Urology II Flashcards

Question

``` Which of the following is not a recognised complication of circumcision? (Please select 1 option) Bleeding Damage to the glans Delayed healing Orchitis Pain ```

Answer 1

Orchitis The post-operative complications following circumcision is estimated to be between 2-10%. The most common complication is pain, bleeding and infection. Damage to the glans may not become apparent until the child grows into adulthood and results from excessive skin removal or scarring.

Answer 2

Irreducible inguinal hernia With any acute swollen scrotum the fear is of torsion of testis. This is uncommon in the neonate and is much commoner around puberty. Presentation is with a hard tender testis and spermatic cord -/+ a red scrotum. Torsion of the appendage of testis has a peak incidence of between 4 and 8 years of age as does acute idiopathic scrotal oedema. In the former, there is a tender upper pole of testis with a blue spot on transillumination. In the latter the erythema extends beyond the scrotum and the testis is minimally tender. Epididymitis is rare before puberty, and presents with a tender epididymus (urological investigations are needed, as it is associated with reflux of infected urine via the vas deferens). Inguinal herniae that are irreducible have a peak incidence below 2 years of age. A firm immobile tender swelling is found in the scrotum, which becomes inflamed as the strangulation occurs. Occasionally, acute hydroceles can also present with a mobile blue transilluminating swelling at 1-3 years of age.

Answer 3

Ultrasound scan This is the correct answerThis is the correct answer If the testis is ectopic then it may be palpable outside the normal line of descent. However in obese boys ultrasound may be useful in identifying its location. Radionucleotide scans and x rays should be avoided and hormonal testing may be useful in cases of bilateral impalpable testes to detect the presence of testicular tissue within the body. Laparoscopy is the investigation of choice if the testes are impalpable to determine whether they are absent or intra-abdominal.

Answer 4

In infants under one year approximately 50% present with incarceration This is the correct answerThis is the correct answer Inguinal hernias are the commonest surgical condition of childhood. Approximately 2% of male infants will develop an inguinal hernia and 99% will be indirect. The male:female ratio is 9:1. Inguinal hernias are more common on the right and 10% are bilateral. Prematurity is a significant risk factor. The risk of incarceration is increased in infants and therefore a hernia presenting before one year of age requires urgent surgical assessment. Approximately 20% will develop a contralateral hernia. The role of contralateral groin exploration at the time of a unilateral herniotomy is controversial.

Answer 5

Requires contralateral orchidopexy if a torsion is confirmed The commonest causes of the 'acute scrotum' in childhood are testicular torsion, torsion of an appendix testis and idiopathic scrotal oedema. Testicular torsion can occur at any age with a peak incidence between 14 and 20 years. It usually presents with severe testicular pain but this may be absent and the testis should be examined in all boys with abdominal symptoms. If torsion is clinically suspected then radiological investigations have little to offer. None are diagnostic and may delay surgery. Testicular viability is reduced with increasing time from the onset of symptoms. Following reduction of a torsion, 3-point fixation with an non-absorbable suture should be performed. The contralateral testis should also be fixed.

Answer 6

The maldescended right testis is often palpable in the groin By 18 months the testicles should have descended. If they are not in the scrotum it is important to determine whether they are undescended, retractile and ectopic or absent. The maldescended testicle is often palpable in the groin and is often associated with indirect inguinal hernias. Orchidopexy needs to be carried out in the second year of life to minimise the risk of complications. Depending on the location of the testicle, surgery may or may not be required. If the testicle is considered to be retractile the patient needs to be monitored, and if maldescended, orchidopexy is required.

Answer 7

An operation is required for an inguinal hernia A hydrocele is an accumulation of fluid in the tunica vaginalis. Small hydroceles tend to disappear spontaneously by the age of 1 year. Larger ones may need surgical correction. When the amount of fluid varies there is communication with the peritoneal cavity and these hydroceles need to be treated as indirect inguinal hernias. The treatment for inguinal hernias is called a herniotomy. This is the excision of the hernial sac. A herniorrhaphy is carried out in addition to herniotomy in older patients and involves the repair of the posterior weak muscle wall. In adults muscle weakness is an important cause for the development of hernias, however in children they form during embryology. Testes descend into the scrotum during the seventh month of gestation. They are preceded by processus vaginalis - an outpouching of peritoneum. This obliterates before birth, and failure to do so results in inguinal hernia, hydrocele of the cord or hydrocele.

Answer 8

Cerebral oedema Bladder irrigation with glycine can result in acute hyponatraemia, the so called TURP syndrome, which may precipitate cerebral oedema, and in turn result in relative hypotension with a bradycardia.

Answer 9

Can be treated with 5-alpha-reductase-inhibitor BPH mainly affects the inner transitional zone. The outer peripheral zone is usually compressed and feels smooth to digital rectal examination. Any palpable nodule or irregularity should raise the possibility of malignancy. BPH seems to be an androgen-driven disease. Castration prior to puberty seems to prevent the disease. Alpha-blockers cause relaxation of smooth muscles and improve symptoms, whereas anticholinergic drugs could worsen symptoms and precipitate acute urinary retention.

Answer 10

Schistosoma haematobium infection Painless haematuria is typical of bladder transitional cell carcinoma, not squamous cell carcinoma. Schistosomiasis is a tropical disease caused by a worm. It typically presents with frequency and painless haematuria.

Answer 11

Urine culture Further investigation of young patients with a second episode of renal colic is recommended. Clearly urine culture is an important investigation to exclude concurrent infection, and infection associated with stone formation. x Ray of hands is really not required, nor is renal biopsy. A urinary amino-acid chromatography and plasma calcium are also important, and assessment for cystinuria/renal tubular acidosis is also required.

Answer 12

Poorly oxygenated blood within the corpora cavernosa is indicative of low flow (veno-occlusive) priapism The peak systolic velocity in the cavernosal arteries is normally less than 0.4 m/s. A higher flow in the presence of priapism is indicative of high-flow (arterial) priapism. Priapism is primary or idiopathic in 60% of cases. Twenty per cent of secondary priapism cases are haematologic in origin, for example: Sickle cell disease Leukaemia, and Heparin therapy. Other causes are: Neurogenic Traumatic, and Infectious. On the basis of aetiology, priapism can be broadly divided into low flow (veno-occlusive) and high flow (arterial) varieties. The former involves a physiologic or mechanical obstruction to venous drainage of the penis which causes a build-up of viscous, poorly oxygenated blood within the corpora cavernosa. The origin of priapism in these cases may be secondary to multiple areas of sludging and thrombosis. The major causes of veno-occlusive priapism are: Complication of sickle cell disease Haematopoietic malignancy, and A hypercoagulable state. Arterial (high-flow) priapism is a physiologically distinct entity which is markedly less common than the veno-occlusive form. Arterial priapism results from unregulated inflow of arterial blood into the lacunar spaces of the corpora cavernosa from a lacerated cavernous artery, bypassing regulatory function of helicine arterioles. Aetiology of increased arterial inflow may be: Secondary to arteriovenous fistula Frank arterial laceration with extravasation, and A pseudoaneurysm. Although most cases of high flow priapism are secondary to blunt or penetrating trauma to the perineum or penis, a large majority of cases - especially in adults - may be idiopathic, without history of pertinent trauma or findings of anatomic abnormalities. Arterial priapism may be treated with arterial ligation or percutaneous embolisation. Other therapeutic modalities, such as sustained perineal compression and ice packs, or intracavernous administration of alpha-adrenergic agonists have proven to be less effective.

Answer 13

Proteolytic enzyme PSA is a serine proteinase, a proteinolytic enzyme that is produced by the epithelial cells of the prostate and is involved in the liquefaction of the seminal fluid. Small concentrations may be found in the blood and these may occur due to absorption across the prostate and urethral epithelium particularly following ejaculation. Hence the recommendation is to avoid measuring PSA for two days after ejaculation. It does not appear to have any detrimental effect when released into the blood. Levels can rise following manipulation but evidence would indicate that there is no or just a small rise after rectal examination. However, levels may rise after more direct manipulation such as catheterisation or cystoscopy.

Answer 14

Occupational history may be of relevance Haematuria is the commonest presenting feature in TCC and TCC is found in approximately 20% of patients presenting with frank haematuria. It is strongly associated with cigarette smoking and occupational exposure to certain chemicals (for example, â-napthalamine) greatly increases the risk of TCC. Ureteric obstruction, when present, is usually in the presence of an invasive TCC. TCC recurs frequently and in a proportion of patients will progress. Cystoscopic surveillance is carried out on all patients following a diagnosis of TCC.

Answer 15

Recurrent balanitis This is the correct answerThis is the correct answer Circumcision is contraindicated in hypospadiasis since the tissue of the foreskin may be required for urethral reconstruction. Circumcision should be considered in the setting of recurrent urinary tract infections and particularly balanitis. The foreskin would not necessarily be retractable at aged 5.

Answer 16

Can lead to polycythaemia Adenocarcinoma (hypernephroma), arising from renal tubular cells, is the most common neoplasm of the kidney (75%). It is more prevalent in patients over 40 years of age and affects more males than females (2:1). Haematuria with occasional clot colic is the usual presenting symptom. A dragging discomfort in the loin is felt in a significant proportion of the patients. An abdominal mass is palpable in only about 25-45% of the cases. In men, a rapidly developing varicocele (most often on the left) is a rare but impressive sign. This is because the left testicular vein drains into the left renal vein, whilst the right testicular vein drains directly into the inferior vena cava. Polycythaemia occurs in about 4% of cases as a result of erythropoietin production by tumour cells. The other symptoms (features) or presentations include Pyrexia Hypertension Hypercalcaemia and Nephrotic syndrome.

Answer 17

The incidence is approximately 0.3% of male infants This is the correct answerThis is the correct answer Hypospadias, which is a defect in the ventral aspect occurs in three in 1000 births. Epispadius is a defect in the dorsal aspect of the penis and this is much rarer occurring in one in 30,000 births. (Therefore the majority have hypospadias - ventral aspect). It may occur on its own but is associated with exstrophy of the bladder (when the bladder mucosa is exposed to the outside). The abnormalities associated with abnormal opening of the urethral meatus include: A hooded prepuce (foreskin formed completely only on the dorsum) Chordee: ventral curvature, present only in the worst cases. The incidence is 0.3% of males and surgery is usually undertaken before the age of 2 in order to create a terminal urethral meatus and a straight erection. The foreskin is essential for surgical correction and should always be preserved.

Answer 18

Hyperoxaluria Pre-disposing causes for renal calculi include: ``` Urinary tract infection (especially Proteus) Structural urinary tract abnormalities Metabolic problems Idiopathic hypercalciuria Hyperuricosuria Hyperoxaluria Hypercystinuria. Infected stones tend to be composed of magnesium ammonium phosphate and calcium phosphate. ``` Nephrocalcinosis can be a complication of furosemide therapy in the neonate. Presentation is usually with haematuria, loin or abdominal pain, urinary tract infection or passage of a stone.

Answer 19

AD PCKD It is essential that all abdominal masses are promptly investigated using an ultrasound scan. Causes of palpable kidneys include: • Unilateral: ``` Multicystic kidneys Compensatory hypertrophy Obstructive hydronephrosis Wilm's tumour Renal vein thrombosis. • Bilateral: ``` Autosomal recessive polycystic disease Autosomal dominant polycystic disease (presents in adulthood) Tuberous sclerosis Renal vein thrombosis.

Urology II Flashcards

(43 cards)