Urology Flashcards
Stress incontinence aetiology
Detrusor pressure > Closing pressure of urethra
Obesity
Menopause - Lack of oestrogen
Pelvic radiation
Childbirth / pregnancy
Stress incontinence presentation and investigations
Involuntary passage of urine with increase in intra-abdominal pressure
- Coughing
- Sneezing
- Laughing
Urine dip / MC&S - Infection?
F/V chart - Normal
Urodynamics - Pre-surgery
Stress incontinence management
Conservative
- Lose weight
- Stop smoking
- Pelvic floor exercises - 3 months
- Decrease caffeine
- Reduce fluid intake
SSRI - Duloxetine
Surgery - TVT
Urge incontinence aetiology
Overactive bladder
Overactive detrusor muscle
Obesity
Neuro disease
- MS
- Stroke
- Parkinson’s
Urge incontinence presentation and investigations
Key in door syndrome!
- Urgency
- Frequency
- Nocturia
Investigations
- Urine dip / MC&S - Infection?
- F/V chart - Increased frequency
- Urodynamics - Pre-surgery
Urge incontinence management
Conservative - Bladder retraining!
- Lose weight
- Stop smoking
- Pelvic floor exercises - 3 months
- Decrease caffeine intake
- Reduce fluid intake
Ach antagonist - Oxybutynin - Falls risk!
M3 agonist - Mirabegron
Botox injections
BPH aetiology
5a reductase converts testosterone into dihydrotestosterone
Hypertrophy of cells in transitional zone
Narrowing of urethra
Increase in smooth muscle contractility
50% of men aged 50 - 30% symptomatic
80% of men aged 80
BPH presentation
Voiding symptoms - Obstructive
- Weak / intermittent flow
- Straining
- Hesitancy
- Terminal dribbling
- Incomplete emptying
Storage symptoms - Irritative
- Urgency
- Frequency
- Urgency incontinence
- Nocturia
BPH investigations
- PSA - Prostate cancer?
- DRE
- TRUS
Scoring system - International Prostate Scoring System
Urine dip / MC&S
USS-KUB
F/V chart
BPH management
Behavioural - E.g. fluid restriction at night
A-blocker - Tamsulosin / Doxasozin
- Postural hypotension
- Sexual dysfunction
5a reductase inhibitor
- Finasteride
- Gynaecomastia
Surgery - TURP
BPH complications
Urinary retention
Hydronephrosis
Stones
Infection
TURP syndrome!
- Aetiology - Long surgery / Large blood loss
- Clinical features - Fluid overload, hyponatraemia, headache
- Management - Supporting, correct hyponatraemia
Prostate cancer aetiology
Peripheral zone
Adenocarcinoma
Family history Black ethnicity Dietary fat BRCA HPC-1
Prostate cancer presentation
Bladder outlet obstruction
- Nocturia
- Frequency
- Hesitancy
Haematuria
Pain
- Perineal
- Testicular
- Back - Secondary to metastases
Weight loss
Prostate cancer investigations
- PSA
- TRUS + Biopsy
- DRE - Asymmetrical, hard, nodular, loss of median sulcus
+ MRI
+ CT/PET staging
Urine dip / MC&S
+ Markers
- Serum - PSMA
- Urinary - PCA3
Prostate cancer metastases and staging
Bone
Lung
Liver
Staging
- Non-palpable / non-visible
- Palpable / visible
- Beyond capsule
- Beyond seminal vesicles
Prostate cancer management
T1/2
- Active monitoring
- Brachytherapy
- Prostatectomy
T3/4
- Hormonal
- Brachytherapy
- Prostatectomy
Metastatic
- Synthetic GnRH
- Anti-androgen
- Orchidectomy
Prostate cancer treatment complications
Incontinence
Sexual dysfunction
Gynaecomastia
Radiation - Cancer risk
- Bladder
- Colon
- Rectal
PSA
Increased…
- Prostate cancer
- BPH
- Vigorous exercise
- Ejaculation
- Infection
- Urinary retention
Age
- 50-59 (< 3.0)
- 60-69 (< 4.0)
- > 70 (< 5.0)
Bladder cancer pathophysiology
Blood supply + Lymph
Transitional cell carcinoma
Squamous cell carcinoma - Schistosomiasis
Bladder blood supply
- Superior vesical artery
- Umbilical artery
- – Internal iliac artery
Lymph node spread
- Obturator
- Internal/external iliac
Bladder cancer risk factors and presentation
Smoking Printing /textile industry - Aniline dyes - 2-naphthylamine Pelvic radiation Schistomiasis - SCC HNPCC Family history Chronic bladder inflammation
Presentation - Painless haematuria!
+ Weight loss
Bladder cancer investigations / staging / management
Urinalysis - Haematuria
Flexible cystoscopy + Biopsy - 2ww referral
CT/PET staging
Stage (s/r)
- Lamina propria (90%)
- Beyond muscle (60%)
- Beyond fat (35%)
- Metastases (25%
Management
- TURBT ± Intravesical chemotherapy
- Cystectomy ± Chemo
Testicular torsion
Twisting of spermatic cord - Ischaemia + Necrosis
Risk factors - Peak incidence 13-15 years
- Bell-clapper deformity
- Trauma
Presentation
- Sudden severe groin/abdo pain ± N/V
- Absent cremasteric reflex
- Red swollen testis
- Elevating the testis does not relieve pain
Investigations - USS - Whirlpool sign
Management - Surgical repair - Bilateral
Hydrocoele aetiology
Accumulation of fluid in tunica vaginalis
Communicating - Peritoneal fluid drains into scrotum
Non-communicating - Excessive fluid production in TV
Secondary to…
- Epididymo-orchitis
- Torsion/cancer
- Failure of processus vaginalis closure
Hydrocoele presentation / investigations / management
Swelling - Anterior/inferior
- Increases with activity
- Diurnal variation
- Confined to scrotum - Can get above mass
- Testis difficult to palpate
Investigations
- Pen torch - Transilluminates
- USS
Management - Conservative
- Surgery if processus vaginalis defect
- Aspiration
Varicocoele aetiology and clinical features
Enlargement of pampiniform plexus
Aetiology - Idiopathic
- Compression of venous drainage - E.g. tumour
- More common on the LEFT - LTV drains into LRV
Clinical features - “Bag of worms”
- Dull ache / heaviness
- Visible veins - More prominent on valsalva
Varicocoele investigations / management / complications
Investigations
- Pen torch - Transilluminates
- USS - Colour doppler
- Investigate cause - CT
Management - Conservative
Complications
- Increased blood flow to prostate - BPH
- Increased temperature of testis - Subfertility
Testicular cancer aetiology
Most common malignancy in young adult men - 20-34
Germ cell
- Seminoma - LDH
- Non-seminoma - Teritoma, Yolk-sac - AFP + hCG
Non germ cell
- Leydig
- Sarcoma
Risk factors
- Family history
- Infertility
- Cryptorchidism
- Klinefelters
- Mumps
Testicular cancer presentation / investigations / management / prognosis
Painless scrotal swelling Haematospermia Hydrocoele Varicocoele Gynaecomastia
Investigations
- USS
- CT/PET staging
- bHCG - Teritoma / Yolk sac
- AFP - Teritoma / Yolk sac
- LDH - Seminoma
Management
- Orchidectomy
- Chemo/Radio
Prognosis - 85-95% survival
Lymph node spread
- Retroperitoneal
- Para-aortic
Urolithiasis aetiology
Renal stones
- Calcium oxalate - 85%
- Calcium phosphate
- Struvite - Magnesium, ammonia, sulphate
- Urate - Gout, ileostomy
- Crystine
Risk factors
- Dehydration
- HYPER - Hypercalciuria, hyperPTH, hypercalcaemia
- PKD
- Obstruction - BPH
Drugs causing stones
- Loop diuretics
- Steroids
- Acetazolamide
- Theophylline
Urolithiasis clinical features / investigations
Loin to groin pain - Severe ± N/V Urinary frequency / urgency Haematuria Testicular pain Fever
Investigations
- Urine dip / MC&S - Haematuria
- CTKUB - Within 14 hours
- Serum calcium / urate
- CRP - Infection?
- U&E
Urolithiasis management and complications
< 5mm - Pass spontaneously
- Analgesia - Diclofenac / Morphine
- IV fluids
- Anti-emetic
< 10mm - Tamsulosin PO
Shockwave lithotripsy - CI in pregnancy
Ureteroscopy
Percutaneous nephrolithotomy
Complications
- Hydronephrosis - Nephrostomy
- Obstruction / retention
- Rupture - Sepsis
Urolithiasis prophylaxis
Hypercalciuria
- High fluid intake
- Low animal protein
- Low salt diet
- Thiazides - Increased distal tubular calcium resportion
Oxalate - Reduce urinary oxalate secretion
- Cholestyramine
- Pyridoxine
Uric acid
- Allopurinol
- Urinary alkalinisation - Bicarbonate
Haematuria aetiology
Cancer - Prostate / Renal BPH UTI Stones Renal disease - Glomerular disease - Nephritic syndrome Bleeding disorder Catheter
Haematuria investigations
Urine dip / MC&S FBC Clotting U&E LFT Flexible cystoscopy CT
Urinary retention aetiology and management
Neurological - Stroke / MS
Infection - UTI
Obstruction
- Malignancy
- BPH
- Stones
- Strictures
- Structural abnormalities
- Constipation
Drugs
- Anti-cholinergics
- Tricyclics
- Antihistamines
- Opioids
- Benzos
Management - Catheter
If > 400ml urine output - Retention confirmed
UTI aetiology
E.Coli Enterobacter Klebsiella - Stones Proteus - Stones Pseudomonas
Risk factors
- Catheter
- Female - Sexually active
- Structural abnormality
- Immunocompromise
- Pregnancy
UTI presentation and investigations
Dysuria Urgency / frequency Cloudy offensive smelling urine Suprapubic pain Fever Haematuria
Investigations - Septic screen?
- Urine dip / MC&S
- ESR / CRP
- Blood cultures
- KUB-USS - Check for underlying cause
- MCUG - Check for underlying cause
- DMSA - Check for scarring
UTI management and complications
Non-pregnant women - Trimethoprim / Nitro
Pregnant women - Amoxicillin
Men - Trimethoprim / Nitro
Complications
- Urinary retention
- Stones - Klebsiella/Proteus
- Sepsis
- Abscess formation
- Pyelonephritis - Give IV/PO Cef
Prostatitis
Aetiology - E.Coli
- UTI
- Post urological instrumentation
- BPH
Presentation
- Painful perineum
- Painful ejaculation
- Obstructive urinary symptoms
- Fever / Rigors
Investigations
- DRE - Boggy prostate
- Urine MC&S - UTI screen
- STI screen
- PSA
Management - Cipro
Epididymo-orchitis
Aetiology
- STI - Chlamydia / Gonorrhoea
- UTI
Presentation
- UTI symptoms
- STI symptoms - Discharge
- Unilateral pain and swelling
- Cremasteric reflex present
Investigations - Rule out testicular torsion!
- STI screen
- UTI screen - Urine MC&S
- USS doppler
Management
- IM Cef
- PO Doxy - 2 weeks
