Urology Flashcards

Question

Do vacuum devices have a place in managment of erectile dysfunction?

Answer 1

Where pharmacological therapies have failed or are inappropriate VEDS are often poorly tolerated long term due to sideeffects: pain inability to ejaculate bruising paraesthesia

Answer 2

1. Malleable penile prosthesis 2. Inflatable penile prosthesis

Answer 3

After Dx of DM - 50% patients will have erectile issues in 10 years Overall prevalence of ED in DM population is 35-70% Men with DM have 2x more ED than men without DM

Answer 4

If = collected from a woman during menses shortly after vigorous exercise shortly after acute trauma -Repeat urinalysis in 6 weeks with microscopy. Mimics of haematuria: Beeturia Pigmenturia Menstruation Drugs - rifampicin, phenytoin, nitrofurantoin

Answer 5

Potentially life threatening emergency - can lead to gram negative sepsis. Immediate transfer to Emergency department for urgent urological review and management.

Answer 6

RF's: single kidney anuria bilateral obstruction severe premorbid renal failure

Answer 7

Usually stones less than 7 mm

Answer 8

NSAIDS Regular Tamsulosin can help passage of stone

Answer 9

Outpatient urology referral

Answer 10

Dysuria, haematuria, flank pain, urgency. Normal for patients with ureteric stents. Dipstick not helpful in patients with stents

Answer 11

Tamsulosin and/or anticholinergic meds

Answer 12

Keep well hydrated Diet low in salt, oxalate and protein

Answer 13

2 out of 3 dipsticks positive for blood

Answer 14

Repeat urine MCS in 6 weeks to confirm haematuria has settled

Answer 15

Myoglobin - rhabdomyolisis urinary haemolysis - intravascular haemolysis semen in urine - can falsely test as blood on dipstick IN these groups - Urine microscopy would not show RBC

Answer 16

Also OSA, Diabetes insipidius, CVA,Dementia Drugs - lithium, diuretics, anticholinergics,

Answer 17

Obstructed indirect inguinal hernia Attempt manual reduction. If irreducible transfer urgently for surgical reduction.

Answer 18

Lump appears when baby is crying But reduces. examination - 1) thick spermatic cord 2) may feel a lump on abdominal palpation Management: Always needs ultrasound -of BILATERAL INGUINAL REGIONS. **6-2 rule** Less than 6 weeks old - surgery within 2 days 6 weeks to 6 months - surgery within 2 weeks Greater than 6 months - surgery within 2 months

Answer 19

surgery at 3 years

Answer 20

Painless testicular lump often bilateral nil impulse with cry can vary in size from day to day May resolve : 1. Do an ultrasound - to see if primary or secondary 2. Surgery/surgical assessment at **one and half years**

Answer 21

Excellent prognosis in first year if orchidopexy performed. If testes are left at 37 degrees - by end of year one the germ cells become damaged and fertility is affected. Cancer risk increases

Answer 22

No. Reduces but doesnt eliminate risk. Should happen in first year of life if possible.

Answer 23

Testosteron Insuline Like Peptide 3 Released from leydig cells

Answer 24

2.5% 90 % will felt in groin 10% not felt at all

Answer 25

Review in 3 months IF still in groin (50%) - refer to surgeon for orchidopexy If now in scrotum (50%) - patient needs yearly review as it can become and aquired UDT

Answer 26

1. Look for hypoplastic scrotum - sign that testes have never been in scrotum 2. Consider female with congenital adrenal hyperplasia (virilisation) 3. Perform karyotyping 4. UEC - as they can have low Na+ secondary to hypoaldosteronism 4. Ultrasound of scrotum/abdomen - to assess for internal organs - testes or for ovaries/uterus

Answer 27

Size of glans penis

Answer 28

Ultrasound needed to exclude cancer - seminoma REFER To surgeon

Answer 29

REfer to surgeon for laporoscopic exploration (could be absent, retractile or Acquired UDT)

Answer 30

IF - no testes at all - to check for uterus/ovaries If one testis is large or irregular - to check for cancer/seminoma

Answer 31

33 degrees in scrotum 37 in body

Answer 32

cancer risk (Seminoma) as well as risk of subfertility

Answer 33

Processus vaginalis is not obliterated at birth 50% will go on to stay in testes (obliterates) 50% will get worse - more retractile and can cause acquired UDT Usually presents between 2-6 years of age REFER TO SURGEON

Answer 34

If it doesnt stay in scrotum - needs surgery If it does stay - Then annual review of retractile testis to ensure it doesnt become an acquired undescended testicle (as soon as this occurs - needs orchidopexy) Whilst it may not pose a cancer risk if descended before 12 months - it still can affect fertility. Testosterone at puberty will cause testes to descend

Answer 35

These are descended testicles that have been pulled into a suprascrotal position by the cremasteric reflex. Can be pulled down - need to overcome reflex for one minute

Answer 36

NO. needs exploratory surgery

Answer 37

Cryptorchid testes can be absent or undescended. (hidden testes) Undescended - has formed but has not descended into scrotum

Answer 38

Balanitis xerotica obliterans Icing sugar appearance to glans Can get meatal stenosis Bleeding/ulceration/phimosis/ painful erections Mx. Mild cortiocsteroid ointment or cream first 2. will need circumcision if not settling

Answer 39

1. Chemical irritation - urine trapping, soiled nappies, soap residue. 2. Physical trauma - forcible retraction. 3. Candida nappy rash in infants Mx: Soak in warm salt water - settles discomfort Barrier or 1% hydrocortisone cream Antifungal cream if candida is suspected Dont retract foreskin during acute inflammation as this can lead to paraphimosis If fever, dysuria present - check Urine MSU Group A strep can cause a genital rash that is weeping and raw - fluclox 25mg/kg six hourly for seven days or cephalexin 25mg/kg six hourly for seven days

Answer 40

Inflammation of glans penis and prepuce

Answer 41

Commonly due to contact irritant dermatitis from urine trapping under foreskin being converted to NH3 or to fragrances, rubber in condoms Systemic causes - scabies, lichen planus, psoriasis,syphilis, fixed drug eruption (look for evidence of other features) Mx - Swab to distinguish bacterial from fungal If fungal: Hydrozole cream 1% BD for two weeks IN kids - if GAS - treat with fluclox/cephalexin 25mg/kg 6hrly for seven days if candida (clotrimazole) - suggests contact irritant dermatitis Reduce inflammation with: Methylprednisolone aceponate 0.1 % once daily for seven days

Answer 42

Recurrent balanoposthitis Balanitis xerotica obliterans Phimosis paraphimosis Recurrent UTI with upper UT anomaly Side effects - bleeding, pain, infection Takes 10 days for discomfort to settle

Answer 43

Inflammation and crusting of the glans penis for a few days after circ is common. - vaseline liberally to the nappy or panty liner helps Infection - treat Bleeding - apply compressive pressure to the area and seek surgical advice

Answer 44

Some benefit in preventing UTIS in boys, esp with urinary tract abnormality reduces penile cancer - poss by preventing phimosis HIV? - not as effective as safe sex practices in low risk populations May have some benefit in reducing Cervical ca in high risk populations but not as good as the HPV vaccination NO effect on prostate ca

Answer 45

Only once natural separation of foreskin from glans penis has occurred

Answer 46

1. Should only be retracted by the owner (or a health professional) 2. should NOT be retracted forcibly 3. Once spontaneous retraction has occurred, encourage daily retraction and gentle cleansing in bath or shower.

Answer 47

during shower or bath slide foreskin back towards your body Wash the end of the penis and foreskin with soap and water and then rinse off THen dry the area and replace foreskin If foreskin gets irritated and smelly - slide foreskin back sufficiently to allow free urination

Answer 48

At birth non retractile prepuce - NOT phimosis 40% become retractile at 1 year 90% by 4 years 99% by 15 years Phimosis is prepuce becoming non retractile because of: 1. Infections 2. BXO 3. Forceful retraction and scarring

Answer 49

difficult to retract foreskin may have scarring was retractile - now is not Balooning of foreskin with micturition OR non retractile by puberty - possibly had it forcibly retracted as child and now is phimosed Rx - Betamethasone 0.05% 4 x daily for four weeks iF fails - surgery

Answer 50

Gangrene, ischaemia and amputation

Answer 51

Urgent manual reduction - with a penile block (dont use adrenaline) or generous application of 2% lignocaine gel 5 - 10 minutes before hand If fails needs urgent referral for surgery

Answer 52

Persistent, recurrent ejaculation before, on, or shortly after penetration (majority within one minute of penetration/minority 1-2 minutes after) Primary: lifelong Secondary: situational factors/secondary to erectile dyfunction

Answer 53

IN secondary - treat the underlying cause In primary - reduce the sensitivity of the glans penis and certain SSRIs delay ejaculation 1. Topical cream - Lignocaine + prilocaine 2.5 % + 2.5% 10 to 20 minutes before sex 2. Sertaline 50mg 3 hours before sex

Answer 54

Low flow (ischaemic) Decreased venous outflow - most common -Hypercoagulable state - sickle cell, thalassemia Neurological disease - Spinal cord stenosis Metastatic disease - Prostatic Cancer, bladder cancer Medications relaxing smooth muscle - eg prostaglandins, PDE5 inhibitors, hydralazine NB MOST COMMON CAUSE IS intracavernosal alprostadil HIGH flow = increased arterial inflow (non-ischaemic) Penile/Perineal trauma -rupture of cavernous artery --\> fistulat formation between cavernosal artery and corpus cavernosum

Answer 55

Persistent involuntary erection,unrelated to sexual stimulation, unrelieved by ejaculation

Answer 56

_Low flow_ - usu painful - RIgid erection - dark blood on coporeal aspiration _High flow_ Not painful episodic trauma evidence

Answer 57

If erection lasts longer than 2 hours 1. hot shower. 2. Pseudoephedrin 120 mg orally immediate release (also can try a cold pack if by 4 hrs no improvement one more 120mg tablet and call doctor if by 6hrs no improvement - attend ED for aspiration and drainage of copora cavernosa Complications - erectile dysfunction/disfigurement

Answer 58

Fever \> 38 degrees celsius systemic features - chills/sweats sepsis/septic shock Needs IV antibiotics in hospital

Answer 59

Ecoli Klebsiella proteus Also Chlamydia and gonorrhea

Answer 60

Urine MCS if concerned about prostatic abcess - then u/s

Answer 61

Recurrent UTI with culture of a recognised Uropathogen from urine or prostatic fluid Confirmed with the two glass test Urine culture and leukocyte counts pre and post prostatic massage FOUR WEEKS OF ANTIBIOTICS - eg cipro 500mg bd or trimethoprim 300mg daily (depending on susceptibilities)

Answer 62

1. RCC (renal cell carcinoma 2. Transitonal cell 3. Wilms tumour in kids (nephroblastoma) Can be primary or secondary cancers - and its primary that are clinically significant (Dont need to worry about secondary)

Answer 63

Complex cyst or solid mass Simple cysts dont need further follow up

Answer 64

Bosniak categories

Answer 65

More men than women Age Indigenous status Family history History of previous stone (30-50% of ppl with a stone will have another in 5 years)

Answer 66

Renal colic +/- haematuria Also can present as vague abdo pain/flank pain/urgency/ frequency/stranguria (small painful voids)/penile or testicular pain/difficulty voiding

Answer 67

Urine Dipstick Urine MCS UEC - check GFR CT KUB (simultaneously do a KUB Xray (for follow up surveillance)

Answer 68

1. Analgesia with paracetamol, NSAID and codeine If no red flags: 2. Tamsulosin 400mcg daily to help passage of stones 3. Increase FLuid intake 4. If conservatively managed - advise patient to strain urine to avoid unnecessary imaging later 5. Repeat Xray KUB in 4 weeks if stone not passed 6. review in 4-6 weeks

Answer 69

- If no fever - responds to analgesia - has two kidneys/ no retention - Small stone on CT \< 5mm and distal

Answer 70

Serum Calcium uric acid PTH stone analysis Urine M/C/S 24 hour urine for calcium, oxalate, citrate, uric acid if patient is keen on going on stone prophylaxis (eg allopurinol, thiazide diuretic, potassium citrate)

Answer 71

Calcium oxalate (80%)

Answer 72

1. Increasing fluid intake throughout the day (to maintain 2L of urine/day) 2. Increase dietary potassium and phytate. 3. Decrease intake of oxalate, animal protein, sodium and supplemental calcium 4. Referal to a dietician

Answer 73

Thiazide diuretics - to reduce calcium excretion allopurinol - to reduce hyperuricosuria citrate - for hypocitraturia

Answer 74

1. Oral Paracetamol 1g qid prn 2. Indomethacin 50mg orally, three times daily 3. Tamsulosin 400micrograms daily for ureteric relaxation with or without oxycodone 5mg qid prn 4. PRESENT directly to the Emergency department if: - fever - becomes unwell - nausea and vomiting - unable to tolerate oral fluids - becomes non reponsive to pain medication 5. Strain her urine to catch the stone, - either use a seive or urinate into a white ice cream tub. Bring the stone in for stone analysis and to confimr passage. 6. Repeat imaging in 4 weeks 7. If stone not passed in 6 weeks - refer to urology

Answer 75

1. Anatomical - single functioning kidney bilateral ureteric obstruction 2. Systemic - concurrent UTI or sepsis and obstruction, premorbid CKD stage 4 or 5, eGFR less than 30, Anuric renal failure, poorly controlled diabetes, 3. Pain - intractable pain and nausea

Answer 76

1. Persistent pain 2. Stone unlikely to pass spontaneously 3. significant renal impairment 4. evidence of sepsis

Answer 77

Ureteroscopy and stenting Extracorporeal shockwave lithotripsy nephrostomy

Answer 78

1. Stone size (50% of 5mm stones will pass) 2. Stone location - stones in upper ureter or PUJ are less likely to pass than stones in the VUJ 3. Prior history of capacity to pass small stones

Answer 79

1. frequency, dysuria, haematuria and flank pain are classic 2. to diagnose a UTI here dipstick is not useful- can do a MSU culture, check inflammatory markers and look for fever, tachycardia 3. In the absence of infection - manage with NSAIDS - indomethacin 50mg TDS prn, tamsulosin 400micrograms daily and oxybutinin hydrochloride 2.5mg bd (Warn about anticholinergic side effects)

Answer 80

Any medical conditions? Depression? mood disorders? Loss of libido - male hypoactive sexual desire disorder Erection? Ejaculation? When did secondary sexual characteristics first appear? how did they manifest? Frequency and timing of sex? PMHx - orchitis, STI, trauma, mumps PHx of undescended testis and surgery - cryptorchisdsim and orchidopexy MEDS - anabolic steroids, opioids, chemotherapy

Answer 81

Cryptorchid - need to have had orchidopexy by 6 months. Still increased testicular cancer risk c/f rest of population - so need regular testicular examination. Fertility may be affected depending on time to orchidopexy. this would be indicated bya) poorly developed secondary sexual characteristics b) small testis c) low testosterone despite high FSH and LH. Despite low test and sperm count - 30% will still be able to conceive. DO NOT give exogenous testosterone in these patients if they want to be fertile. As testosterone will inhibit GnRH and LH secretion - which will decrease fertility subsequently

Answer 82

1. Examine standing first (varicocele fills) 2. Then examine lying down 3. Inspect testicles - size and shape 4. Inspect skin - sebaceous cyst? erythema? 5. If there's a lump - can you get above it/is it transilluminable/ is it separate to the testis? 6. Examine the testis 7. Examine the Epidydimis 8. Examine the spermatic cord 9. Examine hernial orifices 10. Examine cremasteric reflex (gentle stroke inner thight) raises ipsilateral testes. Absent in tortion. (most sensitive test in tortion but absent in boys less than 2.5 years) 11. Examine the prostate - associated prostatitis?

Answer 83

Onset - acute or gradual (tortion - acute, no fever, severe pain) Fever? Nausea and vomiting? (tortion) Symptoms of dysuria? (Epidydimoorchitis) Trauma? Haematocele Any voiding difficulties HIstory of recent surgery or instrumentation Sexual history - any unprotected anal sex? REGARDLESS OF AGE - think of mumps - ARE THEY UP TO DATE WITH IMMUNISATIONS? Any flu like symptoms a week ago?

Answer 84

1. tortion of testis 2. tortion of testicular appendage 3. Epidydimo orchitis/orchitis/mumps orchitis 4. strangulated hernia 5. hydrocele 6. varicocele. 7. Trauma haematocele 8. Testicular tumor (Rapid growing can in rare instance cause pain

Answer 85

Symptoms: Sudden onset no fever trauma sometimes nausea and vomiting Signs: Asymettric high riding testis negative phrens sign absent cremasteric reflex

Answer 86

symptoms Insidious onset fever and rigors LUTS Sexual histoty symptoms SIgns Indurated testis Tender upper pole Positive Phrens sign Intact cremasteric

Answer 87

- gradual onset - moderate to severe pain - often localised to upper pole - often lacks systemic symptoms cremasteric reflex is often intact Signs: Localised tenderness to anterior testis BLUE DOT sign

Answer 88

Young kids - one or both testes affected - MUMPS orchitis - ask about glands swollen in the neck Sexually active young adults - N.gonorrhea and Chlamydia Trachomatis are the most common under the 35 Older people - Ecoli, other coliforms and pseudomonas often with obstructive uropathy from BPH

Answer 89

INsertive anal sex from exposure to coliforms in the rectum

Answer 90

Urine M/C/S urine for gonorrhea and chlamydia Swab NAAT if discharge STI screen in young adults FBE CRP

Answer 91

sexually aquired - treat with ceftriaxone 500mg IM and doxycylcine 100mg bd for 14 days (or azithromycin 1g stat) UTI related - treat same as for prostatatis trimethoprim 300mg daily for 14 days

Answer 92

hydatid of morgani

Answer 93

blue dot sign/anterior localised pain Needs surgical exploration for definitivie differentiation

Answer 94

Phrens and cremasteric negative Phrens is relief of pain when you lift up testicle - points to epidydimorchitis

Answer 95

Both need surgical exploration acute setting to exclude rupture of testicle in chronic to look for cancer

Answer 96

Blunt penetrating trauma/contusion o/e bruising/loss of testicular contour/swelling ULTRASOUND is investigation of choice Surgical exploration Haematocele is a collection of blood between two layers of tunica vaginalis - drain and repair the tunic vaginalis - may have lasting testicular damage and may need removal

Answer 97

ultrasound to exclude underlying pathology like tumour 1st line - conservative management - reassurance and scrotal support 2nd line - surgical aspiration +/- scelerosing agent With repeat aspirations there is a risk of bleeding/infection

Answer 98

Common - 8-10% of men Left sided in 98% of cases May have dragging sensation. Bag of worms appearance Associated with infertility MAY PRESENT WITH ANY OF : Left sided dull pain worse with standing and relieved by recumbency Decreased fertility Atrophy of left testicle

Answer 99

1. Generally doesnt need acute management 2. Tight underwear may settle dragging sensation. 3. **Surgery has three indications:** 1. Draggins sensation, symptomatic and doesnt settle with tight underwear 2. interferes with testicular growth esp in young patient 3. reduced fertility with reduced sperm quality - can check 1-2 years in pt with varicocele 4. If its associated with testicular atrophy

Answer 100

Cause: organic, psychosocial or combined * Patient and partner preferences * Benefits, risks and costs of treatment options Treatment summary 1st line • Alter modifiable risk factors and causes • Facilitate sexual health 2nd line • Oral agents (PDE5 inhibitors) * Counselling and education * Vacuum devices/rings 3rd line * Consider specialist referral * Intracavernous vasoactive drug injection 4th line * Specialist referral * Surgical treatment (penile implants)

Answer 101

Lifestyle - esp CV risk factors, General health, Chronic CV or neurological disease, Medications (CV, neuro, psych, hormonal) ## Footnote Define the nature of the sexual dysfunction, ED onset, Spontaneous morning erections, Genital disease Penetration possible Maintenance of erection Depression Anxiety Relationship difficulties Sexual abuse

Answer 102

1st line treatment **Alter modifiable risk factors and causes** * Modify medication regime: Change current medications linked to ED (e.g. antidepressants, antihypertensives) when possible * Manage androgen deficiency: When diagnosed and a cause is established, androgen replacement therapy * Address psychosocial issues: Includes relationship difficulties, anxiety, lifestyle changes or stress **Facilitating sexual health** • Lifestyle changes: Smoking cessation, reduced alcohol, improved diet and exercise, weight loss, stress reduction, illicit drug cessation, compliance with diabetes and cardiovascular medications • Discuss sexual misinformation: Includes importance of suffi cient arousal and lubrication, and realistic expectations, such as normal age-related changes

Answer 103

Adapt dose as necessary, according to the response and sideeffects * Treatment is not considered a failure until full dose is trialled 7-8 times * Ensure patient knows that sexual stimulation is required for drug to work * Common side-effects: headaches, fl ushing, dyspepsia, nasal congestion, backache and myalgia * Contraindicated in patients who take long and short-acting nitrates, nitrate-containing medications, or recreational nitrates (amyl nitrate) * Exercise caution when considering PDE5 inhibitors for patients with: active coronary ischaemia, congestive heart failure and borderline low blood pressure, borderline low cardiac volume status, a complicated multi-drug antihypertensive program, and drug therapy that can prolong the half-life of PDE5 inhibitors **Counselling and education** • Offer brief counselling and education to address psychological issues linked with ED, such as relationship difficulties, sexual performance concerns, anxiety and depression • Consider concurrent patient/couple counselling with a psychologist, to address more complex issues, and/or to provide support during other treatment trials **Vacuum devices and rings** • Suitable for men who are not interested in, or have contraindications for pharmacologic therapies • Not suitable for men with severe ED • Typically suitable for patients in long-term relationships • Adverse effects include penile discomfort, numbness and delayed ejaculation

Answer 104

3rd line treatment ## Footnote • Consider referral or specialist training Intracavernous vasoactive drug injection • Alprostadil (Caverject Impulse®): 10 and 20 mcg is the first choice for its high rate of effectiveness and low risk of priapism and cavernosal fibrosis. If erection is not adequate with alprostadil alone, it may be combined with other vasoactive drugs (bimix/trimix) to increase efficacy or reduce side-effects * Commence with minimum effective dose and titrate upwards if necessary * Initial trial dose should be administered under supervision of an experienced GP or specialist * Erection usually appears after 5 to 15 minutes and lasts according to dose injected. Aim for hard erection not to last longer than 60 minutes * Recommended maximum usage is 3 times a week, with at least 24 hours between uses * Contraindicated in men with history of hypersensitivity to drug or risk of priapism * Patient comfort and education are essential. Inform patient of side-effects (priapism, pain, fibrosis and bruising, particularly if on Aspirin or Warfarin). Provide a plan for urgent treatment of priapism if necessary

Answer 105

4th line treatment ## Footnote * Refer to urologist (surgical treatments) * Penile prosthesis: A highly successful option for patients who prefer a permanent solution or have not had success with pharmacologic therapy. Surgery is irreversible and eliminates the normal function of the corpus cavernosa. Cost may be a limiting factor for some patients • Vascular surgery: Microvascular arterial bypass and venous ligation surgery can increase arterial in flow and decrease venous outflow but restoration of normal function is uncommon

Answer 106

All patients should have _a urine microscopy, culture and sensitivity (MCS), urine cytology, and a full blood count and coagulation studies performed._ Other investigations may be considered in those patients with high risk (red flag) features such as: patient’s age (\>40 years) recurrent or persistent haematospermia prostate cancer risk factors (eg positive family history or African heritage) constitutional symptoms (eg weight loss, anorexia, bone pain). _If an STI is suspected,_ **urine NAAT for chlamydia and gonorrhoea** should be performed, ideally with a first-pass urine specimen. A prostate-specific antigen **(PSA)** assay should be performed in _men \>40 years of age or if DRE is abnormal or significant prostate cancer risk factors_ are present.

Urology Flashcards

(153 cards)