Urology Flashcards
(126 cards)
1
Q
Define dysuria
A
- pain or discomfort with micturiation
2
Q
Define urinary frequency
A
- micturition at short intervals that is bothersome
3
Q
Define urgency
A
- sudden, compelling urge to urinate that is difficult to avoid
4
Q
Define pyuria
A
men = presence of >2 leukocytes/HPF women = presence of >5 leukocytes/HPF
5
Q
Define cystitis
A
- dysuria, urinary frequency and urgency, sometimes with suprapubic pain and often in presence of pyuria
6
Q
What are protective factors for men re: UTI?
A
- long male urethra
- bactericidal properties of prostate secretions
7
Q
Classify UTI re: anatomic
A
- upper: pylonephritis, ureteritis
- lower: cystitis, prostatitis, orchiepididymitis, epididymo-orchitis
8
Q
Classify UTI re: clinical
A
- uncomplicated: structurally normal urinary tract who respond to short course of abx (mostly female)
- complicated: abnormal GU tract, male, pregnant, children, elderly, DM, immunocompromised, urolithiasis, recent instrumentation, nocosomial
9
Q
Classify UTI re: clinical/ chronologic
A
- isolated (sporadic) - first infection or remotely occurring infection; most common
- unresolved bacteriuria - urine not sterilized by abx (bacterial resistance, azotemia, pt noncompliance, rapid reinfection, papillary necrosis, infected calculi, tumor, foreign object)
- recurrent - repeated infection after tx interrupted by periods of sterile urine (often predisposing condition) -> relapse (within 2wk, same bacteria), reinfection (>2wk post treatment)
10
Q
UTI risk factors
A
<5yr old: anatomic anomalies (UPJ, VUR), uncircumcised in male
6-15yr: functional anomalies (dysfunctional voiding)
16-35 yr: female - sexual intercourse, spermicidal use
36+: female= gyne surgery, genital prolapse; male= obstruction
50+ yr: female = postmenopausal
11
Q
Etiology UTI re:
- non-infectious
- infection
- external to lower urinary tract
A
Non-infectious urinary tract inflammation
- trauma
- interstitial cystitis
- bladder cancer
- bladder stones
- ureteral stones
- urethral stricture
Infection of urinary tract
- urethritis
- prostatitis
- cystitis
- pyelonephritis
External to lower urinary tract
- vulvovaginitis
12
Q
Pyelonephritis complications and predisposing factors
A
complications
- bacteremia and septic shock
- renal parenchymal damage - pyonephrosis, emphysematous pyelonephritis, renal abscess
- papillary necrosis
predisposing
- VUR
- nephrolithiasis
- cystitis
- UPJ
13
Q
Cystitis complications and predisposing factors
A
complications
- evolution to pyelonephritis
- relapse of infection
- bacterial persistence
predisposing
- female
- obstruction
- indwelling catheter
- sexual intercourse
- urolithiasis
- foreign bodies
14
Q
What is next step investigation for suspected upper and lower tract UTI, male UTI, febrile UTI, complicated UTI?
A
urine culture
15
Q
What can VCUG detect?
A
VUR
16
Q
What can 99mTc-DMSA detect?
A
Acute pyelonephritis or renal scarring
Evaluate function of each kidney separately
17
Q
What components indicate UTI in dipstick urinalysis
A
- nitrites
- leukocyte esterase
18
Q
Pathogens causing UTIs
A
E coli Klebsiella spp. Proteus mirabilis S. aureus Psudomonas aeruginosa
19
Q
Empiric abx UTI tx
A
Uncomplicated
acute cystitis = TMP-SMX (or Ciprofloxacin) PO x 3d
acute pyelonephritis:
- mild: Ciprofloxacin PO x7-14d
- severe: Ciprofloxacin + 3rd gen cephalosporin IV
20
Q
Abx tx gram + uncomplicated UTI
A
Assume enterococci - amoxicillin+/- clavulante PO
- if severe = amoxil + clav + gentamicin IV
21
Q
Empiric abx tx complicated UTI
A
Cystitis or pyelonephritis
- 3rd gen cephalosporin or ciprofloxacin IV
if gram + stain (assume enterococci) = ampicillin + gentamicin
22
Q
When do you treat asx bacteruria?
A
- pregnancy
- urologic procedure
- GU tract obstruction
- kids with vesicoureteral reflux
- Proteus and Pseudomonas species
23
Q
Erectile dysfunction definition
A
- persistent or recurrent inability to achieve and maintain a penile erection of sufficient rigidity to permit satisfactory sexual activity for at least 3mo (>75% of time)
80% primary organic cause
24
Q
Pathophys erection
A
Stimulation -> neural discharge and response -> release NO -> increase intracellular cGMP -> hemodynamic changes = intracavernousal arteriolar dilation
neural d/c and response:
- parasymp S2-S4: pelvic n
- symp T12-L2: hypogastric n
- somatic S2-S4: pudendal n
25
Mechanism of testosterone in erection?
- maintains intrapenile levels of NO synthase
26
Site of action of drugs for ED?
Sildenafil
Tadalafil
Vardenafil
-> inhibit PDE-5
PDE-5 inactivates cGMP which causes intracavernousal arteriolar dilation
27
Cause conditions of ED? (IMPOTENCE)
Inflammatory - prostatitis, urethritis, stricture
Mechanical - cord, Peyronie disease, phimosis
Occlusive - arteriogenic
Traumatic - pelvic #, urethral rupture
Endurance - CVD
Neurologic - neuropathy, temporal lobe epilepsy, MS
Chemical - EtOH, cannabis, rx drugs (SSRI, b-blocker, thiazide, hormone modulator, 5-alpha reductase inhibitors)
Endocrine - testicular failure, pituitary failure, hyperprolactinemia, DM
28
Important questions re: psychogenic ED?
- incidence of involuntary erections (morning erections)
- performance with manual stimulation (masturbation)
- perceived acute situational ED or associated performance anxiety
29
Physical exam for ED?
- BP
- neurologic exam, including bulbocavernous reflex
- GU exam - anatomical survey and testicular exam for hypogonadism
30
Investigations for ED?
- cbc, urinalysis, serum prolactin, FSH, LH, TSH
- testosterone
- fasting glucose, HBA1C, lipids
31
Medical tx ED?
- PDE-5 inhibitors: sildenafil, tadalafil, vardenafil (1st line)
- intracavernous injections: smooth muscle relaxants and vasodilators
- MUSE intraurethral suppository
- androgen replacement (IF androgen deficiency)
32
CI PDE-5 inhibitors?
absolute: nitrate use (notroglycerine) or allergy
relative: baseline hypoTN, liver or renal insufficiency, use of pharmacologic agents that inhibit cytochrome P450 (olanzapine), CHF NYHA >=2, MI/stroke in last 6mo
33
What is hematuria?
- gross (visible)
| - microscopic (>=3 RBC/HPF on 2 UA)
34
What filters blood molecules based on size and electrical charge?
- glomerular capillaries
35
Is basement membrane positively or negatively charged? How does this affect filtration of molecules?
Negatively charged proteoglycans
| - repels molecules with negative electrical charge (e.g. albumin)
36
How can immune system alter renal filtration at basement membrane?
- humoral and cellular immunity pathways and complement system alters BM properties -> albumin and RBCs can be filtered and reach Bowman's capsule = proteinuria and hematuria
37
Causes of non-RBC red urine (heme + and heme -)
heme +
- hemoglobinuria: dialysis, hemolysis
- myoglobinuria: rhabdomyolysis, rifampin, trauma
heme -
- drugs: sulfa, nitrofurantoin, salicylate, phenytoin
- foods: beets, food colouring
- metabolites
38
Common causes hematuria age 0-20?
glomerulonephritis
UTI
congenital anomalies
39
Common causes hematuria age 20-40?
UTI
| calculi
40
Common causes hematuria age 40-60?
female: UTI> calculi > bladder tumor
male: bladder tumor> calculi, UTI
41
Common causes hematuria age >60?
female: bladder tumor > UTI
male: BPH > bladder tumor > UTI
42
RF for bladder cancer?
- cyclophosphamide
- occupational exposure to chemicals (benzenes or aromatic amines)
- blackfoot disease
- radiation to pelvis
- A. fangchi
- smoking
- chronic UTI
- analgesia abuse
- renal transplant recipient
- Schistosomiasis hematobium
43
Classic triad for renal cell carcinoma?
- flank pain
- palpable flank mass
- hematuria
44
Workup microscopic hematuria for pt high risk or >40 yrs?
- UA
- urine culture
- urine cytology
- upper tract imaging (US of kidneys, bladder)
- cystoscopy for lower tract
45
Workup microscopic hematuria for pt low risk?
- repeat UA
| - if repeat UA + then same eval as high risk pt excluding cystoscopy
46
Workup asx gross hematuria?
- urine cytology
- UA
- upper tract imaging (CT-IVP)
- cystoscopy
47
Indications for nephrology referral?
- proteinuria
- red cell casts
- dysmorphic red blood cells
- elevated Cr
- > suggestive of glomerular cause of hematuria
48
Follow up for hematuria?
- Fam physician fup with UA, urine cytology and BP checks at 6, 12, 24, 36 mo
49
What is involuntary loss of urine?
Urinary incontinence
50
Causes of urgency incontinence?
overactive bladder (detrusor contraction overcomes sphincter inhibition)
- irritation of bladder mucosa
- neurogenic
- iatrogenic
- idiopathic
51
Causes of stress incontinence?
insufficient outlet pressure
- lack of pelvic floor support
- iatrogenic
52
Causes of overflow incontinence?
bladder underactive (detrusor atony)
- neurologic lesion (trauma/ other) -> sacral region (S2- S5) or peripheral nerves (pudendal or pelvic n)
- congenital defect (spina bifida)
outlet obstruction (mechanical hindrance to flow)
- extrinsic obstruction
- intrinsic obstruction
53
Ddx neurogenic bladder?
- MS
- Spinal trauma (including iatrogenic)
- stroke
- DM
54
Transient causes of incontinence in elderly (DIAPPERS)?
- delirium
- infection
- atrophic urethritis or vaginitis
- pharmaceuticals
- psychogenic
- excessive urine output
- restricted mobility
- stool impaction
55
Dx and pathophys
- involuntary loss of urine with efforts that cause increased intra-abdominal pressure (coughing, sneezing, laughing, lifting)
Stress incontinence
| - increase abdo pressure = transmitted to bladder and due to reduced pelvic support allows leakage of urine
56
Dx and pathophys
| - involuntary urine leakage accompanied by need to urinate
Urge incontinence
- uninhibited bladder contractions cause increased intravesical pressure, which, when higher than urethral resistance causes leakage
57
What investigations if incontinence likely from BPH?
- uroflowmetry
| - post void residual assessment
58
Investigations of incontinence with concurrent lower urinary tract sx and hematuria?
- cystourethroscopy
59
What is the indication for urodynamic study?
- dx uncertain after history and physical
- failed medical tx
- history suggests incontinence with mixed etiology
60
Dx incontinence
R/O UTI!! (urinalysis and culture)
| based on history re: stress vs. urge incontinence
61
Tx urge incontinence
- anticholinergics, lifestyle
62
Tx stress incontinence
- Kegel exercises
- pelvic floor physiotherapy
- pessaries/ endovaginal cone
- surgical procedures (urethral sling or artificial urinary sphincter)
63
What is enuresis?
- repeated voiding of urine into child's clothes or bed after the developmental (not necessarily chronological) age of 5yr
- at least 2x/wk over 3mo OR cause significant distress and impairment
64
Classification of enuresis
- diurnal or nocturnal
| - primary (never been consistently dry at night) or secondary (resumes wetting after 6mo of continence/ dryness)
65
Is increase or decrease ADH associated with nocturesis?
- less secretion or blunted response to nocturnal ADH
66
What is needed for child's readiness to toilet train?
1. child's interest (20-30mo), dependent on culture
2. physiologic readiness: voluntary coordination of sphincter control; myelination of pyramidal tracts (12-18mo), acquiring larger bladder capacity
3. behavioural readiness: ambulation to toilet, communication with parents
67
Investigations enuresis?
```
Urinalysis
- UTI
- renal disease
- DM
Voiding diary
Renal US in older kids or not responding to tx
```
68
Tx enuresis?
conditioning therapy
- enuresis alarms
- conditioned awakening and timed voiding
reward system
- bladder stretching by having child progressively refrain from urinating for increasing periods of time coupled with reward
pharmacotherapy
- DDAVP
- oxybutynin
69
Define infertility
- inability to conceive after 1 yr of intercourse without contraception
- > investigate both partners
70
Why are testes outside the body?
- spermatogenesis occurs at lower temperatures than core temperature
- > increased temp affects spermatogenesis
71
What is a varicocele? Can it affect fertility?
- dilated veins of pam-uniform complex
| = increase in temperature of scrotal content and reflux of toxins from body -> result is poorer spermatogenesis
72
Pathophys spermatogenesis
- GnRH -> anterior pituitary
-> LH acts on Leydig cells -> activin and testosterone negative feedback to anterior pituitary and hypothalamus
AND testosterone from testicle -> sertoli cells
-> FSH acts on Sertoli cells -> inhibin negatively feedback to pituitary
and prolactin released from pituitary -> negative feedback to hypothalamus
73
Ddx male infertility
Pretesticular
- hypothalamic disease (e.g. Kallmann syndrome = gonadotropin deficiency)
- pituitary disease
Testicular
- chromosomal
- cryptochidism
- testicular trauma
- viral orchitis
- varicocele
- radiation
- drugs (ROH, lithium, alpha blockers, TCAs, CCB, steroids)
- idiopathic
Posttesticular
- obstruction
- sperm motility or function
- disorders of coitus
74
Investigations male infertility
semen analysis x2
- ejaculate volume (>1.5mL)
- pH (>7.2)
- sperm concentration
- total sperm count
- motility
- morphology
- WBC
other investigations
- karyotype
- FSH, LH
- testosterone
- scrotal/ prostatic US
75
Intercourse timing with ovulation?
2d before ovulation x5d
76
Abnormal sperm analysis?
- oligospermia (small number spermatozoids)
- low volume
- low mobility
- teratospermia (structural defects)
- combination -> oligoteratospermia (OAT) = most commonly associated with varicocele
77
Embryology of male gonads and anatomy re: clinical entities
- gonads arise in retroperitoneum near kidneys and descent into scrotum by pushing into peritoneum and out through abdominal wall
- left gonadal vein drains into left renal vein (varicocele)
- liquid accumulating in tunica vaginalis, which originates from peritoneum (hydrocele)
- weakness of abdo wall at internal inguinal ring (inguinal hernia)
- spread of testicular cancer through lymphatics directly into retroperitoneum
78
Ddx scrotal mass
- testicular cancer
- hydrocele
- hematocele
- communicating hydrocele
- spermatocele/ epididymal cyst
- varicocele
- infectious (orchitis/ epididymitis)
79
Definition and aetiologies of testicular cancer
- 95% germ cell tumors
- seminomas
- nonseminomas
etiology - RF
- cryptorchidism (up to 14-fold)
- testicular atrophy
- testicular dysgenesis
- HIV
80
Definition and aetiologies of hydrocele
collection of fluid within tunica vaginalis, surrounding the testicle
- idiopathic
- tumor
- epididmytis/ orchitis
- trauma
- torsion (reactive)
81
Definition and aetiologies of hematocele
- collection of blood within tunica vaginalis
- mass not separated from testicle
- trauma
- post-up complication
82
Definition and aetiologies of communicating hydrocele
- incomplete obliteration of process vaginalis, allowing peritoneal fluid to pass into scrotum
- congenital
83
Definition and aetiologies of spermatocele/ epididymal cyst
sperm filled collection of epididymus, resulting in cyst-like structure superior to testicle
- idiopathic
- associated with von Hippel-Lindaw disease
84
Definition and aetiologies of varicocele
dilated and tortuous veins of pam-uniform plexus of spermatic cord
- L>R
- right sided may be due to intra-abdominal pathology
85
Definition and aetiologies of infectious orchitis/ epididymitis
scrotal pain and swelling, associative tenderness and erythema
- <35 = gonorrhoea, chlamydia
- >35 = E coli
86
What is often left sided and disappears when supine?
varicocele -> bag of worms
87
Likely dx if painless firm enlargement of testicle?
testicular cancer
88
Imaging for scrotal mass?
Scrotal US
- cystic vs. solid
- doppler US for vascularization
89
Do you do a transscrotal biopsy of intratesticular mass?
NO - risk of cancer dissemination
90
Investigations for testicular cancer?
- serum tumor markers - b-hCG, AFP, LDH
- abdominal and pelvic CT
- CXR
91
Treatment testicular cancer?
- radical inguinal orchidectomy + adjuvant therapy if indicated
92
Tx varicocele?
- surgical ligation of testicular vein
93
Are hydroceles, and spermatoceles treated medically or surgically?
Surgical excision
94
Define bell clapper deformity
- congenital malformation in which the testis is inadequately affixed to scrotum (40% men bilaterally and 17% unilaterally)
- absence of properly formed gubernaculum testis (scrotal ligament) allows the testis to move freely on its axis, rendering it susceptible to torsion
95
Define testicular torsion
- spermatic cord twists on itself causing acute testicular torsion, irreversible ischemic injury to tests can begin 4h after occlusion of cord, often 6h window of preservation
96
Ddx acute scrotal pain
- testis - orchitis, testicular hemorrhage into tumor, testicular #/rupture
- testicular appendix - torsion
- epididymis - acute epididymitis
- spermatic cord - testicular torsion
- tunica vaginalis - hematocele
- inguinal - incarcerated/ strangulated inguinal hernia
- distal ureter - referred pain from distal ureteric calculus
97
Dx
- no cremasteric reflex (elevation of ipsilateral testicle by scratching inner superior aspect of thigh)
- no relief with elevation of testicle (negative Prehn sign)
- testicle may be high riding or horizontal lie
Testicular torsion
98
Dx
- cremasteric reflex present
- Pregn sign (pain relieved with teste elevation)
- epididymal swelling and focal point of pain
acute epididymitis
99
Dx
| - blue dot sign
torsion of appendix testis
100
Is dx testicular torsion clinical or based on investigations?
- clinical dx
| - can do doppler US to assess testicular blood flow
101
How do you attempt to detort a testicular torsion?
open book
| - lateral detorsion
102
Is testicular detorsion definitive treatment?
No
| - pt needs urgent surgical evaluation for definitive testicular affixation (orchiopexy)
103
Is the patient at increased risk of torsion in other testicle?
Yes - often bilateral orchiopexy is performed
104
Treatment acute epididymitis
```
ceftriaxone 250mg IM x1
tetracycline 500 mg QID x10d
doxycycline 100mg BID x10d
evaluate partner
counsel re: safe sex practices
```
105
Sx renal trauma
- flank bruising, palpable mass, pain, tenderness
| - hematuria (gross or microscopic)
106
Sx ureteral trauma
- iatrogenic cause often dx postop
| - flank pain, fever, sepsis, urinoma, prolonged ileus, acute kidney injury
107
Sx bladder injury
- 95% have gross hematuria
| - suprapubic pain, bruising, pelvic mass, urinary retention, peritonitis
108
Sx urethral injury
- often pelvic #
- blood at tip of meatus, hematuria, perineal or scrotal bruising (butterfly hematoma), high-riding prostate, urinary retention, penile swelling
109
Investigations renal and ureteral injuries
CT
- renal = CT-IVP
- ureteral = contrast CT with delayed imaging to assess leakage retrograde pyelography
110
Investigations bladder injury
- cystogram
111
Investigations urtheral injury
- retrograde urethrogram
112
Is intraperitoneal or extraperitoneal bladder rupture treated with surgery?
- intraperitoneal = surgery
| - extraperitoneal = Foley
113
Classification of urinary obstruction?
- acute vs. chronic
- complete vs. partial
- unilateral (usually upper tract) vs. bilateral (usually lower tract)
114
Etiology of HTN in unilateral vs. bilateral urinary tract obstruction
unilateral- vasoconstriction from RAAS
| bilateral - volume expansion
115
Sx lower tract - voiding LUTS and physical exam
- hesitancy
- weak stream
- post void dribbling
- frequency, nocturne, urgency
- inability to empty bladder
- hematuria +/- clots
HTN
palpable bladder
palpable urethral stricture
enlarged prostate
116
Sx upper tract obstruction and physical exam
- flank pain +/- radiation to groin or RLQ or LLQ
- hematuria
- GI sx (n/v)
HTN
CVA tenderness
117
Management of patient with urinary obstruction and fever and chills?
- urologic emergency
| - restore urine flow -> insert nephrostomy tube or ureteric stent with IV abx
118
Dx location of renal colic
| - renal colic with flank pain
Ureteropelvic junction
119
Dx location of renal colic
| - RLQ or LLQ pain; may mimic appendicitis, diverticulitis, ectopic pregnancy
pelvic brim (as ureter crosses iliacs)
120
Dx location of renal colic
| - renal colic with irritative (urgency, dysuria, frequency) lower urinary tract sx and radiation to ipsilateral testicle
ureterovesical junction
121
Investigations of LUTS of obstruction
- UA, urine culture
+/- cbc, Cr, BUN, lytes, glucose, PSA
others
- bladder scan/ urinary catheter re: post void residual
- cystoscopy
- uroflow
- us/CT scan
- transrectal US guided prostate biopsy to r/o prostate cancer
122
Investigations of upper tract obstruction
- UA, urine culture, serum Cr, lytes
- US - assess hydronephrosis and bladder residual volume
- CT - without contrast to see stones; contrast for lesions other than stones causing hydronephrosis
- renal scintigraphy (DTPA, MAG-3 with furosemide) - functional evaluation of kidneys
other:
- cystoscopy
- retrograde pyelography
- ureteroscopy
123
Medical and surgical treatment of benign prostatic obstruction?
medical
- alpha blockers (sx tx)
- 5 alpha reductase inhibitors (shrinks volume of prostate)
surgical
- TURP
- laser photo-vaporization
- open simple prostatectomy
124
Conservative tx kidney stones
- calculus <5mm (90% pass spontaneously)
- alpha blockers
- analgesics
- hydration (>2L/d)
125
Where is hyperplasia located in BPH?
- transitional zone
126
Most common type of prostate cancer?
adenocarcinoma
| - peripheral zone > transitional zone > central zone
