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Urology Flashcards

1
Q

What are the causes of lower urinary tract symptoms

A

BPH

UTI

Urological malignancy

Detrusor muscle weakness/instability

Chronic prostatitis

Urethral strictures

External compression

Neurological disease

Drinking fluids late at night

Alcohol excess

Excess caffeine intake

Polyuria

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2
Q

What are the classifications of lower urinary tract symptoms

A

Storage symptoms: urgency, frequency, nocturia, urge incontinence

Voiding symptoms: bladder outflow obstruction, hesitancy, intermittency, straining, terminal dribbling, incomplete emptying

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3
Q

What additional symptoms should be asked about in a lower urinary tract symptoms history

A

Visible haematuria

Suprapubic discomfort

Colicky pain

Medications: anticholinergics, antihistamines, bronchodilators

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4
Q

What investigations are needed for lower urinary tract symptoms

A

Post-void bladder scan

Flow rate

Urinalysis

Urine culture

Routine bloods (+ PSA)

Urodynamic studies (flow rate, detrusor pressure, storage capacity)

Cystoscopy (recent infection, haematuria)

Upper urinary tract imaging (chronic infections, recent infection, haematuria)

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5
Q

What is the management for lower urinary tract symptoms

A

Treat underlying cause

Regulate fluid intake

Urethral milking

Double voiding

Pelvic floor exercises (stress incontinence)

Bladder training (urge incontinence)

Anticholinergics (oxybutynin, for urge incontinence)

Alpha blockers (tamsulosin, for BPH)

Loop diuretics (take mid-afternoon to prevent nocturia)

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6
Q

What is the urgent referral criteria for haematuria

A

> 45: unexplained visible haematuria without UTI/despite successful treatment of UTI

> 60: unexplained non-visible haematuria with dysuria/raised WCC

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7
Q

What are the causes of haematuria

A

UTI

Urothelial carcinoma

Stone disease

Adenocarcinoma of prostate

BPH

Infection (pyelonephritis, cystitis, prostatitis)

Malignancy

Renal calculli

Trauma

Recent surgery

Radiation cystitis

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8
Q

What investigations are needed for haematuria

A

Urinalysis

Bloods (routine + clotting + PSA)

Flexible cystoscopy

US KUB

CT urogram

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9
Q

What is acute urinary retention

A

New onset inability to pass urine

Leads to pain, discomfort, and significant residual volume

Most common in older males (BPH)

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10
Q

What are the causes of acute urinary retention

A

BPH

Urethral strictures

Prostate cancer

Urinary tract infection

Constipation

Severe pain

Anti-muscarinics

Peripheral neuropathy, iatrogenic nerve damage, upper motor neurone disease

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11
Q

How might acute urinary retention present

A

Acute suprapubic pain

Inability to micturate

Symptoms predisposing to retention: UTI, change in medication, LUTS

Palpable distended bladder

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12
Q

What investigations are needed for acute urinary retention

A

PR

Post-void bladder scan

Bloods

Catheterised specimen of urine

Ultrasound (hydronephrosis)

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13
Q

What is the management for acute urinary retention

A

Urethral catheterisation

Treat underlying cause

Antibiotics if have UTI

Medication review

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14
Q

What is chronic urinary retention

A

Painless inability to pass urine

Significant bladder distension

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15
Q

What are the causes of chronic urinary retention

A

BPH

Urethral strictures

Prostate cancer

Pelvic prolapse

Large fibroids

Peripheral neuropathies

Motor neurone disease

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16
Q

How might chronic urinary retention present

A

Painless urinary retention

Voiding LUTS

Reduced functional capacity

May have overflow incontinence

Palpable distended bladder

No/minimal tenderness

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17
Q

What investigations are needed for chronic urinary retention

A

DRE

Post-void bladder scan

Bloods

Ultrasound (if have high-pressure retention)

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18
Q

What is the management for chronic urinary retention

A

High volumes (>1 L): long-term catheterisation, monitor urine output

Do not TWOC (likely to get renal injury)

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19
Q

What investigations are needed for scrotal lumps

A

Ultrasound scrotum

Tumour markers for testicular cancer (LDH, AFP, beta-HCG)

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20
Q

Give an overview of hydrocele

A

Abnormal collection of peritoneal fluid between parietal and visceral layers of tunica vaginalis

Presentation: painless fluctuant swelling, transilluminates, unilateral/bilateral, discomfort on sitting/walking if very large

Neonates: regresses spontaneously within a couple of years

Infants: due to patent processus vaginalis, needs ligation

In 20-40s: need urgent ultrasound

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21
Q

Give an overview of varicocoele

A

Abnormal dilation of pampiniform venous plexus

Bag of worms

Disappears on lying flat

90% on left side (left spermatic vein drains directly into left renal vein)

Can cause infertility and testicular atrophy

Red flags: acute onset, right sided, remains when lying flat

If asymptomatic, no treatment needed

Surgery: embolisation, ligation of spermatic vein

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22
Q

Give an overview of epidermal cyst

A

Spermatocele

Benign, fluid-filled sac arising from epidermis

Presentation: smooth fluctuant nodule, above and separate to testis, transilluminates, common in middle aged men

Do not usually need treatment

Surgery if very large or painful

Avoid surgery in young men, causes infertility

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23
Q

Give an overview of epididymitis

A

Inflammation of epididymis

Presentation: unilateral acute onset scrotal pain, swelling, erythematous overlying skin, systemic symptoms, tender

Pain relieved by elevation of testis (Prehn’s sign)

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24
Q

Give an overview of testicular tumours

A

Painless lump in testis

Firm, irregular mass

Does not transilluminate

Most common malignancy in 20-40 men

Urgent ultrasound

Tumour markers

May need radical inguinal orchidectomy

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25
Give an overview of testicular torsion
Twisting of testis on spermatic cord Leads to ischaemia Presentation: sudden onset severe unilateral scrotal pain, may have nausea and vomiting Mostly in pubescent boys Bell-clapper deformity: high attachment of tunica vaginalis allows for rotation Examination: very tender, testis raised, swelling, loss of cremasteric reflex Surgical emergency: surgical exploration and fixation of both testes
26
What are some benign testicular lesions
Leydig cell tumours Sertoli cell tumours Lipomas Fibromas
27
Give an overview of orchitis
Inflammation of testis Usually associated with mumps Need rest and analgesia If have intra-testicular abscess: drainage, may need orchidectomy
28
What are the 2 types of renal cysts
Simple: well-defined outline, homogenous features, common in elderly, develop from renal tubule epithelium Complex: complicated structure (thick wall, septation, calcification), risk of malignancy
29
What are the risk factors for renal cysts
Increasing age Smoking Hypertension M>F Genetic conditions (polycystic kidney disease - autosomal dominant, PKD1/2)
30
How might renal cysts present
Usually incidental finding Usually asymptomatic Flank pain (if ruptured/infected) Haematuria In polycystic disease: uncontrolled HTN, flank mass
31
What investigations are needed for renal cysts
U&Es CT/MRI
32
What is the Bosniak scoring system
For risk of renal cysts being malignant Stage 1: simple, 1% malignancy, no follow up Stage 2: complex, 3% malignancy, no follow up Stage 2F: complex, 5% malignancy, CT scan at 3,6, 12 months Stage 3: complex, 50-70% malignancy, surveillance or surgery Stage 4: complex, 90-100% malignancy, surgery
33
What are renal tract calculi
Renal/ureteric stones Males > 65 Mostly calcium (calcium oxalate, calcium phosphate, mixed) Can be struvite or cystine
34
What is the criteria for admission in renal tract calculi
Post-obstructive AKI Uncontrollable pain on simple analgesia Evidence of infection Large (>5cm)
35
What are the likely sites of impaction of renal tract calculi
Pelviureteric junction (PUJ) Crossing pelvic brim Vesicoureteric junction (VUJ)
36
How might renal tract calculi present
Sudden onset severe pain Loin to groin Ureteric colic Nausea and vomiting Haematuria
37
What investigations are needed for renal tract calculi
Urine dip Bloods (+ urate + calcium) Non-contrast CT (gold standard) Ultrasound (for hydronephrosis)
38
What is the management for renal tract calculi
A to E Most pass stones spontaneously Analgesia If infection, IV antibiotics Stent insertion Extracorporeal shock wave lithotripsy Percutaneous nephrolithotomy Flexible uretero-renoscopy
39
What is pyelonephritis
Inflammation of kidney parenchyma and renal pelvis 15 - 29s Complicated: structurally and functionally normal urinary tract, non-immunocompromised Complicated: structurally or functionally abnormal urinary tract, immunocompromised host UTIs in males always complicated
40
What are the common causative organisms of pyelonephritis
E coli Klebsiella Proteus Staph aureus Psuedomonas
41
What are the risk factors for pyelonephritis
Obstructed urinary tract Spinal cord injury F>M Indwelling catheter Ureteric stents Structural renal abnormality Diabetes, untreated HIV Corticosteroid use Renal calculi Menopause
42
How might pyelonephritis present
Classic triad: fever, unilateral loin pain, nausea and vomiting Usually develops over 24-48 hrs Symptoms of UTI Haematuria Pyrexia Costovertebral angle tenderness Suprapubic tenderness Post-void residual volume
43
What investigations are needed for pyelonephritis
Urinalysis Bloods Renal ultrasound CT (if suspect obstruction)
44
What is the management for pyelonephritis
A to E IV empirical antibiotics Fluids Analgesia Antiemetics Catheterisation Consider HDU monitoring in severe cases
45
What are some types of renal cancer
Renal cell carcinoma (most common) Transitional cell carcinoma Wilm's tumour Squamous cell carcinoma
46
What are the risk factors for renal cancers
Smoking (major risk factor) Industrial exposure to carcinogens Dialysis Hypertension Obesity Polycystic kidneys Horseshoe kidneys
47
How might renal cancers present
Haematuria Flank pain Flank mass Lethargy Weight loss Left varicocele
48
How might a paraneoplastic syndrome due to renal cell carcinoma present
Polycythaemia (abnormal EPO) Hypercalcaemia (abnormal PTH) Hypertension (abnormal renin) Pyrexia of unknown origin
49
What are the subtypes of urinary incontinence
Stress Urge Mixed Overflow Continuous
50
Give an overview of stress incontinence
Urine leakage when intra-abdominal pressure goes above urethral pressure Coughing, straining, laughing, lifting Common post-partum (damaged pelvic floor muscles, weakness of urethral sphincter) Risk factors: constipation, obesity, post-menopausal, pelvic surgery
51
Give an overview of urge incontinence
Overactive bladder (detrusor hyperactivity) Uninhibited bladder contractions - rise in intravesical pressure Causes: neurological (stroke), infection, malignancy, idiopathic, medications (cholinesterase inhibitors)
52
Give an overview of mixed incontinence
Mixture of stress incontinence and urge incontinence
53
Give an overview of overflow incontinence
Usually a complication of chronic urinary retention: progressive stretching of bladder wall, damage to efferent fibres of sacral reflex, loss of bladder sensation Constant dribbling of urine Causes: BPH, spinal cord injury, congenital defects
54
Give an overview of continuous incontinence
Anatomical abnormalities (ectopic ureter) Bladder fistulae Severe overflow incontinence
55
What investigations are needed for urinary incontinence
Midstream urine dipstick Post-void bladder scan Urodynamic assessment Overflow urodynamics Cystoscopy IV urogram Speculum MRI
56
What is the conservative management for stress incontinence
Supervised pelvic floor muscle training (at least 3 months) Duloxetine
57
What is the conservative management for urge incontinence
Bladder retraining (at least 6 weeks) Antimuscarinics (oxybutynin, tolterodine)
58
What is the surgical management for stress incontinence
Tension-free vaginal tape Open colposuspension (elevation of bladder neck and urethra) Intramural bulking agents Artificial urinary sphincter
59
What is the conservative management for urge incontinence
Botulinum toxin A injections Percutaneous sacral nerve stimulation Augmentation cystoplasty Urinary diversion
60
What are the subtypes of bladder cancer
Transitional cell carcinoma (most common) Squamous cell carcinoma Adenocarcinoma Sarcoma
61
What are the 4 layers of the bladder
Transitional epithelium (inner) Lamina propria Muscularis propria Fatty connective tissue (outer)
62
What are the risk factors for bladder cancer
Smoking Increasing age Exposure to industrial carcinogens Schistosomiasis Previous radiation to pelvis
63
What are the risk factors for BPH
Age Family history Afro-Caribbean ethnicity Obesity
64
How might BPH present
LUTS Haematuria Haematospermia
65
What investigations are needed for BPH
Urinary frequency and volume chart Urinalysis Post-void bladder scan PSA Ultrasound Urodynamic studies
66
What is the management for BPH
Alpha blocker (tamsulosin - relaxes prostatic smooth muscle) 5 alpha-reductase inhibitor (finasteride - prevents conversion of testosterone to DHT) TURP (trans-urethral resection of prostate_ Laser enucleation of prostate Photoselective vaporisation of prostate
67
What is TURP syndrome
Fluid overload and hyponatraemia during TURP procedure Confusion, nausea, agitation, visual changes
68
What are the 2 common types of prostate cancer
Acinar adenocarcinoma (from glandular cells lining prostate) Ductal adenocarcinoma (from cells that line ducts of prostate)
69
Which hormones influence the growth of prostate cancer
Testosterone Dihydrotestosterone (DHT)
70
What are the causes of prostatitis
E coli Enterobacter Serratia Pseudomonas STIs
71
What are the risk factors for prostatitis
Acute bacterial: indwelling catheter, phimosis, urinary strictures, recent surgery, immunocompromised state Chronic: all the above, intraprostatic ductal reflux, neuroendocrine dysfunction, dysfunctional bladder
72
How might prostatitis present
LUTS Features of systemic infection Perineal pain Suprapubic pain Urethral discharge 'Boggy' prostate Inguinal lymphadenopathy Lower back/rectum pain
73
What investigations are needed in prostatitis
Urine culture STI screen Bloods PSA Transrectal prostatic ultrasound/CT
74
What is the management for prostatitis
Prolonged antibiotics Analgesia Tamsulosin, finasteride
75
What are the risk factors for epididymitis
STIs Instrumentation Catheterisation Bladder outflow obstruction Immunocompromised state
76
How might epididymitis present
Unilateral scrotal pain Swelling Fever Dysuria LUTs Urethral discharge May have hydrocele
77
What are the special tests for epididymitis
Intact cremasteric reflex Prehn's sign (pain relieved by elevating scrotum)
78
What investigations are needed for epididymitis
Urine dipstick Urine culture STI screen Bloods Consider ultrasound
79
What is the management for epididymitis
Antibiotics Analgesia Bed rest Scrotal support
80
What is testicular torsion
Spermatic cord twists within tunica vaginalis Compromised blood supply to testis Peaks in neonates and 12-25s Associated with 'bell-clapper' deformity (horizontal lie to testis) Risk higher if had undescended testis
81
How might testicular torsion present
Sudden onset severe testicular pain Unilateral Nausea and vomiting Referred abdominal pain High, horizontal lie to testis Swollen Very tender Absent cremasteric reflex Pain persists when testis elevated (negative Prehn's sign)
82
What are the investigations for testicular torsion
Clinical diagnosis Immediate scrotal exploration If uncertain, doppler ultrasound
83
What is the management for testicular torsion
Emergency surgery (both testes fixed to scrotum) Strong analgesia Antiemetics NBM If testis not viable, orchidectomy
84
What are the types of testicular cancer
Germ cell: semonimas, non-seminomas Non-germ cell: leydig cell, sertoli cell
85
What are the risk factors for testicular cancer
Undescended testes Previous testicular malignancy Family history Kleinfelter's syndrome
86
What are the tumour markers for testicular cancer
Beta-HCG AFP LDH
87
What is the staging system for testicular cancer
Royal Marsden classification Stage 1: confined to testes Stage 2: infra-diaphragmatic lymph node involvement Stage 3: supra and intradiaphragmatic lymph node involvement Stage 4: extralymphatic metastatic spread
88
What are the common causes of urethritis
Gonococcal Non-gonococcal (other STIs)
89
What are the risk factors for ureteritis
< 25 MSM Previous STI Recent new sexual partner > 1 sexual partner in last year
90
How might ureteritis present
Dysuria Penile irritation Discharge from urethral meatus
91
What investigations are needed for ureteritis
Urethral swab gram stain STI testing Urine cultures
92
What is the management for ureteritis
Antibiotics Normal STI advice
93
What is Fornier's gangrene
Necrotising fasciitis of the perineum Urological emergency Due to: group A strep, C perfringens, E coli Testes and epididymis not usually affected
94
What are the risk factors for Fornier's gangrene
Diabetes Alcohol Poor nutritional state Steroid use Haematological malignancy Recent trauma
95
How might Fornier's gangrene present
Severe pain (out of proportion to clinical signs) Pyrexia Crepitus Skin necrosis Haemorrhagic bullae Sensory loss over skin Often go into septic shock
96
What is the scoring system for Fornier's gangrene
Laboratory risk indicator for necrotising fasciitis Based on: CRP, WCC, Hb, Na+, creat, glucose
97
What investigations are needed for Fornier's gangrene
Clinical diagnosis Routine bloods Blood cultures CT (fascial swelling, gas in soft tissue)
98
What is the management for Fornier's gangrene
Urgent surgical debridement Consider orchidectomy Broad spectrum antibiotics HDU Close monitoring Often need further surgical debridement
99
What is paraphimosis
Inability to pull forward a retracted foreskin Mostly due to tight constricting band as part of foreskin Glans becomes oedematous (vascular engorgement of distal penis, further oedema) If untreated: penile ischaemia, Fornier's gangrene A urological emergency
100
What are the risk factors for paraphimosis
Phimosis Indwelling catheter non-replaced foreskin) Poor hygiene Previous episode
101
How might paraphimosis present
Progressive pain Swelling Unable to pull foreskin over glans May have repeat admissions
102
How is paraphimosis managed
Analgesia Penile block Manual pressure: reduce glans oedema Dextrose-soaked gauze: osmotic effect, reduces glans oedema Dundee technique: puncture glans with needle, squeeze out oedematous fluid Dorsal slit (incision of prepuce) Consider circumcision
103
What is a priapism
Unwanted painful erection Not associated with sexual desire > 4 hours
104
What are the 2 types of priapism
High flow: non-ischaemic, unregulated cavernous arterial flow, arterial blood enters corpus cavernosum faster than it can be drained, associated with trauma/sexual stimulation Low flow: ischaemic priapism, veno-occlusive
105
What are the causes of priapism
Idiopathic Penile trauma Perineal trauma Spinal cord injury Iatrogenic (drugs for impotence) Sickle cell disease Haematological disorders Pelvic malignancy
106
How might priapism present
Ongoing unwanted erection Ischaemic: painful, rigid penis Non-ischaemic: painless, not fully rigid penis
107
What investigations are needed for priapism
Clinical diagnosis Routine bloods Corporeal blood gas (work out if it is ischaemic or non-ischaemic)
108
What is the management for priapism
Corporeal aspiration (large bore needle into lateral edge of one corpus cavernosum) Intracavernoseal injection (sympathomimetic agent) Surgical shunting between corpus cavernosum and glans
109
What are the risk factors for penile cancer
HPV (16, 18, 6) Phimosis Smoking Lichen sclerosis Untreated HIV Previous psoriasis treatment
110
What is penile fracture
Traumatic rupture of corpus cavernosa Usually on right side Due to blunt trauma Easy to fracture as tunica albuginea very thin during erection
111
How might penile fracture present
Popping sensation Hear a 'snap' Immediate pain Swelling Detumescence Penile swelling Discolouration (aubergine sign) Deviation to opposite side of lesion Firm, immobile haematoma in shaft (rolling sign) Urethral injury (haematoma in perineum)
112
What investigations are needed for penile fracture
Clinical diagnosis Routine bloods Cavernosography Retrograde urethrography (if have symptoms of urethral injury)
113
What is the management for penile fracture
Analgesia Antiemetics Surgical exploration and repair Abstinence from sexual activity for 6-8 weeks

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