Urology Flashcards
A 33-year-old man presents with a two day history of the gradual onset of pain and swelling in the right testicle. The pain is described as 5/10 on the pain scale. Around four weeks ago he returned from a holiday in Spain but reports no dysuria or urethral discharge. On examination he has a tender, swollen right testicle. On examination the heart rate is 84/min and his temperature is 36.8ºC. What is the most likely underlying diagnosis?
epididymo orchitis
stoorage symptoms are
FUN
frequency
urgency
nocturia
voiding symptoms are
terminal dribbling/ poor flow intermittent stream straining hesitancy incomplete emptying
definition of nocturnal polyruria
voiding >1/3 of their total daily output overnight
what is normal voiding at night
1-2 times
what is q max and what is a representative flow
-q max is max rate of flow
need >150ml to be passed
>15 is normal in men
2 types of haematuria
visible
non visible : symptomatic or asymptomatic
definition of non visible haematuria
dipstick is signficant if more than or equal to 1+ RBC on 2 or more occasions
causes of haematuria
congenital
acquired
congenital
- coagulation disorders
- haemophilia
- sickle cell disease
acquired
- tumour- bladder, renal, ureter, prostate
- BPH
- trauma
- stones
- infection- UTI , schistosomiasis prostatitis
- hyperparathyroidism -renal calcium causes stones
- circulatory, vascular, renal infarction
- medications
- autoimmune IgA , glomerulonephritis, HSP
- inflammation- interstitial nephritis
what are transient causes of haematuria that need excluding first
- menstruation
- strenuous exercise
- UTI
drugs that cause haematuria
anticoagulants- aspirin, clopidogrel, warfarin
penicillins
cyclophosphamide
rifampicin
schistosomiasis presentation
-headache, fever, arthralgia, abdo pain, cystitis, haematuria
can also affect CNS and cause seizures, peripheral neuropathy
rx schistosomiasis
praziquantel
what is significant haematuria?
- any single episode of visible haematuria
- any single episode of symptomatic non visible haematuria (in absence of UTI or other transient cause)
- persistent asymptoamtic NVH
inx for haematuria
- BP and HR
- bloods renal function
- MSSU and culture
- flexible cystoscopy
- CT urogram for high risk
- IV urogram and renall USS for low risk
who gets a CT urogram for haematuria
-high risk so
visible haematuria
>40
smoker
which patients need direct referral to urology for haematuria
- any visible haematuria
- any patients with symptomatic NVH
- any patients with asymptomatic NVH but >40
- all persistent asymptoamtic NVH
reasons to admit patient with haematuria
- symptoms and signs of hypovolaemic shock
- symptomatic/ asymptomatic anaemia
- clot retention or pending clot retention
- acopia
emergency management of haematuria
- Ato E
- fluid resus
- 3 way catheter
- bladder irrigation with saline to prevent clot accumulation in bladder
- bladder washout with catheter tipped suringe
- bladder washout in theatre if clots cannot be irrigated out of bladder
main emergency complication of haematuria
clot retention
examination of a patient with haematuria
-abdo exam
DRE
management of visible haematuria
- refer to urology
- flexible cystoscopy in 2 weeks urgent
- CT urogram as high risk
management of symptomatic low risk non visible haematuria
- refer to urology
- flexible cystoscopy in 4-6 weeks
- USS +/- IV urogram
when to refer haematuria to renal
non visible haematuria asymptomatic with
- fhx of renal problems
- abnormal renal functioning testing
what is the main cancer of the bladder
transitional cell carcinomas
what other types of cancers can be found in bladder
- transitional cell carcinoma
- squamous cell carcinoma
- adenocarcinoma
risk factors and causes for bladder cancer- linked to type
- smoking (TCC)
- aromatic hydrocarbons- paint, dye, tyre, metal, rubber- aniline dye (TCC)
- chronic inflammation (SCC) UTI, stones
- schistosomiasis (SCC)
- exposure to other carcinogens found in the urine (TCC)
- hx of previous pelvic radiotherapy
- cyclophosphamide (TCC)
most common cancer of the bladder inAfrica
schistosomiasis so SCC
what causes adenocarcinoma of bladder
congenital remanant of the urachus
invasion classification of bladder cancers
- 80% are superficial- non muscle invasive bladder cancer NMIBC
- 20% are invasive- invasive muscle bladder cancer MIBC
- carcinoma in situ are very superficical but highly aggressive tumour cells on urothelial lining
grading of bladder cancers
g1 well differentiated
g2 moderately differentiated
g3 poorly differentiated
presentation of bladder cancer
- main presenting symptom is visible painless haematuria 85%
- microscopic haematuria- less common
- storage related LUTS - FUN
- can be symptomatic of anaemia- pallor
- can get recurrent UTI
diagnosis bladder cancer
-hx and rf
-abdo and pelvic exam - often normal
-DRE
check for signs of anaemia
INX
as often visible haematuria get an urgent flexible / rigid cystoscopy
ACTS as dx and RX as with cystoscopy can do a TURBT
and CT urogram -possibly
management of Non muscle invasive bladder cancer
-just the mucosa or submucosa 80%
- cystoscopy and TURBT trans-urethral resection of bladder tumour
- mitomycin C single intravesical dose chemotherapy after TURBT to reduce rate of recurrence
- may need further TURBT at 6 weeks to ensure adequate resection if high grade disease or no detrusor muscle in the initial resection
- In patients, with recurrent/ multifocal disease, intravesical immunotherapy with BCG also used to reduce recurrence risk
long term management of NMIBC
long term surveillance with flexible cystoscopy
management of MIBC and MIBC with mets
20%
- if initial TURBT on cystoscopy showed tumour invading into the detrusor muscle then need a
1. RADICAL CYSTECTOMY (removal of bladder and prostate in men and bladder, uterus, urethra and ovaries in women) and urinary diversion - alternative is radical radiotherapy which can be used to improve haematuria in metastatic disease
- chemotherapy with cisplatin based agents for nodal metastatic disease
inx mets disease
- CT CAP
- MRI pelvis
cystectomy what happens to ureters
form an ilial conduit
contraindications to intravesical BCG
pregnancy immunosuppressed haematological malignancy following traumatic catheterisation symptomatic UTI or VH
prognosis of low grade NMICB
> 90% at 5 yrs
prognosis of high grade NMIBC or invasive
50% at 5 yrs
main risk factors for renal cancer
-smoking
-obesity and HTN
-cadmium exposure
-employment in leather industry- aniline dye
-familail incidence seen with Von hiipel lindau syndrome VHL (AD)
also in PRCC ,leiomyomatosis, hereditary RCC
which is the most lethal of all urological cancers
renal cancer
pathology of renal cell cancer and types
-originates from proximal convoluted tubule epithelial cell (80% ) either clear cell or granular 10%
others -papillary 10-15% -chromophobe collecting duct bellini medullary cell
main cancer type for renal cancer
clear cell
presentation of renal cancer
- usually asymptoamtic 50%- incidental finding
- 10% too late triad- visible haematuria, flank pain and palpable mass
- left varicocele due to block in left renal vein
- pyrexia of UO
- vte, pe and lower limb pedema
paraneoplastic syndromes of renal cancer
-haematopoeitic disorders
anaemia 30%
polcythaemia
raised ESR
-endocrinopathies (secrete renin, EPO, PTH, ACTH) hypercalcaemia erythrocytosis- high concen RBC hypertension cushing syndrome gynaecomastia, amenorrhoea hypoglycaemia
stauffer’s syndrome- hepatic cell dysfunction
abnormal LFT’s
decreased WCC
fever
hepatic necrosis- reversible following nephrectomy
due to IL6
haemodynamic alterations
peripheral oedema
systolic hypertension
metastasis sites for renal
bone brain liver lung
bone pain, night sweats, fatigue, weight loss, haemoptysis
inx for renal cancer
- bloods-FBC, ESR, u and e, lft, coag, LDH, calcium, chP
- renal USS
- CT stage and plan surgery -chest abdo pelvis
staging renal cancer
t1= <7 cm
t2=>7cm
t3=tumour extends into perinephric fat and into renal vein
t4= tumour extend beyond gerotia’s fascia
management of renal cancer not metastasised
- radical nephrectomy -removal of kidney and adrenal with intact gerotia’s fascia
- partial nephrectomy
- immunotherapy (soemtimes for metastatic as immunogenic)
management of metastatic renal cancer
-tyrosine kinase inhibitors eg suntinib, pazonib to inhibit angiogenesis
as renal cancer highly vascular so aim to inhibit development and spread
upper tract transitional cell carcinoma risk factors
similar to bladder cancer smoking phenacetin ingestion- was used for pain relief -Balkan nephropathy -lynch syndrome HNPCC
main type of upper tract transitional cell carcinoma
-papillary TCC 90%
scc
fibroepithelial
benign inverted papilloma
A 64-year-old man presents with painless haematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical examination shows only moderate enlargement of the prostate. Urinalysis is positive for 10 to 15 RBCs and 5 to 10 WBCs per high-power field with no bacteria detected.
bladder cancer
A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity oedema, and 4 days of gross haematuria with clots. On examination, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting oedema to the mid-shins bilaterally, which is worse on the right.
renal cancer
presentation of upper tract transitional cell carcinoma
-visible haematuria 80%
-flank pain “ clot colic” 30%
can be asymptomatic 4%
A 56-year-old obese woman presents to the emergency department with a history suggestive of biliary colic, including epigastric discomfort after a heavy meal. Her past medical history includes cholelithiasis, hypertension (treated with an angiotensin-converting enzyme [ACE] inhibitor), and dyslipidaemia (treated with a statin). She is an ex-smoker, drinks alcohol socially, and has no significant family history. On palpation of her abdomen, she has RUQ pain, but there are no other relevant findings on examination. An abdominal ultrasound is performed, which demonstrates the presence of gallbladder stones without obstruction, and an incidental 5-cm, left-sided renal mass
renal cancer
asymptomatic and incidental finding more common
inx for upper tract transitional cell carcinoma
-CT urogram or renal USS + IV pyelogram
-cystoscopy
+/- retrograde pyelogram
-urine cytology
-flexible ureterorenoscopy plus biopsy
CT CAP
location of upper tract transitional
-uncommon in renal pelvis
rare ureteric TCC
why can USS be tricky for upper transitional cell carcinoma
difficult at detecting renal pelvis and ureter tumours
management of upper tract transitional cell carcinoma non metastatic and normal contra-lateral kidney
radical nephro ureterectomy with bladder cuff excision (and node sampling)
kidney and ureter remove
management of upper tract transitional cell carcinoma if single functioning kidney, bilateral disease, unilateral low grade tumour <1cm or unfit for major surgery
-percutaneous, segmental or ureterenoscopic resection/ laser ablation
+/- mitomycin c
metastatic upper tract transitional cell carcinoma management
- systemic chemo- platinum based
- palliative
- arterial embolisation/ radiotherapy for haematuria
poor prognostic factors of UTCC
-muscle invsive
high grade, stage and age
lymphovascular invasion
prognosis of UTCC
at follow up 50% will develop metachronous bladder TCC and 2% contralateral upper TCC
prostate cancer risk factors
- age >60
- race- african americans
- environmental factors - common scandinavian countries
- diet-animal fat is assoc.
- obesity
- nationality
- endocrine environment
- genetic (increased 1st degree relative)
- exercise can be protective
pathology of prostate cancer
-adenocarcinoma- from glandular epithelium 95%
- 80% arise from outer aspect (peripheral zone) of the prostate gland as tumours enlarge they spread both medially into the remainder of the gland and outwardly to the surrounding tissues especially the seminal vesicles
- 20% arise from the transition zone
main prostate cancer cause
adenocarcinoma from glandular epithelium 95%
where is it common/ uncommon for prostate cancer to invade
- doesnt invade rectum due to denovilliers fascia
- invades into urethral sphincter, corpora of penis, trigone of bladders
gleason score
- prostate cancer
- 1to5
- determined by analysing the histology from 2 separate areas of the tumour specimen and add togeter to get total gleason score =10
- 8 to 10 means aggressive poorly differentiated
T staging prostate cancer
t1= not palpable only under microscope
t2-palpable confined within capsule
t3= breach capsule and invade seminal vesicles or fat
t4= invades adjacent organs and / -bony mets
t2cprostate cancer means
palpable in both lobes
not biopsy bilateral
presentation of prostate cancer
-most are asymptoamtic
-bladder outflow obstruction- voiding symptoms poor stream, flow, straining, hesitancy , nocturia incomplete bladder emptying
-acute urinary retention
haematuria, hermatospermia
40% present with symptoms of advanced prostatic carcinoma caused by either ureteric obstruction or bony metastasis
-pain at night, wake from sleep
signs of prostatic carcinoma on DRE
- sulcus of prostate becomes obliterated
- gland often asymmetrical
- very hard nodule
prostatis on DRE
-boggy and tender prostate
what might a mass above the prostate on DRE indicate
metastatic deposit on Blumer’s shelf- cancer in pouch of douglas
diagnosis of prostate cancer
-DRE
-bloods
-PSA total
PSA free: total ratio
Transrectal USS with needle biopsy TRUS
-isotope bone scan for bone mets if PSA >20 or symptomatic
-MRI for invasion if high risk disease
what does a lower PSA free: total ratio means
suggest more likely to be prostate cancer as
free tends to be less than total
total tends to increase
so get a lower ratio <10% higher risk
PSA total abnormal results
> 3 for <60
4 for 60-70
5 for >70
what else can elevate PSA
BPH UTI- major ejaculation/ DRE TURP/ TRUS acute prostatis chronic prostatitis catetherisation/ retention
function of PSA
liquefied ejaculate and leaks into circualtion
counselling for PSA
- mandatory
- need to highlight potential disadvantages about an abnormal result
- need to balance risks and benefits of having clinically significant disease dx
what should be counselled about for asymptomatic men considering a PSA
- cancer will be identified in <5% of men screened
- benefits remain controversial
- sensitivity only 80%
- specificty only 40-50% ie affected by lots of other things
- if elevated- pathway of DRE and TRUS+biopsy and risks pain infection bleeding
- TRUS biopsy can miss cancer
- may need to repeat biopsy
- treatment may not be necessary or curative
- decreased qofl as a result of treatment complications
what are contraindications to having a PSA done at the time
- an active UTI
- ejaculated in the past 48 hours
- had a prostate biopsy in the past 6 weeks
- exercised vigorously in previous 48 hrs
- had a recent DRE
- avoid receptive anal intercourse for 48hrs before PSA
where does prostate cancer metastasies too
- surrounding tissue especially seminal vesicles
- lymphatic spread to iliac, pre-sacral and para-aortic lymph nodes
- blood spread- to bone , liver and lung
PSA greatest use
detecting recurrence of tumour following treatment
how does prostate cancer spread to vertebrae
via the batson systemic of veins
also goes to pelvis and femur
unsuspected cancer of the prostate stage T0
- prostate normal on DRE but specimen on TURP shows well differentiated tumour
- re-stage patient with a TRUS biopsy and treat by observation and regular DRE and serum PSA levels
localised prostatic cancer stages T1 and T2 management options
-confined to capsule
- radical prostatectomy
- radical radiotherapy
- brachytherapy
- active surveillance
- watchful waiting
risks of radical radiotherapy
-assoc. cystitis, proctitis
what is bracytherapy
internal radiation with radioactive seeds implanted
how is active surveillance for prostate cancer done and who for
regular PSA and DRE and TRUS biopsy to monitor
more popular as with PSA more insignificant prostate cancer seen
men with lower risk but life expectancy 10-20yrs
what men would indicate watchful waiting
life expectancy <10 years
management options for locally advanced prostate cancer T3 and T4
- treatment of choice either
1. radical prostatectomy and/or external beam radiotherapy - in some cases especially those with incipient ureteric obstruction may use androgen deprivation therapy in addition to irradiation
metastatic disease treatment for prostate cancer
-androgen deprivation
GnRH analogues eg goserelin
or orchiectomy
and chemotherapy docetexal
-decrease in testosterone
what is added to GNRH agonist goserelin for the 1st week of treatment in prostate cancer
-need to add androgen receptor antagonist is added to prevent tumour flare up due to
initially get transient increase in FSH and LH so get testosterone surge
eg degarelix, cyproterone acetate
preventing prostate cancer
-low fat consumption soy lycopene in cooked tomatoes selenium vit a and d pomegranate green tea coffee
testicuar cancer risk factors
cryptorchidism fhx age 20-54 race and ethnicity- white men carcinoma in situ cancer of other testis hx HIV infection very tall men
what is the commonest solid tumour in young men
testicualr cancer
presentation of testicualr cancer
- painless hard lump
- lump not separate from testicles
- occasionally present with short hx of painful swollen inflamed testis often secondary to intra-tumour haemorrhage
- few men present with signs of metastatic disease of weight loss, lymphadenopathy, abdo pain
most common type of testicular cancer
Germ cell tumours 90%
three types of Germ cell tumours
- seminomatous (seminomas) 48%-most common
- non seminomatous (teratoma or choriocarcinoma)
- 10% mixed
seminomas
age group
types and presentation
-mostly in 30s
-pale and homogenous
types
-classical
anaplastic
spermatocytic
better prognosis
non seminomatous teratomas
-presentation
age
-typically in 20s
contain things like hair and teeth
look for signs of metastatic disease
increased AFP and HCG
teratoma- undifferentiated, intermediate, differentiated
what are the non germ cell types of testicular cancer are there
- sex cord stromal 3%= leydig, sertoli
- others 7%= lymphoma and metastatic disease
pre-cursor lesion for testicular cancer
TIN testicular intraepithelial neoplasia
examination of testicular cancer
- asymmetrical or slight discoloration of testis
- hard non tender irregular non trans illuminable mass
inx for testicualr cancer
- routine bloods
- USS diagnosis of testicles
- AFP and beta HCG and LDH markers
- staging CT CAP
- MDT refer
teratoma markers
raised AFP
LDH some limited rise
raised B-HCG
seminoma markers
normal AFP
LDH raised - more common with seminoma
raised Bhcg
metastasis sites of testicular cancer
-spreads by direct invasion to lymph nodes- para-aortic 1st
liver lung and bone if breaches tunica albuginea
management testicular cancer options
- radical orchidectomy +/- silicon prosthesis
- radiotherapy for seminoma- EBRT
- chemotherapy cisplatin for non-seminomas
diff dx of testicualr cancer
-hydrocele epididymal cyst indirect inguinal hernia TB-rare syphilis-rare
A 35-year-old man presents with non-specific testicular discomfort and the feeling of a mass in the testis. On examination, a 2 cm by 1 cm smooth, painless mass is palpated in the right testis. The mass does not transilluminate with light. There is no lymphadenopathy.
testicular cancer
spermatocele- epididymal cyst presentation
Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
-transilluminates like cantonees lantern!
Usually occur over 40 years of age
Painless
Lie above and behind testis- upper pole
It is usually possible to ‘get above the lump’ on examination
penile cancer main type
squamous cell carcinoma 95%
rare causes of penile cancer
Kaposi sarcoma
BCC
melanoma
risk factors for penile cancer
-smoking
HPV-genital warts
-keeping foreskin more common
pathology of penile cancer
-starts with penile in situ then SCC starts growing as a flat or ulcerative lesion of gland or shaft
presentation of penile cancer
-painless lump or ulcer on the distal aspect of penis/ glans
rarely
- inguinal mass
- AUR
inx for penile cancer
-bloods
biopsy
CT CAP/ MRI for local
management options for penile cancer
- topical imiquimod for small superficial tumours and PIN
- surgery - circumcision, partial penectomy, total penile amputation with a perineal urethrostomy
3, lymph node sentinel biopsy and inguinal
oncology
-radiotherapy and chemotherapy for advanced disease
differentials of penile cancer
- benign cutaneous lesions eg lichen planus, sclerosis, papules, psoriasis
- benign subcutaneous lesions- peyronnie’s plaque, cysts
- viral -condylomata acuminatum-genital warts
peak age of stone formation
20-50 yrs
m:f 3:1
when and in who is stone formation more common
caucasian populations
more in summer months
risk factors for stone formation
-genetics= cystinuria autosomal recessive trait
-more common in caucasians
-hypercalcaemia- hyperparathyroidism
-hyperoxaluria- bowel resection or AR genetics
-gout
renal anatomy- pujo, horseshoe, MSK
-dehydration
-renal tubular acidosis
-PKD
-beryllium/ cadmium
-ileostomy due to decrease bicarb
-drugs
-diet fluids intake, meat vit d and c
-low mobility
how does hyperoxaluria form
- malabsorption of calcium in gut such as in bowel resection causes excess oxalate absorption from bowel
- dietary excess
- or due to autosomal recessive abnormality of glyoxalate metabolism so get excess oxalate production
what drugs cause stone formation
loop diuretics
steroids
acetazolamide
theophylline
what is cystinuria
autosomal recessive inheritance
get multiple stones
how to prevent cystinuria
-hydration
diet low in cysteine avoid red meat and fish
-give citrate, sodium bicarb to make stones more soluble
main type of kidney stones
80% are calcium oxalate
types of kidney stones
calcium oxalate 80% struvite stones (mg ammonium) 10% calcium phosphate/ oxalate 5-10% urate 5-10 cysteine 1%
which stones are radio-opaque -can be seen
-calcium phosphate
calcium oxalate
struvite
cysteine
more calcium more can be seen
what do cysteine stones look like
“ground glass”
what stones cant be seen on radiography and what inx do they need
-uric acid
and xanthine stones
from hx, urine pH >6 gout, USS,
risk factors for calcium oxalate stones
hypercalcaemia hyperoxaluria hypercalciuria hypocituria hyperuricosuria
risk factors for struvite stones
urease producing bacteria
risk factors for calcium phosphate stones
renal tubular acidosis
risk factors for uric acid stones
gout
myeloproliferative disorders
idiopathic
risk factors for cystine stones
homocystinuria
cystinuria pathology
-defective absorption of cysteine from the intestines and proximal tubule of kidney
presentation of stones.
-renal colic pain- loin to groin
-visible haematuria +/-
-non visible haematuria
-recurrent UTI-struvite
-pyonephrosis, perinephic abscess
n and v
LUTS
examination of a patient with stones
-usually sudden onset colicky loin pain
-loin to groin radiation
waves of increasing severity
patient cant find a comfortable position
where can kidney stones get trapped
- vesico ureteric junction- enters bladder
- uteropelvic junction- leaves renal pelvis
- crossing of iliac vessels
main diff dx of kidney stones
-AAA
pneumonia
appendicitis
ectopic pregnancy-females
calcium oxalate stone formation
- calcium phosphate concretion orginates near renal papilla = Randall’s plaque
- eventually eroded due to alkaline environment through the urothelium and forms a NIDUS for calcium oxalate deposition when directly exposed to urine
- stones then become large enough to break free
uric acid stone formation
-assoc. too
gout, myeloproliferative disorders and hyperuriscoria assoc. to insulin resistance , persistently acidic urine
not radio opaque- radio lucent
calcium phosphate formation
-due to renal tubular acidosis
defect of renal tubular H+ secretion so urine is of high pH and increases supersaturation of urine
-type 1 defect -distal cant maintain proton gradient
causes of calcium phosphate formation
suggest underlying metabolic disorder
- RTA
- primary hyperparathyroidism
- medullary sponge kidney
formation of struvite stones pathology
-magnesium ammonia and phosphate
urease producing bacteria break down urea to ammonia and alkalise urine
-pH >7.2 alkaline urine
which stones cause stag horn calculi
struvite stones
bacteria implicated in struvite stones
proteus
klebsiella
pseudomonas
staph aureus
what is lithostat used for
urease inhibitor can be used for struvite stones as adjunctive
ksp and kf in stone formation
> ksp and >kf
examination of kidney stones
-general temp and signs of sepsis
-patients moves around a lot
-check for pulsating mass AAA
-pregnancy test
dipstick
inx for kidney stones
- bloods (raised WCC, renal funcion, calcium, uric acid)
- MSU
- dipstick for pH and UTI (alkaline in ca phos, acidic in uric acid)
- 24hr urine for ca/ oxalate. uric acid
-CT KUB no contrast
-plain x-ray only shows radiodense
-IVU
-CT urogram
MRU magnetic resonance urography for hydronephrosis
test for renal tubular aciosis
ammonium chloride loading test
pH <7.3 or bicarb <16 but urine pH >5.5 has distal RTA
cystinuria test
cysteine spot test
risks of IVU
anaphylaxis
need to omit metformin 48 hrs prior
best inx for stones
CT KUB no contrrast
what might USS be useful for detecting stones
only renal stones
preventing calcium stones 2
drink
thiazides
preventing uric acid stones 2
-allopurinol
urinary alkalisation bicarbonate
preventing oxalate stones 2
cholestyramine
pyridoxine
acute management of renal stones 4
pain relief NSAID’s 1 st line
fluids
watchful waiting
tamsulosin alpha blocker relax ureteric smooth muscles
indications for emergency intervention for stones
- uncontrolled pain
- infection fever, pyrexia, marked inflammatory
- impaired renal function (solitary kidney) derranged U and E
- prolonged unrelieved obstruction (watchful waiting already for 4-6 weeks)
- social reasons eg pilot
emergency management of obstructed infected kidney stone
- a to e
- wide bore cannula IV fluids
- cultures
- MSU
- broad spec abx
- percutaneous nephrostomy or JJ stenting
- use nephrostomy more as done under LA
discharging a patient after emergency treatment of stones
- discharge patient when pain and blood results improve
- follow up 3-4 weeks later and should have passed otherwise need definitive management
definitive treatment options for stones
- medical- watchful waiting but may not work -trial
- ureteroscopy
- ESWL
- percutaneous nephron-lithotomy PCNL
- nephrectomy
small stones <5-6mm management
-medical: NSAID and alpha blocker, thiazide for calcium, allopurinol for uric
fluids
stone <2cm (>5mm)
ESWL extra-corporeal shockwave lithotripsy
Contraindications for ESWL
- pregnancy
- obese
- anticoagulants
- need to be visible on x-ray so not for uric acid
<2cm stone and pregnancy
ureteroscopy
indications for ureteroscopy and stone extraction
-ESWL failure cysteine stones obese pregnancy bleeding problems- anticoagulant
lower pole stones and stone in calyceal diveriticulum or pelvic kidney- difficult locations
complex renal calculi and staghorn calculi and >3cm management
PNCL percutaneous nephron lithotomy
what is indicated before doing a PNCL
do a DMSA 1st to check that the kidney is functioning as dont do PNCL for a non-functioning kidney
contraindications to medical therapy of stones
> 5mm
struvite (infection) staghorn
complications of stones
infection
obstruction- hydronephrosis, hydroureter, nephromegaly,
perinephric standing - lymphatic congestion with fluid aroudn kidney
main cause of stag horn calculi
due to struvite stones
bladder stone cause
BPH and urinary stasis -same mechanisms as struvite stone
-more seen in patients on long term catheters
management bladder stones
endoscopic or
open cystolitholapaxy
balanitis is
inflammation of the glans penis and sometimes extends to the underside of the foreskin
causes of balanitis
infective
autoimmune causes
management of balanitis
simple hygiene
candidiasis balantitis presentation
acute
usually occurs after intercourse and assoc. to itching and white non-urethral discharge
dermatitis balanitis presentation
contact or allergic
itchy sometimes painful and occasionally assc. with a clear non urethral discharge
not affecting other body areas
dermatitis balanitis presentation
eczema or psoriasis
both acute and chronic very itchy no discharge medical hx of eczema... active areas elsewhere
bacterial balanitis presentation
painful and can be itchy with yellow non-urethral discharge
staph
anaerobic balanitis presentation
acute
may be itchy
most assoc. to a very offensive yellow non-urethral discharge
lichen planus balanitis presentation
may be itchy
wickhams striae
violaceous plaques
lichen sclerosus balanitis
itchy
white plaques
scarring
also called balanitis xerotica
management of balanitis
hyginene saline washes wash under foreskin hydrocortisone short periods candidiasis= topical clotrimazole bacterial-oral flucox or clarith anaerobic= saline wash, metronidazole dermatitis= steroids lichen sclerosus= high potency steroids circumcision also for recurrent cases
prostatitis presentation
perineal pain
pain on ejaculation
tender prostate on DRE
systemically unwell- fevers
management of prostatitis
ofloxacin- fluoroquinolones
epididymitis management
also ofloxacin -levofloxacin
BPH definition
hyperplasia of stroma and epithelium in the transition zone fo the prostate
tone of smooth muscle also plays a key role
cause of BPH
- increase in epithelium and stromal cell numbers
- testosterone diffuses into the prostate epithelial and stromal cells
- in the stromal cells, testosterone is converted into DHT which can act in an autocrine fashion in the stromal cells or in paracrine fashion in the epithelial cells
- converted by alpha reductase
- forms DHT- androgen receptor complex and get increase in growth factors
overall cause is unknown
relates to DHT
presentation of BPH
-voiding symptoms mainly poor flow intermittent stream straining hesitancy
can then go to secondary stroage symptoms
-frequency, urgency, nocturia
acute urinary obstruction haematuria hydronephrosis and renal compromise UTI post-micturition symptoms
inx for BPH
hx assess LUTS use IPSS DRE urinalysis exclude UTI renal function PSA (LE >10 yrs) uroflowmetry
management options for BPH
watful waiting
lifestyle
medical
surgical
contrainidcations to watchful waiting for BPH
-must not be used in complex BPH recurrent UTI's renal impairment due to high pressure chronic retentio bladder stones recurrent haematuria due to BPH
indications for watchful waiting for BPH
- not complex
- low bother score
lifestyle changes for BPH
evening fluid restrict
reduce caffeine intake
medical managementn of BPH
1st line alpha blockers
2nd line 5 alpha reductase inhibitors
-combination therapy
-plus anticholinergics for storage symptoms
alpha blockers
tamsulosin, doxazosin
considered 1st line BPH
alpha 1 receptor in the prostate mediates smooth muscle contraction
idea to decrease smooth muscle tone
SE alpha blockers
retrograde ejaculation dizzy weakness dry mouth headache postural hypotension
5 alpha reductase inhibitors
-eg finasteride
inhibit conversion of testosterone to DHT
cause shrinkage of the prostate epithelium and prostate volume, thus reduce the static element
takes 6 months to imprve
so often combined at beginning
also reduces vascularity and reduce haematuria
SE 5 ari
-loss of libido
impotence
reduced ejaculate volume
surgical management of BPH options
TURP transurethral resection of prostate
laser prostatectoyomy
open millin’s prostatectomy
TURP indications
gold standard
- bothersome LUTS that failed to change to lifesyle or medical therapy
- recurrent acute retention
- renal impairment due to BOO
- recurrent haematuria
- bladder stones
- recurrent UTI
open prostatectomy indications
-large prostate TURP not technically possible failued TURP urethra too long presence of large bladder stones
contraindications to open prostatectomy
small fibrous prostate
prior prostatectomy in which most of gland resected
carcinoma of the prostate
bladder outlet obstruction causes
men
- BPH main cause in men
- urethral stricture
- prostate cancer
women -pelvic prolapse urethral stricture -urethral diverticulum -post surgery for stress incontinence -pelvic mass -Fowler's syndrome
both
-neurological disease
inx for BOO
IPSS DRE PSA U&E flow test and residual volume
upper tract obstruction definition
dilatation of the renal pelvis and calyces- can occur with or without obstruction
obstructive nephropathy is damage to the renal parenchyma from obstruction to the flow of urine anywhere along the urinary tract
presentation of upper tract obstruction
-incidental on CT/ USS
-flank pain
-anuria
-renal failure symptoms
sepsis
signs of upper tract obstruction
-HTN
palpable blader
DRE
palpable mass
inx uto
renal function renal uss CT urogram retrorade pyelogram MAG3
causes of unilateral hydronephrosis
- obstructing stone/ clot
- pelvicureteric junction obstruction PUJO
- ureteric/ bladder TCC
- extrinisc eg pregnancy/ tumour
causes of bilateral hydronephrosis
-BOO bladder outlet obstruction -BPH, prostate, cancer, urethral strictures, DSD detrusor sphincter dyssnergia
bilateral ureteric obstruction at level of bladder
cervical, prostate, renal, bladder cancer
periureteric inflammation eg IBD retroperitoneal fibrosis bilateral PUJO hydronephrosis of pregnancy ileal conduit- normal
strong predictors of AUR
- increased IPSS score
- large prostate volume
- low Q max
- advanced age
- previous episodes of retention
definition of post-obstructive diuresis
polyuria from relief of severe chronic obstruction commonly occurs after catheterisation for high pressure chronic retention
- increased urine output out of proportion to fluid intake
- > 3L/24hrs or >200ml/hr for each 2 consecutive hrs
pathology of post-obstructive diuresis
-physiologic process to salt wasting process
physiological diuresis occurs secondary to excretion of retained urea, sodium and water after relief of obstruction (resolves in 48hrs)
pathologic diuresis occurs secondary to impared concentrating ability of the renal tubules due to inability to maintain the solute gradient
management of post-obstructive diuresis
- admission
- monitoring of hrly output and haemodynamic status
- replace losses if bp drop
- avoid dextrose
- monitor renal funtion
causes of unilatearl hydronephrosis
PACT pujo aberrant renal vessels calculi tumour
causes of bilateral hydronephrosis
SUPER stenosis urethra urethral valve prostatic enlargement extensive bladder tumour retro-peritoneal stenosis
inx for hydronephrosis
USS OBS exam CT KUB if unilateral for stone DRE CT TRUS
management of hydronephrosis
remove obstruction
drain urine
acute upper tract obstruction- nephrostomy
chronic obstruction- ureteric stent/ pyeloplasty
acute urinary retention presentation
painful inability to void
-relieved by catheterisation and drainage
usually 500-800ml
>800=acute on chronic retention
urinary retention causes
- increased urethral resistance BOO
- low bladder pressure
- interruption innervation to the bladder
- central failure of co-ordination of bladder contraction with extenal sphincter DSD
rf for retention in men
advancing age LUTS previous episodes of spontaneous retention low qmax larger prostate volumes
managemen of AUR
-catheterise
renal function check
alpha blocker
definitive management AUR
-TWOC after 1 week
precipiated retention doesnt occur
spontaneous retention does recurr
so need TURP, drugs, long term cathether
chronic retention definition
inability to void with catheterisation >800ml
types of chronic retention
- low pressure
- high pressure
low pressure chronic retention
no hydronephrosis
normal renal function
high pressure chronic retention
hydronephrosis
abnormal cr
intravesical pressure >30
management high pressure chronic retention
catheterise
consider ISC or long term catheter before offering TURP
management low pressure chronic retention
no bothersome LUTS
active surveillance
monitoring
bothersome LUTS
consider TURP
definition of incontinence
involuntary leakage of urine
uretral or extra-urethral
risk factors for incontinence
childbirth
pelvic surgery or radiotherapy
neurological disorders
types of incontinence
stress
urgency
mixed
overflow
inx for incontinence
-hx and exam
sim’s speculum on women for prolapse and cough test
bloods MSSU urinalysis flow studies bladder diaries USS/ cystoscopy if haematuria definitive is urodynamics
what does urodynamics do
-measures the intravesical pressure obtained with bladder filling
testing stress- cough, urge detrusor pressure
management of stress incontinence
- pelvic floor exercises
- lifestyle modification- weight, smoking
3.duloxetine - local oestrogen therapy in post-menopausal women
- surgical
-autologous fascial sling
TVT mid urethral sling
colposuspension
male sling
artifical urinary sphincter
pathology of urge incontinence
due to detrusor over contractivity
abnormal contractions
cystometric assessment
mediated via the parasympathetic system -Ach
management of urge incontinence
- pelvic floor exercises
- lifestyle
-weight
smoking
-alcohol
-caffeeine reduction - anticholinergic Oxybutinin
4.mirabegron beta 3 adrenergic agonist - botulinum toxins
6.neuromodulation posterior tibial nerve stimulation or implantation of sacral neuromodulator - surgical
detrusor mymectomy
CLAM illeocystoplasty
urinary diversion
SE of oxybutinin
dry mouth
dry eyes
constipation
urinary retention
se of duloxetine
n and v
intravesical botulinum indictions
neurogenic idiopathic detrusor overactivity
DSD
risk factors stress incontinence
prostatectomy -removal of proximal sphincter or also damage to the external one radiotherapy TURP childbirth age oestrogen withdrawal previous pelvic surgery obese
gold standard management for post-prostatectomy inccontinence
artificial urethral sphincter
mixed urinary incontinence
complaint of involuntary leakage of urine assoc. with urgency and also with exertion, stress, sneeze
treat based on symptoms
overflow incontinence is
when the bladder is abnormally distended with urine
typically patient has hx of chronic retention and dribbling incontinence
impairment over time
management over flow incontinence
exam- palpable bladder
BOO and chronic retention hx
catheterise
renal function
temporary incontinence
DIAPPERS
loin pain causes
stone infection AAA pneumonia MI ovarian ectopic apenndicitis IBD diveritculitis peptic ulcer testicular torsion
neuropathic bladder cause
most likely urological dysfunction following a cardiovascular accident is DETRUSOR OVERACTIVITY
What is DSD
detrusor sphincter dysnergia
-sign of supra sacral lesion so between pons and L5
bladder overactivity
sphincter spasticity so increase bladder pressures
what is autonomic dysreflexia
sympathetic overactivity
HTN, headache, bradycardia, sweating, flushing
can occur in supra-sacral lesion >T6
risks of long term catheterisation
increased risk of cancer recurrent UTI stones decreased bladder capacity blockages requiring regular changes
UTI definition
inflammatory response of the urothelium to bacterial invasion
>100,000 bacteria/ ml of midstream urine
classification of UTI
cystitis- bladder
pyelonephritis- renal
isolated UTI- interval of 6 months between
recurrent UTI >2 infection in 6 months or 3 in 12 months
uncomplicated- normal functional anatomy
complicated- abnormal anatomy or underlying risk factors or fails to respond to therapy
UTI spread
mostly ascending GI source
haematogenous eg TB
lymphatic
direct eg IBD, diverticulitis
risk factors for UTI
stasis of urine= obstruction foreign body decreased resistance eg immunosuppressed females- shorter urethra smoker low obestrogen retrograde urine eg VUR, stent increase colonisation- sexual activity, spermicide, antibiotics
KEEPS
klebsiella e.coli enterococci proteus/ psuedomonas saphrophyticus
long term catheter UTI causes
- gardenella
- mycoplasma
- ureaplasma
nonsocomial hospital UTI
e.coli kleb pseudonomas providencia serratia
who to inx for UTI
recurrent UTI
haematuria
men
children 1st UTI
inx for UTI
- hx and exam
- urinalysis
- MSSU
- urinary Ph
- POST-VOID RESIDUAL SCAN
-men DRE
blood and blood culture
complicated imaging PVR scan USS plain X-ray KUB flexible cystoscopy
cystitis management
men = trimethoprim or nitro for 7 days
pregnant women= nitro for 7 days first 2 terms
pregnant women= trimeth 7 days at term
non pregnant women= nitro, trimeth for 3 days
dipsticks meaning in children
leucocyte and nitrate treat and do culture
leucocyte only = do a urine sample, dont treat unless good evidence of UTI
nitrites only treat and do culture
pyelonephritis management
-gentamicin and amoxicillin for 7days
oral or IV depending
recurrent UTI management
conservative- high fluids, oestrogen
medical
prophylactic low dose abx
post-intercourse abs dose
self start therapy
surgical for anatomical abnormalities
asymptomatic bacteriuria management
only Rx in pregnancy
who needs test of cure for UTI
pregnancy
pyelonephritis
complicated or relapsing UTI
pyonephrosis
pus hydronephrosis very unwell high fever IV fluids and IV abx urgent nephrostomy
perinephric abscess is
extension of infection outside of the parenchyma of the kidney in acute pyelonephritis
-failure to respond
RF- DM, immunocompromise
unresolving pyelonephritis consider
perinephric abscess
need CT KUB
cause epididymitis
-infection ascends from bladder or urethra
-in sexually active men <35 yrs need to consider STI chlamydia, gonorrhoea
-older men and children- usually UTI cause
-rare- mumps (orchitis after parotiditis, TB, syphilis)
amiodarone
testicle -pain and swelling -fever -pain relieved on elevating testicle -scrotal pain that may radiate to the groin -urethral discharge may be present urethritis -dysuria
epididymitis
main diff dx of epididymitis
testicular torsion
inx for epididymitis
bloods and cultures urine dipstick MSU uretrhal swab scrotal USS
management of epididymitis
- bed rest
- analgesia
- scrotal elevation
- antibiotics depending on suspected pathogen
antibiotic choice for epididymitis
- men <35yrs and suspect chlamydia give ofloxacin (or single dose azithromycin) for 14 days
- in men >35yrs and suspect gonorrhoea then give ciprofloxacin for 14 days
refer to GUM contact tracing
prognosis of epididymitis
pain 48-72hrs to resolve
swelling up to 6 weeks to resolve
prostatitis main causes
KEEPS ascending urethral infection reflux into prostatic ducts often assoc. BOO BPH invasion of rectal bacteria
acute bacterial prostatitis- class I
present
acute onset, fever chills, rectal, perineal pain, lower back pain, haematuria
rx
ciprofloxacin 2-4 weeks
pain relief
treat urinary retention
complication prostatic abscess- pain worsening on rx
DRE for prostatitis
tender, warm, boggy prostate
chronic bacterial prostatitis II
present
recurrent exacerbations of acute prostatitis signs and symptoms
recurrent UTIs with same organism
frequently asymptomatic with normal prostate on DRE
RX
3-4 months ciprofloxacin
plus an alpha blocker to reduce symptoms
urinalysis for chronic bacterial prostatitis
- colony counts in expressed prostatic secretions EPS and urine voided
- massage colony counts should exceed those of initial and midstream urine samples by 10
Chronic abacterial prostatitis/ chronic pelvic syndrome III pathology
-most common and most poorly understood prostatic syndrome
-inflammatory subtype pathogenesis is intraprostatic reflux of urine urethral hypertonia different micro orgganisms autoimmune chemical
presentation chronic abacterial prostatitis
more than 3 months localised pelvic pain- lower back, suprapubic, penile, pain with ejaculation
LUTS
ED
management of chronic abacterial prostatitis
NIH CPSI questionnaire
uroflowmetry and PVR
semen analysis, swabs, TRUS, PSA
-conservative alpha blockers, antib, anti-inflammatory, 5ari neuromodulation prostatic massage pain team referral
hydrocele
fluid in the tunica vaginalis no peritoneall connection usually anterior tranilluminates can get above the swelling
causes hydrocele
idiopathic
consider malignancy in young patients
epididymo-orchitis
management hydrocele
if symptomatic hydrocelectomy done
types of hydroceles
congenital hydrocele- processus vaginalis remains so connected to peritoneum- repair if not resolved by 1-2 yrs
connecting= patency of processus vaginalis in newborn males
non communicating= excess fluid production
varicocele
pamniform plexus veins become dilated and tortuous
more common left 15%
incompetent valves in the internal spermatic vein leads to retrograde blood flow
vessel dilatation and tortuosity of plexus
symptoms varicocele
most are asymptomatic dull ache especially on standing like a bag of worms dragging sensation sudden onset assoc. left side assoc. to renal tumour
investigation varicocele
scrotal doppler USS diagnostic
venography gold standard only consider embolisation
semen analysis
urine USS tract
management varicocele
conservative watchful waiting indication for varicocele repair -adolescents if painful adults for symptoms subfertility to improve semen markers?
varicocele repair
radiological embolisation
epididymal cyst
from the collecting ducts of epidiymis can get above them separate from body of testicles- discrete posterior to testicle discrete soft mass often multiple and loculated spermatocele- accumulation of sperm around epididymis transilluminates can occur post-vasecomy
epididymal cyst maangement
if painful or large remove
orchitis is
inflamamtion of the testis often occurs in assoc. with epididymitis
mumps, e.coli UTI related, chlamydia, gonorrhoea
testicular trauma
can be blunt or penetrating
bleeding can occur from the scrotal wall and its layers leading to a haematoma
haematocele bleeding confined to tunica vaginalis
if sufficient can lead to intra-testicular haemorrhage
presentation testicular haematoma
-severe pain
red
management testicular haematoma
all penetrating trauma needs exploration and fixation
intact haematoma= watch
rupture= explore and repair
sign of ruputured testicle
intraparenchymal haemorrhage- hypoechoic areas suggests testicular rupture
hernia indirect
younger
straight into inguinal canal
risk of strangulation
enters scrotum
testicular torstion
twisting of the testes on its blood supply resulting in strangulation
in neonates this is extravaginal
older intravaginal
presentation torsion
usually 10-30
sudden onset severe pain, often wakin
cna give pain in abdomen as well
can be a hx of similar pain with spontaneous detorsion and resolution of pain
signs of testicular torsion
loss cremasteric reflec slightly swollen tender high riding lying horizontally
management
needs urgent surgical exploration
dont USS
both sides are fixed due to bell clapper abnormality
testicular appednage torsion
blue dot sign
preserved cremasteric reflex
sudden onset pain
production of sperm
GNRH causes FSH release which stimulates the sertoli cell inthe semniferous tubes to produce sperm
and leydig cells to produce testosterone
subfertility
failure to conceive after 12 months of trying
causes of male infertility
idiopathic varicocele cryptorchidism functional sperm disorders erectile problems post-testicular injury eg torsion, trauma, mumps, radiotherapy endocrin excess prolactin oestrogen kleinfelter systemic eg renal liver failure drugs eg chemo, steroids alcohol cannbis infection eg chalmydia
inx for subfertility
semen analysis
hormone measurements FSH, LH testosterone
scrotal USS
transrectal USS- if low ejaculate volumes
venography- if varicocele suspected
reversible causes treatment
lifestyle treat any infection hormonal manipulation- anti OE, hCG,dopamine agonist vitamin E zinc and folic acid treat erectile dysfunction
surgical management
-varicocele embolisation
microsurgery to epididymis
sperm extraction
physiology of erections
parasympathetic s2-s4 Onuf’s- STIMULATE the erection
sympathetic T11 to S2 stimulate ejaculation and detumescence
sensory- dorsal penile and pudendal nerves
brain- medial pre-optic area and paraventricular nucleus
nerve signals activate the veno occlusive mechanism of the corpura cavernosa- increases arterial blood flow to the sinusoidal spaces, relaxation of cavernosal smooth muscle and opening of vascular space
increase in sinusoidal spaces preseses on tunica albuginea which reduces venous outflow
contraction of ischiocavernosus muscles
ED definition
consistent or recurrent inability to attain and / or maintain a penile erection sufficient for sexual intercourse
causes of ED
IMPOTENCE
I- inflammatory prostatitis
M- mechanical peyronnie’s
P- psychological- depression, stress, relationship
O- occlusive vascular eg HTN, smoking, PVD
T-trauma # spinal cord injury
E-extra factors- surgery, prostatectomy, klinefleter
N-neurogenic- MS, parkinsons
C chemical
E endocrine- DM, hypogonoadism, hypothyroidism
drugs that cause ED
beta blockers thiazides ACEi amiodarone SSRIs
risk factors ED
CVD
smoker
alcohol
drugs
when to refer ED to urology
always had difficulty achieving an erection
inx for ED
full hx and exam
blood test- renal, glucose, testosterone, (LH/FSH if low) psa thryoid testing
penile doppler USS
penile arteriography- post trauma
indications of a psychological cause of ED
sudden onset erection stilll on waking reduced libido relationship prolems good quality spontaneous and self-stimulated erecttions phx psychological hx premature ejaculation
organic cause ED
gradual onset
loss of nocturnal and early erejctions
intact libido
lack of tumescence
management of ED
psychosexual lifestyle loose weight PDE5 inhibitors eg siladenafil dopamine receptor agonists intra-urethral eg prostaglandins intra cavernosal injections PGE1 eg aloprostadil vacuum erection device androgen replacement therapy surgical peyronnie
PDE5I SE and CI
-siladenafil
phosphodiesterase 5 inhibitors
block breakdown of cGMP by PDE which helps to dilate corpus cavernosa
CI if takin nitrates, recent MI or hypotension or unstable angina
effective 30 mins after taking and lasts 36hrs must be on empty stomach
assoc. to visual abnormalities
other main treatment for ED
PGE1 prostaglandin eg aloprostadil given intra-cavernosal injections
vaccum erection risks
priaprism
pain
bruise
compliance
priaprism is
rigid and painful erection >4 hours despite absence of sexual stimulation
2 types of priaprism
low flow- ischaemia
high flow- non ischaemia
risk factors low flow priaprism
meds- ssri, maoi, alcohol
neurological
sickle cell
malignancy
risk factors high flow priaprism
trauma
arterio venous fisulation
inx priaprism
butterfly needle aspirate
cavernosal blood gas
low flow treatment
aspirate with butterfly needle
cavernosal irrigation
inject phenylephrine
surgical shunting to glans
phimosis presentation
foreskin cannot be retracted behind the glans
at birth physiological due to adhesions between foreskin and glans
by 3 yrs of age these separate and should be retractile
-asymptomatic
-inflammatory infection
-bleeding
-UTI
-can get balloning of foreskin when voiding as urine gets caught
-pain on sexual activity
management of phimosis
-children and young men- 0.1% betamethasone to soften phimosis 1st line
circumcision recommended for symptomatic phimosis but also for recurrent balanitis, BXO and UTI
causes phimosis
paraphimosis
balanitis
penile cancer - increased risk uncircumscised
STI
paraphimosis is
when the foreskin is retracted from over the glans of penis and becomes oedematous and cant be pulled back over the glans
teenagers or young men
management paraphimosis
-ice glove
dundee- puncture holes for oedema and pull back
dorsal slit under GA and pull back over
peyronnie
curvature of penis due to fibrous plaque
dorsal penile plaques are commonest - so penile cuves upwards as cannot fully lengthen
active phase -pain and changing deformity
stable phase- no pain-stabilised deformity
dont intervene in acute phase
surgery when stable for >12 months
only surgery if >3 months, unable to penetrate, >30 degrees curvature
nesbit procedure shorten the other side
UTI epidemiology children
up to 1 yr of age UTIs are more common in boys
risk factor for UTI in children
age-neonates VUR previous UTI genitorurinary abnormalities abnormal bladder activity female gender uncircumcised boys faecal colonisation chronic constipation
presentation UTI children
non specific fever irritable vomiting lethargy poor feeding
inx
dipstick MSSU USS KUB DMSA MCUG
management UTI children
<3 months refer urgently <6 month refer 3m to 3 yrs refer if medium risk illness and treat if micro positive, clinical, renal anomaly >3yrs send urine and treat based on dipstick treat if symptoms specific treat if anomaly
cryptorchidism types
undescended testes
most resolve by 6 months
retractile ectopic incomplete descent atrophic ascent
risks undescended testes
infertility
testicular cancer
torsion
hernias
cause
abnormal gubernaculum or testes
decreased intra-abdo pressure
endocrine
management of cryptorchidism
orchidoplexy 6 to 18 months
VUR
vesicoureteric retrograde flow of urine from bladder into the ureters and the upper urological tract
often strong FHX
due to abnormality short ratio of intramural ureteric length to diamater
ie length inadequate
primary VUR
due to congenital abnormality of VUJ
secondary VUR
results from an increased intravesical pressure causing damage to the VUJ
eg from posterior urethral valves, urethral stenosis, neuropathic bladder and recurrent cystitis
5 grades VUR
1= reflux limited to ureter
2= limited to renal pelvis
3=mild dilatation of ureter and pelvicalyceal system
4= tortuous ureter with moderate dilatation
5= tortuous ureter with severe dilatation
presentation of VUR
UTI
abdo pain
failure to thrive
vomitting or diarrhoea
inx VUR
urinalysis
USS KUB
DMSA
Cystography selected
management VUR
first line-correct the cause
grade 1-3 resolve spontaneously and only observation
grade 3-5 low dose abx
surgery VUR
only in selected cases for ureteric re-implantation or intramural injection of bulking agents
hypospadias is
failure of ventral tissue of penis
opening of urethra on ventral side
triad hypospadias
ventral curvature of shaft
hooded appearance of foreskin
ventral urethral meatus
anatomical location of hypospadias
anterior
middle
posterior towards scrotum
management of hypospadias
surgery not mandatory if urine stream is straight
posterior can be asssoc. with other tract malformations so need USS KUB
surgical repair between 6-18 months if severe deformity or interferes with voiding or predicted to interefere with sexual function
aims to straighten penile shaft and bring meatus to glans
assoc. to hypospadias
undescended testis
hernias
disorders sexual development
need full exam to determine if other abnormalities eg chromosomal
epispadias is
when the urethra opens onto the dorsal surface of the penis
anywhere from glans to pubic region
upward curvature of penis
most commonly assoc. to exstrophy
need surgery at 6-18 months-urethroplasty
often requires further surgery to reconstruct bladder neck at 5-5 urs
exstrophy is
spectrum of congenital malformation affecting abdo wall, pelvis and GU tract
-eg defective development of anterior bladder and lower abdominal wall resulting in posterior bladder lying exposed on the abdomen
pathology exstrophy
over development of cloacal membrane prevents in growth of the lower abdo mesenchymal tissue
cloacal membrane usually perforates to form the anus and urogenital openings
but in this case it perforates on lower abdo wall
assoc. to exstrophy
all have epispadias bone defects hernias genital defects exposed bladder plate VUR abnormal anus, incontince, rectal prolapse
management exstrophy
at birth bladder and deficit covered with plastic fil and irrigated
then surgical repair
renal trauma
children greater risk due to size of kidneys and lack of fat
management renal trauma
blunt trauma cna be managed conservatively
penetrating trauma needs surgical exloration
decceleration injuries also need surgical exploration as vascular injury
presentation renal trauma
haematuira
loin pain
imaging renal trauma
CT
grading renal trauma
1 contusion
2 <1cm deep parenchymal lacteration of cortex- no urine leak
3 >1cm deep parenchymal laceration no urine leak
4 parenchymal laceration into cotex with urine leak
5 completely shattered kidney
indications for renal imaging in trauma
- visible haematuria
- systolic BP <90 and non visible haematuria
- rapid deceleration injury
- sus[ected renal traum in child
- penetrating trauma
management renal trauma by grade
1-3= bed rest and re-image week later grade4= stenting to prevent urinoma formation and diverty urine- need observation grade5= immediate surgical exploration
renall trauma surgical exploration indications
- penetrating- more likely too
- decelerating injury- more likely too
- grade 5
- persistent bleeding
- bp not responding to fluid resus
- expanding renal haematoma
- pulsatile renal haematoma
complication renal trauma
secondary haemorrhage urine leak and urinoma renal abscess formation arteriovenous fistulas renal impairment HTN
ureteric trauma
most common cause is iatrogenic during surgery
management ureteritc trauma
-often during surgery so repair
otherwise development of hydronephrosis or urinoma should be a consideration
also high drain outputs following
bladder urethral trauma
causes
most common due to Iatrogenic eg TURP/ TURBT
assoc. to pelvic #
can also occur with acceleration deceleration injuries on a full bladder
presentation of bladder/ urethral trauma
- blood at the urethra meatus
- frank haematuria
- urinary retention
- perineal/ scrotal bleeding
- high riding prostate on DRE
- unable to catheterise
what causes a high riding prostate
due to the prostate and bladder detachment from the membranous urethra and pushed forward by developing haematoma
membraneous rupture
inx for bladder / urethral injury
bladder= retrograde cystogram urethral= retrograde urethrogram
NEED TO IMAGE BEFORE CATHETERISE AS MAY NEED SUPRAPUBIC CATHETER IF URETHRAL INJURY
management bladder injury
if extraperitoneal
-urethral catheter and cystogram prior to TWOC
-bladder injury intraperitoneal -open surgical reapir
-urethra injury -suprapubic cather may be required
needs an open approach
TESTICULAR TRAUMA
-EITHER blunt or penetrating
all penetrating need surgical exploration and repair or orchidectomy q
penile fractures
rupture of the tunica albuginea of the erect penis
can go to corpora cavernosa, corpus spongiosum and rupture of the urethra
presentation of penile fracture
swollen and bruised aubergien sign severe bruising snapping or popping sound sudden penile pain immediate detumescence of erection
if buck’s fascia has ruptured the bruising extends onto the lower abdo wall
tender palpable defect
management penile fracture
need surgical repair
catheter for 6-8 weeks
