Urological Presentations Flashcards
(125 cards)
1
Q
What is nephrolithiasis?
A
formation of stones (calculi; composed of calcium oxalate/calcium phosphate/ uric acid/cysteine/struvite) present in the kidneys (nephrolithiasis) or ureters (ureterolithiasis) causing renal colic (colicky pain) due to dilation, stretching and spasm due to acute ureteral obstruction
2
Q
Define the following terms:
- Nephrolithiasis
- Urolithiasis
- Nephrocalcinosis
A
- Nephrolithiasis = calculi within the kidney
- Urolithiasis = calculi within the urinary system
- Nephrocalcinosis = diffuse renal parenchymal calcification
3
Q
State 5 aetiological factors of Urolithiasis/Nephrolithiasis,
A
Mnemonic -> HIDE
- Hyperparathyroidism
- Hypercalcemia
- Hypercalcuria
- Hypomagnesemia
- Hyperoxaluria
- Hypervitaminosis D
- Hyperuricemia/Hyperuricosuria
- Infection
- Inadequate urinary drainage (urine stasis)
- Immobilisation
- Diet (Vitamin A deficiency)
- Dehydration
- Decreased urine citrate
- Distal RTA
- Drugs: Loop diuretics; Thiazide diuretics; Indinavir
4
Q
What 3 forms of urolithiasis are radiolucent?
A
Radiolucent stones -> Mnemonic = ICU
- Indinavir
- Cysteine
- Uric Acid
5
Q
A 47 year old man presents with severe colicky pain in the flank radiating from the loin to groin. He is experiencing increased urinary urgency and has noticed a red tinge in his urine. O/E there is some abdominal distension.
He has no significant medical history other than hypertension.
His urinalysis shows leukocytosis whilst the FBC shows this also.
What would the gold-standard diagnostic test be?
A
CT-KUB
6
Q
A 47 year old man presents with severe colicky pain in the flank radiating from the loin to groin. He is experiencing increased urinary urgency and has noticed a red tinge in his urine. O/E there is some abdominal distension.
He has no significant medical history other than hypertension.
His urinalysis shows leukocytosis whilst the FBC shows this also. A CT-KUB shows no radiological abnormalities but a region of dilatation and stenosis is observed.
What is your DDx?
What type of pathology can be responsible for this DDx?
How would you decide on your management plan?
A
Urolithiasis
Indinavir stone/Cysteine stone/ Uric Acid Stone –> All Radiolucent Stones
Size of stone
- Conservative management: Hydration/Pain control/Anti-emetics (metoclopramide)
- ABX: Nitrofurantoin 100mg PO BD 1-2/52
- Alpha-blocker: Tamsulosin 0.4mg OD
- ESWT
- Surgical removal: Percutaneous nephrolithotomy
7
Q
Which of the following renal calculi is shaped like an envelope?
A. Cysteine
B. Calcium Oxalate
C. Uric Acid
D. Struvite
A
B. Calcium Oxalate
8
Q
Which of the following renal calculi is shaped like a stag horn?
A. Cysteine
B. Calcium Oxalate
C. Uric Acid
D. Struvite
A
D. Struvite
9
Q
Which of the following renal calculi is shaped like a hexagon?
A. Cysteine
B. Calcium Oxalate
C. Uric Acid
D. Struvite
A
A. Cysteine
10
Q
Which of the following renal calculi is shaped like a rhomboid?
A. Cysteine
B. Calcium Oxalate
C. Uric Acid
D. Struvite
A
C. Uric Acid
11
Q
Which of the following renal calculi is shaped like a wedge-shaped prism?
A. Calcium phosphate
B. Calcium Oxalate
C. Uric Acid
D. Struvite
A
A. Calcium phosphate
12
Q
What is urinary obstruction?
A
Blockage of urinary flow, unilateral or bilateral, characterised by flank pain, fever, polyuria, weak stream, incomplete emptying, nocturia and/or bladder distension
13
Q
Define the following terms
- Hydronephrosis
- Pyonephrosis
- Hydroureter
- Obstructive Nephropathy
A
- Hydronephrosis = backpressure of urine causing distension of kidney
- Pyonephrosis = infection of kidneys causing distension of kidney
- Hydroureter = dilation of ureter(s) due to backflow of urine
- Obstructive Nephropathy = urinary tract obstruction causing functional impairment of kidney
14
Q
Outline the two types of Urinary Obstruction
A
- Unilateral obstructive uropathy: Stones; iatrogenic injury; malignancy
- Bilateral obstructive uropathy: BPH; PC; Urethral strictures; Instrumentation
15
Q
State 3 risk factors of Urinary Obstruction.
A
- BPH
- Constipation
- Medication: Narcotic analgesia/Anticholinergics/alpha-agonists
- Malignancy
- Posterior urethral valves
- Urolithiasis
- Neurological disease
16
Q
A 37 year old man presents with severe flank pain radiating from loin to groin on a background of acute fever and dysuria. He reports increased urgency and frequency as well as incomplete voiding. He has no significant medical history other than previous bouts of obstipation and BPH. He has no significant family history.
O/E he had a distended bladder and haematuria from urinalysis.
Urinalysis showed leukocytes and haematuria. FBC showed low haemoglobin. A US-Renal showed hydronephrosis and a CT-KUB showed a radiopaque lesion present in the ureter with distension proximal to the lesion.
What is your DDx? (give more than 1)
What does your Tx depend on?
A
Urolithiasis with 2º Urinary Obstruction, Pyelonephritis and Hydroureter
Size of calculi (1cm) ; Sepsis
• ESWT
OR
• A-blocker: Tamsulosin
-> Stone < 10mm
OR
• Percutaneous nephrolithotomy
-> Stone > 10mm
If Sepsis,
• Analgesia: Morphine (2-4mg IV 3-4 hours) \+ • Fluids \+ • ABX: Ceftriaxone (1-2g IV 12-24 hours) ± • Surgery: Nephrostomy/Stent
Calculi – Sepsis: Unilateral or Bilateral
1st
• Analgesia: Morphine (2-4mg IV 3-4 hours)
+
• Fluids
+
• A-adrenoceptor blocker: Tamsulosin
17
Q
What is a UTI?
A
Umbrella term for infection of the urinary tract (KUBU) characterised by dysuria, polyuria, Nocturia and suprapubic pain
18
Q
Outline the ways of categorising a UTI
A
- Uncomplicated: UTI in healthy individual
- Complicated: UTI with functional or structural impairments e.g. GU tract abnormalities or drug-resistant pathogens
- Acute: Infected urine = infection Sx
- > E.g. Urethritis; Cystitis
- Recurrent: Two separate culture-proven episodes of UTIs within 6/12
- > E.g. Pyelonephritis; Epididymo-orchitis
19
Q
State 3 risk factors for a UTI.
A
- Renal tract obstruction (BPH, stones, stricture)
- Previous UTI
- Age ≥ 50 years
- Instrumentation of renal tract e.g. Catheterisation, Urological
20
Q
Give three pathogens likely to cause a UTI
A
- E. coli (70%)*
- S. saprophyticus
- P. mirabilis
- Klebsiella spp.
21
Q
A 65 year old man presents with painful urination, increased frequency and urgency as well as urinating at night. He has a past medical history consisting of previous UTIs, obstructive nephropathy which was treated with catheterisation. There is no family history of note and no documented developmental or birth defects.
O/E he has suprapubic pain and an inflamed head of penis with itchy urethra.
Urinalysis shows leukocytes and nitrites. Microscopy shows gram-negative, rod-shaped bacterium whilst CT-KUB shows no abnormalities.
What is your DDx?
How would you treat this?
A
UTI with 2º urethritis
• ABX: Ciprofloxacin/Levofloxacin
22
Q
Define pyonephritis
A
inflammation of the kidney due to a bacterial infection
23
Q
Give 3 risk factors for pyonephritis
A
- Acute pyelonephritis
- Vesicoureteral reflux
- Obstruction
- Renal calculi
- Diabetes Mellitus
24
Q
What is the most common pathogen to cause pyonephritis?
A
Escherichia coli (E. coli)
25
State the most common pathogens which cause pyonephritis.
* E. coli (80%)*
* Proteus
* Klebsiella
* S. saprophyticus
* S. aureus
* Candida
26
How may pyonephritis be categorised regarding its stability.
* Uncomplicated Acute Pyelonephritis: Infection of kidney in immunocompetent patient
* Complicated Acute Pyelonephritis: Infection of kidney in immunocompromised individual
27
Outline the common presentation of Pyonephritis in a patient.
* Nausea
* Fever
* Flank pain: Severe, loin-to-groin
* Fish-smelling urine
* Dysuria
28
A 47 year old male presents with acute onset of loin pain. The pain is described as a 8/10 with the presence of fever and nausea. He reports malodorous urine.
O/E you notice tenderness on palpation in the RUQ. He is haemodynamically stable with no other observations of note.
A urinalysis shows positive leukocyte esterase with nitrites (++). There is pus in his urine. His eGFR is reduced and a urine culture is positive for a gram-negative rod-shaped bacteria. A CT-KUB shows the presence of a radiopaque lesion 1.5cm in diameter with proximal distension and enlargement of the kidneys.
Outline your posible differentials.
A. Pyelonephritis
B. Pyonephrosis
C. Urolithiasis with 2º pyonephrosis
D. Urolithiasis with 2º pyelonephritis
How would you differentiate these diagnostically.
Outline your Tx.
C. Urolithiasis with 2º pyonephrosis
- Urinalysis: Presence of leukocytes and nitrites; Pus
- CT-KUB: Renal calculi position, radiological features
Tx:
• ABX: Ciprofloxacin (500mg PO BDS 7-14/7) + Ceftriaxone (1g IV)
29
What is Bilateral Renal Agenesis?
State the eponymous, alternative designated name for this condition.
Congenital disease precipitating absence of both kidneys due to poor intrauterine growth and environment
Potter's Syndrome
30
Outline the Pathophysiology for Potter's Syndrome.
• ∆RDGs + Environment/Drugs ≈ ∆ ureteric bud development + X differentiation of metanephric blastema (both structures develop to kidney) ≈ kidney fails to develop
31
Outline Potters Sequence.
```
Pulmonary hypoplasia
Oligohydramnios
Twisted skin
Twisted face
Extremity deformities
Renal agenesis (bilateral)
```
32
A 35+2 pregnant 32 year old woman presents with fatigue and tachycardia. She is G1 P0 with a previous miscarriage at 14 weeks.
A foetal scan shows oligohydramnios with extremity deformities such as talipes equinovarus. Additionally a CTG shows hypertension in the foetus. Finally, both kidneys are absent.
Give your differential diagnosis
Give your Tx
Potter's Syndrome (BRA)
* RRT: Dialysis/Transplantation
* IV Fluids and electrolytes
* Diuretics: Thiazide diuretics (bendroflumethiazide/Indapamide); Loop diuretics (Spironolactone/Eplerenone)
33
What is PCKD?
congenital disease which results in cysts developing in the kidneys, compromising renal function and predisposing to chronic renal disease
∆PKD1 or PKD2 gene (Autosomal recessive/ dominant) ≈ ∆ cell cycle or ∆ calcium channel ≈ cysts in epithelial organs
34
A 34 year old man presents with abdominal discomfort and distension. He has a background of hypertension.
O/E there is abdominal distension in the both RUQ and LUQ. Abdominal exam is normal apart from renal hypertrophy noted on balloting. His family history shows numerous members with renal conditions in each lineage.
US-Kidneys show bilateral enlargement with increased echogenicity and anechoic masses.
Genetic testing gives one dominant allele precipitating his condition.
Give your Ddx and Tx.
ADPCKD
* Supportive (delay progression): Monitoring/Avoid nephrotoxic substances/Treat arterial hypertension/Treat UTIs
* Treat liver failure
* Genetic counselling
* RRT: Dialysis/Kidney transplantation
35
A 3 year old presents with abdominal distension and pain. He has been growing well, in the 99th percentile for his age.
O/E he is large, pyrexial but haemodynamically stable. There is a hard mass palpable in the RUQ.
Urinalysis shows haematuria and a US-Abdomen shows echogenic solid mass that is heterogeneous.
What is your DDx?
Outline the Tx.
What Genetic condition may this child have?
Wilm's Tumour
Surgical: Radical nephrectomy
±
Post-op Chemo: Dactinomycin + Vincicristine
36
State the treatment for a Wilm's Tumour.
* Surgery: Radical nephrectomy
| * Post-operative chemotherapy: Dactinomycin + Vincristine
37
State the origin of a renal cell carcinoma.
kidney cancer originating in the lining of the proximal convoluted tubule
38
State 5 risk factors for Renal Cell Carcinoma.
* Smoking
* Male
* Age: 55-84 years
* Developed countries
* Obesity
* Hypertension
39
Outline the pathogenesis of a Renal Cell Carcinoma.
• VHL (Von Hippel-Lindau TS) protein∆ -> elevated HIF ≈ transcription promotion of VEGF, PDGF, EGFR and MMPs (aiding oncogenesis and tumour invasion) -> tumorigenesis and invasion
40
A 76 year old man presents with flank pain, weight loss and malaise. He is originally from Bangladesh. He has a PMHx of Diabetes Mellitus Type 2 and Hypertension. His BMI is 43.
O/E his vitals are normal but you note a blood pressure of 159/101 mmHg and a painless mass in the RUQ.
Urinalysis shows microscopic haematuria. LDH is elevated. Additionally a CT-Abdo shows a renal mass with regional lymphadenopathy.
Outline the Ddx.
Give your Tx.
Renal Cell Carcinoma
Surgical resection
41
Give 3 risk factors for bladder cancer
* Smoking/Exposure
* Age > 55 years
* Exposure to chemical carcinogens
* Pelvic radiation
* Systemic chemotherapy
42
A 57 year old man presents with dysuria, increased urgency and polyuria. He has a background is working as a telecommunications engineer and a smoker with 40 pack years.
O/E he is haemodynamically stable with normal vitals. Abdominal distension is noted, as is a painless suprapubic mass.
Urinalysis shows haematuria, FBC shows slightly deranged Hb and a US-renal shows large post-void volume with a local invasive, heterogeneous echogenic mass.
Outline your Ddx and its Tx.
Urothelial cancer
Locally invasive tumours
• Radical/partial cystectomy with pelvic lymph node dissection
• Preoperative + postoperative chemotherapy
43
What is a UTI?
Umbrella term for infection of the urinary tract (KUBU) characterised by dysuria, polyuria, Nocturia and suprapubic pain
44
How may a UTI be differentiated?
* Uncomplicated: UTI in healthy individual
* Complicated: UTI with functional or structural impairments e.g. GU tract abnormalities or drug-resistant pathogens
• Acute: Infected urine = infection Sx
-> E.g. Urethritis; Cystitis
• Recurrent: Two separate culture-proven episodes of UTIs within 6/12
-> E.g. Pyelonephritis; Epididymo-orchitis
45
Give 3 risk factors for a UTI.
* Renal tract obstruction (BPH, stones, stricture)
* Previous UTI
* Age ≥ 50 years
* Instrumentation of renal tract e.g. Catheterisation, Urological surgery
46
What is the most common pathogen to cause a UTI?
• E. coli (70%)*
47
State 3 pathogens which commonly can cause a UTI.
* E. coli (70%)*
* S. saprophyticus
* P. mirabilis
* Klebsiella spp.
48
A 63 year old man presents with LUTS of dysuria, urgency and nocturia. He has a PMHx of hypertension and diabetes mellitus type 2. Previously he has been catheterised for his BPH in 2019.
O/E he has an enlarged prostate and suprapubic pain.
His urinalysis shows leukocytes and pyuria, with urine microscopy showing a gram-negative rod-shaped bacteria. CT-KUB shows no abnormalities.
Give your Ddx and Tx.
Acute UTI (Uncomplicated)
ABX: Ciprofloxacin
49
Define urethritis
Infection of the urethra characterised by dysuria, urethral discharge and pruritus
50
Give the types of Urethritis.
* Gonococcal (GU): N. gonorrhea
* Non-Gonococcal (NGU): C. trachomatis, M. genitalium, U. urealyticum
* Post-traumatic (instrumentation)
51
Give 3 risk factors for Urethritis.
* Age: 15-24 (adolescents)
* Female
* Low socioeconomic class
* Multiple sex partners
* STD
* Unprotected sex
52
Give the common pathogens which may cause urethritis.
* N. gonorrhoeae
* C. trachomatis
* U. urealyticum
* M. genitalium
* E. coli
53
A 21 year old male presents with mucopurelent discharge from the urethra. He reports painful testes (orchalgia). His background is uncomplicated with a known history of asthma which is well-controlled.
O/E you can see an absence of epididymal tenderness and swelling with mucopurulent discharge noted.
He has few risky behaviours, but recently went on numerous frivolous sexual exploits following his recent break-up.
A urinalysis shows pyuria and MSU + NAAT shows a gram-negative diplococci present.
Give your Ddx.
Give your Tx.
Urethritis 2º to Gonorrhoea
```
• ABX: Ceftriaxone (250mg IM) + Azithromycin (1g PO)
+ Notify partner
- 2/52 symptomatic
- 3/12 asymptomatic
- Test if > 14 days after exposure
+
NAAT (test of cure): Negative
```
54
Define Urinary Obstruction
Blockage of urinary flow, unilateral or bilateral, characterised by flank pain, fever, polyuria, weak stream, incomplete emptying, nocturia and/or bladder distension
55
Give the types of Urinary Obstruction.
* Unilateral obstructive uropathy: Stones; iatrogenic injury; malignancy
* Bilateral obstructive uropathy: BPH; PC; Urethral strictures; Instrumentation
56
What is an Obstructive Nephropathy?
urinary tract obstruction causing functional impairment of kidney
57
Give 5 risk factors for urinary obstruction.
* BPH
* Constipation
* Medication: Narcotic analgesia/Anticholinergics/alpha-agonists
* Malignancy
* Posterior urethral valves
* Urolithiasis
* Neurological disease
58
Give 5 aetiological factors which can cause Urinary Obstruction.
* Urolithiasis
* Blood clot
* Phlebolith (calcified veins)
* Malignancy
* Sloughed papilla (GN)
* Stricture
* Neuromuscular: PU dysfunction; neuropathic bladder; congenital urethral valve
• Malignancy: Urothelial/Retroperitoneal/Pelvic/Colon
• AAA
• Retroperitoneal fibrosis (fibrosis of ureters and aorta -> extraluminal obstruction)
-> Back pain, malaise and weight loss with CT showing ureteric deviation
• Prostate Ca/BPH
• Phimosis
59
Define urinary incontinence
Involuntary expulsion of urine occurring due to strenuous physical activity (stress incontinence) or increased urge (urgency incontinence) or both (mixed incontinence) characterised by polyuria, nocturia, lower abdominal (suprapubic) distension and enuresis (if no physical cause found).
60
Give the types of Urinary Incontinence
• Stress: Urination on physical activity (e.g. cough, strain -> IA pressure raised > Urethral P
• Urgency: Increased desire
-> Overflow UI = male outflow obstruction thus oliguria + bladder distension
• Mixed: ∑ (Stress + Urgency)
61
Outline the two phases of the Micturition cycle
* Filing phase: Urine in -> stretch receptors stimulated = bladder relaxes + sphincter contracts (sympathetic alpha receptors)
* Voiding phase (≈ 75% full): Voluntary (EUS) + Reflex/PSNS (IUS/detrusor contraction) = relax sphincters + detrusor contraction -> intravesical P > urethral P = micturition
62
Give the risk factors for Urinary Incontinence
* Pregnancy + Childbirth
* Obesity
* Ageing
* Oestrogen withdrawal
* Pelvic surgery
* Dementia
* Stroke
* Parkinson’s Disease
* Multiple Sclerosis
* Radiotherapy
* Post-prostatectomy (sphincter X)
* Chronic Cough
* Obesity
* High-impact physical activity
* Faecal incontinence
63
A 32 year old woman presents with urinary incontinence, polyuria and nocturia.
She has a PMHx of childbirth G2 P2 and both pregnancies were uncomplicated however the second delivery resulted in a 2nd degree tear. She has a BMI of 32.
O/E she has suprapubic distension.
An Empty Supine Stress Test is positive. A post-void residual measurement is positive.
Give your Ddx and Tx.
Stress urinary incontinence
• Conservative: Pelvic floor training; Weight loss; Smoking cessation; Modify fluid intake; Penile sheath (M)
±
• SNRIs: Duloxetine
± (Failed conservative + medical thus 3rd line)
• Surgery: Suburethral sling/ Urethral bulking agent (Si microparticles; Coaptite)
64
Give the investigations you may utilise in a potential diagnosis of urinary incontinence.
• Bladder diary
• Empty supine stress test (Valsalva manoeuver in dorsal lithotomy position after voiding): Positive (urine leakage)
Dorsal lithotomy/Dorsal recumbent = supine, thighs flexed at 90º and legs up
• Cough stress test (300mL filling + Valsalva manoeuvre in dorsal lithotomy): Urine leakage if positive
• Post-void residual measurement (US following voiding): Elevated if ≥100mL OR ≥ 50% void volume
Note: Valsalva manoeuvre activates PSNS in healthy individuals
• Urinalysis: May show leukocytosis; RBC casts; Infection; Nitrites
• US-KUB
Cystourethroscopy (bladder scope): Fistula/Foreign body/Tumour/Interstitial cystitis/Urethritis
-> Indications: Haematuria
65
Define prostatitis.
Inflammation of prostate caused by infection, characterised by dysuria, polyuria, tender prostate, fever, chills and malaise.
66
What pathogen is most commonly the cause of Prostatitis.
• E. coli (80%)*
67
A 50 year old man presents with fever, chills and dysuria. He describes a 6/10 pain in his perineal region. He has voiding LUTS of intermittency, dribbling and weak stream.
O/E he has a tender prostate, eliciting a sharp pain when touched. He is haemodynamically stable but has a temperature of 39ºC.
Urinalysis shows leukocytes and MSU + culture shows a gram-negative rod bacterium. PSA is elevated by 5.
Give your DDx.
Outline your Tx.
Prostatitis (E. coli)
• ABX: Ciprofloxacin (500mg PO BDS)
±
• NSAID: Ibuprofen (200-400mg 4-6 hours; maximum 2400mg/day)
68
What is Benign Prostatic Hyperplasia?
Enlargement of the prostate due to hyperplasia of transition zone of prostate and peri-urethral zones characterised by storage symptoms (∑ urgency, frequency, Nocturia), voiding symptoms (∑ hesitancy, straining, weak stream, intermittency, post-void dribbling) and urinary retention.
69
Give a risk factor for BPH.
* Age ≥ 50
| * FHx
70
Outline the pathophysiology for BPH.
• Hyperplasia of epithelial and stromal compartments (transition zone) = stromal: epithelial ratio -> obstruction due to stromal smooth muscle tone (dynamic) + epithelial tissue (prostatic)
71
Which specific zone of the prostate enlarges in BPH?
Transition zone
72
A 64 year old man presents with LUTS of voiding nature - describing weak stream, intermittency and post-void dribbling.
O/E there is nothing remarkable.
A urinalysis is normal. PSA is elevated by 2 and a CT-Pelvis shows an enlarged prostate. His IPSS is 17.
What is your Ddx?
Give a Tx.
BPH
• Alpha blocker: Tamsulosin/ Doxazosin
OR
• 5-a-reductase inhibitor: Finasteride
73
A 69 year old man presents with LUTS of voiding nature - describing weak stream and post-void dribbling.
O/E there is nothing remarkable.
A urinalysis is normal. PSA is elevated by 2 and a CT-Pelvis shows an enlarged prostate. His IPSS is 7.
What is your Ddx?
Give a Tx.
BPH
No bothersome Sx (IPSS = Mild)
• Watch and wait -> IPSS mild
74
A 69 year old man presents with LUTS of voiding nature - describing weak stream and post-void dribbling.
O/E there is nothing remarkable.
A urinalysis is normal. PSA is elevated by 2 and a CT-Pelvis shows an enlarged prostate. His IPSS is 30 with a prostate volume of 110g.
What is your Ddx?
Give a Tx.
BPH
Indication for surgery (prostate volume ≥ 80g)
• Surgery: Open prostatectomy
75
A 69 year old man presents with LUTS of voiding nature - describing weak stream and post-void dribbling.
O/E there is nothing remarkable.
A urinalysis is normal. PSA is elevated by 2 and a CT-Pelvis shows an enlarged prostate. His IPSS is 30 with a prostate volume of 40g.
What is your Ddx?
Give a Tx.
BPH
Indication for surgery (prostate volume ≥ 30g)
• Surgery: Transurethral incision of prostate (TUIP)
76
What scoring system can be used for Prostate Cancer?
• Gleason Score (1st + 2nd): Low (≤ 6)/ Intermediate (7); High (8-10)
-> 1-5 x2 thus maximum 10
• TNM
77
What is the Gleason Scoring System?
Gleason scoring system is a grading system for Prostate cancer taking the top two most cancerous sites, allocating 1-5 (cancers usually 3) to generate a score from 2-10 with: Low (<6), Intermediate (7) and High (8-10)
78
Give 3 risk factors for Prostate Carcinoma
* Age > 50
* FHx
* High fat intake
* Caucasian
* Black
79
A 57 year old man presents with back pain localised to his lower, central pain. He describes the pain radiating to his back, deep, with horrible bony pain keeping him up at night. Additionally, he describes urinary symptoms of dysuria, urinary hesitancy and weight loss.
He has a PMHx or CHD and hypertension. His BMI is 35.
O/E you note cervical lymphadenopathy and localisation of the pain.
A DRE shows an asymmetrical, nodular prostate.
PSA shown to be elevated by 11, testosterone is normal and a CT-Pelvis shows an enlarged prostate which bears a radiopaque mass which is heterogeneous.
Give your DDx.
Give your Tx.
Prostate Carcinoma
Dependent on risk
Low-Intermediate risk disease
• Active surveillance: Prostate biopsy + Monitoring
• Brachytherapy (transperineal implantation of radiation)
• Radical prostatectomy ± Lymph node dissection
High-risk disease
• Surgery: Radical prostatectomy + Pelvic lymph node dissection
80
What are the tumours which metastasise to bone?
```
Prostate
Breasts
Kidney
Thyroid
Lung
```
81
Define Acute Epididymitis.
Inflammation of epididymis due to infection characterised by scrotal pain, unilateral swelling and symptoms ≤ 6 weeks.
82
How may acute epididymitis be classified?
* Bacterial
* Viral
* Fungal
* Drug-Induced
* Vasculitis
* Idiopathic
83
Give 3 risk factors for Acute Epididymitis.
* Unprotected sex
* Bladder outflow obstruction
* Instrumentation
* Amiodarone use
* Vasculitis
84
A 45 year old man presents with a pain in the scrotum. He describes it to be hot, tender and red. He has been experiencing difficulty urinating.
He has not recently had sex with anyone, he has a background of arrhythmia for which he takes Amiodarone. He has no other significant medical, family or drug history.
O/E there is enlargement of the testes and a unilateral scrotal swelling.
Urinalysis shows leukocytes absent and MSU + NAAT show no pathogen detected.
Give your Ddx (and the likely cause).
Outline your Tx.
Acute Epididymo-Orchittis due to Amiodarone
Reduce Amiodarone dose or discontinue
+
Supportive measures: Pain relief (NSAIDs)
85
A 45 year old man presents with a pain in the scrotum. He describes it to be hot, tender and red. He has been experiencing difficulty urinating.
He recently had sex with 3 women, 2 of which were unprotected. He has a background of recurrent UTIs. He has no other significant medical, family or drug history.
O/E there is enlargement of the testes and a unilateral scrotal swelling.
Urinalysis shows leukocytes and nitrites present and MSU + NAAT and culture show a gram-negative diplococci.
Give your Ddx (and the likely cause).
Outline your Tx.
Acute Epididymo-orchitis due to bacterial pathogen - Gonorrhoea?
Gonorrhoea Suspected
• Ceftriaxone (250mg IM) + Azithromycin (1mg PO)
86
What is Testicular torsion?
Urological emergency caused by twisting of spermatic cord, constricting vascular supply with resultant ischaemia and/or necrosis of testicular tissue characterised by
87
Give 3 RFs for Testicular Torsion.
* Age < 25 years
* Neonate
* Trauma
* Bell clapper deformity (testes rotate within tunica vaginalis)
88
A 21 year old male presents with sudden onset testicular pain. He is nauseous and close to vomiting. He has experienced some abdominal pain.
He is a university student that plays rugby regularly. He drinks 16 units a week and is a non-smoker.
O/E you note scrotal oedema, scrotal erythema and an absent cremasteric reflex.
What investigations would you do?
What is your DDx?
Give your Tx.
None, suspected testicular torsion is a urological emergency - potential US-Testes/Abdo if available easily
Testicular torsion
Surgical exploration + Orchidopexy (salvageable) Orchiectomy (unsalvageable)
89
What is a varicocele?
Enlargement of pampiniform plexus of scrotum causing low sperm production (hypospermia), reduced concentration (oligoospermia) and low sperm quality (tetrazoospermia/asthenozoospermia)
90
What is low sperm count termed as?
• Oligoospermia: Low count (<15 million/ml)
91
What is reduced sperm volume?
• Hypospermia: Reduced volume (< 1.5ml)
92
What is abnormal sperm morphology?
• Tetrazoospermia: Abnormal morphology (< 4% normal)
93
What is reduced sperm motility?
• Asthenozoospermia: Reduced motility (< 40% moving)
94
Give two risk factors for varicocele.
* FHx
| * BMI extremes (<18.5 cf 30
95
What would you establish O/E of a patient with varicocele?
* Painless scrotal mass (bag of worms)*
* Asymmetrical testes*
* Infertility
96
How do you treat a varicocele?
```
• Supportive (reassurance and observation)
+
• Surgery
- Open repair
- Laparoscopic
- Percutaneous embolization
```
97
What is obstructive azoospermia?
Absence of spermatozoa in ejaculation despite normal spermatogenesis
98
Give 3 risk factors for obstructive azoospermia.
* Trauma
* Surgery
* Infection
* FHx Obstructive Azoospermia
99
What is the Tx for obstructive azoospermia?
• Vasectomy reversal: Vasovasotomy (vas deferens region blocked is excluded and ends sutured) or Vasoepidydmostomy (vas deference connected to tubule of epididymis)
100
What is hydrocele?
Collection of serous fluid between tunica vaginalis or spermatic cord characterised by scrotal oedema that can undergo transillumination
101
Give the 2 types of hydrocele
* Communicating: patent processus vaginalis connects peritoneal cavity and scrotum
* Non-Communicating (Simple): Processus vaginalis closed, fluid production > output (by tunica vaginalis)
102
How do you treat a symptomatic hydrocele?
• Intervention: Surgery/Aspiration/Sclerotherapy
103
What would be a positive examination find for a patient with hydrocele?
• Scrotal mass/oedema
-> Variation during day/Enlargement by activity
• Transillumination
104
A 47 year old man presents with bone pain, weight loss and malaise.
He has no significant PMHx other than hypertension.
O/E you identify a fixed, nodular testicular mass which is immoveable. There is lymphadenopathy noted also.
US-Testes shows an echogenic, heterogeneous mass. XR-Abdo shows metastases in the lumbar vertebrae and CX-R shows lung masses.
What is your Ddx?
Give your Tx.
Testicular cancer with bone and lung metastases
```
• Surgery: Radical orchiectomy
±
• Surveillance
+
• Chemotherapy
```
105
# Define:
- Phimosis
- Paraphimosis
- Epispadias
- Hypospadias
- Buried penis
- Paraphimosis (Foreskin retraction)
- Phimosis (Retract foreskin)
- Hypospadias (urethral opening below penis)
- Epispadias (urethral opening above penis)
- Buried penis (penis present in dartos tissue)
106
What is the Tx for a phimosis?
• Surgery: Circumcision
107
What is the Tx for a paraphimosis?
Paraphimosis
• Medical: Paraphimosis reduction
OR
• Surgery: Surgical reduction (dorsal slit)
108
What is the Tx for an epispadias?
• Surgery: Urethroplasty
| -> CI in incomplete prepuce
109
What is the Tx for a hypospadias?
• Surgery: Urethroplasty
| -> CI in incomplete prepuce
110
What is the Tx for Buried penis?
• Surgery: Phalloplasty
111
What is balanoposthitis?
Inflammation of the glans penis and prepuce caused by inflammatory, infective or pre-cancerous states; characterised by pruritus, erythematous patches, erosions and LUTS (voiding Sx)
112
What is erectile dysfunction?
The consistent or recurrent inability to attain/maintain a penile erection sufficient for sexual intercourse
113
Give 3 risk factors for erectile dysfunction
- Advanced age
- CAD
- PAD
- HTN
- DM
- Smoking
- Hyperlipidemia
- Drugs: Anti-depressants/Anti-hypertensives
- Libido disorder
- Obesity
- SCI
- Pelvic injury
- Neurological disease
- Peyronie’s Disease (fibrous nodules in tunica albuginea)
114
Give the Tx for Erectile Dysfunction.
```
• Tx Underlying Condition
+
• Psychotherapy: CBT
+
PDE5 inhibitors: Sildenafil
± (Peyronie’s Disease/Trauma)
```
OR
• Surgery: Surgical correction/Prosthesis/Revascularisation
115
Which bacterium is most likely to cause acute epididymitis in older men?
Proteus
116
Outline the main RFs for Epididymitis.
* Unprotected sex
* Bladder outflow obstruction
* Instrumentation
* Amiodarone use
* Vasculitis
117
Which antidysrhythmic medication may cause iatrogenic epididymitis?
Amiodarone
118
What type of drug is Bicalutamide?
AR antagonist
119
What type of drug is Gorsorelin?
LHRH analogue
120
For Androgen deprivation therapy, which two drugs are used in combination? How do they work?
Bicalutamide (AR antagonist)
+
Gorsorelin (LHRH analogue)
121
Which anatomical variation predisposes one to testicular torsion?
Bell Clapper deformity (rotation within TV)
122
Which two signs are used to further one's clinical suspicion of testicular torsion?
Absence of cremasteric reflex
Positive Prehn's test
123
Which clinical test may allow differentiation between Epididymitis and Testicular torsion?
Prehn's test
124
Which rule may help you remember the values for hypospermia, oligoospermia, tetrazoospermia and asthenozoospermia?
'The rule of 15 and 4'.
Hypospermia < 1.5mL
Oligospeermia <15million/mL
Tetrazoospermia <4% normal
Asthenozoospermia <40%
125
Which disease can cause ED secondary to fibrous nodules in the tunica albuginea?
Peyronie's Disease - fibrous deposits in the tunica albuginea causing a curved penis
