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Clinical Presentation Of Urological Conditions Flashcards

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1
Q

List the Obstructive voiding symptoms of LUTS

A

Hesitancy

Weak urinary stream

Interrupted stream

Feeling of incomplete voiding

Post-micturation dribbling

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2
Q

List the Irritative voiding symptoms of LUTS

A

Frequency

Nocturia

Urgency

Urge incontinence

Dysuria

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3
Q

What are the complications of bladder outflow obstruction?

A

Chronic renal failure

Infection
• Cystitis
• Pyelonephritis
• Epididymitis

Bladder calculus

Urinary retention

Bladder diverticulum

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4
Q

List the causes of obstructive voiding symptoms in males

A

BPH

Prostate Carcinoma

Urethral strictures

Bladder neck contracture

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5
Q

List the causes of obstructive voiding symptoms in males

A

Urethral diverticulum

Urethral carcinoma

Stricture

Bladder prolapse

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6
Q

What are the causes of irritative voiding symptoms?

A

UTI

Carcinoma in situ

Bladder outflow obstruction

Overactive bladder

Neuropathic bladder

Small bladder capacity
• TB
• interstitial cystitis

PID

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7
Q

Define urinary incontinence

A

Inappropriate involuntary voiding or leakage of urine, producing social and hygiene problems

Inability to suppress reflex bladder contractions

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8
Q

Define total urinary incontinence

A

Continuous dribbling incontinence with low residual volume in the bladder

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9
Q

Define overflow incontinence

A

Continuous dribbling incontinence with high residual volume in the bladder (full bladder)

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10
Q

Define stress incontinence

A

Leakage of urine from the urethra with a rise in intra-abdominal pressure in the absence of a detrusor contraction

Rise in intra-abdominal pressure is caused by:
• coughing
• sneezing
• straining

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11
Q

List 5 types of urinary incontinence

A

Stress incontinence

Overflow incontinence

Total incontinence

Urge incontinence

Paradoxical incontinence

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12
Q

List five possible causes of urge incontinence

A

Age

Cystitis

Radiation

Bladder stones

Bladder tumours

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13
Q

List the non-surgical treatment for stress incontinence

A

Weight loss

Stop smoking

Pelvic floor exercises

Electrical stimulation

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14
Q

List the causes of overflow incontinence

A

Neurogenic bladder

Atonic detrusor muscle

Tricyclic antidepressants

Urethral stricture

Bladder neck stenosis

Prostatic obstruction
• BPH
• Prostate carcinoma

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15
Q

What is the management of urge incontinence?

A

Anticholinergics - Oxybutinin

Augmentation cystoplasty

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16
Q

What is the management of stress/total incontinence?

A

Alpha-adrenergic agonists - pseudoephedrine

Tension free vaginal tape (TVT)

Periurethral injection of Teflon

Artificial urinary sphincter

Bypass urethra by urinary diversion

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17
Q

What is the management of overflow incontinence?

A

Clean intermittent self catheterization

Surgical removal of obstruction

Urethral stricture surgery

Prostatectomy

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18
Q

What are the urological causes of haematuria in the kidney?

A

Blunt/penetrating trauma to the kidneys

Acute pyelonephritis

TB of the kidney

Renal tumor

Renal calculus

Polycystic kidney disease

Renal vein thrombosis

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19
Q

What are the urological causes of haematuria in the bladder?

A

Blunt/Penetrating trauma

Bladder cancer

Bladder calculus

Acute haemorrhagic cystitis

TB of the bladder

Schistosomiasis

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20
Q

Discuss the pathogenesis of a urinary tract infection in adults

A

Urinary tract sterile above the level of the distal urethra

Organisms reach the urinary tract via ascending route

Organisms gain access, adhere to urothelium and multiply

Virulent bacteria overcome normal host defense mechanisms

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21
Q

List the causes of urinary tract infections in adults

A

E. coli

Klebsiella

Proteus

Pseudomonas

Streptococcus infection

Staphylococcal infection

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22
Q

List the common causes of urinary tract infections in immunocompromise patience

A

Candida

Adenovirus

CMV

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23
Q

List the local predisposing factors of UTIs

A

Stones - kidney/ureters

Pelvic ureteric junction obstruction

BPH

Prostate carcinoma

Urethral stricture

Neurogenic bladder

Vesico-ureteric reflux

Vesico-colic fistula

Pregnancy

Vaginal infection

Foreign bodies

Prostate biopsy

Cystoscopy

Urodynamic studies

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24
Q

What is the clinical presentation of acute pyelonephritis?

A

Fever and rigors

Loin or back pain

Nausea and vomiting

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25
What does the complications of acute pyelonephritis?
Septicaemia and septic shock Intra-renal/perinephric abscess Chronic pyelonephritis Renal failure
26
What is the treatment of acute pyelonephritis?
Admit if toxically ill IV fluids Blood culture Antibiotics – Gentamicin, ciprofloxacin, cefotaxime
27
What is the clinical presentation of cystitis?
Frequency Urgency Dysuria Apyrexial Elderly: Incontinence and malodorous urine
28
How would you manage uncomplicated cystitis?
EML Guidelines: Ciprofloxacin 500mg PO BD for 3 days
29
How would you manage complicated cystitis?
EML Guidelines: Ciprofloxacin 500mg PO BD for 7 days
30
How would you manage recurrent cystitis?
High fluid intake Local Hygiene Voiding after sex Topical estrogen for atrophic vaginitis Treat constipation Continuous low dose chemo-prophylaxis - noct for 6-9 months Post-intercourse single dose therapy "Self-start" therapy - patient has a treatment supply and can initiate treatment when symptoms start
31
Who is at risk of erectile dysfunction?
Ischaemic heart disease DM HPT Dyslipidaemia Depression Renal Failure Any hormonal problems that cause low testosterone
32
Discuss normal penis vascular and nerve supply
Arteries * cavernous arteries supply the corpus cavernosum Veins: * superficial dorsal veins * perforating veins > subtunical venous plexus > circumflex veins * cavernous veins * internal pudendal veins Nerves: * Sympathetic - T10-L2 > mediates detumescence * Parasympathetic - S2-S4 > mediates erection
33
List the psychogenic causes of erectile dysfunction
Poor self-esteem / body image Anxiety / stress Depression
34
List the organic causes of erectile dysfunction
CVA Alzeimer's disease Multiple sclerosis Traumatic paraplegia DM - Diabetic neuropathy/vasculopathy Decreased testosterone Surgery Radiotherapy Drugs Smoking and Alcohol abuse Heart disease Renal Disease Peyronie's disease Neglected priaprism Chordee
35
What are the management options for erectile dysfunction?
Psychogenic - Psychotherapy Hypogonadism - Parenteral testosterone Penile deformaties - Penile recontructive surgery All other organic causes - PDE 5 inhibitors - Sildenafil 50mg (Viagra) * ICI therapy * Vacuum device * Penile prosthesis
36
What are the side-effects of PDE 5 inhibitors?
Headache Facial flushing Dyspepsia Nasal congestion Altered vision
37
What are the contraindications for PDE 5 inhibitors
Absolute: * Nitrate use * Unstable angina * Retinitis pigmentosa Relative: * Alpha-blocks > Patients with LUTS * CYP 450 inhibitor use > Ketaconazole, Erythromycin, Prtease inhibitors * MI in last 6 months * CVA
38
Discuss Intra-cavernous injection (ICI) therapy
When oral therapy failed Prostaglandin E1 (Alprostadil) injected into the corpus cavernosa provides 2-3 hour erection
39
What are the side-effects/complications of ICI?
Pain in the penis Priapism
40
Define Peyronie's disease
Acquired penile abnormalityt characterised by fibrosis of the tunica albugina
41
What are the clinical features of Peyronie's disease?
Penile pain associated with erection Penile curvature (chordee) - usually dorsal Loss of erection due to "venous leak"
42
What is the medical management for Peyronie's disease?
50% resolve spontaneously Vitamin E 400mg PO BD + Colchicine 1mg PO BD Intra-lesional injections - Verapamil/Interferon PDE 5 inhibitors
43
What is the surgical management for Peyronie's disease?
Nesbit Procedure - Penile shortening Excision of plaque
44
List the organisms involved in urethral discharge
STDs!!! Gonoccocal: * Neisseria gonorrhoeae Non-Gonoccocal: * Chlamydia trachomatis (50-60%) * Ureaplasma urealyticum (20%) * Trichomonas vaginalis
45
List the complications of urethritis
``` Urethral stricture (>GU) Epididymitis (>NGU) ```
46
What is the clinical presentation of urethritis?
Urethral discharge * GU - Thick, purulent, yellow * NGU - watery, scanty Dysuria Urethral itching
47
Discuss the treatment of gonoccocal urethris
Counselling Ofloxacin 400mg PO STAT Doxycycline 100mg BD for 7 days
48
Discuss the treatment of gonoccocal urethris
Counselling Doxycycline 100mg BD for 7 days
49
Provide a DDx for male genital ulceration
``` Syphilis - Painless Chancroid - Haemophilus ducreyi Lymphogranula venerum Herpes simplex virus Granuloma Inguinale ``` Pre-malignant lesion - Carcinoma in situ/Leukoplakia Malignant lesion - Squamous cell carcinoma of the penis Trauma
50
How do you diagnose syphilis?
VDRL RPR TPHA FTA
51
How do you diagnose HSV?
Immunoflorescent antibody testing against HSV
52
How do you diagnose Chancroid?
Selective culture medium
53
How do you diagnose Granuloma Inguinale?
Donovan bodies on histology
54
What are the clinical features of syphilis?
Cause: Treponema palidum Apyrexial Deep, single painless ulcer with well-defined edges Non-purulent ulcer
55
What are the clinical features of HSV?
Cause: HSV Type 2 Apyrexial Multiple superficial vesicular, painful lesions with erythematous edges Tender bilateral inguinal LN
56
What are the clinical features of Chancroid?
Cause: Haemophilus ducreyi Pyrexial Single deep vesicular lesion with irregular edges Purulent induration Tender unilateral inguinal LN
57
What are the treatment of syphilis?
Benzathine penicillin 2.4 million units IMI STAT
58
What are the treatment of chancroid?
Erythromycin 500mg 8hrly for 5 days OR Ciprofloxacin 500mg PO STAT
59
What are the treatment of HSV?
Acyclovir 200-400mg 5 p/day (5hrly) for 7 days
60
What are the treatment of lymphogranulosa venerum/granuloma inguinale?
Doxycycline 100mg BD | For 3wks in LGV
61
Define a hydrocele
A collection of fluid between the visceral and parietal layers of the tunica vaginalis
62
What are the secondary causes of a hydrocele
Acute epedidymitis Testicular Tumour Testicular torsion Scrotal trauma
63
What are the clinical features of a communicating (congenital) hydrocele?
Scrotal swelling when crying Scrotal swelling larger in evening/morning
64
What are the clinical features of a non-communicating (acquired) hydrocele?
Painless cystic scrotal swelling with transluminates Testis situated posterior to fluid/impalpable
65
Provide a DDx for painless scrotal swelling
Hydrocele Spermatocoele Epididymal cyst Chronic epididymitis Inguinal hernia Varicocele Testicular tumour
66
What is the treatment for a primary non-commuicating hydrocele?
Aspiration and sclerotherapy Hydrolectomy - Lord's procedure
67
Define a varicocle
Varicose veins of the pampiniform plexus of the spermatic cord
68
How does a varicocele affect fertility?
Increased intra-scrotal temperature interferes with spermatogenesis venous anoxia interferes with epididymal function which is vital for sperm maturation
69
What are the clinical features of a varicocele?
Pain - esp when erect Infertility (late) Examination: * "Bag of worms" above testis * Valsalva manoeuvre makes it obvious * Ipsilateral testicular atrophy Semenanalysis: * oligospermia * asthenospermia * teratospermia
70
What is the treatment for a varicocele?
Only for pt's with complications to prevent retrograde flow Open surgical ligation of vessel Spermatic vein embolization * Antegrade sclerotherapy * Retrograde embolization * Laproscopy
71
What are the clinical features of TB (chronic) epididymitis?
Painless scrotal swelling Craggy non-tender mass in epididymis Normal Testis Scrotal sinus Thickened vas deferens Seminal vesicle and prostate is hard on rectal exam
72
How is TB epididymitis diagnosed?
Microscopy > ZN staining and TB culture of urine, semen and pus from scrotal sinus IVP - to exclude urinary TB CXR Histology
73
What is the treatment of TB epididymitis?
Anti-TB medication for 6 months - FDC
74
Define infertility
Failure to conceive after 12 months of unprotected sex
75
What are the testicular causes of male infertility?
Varicocele Undescended testis Previous trauma Mumps orchitis Radiotherapy Previous Surgery
76
List the options for assisted reproduction
Intra-uterine insemination IVF Intra-cytoplasmic sperm injection Donor insemination Adoption
77
How would you counsel a patient before a vasectomy?
Both the patient and his partner A permanent form of male sterilization Pt will not be sterile immediately after surgery All short and long-term complications Sterility cannot be confirm
78
How would you counsel a patient before a vasectomy?
Pt will not be sterile immediately - use other forms of contraceptives Pt may have safe unprotected intercourse after a single negative spermiogram If there is persistent motile spermatozoa in the second spermiogram it indicates vasectomy failure
79
What are the complications of a vasectomy
Pain Haematoma Infection Post-vasectomy pain syndrome
80
What are the mechanical causes of urinary retention?
Males... * BPH * Prostate Ca * Acute prostitis * Urethral Trauma * Urethral Stricture * PUV - Boy kids Females... * Pregnancy * Fibroid uterus * Urethral diverticulum * Urethral stricture * Urethral Ca
81
What are the features of acute urinary retention?
Acute lower abdominal pain Patient wants to void but cannot Palpable tender bladder Rectal and vaginal examinations - to determine cause
82
What is the treatment of acute urinary retention?
Immediate relief by passing a transurethral catheter * Failure may indicate a stricture Suprapubic catheter Treatment dependent on cause
83
What are the features of chronic urinary retention?
A decompensated bladder due to chronic outflow obstruction or neuropathy Painless Obstructive symptoms Disurnal and nocturnal incontinence (overflow)
84
What are the indications for immediate catheterization in chronic bladder retention?
UTI Renal Failure Incontinence Acute on chronic retension
85
What are the complications of immediate catheterisation in chronic retention?
NB!! Admit a CUR patient after immediate catheterisation Complications... * Severe macroscopic haematuria * Post-obstructive diuresis
86
Provide a DDx of acute scrotum
Testicular torsion Epididymitis Orchitis Scrotal cellulitis/abscess Post traumatic Haematocele Ruptured testis after trauma Strangulated inguinal hernia
87
What is the pathophysiology of testicular torsion in an adult?
Twisting of the spermatic cord > venous obstruction > Arterial obstruction > Ischaemic necrosis of testis and epididymis
88
Clinical features of testicular torsion
History... * Minor traums * Sudden onset pain in a previous well patient * Pain radiates to ipsilateral fossa * Associated nausea and vomiting * No urinary symptoms Examination... * Acutely tender unilateral scrotal swelling * Unable to distinguish testes and epididymis * Testes drawn up on affected side * Negative cremaster reflex * Redness (late) * Oedema (late) * Hard testicle (late)
89
What is the emergency management of testicular torsion?
Presentation within 24 hours * Scrotal inscision * If testes viable : Detorsion + orchidopexy * If ischaemic : Orchidectomy * Orchidopexy for contralateral testicle
90
What are the most common causes of acute epididymitis?
<35 years.. * Gonococcal urethral infection * Chlamydial urethral infection >35 years... * BPH * Prostate Ca
91
What is the clinical presentation of acute epididymitis?
Gradual onset pain Hx of Urethral discharge Pyrexia Swollen tender epididymis posteriorly Positive cremaster reflex
92
What is the mangement of acute epididymitis?
Antibiotics for STD * Ceftriaxone 250mg IMI state * Doxycycline 100 BD for 10 days Antibiotics for urological cause * Augmentin Management complications * Scrotal abscess - incision and drainage
93
What is the clinical presentation of acute prostatitis?
Pyrexia and rigors Acute lower abdominal pain Difficult urination / urinary retention Rectal exam - Boggy tender prostate
94
What is the management of acute protatitis?
Admit Blood culture Urine MCS Suprapubic catheter if in retention ABs - Flouroquionolines for 6 weeks * coz' usually gram (-) infection If prostatic abscess then > Transurethral drainage

Urology (5 decks)

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