Urology P3 Flashcards
What is a hydrocele?
accumulation of fluid in tunica vaginalis
What is a communicating hydrocele?
- patency of processus vaginalis allows peritoneal fluid to drain down into scrotum
- common in newborns and resolve in first few months
What is a non-communicating hydrocele?
excessive fluid production within tunica vaginalis
What can hydroceles be secondary to?
- epididymo-orchitis
- testicular torsion
- testicular tumour
Features of hydrocele:
- soft, non tender swelling of hemi-scrotum (usually anterior and below)
- swelling confined to scrotum, can get ‘above mass’
- transilluminates
- testis may be difficult to palpate if hydrocele large
Investigation and management of hydrocele:
- US if unclear diagnosis
- infantile hydroceles generally repaired if no spontaneous resolve
Most common cause of lower genitourinary tract trauma:
- 85% pelvic fractures
- 10% males pelvic associated with urethras or bladder injuries
Types of urethral injury:
- bulbar rupture
- membranous rupture
Bulbar rupture:
- most common
- straddle type injury e.g. bicycles
- triad: urinary retention, perineal haematoma, blood at meatus
Membranous rupture:
- extra or intraperitoneal
- penile or perineal oedema/haematoma
- PR: prostate displaced upwards
Investigating urethral injury and management:
- ascending urethrogram
- suprapubic catheter (surgical placement)
Features of bladder injury:
- rupture intra or extraperitoneal
- haematuria or suprapubic pain
- inability to retrieve all fluid used to irrigate the bladder through Foley catheter indicates injury
Investigation and management of bladder injury:
- IVU or cystogram
- manage with laparotomy if intraperitoneal
- conservative is extraperitoneal
Examinations for lower urinary tract symptoms in men (voiding, storage, post micturition etc.)
- urinalysis: infection, haematuria
- DRE
- PSA
- urinary frequency-volume chart
- IPSS
Management of voiding symptoms:
- conservative: pelvic floor muscle training, bladder training
- alpha blocker
- 9 alpha reductase inhibitor
- mixed symptoms with alpha blocker unresponsive - antimuscarinic
Management of overactive bladder:
- bladder retraining
- anti-muscarincs: oxybutynin, tollerodine, darifenacin
- mirabegron
Management nocutria:
- furosemide 40mg late afternoon
- desmopressin
Priapism:
- persistent erection >4 hours
- ischaemic: impaired vasorelaxation so reduced vascular outflow - congestion and trapping of deoxygenated blood in corpus cavernosa
- non-ischaemic: high arterial inflow, typically fistula or congenital/traumatic
Causes of priapism:
- idiopathic
- sickle cell disease or other haemalobinopathies
- erectile dysfunction medications (sildenafil, PDE-5 inhibitors)
- drugs: anti-hypertensives, anticoagulants, antidepressants, cocaine, cannabis, ecstacy
- trauma
Investigations priapism:
- cavernosal blood gas analysis: ischaemic - pO2 and pH reduced, pCO2 raised
- doppler or duplex ultrasonography
Management priapism:
- ischaemic = medical emergency: aspiration of blood and saline flush to clear viscous blood, intracavernosal injection of vasoconstrictor e.g. phenylephrine and repeat 5 min intervals
- non-ischaemic: observation
Examination of inguinal hernia:
- cannot get above it
- cough impulse present
- reducible
Examination of testicular tumours:
- discrete testicular nodule (may have associated hydrocele)
- symptoms of metastatic disease
- USS scrotum and serum ADP and bHCG
Examination of acute epidiymo-orchitis:
- dysuria and urethral discharge
- swelling tender and eased by elevating testis
- Chlamydia
Examination of epididymal cysts:
- single or multiple cysts
- clear or opalescent fluid
- over 40yo
- painless
- above and behind testis
- able to get above lump
Examination of hydrocele:
- non painful, soft, fluctuant
- clear fluid
- tranilluminates
- may be presenting feature of cancer in young men
Examination of testicular torsion:
- severe, sudden onset testicular pain
- RF: abnormal testicular lie
- adolescents and young males
- tender and pain not eased by elevation
- urgent surgery indicated, contralateral testis also fixed
Examination of varicocele:
- varicosities of pam-uniform plexus
- typically left (testicular vein drains into renal vein)
- presenting feature of RCC
- affected testis may be smaller and bilateral varicoceles may affect fertility
Management of testicular malignancy:
orchidectomy via inguinal approach: high ligation of testicular vessels and avoids exposure of another lymphatic field to tumour
Management hydrocele:
- children: inguinal approach (processus ligated)
- adults: scrotal approach (sac excised or plicated)
Testicular cancer tumour types:
- 95% germ cell tumours: seminomas and non-seminomas
- non germ cell: Leydig cell tumours, sarcomas
Risk factors testicular cancer:
- infertility
- cryptorchidism
- family history
- Klinefelter’s
- mumps orchitis
Features of testicular cancer:
- painless lump most common
- pain in minority
- hydrocele, gynaecomastia
- raised AFP 60% germ cell
- raised LDH 40% germ cell
- seminomas: hCG raised 20%
Diagnosis of testicular cancer:
ultrasound
Features of seminomas, tumour markers and pathology:
- most common subtype
- AFP normal
- hCG elevated 10%
- LDH elevated 10-20%
- sheet like lobular patterns of cells with substantial fibrous component
- fibrous septa contain lymphocytic inclusions and granulomas
Features of non-seminomas, tumour markers and pathology:
- teratoma, yolk sac tumour, choriocarcinoma, mixed germ cell tumours
- younger age peresntation
- advanced disease worse prognosis
- retroperitoneal lymph node dissection needed after chemotherapy
- AFP raised 70%
- hCG elevated 40%
- heterogenous texture with occasional ectopic tissue e.g. hair
What is TURP syndrome?
- rare, life threatening complication
- irrigation with large volumes of glycine (hypoosmolar) - systemically absorbed when prostatic venous sinuses opened during resection
- hyponatraemia, hyperammonia, visual disturbances
- CNS, resp and systemic symptoms
Risk factors TURP syndrome:
- surgical time >1 hour
- height of bag >70cm
- resected >60g
- large blood loss
- perforation
- large amount of fluid used
- poorly controlled CHF
Causes of urethral strictures:
- iatrogenic
- STI
- hypospadias
- lichen sclerosus
What is a varicocele?
- abnormal enlargement testicular veins
- asymptomatic
- infertility
- more common left
- bag of worms
Diagnosis and management of varicoceles:
- ultrasound with doppler
- usually conservative, occasionally surgery if pain
Vascectomy:
- more effective than female sterilisation
- under LA, home within hours
- doesnt work immediately
- semen analysis twice after before sex (16 and 20 weeks)
- bruising, haematoma, infection, sperm granuloma, chronic testicular pain
- success rate reversal 55% if within 10 years
