery
Overflow Incontinence (due to failure to void)
Discuss the medications associated with incontinence
- anti-histamine
- anticholinergic
- ACE inhibitor
- Diuretic
- alpha agonist
Discuss the investigations and management of the types of incontinence
Urge
- diagnosis from urgency on history and urodynamics
- lifestyle modification and bladder habit training
- anti-cholinergics
- botox
Stress
- diagnosis past on history and positive stress test
- lifestyle modification with pelvic floor therapy
- pessary for females
- surgical sling, or sphincter
Overflow
- diagnosis from post-void residual of >200cc
- lifestyle management
- catheterization
- removal of obstruction
Differentiate the causes of urinary retention
Outflow Obstruction - urethra: stricture - bladder neck: stone, foreign body, neoplasm - prostate: BPH, cancer - external obstruction Neurogenic bladder - stroke, Parkinson's - spinal injury, MS - diabetic neuropathy Urinary Tract Irritation - UTI Medications - anticholinergics - narcotics - ephedrine
Discuss the urinary questions
FUNSHED
- Frequency
- Urgency
- Nocturia
- Straining
- Hesitancy
- Dysuria
Describe the 3 zones of the prostate
Peripheral zone
- 70% of volume and most common site of cancer (adenocarcinoma)
Central Zone
- 25% of volume and surround ejaculatory ducts
Peri-urethral transitional zone
- 5% and is site of BPH
Discuss the physiology and histology of the prostate gland
Physiology
- secrete thin, milky fluid which aids in sperm viability and motility
- prostate growth stimulated by andreogens (testosterone and dihydrotestosterone)
Histology
- formed by tubuloalveolar glands surrounded by fibromuscular strom
- line with simple columnar epithelium
- have corpora amylacea in prostatic gland
List the risk factors for prostate cancer
- African descent
- family history
- high dietary fat
- cigarette smoking
Discuss the presentation and management of prostate cancer
Presentation
- asymptomatic early so detected by DRE and PSA
- FUNSHED
- erectile dysfunction
- incontinence
- DRE demonstrate hard, irregular node or diffuse induration
- metastasis to bone (osteoblastic) in axial skeleton
Investigations
- PSA
- biopsy with tans-rectal ultrasound
- CT abdomen
Management
- watchful waiting for short life expectancy
- active surveillance for low grade disease
- brachytherapy for low risk disease
- external beam for locally advanced in older patients
- radical prostatectomy for young patients with high risk disease
- metastasis treat with antiandrogens
Discuss PSA screening
Elevation in PSA
- prostate cancer
- BPH
- prostatitis
- trauma from DRE, catheterization
PSA
- <10% free PSA than high risk for cancer
- >0.75ng/mL/yr velocity than increased risk of cancer
- >0.15ng/mL/g density than increased risk
- <4ug/L is normal (but varies with age and race)
Discuss the presentation and management of benign prostate hyperplasia
Presentation
- FUNSHED
- DRE demonstrate symmetrically enlarged, smooth prostate
Investigation
- post-void residual and urodynamics
Management
- mild symptoms have lifestyle changes of fluid restriction
- moderate use alpha-adrenergic antagonist to reduce stroma smooth muscle tone (tamsulosin (flomax)
- 5-alpha reductase inhibitor to inhibit conversion of testosterone to DHT (finasteride)
- Surgery TURP for renal failure, recurrant UTI/hematuria, urinary retention
Discuss the presentation and management of prostatitis
- most common urologic disease in men <50
- infection with PEEAKS bacteria
Risk Factors - BPH
- recent instrumentation of urinary tract
Presentation - FUNSHED with hematuria
- fever
- rectal, perineal pain
- DRE show tender, warm prostate
Investigation - 4 specimen urine culture
Management - septra PO for 4-6 weeks
List the risk factors for renal calculi
- dehydration
- obesity
- thiazide
- UTI
- gout
- cystinuria, xanthinuria, oxaluria
Discuss the pathophysiology of renal calculi
- predisposition to supersaturation of salt from urinary stasis or low flow, increased solute, low urine pH
- supersaturation of salt leads to formation of crystals where can obstruct urinary tract
List the 4 different types of stones
Calcium - radiopaque on KUB Uric acid - low urine pH, diet rich in purines, gout - radiolucent Struvite - infection with urea splitting organism (Proteus, pseudomonas, klebsiella, mycosplasma) - staghorn calculi in renal pelvis - radio-opaque Cystine - autosomal recessive disorder lead to reduced absorption of cystine - radiolucent
List the most common locations for stones
- Uteropelvic junction
- pelvic brim
- under vas deferens/broad ligament
- uretero-vesical junction
Discuss the presentation and management of renal calculi
Presentation - constantly uncomfortable - nausea, vomiting - flank pain that is severe and radiate to grown - hematuria Investigation - urinalysis and culture - KUB x-ray - CT scan without contrast Management - high likelihood stone will pass if <=5mm - treat with PO fluids, ketorolac, alpha-blockers (flomax)
Discuss the criteria for admission with renal calculi
Urosepsis - urine stasis lead to ascending infection Acute Renal Failure - can be obstructing leading to hydronephrosis and failure High Risk Patient/Stone - solitary kidney - bilateral stones Symptoms - intractable nausea/vomiting
Discuss the surgical intervention for renal calculi
Kidney Stones
- stone <2.5cm possible stent and then extra-corporeal shock wave lithotripsy
- >2cm then percutaneous nephrolithotomy
Uteral Stones
- ESWL and uterosopy to retrieve stone
- if infected stone then place stent and begin antibiotics (amp and gentamicin)
Discuss the prevention measures for stone formation
Dietary Modification
- increase fluid intake >2L
- potassium and citrate intke
- reduce animal protein
- high dose vit C supplementation
- do not decrease calcium intake
Discuss the presentation and management of testicular torsion
Risk Factors - cryptochordism - bell clapper deformity - trauma - intravaginal where twist in tunica vaginalis which occur in puberty (extravaginal occur in neonates) Presentation - acute, severe scrotal pain radiating to groin or abdomen - nausea and vomiting - tender, erythematous that can be high riding or transverse lie - no cremasteric reflex - negative Phren's sign Investigation - urgent go direct to OR - trans-scrotal ultrasound with doppler Treatment - surgical derotation with bilateral orchiopexy, possible orchiectomy
Discuss the presentation and management of epididymitis/orchitis
Risk Factors
- sexual activity and risk factors for STI
- recent instrumentation of urinary tract
Pathogenesis
- <35 most common is e coli, gonorrheae or chlamydia
- >35 infection by e coli
Presentation
- insidious onset of pain associated with dysuria, frequency, nocturia
- fever
- diffuse tenderness
- erythematous, warm, swollen testes with possible discharge
- normal cremasteric reflex and Phren sign
Investigation
- leukocyte
- urine culture and urethral swab
Management
- bed rest with scrotal elevation
- NSAID
- gonorrhea get ceftriaxone, chlamydia get azithromycin, and e coli get ciprofloxacin
Discuss the presentation and management of a hematocele
Presentation - history of trauma with painful scrotal mass - bruising and diffuse tenderness Investigation - ultrasound to visualize blood collection Management - pain control - surgical for fracture of testes
Discuss the presentation and management of hydrocele
Pathogenesis
- collection of serous fluid in the tunica vaginalis
- secondary have testicular pathology that irritate tunica
- defect in tunica from patent processus vaginalis
Presentation
- painless large scrotal mass
- transilluminating mass
- mass not isolated from testis
- palpable spermatic cord
Investigation
- ultrasound show cystic fluid
Management
- most resolve spontaneously
- surgical management for symptomatic, cosmesis, or underlying pathology
Discuss the presentation and management of spermatocele
Pathogenesis
- obstruction of distal duct leading to fluid filled sperm collection in epididymis
Presentation
- non-tender cystic mass in epididymis that transillumintes
- palpate testis seperate from amss
Investigation
- ultrasound show cystic mass
Management
- operate only if symptomatic or cosmesis
Discuss the presentation and management of varicocele
Pathogenesis
- dilatation and tortuosity of pampiniform venous plexus of spermatic cord
- most commonly on left side due to gonadal vein entrance into renal vein
- right side concerning for cancer
Presentation
- infertility
- bag of worms scrotal mass
Investigation
- ultrasound
Management
- operative if infertility, ipsilateral testicular atrophy, symptomatic or cosmesis
Discuss the presentation and management of testicular cancer
Risk Factors
- age <10, 15-35 and >60
- maternal exposure to androgen in pregnancy
- cryptochordism
Presentation
- painless testicular enlargement
- gynecomastia,
Investigation
- scrotal ultrasound showing hypoechoic mass with irregular borders and heterogeneity
- bHCG: risk for seminioma, embryonal, choriocarcinoma
- AFP: increased in non-seminoma
- LDH
Management
- radial orchiectomy for painless mass in right age group with ultrasound suspicion
- Pathology and CT afterwards to determine stage and treatment
List the different types of testicular cancers
Seminoma (35%) - germinal cell - epithelium - stage 1 get surveillance - stage 2 and 3 get radiation an chemotherapy Non-seminoma - Teratoma - embryonal - mixed cell type - yolk sac - chorio - stage 1 get surveillance - stage 2 and 3 get lymph node dissection and chemotherapy
Discuss the lymph node metastasis for testicular cancers
Right Testicle
- medial, para-caval, anterior and lateral lymph nodes
Left testicle
- left lateral and anterior para-aortic lymph nodes
List the most common bacteria for a urinary tract infection
PPEEEAKS
- proteus
- pseudomonas
- e coli
- enterobacter
- enterococcus
- acinobacter
- kliebsiella
- staphyloccocus saprophyticus
List the risk factors for a UTI
Urine stasis - obstruction - functional urinary retention Foreign body - catheter Immune Compromise - diabetes - malignancy Other - female - trauma
Discuss the presentation and management of a UTI
Presentation
- frequency, urgency, dysuria, hematuria
- suprapubic tenderness
- costavertebral tenderness
Investigations
- dipstick: positive leukocytes and nitrites
- urine microscopy 5 WBC/HPF
- culture >100CFU/mL
Management
- Uncomplicated: septra PO for 3 days 1st line or cipro for 3 days as second line
- in men require longer course as most likely obstructive
- pyelonephritis require cirpro for 7-14 days or septra for 7 days
- asymptomatic treat only if pregnant or have manipulation
Differentiate between the different causes of recurrent urinary tract infections
Relapse
- recurrence of same infection within 2 weeks after discontinuation of antibiotics
- must consider anatomy or abnormal voiding
- check resistances
Reinfection
- recurrence of UTI with new organism
Discuss the presentation and management of bladder trauma
Pathophysiology
- contusion have no rupture of bladder
- intra-peritoneal have bladder dome rupture into intra-peritoneal cavity
- extra-peritoneal have anterior or lateral wall rupture
Presentation
- bladder trauma associated with pelvic fracture
- abdominal tenderness with peritoneal signs
- inability to void
Investigation
- CT Cystogram
Management
- Foley
- extra-peritoneal can follow with CT cystograms
- intra-peritoneal require suprapubic catheter and surgery
Discuss the presentation and management of kidney trauma
Presentation
- associated with lower rib or vertebral transverse process fracture
- upper abdominal/flank injury
Investigation
- abdominal and pelvic CT with contrast
Management
- gross hematuria with contusion require hsopitalization with bedrest
List the classification system for renal trauma
Stage 1
- renal contusion
Stage 2
- <1cm laceration without urinary extravation
- >1cm laceration without urinary extravation
- urinary extravation
- shattered kidney
