Urology Flashcards
1
Q
Hematuria definition
A
blood in urine where RBC count >3 per high power field (HPF) on urine microscopy
2
Q
how much blood is usually required in the urine to be macroscopic hematuria
A
usually requiring minimum of 1mL of blood in 1L of urine
3
Q
Differential diagnosis for post renal causes of hematuria
A
“TITS”: trauma, infection, tumor, stone
4
Q
Mimics of hematuria
A
OB & GYN: menstruation, vaginal bleeding
medication: Pyridium, Phenytoin, Rifampin, Nitrofurantoin, Phenolphthalein
dyes: beets, rhodamine B
pigment: hemoglobinuria (hemolytic anemia), myoglobinuria (rhabdomyolysis), porphyria
5
Q
macroscopic painless hematuria suggests what diagnosis
A
macroscopic painless hematuria is malignancy (bladder cancer) until proven otherwise
6
Q
Urology approach to hematuria
A
1) Confirm hematuria
2) Differentiate Pre-Renal vs. Renal vs. Post-Renal
blood work (CBC, blood film, INR, aPTT) to rule in / out pre-renal hematologic causes
renal glomerular vs. post-renal hematuria differentiated based on history and urine analysis
1) Renal Glomerular History Color: tea/cola colored Clots: no clots Bloodwork: renal function high BUN/Cr Urinalysis Microscopy: dysmorphic RBC, RBC casts Dipstick: can have proteinuria
2) Post-Renal History Color: red Clots: may have clots Bloodwork: normal Urinalysis Microscopy: normal shaped RBC, no RBC casts Dipstick: otherwise normal
3) Work-up of Post-Renal
rule out causes of post-renal hematuria other than tumor (i.e. ITS of TITS) based on history, physical exam and investigations
diagnose urinary tract infection based on symptoms on history confirmed by positive urine culture and dipstick
diagnose trauma based on history of trauma or manipulation of urinary tract
diagnose stones based on symptoms on history confirmed by abdominal / pelvis CT
work-up for tumor = renal ultrasound, urine cytology
positive renal ultrasound or urine cytology concerning for malignancy -> referral to urology for cystoscopy
negative renal ultrasound and urine cytology with risk factors for malignancy -> referral to urology for cystoscopy
negative renal ultrasound and urine cytology without risk factors for malignancy -> urine analysis, urine cytology, blood pressure at 6 months, 1 year, 2 years, 3 years
7
Q
Risk factors for bladder cancer
A
age >40 years
smoking history
occupational chemical exposure
gross hematuria
storage or voiding symptoms
recurrent urinary tract infections, recurrent urological disorder
pelvic radiation exposure
8
Q
Renal cell carcinoma epidemiology
A
8th most common malignancy, 3% of all newly diagnosed cancer
3 male : 2 female ratio
peak incidence at age 50-60 years
9
Q
Renal cell carcinoma risk factors
A
top 3 risk factors: smoking, hypertension, obesity
other: horseshoe kidney, acquired renal cystic disease
10
Q
Renal cell carcinoma pathology
A
malignancy arising from proximal convoluted tubule epithelial cells
histological cell types: clear cell (80% cases) papillary (10-15%) chromophoric (5-10%) collecting duct
11
Q
Renal cell carcinoma clinical presentation
A
most commonly asymptomatic and diagnosed incidentally by renal ultrasound or CT
classic triad of late symptoms in 10-15% cases: gross hematuria, flank pain, palpable mass
metastasis to brain, bone, lung and liver in 50% cases
para-neoplastic syndromes in 10-40% patients
12
Q
Renal cell carcinoma para-neoplastic syndromes
A
hematologic: anemia, polycythemia, erythrocytosis, leukopenia, increased ESR
endocrine: hypercalcemia, increased hormones (prolactin, gonadotropin, TSH, insulin, cortisol)
liver: abnormal liver enzymes
hemodynamic: hypertension, peripheral edema
13
Q
Renal cell carcinoma investigations
A
blood work: CBC, electrolytes, Ca, PO4, Mg, albumin, bilirubin, INR, AST, ALT, ALP, GGT, ESR
urine analysis
imaging: abdominal CT with contrast > renal ultrasound for visualization of mass; MRI for evaluation of vascular extension
biopsy: fine needle biopsy if considering observation or other non-surgical therapy
staging requires abdominal / pelvis CT with IV contrast, blood work [liver enzymes (AST, ALT, ALP, GGT); liver function (albumin, bilirubin, INR)], bone scan
14
Q
Renal cell carcinoma management
A
management based on staging
surgical options: partial nephrectomy, radical nephrectomy, surgical removal of solitary metastasis
partial nephrectomy = removal of part of kidney, sparing parenchyma
radical nephrectomy = en bloc removal of kidney, tumour, adrenal gland, Gerota’s capsule and para-aortic lympadenectomy
ablative techniques: cyoablation, radiofrequency ablation
radiotherapy
medication for advanced stage: anti-angiogenesis / anti-VEGF (Bevacizumab), mTOR inhibitor (Temsirolimus, Everolimus), IL-2, IFN-a, tyrosine kinase inhibitor (Sunitinib, Sorafenib)
15
Q
Bladder cancer epidemiology
A
2nd most common urological malignancy
3 male : 1 female ratio
4 white : 1 black ratio
mean age at diagnosis = 65 years
16
Q
Bladder cancer risk factors
A
smoking (implicated in 60% cases)
chemical exposure including aromatic amines
chemotherapy: cyclophosphamide
radiation to pelvis
chronic bladder irritation / inflammation: cystitis, chronic catheterization, bladder stones
17
Q
Bladder cancer pathology
A
cell types: transitional cell carcinoma (TCC) in >90% cases; squamous cell carcinoma in 5-7% cases; adenocarcinoma in 1% cases; others in <1% cases
T staging:
superficial papillary in 75% cases with >80% survival
invasive in 25% cases with 50-60% survival
carcinoma in situ (flat non-papillary erythematous lesion) with poorer prognosis
18
Q
Bladder cancer clinical presentation
A
asymptomatic in 20% cases
urinary symptoms: gross hematuria in 90% cases; pain in 50% cases; clot retention in 20% cases; failure to empty urinary symptoms
metastasis to lymph nodes (which may present with lower extremity lymphedema), bone, liver
bladder cancer have high recurrence rate within bladder due to urine stasis
19
Q
Bladder cancer complications
A
obstruction of ureter -> hydronephrosis -> renal failure and uraemia (nausea, vomiting, diarrhea)
20
Q
Bladder cancer investigations
A
blood work: bladder tumour markers (NMP-22, BTA, Immunocyt, FDP)
urine: R & M, C & S, urine cytology
imaging:
bladder ultrasound
CT scan with IV contrast or IVP for filling defect
cystoscopy with bladder washing (gold standard imaging for bladder cancer)
cystoscopy with bladder washing is initial procedure of choice for diagnosis and staging of bladder cancer
biopsy: resection is gold standard for pathological diagnosis (or cold punch biopsy transurethral)
21
Q
Bladder cancer management
A
superficial (non-muscle invasive) disease: Tis, Ta, T1
- surgical: transurethral resection of bladder tumour (TURBT)
- surgical: consider cystectomy in select patients with high grade disease
- chemotherapy: once dose or 6 week course of intra-vesical chemotherapy or immune therapy (BCG, Mitomycin C) to decrease recurrence rate; maintenance with intravesical chemotherapy with BCG for 2-3 years
invasive disease: T2a, T2b, T3
- radical cystectomy surgical: radical cystectomy + pelvic lymphadenectomy with urinary diversion (ileoconduit, Indiana pouch, ileal neobladder)
- radiation: chemo-radiation for small tumours
- chemotherapy: neo-adjuvant chemotherapy prior to cystectomy
advanced / metastatic disease: T4a, T4b, N+, M+
1. systemic chemotherapy + radiotherapy + surgery
22
Q
Definition lower urinary tract symptoms
A
any combination of urinary symptoms related to failure to store and / or failure to void
male with LUTS classically refer to symptoms due to bladder outlet obstruction (BOO) due to benign prostatic hyperplasia (BPH)
23
Q
Clinical presentation failure to store
A
FUND = frequency, urgency / incontinence, nocturia, dysuria
24
Q
Clinical presentation failure to void
A
SHEDS = stream changes (slow stream, intermittent stream), hesitancy, emptying incompletely, dribbling, straining to void
25
Definitions of
urinary incontinence
urgency incontinence
stress incontinence
mixed incontinence
overflow incontinence
overactive bladder
urinary incontinence = involuntary leakage of urine
urgency incontinence = incontinence accompanied by urgency (sudden and compelling desire to past urine that is difficult to defer)
stress incontinence = involuntary leakage with increased intra-abdominal pressure (e.g. exertion, sneezing and / or coughing)
mixed incontinence = combination of urgency and stress incontinence
overflow incontinence = incontinence due to failure to void (bladder full of urine where intra-vesical pressure exceed urethral pressure)
overactive bladder = syndrome of urgency, frequency, nocturia, urinary incontinence
26
Etiology of urgency incontinence
Urgency incontinence due to bladder (detrusor overactivity or decreased compliance)
A) detrusor overactivity
neurologic: CNS lesion such as spinal cord injury
inflammation: cystitis, stone, tumour
structural: bladder neck obstruction (tumour, stone), BPH
idiopathic
B) decreased bladder compliance
fibrosis of bladder
non-functioning bladder neck or proximal urethra: neurological disease, trauma, surgery, aging
27
Etiology of stress incontinence
stress incontinence due to sphincter / urethra (urethral hyper mobility and / or intrinsic sphincter deficiency)
```
A) urethral hyper mobility = weakened pelvic floor allowing bladder neck and urethra to descend with increased intra-abdominal pressure
(multiple) childbirth
pelvic surgery
aging
levator muscle weakness
```
```
B) intrinsic sphincter deficiency = weakness or failure of urethral sphincter or urethra
aging
hypo-estrogen state
pelvic surgery
neurologic problem
```
28
Mixed incontinence etiology
combination of causes of urgency and stress incontinence
29
Overflow incontinence etiology
causes of failure to void
30
What medications can contribute to urinary incontinence
anti-histamine
anticholinergics
ACE inhibitor, diuretics
anti-depressants, antipsychotics
alpha agonists, alpha 1 blockers
narcotics
ephedrine/pseudoephedrine
31
Neurological levels that control genitoanal region sensation, anal tone and bulbocavernosal reflex
sensation: penis S2, peri-anal S2-3
anal tone: S2
bulbocavernosal reflex (S2-4)
32
Failure to store (urinary incontinence) investigations
urine: urine analysis R & M, C & S
if suspected overflow incontinence, post-voidal residual bladder ultrasound
if severe voiding symptoms, then urine flow rate and possibly urodynamic testing
33
Diagnosis of urgency, stress and overflow incontinence
urgency incontinence: diagnosed based on urgency incontinence on history and urodynamics study
stress incontinence: diagnosed based on stress incontinence on history and positive stress test on physical exam
overflow incontinence: bladder ultrasound showing post-voidal (PVR) residual >200cc
34
Urgency incontinence management
1st line = lifestyle modification, bladder habit training
2nd line = medication:
anti-cholinergics (Tolterodine, Oxybutynin, Trospium, Solifenacin, Darifenacin, TCA)
last line = Botulinum toxin, sacral neuromodulation
35
Stress incontinence management
1st line = lifestyle modification, weight loss, Kegel exercises, bulking agents
2nd line = pessary for female (medical device to provide structural support of vagina)
last line = surgery: slings, tension-free vaginal tape, transobturator tape, artificial sphincter
36
Overflow incontinence management
lifestyle changes
catheterization
treat underlying cause
37
Mixed incontinence management
combination of management for urgency and stress incontinence
38
Failure to void (urinary retention) etiology
1) Outflow obstruction
urethra: stricture, phimosis, traumatic disruption
bladder neck & urethra: stone, clot, foreign body, neoplasm
prostate: BPH, prostate cancer
external obstruction: constipation, pelvic mass
2) Neurogenic bladder
CNS: stroke, tumour, Parkinson’s disease, cerebral palsy
spinal cord: spinal cord injury, disc herniation, multiple sclerosis
autonomic neuropathy: diabetic neuropathy
peripheral: post-pelvic surgery, trauma
3) Urinary tract irritation
inflammation: urinary tract infection, prostatitis, abscess, genital herpes, varicella zoster
traumatic: infected foreign body
```
4) Medications
anticholinergics
narcotics including opioids
anti-hypertensives: ganglionic blocker, methyldopa
anti-histamines
ephedrine, pseudoephedrine
psychosomatic substance
```
39
Urinary retention clinical presentation
LUTS: SHEDS symptoms, may present with overflow incontinence
physical exam: palpable / percussible (dull) bladder
acute vs. chronic urinary retention:
acute retention is a medical emergency characterized by pain, anuria, normal bladder volume and architecture, which have risk of bladder rupture
chronic urinary retention is usually asymptomatic characterized by increased bladder volume, detrusor hypertrophy, detrusor atony
40
Urinary retention investigations
blood work: CBC, electrolytes, creatinine, BUN, PSA
urine: urine R & M, C & S
foley catheter
```
imaging:
bladder ultrasound and post void residual (PVR)
renal ultrasound
CT scan
cystoscopy
urodynamic studies
```
41
Diagnosis of urinary retention
urinary retention confirmed with any of the following
PVR >200cc on ultrasound
large drainage from initial Foley catheterization followed by post-obstructive diuresis (>200cc/hr x 2 hrs after initial foley output)
hydronephrosis on renal ultrasound or CT
hydronephrosis may not develop if acute urinary retention or presence of peri-nephric fibrosis
42
Urinary retention management
1) Treat underlying cause of urinary retention
2) Drainage of bladder
1st line = catheterization
acute retention: immediate catheterization to relieve retention, leave Foley catheter to drain bladder while closely monitor fluid status and electrolytes
chronic retention: intermittent catheterization
2nd line = supra-pubic tube placement
43
Contraindication to foley catheterization
signs of urinary tract injury in setting of trauma including blood at urethral meatus
scrotal hematoma
high riding prostate
obvious disruption of anatomy
44
indications for supra-pubic tube placement
Foley catheter contraindicated
Foley catheter insertion failure (prostates, urethral stricture, severe BPH, other anatomic abnormalities)
45
Urinary tract obstruction classification
upper urinary tract obstruction = above bladder (supra-vesical)
lower urinary tract obstruction = bladder and below (infra-vesical)
acute vs. chronic
unilateral vs. bilateral
anatomical site: intra-renal, ureter, bladder, prostate, urethra
extraluminal vs. intra-luminal vs. intra-mural
46
Etiology of urinary tract obstruction
Extraluminal: lymphadenopathy, mass (tumor, abscess, cyst), BPH, prostate cancer
Intra-luminal: stone, blood clot
Intra-mural: stricture, tumor, polyps
47
Urinary tract obstruction clinical presentation
can be asymptomatic
urinary symptoms: urinary retention, overflow incontinence, SHEDS LUTS, oliguria / anuria
history: recurrent urinary tract infections
other symptoms associated with different causes: renal colic in stones
48
Urinary tract obstruction investigations
Same as failure to void
49
Urinary tract obstruction complications
hydronephrosis -> acute renal failure: uraemia
recurrent urinary tract infection -> urosepsis
stones in kidney, ureter or bladder
50
Urinary tract obstruction management
1) Drain urine to decompress urinary tract
for upper urinary tract obstruction, percutaneous nephrostomy tube to drain kidney or JJ tube to drain ureter
for lower urinary tract obstruction, catheterization or supra-pubic tube to drain and decompress bladder
2) Remove cause of obstruction
if stone, then extraction of stone
if tumor, then resection of tumor
if BPH, then consider medication and / or surgical options
51
Prostate anatomical lobes and their divisions
1 anterior lobe (isthmus) anterior to urethra
2 lateral lobes that are posterior to urethra and adjacent to rectum
lateral lobes are separated from one another and from isthmus by median sulcus
52
3 clinically described prostate zones in adults, their relative volume, location and pathologies that arise there
peripheral zone ~70% of volume and typical site of cancer
central zone ~25% of volume and surround the ejaculatory ducts
peri-urethral transitional zone ~5% of gland and surrounds the urethra, which is typical site of benign prostate hyperplasia
53
Physiology of the prostate gland (what does it contribute, purpose of this, components of this)
seminal vesicles, prostate gland and bulbourethral glands all contribute to semen
prostate gland secrete a thin, milky fluid, which make up 20% of semen volume
prostate secretion is important for sperm viability and motility
prostatic secretion contains citric acid, zinc, acid phosphatase, clotting enzyme and fibrinolysin
fibrinolysin to help break clotted ejaculate, so that sperm can swim away
epithelial cells of prostate gland secrete prostate-specific antigen (PSA), which liquefies semen in seminal coagulum and allow sperm to swim freely
PSA is elevated in setting of prostate cancer, benign prostate hyperplasia, prostatitis, trauma from DRE / catheterization, ejaculation
54
What stimulates the growth of prostate cancer cells
prostate cancer cells growth is stimulated by androgens (mainly testosterone and dihydrotestosterone (DHT) secreted by testicles)
55
Prostate histology
prostate formed by tubuloalveolar glands surrounded by fibromuscular stroma
epithelium of the glands is lined by simple columnar or pseudostratified columnar epithelium
in lumen of protatic gland, there can be corpora amylacea, which are hyaline solid prostatic concretion, which is normal and increase with age
56
Prostate cancer epidemiology
most prevalent cancer in males
2nd leading cause of male cancer deaths; lifetime risk of 1/6
on autopsy, patients age >50 have 10-30% rate of histologic prostate cancer; patients at age 80 have 50% rate of histologic prostate cancer
mean age of diagnosis is 72 (75% cases diagnosed between age 60 and 85)
at age 50, lifetime risk for prostate cancer is 50% and risk of death from prostate cancer is 3%
57
Prostate cancer risk factors
African descent
family history of prostate cancer
high dietary fat
cigarette smoking
58
Prostate cancer pathology (cell types and location)
cell types:
>95% of prostate cancer is adenocarcinoma, often multifocal
5% of prostate cancer is urethelial carcinoma associated with transitional cell carcinoma of bladder, which is not hormone responsive
<1% of prostate cancer is endometrial cancer of the utricle
cancer location
60-70% of prostate cancer arise in peripheral zone
10-20% of prostate cancer arise in transition zone
5-10% of prostate cancer arise in central zone
59
Prostate cancer clinical presentation
early stages: usually asymptomatic, so commonly detected by DRE, elevated PSA or incidental finding on TURP
late stage: LUTS, erectile dysfunction, incontinence, hematuria, hematospermia (blood in semen), lower urinary tract obstruction causing renal failure
metastases:
bony metastasis (osteoblastic, sclerotic) to axial skeletal
less commonly to liver, lung and adrenal
groin lymphadenopathy (obturator > iliac > pre-sacral / para-aortic) can cause leg pain and edema
DRE: hard irregular nodule or diffuse dense induration involving one or both lobes
60
differential diagnosis of prostate nodule on DRE
prostate cancer in 30% cases
BPH prostatitis
prostatic infarct
prostatic calculus
tuberculous prostatitis
61
Prostate cancer investigations
blood work: PSA
differential diagnosis of elevated PSA: prostate cancer, benign prostate hyperplasia, prostatitis, trauma from DRE / catheterization, ejaculation
```
if (abnormal DRE or abnormal PSA) and >10 years life expectancy, trans-rectal ultraounsd (TRUS) for tumor size / local staging and TRUS guided needle biopsy
antibiotic prophylaxis (Fluoroquinolone and Septra) to prevent risk of infection
```
CT abdominal scan for metastases
62
Risk of tans-rectal ultrasound guided needle biopsy for prostate
Infection (prostatitis)
Bleeding
Pain
Urinary retention
False negative result in 30% cases
63
Prostate cancer treatment
T1, T2 (localized, low mortality risk based on PSA, Gleason score, staging)
if adequate life expectancy and no other comorbidity, active surveillance or definitive local treatment
active surveillance = serial PSA, DRE and biopsies
definitive local therapy = radical prostatectomy or brachytherapy or external beam radiotherapy
no difference in cure rate between definitive treatment modalities
in older population: watchful waiting + palliative treatment for symptomatic progression (cancer death rate >10%)
T1, T2 (localized intermediate or high mortality risk based on PSA, Gleason score, staging)
definitive local treatment preferred over active surveillance
T3, T4
external beam radiotherapy +/- androgen deprivation therapy; or radical prostatectomy +/- adjuvant external beam radiotherapy +/- androgen deprivation therapy
androgen deprivation hormonal therapy can be any of the following:
GnRH agonist: Leuprolide (Lupron, Eligard), Goserelin (Zoladex)
anti-androgen: Bicalutamide (Casodex)
past androgen deprivation therapies: bilateral orchiectomy (for removal of 90% testosterone), estrogen (Diethylstilbestrol DES)
N>0 or M>0
hormonal therapy and / or palliative radiotherapy for metastases
palliative radiotherapy includes
local irradiation of painful secondary tumors (e.g. bone metastases)
half-body irradiation
if hormone refractory metastatic prostate cancer, then chemotherapy (Docetazel, Cabazitaxel, Sipuleucel-T)
64
What does PSA screening measure
measured total serum PSA is combination of free (unbound) PSA (15%) and complexed PSA (85%)
65
PSA and correlation with prostate cancer
normal measured total serum PSA at <4ug/L, but may vary with age (higher PSA with increasing age) and ethnicity (Asian < Caucasian < African)
6 ways of making PSA more accurately predict risk of prostate cancer: age, race, PSA level, PSA velocity, free to complex PSA level, PSA density
level of PSA correlate with risk of prostate cancer in a continuous fashion, where higher level of PSA increases risk of prostate cancer, so there is no single justifiable cutoff
PSA >10ng/mL have very high risk of prostate cancer
however, 75% of patients with prostate cancer may have normal PSA
free to total PSA ratio: <10% free PSA level suggestive of cancer; >20% free PSA level suggests benign cause used in PSA 4-10
PSA velocity: increase of >0.75ng/mL/year associated with increased risk of cancer
PSA density (PSA / prostate volume on trans-rectal ultrasound): >0.15ng/mL/g of prostate associated with increased risk of cancer
66
PSA screening Canadian Guidelines
population based routine PSA screening not recommended for men of any ages (Canadian Task Force on Preventive Health Care)
baseline PSA at age 40 (before increased levels confounded by BPH)
based on discussion between patient and physician on risk factors, test charcteristics, risk of over-detection & over treatment, treatment, active surveillance options, men can elect to undergo both PSA and DRE, typically screening at age 50 Q1-2 years until age 75
67
Use of PSA in prostate cancer patients
work up:
prostate cancer with PSA <20.0ng/mL without bony involvement on history or clinical exam have low risk of bone metastasis, so may not require bone scan
disease monitoring: serum PSA falling to low level following radiation therapy is a good prognostic factor
undetectable PSA following radical prostatectomy = good prognostic factor
outcome prediction: metastatic prostate cancer receiving androgen suppression with failure to reach PSA nadir of <4.0ng/mL have very poor prognosis (survival ~1 year)
68
BPH definition
hyperplasia of stroma and epithelium in peri-urethral area of prostate (transition zone)
69
BPH epidemiology
more commonly in older aged men (50% at 50 years old; 80% at 80 years old)
70
BPH clinical presentation
LUTS: both failure to void and failure to store symptoms FUNWISE
FUNWISE = Prostate Symptom Score each symptom have score of 5 where 0-7 = mildly symptomatic; 8-19 moderately symptomatic; 20-35 severely symptomatic
DRE: symmetrically enlarged smooth rubbery prostate
71
BPH complications
urinary retention -> overflow incontinence
obstruction causing hydronephrosis & renal failure
increased risk of urinary tract infection
increased risk of bladder stone
gross hematuria
72
BPH investigations
urine: urine analysis R&M C&S to exclude urinary tract infection (UTI symptoms can mimic BPH such as frequency, urgency)
blood work:
creatinine & BUN for renal function
PSA to rule out prostate cancer
renal ultrasound to assess for hydronephrosis
consider uroflowmetry to measure flow rate
bladder ultrasound with post-void residual (PVR) for urinary retention
73
BPH management
a) Conservative management
indication: mild symptoms
watchful waiting (50% patients improve spontaneously)
lifestyle changes (evening fluid restriction, planned voiding)
b) Medication
alpha-adrenergic antagonist that reduce stromal smooth muscle tone: Terazosin (Hytrin), Doxazosin (Cardura), Tamsulosin (Flomax), Alfuzosin (Xatral)
5-alpha reductase inhibitor that inhibit conversion of testosterone to DHT to reduce prostate size: Finasteride (Proscar), Dutasteride (Avodart)
c) Surgery
surgical options include
trans-urethral resection of prostate (TURP)
open prostatectomy for large prostate, which can have supra-pubic or retro-pubic approach
minimally invasive therapy: prostatic stents, microwave therapy, laser ablation, water induced thermotherapy, cryotherapy, high intensity focused ultrasound (HIFU),
transurethral needle ablation (TUNA)
74
BPH surgery absolute and relative indications
absolute indication:
renal failure due to obstructive uropathy
```
relative indication:
refractory urinary retention
recurrent UTI
recurrent hematuria
bladder stones
```
75
Indication to refer BPH to urology
hematuria
urinary retention with hydronephrosis
recurrent urinary tract infections
abnormal DRE
elevated PSA
76
Prostatitis epidemiology
most common urologic diagnosis in men <50 eyars
| incidence of 10-30%
77
Prostatitis risk factors
BPH
recent instrumentation of urinary tract: cystoscopy, prostatic biopsy
78
Prostatitis etiology
bacterial infection of prostate (usually peripheral zone): KEEPS organisms (Klebsiella, E. coli, Enterococcus, Proteus, Staphylococcus saprophyticus)
ascending urethral infection and reflux into prostatic ducts
may have abacterial prostatitis with inflammatory and non-inflammatory subtypes due to intra-prostatic reflux of urine and urethral hypertonia
79
Prostatitis clinical presentation
urinary symptoms: LUTS, hematuria
systemic symptoms: fever, chills, malaise
rectal, lower back and perineal pain
DRE: may have enlarged, tender and warm prostate
80
Prostatitis investigations
```
urine:
urine analysis C&S from 4 specimens
VB1 = voided bladder urine initial from urethra
VB2 = midstream from bladder
EPS = expressed prostatic secretion
VB3 = postmassage/DRE from prostate)
R & M
colony counts in EPS and VB3 may exceed VB1 and VB2 by 10 times, which suggest prostate source
```
bloodwork: CBC
consider blood culture if systemically unwell
81
Prostatitis management
antibiotics:
Ciprofloxacin or Septra PO for 4-6 weeks
consider IV Ampicillin + Gentamicin if systemically unwell
mid-stream urine C&S at 1 and 3 months post antibiotic therapy to ensure eradication
symptomatic management: anti-pyretics, analgesics, sto ol softeners
admission if sepsis, urinary retention, immune deficiency
small drainage catheter if obstruction suspected
catheterization contraindicated due to risk of bacteremia and systemic infection
82
Differential diagnosis of groin lumps
GI: inguinal hernia, femoral hernia
GU: undescended testis
infection / inflammatory: lymphadenopathy, psoas abscess
vascular: femoral artery aneurysm, saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
neoplasm: soft tissue tumour (muscle, fat e.g. sarcoma, lipoma), lymphoma
83
Physical exam hernia
hernia: usually soft, compressible and may gurgle, usually are reducible
84
Physical exam groin hernia
groin hernia: indirect and direct hernia have bulge that originate from above the inguinal ligament descending into testes, which have cough impulse (descends with cough)
85
Physical exam femoral hernia
femoral hernia: bulge at below inguinal ligament
86
siphena varix physical exam
siphena varix: located below inguinal ligament, usually disappear on lying, have blue tinge, may have venous hum, associated with varicose veins in lower extremities
87
Physical exam femoral arterial aneurysm
femoral arterial aneurysm: located at midpoint below inguinal ligament, pulsatile and expansile, associated with other aneurysms
88
Groin lymphadenopathy physical exam
lymphadenopathy: small firm lymph nodes palpable below inguinal ligament, usually non-tender
groin lymphadenopathy usually drain from vagina, vulva, penis, rectum, anus and lower extremities, so groin lymphadenopathy requires examination of external genitalia, anus and lower extremities to look for source of infection or malignancy
89
Physical exam psoas abscess
psoas abscess: usually have systemic illness (fever, tachycardia, leukocytosis), painful fluctuant mass
90
Physical exam undescended testes
undescended testis: scrotum on ipsilateral side is empty, milking of bulge may retract testis back into scrotum
91
Physical exam soft tissue mass
soft tissue mass: palpable mass that could arise form anywhere in the groin, which may have unclear borders
92
Groin lump investigations
blood work: CBC
ultrasound with doppler: can differentiate arteries & veins vs. solid bumps (lymphadenopathy, tumor) vs. fluid lumps (hernia, abscess)
CT pelvis with IV contrast: can differentiate different aetiologies of groin lumps
hernia: protrusion of bowel through defect
lympadenopathy: homogeneous or hetergeneous enhancing node
abscess: ring enhancing lesion
soft tissue tumor: mass
siphena varix: enlargement of vein
femoral arterial aneurysm: enlargement of femoral artery
93
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Groin lumps treatment for:
hernia
siphena varix
femoral arterial aneurysm
lympadenopathy
psoas abscess
undescended testis
soft tissue tumour
```
hernia: surgical repair
siphena varix: high saphenous ligation
femoral arterial aneurysm: surgical repair (removal of aneurysm & reconstruction using veins)
lymphadenopathy: treat underlying cause for lymphadenopathy
psoas abscess: incision & drainage, antibiotic therapy
undescended testis: surgical orchipexy
soft tissue tumor: surgical resection
94
Renal calculi epidemiology
prevalence of 2-3%
3 male : 1 female ratio
peak incidence at 30-50 years of age
recurrence rate of 10% at 1 year; 50% at 5 years, 60-80% lifetime
95
Renal calculi risk factors
hereditary: renal tubular acidosis, G6PD deficiency, cystinuria, xanthinuria, oxaluria
dietary: vitamin C, oxalate, purine, calcium
dehydration
obesity BMI >30
lithogenic medication: thiazide
urinary tract infection
myeloproliferative disorder
GI disorder: inflammatory bowel disease
gout
diabetes mellitus
hypercalcemia disorder: hyperparathyroidism, sarcoidosis, histoplasmosis
96
Renal calculi pathophysiology
1) factors predispose to supersaturation of salt of acid
predisposing factors include:
urinary stasis, low urine flow, low urine volume
increased solute (ion)
low urine pH
reduced level of natural calculus inhibitor (citrate, magnesium, pyrophosphate, Tamm-Horsfall glycoprotein)
2) supersaturation of salt or acid form crystals by process of nucleation
stones usually adhere to surface at renal papilla, where it can grow and aggregate
3) stone will pass through urinary tract, where it can get stuck causing renal colic
97
Types of renal calculi
1) Calcium (75-85% cases) including calcium oxalate (40% cases) and calcium oxalate - calcium phosphate (30% cases)
causes: hypercalciuria, hyperuricosuria, hyperoxaluria, hypocitraturia
radiopaque on KUB X-ray
2) Uric Acid (5-10% cases)
causes: hyperuricosuria (with hyperuricemia), low urine pH, medication, diet (purine rich red meats), gout
radiolucent on KUB X-ray
3) Struvite (5-10% cases)
cause: infection with urea splitting organism (Proteus, Pseudomonas, Providencia, Klebsiella, Mycoplasma, Serrate, S. aureus) results in alkaline urinary pH and precipitation of struvite (magnesium ammonium phosphate)
can result in staghorn stone in renal pelvis
radio-opaque on KUB X-ray
4) Cystine (1% case)
cause: autosomal recessive defect in small bowel mucosal absorption and renal tubular absorption of dibasic amino acid results in COLA (cystine, omithine, lysine, arginine) in urine
radiolucent on KUB X-ray
98
Location of renal calculi
stones can be located at any of the following locations
1) renal calyx
2) 4 narrowest passage points for upper tract stones: ureteropelvic junction (UPJ); pelvic brim; under vas deferens / broad ligament; uretero-vesical junction (UVJ)
once into the bladder, usually stones can be easily passed due to large diameter of urethra
99
Renal calculi clinical presentation
tachycardia, tachypnea
writhing, never comfortable, diaphoresis
nausea, vomiting
renal colic = flank pain, usually severe waxing and waning pain radiating to groin, testis or penis due to stretch of collecting system / ureter
hematuria (microscopic hematuria in 90% cases)
may have urinary frequency or urgency
100
Renal calculi complications
urine stasis upstream of obstructing stone -> urinary tract infection including urosepsis
obstruction -> hydronephrosis and acute renal failure
101
Renal calculi investigations
Laboratory Studies
blood work: CBC, electrolytes, Ca, PO4, uric acid, creatinine, BUN
urine: urine R&M, C&S, stone analysis
if recurrent stone formers, consider metabolic studies
blood work: Ca, PTH
urine: 24h urine x 2 for urine volume, creatinine, Ca, Na, PO4, uric acid, Mg, oxalate, citrate, cystine
Imaging
KUB X-ray, which is usually not done and replaced by CT
can visualize radiopaque stones (calcium, struvite, cystine)
helical CT scan without contrast = gold standard to diagnosis calculi
can visualize most calculi (calcium, struvite, cystine, uric acid radiopaque)
abdominal ultrasound
abdominal ultrasound may show stone or dilated renal pelvic or hydronephrosis due to obstruction
IVP (intravenous pyelogram) usually not done and replaced by CT
examination of anatomy of urine collecting system, degree of obstruction and extravasation
cystoscopy for bladder stone
102
Renal calculi indications for admission to hospital and urgent intervention
1) urosepsis: fever, positive urine analysis suggestive of urinary tract infection
2) acute renal failure (due to obstruction)
3) high risk of renal failure due to obstruction: solitary kidney, bilateral obstructing stones
4) symptoms: intractable vomiting or pain
103
Renal calculi surgical management
a) kidney stones
if stone 1.5-2.5cm, then stent -> extra-corporeal shock wave lithotripsy (ESWL)
if stone <2cm, then ESWL
if stone >2cm, then percutaneous nephrolithotomy (PCNL)
b) ureteral stones
1st line = ESWL or uteroscopy (URS) to retrieve stone
URS have greater stone free rates, but higher complication rate
2nd line = PCNL
last line = laparoscopic or open stone removal, which is rarely done
c) bladder stone
transurethral stone removal or cystolitholapaxy
remove outflow obstruction (transurethral resection of prostate, stricture dilatation)
104
Indication for PCNL for kidney and ureteral stones
stone >2cm
stag horn stone
UPJ obstruction
calyceal diverticulum
cystine stone
anatomical abnormality
failure of less invasive modalities
105
Ureterscopy complications
ureter perforation
stricture formation
106
Acute in hospital urgen management for renal calculi
1) medical management
analgesia: Tylenol, opioid
anti-emetics: Gravol
IV fluids NS or RL to replace volume from vomiting
medical expulsion therapy (MET): NSAID Ketorolac IV, alpha-blockers (Tamsulosin Flomax), (calcium channel blockers, steroids)
if urosepsis, then IV antibiotics Ampicillin + Gentamicin
2) intervention
indication for intervention: urosepsis, obstructive renal failure
if urosepsis or obstructive renal failure, then urgent decompression via ureteric stent or percutaneous nephrostomy tube
uric acid stone: medical dissolution therapy with urine alkalization (NaHCO3, KHCO3, Na Citrate, K Citrate)
non-uric acid stones: surgical intervention
107
Out patient management of renal calculi
1) Risk Stratification
management based on likelihood of passing spontaneously or not
high likelihood of passing stone spontaneously if stone <5mm, which can be observed with conservative management
low likelihood of passing stone spontaneously if stone >5mm, which should undergo surgical intervention
2A) Conservative Management
PO fluids hydration to increase urine volume to >2 L per day
medical expulsion therapy: NSAID Ketorolac IV, alpha-blockers, (calcium channel blockers, steroids)
stone specific management:
all calcium stones: cellulose phosphate, orthophosphate
calcium oxalate stones: thiazide, K citrate, allopurinol
calcium struvite stones: antibiotics
uric acid: alkalization of urine to pH 6.5-7 (Na HCO3, K citrate), allopurinol
struvite stones: antibiotics for 6 weeks with regular follow up urine cultures
cystine stones: alkalization of urine to pH 6.5-7 (Na HCO3, K citrate), penicillamine / alpha-MPG or Captopril
periodic imaging to monitor stone progression and assess for hydronephrosis
if stone did not pass after 2 months or complications (urosepsis, hydronephrosis), then proceed to interventional management
2B) Interventional Management
108
Prevention of future renal calculi formation
1) Dietary modification
increase fluid intake to have urine output >2 L per day
potassium and citrate intake to inhibit formation of stones
reduce animal protein, oxalate, sodium, sucrose, fructose intake
avoid high dose vitamin C supplement
decreased dietary calcium intake is NOT recommended due to consequent increased oxalate absorption and high urine level of calcium oxalate
2) Medication
thiazide diuretics to treat hypercalciuria
allopurinol to treat hyperuricosuria
potassium citrate to treat hypo-citraturia or hyperuricosuria
3) Monitoring
if recurrent stone former, consider periodic CT imaging (at year 1, then Q2-4 years)
109
Painful scrotal pathology differential
trauma: contusion, rupture
vascular: testicular torsion, hematocele
infection / inflammatory: epididymitis, orchitis
structural: hernia, which can be painful when it is incarcerated (irreducible) or strangulated
110
Painless scrotal pathology differential
structural: varicocele, spermatocele, hydrocele, inguinal hernia
neoplastic: testicular tumour (squamous cell carcinoma), para-testicular tumour (sarcoma, lipoma), metastasis
generalized edema
111
Physical exam torsion
torsion: diffuse tenderness, horizontal lie, absent cremaster reflex, negative Prehn’s sign
112
Physical exam epididymitis/orchitis
epididymitis / orchitis: diffuse tenderness, present cremaster reflex, positive Prehn’s sign
113
Physical exam generalized edema scrotum
generalized edema: diffuse swelling of entire scrotum, swelling of lower extremity, ascites
114
Physical exam tumour scrotum
tumor: hard lump / nodule on palpation
115
Physical exam scrotum hernia
hernia: not possible to palpate above mass (i.e. feel the top), testis separable from hernia, cough impulse may transmit, may be reducible
116
Physical exam varicocele scrotum
varicocele: palpable bag of worms, no transillumination, increases in size with valsalva, decrease in size when supine
117
Physical exam spermatocele scrotum
spermatocele: testis separable from spermatocele, cord palpable, transillumination
118
Physical exam hydrocele scrotum
hydrocele: testis not separable from hydrocele, cord palpable, transillumination (i.e. shines when light is shone through it), history of trauma
119
Physical exam hematocele scrotum
hematocele: diffuse tenderness, no transillumination
120
Testicular torsion etiology
trauma
cryptorchidism
Bell clapper deformity
121
Testicular torsion pathophysiology
testicular torsion = twisting of spermatic cord which cut blood supply to the testicle (venous occlusion & engorgement, arterial ischemia & infarction)
122
Testicular torsion types
testicular torsion can be intravaginal or extravaginal
intravaginal = twisting of spermatic cord inside the tunica vaginalis, which occur in all age groups especially puberty
extravaginal = twisting of spermatic cord outside tunica vaginalis, which only occur in neonates
123
Testicular torsion - how long until testicle necrosis
testicle will necroses within 5-6 hours from onset of symptoms
124
Testicular torsion clinical presentation
acute severely painful scrotal pain often radiating to groin and abdomen
nausea and vomiting
no or minimal trauma
125
Testicular torsion physical examination
patient is unwell due to pain
scrotum: tender, erythematous, swollen testicle
Can be high riding (elevated compared to other testicle) or transverse lie (horizontal orientation)
no cremasteric reflex
negative Prehn’s sign (no relief of pain with elevation of scrotum)
126
Testicular torsion investigation
if urgent (i.e. high clinical suspicion based on symptoms & signs and severe pain), perform surgical exploration without any additional investigations
trans-scrotal ultrasound with doppler: absent blood flow in affected testicle
nuclear 99Tc testicular blood flow scan: absent blood flow in affected testicle (doughnut sign)
127
Testicular torsion diagnosis
testicular torsion diagnosed based on any of following
1. twisted spermatic cord on surgical exploration
2. absent blood flow on ultrasound or nuclear blood flow scan
128
Testicular torsion management
1) emergency manual detorsion (rotate both testicles outward “opening a book”) - not recommended
2) surgical detorsion and elective bilateral orchiopexy
manual detorsion attempted to untwist spermatic cord to restore blood flow and preserve testicle
if testicle is not salvageable, then orchidectomy (removal of the dead testicle)
if testicle is salvageable, then orchidopexy (fix testicle to scrotum to prevent torsion in the future)
in all cases, orchidopexy of contralateral testes is done to ensure the unaffected testes will not twist in the future
129
Epididymitis / Orchitis risk factors
sexual activity and risk factors for STI
recent instrumentation of urinary tract
130
Epididymitis / Orchitis pathogenesis and common pathogens
epididymitis is infection and inflammation of epididymis, which then can spread to testes, causing orchitis (infection and inflammation of testes)
in young adults (<35 years old), infection by e. coli and bacterial STI (gonorrhea, chlamydia)
in older adults (>35 years old), infection by e. coli
if not vaccinated for mumps, orchitis may be due to mumps infection
131
Epididymitis / Orchitis clinical presentation
insidious onset of symptoms
systemic symptoms: fever, chills
lower urinary tract symptoms: dysuria, hematuria, frequency, urgency, nocturia
scrotal symptoms: scrotal pain
132
Epididymitis / Orchitis physical exam
patient can look systemically unwell
scrotum: diffuse tenderness (may have focal tenderness at epididymis); erythematous, warm, swollen testes; may have urethral discharge
normal cremasteric reflex
positive Prehn’s sign (relief of pain with elevation of scrotum)
133
Epididymitis / Orchitis investigations
CBC: may have leukocytosis
urine analysis: may be positive for leukocyte, nitrite and blood
urine culture and sensitivity: may be positive
urethral swab for gonorrhea and chlamydia: may be positive
134
Epididymitis / Orchitis diagnosis
diagnosis of epididymitis / orchitis based on clinical symptoms & signs confirmed by investigation
need to rule out testicular torsion based on clinical presentation or ultrasound
135
Epididymitis / Orchitis treatment
1) pain management
bed rest
scrotal elevation / support and analgesics / anti-inflammatories to relieve pain
2) antibiotic therapy
antibiotics depend on culture
if gonorrhea, Ceftriaxone or Ciprofloxacin
if chlamydia, Azithromycin or Doxycycline
if e. coli, Ciprofloxacin or another Fluoquinolone for 2 weeks
if severe systemic infection, then IV antibiotics
136
Hematocele pathogenesis
collection of blood in tunica vaginalis around testicles, usually as result of trauma
137
Hematocele clinical presentation
history of trauma or injury
painful scrotal mass
138
Hematocele physical exam
scrotum: bruising; diffuse scrotum tenderness; no transillumination
139
Hematocele investigations
ultrasound: visualization of blood collection, can help to exclude fracture of testis which require surgical repair
140
Hematocele management
A) conservative management
pain control: ice packs, analgesia
B) surgical repair
indication for surgical repair = fracture of testis
141
Hydrocele epidemiology
more common in childhood
occur in 1% of adult males
142
Hydrocele pathogenesis
hydrocele is collection of serous fluid in tunica vaginalis
aetiology due to defect or irritation in tunica vaginalis:
secondary hydrocele due to testicular pathology that irritate of tunica vaginalis: testicular tumor, trauma, infection
defect in tunica vaginalis: congenital communicating hydrocele due to patent processus vaginalis; non-communicating non-patent processus vaginalis
idiopathic
143
Hydrocele clinical presentation
painless large scrotal mass (which may change in size during the day suggesting communication with abdominal peritoneum in children)
can have other symptoms from underlying testicular disease in secondary hydrocele
144
Hydrocele physical exam
scrotum: transilluminating mass
testes cannot be isolated from mass
palpable spermatic cord
145
Hydrocele investigation
trans-scrotal ultrasound: cystic fluid
146
Hydrocele diagnosis
hydrocele usually diagnosed based on physical exam of transilluminating mass with palpable testes
trans-scrotal ultrasound can confirm diagnosis if testes is not palpable on physical exam and also rules out testicular tumour
147
Hydrocele treatment
A) conservative management
observe and wait
in children, most will resolve in 1st year, so can wait and observe
if does not resolve, then repair of the communication
B) interventional management
treatment options include:
surgical excision and obliteration of tunica vaginalis (hydrocelectomy)
aspiration of fluid with needle followed by sclerotherapy (injection of doxycycline) to induce sclerosis and closure of tunica vaginalis
148
Hydrocele interventional management indications
symptomatic (discomfort)
cosmesis concerns
underlying testicular pathology causing hydrocele
149
Spermatocele epidemiology
usually occur in older adults (age >40)
150
Spermatocele pathogenesis
spermatocele is a cystic fluid sperm filled collection of epididymis, usually at the head of epididymis
spermatocele usually caused by obstruction of distal duct, aneurysmal dilation of epididymis, agglutinated germ cells
151
Spermatocele clinical presentation
non-tender cystic epididymis mass that transilluminates
usually, testes can be palpated and isolated from epididymis mass
152
Spermatocele physical exam
transilluminating mass
testes palpated and can be isolated from mass
palpable spermatic cord
153
Spermatocele investigation
trans-scrotal ultrasound: cystic fluid
154
Spermatocele diagnosis
spermatocele usually diagnosed based on physical exam
trans-scrotal ultrasound can be used confirm diagnosis and rule out testicular tumour
155
Spermatocele treatment
A) conservative management
observe and wait
B) interventional management
treatment by surgical resection of the cyst (spermatocelectomy)
156
Spermatocele interventional management indications
Symptomatic (discomfort)
Cosmesis concerns
157
Varicocele epidemiology
varicocele is rare prior to puberty
affect 15% of males usually after puberty
158
Varicocele increases the risks of ...
increase risks of infertility
159
Varicocele pathogenesis and location
varicocele = dilatation and tortuosity of pampiniform venous plexus of spermatic cord due to absent or incompetent venous valves
benign varicocele usually occur in left side (90%) cases, due to anatomy
left testicular vein drains to left renal vein at a perpendicular angle that makes drainage difficult and left renal vein is behind superior mesenteric artery which can compress on gonadal vein (nut cracker) blocking venous drainage
right sided varicocele can occur when the right testicular vein is compressed by a mass
160
Varicocele clinical presentation
history of infertility
painless scrotal mass most commonly on the left side, can present with dull ache to discomfort with standing or activity over long period of time
161
Varicocele physical exam
scrotum: “bag of worms” dilated veins around spermatic cord classically on left side but can be bilateral, which is accentuated with patient standing or performing Valsalva maneuver (bearing down); may have palpable vascular thrill
isolated varicocele on right side is suggestive of cancer
varicocele can be graded based on physical exam:
grade 1 = palpable with Valsalva
grade 2 = palpable without Valsalva
grade 3 = visible on inspection
abdominal exam to exclude any abdominal mass that may compress on testicular vein causing varicocele
162
Varicocele investigation
scrotal ultrasound: may show dilated pampiniform venous plexus
163
Varicocele diagnosis
varicocele diagnosed based on physical exam and confirmed by ultrasound
164
Varicocele treatment
A) conservative management
observe and wait
B) interventional management
treatment options include:
surgical resection of dilated veins (varicocelectomy)
embolization approaches
surgical ligation of testicular veins
percutaneous vein occlusion by balloon or sclerosing agents
165
Indications for varicocele interventional management
Infertility
Ipsilateral testicular atrophy
Symptomatic (ache, discomfort)
Cosmesis concerns
166
Benefit of treatment for varicocele
treatment can improve fertility by improving sperm count and motility by 50-75%
167
Testicular cancer epidemiology
most common malignancy in young males age 15-35
incidence of 0.004% in whites and 0.001% in blacks
most commonly affect the right side
168
Testicular cancer risk factors
demographics: age <10, 15-35 or >60 and white
pregnancy risk factors: maternal exposure to androgen during pregnancy
testicular pathology: cryptorchidism (undescended testes), which increase risk by 10-40 times; testicular atrophy; testicular microlithiasis
prior malignancy: prior testicular cancer; prior testicular carcinoma in situ or intra-epithelial germ cell neoplasia
169
Testicular cancer classification
1) Primary Testicular Cancer
primary testicular cancer originated from testes
95% germ cell: seminoma (35%); non-seminoma tumors include mixed (40%), embryonal (20%), teratoma (5%), choriocarcinoma (1%), yolk sac (1%)
5% non-germ cell: Leydig cell, Sertoli cell, gonadoblastoma
2) Para-Testicular Cancer
paratesticular originated from tissues surrounding the testes such as connective tissue and fat
para-testicular cancer include sarcoma and lipoma
3) Secondary Testicular Cancer
secondary testicular cancer did not originate from within the testes
hematologic: leukemia, lymphoma
metastasis: prostate, GI system, lung, kidney or melanoma
170
Testicular cancer pathophysiology of spread
testicular cancer spread locally via lymphatics
right testicle -> medial, para-caval, anterior and lateral lymph nodes
left testicle -> left lateral and anterior para-aortic lymph nodes
systemic spread via blood to lung, liver, bones and kidney
171
Testicular cancer clinical presentation
scrotum:
painless, firm, testicular enlargement or mass (right > left)
dull ache / heaviness in scrotum
acute scrotal pain in intra-testicular hemorrhage or infarction (10% cases)
hydrocele
infertility
systemic: gynecomastia, breast pain
```
metastasis:
lymph nodes (supraclavicular or inguinal lymphadenopathy)
lung (cough, shortness of breath, hemoptysis)
abdomen (mass, pain, nausea & vomiting, back pain, ileus)
```
172
Testicular cancer physical exam
scrotum: painless intra-testicular mass
intra-testicular mass in appropriate age group (15-35) is cancer until proven otherwise
groin: inguinal lymphadenopathy
chest: gynecomastia, supra-clavicular lymphadenopathy, wheezing in lung metastasis
abdomen: palpable mass, ileus
173
Testicular cancer investigations
scrotal ultrasound: can show hypoechoic mass with malignant features such as irregular borders and heterogeneity
tumor markers: BHCG, AFP, LDH
"B-SEC" BHCG increased in seminioma, embryonal and choriocarcinoma
"A-YET" AFP increased in non-seminoma tumours (yolk sac, embryonal and teratocarcinoma)
LDH is a non specific marker for tumor burden
174
Testicular cancer treatment pre-diagnosis
usually, a painless mass with malignant features on physical exam confirmed by ultrasound is enough to warrant a radical orchitectomy
radical orchitectomy = removal of testes and spermatic cord through an incision at lower abdomen inguinal region
175
Testicular cancer diagnosis
diagnosis usually made post orchitectomy based on pathology of resected testes confirming malignancy
176
Testicular cancer work-up and staging
post pathological diagnosis, work up done to stage testicular cancer
imaging for metastatic work-up include chest X-ray, CT body (chest, abdomen & pelvis)
staging:
1 = local disease limited to testes
2 = lymphatic spread below diaphragm
3 = supra-diaphragmatic lymphatic spread or extra nodal metastasis
177
Testicular cancer treatment post-staging
additional therapy based on histology and stage
additional therapy may include radiation therapy, surgical retroperitoneal lymph node dissection, chemotherapy (Cisplatin)
general guidelines:
stage 1 = orchitectomy with possible adjuvant chemotherapy, radiation or lymph node dissection
stage 2 = orchitectomy with lymph node dissection and
chemotherapy
high cure rate for all testicular cancer ~80% for all stages
178
Testicular cancer follow up surveillance
post treatment, patient should be under surveillance for any recurrence by physical exam, tumor marker measurement, chest X-ray, CT abdomen & pelvis
179
uncomplicated UTI definition
uncomplicated UTI = lower UTI in setting of functionally and structurally normal urinary tract
180
complicated UTI definition
complicated UTI = pyelonephritis, and / or structural or functional abnormality (abnormal voiding mechanism)
181
SIRS criteria
Systemic Inflammatory Response Syndrome (SIRS) as >2 of the following
temperature <36C or >38C
heart rate >90 beats / minute
respiratory rate >20 breaths / minute or PaCO2 <32mmHg
WBC <4x109cells/L or >12x109cells/L
182
Urosepsis definition
urosepsis = SIRS criteria + urinary tract infection source
183
Pyelonephritis definition
pyelonephritis = infection and inflammation of kidney (renal parenchyma), which is synonymous with upper urinary tract infection
184
Cystitis definition
cystitis = infection and inflammation of bladder, which is synonymous with lower urinary tract infection
185
UTI microbiology
common bacteria causing UTI that grow on routine urine R&M:
```
KEEEPPS =
Klebsiella sp.
E. coli
Enterobacter
Enterococcus
Proteus mirabilis
Pseudomonas
Staphylococcus
saprophyticus
```
E. coli is responsible for 90% of UTIs
atypical pathogens that may cause UTI and does not grow on routine culture:
tuberculosis (TB)
Chlamydia trachomatis
Mycoplasma (ureaplasma urealyticum)
Fungi (Candida)
186
Source of UTI
UTI may originate from any of the following sources:
ascending infection: pathogens from GI tract enter and ascend urinary tract form urethra to bladder to ureter to kidney
ascending infection is the most common source
hematogenous spread: pathogen in blood enters urinary tract
lymphatic spread: pathogen in lymphatic system enters urinary tract
direct spread: pathogen from within GI tract exits GI tract (usually in context of inflammation) and enters adjacent urinary tract structure
187
UTI predisposing factors
1) urine stasis
obstruction: urolithiasis, posterior urethral valves, vesicoureteral reflux (VUR), benign prostatic hypertrophy, urethral stricture, cystocele
urinary obstruction predispose to pyelonephritis
functional urinary retention: medication causing urinary retention (anticholinergic), neurogenic bladder
2) foreign body: catheter, instrumentation
3) immune compromise: diabetes mellitus, malignancy, immune suppression
4) other factors
female due to short urethra
trauma
anatomic variance
188
UTI complications
pyelonephritis, urosepsis
pyelonephritis -> emphysematous pyelonephritis = severe infection of renal parenchyma that causes gas accumulation (seen on imaging)
pyelonephritis -> renal papillary necrosis = necrosis of renal papilla
pyrlonephritis -> abscesses (renal abscess, peri-renal abscess)
189
UTI clinical presentation
Symptoms
cystitis: failure to store (frequency, urgency, dysuria), gross hematuria, failure to void (hesitancy, post-void dribbling)
pyelonephritis: systemic symptoms (fever, chills, rigors, malaise), nausea & vomiting, CVA / flank pain
Signs
vitals: may have SIRS response including fever, tachycardia, tachypnea, hypotension
abdomen: palpable bladder if urinary retention
costovertebral angle (CVA) tenderness if pyelonephritis
190
UTI investigations
Urine Analysis - mid-stream or catheterized or supra-pubic aspirate urine R&M, C&S
dipstick: positive leukocyte esterase, may have positive nitrite and hematuria
microscopy: >5WBC/HPF, may have positive gram stain or WBC casts
culture: bacteruria >105 CFU/mL
Labs
blood work: CBC, electrolytes, urea, creatinine
if systemically unwell, blood culture
if hematuria, consider urine work-up for hematuria including urine cytology, ultrasound and cytoscopy
Imaging
if pyelonephritis or urosepsis, consider ruling out obstruction with abdominal / pelvis ultrasound and CT
abdominal ultrasound: can evaluate pyelonephritis, can detect complications of pyelonephritis including emphysematous pyelonephritis, renal abscess, peri-renal abscess
abdominal / pelvis CT: can evaluate pyelonephritis, peri-nephric abscesses, emphysematous pyelonephritis and renal papillary necrosis
191
UTI diagnosis
UTI diagnosed if patient has all of the following
1. UTI symptoms
2. positive urine analysis (>5-10WBC/HPF OR positive leukocyte esterase) OR positive urine culture >100 CFU/mL
192
UTI, pyelonephritis and asymptomatic bacturia management
1) Stabilize
2) Correct pre-disposing factors / complications
if pyelonephritis or urosepsis, consider ruling out obstruction with abdominal / pelvis ultrasound and CT
if pyelonephritis due to stone obstruction: admit and emergency stenting or percutaneous nephrostomy tube
if emphysematous pyelonephritis, then emergency nephrectomy
if abscess, then drainage of abscess
3) Antibiotic Therapy
A) Uncomplicated Cystitis in women
1st line = Septra PO for 3 days; or Nitrofurantoin (Microbic) for 5-7 days
2nd line = Ciprofloxacin PO for 3 days; or Levofloxacin PO for 3 days
B) Cystitis in men
cystitis in men usually due to abnormal anatomy or voiding mechanism or predisposing factors
same antibiotics for women, but for longer course >14 days
C) Pyelonephritis
1st line = Ciprofloxacin PO for 7-14 days; or Septra PO for 14 days
if hemodynamically unstable, severe infection, systemically unwell or no improvement with 2-3 days of treatment: IV antibiotics Ampicillin + Gentamicin
D) Asymptomatic Bacteruria
indication to treat asymptomatic bacteruria (urine culture >105 CFU/mL) if any of the following:
1) pregnant female
2) previous urologic manipulation / instrumentation / procedure
193
Most common cause of UTI in men
BPH is most common cause of UTI in men
194
Recurrent UTIs management
1) differentiate between relapse vs. re-infection
relapse = recurrence of urinary tract infection with the same infecting organism that caused previous UTI based on urine culture, which usually reoccur 2 weeks after discontinuation of antibiotics
reinfection = recurrence of urinary tract infection with a new infecting organism that did not cause the previous UTI
2. A) Relapse
exclude abnormal anatomy or abnormal voiding dysfunction
recheck urine culture and sensitivity and prescribe longer course of antibiotic therapy
B) Reinfection
treat current infection
prevention
195
Recurrent UTIs prevention
1) Lifestyle modification
limit caffeine intake, increase fluid / water intake
post-coital voiding
avoidance of diaphragm
2) Antibiotic prophylaxis
daily low dose or post-coital antibiotics: Septra; or Nitrofurantoin; or Ciprofloxacin
196
Recurrent UTIs antibiotic prophylaxis indication
4+ episodes per year
197
Potential etiologies of urethral injury
blunt trauma, motor-vehicle collision, pelvic fracture -> shearing force injuring posterior urethral (membranous and prostatic urethra)
straddle injury -> crushing bulbar urethra against pubic rami, resulting in anterior (bulbar) urethral injury
other causes: instrumentation, prothesis insertion, penile fracture, masturbation with urethral manipulation
198
Is posterior or anterior urethral injury more common
posterior urethral injury more common than anterior urethral injury
199
Urethral injury clinical presentation
blood at external urethral meatus
high riding prostate on DRE
sensation of voiding without urine output
swelling and butterfly perineal hematoma
distended bladder
penile and / or scrotal hematoma
200
Urethral injury investigations
retrograde urethrogram (injection of contrast into external urethral orifice on CT) is gold standard for diagnosis urethral injury based on extravasation of contrast and visualization of discontinuity of urethra
cystoscopy can visualize and define injury
201
Urethral injury management
foley catheterization (by non-urology physician) contraindicated in suspected urethral injury
a) partial urethral disruption
1st line = gentle attempt of catheterization by urology which would stay for 2-3 weeks for urethra to heal if successful
2nd line = surgical cystotomy for antegrade urethral catheter (from bladder down urethra)
b) complete urethral disruption
decompress bladder with supra-pubic catheter
if stable, then immediate surgical re-anastomosis
if unstable, then decompress bladder with supra-pubic catheter as temporary solution and perform delayed surgical re-anastomosis after patient stabilizes
202
Urethral injury follow up
post urethral injury, there is risk of urethral stricture, so follow up should have periodic flow rate and urethrogram to evaluate for stricture formation
203
Bladder trauma etiology
blunt trauma or penetrating trauma to lower abdomen, pelvis or perineum
204
Bladder trauma different types of injury
contusion = no bladder rupture (i.e. no urinary extravasation), damage to mucosa or muscularis
intra-peritoneal rupture = bladder dome rupture into intra-peritoneal cavity
extra-peritoneal rupture = anterior or lateral bladder wall rupture into soft tissue
205
Bladder trauma clinical presentation
bladder trauma associated with pelvic fracture in almost all cases, also long bone fractures
abdominal tenderness, distention, peritoneal signs from uroperitoneum due to intra-peritoneal rupture
suprapubic discomfort or tenderness
inability to void
206
Bladder trauma investigations
urine analysis: gross hematuria in 90% cases
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CT cystogram (pelvis CT with IV contrast where images are taken when IV contrast is being excreted by urinary tract) and post-drainage film to diagnosis bladder
rupture, which shows extravasation of contrast and visualization of defect in bladder
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207
Bladder trauma management
contusion:
Foley catheterization until hematuria resolves
extra-peritoneal rupture:
Foley catheterization with follow ups for 14 days using cystograms (injection of contrast through urethra into bladder on X-ray) to monitor healing
intra-peritoneal rupture:
supra-pubic catheterization followed by immediate surgery
surgery = closure of bladder in 2 layer fashion with suture -> indwelling catheter to facilitate healing of defect
208
Bladder trauma indications for surgery
Infected urine
rectal / vaginal perforation
bony spike into bladder
laparotomy for concurrent injury
bladder neck involvement
persistent urine leak
failure of conservative management
209
Renal trauma etiology
80% cases blunt trauma: motor vehicle collision, assault, falls
20% cases penetrating trauma: stab wounds, gunshot
210
Renal trauma stages and grading
5 stages of renal trauma
stage 1 = renal contusion / hematoma
stage 2 = <1cm laceration without urinary extravation
stage 3 = >1cm laceration without urinary extravasation
stage 4 = urinary extravasation
stage 5 = shattered kidney or avulsion of pedicle
severity classified by minor or major
minor = contusion and superficial laceration (i.e. stage 1-2)
major = laceration extending into medulla and collecting system, major renal vascular injury, shattered kidney (i.e. stage 3-5)
211
Renal trauma clinical presentation
associated with lower rib or vertebral transverse progress in blunt trauma
upper abdominal / flank bruising and tenderness
renal vascular injury -> hypovolemic hypotensive shock from hemorrhage
212
Renal trauma investigations
urine analysis: hematuria (microscopic in minor injury, gross hematuria in major injury)
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abdominal & pelvis CT with IV contrast triphasic to diagnosis and grade kidney trauma:
visualization of laceration
extravasation of contrast
retroperitoneal hematoma
associated intra-abdominal organ injury
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213
Renal trauma management
1. ABCs
2. minor injury + microscopic hematuria: no need for hospitalization, followed as outpatient to monitor healing
3. gross hematuria+ contusion / minor laceration or major injury
A) hospitalization with bed rest and monitoring by clinical evaluation and repeat CT
B) intervention = surgical exploration with nephrectomy or interventional radiology embolization of artery
214
Renal trauma interventional management indications
persistent hemorrhage from kidney and hemodynamic instability
non-viable tissue & major laceration
urinary extravasation
vascular injury
expanding or pulsating peri-renal mass
laparotomy for associated injury
