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Urology Flashcards

1
Q

Causes of scrotal swelling

A 
Painless:
Hernia
Hydrocele
Varicocele 
Idiopathic scrotal oedema
Testicular tumours (rare)

Painful:
Testicular torsion
Torsion of testicular appendage
Epididymitis
Orchitis 
Zipper entrapment
Henoch-Schonlein purpura
Allergic reactions
Insect bites 
Injuries
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2
Q

Inguinal hernia

A

Cannot get above it on examination
Cough impulse may be present
May be reducible

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3
Q

Testicular tumours

A 
Discrete testicular nodule 
May have associated hydrocele
Symptoms of metastatic disease
USS scrotum 
AFP and B-HCG
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4
Q

Acute epididymo-orchitis

A

History of dysuria and urethral discharge
Swelling may be tender and eased by elevated testis
Most cases due to Chlamydia

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5
Q

Epididymal cysts

A

Single or multiple cysts
May contain clear or opalescent fluid (spermatocele)
Usually occur over 40 years of age
Painless
Lie above and behind testis
Usually possible to get above lump on examination

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6
Q

Hydrocele (communicating)

A 
Non-painful, soft fluctuant swelling 
Get above it on examination
Clear fluid
Transilluminate
Feature of testicular cancer
Due to patent processus vaginalis
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7
Q

Testicular torsion

A

Severe, sudden onset testicular pain
Risk factors: abnormal testicular lie
Typically affects adolescents and young males
Testes tender and pain not eased by elevation
Urgent surgery indicated, contra-lateral testis should also be fixed

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8
Q

Varicocele

A

Varicosities of pampiniform plexus
Typically occur on left (testicular vein drains into renal vein)
Presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicocele may affect fertility

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9
Q

Management of testicular malignancy

A

Orchidectomy via inguinal approach
Allows high ligation of testicular vessels
Avoids exposure of another lymphatic field to tumour

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10
Q

Management of testicular torsion

A

Commonest in young teenagers
Intermittent torsion
Prompt surgical exploration and testicular fixation
Sutures or by placement of testis in a Dartos pouch

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11
Q

Management of varicoceles

A

Managed conservatively

If concerns about fertility: surgery/ radiology

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12
Q

Management of epididymal cysts

A

Excised using a scrotal approach

Sclerotherapy

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13
Q

Management of hydrocele

A

Ligate processus

Inguinal approach

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14
Q

Conditions associated with epididymal cysts

A

Polycystic kidney disease
CF
VHL syndrome

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15
Q

Hydroceles may develop secondary to:

A

Epididymo-orchitis
Testicular torsion
Testicular tumours

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16
Q

Acute scrotal disorders in children

A

Testicular torsion: most common around puberty
Irreducible inguinal hernia: most common in children <2 years old
Epididymitis: rare in prepubescent children

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17
Q

Enuresis

A

Involuntary urination

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18
Q

Nocturnal enuresis

A

Bed wetting

Up to 3/4 years

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19
Q

Diurnal enuresis

A

Inability to control bladder function during the day

Up to 2 years

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20
Q

Primary nocturnal enuresis causes

A

Variation on normal development (most common)
FH
Overactive bladder
Fluid intake
Failure to wake
Psychological distress
Chronic constipation, UTI, learning disability, cerebral palsy

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21
Q

Overactive bladder pathophysiology

A

Frequent small volume urination prevents development of bladder capacity
Primary nocturnal enuresis

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22
Q

Management of primary nocturnal enuresis

A

2 week diary: toileting, fluid intake, bed wetting episodes
History and examination
Reassure if <5
Lifestyle changes: reduce fluid, easy toilet access, pass urine before bed
Encouragement and positive reinforcement
Treat any underlying cause or exacerbating factors, e.g. constipation
Enuresis alarms
Pharmacological treatment

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23
Q

Secondary nocturnal enuresis

A

Dry for 6 months

Then start bedwetting

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24
Q

Causes of secondary nocturnal enuresis

A 
UTI
Constipation
TY1 diabetes
Maltreatment
New psychosocial problems
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25
Diurnal enuresis
Stress incontinence Urge incontinence Dry at night More frequent in girls
26
Urge incontinence
Overactive bladder | Little warning before emptying
27
Stress incontinence
Leakage of urine during physical exertion, coughing or laughing
28
Causes of diurnal enuresis
``` Recurrent UTI Psychosocial problems Constipation Urge incontinence Stress incontincne ```
29
Enuresis alarms
Device that makes a noise at first sign of bed wetting Wakes child and stops them from urinating High level of training and commitment Needs to be used consistently for >3 months
30
Medication for nocturnal enuresis
Desmopressin: ADH analogue, reduces volume of urine produced by kidneys, taken at bedtime with intention of reducing nocturnal enuresis Oxybutynin: anticholinergic, reduces contractility of bladder Imipramine: TCA, relaxes bladder and allows sleep
31
Cryptorchidism
Congenital absence of one or both testes in the scrotum due to a failure of the testes to descend during development
32
Epidemiology of cryptorchidism
6% newborns | 1.5-3.5% at 3 months
33
Types of cryptorchidism
True undescended testis: absent from scrotum but lies along the line of testicular descent Ectopic testis: testis found away from normal path of descent Ascending testis: secondary ascent out of scrotum Bilateral: exclude hormonal causes, androgen insensitivity syndrome, disorder of sex development
34
Pathophysiology of Cryptorchidism
Testis descends from abdomen to scrotum | Pulled by gubernaculum within processus vaginalis
35
Risk factors for cryptorchidism
Prematurity Low birth weight Having other abnormalities of genitalia (hypospadias) First degree relative with cryptorchidism
36
Cryptorchidism history
Clarify if testis has even been seen or palpated within scrotum Newborn check Parents noticed testicle in scrotum in certain situations (warm bath)
37
Cryptorchidism examination
Retractile/ normal descended testis Proceed to palpation to locate testis Infant/ child laid flat on bed Palpate along inguinal canal See if testis can be gently milked down to the base of the scrotum (retractile testis) If it is pulled down but under tension in the base: high testes Inguinal undescended testes
38
Impalpable undescended testes
Ectopic Intra-abdominal Absent Impalpably small
39
Differential diagnosis undescended testes
``` Normal retractile testis True undescended testis Ectopic testis Absent testis Bilateral impalpable testis: disordered sexual development, endocrine ```
40
Cryptorchidism urgent referral to senior paediatrician within 24hrs
Disordered sexual development Ambiguous genitalia Hypospadias Bilaterally undescended Access to endocrinology and urology services
41
Presentation of congenital adrenal hyperplasia and cryptorchidism Initial management
Risk of salt-losing crisis Need high-dose NaCl therapy Careful glucose monitoring Steroid replacement
42
Role of imaging in cryptorchidism
No benefit | USS/MRI poor sensitivity
43
Management of cryptorchidism At birth 6-8 weeks: 3 months:
Birth: review at 6-8weeks 6-8 weeks: if fully descended no further action, if unilateral re-examine at 3 months 3 months: follow-up if retractile, refer to surgery/urology for definitive intervention if undescended Examination under anaesthesia, then laparoscopy to locate an impalpable testis
44
Management cryptorchidism | Palpable testes
``` Open orchidopexy If 6-12months of age Via groin incision Processus vaginalis and cremasteric covering is separated from cord Testis mobilised and fixed in scrotum ```
45
Management of cryptorchidism | Intra-abdominal testes
Single stage or Fowler-Stephens procedure (2 stage procedure) Testicular vessels ligated, for collateral to come in Bring testes into scrotum 6 months later
46
Management of cryptorchidism | Atrophic testis
Remove a trophic testis | Groin exploration if vas/testicular vessels blind-ending or entering deep inguinal ring
47
Retractile testes
Scrotum-> inguinal canal Cold or cremasteric reflex Normal variant Orchidopexy if fully retract or fail to descend
48
Surgical complications of undescended testes
Short-term: Infection Bleeding Wound dehiscence Long-term: Testicular atrophy Testicular re-ascent
49
Complications of an undescended testis
Impaired fertility: too warm Testicular cancer Torsion
50
Testicular torsion
``` Spermatic cord and its contents twists within tunica vaginalis Compromising blood supply to testicle Surgical emergency 12-25 years old and neonates Will infarct within hours ```
51
Pathophysiology of testicular torsion
``` Mobile testis rotates on the spermatic cord Reduced arterial blood flow Impaired venous return Venous congestion Resultant oedema Infarction to testis if not corrected ``` Bell-clapper deformity more prone to developing testicular torsion
52
Bell clapper deformity
Horizontal lie to testes More prone to developing testicular torsion Testis lacks normal attachment to tunica vaginalis More mobile, increasing likelihood of it twisting on cord structures
53
Neonatal testicular torsion
Attachment between scrotum and tunica vaginalis not full formed Entire testis and tunica vaginalis can tort Extra-vaginal torsion Can occur in-utero
54
Risk factors for testicular torsion
12-25 age Previous torsion FH Undescended testes
55
Clinical features of testicular torsion
Sudden onset severe unilateral testicular pain Associated with nausea and vomiting, secondary to the pain Referred abdominal pain High position with horizontal lie Swollen and tender Cremasteric reflex absent Pain continues despite elevation (negative Prehn’s sign)
56
DD of testicular torsion
``` Epididymo-orchitis Trauma Inguinal hernia Testicular cancer Renal colic Hydrocele Idiopathic scrotal oedema Torsion of the hydatid of Morgagni ```
57
Torsion of the Hydratid of Morgagni
R4emnant of Müllerian duct Common testicular appendage Common in younger age group Scrotum usually less erythematous with a normal lie of the testis Blue dot may be present in the upper half of the hemi scrotum Visible infarcted hydatid
58
Investigations of testicular torsion
Clinical diagnosis Straight to theatre for scrotal exploration Doppler US: investigate potential compromised blood flow to testis Urine dipstick
59
Management of testicular torsion
Surgical emergency 4-6hr window to salvage testes Urgent surgical exploration Strong analgesia and anti-emetics, NBM, IV fluids Fix both testes to scrotum Bilateral orchidopexy If non-viable: orchidectomy and prosthesis can be inserted
60
Complications of testicular torsion
Testicular infarction Atrophy of affected testicle ``` After scrotal exploration: Chronic pain Palpable suture Risk to future fertility Theoretical risk of future torsion despite fixation ```
61
Epididymitis
Inflammation of epididymis | 15-30 and >60years
62
Pathophysiology of epididymo-orchitis
Local extension of infection From LUT: bladder and urethra Via enteric: classic UTI Or non-enteric: STI
63
Epididymo-orchitis in <35 organisms
Sexual transmission N.gonorrhoea C.trachomatis
64
Epididymo-orchitis in >35 organisms
``` Enteric organism from a urinary tract infection E.coli Proteus spp Klebsiella pneumonia Pseudomonas aeruginosa ``` Bladder outflow obstruction from prostatic enlargement Retrograde ascent of pathogen
65
Mumps orchitis
Post-pubertal boys after mumps viral infection Unilateral or bilateral orchitis Accompanied with a fever, around 4-8 days after onset of mumps parotitis Disease self-resolves within a week with supportive management
66
Complications of mumps orchitis
Testicular atrophy | Infertility
67
Management of mumps orchitis
Mumps IgM/IgG serology Notifiable disease Inform local health protection team if suspicion
68
Risk factors for epididymo-orchitis
Depends on mechanism of disease: STI/UTI Non-enteric causes: MSM, multiple sexual partners, known contact of gonorrhea Enteric causes: recent instrumentation or catheterisation, BOO, immunocompromised state
69
Clinical features of epididymo-orchitis
Unilateral scrotal pain and swelling Fever and rigors Dysuria, storage LUTS, urethral discharge Red and swollen Tender on palpation Associated hydrocele Prehn’s sign positive
70
DD of epididymo-orchitis
``` Testicular torsion Testicular trauma Testicular abscess Epididymal cyst Hydrocele Testicular tumour ```
71
Epididymo-orchitis investigations
``` Urine dipstick Mc&S Collect first-void urine Send urine for NAAT: N.gonorrhoeae, C.trachomatis, M.genitalium STI screen FBC, CRP Bloo cultures USS Doppler for testicular blood flow ```
72
Initial management of epididymitis
``` Outpatient Ax Analgesia Enteric: ofloxacin STI: ceftriaxone and doxycycline ```
73
Complications of epididymitis
Reactive hydrocele Abscess Testicular infarction
74
Hypospadias
Urethral meatus located at abnormal site | Usually on underside of the penis
75
Pathophysiology of hypospadias
Arrest of penile development | Hypoplasia of ventral tissue of the penis
76
Clinical features of hypospadias
Abnormal urinary flow Abnormal penile curvature during erections Ventral opening of urethral meatus Ventral curvature of penis or ‘Chordee’ Dorsal hooded foreskin
77
Classification of hypospadias
``` Glandular Coronal Shaft Scrotal Perineal ```
78
Differential diagnosis of hypospadias
Disorders of sexual development | Congenital adrenal hyperplasia
79
Investigations to rule out DSD | Disorder of sex development
``` Detailed history and examination Karyotype Pelvis US scan Urea and electrolytes Endocrine hormones: testosterone, 17 alpha-hydroxyprogesterone LH FSH ACTH Renin Aldosterone ```
80
Management of hypospadias
Urethroplasty with graft from foreskin (advise against circumcision)
81
Aims of urethroplasty in hypospadias
Bringing the meatus to the glans of the penis Chordee is corrected to straighten the penis Dorsal foreskin is managed with either circumcision or reconstruction, depending on anatomy, parental and surgical preference
82
Short term complications of hypospadias
Post surgical catheter may block, become displaced or kinked Urethral catheter may cause pain and bladder spasms (Give oxybutynin) Bleeding Infection
83
Long term complications of hypospadias
Urethral fistula | Risks of mental or urethral stenosis
84
Complications of untreated BXO
Meatal stenosis Phimosis Erosions of glans and prepuce which can extend to urethra
85
Surgical complications of BXO
Swelling Serous discharg around penis for a week Infection
86
Management of BXO
Circumcision | Send foreskin off to histopathology
87
Balanitis xerotica obliterans
Keratinisation of tip of foreskin causes scarring | Prepuce remains non-retractile
88
Clinical features of BXO
``` Ballooning of foreskin during micturition Self-resolving as prepuce becomes more mobile with age, normal age 2-4 Scarring of urethral meatus Irritation Dysuria Haematuria Local infecton Urinary obstruction ```
89
Examination of BXO
White, fibrotic and scarred prep UTi all tip | Difficult to visualise meatus

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