MedEd urology Flashcards by Aaska Banthiya

What is the most common cause of epididymitis in people under 35?

Gonorrhea and chlamydia

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What bacteria causes most UTIs?

E coli

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What are differentials for scrotal mass?

Testicular torsion
Epididymitis/ orchitis
Testicuar cancer
Variocele
Hydrocele

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What is testicular torsion?

Twisting of spermatic cord resulting in constriction of vascular supply and ischaemia of testicular tissue

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What are the types of testicular torsion and which is more common? How are they differentiated?

Intravaginal- most common and within the tunica vaginalis

Extravaginal- entire testes and tunica vaginalis twists

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What are RF for testicular torsion?

If intravaginal- age under 25 years and bell clapper deformity

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How will someone with testicular torsion present?

Painful
Swollen hot tender erythemous scrotum
Unilateral 
Raised affected testicle
Absent cremasteric reflex

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How do you perform the cremasteric reflex?

Stroke the inner thigh of the affected testicle and see if it rises

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How quickly do you have to treat testicular torsion?

Within 6 hrs of symptom onset

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What is GS investigation for testicuar torsion? What is second line

Emergency exploration of the scrotum within 6hrs of symptom onset
Testicle twisted back and bilateral orchidopexy
second line manual de torsion if surgery is not availbale

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What is epididymitis/orchitis?

Inflammation of the epididymis or testes

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What are causes of epididymitis/orchitis? Describe organisms in under and over 35s

Bacterial infection- chlamydia most common or gonorrhea if under 35
If over 35 mainly klebsiella, e coli, enterococcis faecalis
Non infective= trauma, vasculitis, medication

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What are RF for epididymitis/orchitis?

Unprotected sex
Bladder outflow obstruction
UTI
Immunosupressed- more likely atypicals eg candida

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How does epididymitis/orchitis present?

Painful
Swollen, hot tender erythemous scrotum 
Unilateral
Presents over a few days
urinary syptoms= dysuria, retention

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How can you differentiate epididymitis/orchitis from testicular torsion?

Different RF
Testicular torsion usually in younger people but epidid= all ages
Cremasteric reflex painful but may be present in epidid vs absent in testicular torsion
There will be dysuria and urgency in epididymitis/orchitis

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What inevstigations are done for for epididymitis/orchitis? What will be seen

Urine dip, MSU and MC&s bedside
Bloods- WCC high, UEs
Imaging- colour duplex USS

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How is epididymitis/orchitis managed?

Conservative= bed rest and scrotal elevation
Medical= analgesia, abx to target infection
Surgical= exploration of the testes if torsion can't be excluded and abscess drainage if abscess develops

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What is variocele?

Dilated veins of the pampiniform plexus forming a scrotal mass

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How does variocele arise?

high hydrostatic pressure (esp left renal vein)

imcompetent veinous valves

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What side is variocele more common in?

Left

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How will variocele present?

Asympotmatic

Looks like a bag of worms

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What investigations are done for variocele?

Examine the patient standing up
May be fertility analysis
May do ultrasound if it doesnt diminish when they lie down

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In what position will variocele be less prominent? Why is this important?

Lying down
You have to examine them standing up
If it doesnt reduce when they lie down there is a problem

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How is variocele managed?

Reassure and observe

If fertility is comprimised then surgery

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What is hydrocele?

A collection of serous fluid in the tunica vaginalis

What are the types of hydrocele and how do they differ?

Communicating- processus vaginalis is open- peritoneal fluid flows in from abdomen Non communicating- processus vaginalis is closed

What are RF for hydrocele?

Male Children Non communicating- trauma, infection, testicular torsion, testicular cancer Communicating- increased intraperitoneal fluid eg ascites

How does hydrocele present?

``` Asymptomatic Scrotal swelling Possible to get above swelling Enlarges after activity eg coughing and straining Will transilluminate ```

What investigations are done for hydrocele? Why are they done

Clinical diagnosis Urine dip- rule out infection USS- exclude tumor Bloods- exclude testicular tumor markers

How is hydrocele managed?

Observe | If too uncomfortable offer surgery

What are the types of testicular cancers?

Seminomas | Non seminomatous germ cell tumors

What are RF for testicular cancer?

Cryptorchidism Ectopic testes Testicular atrophy FHX

How does testicular cancer present

``` Painless hard nodular unilateal testicular mass Lymphadenopathy Gynaecomastia Back ache Hydrocele ```

How is testicular cancer inevstigated?

FBC, UEs, LFTs Tumor markers- alpha fetoprotein, beta HCG, LDH Image w testicular ultrasound, CT AP, CXR

What tumor markers are checked for testicular cancer?

alpha fetoprotein, beta HCG, LDH

Where does testicular cancer metastase to and how?

Through para aortic lymph nodes to chest

How is testicular cancer managed?

Ochiectomy | Chemotherapy

What is UTI?

Presence of a pure growth of >10^5 organisms per mL of fresh MSU

What is cystitis?

Infection of bladder

What are RF for UTI?

``` Female Sexual intercourse Immunosupression Catheterisation Urinary tract obstruction- BPH, urinary tract calculi ```

Why are females at higher risk of UTI?

Urethra is way smaller in length than in a man

How will UTI present?

``` Storage symptoms (bladder doesnt want to store urine as its inflammed): Increased frequency Urgency Dysuria Foul smelling ```

How does pyelonephritis present?

Flank pain Fever Malaise

What is GS investigation for UTI? What else will you do and what will you see?

MSU for MC&s | first line Urine dip- +nitrates and WC

What is the most common abx for UTI

Nitroflurotonin

What are the 3 points of urinary tract calculi commonly?

Ureteropelvic junction Pelvic brim where ureters cross iliac vessels Ureterovesical junction

How do kidney stones arise?

Urinary solutes are high in the urine- they supersaturate and precipitate out of the solution

What are RF for kidney stones?

``` Dehydration high protein intake High salt structural abnormality PMHx FHx ```

How is more likely to get kidney stones?

Males 30-50 y/o Hot and dry countries (causes dehydration)

How will kidney stones present?

``` Intially sympotatic If it gets stuck: Acute severe loin to groin pain= renal colic Nausea and vomitting Unable to lie still, writhing in pain Urgency, frequency and haematuria Heamaturia is usually microscopic ```

What are investigations for kidney stones? What is GS imaging? What will you see?

First line urine dip Pregnancy test if female to rule out ectopic pregnancy Bloods- FBC, WCC to rule out UTI, UEs/Cr/Ca to check kidney function GS imaging- non contrast CT KUB

How are kindey stones managed?

``` Acute= fluids, analgesia (diclofenac), anti emetics (ondansetron), urine collection to collect and analysed passed stone <5mm= leave to pass <10mm= alpha blocker (tamsulosin), if not passed in 4-6 weeks surgery >10mm= surgery first line extracoroporeal shock wave lithotripsy ```

What are complications of kidney stones?

``` Pyelonephritis Septicaemia Obstruction Urinary retention Hydronephrosis ```

What is BPH?

Diffuse hyperplasia of the periurethral zone

Who is more likely to get BPH?

Increasing age | Afro carribeans

How does BPH present?

Lower urinary tract symptoms: Storage= urgency, frequency Voiding= hesitancy Bone pain FLAWS

What acronym is used to remember storage and voiding symptoms

FUND HIPS: Fund= storage symptoms= frequency, urgency, nocturia, dysuria Hips= voiding= hesitency, incomplete voiding, poor stream

How is BPH investigated? What will you see? What is GS imaging

Urinalysis to exclude UTI DRE- smoothly enlarged palpable midline grooce PSA- high UEs to check renal function GS imaging- transrectal US guided needle biopsy

What is used to check for mets in prostate cancer?

Isotope bone scan | CXR

How is BPH managed?

Lifetsyle adv= avoid caffeine Review thier medications- anticholinergics cause it 1st line= alpha tamsulosin (a1 blocker) 2nd line= 5a reductase inhib= finasteride surgery= transurethral resection of prostate

What are the 2 main types of bladder cancer? Which is more common

urothelial carcinoma- most common | squamous cell carcinoma

What are RF for bladder cancer

General: males, over 55 years | Urothelial- smoking, carcinogen exposure, aromatic amines, arsenic, painters and hairdressers

How will bladder cancer present?

Painless macroscopic haematuria FLAWS Storage and voiding problems- FUND HIPS

What are investigations for bladder cancer?

``` 1st line= urinalysis FBC ALP- high if bone mets UEs GS imaging- cystoscopy and biopsy Also do MRI, to check mets isotope bone scan and CXR ```

What type of testicular torsion is more common in neonates?

Extravaginal

What is the difference between intravaginal and extravaginal testicular torsion?

``` Intravaginal= twisting is within the tunica vaginalis Extravaginal= twisting is of the entire testes and tunica vaginalis ```

What deformity increases risk of intravaginal testicular torsion?

Bell clapper deformity

What bacterial organisms cause epdidymitis/orchitis in under 35s?

Chlamydia most commonly | Gonorrhea

What bacterial organisms cause epdidymitis/orchitis in over 35s?

Klebsiella | E coli

What should happen in variocele when you get the patient to lie down?

The vessels should disappear

What lymph nodes are involved with metastasis of testicular cancer?

Para aortic

What will you see on MC&S and MSU in pyelonephritis?

White cell casts

What are the types of urinary tract calculi and which is most common?

Calcium oxalate is most common Struvite Urate/uric acid Hydroxyapatite

What urinary tract calculi is not visible on x ray?

Urate or uric acid

What are some causes of urinary tract calculi?

High Ca, uric acid, oxalate or Na Metabolism eg hyperparathyroidism causing high ca Infection Drugs

What is the difference between BPH and prostate cancer on DRE?

BPH= smoothly enlarged prostate with palpable midline groove Prostate cancer= asymmetrical hard nodular prostate with loss of midline sulcus

What is the difference between PSA levels in BPH and prostate cancer?

Levels are high in both (>4)

What is the GS ix for prostate cancer and BPH?

Transrectal US guided needle biopsy | If cancer then isotope bone scan to check for mets

What professions are more likely to have bladder cancer?

Painters | Hairdressers

What type of kidney stones are patients predisposed to if they have recurrent UTIs with recurrent urease positive bacteria?

Struvite