Urology surgery

Question 1

Urinary retention

Answer 1

Urinary retention: inability to pass urine
Acute: new onset inability to pass urine, leads to pain
Chronic: painless inability to pass urine

Causes: Obstruction anywhere from renal calyces to urethral meatus. Can be partial/ complete, unilateral/bilateral

Unilateral obstruction can have normal UO, UEs (if other kidney functioning)
Bilateral obstruction, or with infection - requires urgent treatment

Acute upper urinary tract obstruction
Loin pain radiates to groin, infection, enlarged kidney

Acute lower urinary tract obstruction 
Suprapubic pain+acute confusion (elderly) 
Distended bladder (600ml), dull to percussion 
Causes: prostatic obstruction, urethral strictures, anti-cholinergics, constipation, neuro (cauda equina) 

Chronic upper urinary tract obstruction
Flank pain, renal failure, infection, polyuria (as can’t concentrate urine)

Chronic lower urinary tract obstruction
Urinary frequency, hesistancy
Distended bladder (>1.5L)+large prostate PR
Complications: UTI, urinary retention
Causes: prostatic hypertrophy, pelvic malignancy, MS

Acute urinary retention
Causes: BPH, UTI, constipation
Sx: Acute suprapubic pain, inability to micturate
Signs: palapble, distended bladder, enlarged prostate PR

Ix: FBC (anaemia, WCs), UEs (creatinine), urine dipstick (infection), urine culture (infection), bladder scan (vol retained urine), US (hydronephrosis)

Tx: catheter, treat underlying cause (tamsulosin - BPH, abx -UTI)
Monitor post-obstructive diuresis (if residual vol high >1L) - kidneys can over diurese, worsening AKI - tx: IV fluids

Chronic urinary retention
Long standing retention leading to bladder
desensitisation - painless
Causes: BPH, prostate Ca, urethral strictures
Females: pelvic prolapse, pelvic mass (fibroids)
MS, PD

Sx: painless urinary retention, lower urinary tract symptoms (urinary dribbling, weak flow)
overflow incontinence, nocturnal enuresis (night time bed wetting) due to sphincter relaxation
Signs: palpable bladder, PR

Ask:
PMH - UTI, urinary tract stones, constipation
Drugs - anticholinergics, alpha blockers, anything that affects renal function

Ix: FBC, UEs (creatinine), bladder scan
If have high-pressure retention (urinary retention leads to high pressure that backs up - hydronephrosis) - requires US

Tx:
Normal renal function, no hydronephrosis: asymptomatic: observe, symptomatic: catheterise
Abnormal renal function/hydronephrosis: catheterise, weight, fluid balance, consider TURP (transurethral resection prostate), long term catheter

Acute on chronic retention:
Pts with chronic retention can go into acute retention due to worsening of their pathology, or new superimposed pathology
Sx: little pain, overflow incontinence, very high residual vol
Ix: renal US

When to refer for specialist treatment:
Suspected hydronephrosis
Urinary tract sepsis

Question 2

BPH

Answer 2

Benign proliferation of prostate
Inner transitional zone enlarges (in contrast to peripheral layer in prostate Ca)

Risk fx: age, obesity, Afro-Carribean

Sx: LUTS (dribbling, hesitancy, poor flow), haematuria

DDx: Prostate Ca, UTI

Ix: MSU, PR, PSA, UEs, kidney US (hydronephrosis), transrectal US+/i biopsy

Tx: Tamsulosin (alpha blocker - relaxes smooth muscle of bladder and prostate) SE: depression, hypotension
Finasteride (5-a reductase inhibitor - inhibits conversion of testosterone to DHT. Reduces size of prostate) SE: decrease libido, impotence

Surgery: TURP (transurethral resection of prostate) SE: post-TURP syndrome (hyponatraemia, fluid overload)
Robotic prostatectomy (risks: erectile dysfunction, haematuria, urethral stricture)

Question 3

Renal tract stones (urolithiasis)

Answer 3

Renal (can be asymptomatic) or ureteric stones (usually pelviureteric junction, pelvic brim, vesicoureteric junction)
Risk fx: male, <65 yrs

80% Calcium oxalate, phosphate
Urate (cant see on Xrays, high levels of pruine e.g. red meat)
Struvite (Mg, ammonia, phosphate) - staghorn. Assoc with proteus, psudeomonas infection
Cystine - autosomal recessive disorder - hypocystinuria (citrate stone inhibitor)

Sx: flank pain radiating to groin (loin to groin pain), haematuria, N+V, can’t lie still (differentiates from peritonitis)
Signs: tenderness at renal angle

DDx: pyelonephritis, ruptured AAA, bowel obstruction
+
Ix: FBC/CRP (infection), UEs, serum Ca+, urate,
Dipstick (blood), MSU

Ix: Gold standard (CT-KUB non contrast)
US renal tract (hydronephrosis)

Tx: PR diclofenac + IV fluids
IV abx if infection

<5mm: 90% pass spontaneously
<2cm: ESWL SE: renal injury
>2cm: percutaneous nephrolithotomy

Indications for emergency intervention:
Infection+obstruction - percutaneous nephrostomy (tube placed in renal pelvis) or stent
Urosepsis, bilateral stones

Indications admission: (most treated outpt)
Uncontrollable pain from simple analgesics
Infected stone
Large stone >5mm

Complications
Renal stone: renal scarring
Ureteric stone: infection, post-renal AKI

Prevention:
Calcium stones: drink fluids, normal Ca diet, thiazide diuretic
Oxalate: pyridoxine, decrease oxalate intake (reduce tea, dark choc)
Struvite: treat infection
Urate: urine alkalization - pottasium citrate
Cystine: IV fluids, pottasoium citrate

Question 4

Erectile dysfunction

Answer 4

Inability to achieve erection required for sexual intercourse

Erection results from neuronal release of NO and Ca2+ - hyperpolarisation - relaxes smooth muscle cells, allowing engorgement.

Organic causes: smoking, alcohol, diabetes, CVD, drugs (SSRIs,Bblockers), PD, MS
Psychogenic: stress, performance anxiety

Ix: psychosexual history (sexual function (duration of erections, morning), libido, sexual relationships, current mood)
LFTs (GGT -alcohol), testosterone levels, FSH/LH, hyperthyroidism, BM (diabetes)

Tx: lifestyle modification, counselling

Sildefanil (phosphodiesterase 5 inhibitor) - promotes smooth muscle relaxation
SE: headache, blue tinged vision, flushing
Contra-ind: nitrates, recent stroke/MI, hypotension
Vardenafil
Protheses