Urology Flashcards
1
Q
What type of scrotal mass conditions are symptomatic (present with pain)?
A
- testicular torsion
- epididymitis
- orchitis
2
Q
What is the definition of testicular torsion?
A
twisting of the spermatic cord, resulting in constriction of vascular supply and ischaemia of testicular tissue
3
Q
What are the 2 types of testicular torsion?
Why is it important to recognise early?
A
- intravaginal
- extravaginal
it is a SURGICAL EMERGENCY as there is a risk of death of the testes when blood supply is compromised
4
Q
What is meant by intravaginal testicular torsion?
Who does this tend to affect?
A
there is twisting WITHIN the tunica vaginalis
- this is the most common cause of acute scrotal pain in 10-18 year olds
this is the most common form of testicular torsion
5
Q
What is meant by extravaginal testicular torsion?
Who does this tend to affect?
A
there is twisting of the entire testes AND tunica vaginalis
- this is more common in neonates
6
Q
What are the risk factors for intravaginal testicular torsion?
A
- age < 25
- Bell clapper deformity (90% cases)
7
Q
What is the Bell clapper deformity?
A
- there is high attachment of the tunica vaginalis
- this allows the testicle to rotate freely within the tunica vaginalis
8
Q
How does testicular torsion present?
A
- painful
- swollen, hot, tender, erythematous scrotum
- unilateral
- high-riding testicle
- ABSENT CREMASTERIC REFLEX
cremasteric reflex:
stroking of the inner thigh will cause the ipsilateral testicle to elevate via contraction of the muscle
high-riding testicle:
the testicle that has torsion will be raised higher than the other
9
Q
When must treatment for testicular torsion be performed?
A
treatment must be performed within 6 hours of the ONSET of symptoms in order to save the testis
!! this is NOT 6 hours from when they present !!
it is from the instant that the symptoms start
10
Q
What is the first line investigation and treatment for testicular torsion?
A
emergency exploration of the scrotum within 6 hours of symptom onset
after the testicle is twisted back, bilateral orchidopexy is performed
!! DO NOT DELAY SURGERY FOR DOPPLER USS !!
11
Q
What is a bilateral orchidopexy and why is it performed?
A
- the spermatic cord is fixed down on both sides to prevent twisting in the future
- it is performed bilaterally as testicular torsion is likely to recur and could affect either side
12
Q
What is the second line management for testicular torsion?
A
manual detorsion
this is only performed when surgery is not available within 6 hours
13
Q
If Doppler USS is performed in testicular torsion, what is seen?
A
Whirlpool sign
- if testicular torsion is suspected, Doppler USS should NOT be done as this is a SURGICAL EMERGENCY
14
Q
What is the difference between epididymitis and orchitis?
Why are they often grouped together?
A
Epididymitis:
- inflammation of the epididymis
Orchitis:
- inflammation of the testes
Epididymo-orchitis:
- concurrent inflammation of the epididymis and testes
- 60% cases of epididymitis are associated with orchitis
- nearly all cases of orchitis are associated with epididymitis
15
Q
What is the major cause of epidiymitis / orchitis in < 35s?
What question is important in the history?
A
- Chlamydia trachomatis is the most common cause
- followed by Neisseria gonorrhoeae
unprotected sex is a risk factor so it is important to ask about sexual history
16
Q
What is the major cause of epidiymitis / orchitis in > 35s?
What risk factors make infection more likely?
A
- mainly caused by coliforms, such as Klebsiella, E. coli and Enterococcus faecalis
- RFs are UTIs and bladder outflow obstruction
17
Q
Why is bladder outflow obstruction a RF for epidiymitis / orchitis?
A
- when there is an outflow obstruction, the urine is static for longer
- there is more time for bacteria to colonise and grow and cause infection in surrounding structures
- higher voiding pressure can result in reflux of infected urine into the ductal system and spread of pathogens to the epididymis
18
Q
What are the possible non-infective causes of epidiymitis / orchitis?
A
- trauma
- vasculitis - e.g. Behcet’s disease
- medication e.g. amiodarone
19
Q
What are other possible risk factors for epidiymitis / orchitis?
A
- immunosuppression can result in colonisation by atypical organisms, such as Candida
20
Q
What symptoms do testicular torsion and epidiymitis / orchitis have in common?
A
- painful
- swollen, hot, tender, erythematous scrotum
- unilateral
21
Q
How does epidiymitis / orchitis differ from testicular torsion?
A
- it is less acute than torsion (develops over a few days rather than a few hours)
- dysuria & urgency as a result of infection
- present Cremasteric reflex (but may be painful to elicit)
- can affect any age group (not just < 25s)
- there may be symptoms of the cause (e.g. penile discharge in STI)
- as this is an infection, there is pyrexia
22
Q
What are the initial investigations for epidiymitis / orchitis?
A
- urine dipstick
- MSU for MC&S to identify pathogen
23
Q
What blood tests may be performed in epidiymitis / orchitis?
A
- FBC - will show high WCC
- U&Es - always check renal function when urinary symptoms present
24
Q
When is imaging performed in epidiymitis / orchitis?
What will this show?
A
- colour duplex USS
- surgical exploration may be done if testicular torsion cannot be excluded
it is very rare for imaging to be needed as this can usually be diagnosed through bedside / bloods ix
25
What is involved in the management of epidiymitis / orchitis?
**Conservative:**
* bed rest
* scrotal elevation
**Medical:**
* simple analgesia (paracetamol / ibuprofen)
* antibiotics to target infection
## Footnote
**surgical management** is rarely needed:
* surgical exploration if testicular torsion cannot be excluded
* abscess drainage if this develops
26
What is the definition of varicocele?
Why does it occur?
**dilated veins** of the **pampiniform plexus** forming a scrotal mass
**Occurs due to:**
* incompetent venous valves
* increased hydrostatic pressure in the left renal vein
27
Why do 80-90% varicoceles occur on the left side?
* the left pampiniform plexus is subjected to **increased hydrostatic pressures** due to the **perpendicular insertion** of the **left testicular vein** into the **left renal vein**
* the left internal spermatic vein is longer, resulting in increased hydrostatic pressure transmission
* **incompetent valves** at the point where LTV meets LRV
28
How does varicocele present?
* it is asymptomatic
* it has a **"bag of worms"** appearance
29
What is involved in the investigations for varicocele?
* physical examination for which patient must be **STANDING**
* **fertility analysis** - sperm count / semen analysis
* **retroperitoneal USS / CTAP** only if mass **DOES NOT diminish** in supine position
30
Why must varicocele examination be performed when standing?
* the appearance of the mass may **reduce when lying down** due to the effect of gravity
* standing up causes the blood to pool down towards the scrotum
31
Why is retroperitoneal USS / CTAP performed if varicocele does not reduce when lying down?
* if varicocele does not diminish when supine, it may be a different diagnosis
* need to **exclude abdo/retroperitoneal mass** causing physical obstruction of testicular venous return
32
What is involved in the management of varicocele?
reassurance & observation
## Footnote
if **semen analysis** is abnormal, **surgical repair** should be offered
33
What is the definition of a hydrocele?
an excessive collection of **serous fluid** within the **tunica vaginalis**
34
What are the 2 different types of hydrocele?
**communicating:**
* the processus vaginalis is ***OPEN***
* peritoneal fluid can flow freely **from the abdomen** into the tunica vaginalis
**non-communicating:**
* the processus vaginalis is ***CLOSED***
* **more fluid is produced** by the tunica vaginalis than is **being absorbed**
35
What are the 2 major risk factors for both types of hydrocele?
* **male gender** (but can affect females too)
* very common in children in **first year of life**
36
What are the risk factors for non-communicating hydrocele?
* **inflammation / injury to the scrotum** (e.g. trauma, infection, testicular torsion)
* epididymo-orchitis
* testicular cancer
37
What are the risk factors for communicating hydrocele?
* increased intraperitoneal fluid (e.g. ascites)
38
How does hydrocele present?
* it is an asymptomatic **scrotal swelling**
* it is possible to get above the swelling
* it **enlarges** following activity such as **coughing / straining**
* it **transilluminates**
## Footnote
transilluminates = has a glowing appearance when a light is shone on it
39
What investigations are performed for hydrocele?
**urine dip:**
* to exclude infection
**USS:**
* to exclude tumour / abnormal testis
**blood tests:**
* testicular tumour markers - a-fetoprotein, b-hcg, LDH
| diagnosis can be made once **ALL** tests have come back **negative**
40
Why are testicular tumour markers measured in suspected hydrocele?
* testicular cancer can present with hydrocele so it is important to rule this out
41
What is involved in the management of hydrocele?
observation
| surgery is considered if it becomes too uncomfortable
42
What are the 2 different types of testicular cancer?
* the majority of testicular cancers are **seminomas**
* they may also be *non-seminomatous germ cell tumours* and *teratomas*
43
What are the risk factors for testicular cancer?
anything that ***disrupts the underlying structure / function*** of the testes
1. cryptochidism
2. ectopic testes
3. testicular atrophy
4. family history of testicular cancer
## Footnote
cryptorchidism = one / both of the testes fail to descend
44
How does testicular cancer present?
**PAINLESS HARD NODULAR** TESTICULAR MASS
* unilateral
* may be associated with **hydrocele**
* lymphadenopathy
* **gynaecomastia**
* **back pain**
45
Why does gynaecomastia occur in testicular cancer?
it occurs as the tumour produces **hCG**
46
Why does back pain occur in testicular cancer?
* metastases travel via the para-aortic lymph nodes
* **para-aortic lymph node enlargement** causes back pain
47
What blood tests are performed in suspected testicular cancer?
**FBC**
**U&Es**
**LFTs:**
* there will be ***high ALP*** in **bone mets**
* ***high GGT*** in some seminomas
**tumour markers:**
* lactate dehydrogenase (LDH)
* a-fetoprotein
* B-hcg
48
What imaging techniques are performed in testicular cancer and why?
**testicular USS:**
* confirms the ***presence*** of the tumour
**CTAP:**
* provides a ***clearer image*** of the tumour
* used throughout treatment to ***monitor response***
**CXR:**
* used to assess for ***mediastinal and lung masses***
* testicular cancer travels via the para-aortic lymph nodes so mets are likely to be within this area
49
How is a urinary tract infection defined?
the presence of a pure growth of > 105
organisms per mL of fresh MSU
50
How can UTIs be categorised into 3 groups?
**urethritis:**
affecting the urethra
**cystitis:**
affecting the bladder
**pyelonephritis:**
affecting the kidney
## Footnote
can have different symptoms / severity depending on which part is affected
51
What is the major causative organism of UTIs?
Escherichia coli
52
Why are UTIs more common in females than males?
**shorter urethra:**
* bacteria seeded at urethral opening have a shorter distance to travel to infect the bladder
**shorter distance between urethral + anal opening:**
53
Other than being female, what are other risk factors for UTIs?
* sexual intercourse
* pregnancy
* immunosuppression
* catheterisation
* urinary tract obstruction (BPH / calculi)
## Footnote
obstruction can result in infection as bacteria have **longer to grow / colonise** when urine is static for long periods
54
How does a UTI present?
it presents with **storage symptoms**:
* dysuria
* increased frequency
* urgency
* foul-smelling urine
## Footnote
storage symptoms occur due to the **bladder becoming irritated** and being **unable to hold urine**
55
How does acute pyelonephritis present differently to an oridinary UTI?
* flank pain
* fever
* malaise
56
What is the first line and gold standard investigation for UTI?
**first line:**
* urine dipstick
* this will show ***+ve leucocytes*** and ***nitrites***
**gold standard:**
* MSU for MC&S
* this allows identification of the bacteria
* pyelonephritis will have **white cell casts**
57
When might blood cultures be performed in UTI?
if the patient is systemically unwell and there is risk of **urosepsis**
58
What is involved in the management of UTIs?
empirical antibiotics
| this is usually **nitrofurantoin**
59
What is the definition of urinary tract calculi?
Where can they occur?
the **presence of calculi** within the urinary system at any one of **three points of narrowing**
## Footnote
1. **ureteropelvic junction** (kidneys and ureters attach)
2. **pelvic brim** (ureters cross the iliac vessels)
3. **ureterovesical junction** (ureters attach to bladder)
60
What are the 4 different types of kidney stone?
* **calcium oxalate** (most common)
* **struvite** (magnesium ammonium phosphate)
* **urate / uric acid** - NOT visible on XR
* **hydroxyapatite**
61
Why do urinary tract calculi occur?
* many things can cause a **high concentration of urinary solutes**
* the urine becomes **supersaturated** and cannot hold any more solutes inside it
* the solutes **precipitate out** of solution, **become solids** and clump together to form stones
62
What metabolic factors can contribute to increased urinary solutes?
* hypercalcaemia
* hyperuricaemia
* hypercystinuria
* hyperoxaluria
* hypocitraturia
* hyperparathyroidism
* renal tubular acidosis
63
What infectious factors can contribute to high urinary solutes?
* hyperuricaemia
* recurrent UTIs
* chronic UTI
64
Which drugs can contribute to high concentration of urinary solutes?
* indinavir, atazanavir
* diuretics
* antacids (Ca-containing)
* carbonic anhydrase inhibitors
* Na- and Ca-containing medications
* Vit D + C
* corticosteroids
65
What are the risk factors for urinary tract calculi?
* dehydration
* high protein intake
* high salt intake
* structural abnormalities
* past medical history of kidney stones
* family history
## Footnote
dehydration = high conc of urinary solutes due to low urine volume
66
Who is more at risk of urinary tract calculi?
* 3x more common in **males**
* more common in **30-50 years**
* higher prevalence in **hot, dry countries**
67
How do urinary tract calculi tend to present?
they tend to be **asymptomatic** until the **calculi gets stuck**
* **renal colic** (acute SEVERE loin to groin pain)
* N&V
* unable to lie still / writhing in pain
## Footnote
renal colic occurs as the body responds to a stuck stone by trying to squeeze/contract to push it out
68
What urinary symptoms are renal tract calculi associated with?
* urgency
* frequency
* **haematuria**
## Footnote
haematuria is usually **microscopic** (cannot see the blood), but is macroscopic in 15% cases
69
What is the first line investigation for urinary tract calculi?
**urine dipstick**
* this is performed to **confirm / exclude haematuria**
## Footnote
a **pregnancy test** should be performed in ALL women of child-bearing age to exclude **ectopic pregancy** (severe pain in L/R iliac fossa)
70
What blood tests are performed in renal tract calculi?
* FBC (raised WCC in UTI)
* U&Es
71
What is the gold-standard investigation to confirm urinary tract calculi?
**non-contrast CT-KUB**
| USS used if pregnant
72
What is involved in the acute management of urinary tract calculi?
* fluids
* analgesia (**diclofenac**)
* anti-emetics (**ondansetron**)
* urine collection to collect passed stone
## Footnote
if the stone does pass in this time, its composition can be analysed to direct further tests
73
What is the management for a kidney stone < 5mm?
leave to pass spontaneously with increased fluid intake
74
What is the management for a kidney stone 5-10mm?
* give **alpha-blocker (tamsulosin)**
* surgery performed if stone not passed after 4-6 weeks
75
What is the management for a kidney stone > 10mm (or failed therapy)?
**surgical removal**
* this is usually performed via ***extracorporeal shock wave lithotripsy (ESWL)***
* ***percutaenous nephrostolithotomy (PCNL)*** is key-hole surgery used for difficult stone shapes e.g. staghorn
76
What is involved in extracorporeal shock wave lithiotripsy (ESWL)?
1 - scope passed into the bladder and up the ureter to visualise the stone
2 - electromagnetic wave is focussed onto the stone to break it up into smaller fragments
3 - small fragments are asymptomatically passed in the urine
77
What are the potential complications of urinary tract calculi?
* pyelonephritis
* septicaemia
* obstruction
* urinary retention
* hydronephrosis / AKI
78
What is the definition of benign prostatic hyperplasia?
diffuse **hyperplasia** of the **periurethral (transitional) zone**
79
Who is at greater risk of BPH?
* prevalence increases with age
* more common in Afro-Caribbeans
80
What type of symptoms are present in both prostate cancer and BPH?
they both present with **lower urinary tract symptoms (LUTS)** that can be divided into **storage** and **voiding symptoms**
81
What LUTS are common to both prostate cancer and BPH?
| What mnemonic can be used to remember these?
**FUND HIPS**
* F - frequency
* U - urgency
* N - nocturia
* D - dysuria
* H - hesitancy
* I - incomplete voiding
* P - poor stream
* S - straining
## Footnote
FUND = storage symptoms (due to bladder irritation)
HIPS = voiding symptoms (due to obstruction of urine outflow)
82
What symptoms may be present in prostate cancer but NOT in BPH?
* **haematuria**
* symptoms of metastatic spread - **bone pain / cord compression**
* **FLAWS**
83
What are the investigations involved in both prostate cancer and BPH?
**urinalysis:**
* to exclude UTI + assess for ***haematuria***
**DRE:**
* to determine the nature of the growth
**bloods:**
* ***PSA*** - will be ***raised < 4 in both***
* U&Es to check for impaired renal function
**imaging:**
* ***transrectal USS-guided needle biopsy***
* if prostate ca confirmed - isotope bone scan to look for mets
84
How can prostate cancer be distinguised from BPH on DRE?
**prostate cancer:**
* asymmetrical hard nodular prostate
* loss of the midline sulcus
**BPH:**
* prostate is smoothly enlarged
* palpable midline groove
85
What is needed to definitively distinguish between prostate cancer and BPH?
transrectal ultrasound-guided needle biopsy
| this is diagnostic
86
What is involved in the emergency management of BPH?
* may present with **acute urinary retention**
* **catheterisation** is performed
| this is when the patient is unable to urinate at all
87
What is involved in the conservative management of BPH?
* monitor symptom progression
* lifestyle advice - e.g. avoid caffeine
* **medication review**
## Footnote
e.g. **anticholinergics** can lead to urinary retention
**diuretics**
88
What is involved in the medical management of BPH?
**first-line:**
* selective **alpha1-blockers** (e.g. ***tamsulosin***)
* this makes it easier to pass urine
**second-line:**
* **5a-reductase inhibitors** (e.g. ***finasteride***)
* indicated when prostate is significantly large and there is high risk of disease progression
89
When may surgery be performed for BPH?
What does this involve?
***transurethral resection of the prostate (TURP)***
* performed if chosen or refractory to medical treatment
## Footnote
prostate is visualised through the urethra and a device is used to move tissue by electrocautery / sharp dissection
90
What are the 2 different types of bladder cancer?
Who is more likely to be affected?
* 90% of cases are **urothelial carcinomas**
* **squamous cell carcinoma** can also occur
* 4x more common in **men** and prevalence increases **> 55**
91
What are the risk factors for urothelial carcinoma?
* smoking
* carcinogen exposure
* aromatic amines
* polycyclic aromatic hydrocarbons
* arsenic
| **PAINTERS and HAIRDRESSERS** are more at risk
92
What are the risk factors for squamous cell carcinoma?
* chronic UTIs
* schistosoma haematobium (parasitic worm that causes bladder inflammation)
| it is associated with **chronic inflammation** of the bladder
93
What symptoms are associated with bladder cancer?
* painless **MACROSCOPIC haematuria**
* **storage symptoms** of FUNDHIPS (frequency, urgency, nocturia, dysuria)
* FLAWS
## Footnote
if someone presents with **macroscopic haematuria**, it is ***treated as bladder cancer until proven otherwise***
94
What is the first line investigation for bladder cancer?
urinalysis to confirm haematuria
95
What blood tests may be performed in suspected bladder cancer?
* **FBC** - to check that patient is not **anaemic** from blood lost in the urine
* **ALP** - raised if there are **bony mets**
* **U&Es** - to check kidney function when presenting with urinary symptoms
96
What imaging techniques may be performed in bladder cancer?
**cystoscopy + biopsy:**
* gold standard and diagnostic
**CTAP / MRI AP:**
* to exclude calculi and visualise the cancer
**isotope bone scan:**
* to assess for bony mets
**CXR:**
* to assess for lung mets
