Miscellaneous Urology

Question 1

Acute bacterial prostatitis

Answer 1

E. coli

Recent UTI, catheterisation, prostate biopsy

Painful rectum, voiding symptoms, fever, rigors, DRE- tender, boggy prostate

14-day course of quinolone eg. Ciprofloxacin, screen for STI

Question 2

Causes of acute urinary retention

Answer 2

BPH
Urethral strictures, calculi, constipation, pelvis masses (NB- not ureters, we have two, so both need compressing to cause AUR)
Drugs- anticholinergics, TCA, opioids, benzodiazapenes, antihistamines
Neurological- MS, PD, spinal cord lesion
UTI
Postoperative

Question 3

Features of AUR

Answer 3

Inability to pass urine
Lower abdominal discomfort
Considerable pain or distress
Delirium (esp. elderly)

Question 4

AUR vs CUR

Answer 4

Typically painless and overflow incontinence (nocturia)

Question 5

Investigations for AUR

Answer 5

Urinalysis, microscopy culture and sensitivities
UE, FBC, CRP
Bladder USS (volume of greater than 300cc)

Question 6

Subtypes of CUR

Answer 6

High pressure- impaired renal function and bilateral hydronephrosis (due to bladder outflow obstruction)

Low pressure- normal renal function and no hydronephrosis

Decompression haematuria commonly occurs after catheterisation for CUR due to rapid decrease in pressure. Requires no treatment.

Question 7

Medical indications for circumscision

Answer 7

Phimosis
Recurrent balantitis
Balantitis xerotica obliterans
Paraphimosis

NB- must exclude hypospadias prior to circumscion

Question 8

Epididymal cysts

Answer 8

Most common cause of scrotal swelling seen in primary care

Separate from body of testicle
Posterior to testicle

Associated- PKD, CF, Von hippel lindau syndrome

USS diagnosis

Question 9

Epididymo-orchitis

Answer 9

Infection of epididymis or testes resulting in pain and swelling- usually due to spread of infection from genital tract or bladder

20’s and sexually active- chlamydia trachomasis, (Neisseria gonnorhoea less so)
Over 35’s- E coli

Question 10

Features of EO

Answer 10

NB- need to exclude testicular torsion

Unilateral testicular pain and swelling
Urethral discharge

If organism unknown, ceftriaxone 500mg IM once, plus doxycycline 100mg BD for 10-14 days

Question 11

Factors favouring an organic cause of ED

Answer 11

Gradual onset of symptoms
Lack of swelling
Normal libido

NB- vascular are the most common organic causes of ED

Question 12

Factors favouring a psychogenic cause of ED

Answer 12

Sudden onset
Decreased libido
Spontaneous or self stimulated erections
Major life events
Problems or changes in a relationship
Previous psychological problems
History of premature ejaculation

Question 13

Risk factors for ED

Answer 13

Advancing age
CVD- obesity, DM, smoking, dyslipidaemia, HTN
Alcohol use
Drugs- SSRI, beta blockers

NB- vascular are the most common organic causes of ED

Question 14

Investigations for ED

Answer 14

Calculate 10 year cardiovascular risk
Testosterone (between 9 and 11am)

Question 15

Management of ED

Answer 15

PDE5 inhibitors (slidenafil, viagra)
Vacuum erection devices if people cannot take PDE5 inhibitor (ie. recent MI)

Question 16

Hydrocele

Answer 16

Accumulation of fluid in the tunica vaginalis
Communicating- peritoneal fluid enters scrotum (common in newborn males and resolve within first month of life)
Non communicating- excess production

They can develop secondary to- epididymo-orchitis, testicular torsion, testicular tumours

Question 17

Features and management of hydrocele

Answer 17

Soft non tender swelling of the scrotum (anterior and below scrotum usually)
Transillumimates
May be difficult to palpate if hydrocele is large

USS to rule out underlying pathology (although can be clinical)

Children- repaired if don’t resolve by 1-2 years
Adults- conservative. USS to rule out underlying pathology

Question 18

Causes of hydronephrosis

Answer 18

Unilateral- PACT

Pelvic ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

Bilateral- SUPER

Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro peritoneal fibrosis

Question 19

Investigation and management of hydronephrosis

Answer 19

USS
CT KUB

Remove obstruction and drain urine
Acute- nephrostomy tube
Chronic- ureteric stent or pyleoplasty

Question 20

Renal cell carcinoma

Answer 20

Most common is clear cell

Associations- middle aged men, smoking, Von hippel lindau syndrome, tuberous sclerosis, slight increase with ADPKD (not much)

Question 21

Features of renal cell carcinoma

Answer 21

Triad- haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Endocrine effects- EPO (polycythaemia), PTH (hypercalacemia), ACTH
Paraneoplastic hepatic dysfunction syndrome
Varicocele (left sided, tumour suppresses veins)

NB- varicocele can be a testicular tumour or a renal one

Management- nephrectomy, alpha interferon and IL2

NB- patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy (more= radical nephrectomy)

Question 22

Risk factors for renal calculi

Answer 22

Dehydration
Hypercalcuria, hypercalcaemia, hyperparathyroidism
Cystinuria
High dietary oxalate
Rental tubular acidosis
PKD
Drugs- calcium stones: loop diuretics (furosemide, bumetinide), steroids, acetazolamide, theophylline (thiazides (indapamide, bendroflumethazide), prevent calcium stones by causing hypocalcuria)

Urate stones- gout, ileostomy (acidic urine, bicarbonate lost)

Question 23

Potassium sparing diuretics

Answer 23

Aldosterone antagonists
Spironalactone, eplenrone

Question 24

Varicocele

Answer 24

Abnormal enlargement of testicular veins (associated with infertility)

Commonly on left side
Look and feel like a bag of worms
Subfertility

Diagnose with Doppler

Usually conservative management, occasionally surgery if pain

Question 25

Testicular cancer

Answer 25

95% are germ cell tumours (seminomas and non seminomas (embryonal, yolk sac, teratoma etc.) Non germ cell tumours include leydig cell tumours and sarcomas

Question 26

Risk factors for testicular cancer

Answer 26

Infertility Cryptorchidism FH Kilenfelters syndrome Mumps orchiditis (Teratoma-25 years, seminoma- 35 years)

Question 27

Features of testicular cancer

Answer 27

Painless lump is most common presentation Pain in minority Hydrocele Gynaecomastia (increased oestrogen to androgen ratio) Germ cell tumours release hCG

Question 28

Tumour markers

Answer 28

Germ cell tumours Seminoma- hCG elevated Non-seminomas- AFP/beta hCG elevated LDH elevated USS first line Refer to urology, then chemo, radio, and orchidectomy NB- non-seminoma is 2 words, so 2 markers are raised

Question 29

Features of testicular torision

Answer 29

Pain is severe and sudden onset Pain may be referred to lower abdomen Nausea and vomiting may be present Swollen, tender testis retracted upwards Red skin Cremasteric reflex lost Elevation of testes doesn’t ease the pain (Prehns sign) Urgent surgical exploration (if tortes testes identified them both testes fixed as condition of a bell clapper testes is often bilateral)- never elective (even if patient has had episodes before and not presented) NB- USS is imaging modality of choice (whirlpool sign)

Question 30

TURP syndrome

Answer 30

Large volumes of glycine absorbed during TURP procedure, causes hyponatrameia, hyper ammonia (get CNS, respiratory and systemic Sx)

Question 31

Causes of urethral stricture

Answer 31

Iatrogenic (traumatic placement of indwelling catheter lines) STI (gonorrhoea) Hypospadias Lichen sclerosus

Question 32

Vasectomy

Answer 32

More effective than female sterilisation Contraception until semen analysis reveals azoospermia twice before unprotected sex (usually 16/20 weeks- doesn’t work right away) Chronic testicular pain, bruising, hameatoma, infection, sperm granuloma

Question 33

Which testicular cancer is associated with cystic lesions containing heterogeneous solid echoes?

Answer 33

Teratoma

Question 34

Complication of goserelin treatment (GnRH analogue)

Answer 34

During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer. This is known as the 'flare effect' and is caused by an initial increase in luteinizing hormone production prior to receptor down-regulation. Flutamide, a synthetic antiandrogen, can be used pre-emptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.

Question 35

Paediatric phimosis

Answer 35

In children less than 2 years of age, phimosis (a non-retractable foreskin) is normal and will most likely resolve with time

Question 36

Vesicovaginal fistulae

Answer 36

Vesicovaginal fistulae should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services. A dye stains the urine and hence identifies the presence of a fistula.

Question 37

Investigating UTI's in children

Answer 37

All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks (or during the illness if there are recurrent UTIs or atypical bacteria)- send for MCUG if recurrent UTI's under 6 months Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks Children with atypical UTIs should have an abdominal ultrasound during the illness

Question 38

Mnemonic for LUTS

Answer 38

FUN WISE (storage and voiding) Frequency Urgency Nocturia Weak stream Intermittency/hesitancy Straining Emptying incomplete

Question 39

PDE5 inhibitors

Answer 39

eg. sildenafil (viagra) Contraindications patients taking nitrates and related drugs such as nicorandil hypotension recent stroke or myocardial infarction (NICE recommend waiting 6 months) Side effects visual disturbances ie. blue discolouration/ischaemic neuropathy nasal congestion flushing gastrointestinal side-effects headache priapism NB- blue tablet for blue discoloration

Question 40

Varicocele that doesn't dimmish when lying down

Answer 40

This patient has signs and symptoms consistent with a varicocele (subfertility and a testicular mass similar in feeling to a 'bag of worms') that does not diminish when lying down. This should raise suspicion of compression of the renal vein which suggests the presence of an abdominal or retroperitoneal mass, such as malignancy. As well as this, right-sided varicoceles alone are rare and should further raise suspicion of this, therefore necessitating an urgent referral for suspected malignancy. It is important to note that this may be a sign of renal cell carcinoma, and up to 50% of cases are diagnosed incidentally.

Question 41

Preservation of cremaster reflex in testicular torsion

Answer 41

The cremasteric reflex is usually preserved when the torsion affects the appendage only.

Question 42

Phimosis management

Answer 42

Under 2- conservative