Urology Flashcards
(155 cards)
1
Q
Define an isolated UTI
A
Interval of >6 months between urinary infections
2
Q
Define recurrent UTI
A
> 2 infections in 6 months
OR
> 3 infections within 12 months
3
Q
Common causative organisms of UTIs
A
- Klebsiella
- E. Coli
- Enterococci
- Proteus
- Pseudomonas
- S. Saprophyticus
- Candida albicans (patients on long-term antibiotics)
- Cryptococcus (immunosuppressed patients)
- Schistoma (Middle Eastern countries)
- Mycobacterium TB
4
Q
Risk factors for cystitis
A
- Urine stasis/outflow obstruction
- Foreign body e.g. stone, catheter, instrumentation
- Immunosuppression e.g. diabetes, malignancy
- Congenital lower urinary tract abnormalities
- Pregnancy
- Sex - males in infancy and after >40, female after puberty
- Smoking
- Menopause
5
Q
Risk factors for pyelonephritis
A
- Urinary tract obstruction (congenital or acquired)
- Vesicoureteral reflux
- Foreign body e.g. stones, instrumentation, catheter
- Sexual intercourse
- Immunosuppression e.g. diabetes, HIV, lymphoma
6
Q
Clinical features of cystitis
A
- Urgency
- Dysuria
- Frequency
- Polyuria
- Haematuria
- Supra-pubic pain
- Urethral burning
7
Q
Clinical features of pyelonephritis
A
- Lower UTI symptoms (dysuria, urgency, frequency)
- Malaise
- Fever/chills
- Loin pain
- Nausea/vomiting
8
Q
Which UTI patients require further investigation?
A
- Recurrent UTIs
- Frank haematuria
- Men with UTIs
- Children with UTIs
9
Q
What investigations would you consider in a patient with UTIs?
A
- Urine dipstick
- Urine C&S
- Blood cultures
- Post-void residual volume scan
- Renal US
- Plain X-ray KUB
- Flexible cystoscopy
10
Q
When is a urine dipstick indicated in a women with a suspected UTI?
A
- Women <65, otherwise healthy, <2 classic UTI symptoms or unclear diagnosis
11
Q
Management of uncomplicated in a female patient
A
1) 3 days Trimethoprim PO
2) 3 days Nitrofurantoin PO
12
Q
Management of cystitis in a male patient
A
1) 7 days Trimethoprim PO
2) 7 days Nitrofurantoin PO
13
Q
Management of pyelonephritis
A
1) Gentamicin + Amoxicillin IV
2) Gentamicin + Vancomycin
14
Q
Lifestyle advice/conservative management for a patient with a UTI
A
- Maintain high fluid intake
- Regular bladder emptying
- Avoid spermicides
- Drink cranberry juice
- Use oestrogen replacement
- Urinate after intercourse
- Wipe front to back
15
Q
Contra-indications for nitrofurantoin
A
- Pyelonephritis
- eGFR<45
- In combination with alkalising agents
16
Q
Complications of pyelonephritis
A
- Renal papillary necrosis
- Perinephric abscess
- Pyonephrosis
- Chronic pyelonephritis
- Fibrosis and scarring
17
Q
Common pathogens causing Epididymitis/orchitis
A
Sexually active men <35:
- N. Gonorrhea
- C. Trachomatis
- Coliforms
Older men or children:
- E. Coli
18
Q
Clinical features of orchitis/epididymitis
A
- Fever
- Testicular swelling
- Scrotal pain (may radiate to the groin)
- Scrotal erythema
- Reactive hydrocele
- Evidence of underlying infection e.g. urethral discharge, urethritis, cystitis, prostatitis
19
Q
Main differential for orchitis/epididymitis
A
Testicular torsion - surgical exploration required if any uncertainty
20
Q
What investigations would you consider in a patient with ?orchitis/epididymitis?
A
- Bloods - FBC, U&Es, CRP, blood cultures
- Urine dipstick and MSU
- Urethral swab
- Scrotal ultrasound
21
Q
Management of a man <35 (or with suspected C. trichomatis) with orchitis/epididymitis
A
14 days BD Ofloxacin
Or
Single dose azithromycin
22
Q
Management of a man >35 (or with suspected Gonorrhoea) with orchitis/epididymitis
A
14 days BD Ciprofloxacin
23
Q
Common pathogens in prostatitis
A
Klebsiella E. Coli Enterococci Proteus Pseudomonas S. Saprophyticus
24
Q
Clinical features of acute prostatitis
A
- Malaise
- Fever/rigors
- Difficulty passing urine
- Dysuria
- Perineal/rectal/lower back tenderness
- Haematuria
25
Typical DRE findings in acute prostatitis
Soft, tender enlarged prostate
May be boggy if prostatic abscess present
26
Investigations to consider in a patient with ?acute prostatitis
- DRE
- MSU C&S
- Bloods - FBC and blood culture
27
Treatment of acute prostatitis
2-4 weeks ciprofloxacin
28
Main complication of acute prostatitis
Prostatic abscess
29
Clinical features of chronic bacterial prostatitis
- Recurrent exacerbations of acute prostatitis symptoms
- Recurrent UTIs with the same organism
Patients are frequently asymptomatic with a normal prostate on DRE
30
Investigations to be considered in a patient with ?chronic bacterial prostatitis
- DRE (frequently normal)
- Urinalysis (colony counts in expressed prostatic secretion and urine void) - massage colony counts should exceed initial and MSU samples by >10x
31
Management of chronic bacterial prostatitis
3-4 months of fluoroquinolone + alpha blocker
32
Clinical features of chronic abacterial prostatitis
- >3 months of localised pelvic/perineal/suprapubic/penile/groin/lower back pain
- Pain on ejaculation
- Lower UTI symptoms
- Erectile dysfunction
33
Investigations to consider in a patient with ?chronic abacterial prostatitis
- NIH-CPSI questionnaire
- PVR
- Segemented urine and expressed prostatic secretions C&S
- Semen analysis
- Urethral swab
- Urine cytology
- Urodynamics
- Cytoscopy
- TRUS
- PSA
34
Management options for chronic bacterial prostatitis
- Conservative options e.g. counselling, biofeedback, education, anxiety reduction
- Alpha blockers
- Antibiotics
- Anti-inflammatory medications
- 5-alpha-reductase inhibitors
- Neuromodulation
- Prostatic massage (2-3/week for 6 weeks with antibiotics)
- Pain team referral
35
3 causes of transient haematuria
- Vigorous exercise
- Sexual intercourse
- Menstruation
36
3 benign causes of visible haematuria
1) UTI
2) BPH
3) Stones
37
3 malignant causes of visible haematuria
1) Bladder cancer
2) Renal cell carcinoma
3) Upper tract transitional cell carcinoma
38
Causes of haematuria
- Coagulation disorders
- Haemophilia
- Sickle cell disease
- Tumours e.g. renal, bladder, ureteric, prostate
- BPH
- Trauma
- Stones
- Infection
- Circulatory disorders e.g. vascular malformations, renal infarction
- Medications e.g. anticoagulants, penicillin, cyclophosphamide
- Autoimmune disease e.g. IgA nephropathy, glomerulonephritis, HSP
- Inflammatory disorders e.g. interstitial cystitis
39
Investigations to perform in a patient with visible haematuria
1) Bloods - FBC, U&Es, CRP, clotting screen, group and save
2) MSU C&S
3) Flexible cytoscopy
4) CT Urogram or IVU and renal USS
(and vital signs for signs of haemodynamic compromise)
40
Red flags for visible haematuria
- Blood clots
- Anaemia
- Haemodynamic instability
41
What would you do with a patient with visible haematuria and red flag symptoms?
IMMEDIATE referral to SAU for bladder irrigation
42
All visible haematuria should be investigated with ??? within ?? weeks
Flexible cystoscopy
| 2 weeks
43
All symptomatic non-visible haematuria should be investigated with ?? within ?? weeks
Flexible cystoscopy
| 4-6 weeks
44
All asymptomatic non-visible haematuria patients under age ?? should be referred to ??
40
Renal
(refer those over 40 to urology)
45
Main type of cancer in bladder cancer
Transitional cell carcinoma
46
Risk factors for bladder cancer
- Smoking (TCC)
- Previous pelvic radiotherapy
- Aromatic hydrocarbons (TCC)
- Chronic inflammation (SCC)
- Schistosomiasis infection (SCC)
- Exposure to other carcinogens found in the urine (TCC)
- Male sex (3:1 male: female ratio)
- Age (incidence rises >50, peaks at 70
47
What percentage of bladder cancers are superficial non-muscle invasive cancers>
80%
48
Clinical features of bladder cancer
- VISIBLE PAINLESS HAEMATURIA
- Microscopic haematuria
- Storage related lower urinary tract symptoms
- Anaemia symptoms (breathlessness, palpitations)
49
Management steps for a NIMBC
1) TURBT and single dose intravesical chemotherapy with Mitomycin C
2) Further TURBT after 6 weeks to ensure adequate resection (in those with high grade disease or no detrusor muscle in initial resection)
3) Intravesical immunotherapy with BCG to reduce recurrence risk (those with recurrent/multifocal disease)
4) Long term cystoscopy follow up
50
Management of a MIBC
1) TURBT and single dose intravesical chemotherapy with Mitomycin C
2) Radical cystectomy and urinary division
OR
Radical radiotherapy
3) Chemotherapy with cisplatin
51
Prognosis for bladder cancer patients
- >90% at 5 years for low grade tumours
| - ~50 at 5 years for high grade/invasive tumours
52
Risk factors for renal cell carcinoma
- Smoking
- Obesity
- Cadmium exposure
- Employment in the leather industry
- Von Hippel Lindau syndrome
- Male (3:1 male: female ratio)
- Age (peak incidence between 50-60)
53
Clinical features of renal cell carcinoma
Usually ASYMPTOMATIC (50%)
10% present with the 'too late triad':
1) Visible haematuria
2) Flank pain
3) Palpable mass
Can present with paraneoplastic syndromes:
- Anaemia
- Polycythaemia
- Raised ESR
- Hypercalcaemia
- Erythocytosis
- Hypertension
- Abnormal LFTs
- Decreased WCC
- Fever
- Hepatic necrosis
- Peripheral oedema
30% present with symptoms of metastasis:
- Bone pain
- Night sweats
- Fatigue
- Weight loss
- Haemoptysis
54
Common sites of metastasis of renal cell carcinoma
- Bone
- Brain
- Lung
- Liver
55
Investigations to consider in a patient with ?RCC
- Bloods - FBC, ESR, U&Es, LFTs, coagulation screen, LDH, calcium, chP
- Renal US
- CT
- CT chest, abdo, pelvis and bone scan (if clinical evidence of metastasis)
56
Surgical options for management of an RCC
- Radical nephrectomy
- Partical nephrectomy
- Immunotherapy
57
Oncological option for management of an RCC
Tyrosine kinase inhibitors e.g. sunitinib, pazopanib
58
Risk factors for upper tract TCC
- Smoking
- Phenacetin ingestion
- Balkan nephropathy
- Lynch syndrome
- Male sex (3:1)
- Age
59
Clinical features of Upper tract TCC
- Visible haematuria
- Flank pain ('clot colic')
- Asymptomatic
60
Investigations to consider in a patient with suspected UTTCC
- CT urogram or renal US and IVP
- Cystoscopy +/- retrograde pyelogram
- Urine cytology
- Flexible ureteroenscopy + biopsy
- CT chest/abdo/pelvis for staging
61
Management of a patient with non-metastatic UTTCC with a normal contralateral kidney
- Radical nephro-ureterectomy with bladder cuff excision
62
Indications for percutaneous, segmental or Oureteroendoscopic resection or laser ablation +/- Mitomycin C in UTTCC
- Single functioning kidney
- Bilateral disease
- Unilateral low grade tumour <1cm
- Unfit for surgery
63
Risk factors for prostate cancer
- Age
- Race - African Americans
- Environmental factors - common in Scandinavia, uncommon in Asia
- Diet - animal fat associated with prostate cancer
- Obesity
- Nationality
- Endocrine environment
- Family history
64
Clinical features of prostate cancer
Most patients are ASYMPTOMATIC
Symptoms can include:
- Poor stream
- Hesitancy
- Nocturia
- Incomplete bladder emptying
- Acute urinary retention
40% of patients present with symptoms of local invasion or metastasis:
- Anaemia
- Bone pain
- Ureteric obstruction
65
Investigations to consider in a patient with suspected prostate cancer
- Bloods - FBC, U&Es, LFTs
- PSA (total and free levels)
- DRE
- MRI
- TRUS + biopsy (if indicated)
66
Indications for a TRUS biopsy
- <60 year old with PSA >3
- 60-70 year old with PSA >4
- >70 year old with PSA >5
67
A hard nodular, irregular prostate would make you suspect ...?
Prostatic carcinoma
68
A boggy, tender prostate on DRE would make you suspect ...?
Prostatitis
69
Risks/side effects of TRUS and biopsy
- Infection
- Haematuria
- Haematospermia
- Haemtochezia
- Urinary retention
- Sepsis
70
Causes of a raised PSA
- Trauma
- BPH
- UTI
- Recent ejaculation
- Prostate cancer
- DRE
- TURP/TRUS
- Acute or chronic prostatitis
- Catheterisation
- Urinary retention
71
Describe the TNM staging of prostate cancer
```
T1 - non-palpable tumour
T2 - Palpable tumour confined within prostate capsule
- 2a = <50% of one lobe
- 2b = >50% of one lobe
- 2c = both lobes involved
T3 - tumour locally invading
- 3a = breaching the capsule
- 3b = invading the seminal vesicles
T4 - invading adjacent organs +/- metastasis
```
72
What 3 features determine risk in prostate cancer?
1) PSA level
2) Gleason score
3) Clinical TNM stage
73
Management options for a low risk prostate cancer
1) Watchful waiting - scan if symptomatic (life expectancy <10 years, unfit for treatment)
2) Active surveillance (PSA every 3 months, DRE every 6 months, TRUS every year)
3) Radical prostatectomy OR
4) Radical radiotherapy - brachytherapy or external beam radiation
74
Management options for a intermediate risk prostate cancer
1) Radical prostatectomy +/- external beam radiotherapy
| 2) + androgen deprivation therapy (GnRH antagonists or LHRH agonists)
75
Management options for metastatic prostate cancer
1) Androgen deprivation therapy - LHRH agonist, GnRH antagonists or orchidectomy
2) Chemotherapy
76
Risk factors for testicular cancer
- Age - most common between 20-50 year olds with a peak in the 20s
- Ethnicity - most common in white ethnic groups
- Family history
- History of cryptorchidism
- HIV
77
Clinical features of testicular cancer
Most present with a painless testicular lump.
Can also present with a painful, swollen testicle or features of metastasis
78
Most common sites of metastasis of testicular cancer
- Bone
- Liver
- Lungs
79
Differentials for testicular cancer
- Hydrocele
- Epididymal cyst
- Indirect inguinal hernia
- TB or syphilis
80
Investigations to consider in a man with suspected testicular cancer
- Ultrasound (diagnostic)
- Serum tumour markers (LDH, AFP, BHCG)
- CT chest/abdo/pelvis (for staging)
81
Management of a man with a testicular seminoma
1) Inguinal orchidectomy
(+/- retroperitoneal node dissection)
2) Radiotherapy
82
Management of a man with a testicular non-seminona
1) Inguinal orchidectomy
(+/- retroperitoneal node dissection)
2) Cisplatin-based chemotherapy
83
Risk factors for penile cancer
- Foreskin presence
- Smoking
- HPV/genital warts
- Age - incidence increases with age and peaks in the 70s
- Ethnicity - commonest in South America
84
Clinical features of penile cancer
Most present with a painless lump or ulcer on the distal aspect of the penis/glans.
Rarely patients present with an inguinal mass or acute urinary retention
85
Investigations to consider in a man with suspected penile cancer
- Bloods - FBC, U&Es, Calcium, LFTs
- Biopsy
- MRI (to assess local invasion)
- CT chest/abdo/pelvis (for staging)
86
Risk factors for renal stones
- Hypercalcemia
- Hyperuricosuria
- Hyperoxaluria
- Gout
- Cysteinuria
- Infection
- Renal tubula acidosis
- Renal disease e.g. polycystic kidneys
- Dehydration
- Age - peak incidence between 20-50
- Male sex (3:1 male:female ratio)
- Family history
- Hotter climates
- Caucasian ethnicity
- Seasonal variation - more in summer
87
Clinical features of kidney stones
Classic presentation is 'loin to groin' pain. Other symptoms include:
- Haematuria
- Sweating
- Pallor
- Nausea and vomiting
- Strangury
88
Differential diagnoses for renal stones
- Ruptured AAA
- Pneumonia
- Appendicitis
- Ectopic pregnancy
89
Which investigations would you consider in a patient with ?kidney stones?
- Bloods - FBC, U&Es, CRP
- Urinalysis
- Stone analysis
- CTKUB (no contrast)
- Plain X-ray KUB
- USS
- IV urography
90
How would you manage a patient with a small kidney stone?
1) NSAIDs and an alpha blocker
Small stones usually take 3 weeks to pass and if they don't pass within 2 months of diagnosis, it is unlikely that they will pass spontaneously.
91
3 indications for ureteric stenting in a renal stone patient
1) Infection (pyrexia, raised ESR)
2) Compromised renal function (deranged U&Es)
3) Pain not responsive to opiates
92
3 definitive treatment options for renal stones
1) Extra-corporal shock wave lithotripsy (ESWL) - for proximal stones <1cm
2) Ureteroscopy
3) Percutaneous nephrolithotomy (for calyceal stones and stones >3cm)
93
Define urge urinary incontinence
Involuntary leakage of urine accompanied by or immediately preceded by urgency (a sudden compelling desire to pass urine which is difficult to defer)
94
Causes of urge incontinence
- Lower urinary tract infection/inflammation
- Bladder hyperreflexia
- Stroke
- Parkinson's disease
- Alzheimer's disease
- Old age
- Herniated spinal disc
- Detrusor overactivity
- Benign prostatic hypertrophy and obstruction
- Loop diuretics
95
Define Overactive Bladder Syndrome
A symptom complex characterised by urgency (with/without urge incontinence, usually accompanied by frequency and nocturia).
96
Management of overactive bladder syndrome
1) Lifestyle advice
- Fluid management
- Reduce caffeine, alcohol, diuretics and smoking
- Bladder retraining - regular voiding by the clock with gradual increase in time between voids, double voiding
- Continence devices
2) Anti-muscarinics e.g. oxybutin, tolterodine, darifenacin
3) Beta-3 adrenergic agonist e.g. Mirabegron, Betmiga
4) Botulinum toxin to relax detrusor muscle injections round bladder (Type A)
5) Surgical options - now rare e.g. detrusor myectomy, augmentation CLAM ileocytoplasty
97
Side effects of anti-muscarinics
- Dry eyes
- Blurred vision
- Dry mouth
- Lightheadedness
- Constipation
- Theoretical risk of increased residual volume
98
Define stress urinary incontinence
Involuntary leakage of urine on increase in intra-abdominal pressure e.g coughing, exertion, sneezing
99
Describe the grading system for stress urinary incontinence
Grade 0 - reports leakage but no clinical evidence
Grade 1 - leakage occurs during stress with <2cm descent of bladder base below upper border of pubic symphysis
Grade 2 - leakage on stress accompanied by marked bladder descent (>2cm) occurring only during stress (2a) or permanently (2b)
Grade 3/Intrinsic sphincter deficiency - Bladder neck and proximal urethra are already open at rest (with or without descent)
100
Management of stress urinary incontinence
1) Lifestyle
- Physiotherapy e.g. pelvic floor exercises
- Vaginal cones
- Devices for reinforcement
- Biofeedback
- Weight loss
2) high dose Duloxetine
3) Urethral injection - injection of bulking materials into bladder neck and periurethral muscles, 50-70% success rate
4) Pubovaginal sling - mainly used in those with poor urethral function
101
Side effects of duloxetine
Upper GI side effects e.g. nausea
102
Define overflow incontinence
Incontinence occurring when the bladder is abnormally distended with urine - typically due to chronic urinary retention
103
Causes of overflow incontinence
- Outlet obstruction e.g. faecal impaction, benign prostatic hypertrophy
- Under-active detrusor muscle
- Bladder neck stricture
- Urethral stricture
- Drugs e.g. alpha-agonists, anticholinergics, calcium channel blockers, sedatives
- Intra- or post-operative over-distention
- Bladder generation following surgery
104
Causes of temporary incontinence
- Delirium/dementia
- Infection
- Atrophic vaginitis
- Pharmaceuticals
- Psychological causes
- Endocrine
- Restricted mobility
- Stool impaction
105
Define total incontinence
Continuous loss of urine with no voluntary control
106
Clinical features of BPH
- Lower urinary tract symptoms (hesitancy, straining, poor stream, incomplete bladder emptying)
- Acute urinary retention
- Haematuria
- Hydronephrosis and renal compromise
- UTI
107
Investigations to consider in a patient with ?BPH
- DRE
- Urinalysis
- U&E
- PSA
- Uroflowmetry
108
Management of BPH
1) Watchful waiting and lifestyle changes
2) Alpha antagonists e.g. tamsulosin
3) 5-alpha reductase inhibitors e.g. finasteride
(Plus anticholinergics for storage symptom relief)
4) TURP
5) Laser prostatectomy
6) Open (Millin's) prostatectomy
109
Causes of upper tract urinary obstruction/hydronephrosis
Unilateral:
- Obstructing stone/clot
- Pelvic-ureteric junction obstruction
- Ureteric or bladder TCC
- Extrinsic mass e.g. pregnancy, tumour
Bilateral:
- BPH
- Prostate cancer
- Urethral stricture
- Detrusor sphincter dyssynergia
- Cervical cancer
- Rectal cancer
- Bladder cancer
- Poor bladder compliance
- Adjacent GI disease e.g. Crohn's, UC, diverticulitis
- Retroperitoneal fibrosis
- Bilateral PUJO
- Hydronephrosis of pregnancy (physiological)
- Ileal conduit (normal)
110
Clinical features of hydronephrosis
- Flank pain
- Anuria
- Renal failure symptoms e.g. nausea, lethargy, fatigue
- Sepsis symptoms
- Hypertension
- Palpable bladder
- Palpable mass on DRE
111
Investigations to consider in a patient with hydronephrosis
- U&Es
- Renal USS
- CT urogram/retrograde pyelogram
- MAG3 renogram
112
Define post-obstructive diuresis
>3L in 24 hours or >200ml/hour over each 2 consecutive hours
113
Management of post-obstructive diuresis
- Admit patient and monitor hourly urine output, haemodynamic status and electrolytes
- NaCl if postural drop in BP
- Monitor creatinine and urea until normal
114
What fluid should be avoided in post-obstructive diuresis and why?
Glucose - it can cause continuing diuresis
115
Clinical features of an inguinal hernia in the testis
- Positive cough impulse
- Usually reduces with direct pressure
- Not possible to get above the lump
116
Causes of hydrocele
- Congenital
- Idiopathic
- Infection
- Traumatic
- Associated with underlying testicular tumour
117
Clinical features of a testicular hydrocele
- Painless
- Can be large and tense
- Trans-illuminates
- Can get above lump
118
Investigations to consider in a testicular hydrocele
Testicular US to rule out a testicular tumour
119
Management of testicular hydrocele
- No treatment required if asymptomatic
| - Surgical drainage can be done to remove tense or large symptomatic hydrocele
120
The sudden onset of a large varicocele is a red flag for ???
Renal tumour
121
Clinical features of a varicocele
- More common on the left side
- 'Bag of worms' appearance
- Dragging sensation
122
How would you diagnose a varicocele?
Clinically - examine the patient in the upright and supine position
(Semen analysis can be considered if the patient is infertile)
(US can be considered if an underlying malignancy is suspected)
123
Management of varicocele
All:
- Regular testicular size measurements
Older men who don't want children:
- Conservative management e.g. NSAIDs, scrotal support
Young men with retarded growth of a test or abnormal sperm count who want children:
- Varicocelectomy
124
Clinical features of an epididymal cyst
- Slow growing
- Can get above them
- Usually lie above and behind the testis
125
Clinical features of testicular trauma (causing bleeding)
- Severe pain
- Signs of external injury
- Testis may not be palpable
- Bruising to the scrotal wall
126
Investigation of choice in testicular trauma
Testicular US - testicular rupture will appear as hypo-echoic areas
127
Management of testicular rupture
- Surgical exploration and fixation of the damaged structure e.g. tunica albuginea
128
Clinical features of testicular torsion
- Age 10-30 (peak at 13-15)
- Sudden onset severe pain in the scrotum, often waking patient from sleep
- Groin, loin or epigastric pain
- May have history of similar pain which spontaneously resolved
On examination:
- Slightly swollen testis
- Very tender to touch
- High riding and horizontally lying testis
- Absent Cremaster reflex (Rabinowitz's sign)
129
Management of testicular torsion
- Urgent surgical exploration and de-torsion
| Bilateral fixation is done at this stage as bell-clapper abnormality can occur bilaterally
130
Define sub fertility
Failure to conceive after a minimum of 12 months unprotected intercourse
131
Causes of male infertility
- Idiopathic
- Varicocele
- Cryptorchidism
- Functional sperm disorders
- Erectile problems
- Post-testicular injury
- Endocrine disorders
- Genetic disorders
- Systemic disease
- Drugs e.g. chemotherapy, steroids, alcohol, cannabis, tobacco
- Infections
132
Investigations to consider in male infertility
- Semen analysis
- Hormone measurements
- Scrotal US
- Trans-rectal US (if low ejaculate volume present)
- Venography (if varicocele suspected)
133
Management options for male infertility
- Lifestyle modification e.g. decrease alcohol intake, smoking cessation
- Treat any infection
- Hormonal manipulation
- Vitamin E, zinc and folic acid supplementation
- Treat erectile dysfunction
- Surgical management e.g. micro-surgery to blockages, assisted contraception
134
Define erectile dysfunction
Consistent or recurrent inability to attain and/or maintain a penile erection sufficient for sexual intercourse
135
Causes of erectile dysfunction
- Inflammatory e.g. prostatitis
- Mechanical e.g. Pyrenees' disease
- Psychological e.g. depression, anxiety, relationship problems
- Occlusive vascular factors e.g. hypertension, smoking, diabetes, peripheral vascular disease
- Trauma
- Extra factors e.g. surgery, prostatectomy
- Neurogenic e.g. MS, Parkinson's, spina bifida
- Chemical - B-blockers, thiazides, ACE inhibitors, amiodarone, SSRIs, tricyclics, benzodiazepines, finasteride, GnRH analogues, levodopa, alcohol
- Endocrine e.g. diabetes, hypogonadism, hypothyroidism
136
Investigations to consider in a man with erectile dysfunction
- Bloods: U&Es, fasting glucose, testosterone, LH/FSH, PSA, TFTs
- Penile Doppler US (pre and post PGE1 injection)
- Penile arteriography (after trauma in young men)
137
Management options for erectile dysfunction
- Psychosexual therapy
- PDE5 inhibitors
- Dopamine receptor agonists
- Intra-urethral therapies
- Intra-cavernosal injections
- Vacuum erection device
- Penile prosthesis
- Androgen replacement therapy
138
Risk factors for UTIs in children
- Age - infants and neonates
- VUR
- Previous UTI
- Genito-urinary abnormalities
- Abnormal bladder activity
- Female sex
- Uncircumcised boys
- Faecal colonisation
- Chronic constipation
139
Clinical features of UTIs in young children
- Fever
- Irritability
- Vomiting
- Lethargy
- Poor feeding
140
Investigations to consider in a child with a suspected UTI
- Urine dip and MSSU
- US KUB
- DSMA
- Micturating cystogram
141
Clinical features of phimosis
- Foreskin can not be retracted behind the glans
- Inflammation/infection (balanitis)
- Bleeding
- UTIs
- Ballooning of the foreskin during urine voiding
- Pain or skin trauma during sexual intercourse
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Management of phimosis
1) 0.1% betamethasone (in children and young men)
| 2) Circumcision/preputioplasty (in symptomatic phimosis or recurrent infection)
143
Complications of phimosis
- Paraphimosis (can lead to arterial occlusion and necrosis)
- Balanitis
- Penile cancer
- STIs
144
Management of cryptorchidism
- Orchidopexy (between 6-18 months)
Or
- Orchidectomy (in very small testes)
145
Complications of cryptorchidism
- Increased risk of testicular cancer
- Increased risk of infertility
- Increased risk of testicular torsion
- Increased risk of indirect inguinal hernias
146
Clinical features of VUR
- More common in males
- Family history
- UTIs
- Abdominal pain
- Failure to thrive
- Vomiting and diarrhoea
147
Investigations to consider in a child with suspected VUR
- Urine dip and MSSU
- US KUB
- DMSA renogram
- Cystography
- Urodynamic studies
148
Classifications of VUR
1) reflux limited to ureter
2) reflux into renal pelvis
3) mild dilation of the ureter and pelvic-calyceal system
4) Tortuous ureter with moderate dilation, preserved papillary impression
5) Tortuous ureter with severe dilation and loss of papillary impression
149
Management of VUR in children
1) Correct underlying cause
2) Grade 1-3 usually resolve without treatment
Grade 3-5 may require low dose antibiotics
3) Surgery in select cases
150
Abnormalities associated with exstrophy
- Epispadias
- Bone defects (widening of the pubic symphysis)
- Genital defects
- Exposed bladder plate
- VUR
- Abnormally positioned anus, rectal prolapse or incontinence
151
Diagnosis of exstrophy
- usually diagnosed ante-nasally on 20 week metal abnormality scan
152
Abnormalities associated with hypospadias
- Hooded foreskin
- Ventral curvature of the penis
- Undescended testes
- Inguinal hernias
- Disorders of sexual development
153
Management of hypospadias
Surgical repair between 6-18 months in children with a severe deformity, problems with voiding or predicted problems with sexual function
154
Abnormalities associated with epispadias
- Exstrophy
- Other congenital defects of the urogenital tract
- VUR
155
Management of epispadias
- Urethroplasty and cosmetic reconstruction between 6-18 months and further surgery to reconstruct the bladder neck at 4-5 years
