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Y4 - CCC & PC > Urology > Flashcards

Urology Flashcards

1
Q

What type of scrotal mass conditions are symptomatic (present with pain)?

A
  • testicular torsion
  • epididymitis
  • orchitis
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2
Q

What is the definition of testicular torsion?

A

twisting of the spermatic cord, resulting in constriction of vascular supply and ischaemia of testicular tissue

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3
Q

What are the 2 types of testicular torsion?

Why is it important to recognise early?

A
  • intravaginal
  • extravaginal

it is a SURGICAL EMERGENCY as there is a risk of death of the testes when blood supply is compromised

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4
Q

What is meant by intravaginal testicular torsion?

Who does this tend to affect?

A

there is twisting WITHIN the tunica vaginalis

  • this is the most common cause of acute scrotal pain in 10-18 year olds

this is the most common form of testicular torsion

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5
Q

What is meant by extravaginal testicular torsion?

Who does this tend to affect?

A

there is twisting of the entire testes AND tunica vaginalis

  • this is more common in neonates
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6
Q

What are the risk factors for intravaginal testicular torsion?

A
  • age < 25
  • Bell clapper deformity (90% cases)
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7
Q

What is the Bell clapper deformity?

A
  • there is high attachment of the tunica vaginalis
  • this allows the testicle to rotate freely within the tunica vaginalis
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8
Q

How does testicular torsion present?

A
  • painful
  • swollen, hot, tender, erythematous scrotum
  • unilateral
  • high-riding testicle
  • ABSENT CREMASTERIC REFLEX

cremasteric reflex:
stroking of the inner thigh will cause the ipsilateral testicle to elevate via contraction of the muscle

high-riding testicle:
the testicle that has torsion will be raised higher than the other

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9
Q

When must treatment for testicular torsion be performed?

A

treatment must be performed within 6 hours of the ONSET of symptoms in order to save the testis

!! this is NOT 6 hours from when they present !!

it is from the instant that the symptoms start

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10
Q

What is the first line investigation and treatment for testicular torsion?

A

emergency exploration of the scrotum within 6 hours of symptom onset

after the testicle is twisted back, bilateral orchidopexy is performed

!! DO NOT DELAY SURGERY FOR DOPPLER USS !!

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11
Q

What is a bilateral orchidopexy and why is it performed?

A
  • the spermatic cord is fixed down on both sides to prevent twisting in the future
  • it is performed bilaterally as testicular torsion is likely to recur and could affect either side
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12
Q

What is the second line management for testicular torsion?

A

manual detorsion

this is only performed when surgery is not available within 6 hours

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13
Q

If Doppler USS is performed in testicular torsion, what is seen?

A

Whirlpool sign

  • if testicular torsion is suspected, Doppler USS should NOT be done as this is a SURGICAL EMERGENCY
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14
Q

What is the difference between epididymitis and orchitis?

Why are they often grouped together?

A

Epididymitis:

  • inflammation of the epididymis

Orchitis:

  • inflammation of the testes

Epididymo-orchitis:

  • concurrent inflammation of the epididymis and testes

  • 60% cases of epididymitis are associated with orchitis
  • nearly all cases of orchitis are associated with epididymitis
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15
Q

What is the major cause of epidiymitis / orchitis in < 35s?

What question is important in the history?

A
  • Chlamydia trachomatis is the most common cause
  • followed by Neisseria gonorrhoeae

unprotected sex is a risk factor so it is important to ask about sexual history

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16
Q

What is the major cause of epidiymitis / orchitis in > 35s?

What risk factors make infection more likely?

A
  • mainly caused by coliforms, such as Klebsiella, E. coli and Enterococcus faecalis
  • RFs are UTIs and bladder outflow obstruction
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17
Q

Why is bladder outflow obstruction a RF for epidiymitis / orchitis?

A
  • when there is an outflow obstruction, the urine is static for longer
  • there is more time for bacteria to colonise and grow and cause infection in surrounding structures
  • higher voiding pressure can result in reflux of infected urine into the ductal system and spread of pathogens to the epididymis
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18
Q

What are the possible non-infective causes of epidiymitis / orchitis?

A
  • trauma
  • vasculitis - e.g. Behcet’s disease
  • medication e.g. amiodarone
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19
Q

What are other possible risk factors for epidiymitis / orchitis?

A
  • immunosuppression can result in colonisation by atypical organisms, such as Candida
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20
Q

What symptoms do testicular torsion and epidiymitis / orchitis have in common?

A
  • painful
  • swollen, hot, tender, erythematous scrotum
  • unilateral
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21
Q

How does epidiymitis / orchitis differ from testicular torsion?

A
  • it is less acute than torsion (develops over a few days rather than a few hours)
  • dysuria & urgency as a result of infection
  • present Cremasteric reflex (but may be painful to elicit)
  • can affect any age group (not just < 25s)
  • there may be symptoms of the cause (e.g. penile discharge in STI)
  • as this is an infection, there is pyrexia
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22
Q

What are the initial investigations for epidiymitis / orchitis?

A
  • urine dipstick
  • MSU for MC&S to identify pathogen
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23
Q

What blood tests may be performed in epidiymitis / orchitis?

A
  • FBC - will show high WCC
  • U&Es - always check renal function when urinary symptoms present
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24
Q

When is imaging performed in epidiymitis / orchitis?

What will this show?

A
  • colour duplex USS
  • surgical exploration may be done if testicular torsion cannot be excluded

it is very rare for imaging to be needed as this can usually be diagnosed through bedside / bloods ix

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25
Q

What is involved in the management of epidiymitis / orchitis?

A

Conservative:

  • bed rest
  • scrotal elevation

Medical:

  • simple analgesia (paracetamol / ibuprofen)
  • antibiotics to target infection

surgical management is rarely needed:

  • surgical exploration if testicular torsion cannot be excluded
  • abscess drainage if this develops
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26
Q

What is the definition of varicocele?

Why does it occur?

A

dilated veins of the pampiniform plexus forming a scrotal mass

Occurs due to:

  • incompetent venous valves
  • increased hydrostatic pressure in the left renal vein
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27
Q

Why do 80-90% varicoceles occur on the left side?

A
  • the left pampiniform plexus is subjected to increased hydrostatic pressures due to the perpendicular insertion of the left testicular vein into the left renal vein
  • the left internal spermatic vein is longer, resulting in increased hydrostatic pressure transmission
  • incompetent valves at the point where LTV meets LRV
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28
Q

How does varicocele present?

A
  • it is asymptomatic
  • it has a “bag of worms” appearance
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29
Q

What is involved in the investigations for varicocele?

A
  • physical examination for which patient must be STANDING
  • fertility analysis - sperm count / semen analysis
  • retroperitoneal USS / CTAP only if mass DOES NOT diminish in supine position
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30
Q

Why must varicocele examination be performed when standing?

A
  • the appearance of the mass may reduce when lying down due to the effect of gravity
  • standing up causes the blood to pool down towards the scrotum
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31
Q

Why is retroperitoneal USS / CTAP performed if varicocele does not reduce when lying down?

A
  • if varicocele does not diminish when supine, it may be a different diagnosis
  • need to exclude abdo/retroperitoneal mass causing physical obstruction of testicular venous return
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32
Q

What is involved in the management of varicocele?

A

reassurance & observation

if semen analysis is abnormal, surgical repair should be offered

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33
Q

What is the definition of a hydrocele?

A

an excessive collection of serous fluid within the tunica vaginalis

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34
Q

What are the 2 different types of hydrocele?

A

communicating:

  • the processus vaginalis is OPEN
  • peritoneal fluid can flow freely from the abdomen into the tunica vaginalis

non-communicating:

  • the processus vaginalis is CLOSED
  • more fluid is produced by the tunica vaginalis than is being absorbed
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35
Q

What are the 2 major risk factors for both types of hydrocele?

A
  • male gender (but can affect females too)
  • very common in children in first year of life
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36
Q

What are the risk factors for non-communicating hydrocele?

A
  • inflammation / injury to the scrotum (e.g. trauma, infection, testicular torsion)
  • epididymo-orchitis
  • testicular cancer
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37
Q

What are the risk factors for communicating hydrocele?

A
  • increased intraperitoneal fluid (e.g. ascites)
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38
Q

How does hydrocele present?

A
  • it is an asymptomatic scrotal swelling
  • it is possible to get above the swelling
  • it enlarges following activity such as coughing / straining
  • it transilluminates

transilluminates = has a glowing appearance when a light is shone on it

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39
Q

What investigations are performed for hydrocele?

A

urine dip:

  • to exclude infection

USS:

  • to exclude tumour / abnormal testis

blood tests:

  • testicular tumour markers - a-fetoprotein, b-hcg, LDH

diagnosis can be made once ALL tests have come back negative

40
Q

Why are testicular tumour markers measured in suspected hydrocele?

A
  • testicular cancer can present with hydrocele so it is important to rule this out
41
Q

What is involved in the management of hydrocele?

A

observation

surgery is considered if it becomes too uncomfortable

42
Q

What are the 2 different types of testicular cancer?

A
  • the majority of testicular cancers are seminomas
  • they may also be non-seminomatous germ cell tumours and teratomas
43
Q

What are the risk factors for testicular cancer?

A

anything that disrupts the underlying structure / function of the testes

  1. cryptochidism
  2. ectopic testes
  3. testicular atrophy
  4. family history of testicular cancer

cryptorchidism = one / both of the testes fail to descend

44
Q

How does testicular cancer present?

A

PAINLESS HARD NODULAR TESTICULAR MASS

  • unilateral
  • may be associated with hydrocele
  • lymphadenopathy
  • gynaecomastia
  • back pain
45
Q

Why does gynaecomastia occur in testicular cancer?

A

it occurs as the tumour produces hCG

46
Q

Why does back pain occur in testicular cancer?

A
  • metastases travel via the para-aortic lymph nodes
  • para-aortic lymph node enlargement causes back pain
47
Q

What blood tests are performed in suspected testicular cancer?

A

FBC

U&Es

LFTs:

  • there will be high ALP in bone mets
  • high GGT in some seminomas

tumour markers:

  • lactate dehydrogenase (LDH)
  • a-fetoprotein
  • B-hcg
48
Q

What imaging techniques are performed in testicular cancer and why?

A

testicular USS:

  • confirms the presence of the tumour

CTAP:

  • provides a clearer image of the tumour
  • used throughout treatment to monitor response

CXR:

  • used to assess for mediastinal and lung masses
  • testicular cancer travels via the para-aortic lymph nodes so mets are likely to be within this area
49
Q

How is a urinary tract infection defined?

A

the presence of a pure growth of > 105
organisms per mL of fresh MSU

50
Q

How can UTIs be categorised into 3 groups?

A

urethritis:
affecting the urethra

cystitis:
affecting the bladder

pyelonephritis:
affecting the kidney

can have different symptoms / severity depending on which part is affected

51
Q

What is the major causative organism of UTIs?

A

Escherichia coli

52
Q

Why are UTIs more common in females than males?

A

shorter urethra:
* bacteria seeded at urethral opening have a shorter distance to travel to infect the bladder

shorter distance between urethral + anal opening:

53
Q

Other than being female, what are other risk factors for UTIs?

A
  • sexual intercourse
  • pregnancy
  • immunosuppression
  • catheterisation
  • urinary tract obstruction (BPH / calculi)

obstruction can result in infection as bacteria have longer to grow / colonise when urine is static for long periods

54
Q

How does a UTI present?

A

it presents with storage symptoms:

  • dysuria
  • increased frequency
  • urgency
  • foul-smelling urine

storage symptoms occur due to the bladder becoming irritated and being unable to hold urine

55
Q

How does acute pyelonephritis present differently to an oridinary UTI?

A
  • flank pain
  • fever
  • malaise
56
Q

What is the first line and gold standard investigation for UTI?

A

first line:
* urine dipstick
* this will show +ve leucocytes and nitrites

gold standard:
* MSU for MC&S
* this allows identification of the bacteria
* pyelonephritis will have white cell casts

57
Q

When might blood cultures be performed in UTI?

A

if the patient is systemically unwell and there is risk of urosepsis

58
Q

What is involved in the management of UTIs?

A

empirical antibiotics

this is usually nitrofurantoin

59
Q

What is the definition of urinary tract calculi?

Where can they occur?

A

the presence of calculi within the urinary system at any one of three points of narrowing

  1. ureteropelvic junction (kidneys and ureters attach)
  2. pelvic brim (ureters cross the iliac vessels)
  3. ureterovesical junction (ureters attach to bladder)
60
Q

What are the 4 different types of kidney stone?

A
  • calcium oxalate (most common)
  • struvite (magnesium ammonium phosphate)
  • urate / uric acid - NOT visible on XR
  • hydroxyapatite
61
Q

Why do urinary tract calculi occur?

A
  • many things can cause a high concentration of urinary solutes
  • the urine becomes supersaturated and cannot hold any more solutes inside it
  • the solutes precipitate out of solution, become solids and clump together to form stones
62
Q

What metabolic factors can contribute to increased urinary solutes?

A
  • hypercalcaemia
  • hyperuricaemia
  • hypercystinuria
  • hyperoxaluria
  • hypocitraturia
  • hyperparathyroidism
  • renal tubular acidosis
63
Q

What infectious factors can contribute to high urinary solutes?

A
  • hyperuricaemia
  • recurrent UTIs
  • chronic UTI
64
Q

Which drugs can contribute to high concentration of urinary solutes?

A
  • indinavir, atazanavir
  • diuretics
  • antacids (Ca-containing)
  • carbonic anhydrase inhibitors
  • Na- and Ca-containing medications
  • Vit D + C
  • corticosteroids
65
Q

What are the risk factors for urinary tract calculi?

A
  • dehydration
  • high protein intake
  • high salt intake
  • structural abnormalities
  • past medical history of kidney stones
  • family history

dehydration = high conc of urinary solutes due to low urine volume

66
Q

Who is more at risk of urinary tract calculi?

A
  • 3x more common in males
  • more common in 30-50 years
  • higher prevalence in hot, dry countries
67
Q

How do urinary tract calculi tend to present?

A

they tend to be asymptomatic until the calculi gets stuck

  • renal colic (acute SEVERE loin to groin pain)
  • N&V
  • unable to lie still / writhing in pain

renal colic occurs as the body responds to a stuck stone by trying to squeeze/contract to push it out

68
Q

What urinary symptoms are renal tract calculi associated with?

A
  • urgency
  • frequency
  • haematuria

haematuria is usually microscopic (cannot see the blood), but is macroscopic in 15% cases

69
Q

What is the first line investigation for urinary tract calculi?

A

urine dipstick

  • this is performed to confirm / exclude haematuria

a pregnancy test should be performed in ALL women of child-bearing age to exclude ectopic pregancy (severe pain in L/R iliac fossa)

70
Q

What blood tests are performed in renal tract calculi?

A
  • FBC (raised WCC in UTI)
  • U&Es
71
Q

What is the gold-standard investigation to confirm urinary tract calculi?

A

non-contrast CT-KUB

USS used if pregnant

72
Q

What is involved in the acute management of urinary tract calculi?

A
  • fluids
  • analgesia (diclofenac)
  • anti-emetics (ondansetron)
  • urine collection to collect passed stone

if the stone does pass in this time, its composition can be analysed to direct further tests

73
Q

What is the management for a kidney stone < 5mm?

A

leave to pass spontaneously with increased fluid intake

74
Q

What is the management for a kidney stone 5-10mm?

A
  • give alpha-blocker (tamsulosin)
  • surgery performed if stone not passed after 4-6 weeks
75
Q

What is the management for a kidney stone > 10mm (or failed therapy)?

A

surgical removal

  • this is usually performed via extracorporeal shock wave lithotripsy (ESWL)
  • percutaenous nephrostolithotomy (PCNL) is key-hole surgery used for difficult stone shapes e.g. staghorn
76
Q

What is involved in extracorporeal shock wave lithiotripsy (ESWL)?

A

1 - scope passed into the bladder and up the ureter to visualise the stone

2 - electromagnetic wave is focussed onto the stone to break it up into smaller fragments

3 - small fragments are asymptomatically passed in the urine

77
Q

What are the potential complications of urinary tract calculi?

A
  • pyelonephritis
  • septicaemia
  • obstruction
  • urinary retention
  • hydronephrosis / AKI
78
Q

What is the definition of benign prostatic hyperplasia?

A

diffuse hyperplasia of the periurethral (transitional) zone

the transitional zone surrounds the urethra, so as it enlarges it begins to compress the urethra
79
Q

Who is at greater risk of BPH?

A
  • prevalence increases with age
  • more common in Afro-Caribbeans
80
Q

What type of symptoms are present in both prostate cancer and BPH?

A

they both present with lower urinary tract symptoms (LUTS) that can be divided into storage and voiding symptoms

81
Q

What LUTS are common to both prostate cancer and BPH?

What mnemonic can be used to remember these?

A

FUND HIPS

  • F - frequency
  • U - urgency
  • N - nocturia
  • D - dysuria
  • H - hesitancy
  • I - incomplete voiding
  • P - poor stream
  • S - straining

FUND = storage symptoms (due to bladder irritation)

HIPS = voiding symptoms (due to obstruction of urine outflow)

82
Q

What symptoms may be present in prostate cancer but NOT in BPH?

A
  • haematuria
  • symptoms of metastatic spread - bone pain / cord compression
  • FLAWS
83
Q

What are the investigations involved in both prostate cancer and BPH?

A

urinalysis:
* to exclude UTI + assess for haematuria

DRE:
* to determine the nature of the growth

bloods:
* PSA - will be raised < 4 in both
* U&Es to check for impaired renal function

imaging:
* transrectal USS-guided needle biopsy

  • if prostate ca confirmed - isotope bone scan to look for mets
84
Q

How can prostate cancer be distinguised from BPH on DRE?

A

prostate cancer:
* asymmetrical hard nodular prostate
* loss of the midline sulcus

BPH:
* prostate is smoothly enlarged

  • palpable midline groove
85
Q

What is needed to definitively distinguish between prostate cancer and BPH?

A

transrectal ultrasound-guided needle biopsy

this is diagnostic

86
Q

What is involved in the emergency management of BPH?

A
  • may present with acute urinary retention
  • catheterisation is performed

this is when the patient is unable to urinate at all

87
Q

What is involved in the conservative management of BPH?

A
  • monitor symptom progression
  • lifestyle advice - e.g. avoid caffeine
  • medication review

e.g. anticholinergics can lead to urinary retention
diuretics

88
Q

What is involved in the medical management of BPH?

A

first-line:
* selective alpha1-blockers (e.g. tamsulosin)
* this makes it easier to pass urine

second-line:
* 5a-reductase inhibitors (e.g. finasteride)
* indicated when prostate is significantly large and there is high risk of disease progression

89
Q

When may surgery be performed for BPH?

What does this involve?

A

transurethral resection of the prostate (TURP)

  • performed if chosen or refractory to medical treatment

prostate is visualised through the urethra and a device is used to move tissue by electrocautery / sharp dissection

90
Q

What are the 2 different types of bladder cancer?

Who is more likely to be affected?

A
  • 90% of cases are urothelial carcinomas
  • squamous cell carcinoma can also occur
  • 4x more common in men and prevalence increases > 55
91
Q

What are the risk factors for urothelial carcinoma?

A
  • smoking
  • carcinogen exposure
  • aromatic amines
  • polycyclic aromatic hydrocarbons
  • arsenic

PAINTERS and HAIRDRESSERS are more at risk

92
Q

What are the risk factors for squamous cell carcinoma?

A
  • chronic UTIs
  • schistosoma haematobium (parasitic worm that causes bladder inflammation)

it is associated with chronic inflammation of the bladder

93
Q

What symptoms are associated with bladder cancer?

A
  • painless MACROSCOPIC haematuria
  • storage symptoms of FUNDHIPS (frequency, urgency, nocturia, dysuria)
  • FLAWS

if someone presents with macroscopic haematuria, it is treated as bladder cancer until proven otherwise

94
Q

What is the first line investigation for bladder cancer?

A

urinalysis to confirm haematuria

95
Q

What blood tests may be performed in suspected bladder cancer?

A
  • FBC - to check that patient is not anaemic from blood lost in the urine
  • ALP - raised if there are bony mets
  • U&Es - to check kidney function when presenting with urinary symptoms
96
Q

What imaging techniques may be performed in bladder cancer?

A

cystoscopy + biopsy:
* gold standard and diagnostic

CTAP / MRI AP:
* to exclude calculi and visualise the cancer

isotope bone scan:
* to assess for bony mets

CXR:
* to assess for lung mets

Y4 - CCC & PC (34 decks)

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