Urology Flashcards
Hospital treatment for pyelonephritis
ciprofloxacin
(oral is as good as IV for penetration into kidney)
If not working would then consider IV gentamicin
invex for high psa
mri prostate
prostate biopsy
bone scan
what is the imaging of choice for prostate
MRI
can you use nitrofurantoin for pyelonephritis
no - does not penetrate kidney’s well
management of prostate cancer: locally advanced and high grade
androgen therapy
chemotherapy
what genes are linked to prostate cancer
Hereditary prostate cancer 1 = HPC-1
BRCA 1
BRCA-2
When asking family hx in suspected prostate cancer what other cancers should you consider asking about
Breast cancer
BRCA 1 and 2 linked
what part of the prostate are most cancers found in
peripheral zone (75%)can feel this on prostate exam
in what part of the prostate is most BPH found
transitional zone - cant feel this from rectum but prostate may feel enlarged
what type of cancer is prostate cancer
adenocarcinoma
how does prostate cancer spread
Through capsule, into lymph nodes and to bones
Occasionally spread to organs but more common to lymph nodes and bones
how is prostate cancer diagnosed
DRE - digital rectal exam PSA If these abnormal - pt goes on to have prostate biopsy In 40s <2.5 50s: <3 60s: <4 70s: <5
list some other causes of raised PSA
UTI
BPH (age)
Instrumentation of urinary tract (catheter or cytoscope)
Retention
It is a protease produced by prostatic epithelium - prevents coagulation of seminal fluid
DRE can slightly raise PSA but only v small amount
Arguments for and against screening for prostate cancer
PSA not specific enough for screening
Morbidity with biopsies
Over diagnosis - some cancers wont go on to cause any harm
Over treatment
Anxiety that can come from a raised PSA but no cause found
how would a tumour feel on DRE
Asymmetry
Nodule
Craggy mass (hard, irregular?)
NB. Most cancers found on DRE will be locally advanced (60%) - 50% of positive DRE are prostate cancer
Investigations for prostate cancer
MRI prostate - best practice pre biopsy
Transrectal ultrasound and prostate biopsy
What are the risks of prostate biopsy
Infection (1-2% sepsis) Bleeding (semen, urine, stool) Discomfort Acute retention False negative
What are the risks of prostate biopsy
Infection (1-2% sepsis) Bleeding (semen, urine, stool) Discomfort Acute retention False negative (still possible to miss some cancers in prostate even on biospy - MRI should help prevent this)
What is the scoring system for prostate cancer
Gleason score (1-5)
Two most common scores are added together
Dont really see gleasons 1-2, mainly see 3-5 as these are when patients are symptomatic
Now graded (1-5)
How is a gleasons score calculated
A total score is calculated based on how cells look under a microscope, with the first half of the score based on the dominant, or most common cell morphology (scored 1—5), and the second half based on the non-dominant cell pattern with the highest grade (scored 1—5). These two numbers are then combined to produce a total score for the cancer.
Describe the staging of prostate cancer
T1 - impalpable but localised (not picked up on DRE, would be picked up by PSA and biopsy)
T2 - palpable but localised (picked up on DRE)
T3 - locally advanced eg into seminal vesicle, lymph nodes
T4 - advanced into other organs
what is active surveillance vs watchful waiting
active surveillance - deferred radical treatment for pts with a low grade cancer (waiting for right time to treat)
watchful waiting - deferred androgen deprivation therapy for pts not eligible for radical treatment (waiting to see if need any non-radical treatment)
What is the management of localised prostate cancer
active surveillance radical prostatectomy (removal of prostate and seminal vesicle) external beam radiotherapy (neo-adjuvancts used to shrink prostate before hand) brachytherapy (radioactive seeds into prostate - one off procedure - ultrasound guided transperineal implantation of radioactive seeds)
what do seminal vesicles do
add sugar (fructose) to semen for sperm
what is a neoadjuvant
Neoadjuvant therapy is the administration of therapeutic agents before a main treatment.
side effects of radiotherapy for prostate cancer
erectile dysfunction
LUTS
risk of second malignancy - need to consider this in a younger man
what is the management of locally advanced prostate cancer (T3-4)
radical prostatectomy
radiotherapy + androgen deprivation therapy
ADT alone
what are the different types of androgen deprivation therapy
Surgical orchiectomy (removal of testes) LHRH agonists (work slowly - initial surge and then downregulation of LHRH receptor, so stimulate and then inhibit the axis) LHRH antagonists (work quickly) Peripheral androgen receptor antagonists
how is metastatic prostate cancer treated
Androgen deprivation therapy Chemotherapy (if pt fit enough) Plus: Bone targetted therapies - bisphosphonates palliative radiotherapy
complications of metastatic prostate cancer
Bone pain Fractures Hypercalcaemia Spinal cord compression Retention Obstructive uropathy
List some lower urinary tract symptoms
Urgency Nocturia Poor flow Hesitancy Post micturation dribbling
Red flags prostate cancer
Back pain Weight loss Lethargy Erectile dysfunction Haematuria
What is the PSA cut off for urgent urology referal
> 3
what examination finding is suspicious of prostate cancer
Hard and nodular mass
Which men can request a PSA
Over 50
When should you do PSA testing
LUTS - unexplained by UTI or alternative diagnosis, or if other red flags
Any red flags for prostate cancer - haematuria, back pain, weight loss, lethargy
What must you do before offering PSA testing
Counsel patient about pros and cons of PSA testing - what the result will mean
When should you do a DRE
Any lower urinary tract symptoms (LUTS), such as nocturia, urinary frequency, hesitancy, urgency or retention.
Erectile dysfunction.
Visible haematuria.
Unexplained symptoms that could be due to advanced prostate cancer (for example lower back pain, bone pain, weight loss).
Concerns about the possibility of prostate cancer, for example increased prostate-specific antigen (PSA) levels.
When should a man be referred 2 we for prostate
Hard, nodular mass on DRE exam (+ve DRE)
PSA >3 (if over 50)
How is a diagnosis of prostate cancer confirmed in secondary care
Transrectal ultrasound and biopsy
Additional imaging - MRI
(not all referrals will have imagine, depends on DRE and other RFs evaluated in secondary care)
What examination should you do for a man with LUTS
Abdominal exam (distended bladder, suprapubic dullness)
GU - phimosis, meatal stenosis, penile cancer
Perineum - sensory changes
DRE
What are the different types of LUTS in men
Storage symptoms, including urgency, daytime urinary frequency, nocturia, urinary incontinence, and feeling the need to urinate again just after passing urine. The man should also be asked about bedwetting, which can be a sign of chronic urinary retention.
Voiding symptoms, including hesitancy, weak or intermittent urinary stream sometimes causing splitting or spraying, straining, incomplete emptying, and terminal dribbling.
Post-micturition symptoms, including post-micturition dribble and the sensation of incomplete emptying.
What investigations should you do and why in a man with LUTS
Dipstick (UTI, Haematuria)
U&E - creatinine (retention, renal stones)
FBC - infection, cancer
PSA if indicated and discussed with patient
Prostate cancer/ LUTS differentials and investigations
BPH UTI Prostatitis Diabetic neuropathy (erectile dysfunction) MS
What reasons should you delay PSA testing
An active urinary infection (PSA may remain raised for many months).
Ejaculation in the previous 48 hours.
Vigorous exercise in the previous 48 hours.
A prostate biopsy in the previous 6 weeks.
Where do LHRH agonists exert their effects
anterior pituitary
management of cord compression
Urgent MRI spine
Dexamethasone 8MG BD 8am and 2pm otherwise dont sleep
Plus PPI
How long does it take an lhrh agonist to bring testosterone down
1 month
First line management for kidney stones
Analgesia
Imaging - CTKUB (non contrast) - first line imaging to look for a stone
KUB x ray as follow up to see if stone has gone?
what safety netting should be given to pt with kidney stone in ureter
if get fever, loin pain or feel unwell, must seek medical help - bc of risk of pyelonephritis
Indications for gonorrhea treatment
Identification of intracellular Gram-negative diplococci on microscopy
A positive culture for gonorrhoeae
A confirmed positive NAAT for gonorrhoeae
Sexual partner of confirmed case of gonococcal infection
when can you do a HIV test
From 3 weeks
But usually takes longer to seroconvert - 6 weeks
Repeat test in 4 weeks if negative and clinical suspicion
complications of gonorrhea and chlamydia for baby
opthalmia neonatarum
conjunctivitis from chlamydia or gonorrhea
can lead to blindness (panopthlamitis) or corneal scarring/ ulceration
Gonorrhea needs iv ceftriaxone
Chlamydia needs iv azithromycin
management of chlamydia in pregnancy
erythromycin 500 mg BD 10-14 days
management of chlamydia - not pregnant
Doxycycline
Azithromycin
7 day course for each
treatment of uncomplicated gonorrhea
IM ceftriaxone 1g
which common STIs need to be treated differently in pregnancy/ cause pregnancy/ fetal risk
Bacterial Vaginosis
Chlamydia
Gonorrhea
BCG
what other sti often co-exists with trichomonas
gonorrhea
how are chlamydia and gonorrhea managed in terms of index and contact patient
Index - confirm diagnosis and treat
Contact - investigate and treat empirically
when do HIV symptoms present
2-3 months post infection
when does primary syphillis present
3 weeks after infection
what is the incubation period for syphilis
3 weeks
what is the time course for syphilis
primary - days-weeks (usually 3) - painless ulcer
secondary - 1-3 months (systemic -skin, lymph nodes)
tertiary - years - brain, heart, gumma - granuloma - rubber with necrotic tissue
what is the 2 ww criteria for bladder cancer
> 45 and unexplained visible haematuria
>60 and unexplained non-visible haematuria AND raised WCC OR dysuria
when should you do a non-urgent referral for bladder cancer
> 60 and persistent/ recurrent UTI
What HPV types does vaccine cover
HPV 16 and 18, and 6 and 11 (for genital warts)
what STI doesnt need partner notification/ contract tracing
genital warts
how many drugs are in prep
how many drugs are in post exposure prophylaxis
2 drugs - can be given up to 48 hrs after sex
3 drugs - post exposure
men who have sex w men sexual health screen
throat, rectal, urine gc/ chlamydi, HEP C SEROLOGY
commonest STI cause of epididymo-orchitis
chlamydia
most common cause of epididymitis
UTI, sti, mumps
what should you always think of in rash differential in neonate
syphillis
what are the different types of tests for syphilis
what are the functions
Ones that test for bacteria (treponema test) - serological test - is IgG and IgM to bacteria (good for diagnosis of secondary and latent syphillis). Not useful for monitoring disease.
Direct tests - look for bacteria in swabs taken from lesions: dark field microscopy, and PCR.
Ones that dont test for bacteria, but test for antibodies produced from antigens released by cells damaged by T pallidum (non-treponema tests) - VDRL
VDRL is good for detecting secondary syphilis and can be used when patient doesnt have any symptoms (i.e. lesions to swab). Good for monitoring disease.
what tests should be used to diagnosed syphilis
Primary lesion: microscopy or PCR
Secondary syphilis (eg systemic symptoms): Serological test - can be treponema or non treponema
Latent - serological tests (treponema or non treponema)
Tertiary - serological treponema test (or direct from gumma ?)
VDRL only used to monitor disease
What imaging should be first line for visible haematuria
CT urogram (CT with contrast) this allows visualisation of renal pelvis, ureters, bladder and urethra (i.e. urinary tract) USS can be used, but can miss stones and some cancers
What neurological condition should you always consider and rule out in any acute urological presentation
Cauda equina
List red flags to ask in urological hx
Pain / pain less (painless - malignancy, pain - acute trauma/ retention/ pathology)
Blood in urine
Perineal sensation / perianal sensation - cauda equina
Differential diagnosis for acute scrotal pain
Testicular torsion
Epididymo-orchitis
torted hydatid of morgagni
How does testicular torsion lay
Transverse when compared with other testis
What is testicular torsion like on examination
High riding, fixed testicle Extremely tender Horizontal lay Swelling Discolouration of scrotal skin
How do you manage testicular torsion
ABCDE IV access Fluid resus if needed Bloods - FBC, CRP, clotting, U&E Full hx Examine Urine dip (exclude epidiymo-orchitis as differential) Inform senior Keep NBM Inform surgical team and anaesthetics
What should you ask in testicular torsion hx
Infection/ Torsion: When did pain come on Has it changed over time Does it radiate (can radiate to loin/ groin) Trauma Recent unprotected sex Penile discharge Dysuria Fever LUTS UTIs? Recent instrumentation/ catheterisation of urinary tract Recent surgery
Hx for acute testicular pain
Onset - acute (torsion), sub-acute (infection) N&V - torsion Recent unprotected sex (infection) UTI symptoms (infection) Urethral discharge (infection) Fever (infection) Trauma (torsion) After strenuous activity (torsion) During sleep (torsion) Low temperatures (torsion)
What age group is testicular torsion most common in
15-30
What catheter should you use for haematuria
3 way - large central tube so clots can pass
what must you do when managing acute urinary retention
two way catheter - measure residual volume
urine sample
monitor for diuresis
fluid monitoring
what should you include in differential diagnosis of acute urinary retention
Urological obstructions - cancers, strictures, inflammation
GI obstructions - constipation, cancers, IBD
Neuro causes - MS, GBS
Drugs - anticholinergics
Systemic causes - infection
What must you always rule out with acute urinary retention
Cauda equina syndrome
Ask about weakness, perineal sensory change, bowel changes
what is the hydatid of morgagni
remnant of the Müllerian duct
what is the main differential diagnosis for testicular torsion
epididymo-orchitis
management of obstructed kidney
ABCDE
Access and bloods - infection focused, cultures, CRP, lactate, calcium (stone)
Urine dip, pregnancy test
Fluid monitoring
CTKUB
JJ stent or nephrostomy to drain infected kidney
Then definitive treatment to remove the stone
advice to reduce kidney stones
Stay hydrated
Ensure adequate calcium (low calcium causes more calcium oxalate)
Lower sodium - more sodium causes more renal calcium
Reduce red meat - lower uric acid in kidney
management of acute retention (lower urinary tract obstruction)
ABCDE IV access Bloods - FBC (malignancy), PSA, Cultures, CRP (infection), U&E (hyperkalaemia and for monitoring), Lactate Catheter - 3 way (to help clots come out) - urine sample - MCS Measure residual volume Pregnancy test (if female) Monitor for diuresis (>1L) Replace losses if diuresis Monitor for electrolyte disturbances
management of acute obstructed kidney (upper urinary tract)
ABCDE IV access Fluid resus Bloods - cultures, CRP, U&E, FBC, Calcium, urate, lactate Urine sample - MCS Pregnancy test Start antibiotics if ?infection (later - uteric stent, or nephrostomy)
presentation of upper urinary tract obstruction
Pain - loin to groin Renal angle tenderness Mid ureter - appendicitis Infection symptoms Haematuria Normal to oligouria
presentation of retention (lower urinary tract obstruction)
Suprapubic pain
Restless
Anuria
Perineal pain
causes of acute upper urinary tract obstruction (obstructed kidney)
Stones - common - calcium, urate, cystein (renal pathology) - magnesium (recurrent UTIs)
Renal malignancy/ rethroperitoneal malignancy
Infection
Trauma
Renal pathology - glomerulonephritis
common sites for renal stones
pelvic-uteric junction
over iliac vessels
vesico-uteric junction
common investigations to upper and lower urinary tract
Upper - CT KUB (stones), CT Urogram (contrast - malignancy, more detail than CT with no contrast)
Lower - Bladder scan (USS), cystoscopy, CT pelvis, MRI prostate
Ureteric referred pain
Nervous supply to the ureters is delivered via the renal, testicular/ovarian and hypogastric plexuses. Sensory fibres from the ureters enter the spinal cord at T11-L2, with ureteric pain referred to those dermatomal areas.
Symptoms of ureteric injury
Insidious onset of: abdominal pain (T11-L2) peritonitis Ileus Cause is always iatrogenic (abdominal surgery, or instrumentation of ureters)
Investigation for renal trauma
Example of blunt trauma injuries
CT Urogram (contrast) Sports injuries, car injuries
When should bladder injury be suspected
Any pelvic trauma
How should a patient with bladder trauma be catheterised
By someone senior in urology
Signs and symptoms of bladder trauma
Imaging of choice
Abdominal distension Peritonism Any pelvic trauma/ fracture Ileus Anuria/ oliguria Haematuria Perineal scrotal bruising Cystogram
penis fracture - presentation and management
‘snap’ ‘pop’ followed by detumesence
Swelling, bruising
Urgent urology review and surgery to preserve erectile function
What is paraphimosis, presentation and management
Tight retraction of foreskin behind glans - swelling of glams and cant be pulled back into place Presentation: Retracted foreskin Glans odema Discolouration (ischemia) Pain Management: reduce swelling: 1. Lidocaine and ice 2. Sugar 3. Surgical intervention - cut foreskin Always need follow up with urology
Cause of paraphimosis and risks associated
Catheterised patients whose foreskin has not been put back properly
Risks - ischemic necrosis
What is Fournier’s gangrene - causes and presentation
Necrotising fasciitits of genitals/ perineum
Causes: being immune compromised, DM, steroids, perineal infection
Presentation: red area, blistering, perineum, extremely painful, creptitis, systemically unwell
Management of fournier’s gangrene
ABCDE Access Bloods - infection focussed, cultures, CRP, lactate Antibiotics On call urologist Inform anaesthetists Inform ITU Inform general surgeons
What is priapism, what are the types
Erection >4 hours - absence of sex stimulation
Low flow - venous occlusion, painful and ridid
High flow - arterial shunt - caused by trauma, vessels rupture and too much blood flows into penis - semi rigid and not painful, can be managed conservatively or if needed artery embolisation
Recurrent - cause sickle cell crisis in penis
Management of priapism
Need to call on-call urologist
Low flow - emergency. Can ask pt to do exercise - walk up and down stairs (increases venous return), ice packs, needs surgical aspiration, or injection of alpha agonist (vasoconstrictors), or shunt - high chance of ED if gets to this level
High flow - conservative, if doesnt work artery embolisation
Recurrent - hyperhydrate, hyperoxygenate (promotes vasodilation to help sickle occlusion to pass), analgesia
Causes of recurrent priapism
Haem problems: sickle cell
Neuro problems and valcular tone: DM, spinal cord pathology, anything that can cause nephropathy
What cancer should you consider in a pt with left sided varicocele
Renal cancer
Left gonadal vein drains into left renal vein
what is stauffers syndrome
Paraneoplastic syndrome of renal cell carcinoma where you get liver damaged from RCC (raised LFTs)
List some congenital kidney diseases - what associated kidney pathology is there
Horseshoe kidney - kidneys fuse, cant ascend higher than inferior mesenteric artery - risk of stones and reflux/ kidney damage
Polycystic kidney disease - autosomal dominant and recessive - different types - CKD, HTN - loss of renal tubules from cysts - progressively lose kidney function
Ectopic kidney
What is most common renal cancer, what is presentation, what are risk factors
Renal cell carcinoma - incidental usually, classic triad of haematuria, mass and loin pain is rare presentation. RFs: any progressive kidney damage/ inflammations: HTN, CKD, smoking, Age, men, Family hx cancer - overlap with HNPCC, cowdens, congenital abnormalities
Transitional cell carcinoma
Signs and symptoms of renal cancer
Haematuria Flank pain Abdominal mass Left varicocele Lethargy (anaemia symptoms) Night sweats Weight loss Haemoptysis consitpation (possibly) Presence of RFs: smoking, any renal hx (dialysis, CKD, congenital disease), other cancer family hx, HTN Paraneoplastic symptoms - symptoms of hypercalcaemia (thirst, groans, bones, moans, stones), liver - abnormal LFTs
What is the main important differential diagnosis of kidney stones
List some other important ones and how to differentiate
AAA
Peritonitis - pt cant sit still with kidney stones
Signs and symptoms of renal stones
Loin to groin pain
Unable to stay still (differentiate from peritonitis)
Haematuria
Nausea
Clammy
Tachycardia
Dont usually have loin tenderness unless infection, can have renal angle tenderness - L shape between T12 - muscle next to lumbar vertebra
red flags for renal stones (requiring hospital admission)
Any signs infection - tachycardia, pyrexial, tachypnea, raised inflammatory markers
Types of stones
Calcium oxalate - most common Uric acid - high protein/ purine diet Struvite - Kidney infections Cystine - genetic Calcium phosphate - rare
Causes / RFs for renal stones
Low calcium
Dehydration
Male - testosterone (increases oxalate)
recurrent UTIs
High sodium diet
High meat diet
Any kidney pathology making stasis more likely - eg horseshoe kidney,
Any medical condition causing more calcium in kidney - hyperparathyroid
Any medications causing calciuria - loop diuretics, steroids, antiepileptics
Management of renal stones
If no red flags:
Conservative - hydration and sometimes Tamsulosin - most will pass in 3 days (especially if in lower ureter)
If doesnt work can do extracorporeal shockwave lithotripsy
Can also do urteroscopy (go in and fragment and pull out)
If high up and in kidney - can do percutaneous nephrolithotomy
(open nephrolithotomy rarely done)
Bladder stones signs and symptoms
Suprapubic pain Haematuria LUTS UTI symptoms Distended bladder (if obstruction) Perineal pain (if obstruction) Anuria or oligouria (only if there is obstruction)
What are the common causes of bladder stones
Urine stasis - obstruction eg prostate englargment
Catheter - form on tip of catheter
What imaging should you do for suspected bladder stones
USS
Flexible cystoscopy
Management of bladder stones
Cystolitholapaxy (scope and stone crusher)
Laser fragmentation
Pneumatic lithotripsy
Types of bladder cancer
Transitional cell carcinoma (most common)
Adenocarcinoma (uncommon)
Squamous cell carcinoma (uncommon)
What are the Risk factors for bladder cancer
Smoking * Long term catheter * Aromatic amine exposure - paint, rubber* HNPCC Schistosomiasis Recurrent UTIs Drugs - cyclophosphamide
Signs and symptoms of bladder cancer
Haematuria - visible/ non-visible
Suprapubic mass
LUTS - obstruction/ retention presentation
Recurrent UTI
Bladder/ abdominal/ loin pain
Other malignancy symptoms: weight loss, night sweats, lethargy
Investigations / first line management of bladder cancer
Bloods: FBC (Raised WCC), U&E, LFT (renal cancer paraneoplastic), Calcium, CRP (infection screen)
Imaging: USS/ CT, Flex cystoscopy
Testicular cancer tumour markers
HCG
Alpha feto protein
Lactate dehydrogenase
Risk factors for testicular cancer
Age: 20-45 years
Cryptorchidism - undescended testicles
HIV
Testicular cancer red flags
Age Hard testicular lump that you can get above (i.e. it is in the testicle) Does not transluminate Palpable local lymph nodes (spread) Subfertility** Haemoptysis (spread) Hepatomegaly (spread) Hx of cryptorcidism HIV
Types of testicular tumours
Germ cell : Seminoma (most common), teratoma, choriocarcinoma, yolk sac
Non-cerm cell: Sertoli, leydig, lymphoma, mesenchymal
Spread of testicular cancer and grades
Testicle (I)
Lymph nodes and kidneys (II)
Liver, lungs (III)
Signs and symptoms
Any young man with urology/ renal symptoms, flank/ loin pain/ tenderness, examine scrotum for lump/ swelling - remember left gondal vein Hard testicular lump Painless/ or painful Enlarged lymph nodes Haemoptysis Hepatomegaly Weight loss Fatigue Night sweats
History (what to ask) and exam (what to check)
Check red flags: Haemoptysis, abdominal pain (liver mets), B symptoms, any other urology (kidney mets), hx of undescended testicles, any suggestion of being immune compromised - HIV, Family hx of cancer
**Subfertility
Differential - infection/ hernia, cyst - penile discharge, recent unprotected sex, worse on movement
Investigations for ?testicular cancer and first line management
Bloods: FBC (anaemia of malignancy), LFT (mets), U&E (mets), tumour markers (alpha feto protein, HCG, Lactate dehydrogenase), calcium
SAME DAY ULTRASOUND
Urology will then do: CXR (mets), CT
Management will be orchidectomy plus minus chemo/ radiotherapy
When should testes descend
Term babies - at term
Prem - by 3 months
What are the different types/ presentation of undescended testes
Palpable / unpalpable
Maldescended (along normal path) / ectopic (somewhere else - abdomen/ thigh)
Feel if palpable testes in inguinal canal - if so, can it be brought down (retractable? - this is a normal variant but needs some monitoring in case it ascends and need orchiopexy - fixing in scrotum), if cant be brought down then needs referral
If unpalpable - referral
If two unpalpable testes - needs referral and karyotyping
What are risk of undescended testes
Infertility
Cancer
Torsion
What is the management of undescended testes
Orchiopexy - fixing in the scrotum
List common testicular lumps and features
Hydrocele - can be primary (not a worry), secondary to malignancy or infection. If communicating with peritoneum may change size with laying up down.
Varicocele - bag of worms, aching, dragging.
Epididymal cyst - fluctuates, can be painful/ painless
Sebaceous scrotal cyst - on skin, not attaches to testicles
When should you be concerned about a new testicular lump that appears benign
If new left sided - consider renal cancer
what testicular lumps fluctuate in size
hydrocele
epididymal cyst
What is epididymo-orchitis
Infection of epididymis and testicle
Causes of epididymo-orchitis
UTI - ecoli
STI - chlamydia, gonorrhea
Mumps
Presentation of epididymo-orchitis and main differential diagnosis
Hot, swollen, painful testicle (hemi testicle)
Fever
Penile discharge
DD: testicular torsion
What gland should you check in suspected epididymo-orchitis
Parotid glands - mumps
What should you include in history for epididymo-orchitis
Sexually health history Urinary tract Trauma - torsion Penile discharge Recent unprotected sex LUTS Mumps - recent viral symptoms, swollen glands?
Management of epididymo orchitis
Rule out torsion
STI screen - urine NAAT chlamydia and gonorrhea
UTI screen - urine sample - MCS
Treat with relevant antibiotics for 10-14 days, follow up with GP
Causes of erectile dysfunction
- Psychogenic:
Stress, anxiety, depression - Organic:
CVS - HTN, Diabetes, Hyperlipidaemia, Atherosclerosis
Neurology - Parkinsons, any spinal cord disease via distruption of parasympathetic/ sympathetic pathways, eg MS
Endocrine - Diabetes, Hyperprolactinaemia, Low testosterone (drugs eg steroids or adrenal insufficiency), Hypopituitarism
Drugs - SSRIs, SNRIs, antiHTN, antiCholinergics, steroids
Anatomical - prostate cancer, pelvic surgery/ radiotherapy/ chemo
definition of erectile dysfunction
inability to achieve and maintain erection for satisfactory sex
investigations for erectile dysfunction
Bloods: CVS: lipids Hormones: Testosterone, sex binding globulin, LH, FSH, prolactin, TFT Glucose ?PSA
Management of erectile dysfunction
Psychogeneic - psychosexual therapy
Organic - PDE5 inhibitors, prostaglandin injections, intracavernosal injection, vacuum pump, testosterone replacement, prostheses
Questions to ask in hx to identify if psychogenic cause of erectile dysfunction
Morning erection
Able to masturbate
Able to achieve erection, if so for how long, pain
What questions should you ask to elicit psychosexual history in pt with erectile dysfunction
Ask about relationship status, difficulties, anxiety and depression
What is penile fracture
Rupture of tunica albuginea (sheath that encases corpus cavernosum and spongiosum)
what is peyronies disease
curvature of the penis caused by firbotic tissue in the tunica albugina
what is the cause of peyronies disease
unknown but thought to be because of minor trauma to tunica albugina
what diseases is peyronies disease associated with
Diabetes, high cholesterol, dupetrens contracture, plantar fasciitis
presentation of peyronies disease
Curvature of penis when erect (not when flaccid)
Penile pain
Erectile dysfunction
Penile shortening
Palpable fibrous plaque along shaft of the penis
management of peyronies disease
Not for surgery unless plaque is known to be stable
Meds - phentoxyfyline, verapamil
Non meds - vacuum
what is phimosis
tight foreskin that is unable to retract over glans
signs and symptoms of phimosis
ballooning of foreskin during micturation
painful sex
infection of foreskin and glans (balanoposthitis)
management of phimosis
circumcision
what is physiological phimosis
phimosis in <16 years
what is balantis xerotica obliterans
Male lichens sclerosis
Inflammatory condition
Hardening of foreskin
Fibrous tight foreskin that is grey/ white
what is urethral stricture disease
fibrosis within the corpus spongiosum restricting the urethra
causes of urethral stricture disease
catheter, inflammation (urethritis)
what should you ask in a hx for urethral stricture disease
sexual health hx (chronic urethritis) Incontinence Hx of urological surgery Hx of catheter use Hx of recurrent UTIs
what are the symptoms of urethral stricture disease
retention
LUTS
UTIs
what is the treatment of urethral stricture disease
Surgical dilation of urethra
Outline the management of UTIs
Uncomplicated = females <65, not pregnant
If have 3 of classic symptoms (dysuria, frequency, urgency, suprapubic pain, polyuria, haematuria) then dont dip, can treat empirically. 3 day course of abx.
If have <3 symptoms - dipstick and treat.
Complicated = everyone else: men, pregnant, children
Dont use dipstick - MSU. Treat 7 day course empirically - first line usually nitrofurantoin.
Management of BPE
Mild - conservative
Moderate - alpha blockers, 5 alpha reductase inhibitors (Finasteride), add on anticholinergic if needed
Severe - surgery - TURP
Differentials for pyelonephritis
PID, LL pneumonia, cystitis, prostatitis, pelvic pain syndrome
How do you identify an obstructed kidney
1.Urine output :
Anuria
Oliguria
2. Clinic presentation of urinary obstruction:
stone
malignancy
stricture
3. Size of stone on CTKUB, if >5mm needs to be removed
4. Clinical stability (eg signs of distributive shock/ collapse)
5. Bloods - worsening AKI - signs of kidney deterioration
What is the difference between a GnRH agonist and antagonist in regards to androgen deprivation therapy
Agonist - not immediate effect - takes days (2-3 days - can get flare of prostate cancer symptoms as a result of this for about 1 week). Has agonist phase (cancer may get worse) and then antagonistic phase. Slower transition of side effects.
Antagonist. Immediate effect. Abrupt onset of side effects.
