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Flashcards in urology Deck (70):

what is varicocele?

dilation of testicular vein and pampiniform plexus

-predominantly occurs on Left side

-typically asymptomatic (sometimes dull ache)


PE findings for varicocele?

"bag of worms" - often found on ultrasound


is varicocele associated with male-factor infertility?

yes but not all men with varicoceles are infertile (impaired spermatogenesis from elevated temperatures)


varicocele grades

subliclinical (only detected by US, veins > 3 mm)

grade I - small, palpable with valsalva only

grade II- easily palpable at rest without valsalva

grade III- grosly palpable


how is varicocele treated?

subclinical is not treated

treated with syptoms or with infertility or impaired testicular growth. surgical-inbuinal, subinguinal microscopic, laparoscopic varicocelectomy

*abnormal semen analysis/infertility can be reversed with varicocelectomy


collections of fluid in the epididymis (epididymal cysts). PE is smooth, painless, transilluminate

spermatocele - tx rarely needed


twisting of the testis around the cord causing ischemia

testicular torsion


what is a risk of testicular torsion?

bell-clapper deformity - congenital malformation where tunical vaginalis attaches high/improperly on cord **surgical emergency


what is the presentation of testicular torsion?

sudden/acute testicular/scrotal pain, swelling

PE: **absent cremasteric reflex, anormal testicular lie


treatment of testicular torsion

surgery - manual detorsion "open the book" - physician stands at patient's feet and manually rotates affected testicle away from midline

ischemia/pain 24 hours - 10% salvage


inflammation of the epididymis/testicle, very common in age 20-35

epididymitis/orchitis - can be bacterial (mostly), viral, fungal, idiopathic

Sexually active males 35 yrs think E. Coli


presentation of epididymitis/orchitis

pain and swelling over several days, also fever, scrotal erythema, testicular pain, dysuria. can mimic testicular torsion


risk factors for epididymitis/orchitis

sexual activity, bladder outlet obstruction, urologic surgery


tx for epididymitis/orchitis

males 35 yrs old:
Levofloxacin 500 mg PO daily for 10 days OR Ofloxacin 300 mg PO BID for 10 days

Also, analgesics, scrotal elevation, ice PRN


fluid collection between layers of tunic vaginalis


Communicating: Patent processus vaginalis allows fluid to pass from peritoneum to scrotum

Non-Communicating: No connection


difference between communicating and non-communicating hydrocele

Lymphatic or venous obstruction from trauma or infection
Develop slowly
Most common hydrocele in adults

Present at birth or first year of life
Most will resolve by age 2


how do you diagnose hydrocele?

scrotal mass that transilluminates. treat with surgical excision and observation


risk factors for ED

shared with CV disease:
Metabolic Syndrome
Physical inactivity

ED is a risk factor for CV disease**

prostate cancer treatments

hypogonadism (low testosterone)

Peyronie’s Disease

neurologic conditions (MS, strokes)


prescription drugs that are a risk factor for ED

antihypertensives (diuretics, HCTZ, metoprolol)

antidepressants/antianxiety (sertraline, fluoxetine, lorazepam) - SSRIs are prescribed for premature ejaculation

antiandrogens, etc, (lueprolide, bicalutimide)


first line treatment for ED


Inhibit PDE5 --> smooth muscle relaxation --> incr blood flow -->veno-occlusive mechanism

-Tadalafil (cialis) has longest half life and also helps BPH


lower urinary tract symptomes (LUTS) of BPH

hesitancy, weak/slow stream
post-void dribbling
incomplete bladder emptying

Static component- direct bladder outlet obstruction from enlarged tissue
Dynamic phase- increased smooth muscle tone and resistance within the enlarged gland


digital rectal exam (DRE) for BPH

typically smooth enlargement, rubbery (Pca can be firm, hard, irregular)


Treatment of BPH

Surveillance (if mild symptoms, if symptoms are moderate/severe but patient has little or no bother, no complications) - monitor annually

Medical therapy- alpha blockers, alpha reductase inhibitors (decrease PSA by 50%)**have been shown to decrease risk of prostate cancer, combo therapies, phosphodiesterase inhibitors(cialis, MOA not well known)

Minimally invasive therapies
1. transurethral needle ablation of prostate- TUNA and transurethral microwave thermotherapy-TUMT
-done outpatient without general anesthesia
2. Urolift system - trans-prostatic urethral implant that lifts and compresses prostate tissue

Surgical therapies
-transurethral resection of prostate
-laser vaporization of prostate ( *gold standard)/photoselective vaporization of prostate -->shorter hospital stay, no risk of TUR syndrome, decreased bleeding
-simple prostatectomy - more "invasive", typically done in patients with larger prostates (>100-120 cc) or with large bladder stones


most common urologic diagnosis in males

prostatitis - inflammation or infection of prostate that presents as several syndromes with varying clinical features


acute bacterial prostatitis and chronic bacterial prostatitis pathogens

80% E coli
10-15% psuedomonas, klebsiella, proteus
5-10% enterococcus


category I - acute bacterial prostatitis presentation and treatment

presents with dysuria, frequency, perineal pain, back pain, fever/chills

DRE- enlarged, boggy, tender prostate

labs: elevated WBC, UA - pyuria, bacteria

tx: antibiotics (IV cipro for in patient,, PO levofloxacin for outpatient), antipyretics, IVF, suprapubic catheter drainage


category II - chronic bacterial prostatitis presentation and treatment

Presentation-acute episodes of dysuria, perineal pain, frequency with culture-documented UTI (same organism each time)

asymptomatic in between

*can be ruled out if no culture-documented UTI present

tx: TMP-SMX and fluoroquinolones (penetrate prostate) x 4-6 weks


Category III: Chronic prostatitis and chronic pelvic pain syndrome (CPPS) presentation and tx

Chronic/recurring episodes perineal, pelvic, testicular, penile pain, sometimes assoc with voiding dysfunction in absence of infection

Causes-a primary event leading to immunologic stimulation followed by inflammatory response with persistent stimulation and neuropathic damage
No infectious pathogens

Empiric ABX, sitz baths, NSAIDs, alpha blockers, etc
Poorly understood and challenging synrome=Many frustrated patients


Category IV
Asymptomatic Inflammatory Prostatitis presentation and tx

Can be found incidentally on prostate biopsy
No treatment indicated


risk factors for prostate cancer

increasing age (more than 80% are diagnosed in men older than 65 years of age)

family history (first degree relatives - two to three X greater risk)

race (AA 1.6 more likely to get and also higher mortality)

dietary factors (high animal fat)

exposures (agent orange)


T or F: prior vasectomy and benign prostatic hypertrophy (BPH) increase risk of prostate cancer



prostate cancer development

develops in epithelium (possibly from basal cell later)

requires androgens (testosterone)

increased cell proliferation and decreased apoptosis


more than 95% or primary prostate cancers are what?



who should be screened for prostate cancer?

**do not screen younger than 40
-individualized screening fro men between 40-54 years
-men 55-69 shared decision making


clinical manifestations of prostate cancer

can be asymptomatic and picked up by PSA >4

obstructive voiding symptoms (hesitancy, intermittent urinary stream, decreased force of stream) - typically indistinguishable from BPH

***hematuria and hematospermia

edema of lower extremities or discomfort in pelvic and perineal areas


most common mets for prostate cancer

bone - can result in pathologic fractures of the long bones or spinal cord compression


what should prompt a biopsy for Prostate cancer?

a palpable nodule on digital rectal exam


what is the PSA threshold for prostate cancer?

4 ng/mL- 70-80% or tumors are detected

**age adjusted values
40-49: 0-2.5
50-59: 0-3.5
60-69: 0-4.5
70-79: 0-6.5


what is a genomic prostate score (GPS)?

assesses prostate biopsy tissue, assigns a score based on 17 genes to predict the likelihood of high grade or advanced stage disease (T3)


prostate biopsy

only a snap shot. advanced imaging with 3T MIR dedicated to the prostate can help determine extent of disease. can also help to guide treatment choice


where does prostate cancer develop?

in the peripheral zone of the prostate (so biopsies directed towards here)


what is a gleason score?

sum of the two most common histologic patterns seen on each tissue specimen - very predictive of metastases and outcome


prostate cancer treatments

-watchful waiting
-active surveillance
-hormone therapy - androgen deprivation with lutenizing hormone releasing hormone
-surgery (robotic is most preferred)


what is PCA 3?

simple urine test. for men with life expectancy of greater than or equal to 10 years and 1 or more negative biopsies, and PSA of 3 or more


most common subtypes of renal cell carcinoma

clear cell (75-85%)-proximal tubule origin, abnormalities in chromosome 3p

paillary (15%) - 85% of these are dx as stage I tumors, also proximal tubule in origin


epidemiology of renal cell carcinoma

male predominance, highest incidence between age 60-80


classic triad and presentation of renal cell carcinoma presentaiton

flank pain, hematuria, palpable abdominal mass

hematuria present in 40% of patients- often with clots (non-glomerular)


how do you diagnose renal cell carcinoma?

ultrasound : solid vs. cystic lesions

contrast CT: test of choice to evaluate tumor size, location, lymph node involvement


75-86% of RCC is what type?

clear cell


differences in RCC staging

TNM staging system

Stage I-III: localized disease
I: tumor 7 cm- 5 yr survival 88%
III: tumor in major veins or adrenal gland, tumor within gerota's fascia, or 1 regional lymph node involvement yr survival 59%

Stage IV: advanced, metastatic disease


poor prognostic indications for RCC

poor performance status, anemia, hypercalcemia, and elevated LDH


localized RCC treatment

radical nephrectomy is gold standard (open or laparoscopic depending on size and experience) - no role for adjuvant therapy except under investigational protocol

cytoreductive nephrectomy in patients with good performance status


advanced RCC treatment

primary treatments are systemic therapy with molecularly targeted therapy or immunotherapy


what are immunotherapy treatments for advanced RC?

IL-2, sorafenib, sunitinib, and temsirolimus


does chemo work with RCC?

only minimally responsive (overall response 6%)


epidemiology of bladder CA

older persons (median age is 65)

3 times more common in men (women have worse prognosis)

more prevelant in white persons


best known behavioral risk factor for bladder cancer

cigarette smoking


parasitic infection that is a risk factor for bladder cancer

schistosoma haematobium (schistosomiasis) - not common in US but is endemic in africa and middle east


most common and classic presentation of bladder cancer

Frank hematuria. **painless gross hematuria (consider all patients with gross hematuria to have bladder cancer until proven otherwise)


noninvasive test for the diagnosis of bladder cancer

voided urine cytology - used to identify high-grade tumors and monitor patients for persistent or recurrent disease following treatment


mainstay for diagnosis and surveillance of bladder cancer

cystoscopy - provides info about tumor size, location, appearance, and size (direct visualization of the bladder)


if a lesion is detected on cystoscopy, what is the next step for bladder cancer?

transurethral resection of bladder tumor - under general anesthesia

***if a patient has a positive voided cytology, move straight to the TUR**


all patients with bladder cancer need what?

to evaluate the upper urinary tract -renal ultrasonography, CT with and without IV contrast (urography), MRI


treatment for bladder cancer

non-muscle invasive tumors: transurethral resection, followed by close observation or intravesical chemotherapy or immunotherapy
*high rate of disease recurrence and progression in non-muscle invasive bladder cancer

muscle invasive disease: radical cystectomy with pelvic lymphadenectomy


indications for urine culture

children, pregnant women
patients with structural abnormalities of the urinary tract
recurrent UTI


diagnostic criteria for UTI

historically 100,000 colonies/mL of single organism.. lower colony count of 1,000 colonies is accepted now


Urine for GC/chlamydia

should be first voided urine, needs to be processed as quickly as possible


what is the diagnostic procedure to visualize into the bladder?

cystoscopy- assess for stone, tumor, cystitis, diverticula


indications for diagnostic imaging/evaluation

fever after 3 days of antibiotics

proteus in urine if ph > 8 (think struvite stones)

hematuria, suspected obstruction, diabetes, stone disease


TMP/SMX treatment

Inhibits bacterial synthesis, therefore growth; useful except with P aeruginosa
Dosing: 160 mg TMP/800mg SMX po q 12 hours
UTI 3- 7 days
Uncomplicated pyelonephritis 10-14 days
May use with/without SMX