Urology Flashcards

Question

VUR in children

Answer 1

Incidence Females>>> RF: Family history Aetiology Primary VUR - Due to congenital abnormality of VUJ Secondary VUR- Due to increased intravesicular pressure (e.g. urethral stenosis, neuropathic bladder, recurrent cystitis) Complication- Reflex nephropathy and renal scarring --> HTN and renal failure Grading Grade 1-2 = VUR contained to ureter and renal pelvic Grade 3 = Mildly dilated ureter and pelvicalyceal system Grade 4-5 = Ureter tortuous and dilated, papillary impression at risk ``` Presentation With UTI (abdo pain, failure to thrive, Vom, diarrhoea) ``` Investigations 1st line - Urinalysis + MSU, US KUB, DSMA. 2nd line- Cytogrpahy, urodynamics Management 1st line: Grades 1-3 W/W. Grade 3-5 may require low dose Abx. 2nd line- Surgery

Answer 2

What? Inability to reduce foreskin that have been retracted behind the glands. Progression: Pain + swelling --> Ischaemia Mx: 1st line: Urgent reduction +/- emergency circumcision if necrotic foreskin

Answer 3

Incidence: Between the ages 20-50 (peaks in 20s) Caucasian> Risk factors: FHx in 1st degree, HIV, UDT Pathology Type: 90% are germ cell tumours either (Seminoma>non-seminoma) Spread: By local invasion and lymph nodes. Breach of tunica albuginea increases mets Presentation: -**Painless testicular lump DDx: - Inguinal hernia - Hydrocele - Spermatocele - Syphilis/TB (rare) ``` Ix: 1st line: - History + exam -Testicular USS - Tumour markers (beta-HCG, LDH, AFP) Staging: Tumour markers and CT CAP ``` Management 1st line: Inguinal orchidectomy +/- Retroperitoneal lymph node dissection. Considen semen cryopreservation. 2nd line: Oncology (RT --> Seminomas. Cisplatin chemo --> Non-seminomas)

Answer 4

Definition Narrow preputial orifice therefore foreskin cannot be retracted over glans penis Classified as physiological (scarring present) or pathological Incidence 70% in 5yr/olds Aetiology In children - BXO (balanitis xerotica obliterans) in adults - BXO or recurrent UTIs Presentation Children- Usually asymptomatic Adults - Painful intercourse, ballooning of foreskin on micturition Complications - Paraphimosis - Balanoposhitis - (Penile cancer) Management Physiological phimosis: Conservative management (mobilise foreskin in hot bath. ?Betnovate cream) Pathological phimosis: Circumcision Balanoposhitis: 1st line Conservative (cleaning measures). 2nd line Abx. Consider circumcision once resolved. Paraphimosis: 1st line Compression of glans penis + cold compress / LA/ hyperosmotic agents to glans. 2nd line If severe, ?dorsal slit or circumcision

Answer 5

Epidemiology Over 60s V common Risk factors: - Age - Race - Environment - Diet (High animal fat. Lycopenes and soya protective) - Obsesity Pathology: Type: Adenocarcinoma>> Location: Orginates in peripheral zone then spreads medially Scoring 1. Grading by Gleason scores - Based from two biopsy histology results. scores 2-10. 6 = low risk, 7= med, 8-high risk. Combined with PSA to risk stratify 2. Staging by TNM Presentation - Asymptomatic >> - If symptomatic e.g. haematospermia, rapid ED, BOO, Acute urinary retention - Sx of advanced disease e.g. ureteric obstruction of bony mets DDx: Cause of raised PSA - BPH - Ejac - Instrumentation - DRE - UTI ``` Ix: 1st line - PSA - DRE - Bloods (FBC, LFTs, U+Es) - TRUSBx ``` 2nd line - PSA >20ug/l or patient symptomatic --> Isotrope bone scan. If high risk --> - MRI for local invasion and regional lymphadenopathy Management Unsuspected PrCa --> Restage with TRUS Bx. Monitor patient with regular DRE and PSA Localised PrCa --> Radial prostatectomy + radiotherapy (brachytherapy or EBRT). Followed by active surveillance with PSA, DRE and TRUSBx about 6 monthly. Locally Advanced PrCa --> Radial prostatectomy +/- EBRT +/- hormone therapy (Gosarelin with pre-treatment Flutamide) . Selective patients for observation Metastatic Disease --> Androgen deprivation therapy (ADT) using GnRH analogues. Give with androgen receptor antagonist in 1st week to prevent flare*. Prognosis Dependent of extent of disease

Answer 6

What? Urethra opens onto dorsal surface of penis (anywhere from the glans to the pubic region) and with an upward curvature of the penis Association: Exstrophy, or other congenital malformations, VUR Mx: Urethroplasty and cosmetic reconstruction between 6-18 months. Often surgery at 4-5yrs for bladder neck reconstruction, to achieve continence

Answer 7

What? Urethral opening on the ventral penis Incidence? Rare Presentation: Symptoms - Difficulty in urination Signs - Ventral urethral meatus, hood prepuce Associations: Isolated disorder usually, UDT can co-exist Management: SURGERY before 2 years old (child must be be circumcised)

Answer 8

Definition: Undescended testes by the age of 3 months. Incidence: 5% of boys born with have UDT Cause: Associated with congenital defects DDx: - Retractile testes - Absent bilateral testes, intersex condition? Mx: 1st line: Manual bring down testes 2nd line: SURGERY -Orchidopexy at 6-18 months old. If presenting >2 years and untreated, then consider orchidectomy due to lost function and increase Cancer risk - If intra-abdominal, evaluate laparoscopically and mobilise Benefits of correction: - Monitoring for testicular cancer (increases risk of Testicular Ca due to UDT) - Improved fertility - Cosmesis - Avoid testicular torsion

Answer 9

What? Ejac with minimal stimulation before / shortly after penetration Causes: Psychological or biological (penile hypersensitivity, hyperexcitable ejac reflex) Incidence: 20-30% Duration: Can be life-long or acquired Ix: History and exam (in latency time to ejac <2 mins is suggestive, <15 secs confirms) Mx: Options: Behavioural (Stop-start manouvre / squeeze technique) or pharmacological (TOP LA under condom / SSRI)

Answer 10

What? Prolonged, involuntary erection of the penis that is usually painful Classification: High flow - Ischaemic (more common) Low flow - Non-ischaemic Cause: Low flow - Meds, Neurological, Sickle cell disease, malignancy High flow - Trauma Presentation: >4 hours of rigid, painful erection in absence of sexual stimulation Investigations: Diagnosis by cavernosal blood gas analysis to determine if it's high or low flow Mx of Low-flow 1. LA of penis, 16-18G butterfly into corpora cavernosa then aspirate until bright red 2. Irrigiation w/ normal saline 3. Intracavernosal therapy until tumescence is achived e.g. phenylphrine 4. Surgical shunting Risk: If >12 hours then risk of ED

Answer 11

What? Acquired benign penile condition characterised by curvature of the penile shaft due to formation of fibrous plaques in the penile tunica albuginea (mainly dorsal) Incidence 3% of men after 40-60 years Cause: Unknown Association: DM, Vasc disease, Dupytren's contractures, plantar fascial contracture Presentation Progression: Fluctuated with active and chronic phases Symptoms: Pain, curvature, penile shortening Ix 2y care w/ Artificial erection test, Doppler USS, MRI Mx 1st line: Andrologist referral. Intervention during chronic phase with either medication or surgical options

Answer 12

Definition: Inability to maintain erectile in order to perform sexual intercourse Incidence: Men 30-50s Cause: "IMPOTENCE" Inflammatory (prostatitis) Mechanical (Peyronie's) Pyschological (stress, depression, anxiety) Occlusive vascular factors *** (HTN, DM, PVD, priapism Hx) Trauma Extra (Pelvic surgery, postatectomy) Neurogenic (MS, parkinson's, spina bifida) Chemical (BB, diuretics, amiodarine, SSRIs, TCA, Benzo, finasteride, alcohol) Endocrine (DM, hypogonadism, hypothyroidism) Investigations: 1st line: - Bloods - FBC, U+Es, Fasting lipids, HbA1c, lipid profile, Free testosterone (if abnormal check FSH, LH and prolactin) - Clinical examination- CVS (BP and peripheral pulse, BMI), abdomen (masses and AAA), neuro, DRE (Phimosis, hypospadias, peyronie plaque) and testes (atrophy and asymmetry) Specialised investigations: - Penile USS (+/- PGE1 infection) - Penile arteriography - Cavernosonography Referal: - Abnormal hormone studies --> Endocrinology - Hx of ED --> Urology Management 1st line: Lifestyle (lose weight) + Medications (PDE-5 inhibitors e.g. Sildenafil* OR PGE1 inhibitors e./g. alprostadil) 2nd line: Medication with intraurethral PGs via MUSE 3rd line : Vacuum erection devices 4th line: Surgery 5th line: Androgen replacement *Note: PGE-5 contraindicated by recent MI, CVA, hypotension or nitrates

Answer 13

Normal Prostate: Firm, rubbery, bi-lobed mass with central furrow. Becomes firmer with age Prostatic enlargement: sulcus obliterated and gland is asymmetrical Carcinoma: Very hard nodule, can be craggy Prostatitis: Boggy and tender Met as Cancer of Pouch of Douglas: Mass above prostate on Blumer's shelf

Answer 14

Cautions: - Trimethoprim and nitrofurantoin: Caution in CKD - Trimethoprim can increase K+ and creat - Gentamicin is nephrotoxic and ototoxic so requires dose adjustment Indications - Trimethoprim --> Most uropathogens except enterococcus and pseudomonas - Nitrofurantoin --> Most uropathogens except pseudomonas and proteus - Penicillins --> Gram + and -, given with B-lactamase inhibitor as co-amoxiclav - Quinolones --> Gram + and -, including proteus - Aminoglycosides (Gentamicin) --> - Metronidazole --> Anaerobics - Vancomycin --> Gram +

Answer 15

Definition: "subfertility" is no conception after 1 year of regular, unprotected sexual intercourse. Either: Primary or secondary Incidence: 1/6 couples ``` Cause of infertility: 30% male problem 25% Ovulation issue 20% tubular problem 10& Uterine or peritoneal disorders ``` Male causes of infertility: - Idiopathic (25%) - Varicocele (40%) - Endocrine (e.g. Prolactin secreting tumour, pituitary adenoma, Prader-willi, adrenal tumour, obesity) - Genetic (e.g. Kleinfelter's) - Obstructive - Trauma (UDT, surgery) - Drugs (e.g. anabolic steroids, alcohol, smoking, chemo, sulfasalazine) - Systemic (CKD, cirrhosis, CF) - Infection (e.g. epididymo-orchitis if mumps history, STIs) Ix: 1st line for all men- - Hormone assay: Testosterone, Prolactin, LH, FSH - Semen analysis (sample after 2-7 days of abstinence) - Chlamydia screen 2nd line: If semen analysis abnormal, repeat in 3 months 2y care investigations: ? obstruction --> Vasography ?Azoospermia --> Genetic studies and testes biopsoes ?Low ejac volume --> TRUS ?Varicocele or testes disorder --> Scrotal USS ?Oligospermia or atrophic testes but high FSH --> Genetic studies Management General lifestyle advice: Quit smoking, weight control, stress management, ED?, sex 2-3/ week Approach depends on the cause: -If hypogonadotrophic hypogonadism --> Gonadotrophins - If Varicocele --> Repair - If obstructive --> Surgical correction - Assisted conception by MESA, TESE or IVF IVF Requirement in NHS Women <40 offered 3 cycles if no conception for 2 year and 12 failed IUI cycles Women 40-42 offered 1 cycle of IVF if all criteria met.

Answer 16

Azoospermia: No sperm Oligozoospermia: Decreased number Asthenozoospermia: Decreased mobility Teratozoospermia: Abnormal morphology

Answer 17

Definition: Isolated = 6 month interval between infections Recurrent = >2 in 6months or >3 in 12 months ``` Aetiology: Causes: - Ascending infection - Lymphatic -Haematogenous (TB, perinephritic abscess) -Direct (IBD, diverticulitis) ``` Risk factors: - Reduced urinary flow (e.g. BOO, neuropathic bladder, poor fluid intake) - Increased colonisation - Retrograde infection / ascent - Immunosuppresion Pathology Pathogens = "KEEPS" Presentation: Cystitis --> Suprapubic pain, urgency, urethral burning Pyelonephritis --> Fever, loin pian, chills, irritative LUTS ``` Investigations: All patients for MSU and DRE Consider for men/ women with recurrent / children / haematuria - FBC - U+Es - Blood culture if febrile - Imaging if complex w/ CT and renal USS -PVR - Flow test -Cystoscopy - Pregnancy test? ``` Management: - GENERAL conservative options: High fluid intake, avoid spermatocides, post-coital voiding - MEDICAL Mx is pathology dependent - 1. Cystitis = 3-5 days of trimethoprim or nitrofurantoin. If recurrent consider 3 month low-dose prophylaxis 2. Acute pyelonephritis = Outpatient? 7 days BD cipro OR 14 days BD TMP-SMX OR one time IV agent such as Ceftriazone. Inpatient? Culture dependent.... e.g. IV Gent and Amox for 14 days. Consider IV-oral switch after 48 hours 3. Acute pyelonephritis w/ abscess = Dx bu CTKUB. Treat as above + drainage 4. Asymptomatic bacteriuria = No treatment unless pregnancy. Common in elderly or patients with indwelling catheter - SURGICAL Mx for structural abnormalities e.g. stones or BOO Follow-up: Repeat culture for pregnancy, pyelonephritis or complicated/recurrent UTI

Answer 18

MAG3 Provides: Dynamic function of the kidney Indication: Obstruction DMSA Provides: Static picture of the kidney that indicates its functionality Indication: Assessing defective areas e.g. scarring from recurrent UTI

Answer 19

Definition Inflammation of the epididymis, usually with testes inflammation as well Pathology MoA: Infection spread from the bladder or urethra Organisms: - Men <35 think gonorrhoea or *chlamydia* - Older men or children think E.coli - Rare: Mumps, TB, syphilis Presentation - Scrotal pain - Scrotal erythema - Testicular swelling - Fever - Reactive hydrocele - Signs of underlying infection: Prostatitis, urethritis, cystitis, urethral discharge DDx - Testicular torsion** bc there is scrotal PAIN Investigation 1st line: FBC, CRP, Blood culture, MSU, Urethral swab, Scrotal USS Treatment 1st line: Bed rest, analgesia, scrotal elevation, Abx either oral ofloxacin or IV gent+amox 2nd line: - For men <35 or Suspected chlamydia? 14 days oxfloxacin BD - Men >35 or suspected gonorrhoea? 14 days Ciprofloxacin BD - Refer to GUM for contact tracing 3rd line: If IV Abx fail to improve patient condition, the surgical exploration and drainage for ?Abscess Prognosis Pain takes 2-3 days to resolve, swelling takes up to 6 weeks

Answer 20

Definition: Infection +/- inflammation of the prostate Epidemiology: 50% of men at some point Aetiology: - Ascending urethral infection - Reflux into prostatic ducts Associations: BOO, BPH and invasion of rectal bacteria Pathology Pathogens: "KEEPS" Location: Peripheral prostate zone Classification: 1. Acute bacterial prostatitis Px - Acute onset, fever, rectal/ perineal/ lower back pain, haematuria, pain on ejac, chills, Ix - DRE, MSE, FBC, blood culture, PVR Tx - 2-4 weeks oral ofloxacin + analgesia. If clinical unwell, IV amox and gent. Complication - Prostatic abscess doesnt resolve on Tx, investigate with urgent CT and surgical drainage 2. Chronic bacterial prostatitis Px - Recurremt exacerbation of acute prostatitis Ix - Colony count in EPS and urine, PVR Tx -3-4 month Abx + alpha-blocker 3. Chronic abacterial prostatitis / chronic pelvic pain

Answer 21

Classification: - Acute (500-800ml) - Chronic --> High pressure OR Low pressure (750ml +) CHRONIC URINARY RETENTION Presentation: High pressure = ?Bed wetting Onset can be painless Mx Catheterise and check U+Es. Observe for post-obstructive diuresis with hourly O/U. Consider TUPR and long term catheter. High pressure has renal impairment, low pressure does not. Low pressure can TWOC ACUTE URINARY RETENTION Cause • Commonest cause in men = BPH Presentation • Sudden (over hours or less) inability to pass urine • Lower abdominal discomfort • Considerable pain/distress • Overflow incontinence if on a background of chronic retention (painless) • Palpable bladder Ix • All patients should have rectal and neurological exam • Bladder USS: volume of >300 cc confirms the diagnosis • Other Ix: Urine MCS, serum U+Es (?AKI), FBC + CRP (?infection) • If recurrent or failed trials of alpha adrenergic antagoinst: TURP Mx 1st line Decompress the bladder via urinary catheterisation. Measure the volume of urine drained in 15 minutes measured + Start Finasteride/Tamsulosin • <200ml rules out acute urinary retention • >400ml 🡪 catheter should be left in place. • Consider IV fluid replacement if patient has a post-obstructive diuresis 2nd line- Admit

Answer 22

Tx: PCNL Pathogen: Proteus >>>> klebsiella

Answer 23

Postural hypotension

Urology Flashcards

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