urology Flashcards
benign prostatic hyperplasia def patho symps ix ddx mgmt comps
def
Benign, nodular or diffuse proliferation
of musculofibrous and glandular layers
of the prostate. Enlargement of the inner
transitional zone
pathp
1. LUTS due to bladder outlet obstruction
due to:
2. Static component - increasing epithelial tissue in transitional zone bulk leads to narrowing urethral lumen
3. Dynamic component - increase in prostatic smooth muscle tone mediated by alpha-1a adrenergic receptors
symps Storage symptoms FUN - frequency, urgency, nocturia Voiding symptoms HIIPP - hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling
ix
TRIAD - DRE, transrectal USS+/-biopsy, PSA
urinalysis - MSU/dip to rule out pyuria and complicated UTI
scoring system - IPSS
International Prostate Symptom Score (0-35) also includes quality of life
Mild = 0-7, Mod = 8-19, Severe = 20+
volume chart
USS KUB - rule out hydronephrosis, urolithiasis, mass
ddx OAB prostatitis prostate cancer UTI
mgmt
all - avoid caffeine, alc, void twice in a row, limit fluids
mild - no bother = watch + wait
- bother = FIRST alpha blocker eg tamsulosin or doxazosin or 5-alpha reductase eg finasteride or NSAID (celecoxib)
mod-severe = as above
abnormal DRE or raised PSA? -> surgical referral, prostate <80g Transurethral resection or vaporisation, prostate >80g open prostatectomy
comps
- Progression - reduced by alpha blockers
- Sexual dysfunction - due to alpha blockers, 5-alpha reductase inhibitors or surgical management
- Acute urinary retention (roughly 2.5% over 5 years)
- TURP syndrome
alpha blocker
how works
example
SE
how works
smooth muscle relaxation in prostate and bladder neck
example - tamsulosin, doxazosin
SE - post hypo, dry mouth
5-alpha reductase
example
how works
example
finasteride
reduced conversion of testosterone to dihydrotestosterone
TransUrethral Resection of Prostate syndrome what is it why symps mgmt
Rare but potentially life threatening
Consequence of absorption of irrigating fluids into prostatic venous sinuses
symps
Fluid overload, disturbed electrolyte balance, hyponatraemia and hypothermia (bladder source of heat loss) i.e. hypertension + reflex bradycardia, restless, headache, N + V, confusion
MGMT: is supportive, 100% O2 non-rebreather, monitor BP with arterial line, correct hyponatraemia
common causes for acute urinary retention
Men
*BPH (by far most common of all) , prostate cancer, meatal stenosis
Women Prolapse (cystocele, rectocele, uterine), pelvic mass (uterine fibroid, ovarian cyst, gynae malig)
Both
Bladder/urethral calculi, bladder cancer, faecal impaction
Infectious/inflammatory
M: balanitis, prostatitis, F: vulvovaginitis, B: bilharzia (schisto), cystitis
Drug-related
*ANTICHOLINERGICS (antipsych, antidep, antichol resp agents), ALCOHOL, opioids, alpha agonists
Neurological Autonomic neuropathy (DM), spinal cord damage (disc disease, MS, spinal stenosis, cauda equina, cord compression), pelvic surgery
ix of acute urinary retention
USS bladder - post void residual urine <50ml normal
<100ml is acceptable
hydronephrosis
structural abnormalities
urinalysis - infection, haematuria, proteinuroa, glucosuria
MSU -infection
bloods: FBC U/E Cr eGFFR PSA
hunting for cause:
CT Abdo pelvis - looking for mass
MRI spine - disc prolapse, cauda equina, spinal cord compression, MS
mgmt + comps acute urinary retention
Management:
Immediate and complete bladder decompression with catheter
Men should be offered an alpha blocker prior to removal
Secondary management:
Prostate surgery? TWOC?
Complications:
UTI, AKI
prostate cancer def spread epi causes staging grade screen pres ix prog mgmt comps
def malignant neoplasm of glandular origin (adenocarcinoma) arising in the peripheral prostate
spread
local - through capsule to seminal vesicles, bladder, rectum
lymphatic - pelvic LNs
haematogenous - bone sclerotic (90%), lung, liver
epi
most common male cancer
80% over 80
causes
+ve fh x2 for one relative
increased testosterone
BRCA and HPC-1
stage T1 - not palp or visible on imaging T2 - palp or visible on imagining (a <50% one lobe, b >50% one lobe, c = both lobes) T3 - through capsule T4 - beyond seminal vesicles N1 - regional LN M1 - mets to non-regional LN, bone
grade Gleason - level of differentiation each biopsy specimen given score 1-5 based on degree of diff of tumour low = 0-6 inter = 7 high = 8-10
screen
?PSA + DRE (40s 2.5, 50s 3, 60s 4, 70s 5)
For: commonest cancer in men, 3% men die of PC
Against: uncertain natural history, PSA not specific
pres >50M LUTS: fill and void Haematuria Weight loss/anorexia/lethargy (advanced metastatic) Bone pain (advanced metastatic) Palpable LNs (advanced metastatic)
ix
PSA (protease responsible for liquefaction of semen - prostate specific not prostate cancer specific)
Normal = 0-4 ng/ml
DRE - hard and irregular prostate
TRUSS + biopsy (infection 1pc serious, bleed, retention, fp)
Abnormal cells in 2 different samples
MRI + CT for staging
Isotope bone scan for metastasis (If PSA > *20)
Testosterone (baseline if considering androgen deprivation)
FBC/LFT - normal
Remember PSMA (prostate specific membrane antigen) and PCA3 in urine
prog
overall good
mgmt
V. LOW RISK
Active surveillance i.e. T1, PSA < 10, Gleason <=6
± brachytherapy (radioactive source to prostate)/external beam radiotherapy (if > 20 year survival)
Check PSA 6M, DRE 12M, biopsy 12M
LOW/INTER RISK
<10Y or > 10Y
Expectant management ± brachytherapy or external beam radiotherapy
HIGH RISK
Low volume: T3/4, PSA > 20, Gleason 8-10
- Radical prostatectomy plus pelvic LN dissection
- External beam radiotherapy (every day M:F 7-8W) + brachytherapy/androgen deprivation (shrinks tumour)
Large volume/fixed
- External beam radiotherapy + brachytherapy/androgen deprivation
comps
Erectile dysfunction - radiation, surgery, androgen deprivation
Hormone induced gynaecomastia (prevent w/ tamoxifen)
Hormone induced hot flush
Radiation induced LUTS for a few weeks + haematuria + bowel bleeding
mgmt for metastatic prostate cancer
80% are androgen sensitive -> castration leads to remission
Androgen deprivation therapy/chemical castration
- Goserelin (GnRH analogue - stimulates then inhibits pituitary gonadotrophin so symptoms may get worse, offer an anti-androgen e.g. flutamide) + tamoxifen + flutamide
Surgical castration - risk of impotence if cut cavernous nerve of penis
if castration resistant
Bisphosphonates/denosumab to reduce pain/treat hypercalcaemia or
Palliative radiotherapy
causes of discoloured urine - pseudohaematuria
myoglobinuria - rhado or muscle destruction
haemoglobulinuria - haemolytic anaemias
beeturia - beetroot
rifampicin
when to worry with haematurias
All frank hematurias are relevant
Symptomatic microscopic hematuria is relevant
Microscopic haematuria = 3 or more RBC/high power field in 2 or 3 samples
50% are idiopathic
> 35yrs worry about GU cancer
what does initial or terminal haematuria indicate
urethra, prostate, seminal vesicles or bladder neck
what does total haematuria indicate
bladder or upper tract (kidney/ureter)
microscopic haematuria causes
Menstruation, cystitis, pyelonephritis, nephrolithiasis, acute prostatitis, BPH, trauma
haematuria ix
Urine dip - protein implies renal Culture - infection DRE - prostate Bloods FBC: Hb/pt Clotting/coagulation studies/INR WCC (infx) PSA Nephrological - eGFR, Cr Imaging USS KUB Flexible cystoscopy Non-contrast CT - stone Contrast CT urogram - excreting for malignancy
catheters
types - pros/cons
indications
comps
Urethral Foley catheter or suprapubic catheter
SPC more comfortable, more convenient change, better self-image, better sexual function
SPC increased risk cellulitis, leakage, prolapse through urethra
NOTE: more painful than ABG or LP!!
indications
Acute urinary retention
Pre-op prophylactic emptying
Monitoring urine output in critically ill patients
Chronic urinary retention (bladder outlet obs)
Management of incontinence (MS, terminal)
comps
Failure e.g. phimosis, BPH (try a larger catheter)
Create false passages
Urethral strictures/perforation/bleeding
Infection (E.coli) bacteriuria is inevitable 5% per day, 50% in one week 100% in one month
UTI RF
Female, sex, spermicide (decrease lactobacilli), pregnancy, decreased host defense (immunosuppression, DM), obstruction, stones, catheter, malformation
UTI organisms
E.coli - 70-95% of uncomplicated
Staph saprophyticus 5-20% (coagulase -ve)
Enterobacteria:
- Proteus mirabilis
- Klebsiella
- Enterococci
- GBS
(note for proteus and kleb = Account for 12% of hospital UTIs
Urease secreting -> form NH3 and raise pH of urine -> precipitate stones (STRUVITE stag horn)
host defence to UTI
Antegrade urine flush (lost in stasis, reflux, preg), low urine pH, Tamm-Horsfall protein (mucopolysaccharide), urinary IgA
define bacteriuria
Bacteria in the urine, may be symptomatic or asymptomatic -> requires Rx in pregnancy due to high risk pyelonephritis
define pyuria
Presence of leucocytes in urine associated with infection
define sterile pyuria
Elevated white cells in urine but cannot culture bacteria using standard techniques (?fastidious organism, recently treated UTI, chlamydia)
reasons for it being comp UTI
Functional impairment Structural impairment Kidney involvement UTI in pregnancy Indwelling catheter Immunosuppressed
UTI ddx
Overactive bladder (-ve dipstick)
Urothelial Ca (positive urine cytology)
Non-infectious urethritis (dysuria in absence of UTI)
STI (discharge) - -ve urine dipstick, analysis and MC+S
Interstitial cystitis - painful bladder syndrome, pain associated with bladder filling + urgency and frequency in absence of UTI
Atypical infx (fungal, adenovirus, TB) may present with recurrent voiding - symptom of sterile pyuria
rough UTI abx guide
Trimethoprim 3 days (in uncomplicated)
Nitrofurantoin 7 days (in pregnancy as trimethoprim is teratogenic)
Men -> ciprofloxacin (500mg orally BD for 1-2 days)
UTI pres
RFs + DUF (dysuria, urgency, frequency)
Haematuria
Back/flank/suprapubic pain
Offensive/cloudy urine
UTI ix
Urine dipstick (nitrites and leukocyte esterase)
Urine microscopy (bacteria, WBC, RBC, epithelial = contamination) -> to confirm org type in complicated UTI or pyelo
*MC + S of MSU (gold standard) > 105 CFU/ml (colony forming units)
Consider
PVR (post void residual >100ml - predispose), renal USS (stone, hydronephrosis, scarring, abscess), cystoscopy (tumour, bladder stones)
UTI mgmt + comp in women
Uncomplicated
No resistance -> trimethoprim or nitrofurantoin
Known or suspected ABX resistance - ciprofloxacin
Complicated
Outpatient + pregnant - nitrofurantoin or cephalexin
Requiring hospitalisation + not pregnant - IV gentamicin
Recurrence
Uncomplicated (Sex related) - post coital trimethoprim/nitrofurantoin oral single dose
Unrelated to sex - prophylactic nitrofurantoin or trimethoprim
comp
renal abscess
UTI causes men
e.coli
but men normally comp so klebsiella + proteus
UTI ix men
Dipstick Urine microscopy Urine culture (>10^2) CT renal tract (perirenal abscess, urinary calculi, tumour) KUB USS (stone, abscess)
UTI mgmt men
Not severe:
As complicated use oral fluoroquinolone (14 days):
Levofloxacin or ciprofloxacin
Severe: use IV
prostatitis cause symps O/E patho rf ix mgmt
cause
e.coli (80%) + enterococcus/pseudomonas
symps
lower abdominal, ejaculatory, rectal and perineal pain
1. Acute prostatitis is painful inflammation of prostate accompanied by evidence of recent or ongoing infection (acute LUTS + fever, chills, malaise)
2. Chronic prostatitis - irritation lasting ≥ 3 months, may be bacterial or abacterial
3. Chronic pelvic pain (prostatodynia)
O/E
warm or soft, exquisitely boggy prostate
patho intraprostatic reflux (urine into prostatic duct)
RF
UTI is single biggest risk factor for developing prostatitis (+ surgery) - catheters, STI
IX
Urinalysis (microscopy - leukocytes, bacteria), urine culture (MSU, MC+S)
Culture of prostatic secretions (by massage)
Blood cultures (important in acute + febrile)
Serum PSA (may be elevated)
STI screen
TRUSS (?prostatic abscess)
MGMT
?Sepsis -> IV taz + gent + NSAID + relief of obstruction + drainage of abscess
No sepsis - fluoroquinolone oral for 2-4 weeks (ciprofloxacin 500mg PO BD) + NSAID + relief of obstruction + drainage of abscess
Chronic - 4/6 weeks ciprofloxacin ± alpha blocker ± NSAID
contents of spermatic cord
ductus deferens artery of ducuts deferens testicular art pampiniform plexus of veins genital branch of genitofemoral nerve sympathetic and visceral afferent nerve lymphatics remnants of the process vaginalis cremasteric art and vein
testicular lump is what
cancer until proven otherwise
acute tender enlargement is what
torsion until proven otherwise
ddx testicular lumps
Separate and cystic
Epididymal cyst
Separate and solid
Epididymitis or varicocele
Testicular and cystic
Hydrocoele
Testicular and solid
Tumour/orchitis
Can’t get above
Inguinal hernia
