Urology Flashcards
(392 cards)
1
Q
A 33-year-old man presents with a two day history of the gradual onset of pain and swelling in the right testicle. The pain is described as 5/10 on the pain scale. Around four weeks ago he returned from a holiday in Spain but reports no dysuria or urethral discharge. On examination he has a tender, swollen right testicle. On examination the heart rate is 84/min and his temperature is 36.8ºC. What is the most likely underlying diagnosis?
A
epididymo orchitis
2
Q
stoorage symptoms are
A
FUN
frequency
urgency
nocturia
3
Q
voiding symptoms are
A
terminal dribbling/ poor flow intermittent stream straining hesitancy incomplete emptying
4
Q
definition of nocturnal polyruria
A
voiding >1/3 of their total daily output overnight
5
Q
what is normal voiding at night
A
1-2 times
6
Q
what is q max and what is a representative flow
A
-q max is max rate of flow
need >150ml to be passed
>15 is normal in men
7
Q
2 types of haematuria
A
visible
non visible : symptomatic or asymptomatic
8
Q
definition of non visible haematuria
A
dipstick is signficant if more than or equal to 1+ RBC on 2 or more occasions
9
Q
causes of haematuria
congenital
acquired
A
congenital
- coagulation disorders
- haemophilia
- sickle cell disease
acquired
- tumour- bladder, renal, ureter, prostate
- BPH
- trauma
- stones
- infection- UTI , schistosomiasis prostatitis
- hyperparathyroidism -renal calcium causes stones
- circulatory, vascular, renal infarction
- medications
- autoimmune IgA , glomerulonephritis, HSP
- inflammation- interstitial nephritis
10
Q
what are transient causes of haematuria that need excluding first
A
- menstruation
- strenuous exercise
- UTI
11
Q
drugs that cause haematuria
A
anticoagulants- aspirin, clopidogrel, warfarin
penicillins
cyclophosphamide
rifampicin
12
Q
schistosomiasis presentation
A
-headache, fever, arthralgia, abdo pain, cystitis, haematuria
can also affect CNS and cause seizures, peripheral neuropathy
13
Q
rx schistosomiasis
A
praziquantel
14
Q
what is significant haematuria?
A
- any single episode of visible haematuria
- any single episode of symptomatic non visible haematuria (in absence of UTI or other transient cause)
- persistent asymptoamtic NVH
15
Q
inx for haematuria
A
- BP and HR
- bloods renal function
- MSSU and culture
- flexible cystoscopy
- CT urogram for high risk
- IV urogram and renall USS for low risk
16
Q
who gets a CT urogram for haematuria
A
-high risk so
visible haematuria
>40
smoker
17
Q
which patients need direct referral to urology for haematuria
A
- any visible haematuria
- any patients with symptomatic NVH
- any patients with asymptomatic NVH but >40
- all persistent asymptoamtic NVH
18
Q
reasons to admit patient with haematuria
A
- symptoms and signs of hypovolaemic shock
- symptomatic/ asymptomatic anaemia
- clot retention or pending clot retention
- acopia
19
Q
emergency management of haematuria
A
- Ato E
- fluid resus
- 3 way catheter
- bladder irrigation with saline to prevent clot accumulation in bladder
- bladder washout with catheter tipped suringe
- bladder washout in theatre if clots cannot be irrigated out of bladder
20
Q
main emergency complication of haematuria
A
clot retention
21
Q
examination of a patient with haematuria
A
-abdo exam
DRE
22
Q
management of visible haematuria
A
- refer to urology
- flexible cystoscopy in 2 weeks urgent
- CT urogram as high risk
23
Q
management of symptomatic low risk non visible haematuria
A
- refer to urology
- flexible cystoscopy in 4-6 weeks
- USS +/- IV urogram
24
Q
when to refer haematuria to renal
A
non visible haematuria asymptomatic with
- fhx of renal problems
- abnormal renal functioning testing
25
what is the main cancer of the bladder
transitional cell carcinomas
26
what other types of cancers can be found in bladder
1. transitional cell carcinoma
2. squamous cell carcinoma
3. adenocarcinoma
27
risk factors and causes for bladder cancer- linked to type
- smoking (TCC)
- aromatic hydrocarbons- paint, dye, tyre, metal, rubber- aniline dye (TCC)
- chronic inflammation (SCC) UTI, stones
- schistosomiasis (SCC)
- exposure to other carcinogens found in the urine (TCC)
- hx of previous pelvic radiotherapy
- cyclophosphamide (TCC)
28
most common cancer of the bladder inAfrica
schistosomiasis so SCC
29
what causes adenocarcinoma of bladder
congenital remanant of the urachus
30
invasion classification of bladder cancers
- 80% are superficial- non muscle invasive bladder cancer NMIBC
- 20% are invasive- invasive muscle bladder cancer MIBC
- carcinoma in situ are very superficical but highly aggressive tumour cells on urothelial lining
31
grading of bladder cancers
g1 well differentiated
g2 moderately differentiated
g3 poorly differentiated
32
presentation of bladder cancer
- main presenting symptom is visible painless haematuria 85%
- microscopic haematuria- less common
- storage related LUTS - FUN
- can be symptomatic of anaemia- pallor
- can get recurrent UTI
33
diagnosis bladder cancer
-hx and rf
-abdo and pelvic exam - often normal
-DRE
check for signs of anaemia
INX
as often visible haematuria get an urgent flexible / rigid cystoscopy
ACTS as dx and RX as with cystoscopy can do a TURBT
and CT urogram -possibly
34
management of Non muscle invasive bladder cancer
-just the mucosa or submucosa 80%
1. cystoscopy and TURBT trans-urethral resection of bladder tumour
2. mitomycin C single intravesical dose chemotherapy after TURBT to reduce rate of recurrence
3. may need further TURBT at 6 weeks to ensure adequate resection if high grade disease or no detrusor muscle in the initial resection
4. In patients, with recurrent/ multifocal disease, intravesical immunotherapy with BCG also used to reduce recurrence risk
35
long term management of NMIBC
long term surveillance with flexible cystoscopy
36
management of MIBC and MIBC with mets
20%
- if initial TURBT on cystoscopy showed tumour invading into the detrusor muscle then need a
1. RADICAL CYSTECTOMY (removal of bladder and prostate in men and bladder, uterus, urethra and ovaries in women) and urinary diversion
- alternative is radical radiotherapy which can be used to improve haematuria in metastatic disease
- chemotherapy with cisplatin based agents for nodal metastatic disease
inx mets disease
- CT CAP
- MRI pelvis
37
cystectomy what happens to ureters
form an ilial conduit
38
contraindications to intravesical BCG
```
pregnancy
immunosuppressed
haematological malignancy
following traumatic catheterisation
symptomatic UTI or VH
```
39
prognosis of low grade NMICB
>90% at 5 yrs
40
prognosis of high grade NMIBC or invasive
50% at 5 yrs
41
main risk factors for renal cancer
-smoking
-obesity and HTN
-cadmium exposure
-employment in leather industry- aniline dye
-familail incidence seen with Von hiipel lindau syndrome VHL (AD)
also in PRCC ,leiomyomatosis, hereditary RCC
42
which is the most lethal of all urological cancers
renal cancer
43
pathology of renal cell cancer and types
-originates from proximal convoluted tubule epithelial cell (80% ) either clear cell or granular 10%
```
others
-papillary 10-15%
-chromophobe
collecting duct bellini
medullary cell
```
44
main cancer type for renal cancer
clear cell
45
presentation of renal cancer
- usually asymptoamtic 50%- incidental finding
- 10% too late triad- visible haematuria, flank pain and palpable mass
- left varicocele due to block in left renal vein
- pyrexia of UO
- vte, pe and lower limb pedema
46
paraneoplastic syndromes of renal cancer
-haematopoeitic disorders
anaemia 30%
polcythaemia
raised ESR
```
-endocrinopathies (secrete renin, EPO, PTH, ACTH)
hypercalcaemia
erythrocytosis- high concen RBC
hypertension
cushing syndrome
gynaecomastia, amenorrhoea
hypoglycaemia
```
stauffer's syndrome- hepatic cell dysfunction
abnormal LFT's
decreased WCC
fever
hepatic necrosis- reversible following nephrectomy
due to IL6
haemodynamic alterations
peripheral oedema
systolic hypertension
47
metastasis sites for renal
bone brain liver lung
| bone pain, night sweats, fatigue, weight loss, haemoptysis
48
inx for renal cancer
- bloods-FBC, ESR, u and e, lft, coag, LDH, calcium, chP
- renal USS
- CT stage and plan surgery -chest abdo pelvis
49
staging renal cancer
t1= <7 cm
t2=>7cm
t3=tumour extends into perinephric fat and into renal vein
t4= tumour extend beyond gerotia's fascia
50
management of renal cancer not metastasised
- radical nephrectomy -removal of kidney and adrenal with intact gerotia's fascia
- partial nephrectomy
- immunotherapy (soemtimes for metastatic as immunogenic)
51
management of metastatic renal cancer
-tyrosine kinase inhibitors eg suntinib, pazonib to inhibit angiogenesis
as renal cancer highly vascular so aim to inhibit development and spread
52
upper tract transitional cell carcinoma risk factors
```
similar to bladder cancer
smoking
phenacetin ingestion- was used for pain relief
-Balkan nephropathy
-lynch syndrome HNPCC
```
53
main type of upper tract transitional cell carcinoma
-papillary TCC 90%
scc
fibroepithelial
benign inverted papilloma
54
A 64-year-old man presents with painless haematuria. He had a similar episode 1 year ago and was given antibiotics for a presumed urinary infection and his bleeding resolved. He has a decreased urinary stream and nocturia twice a night. He has smoked a pack of cigarettes daily for 45 years. Physical examination shows only moderate enlargement of the prostate. Urinalysis is positive for 10 to 15 RBCs and 5 to 10 WBCs per high-power field with no bacteria detected.
bladder cancer
55
A thin 65-year-old man with no significant past medical history presents with a 5-month history of right-sided flank discomfort and abdominal fullness. He finally seeks medical attention because of 2 weeks of lower extremity oedema, and 4 days of gross haematuria with clots. On examination, his blood pressure is 160/90 mmHg, heart rate is 120 bpm and regular, and he is afebrile. He is found to have a palpable right-sided lower abdominal mass, and pitting oedema to the mid-shins bilaterally, which is worse on the right.
renal cancer
56
presentation of upper tract transitional cell carcinoma
-visible haematuria 80%
-flank pain " clot colic" 30%
can be asymptomatic 4%
57
A 56-year-old obese woman presents to the emergency department with a history suggestive of biliary colic, including epigastric discomfort after a heavy meal. Her past medical history includes cholelithiasis, hypertension (treated with an angiotensin-converting enzyme [ACE] inhibitor), and dyslipidaemia (treated with a statin). She is an ex-smoker, drinks alcohol socially, and has no significant family history. On palpation of her abdomen, she has RUQ pain, but there are no other relevant findings on examination. An abdominal ultrasound is performed, which demonstrates the presence of gallbladder stones without obstruction, and an incidental 5-cm, left-sided renal mass
renal cancer
| asymptomatic and incidental finding more common
58
inx for upper tract transitional cell carcinoma
-CT urogram or renal USS + IV pyelogram
-cystoscopy
+/- retrograde pyelogram
-urine cytology
-flexible ureterorenoscopy plus biopsy
CT CAP
59
location of upper tract transitional
-uncommon in renal pelvis
| rare ureteric TCC
60
why can USS be tricky for upper transitional cell carcinoma
difficult at detecting renal pelvis and ureter tumours
61
management of upper tract transitional cell carcinoma non metastatic and normal contra-lateral kidney
radical nephro ureterectomy with bladder cuff excision (and node sampling)
kidney and ureter remove
62
management of upper tract transitional cell carcinoma if single functioning kidney, bilateral disease, unilateral low grade tumour <1cm or unfit for major surgery
-percutaneous, segmental or ureterenoscopic resection/ laser ablation
+/- mitomycin c
63
metastatic upper tract transitional cell carcinoma management
- systemic chemo- platinum based
- palliative
- arterial embolisation/ radiotherapy for haematuria
64
poor prognostic factors of UTCC
-muscle invsive
high grade, stage and age
lymphovascular invasion
65
prognosis of UTCC
at follow up 50% will develop metachronous bladder TCC and 2% contralateral upper TCC
66
prostate cancer risk factors
- age >60
- race- african americans
- environmental factors - common scandinavian countries
- diet-animal fat is assoc.
- obesity
- nationality
- endocrine environment
- genetic (increased 1st degree relative)
- exercise can be protective
67
pathology of prostate cancer
-adenocarcinoma- from glandular epithelium 95%
- 80% arise from outer aspect (peripheral zone) of the prostate gland as tumours enlarge they spread both medially into the remainder of the gland and outwardly to the surrounding tissues especially the seminal vesicles
- 20% arise from the transition zone
68
main prostate cancer cause
adenocarcinoma from glandular epithelium 95%
69
where is it common/ uncommon for prostate cancer to invade
- doesnt invade rectum due to denovilliers fascia
| - invades into urethral sphincter, corpora of penis, trigone of bladders
70
gleason score
- prostate cancer
- 1to5
- determined by analysing the histology from 2 separate areas of the tumour specimen and add togeter to get total gleason score =10
- 8 to 10 means aggressive poorly differentiated
71
T staging prostate cancer
t1= not palpable only under microscope
t2-palpable confined within capsule
t3= breach capsule and invade seminal vesicles or fat
t4= invades adjacent organs and / -bony mets
72
t2cprostate cancer means
palpable in both lobes
| not biopsy bilateral
73
presentation of prostate cancer
-most are asymptoamtic
-bladder outflow obstruction- voiding symptoms poor stream, flow, straining, hesitancy , nocturia incomplete bladder emptying
-acute urinary retention
haematuria, hermatospermia
40% present with symptoms of advanced prostatic carcinoma caused by either ureteric obstruction or bony metastasis
-pain at night, wake from sleep
74
signs of prostatic carcinoma on DRE
- sulcus of prostate becomes obliterated
- gland often asymmetrical
- very hard nodule
75
prostatis on DRE
-boggy and tender prostate
76
what might a mass above the prostate on DRE indicate
metastatic deposit on Blumer's shelf- cancer in pouch of douglas
77
diagnosis of prostate cancer
-DRE
-bloods
-PSA total
PSA free: total ratio
Transrectal USS with needle biopsy TRUS
-isotope bone scan for bone mets if PSA >20 or symptomatic
-MRI for invasion if high risk disease
78
what does a lower PSA free: total ratio means
suggest more likely to be prostate cancer as
free tends to be less than total
total tends to increase
so get a lower ratio <10% higher risk
79
PSA total abnormal results
>3 for <60
>4 for 60-70
>5 for >70
80
what else can elevate PSA
```
BPH
UTI- major
ejaculation/ DRE
TURP/ TRUS
acute prostatis
chronic prostatitis
catetherisation/ retention
```
81
function of PSA
liquefied ejaculate and leaks into circualtion
82
counselling for PSA
- mandatory
- need to highlight potential disadvantages about an abnormal result
- need to balance risks and benefits of having clinically significant disease dx
83
what should be counselled about for asymptomatic men considering a PSA
- cancer will be identified in <5% of men screened
- benefits remain controversial
- sensitivity only 80%
- specificty only 40-50% ie affected by lots of other things
- if elevated- pathway of DRE and TRUS+biopsy and risks pain infection bleeding
- TRUS biopsy can miss cancer
- may need to repeat biopsy
- treatment may not be necessary or curative
- decreased qofl as a result of treatment complications
84
what are contraindications to having a PSA done at the time
- an active UTI
- ejaculated in the past 48 hours
- had a prostate biopsy in the past 6 weeks
- exercised vigorously in previous 48 hrs
- had a recent DRE
- avoid receptive anal intercourse for 48hrs before PSA
85
where does prostate cancer metastasies too
- surrounding tissue especially seminal vesicles
- lymphatic spread to iliac, pre-sacral and para-aortic lymph nodes
- blood spread- to bone , liver and lung
86
PSA greatest use
detecting recurrence of tumour following treatment
87
how does prostate cancer spread to vertebrae
via the batson systemic of veins
| also goes to pelvis and femur
88
unsuspected cancer of the prostate stage T0
- prostate normal on DRE but specimen on TURP shows well differentiated tumour
- re-stage patient with a TRUS biopsy and treat by observation and regular DRE and serum PSA levels
89
localised prostatic cancer stages T1 and T2 management options
-confined to capsule
1. radical prostatectomy
2. radical radiotherapy
3. brachytherapy
4. active surveillance
5. watchful waiting
90
risks of radical radiotherapy
-assoc. cystitis, proctitis
91
what is bracytherapy
internal radiation with radioactive seeds implanted
92
how is active surveillance for prostate cancer done and who for
regular PSA and DRE and TRUS biopsy to monitor
more popular as with PSA more insignificant prostate cancer seen
men with lower risk but life expectancy 10-20yrs
93
what men would indicate watchful waiting
life expectancy <10 years
94
management options for locally advanced prostate cancer T3 and T4
- treatment of choice either
1. radical prostatectomy and/or external beam radiotherapy
- in some cases especially those with incipient ureteric obstruction may use androgen deprivation therapy in addition to irradiation
95
metastatic disease treatment for prostate cancer
-androgen deprivation
GnRH analogues eg goserelin
or orchiectomy
and chemotherapy docetexal
-decrease in testosterone
96
what is added to GNRH agonist goserelin for the 1st week of treatment in prostate cancer
-need to add androgen receptor antagonist is added to prevent tumour flare up due to
initially get transient increase in FSH and LH so get testosterone surge
eg degarelix, cyproterone acetate
97
preventing prostate cancer
```
-low fat consumption
soy
lycopene in cooked tomatoes
selenium
vit a and d
pomegranate
green tea
coffee
```
98
testicuar cancer risk factors
```
cryptorchidism
fhx
age 20-54
race and ethnicity- white men
carcinoma in situ
cancer of other testis hx
HIV infection
very tall men
```
99
what is the commonest solid tumour in young men
testicualr cancer
100
presentation of testicualr cancer
- painless hard lump
- lump not separate from testicles
- occasionally present with short hx of painful swollen inflamed testis often secondary to intra-tumour haemorrhage
- few men present with signs of metastatic disease of weight loss, lymphadenopathy, abdo pain
101
most common type of testicular cancer
Germ cell tumours 90%
102
three types of Germ cell tumours
1. seminomatous (seminomas) 48%-most common
2. non seminomatous (teratoma or choriocarcinoma)
3. 10% mixed
103
seminomas
age group
types and presentation
-mostly in 30s
-pale and homogenous
types
-classical
anaplastic
spermatocytic
better prognosis
104
non seminomatous teratomas
-presentation
age
-typically in 20s
contain things like hair and teeth
look for signs of metastatic disease
increased AFP and HCG
teratoma- undifferentiated, intermediate, differentiated
105
what are the non germ cell types of testicular cancer are there
- sex cord stromal 3%= leydig, sertoli
| - others 7%= lymphoma and metastatic disease
106
pre-cursor lesion for testicular cancer
TIN testicular intraepithelial neoplasia
107
examination of testicular cancer
- asymmetrical or slight discoloration of testis
| - hard non tender irregular non trans illuminable mass
108
inx for testicualr cancer
- routine bloods
- USS diagnosis of testicles
- AFP and beta HCG and LDH markers
- staging CT CAP
- MDT refer
109
teratoma markers
raised AFP
LDH some limited rise
raised B-HCG
110
seminoma markers
normal AFP
LDH raised - more common with seminoma
raised Bhcg
111
metastasis sites of testicular cancer
-spreads by direct invasion to lymph nodes- para-aortic 1st
| liver lung and bone if breaches tunica albuginea
112
management testicular cancer options
- radical orchidectomy +/- silicon prosthesis
- radiotherapy for seminoma- EBRT
- chemotherapy cisplatin for non-seminomas
113
diff dx of testicualr cancer
```
-hydrocele
epididymal cyst
indirect inguinal hernia
TB-rare
syphilis-rare
```
114
A 35-year-old man presents with non-specific testicular discomfort and the feeling of a mass in the testis. On examination, a 2 cm by 1 cm smooth, painless mass is palpated in the right testis. The mass does not transilluminate with light. There is no lymphadenopathy.
testicular cancer
115
spermatocele- epididymal cyst presentation
Single or multiple cysts
May contain clear or opalescent fluid (spermatoceles)
-transilluminates like cantonees lantern!
Usually occur over 40 years of age
Painless
Lie above and behind testis- upper pole
It is usually possible to 'get above the lump' on examination
116
penile cancer main type
squamous cell carcinoma 95%
117
rare causes of penile cancer
Kaposi sarcoma
BCC
melanoma
118
risk factors for penile cancer
-smoking
HPV-genital warts
-keeping foreskin more common
119
pathology of penile cancer
-starts with penile in situ then SCC starts growing as a flat or ulcerative lesion of gland or shaft
120
presentation of penile cancer
-painless lump or ulcer on the distal aspect of penis/ glans
rarely
- inguinal mass
- AUR
121
inx for penile cancer
-bloods
biopsy
CT CAP/ MRI for local
122
management options for penile cancer
1. topical imiquimod for small superficial tumours and PIN
2. surgery - circumcision, partial penectomy, total penile amputation with a perineal urethrostomy
3, lymph node sentinel biopsy and inguinal
oncology
-radiotherapy and chemotherapy for advanced disease
123
differentials of penile cancer
- benign cutaneous lesions eg lichen planus, sclerosis, papules, psoriasis
- benign subcutaneous lesions- peyronnie's plaque, cysts
- viral -condylomata acuminatum-genital warts
124
peak age of stone formation
20-50 yrs
| m:f 3:1
125
when and in who is stone formation more common
caucasian populations
| more in summer months
126
risk factors for stone formation
-genetics= cystinuria autosomal recessive trait
-more common in caucasians
-hypercalcaemia- hyperparathyroidism
-hyperoxaluria- bowel resection or AR genetics
-gout
renal anatomy- pujo, horseshoe, MSK
-dehydration
-renal tubular acidosis
-PKD
-beryllium/ cadmium
-ileostomy due to decrease bicarb
-drugs
-diet fluids intake, meat vit d and c
-low mobility
127
how does hyperoxaluria form
- malabsorption of calcium in gut such as in bowel resection causes excess oxalate absorption from bowel
- dietary excess
- or due to autosomal recessive abnormality of glyoxalate metabolism so get excess oxalate production
128
what drugs cause stone formation
loop diuretics
steroids
acetazolamide
theophylline
129
what is cystinuria
autosomal recessive inheritance
| get multiple stones
130
how to prevent cystinuria
-hydration
diet low in cysteine avoid red meat and fish
-give citrate, sodium bicarb to make stones more soluble
131
main type of kidney stones
80% are calcium oxalate
132
types of kidney stones
```
calcium oxalate 80%
struvite stones (mg ammonium) 10%
calcium phosphate/ oxalate 5-10%
urate 5-10
cysteine 1%
```
133
which stones are radio-opaque -can be seen
-calcium phosphate
calcium oxalate
struvite
cysteine
more calcium more can be seen
134
what do cysteine stones look like
"ground glass"
135
what stones cant be seen on radiography and what inx do they need
-uric acid
and xanthine stones
from hx, urine pH >6 gout, USS,
136
risk factors for calcium oxalate stones
```
hypercalcaemia
hyperoxaluria
hypercalciuria
hypocituria
hyperuricosuria
```
137
risk factors for struvite stones
urease producing bacteria
138
risk factors for calcium phosphate stones
renal tubular acidosis
139
risk factors for uric acid stones
gout
myeloproliferative disorders
idiopathic
140
risk factors for cystine stones
homocystinuria
141
cystinuria pathology
-defective absorption of cysteine from the intestines and proximal tubule of kidney
142
presentation of stones.
-renal colic pain- loin to groin
-visible haematuria +/-
-non visible haematuria
-recurrent UTI-struvite
-pyonephrosis, perinephic abscess
n and v
LUTS
143
examination of a patient with stones
-usually sudden onset colicky loin pain
-loin to groin radiation
waves of increasing severity
patient cant find a comfortable position
144
where can kidney stones get trapped
- vesico ureteric junction- enters bladder
- uteropelvic junction- leaves renal pelvis
- crossing of iliac vessels
145
main diff dx of kidney stones
-AAA
pneumonia
appendicitis
ectopic pregnancy-females
146
calcium oxalate stone formation
1. calcium phosphate concretion orginates near renal papilla = Randall's plaque
2. eventually eroded due to alkaline environment through the urothelium and forms a NIDUS for calcium oxalate deposition when directly exposed to urine
3. stones then become large enough to break free
147
uric acid stone formation
-assoc. too
gout, myeloproliferative disorders and hyperuriscoria assoc. to insulin resistance , persistently acidic urine
not radio opaque- radio lucent
148
calcium phosphate formation
-due to renal tubular acidosis
defect of renal tubular H+ secretion so urine is of high pH and increases supersaturation of urine
-type 1 defect -distal cant maintain proton gradient
149
causes of calcium phosphate formation
suggest underlying metabolic disorder
1. RTA
2. primary hyperparathyroidism
3. medullary sponge kidney
150
formation of struvite stones pathology
-magnesium ammonia and phosphate
urease producing bacteria break down urea to ammonia and alkalise urine
-pH >7.2 alkaline urine
151
which stones cause stag horn calculi
struvite stones
152
bacteria implicated in struvite stones
proteus
klebsiella
pseudomonas
staph aureus
153
what is lithostat used for
urease inhibitor can be used for struvite stones as adjunctive
154
ksp and kf in stone formation
>ksp and >kf
155
examination of kidney stones
-general temp and signs of sepsis
-patients moves around a lot
-check for pulsating mass AAA
-pregnancy test
dipstick
156
inx for kidney stones
- bloods (raised WCC, renal funcion, calcium, uric acid)
- MSU
- dipstick for pH and UTI (alkaline in ca phos, acidic in uric acid)
- 24hr urine for ca/ oxalate. uric acid
-CT KUB no contrast
-plain x-ray only shows radiodense
-IVU
-CT urogram
MRU magnetic resonance urography for hydronephrosis
157
test for renal tubular aciosis
ammonium chloride loading test
| pH <7.3 or bicarb <16 but urine pH >5.5 has distal RTA
158
cystinuria test
cysteine spot test
159
risks of IVU
anaphylaxis
| need to omit metformin 48 hrs prior
160
best inx for stones
CT KUB no contrrast
161
what might USS be useful for detecting stones
only renal stones
162
preventing calcium stones 2
drink
| thiazides
163
preventing uric acid stones 2
-allopurinol
| urinary alkalisation bicarbonate
164
preventing oxalate stones 2
cholestyramine
| pyridoxine
165
acute management of renal stones 4
pain relief NSAID's 1 st line
fluids
watchful waiting
tamsulosin alpha blocker relax ureteric smooth muscles
166
indications for emergency intervention for stones
1. uncontrolled pain
2. infection fever, pyrexia, marked inflammatory
3. impaired renal function (solitary kidney) derranged U and E
4. prolonged unrelieved obstruction (watchful waiting already for 4-6 weeks)
5. social reasons eg pilot
167
emergency management of obstructed infected kidney stone
1. a to e
2. wide bore cannula IV fluids
3. cultures
3. MSU
5. broad spec abx
6. percutaneous nephrostomy or JJ stenting
- use nephrostomy more as done under LA
168
discharging a patient after emergency treatment of stones
- discharge patient when pain and blood results improve
| - follow up 3-4 weeks later and should have passed otherwise need definitive management
169
definitive treatment options for stones
- medical- watchful waiting but may not work -trial
- ureteroscopy
- ESWL
- percutaneous nephron-lithotomy PCNL
- nephrectomy
170
small stones <5-6mm management
-medical: NSAID and alpha blocker, thiazide for calcium, allopurinol for uric
fluids
171
stone <2cm (>5mm)
ESWL extra-corporeal shockwave lithotripsy
172
Contraindications for ESWL
- pregnancy
- obese
- anticoagulants
- need to be visible on x-ray so not for uric acid
173
<2cm stone and pregnancy
ureteroscopy
174
indications for ureteroscopy and stone extraction
```
-ESWL failure
cysteine stones
obese
pregnancy
bleeding problems- anticoagulant
```
lower pole stones and stone in calyceal diveriticulum or pelvic kidney- difficult locations
175
complex renal calculi and staghorn calculi and >3cm management
PNCL percutaneous nephron lithotomy
176
what is indicated before doing a PNCL
do a DMSA 1st to check that the kidney is functioning as dont do PNCL for a non-functioning kidney
177
contraindications to medical therapy of stones
>5mm
| struvite (infection) staghorn
178
complications of stones
infection
obstruction- hydronephrosis, hydroureter, nephromegaly,
perinephric standing - lymphatic congestion with fluid aroudn kidney
179
main cause of stag horn calculi
due to struvite stones
180
bladder stone cause
BPH and urinary stasis -same mechanisms as struvite stone
| -more seen in patients on long term catheters
181
management bladder stones
endoscopic or
| open cystolitholapaxy
182
balanitis is
inflammation of the glans penis and sometimes extends to the underside of the foreskin
183
causes of balanitis
infective
| autoimmune causes
184
management of balanitis
simple hygiene
185
candidiasis balantitis presentation
acute
| usually occurs after intercourse and assoc. to itching and white non-urethral discharge
186
dermatitis balanitis presentation
| contact or allergic
itchy sometimes painful and occasionally assc. with a clear non urethral discharge
not affecting other body areas
187
dermatitis balanitis presentation
| eczema or psoriasis
```
both acute and chronic
very itchy
no discharge
medical hx of eczema...
active areas elsewhere
```
188
bacterial balanitis presentation
painful and can be itchy with yellow non-urethral discharge
| staph
189
anaerobic balanitis presentation
acute
may be itchy
most assoc. to a very offensive yellow non-urethral discharge
190
lichen planus balanitis presentation
may be itchy
wickhams striae
violaceous plaques
191
lichen sclerosus balanitis
itchy
white plaques
scarring
also called balanitis xerotica
192
management of balanitis
```
hyginene
saline washes
wash under foreskin
hydrocortisone short periods
candidiasis= topical clotrimazole
bacterial-oral flucox or clarith
anaerobic= saline wash, metronidazole
dermatitis= steroids
lichen sclerosus= high potency steroids
circumcision also for recurrent cases
```
193
prostatitis presentation
perineal pain
pain on ejaculation
tender prostate on DRE
systemically unwell- fevers
194
management of prostatitis
ofloxacin- fluoroquinolones
195
epididymitis management
also ofloxacin -levofloxacin
196
BPH definition
hyperplasia of stroma and epithelium in the transition zone fo the prostate
tone of smooth muscle also plays a key role
197
cause of BPH
- increase in epithelium and stromal cell numbers
- testosterone diffuses into the prostate epithelial and stromal cells
- in the stromal cells, testosterone is converted into DHT which can act in an autocrine fashion in the stromal cells or in paracrine fashion in the epithelial cells
- converted by alpha reductase
- forms DHT- androgen receptor complex and get increase in growth factors
overall cause is unknown
relates to DHT
198
presentation of BPH
```
-voiding symptoms mainly
poor flow
intermittent stream
straining
hesitancy
```
can then go to secondary stroage symptoms
-frequency, urgency, nocturia
```
acute urinary obstruction
haematuria
hydronephrosis and renal compromise
UTI
post-micturition symptoms
```
199
inx for BPH
```
hx assess LUTS use IPSS
DRE
urinalysis exclude UTI
renal function
PSA (LE >10 yrs)
uroflowmetry
```
200
management options for BPH
watful waiting
lifestyle
medical
surgical
201
contrainidcations to watchful waiting for BPH
```
-must not be used in complex BPH
recurrent UTI's
renal impairment due to high pressure chronic retentio
bladder stones
recurrent haematuria due to BPH
```
202
indications for watchful waiting for BPH
- not complex
| - low bother score
203
lifestyle changes for BPH
evening fluid restrict
| reduce caffeine intake
204
medical managementn of BPH
1st line alpha blockers
2nd line 5 alpha reductase inhibitors
-combination therapy
-plus anticholinergics for storage symptoms
205
alpha blockers
tamsulosin, doxazosin
considered 1st line BPH
alpha 1 receptor in the prostate mediates smooth muscle contraction
idea to decrease smooth muscle tone
206
SE alpha blockers
```
retrograde ejaculation
dizzy
weakness
dry mouth
headache
postural hypotension
```
207
5 alpha reductase inhibitors
-eg finasteride
inhibit conversion of testosterone to DHT
cause shrinkage of the prostate epithelium and prostate volume, thus reduce the static element
takes 6 months to imprve
so often combined at beginning
also reduces vascularity and reduce haematuria
208
SE 5 ari
-loss of libido
impotence
reduced ejaculate volume
209
surgical management of BPH options
TURP transurethral resection of prostate
laser prostatectoyomy
open millin's prostatectomy
210
TURP indications
gold standard
1. bothersome LUTS that failed to change to lifesyle or medical therapy
2. recurrent acute retention
3. renal impairment due to BOO
4. recurrent haematuria
5. bladder stones
6. recurrent UTI
211
open prostatectomy indications
```
-large prostate
TURP not technically possible
failued TURP
urethra too long
presence of large bladder stones
```
212
contraindications to open prostatectomy
small fibrous prostate
prior prostatectomy in which most of gland resected
carcinoma of the prostate
213
bladder outlet obstruction causes
men
- BPH main cause in men
- urethral stricture
- prostate cancer
```
women
-pelvic prolapse
urethral stricture
-urethral diverticulum
-post surgery for stress incontinence
-pelvic mass
-Fowler's syndrome
```
both
-neurological disease
214
inx for BOO
```
IPSS
DRE
PSA
U&E
flow test and residual volume
```
215
upper tract obstruction definition
dilatation of the renal pelvis and calyces- can occur with or without obstruction
obstructive nephropathy is damage to the renal parenchyma from obstruction to the flow of urine anywhere along the urinary tract
216
presentation of upper tract obstruction
-incidental on CT/ USS
-flank pain
-anuria
-renal failure symptoms
sepsis
217
signs of upper tract obstruction
-HTN
palpable blader
DRE
palpable mass
218
inx uto
```
renal function
renal uss
CT urogram
retrorade pyelogram
MAG3
```
219
causes of unilateral hydronephrosis
- obstructing stone/ clot
- pelvicureteric junction obstruction PUJO
- ureteric/ bladder TCC
- extrinisc eg pregnancy/ tumour
220
causes of bilateral hydronephrosis
-BOO bladder outlet obstruction -BPH, prostate, cancer, urethral strictures, DSD detrusor sphincter dyssnergia
bilateral ureteric obstruction at level of bladder
cervical, prostate, renal, bladder cancer
```
periureteric inflammation eg IBD
retroperitoneal fibrosis
bilateral PUJO
hydronephrosis of pregnancy
ileal conduit- normal
```
221
strong predictors of AUR
1. increased IPSS score
2. large prostate volume
3. low Q max
4. advanced age
5. previous episodes of retention
222
definition of post-obstructive diuresis
polyuria from relief of severe chronic obstruction commonly occurs after catheterisation for high pressure chronic retention
1. increased urine output out of proportion to fluid intake
2. >3L/24hrs or >200ml/hr for each 2 consecutive hrs
223
pathology of post-obstructive diuresis
-physiologic process to salt wasting process
physiological diuresis occurs secondary to excretion of retained urea, sodium and water after relief of obstruction (resolves in 48hrs)
pathologic diuresis occurs secondary to impared concentrating ability of the renal tubules due to inability to maintain the solute gradient
224
management of post-obstructive diuresis
- admission
- monitoring of hrly output and haemodynamic status
- replace losses if bp drop
- avoid dextrose
- monitor renal funtion
225
causes of unilatearl hydronephrosis
```
PACT
pujo
aberrant renal vessels
calculi
tumour
```
226
causes of bilateral hydronephrosis
```
SUPER
stenosis urethra
urethral valve
prostatic enlargement
extensive bladder tumour
retro-peritoneal stenosis
```
227
inx for hydronephrosis
```
USS
OBS
exam
CT KUB if unilateral for stone
DRE
CT
TRUS
```
228
management of hydronephrosis
remove obstruction
drain urine
acute upper tract obstruction- nephrostomy
chronic obstruction- ureteric stent/ pyeloplasty
229
acute urinary retention presentation
painful inability to void
-relieved by catheterisation and drainage
usually 500-800ml
>800=acute on chronic retention
230
urinary retention causes
- increased urethral resistance BOO
- low bladder pressure
- interruption innervation to the bladder
- central failure of co-ordination of bladder contraction with extenal sphincter DSD
231
rf for retention in men
```
advancing age
LUTS
previous episodes of spontaneous retention
low qmax
larger prostate volumes
```
232
managemen of AUR
-catheterise
renal function check
alpha blocker
233
definitive management AUR
-TWOC after 1 week
precipiated retention doesnt occur
spontaneous retention does recurr
so need TURP, drugs, long term cathether
234
chronic retention definition
inability to void with catheterisation >800ml
235
types of chronic retention
- low pressure
| - high pressure
236
low pressure chronic retention
no hydronephrosis
| normal renal function
237
high pressure chronic retention
hydronephrosis
abnormal cr
intravesical pressure >30
238
management high pressure chronic retention
catheterise
| consider ISC or long term catheter before offering TURP
239
management low pressure chronic retention
no bothersome LUTS
active surveillance
monitoring
bothersome LUTS
consider TURP
240
definition of incontinence
involuntary leakage of urine
| uretral or extra-urethral
241
risk factors for incontinence
childbirth
pelvic surgery or radiotherapy
neurological disorders
242
types of incontinence
stress
urgency
mixed
overflow
243
inx for incontinence
-hx and exam
sim's speculum on women for prolapse and cough test
```
bloods
MSSU urinalysis
flow studies
bladder diaries
USS/ cystoscopy if haematuria
definitive is urodynamics
```
244
what does urodynamics do
-measures the intravesical pressure obtained with bladder filling
testing stress- cough, urge detrusor pressure
245
management of stress incontinence
1. pelvic floor exercises
2. lifestyle modification- weight, smoking
3.duloxetine
4. local oestrogen therapy in post-menopausal women
5. surgical
-autologous fascial sling
TVT mid urethral sling
colposuspension
male sling
artifical urinary sphincter
246
pathology of urge incontinence
due to detrusor over contractivity
abnormal contractions
cystometric assessment
mediated via the parasympathetic system -Ach
247
management of urge incontinence
1. pelvic floor exercises
2. lifestyle
-weight
smoking
-alcohol
-caffeeine reduction
3. anticholinergic Oxybutinin
4.mirabegron beta 3 adrenergic agonist
5. botulinum toxins
6.neuromodulation posterior tibial nerve stimulation or implantation of sacral neuromodulator
7. surgical
detrusor mymectomy
CLAM illeocystoplasty
urinary diversion
248
SE of oxybutinin
dry mouth
dry eyes
constipation
urinary retention
249
se of duloxetine
n and v
250
intravesical botulinum indictions
neurogenic idiopathic detrusor overactivity
| DSD
251
risk factors stress incontinence
```
prostatectomy -removal of proximal sphincter or also damage to the external one
radiotherapy
TURP
childbirth
age
oestrogen withdrawal
previous pelvic surgery
obese
```
252
gold standard management for post-prostatectomy inccontinence
artificial urethral sphincter
253
mixed urinary incontinence
complaint of involuntary leakage of urine assoc. with urgency and also with exertion, stress, sneeze
treat based on symptoms
254
overflow incontinence is
when the bladder is abnormally distended with urine
typically patient has hx of chronic retention and dribbling incontinence
impairment over time
255
management over flow incontinence
exam- palpable bladder
BOO and chronic retention hx
catheterise
renal function
256
temporary incontinence
DIAPPERS
257
loin pain causes
```
stone
infection
AAA
pneumonia
MI
ovarian
ectopic
apenndicitis
IBD
diveritculitis
peptic ulcer
testicular torsion
```
258
neuropathic bladder cause
most likely urological dysfunction following a cardiovascular accident is DETRUSOR OVERACTIVITY
259
What is DSD
detrusor sphincter dysnergia
-sign of supra sacral lesion so between pons and L5
bladder overactivity
sphincter spasticity so increase bladder pressures
260
what is autonomic dysreflexia
sympathetic overactivity
HTN, headache, bradycardia, sweating, flushing
can occur in supra-sacral lesion >T6
261
risks of long term catheterisation
```
increased risk of cancer
recurrent UTI
stones
decreased bladder capacity
blockages requiring regular changes
```
262
UTI definition
inflammatory response of the urothelium to bacterial invasion
>100,000 bacteria/ ml of midstream urine
263
classification of UTI
cystitis- bladder
pyelonephritis- renal
isolated UTI- interval of 6 months between
recurrent UTI >2 infection in 6 months or 3 in 12 months
uncomplicated- normal functional anatomy
complicated- abnormal anatomy or underlying risk factors or fails to respond to therapy
264
UTI spread
mostly ascending GI source
haematogenous eg TB
lymphatic
direct eg IBD, diverticulitis
265
risk factors for UTI
```
stasis of urine= obstruction
foreign body
decreased resistance eg immunosuppressed
females- shorter urethra
smoker
low obestrogen
retrograde urine eg VUR, stent
increase colonisation- sexual activity, spermicide, antibiotics
```
266
KEEPS
```
klebsiella
e.coli
enterococci
proteus/ psuedomonas
saphrophyticus
```
267
long term catheter UTI causes
1. gardenella
2. mycoplasma
3. ureaplasma
268
nonsocomial hospital UTI
```
e.coli
kleb
pseudonomas
providencia
serratia
```
269
who to inx for UTI
recurrent UTI
haematuria
men
children 1st UTI
270
inx for UTI
1. hx and exam
2. urinalysis
3. MSSU
4. urinary Ph
5. POST-VOID RESIDUAL SCAN
-men DRE
blood and blood culture
```
complicated imaging
PVR scan
USS
plain X-ray KUB
flexible cystoscopy
```
271
cystitis management
men = trimethoprim or nitro for 7 days
pregnant women= nitro for 7 days first 2 terms
pregnant women= trimeth 7 days at term
non pregnant women= nitro, trimeth for 3 days
272
dipsticks meaning in children
leucocyte and nitrate treat and do culture
leucocyte only = do a urine sample, dont treat unless good evidence of UTI
nitrites only treat and do culture
273
pyelonephritis management
-gentamicin and amoxicillin for 7days
| oral or IV depending
274
recurrent UTI management
conservative- high fluids, oestrogen
medical
prophylactic low dose abx
post-intercourse abs dose
self start therapy
surgical for anatomical abnormalities
275
asymptomatic bacteriuria management
only Rx in pregnancy
276
who needs test of cure for UTI
pregnancy
pyelonephritis
complicated or relapsing UTI
277
pyonephrosis
```
pus hydronephrosis
very unwell
high fever
IV fluids and IV abx
urgent nephrostomy
```
278
perinephric abscess is
extension of infection outside of the parenchyma of the kidney in acute pyelonephritis
-failure to respond
RF- DM, immunocompromise
279
unresolving pyelonephritis consider
perinephric abscess
| need CT KUB
280
cause epididymitis
-infection ascends from bladder or urethra
-in sexually active men <35 yrs need to consider STI chlamydia, gonorrhoea
-older men and children- usually UTI cause
-rare- mumps (orchitis after parotiditis, TB, syphilis)
amiodarone
281
```
testicle
-pain and swelling
-fever
-pain relieved on elevating testicle
-scrotal pain that may radiate to the groin
-urethral discharge may be present
urethritis
-dysuria
```
epididymitis
282
main diff dx of epididymitis
testicular torsion
283
inx for epididymitis
```
bloods and cultures
urine dipstick
MSU
uretrhal swab
scrotal USS
```
284
management of epididymitis
- bed rest
- analgesia
- scrotal elevation
- antibiotics depending on suspected pathogen
285
antibiotic choice for epididymitis
- men <35yrs and suspect chlamydia give ofloxacin (or single dose azithromycin) for 14 days
- in men >35yrs and suspect gonorrhoea then give ciprofloxacin for 14 days
refer to GUM contact tracing
286
prognosis of epididymitis
pain 48-72hrs to resolve
swelling up to 6 weeks to resolve
287
prostatitis main causes
```
KEEPS
ascending urethral infection
reflux into prostatic ducts often assoc. BOO
BPH
invasion of rectal bacteria
```
288
acute bacterial prostatitis- class I
present
acute onset, fever chills, rectal, perineal pain, lower back pain, haematuria
rx
ciprofloxacin 2-4 weeks
pain relief
treat urinary retention
complication prostatic abscess- pain worsening on rx
289
DRE for prostatitis
tender, warm, boggy prostate
290
chronic bacterial prostatitis II
present
recurrent exacerbations of acute prostatitis signs and symptoms
recurrent UTIs with same organism
frequently asymptomatic with normal prostate on DRE
RX
3-4 months ciprofloxacin
plus an alpha blocker to reduce symptoms
291
urinalysis for chronic bacterial prostatitis
- colony counts in expressed prostatic secretions EPS and urine voided
- massage colony counts should exceed those of initial and midstream urine samples by 10
292
Chronic abacterial prostatitis/ chronic pelvic syndrome III pathology
-most common and most poorly understood prostatic syndrome
```
-inflammatory subtype
pathogenesis is intraprostatic reflux of urine
urethral hypertonia
different micro orgganisms
autoimmune
chemical
```
293
presentation chronic abacterial prostatitis
more than 3 months localised pelvic pain- lower back, suprapubic, penile, pain with ejaculation
LUTS
ED
294
management of chronic abacterial prostatitis
NIH CPSI questionnaire
uroflowmetry and PVR
semen analysis, swabs, TRUS, PSA
```
-conservative
alpha blockers, antib, anti-inflammatory, 5ari
neuromodulation
prostatic massage
pain team referral
```
295
hydrocele
```
fluid in the tunica vaginalis
no peritoneall connection
usually anterior
tranilluminates
can get above the swelling
```
296
causes hydrocele
idiopathic
consider malignancy in young patients
epididymo-orchitis
297
management hydrocele
if symptomatic hydrocelectomy done
298
types of hydroceles
congenital hydrocele- processus vaginalis remains so connected to peritoneum- repair if not resolved by 1-2 yrs
connecting= patency of processus vaginalis in newborn males
non communicating= excess fluid production
299
varicocele
pamniform plexus veins become dilated and tortuous
more common left 15%
incompetent valves in the internal spermatic vein leads to retrograde blood flow
vessel dilatation and tortuosity of plexus
300
symptoms varicocele
```
most are asymptomatic
dull ache
especially on standing
like a bag of worms
dragging sensation
sudden onset assoc. left side assoc. to renal tumour
```
301
investigation varicocele
scrotal doppler USS diagnostic
venography gold standard only consider embolisation
semen analysis
urine USS tract
302
management varicocele
```
conservative watchful waiting
indication for varicocele repair
-adolescents if painful
adults for symptoms
subfertility to improve semen markers?
```
varicocele repair
radiological embolisation
303
epididymal cyst
```
from the collecting ducts of epidiymis
can get above them
separate from body of testicles- discrete
posterior to testicle
discrete soft mass
often multiple and loculated
spermatocele- accumulation of sperm around epididymis
transilluminates
can occur post-vasecomy
```
304
epididymal cyst maangement
if painful or large remove
305
orchitis is
inflamamtion of the testis often occurs in assoc. with epididymitis
mumps, e.coli UTI related, chlamydia, gonorrhoea
306
testicular trauma
can be blunt or penetrating
bleeding can occur from the scrotal wall and its layers leading to a haematoma
haematocele bleeding confined to tunica vaginalis
if sufficient can lead to intra-testicular haemorrhage
307
presentation testicular haematoma
-severe pain
| red
308
management testicular haematoma
all penetrating trauma needs exploration and fixation
intact haematoma= watch
rupture= explore and repair
309
sign of ruputured testicle
intraparenchymal haemorrhage- hypoechoic areas suggests testicular rupture
310
hernia indirect
younger
straight into inguinal canal
risk of strangulation
enters scrotum
311
testicular torstion
twisting of the testes on its blood supply resulting in strangulation
in neonates this is extravaginal
older intravaginal
312
presentation torsion
usually 10-30
sudden onset severe pain, often wakin
cna give pain in abdomen as well
can be a hx of similar pain with spontaneous detorsion and resolution of pain
313
signs of testicular torsion
```
loss cremasteric reflec
slightly swollen
tender
high riding
lying horizontally
```
314
management
needs urgent surgical exploration
dont USS
both sides are fixed due to bell clapper abnormality
315
testicular appednage torsion
blue dot sign
preserved cremasteric reflex
sudden onset pain
316
production of sperm
GNRH causes FSH release which stimulates the sertoli cell inthe semniferous tubes to produce sperm
and leydig cells to produce testosterone
317
subfertility
failure to conceive after 12 months of trying
318
causes of male infertility
```
idiopathic
varicocele
cryptorchidism
functional sperm disorders
erectile problems
post-testicular injury eg torsion, trauma, mumps, radiotherapy
endocrin
excess prolactin oestrogen
kleinfelter
systemic eg renal liver failure
drugs eg chemo, steroids alcohol cannbis
infection eg chalmydia
```
319
inx for subfertility
semen analysis
hormone measurements FSH, LH testosterone
scrotal USS
transrectal USS- if low ejaculate volumes
venography- if varicocele suspected
320
reversible causes treatment
```
lifestyle
treat any infection
hormonal manipulation- anti OE, hCG,dopamine agonist
vitamin E
zinc and folic acid
treat erectile dysfunction
```
surgical management
-varicocele embolisation
microsurgery to epididymis
sperm extraction
321
physiology of erections
parasympathetic s2-s4 Onuf's- STIMULATE the erection
sympathetic T11 to S2 stimulate ejaculation and detumescence
sensory- dorsal penile and pudendal nerves
brain- medial pre-optic area and paraventricular nucleus
nerve signals activate the veno occlusive mechanism of the corpura cavernosa- increases arterial blood flow to the sinusoidal spaces, relaxation of cavernosal smooth muscle and opening of vascular space
increase in sinusoidal spaces preseses on tunica albuginea which reduces venous outflow
contraction of ischiocavernosus muscles
322
ED definition
consistent or recurrent inability to attain and / or maintain a penile erection sufficient for sexual intercourse
323
causes of ED
IMPOTENCE
I- inflammatory prostatitis
M- mechanical peyronnie's
P- psychological- depression, stress, relationship
O- occlusive vascular eg HTN, smoking, PVD
T-trauma # spinal cord injury
E-extra factors- surgery, prostatectomy, klinefleter
N-neurogenic- MS, parkinsons
C chemical
E endocrine- DM, hypogonoadism, hypothyroidism
324
drugs that cause ED
```
beta blockers
thiazides
ACEi
amiodarone
SSRIs
```
325
risk factors ED
CVD
smoker
alcohol
drugs
326
when to refer ED to urology
always had difficulty achieving an erection
327
inx for ED
full hx and exam
blood test- renal, glucose, testosterone, (LH/FSH if low) psa thryoid testing
penile doppler USS
penile arteriography- post trauma
328
indications of a psychological cause of ED
```
sudden onset
erection stilll on waking
reduced libido
relationship prolems
good quality spontaneous and self-stimulated erecttions
phx psychological
hx premature ejaculation
```
329
organic cause ED
gradual onset
loss of nocturnal and early erejctions
intact libido
lack of tumescence
330
management of ED
```
psychosexual
lifestyle loose weight
PDE5 inhibitors eg siladenafil
dopamine receptor agonists
intra-urethral eg prostaglandins
intra cavernosal injections PGE1 eg aloprostadil
vacuum erection device
androgen replacement therapy
surgical peyronnie
```
331
PDE5I SE and CI
-siladenafil
phosphodiesterase 5 inhibitors
block breakdown of cGMP by PDE which helps to dilate corpus cavernosa
CI if takin nitrates, recent MI or hypotension or unstable angina
effective 30 mins after taking and lasts 36hrs must be on empty stomach
assoc. to visual abnormalities
332
other main treatment for ED
PGE1 prostaglandin eg aloprostadil given intra-cavernosal injections
333
vaccum erection risks
priaprism
pain
bruise
compliance
334
priaprism is
rigid and painful erection >4 hours despite absence of sexual stimulation
335
2 types of priaprism
low flow- ischaemia
| high flow- non ischaemia
336
risk factors low flow priaprism
meds- ssri, maoi, alcohol
neurological
sickle cell
malignancy
337
risk factors high flow priaprism
trauma
| arterio venous fisulation
338
inx priaprism
butterfly needle aspirate
| cavernosal blood gas
339
low flow treatment
aspirate with butterfly needle
cavernosal irrigation
inject phenylephrine
surgical shunting to glans
340
phimosis presentation
foreskin cannot be retracted behind the glans
at birth physiological due to adhesions between foreskin and glans
by 3 yrs of age these separate and should be retractile
-asymptomatic
-inflammatory infection
-bleeding
-UTI
-can get balloning of foreskin when voiding as urine gets caught
-pain on sexual activity
341
management of phimosis
-children and young men- 0.1% betamethasone to soften phimosis 1st line
circumcision recommended for symptomatic phimosis but also for recurrent balanitis, BXO and UTI
342
causes phimosis
paraphimosis
balanitis
penile cancer - increased risk uncircumscised
STI
343
paraphimosis is
when the foreskin is retracted from over the glans of penis and becomes oedematous and cant be pulled back over the glans
teenagers or young men
344
management paraphimosis
-ice glove
dundee- puncture holes for oedema and pull back
dorsal slit under GA and pull back over
345
peyronnie
curvature of penis due to fibrous plaque
dorsal penile plaques are commonest - so penile cuves upwards as cannot fully lengthen
active phase -pain and changing deformity
stable phase- no pain-stabilised deformity
dont intervene in acute phase
surgery when stable for >12 months
only surgery if >3 months, unable to penetrate, >30 degrees curvature
nesbit procedure shorten the other side
346
UTI epidemiology children
up to 1 yr of age UTIs are more common in boys
347
risk factor for UTI in children
```
age-neonates
VUR
previous UTI
genitorurinary abnormalities
abnormal bladder activity
female gender
uncircumcised boys
faecal colonisation
chronic constipation
```
348
presentation UTI children
```
non specific
fever
irritable
vomiting
lethargy
poor feeding
```
349
inx
```
dipstick
MSSU
USS KUB
DMSA
MCUG
```
350
management UTI children
```
<3 months refer urgently
<6 month refer
3m to 3 yrs refer if medium risk illness and treat if micro positive, clinical, renal anomaly
>3yrs
send urine and treat based on dipstick
treat if symptoms specific
treat if anomaly
```
351
cryptorchidism types
undescended testes
most resolve by 6 months
```
retractile
ectopic
incomplete descent
atrophic
ascent
```
352
risks undescended testes
infertility
testicular cancer
torsion
hernias
353
cause
abnormal gubernaculum or testes
decreased intra-abdo pressure
endocrine
354
management of cryptorchidism
orchidoplexy 6 to 18 months
355
VUR
vesicoureteric retrograde flow of urine from bladder into the ureters and the upper urological tract
often strong FHX
due to abnormality short ratio of intramural ureteric length to diamater
ie length inadequate
356
primary VUR
due to congenital abnormality of VUJ
357
secondary VUR
results from an increased intravesical pressure causing damage to the VUJ
eg from posterior urethral valves, urethral stenosis, neuropathic bladder and recurrent cystitis
358
5 grades VUR
1= reflux limited to ureter
2= limited to renal pelvis
3=mild dilatation of ureter and pelvicalyceal system
4= tortuous ureter with moderate dilatation
5= tortuous ureter with severe dilatation
359
presentation of VUR
UTI
abdo pain
failure to thrive
vomitting or diarrhoea
360
inx VUR
urinalysis
USS KUB
DMSA
Cystography selected
361
management VUR
first line-correct the cause
grade 1-3 resolve spontaneously and only observation
grade 3-5 low dose abx
362
surgery VUR
only in selected cases for ureteric re-implantation or intramural injection of bulking agents
363
hypospadias is
failure of ventral tissue of penis
| opening of urethra on ventral side
364
triad hypospadias
ventral curvature of shaft
hooded appearance of foreskin
ventral urethral meatus
365
anatomical location of hypospadias
anterior
middle
posterior towards scrotum
366
management of hypospadias
surgery not mandatory if urine stream is straight
posterior can be asssoc. with other tract malformations so need USS KUB
surgical repair between 6-18 months if severe deformity or interferes with voiding or predicted to interefere with sexual function
aims to straighten penile shaft and bring meatus to glans
367
assoc. to hypospadias
undescended testis
hernias
disorders sexual development
need full exam to determine if other abnormalities eg chromosomal
368
epispadias is
when the urethra opens onto the dorsal surface of the penis
anywhere from glans to pubic region
upward curvature of penis
most commonly assoc. to exstrophy
need surgery at 6-18 months-urethroplasty
often requires further surgery to reconstruct bladder neck at 5-5 urs
369
exstrophy is
spectrum of congenital malformation affecting abdo wall, pelvis and GU tract
-eg defective development of anterior bladder and lower abdominal wall resulting in posterior bladder lying exposed on the abdomen
370
pathology exstrophy
over development of cloacal membrane prevents in growth of the lower abdo mesenchymal tissue
cloacal membrane usually perforates to form the anus and urogenital openings
but in this case it perforates on lower abdo wall
371
assoc. to exstrophy
```
all have epispadias
bone defects
hernias
genital defects
exposed bladder plate
VUR
abnormal anus, incontince, rectal prolapse
```
372
management exstrophy
at birth bladder and deficit covered with plastic fil and irrigated
then surgical repair
373
renal trauma
children greater risk due to size of kidneys and lack of fat
374
management renal trauma
blunt trauma cna be managed conservatively
penetrating trauma needs surgical exloration
decceleration injuries also need surgical exploration as vascular injury
375
presentation renal trauma
haematuira
| loin pain
376
imaging renal trauma
CT
377
grading renal trauma
1 contusion
2 <1cm deep parenchymal lacteration of cortex- no urine leak
3 >1cm deep parenchymal laceration no urine leak
4 parenchymal laceration into cotex with urine leak
5 completely shattered kidney
378
indications for renal imaging in trauma
1. visible haematuria
2. systolic BP <90 and non visible haematuria
3. rapid deceleration injury
4. sus[ected renal traum in child
5. penetrating trauma
379
management renal trauma by grade
```
1-3= bed rest and re-image week later
grade4= stenting to prevent urinoma formation and diverty urine- need observation
grade5= immediate surgical exploration
```
380
renall trauma surgical exploration indications
- penetrating- more likely too
- decelerating injury- more likely too
- grade 5
- persistent bleeding
- bp not responding to fluid resus
- expanding renal haematoma
- pulsatile renal haematoma
381
complication renal trauma
```
secondary haemorrhage
urine leak and urinoma
renal abscess formation
arteriovenous fistulas
renal impairment
HTN
```
382
ureteric trauma
most common cause is iatrogenic during surgery
383
management ureteritc trauma
-often during surgery so repair
otherwise development of hydronephrosis or urinoma should be a consideration
also high drain outputs following
384
bladder urethral trauma
causes
most common due to Iatrogenic eg TURP/ TURBT
assoc. to pelvic #
can also occur with acceleration deceleration injuries on a full bladder
385
presentation of bladder/ urethral trauma
- blood at the urethra meatus
- frank haematuria
- urinary retention
- perineal/ scrotal bleeding
- high riding prostate on DRE
- unable to catheterise
386
what causes a high riding prostate
due to the prostate and bladder detachment from the membranous urethra and pushed forward by developing haematoma
membraneous rupture
387
inx for bladder / urethral injury
```
bladder= retrograde cystogram
urethral= retrograde urethrogram
```
NEED TO IMAGE BEFORE CATHETERISE AS MAY NEED SUPRAPUBIC CATHETER IF URETHRAL INJURY
388
management bladder injury
if extraperitoneal
-urethral catheter and cystogram prior to TWOC
-bladder injury intraperitoneal -open surgical reapir
-urethra injury -suprapubic cather may be required
needs an open approach
389
TESTICULAR TRAUMA
-EITHER blunt or penetrating
all penetrating need surgical exploration and repair or orchidectomy q
390
penile fractures
rupture of the tunica albuginea of the erect penis
| can go to corpora cavernosa, corpus spongiosum and rupture of the urethra
391
presentation of penile fracture
```
swollen and bruised
aubergien sign
severe bruising
snapping or popping sound
sudden penile pain
immediate detumescence of erection
```
if buck's fascia has ruptured the bruising extends onto the lower abdo wall
tender palpable defect
392
management penile fracture
need surgical repair
| catheter for 6-8 weeks
