Urology fifth yr Flashcards
(47 cards)
Summary of acute bacterial prostatitis?
typically caused by gram-negative bacteria entering the prostate gland via the urethra.
E. coli most common
RF’s - recent UTI, urogenital instrumentation, intermittent bladder catheterisation, recent prostate biopsy
Sx - referred pain to perineum, penis, rectum, back, obstructive voiding Sx, fever, rigours, DRE - tender, boggy prostate
Tx - 14 days of quinolone, screen for STIs
Summary of acute urinary retention?
most common urological emergency
when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine
common in men, rare in women. increases with age
Causes - BPH, urethral strictures, calculi, cystocele, constipation or masses. Medications (anticholinergics, TCAs, antihistamines, opioids, BDZs), can also be neuro cause, after UTI, post-op and post partum too
Sx - inability to pass urine, lower abdominal discomfort, pain/distress, acute confusion in elderly pt’s
O/E - palpable distended urianry bladder (on abdo or rectal), lower abdo tenderness, do rectal and neuro exam to assess for cause! women have pelvic exam
Differs from chronic urinary retention which is typically painless. Acute on chronic urinary retention may present as overflow incontinence
Ix - urine MC&S, urine catheterisation, U&Es, FBC, CRP
Tx - bladder ultrasound, catheterisation (measure urine in 15 minutes), depending on cause referral to appropriate specialist
Complications - post-obstructive diuresis - kidneys increase diuresis due to loss of medullary concentration gradient and takes time to re-equilibrate. Lead to volume depletion and worsening of AKI. May need IV fluids to correct this temporarily
Summary of balanitis?
inflammation of the glans penis and sometimes extends to the underside of the foreskin which is known as balanoposthitis
most common causes = infective (bacterial + fungal), AI
candidiasis - after intercourse, itching, white non-urethral discharge - treat with topical clotrimazole for 2 wks
dermatitis (contact or allergic) - itchy, painful, clear non-urethral discharge - mild corticosteroid
dermatitis (eczema or psoriasis) - itchy, no discharge, Hx of inflammatory skin condition
bacterial - painful, itchy, yellow non-urethral discharge, Staph spp. - oral fluclox. or clarithromycin
Anaerobic - itchy, very offensive yellow non-urethral discharge - topical or oral metronidazole if washing not helping
Lichen Planus - itchy, Wickhams striae, violaceous papules
Lichen sclerosus - balanitis xerotica obliterans - itchy, white plaques, significant scarring - high potency topical steroids (clobetasol), circumcision
plasma cell balanitis of Zoon - non itchy, clearly circumscribed areas of inflammation - clobetasol
Circinate balanitis - non itchy, no discharge, painless erosions, associated with reactive arthritis - mild corticosteroid
Ix - clinical diagnosis, swab for MC&S, biopsy in extensive cases
Tx - hygiene (saline washes, washing under foreskin) 1% hydrocortisone if severe irritation
Risk factors for BPH?
age
around 50% of 50-year-old men will have evidence of BPH and 30% will have symptoms
around 80% of 80-year-old men have evidence of BPH
ethnicity: black > white > Asian
Sx of BPH?
Voiding Sx (obstructive) - weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
Storage Sx - urgency, frequency, urgency incontinence, nocturia
Post-micturition - dribbling
Complications - UTI, retention, obstructive uropathy
Ix for BPH?
Urinalysis
U&Es - esp. if chronic retention suspected
PSA - if obstructive Sx, or concerns about prostate ca
urine frequency-volume chart - for 3 days
IPSS - >20 severely symptomatic
Management of BPH?
watchful waiting
alpha-1 antagonists - tamsulosin, alfuzosin - decreases smooth muscle tone of prostate and bladder - first-line - SE = dizziness, postural hypotension, dry mouth, depression
5 alpha-reductase inhibitors - finasteride - block conversion of testosterone to dihydrotestosterone, which is known to induce BPH - indicated if signicantly large prostate and high risk of progression - causes reduction in prostate volume and hence may slow disease progression - Sx may not improve for 6m - can decrease PSA concentrations up to 50% - SE = ED, reduced libido, ejaculation problems, gynaecomastia
use of both if moderate to severe voiding Sx and prostatic enlargement
if there is a mixture of storage symptoms and voiding symptoms that persist after treatment with an alpha-blocker alone, then an antimuscarinic (anticholinergic) drug such as tolterodine or darifenacin may be tried
Surgery - TURP
Epidemiology of bladder cancer?
second most common urological cancer
males aged between 50 and 80 years of age.
benign tumours - inverted urothelial papilloma and nephrogenic adenoma are uncommon
RFs for bladder cancer?
TCC:
Smoking
Exposure to aniline dyes (printing and tactile industry)
Rubber manufacture
Cyclophosphamide
SCC:
Schisosomiasis
Smoking
Types of bladder malignancies?
Urothelial (transitional cell) carcinoma (>90% of cases)
Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis)
Adenocarcinoma (2%)
Sx of bladder cancer?
painless, macroscopic haematuria
Ix and Tx of bladder cancer?
cystoscopy and biopsies or TURBT
pelvic MRI
CT scanning for distant disease
PET CT for unknown nodes
TNM staging
Tx:
Superifical lesions - TURBT - transurethral resection of bladder tumour
Recurrences or higher grade/ risk on histology may be offered intravesical chemotherapy
T2 disease are usually offered either surgery (radical cystectomy and ileal conduit) or radical radiotherapy
Summary of chronic urinary retention?
Painless and insidious
High pressure retention - impaired renal function, bilateral hydroneprhosis, typically due to BOO
Low pressure retention - normal renal function, no hydronephrosis
Decompression haematuria occurs commonly after catheterisation for chronic retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment.
Summary of circumcision?
performed in a variety of cultures - Jewish and Islamic.
Medical benefits of routine circumcision - reduces risk of: penile cancer, UTI, acquiring STIs
Medical indications for circumcision - phimosis, recurrent balanitis, balanitis xerotica obliterans, paraphimosis
Need to exclude hypospadias prior to circumcision as the foreskin may be used in surgical repair.
Circumcision may be performed under a local or general anaesthetic.
Summary of epididymal cysts?
most common cause of scrotal swellings seen in primary care.
Sx - separate from body of testicle, found posterior to testicle
Associated conditions - polycystic kidney disease, CF, von Hippel-Lindau syndrome
Dx - USS
Summary of epididymo-orchitis?
an infection of the epididymis +/- testes resulting in pain and swelling
Commonly from local spread of infection from genital tract (Chlamydia or Gonorrhoea in younger pt’s) or bladder (E. coli in older adults)
Sx - unilateral testicular pain and swelling, urethral discharge may be present - need to exclude testicular torsion!!
Ix - younger - STI screen, older - MC&S
Tx -
STI - refer to clinical, if unknown organism - IM ceftriaxone + PO doxycycline
Enteric organism - oral quinolone for 2 weeks (SE - tendon damage/rupture, lower seizure threshold)
Summary of erectile dysfunction?
persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance
Symptom - not a disease
Causes - organic, psychogenic, mixed
Factors favouring organic - gradual onset, lack of tumescence, normal libido
Factors favouring psychogenic - sudden onset, decreased libido, good quality spontaneous or self-stimulated erections, major life events, problems in relationship, previous psychological problems, Hx of premature ejaculation
RFs - increasing age, CVD (obesity, DM, dyslipidaemia, metabolic syndrome, HTN, smoking), alcohol use, drugs (SSRIs, beta-blockers)
Ix - have 10-year CVD risk calculated, free testosterone in AM, if low - repeat with FSH, LH, and prolactin - if abnormal, refer to endocrinology
Tx
PDE-5 inhibitors
Vacuum erection devices if can’t take PDE-5 inhibitor
for a young man who has always had difficulty achieving an erection, referral to urology is appropriate
people with erectile dysfunction who cycle for more than three hours per week should be advised to stop
Summary of hydrocele?
describes the accumulation of fluid within the tunica vaginalis
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
Secondary to: epididymo-orchitis, testicular torsion, testicular tumours
Sx - soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle, you can get ‘above’, transilluminates, testes difficult to palpate if large
Dx - clinical, or US if in doubt or underlying testes cannot be palpated
Tx - 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. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
Causes of unilateral hydronephrosis?
PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Causes of bilateral hydronephrosis?
SUPER
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
Ix and Tx of hydronephrosis?
Ix
US - identifies presence of hydronephrosis, assesses kidney
IVU - assess position of obstruction
Antegrade or retrograde pyelography- allows treatment
if suspect renal colic: CT scan (majority of stones are detected this way)
Tx:
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: nephrostomy tube
Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty
Summary of lower genitourinary tract trauma?
Mostly due to blunt trauma. 85% associated with pelvic fractures
Urethral injury
mainly in males, blood at meatus, 2 types
bulbar rupture - most common, straddle type injury e.g. bicycles, triad signs: urinary retention, perineal haematoma, blood at the meatus
Membranous rupture - extra/intraperitoneal, commonly due to pelvic fracture, penile or perineal oedema/haematoma, PR - prostate displaced upwards
Ix - ascending urethrogram
Tx - suprapubic catheter - surgical placement, not percutaneously
External genitalia injuries - secondary to penetration, blunt trauma, devices, mutilation
Bladder injury
rupture is intra or exztraperitoneal
haematuria or suprapubic pain
Hx of pelvic fracture and inability to void - always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through Foley catheter indicates bladder injury
Ix - IVU or cystogram
Tx - laparotomy if intraperitoneal, conservative if exztraperitoneal
3 groups of LUTS?
Voiding - hesitancy, poor/intermittent stream, straining, incomplete emptying, terminal dribbling
Storage - urgency, frequency, nocturne, urinary incontinence
Post-micturition - dribbling, sensation of incomplete emptying
Summary of nephroblastoma?
Wilms tumour
Usually presents in first 4 years of life
May often present as a mass associated with haematuria (pyrexia may occur in 50%)
Often metastasise early - usually to lung
Treated by nephrectomy
Younger children = better prognosis
