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Urology Flashcards

1
Q

What is the can’t miss diagnosis of an acute scrotum?

A

TESTICULAR TORSION

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2
Q

Differential Diagnosis for an acute scrotum

A
  • Testicular torsion
    —- Torsion of the appendix testis or appendix epididymis — - - – —- Infectious epididymitis/epididymo-orchitis
    —. Rare in prepubertal male with normal urinary tract —
    If afebrile, screen with urine dip
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3
Q

When should you get a scrotal US for suspected testicular torsion?

A

Role of scrotal US:
— US not indicated if you can confidently rule out testicular torsion.
— US not indicated to rule in testicular torsion when you strongly suspect it
— Surgery consult ASAP! — Reserve for equivocal cases

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4
Q

Characteristics of testicular torsion

A

Testicular Torsion

Pain:Severe

Sudden onset of severity

Nausea & Vomiting: Often

Testis position: +/- High riding, +/- Transverse lie

Testis tenderness: Throughout

Urine dipstick: Negative

Cremasteric reflex: Often absent

Blue dot sign: Never

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5
Q

Characteristics of Torsion of appendix testis or appendix epididymis

A

Pain: Mild to severe
Gradual onset

Nausea & Vomiting: Occasional

Testis position: Normal location, Normal lie

Testis tenderness: Localized to upper pole

Urine dipstick: Negative

Cremasteric reflex: Often present

Blue dot sign: Rarely present, but pathognomonic

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6
Q

Doppler US findings for testicular torsion

A

Decreased flow to testis -flow can be entirely normal

+/- reactive hydrocele

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7
Q

Doppler US findings for Torsion of appendix testis or appendix epididymis

A

Normal or increased flow to testis

Normal or increased flow to head of epididymis Note: may be reported as “epididymitis” on US, but NOT infected, just inflamed from surrounding ischemia

+/- reactive hydrocele

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8
Q

Treatment of testicular torsions

A
  • Surgical reduction, ideally w/in 4-6 hrs of onset of pain

- Attempt at manual detorsion an option, but risk of incomplete detorsion. Reserve for when timely surgery not available

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9
Q

Treatment of Torsion of appendix testis or appendix epididymis

A

Non-steroidal anti-inflammatories (NSAIDs) & decreased activity until pain settles

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10
Q

What can a VCUG assess?

A

Indications: Assess for VUR (M & F) & PUV (M)

  • Advantages: Provides anatomical detail of refluxing collecting systems, bladder & urethra. Allows for IRS grading (VUR grade I-V) (unlike a NC)
  • Disadvantages: Invasive (catheter). Radiation.
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11
Q

What does a nuclear cystogram assess?

A

Indications: Initial assessment for VUR in F only. Follow-up of VUR in both M & F

  • Advantage: Potentially less radiation than VCUG
  • Disadvantages: Invasive (catheter). Radiation. Does NOT assess for PUV. Therefore, should NOT be 1 line cystogram for a M w/ congenital hydronephosis or UTI
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12
Q

Nuclear Renal Scans indications

A

Indications: Multiple. Different radionuclides for different indications:
— All provide differential renal function (DRF)
— A diuretic is only used for assessing obstruction —
Only DMSA detects renal scarring. MAG 3 diuretic shows obstruction.
—
Advantages: Provides “functional” information

Disadvantages: Invasive (IV +/- urethral catheter). Radiation. Child must be held still

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13
Q

Renal Bladder US indications

A

Indications: “Anatomical” imaging of the urinary tract

Advantages: Non-invasive. No radiation exposure. Clarifies cystic vs. solid masses
—
Disadvantages: Not as sensitive as CT. May miss stones/masses

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14
Q

What are the indications for a urodynamic cystogram

A

Indications in children:
—- To diagnose source of urinary incontinence
—- To assess bladder pressures in neurogenic bladder
—
Disadvantages: requires catheters in urethra AND rectum
— Invasive (therefore, we will usually trial medication for children with
presumed overactive bladder without a confirmed diagnosis)

— Unreliable if crying/upset child

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15
Q

What is hypospadias?

A

An arrest during embryologic penile development. Results in a combination of 3 separate defects:

  1. Foreskin is incomplete ventrally
  2. Urethral meatus not at tip of penis
  3. Erections curved downward (AKA Chordee)
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16
Q

Should hypospadias have renal imaging?

A

No role for renal imaging in non-syndromic hypospadias

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17
Q

If hypospadias, and undescended testicles, what would you be thinking of?

A

Consider Mixed Gonadal Dysgenesis

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18
Q

An otherwise healthy 9 month old boy presents with a persistent intra-abdominal right testis. Left testis is in the scrotum and normal. Indications for right orchiopexy include all except:
A. Improved fertility
B. Decreased risk of left testicular hypertrophy.
C. Decreased risk of future testicular cancer
D. Improved ability to detect testicular cancer

A

Decreased risk of left testicular hypertrophy:
this may occur if the right testes atrophies but it is not an indication for surgery

—There is now evidence to support that bringing testis down prior to age 10 lowers risk of testicular cancer (however, still higher than general population)

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19
Q

Congenital Hydronephrosis is how common?

A

CH affects 1% of pregnancies (most common fetal anomaly) —

Transient in 44-88%

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20
Q

IS there a correlation between the degree of congenital hydronephrosis and the degree of VUR?

A

No correlation between severity of CH & risk of VUR (all carry a 10-15% risk of VUR)

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21
Q

Congenital Hydronephrosis has what risk of VUR?

A

10-15%

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22
Q

Which babies with congenital hydronephrosis need postnatal imaging?

A

All need it. But if APD>15mm in 3rd trimester or if SFU grade 3-4 then need it within 1-2 weeks.

Otherwise can get it within 1-3 months of birth.

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23
Q

Low Grade Congenital Hydronephrosis RBUS

A 
“Minimal” hydronephrosis — 
“Mild” hydronephrosis
—SFU grade I or II
Calyces not dilated — 
APD <10mm
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24
Q

High Grade Congenital Hydronephrosis on RBUS

A 
“Moderately severe” HN
“Severe” hydronephrosis
—Dilated calyces
—Parenchymal thinning — 
SFU grade III or IV
—APD >15mm
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25
What imaging should be done on a baby with congenital Hydronephrosis
RBUS No role for VCUG or Renal scan. refer to urology before that.
26
Four most common causes of high grade congenital hydronephrosis
1. UPJO: Ureteropelvic junction obstruction 2. High grade VUR: High grade vesicoureteral reflux 3. UVJO: Ureterovesical junction obstruction 4. PUV: Posterior urethral valves
27
UPJO: Ureteropelvic junction obstruction what is it?
Uretero-pelvic junction obstruction — Sig hydronephrosis without hydroureter
28
What do high grade VUR and UVJO look like on US
Sig hydroureteronephrosis (HUN) —
29
What does PUV look like on US
Bilateral sig hydroureternephrosis in a Male —Due to bladder outlet obstruction Bladder anomalies would likely be noted keyhole bladder
30
When do you suspect PUV in utero?
``` Often suspected in utero when severe — -Male -Bilateral hydronephrosis —-Distended, thick walled bladder — Keyhole sign —-Oligohydramnious ```
31
How do you manage PUV post natally
``` Stabilize if respiratory issues —Urgent postnatal RBUS —Bladder decompression with a catheter — Serial serum creatinine levels —Confirmatory VCUG —Consultation with Nephrology —Fluid, acid-base, electrolyte management —Consultation with Urology — Surgical management ```
32
Most common cause of non infectious day time incontinence
Idiopathic overactive bladder (OAB)
33
Common features of OAB
No neurologic anomalies Frequency (>8 voids/day) Urgency Urge incontinence Note: May experience no sense of urgency before a leak w/ OAB Urine holding postures Small functional bladder capacity Commonly associated w/recurrent cystitis Commonly associated w/ constipation Commonly associated w/ nocturnal enuresis
34
How to treat an OAB
``` 1st line treatment of OAB • Treat constipation (diet/PEG 3350) • Treat UTIs • Observation is an option if not bothersome to family/child (usually resolves eventually) • Timed voiding (every 1.5-2h) ``` 2nd line treatment of OAB • Anticholinergics (AKA Antimuscarinics) • Commonly: oxybutinin, tolteridine (off- label), solifenacin (off-label) • Note: Anticholinergics may worsen constipation & aggravate OAB
35
List the types of Duplex Kidneys
Duplex kidney (kidney w/ 2 renal pelvises) —Complete duplication: Upper & lower pole ureters never merge may both enter bladder or may enter weird locations (Increased risk of UVJO (upper pole) & VUR (lower pole)) — Partial duplication: Upper & lower pole ureters merge before entering bladder (no increased risks of obstruction or VUR) — If no hydronephrosis, US cannot distinguish complete from partial — “Uncomplicated duplication”: US term for duplex kidney with no hydronephrosis
36
What needs to be routinely done for a duplex kidney
Not of concern unless history of febrile UTI (no referral to Urology)
37
What complications can occur because of a horseshoe kidney?
Increased risk of UPJO (only relevant if HN) —Majority are asymptomatic Incidental finding of horseshoe kidney is NOT of concern unless HN or current or future development of abdominal pain
38
Most reliable way to view renal stones
CT KUB
39
Best first line imaging modality for renal stones
Renal ultrasound Excellent first line investigation as no radiation May miss small ureteric stones, especially if no proximally dilated ureter usually do US looking for evidence of stones…like obstruction etc. then do a CT scan
40
Treatment of Renal Stones
Conservative treatment of renal colic — Analgesics & α blockers (ex: tamsulosin) to hasten passage of small ureteric stones and hydration Interventional treatment —Reserved for large stones (too large to pass); unremitting pain; persistent severe obstruction; solitary kidney or; infected, obstructed kidney
41
What are the characteristics of a hydrocele
``` Fluid around or adjacent to testis —Generally asymptomatic —Diagnose with trans-illumination —note: fat/omentum can trans-illuminate) — Try to see (shadow)/feel testis...can be difficult with large or tense hydroceles ```
42
When to refer a communicating hydrocele
Congenital defect, although not always clinical (can be patent with nothing coming through it) - Risk is development of indirect hernia - Allow up to age 18 mo for resolution before referral
43
When to refer a non communicating hydrocele
- May be part of continuum of resolution of communication hydrocele - May be reactive (infection, trauma, tumour) - think about tumour in adolescents - Imbalance of secretion>absorption. - Refer if large/bothersome
44
Why would you ultrasound a hydrocele?
- To confirm scrotal testis (>6mo of age); • To differentiate from inguinal hernia; • To rule out testis tumor (adolescent age); • When associated with scrotal pain N YD (? Associated with a more sinister diagnosis)
45
Initial investigation for abdominal mass?
Abdo US
46
What is a congenital mesoblastic nephroma
Benign (usually) —Most common solid renal tumor in fetuses, neonates & infants —Treatment: Complete surgical excision
47
Where do neuroblastomas typically occur?
Most common extracranial solid tumour in childhood — 75% are abdominal; majority are adrenal — Arise from cells of the neural crest (adrenal medulla and sympathetic ganglion) —
48
What is the most common malignancy of infancy?
Neuroblastoma
49
How do Neuroblastomas usually present?
89% of cases < age 5y — Presentation: Incidental – Note: small nodules identified on perinatal or neonatal US are often observed as regression likely Symptomatic: abd. pain or abd. mass; 70% already metastatic —Skin mets look like “blueberry muffins” in infants
50
How do you treat a Stage IV-S neuroblastoma
— Stage IV-S: Infants w/ small 1o tumor w/ liver, skin & bone marrow mets, but NO radiographic evidence of bone mets. Many undergo spontaneous regression
51
What labs would you order for a suspected neuroblastoma?
—Lab: Elevated urinary catecholamines, vanillyl mandelic acid (VMA) & (HVA) homovanillic acid in >90% of patients
52
Should you biopsy renal masses?
— Renal biospy for renal mass discouraged in children, as counts as “tumour spillage” which upstages the tumour —
53
What is the most common primary renal tumour in childhood
Wilms: AKA “Nephroblastoma” — Most common primary renal tumour in childhood — Arise from remnants of immature kidney
54
Associated syndromes of Wilms Tumours
— 10% associated with congenital anomalies and syndromes — 50% risk of WT in WAGR & Denys Drash syndromes
55
When should you consider surgical correction of phimosis (ie//circumcision)
Indications for surgical consultation: — Scarred phimosis —Recurrent balanoposthitis —Recurrent UTIs —Delayed retraction of the foreskin >10 years of age
56
True or false, CPS recommends routine circumscision
— The CPS does not recommend the routine circumcision of every newborn male — Rate of Canadian newborn circumcision: 32% — Increased risk of STI transmission and penile cancer does not justify recommendation of routine circumcision`
57
When do most foreskins retract by?
— Age 6 years: 50% of foreskins retract — Age 17 years: 95% of foreskins retract —Topical steroids recommended for hastening retraction of foreskin and release of adhesions — Meatal stenosis (seen following 2-10% of newborn circumcisions) can be prevented by applying petroleum jelly to the glans for up to 6 mo following circumcision
58
What are basic foreskin caring techniques
In diapers: — To wash, retract as far as it wants to go — Do NOT retract to the point of pain or bleeding — Always “reduce” to normal position, to prevent a paraphimosis Pre-puberty & asymptomatic: No intervention required • Note: non-obstructive ballooning of the foreskin is not pathological Approaching puberty & still does not retract: 1. Child to start routinely making attempts at foreskin retraction 2. If fails, add application of topical steroids twice daily for 6 weeks to weaken skin and release adhesions. Options include betamethasone 0.05%, triamcinilone 0.1% (my preference, as an ointment), & mometasone furoate 0.1% (CPS 2015)
59
Imaging needed after first febrile UTI at what ages?
Children Age 2 months - 2 years —RBUS after 1st febrile UTI —VCUG (or NC in female) is reserved for those w/ an abnormal RBUS or if have a 2nd febrile UTI
60
Which children with febrile UTIs do you refer to urology
No antibiotic prophylaxis for VUR I-III, even w/ hx of febrile UTI — Referral/discussion with Urologist or Nephrologist for VUR IV-V or significantly abnormal RBUS findings
61
What is vesicle-ureteric reflux
VUR is the retrograde flow of urine from the bladder to the kidneys
62
Does VUR cause UTIs
* VUR itself does not cause UTIs * Exception: high volume VUR preventing adequate bladder emptying * VUR does allow easy access of bacteria in the bladder up to the kidney to cause a pyelonephritis * Asymptomatic, low grade VUR does not require intervention * Therefore, diagnostic VCUG should be limited to SFU III-IV CH, febrile UTI work up, and suspicion of PUV
63
Do children with cystitis need imaging?
No
64
How long do you treat cystitis
2-4 days
65
What are the symptoms of cystitis
“cystitis” refers to bacteruria resulting in local “bladder” symptoms only (voiding symptoms/suprapubic +/or lower back pain)
66
How do you manage recurrent Cystitis
Unlike febrile UTIs, investigation & management of recurrent cystitis focuses on behavioral anomalies rather than anatomical ones — Do NOT look for structural anomalies – ie RUS and VCUG not routinely indicated — Look for bladder and bowel dysfunction — - Constipation —- Infrequent voiding - Voiding postponement - Daytime urinary incontinenc/Overactive bladder (OAB) — - - Incomplete emptying
67
What antibiotics do you use for UTI prevention?
— Highlights: —Managing constipation appropriately may be helpful for decreasing UTI recurrences — If prophylaxis used, should be used for no more than 3 – 6 mo & use reevaluated thereafter — Choice antimicrobial is TMP/SMX or nitrofurantoin — Switch antimicrobial if urine culture shows resistant organism, even if suspect contamination — If urine isolate shows resistance to both TMP/SMX & nitrofurantoin, consider stopping CAP rather than using broad spectrum antimicrobial for CAP
68
When to consider not OAB
Infrequent voiding: Leakage after prolonged interval of no void Voiding postponement: Urine holding postures w/o urinary frequency Vaginal voiding: Post void dribbling in female Giggle incontinence: Leaks ONLY with laughter Ectopic ureter: Continuous dribbling Cystitis: Positive urine culture – Symptoms resolve w/tx Bladder outlet obstruction: Slow urinary flow/Symptoms of obstructive voids Neuropathic: Neurologic conditions or symptoms Stress incontinence: Leaks w/ ↑ abd pressure

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