Flashcards in Urology Deck (45):
A 67-year-old man presents in painful retention of urine with a prior history of intermittent macroscopic haematuria for two months. Attempts at urethral catheterisation have failed.
This patient is in retention but urethral catheterisation has failed. Suprapubic catheterisation is contraindicated as he may have a bladder tumour accounting for his history of haematuria and he should therefore undergo cystoscopy and insertion of a catheter.
An 11-year-old boy presents to the Emergency department after losing control of his bicycle riding down a hill and crashing into a wall. He has macroscopic haematuria. On examination, his pulse is 90 bpm, blood pressure is 110/70 mmHg. He has no other injury.
The presence of haematuria (micro or macro) following a history of trauma in a child necessitates imaging. The investigation of choice is a CT with contrast, with delayed films to demonstrate the collecting system.
A 36-year-old female with no prior medical history presents on the emergency take with right sided loin to groin pain, rigors, pyrexia of 38.5oC. Bedside testing reveals microscopic haematuria, heart rate 100 bpm, a BP of 100/60 mmHg with normal urea and electrolytes. An x ray of the kidneys, ureter, and bladder (KUB) reveals an 8 mm opacity in the region of the right vesicoureteric junction and ultrasound shows a right sided hydronephrosis.
Cystoscopy and retrograde ureteric stent.
The patient illustrated has an infected obstructed system. The stone is at the vesico-ureteric junction so should be treatable by cystoscopy plus stent (+/- stone extraction)rather than a percutaneous nephrostomy tube.
A 24-year-old man was riding his bike home from the pub and crashed into a parked car. He is unsure of how it happened but he has no other injury aside from bleeding per urethra and is unable to pass urine.
In trauma where there is blood at the external meatus an ascending urethrogram should be performed prior to catheterisation. If this confirms urethral injury a suprapubic catheter should be placed.
A 76-year-old man presents to hospital for the first time passing only very small volumes of urine and feeling generally unwell. He has a urethral catheter in place which has not drained any urine since being placed on arrival in the Emergency department.
Serum biochemistry reveals:
Sodium 135 mmol/L (133-144)
Potassium 6.4 mmol/L (3.5-5)
Urea 45 mmol/L (3.5-8)
Creatinine 470 µmol/L (50-100)
Rectal examination reveals a clinically locally advanced malignant prostate gland.
This man has ureteric obstruction due to prostate cancer. He should be treated with percutaneous nephrostomy tube insertion to treat his renal failure.
Although this man is now oliguric his renal function may have been deteriorating for some time as the tumour has been growing and occluding his urethra. He is likely to be generally unwell due to progressive uraemia. His renal failure needs careful management but it is also important to be sure of the diagnosis before a percutaneous nephrostomy in case there is a renal/ureteric cause.
In this setting, a CTU is the procedure of choice in defining the anatomical location and extent of the obstruction. This patient is likely to require renal support regardless of the use of contrast.
A 55-year-old male, who had his right kidney removed five years previously for a renal cell cancer, presents with left loin to groin pain and absolute anuria. He is apyrexial, pulse 80 bpm regular, blood pressure 140/70 mmHg. A KUB and non-contrast CT reveal a 5 mm opacity in the left ureter at the level of L4.
Serum biochemistry reveals:
Sodium 134 mmol/L (133-144)
Potassium 5.3 mmol/L (3.5-5)
Urea 15.3 mmol/L (3.5-8)
Creatinine 390 µmol/L (50-100)
Cystoscopy and retrograde ureteric stent.
This gentleman has an obstructed single kidney and should be treated with retrograde ureteric stent insertion as there is a risk of damage to the kidney with percutaneous nephrostomy tube placement.
An 83-year-old man presents with a three day history of macroscopic haematuria with clots. Over the last 24 hours he has found it increasingly difficult to pass urine and is now in considerable discomfort.
This man is in clot retention and should be treated with the insertion of a 3-way catheter and bladder irrigation.
A 40-year-old man with a history of gout presents with right renal colic. A KUB does not demonstrate any renal tract calcification, non-contrast CT shows a stone in the right mid ureter.
Hyperuricaemia is associated with gout and results in uric acid stones, which are not visible on plain x ray. Treatment is with allopurinol.
Metabolic causes account for approximately 50% of urinary tract calculi.
Metabolic disorders result in an increase in the concentration of substances in the urine that constitute stone formation.
Absorptive hypercalciuria is the most common abnormality detected in patients with calcium oxalate stones and is due to increased intestinal absorption of calcium.
Treatment is aimed at binding calcium in the gastrointestinal tract and thus reducing its absorption.
A 15-year-old boy presents with a good history of right sided renal colic. KUB does not reveal any renal tract calcification, but a lower ureteric calculus is demonstrated on non-contrast CT.
Cystinuria is due to an inherited defect in cystine, lysine, argnine and ornithine metabolism. Cystine is insoluable in urine and its excretion results in stone formation. Patients usually present after puberty and the stones are often not visible on plain x ray.
Lesch-Nyhan syndrome (LNS) is a rare X linked recessive condition associated with deficiency of the enzyme hypoxanthine-guanine phosphoribosyltransferase giving rise to hyperuricaemia. The symptoms of LNS usually appear between the ages of 3 and 6 months.
A 55-year-old female with a history of depression presents with left renal colic, KUB / IVU show a calculus at the left vesicoureteric junction. Biochemistry reveals a serum calcium of 2.85mmol/l.
Renal hypercalciuria occurs when the kidneys fail to conserve calcium, treatment is with a thiazide diuretic.
Hyperparathyroidism is more common in females, particularly middle aged and is recognised by the finding of raised serum calcium associated with a raised or normal PTH. Patients will often complain of associated depression, abdominal pains, constipation, bone pain/fractures, duodenal ulceration and pancreatitis may occur.
Rather than any of the other diagnoses associated with hypercalcaemia, the most likely cause in this case is hyperparathyroidism.
A 73-year-old man presents as an emergency with general malaise and a long history of worsening lower urinary tract symptoms of bladder outlet obstruction. Examination reveals a markedly enlarged bladder; rectal examination reveals a large smooth, soft, symmetrical prostate gland. Serum biochemistry reveals
Sodium 134 mmol/l (133-144)
Potassium 6.2 (3.5-5)
Urea 34.2 mmol/l (3.5-8)
Creatinine 453 µmol/l (50-110)
This patient presents with a long history of bladder outlet obstruction symptoms preceding his acute presentation with renal failure. His prostate is clinically benign.
His renal failure is due to bladder outflow obstruction and consequent obstructive uropathy. He should be treated with insertion of a urinary catheter, insertion of IV cannula and IV fluids, hourly urine output (as he is likely to undergo a post-obstructive diuresis) and monitoring of his renal function.
A 66-year-old man presents to the outpatient department with a history of worsening symptoms of bladder outlet obstruction over the last six months. He had a transurethral resection of the prostate (TURP) for benign disease four years previously. Rectal examination reveals a small prostatic remnant and a flow rate shows a flat trace with a maximal flow of 4 ml/s.
Bladder neck stenosis
This patient presents with worsening lower urinary tract symptoms following a TURP. The presence of a flat trace on the uroflow would suggest a stricture - either urethral or bladder neck. Bladder neck strictures are a complication of TURP and are more common in patients who undergo a TURP on a small prostate.
A 76-year-old man presents to the physicians 'off his legs'. He has a three month history of back pain. Clinical examination reveals loss of perineal sensation, lower limb weakness, and a large hard craggy prostate gland. Biochemistry reveals a PSA of 436 ng/ml.
Metastatic prostate cancer
About half the patients who present with prostatic carcinoma have evidence of metastatic disease on investigation. Many of these metastases are asymptomatic. This patient has spinal metastases with neurological signs. After an MRI he should be treated with high dose steroids (dexamethasone).
Immediate radiotherapy should be given for those with minimal paraparesis. For those with severe neurological signs (severe weakness, unable to walk or paraplegia) or who deteriorate despite radiotherapy, immediate surgery may, depending on the overall prognosis, be appropriate. The survival time is short, especially if the patient is paraplegic at presentation.
A 34-year-old male presents to the Emergency department with painful haematuria following a stag weekend. He has no past medical or surgical history. On examination he is tender in his left loin with the "worst pain of his life".
This is a classic history of a young person who has become dehydrated through alcohol and formed a stone. The diagnosis can be confirmed with a urine dipstick being positive for blood. Treatment will be fluids and analgesia whilst awaiting investigation; one can either use ultrasound (preferred) or intravenous pyelogram (IVP). The ultrasound is preferred since it is quick, cheap, does not involve the risk of contrast and avoids ionising radiation. Most likely this will show that the renal/ureteric tract is clear and if analgesic control is adequate the patient can go home with advice to take fluids, avoid alcohol and see their GP and ensure the haematuria has settled. If the tract is obstructed the patient should be admitted, urea and electrolytes (U&E) monitored. Investigations include ultrasound, CT KUB (again, think of radiation dose if symptoms improving). Lithotripsy, ureteroscopy and percutaneous nephrostomy may be considered (depending on site and circumstance) if there is no movement of the stone and resolution of the obstruction.
A 64-year-old man presents to the Emergency department with severe left loin pain of spontaneous onset. He has no past surgical history but has hypertension controlled by a beta blocker. He is sweaty and clammy.
Leaking abdominal aortic aneurysm
Although this is almost an identical clinical scenario to the one above, this man is in the wrong age group for first onset renal colic, but in the right age group for an aneurysm. Clinical examination may not detect a pulsatile mass, but in view of the fact he is clammy and sweaty he should be moved into the emergency department resususcitation area, the on call vascular (or general surgical) team notified, cannulated, blood taken for full blood count, U&E, clotting and six unit cross match. Senior surgeons may be able to feel an aneurysm, if not he should have an ultrasound ASAP to assess his aorta. If this study is inadequate a CT should be done. Never send an older gentleman home with renal colic until you are sure that his aorta is normal - it is an indefensible error!
A 68-year-old gentleman presents with painless haematuria and loss of weight of four months duration. He worked in the dye industry before his retirement.
Transitional cell carcinoma of the bladder
Transitional cell carcinoma of the bladder is common in men over 50 years of age. The aetiology of this condition includes cigarette smoking, working in the aniline dye and rubber industry (because of excretion of beta-naphthyl-amine in the urine), and long term catheterisation in paraplegic patients. Patients may present with painless haematuria, dysuria, frequency and urgency of micturition.
A 52-year-old smoker presents with haematuria and occasional clots. On examination, he has a left-sided varicocele.
Adenocarcinoma of the kidney
Adenocarcinoma of the kidney affects more males than females (2:1) and is more prevalent in patients over 40 years of age. Risk factors include a high intake of fat, oil and milk, exposure to toxins like lead, cadmium, asbestos and petroleum products, smoking and genetic factors. Clinical features include a triad of haematuria (with occasional clot colic), flank pain (in 35-40%) and palpable abdominal mass (in 25-45%).
In men, a rapidly developing varicocele (most often on the left) is a characteristic sign. This is because the left testicular vein drains into the left renal vein, whilst the right testicular vein drains directly into the inferior vena cava. Hypertension, erythrocytosis and hypercalcaemia may also be present.
An 18-month-old infant is brought to the emergency department by the child's mother who gives a history of failure to thrive, fever and occasional blood in the nappy. On examination, a renal mass is felt.
Nephroblastoma (Wilm’s tumour) is a malignant mixed tumour seen in infancy. The tumours are usually solitary, soft, lobulated and tan or grey in colour. The infant may present with pyrexia, haematuria (blood in the nappy), failure to thrive, and abdominal (flank) mass. It is usually treated by total nephrectomy followed by radiotherapy or partial nephrectomy in children with bilateral disease.
A 60-year-old man is experiencing discomfort and is yet to pass urine eight hours following a hernia repair under spinal anaesthesia. On examination, his pulse is 100 bpm and his blood pressure is 140/60 mmHg. There is a palpable bladder on examination of the abdomen and a PR is normal.
Post spinal urinary retention
In view of retention with no obvious cause of obstruction, this 60-year-old probably has post spinal retention due to autonomic nerve blockade.
A 55-year-old woman is in the high dependency unit following an abdomino-perineal resection. The surgery was complicated by bleeding in the perineum that required packing. Her pulse is 90 bpm, blood pressure is 100/60 mmHg (on inotropes), central venous pressure +10 cmH2O but her urine output has been
Acute renal failure
The lady with abdomino-perineal resection has a normal central venous presssure and is requiring inotrope support for maintaining her blood pressure. Her oliguria, well into eight hours post operatively, probably is secondary to acute renal failure.
A 65-year-old man is complaining of severe abdominal pain. He has had a transurethral resection of the prostate about six hours ago. Abdominal examination reveals a distended bladder and in spite of irrigation there is no return in the catheter.
The 60-year-old man has a blocked catheter.
An 80-year-old woman has undergone a dynamic hip screw fixation for a fractured neck of femur four hours ago. She is confused on the ward. Her pulse is 120 bpm, blood pressure is 80/60 mmHg and oxygen saturation is 90%. Her urine output is 15 ml/hr over the last two hours.
The 80-year-old woman probably has hypovolaemia as evidenced by hypoxic confusion, tachycardia and hypotension.
A 55-year-old businessman presents with symptoms of impotence. He has been married for 30 years and has normal sexual relations with his wife. However, he has a mistress who is 20 years younger than he is and he has been unable to consummate the relationship due to impotence. Examination is normal and his testosterone concentration is 13.5 nmol/l.
Impotence is a common disorder with approximately 50% of males over the age of 50 suffering impotence at any time.
Causes range from the psychological to neurological and hormonal.
In the majority of cases impotence is psychological and can be improved by addressing the fundamental issues that may be problematic in relations or relating to the sex itself.
A 37-year-old male with a 15 year history of type 1 diabetes is found at annual review to have problems with impotence. He takes basal bolus insulin and losartan. He has a normal libido but is aware of poor and unsustainable erections. Examination reveals normal pulses, but a peripheral sensory neuropathy and background diabetic retinopathy. His testosterone concentration is 15.5 nmol/l.
In those that are not psychological drug therapy is often contributory and removing/altering the medication may assist.
The first line treatment for impotence is an oral prostaglandin inhibitor such sildenafil.
In the case of the man with diabetes the patient has impotence associated with a probable neuropathy and the most appropriate and satisfying initial treatment would be sildenafil. If this were to fail then a vacuum device could be offered but this is not often acceptable for the patient. Therefore intracavernosal injections could be tried and are successful in approximately 80%.
A 38-year-old man complains of a painless lump in the scrotum that has been present for around three months. On examination the right testis is enlarged, hard and non-tender. A scar is noticed in the groin and the patient comments that this was from an operation to put the testis into the scrotum when he was a teenager.
Testicular tumours, the majority of which are seminomas and teratomas (10% are lymphomas) are the most common tumours in young males. There is a 30x increased incidence of malignancy in imperfectly descended testes. Teratomas affect men between 20-30 years, seminomas between 30-40 years (Think: teratomas affect the troops, seminomas affect the sergeants). They present as a painless swelling in the scrotum which maybe associated with a hydrocele.The swelling, if discrete,usually occurs at the lower pole,but diffuse enlargement of the whole testis is perhaps commoner.
A 21-year-old army recruit is found to have a swelling in the left scrotum. He says it has been present for at least two years. On examination there is a large swelling that is non-tender. It is possible to get above the swelling and it transilluminates brightly.
A hydrocele is a collection of fluid in the tunica vaginalis. They may be primary (or idiopathic) occurring generally from middle age on, or secondary occurring in a younger age group. Secondary hydroceles may be due to an underlying malignancy or inflammation.
Clinically there is a cystic feeling swelling in the scrotum, in which the testis cannot be felt separately. The examiner is able to get above the swelling and it transilluminates.
A 14-year-old boy is admitted to hospital complaining of sudden onset severe central abdominal pain and pain in the scrotum. He has been previously well apart from a recent upper respiratory tract infection. On examination the left side of the scrotum appears normal but the right side is swollen and very tender. The right testis appears to be lying high in the scrotum.
Torsion of the testis
Torsion of the testes is a surgical emergency. It occurs as a result of intereference of the blood supply to the testis. It is associated with imperfectly descended testes, horizontal lying testes or when the testis and epididymis are separated by a mesorchium. Clinically the patient (usually a male between 10-20 years) presents with acute onset of pain in the scrotum/groin radiating to the lower abdomen with vomiting. The testis is exquisitely tender and drawn up in the scrotum.
It is difficult to distinguish between torsion and epididymo-orchitis or orchitis, however, in an inflammatory condition there will be signs of infection, for example, increased white cell count, temperature, positive dipstix, etc. In addition to this the testis is not (generally) high lying in infection. Torsion of hydatid of Morgagni may also mimic testicular torsion, however, should there be any diagnostic uncertainty, the testicle should be explored immediately.
A 39-year-old male is found to have a high riding prostate on digital examination following a road traffic accident.
Posterior urethral injuries result from pelvic fractures often sustained in motorcycle injuries. Treatment should usually be delayed for 3 months (unless there is an open wound). A completely transected urethra requires debridement, mobilisation and urethral anastomosis over a urethral catheter.
An 8-year-old boy sustained a straddle injury on a bicycle cross bar. On examination he is found to have perineal bruising.
Anterior urethral trauma usually results from iatrogenic manipulation or straddle injuries. The diagnosis of urethral trauma is confirmed by retrograde urethrogram. Most anterior urethral injuries are treated conservatively with urethral catheterisation and systemic antibiotics.
A 22-year-old male is found to have free intra-peritoneal fluid following a kick to the lower abdomen.
Bladder injuries most commonly result from blunt trauma. Full thickness tears anteriorly or posteriorly result in extraperitoneal extravasation of urine causing suprapubic pain, tenderness and swelling. A full thickness tear in the dome of the bladder results in an intraperitoneal rupture. The diagnosis is confirmed by computer tomographic cystography.
Extraperitoneal ruptures are usually managed conservatively while intraperitoneal ruptures require laparotomy and two layered closure of the bladder
A 62-year-old man has a five month history of fatigue, perineal discomfort, lower back and loin pain. He experiences pain on micturition.
Chronic bacterial prostatitis
One main difference between prostate cancer and chronic bacterial prostatitis is that cancer does not usually present with perineal pain.
A 21-year-old woman complains of an 18 hour history of urgency of micturition, dyspareunia and malaise.
In cystitis, dyspareunia (pain during sexual intercourse) is common.
A 60-year-old man complains of dysuria and urgency.He gets some suprapubic pain which is relieved lying supine,and occasional terminal haematuria. There is no abnormality on examination of the abdomen.
Painful haematuria, and pain relieved by lying down, suggests calculi, whereas painless haematuria suggests a possible occult malignancy.
A 72-year-old man presents to the Emergency department with acute back pain and leg weakness. He also mentions that he has been experiencing hesitancy and dribbling of urine for the last 12 months. On examination he has a spastic paraparesis and palpable bladder.
The 72-year-old man is showing signs of collapsed vertebrae. This is a not uncommon presentation of metastatic prostate cancer and is a urological emergency. Not uncommonly the spinal cord compression is dorsal and the first presenting symptoms may be stamping gait due to proprioceptive loss.
A 52-year-old woman presents to the Emergency department with severe colicky pain radiating from her right loin to the groin. Analysis of her urine reveals +++ blood.
Colicky pain that radiates from the loin to the groin always suggests renal colic. With haematuria, this is a common presentation of renal calculi.
A 21-year-old man presents with malaise, fever and bilateral large, tender testes.
Testicular lumps should always be investigated thoroughly. Bilateral involvement of the testes, which are tender, always suggests an infection of some sort. Orchitis is common in young men.
A 32-year-old man complains of a dull ache and dragging sensation in his left groin. On examination, there is a mass behind his left testicle which has the characteristics of 'a bag of worms'.
A lump behind the testes which feels like a bag of worms is characteristic of the dilated blood vessel plexus that occurs in varicocele.
A 27-year-old man complains that there is a lump on his right testicle which does not transilluminate. He had a vasectomy two years earlier. Examination reveals a small, non-tender, smooth, 1 cm mass arising from the superior pole of the testis.
A small non-tender and smooth lump on the top of the testis usually suggests spermatocele. These are usually benign and do not cause any problems.
A 26-year-old tall, thin man presents to his general practitioner with a six month history of dragging discomfort in his left groin and a left sided scrotal swelling. On examination, the swelling is compressible, increases on standing and disappears on lying down. In addition, there is cough impulse, the scrotum on the left side hangs lower and the left testis is smaller than the right.
Varicocele is the varicose dilatation of the veins draining the testis. Although generally asymptomatic, it may cause a vague and dragging discomfort. The scrotum on the affected side hangs lower than the other side. Cough impulse may be present. On examination, the varicocele feels like a 'bag of worms'. The varicosities are more prominent when the patient is standing and disappear or decrease in size when the patient lies down.
In longstanding cases, the affected testis is smaller and softer because of a minor degree of atrophy. More than 95% of varicoceles occur on the left side.
A 32-year-old man presents to the surgical outpatient clinic with a six week history of right sided painless scrotal swelling. On examination, the testis feels firm but there is an irregular swelling at the upper pole,and in the body of the testis. The testicular sensation is lost.
Teratomas and seminomas are the commonest type of testicular tumours. Most men present with a painless swelling although 10% may present with sudden onset testicular pain. The usual presentation is a sensation of heaviness in the testis and the groin. Testicular sensation is lost early and is an important diagnostic sign. A small hydrocele may be present and the spermatic cord may be thickened from malignant infiltration. An urgent ultrasound is indicated in patients suspected of having a testicular tumour.
A 43-year-old man presents to his general practitioner with a four month history of right sided scrotal swelling. On examination the testis is not palpable and there is dullness on percussion. The swelling is transilluminant and it is possible to get above the swelling. Cough impulse is absent.
Hydrocele is mostly seen in middle aged men. It may either be primary or secondary to an associated underlying malignancy. In primary hydrocele the common presenting complaint is a longstanding painless scrotal swelling. On examination the swelling is dull to percuss and cough impulse is absent. It is possible to get above the swelling. The swelling is transilluminant. The testis is usually not palpable since the fluid of the hydrocele surrounds the body of the testis.
An otherwise well 13-year-old boy is admitted complaining of sudden onset severe left sided testicular pain two hours prior to admission. He gives no history of trauma, dysuria or frequency.
On examination he is found to have a tender, high-riding testicle.
What is the most appropriate next step in this young man's management?
(Please select 1 option)
FBC and U&E
Scrotal Doppler ultrasound as an emergency
Scrotal Doppler ultrasound on the next available list
Surgical exploration of his scrotum
Surgical exploration of his scrotum
This patent should be suspected of having a testicular torsion. Because time is essential he should proceed straight to theatre.
In a well 13-year-old routine blood tests are not necessary and will not change the management plan.
Although scrotal Doppler ultrasound may make the diagnosis to wait for this investigation is inappropriate.
A 35-year-old gentleman is admitted complaining of severe right loin pain that radiates to the groin. He reports that the pain seems to come in waves.
Abdominal examination is unremarkable. Urine microscopy shows red cells but no white cells. An IVU is performed which is reported as showing obstruction at the vesico-ureteric junction. 24 hours later he passes a small stone.
What is the most likely biochemical composition of the stone?
(Please select 1 option)
Magnesium ammonium phosphate
Oxalate and mixed oxalate/ phosphate stones account for around 75% of urinary tract calculi, usually caused by hypercalciuria.
Magnesium ammonium phosphate stones account for one sixth and are usually associated with Proteus infection.
Xanthine stones are rare.
Sodium chloride is readily dissolvable.
A 34-year-old woman presents to the Emergency department with a two day history of severe right-sided abdominal pain and increased temperature associated with chills and rigors. She also complains of burning micturition.
She had undergone cystoscopy six days ago. On examination, her temperature is 39.3ºC, she has warm and sweaty peripheries, and is tender over her right loin region. Urine microscopy reveals pus cells and casts.
From the options below choose the one which you think is the most likely diagnosis in this patient:
(Please select 1 option)
Urinary tract infection
This patient is most likely to have pyelonephritis secondary to the urological tract intervention, that is, cystoscopy. The risk factors for pyelonephritis include use of
Surgeries on the urinary tract
Enlarged prostate in males.
Pyelonephritis usually presents with severe loin pain, chills, rigor, pyrexia, warm and moist peripheries, burning micturition, and increased urinary frequency and urgency. There may be renal tenderness and tenderness over the affected iliac fossa. There may be associated constitutional symptoms such as headache, lassitude and nausea.
Urine microscopy reveals pus cells and cast cells. Ultrasound is a very useful investigation to clinch the diagnosis.
Other relevant investigations include intravenous pyelogram (IVP) and CT scan of the abdomen. IVU or CT scan of the abdomen may show enlarged kidneys with poor flow of dye through the kidneys (may also indicate underlying disorders).
The complications of acute pyelonephritis include
Progression to chronic pyelonephritis.