Urology Investigations and Management Flashcards
When would you do cystoscopy with LUTS?
If previous urological surgery Haematuria Profound symptoms Pain Recurrent UTIs
What 2 classes of drugs are used in BPH?
Alpha blockers first line e.g. tamsulosin
5-alpha reductase inhibitors e.g. finasteride
What is the main surgical option for BPH?
TURP
Investigations for bladder tumour?
Cystoscopy with biopsy
CT urogram (diagnostic and staging)
Can do urine microscopy or cytology
MRI can show nodal involvement
Management of bladder cancer not invading the muscle.
Diathermy/transurethral resection of bladder tumour (TURBT)
Management of bladder cancer invading muscle.
Radical cystectomy.
Management of stones <5mm in lower ureter.
90-95% pass spontaneously, give fluids.
Alpha blocker
Management of stones >5mm/pain not resolving.
- Extracorporeal shock wave lithotripsy (ESWL)
- Endoscopic retrograde laser evaporation of the stone
Both first line
What are the imaging modalities for staging prostate cancer?
Bone scan
MRI
CT
List potential managements of organ-confined disease
Watchful waiting
Active monitoring
Radical prostatectomy
Radical radiotherapy
List managements of locally advanced prostate cancer
Radiotherapy with neo-adjuvant hormonal therapy (curative)
Watchful waiting
Hormonal therapy (palliative)
List managements of metastatic prostate cancer
- Androgen deprivation therapy (hormone therapy, bilateral subcapusular orchidectomy, maximal androgen blockade)
- Diethylstilbesterol/steroids
- Cytotoxic chemotherapy
What must be done for all patients >40 with frank haematuria?
Cytoscopy
CT urogram
Management of acute urinary obstruction
Catheterisation
Maybe trial without catheter afterwards (give alpha blocker before this)
Investigation and management of post-obstructive diuresis
Monitor fluid balance. Beware if output >200ml/hour
Usually resolves in 24-48 hours but may need IV fluid and sodium replacement
Ureteric colic management
NSAID and maybe opiate
Alpha blocker for small stones expected to pass
Indications to treat ureteric stone urgently
Pain unrelieved
Pyrexia
Persistent nausea/vomiting
High-grade obstruction
Management of acute ureteric stone
Ureteric stent or stone fragmentation/removal
Percutaneous nephrostomy if infected
Clot retention management
3 way catheter
Testicular torsion investigation
Doppler US sometimes helpful
Management of testicular torsion
Prompt exploration (irreversible ischaemic injury may begin as soon as 4 hours) 2-3 point fixation with fine non-absorbable sutures (also contralateral side) If testis necrotic then remove
Management of torsion of appendix testis
Nothing, will resolve spontaneously
Investigation for epididymitis
Doppler US (swollen epididymis, increased bloodflow) Urine culture and chlamydia PCR
Epididymitis management
Analgesia and scrotal support, bed rest
Ofloxacin 400mg/day for 14 days
Management of paraphimosis
Iced glove, granulated sugar for 1-2 hours, multiple punctures in oedematous skin
Manual compression of glans with distal traction of oedematous foreskin
Dorsal slit
Priapism investigation
Aspirate blood from corpus cavernosum (dark, low O2, high CO2 in low flow, normal in high flow)
Colour duplex USS (minimal or absent in low flow, normal to high flow in non-ischaemic)
Ischaemic priapism management
Aspiration and irrigation with saline
Injection of alpha agonist e.g. phenylephrine
Surgical shunt
Unlikely to respond to intracavernosul treatment >48-72 hours
Very delayed may think immediate replacement of penile prosthesis
Non-ischaemic priapism management
Observe, may resolve spontaneously
Selective arterial embolisation with non-permanent materials
Fournier’s gangrene investigation
Plain x-ray or USS may confirm gas in tissues
Fournier’s gangrene management
Antibiotics and surgical debridement
Emphysematous pyelonephritis investigations
KUB x-ray (gas)
CT
Emphysematous pyelonephritis management
Often requires nephrectomy
Perinephric abscess investigation
CT
Perinephric abscess management
Antibiotics
Percutaneous or surgical drainage
Renal trauma imaging indications
Frank haematuria in adults
Frank or occult haematuria in child
Occult haematuria and shock
Penetrating injury with any degree of haematuria
Renal trauma investigation
CT with contrast
Renal trauma management
98% of blunt managed non-operatively
Angiograph/embolisation
Surgery (persistent renal bleeding, expanding perirenal haematoma, pulsatile perirenal haematoma, urinary extravasation, non-viable tissue, incomplete staging)
Bladder injury imaging
CT cystography (if extraperitoneal will have flame shaped collection of contrast in pelvis)
Bladder injury management
Large-bore catheter
Antibiotics
Repeat cystogram in 14 days
If intraperitoneal will need laparotomy
Urethral injury investigation
Retrograde urethrogram
Urethral injury management
Suprapubic catheter
Delayed reconstruction after at least 3 months
Penile fracture management
Prompt exploration and repair
Circumcision incision with degloving of penis to expose all 3 compartments
Testicular injury investigation
USS to assess integrity/vascularity
Testicular injury management
Early exploration/repair
Renal tumour imaging
FBC (renal and liver functions)
USS
CT chest, abdomen and pelvis for staging
Biopsy
Oncocytoma CT appearance
Spoke wheel pattern
Angiomyolipoma USS and CT appearance
USS: bright echo pattern
CT: fatty tumour of low density
Management of angiomyolipoma
Treat after 4cm
Elective: embolisation/partial nephrectomy
Emergency: embolisation/emergency nephrectomy
Renal cell carcinoma management
<3cm: surveillance in elderly unfit patients, ablation techniques in fit elderly patients and selected younger patients
> 3cm: partial nephrectomy (robotic) or radial nephrectomy
Large tumours: radical nephrectomy (laparoscopic approach gold standard)
Follow up from RCC
FBC/renal and liver functions
CT/USS and CXR
Duration 5-10 years
Testicular cancer investigations
USS testicle CT chest and abdomen for staging Serum tumour markers (aFP, b-HCG, LDH) FBC LFTs Kidney function
Testicular cancer management
Radical inguinal orchidectomy (offer sperm preservation, testicular prosthesis)
Re-check tumour markers 1 week post-operative (chase CT scan if still raised)
Further follow up by oncologist (chemo as adjuvant even in non-metastatic cases)
Penile cancer investigation
MRI (assess tumour depth)
CT abdomen, pelvis, chest in advanced disease
Penile cancer management
Circumcision Glans resurfacing Glansectomy Total penile amputation with formation of perineal urethrostomy Inguinal lymphadenectomy
Basic incontinence investigations
Urinalysis (and culture) Bladder diary (frequency/volume chart) Urodynamics: uroflowmetry and cystometry (more invasive)
Urodynamics only if surgery being considered, uncertain of diagnosis, check for voiding dysfunction or if drug treatment for urge has failed
Stress incontinence conservative management
Lifestyle modification
Pelvic floor exercises
Biofeedback
Stress incontinence medication
Duloxetine (SSRI)
Stress incontinence surgical management
Injection of bulking agents
Tension free vaginal tape (or pubovaginal slings)
Burch culposuspension (retropubic suspension, not used as much)
Artificial urinary sphincter
Urge incontinence conservative management
Lifestyle advice
Bladder retraining
Medication (anticholinergics, B-agonists)
Urge incontinence invasive management
Intravesical botulinum toxin A
Neuromodulation
Augmentation “clam” ileocytoplasty
Ileal conduit urinary diversion
