Urology - Passmedicine Flashcards
What are causes of scrotal swellings?
Inguinal hernia Testicular tumours Acute epididymo-orchtis Epididymal cysts Hydrocele Testicular torsion Variocele
What does an inguinal hernia present like?
Inguinoscrotal swelling (can’t get above it)
Cough impulse may be present
May be reducible
How do testicular tumours tend to present?
Discrete testicular nodules
What investigations are required in suspected testicular tumour?
USS scrotum
Serum AFP
bHCG
How does acute epididymo-orchitis tend to present?
Hx dysuria, urethral discharge
Swelling may be tender + eased by elevating testis
What causes most cases of epididymo-orchitis?
Chlamydia
At what age are epididymal cysts more common?
> 40 years
How do epididymal cysts tend to present?
Painless cyst above and behind the testis (may contain clear/opalescent fluid)
Usually possible to get above the lump
How does a hydrocele present?
Non-painful, soft, fluctuant swelling
Can get above it
Contains clear fluid + will transilluminate
What may a hydrocele be a presenting feature of?
Testicular cancer in young men
How does testicular torsion present?
Severe, sudden onset testicular pain Usually in a young male O/e testis is tender and pain not eased by elevation (Prehn's sign), swollen, tender testis is retracted upward, skin may be reddened Pain may be referred to lower abdomen NV
What are risk factors for testicular torsion?
Abnormal testicular lie
How is testicular torsion managed?
Urgent surgery
Contralateral testis also fixed
What is a variocele?
Varicosities of the pampiniform plexus
Where do varioceles typically occur and why?
On the left (as the testicular vein drains into the renal vein)
What can a variocele be a presenting feature of?
Renal cell carcinoma
Do varioceles affect fertility?
They can if they are bilateral
How is testicular malignancy treated?
Orchidectomy via inguinal approach - allows high ligation of testicular vessels + avoids exposure of another lymphatic field to the tumour
How can torted testicles be fixed?
Sutures or placement of the testis in a Dartos pouch
How are varioceles managed?
Usually conservatively
If concerns about testicular function/infertility then surgery/radiological management may be considered
How can epididymal cysts be excised?
Via scrotal approach
How are hydroceles managed?
In children (pathology is due to patient processus vaginalis + so) inguinal approach to ligate processus is used
In adults a scrotal approach is preferred + the hydrocele sac is excised/plicated (Lords or Jabouley procedure)
95% of testicular cancers are what?
Germ cell tumours
How are germ cell tumours divided?
Seminoma
Non-seminomatous germ cell tumours
What are the kinds of Non-seminomatous germ cell tumours?
Teratoma
Yolk sac tumour
Choriocarcinoma
Mixed germ cell tumour
What is the commonest subtype of testicular tumour?
Seminoma
What is the average age of diagnosis with a seminoma?
40
How is survival with a seminoma?
Good
What do the tumour markers tend to show in a seminoma?
HCG and AFP often normal
Lactate dehydrogenase raised in 10-20%
What do you see on the histology of a seminoma?
Sheet like lobular patterns of cells with substantial fibrous component
Fibrous septa contains lymphocytic inclusions + granulomas
What is the average age of diagnosis of non-seminoma germ cell tumours?
20-30
What is the prognosis of non-seminoma germ cell tumours?
Much worse
Apart from excision what additional treatments may be required to manage non-seminoma germ cell tumours?
Retroperitoneal LN dissection after chemo
What do you tend to see in the tumour markers of someone with a non-seminoma germ cell tumour?
AFP raised 70%
HCG raised 40%
What is the histology of non-seminoma germ cell tumours?
Heterogenous texture with occasional ectopic tissue, e.g. hair
What are RFs for testicular cancer?
Cryptorchidism Infertility FH Klinefelter's syndrome Mumps orchitis
What is the most common presenting symptom for testicular cancer?
Painless lump
other features: hydrocele, gynaecomastia
What is the first line imaging for suspected testicular cancer?
US
+ tumour markers
What imaging is used to stage testicular cancer?
CT chest/abdo/pelvis
How is testicular cancer managed?
Orchidectomy (inguinal approach)
Chemo/radio depending on stage
Abdominal lesions >1cm following chemo may req. retroperitoneal lymph node dissection
What is acute epididymitis?
Acute inflammation of the epididymis
What drug can cause epididymitis?
Amiodarone
How can you differentiate epididymitis from torsion?
In epididymitis, the tenderness is usually confined to the epididymis
Torsion usually affects the entire testis
What is testicular torsion?
Twist of spermatic cord leading to testicular ischaemia and necrosis
When is it most common to get a testicular torsion?
Aged between 10 and 30
What is the pain of testicular torsion like?
Usually severe + of sudden onset
What reflex is lost in testicular torsion?
Cremasteric
How is testicular torsion treated?
Surgical exploration
In younger men, why should hydrocele be investigated with testicular US?
To rule out tumour
What diagnosis must you exclude when someone presents with epididymo-orchitis?
Testicular torsion!!
What factors may suggest torsion over epididymo-orchitis?
Age <20
Severe pain
Sudden onset
How does epididymo-orchitis tend to present?
Unilateral testicular pain + swelling
Urethral discharge may be present, but urethritis is often asymptomatic
How should you treat epididymo-orchitis if the organism is unknown?
Ceftriaxone 500mg IM single dose + doxycycline 100mg PO BD 10-14d
In sexually active men <35y the commonest cause of epididymo-orchitis is chlamydia. what is the most common cause in men >35y?
Usually enteric organisms (e.g. E. coli, E. faecalis) that cause UTIs
What is the analgesic of choice for renal colic?
IM diclofenac
Is circumcision for religious/cultural reasons available on the NHS?
No
What are the medical benefits of circumcision?
Reduces risk of penile cancer, UTIs, STIs (incl. HIV)
What are medical indications for circumcision?
Phimosis
Recurrent balanitis
BXO
Paraphimosis
What is it important to check for before circumcising a boy and why?
Exclude hypospadias as foreskin may be used in surgical repair
What type of anaesthetic is used to perform a circumcision?
LA or GA
What is priapism?
A persistent penile erection (typically defined as lasting >4 hours and is not associated with sexual stimulation0
What are the two types of priapism?
Ischaemic
Non-ischaemic
What causes ischaemic priapism?
Impaired vasorelaxation and therefore reduced vasocular outflow –> congestion and trapping of de-oxygenated blood in the corpus cavernosa
What are causes of non-ischaemic priapism?
High arterial inflow, typically due to fistula formation (congenital/traumatic)
At what ages is it most common to get priapism?
5-10y or 20-50y
What are causes of priapism?
Idiopathic Sickle cell dx/haemoglobinopathies Erectile dysfunction mediation Drugs - anti-hypertensives, anticoagulations, antidepressants, cocaine, cannabis, ectasy Trauma
How does priapism tend to present?
Persistent erection
Pain localised to the penis
Hx of haemoglobinopathy/medication
Hx trauma to genital/perineal region
What features in the history would be more suggestive of non-ischaemic priapism compared to ischaemic priapism?
A non-pain erection or an erection that is not fully rigid
What is the best investigation to differentiate between non-ischaemic priapism and ischaemic priapism?
Cavernosal blood gas analysis
Doppler/duplex can be used as alternative
What other investigations may be done for priapism?
FBC, toxicology to assess for cause
How is priapism diagnosed?
Clinically
Investigations to help decide if ischaemic or not
Why does ischaemic priapism require urgent treatment?
Delayed treatment can lead to permanent tissue damage and long-term erectile dysfunction
How is ischaemic priapism managed?
Aspiration of blood from cavernosa (often combined with injection of saline flush to help clear viscous blood that has pooled)
If this fails - intracavernosal injection of vasoconstrictive agent, e.g. phenylephrine used and repeated at 5 min intervals
If this fails - consider surgery
How is non-ischaemic priapism managed?
Normally observation first line (not medical emergency)
What post-void volumes are considered physiological in patients <65 years old?
<50ml
What post-void volumes are considered physiological in patients >65 years old?
<100ml
What is prostate specific antigen?
A serine protease enzyme produced by normal and malignant prostate epithelial cells
What are the age adjusted upper limits for PSA?
a. 50-59
b. 60-69
c >70
a. 3
b. 4
c. 5
What things may raised PSA levels (not to do with prostate cancer)?
BPH Prostatitis and UTI Ejaculation Vigorous exercise Urinary retention Instrumentation of the urinary tract
How long after an episode of prostatitis or UTI should you wait to have your PSA checked?
At least 1 month after treatment
How long before getting your PSA checked should you avoid ejaculation?
48 hours
How long before getting your PSA checked should you avoid vigorous exercise?
48 hours
What % of men with prostate cancer will have a normal PSA?
20%
Which drugs are sometimes used to aid the spontaneous passage of a renal stone?
CCBs
Define erectile dysfunction
Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
How are the causes of ED split?
Organic cause
Psychogenic cause
Mixed
What factors favour an organic cause of ED?
Gradual onset of symptoms
Lack of tumescence
Normal libido
What factors favour a pyschogenic cause of ED?
Sudden onset of symptoms Decreased libido Good quality spontaneous/self-stimulated erections Major life events Problems/changes in relationship Prev. psychological prolems Hx of premature ejaculation
What are RFs for ED?
CV disease RFs - obesity, DM, dyslipidaemia, metabolic syndrome, HTN, smoking
Alcohol use
What drugs can cause ED?
SSRIs, beta blockers
What investigations should be done for someone with ED?
10 year CV risk
Free testosterone measured between 9-11am (if low/borderline repeat with FSH and LH and prolactin, if abnormal - refer to endocrine)
What is involved in the treatment of ED?
1st line: PDE-5 inhibitors (e.g. sildenafil (Viagra) - given for all aetiologies
2nd line - vaccuum erection devices
If a young man has always had difficulty achieving an erection what additional management should be have?
Referral to urology
People with ED doing what activity for >3 hours a week should be advised to stop?
Cycling
What is the most common cancer in males in the UK?
Prostate cancer
What are RFs for prostate cancer?
Increasing age
Obesity
Afro-carribbean
FH
Why are localised/early prostate cancers usually asymptomatic?
Cancers tend to develop in periphery of prostate and don’t cause obstructive symptoms early on
What are features of prostate cancer?
BOO: hesistancy, urinary retention
Haematuria, haematospermia
Pain: back, perineal, testicular
What would you feel on DRE in someone with prostate cancer?
Asymmetrical, hard, nodular enlargement with loss of median sulcus
Where do Wilm’s tumours tend to metastasise to?
Lungs
What is the treatment of localised prostate cancer (T1/2)?
Conservative - wathcful waiting and active monitoring
Radial prostatectomy
Radiotherapy - external beam and brachy
What is the treatment of localised advanced prostate cancer (T3/4)?
Hormonal therapy
Radical prostatectomy
Radiotherapy - external beam + brachy
What are SEs of radical prostatectomy?
ED
Incontinence
Urethral stenosis
What are complications of TURP?
Retrograde ejaculation
TURP syndrome
Urethral stricture/UTI
Perforation of prostate
What are adverse effects of radiotherapy for prostate cancer?
Increased risk of bladder, colon and rectal cancer
How is metastatic prostate cancer managed?
Hormone therapy
Orchidectomy
What hormone therapies are used in prostate cancer?
Synthetic GnRH agonists (e.g. Goserelin - initially given with antiandrogen to prevent rise in testosterone)
Anti-androgen - cryproterone acetate prevents DHT binding from intracytoplasmic protein complexes
How do RCCs tend to present?
Haematuria
What is the most common renal tumour?
RCC
What paraneoplastic features are associated with RCC?
HTN
Polycythaemia
How is RCC treated?
Radical/partial nephrectomy
How does 90% of nephroblastoma present?
Mass in flank
NB 50% hypertensive
What is the diagnostic workup of someone with suspected nephroblastoma?
USS and CT
How is nephroblastoma managed?
Surgical resection
Chemo - vincristine, actinomycin D, doxorubicin
What is a neuroblastoma?
Most common extracranial tumour of childhood
Tumour of neural crest cells (50% occur in adrenal)
Tumour usually calcified
What scanning may be used to diagnose a neuroblastoma?
MIBG scanning
What scanning is used to stage a neuroblastoma?
CT
How are neuroblastomas managed?
Surgical resection
Radio
Chemo
Where are transitional cell carcinomas most common?
90% of lower urinary tract tumours
ONLY 10% of renal tumours
What are RFs for transitional cell carcinomas?
Occupaitonal exposure to industrial dies and rubber chemicals
Being male
How do most TCCs present?
Painless haematuria
How is TCC diagnosed and staged?
CT IVU
How is TCC managed?
Radical nephroureterectomy
What kind of lesions are angiomyolipomas?
Hamartoma type lesions (tumour composed to blood vessels, smooth muscle and fat)
What disease are angiomyolipomas associated with?
Tuberous slcerosis
Massive bleeding occurs in what % of angiomyolipomas?
10%
How are angiomyolipomas managed?
If big enough or symptomatic will require surgical resection
Following neobladder construction, what are patients at increased risk of?
Adenocarcinoma
What is a hydrocele?
A collection of serous fluid in the tunica vaginalis
What is the first line treatment for BPH?
Alpha-1-agonists
What is the most common cause of acute bacterial prostatitis?
Gram-negative bacteria (E. coli most common) entering the prostate gland via the urethra
What are RFs for acute bacterial prostatitis?
Recent UTI, urogenital instrumentation, intermittent bladder catheterisation, recent prostate biopsy
What clinical features are associated with acute bacterial prostatitis?
Pain: perineum, penis, rectum, back
Obstructive voiding symptoms
Fever, rigor
What do you feel on DRE with acute bacterial prostatitis?
Tender, boggy prostate gland
How is acute bacterial prostatitis managed?
14 day course quinolones
In younger men screen for STI as a significant minority is caused by chlamydia/gonorrhoea
Pain relief on elevating the testis points towards what?
Epididymo-orchitis
Epididymo-orchitis with a slow STI risk, is likely due to what organism?
Enteric organisms, esp. E. coli
Give e.g.s of non-germ cell testicular tumours
Leydig cell tumours, sarcomas
Infertile men are how many times more likely to develop testicular cancer?
3X
What are the 3 categories of LUTS?
Voiding
Storage
Post-micturition
What are voiding LUTS?
Hesitancy Poor/intermittent stream Straining Incomplete emptying Terminal dribbling
What are storage LUTS?
Urgency
Frequency
Nocturia
Urinary incontinence
What are post-micturition LUTS?
Post-micturition dribbling
Sensation of incomplete emptying
What investigations should be done in someone presenting with LUTS?
Urinalysis - exclude infection, check for haematuria
DRE - size/consistency of prostate
PSA may be indicated
What things might you ask someone presenting with LUTS to complete in order to guide management?
Urinary frequency-volume chart
International prostate symptom score (symptom severity + impact on life)
How are predominantly voiding LUTS managed?
PFMT, bladder retraining, prudent fluid intake
Moderate/severe - alpha blocker
If prostate enlarged + considered at high risk of progression - 5alpha reductase inhibitor
If enlarged prostate + moderate/severe symptoms - offer alpha blocker + 5alpha reductase inhibitor
If mixed with storage symptoms and not responding to alpha blocker consider anti-muscarinic
How are predominantly storage LUTS managed?
Moderate fluid intake
Bladder retaining
Antimuscarinics, e.g. oxybutinin, tolterodine, darifenacin
Mirabegron if 1st line drugs fail
How is nocturia managed?
Advise re moderating fluid at night
Furosemide 40mg in late afternoon
Desmopressin
What are the most common cause of scrotal swelling?
Epididymal cysts
What conditions are epididymal cysts associated with?
PKD
CF
vHL
How can you confirm the diagnosis of an epididymal cyst?
USS
What are the two types of hydroceles?
Communicating
Non-communicating
What causes communicating hydroceles?
Patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum
Who are communicating hydroceles common in?
Newborn males (they usually resolve in the first few months of life)
What causes non-communicating hydroceles?
Excessive fluid production in the tunica vaginalis
What 3 things may hydroceles develop secondary to?
Epididymo-orchitis
Testicular torsion
Testicular tumours
How are hydroceles diagnosed?
May be clinical or if doubt USS can be used
How are infantile hydroceles managed?
Repair only if they do not resolve themself by age 1-2
How are hydroceles in adults managed?
Usually conservatively
Further investigation may be done to exclude an underlying cause
What may varioceles be associated with?
Infertility
What are varioceles classically described as feeling like?
A bag of worms
What may aid the diagnosis of a variocele?
USS with doppler studies
How are varioceles managed?
Usually conservatively
Occasionally surgery if pain is an issue
What imaging technique is used to confirm a diagnosis of renal stones?
Non-contrast CT
What are some key points about vasectomy to remember?
Doesn’t work immediately
Day case - under LA or GA
Semen analysis needs to be performed 2x following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
What complications are associated with vasectomy?
Bruising Haematoma Infection Sperm granuloma Chronic testicular pain
Why can variocele be a sign of malignancy?
Due to compression of the renal vein between the abdominal aorta and superior mesenteric vein
How can metastatic prostate cancer present?
Bone pain
What is involved in the diagnosis of prostate cancer?
PSA
DRE
Trans-rectal USS +/- biopsy
MRI/CT for staging
What are 95% of prostate cancers?
Adenocarcinoma
NB they are often multifocal
70% of prostate cancers are found where?
Peripheral zone
What system is used to grade prostate cancer?
Gleason grading system - two grades awarded 1 for the most dominant grade (1-5) and 2 for the second most dominant grade (1-5)
Added together to give Gleason score
2 best prognosis
10 worst
Where does lymphatic spread of prostate cancer tend to go to first?
Obturator nodes
Where does prostate cancer locally spread to first?
Seminal vesicles
What surgery is performed for prostate cancer?
Radial prostatectomy
Why might a bilateral orchidectomy be used in the treatment of prostate cancer?
Testosterone stimulates prostate tissue (prostate cancers are testosterone dependent)
What is the preferred management of prostate cancer for low risk men?
Active surveillance
If they are stage T1c, Gleason 3+3, PSA density <0.15ng/ml/ml, who have cancer in <50% of their biopsy cores, with <10mm of any core involved
What investigation should be performed in the context of a suspicious DRE regardless of PSA?
US guided biopsy of prostate
What is TURP syndrome?
A rare + life-threatening complication of TURP surgery caused by irrigation with large volumes of glycine which is hypo-osmolar + systemically absorbed when prostatic venous sinuses are opened up during prostatic resection
It leads to hyponatraemia when glycine is broken down in the liver to ammonia, hyperammonia and visual disturbances
What are risk factors for developing TURP syndrome?
Surgical time >1h Height of bag >70cm Resected >60g Large blood loss Perforation Large amount of fluid used Poorly controlled CHF
In which gender are urethral injuries mainly seen?
Males
What do you often see in urethral injuries?
Blood at the meatus
What are the two types of urethral injuries?
Bulbar rupture
Membranous rupture
What things tend to cause bulbar rupture?
Straddle type injuries, e.g. bicycles
What are the triad of signs commonly seen in bulbar rupture?
Urinary retention
Perineal haematoma
Blood at meatus
What commonly causes membranous rupture?
Pelvic fractures
What might you see in membranous rupture?
Penile/perineal oedema/haematoma
PR: prostate displacement upwards
How should you investigate a suspected urethral injury?
Ascending urethrogram
How should urethral injury be managed?
Suprapubic catheter (surgical placement)
How does bladder rupture tend to present?
Haematuria or suprapubic pain
Inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
What investigation should be used if bladder rupture is supsected?
IVU or cystogram
How is bladder rupture managed?
Laparotomy if intraperitoneal
Conservative if extraperitoneal
History of pelvic fracture and inability to void should ALWAYS raise suspicion of what?
Urethral injury!!
How is all acute upper urinary tract obstruction managed?
Nephrostomy (prevent loss of renal function)
What are the causes of unilateral hydronephrosis?
PACT Pelvic-ureteric obstruction Abberant renal vessels Calculi Tumours of the renal pelvis
What are causes of bilateral hydronephrosis?
SUPER Stenosis of the urethra Urethral valve Prostate enlargement Extensive bladder tumour Retroperitoneal fibrosis
What investigation is used first line to identify hydronephrosis?
USS
What other investigations may be used after USS confirms hydronephrosis?
IVU - assess position of obstruction
Antegrade/retrograde pyelography - allows treatment
If suspect renal colic - CT scan
How are chronic upper urinary tract obstructions managed?
Ureteric stent/pyeloplasty
How does hydronephrosis present on examination?
Ballotable mass
What is the first line investigation of a testicular mass?
USS
What is the difference between active surveillance and watchful waiting?
Active surveillance requires more routine follow up and physical examination
Watchful waiting is guided by symptomatology + is preferred for those with low grade disease + significant comorbs
What are staghorn calculi composed
Struvite (phosphate, magnesium, ammonium)
What kind of urine do staghorn calculi form in?
Alkaline urine (ammonia producing bacteria, e.g. ureaplasma urealyticum and proteus therefore predispose)
Stones under which size can be considered for lithotripsy?
2cm
What are large proximal renal stones best treated with?
Percutaneous nephrolithotomy
What testicular pathology is associated with mumps infection?
Orchitis
What sign may indicate recent stone passage if a ureteric calculus is not present?
Periureteric fat stranding
PSA should not be measured within ____ of having a prostate biopsy
6 weeks
PSA should not be measured within ____ of having a DRE
1 week
What is the most common organic cause of EF?
Vascular causes (including CVD, HTN, hyperlipidaemia, DM, smoking)
What is balanitis?
Inflammation of the glans penis
if affects underside of foreskin too = balanoposthitis
What are causes of balanitis?
Infective - bacterial/candidal
Autoimmune diseases
How is balanitis diagnosed?
Through hx and ex
Describe the balanitis experienced with a candidal infection
Tends to occur after intercourse
Associated with itching and white non-urethral discharge
What is balanitis due to dermatitis (allergic/contact) like?
Itchy, painful
Occasionally associated with a clear non-urethral discharge
What is balanitis due to dermatitis (eczema/psoriasis) like?
Very itchy
No discharge
Hx inflammatory skin condition on body elsewhere
What is balanitis due to bacterial infection like?
Painful, itchy
Yellow non-urethral discharge
What is the most common balanitis causing bacterial organism?
Staphylococcal spp.
What kind of organism causes a very offensive yellow discharge with balanitis?
Anaerobic organisms
What are features of lichen planus (penile)?
Itchy
Wickham’s striae
Violaceous papules
How common is lichen sclerosus (BXO)?
Rare
What are features of BXO?
Itchy
Associated with white papules and can cause significant scarring
How does plasma cell balanitis of Zoon present?
Non-itchy, clearly circumscribed areas of inflammation
How does circinate balanitis present?
Painless erosions
Can be associated with Reiter’s
How is balanitis managed?
Gentle saline washes
Ensuring to wash properly under the foreskin
If more severe - 1% hydrocortisone can be used
What is the treatment of candidial balanitis?
Topical clotrimazole for 1 weeks
What is the treatment of bacterial balanitis?
Oral fluclox or clarithromycin if penicillin allergic
How is anaerobic balanitis managed?
Saline washing, topical/oral metronidazole if not settling
How are dermatitis and circinate balanitis managed?
Hydrocortisone
How are lichen sclerosus and plasma cell balanitis of Zoon managed?
High potency topical steroids
How is BXO managed?
Circumcision
What can BXO in an uncircumcised mail lead to?
Phimiosis
What is the first line investigation for suspected prostate cancer?
Multiparametric MRI
What score on the Linkert scale in a multiparametric MRI would indicate need for a prostate biopsy?
> =3
What is the investigation of choice for diagnosing bladder cancer?
Cystoscopy
What are causes of urethral stricutres?
Iatrogenic, e.g. traumatic placement of indwelling urinary catheters
STIs
Hypospadias
Lichen sclerosus
