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Year 5 > Urology > Flashcards

Urology Flashcards

1
Q

Define an isolated UTI

A

Interval of >6 months between urinary infections

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2
Q

Define recurrent UTI

A

> 2 infections in 6 months

OR

> 3 infections within 12 months

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3
Q

Common causative organisms of UTIs

A
  • Klebsiella
  • E. Coli
  • Enterococci
  • Proteus
  • Pseudomonas
  • S. Saprophyticus
  • Candida albicans (patients on long-term antibiotics)
  • Cryptococcus (immunosuppressed patients)
  • Schistoma (Middle Eastern countries)
  • Mycobacterium TB
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4
Q

Risk factors for cystitis

A
  • Urine stasis/outflow obstruction
  • Foreign body e.g. stone, catheter, instrumentation
  • Immunosuppression e.g. diabetes, malignancy
  • Congenital lower urinary tract abnormalities
  • Pregnancy
  • Sex - males in infancy and after >40, female after puberty
  • Smoking
  • Menopause
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5
Q

Risk factors for pyelonephritis

A
  • Urinary tract obstruction (congenital or acquired)
  • Vesicoureteral reflux
  • Foreign body e.g. stones, instrumentation, catheter
  • Sexual intercourse
  • Immunosuppression e.g. diabetes, HIV, lymphoma
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6
Q

Clinical features of cystitis

A
  • Urgency
  • Dysuria
  • Frequency
  • Polyuria
  • Haematuria
  • Supra-pubic pain
  • Urethral burning
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7
Q

Clinical features of pyelonephritis

A
  • Lower UTI symptoms (dysuria, urgency, frequency)
  • Malaise
  • Fever/chills
  • Loin pain
  • Nausea/vomiting
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8
Q

Which UTI patients require further investigation?

A
  • Recurrent UTIs
  • Frank haematuria
  • Men with UTIs
  • Children with UTIs
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9
Q

What investigations would you consider in a patient with UTIs?

A
  • Urine dipstick
  • Urine C&S
  • Blood cultures
  • Post-void residual volume scan
  • Renal US
  • Plain X-ray KUB
  • Flexible cystoscopy
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10
Q

When is a urine dipstick indicated in a women with a suspected UTI?

A
  • Women <65, otherwise healthy, <2 classic UTI symptoms or unclear diagnosis
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11
Q

Management of uncomplicated in a female patient

A

1) 3 days Trimethoprim PO

2) 3 days Nitrofurantoin PO

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12
Q

Management of cystitis in a male patient

A

1) 7 days Trimethoprim PO

2) 7 days Nitrofurantoin PO

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13
Q

Management of pyelonephritis

A

1) Gentamicin + Amoxicillin IV

2) Gentamicin + Vancomycin

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14
Q

Lifestyle advice/conservative management for a patient with a UTI

A
  • Maintain high fluid intake
  • Regular bladder emptying
  • Avoid spermicides
  • Drink cranberry juice
  • Use oestrogen replacement
  • Urinate after intercourse
  • Wipe front to back
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15
Q

Contra-indications for nitrofurantoin

A
  • Pyelonephritis
  • eGFR<45
  • In combination with alkalising agents
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16
Q

Complications of pyelonephritis

A
  • Renal papillary necrosis
  • Perinephric abscess
  • Pyonephrosis
  • Chronic pyelonephritis
  • Fibrosis and scarring
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17
Q

Common pathogens causing Epididymitis/orchitis

A

Sexually active men <35:

  • N. Gonorrhea
  • C. Trachomatis
  • Coliforms

Older men or children:
- E. Coli

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18
Q

Clinical features of orchitis/epididymitis

A
  • Fever
  • Testicular swelling
  • Scrotal pain (may radiate to the groin)
  • Scrotal erythema
  • Reactive hydrocele
  • Evidence of underlying infection e.g. urethral discharge, urethritis, cystitis, prostatitis
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19
Q

Main differential for orchitis/epididymitis

A

Testicular torsion - surgical exploration required if any uncertainty

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20
Q

What investigations would you consider in a patient with ?orchitis/epididymitis?

A
  • Bloods - FBC, U&Es, CRP, blood cultures
  • Urine dipstick and MSU
  • Urethral swab
  • Scrotal ultrasound
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21
Q

Management of a man <35 (or with suspected C. trichomatis) with orchitis/epididymitis

A

14 days BD Ofloxacin

Or

Single dose azithromycin

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22
Q

Management of a man >35 (or with suspected Gonorrhoea) with orchitis/epididymitis

A

14 days BD Ciprofloxacin

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23
Q

Common pathogens in prostatitis

A 
Klebsiella
E. Coli
Enterococci
Proteus
Pseudomonas
S. Saprophyticus
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24
Q

Clinical features of acute prostatitis

A
  • Malaise
  • Fever/rigors
  • Difficulty passing urine
  • Dysuria
  • Perineal/rectal/lower back tenderness
  • Haematuria
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25
Q

Typical DRE findings in acute prostatitis

A

Soft, tender enlarged prostate

May be boggy if prostatic abscess present

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26
Q

Investigations to consider in a patient with ?acute prostatitis

A
  • DRE
  • MSU C&S
  • Bloods - FBC and blood culture
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27
Q

Treatment of acute prostatitis

A

2-4 weeks ciprofloxacin

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28
Q

Main complication of acute prostatitis

A

Prostatic abscess

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29
Q

Clinical features of chronic bacterial prostatitis

A
  • Recurrent exacerbations of acute prostatitis symptoms
  • Recurrent UTIs with the same organism

Patients are frequently asymptomatic with a normal prostate on DRE

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30
Q

Investigations to be considered in a patient with ?chronic bacterial prostatitis

A
  • DRE (frequently normal)
  • Urinalysis (colony counts in expressed prostatic secretion and urine void) - massage colony counts should exceed initial and MSU samples by >10x
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31
Q

Management of chronic bacterial prostatitis

A

3-4 months of fluoroquinolone + alpha blocker

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32
Q

Clinical features of chronic abacterial prostatitis

A
  • > 3 months of localised pelvic/perineal/suprapubic/penile/groin/lower back pain
  • Pain on ejaculation
  • Lower UTI symptoms
  • Erectile dysfunction
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33
Q

Investigations to consider in a patient with ?chronic abacterial prostatitis

A
  • NIH-CPSI questionnaire
  • PVR
  • Segemented urine and expressed prostatic secretions C&S
  • Semen analysis
  • Urethral swab
  • Urine cytology
  • Urodynamics
  • Cytoscopy
  • TRUS
  • PSA
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34
Q

Management options for chronic bacterial prostatitis

A
  • Conservative options e.g. counselling, biofeedback, education, anxiety reduction
  • Alpha blockers
  • Antibiotics
  • Anti-inflammatory medications
  • 5-alpha-reductase inhibitors
  • Neuromodulation
  • Prostatic massage (2-3/week for 6 weeks with antibiotics)
  • Pain team referral
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35
Q

3 causes of transient haematuria

A
  • Vigorous exercise
  • Sexual intercourse
  • Menstruation
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36
Q

3 benign causes of visible haematuria

A

1) UTI
2) BPH
3) Stones

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37
Q

3 malignant causes of visible haematuria

A

1) Bladder cancer
2) Renal cell carcinoma
3) Upper tract transitional cell carcinoma

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38
Q

Causes of haematuria

A
  • Coagulation disorders
  • Haemophilia
  • Sickle cell disease
  • Tumours e.g. renal, bladder, ureteric, prostate
  • BPH
  • Trauma
  • Stones
  • Infection
  • Circulatory disorders e.g. vascular malformations, renal infarction
  • Medications e.g. anticoagulants, penicillin, cyclophosphamide
  • Autoimmune disease e.g. IgA nephropathy, glomerulonephritis, HSP
  • Inflammatory disorders e.g. interstitial cystitis
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39
Q

Investigations to perform in a patient with visible haematuria

A

1) Bloods - FBC, U&Es, CRP, clotting screen, group and save
2) MSU C&S
3) Flexible cytoscopy
4) CT Urogram or IVU and renal USS

(and vital signs for signs of haemodynamic compromise)

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40
Q

Red flags for visible haematuria

A
  • Blood clots
  • Anaemia
  • Haemodynamic instability
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41
Q

What would you do with a patient with visible haematuria and red flag symptoms?

A

IMMEDIATE referral to SAU for bladder irrigation

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42
Q

All visible haematuria should be investigated with ??? within ?? weeks

A

Flexible cystoscopy

2 weeks

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43
Q

All symptomatic non-visible haematuria should be investigated with ?? within ?? weeks

A

Flexible cystoscopy

4-6 weeks

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44
Q

All asymptomatic non-visible haematuria patients under age ?? should be referred to ??

A

40
Renal

(refer those over 40 to urology)

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45
Q

Main type of cancer in bladder cancer

A

Transitional cell carcinoma

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46
Q

Risk factors for bladder cancer

A
  • Smoking (TCC)
  • Previous pelvic radiotherapy
  • Aromatic hydrocarbons (TCC)
  • Chronic inflammation (SCC)
  • Schistosomiasis infection (SCC)
  • Exposure to other carcinogens found in the urine (TCC)
  • Male sex (3:1 male: female ratio)
  • Age (incidence rises >50, peaks at 70
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47
Q

What percentage of bladder cancers are superficial non-muscle invasive cancers>

A

80%

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48
Q

Clinical features of bladder cancer

A
  • VISIBLE PAINLESS HAEMATURIA
  • Microscopic haematuria
  • Storage related lower urinary tract symptoms
  • Anaemia symptoms (breathlessness, palpitations)
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49
Q

Management steps for a NIMBC

A

1) TURBT and single dose intravesical chemotherapy with Mitomycin C
2) Further TURBT after 6 weeks to ensure adequate resection (in those with high grade disease or no detrusor muscle in initial resection)
3) Intravesical immunotherapy with BCG to reduce recurrence risk (those with recurrent/multifocal disease)
4) Long term cystoscopy follow up

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50
Q

Management of a MIBC

A

1) TURBT and single dose intravesical chemotherapy with Mitomycin C
2) Radical cystectomy and urinary division
OR
Radical radiotherapy
3) Chemotherapy with cisplatin

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51
Q

Prognosis for bladder cancer patients

A
  • > 90% at 5 years for low grade tumours

- ~50 at 5 years for high grade/invasive tumours

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52
Q

Risk factors for renal cell carcinoma

A
  • Smoking
  • Obesity
  • Cadmium exposure
  • Employment in the leather industry
  • Von Hippel Lindau syndrome
  • Male (3:1 male: female ratio)
  • Age (peak incidence between 50-60)
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53
Q

Clinical features of renal cell carcinoma

A

Usually ASYMPTOMATIC (50%)

10% present with the ‘too late triad’:

1) Visible haematuria
2) Flank pain
3) Palpable mass

Can present with paraneoplastic syndromes:

  • Anaemia
  • Polycythaemia
  • Raised ESR
  • Hypercalcaemia
  • Erythocytosis
  • Hypertension
  • Abnormal LFTs
  • Decreased WCC
  • Fever
  • Hepatic necrosis
  • Peripheral oedema

30% present with symptoms of metastasis:

  • Bone pain
  • Night sweats
  • Fatigue
  • Weight loss
  • Haemoptysis
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54
Q

Common sites of metastasis of renal cell carcinoma

A
  • Bone
  • Brain
  • Lung
  • Liver
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55
Q

Investigations to consider in a patient with ?RCC

A
  • Bloods - FBC, ESR, U&Es, LFTs, coagulation screen, LDH, calcium, chP
  • Renal US
  • CT
  • CT chest, abdo, pelvis and bone scan (if clinical evidence of metastasis)
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56
Q

Surgical options for management of an RCC

A
  • Radical nephrectomy
  • Partical nephrectomy
  • Immunotherapy
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57
Q

Oncological option for management of an RCC

A

Tyrosine kinase inhibitors e.g. sunitinib, pazopanib

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58
Q

Risk factors for upper tract TCC

A
  • Smoking
  • Phenacetin ingestion
  • Balkan nephropathy
  • Lynch syndrome
  • Male sex (3:1)
  • Age
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59
Q

Clinical features of Upper tract TCC

A
  • Visible haematuria
  • Flank pain (‘clot colic’)
  • Asymptomatic
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60
Q

Investigations to consider in a patient with suspected UTTCC

A
  • CT urogram or renal US and IVP
  • Cystoscopy +/- retrograde pyelogram
  • Urine cytology
  • Flexible ureteroenscopy + biopsy
  • CT chest/abdo/pelvis for staging
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61
Q

Management of a patient with non-metastatic UTTCC with a normal contralateral kidney

A
  • Radical nephro-ureterectomy with bladder cuff excision
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62
Q

Indications for percutaneous, segmental or Oureteroendoscopic resection or laser ablation +/- Mitomycin C in UTTCC

A
  • Single functioning kidney
  • Bilateral disease
  • Unilateral low grade tumour <1cm
  • Unfit for surgery
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63
Q

Risk factors for prostate cancer

A
  • Age
  • Race - African Americans
  • Environmental factors - common in Scandinavia, uncommon in Asia
  • Diet - animal fat associated with prostate cancer
  • Obesity
  • Nationality
  • Endocrine environment
  • Family history
64
Q

Clinical features of prostate cancer

A

Most patients are ASYMPTOMATIC

Symptoms can include:

  • Poor stream
  • Hesitancy
  • Nocturia
  • Incomplete bladder emptying
  • Acute urinary retention

40% of patients present with symptoms of local invasion or metastasis:

  • Anaemia
  • Bone pain
  • Ureteric obstruction
65
Q

Investigations to consider in a patient with suspected prostate cancer

A
  • Bloods - FBC, U&Es, LFTs
  • PSA (total and free levels)
  • DRE
  • MRI
  • TRUS + biopsy (if indicated)
66
Q

Indications for a TRUS biopsy

A
  • <60 year old with PSA >3
  • 60-70 year old with PSA >4
  • > 70 year old with PSA >5
67
Q

A hard nodular, irregular prostate would make you suspect …?

A

Prostatic carcinoma

68
Q

A boggy, tender prostate on DRE would make you suspect …?

A

Prostatitis

69
Q

Risks/side effects of TRUS and biopsy

A
  • Infection
  • Haematuria
  • Haematospermia
  • Haemtochezia
  • Urinary retention
  • Sepsis
70
Q

Causes of a raised PSA

A
  • Trauma
  • BPH
  • UTI
  • Recent ejaculation
  • Prostate cancer
  • DRE
  • TURP/TRUS
  • Acute or chronic prostatitis
  • Catheterisation
  • Urinary retention
71
Q

Describe the TNM staging of prostate cancer

A 
T1 - non-palpable tumour
T2 - Palpable tumour confined within prostate capsule
- 2a = <50% of one lobe
- 2b = >50% of one lobe
- 2c = both lobes involved
T3 - tumour locally invading
- 3a = breaching the capsule
- 3b = invading the seminal vesicles
T4 - invading adjacent organs +/- metastasis
72
Q

What 3 features determine risk in prostate cancer?

A

1) PSA level
2) Gleason score
3) Clinical TNM stage

73
Q

Management options for a low risk prostate cancer

A

1) Watchful waiting - scan if symptomatic (life expectancy <10 years, unfit for treatment)
2) Active surveillance (PSA every 3 months, DRE every 6 months, TRUS every year)

3) Radical prostatectomy OR
4) Radical radiotherapy - brachytherapy or external beam radiation

74
Q

Management options for a intermediate risk prostate cancer

A

1) Radical prostatectomy +/- external beam radiotherapy

2) + androgen deprivation therapy (GnRH antagonists or LHRH agonists)

75
Q

Management options for metastatic prostate cancer

A

1) Androgen deprivation therapy - LHRH agonist, GnRH antagonists or orchidectomy
2) Chemotherapy

76
Q

Risk factors for testicular cancer

A
  • Age - most common between 20-50 year olds with a peak in the 20s
  • Ethnicity - most common in white ethnic groups
  • Family history
  • History of cryptorchidism
  • HIV
77
Q

Clinical features of testicular cancer

A

Most present with a painless testicular lump.

Can also present with a painful, swollen testicle or features of metastasis

78
Q

Most common sites of metastasis of testicular cancer

A
  • Bone
  • Liver
  • Lungs
79
Q

Differentials for testicular cancer

A
  • Hydrocele
  • Epididymal cyst
  • Indirect inguinal hernia
  • TB or syphilis
80
Q

Investigations to consider in a man with suspected testicular cancer

A
  • Ultrasound (diagnostic)
  • Serum tumour markers (LDH, AFP, BHCG)
  • CT chest/abdo/pelvis (for staging)
81
Q

Management of a man with a testicular seminoma

A

1) Inguinal orchidectomy
(+/- retroperitoneal node dissection)
2) Radiotherapy

82
Q

Management of a man with a testicular non-seminona

A

1) Inguinal orchidectomy
(+/- retroperitoneal node dissection)

2) Cisplatin-based chemotherapy

83
Q

Risk factors for penile cancer

A
  • Foreskin presence
  • Smoking
  • HPV/genital warts
  • Age - incidence increases with age and peaks in the 70s
  • Ethnicity - commonest in South America
84
Q

Clinical features of penile cancer

A

Most present with a painless lump or ulcer on the distal aspect of the penis/glans.

Rarely patients present with an inguinal mass or acute urinary retention

85
Q

Investigations to consider in a man with suspected penile cancer

A
  • Bloods - FBC, U&Es, Calcium, LFTs
  • Biopsy
  • MRI (to assess local invasion)
  • CT chest/abdo/pelvis (for staging)
86
Q

Risk factors for renal stones

A
  • Hypercalcemia
  • Hyperuricosuria
  • Hyperoxaluria
  • Gout
  • Cysteinuria
  • Infection
  • Renal tubula acidosis
  • Renal disease e.g. polycystic kidneys
  • Dehydration
  • Age - peak incidence between 20-50
  • Male sex (3:1 male:female ratio)
  • Family history
  • Hotter climates
  • Caucasian ethnicity
  • Seasonal variation - more in summer
87
Q

Clinical features of kidney stones

A

Classic presentation is ‘loin to groin’ pain. Other symptoms include:

  • Haematuria
  • Sweating
  • Pallor
  • Nausea and vomiting
  • Strangury
88
Q

Differential diagnoses for renal stones

A
  • Ruptured AAA
  • Pneumonia
  • Appendicitis
  • Ectopic pregnancy
89
Q

Which investigations would you consider in a patient with ?kidney stones?

A
  • Bloods - FBC, U&Es, CRP
  • Urinalysis
  • Stone analysis
  • CTKUB (no contrast)
  • Plain X-ray KUB
  • USS
  • IV urography
90
Q

How would you manage a patient with a small kidney stone?

A

1) NSAIDs and an alpha blocker

Small stones usually take 3 weeks to pass and if they don’t pass within 2 months of diagnosis, it is unlikely that they will pass spontaneously.

91
Q

3 indications for ureteric stenting in a renal stone patient

A

1) Infection (pyrexia, raised ESR)
2) Compromised renal function (deranged U&Es)
3) Pain not responsive to opiates

92
Q

3 definitive treatment options for renal stones

A

1) Extra-corporal shock wave lithotripsy (ESWL) - for proximal stones <1cm
2) Ureteroscopy
3) Percutaneous nephrolithotomy (for calyceal stones and stones >3cm)

93
Q

Define urge urinary incontinence

A

Involuntary leakage of urine accompanied by or immediately preceded by urgency (a sudden compelling desire to pass urine which is difficult to defer)

94
Q

Causes of urge incontinence

A
  • Lower urinary tract infection/inflammation
  • Bladder hyperreflexia
  • Stroke
  • Parkinson’s disease
  • Alzheimer’s disease
  • Old age
  • Herniated spinal disc
  • Detrusor overactivity
  • Benign prostatic hypertrophy and obstruction
  • Loop diuretics
95
Q

Define Overactive Bladder Syndrome

A

A symptom complex characterised by urgency (with/without urge incontinence, usually accompanied by frequency and nocturia).

96
Q

Management of overactive bladder syndrome

A

1) Lifestyle advice
- Fluid management
- Reduce caffeine, alcohol, diuretics and smoking
- Bladder retraining - regular voiding by the clock with gradual increase in time between voids, double voiding
- Continence devices

2) Anti-muscarinics e.g. oxybutin, tolterodine, darifenacin
3) Beta-3 adrenergic agonist e.g. Mirabegron, Betmiga
4) Botulinum toxin to relax detrusor muscle injections round bladder (Type A)
5) Surgical options - now rare e.g. detrusor myectomy, augmentation CLAM ileocytoplasty

97
Q

Side effects of anti-muscarinics

A
  • Dry eyes
  • Blurred vision
  • Dry mouth
  • Lightheadedness
  • Constipation
  • Theoretical risk of increased residual volume
98
Q

Define stress urinary incontinence

A

Involuntary leakage of urine on increase in intra-abdominal pressure e.g coughing, exertion, sneezing

99
Q

Describe the grading system for stress urinary incontinence

A

Grade 0 - reports leakage but no clinical evidence
Grade 1 - leakage occurs during stress with <2cm descent of bladder base below upper border of pubic symphysis
Grade 2 - leakage on stress accompanied by marked bladder descent (>2cm) occurring only during stress (2a) or permanently (2b)
Grade 3/Intrinsic sphincter deficiency - Bladder neck and proximal urethra are already open at rest (with or without descent)

100
Q

Management of stress urinary incontinence

A

1) Lifestyle
- Physiotherapy e.g. pelvic floor exercises
- Vaginal cones
- Devices for reinforcement
- Biofeedback
- Weight loss

2) high dose Duloxetine
3) Urethral injection - injection of bulking materials into bladder neck and periurethral muscles, 50-70% success rate
4) Pubovaginal sling - mainly used in those with poor urethral function

101
Q

Side effects of duloxetine

A

Upper GI side effects e.g. nausea

102
Q

Define overflow incontinence

A

Incontinence occurring when the bladder is abnormally distended with urine - typically due to chronic urinary retention

103
Q

Causes of overflow incontinence

A
  • Outlet obstruction e.g. faecal impaction, benign prostatic hypertrophy
  • Under-active detrusor muscle
  • Bladder neck stricture
  • Urethral stricture
  • Drugs e.g. alpha-agonists, anticholinergics, calcium channel blockers, sedatives
  • Intra- or post-operative over-distention
  • Bladder generation following surgery
104
Q

Causes of temporary incontinence

A
  • Delirium/dementia
  • Infection
  • Atrophic vaginitis
  • Pharmaceuticals
  • Psychological causes
  • Endocrine
  • Restricted mobility
  • Stool impaction
105
Q

Define total incontinence

A

Continuous loss of urine with no voluntary control

106
Q

Clinical features of BPH

A
  • Lower urinary tract symptoms (hesitancy, straining, poor stream, incomplete bladder emptying)
  • Acute urinary retention
  • Haematuria
  • Hydronephrosis and renal compromise
  • UTI
107
Q

Investigations to consider in a patient with ?BPH

A
  • DRE
  • Urinalysis
  • U&E
  • PSA
  • Uroflowmetry
108
Q

Management of BPH

A

1) Watchful waiting and lifestyle changes
2) Alpha antagonists e.g. tamsulosin
3) 5-alpha reductase inhibitors e.g. finasteride
(Plus anticholinergics for storage symptom relief)
4) TURP
5) Laser prostatectomy
6) Open (Millin’s) prostatectomy

109
Q

Causes of upper tract urinary obstruction/hydronephrosis

A

Unilateral:

  • Obstructing stone/clot
  • Pelvic-ureteric junction obstruction
  • Ureteric or bladder TCC
  • Extrinsic mass e.g. pregnancy, tumour

Bilateral:

  • BPH
  • Prostate cancer
  • Urethral stricture
  • Detrusor sphincter dyssynergia
  • Cervical cancer
  • Rectal cancer
  • Bladder cancer
  • Poor bladder compliance
  • Adjacent GI disease e.g. Crohn’s, UC, diverticulitis
  • Retroperitoneal fibrosis
  • Bilateral PUJO
  • Hydronephrosis of pregnancy (physiological)
  • Ileal conduit (normal)
110
Q

Clinical features of hydronephrosis

A
  • Flank pain
  • Anuria
  • Renal failure symptoms e.g. nausea, lethargy, fatigue
  • Sepsis symptoms
  • Hypertension
  • Palpable bladder
  • Palpable mass on DRE
111
Q

Investigations to consider in a patient with hydronephrosis

A
  • U&Es
  • Renal USS
  • CT urogram/retrograde pyelogram
  • MAG3 renogram
112
Q

Define post-obstructive diuresis

A

> 3L in 24 hours or >200ml/hour over each 2 consecutive hours

113
Q

Management of post-obstructive diuresis

A
  • Admit patient and monitor hourly urine output, haemodynamic status and electrolytes
  • NaCl if postural drop in BP
  • Monitor creatinine and urea until normal
114
Q

What fluid should be avoided in post-obstructive diuresis and why?

A

Glucose - it can cause continuing diuresis

115
Q

Clinical features of an inguinal hernia in the testis

A
  • Positive cough impulse
  • Usually reduces with direct pressure
  • Not possible to get above the lump
116
Q

Causes of hydrocele

A
  • Congenital
  • Idiopathic
  • Infection
  • Traumatic
  • Associated with underlying testicular tumour
117
Q

Clinical features of a testicular hydrocele

A
  • Painless
  • Can be large and tense
  • Trans-illuminates
  • Can get above lump
118
Q

Investigations to consider in a testicular hydrocele

A

Testicular US to rule out a testicular tumour

119
Q

Management of testicular hydrocele

A
  • No treatment required if asymptomatic

- Surgical drainage can be done to remove tense or large symptomatic hydrocele

120
Q

The sudden onset of a large varicocele is a red flag for ???

A

Renal tumour

121
Q

Clinical features of a varicocele

A
  • More common on the left side
  • ‘Bag of worms’ appearance
  • Dragging sensation
122
Q

How would you diagnose a varicocele?

A

Clinically - examine the patient in the upright and supine position

(Semen analysis can be considered if the patient is infertile)

(US can be considered if an underlying malignancy is suspected)

123
Q

Management of varicocele

A

All:
- Regular testicular size measurements

Older men who don’t want children:
- Conservative management e.g. NSAIDs, scrotal support

Young men with retarded growth of a test or abnormal sperm count who want children:
- Varicocelectomy

124
Q

Clinical features of an epididymal cyst

A
  • Slow growing
  • Can get above them
  • Usually lie above and behind the testis
125
Q

Clinical features of testicular trauma (causing bleeding)

A
  • Severe pain
  • Signs of external injury
  • Testis may not be palpable
  • Bruising to the scrotal wall
126
Q

Investigation of choice in testicular trauma

A

Testicular US - testicular rupture will appear as hypo-echoic areas

127
Q

Management of testicular rupture

A
  • Surgical exploration and fixation of the damaged structure e.g. tunica albuginea
128
Q

Clinical features of testicular torsion

A
  • Age 10-30 (peak at 13-15)
  • Sudden onset severe pain in the scrotum, often waking patient from sleep
  • Groin, loin or epigastric pain
  • May have history of similar pain which spontaneously resolved

On examination:

  • Slightly swollen testis
  • Very tender to touch
  • High riding and horizontally lying testis
  • Absent Cremaster reflex (Rabinowitz’s sign)
129
Q

Management of testicular torsion

A
  • Urgent surgical exploration and de-torsion

Bilateral fixation is done at this stage as bell-clapper abnormality can occur bilaterally

130
Q

Define sub fertility

A

Failure to conceive after a minimum of 12 months unprotected intercourse

131
Q

Causes of male infertility

A
  • Idiopathic
  • Varicocele
  • Cryptorchidism
  • Functional sperm disorders
  • Erectile problems
  • Post-testicular injury
  • Endocrine disorders
  • Genetic disorders
  • Systemic disease
  • Drugs e.g. chemotherapy, steroids, alcohol, cannabis, tobacco
  • Infections
132
Q

Investigations to consider in male infertility

A
  • Semen analysis
  • Hormone measurements
  • Scrotal US
  • Trans-rectal US (if low ejaculate volume present)
  • Venography (if varicocele suspected)
133
Q

Management options for male infertility

A
  • Lifestyle modification e.g. decrease alcohol intake, smoking cessation
  • Treat any infection
  • Hormonal manipulation
  • Vitamin E, zinc and folic acid supplementation
  • Treat erectile dysfunction
  • Surgical management e.g. micro-surgery to blockages, assisted contraception
134
Q

Define erectile dysfunction

A

Consistent or recurrent inability to attain and/or maintain a penile erection sufficient for sexual intercourse

135
Q

Causes of erectile dysfunction

A
  • Inflammatory e.g. prostatitis
  • Mechanical e.g. Pyrenees’ disease
  • Psychological e.g. depression, anxiety, relationship problems
  • Occlusive vascular factors e.g. hypertension, smoking, diabetes, peripheral vascular disease
  • Trauma
  • Extra factors e.g. surgery, prostatectomy
  • Neurogenic e.g. MS, Parkinson’s, spina bifida
  • Chemical - B-blockers, thiazides, ACE inhibitors, amiodarone, SSRIs, tricyclics, benzodiazepines, finasteride, GnRH analogues, levodopa, alcohol
  • Endocrine e.g. diabetes, hypogonadism, hypothyroidism
136
Q

Investigations to consider in a man with erectile dysfunction

A
  • Bloods: U&Es, fasting glucose, testosterone, LH/FSH, PSA, TFTs
  • Penile Doppler US (pre and post PGE1 injection)
  • Penile arteriography (after trauma in young men)
137
Q

Management options for erectile dysfunction

A
  • Psychosexual therapy
  • PDE5 inhibitors
  • Dopamine receptor agonists
  • Intra-urethral therapies
  • Intra-cavernosal injections
  • Vacuum erection device
  • Penile prosthesis
  • Androgen replacement therapy
138
Q

Risk factors for UTIs in children

A
  • Age - infants and neonates
  • VUR
  • Previous UTI
  • Genito-urinary abnormalities
  • Abnormal bladder activity
  • Female sex
  • Uncircumcised boys
  • Faecal colonisation
  • Chronic constipation
139
Q

Clinical features of UTIs in young children

A
  • Fever
  • Irritability
  • Vomiting
  • Lethargy
  • Poor feeding
140
Q

Investigations to consider in a child with a suspected UTI

A
  • Urine dip and MSSU
  • US KUB
  • DSMA
  • Micturating cystogram
141
Q

Clinical features of phimosis

A
  • Foreskin can not be retracted behind the glans
  • Inflammation/infection (balanitis)
  • Bleeding
  • UTIs
  • Ballooning of the foreskin during urine voiding
  • Pain or skin trauma during sexual intercourse
142
Q

Management of phimosis

A

1) 0.1% betamethasone (in children and young men)

2) Circumcision/preputioplasty (in symptomatic phimosis or recurrent infection)

143
Q

Complications of phimosis

A
  • Paraphimosis (can lead to arterial occlusion and necrosis)
  • Balanitis
  • Penile cancer
  • STIs
144
Q

Management of cryptorchidism

A
  • Orchidopexy (between 6-18 months)
    Or
  • Orchidectomy (in very small testes)
145
Q

Complications of cryptorchidism

A
  • Increased risk of testicular cancer
  • Increased risk of infertility
  • Increased risk of testicular torsion
  • Increased risk of indirect inguinal hernias
146
Q

Clinical features of VUR

A
  • More common in males
  • Family history
  • UTIs
  • Abdominal pain
  • Failure to thrive
  • Vomiting and diarrhoea
147
Q

Investigations to consider in a child with suspected VUR

A
  • Urine dip and MSSU
  • US KUB
  • DMSA renogram
  • Cystography
  • Urodynamic studies
148
Q

Classifications of VUR

A

1) reflux limited to ureter
2) reflux into renal pelvis
3) mild dilation of the ureter and pelvic-calyceal system
4) Tortuous ureter with moderate dilation, preserved papillary impression
5) Tortuous ureter with severe dilation and loss of papillary impression

149
Q

Management of VUR in children

A

1) Correct underlying cause
2) Grade 1-3 usually resolve without treatment
Grade 3-5 may require low dose antibiotics
3) Surgery in select cases

150
Q

Abnormalities associated with exstrophy

A
  • Epispadias
  • Bone defects (widening of the pubic symphysis)
  • Genital defects
  • Exposed bladder plate
  • VUR
  • Abnormally positioned anus, rectal prolapse or incontinence
151
Q

Diagnosis of exstrophy

A
  • usually diagnosed ante-nasally on 20 week metal abnormality scan
152
Q

Abnormalities associated with hypospadias

A
  • Hooded foreskin
  • Ventral curvature of the penis
  • Undescended testes
  • Inguinal hernias
  • Disorders of sexual development
153
Q

Management of hypospadias

A

Surgical repair between 6-18 months in children with a severe deformity, problems with voiding or predicted problems with sexual function

154
Q

Abnormalities associated with epispadias

A
  • Exstrophy
  • Other congenital defects of the urogenital tract
  • VUR
155
Q

Management of epispadias

A
  • Urethroplasty and cosmetic reconstruction between 6-18 months and further surgery to reconstruct the bladder neck at 4-5 years

Year 5 (9 decks)

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