Urology intro lecture Flashcards
Renal colic.
a) Presentation
b) Stones composition
c) Emergency indications
d) Emergency management
e) Non-emergency management
f) Risk factors
a) Pain (worse than childbirth,
b) Calcium oxalate (visible on XR), uric acid, struvite
c) Infected-obstructed system (sepsis), AKI
d) External drainage (nephrostomy), internal drainage (stent)
e) Lithotripsy, watch and wait (most common)
f) Past history of stones, metabolic (e.g. hyperPTH)
Testicular torsion.
a) Incidence peaks
b) Symptoms
c) Signs
d) Differentials
e) How to rule out differentials
f) Why does it happen?
g) Management
a) Neonates. Pre-pubescent boys (when testes begin to enlarge and descend: age 14 - 20; very rare above 30)
b) Pain (may be referred to abdomen), nausea and vomiting
c) Tenderness, loss of cremasteric reflex, horizontal lie and high-riding testicle
d) Epididymo-orchitis, torsion of appendix testis (blue dot, often found in theatre), trauma
e) Sexual history, history of trauma, MMR jab, urine dipstick (UTI)
f) Bell-clapper deformity (freely-moving testes; usually bilateral), exercise, trauma, intercourse-related
g) Orchidopexy (if viable; usually bilateral), orchidectomy if non-viable
Haematuria.
a) Similar
b) Types
c) Causes
d) Ix
a) Rhabdomyolisis, beetroturia
b) Visible (macroscopic), microscopic
c) Infection (UTI), ureteric stones, malignancy (bladder, kidney, other urological), coagulopathy
d) Urine dip, USS KUB (gross tumours, hydronephrosis), cystoscopy. If all negative - CT scan to assess ureters, or even ureteroscopy
Urinary retention.
a) Acute vs chronic
b) Normal bladder volume pre-micturition
c) Issues in retention
d) Causes
e) Management
f) Types of catheters
g) Ix
a) Acute (very painful), Chronic (painless)
b) ~ 300ml
c) High-pressure retention (hydronephrosis and AKI), infection
d) Obstructions (BPH, prostate tumour, pelvic stuff - malignancy, fibroids), post-anaesthetic, constipation, neurological (MS, cord compression, etc. - be especially worried in young women)
e) Catheterise
f) Indwelling urethral/suprapubic catheter, intermittent self-catheterisation, free-flow vs valve catheters
g) Ix: Urine dip, UEs and creatinine, CT KUB, USS, plain abdo XR, MRI spine if worried about neurology
Urological emergencies
- what are urologists woken up for in the night?
- Difficult catheter (?acute retention)
- Acute scrotum
- Infected-obstructed kidney
- Certain cases of haematuria - clot-induced retention, symptomatic anaemia
Retention.
a) Acute (painful) - 2 types
b) Chronic (painless) - 2 types
c) Management of chronic high pressure retention
a) - Spontaneous - majority (eg. BPH, strictures)
- Precipitated - eg. general anaesthetic, UTI, abdominal surgery, drugs
(patients usually get discomfort at bladder volumes > 600mls in acute; but in chronic retention may hold much more without pain)
b) - Low pressure - more common, can progress to acute-on-chronic
- High pressure - causes hydronephrosis and renal failure (check creatinine); may have night-time bed-wetting
c) Catheterise, long-term - drugs, TURP
- Can NOT have a TWOC
Management.
- Catheterise
- Bladder scan, check residual volume
- Rectal exam
- Bloods - U+Es, ?serum PSA
- Monitor urine output - if >200mls/hr, need further monitoring and IV fluids. If < 200mls/hr, may be TWOC’ed and discharged
TWOC.
a) How to do
b) Why should it not be done for high pressure chronic retention
a) - Send home with tamsulosin
b) - Retention will recur if you take catheter out
- They will then go back into renal failure
- Instead, they need TURP or long-term catheter
Catheterisation.
a) Most common
b) 3-way - explain
c) When are females difficult?
d) When might males be difficult?
e) Tips for making males easier
a) Two-way Foley (one lumen to inflate balloon, one to drain urine):
- 14 - most common in males
- 12 - most common in females
b) - Three-way catheters are available with a third channel to facilitate continuous bladder irrigation or for instillation of medication
- Used for bladder/prostate tumours and/or where there is clot-induced retention* or other debris to irrigate and clear - reduces risk of developing further clots
*Need bladder washout to get rid of current clots
c) - Atrophic vaginitis
- Very fat
- Obstetric
d) - Phimosis
- Scrotal/penile oedema
- Urethral strictures (beware of crunching sensation or any blood)
- Prostate tumours
e) - Curved tip and more rigid catheter
- Catheterise penis in 2nd gear (aiming more superiorly) rather than 1st gear to avoid false passage (these are usually inferior to bladder)
- More lube
- Better penis gripping - like a pint glass, not a wine glass
- Better positioning, move fat/hernia/fluid out of the way
- Get patient to cough
Frank haematuria/ clot retention: management
- 3 way catheter
- Bladder wash out to break down clots - do this until urine runs clear
- Continuous irrigation to prevent further clot formation
- Stop anticoagulation
- TxA not generally recommended as this will make larger clots which are harder to pass - unless they have life-threatening haematuria
Torsion
a) Symptoms
b) Signs
c) Management
a) Acute… testicular pain, abdo pain, nausea/vomiting, etc
b) - LOSS of cremasteric reflex
- Absent Prehn’s sign* (Elevation Eases Epididymitis)
- Horizontal lie, bell clapper
- Redness , black (?necrotic!)
*Rubbish sign for torsion - don’t let it dictate management
c) - Call urologist!
- Bilateral orchidopexy
Infected-obstructed urinary system*: management
- Infected urine (UTI) with a blockage (eg. stone) - usually presents as pyelonephritis/urosepsis in patient with known obstruction
- Sepsis 6
- Decompression - percutaneous nephrostomy or
- HDU/ITU
Penile fracture.
a) What is ‘fractured’?
b) Causes
c) Signs
a) Tunica albuginea - covering of the corpora cavernosa
b) Vigorous intercourse (more common in position where man is not in control) or masturbation
c) Pain, swelling, popping sound, urethral injury, aubergine sign
Fournier’s gangrene.
a) What is it?
b) Risk factors
c) Management
d) Prognosis
a) - Nec fasc of the perineum
- Rapidly evolving infection that spreads across fascial planes (flesh-eating bacteria)
b) Diabetes, immunosuppression, indwelling catheters
c) - Sepsis 6
- Urgent urological assessment
d) Approx. 50% mortality
Priapism.
a) Define
b) Risk factors
c) Management
a) - Acutely painful erection lasting > 4 hours
b) - Sickle cell
c) - Analgesia
- Call urologist
- They will aspirate blood +/- phenylephrine injection
- If these fail - surgery
