urology Flashcards
what are renal cysts?
Renal cysts are fluid-filled sacs found in the kidney. They can be classified as either simple or complex.
what are simple renal cysts?
they have a well defined outline
homogenous features
common in older patients
they are though to develop from the renal tubule epithelium in response to previous ischaemia (exact physiology is not fully understood)
what are complex renal cysts?
Complex cysts have more complicated structures, including thick walls, septations, calcification, or heterogeneous enhancement on imaging.
They can be classified using the Bosniak classification. All complex cysts have a risk of malignancy and this risk increases with its increasing complexity.
what are risk factors for renal cysts?
increasing age
smoking
hypertension
male gender
genetic conditions - polycystic kidney disease, tuberous sclerosis, von hipperl-landau disease
what are the clinical features of renal cysts?
usually found incidentally
usually asymptomatic if simple
clinical features can include:
- flank pain (if ruptures or becomes infected)
- haematuria
- uncontrolled HTN in PKD
- flank mass
what investigations would you perform for renal cysts?
CT or MRI with pre and post enhancement scans with IV contrast
Bosnaik scoring can then be used to further characterise the cyst/mass
USS often picks up incidental finding of renal cysts
serum U&E’s to check renal function
how are renal cysts managed?
asymptomatic simple cysts - no follow up or treatment
symptomatic simple cysts - simple analgesia, needle aspiration or cyst deroofing may be warranted if significantly impacts the patient
complex cysts - managed depending on their bosniak stage and this may involve continued surveillance or surgical intervention
what is fournier’s gangrene?
a form of necrotising fasciitis that affects the perineum
it is rare but is a urological emergency
it can be mono or a polymicrobial infection with causative organisms including group A step, c perfringes and E.coli
risk factors for fournier’s gangene?
diabetes mellitus excess alcohol poor nutritional state steroid use haematological malignancies recent trauma to the region
what are the clinical features of Fournier’s gangrene?
severe pain - out of proportion to clinical signs
pyrexia
often non-specific until significant deterioration
as condition progresses - crepitus, skin necrosis and haemorrhagic bullae may begin to develop
patients will rapidly deteriorate and become unwell with sepsis and shock
what are the investigations for Fournier’s gangrene?
diagnosis is largely clinical
any suspected cases should be taken for immediate surgical exploration
routine bloods
CT may show fascial swelling and soft tissue gas
how is Fournier’s gangrene managed?
urgent surgical debridement - this usually encompasses partial or total orchiectomy
broad spectrum antibiotics
transfer to HDU
fluid resus and close monitoring
what is priapism?
unwanted painful erection of the penis - not associated with sexual desire, lasting for more than four hours
what are the two types of priapism?
ischaemic priapism/low flow = urological emergency this is veno-occlusive in nature, caused by blockage to the venous drainage of the corpus cavernosum
high flow/ non ischaemic - his is caused by unregulated cavernous arterial inflow, whereby arterial blood rapidly enters the corpus cavernosum more quickly than it can be drained
Most often associated with trauma as an underlying cause and can be triggered by sexual stimulation
what are the causes of priapism?
Non-ischaemic causes are typically caused following penile or perineal trauma or spinal cord injury, whereby damage to the vasculature creates an arterial-sinusoidal shunt within the corpus cavernosum
Ischaemic causes include:
Iatrogenic – Intracavernosal drug therapy* (for impotence), such as papaverine or alprostadil
Sickle cell disease
Other haematological disorders, such as leukaemia or thalassaemia
Pelvic malignancy (rare)
what investigations would you perform for priapism ?
obtain a corporeal blood gas - will help to determine if it is ischaemic or not
routine bloods
non-ischaemic causes - look for any potential spinal injury
colour doppler USS can also be helpful for initial diagnosis.
how do you manage priapism?
The mainstay of initial management* is through corporeal aspiration, which achieves detumescence in around 30% of cases.
If there is no response from aspiration, intracavernosal injection of a sympathomimetic agent, such as phenylephrine, may be trialled.
if this ineffective - prompt surgical shunt between the corpus cavernosa and glans is fashioned.
what is penile cancer associated with ?
it has a strong association with HPV related carcinogenesis
what is the most common type of penil cancer?
The most common penile malignancy is squamous cell carcinoma (SCC), usually arising from the epithelium of the inner prepuce or the glans, and accounts for 95% of cases. Other types include basal cell carcinomas, sarcomas, melanomas, or urethral carcinoma.
risk factors for penile cancer?
HPV infection phimosis smoking lichen sclerosis untreated HIV infection
circumcision is deemed protective
what are the risk factors for penile cancer?
usually a palpable or ulcerating lesion on the penis
most commonly on the glans
however can be found on the foreskin, penile shaft and scrotum
typically painless lesions - they may discharge or be prone to bleeding
investigations for penile cancer?
penile biopsy
PET CT imaging to stage
TNM staging is classically used
management of penile cancer?
complete tumour removal
combination of surgery, radiotherapy and chemotherapy
what is a penile fracture?
a rare urological emergency which warrants prompt surgical intervention
A penile fracture is the traumatic rupture of corpus cavernosa and tunica albuginea in an erect penis.
what are the clinical features of a penile fracture?
Patients will often report slipping of the penis from the vagina (or rectum), with a forceful thrusting to the pubic symphysis or perineum of the partner.
This will then be followed by a popping sensation or hearing a “snap”, with immediate pain, swelling, and detumescence.
On examination, the patient will have penile swelling and discolouration (secondary to the haematoma), colloquially termed “aubergine sign”, with potential deviation towards the opposite side of the lesion.
A firm immobile haematoma may be palpated in the shaft, called “rolling sign”. A butterfly shaped haematoma in the perineum may suggest a urethral injury.
how is a penile fracture diagnosed?
usually clinical diagnosis
cavernosography can be used in cases of suspected penile fractures
how should penile fractures be managed?
analgesia
anti-emetics
surgical exploration and repair
complications of penile fractures?
penile curvature
penile paraesthesia
dyspareunia
what is acute urinary retention?
the inability to pass urine
acute urinary retention is defined as a new onset inability to pass urine which subsequently leads to pain and discomfort with significant residual volumes
(most prevalent in older males)
what are the causes of urinary retention?
benign prostatic hyperplasia - most common
UTI
Constipation
severe pain can causes patients to enter acute retention
neurological causes (can include peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, MS, parkinsons, bladder sphincter dysinergy
what are the clinical features of acute urinary retention?
acute suprapubic pain
inability to micturate
may be associated with symptoms suggestive of predisposing cause, such as a UTI, change to meds
O/E - palpable distended bladder with suprapubic tenderness
what investigations would you perform for urinary retention ?
make sure to do a PR exam to look for prostate pathology
post void bedside bladder scan (will show volume of retained urine)
routine bloods
USS to look fo associated hydronephrosis
what is high pressure urinary retention ?
High Pressure Urinary Retention refers to the urinary retention causing such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract leading to hydroureter and hydronephrosis, impairing the kidneys’ clearance levels.
they will present with deranged renal function
repeat episodes can cause permanent renal scarring and CKD
how is acute urinary retention managed?
immediate urethral catheterisation
ensure to measure volume drained
treat underlying causes
ensure to check and treat infection
patients with high pressure urinary retention will have to keep their catheters in situ until definitive management can be arranged (TURP)
complications of urinary retention?
AKI
renal scarring
UTI
renal stones
what is chronic urinary retention?
Chronic urinary retention is the painless inability to pass urine. These patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation, therefore minimal discomfort despite potential large intra-vesical volumes.
what are the causes of chronic urinary retention
benign prostatic hyperplasia
in woman - pelvic prolapse or pelvic masses
neurological causes can also cause chronic retention - peripheral neuropathies or MS or parkinson’s
what are the clinical features of chronic urinary retention?
often painless urinary retention
associated voiding lower urinary tract symptoms such as weak stream and hesitancy
overflow incontinence
palpable distended badder
*dont forget to do a PR
investigations for chronic retention?
post void bedside bladder scan
routine bloods
USS
how is chronic urinary retention managed?
catheterised with long term catheter
treat underlying cause
