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Urology Flashcards

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1
Q

What is nephrolithiasis, ureterolithiasis and cystolithiasis?

A

Nephrolithiasis – kidney stone
Ureterolithiasis – ureteric stone
Cystolithiasis – bladder stone

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2
Q

What are the risk factors for stone formation?

A

Obesity
Dehydration
Hypercalciuria, Hyperparathyroidism and hypercalcaemia
Metabolic conditions – cystinuria, high dietary oxalate
Renal tubular acidosis
Medullary sponge kidney and polycystic kidney disease
Beryllium or cadmium exposure
Gout and ileostomies (loss of bicarbonate and fluids results in acidotic urine)
Drugs – diuretics, steroids, acetazolamide, theophylline

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3
Q

What causes stone formation?

A

Proteus species common cause of stones
Abnormal calcium, phosphate, urate and cystine levels in the body
Pregnancy and right sided stones

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4
Q

What are the main types of stones that form and what pH do they form under?

A

Calcium oxalate (most common) occurs in variable urine pH
Calcium Phosphate (5-10%) due to normal pH or alkalotic urine
Struvite (ammonium magnesium phosphate) (5-10%) due to infections in the urinary system and alkaline pH
Urate (radiolucent) due to persistently acidic urine
Cystine (rare) due to genetic disorders and occurs in normal pH urine

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5
Q

What are the clinical feature of renal stones?

A 
Sever urinary colic pain in the flanks that can radiate to the groin (testicle and labia)
Haematuria but visible and invisible
Painful urination 
Urinary urgency
Nausea and vomiting 
Sweating
Hydronephrosis of affected kidney
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6
Q

How should suspected renal stones be investigated?

A

Urinalysis with dipstick and culture
Renal function + bone profile (including urate)
Routine inflammatory markers for signs of infection
Group and save, crossmatch and clotting if surgery likely
USS to assess for stones and hydronephrosis
CT KUB (non-contrast) within 14 hours of admission)

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7
Q

How should pain be managed in renal colic?

A

Analgesia – NSAIDS, most commonly diclofenac IM/PR or ibuprofen

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8
Q

What might suggest a more invasive management is needed for dealing with renal stones?

A

More invasive management may be required if ureteric obstruction, renal developmental abnormality, and previous renal transplant.

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9
Q

What surgical emergency can stones cause and how is it managed?

A

Ureteric obstruction due to stones + infection is surgical emergency, must release compression – nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placements.

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10
Q

When is a conservative approach to stones indicated?

A

If stone is small (<5mm) will probably pass spontaneously if not it may need to be removed

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11
Q

What are the surgical options for renal stones and when are they indicated?

A
  • ESWL (extra corporeal shock wave Lithotripsy) – external shock waves, can cause solid organ damage and patient required analgesia. Indicated in stone burden <2cm in aggregate
  • PCNL Percutaneous nephrolithotomy – access gain to the renal collecting system then intra corporal lithotripsy is performed and stone fragments removed. Indicated in complex renal calculi and staghorn calculi.
  • Flexible Ureteroscopy passed into the renal pelvis, indicated when lithotripsy is contraindicated e.g. pregnant females, stent usually left in situ for 4 weeks.
  • Open surgery
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12
Q

What advice/drugs can we give to prevent renal stone formation?

A
  • Thiazide diuretics to increase distal tubular calcium resorption
  • Increase fluid intake
  • Increase citrate intake
  • Limit sodium intake
  • Avoid vitamin C supplements
  • Limit animal protein
  • Limiting soft drinks
  • Oxalate stones – cholestyramine or pyridoxine
  • Uric acid stones – allopurinol or urinary alkalization with oral bicarbonate or acetazolamide
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13
Q

What is an epididymal cyst?

A

Epididymal cysts are the most common cause of scrotal swellings seen in primary care.

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14
Q

What are the clinical features of an epidiymal cyst?

A

Separate from the body of the testicle
Found posterior to the testicle
Diagnosis may be confirmed by ultrasound

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15
Q

What conditions are epididymal cysts associated with?

A

Associated with polycystic kidney disease, cystic fibrosis, and von Hippel-Lindau syndrome

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16
Q

How should epidiymal cysts be managed?

A

Management – supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts

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17
Q

What is a hydrocele and what are the two types?

A

A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
• Communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in Newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
• Non-communicating: caused by excessive fluid production within the tunica vaginalis

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18
Q

What can cause hydroceles?

A

Epididymo-orchitis
Testicular torsion
Testicular tumours

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19
Q

What are the clinical features of a hydrocele?

A

Soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
Transilluminates with a pen torch
The testis may be difficult to palpate if the hydrocele is large

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20
Q

What investigations should be done in a hydrocele?

A

Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated.

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21
Q

How are hydroceles managed?

A

Infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years.

In adults a conservative approach may be taken depending on the severity of the presentation.

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22
Q

What is a varicocele?

A

A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.

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23
Q

What are the clinical features of a varicocele?

A

Varicoceles are much more common on the left side (> 80%).
Classically described as a ‘bag of worms’
Subfertility
Sometimes painful

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24
Q

How should varicoceles be investigated?

A

Ultrasound with Doppler studies

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25
How are varicoceles managed?
Usually conservative Occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
26
What is acute bacterial prostatitis?
Gram negative bacterial entering the prostate gland via the urethra, usually this is E.coli. Most common this occurs as a result of recent urinary tract infections, urogenital instrumentation, intermittent bladder catheterisation and recent prostate biopsy.
27
What are the clinical features of acute bacterial prostatitis?
Pain that can be referred to the perineum, penis, rectum or back Obstructive voiding symptoms Fever and rigors DRE – tender boggy prostate
28
How is acute bacterial prostatitis managed?
14-day course of a quinolone such as ciprofloxacin or ofloxacin Screen for STIs
29
What is balanitis?
Definition – inflammation of the glans penis which sometimes extends to the underside of the foreskin (balanoposthitis).
30
What can cause balanitis?
``` Infective – bacterial (staph species and E.coli) and candida Autoimmune Dermatitis (contact or allergic) Dermatitis (psoriasis or eczema) Lichen planus (most commonly adults) ```
31
What are the clinical features of balanitis?
Candida – occurs following intercourse and is associated with itching and white non-urethral discharge Allergic/contact dermatitis – itchy, painful, and clear non-urethral discharge Psoriatic/eczema dermatitis – very itchy but no discharge Bacterial – painful and itchy with yellow (+/_- offensive) non-urethral discharge
32
How should suspected balanitis be investigated?
Mostly a clinical diagnosis Swab of the glans and any discharge Biopsy if unsure and extensive skin changes
33
What is the general management of balanitis and specific management for Candidal, bacterial or dermatitis balanitis?
Gentle saline washes Ensuring to wash properly under the foreskin 1% hydrocortisone in severe irritation Candida – topical clotrimazole for 2 weeks Bacterial – flucloxacillin or clarithromycin (+ oral metronidazole of anaerobic) Dermatitis balanitis – mild potency topical corticosteroids such as hydrocortisone Circumcision can help in lichen planus
34
What is epididymo-orchitis?
Infection of the epididymis +/- testes resulting in pain and swelling. Most commonly local spread of infections from the genital tract such as chlamydia or gonorrhoea or from the bladder e.g. E.coli.
35
What are the clinical features of epidiymo-orchitis?
Unilateral testicular pain and swelling History of dysuria Urethral discharge Swelling is tender and eased be elevating testis
36
How should epidiymo-orchitis be investigated?
Rule out testicular torsion – factors suggesting torsion = <20y, severe pain and acute onset
37
How is epididymo-orchitis managed?
Unknown organism – ceftriaxone IM single dose plus Doxycycline PO BD for 10-14 days Further investigations following treatment to exclude underlying structure abnormalities
38
What can cause unilateral and bilateral hydronephrosis?
``` Unilateral (PACT) • Pelvic-ureteric obstruction (congenital or acquired) • Aberrant renal vessels • Calculi • Tumours of the renal pelvis ``` ``` Bilateral (SUPER) • Stenosis of the urethra • Urethral valve(s) • Prostatic enlargement • Extensive bladder tumour • Retro-peritoneal fibrosis ```
39
How should hydronephrosis be investigated?
USS – first line and identifies the presence of hydronephrosis IVU – ass the position of the obstruction Antegrade or retrograde pyelography – allows treatment If suspecting renal colic – CT scan
40
How should hydronephrosis be managed?
Removal of the obstruction Acute upper urinary tract obstruction – nephrostomy tube Chronic upper urinary tract obstruction – ureteric stent or pyeloplasty
41
What is the difference between high and low pressure urinary retention?
High pressure retention – impaired renal function and bilateral hydronephrosis, typically due to bladder outflow obstruction Low pressure retention – normal renal function and no hydronephrosis
42
What is acute urinary retention?
Definition – sudden or rapidly becomes unable to voluntarily pass urine and is painful
43
What causes acute urinary retention?
* Benign prostatic hyperplasia * Urethral obstructions – strictures, calculi, cystocele, constipation, or masses * Drugs – anticholinergics, TCAs, antihistamines, opioids, and benzodiazepines * Neurological – MND, MS and Parkinson’s * UTI in predisposed patients * Postoperatively and postpartum due to combination of above * Constipation
44
What are the clinical features of acute urinary retention?
Inability to pass urine Lower abdominal discomfort Considerable pain and distress (different to chronic which is painless) Acute confusional state in elderly patients In a background of chronic retention acute may present with overflow incontinence Palpable distended bladder
45
How should acute urinary retention be investigated?
Urine sample and urinalysis and culture (usually after catheterisation) Routine bloods especially looking at AKI DRE may be appropriate Post void bladder scan
46
How is acute urinary retention managed?
Catheterisation – if less than 200ml drain in 15 mins then patient was not in retention, if over 400ml then leave the catheter in and if in between up to clinical decision Manage cause If high pressure then keep catheter in situ until definitive management is in place
47
What is post obstructive diuresis?
Post obstructive Diuresis – kidneys may increase diuresis due to the loss of medullary concentration gradient which can take time to equilibrate, this can lead to volume depletion and worsening of AKI and some patients may as a result require temporary IV fluids.
48
What is chronic urinary retention and how does it present?
The painless inability to pass urine and is usually insidious. ``` Clinical Features LUTS Reduced urine output Overflow incontinence Palpable distended bladder ```
49
How should chronic urinary retention be investigated?
Post void bladder scan Routine bloods If high pressure, then USS of urinary tract
50
How is chronic urinary retention managed?
If high pressure or very large volumes, then long term catheterisation Monitor for post void diuresis Do not TWOC until definitive management is in place for the cause Can use intermittent self-catheterisation if patients want to avoid long term catheters Decompression haematuria is common following catheterisation for chronic retention due to the rapid decrease in pressure – usually does not require further treatment
51
What is erectile dysfunction?
Persistent inability to attain and maintain an erection sufficient to permit sexual intercourse.
52
What are the 3 types of causes of erectile dysfunction and what features suggest each of them?
* Organic – gradual onset, lack of tumescence and normal libido * Psychogenic – sudden onset, decreased libido, good quality spontaneous or self-stimulated erections, major life events, problems or change in relationship, previous psychological problems, and history of premature ejaculation * Mixed
53
What are the risk factors for erectile dysfunction?
Cardiovascular disease – obesity, diabetes, dyslipidaemia, metabolic syndrome, hypertension, and smoking Alcohol use Drugs – SSRIs and beta blockers
54
How should erectile dysfunction be investigated?
``` Calculate 10-year cardiovascular risk assessment (lipids and fasting glucose) Free testosterone (morning 9a-11am) If free testosterone is low or borderline then repeat along with FSH, LH and prolactin. If any of these are abnormal then refer to endocrinology. ```
55
How is erectile dysfunction managed?
PDE-5 inhibitors – sildenafil or Viagra, prescribe to all patients regardless of cause If Sildenafil is contraindicated, then vacuum devices are first line If young and always had issues with achieving erections, then referral to urology is appropriate People with erectile dysfunction who cycle for more than 3 hours per week should be advised to stop
56
What are the contraindications for sildenafil?
* Inherited degenerative retinal disorders * Optic neuropathy * Recent MI or stroke * Systolic BP < 90 * Recent unstable angina * Active peptic ulceration * Anatomical deformity or predisposition to priapism * Autonomic dysfunction
57
What is priapism?
Persistent penile erection typically defined as lasting longer than 4 hours and is not associated with any sexual stimulation.
58
How is priapism classified?
Ischaemic – impaired vasorelaxation and therefore reduced vascular outflow resulting in congestion and trapping of de-oxygenated blood within the corpus cavernosa Non-ischaemic – is due to high arterial inflow typically due to fistula formation congenitally or via trauma mechanisms
59
What are the causes of priapism?
Idiopathic Sickle cell disease or other haemoglobinopathies Sildenafil or intracavernosal injected therapies Other drugs – anti-hypertensives, anticoagulants, antidepressants and recreational Trauma
60
What are the clinical features of priapism?
Persistent erection Pain localised to the penis History linking to a cause Non painful or semi-erection suggest non-ischaemic priapism History of trauma also suggestive of non-ischaemic priapism
61
How should priapism be investigated?
Cavernosal blood gas analysis to differentiate cause Doppler or duplex US is an alternative FBC and toxicology screen Clinical Diagnosis
62
How is priapism managed?
Medical emergency if ischaemic If priapism has lasted longer than 4 hours then first line treatment is aspiration of blood from the cavernosa (+saline flush to clear viscous blood that has pooled) Intracavernosal injection of a vasoconstrictive agents such as phenylephrine and repeat at 5 minutes Surgical options considered after this Non-ischaemic priapism is non-emergency and normally suitable for observation

Surgery (6 decks)

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