Urology Flashcards
1
Q
What are the risk factors for renal calculi?
A
- Dehydration - concentrated urine more likely to form stones
- Recurrent UTI
- Metabolic abnormalities (particularly hypercalcemia which leads to hypercalcuria)
- Urinary tract abnormalities
- Foreign bodies
- Drugs
- Family history
MORE COMMON IN CAUCASIAN MALES
2
Q
Which urinary tract abnormalities may predispose to renal calculi?
A
Hydronephrosis, hotshot kidney, ureterocele, vesicoureteric reflux, stricture
3
Q
What is the main type of renal calculus and how do they appear on imaging?
A
Calcium oxalate - spiky, radio-opaque on x-ray
4
Q
Where do renal calculi typically deposit?
A
Stones form in collecting ducts and are classically deposited in:
- Pelviureteric junction
- Pelvic brim
- Vesicoureteric junction
5
Q
How do renal stones present (6 presentations)?
A
- Renal colic - loin to groin pain, nausea and vomiting, cant lie still
- Renal obstruction - felt in loin between rib 12 and lumbar muscles, not colicky, worsened by particular movements
- Mid ureteric obstruction - mimics appendicitis/diverticulitis
- Lower ureteric obstruction - bladder irritability, penile/labial pain
- Obstruction in bladder/urethra - pelvic pain, dysuria, interrupted flow
- Pyelonephritis/UTI - pain, dysuria, haematuria
6
Q
What examination findings may be present in renal calculi?
A
Often no tenderness on palpation, may have renal angle tenderness especially to percussion (indicates retroperitoneal inflammation)
7
Q
What investigations should be done in suspected renal calculi?
A
BEDSIDE: obs, urinalysis (blood), MC&S, pregnancy test. 24hr urine monitoring for calcium/oxalate/urate/citrate
BLOODS: FBC, U&E, LFT, CRP, calcium, phosphate, glucose, urate
IMAGING: spiral non-contrast CT KUB (consider US for hydronephrosis/ KUB xray)
8
Q
What are some predisposing factors for kidney stone formation?
A
- Hypercalciruia
- Drugs (loop diuretics, antacids, glucocorticoids, theophylline, vitamin D)
9
Q
What symptoms indicate urgent intervention in renal stones?
A
Urosepsis, intractable pain or vomiting, obstruction in a solitary kidney, bilateral stones
10
Q
What is the ongoing management for renal calculi?
A
Pain management
- NSAIDS and paracetamol
- Alpha blockers for distal ureteric stones <10mm
Antibiotics:
- As per UTI
- IV abx if unwell
Renal stones:
- Watchful waiting if <5mm
- Shockwave lithotripsy if 5-10mm (contraindicated if pregnant)
- Shockwave lithotripsy or ureteroscopy if 10-20mm
- Percutaneous nephrolithotomy if >20mm
Ureteric stones:
- Shockwave lithotripsy +/- alpha blockers if <10mm
- Ureteropscy if 10-20mm
Ureteric obstruction:
- + infection = emergency, needs urgent decompression with nephrostomy tube, insertion of ureteric catheters and ureteric stent placement
11
Q
What are the main causes of urinary tract obstruction ?
A
Luminal:
- Calculus
- Blood clot
- Sloughed papilla
- Tumour
Mural:
- Congenital/acquired stricture
- Neuromuscular dysfunction
- Neuropathic bladder
Extra mural:
- Mass/tumour
- Retroperitoneal fibrosis
- Post surgery
- Diverticulitis
- AAA
- Prostatic obstruction
12
Q
How does urinary tract obstruction affect the kidney?
A
- Continuing urine formation leads to rise in intraluminal pressure
- Dilatation proximal to the site of obstruction
- Compression and thinning of renal parenchyma
- Decreased size of kidney and renal damage
When kidney function is affected, it is determined obstructive neuropathy
13
Q
What is hydronephrosis?
A
Dilation of the renal pelvis, with or without obstruction
14
Q
What are the symptoms of acute urinary tract obstruction?
A
UPPER - loin to groin pain, infection, enlarged kidney, anuria
LOWER - severe suprapubic pain, urinary obstructive symptoms, palpable bladder , anuria , polyuria (if unilateral, compensation)
15
Q
What are the symptoms of chronic urinary tract obstruction?
A
UPPER - flank pain, renal failure, infection, polyuria
LOWER - urinary frequency, hesitancy, poor stream , overflow incontience, distended bladder (think symptoms of BPH)
16
Q
What investigations should be done in urinary obstruction?
A
BEDSIDE: urinalysis, MC&S
BLOODS: FBC, U&E, creatinine, PSA, specific tumour markers
IMAGING: renal USS, CT abdo pelvis (determines level of obstruction), radionuclide imaging
17
Q
How is urinary obstruction not due to calculi managed?
A
UNILATERAL - stent, analgesia, antibiotics, treat underlying cause
BILATERAL - catheter, antibiotics, alpha blockers, treat underlying cause
18
Q
What is retroperitoneal fibrosis?
A
Ureters get embedded in dense, fibrous tissue resulting in progressive bilateral ureteric obstruction.
May be idiopathic, autoimmune.
Required stent placement to relieve obstruction and ureterolysis
19
Q
What is PUJ obstruction?
A
Disturbance of peristalsis of collecting system WITHOUT mechanical obstruction
20
Q
What is the definition of acute and chronic urinary retention?
A
Acute - Sudden, painful inability to void despite having a full bladder. Medical emergency.
Chronic - Gradual development of painless retention, characterised by residual bladder volume >1L or associated with presence of distended or palpable bladder
21
Q
What causes urinary retention?
A
Obstruction
* BPH (most likely men)
* Strictures
* Constipation
* Malignancy
* Bladder stone
* Pelvic prolapse
Drug treatment
* Antimuscarinics
* Sympathomimetics
* Tricyclic antidepressants
* Anaesthetic agents
* Morphine
Reduced detrusor contraction
* Neurogenic (cauda equina, MS)
* Postpartum/postoperative
Bladder over-distension
* Alcohol
* Post-operative pain
22
Q
What investigations should be done in urinary retention?
A
BEDSIDE: urinalysis, C&S
BLOODS: FBC, U&E, PSA (if chronic)
IMAGING: flow analysis, bladder post-void residual volume, renal US, MRI spine
23
Q
Why is PSA not useful in acute urinary retention?
A
It will give a false positive - defer by 2 weeks
24
Q
How is acute urinary retention managed?
A
- Immediate catheterisation (urethral/suprapubic)
- Alpha-adrenoreceptor blocker (eg. tamsulosin) for at least 2 days before catheter removal (TWOC)
- If TWOC is unsuccesful (no void), further TWOCs can be attempted but failure may warrant long-term catheter
25
How is chronic urinary retention managed?
CONSERVATIVE – treat cause, voiding tips
MEDICAL – alpha-adrenoreceptor blocker and review after 4-6 weeks then every 6-12 months, consider finasteride
OTHER – indwelling catheter
NB - do not TWOC for chronic retention, either discharge with catheter until TURP or discharge with long term catheter
26
What is a contraindication for suprapubic catheter?
Suspected bladder cancer - there is a risk of seeding and spreading
27
What are the indications for an indwelling catheter?
Incontinence, repeated infection, renal dysfunction, no surgical solution
28
What is post obstructive diuresis?
Severe dehydration, postural hypotension and deranged U&Es following relief of urinary retention.
Patients may pass as much as 8-20L/day. Be aware in pts with renal/cardiac failure
(aiming for <200ml/hour)
29
What is the pathophysiology of BPH?
1. Proliferation of musculofibrous and glandular layer of the prostate
2. Inner transitional zone of prostate enlarges
3. Enlargement of gland distorts the urethra, obstructing bladder outflow
30
What is the function of the prostate?
Secretion of alkaline fluid that comprises 70% of seminal volume
31
What are the symptoms of BPH?
Storage sx - frequency, urgency, nocturne, incontinence
Voiding sx - weak stream, dribbling, dysuria, straining
32
What is the normal size of the prostate? What is the normal PSA value?
<30g (size of a walnut).
PSA changes as you age, usually below 3ng/ml.
Before a PSA test men should not have had a UTI or urological intervention in past 6 weeks, ejaculated or exercised in last 48h
Also must wait 2 week post UTI and 1 month post prostatitis
33
How is BPH managed?
Mild-moderate - watchful waiting, avoid caffeine/alcohol, voiding tips, bladder training
Use IPSS to classify severity of LUTS
Moderate (IPSS >= 8)
1st line - alpha blockers (tamsulosin) - work by relaxing smooth muscle
2nd line, enlarged prostate - 4 alpha reductase inhibitors (finasteride) - work by shrinking the prostate
3rd line - tolterodine, darifenacin (antimuscarinics) use if persistent storage/voiding sx after treatment with alpha blocker alone
Surgery:
Transurethral resection of prostate
Transurethral incision of prostate
Retropubic prostatectomy
TULIP
34
How do alpha blockers work?
Relax smooth muscle in prostate and bladder neck
35
How do 5a reductase inhibitors work and what are the side effects?
Decrease conversion of testosterone to dihydrotestosterone so shrink the prostate itself
SE: ED, reduced libido, ejaculation issues, gynaecomastia
36
What are the differences between TURP, TUIP and TULIP?
TURP - moderately invasive, lots of unwanted sexual side effects (impotence) and bleeding
TUIP - less destruction, relieves pressure on urethra, fewer side effects
TULIP - uses lasers to ablate tissue, less bleeding, fewer side effects
37
When should prostatectomy be considered?
Prostate >80g, good surgical candidates.
This isn't used much as the other options are better!!
38
What is prostatitis? What are the symptoms?
Acute or chronic (>3 months) inflammation of the prostate, usually due to s.faecalis or e.coli, or chlamydia
Causes UTI, retention, pain, haematospermia, fever, swollen/boggy prostate
39
What investigations should be ordered in prostatitis?
BEDSIDE: urinalysis, culture, prostatic secretion culture
BLOODS: FBC, CRP, blood cultures, PSA
IMAGING: cystoscopy, transracial US, 4-glass test
40
How is prostatitis managed?
Oral ciprofloxacin/levofloxacin
If pain - NSAIDS
If obstruction - catheter
If abscess - aspiration, IV abx
41
What are the symptoms of prostate cancer?
Prostatism (nocturia, urinary frequency, hesitancy, dysuria, terminal dribbling)
Systemic (weight loss, night sweats, bone pain ) - suggests mets
42
What are the RF for prostate cancer?
- Positive family history
- Age
- Increased testosterone
- African american ethnicity
- High levels dietary fat
43
What is the histopathology of prostate cancer?
ADENOCARCINOMAS arising in peripheral prostate.
Can spread locally via lymph or haematogenously, causing sclerotic bony lesions
44
What investigations are done for suspected prostate cancer?
BEDSIDE: obs, urinalysis, DRE exam
BLOODS: FBC, testosterone PSA, calcium, CRP, U&E, LFT (looking for mets)
IMAGING: 1st line is multiparametric MRI, if Likert scale >3 offer biopsy
45
How is diagnosis of prostate cancer confirmed?
Prostatic biopsy or MRI
If clinical suspicion of prostate cancer is high, only do MRI
46
How is prostate cancer staged and graded?
Staging - TNM
| Grading - Gleason score from 1 to 5
47
How is the Gleason score calculated?
Pathologist analyses histology from two areas of tumour and adds together to get a total score from 2-10.
2-4 - indolent
5-7 - intermediate
8-10 - aggressive
48
How is prostate cancer managed (no mets)?
- Radical prostatectomy
- Radical radiotherapy (with hormonal therapy)
- Hormone therapy alone (not curative - elderly patients with high risk disease)
- Active surveillance (if >70yo, low risk, review PSA yearly)
49
How is prostate cancer managed (mets)?
- Hormonal therapy - LHRH agonists eg. goserelin and antagonists eg. degarelix
- Orchidectomy (testicular removal)
50
What is multi parametric MRI?
Pre-biopsy imaging, aims to accurately locate clinically significant prostate cancer and facilitate targeted biopsy
51
What is androgen deprivation therapy? How can you managed the side effects?
Hormone therapy used to reduce androgen levels and shrink the cancer. Used if surgery/radiation not possible. Can give LHRH agonists or antagonists.
Hot flushes - medroxyprogesterone
Sexual dysfunction - PDE5 inhibitors
Osteoporosis - bisphosphonates
52
What is Wilms tumour?
A childhood tumour (<3yo) of the renal tubules and mesenchymal cells - presents with abdo mass and haematuria
53
How is Wilms tumour managed?
Nephrectomy, radiotherapy and chemotherapy - 5 year survival is 90%
54
What is the most common type of bladder cancer?
Transitional cell carcinoma
55
How does bladder cancer present?
Painless haematuria
Recurrent UTIs
Voiding irritability
56
What are the RF for bladder cancer?
- Smoking
- Aromatic amines (rubber industry)
- Chronic cystitis
- Schistosomiasis (more likely squamous cell carcinoma)
- Pelvic irradiation
57
Which investigations should be done in suspected bladder cancer?
BEDSIDE: urinalysis (although asymptomatic haematuria is not v helpful), c&s (may cause sterile pyuria)
BLOODS:
IMAGING: cystoscopy with biopsy (diagnostic), CT urogram (staging), bimanual EUA (assess spread), MRI (nodes)
58
How is bladder cancer staged?
```
TNM staging
Tis - in situ
Ta - epithelium
T1 - lamina propria
T2 - superficial muscle
T3 - deep muscle
T4 - invasion beyond bladder
```
- nothing felt at EUA (exam under anaesthetic) until T2, when superficial muscle becomes involved
59
Describe the histology of bladder cancer?
Grade 1 - differentiated
Grade 2 - intermediate
Grade 3 - poorly differentiated
60
How is bladder TCC managed?
Tis/Ta/T1 - diathermy, transthurethral resection of bladder tumour. Good 5 year survival!!! (95%)
T2-3 - radical/partial cystectomy with pelvic lymph node dissection (consider adjuvant radiotherapy and chemotherapy)
T4 - palliative chemo/radio
61
What does radical cystectomy involve?
Male - removal of bladder, prostate and seminal vesicles
Female - removal of bladder, uterus, ovaries and part of the vagina
The surgeon will then do either a:
1. Ileal conduit - uses small intestine to create a tube that attaches to ureters and forms stoma
2. Neobladder reconstruction - using small intestine
3. Continent urinary reservoir - needs a catheter to drain
62
What is the follow up for bladder cancer?
Regular cystoscopy
Low risk tumours - once after 9 months then yearly
High risk tumours - every 3 months for 2 yrs then every 6 months
63
What causes urinary incontinence in males?
- Prostate enlargement
- Overflow in urinary retention (palpate bladder!)
- Pelvic surgery
- Bladder neck obstruction
- Urethral stricture (eg after gonorrhoea)
64
What are the 4 types of incontinence in women?
1. Functional
2. Stress
3. Urge/overactive bladder
4. Overflow
65
How much urine can our bladders store?
500mL - urge to void starts at around 200mL
66
How does the micturition reflex work?
Distention of the bladder wall causes contraction of the detrusor muscle via parasympathetic nerve fibres, controlled by the pons.
67
When does micturition occur, in terms of pressure?
Bladder pressure > urethral pressure
This occurs because:
1. Detrusor muscle causes increased bladder pressure
2. Pelvic floor relaxation causes decreased urethral pressure
68
What is functional incontinence?
Incontinence due to inability to get to the toilet - due to disability or environmental factors
69
What is stress incontinence? What causes it?
Increased intra-abdominal pressure (eg when coughing or sneezing) is transmitted to the bladder but not the urethra.
Usually due to weakened pelvic floor muscles, incompetent sphincter or urethral stricture. Common after pregnancy and elderly women, prolapse.
70
What is urge incontinence? What causes it?
Uncontrolled increases in detrusor pressure due to overactive bladder.
Usually due to neurogenic mechanisms or bladder muscle problem, may be due to organic brain damage. May be due to infection, diabetes, diuretics, vaginitis or urethritis
71
How can you distinguish between stress and urge incontinence in the history?
Stress - small but frequent amounts of urine lost when sneezing/coughing/exercising.
Urge - precipitated by cold, cold, caffeine, sound of running water.
72
What is overflow incontinence? What causes it?
Leakage of urine from a full distended bladder.
Usually due to prostatic obstruction and urinary retention, following surgery or spinal cord injury.
73
What investigations should be done in suspected incontinence?
BEDSIDE: urinalysis, MC&S
BLOODS: FBC, U&E, CRP
IMAGING: cough stress test, urodynamic studies, post-void bladder US, cystoscopy, CT (look at ureter and dye test)
74
How does urodynamics (cystometry) work?
Uses catheters to look at:
- bladder pressure on coughing with a full bladder
- abdo pressure using a pressure transducer in the rectum
If there is an involuntary detrusor contraction during test = URGE/OVERRACTIVE
If leakage during test = STRESS
75
Which acute causes of incontinence should be excluded?
```
UTI
DM
Diuretic use
Faecal impaction
Palpable bladder
```
76
How is stress incontinence managed?
CONSERVATIVE - pelvic floor exercises, vaginal cones
MEDICAL - pseudoephedrine, duloxetine
SURGICAL - tapes/pessaries, colposuspension (lift up bladder neck)
OTHER - intravaginal electrical stimulation
77
How is urge incontinence managed?
CONSERVATIVE - incontinence chart, reduce fluid intake, medication review, bladder training
MEDICAL - oxybutynin (anticholinergic), oestrogen (if post menopausal), botox (risk of retention)
SURGERY - clam ileocystoplasty (aka bladder augmentation - bisect bladder and sew in ileum, makes it larger)
OTHER - neuromodulation/sacral nerve stimulation (improves ability to suppress detrusor contractions)
78
What 3 columns of tissue is the penis made up of?
1. Corpora cavernosa (x2) - spaces get filled with blood and lead to erections
2. Corpus spongiosum - contains male urethra
79
What is the function of the scrotum?
- Protects testis
- Maintains testicular temperature at 2-3C lower than body temp to allow spermatogenesis
- Contains many blood vessels and nerves
80
What is the cremaster muscle?
A muscle in the scrotum that contracts and pulls the scrotum closer to the body when temperature falls too low
81
What is the function of the testis?
1. Production of male gametes
| 2. Production of testosterone
82
What are the two coverings of the testes?
Tunica vaginalis - extension of peritoneum
Tunica albufeira - dense connective tissue, divides testes into lobules of semineforous tubules
83
What are the different cell types present in the testes?
1. Leydig cells - produce testosterone
2. Sertoli cells - protect and provide growth to developing germ cells
3. Germ cells - gametes
84
What is the epididymis?
A highly coiled tube like structure connecting the testis to vas deferens.
Immature sperm passes through here as matures - gain motility and fertility
85
What is the vas deferens?
30cm long tube connecting the epididymis to the ejactulatory duct.
86
What is epididymo-orchitis and how is it managed?
Cetriaxone 500mg IM STAT + oral dyxocycline 100mg BD for 10-14 days
This covers gonorrhea and chlamydial infection
If suspecting enteric organism - send MSU and treat empirically with oral quinolone for 2 weeks
87
What is an epididymal cyst? How is it managed?
Cyst lying above and behind the testis - contains clear or milky fluid.
Can remove if symptomatic but can leave.
88
What is a hydrocele? How is it managed?
Fluid within the tunica vaginalis of the testis. Can be:
1. Primary (patent processus vaginalis, self-resolving)
2. Secondary (tumour, infection, trauma)
Located superior and anterior to the testes, can transilluminate on examination, may be uncomfortable.
Surgical repair (Lords/Jaboulay) - can leave if asymptomatic but need to US to exclude tumour
89
What is epididymis-orchitis? How is it managed?
Inflammation of the epididymis and/or testis. Usually due to UTI/STI. May have systemic features and discharge.
Treat STI (doxycycline and add ceftriazone if gonorrhoea suspected) or UTI (ciprofloxacin) for 2-4 weeks - warn of possible infertility! Give analgesia and scrotal support.
90
What is a varicocele? How is it managed?
Dilated veins of the pam-uniform plexus, commonly affecting the left side due to anatomy of the venous drainage system - due to incompetent valves. Looks like a bag of worms and may be dull pain!
Repair via surgery/embolization or risk of subfertility. If aged over 50 dip urine for haematuria as renal cancer can present like this!
91
What is a haematocele? How is it managed?
Blood in the tunica vaginalis, often due to trauma.
Drainage/excision
92
What is a spermatocele? How is it managed?
Located superior and posterior to the testis, milky fluid on aspiration
93
What is the most common type of testicular tumour?
Seminoma (30-65yrs) - from seminiferous tubules
| Non-seminomatous germ cell (20-30yrs) - from germ cells
94
What are the symptoms of testicular cancer?
Painless lump
| May have haematospermia, secondary hydrocele, pain, systemic symptoms
95
How is testicular cancer staged?
1 - no mets
2 - infradiaphragmatic nodes
3 - supadiaphragmatic nodes
4 - lungs
96
Which tumour markers are used in testicular cancer?
How is the cancer diagnosed?
aFP - teratoma
bHCG - seminoma
LDH
Diagnosis by ultrasound
97
How is testicular cancer managed?
Radical orchidectomy and radiotherapy (seminomas)
Radical orchidectomy and chemotherapy (NSGCT)
Highly curable if diagnosed early! Good prognosis. May need testicular prosthesis or sperm banking.
98
What are the symptoms of testicular torsion?
Sudden onset unilateral testicular pain
Abdo pain, N&V
99
What are the signs of testicular torsion?
Inflamed, red, affected testis may lie high and transversely
100
What age groups does testicular torsion commonly affect?
- Babies
| - 11-30yo
101
What is a blue spot sign?
Due to torsion of the hydatid of morgagni which is an embryological remnant of the Mullerian duct - may tort aged 7-12yrs due to gonadotrophin surge in puberty. Less painful.
Treat as testicular torsion.
102
What are the DDs for testicular torsion?
- Epidiymo-orchitis
- Tumour
- Trauma
- Acute hydrocele
- Idiopathic scrotal oedema (no pain!!)
103
How is testicular torsion investigated?
Doppler US - shows lack of blood flow
Often investigation not necessary - if any doubt SURGERY !!!
104
How is testicular torsion managed?
Surgery - expose and untwist testis within 6 hours. Usually will do bilateral orchidopexy (fix each tumour to the tunica vaginalus to prevent recurrence)
Explain possibility or orchidectomy and bilateral fixation
105
What other lumps can be found in the groin?
- Testicular lumps
- Psoas abscess
- Femoral artery aneurysm
- Hernia (femoral/inguinal)
- Lymph node
- Cryptorchidism
106
What are the different types of undescended testes?
CRYPTORCHIDISM - Complete absence of testicle from scrotum
RETRACTILE TESTES - excessive cremasteric reflex
MALDESCENDED TESTS - can be found from abdomen to groin
ECTOPIC TESTES - found in superior inguinal pouch
107
How is undescended tested treated?
1. Orchidopexy - bring forward testicle through a hole made in the dartos muscle
2. Hormone therapy if in inguinal cancel (hcg)
108
What are the complications of undescended testes?
- Infertility
- Testicular cancer
- Trauma/torsion
- Hernias
109
What is Fournier's gangrene?
Necrotiscing fascitis of the genitals, perineal and perianal region.
Syngerstic infection of 3 or more anaerobes - likely in immunocompromised/homeless/alcoholics
110
How is Fournier's gangrene managed?
- Broad spectrum IV abx
- Fluid resuscitation
- Aggressive surgical debridement and reconstructive surgery
THIS HAS A REALLY HIGH MORBIDITY AND MORTALITY!!
111
What is hypospadias?
A congenital condition in males in which the opening of the urethra (meatus) is on the underside of the penis
112
What is phimosis?
Tightening of the foreskin
113
What is paraphimosis?
Tightening of the foreskin to the extent that the foreskin can no longer be pulled over the glans penis so remains retracted. Can be iatrogenic after catheterisation.
114
How do you manage paraphimosis?
- Compress affected area to reduce oedema then pull back
| - If ineffective may need penile block
115
How effective is vasectomy? What are the complications?
Very - need to perform semen analysis twice (16, 20 weeks) before unprotected sex
Complications include bruising, sperm granuloma and chronic testicular pain
116
What causes unilateral hydronephrosis?
```
PACT:
Pelvic-ureteric obstruction
Aberrant renal vessels
Calculi
Tumours of renal pelvis
```
117
What causes bilateral hydronephrosis?
```
SUPER:
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
```
118
What is the 1st line investigation in hydronephrosis?
USS
119
How is hydronephrosis managed?
1. Remove obstruction and drain urine (catheter)
If acute obstruction - nephrostomy tube
If chronic obstruction - ureteric stent, pyeloplasty
120
What is TURP syndrome?
Complication of prostate surgery, due to irrigation with large volumes of glycine
Causes hyponatremia, hyperammonia, visual disturbances and CNS, respiratory, systemic symptoms
121
What is priapism? What are the sub-types?
Persistent penile erection >4h which is not associated with sexual stimulation
Types:
Ischaemic - impaired vasorelaxation and reduced vascular outflow causing congestion and trapping of de-oxygenated blood within the corpus cavernosa
Non-ischaemic - due to high arterial inflow, typically due to fistula formation as a result of congenital or traumatic mechanisms
122
What causes priapism?
- Idiopathic
- Sickle cell and other haemoglobinopathies
- ED meds eg. sildenafil and other PDE-5 inhibitors
- Pharmacological eg. anti-hypertensives, anticoagulants, antidepressants
- Recreational eg. cocaine, cannabis, ecstasy
- Trauma
123
How do you differentiate symptoms of ischaemic and non-ischaemic priapism?
Non-ischaemic tends to be non-painful and not fully rigid
124
How is priapism investigated?
1st line is cavernosal blood gas - in ischaemic priapism p02 and pH would be reduced whilst pC02 would be increased (as blood is de-oxygenated)
Also:
- doppler USS
- FBC/toxicology
125
How is ischaemic priapism managed?
MEDICAL EMERGENCY!!! TREATMENT DELAY > PERMANENT DAMAGE > LONG TERM ED
1st line treatment is aspiration of blood combined with injection of saline flush to help clear viscous blood
If this fails, intracaversonal injection of vasoconstrictor eg. phenyl epinephrine, repeat at 5 minute intervals
If both fail > surgery
126
How is non-ischaemic priapism managed?
Observation
127
What are the features of renal cell cancer?
- Usually clear cell, arises from proximal tubular epithelium
- RF include tuberous sclerosis, smoking, VHL syndrome
- Triad of haematuria, loin pain and abdominal mass
- Often have varicocele or endocrine effects
128
What is Stauffer syndrome?
- Paraneoplastic disorder associated with renal cell cancer
- Typically presents as cholestasis/hepatosplenomegaly
- Thought to be secondary to increased levels of IL-6
129
What are the features of penile fracture?
- Traumatic rupture of the corpus cavernosum
- May occur due to sexual intercourse or sudden balunt trauma
- Patient describe a dnapping sound with immediate tumescence
- 'Eggplant' deformity
- Diagnose clinically or on MRI
- Manage with retrograde urethorgraphy and surgical therapy involveing evacuation of haematoma, correcting defect in tunica and repairing urethral injury
130
Which drugs may cause erectile dysfunction?
- Antihypertensives (thiazides and beta blockers)
- Phenothiazines
- Benzodiazepines
- TCAs/MAOIs
- Finaseteride
- Cimetidine
- Oestrogens
- Antiandrogens
131
What are the features of urethral injury?
Anterior:
- Located distal to the membranous urethra
- Due to blunt trauma to perineum
- May appear years later as a stricture
Posterior:
- Located in the membranous and prostatic urethra
- Related to major blunt trauma such as RTA/falls and often associated with pelvic fractures
Present with perineal bruising, blood at meatus, abnormally high riding prostate or inability to palpate the prostate
DO NOT ATTEMPT URETHRAL CATHETERISATION - REFER TO UROLOGY ASAP
