Urology fifth yr

Question 1

Summary of acute bacterial prostatitis?

Answer 1

typically caused by gram-negative bacteria entering the prostate gland via the urethra.

E. coli most common

RF’s - recent UTI, urogenital instrumentation, intermittent bladder catheterisation, recent prostate biopsy

Sx - referred pain to perineum, penis, rectum, back, obstructive voiding Sx, fever, rigours, DRE - tender, boggy prostate

Tx - 14 days of quinolone, screen for STIs

Question 2

Summary of acute urinary retention?

Answer 2

most common urological emergency

when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine

common in men, rare in women. increases with age

Causes - BPH, urethral strictures, calculi, cystocele, constipation or masses. Medications (anticholinergics, TCAs, antihistamines, opioids, BDZs), can also be neuro cause, after UTI, post-op and post partum too

Sx - inability to pass urine, lower abdominal discomfort, pain/distress, acute confusion in elderly pt’s

O/E - palpable distended urianry bladder (on abdo or rectal), lower abdo tenderness, do rectal and neuro exam to assess for cause! women have pelvic exam

Differs from chronic urinary retention which is typically painless. Acute on chronic urinary retention may present as overflow incontinence

Ix - urine MC&S, urine catheterisation, U&Es, FBC, CRP

Tx - bladder ultrasound, catheterisation (measure urine in 15 minutes), depending on cause referral to appropriate specialist

Complications - post-obstructive diuresis - kidneys increase diuresis due to loss of medullary concentration gradient and takes time to re-equilibrate. Lead to volume depletion and worsening of AKI. May need IV fluids to correct this temporarily

Question 3

Summary of balanitis?

Answer 3

inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis

most common causes = infective (bacterial + fungal), AI

candidiasis - after intercourse, itching, white non-urethral discharge - treat with topical clotrimazole for 2 wks
dermatitis (contact or allergic) - itchy, painful, clear non-urethral discharge - mild corticosteroid
dermatitis (eczema or psoriasis) - itchy, no discharge, Hx of inflammatory skin condition
bacterial - painful, itchy, yellow non-urethral discharge, Staph spp. - oral fluclox. or clarithromycin
Anaerobic - itchy, very offensive yellow non-urethral discharge - topical or oral metronidazole if washing not helping
Lichen Planus - itchy, Wickhams striae, violaceous papules
Lichen sclerosus - balanitis xerotica obliterans - itchy, white plaques, significant scarring - high potency topical steroids (clobetasol), circumcision
plasma cell balanitis of Zoon - non itchy, clearly circumscribed areas of inflammation - clobetasol
Circinate balanitis - non itchy, no discharge, painless erosions, associated with reactive arthritis - mild corticosteroid

Ix - clinical diagnosis, swab for MC&S, biopsy in extensive cases

Tx - hygiene (saline washes, washing under foreskin) 1% hydrocortisone if severe irritation

Question 4

Risk factors for BPH?

Answer 4

age
around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms
around 80% of 80-year-old men have evidence of BPH

ethnicity: black > white > Asian

Question 5

Sx of BPH?

Answer 5

Voiding Sx (obstructive) - weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying

Storage Sx - urgency, frequency, urgency incontinence, nocturia

Post-micturition - dribbling

Complications - UTI, retention, obstructive uropathy

Question 6

Ix for BPH?

Answer 6

Urinalysis

U&Es - esp. if chronic retention suspected

PSA - if obstructive Sx, or concerns about prostate ca

urine frequency-volume chart - for 3 days

IPSS - >20 severely symptomatic

Question 7

Management of BPH?

Answer 7

watchful waiting

alpha-1 antagonists - tamsulosin, alfuzosin - decreases smooth muscle tone of prostate and bladder - first-line - SE = dizziness, postural hypotension, dry mouth, depression

5 alpha-reductase inhibitors - finasteride - block conversion of testosterone to dihydrotestosterone, which is known to induce BPH - indicated if signicantly large prostate and high risk of progression - causes reduction in prostate volume and hence may slow disease progression - Sx may not improve for 6m - can decrease PSA concentrations up to 50% - SE = ED, reduced libido, ejaculation problems, gynaecomastia

use of both if moderate to severe voiding Sx and prostatic enlargement

if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried

Surgery - TURP

Question 8

Epidemiology of bladder cancer?

Answer 8

second most common urological cancer

males aged between 50 and 80 years of age.

benign tumours - inverted urothelial papilloma and nephrogenic adenoma are uncommon

Question 9

RFs for bladder cancer?

Answer 9

TCC:
Smoking
Exposure to aniline dyes (printing and tactile industry)
Rubber manufacture
Cyclophosphamide

SCC:
Schisosomiasis
Smoking

Question 10

Types of bladder malignancies?

Answer 10

Urothelial (transitional cell) carcinoma (>90% of cases)

Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)

Adenocarcinoma (2%)

Question 11

Sx of bladder cancer?

Answer 11

painless, macroscopic haematuria

Question 12

Ix and Tx of bladder cancer?

Answer 12

cystoscopy and biopsies or TURBT
pelvic MRI
CT scanning for distant disease
PET CT for unknown nodes

TNM staging

Tx:
Superifical lesions - TURBT - transurethral resection of bladder tumour
Recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy
T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy

Question 13

Summary of chronic urinary retention?

Answer 13

Painless and insidious

High pressure retention - impaired renal function, bilateral hydroneprhosis, typically due to BOO

Low pressure retention - normal renal function, no hydronephrosis

Decompression haematuria occurs commonly after catheterisation for chronic retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment.

Question 14

Summary of circumcision?

Answer 14

performed in a variety of cultures - Jewish and Islamic.

Medical benefits of routine circumcision - reduces risk of: penile cancer, UTI, acquiring STIs

Medical indications for circumcision - phimosis, recurrent balanitis, balanitis xerotica obliterans, paraphimosis

Need to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair.

Circumcision may be performed under a local or general anaesthetic.

Question 15

Summary of epididymal cysts?

Answer 15

most common cause of scrotal swellings seen in primary care.

Sx - separate from body of testicle, found posterior to testicle

Associated conditions - polycystic kidney disease, CF, von Hippel-Lindau syndrome

Dx - USS

Question 16

Summary of epididymo-orchitis?

Answer 16

an infection of the epididymis +/- testes resulting in pain and swelling

Commonly from local spread of infection from genital tract (Chlamydia or Gonorrhoea in younger pt’s) or bladder (E. coli in older adults)

Sx - unilateral testicular pain and swelling, urethral discharge may be present - need to exclude testicular torsion!!

Ix - younger - STI screen, older - MC&S

Tx -
STI - refer to clinical, if unknown organism - IM ceftriaxone + PO doxycycline
Enteric organism - oral quinolone for 2 weeks (SE - tendon damage/rupture, lower seizure threshold)

Question 17

Summary of erectile dysfunction?

Answer 17

persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

Symptom - not a disease

Causes - organic, psychogenic, mixed

Factors favouring organic - gradual onset, lack of tumescence, normal libido

Factors favouring psychogenic - sudden onset, decreased libido, good quality spontaneous or self-stimulated erections, major life events, problems in relationship, previous psychological problems, Hx of premature ejaculation

RFs - increasing age, CVD (obesity, DM, dyslipidaemia, metabolic syndrome, HTN, smoking), alcohol use, drugs (SSRIs, beta-blockers)

Ix - have 10-year CVD risk calculated, free testosterone in AM, if low - repeat with FSH, LH, and prolactin - if abnormal, refer to endocrinology

Tx
PDE-5 inhibitors
Vacuum erection devices if can’t take PDE-5 inhibitor
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop

Question 18

Summary of hydrocele?

Answer 18

describes the accumulation of fluid within the tunica vaginalis

communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis

Secondary to: epididymo-orchitis, testicular torsion, testicular tumours

Sx - soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle, you can get ‘above’, transilluminates, testes difficult to palpate if large

Dx - clinical, or US if in doubt or underlying testes cannot be palpated

Tx - infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour

Question 19

Causes of unilateral hydronephrosis?

Answer 19

PACT

Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

Question 20

Causes of bilateral hydronephrosis?

Answer 20

SUPER

Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis

Question 21

Ix and Tx of hydronephrosis?

Answer 21

Ix
US - identifies presence of hydronephrosis, assesses kidney
IVU - assess position of obstruction
Antegrade or retrograde pyelography- allows treatment
if suspect renal colic: CT scan (majority of stones are detected this way)

Tx:
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: nephrostomy tube
Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty

Question 22

Summary of lower genitourinary tract trauma?

Answer 22

Mostly due to blunt trauma. 85% associated with pelvic fractures

Urethral injury
mainly in males, blood at meatus, 2 types
bulbar rupture - most common, straddle type injury e.g. bicycles, triad signs: urinary retention, perineal haematoma, blood at the meatus
Membranous rupture - extra/intraperitoneal, commonly due to pelvic fracture, penile or perineal oedema/haematoma, PR - prostate displaced upwards
Ix - ascending urethrogram
Tx - suprapubic catheter - surgical placement, not percutaneously

External genitalia injuries - secondary to penetration, blunt trauma, devices, mutilation

Bladder injury
rupture is intra or exztraperitoneal
haematuria or suprapubic pain
Hx of pelvic fracture and inability to void - always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through Foley catheter indicates bladder injury
Ix - IVU or cystogram
Tx - laparotomy if intraperitoneal, conservative if exztraperitoneal

Question 23

3 groups of LUTS?

Answer 23

Voiding - hesitancy, poor/intermittent stream, straining, incomplete emptying, terminal dribbling

Storage - urgency, frequency, nocturne, urinary incontinence

Post-micturition - dribbling, sensation of incomplete emptying

Question 24

Summary of nephroblastoma?

Answer 24

Wilms tumour
Usually presents in first 4 years of life
May often present as a mass associated with haematuria (pyrexia may occur in 50%)
Often metastasise early - usually to lung
Treated by nephrectomy
Younger children = better prognosis

Question 25

Summary of priapism?

Answer 25

persistent penile erection, typically defined as lasting longer than 4 hours and is not associated with sexual stimulation.

ischaemic or non-ischaemic
Ischaemic priapism is typically due to impaired vasorelaxation and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within the corpus cavernosa.
Non-ischaemic priapism is due to high arterial inflow, typically due to fistula formation often either as the result of congenital or traumatic mechanisms.

bimodal distribution - 5-10yrs and 20-50yrs

Causes - idiopathic, sickle cell disease or other haemoglobinpathies, ED medication, drugs (antihypertensives, anticoagulants, antidepressants, and recreational - cocaine, cannabis, ecstasy), trauma

Sx - persistent erection over 4 hours, pain localised to penis, history of either known haemoglobinopathy or use of medications listed above, non-painful erection or erection not fully rigid is indicative of non-ischemic priapism,Hx of trauma also indicative of non-ischaemic priapism

Ix - Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
Doppler/duplex USS
FBC
Toxicology screen

Tx
- ischaemic is emergency - can lead to permanent tissue damage and long-term ED
If the priapism has lasted longer than 4 hours, the first-line treatment is aspiration of blood from the cavernosa, this is often combined with injection of a saline flush to help clear viscous blood that has pooled.
If aspiration and injection fails, then intracavernosal injection of a vasoconstrictive agent such as phenylephrine is used and repeated at 5 minute intervals.
If medical therapy fails then surgical options can be considered.
- non-ischaemic - not medical emergency so observation first-line option

Question 26

Features of prostate cancer?

Answer 26

Localised - often symptomatic as develop in periphery and hence don’t cause obstructive Sx early on

Bladder outlet obstruction - hesitancy, urinary retention

Haematuria, haemotspermia

Pain - back, perineal, testicular

DRE - asymmetrical, hard, nodular enlargement with loss of median sulcus

Mets - bone pain

Question 27

RFs for prostate cancer?

Answer 27

increasing age
obesity
Afro-Caribbean ethnicity
family history: around 5-10% of cases have a strong family history

Question 28

Investigation of prostate cancer?

Answer 28

First line - multi parametric MRI

Previous first line was TRUS biopsy (complications - sepsis, pain, fever, haematuria, rectal bleeding)

PSA - men aged 50-69 years should be referred if the PSA is >= 3.0 ng/ml OR there is an abnormal DRE

Question 29

Management of prostate cancer?

Answer 29

Treatment depends on life expectancy and patient choice. Options include:
conservative: active monitoring & watchful waiting (elderly, multiple comorbidities, low Gleason score)
radical prostatectomy
radiotherapy: external beam and brachytherapy

Localised advanced disease - hormonal therapy, radical prostatectomy (SE = ED), radiotherapy (external beam, brachytherapy - SE = proctitis, increased risk of bladder, colon and rectal cancer)

Metastatic prostate cancer - hormonal therapy - reducing androgen levels

Anti-androgen therapy:
synthetic GnRH agonist (Goserelin) - reduce LH long term by causing overstimulation, initial therapy covered by anti-androgen to prevent tumour flare
GnRH antagonists (degarelix) - suppress testosterone, avoiding tumour flare
Bicalutamide - non-steroidal anti-androgen, blocks androgen receptor
Cyproterone acetate - steroidal anti-androgen, prevents DHT binding from intracytoplasmic protein complexes
Abiraterone - androgen synthesis inhibitor
Bilateral orchidectomy

Chemo with docetaxellder

Question 30

Causes of raised PSA?

Answer 30

Prostate cancer

benign prostatic hyperplasia (BPH)

prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)

ejaculation (ideally not in the previous 48 hours)

vigorous exercise (ideally not in the previous 48 hours)

urinary retention

instrumentation of the urinary tract

Question 31

Pathophysiology of prostate cancer?

Answer 31

95% adenocarcinoma

70% lie in periphery

Graded using the Gleason grading system, two grades awarded 1 for most dominant grade (on scale of 1-5) and 2 for second most dominant grade (scale 1-5). The two added together give the Gleason score. Where 2 is best prognosis and 10 the worst.

Lymphatic spread occurs first to the obturator nodes and local extra prostatic spread to the seminal vesicles is associated with distant disease.

Question 32

Summary of renal cell cancer?

Answer 32

hypernephroma and accounts for 85% of primary renal neoplasms

arises from proximal renal tubular epithelium

most common subtype - clear cell

associations - middle-aged men, smoking, von Hippel-Lindau syndrome, tuberous sclerosis, slight increase in ADPKD

Features - triad (haematuria, loin pain, abdominal mass), pyrexia od unknown origin, endocrine effects (EPO secretion, PTHrp - hypercalcaemia, renin, ACTH), 25% mets at presentation, varicocele (L sided, caused by tumour compressing veins), Stauffer syndrome (paraneoplastic syndrome, presents as cholestasis/hepatosplenomegaly, secondary to increased levels of IL-6)

TNM staging

Tx
confined disease - partial or total nephrectomy depending on tumour size
alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases
receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha

Question 33

Types of renal stones?

Answer 33

Calcium oxalate (85%) - hypercalciuria major RF, hyperoxaluria, stones radio-opaque - variable urine

Cystine - inherited recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestine and renal tubule, multiple stones, radio dense - normal urine - semi opaque, ground glass appearance

Uric acid - product of purine metabolism, precipitate when urinary pH is low, may be caused by diseases with extensive tissue breakdown (e.g., malignancy), common in children with inborn errors of metabolism, radiolucent! - acid urine

Calcium phosphate - occur in renal tubular acidosis, high urinary pH, RTA type 1 and 3 increase risk of stone formation, radio-opaque - normal-alkaline urine

Struvite - magnesium, ammonium, phosphate, result of urease producing bacteria (so associated with chronic infections), under alkaline conditions crystals can precipitate, slightly radio-opaque - alkaline urine - stag horn calculi

Xanthine - radiolucent

Question 34

RFs for renal stones?

Answer 34

dehydration
hypercalciuria, hyperparathyroidism, hypercalcaemia
cystinuria
high dietary oxalate
renal tubular acidosis
medullary sponge kidney, polycystic kidney disease
beryllium or cadmium exposure

For urate stones - gout, ileostomy (loss of bicarb and fluid = acidic urine)

Drug causes
- calcium stones - loop diuretics, steroids, acetazolamide, theophylline
- thiazides - prevent calcium stones (as increase distal tubular calcium resorption)

Question 35

Management of renal stones?

Answer 35

NSAID - parenteral analgesic (e.g., IM diclofenac)

<5mm pass spontaneously within 4 weeks - lithotripsy and nephrolithotomy for severe cases

if ureteric obstruction, renal development abnormality (horseshoe kidney), previous renal transplant = more intensive and urgent Tx

ureteric obstruction and infection = surgical emergency = needs decompression - nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement

stone burden of less than <2cm in aggregate = lithotripsy

stone burden of less than <2cm in pregnant females = lithotripsy is contraindicated, so ureteroscopy!! - stent can be left in situ for 4 weeks after the procedure

complex renal calculi and stag horn calculi - percutaneous nephrolithotomy - access gained to renal collecting system. then intra corporeal lithotripsy or stone fragmentation is performed

ureteric calculi less than 5mm = manage expectantly

Question 36

Prevention of renal stones?

Answer 36

Calcium stones due to hypercalciuira = high fluid intake, low animal protein, low salt diet, thiazide diuretics

Oxalate stones = cholestyramine, pyridoxine

Uric acid stones = allopurinol, urinary arlkalinization (.e.g. oral bicarbonate)

Question 37

Ix of renal stones?

Answer 37

Urine dipstick + culture
Serum creatinine and electrolytes - checking renal function
FBC/CRP - any associated infection
Calcium/urate - look for underlying causes
Clotting - if percutaneous intervention planned
Blood cultures - if pyrexial or signs of sepsis

CT KUB within 14 hours on all pt’s
If fever, solitary kidney or uncertain diagnosis - immediate CT KUB

Question 37

Ix of renal stones?

Answer 37

Urine dipstick + culture
Serum creatinine and electrolytes - checking renal function
FBC/CRP - any associated infection
Calcium/urate - look for underlying causes
Clotting - if percutaneous intervention planned
Blood cultures - if pyrexial or signs of sepsis

CT KUB within 14 hours on all pt’s
If fever, solitary kidney or uncertain diagnosis - immediate CT KUB

Question 38

Summary of varicocele?

Answer 38

an abnormal enlargement of the testicular veins - pampiniform plexus

usually asymptomatic

associated with infertility + RCC

Sx - more common on left side (as testicular vein drains into renal vein), ‘bag of worms’, subfertility

Ix - US with doppler studies

Tx - conservative, surgery if causing pain

Question 39

Summary of vasectomy?

Answer 39

Male sterilisation

failure rate: 1 per 2,000 - more effective than female sterilisation

can be done under LA (some GA)

doesn’t work immediately

semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 12 weeks)

complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)

the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years

Question 40

Causes of urethral stricture?

Answer 40

iatrogenic e.g. traumatic placement of indwelling urinary catheters

sexually transmitted infections

hypospadias

lichen sclerosus

Question 41

Summary of TURP syndrome?

Answer 41

are and life-threatening complication of transurethral resection of the prostate surgery

caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection
results in hyponatraemia
when glycine broken down by liver > hyper-ammonia and visual disturbances

Sx - CNS, respiratory and systemic symptoms

RFs - surgical time >1hr, height of bag >70cm, resected >60g, large blood loss, perforation, large amount of fluid used, poorly controlled CHF

Question 42

Summary of testicular torsion?

Answer 42

twist of the spermatic cord resulting in testicular ischaemia and necrosis.

most common in males aged between 10 and 30 (peak incidence 13-15 years)

Sx - pain severe, sudden onset, referred to lower abdomen N+V

O/E - swollen, tender testis retracted upwards. skin may be reddened. cremasteric reflex is lost. elevation of testis does not ease pain (Phrens sign)

Tx - urgen surgical exploration - if touted testis, then both testis should be fixed as bell clapper testis often B/L

A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position

Question 43

Summary of testicular cancer?

Answer 43

most common malignancy in men aged 20-30 years.

95% are germ cell tumours - these are divided into seminomas (hCG raised in 20%) and non-seminomas (embryonal, yolk sac, teratoma, choriocarcinoma) (AFP and/or b-hCG elevated in 80-85%) - LDH raised in 40% of germ cell tumours

Non-germ cell tumours - Leydig cell tumours and sarcomas

Question 44

RFs for testicular cancer?

Answer 44

infertility (increases risk by a factor of 3)
cryptorchidism
family history
Klinefelter’s syndrome
mumps orchitis

Question 45

Sx of testicular cancer?

Answer 45

a painless lump is the most common presenting symptom

pain may also be present in a minority of men

hydrocele

gynaecomastia
this occurs due to an increased oestrogen:androgen ratio
germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
leydig cell tumours → directly secrete more oestradiol and convert additional androgen precursors to oestrogens

Question 46

Ix and Tx of testicular cancer?

Answer 46

Ix - USS

Tx
treatment depends on whether the tumour is a seminoma or a non-seminoma
orchidectomy
chemotherapy and radiotherapy may be given depending on staging and tumour type