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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
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?
Testicular torsion Cremasteric reflex- stroke inner thigh and testicle doesnt rise in torsion Prehn's sign negative - lifting testicle doesnt' relieve pain
26
How can you differentiate epidymo-orchitis from testicular torsion?
Difficult but Prehn's sign will be positive and may have fevers and other signs of infection
27
What else might you see on examination of the testicles in testicular torsion?
Testes lying horizontally - bell clapper deformity
28
How will you manage a boy with testicular torsion?
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
29
A boy has testicular torsion but surgery is not available until 8 hours. What are you going To do?
Manually detort it if surgery >6h but then will need surgery.
30
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?
Epididymo-orchitis | Causes: STIs, UTIs
31
How would you manage epidiymo-orchitis?
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
32
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?
Paraphimosis- foreskin retracted and left behind the glans causing oedema of glans penis RF: tight foreskin (phimosis), recent catheter use.
33
How do you treat paraphimosis?
If not ischaemic: manual reduction with topical lidocaine eg. ice in towel If ischaemic: surgery Circumcision to prevent recurrence
34
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?
Priapisim- low flow as painful
35
What is the difference between low flow and high flow priapism? RF, symptoms and investigations
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.
36
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?
emergency!, call urologist Needs cooling with ice packs + analgesia + antibiotics surgery for aspiration and washout of corpus cavernousum with injection of phenylephrine
37
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?
High flow priapism | Management is conservative- analgesia, Abx.
38
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?
Renal tract stones | Non contrast CT KUB
39
What investigation would you do if the patient was pregnant or <16 years old? in renal tract stones?
USS KUB
40
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?
Infected stone
41
What are the 3 most common sites for renal tract stones?
1. PUJ- pelvic ureteric junction 2. Where the ureters cross the iliac vessels 3. VUJ- vesicoureteric junction - where ureters enter bladder
42
What are the commonest composite types of renal tract stone?
Calcium oxalate Uric acid Struvite Calcium phosphate
43
What are some risk factors for renal tract stones?
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
44
What is the most common organism causing struvite stones and what would you see on X ray?
Proteus | X ray: staghorn calculus
45
What investigations would you do in a patient with renal tract stones?
Bedside: urine dipstick -haematuria, MC&S if dysuria Bloods: FBC, U&E, LFTs, Calcium, phosphate, uric acid , clotting Imaging: CT non contrast KUB
46
Why is X ray not the gold standard in renal tract stones?
Not all stones show up - uric acid stones are radiolucent
47
What is the immediate management for renal tract stones?
``` ABCDE IV fluids Analgesia- PR/PO diclofenac Anti-emetics Investigations as before ```
48
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?
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
49
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?
Watchful waiting and can give tamsulosin to help.
50
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?
Extracorpeal shockwave lithotripsy (ESWL) | If that doesnt work: uteroscopy and stone removal
51
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?
>10mm, <20mm: Percutaneus coronary nephrolithiotomy (PCNL)
52
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?
<5mm and distal: Conservative- analgesia, wait and give tamsulosin If this doesnt work: ESWL
53
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?
Extracorpeal shockwave lithotripsy (ESWL) | if large: rigid utersocopy
54
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?
CT angio | This is a triple A rupture! can present similarly to renal tract stones
55
What is the most common histology of renal cancer?
RCC: adenocarcinoma
56
What is the most common renal cancer in children?
Wilms tumour/nephroblastoma
57
What symptoms and signs may you see with a patient with renal cancer?
Abdo mass Abdo/loin pain Haematuria B sx: weight loss, night sweats, fatigue, loss of appetite Mets: bone pain/fractures, haemopytsis (lung)
58
What investigations might you do in a patient with renal cancer?
Bedside: urinalysis- haematuria Bloods: FBC, U&E, Calcium, LFTs, clotting Imaging: Ultrasound , definitive: CT abdo pelvis
59
What is the classic CXR sign of renal cancer metastasis?
cannonball mets
60
What are the most common risk factors for bladder calculi?
Chronic urinary retention - BPH, prostate cancer UTIs Long term catheter
61
How do bladder calculi present?
Abdo pain LUTS- frequency, urgency, nocturia, weak stream Haematuria UTIs
62
How would you investigate bladder calculi?
Bedside: urine dip and MC&S Bloods: FBC, U&E, CRP, Calcium Imaging: US, X ray Special: flexible cystoscopy!
63
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?
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
What are the two most common histologies of bladder cancer?
Transitional cell carcinoma = most common UK | Squamous cell carcinoma- most common worldwide
65
What are some risk factors for bladder cancer?
``` Smoking Rubber/dye industry Caucasian Age Chronic cystitis and catheterisation Shistosomiasis- SCC ```
66
What staging system is used for bladder cancer and what level is muscle invasive?
TNM | T2 and over- muscle invasive
67
How can you treat non-muscle invasive bladder cancer? (below T2)
TURBT- transurethral resection of the bladder tumour | And chemotherapy- intravesical BCG
68
How can you treat muscle invasive bladder cancer? (above and including T2)
Radical cystectomy with ileal conduit dieversion | If can't have surgery: radical radiotherapy / chemotherapy
69
What are the two zones of the prostate called? which zone has the increased risk of cancer?
Peripheral zone- makes up most of the prostate Transitional zone - surrounds the urethra Increased risk in peripheral zones
70
Name the LUTS symptoms
Storage: frequency, urgency, nocturia, incontinece Voiding: weak steam, hesitancy, terminal dribbling, incomplete emptying
71
What else would you ask in a history with a patient presenting with LUTS symptoms?
``` 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
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?
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
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?
Conservative: reduce alcohol and caffeine, bladder diary, review medications eg diuretics, treat any constipation /diabetes Medical: alpha blockers- tamsulosin, 5alpha reductase inhibitors- finasteride
74
What are the main side effects of tamsulosin and finasteride (1 each)
Tamsulosin: postural hypotension Finasteride: ED (reduces conversion of testosterone)
75
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?
TURP- transurethral resection of the prostate
76
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?
``` 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
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?
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
What can PSA be falsely raised in?
``` Recent ejaculation Run to test Recent catheterisation BPH UTI Prosatatitis ```
79
What is the most common histological type of prostate cancer?
Adenocarcinoma
80
What grading system is used in prostate cancer?
Gleason grading. Risk stratification: PSA, Gleason grade and clinical stage
81
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?
Active surveillance - low grade and stage | 6 monthly DRE
82
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?
Radical prostatectomy. | if unfit for surgery: radical radiotherapy
83
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?
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
What questions are you going to ask a patient who has presented with a scrotal lump?
``` 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
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?
Testicular tumour
86
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?
Hydrocele
87
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?
Epididymal cyst
88
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?
Inguinal hernia
89
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?
Hydrocele secondary to a testicular tumour
90
What investigation do you need to do in a young man presenting with a hydrocele?
Ultrasound! to rule out testicular tumour
91
How do you manage a hydrocele?
Rule out testicular tumour Conservative measures If heavily symptomatic- surgery
92
What is the common cause of hydrocele in infants?
Patent processes vaginalis
93
How do you treat a hydrocele in infants?
Surgery if doesn't resolve by age 2
94
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?
Varicocele Conservative treatment at the moment. If troubled by pain: surgical ligation
95
What is the cause of varicocele?
Dilation of testicular veins
96
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?
Epididymal cyst
97
How do you manage a epididymal cyst?
conservative- usually no treatment needed | Surgical excision - if they become large/ painful
98
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?
Inguinal hernia- direct because re-herniates on cough impulse (cover the deep inguinal ring, get them to cough and re-herniates)
99
How are you going to treat an inguinal hernia?
Conservative first- weight loss, high fibre diet, treat constipation and cough, stop smoking If it is big/lots of symptoms: surgery
100
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?
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
What is the inguinal canal?
Pathway that allows structures to pass from the abdomen wall to the external genitalia via the deep and superficial inguinal rings
102
What is the difference between a direct and indirect inguinal hernia?
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
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?
Femoral hernia
104
How do you manage a femoral hernia?
Needs surgical repair regardless as a higher risk of strangulation and obstruction compared to inguinal
105
Where do inguinal hernias sit in relation to the pubic tubercle?
Superior and medial
106
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?
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
What are some risk factors for testicular cancer?
``` Cryptoorchidism- undescended testes Family history of testicular cancer Previous history of testicular cancer Infertility HIV infection ```
108
What are the two main types of testicular cancer? Who do they affect?
Seminomas (germ cell tumours): middle aged men. most common. Non-seminomas (germ cell tumours): younger (20-30s)- worse prognosis
109
How do you treat testicular cancer?
Radical orchidectomy- removal of testicle | IF metastatic: radiotherapy and chemotherapy too with lymph node dissection if affected
110
What are the main 3 complications of undescended testes?
Infertility Malignancy Testicular torsion
111
What are some causes of erectile dysfunction? (5)
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
What bloods might you do in a patient with ED?
Bloods: FBC, U&E, LFTs, TFTs, testosterone, FSH and LH, prolactin, glucose, lipid
113
How do you manage erectile dysfunction?
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
A 50 year lady has come to clinic complaining of urinary incontinence. What questions would you like to ask her?
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
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?
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
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?
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
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?
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
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?
Yes- they have a higher risk of pyelonephritis | Treat with nitrofurantoin (unless at term) or amoxicillin for 7 days.
119
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?
No - do not treat asymptomatic bacteriuria in those with catheters
120
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?
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
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?
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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