11. Urology

Question 1

What is testicular torsion?

Answer 1

Surgical emergency when twisting of spermatic cord causes constriction of vascular supply.
Two types
Intravaginal
Extravaginal - torsion occurs at the level of the external inguinal ring. seen in neonates.

Question 2

Risk factors for testicular torsion?

Answer 2

Age under 25 years

Bell clapper deformity

Question 3

How does testicular torsion present?

Answer 3

Painful
Swollen, hot, tender scrotum
Unilateral
High riding testicle
Absent cremasteric reflex (stroke thigh on right thigh, right testicle lifts and vice versa)

Question 4

How do we treat testicular torsion?

Answer 4

Emergency exploration of scrotum within 6 hours surgically to twisted it back

If surgery unavailable, manual de-torsion

Question 5

What is epididymitis and orchitis?

Answer 5

Inflammation of those structures. Can occurs at same time. Most cases are caused by bacterial infection, chlamydia most common under 35, klebsiella over this age.

Risk factor is unprotected sex, bladder outflow obstruction and UTIs

Question 6

How do epididymitis or orchitis present?

Answer 6

Pain
Swollen, hot, tender scrotum
Unilateral
Less acute than torsion
Dysuria and urgency and penile discharge - symptoms of cause

Question 7

How do we investigate epididymitis and orchitis?

Answer 7

Urine dipstick
Bloods
Colour duplex USS (if unsure)
Surgical exploration if torsion can’t be excluded

Question 8

How to manage epididymitis and orchitis?

Answer 8

Bed rest
Scrotal elevation
Analgesia
Antibiotics

Question 9

What is a variocele?

Answer 9

Dilated veins of the pampiniform plexus forming a scrotal mass.
Caused by increased hydrostatic pressure in left renal vein or incompetent veinous valves.

Question 10

How do varicoceles present?

Answer 10

Asymptomatic
Stand patient up, see “bag of worms” appearance.
Fertility analysis (sperm count)
Retroperitonaeal USS

If anything’s abnormal, surgical repair but normally left alone with obs.

Question 11

What is a hydrocele?

Answer 11

Excessive collection of serous fluid in the tunica vaginalis (so can occur in women)

Communicating - open so peritoneal fluid can flow freely - inflammation, trauma, cancer
Non-communication - closed so more fluid produced is absorbed - increased fluid e.g. ascites

Question 12

Presentation of hydrocele and investigations?

Answer 12

Scrotal swelling
Enlarges with coughing etc.
Transilluminates

Urine dip, USS and bloods to exclude worrying causes. Observation is solution or surgery if bad.

Question 13

What are the most common testicular cancers?

Answer 13

Seminomas - 50%
Non - 30%
Cryptochidism, ectopic testes, test atrophy and FHx are risk factors.

Question 14

How do testicular cancers present?

Answer 14

Painless nodules
Lymphadenopathy
Gynaecomastia
Backache
Hydroceles

Question 15

How to investigate testicular cancer?

Answer 15

FBCs
U&Es
LFTs
Tumour markers - LDH, alpha fetoprotein, beta hcg
Testicular ultrasound, CTAP, CXR

Treat with chemo or removal

Question 16

Most common UTI?

Answer 16

E.coli

Question 17

UTI symptoms?

Answer 17

Increased frequency
Urgency
Dysuria (urine smells too)

Red flag for acute pyelo
Flank pain
Fever
Malaise
Acute pyelonephritis

Question 18

What are the three points for urinary tract calculi?

Answer 18

Ureteopelvic junction
Pelvic brim
Ureterovesical junction

Question 19

What causes urinary tract calculi?

Answer 19

Urinary solutes are highly concentrated which precipitate out of solution. Can be uric acid, calcium, oxalate and sodium.
Can be metabolic, infection, drug causes etc. catheters and stents etc.

Question 20

Risk factors for urinary tract calculi?

Answer 20

Dehydration
High protein intake
High salt
Structural abnormalities
Male
30-50

Question 21

How do renal stones present?

Answer 21

When they get stuck it can cause acute, severe loin to groin pain called renal colic.
Can cause N&V and are unable to lie still
Urgency, frequency and microscopic haematuria.

Question 22

Renal stone investigations?

Answer 22

Urine dipstick (pregnancy in females too as could be ectopic)
FBC
Non-contrast CT-KUB or USS if pregnant.

Question 23

How to manage renal stones?

Answer 23

Fluids
Analgesia
Anti-emetics
Urine collection to collect any passed stone (see composition)

<5mm leave to pass with increased urine
<10mm alpha-blocker, tamsulosin, to let pass and after 4-6 week surgery
>10mm (or staghorn) surgical removal - shock wave lithotripsy (ESWL) or percutaneous nephrostolithotomy

Question 24

How does BPH present?

Answer 24

LUTS, storage and voiding symptoms.
Presents like prostate cancer - 
Frequency
Urgency
Nocturia
Dysuria
Hesistancy
Incomplete voiding
Poor stream

Question 25

How to investigate BPH?

Answer 25

Urinalysis
DRE for cancer (asymmetrical, hard nodular prostate. BPH would be smoothly enlarge with palpable groove)
PSA
U&Es
Transrectal US guided needle biopsy

Question 26

How to manage BPH?

Answer 26

Catheterisation if acute
Normally monitor, lifestyle
Alpha blockers
5A-reductase inhibitors
Surgical TURP

Question 27

Bladder cancer types?

Answer 27

Urothelial carcinoma (painters and hairdressers at risk)
Squamous cell carcinoma (schissto...)

Question 28

How do bladder cancers present?

Answer 28

Irritative/storage symptoms (normally painless)

FLAWS

Question 29

What is cystitis?

Answer 29

Inflammation of bladder caused by UTI or non-infectious cause

Question 30

What’s recurrent UTIs?

Answer 30

2 or more in last six months

3 or more in a year

Question 31

How do we treat recurrent UTIs?

Answer 31

Reccurent ABx possibility but unlikely
Manage acute UTIs
Consider referral for investigation e.g. urine stasis, HIV, structural causes
Discuss behaviour of hygiene e.g. peeing after sex and wiping

Question 32

Complications of UTIs?

Answer 32

Pyelonephritis, renal abscess, renal failure, urosepsis

Pre-term delivery or low birth weight of children.