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Phase 4 > Urology > Flashcards

Urology Flashcards

1
Q

What are some 2 week wait criteria in patients presenting with haematuria?

A

Unexplained visible haematuria with no UTI or persisting after treatment for UTI
unexplained visible haematuria >60

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2
Q

What are some causes of haematuria?

A

MIST(e)
Malignancy- of renal (RCC), ureters, bladder, prostate, urethra
Infection- pyelonephritis, ureteric infection, cystitis, prostatitis
Stones- renal stones, ureteric stones, bladder stones
Trauma- bladder and prostate trauma (from catheter), urethral trauma (rrom catheter)
Extra- BPH, rhabdo, beetroot, rifampicin, nephritic syndrome, menstrual blood

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3
Q

A 55 year old man presents to clinic and describes dark coloured urine. What questions are you going to ask him?

A

Onset - when did it start?
Is it intermittent or constant?
Urine colour? has it changed?
Clots in urine?
Mixed with urine or separate?
Timing of haematuria- initially or through stream or at end
Other symptoms- LUTS (frequency, urgency, poor stream, hesistancy, terminal dribbling, nocturia), dysuria, discharge, abdominal pain
Red flag sx: weight loss, night sweats, fevers, fatigue
PMH:
DH: anticoagulants? rifampicin? NSAIDS
SH: smoker, rubber/dye industry, beetroot

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4
Q

A 55 year old man presents to clinic and describes dark coloured urine. You have taken a full history. What examinations and investigations might you do?

A

Examination: Abdo exam, PR exam
Ix:
Bedside: urinalysis and MC&S
Bloods: FBC, U&E, clotting, CRP, group and save, LFTs, PSA, suspect stones- calcium, urate, phosphate
Imaging: dependent on cause eg. stones: non contrast KUB, bladder Ca: flexible cystoscopy

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5
Q

How would you manage an acute presentation of haematuria?

A

ABCDE
Oxygen if sats are low
Bloods- FBC, U&E, clotting, cross-match, LFTs
Blood cultures if feverish
IV NaCl 0.9% - bolus if hypotensive
Transfuse if <70/ <80 with cardiac disease
Correct clotting abnormalities if present
May have to insert 3 way catheter if suspect clot retention to wash out
Stop any anticoagulants

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6
Q

You are working in A&E. A 50 year old woman comes in looking quite unwell. She describes quite severe flank pain and has been feverish. She also is complaining of burning and stinging when going to the toilet and is having to go a lot more. She says she went to the GP for this last week and was given some antibiotics which hasn’t helped. On examination, she’s tachycardia and hypotensive, she looks quite unwell. What is the likely diagnosis and cause?

A

Urosepsis caused by untreated complicated UTI

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7
Q

What are the main causes of urosepsis?

A

Complicated UTI
Infected renal tract stone
Infected tumour
Urological procedures eg. stents/nephrostomy
Neurogenic bladder causing impaired voiding

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8
Q

What are the common organisms of urosepsis?

A

E.coli and proteus mainly!
Klebsiella
Enterobacter

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9
Q

You are working in A&E. A 50 year old woman comes in looking quite unwell. She describes quite severe flank pain and has been feverish. She also is complaining of burning and stinging when going to the toilet and is having to go a lot more. She says she went to the GP for this last week and was given some antibiotics which hasn’t helped. On examination, she’s tachycardia and hypotensive, she looks quite unwell. Given the likely diagnosis , how you are going to manage?

A

urosepsis: sepsis 6
ABCDE assessment
High flow oxygen with non-rebreathe max
IV access and bloods: FBC, U&E, CRP/ESR, clotting, LFTS, VBG- lactate, glucose, blood cultures
IV fluids- NaCl 0.9% 500ml bolus over 15 mins and reassess
IV Antibiotics broad spectrum- according to local guidelines
Measure urine output - may need catheterisation
Investigations:
Bedside: urinalysis and MC&S
Bloods: as above
Imaging: renal tract US or non contrast CT dependent on cause

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10
Q

You are working in A&E. A 45 year old gentleman presents acutely unwell, he is hypotensive and tachycardia on observations. You ask him a bit of a history and he tells you he has had some pain around his genitalia for the last few days that has got a lot worse this morning. You have a look at his genitals and they have erythematous and tender with some blistering noted on inspection. On palpation you can feel some crepitus. PMH: diabetes. What is the likely diagnosis and the cause?

A

Urosepsis caused by Fournier’s gangrene

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11
Q

What is Fournier’s gangrene? What symptoms might you get?

A

Necrotising fasciitis of genitalia/perineum
Painful tender genitalia, signs of sepsis, genitalia might be blue/black due to necrosis, might be crepitus on palpation.

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12
Q

How do you treat urosepsis caused by Fournier’s gangrene?

A

A->E assessment and sepsis 6
High flow oxygen with non-rebreathe max
IV access and bloods: FBC, U&E, CRP/ESR, clotting, LFTS, VBG- lactate, group and save, glucose, blood cultures
IV fluids- NaCl 0.9% 500ml bolus over 15 mins and reassess
IV Antibiotics broad spectrum- according to local guidelines
Measure urine output - may need catheterisation
Patient NBM
Definitive: immediate debridement of necrotic tissue !

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13
Q

Mike has BPH and is awaiting a TURP operation. A week before the operation, Mike becomes unable to pass urine and is describing considerable abdominal pain. On examination he has a palpable distended urinary bladder. What is the diagnosis? and what investigation can you do to confirm it?

A

Acute urinary retention

Confirm with bladder ultrasound

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14
Q

What are some causes of acute urinary retention?

A 
Urological: prostate cancer, BPH , urethral stricture/calculus, UTI, blood clot retention  
Drugs: anticholingergics, opiates, TCAs
Post-operatively
GI: constipation, infection 
Neuro: cauda equina, multiple sclerosis
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15
Q

What symptoms may you get in a patient with acute urinary retention/what do you need to ask about in history?

A 
Suprapubic pain 
Anuria/oliguria
LUTS eg. urgency, hesitancy 
Restless 
Ask about haematuria (clot retention), painless (chronic) v painful, dysuria , red flags of cauda equina- back pain, leg weakness, saddle anaesthesia, incontinence.
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16
Q

Mike has BPH and is awaiting a TURP operation. A week before the operation, Mike becomes unable to pass urine and is describing considerable abdominal pain. On examination he has a palpable distended urinary bladder. Bladder US confirms acute urinary retention. What is the immediate management? What will be given specific to Mike since he has BPH?

A

ABCDE
Urinalysis- MC&S and dipstick
Bloods- FBC, U&E, CRP/ESR, LFTs, PSA
Urethral catheterisation and drain bladder
Record residual volume of urine
Treat BPH: tamsulosin and treat other causes eg. abx for UTI, laxatives for constipation
Then TWOC- trial without catheter and monitor for recurrence of sx

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17
Q

Mike has just been admitted for acute urinary retention secondary to BPH and has been treated appropriately. You have tried to TWOC him but he has had recurrence of symptoms after that as well as his bladder having a residual volume of >1L. What is the likely diagnosis?

A

Chronic urinary retention.

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18
Q

Why is low pressure Chronic urinary retention less worrying than high pressure chronic urinary retention?

A

high pressure causes renal failure

low pressure- neurological, treat as acute urinary retention

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19
Q

What does high pressure chronic urinary retention mean?

A

Consistent high pressure in storage and voiding

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20
Q

What is the most common complication of high pressure chronic urinary retention?

A

Renal failure

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21
Q

What is the most common cause of high pressure chronic urinary retention?

A

Prostatic obstruction

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22
Q

What symptoms and signs may you expect with a patient with high pressure chronic urinary retention?

A

PAINLESS
Incontinence- particularly at night
LUTS eg. dribbling
Renal failure- ankle oedema, SOB

Signs: palpable distended bladder, DRE: enlarged prostate

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23
Q

How would you manage a patient with high pressure chronic urinary retention?

A

Bedside: urinalysis, bladder US
Bloods: FBC, U&E, LFTs, PSA
Imaging: US KUB- assess for hydronephrosis Catheterisation and drainage (if acute on chronic- pain, anuria). Monitor urine output
Refer to urology: TURP if prostate, intermediate self catheterisation, long term catheter

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24
Q

Can patients with high pressure chronic urinary retention have a TWOC?

A

No- they will just have symptoms again and worsen their renal failure

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25
Q

A 13-year old male presents to A&E with a swollen painful left testicle. The pain came on suddenly. He has vomited once.
On examination, his testicle is swollen and hot to touch.
What is the likely diagnosis?
What else do you want to do in your examination?

A

Testicular torsion
Cremasteric reflex- stroke inner thigh and testicle doesnt rise in torsion
Prehn’s sign negative - lifting testicle doesnt’ relieve pain

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26
Q

How can you differentiate epidymo-orchitis from testicular torsion?

A

Difficult but Prehn’s sign will be positive and may have fevers and other signs of infection

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27
Q

What else might you see on examination of the testicles in testicular torsion?

A

Testes lying horizontally - bell clapper deformity

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28
Q

How will you manage a boy with testicular torsion?

A

A to E assessment
Bloods: FBC, U&E, CRP, group and save, clotting
Urine dipstick
IV fluids if needed
NBM
Analgesia- IV morphine + IV cyclising
do not delay surgery!- needs within 6h - urgent surgical exploration of testes- untwist to reperfuse. If viable: orchidopexy bilaterally, if not viable: orchidectomy and orchidopexy of other scrotum

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29
Q

A boy has testicular torsion but surgery is not available until 8 hours. What are you going To do?

A

Manually detort it if surgery >6h but then will need surgery.

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30
Q

A 18 year old man presents to A&E with a gradual onset swollen and painful scrotum. He also is feeling quite feverish and has noticed some increased frequency of urination and burning and stinging on urination. On examination you see a red, hot , swollen scrotum which is tender to touch. The cremasteric reflex is present and Prehn’s sign is positive. He is a sexually active young man. What is the likely diagnosis and what are the two main causes of this?

A

Epididymo-orchitis

Causes: STIs, UTIs

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31
Q

How would you manage epidiymo-orchitis?

A

Bedside: urinalysis (rule out UTI), first void urine for NAAT - rule out STI
Bloods: FBC, U&E, CRP
Treatment: treat the cause: UTI- ciprofloxacin, STI- doxycycline + ceftraixone
Analgesia

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32
Q

A young lad around 16 years old comes in with a painful penis. He has no other symptoms. You examine him and see the foreskin is pulled back and there is a lot of oedema of the penis. The penis is slightly discoloured as well. He said he recently had to have a catheter put in due to a serious infection. What is the likely diagnosis and what are some risk factors?

A

Paraphimosis- foreskin retracted and left behind the glans causing oedema of glans penis
RF: tight foreskin (phimosis), recent catheter use.

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33
Q

How do you treat paraphimosis?

A

If not ischaemic: manual reduction with topical lidocaine eg. ice in towel
If ischaemic: surgery
Circumcision to prevent recurrence

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34
Q

A 50 year old man comes into A&E due to an erection that has lasted almost 6 hours now and is unwanted. It is very painful now and on examination looks very rigid. He tells you he takes viagra regularly as he needs it now. What is the diagnosis?

A

Priapisim- low flow as painful

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35
Q

What is the difference between low flow and high flow priapism? RF, symptoms and investigations

A

Low flow: vascular occlusion. RF- sildenafil etc, sickle cell disease. Sx: painful, rigid erection. Ix: cavernous sinus aspiration: dark red, hypoxic blood
high flow: arterial occlusion. RF- blunt trauma. Sx: painless, semi-rigid erection. Ix: cavernous sinus aspiration: bright red, oxygenated blood.

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36
Q

A 50 year old man comes into A&E due to an erection that has lasted almost 6 hours now and is unwanted. It is very painful now and on examination looks very rigid. He tells you he takes viagra regularly as he needs it now. Cavernous sinus aspiration shows dark red, hypoxic blood confirming the diagnosis of low flow priapism. What is your management?

A

emergency!, call urologist
Needs cooling with ice packs + analgesia + antibiotics
surgery for aspiration and washout of corpus cavernousum with injection of phenylephrine

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37
Q

A 50 year old man comes into A&E due to an erection that has lasted almost 6 hours now and is unwanted. It is painless and on examination is semi-rigid. He has had some trauma to the area recently. Cavenous sinus aspiration shows bright red, oxygenated blood. What is the diagnosis and management?

A

High flow priapism

Management is conservative- analgesia, Abx.

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38
Q

You are the F1 doctor in A&E. A 40 year old man has come in with severe flank pain that is radiating to his groin, He feels very nauseaus and has vomited once. You take a history and he says he has peed blood this morning. His obs are stable at the moment, slightly tachycardic due to pain. He has no allergies. What is the likely diagnosis and what is the best investigation to diagnose this?

A

Renal tract stones

Non contrast CT KUB

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39
Q

What investigation would you do if the patient was pregnant or <16 years old? in renal tract stones?

A

USS KUB

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40
Q

The nurse comes to get you asking for your help urgently while you’re ordering the CT KUB for a patient you suspect has renal stones. She says his NEWS have rapidly increased – temp is now 39, HR is 120, RR 25. You go and see him and he is shaking and breathing very fast, he looks unwell.
What might this add to your diagnosis?

A

Infected stone

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41
Q

What are the 3 most common sites for renal tract stones?

A
  1. PUJ- pelvic ureteric junction
  2. Where the ureters cross the iliac vessels
  3. VUJ- vesicoureteric junction - where ureters enter bladder
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42
Q

What are the commonest composite types of renal tract stone?

A

Calcium oxalate
Uric acid
Struvite
Calcium phosphate

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43
Q

What are some risk factors for renal tract stones?

A

Dehydration –> supersaturation of urine
High salt/ purine diet eg. red meats
Gout - for uric acid stones
Renal tubular acidosis
Male
Congenital abnormalities of kidney eg. horshoe kidney
Genetics

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44
Q

What is the most common organism causing struvite stones and what would you see on X ray?

A

Proteus

X ray: staghorn calculus

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45
Q

What investigations would you do in a patient with renal tract stones?

A

Bedside: urine dipstick -haematuria, MC&S if dysuria
Bloods: FBC, U&E, LFTs, Calcium, phosphate, uric acid , clotting
Imaging: CT non contrast KUB

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46
Q

Why is X ray not the gold standard in renal tract stones?

A

Not all stones show up - uric acid stones are radiolucent

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47
Q

What is the immediate management for renal tract stones?

A 
ABCDE 
IV fluids 
Analgesia- PR/PO diclofenac
Anti-emetics 
Investigations as before
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48
Q

The nurse comes to get you asking for your help urgently while you’re ordering the CT KUB for a patient you suspect has renal stones. She says his NEWS have rapidly increased – temp is now 39, HR is 120, RR 25. You go and see him and he is shaking and breathing very fast, he looks unwell.
How are you going to manage this now given the diagnosis?

A

Infected stone
A to E assessment
Sepsis 6 - BUFALO: blood cultures and bloods - lactate, IV fluids, IV antibiotics (broad spectrum), oxygen
Drainage in surgery- stent/nephrostomy

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49
Q

You have diagnosed your patient with renal stones. non contrast CT KUB has confirmed the stone to be 3mm and the patient is feeling fine. What is going to be your management?

A

Watchful waiting and can give tamsulosin to help.

50
Q

You have diagnosed your patient with renal stones. non contrast CT KUB has confirmed the stone to be 8mm. What is going to be your management?

A

Extracorpeal shockwave lithotripsy (ESWL)

If that doesnt work: uteroscopy and stone removal

51
Q

You have diagnosed your patient with renal stones. non contrast CT KUB has confirmed the stone to be 15mm. What is going to be your management?

A

> 10mm, <20mm: Percutaneus coronary nephrolithiotomy (PCNL)

52
Q

You have diagnosed your patient with ureteric stones. non contrast CT KUB has confirmed the stone to be 3mm and distal. What is going to be your management?

A

<5mm and distal:
Conservative- analgesia, wait and give tamsulosin
If this doesnt work: ESWL

53
Q

You have diagnosed your patient with ureteric stones. non contrast CT KUB has confirmed the stone to be 8mm and proximal. What is going to be your management?

A

Extracorpeal shockwave lithotripsy (ESWL)

if large: rigid utersocopy

54
Q

68 year old male attends A&E after an episode of syncope. In his history he describes new onset back and R flank pain and one episode of vomiting
PMH: HTN, hypercholesterolaemia, PVD, renal stones
DH: bisoprolol, atorvastatin, ramipril, clopidogrel
Obs: sats 98%, RR 24, HR 93, BP 98/76, temp 36.7
What is the diagnostic investigation?

A

CT angio

This is a triple A rupture! can present similarly to renal tract stones

55
Q

What is the most common histology of renal cancer?

A

RCC: adenocarcinoma

56
Q

What is the most common renal cancer in children?

A

Wilms tumour/nephroblastoma

57
Q

What symptoms and signs may you see with a patient with renal cancer?

A

Abdo mass
Abdo/loin pain
Haematuria
B sx: weight loss, night sweats, fatigue, loss of appetite
Mets: bone pain/fractures, haemopytsis (lung)

58
Q

What investigations might you do in a patient with renal cancer?

A

Bedside: urinalysis- haematuria
Bloods: FBC, U&E, Calcium, LFTs, clotting
Imaging: Ultrasound , definitive: CT abdo pelvis

59
Q

What is the classic CXR sign of renal cancer metastasis?

A

cannonball mets

60
Q

What are the most common risk factors for bladder calculi?

A

Chronic urinary retention - BPH, prostate cancer
UTIs
Long term catheter

61
Q

How do bladder calculi present?

A

Abdo pain
LUTS- frequency, urgency, nocturia, weak stream
Haematuria
UTIs

62
Q

How would you investigate bladder calculi?

A

Bedside: urine dip and MC&S
Bloods: FBC, U&E, CRP, Calcium
Imaging: US, X ray
Special: flexible cystoscopy!

63
Q

A 65 year old man presents complaining of blood in his urine. He can see the fresh red blood when he urinates and has some lower back pain but no pain of urinating. On direct questioning he says he thinks he has lost weight in the last few weeks and does feel a lot more tired than usual but puts it down to stress. He smokes every day and has done since he was 18, he used to work in the dye industry. Given the likely diagnosis, what investigations do you want to do?

A

Painless visible haematuria- think bladder cancer if risk factors
Bedside: urine dipstick and MC&S
Bloods: FBC, U&E, CRP, LFTs, clotting
Imaging: US KUB, CT KUB with contrast.
Special tests: flexible cystoscopy with biopsy.
CT for staging of cancer

64
Q

What are the two most common histologies of bladder cancer?

A

Transitional cell carcinoma = most common UK

Squamous cell carcinoma- most common worldwide

65
Q

What are some risk factors for bladder cancer?

A 
Smoking 
Rubber/dye industry 
Caucasian 
Age
Chronic cystitis and catheterisation 
Shistosomiasis- SCC
66
Q

What staging system is used for bladder cancer and what level is muscle invasive?

A

TNM

T2 and over- muscle invasive

67
Q

How can you treat non-muscle invasive bladder cancer? (below T2)

A

TURBT- transurethral resection of the bladder tumour

And chemotherapy- intravesical BCG

68
Q

How can you treat muscle invasive bladder cancer? (above and including T2)

A

Radical cystectomy with ileal conduit dieversion

If can’t have surgery: radical radiotherapy / chemotherapy

69
Q

What are the two zones of the prostate called? which zone has the increased risk of cancer?

A

Peripheral zone- makes up most of the prostate
Transitional zone - surrounds the urethra
Increased risk in peripheral zones

70
Q

Name the LUTS symptoms

A

Storage: frequency, urgency, nocturia, incontinece
Voiding: weak steam, hesitancy, terminal dribbling, incomplete emptying

71
Q

What else would you ask in a history with a patient presenting with LUTS symptoms?

A 
All the LUTS sx- voiding and storage 
Haematuria 
Dysuria 
Any suprapubic/abdominal pain?
Red flags: bone pain, weight loss, night sweats, fatigue, loss of appetite 
Bowel symptoms? 
UTIs?
PMH: malignancy, prostate issues 
DH: anticholinergics, diuretics 
SH: caffeine, smoking , alcohol
72
Q

A 50 year old man with a history of well controlled diabetes presents to clinic complaining of increased urinary frequency and urgency. He says there has bee na few times where he has been incontinent. On direct questioning he says it does take him a while to get his stream going and sometimes it doesnt reach the bowl. These symptoms started a couple of months ago and have been getting worse. He denies weight loss, bone pain or night sweats. He has a PMH of diabetes well controlled on metformin and takes no medications. He doesn’t smoke or drink alcohol. Given the likely diagnosis, what will be your next steps in management?

A

Bedside- DRE (BPH: soft enlarged prostate), urine dipstick and MC&S. Pre and post void bladder scan to rule out retention.
Bloods: FBC, U&E, CRP, LFTs, PSA! (ideally before DRE), HbA1c and blood glucose
Imaging: US of prostate if suspect retention/raised PSA
Special tests: flow studies, frequency-volume chart and diary, international prostate system score

73
Q

You have diagnosed your patient with BPH. He would like medical treatment as his symptoms are really interfering with his life. What treatment will you offer and what lifestyle advice will you give?

A

Conservative: reduce alcohol and caffeine, bladder diary, review medications eg diuretics, treat any constipation /diabetes
Medical: alpha blockers- tamsulosin, 5alpha reductase inhibitors- finasteride

74
Q

What are the main side effects of tamsulosin and finasteride (1 each)

A

Tamsulosin: postural hypotension
Finasteride: ED (reduces conversion of testosterone)

75
Q

You are reviewing a patient who was diagnosed with BPH 6 months ago. He was started on tamsulosin then and recently has added finasteride (last 3 months) as his sx were uncontrolled. His symptoms are still uncontrolled and he is desperate for some treatment. What treatment option can you offer?

A

TURP- transurethral resection of the prostate

76
Q

Your patient is recovering on the ward well after his TURP. However today you have been bleeped by the nurses because he is unwell. He is complaining of nausea and has vomited a few times, he is also saying his vision is blurry and seems a bit confused as to where he is and who people are. What is the likely diagnosis? How are you going to treat?

A 
TURP syndrome- rapid absorbing of the irrigation solution used leads to fluid overload and hyponatraemia. 
Tx:
A to E assessment
Oxygen
Careful hypertonic saline 
IV furosemide for fluid overload
77
Q

A 50 year old man with a history of well controlled diabetes presents to clinic complaining of increased urinary frequency and urgency. On direct questioning he says it does take him a while to get his stream going and sometimes it doesn’t reach the bowl. These symptoms started a couple of months ago and have been getting worse. He has noticed blood in his urine on occasion. He also has noticed some weight loss over this time and says his back in particularly has been very painful. He has a PMH of diabetes well controlled on metformin and takes no medications. He doesn’t smoke or drink alcohol. Given the likely diagnosis, what will be your next steps in management?

A

Bedside: DRE (prostate cancer: hard irregular craggy prostate), urine dipstick and MC&S
Bloods: FBC, U&E, LFTs, clotting, PSA!
Imaging: MRI prostate (localised) and transrectal prostate biopsy
CT abdo pelvis for staging

78
Q

What can PSA be falsely raised in?

A 
Recent ejaculation 
Run to test
Recent catheterisation 
BPH 
UTI 
Prosatatitis
79
Q

What is the most common histological type of prostate cancer?

A

Adenocarcinoma

80
Q

What grading system is used in prostate cancer?

A

Gleason grading. Risk stratification: PSA, Gleason grade and clinical stage

81
Q

You have diagnosed your patient with prostate cancer. After discussion with the urologists and investigation the patient is deemed to have low risk disease due to a low grade and stage. What management options can be offered?

A

Active surveillance - low grade and stage

6 monthly DRE

82
Q

You have diagnosed your patient with prostate cancer. After discussion with the urologists and investigation the patient is deemed to have moderate-high risk disease due to a higher grade and stage. It is a localised cancer. What management options can be offered?

A

Radical prostatectomy.

if unfit for surgery: radical radiotherapy

83
Q

You have diagnosed your patient with prostate cancer. After discussion with the urologists and investigation the patient is deemed to have high risk disease due to a higher grade and stage. Unfortunately it is also metastatic. What management options can be offered?

A

Hormonal: androgen deprivation therapy with LHRH agonists eg. goserilin (overstimulates the testes to stop producing testosterone) or LHRH antagonists eg. degarelix (if severe sx of mets).
Other options: chemotherapy, radiotherapy

84
Q

What questions are you going to ask a patient who has presented with a scrotal lump?

A 
Where is it? 
When did you first notice it? 
Did it come on suddenly or gradually?
Any pain associated with it? In scrotum or in back/abdo 
What does it feel like? Does it feel hot? swollen? 
Have you tried pushing it down to see what happens?
Any LUTS? 
Any dysuria ?
Any haematuria?
Systemic: fevers? weight loss, appetite 
Any trauma to the area
Any skin changes noticed? 
Any discharge?
85
Q

The patient presents with a scrotal lump. You can get above it, it arises from the body of the scrotum and it doesnt transilluminate. What could this be?

A

Testicular tumour

86
Q

The patient presents with a scrotal lump. You can get above it, you feel a diffuse swelling through the scrotum and it transilluminates. What could this be?

A

Hydrocele

87
Q

The patient presents with a scrotal lump. You can get above it, you feel a diffuse cystic swelling through the scrotum and it transilluminates. What could this be?

A

Epididymal cyst

88
Q

The patient presents with a scrotal lump. You cannot get above it, the mass feels separate to the scrotum and it doesnt transilluminate. What could this be?

A

Inguinal hernia

89
Q

A 21 year old male presents to clinic with a new lump he’s felt in his scrotum. He says its been there for a month now and is painless. He has come today because it has become his scrotum has become swollen. You feel the lump and you can get above it and it is fluctuant and soft and transilluminates. He has had some weight loss recently and been off his food.
Him and his partner have been struggling to conceive for 2 years.
PMHx: cryptorchidism
What is the likely lump diagnosis and underlying diagnosis?

A

Hydrocele secondary to a testicular tumour

90
Q

What investigation do you need to do in a young man presenting with a hydrocele?

A

Ultrasound! to rule out testicular tumour

91
Q

How do you manage a hydrocele?

A

Rule out testicular tumour
Conservative measures
If heavily symptomatic- surgery

92
Q

What is the common cause of hydrocele in infants?

A

Patent processes vaginalis

93
Q

How do you treat a hydrocele in infants?

A

Surgery if doesn’t resolve by age 2

94
Q

A young man comes in complaining of a lump in his left scrotum. He says it aches a bit but it is not acutely painful. He says when he feels it , it feels like a bag of worms. He has had no other symptoms and feels well in himself. Given the likely diagnosis, what treatment are you going to offer?

A

Varicocele
Conservative treatment at the moment.
If troubled by pain: surgical ligation

95
Q

What is the cause of varicocele?

A

Dilation of testicular veins

96
Q

A 50 year old man comes in complaining of a new lump in his scrotum. It is not acutely painful but it is uncomfortable. He has had no other symptoms and feels well in himself. On examination, you can get above the lump and the lump feels soft smooth and spherical. It does transilluminate. What is the diagnosis?

A

Epididymal cyst

97
Q

How do you manage a epididymal cyst?

A

conservative- usually no treatment needed

Surgical excision - if they become large/ painful

98
Q

A 50 year old man presents to GP with a new lump in his scrotum. He says its painless but he notices it more when he coughs or strains. On examination, you cannot get above the lump, it feels like it’s sat above the testes and it doesn’t transilluminate. Testing for cough impulse causes it to protrude more. PMH: chronic constipation. What is the diagnosis and which type is it?

A

Inguinal hernia- direct because re-herniates on cough impulse (cover the deep inguinal ring, get them to cough and re-herniates)

99
Q

How are you going to treat an inguinal hernia?

A

Conservative first- weight loss, high fibre diet, treat constipation and cough, stop smoking
If it is big/lots of symptoms: surgery

100
Q

You have tried conservative management with the 50 year old man that you diagnosed with an inguinal hernia. However he presents to A&E in 3 days time complaining of severe pain. He says the lump is tender to touch and no longer can push it down. He is feeling very nauseas and his abdomen looks distended. What has happened now and how are you going to manage it?

A

Strangulation of inguinal hernia- twists and cuts off blood supply to intestine.
Management:
ABCDE
Nil by mouth and IV fluids (dip and suck)
Analgesia + cyclizine
Bloods- FBC, U&E, LFTs, CRP, glucose, amylase, G&S
Imaging: Abdo XR (bowel obstruction)
Needs urgent surgery

101
Q

What is the inguinal canal?

A

Pathway that allows structures to pass from the abdomen wall to the external genitalia via the deep and superficial inguinal rings

102
Q

What is the difference between a direct and indirect inguinal hernia?

A

Direct: protrudes straight through due to the defect in posterior wall of inguinal ring. RF: constipation, cough etc
Indirect: protrudes via the deep inguinal ring. Cx: congenital

103
Q

A 55 year old woman comes to clinic as she has noticed this new lump in her groin. It is very small and not painful. She has had no other symptoms at all. On examination, it’s sat lateral and inferior to the pubic tubercle. What is the likely diagnosis?

A

Femoral hernia

104
Q

How do you manage a femoral hernia?

A

Needs surgical repair regardless as a higher risk of strangulation and obstruction compared to inguinal

105
Q

Where do inguinal hernias sit in relation to the pubic tubercle?

A

Superior and medial

106
Q

A 30 year old male presents with a painless lump in his right testicle. He has had it for a few months and says it feels quite hard now. On examination, the lump feels hard and irregular within the scrotum and is non-transilluminable. You can get above the lump. He has also had some shortness of breath and back pain in the last few months too.
Him and his partner have been struggling to conceive for 2 years.
PMHx: cryptorchidism
What is the likely diagnosis and what investigations do you want to do?

A

Testicular cancer
Bloods: FBC, U&E, LFTs, tumour markers- to monitor: beta HCG, LDH, alpha fetoprotein
Imaging: ULTRASOUND testes . CT chest, abdo and pelvis for staging. CXR: lung mets

107
Q

What are some risk factors for testicular cancer?

A 
Cryptoorchidism- undescended testes
Family history of testicular cancer
Previous history of testicular cancer
Infertility 
HIV infection
108
Q

What are the two main types of testicular cancer? Who do they affect?

A

Seminomas (germ cell tumours): middle aged men. most common.
Non-seminomas (germ cell tumours): younger (20-30s)- worse prognosis

109
Q

How do you treat testicular cancer?

A

Radical orchidectomy- removal of testicle

IF metastatic: radiotherapy and chemotherapy too with lymph node dissection if affected

110
Q

What are the main 3 complications of undescended testes?

A

Infertility
Malignancy
Testicular torsion

111
Q

What are some causes of erectile dysfunction? (5)

A

Chronic diseasee: diabetes, peripheral vascular disease, HTN, neurological disease eg. stroke, MS
Psychological: relationship difficulties, anxiety , depression
Iatrogenic: medication- antipsychotics, antidepressants and surgery eg. post prostate surgery
Hormonal: androgen deficiency, hypo/hyperthyroidism
Pain

112
Q

What bloods might you do in a patient with ED?

A

Bloods: FBC, U&E, LFTs, TFTs, testosterone, FSH and LH, prolactin, glucose, lipid

113
Q

How do you manage erectile dysfunction?

A

Conservative: reducing weight, improving diet and physical activity
Pyschosexual therapy
Medication:
1. PDE5 inhibitor- sildenafil or tadalafil
2. injectable prostaglandins eg. alprostadil
Non-medical:
Penile/scrotal rings, vacuum erection devices
Prosthetic implants to keep penis rigid

114
Q

A 50 year lady has come to clinic complaining of urinary incontinence. What questions would you like to ask her?

A

When did it start?
Has it been getting worse?
What are the exact symptoms- rushing to get to toilet or feeling urgency?
Pain?
Dysuria?
Haematuria?
Nocturia?
Ever been incontinent?
Are the symptoms worsened by anything? eg. coughing
Bowels?
Tried anything to help?
Obstetric history- had children? how was delivery?
Post-menopausal?
Any trauma to area?
Rule out retention- when was their last wee?
If man: LUTS
PMH: uro/gynae surgery, pelvis radiotherapy, diabetes? constipation or chronic cough?
DH: anticholinergics , diuretics
SH: alcohol, caffeine, smoking

115
Q

A 50 year lady has come to clinic complaining of urinary incontinence. You have taken a full history from her. What investigations would you like to do?

A

Bedside: urinalysis- urine dipstick and MC&S. Men: DRE. Women: pelvic exam
Bloods: FBC, U&E, LFTs, glucose, CRP. Men: PSA
Imaging: post void bladder scan- rule out retention.
Urodynamic testing - can help confirm diagnosis- only for complicated cases

116
Q

A 50 year lady has come to clinic complaining of urinary incontinence. You have taken a full history from her and you find out she is having episodes of leaking into her underwear particularly on exertion for example if she coughs or sneezes. She has never been fully incontinent. She has no dysuria, haematuria or pain. She has had 3 children all vaginal delivery with no issues and is now post-menopausal. What is the likely diagnosis and how will you manage?

A

Stress urinary incontinence
Mx:
Conservative: incontinence pads, weight loss if necessary, stop smoking , caffeine and alcohol reduction, medication review
1. Pelvic floor training
2. Duloxetine - SNRI or pseudoephedrine
3. surgical - tape or intra-urethral bulking agents

117
Q

A 50 year lady has come to clinic complaining of urinary incontinence. You have taken a full history from her and find out she is having episodes where she feels like she immediately needs to wee and has to run to the toilet. There have been 2 instances where she has not made it to the toilet in time. She is going a lot more frequently, particularly at night. There is no dysuria, haematuria or pain. What is the diagnosis and what are the options for management?

A

Urge incontinence
Conservative: incontinence pads, weight loss if necessary, stop smoking , caffeine and alcohol reduction, meds review
1. Bladder training
2. Oxybutinin - anticholinergic
3. neuromodulation- sacral/tibial nerve stimulation
Botulin toxin injection

118
Q

A pregnant woman has had a routine urine dipstick and MC&S (2 samples) which have both shown positive cultures and leukocytes. She has no symptoms at present. Do you treat? If so- with what?

A

Yes- they have a higher risk of pyelonephritis

Treat with nitrofurantoin (unless at term) or amoxicillin for 7 days.

119
Q

A man with a catheter in situ due to urinary retention has found to have positive cultures and leukocytes on routine urine dipstick and MC&S. He doesnt have any symptoms. Do you treat?

A

No - do not treat asymptomatic bacteriuria in those with catheters

120
Q

A young woman aged 25 years old comes to A&E. She looks very unwell and is complaining of severe lower back pain. She also has had fevers and shakes which have all started this morning. Additionally she tells you she has been having some stinging and burning on urinating for the past day and has been having to go more often than usual. She has no other symptoms, no haematuria. She has a PMH of diabetes, well controlled on insulin. Given the diagnosis, What investigations would you want to do on this lady?

A

Pyelonephritis
Bedside: urinalysis- dipstick and MC&S. Abdominal examination
Bloods: FBC, U&E, CRP, LFTs, blood cultures!
Imaging: may do USS to rule out hydronephrosis

121
Q

A young woman aged 25 years old comes to A&E. She looks very unwell and is complaining of severe lower back pain. She also has had fevers and shakes which have all started this morning. Additionally she tells you she has been having some stinging and burning on urinating for the past day and has been having to go more often than usual. She has no other symptoms, no haematuria. She has a PMH of diabetes, well controlled on insulin. You have asked for a set of obs which show a low BP and some tachycardia. Given the diagnosis, how will you treat this lady?

A

ABCDE
IV access and take bloods
IV fluids - 500ml bolus NaCl first and then regular
IV antibotics broad spectrum eg. co-amoxiclav (cefalexin if pregnant)
Anaglesia and anti-emetics
Catheterise

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