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3b specialties > Urology > Flashcards

Urology Flashcards

1
Q

differentials of scrotal swelling?

A 
inguinal hernia
testicular tumour
acute epididymo-orchitis
epididymal cysts
hydrocele
testicular torsion
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2
Q

features of epididymal cyst?

A

lump found posterior and separate from the body of the testicle

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3
Q

associated condition of epididymal cysts?

A

polycystic kidney disease
CF
Von Hippel-Lindau syndrome

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4
Q

diagnosis of epididymal cysts?

A

USS

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5
Q

Mx of epididymal cysts?

A

supportive therapy

surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts

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6
Q

what is a hydrocele?

A

an abnormal collection of fluid between the 2 layers of the tunica vaginalis

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7
Q

causes of hydrocele?

A
  • non-communicating or simple hydrocele- over production of fluid within the tunica vaginalis
  • communicating hydrocele- the processus vaginalis fails to close allowing peritoneal fluid to communicate freely with the scrotal portion
  • hydrocele of the cord- processus vaginalis closes segmentally, trapping fluid within the spermatic cord
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8
Q

presentation of hydrocele?

A

scrotal enlargement with a soft non-tender swelling
No pain
Will trans illuminate with pen torch
Can get above the mass on examination
Testis may be difficult to palpate if the hydrocele is large

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9
Q

Ix of hydrocele?

A

none required for simple hydrocele
USS if in doubt of diagnosis
suplex sonography
serum AFP and HCG levels to exclude malignant teratomas or other germ cell tumours

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10
Q

tx of hydrocele?

A

If in infancy, many resolve spontaneously
In adults, conservative approach may be taken depending on the severity of the presentation
Scrotal support
Therapeutic aspiration
Surgical removal in some cases

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11
Q

what is varicocele?

A

an abnormal dilatation of the testicular veins in the pampiniform venous plexus, caused by venous reflux

  • usually asymptomatic, need to rule out RCC (due to compression of renal vein- swollen testicles can be a symptom)
  • can be associated with infertility
  • reflux
  • valve incompetence
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12
Q

is a varicocele more common on the left or right?

A

LEFT as left testicle vein drains into the left renal vein which has more chance of compression

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13
Q

epidemiology of varicocele?

A

incidence increases after puberty

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14
Q

features of varicocele?

A

usually asymptomatic
scrotum feels like a ‘bag of worms’
scrotal heaviness
infertility

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15
Q

Ix of varicocele?

A

sperm count
USS colour doppler studies
Venography, thermography, CT
Serum FSH/LH/LHRH

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16
Q

tx of varicocele?

A

surgical repair where there is pain, infertility and testicular atrophy

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17
Q

what is testicular torsion?

A

twisting of the spermatic cord resulting in testicular ischaemia and necrosis

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18
Q

RFs for testicular torsion?

A

10-30 years, L sided more commonly affected

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19
Q

features of testicular torsion?

A 
acute swelling of the scrotum
pain-sudden and severe in one testicle 
testicle retracts upwards
loss of cremasteric reflex
lower abdo pain
can come on during sport or physical activity
reddening of the scrotal skin
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20
Q

Ix of testicular torsion?

A

mainly a clinical diagnosis
urinalysis to exclude infection and epididymitis
doppler ultrasound scan- GOLD STANDARD- shows reduced blood flow

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21
Q

tx of testicular torsion?

A

surgery within 6 hours to save testicle

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22
Q

what does the prostate secrete?

A

seminal fluid. it nourishes the sperm

stimulated by the dihydrotestosterone

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23
Q

features of BPH?

A

LUTS:

  • voiding symptoms (obstructive) - weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
  • storage symptoms (irritative) - urgency, frequency, urinary incontinence, nocturia
  • post-micturition- dribbling
  • complications- UTI, retention, obstructive uropathy
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24
Q

Ix of BPH?

A

DRE- enlarged prostate
serum electrolyte and renal USS
serum PSA
referral and biopsy if suspicious of malignancy

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25
tx of BPH?
1) Alpha blockers- e.g. Tamsulosin, alfuzosin- a1 receptor antagonists - relax smooth muscle in the bladder neck and prostate - increase urinary flow rate and an improvement in obstructive symptoms 2) 5-alpha reductase inhibitors e.g. finasteride - blocks conversion of testosterone to dihydrotestosterone (responsible for prostate growth)- may take 6 months before results are seen - can slow progression 3) urethral or suprapubic catheterisation 4) prostatectomy/TURP or permanent catheter
26
SEs of alpha blockers
dizziness postural hypotension dry mouth depression
27
SE of 5-alpha-reductase inhibitors
``` ED reduced libido ejaculation problems gynaecomastia (due to lack of testosterone) ```
28
complications of BPH?
``` Bladder obstruction-retention infections stones haematuria interactive obstructive uropathy ```
29
what are the majority of bladder cancers?
>90% are transitional cell carcinomas 2nd type is SCC incidence peaks in the 8th decade
30
RFs for transitional cell bladder cancer?
``` smoking aniline dyes rubber manufacture cyclophosphamide pelvic irritation ```
31
RFs for SCC bladder cancer?
schistosomiasis BCG treatment smoking
32
what is the grade of a cancer?
biological potential to invade and metastasise
33
what is the stage of a cancer?
how far it has spread
34
features of bladder cancer?
``` painless haematuria **red flag** recurrent UTIs voiding irritability LUTS dysuria **red flag** abdo pain weight loss/bone pain ```
35
Ix of bladder cancer?
``` urine dipstick-microscopic haematuria bloods- FBC, U&E, LEFTs flexible cystoscopy with biopsy is diagnostic urine- microscopy and cytology CT urogram MRI ```
36
tx of bladder cancer?
TURBT (resection) +/- intravesicle chemotherapy 2 main agents- mitomycin and BCG vaccine If muscle invasive- radical surgery and radiotherapy Chemotherapy
37
2 week wait for suspected urological malignancy?
>45 years and unexplained macroscopic haematuria or persists after Tx for UTI >60 years and unexplained microscopic haematuria and either dysuria or increased ECC on testing Consider non-urgent referral if >60 and recurrent or persistent UTI
38
what is the most common type of prostate cancer?
95% are adenocarcinomas
39
causes/RFs of prostate cancer?
``` age- disease of the elderly obesity afro-Caribbean ethnicity FH mutations in androgen receptor genes ```
40
features of prostate cancer?
``` localised disease- often asymptomatic LUTS pain- back, perineal or testicular mets to bone- hypercalcaemia B-symptoms Marrow replacement- purpura, anaemia, immune suppression ```
41
Ix of prostate cancer?
``` DRE- asymmetrical, hard, craggy, loss of median sulcus PSA screening tool PSMA in serum Urine test for PCA3 Multiparametric MRI TRUSS- transrectal USS Prostate biopsy CT ```
42
when should men be referred for further investigation?
men aged 50-69 should be referred if PSA .3 OR there is an abnormal DRE
43
causes of false positive PSA?
``` prostatis- wait 1 month UTI- wait 4 weeks Vigorous DRE- wait 1 week Vigorous exercise- wait 48 hours Ejaculation- wait 48 hours Urinary retention Surgery/instrument used BPH ```
44
what is the grading system for prostate cancer?
GLEASON GRADING SYSTEM
45
TX of prostate cancer?
radical prostatectomy and radiotherapy focal therapy- high intensity USS watchful waiting to see if the cancer progresses active surveillance- follow up examination and PSA level monitoring brachytherapy- radiotherapy beads
46
how to manage metastatic prostate cancer?
1) Androgen deprivation- -surgical castration (removing testicles) -medical castration-> GnRH analogues- buserelin, goserelin, LH antagonists, peripheral androgen receptor antagonists (need to co-prescribe anti-androgen tx such as cryproterone acetate or flutamide- presents increase in symptoms) Second line- hormone therapy (abiraterone), cytotoxic chemo, bisphosphonates, palliation of pain, ureteric obstruction, anaemia
47
what is a complication of TURP?
TURP syndrome venous destruction and absorption of the irrigation fluid causes restlessness, headache, tachypnoea, burning sensation in the face and hands causes hyponatraemia, fluid overload, glycine toxicity
48
mx of TURP syndrome?
ABCDE and resuscitation and O2 | fluid overload managed with furosemide
49
what produces testosterone and what produces sperm?
testosterone- Leydig cells | sperm- sertoli cells
50
cause of testicular cancer?
FH genetic factors- abnormality in Chr 12, Klinefelter's syndrome Unknown- majority
51
RFs for testicular cancer?
25-35 years cryptorchidism (undescended testis) infertility mumps
52
types of testicular cancer?
95% arise from germ cells- seminomas and teratomas | non germ-cell tumours- Leydig cells, Sertoli cells, sarcomas
53
features of testicular cancer?
``` painless lump testicular and/or abdominal pain dragging sensation in the testicles hydrocele gynaecomastia from B-HCG production Mets in lungs or para-aortic lymph nodes ```
54
Ix of testicular cancer?
USS Tumour markers- AFP and Beta-HCG CXR and CT of chest, abdomen and pelvis
55
tx of testicular cancer?
orchidectomy radiotherapy- for seminomas with mets below the diaphragm chemotherapy sperm banking
56
what is epididymo-orchitis?
infection of the epididymis and/or testes resulting in pain and swelling
57
causes of epididymo-orchitis?
local spread of infections from genital tract or bladder age <35= STI >UTI age <35= UTI>STI following urological intervention in the elderly -> predominantly catheter related
58
features of epididymo-orchitis?
unilateral testicular pain and swelling urethral discharge **rule out testicular torsion**
59
Ix of epididymo-orchitis?
void urine and the perform CT +/- urethral swab MSSU USS to rule out abscesses Sexual history
60
tx of epididymo-orchitis?
if STI suspected- refer to GUM Abx- quinolone of >35 and not suspecting UTI doxycycline +/- stat azithromycin if STI more likely if organism unknown- IM ceftriaxone 500mg single dose plus doxycycline 100mg by mouth BD for 10-14 days Supportive underwear NSAIDS if required
61
what is hydronephrosis?
dilatation of the renal pelvis or calyces as a result of obstruction of the outflow of urine distal to the renal pelvis
62
causes of hydronephrosis?
``` SUPER (bilateral) PACT (unilateral) S- stenosis of the urethra U-urethral valve P-prostatic enlargement E- extensive bladder tumour R- retroperitoneal fibrosis ``` P- pelvic-ureteric obstruction (congenital or acquired) A- abnormal renal pelvis C-calculi T-tumours of the renal pelvis
63
Ix of hydronephrosis?
USS IV urogram antegrade or retrograde pyelography CT scan- if suspected renal colic
64
tx of hydronephrosis?
treat cause catheter nephrostomy tube- acute upper urinary tract obstruction ureteric stent or pyeloplasty- chronic upper UT obstruction
65
what is obstructive uropathy?
``` functional or anatomical obstruction of urine flow at any level of the urinary tract can be supravesivle (above the bladder) or infravesicle (below the bladder) ```
66
renal causes of obstructive uropathy?
cysts (PKD) Neoplastic- wilm's tumour, RCC, TCC Inflammatory- TB, echinococcosis infection Metabolic- kidney stones Miscellaneous- sloughed papillae, trauma, renal artery aneurysm
67
ureter causes of obstructive uropathy?
congenital- strictures, ectopic kidney cancer- TCC of the ureter, mets inflammatory- TB, schistosomiasis, endometriosis misc- retroperitoneal fibrosis, AA, pelvic lipomatosis, pregnancy kidney stones
68
bladder and urethra causes of obstructive uropathy?
congential- phimosis (narrow foreskin), abnormal opening of urethra neoplastic- cancers misc- BPH
69
what is post obstructive diuresis?
urine output increases to >200ml/hr ends when normal levels have been achieved again normal physiological resonse
70
features of obstruction of urinary tract?
dull ache in flank/loin complete anuria LUTS
71
Ix of obstruction of urinary tract?
imaging- CT, USS serum creatinine- shows function of the affected kidney bloods- FBC, U&E, coagulation, ABG Urine- dipstick, MC&S to rule out infection as cause
72
tx of obstruction of urinary tract?
``` ABCDE fluids analgesia antibiotics catheter stents nephrostomies ```
73
what is acute urinary retention?
sudden (<6 hours) inability to voluntarily pass urine PAINFUL palpable distented bladder
74
causes of acute urinary retention?
BPH urethral obstruction meds- anticholinergics, TCAs, antihistamines, opioids, benzodiazepines neurological- cauda equina, spinal cord compression UTI Postoperative Postpartum
75
Ix of acute urinary retention?
DRE neurological examination/ pelvic exam in women urinalysis and culture U&Es and creatinine FBC and CRP bladder USS to confirm diagnosis- volume >300cc
76
mx of acute urinary retention?
catheterisation | further Ix for underlying cause
77
features of chronic urinary retention?
``` PAINLESS incomplete bladder emptying frequency, urgency, hesitancy, dribbling nocturia incontinence ```
78
red flag causes of chronic urinary retention?
``` spinal cord injury pelvic/sacral fracture herniated disc infections MS myogenic failure due to chronic detrusor overdistension ```
79
Ix of chronic urinary retention?
``` urinalysis MSSU bloods (U&Es and creatinine) bladder diary imaging of urinary tract ```
80
mx of chronic urinary retention?
``` intermittent self-catheterisation indwelling catheter stop precipitating drugs tx for BPH lifestyle- reduce alcohol and caffeine, reduce evening alcohol, bladder training ```
81
complications of chronic urinary retention?
acute on chronic retention hypertrophy of detrusor muscle and formation of bladder diverticula hydronephrosis- leading to AKI or CKD urinary incontinence due to overflow
82
indications for surgery in urinary problems?
``` RUSHES Retention UTIs Stones Haematuria Elevated creatinine due to bladder outlet obstruction Symptom deterioration ```
83
what causes erectile dysfunction?
erections are caused by inflow of blood to the corpora cavernosum (corpus spondiosum contains urethra) -> trabecular smooth muscle relaxation and arteriolar dilatation (through nitric oxide mediator) -> phosphodiesterase causes penis to return to flaccid state
84
what are the nerves responsible for an erection?
parasympathetic- S2,3,4- responsible for erections | sympathetic nerves T11-L2- responsible for ejaculation
85
RFs for ED?
``` lack of exercise obesity smoking hypercholesterolaemia hypertension metabolic syndrome DM ```
86
causes of ED?
1. Vascular 2. Central neurological 3. Peripheral neurological 4. Hormone 5. low testosterone 6. anatomical 7. drug causes 8. psychosexual- lack of arousability, situational
87
central neurological causes of ED?
Central neurological- PD, stroke, MS, tumours, traumatic brain injury, CVD, IV disc disease, spinal cord disease or injury
88
peripheral neurological causes of ED?
Peripheral neurological- polyneuropathy, DM, alcoholism, uraemia, surgery, peripheral neuropathy
89
hormonal causes of ED?
Hormone- hypogonadism, hyperprolactinaemia, cushings disease
90
low testosterone causes of ED?
Primary- pituitary, hypothalamus Secondary- testes (tumour, injury, drugs), Klinefelter's syndrome, Noonan's
91
anatomical causes of ED?
Peyroine's disease- penis bends over when it gets on erection to fibrous growth
92
drug causes of ED?
``` Beta-blockers anti-depressants e.g. SSRIs, TCAs anti-hypertensives recreational drugs H2 antagonists- ranitidine ```
93
Ix of ED?
``` physical exam and ED fasting glucose lipid profile morning testosterone if low testosterone-> perform prolactin, FSH and LH ```
94
tx of ED?
1st line- lifestyle modification phosphodiesterase inhibitors- PDE5 inhibitors e.g. sildenafil (Viagra)- effective for 30 mins Vacuum erection devices 1st line if can't take PDE5 inhibitors
95
SEs of Viagra?
``` headache flushing dyspepsia nasal congestion dizziness visual disturbance ```
96
CI of Viagra?
``` nitrates (decrease BP) alpha blockers (decrease BP) ```
97
what is priapism?
prolonged erection if lasts >4 hours there's a risk of permanent ischaemic damage to the corpora treat by aspirating the corpora with a 19 gauge needle or inject phenylephrine
98
what is persistent non-visible haematuria?
blood present in 2/3 samples tested 2-3 weeks apart
99
causes of persistent non-visible haematuria?
``` cancer stones BPH prostatis urethritis e.g. chlamydia renal causes e.g. IgA nephropathy ```
100
causes of transient or spurious non-visible haematuria?
UTI menstruation vigorous exercise sexual intercourse
101
causes of red/orange urine without blood on dipstick?
beetroot, rhubarb | rifampicin, doxorubicin
102
Ix of haematuria?
urine dipstick renal function, albumin:creatinine (ACR) ratio BP check urine microscopy
103
tx of haematuria?
urgent referral- >45 years AND -unexplained visible haematuria without UTI or -visible haematuria that persists or recurs after successful treatment of UTI
104
organisms causing UTI?
Gram negative- E.coli, klebsiella, proteus, Enterobacter | Gram positive- enterococcus
105
RFs for UTI?
``` sexual intercourse female (shorter urethra) post-menopause (decrease oestrogen causes loss of protective vaginal flora) foley catheter DM infant boys with foreskin impaired bladder emptying urinary stasis ```
106
Ix of UTI?
Urinalysis- pyuria (leukocytes), nitrites Urine culture Renal USS VCUG- voiding cystourethrogram- vesicoureteral reflux Renal scintigraphy
107
what is sterile pyuria a sign of?
pyuria and urine culture (negative) suggests urethritis e.g. gonorrhoea or chlamydia
108
tx of UTI?
Abx- trimethoprim or nitrofurantoin for 3 days | fluids
109
CI of trimethoprim?
methotrexate, 1st trimester pregnancy
110
CI of nitrofurantoin?
breastfeeding
111
mx of pyelonephritis?
admit and broad-spectrum cephalosporin (cefotaxime, ciprofloxacin) or a quinolone for 10-14 days
112
features of pyelonephritis?
``` fever rigors loin pain vomiting white cell casts in urine ```
113
mx of overactive bladder?
moderate fluid intake bladder training antimuscarinics e.g. oxybutynin, tolterodine or darifenacin
114
signs of a bladder rupture?
pelvic fracture and lower abdo peritonism, free fluid in pelvis

3b specialties (7 decks)

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