urology Flashcards
Bladder cancer: risk factors
Risk factors for transitional cell carcinoma of the bladder include:
Smoking
Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine
Rubber manufacture
Cyclophosphamide
Risk factors for squamous cell carcinoma of the bladder include:
Schistosomiasis
Smoking
Stag-horn calculi composition
composed of Struvite (ammonium magnesium phosphate, triple phosphate)
form in alkaline urine (ammonia producing bacteria such as Ureaplasma urealyticum and Proteus therefore predispose)
Hydrocele
Non painful, soft fluctuant swelling
Often possible to ‘get above it’ on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men
overactive bladder mx
conservative measures include moderating fluid intake
bladder retraining should be offered
antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron may be considered if first-line drugs fail
Periureteric fat stranding
recent stone passage, if a ureteric calculus is not present.
peyronies
hypospadias
fibrotic bending of penis
urethra on underside of penis
risk facotrs for testicular cancer
infertility (increases risk by a factor of 3) cryptorchidism family history Klinefelter's syndrome mumps orchitis
hydronephrosis Unilateral: PACT Bilateral: SUPER
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Stenosis of the urethra Urethral valve Prostatic enlargement Extensive bladder tumour Retro-peritoneal fibrosis
priaprism ix
Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.
PSA levels may also be raised by
benign prostatic hyperplasia (BPH)
prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract
bph mx
watchful waiting
medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The use of combination therapy was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial
surgery: transurethral resection of prostate (TURP)
radiolucent stones
urate and xanthine
types of hydrocele
communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis
Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.
Angiomyolipoma
80% of these hamartoma type lesions occur sporadically, the remainder are seen in those with tuberous sclerosis
Tumour is composed of blood vessels, smooth muscle and fat
Massive bleeding may occur in 10% of cases
turp syndrome
TURP syndrome is a rare and life threatening complication of transurethral resection of the prostate surgery. The pathophysiology is venous destruction and absorption of the irrigation fluid.
There are risk factors for developing TURP syndrome are : surgical time > 1 hr height of bag > 70cm resected > 60g large blood loss perforation large amount of fluid used poorly controlled CHF
bladder volumes
Post-void volumes of <50 ml are considered physiological in patients aged < 65 years old.
Post-void volumes of < 100ml are considered physiological in patients aged > 65 years old.
Chronic urinary retention is defined by the presence of >500ml within the bladder after voiding.
Post-catheterisation urine volume of >800 ml suggests acute-on-chronic urinary retention.
vasectomy fx
Male sterilisation - vasectomy
failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation
simple operation, can be done under LA (some GA), go home after a couple of hours
doesn’t work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
a1 blocker side effects tamsulosin
adverse effects: dizziness, postural hypotension, dry mouth, depression
stone mx without hydronephrosis
smaller than 2cm
large
lithotripsy
percutaneous nephrolithotomy
LUTS
Voiding Hesitancy Poor or intermittent stream Straining Incomplete emptying Terminal dribbling
Storage Urgency Frequency Nocturia Urinary incontinence
Post-micturition
Post-micturition dribbling
Sensation of incomplete emptying
bladder injury
Basics
rupture is intra or extraperitoneal
presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void: always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
Investigation
IVU or cystogram
Management
laparotomy if intraperitoneal, conservative if extraperitoneal
urethral injury
Bulbar rupture
most common
straddle type injury e.g. bicycles
triad signs: urinary retention, perineal haematoma, blood at the meatus
Membranous rupture can be extra or intraperitoneal commonly due to pelvic fracture Penile or perineal oedema/ hematoma PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)
Investigation
ascending urethrogram
Management suprapubic catheter (surgical placement, not percutaneously)
ix in unresolving varicocele after cystoscopy
In an unresolving left varicocoele we are concerned patients are suffering from a renal tract cancer. This is due to the embryological anatomy linking the left renal vein and the left testicular vein.
drugs that can help passage of stone
alpha blocker, calcium channel blocker
co prescribe with goserelin (gnrh agonist)
Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues due to the risk of tumour flare. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels.
The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.
psychogenic cause of ED
Symptoms which suggest a psychogenic cause include: Sudden onset. Early collapse of erection. Self-stimulated or waking erections. Premature ejaculation or inability to ejaculate. Problems or changes in a relationship. Major life events. Psychological problems.
rf for ED
Other than increasing age, risk factors include:
cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
alcohol use
drugs: SSRIs, beta-blockers
