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RLH Urology > 1 - Signs and symptoms > Flashcards

1 - Signs and symptoms Flashcards

1
Q

Types of Heamaturia

A
  • Visible haematuria (frank/gross)
  • Microscopic/non-visible haematuria (dipstick): >1, Trace = negative
    • Symptomatic: LUTS
      • FUNDI (storage): Frequency, Urgency, Nocturia, Dysuria, Incontinence
      • SHIWID: Straining, Hesitancy, Intermitency, Weak stream, Incomplete emptying
    • Asymptomatic
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2
Q

What does urine dipstick test for?

A

Tests for Heam - haemoglobin or myoglobin

Haem catalyses oxidation of orthotolidine by organic peroxidases -> blue

  • False positive: myoglobinuria, bacterial peroxidases, povidone, hypochlorite
  • False negative (rare): reducing agent e.g. ascorbic acid - prevents oxidation of orthotolidine
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3
Q

What is significant haematuria

A
  • single episode of VH
  • Single episode of s-NVH - in absence of UTI/transient causes
    • UTI - as indicated by the presence of leucocytes and nitrites - Rx UTI and repeat
    • Exercise induced haematira/myoglobinuria - rpt dipstick post absenance
    • Sexual intercourse
    • Menstual contamination
  • Persistent a-NVH - i.e. 2 of 3 dipsicks positive for NVH in absence of transient cause
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4
Q

Initial investigations for sNVH and persistent a-NVH

A

Exclude UTI and other transient causes (SI/Exercise/menstruation)

PLasma creatinine/eGFR

Measure proteinuria on random sample

Blood pressure

Urology referral:

  • VH
  • s-NVH - with excluded transient causes
  • a-NVH and >40yrs
  • a-NVH - persists - 2 of 3

Note - if eGFR<60ml/min or BP >140/90 or proteinuria -> Nephrological referral

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5
Q

Causes of NVH

A

70% with NVH have NO UROLOGICAL PATHOLOGY

  • Cancer: Kidney (adenocarcinoma), Renal pelvis TCC, Ureter (TCC), bladder (TCC/SCC), Prostate (adeno),
  • Stones: Kidney, ureter, bladder
  • Infection: Bacterial, myobacterial (TB), parasitic (schistosomiasis), infective urethritis
  • Inflammation: cyclophosphamide cystitis, interstitial cyctitis
  • Trauma: Kidney, bladder, urethra (catheterisation?), pelvic fracture causing urethral rupture
  • Renal cysts: medullary sponge kidney
  • Other urological causes: benign prostatic enlargement, loin pain haematuria syndrome, vascular malformations
  • Nephrological causes: (children.young adults): IgA nephropathy, post infectious glomerulonephritis, membrano-proliferative glomerulonephritis, Henoch-Schonlein purpura, vasculitis, Alport’s syndrome, thin basement membrane disease, Fabry’s disease
  • Other ‘Medical’ Causes: Coagulation disorder - haemophilias, anticoagulation therapy (warfarin), SCT/D, renal papilary necrosis, vascular disease (emobili to kidney -> infarct -> haematuria)
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6
Q

What percentage of patients with haematuria have urological cancers?

A
  • Microscopic: 5-10%
  • Macroscopic: 20-25%
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7
Q

Urological investigations of hamaturia

(VH, s-NVH, a-NVH>40yrs, a-NVH 2 of 3)

A
  • Urine culture - if Sx of cystitis - exclude UTI
  • Urine cytology
  • Cystoscopy
    • Flexible cystoscope (unless CT has revealed bladder Ca -> ridig and Bx under anaesthetic - TURBT)
    • In aNVH<40, this may be reserved for ‘high risk’ patients e.g. smokers, occupational exposured to chemicals/dyes (bensines/aromatic amines), analgesic abuse (phenacetin), previous pelvic irratiation, previous cyclophosphamide Rx
  • Renal US
  • CTU
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8
Q

Haemospermia: definition

A

Presence of blood in semen

Usually intermittent, benign, self limitting, no cause identified

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9
Q

Haemospermia: causes

A
  • <40yrs:
    • inflammatory - prostatitis, epididymo-orchitis, urethritis
    • Infective: STD gonococcus, non-STD Enterococcus faecalas, Chlamydia trachomatis, ureaplasma urealyticum, viral Herpes simplex, urethral warts
    • Idiopathic
    • Testicular tumor (Rare)
    • Perineal/testicular trauma (rare)
  • >40yrs:
    • post TRUS biopsy of prostate (common), post external baem radiotherapy/brachytherapy for prostate Ca
    • Ca (3.5%): prostate, bladder, testicular, seminal vesicles, epididymal
    • BPE
    • dilated veins in prostatic urethra, prostatatic, seminal vesicle calculi
    • HTN
    • Sarcinoma of seminal vesicles
  • Rare:
    • Bleeding diathesis - vWbD, haemophilia, acquired coag defects
    • Utricular, mullerian, seminal vesicle cysts - obstruction/dilation/distension/rupture of blood vessles
    • Infection - TB, schistosomiasis
    • Amyloid - prostate/seminal vesicles
    • Post inj of haemorrhoids
    • VERY RARE: confused with melanospermia - urinary tract melanoma
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10
Q

Haemospermia: Examination

A

Testes, epididymis, prostate, seminal vesicle

Measure BP

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11
Q

Haematospermia: Investigations

A
  • Send urine for culture
  • STD clinic/screen
  • If persists
    • PSA, FBC, LFT, Clotting
    • TRUS
    • Flexible cystoscopy (urethral polyps, urethritis, prostatic cysts, urethral foreign bodies, stones, vascular abnormalities)
    • Renal US
    • Pelvic MRI
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12
Q

Lower Urinary Tract Symptoms

A
  • hesitancy, poor flow, frequency, urgency, nocturia, and terminal dribbling
    • assoc VH/NVH - bladder CA - frequency/urgency/suprapubic pain
    • Incontinence/bed wetting in elderly man = Hight pressure Chronic Retention
    • Assoc back pain, sciatica, ejac disturbance, sensory disturbance in legs and perineum -> neurological
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13
Q

Nocturia: definition

A
  • Nocturia ≥2
    • is common and bothersome (sleep disturbance)
    • Associated with 2x increase risk of falls and inj in ambulant elderly
  • Nocturia >2
    • Associated with 2x increase risk of death
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14
Q

Causes of nocturia

A
  • Urological:
    • BPO
    • OAD
    • Incomplete bladder emptying
  • Non-Urological:
    • Renal failure
    • Idiopathic nocturnal polyuris
    • DM
    • Central/nephrogenic diabetes insipidus
    • Primary polydipsia
    • Hypercalcaemia
    • Drugs
    • Autonomic failure
    • OSA
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15
Q

Nocturia: assessment

A
  • Frequency-Volume Chart over 24hr period for 7 days:
    • polyuric v non-polyuric
      • timing of polyuria

Polyuria = >3L of urine/24hr

  • Solute diuresis (>300mOsm/kg urine osmolality)
    • e.g. DM - glucose
  • Water diuresis (<250mOsm/Kg)
    • pimary polydipsia and DI (nephrogenic DI - pt on lithium)

Nocturnal polyuria = >1/3rd of 24hr urine is between midnight and 8am

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16
Q

Causes of Acute loin/flank pain

A

Urological

  • Ureteric stone:
    • Colicky, radiates to groin, (@penis + desire to void = intramural part of ureter)
    • commonly 20-60 yo M>F
  • Clot or tumour colic: RCC/TCC (renal pelvis/ureteric pelvis) -> clot, TCC -> ureteric obstruction and acute loin pain
  • Pelviureteric junction obstruction (PUJ) - CT -> hydronephrosis with normal calibre ureter below the pelviureteric junction and no stone, MAG3 renography confirms the disease
  • Infection e.g. acute pyelonephritis, pyonephrosis, emphysematous pyelonephrotis, xanthogranulomatous pyelonephritis. Fevers + systemically unwell. Radiological evidence of infection within the kidney and perirenal tissues (oedema)
  • Testicular torsion

Non-Urological

  • Vascular:
    • Leaking abdominal aortic aneurysm
  • ‘Medical’
    • Pneumonia
    • Myocardial infarction
    • Malaria - bilateral loin pain, dark haematuria
  • O&G:
    • Ovarian pathology
    • Ectopic pregnancy
  • GI:
    • Acute appendicitis
    • IBS (Crohn’s, UC)
    • Diverticulitis
    • Burst peptic ulcer
    • Bowel obstruction
  • Spinal cord disease
    • Prolapsed intervebral disc

Abdo exam - peritonitis (abdo tenderness/guarding), abdo masses (pulsatile and expansile = leaking AAA), Ex Back/chest/testicles. Pregnancy test

17
Q

Causes of chronic loin pain

A

Urological

  • Renal/ureteric cancer:
    • RCC
    • TCC - renal pelvis/ureter
  • Renal stones:
    • Staghorn calculi
    • Non-staghorn calculi
  • Renal infection:
    • TB
  • PUJO
  • Testicular pathology (referred)
    • Testicular neoplasm
  • Ureteric pathology:
    • Ureteric reflux
    • Ureteric stone

Non-urological

  • GI
    • Bowel neoplasm
    • Liver disease
  • Spinal disease
    • Prolapsed intervertebral disc
    • Degenerative disease
    • Spinal metastases
18
Q

Define urinary incontinence

A
  • Urinary incontinence: complaint of any involuntary leakage of urine
  • Stress urinary incontinence: UI on effort or exertion or sneezine or coughing. Urodynamic SUI - during filling cystometry involuntary leakage of urine during a rise in abdo pressure (induced by coughing) in the absence of detrusor contraction
    • due to bladder neck/urethral hypermobility &/or neuromuscular defects causing intrinsic sphincter deficiency
    • Urine leaks when resistance exceeded by incr abdo pressure
  • Urge urinary incontinence: UI accompanied/immediately prededed by urgency
    • bladder over-activity/ irriation of the bladder (infection, stone, tumor)
  • Mixed urinary incontinence: combination of SUI and UUI

Other classifications:

  • Bedwetting - in elderly man = High Pressure chronic retention
  • Constant leak - fistulous communication e.g. bladder-vagina or ectopic ureter draining into vagina
19
Q

Causes acute of scrotal pain

A
  • Scrotal pathology:
    • Torsion of the testicles
      • ischemic pain, therefore severe, can wake pt from sleep, can radiate groin/loin, 5-10% Hx of trauma, previous episodes, tender, high riding, horizontal lie, scrotal oedema
    • Torsion of the testicular appendages
    • Epididymo-orchitis
      • Tenderness localised to epididymis
    • Testicular Tumour
      • 20% present with testicular pain
  • Referred pain:
    • Ureteric colic
20
Q

Acute presentation of testicular tumours

A
  • Testicular swelling may occur rapidly
  • 2ndary hydrocele
    • Young pt with hydrocele requires US exclusion of Tx
  • High volume metastatic disease:
    • Retroperitoneum, check, neck, back, abdo, SOB
    • 10-15% - signs suggestive of inflammation:
      • epididymo-orchitis
        • Tender, swollen, erythematous scrotal skin, fever
21
Q

Causes of Chronic Scrotal Pain

A
  • Testicular pain syndrome c.75%
    • Testicular tumour
    • Previous trauma/surgery e.g. hernia repair, hydrocele repair, epididymal cyst removal, varicocele repair
    • Post infection
    • Diabetic neuropathy
    • Polyarteritis nodosa
    • If radiational consider primary sources:
      • Vertebrae (polapsed disc/Tx), Ureter (stone), retroperitoneal Tx
  • Post-vasectomy pain syndrome: 1-15% (?obstruction to vas, sperm granuloma, chronic epididymitis)
  • Epididymal pain syndrome:
    • Chronic bacterial infection
    • STDs
    • Trauma
  • Post laparoscopic nephrectomy -55% of men
  • Post Radical nephrectomy - 20% of men
  • Chronic prostatitis - tender prostate on DRE
  • Pudendal neuralgia
22
Q

Scrotal pain: assessment

A

Examination: testes, DRE, Abdo

Ix: Mid-stream urine MSU & scrotal USS

23
Q

Define priapsim

A

Painful, persistent, prolonged erection (>4h) of the penis not related to sexual stimulation

  • Two broad categories:
    • Low-flow priapism—haematological disease, malignant infiltration of the corpora cavernosa with malignant disease, or drugs; painful because the corpora are ischaemic.
    • High-flow priapism— perineal trauma -> arteriovenous fistula; painless

Examine the abdomen for evidence of malignant disease, and perform a DRE to examine the prostate and check anal tone.

24
Q

Causes of enlarged kidney

A
  • renal carcinoma
  • hydronephrosis
  • pyonephrosis
  • perinephric abscess
  • polycystic disease
  • nephroblastoma
25
Q

Causes of englarged liver

A
  • infection
  • congestion (heart failure, hepatic vein obstruction—Budd–Chiari syndrome)
  • cellular infiltration (amyloid)
  • cellular proliferation
  • space-occupying lesion (polycystic disease, metastatic infiltration, primary hepatic cancer, hydatid cyst, abscess)
  • cirrhosis
26
Q

Causes of englarged spleen

A
  • bacterial infection (typhoid, typhus TB, septicaemia) viral infection (glandular fever); protozoal infection (malaria, kala-azar); spirochaete infection (syphilis, leptospirosis—Weil’s disease)
  • cellular proliferation (myeloid and lymphatic leukaemia, myelosclerosis, spherocytosis
  • thrombocytopenic purpura, pernicious anaemia)
  • congestion (portal hypertension—cirrhosis, portal vein thrombosis, hepatic vein obstruction, congestive heart failure)
  • cellular infiltration (amyloid, Gaucher’s disease)
  • space-occupying lesions (solitary cysts, hydatid cysts, lymphoma, polycystic disease)
27
Q

Causes of abdo distension

A
  • Fetus—smooth, firm mass, dull to percussion, arising out of the pelvis.
  • Flatus—hyperresonant (there may be visible peristalsis if the accumulation of flatus is due to bowel obstruction).
  • Faeces—palpable in the flanks and across the epigastrium, firm, and may be indentable; there may be multiple separate masses in the line of the colon.
  • Fat.
  • Fluid (ascites)—fluid thrill, shifting dullness.
  • Large abdominal masses (massive hepatomegaly or splenomegaly, fibroids, polycystic kidneys, retroperitoneal sarcoma)
28
Q

Lumps in the groin: differetial diagnosis

A
  • Hernia: cough impulse (expands on coughing), redices with lying down, not possible to ‘get above’ the lump
    • Inguinal: reduced through abdo wall at a point above and medial to PT. Indirect = descends into scrotum Direct = rarely descentds
    • Femoral: reduced through abdo wall at a point below and lateral to PT
  • Enlarged inguinal LN
  • Saphena varynx: expansile cough impulse, fluid thrill when percussed
  • Hydrocele of cord - increased peritoneal fluid between parietal and visceral layers of tunica vaginalis - In female aka Canal of Nuck
  • Undescended testis - no testis in scrotum
  • Lipoma of cord
  • Femoral aneurysm - common femoral artery, below inguinal ligament, expansile but no expansile cough impulse
  • Psoas abscess - within femoral triangle
29
Q

Lumps in the scrotum: differential diagnosis

A
  • Inguinal hernia: expansile cough impulse, reduced on lying down, unable to get above
  • Hydrocele: smooth, can get above, transiluminates
    • Primary - slow growing over years
    • Secondary: infection/tumour/trauma - ‘effusion’
  • Epididymal cyst/spermatocele (if spermatozoa in contained fluid) - collecting tubules, develop slowly, multiloculated
  • Orchitis - e,g, mumps (+enlargement of salivary glands)
  • TB epididymo-orchitis - absence of pain and tenderness - irregular surface, thickened cords, hard vas deferens (string of beads)
  • Terticular tumour: firm/hard, smooth/irregular, + abdo exam + supraclavicular lymph nodes
    • Seminoma
    • Teratoma
  • Gumma of testis - syphilis -> round/hard/insensitive mass aka billiard ball
  • Varicocele - dilation of pampiniform plexus - extends up spermatic cord - dragging/ache, bag of worms
  • Sebaceous cyst
  • Carcinoma of scrotal skin
    • ulcer with purulent/bloody discharge

RLH Urology (2 decks)

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