Urology P3

Question 1

What is a hydrocele?

Answer 1

accumulation of fluid in tunica vaginalis

Question 2

What is a communicating hydrocele?

Answer 2

• patency of processus vaginalis allows peritoneal fluid to drain down into scrotum
• common in newborns and resolve in first few months

Question 3

What is a non-communicating hydrocele?

Answer 3

excessive fluid production within tunica vaginalis

Question 4

What can hydroceles be secondary to?

Answer 4

• epididymo-orchitis
• testicular torsion
• testicular tumour

Question 5

Features of hydrocele:

Answer 5

• soft, non tender swelling of hemi-scrotum (usually anterior and below)
• swelling confined to scrotum, can get ‘above mass’
• transilluminates
• testis may be difficult to palpate if hydrocele large

Question 6

Investigation and management of hydrocele:

Answer 6

• US if unclear diagnosis

- infantile hydroceles generally repaired if no spontaneous resolve

Question 7

Most common cause of lower genitourinary tract trauma:

Answer 7

• 85% pelvic fractures

- 10% males pelvic associated with urethras or bladder injuries

Question 8

Types of urethral injury:

Answer 8

• bulbar rupture

- membranous rupture

Question 9

Bulbar rupture:

Answer 9

• most common
• straddle type injury e.g. bicycles
• triad: urinary retention, perineal haematoma, blood at meatus

Question 10

Membranous rupture:

Answer 10

• extra or intraperitoneal
• penile or perineal oedema/haematoma
• PR: prostate displaced upwards

Question 11

Investigating urethral injury and management:

Answer 11

• ascending urethrogram

- suprapubic catheter (surgical placement)

Question 12

Features of bladder injury:

Answer 12

• rupture intra or extraperitoneal
• haematuria or suprapubic pain
• inability to retrieve all fluid used to irrigate the bladder through Foley catheter indicates injury

Question 13

Investigation and management of bladder injury:

Answer 13

• IVU or cystogram
• manage with laparotomy if intraperitoneal
• conservative is extraperitoneal

Question 14

Examinations for lower urinary tract symptoms in men (voiding, storage, post micturition etc.)

Answer 14

• urinalysis: infection, haematuria
• DRE
• PSA
• urinary frequency-volume chart
• IPSS

Question 15

Management of voiding symptoms:

Answer 15

• conservative: pelvic floor muscle training, bladder training
• alpha blocker
• 9 alpha reductase inhibitor
• mixed symptoms with alpha blocker unresponsive - antimuscarinic

Question 16

Management of overactive bladder:

Answer 16

• bladder retraining
• anti-muscarincs: oxybutynin, tollerodine, darifenacin
• mirabegron

Question 17

Management nocutria:

Answer 17

• furosemide 40mg late afternoon

- desmopressin

Question 18

Priapism:

Answer 18

• persistent erection >4 hours
• ischaemic: impaired vasorelaxation so reduced vascular outflow - congestion and trapping of deoxygenated blood in corpus cavernosa
• non-ischaemic: high arterial inflow, typically fistula or congenital/traumatic

Question 19

Causes of priapism:

Answer 19

• idiopathic
• sickle cell disease or other haemalobinopathies
• erectile dysfunction medications (sildenafil, PDE-5 inhibitors)
• drugs: anti-hypertensives, anticoagulants, antidepressants, cocaine, cannabis, ecstacy
• trauma

Question 20

Investigations priapism:

Answer 20

• cavernosal blood gas analysis: ischaemic - pO2 and pH reduced, pCO2 raised
• doppler or duplex ultrasonography

Question 21

Management priapism:

Answer 21

• ischaemic = medical emergency: aspiration of blood and saline flush to clear viscous blood, intracavernosal injection of vasoconstrictor e.g. phenylephrine and repeat 5 min intervals
• non-ischaemic: observation

Question 22

Examination of inguinal hernia:

Answer 22

• cannot get above it
• cough impulse present
• reducible

Question 23

Examination of testicular tumours:

Answer 23

• discrete testicular nodule (may have associated hydrocele)
• symptoms of metastatic disease
• USS scrotum and serum ADP and bHCG

Question 24

Examination of acute epidiymo-orchitis:

Answer 24

• dysuria and urethral discharge
• swelling tender and eased by elevating testis
• Chlamydia

Question 25

Examination of epididymal cysts:

Answer 25

- single or multiple cysts - clear or opalescent fluid - over 40yo - painless - above and behind testis - able to get above lump

Question 26

Examination of hydrocele:

Answer 26

- non painful, soft, fluctuant - clear fluid - tranilluminates - may be presenting feature of cancer in young men

Question 27

Examination of testicular torsion:

Answer 27

- severe, sudden onset testicular pain - RF: abnormal testicular lie - adolescents and young males - tender and pain not eased by elevation - urgent surgery indicated, contralateral testis also fixed

Question 28

Examination of varicocele:

Answer 28

- varicosities of pam-uniform plexus - typically left (testicular vein drains into renal vein) - presenting feature of RCC - affected testis may be smaller and bilateral varicoceles may affect fertility

Question 29

Management of testicular malignancy:

Answer 29

orchidectomy via inguinal approach: high ligation of testicular vessels and avoids exposure of another lymphatic field to tumour

Question 30

Management hydrocele:

Answer 30

- children: inguinal approach (processus ligated) | - adults: scrotal approach (sac excised or plicated)

Question 31

Testicular cancer tumour types:

Answer 31

- 95% germ cell tumours: seminomas and non-seminomas | - non germ cell: Leydig cell tumours, sarcomas

Question 32

Risk factors testicular cancer:

Answer 32

- infertility - cryptorchidism - family history - Klinefelter's - mumps orchitis

Question 33

Features of testicular cancer:

Answer 33

- painless lump most common - pain in minority - hydrocele, gynaecomastia - raised AFP 60% germ cell - raised LDH 40% germ cell - seminomas: hCG raised 20%

Question 34

Diagnosis of testicular cancer:

Answer 34

ultrasound

Question 35

Features of seminomas, tumour markers and pathology:

Answer 35

- most common subtype - AFP normal - hCG elevated 10% - LDH elevated 10-20% - sheet like lobular patterns of cells with substantial fibrous component - fibrous septa contain lymphocytic inclusions and granulomas

Question 36

Features of non-seminomas, tumour markers and pathology:

Answer 36

- teratoma, yolk sac tumour, choriocarcinoma, mixed germ cell tumours - younger age peresntation - advanced disease worse prognosis - retroperitoneal lymph node dissection needed after chemotherapy - AFP raised 70% - hCG elevated 40% - heterogenous texture with occasional ectopic tissue e.g. hair

Question 37

What is TURP syndrome?

Answer 37

- rare, life threatening complication - irrigation with large volumes of glycine (hypoosmolar) - systemically absorbed when prostatic venous sinuses opened during resection - hyponatraemia, hyperammonia, visual disturbances - CNS, resp and systemic symptoms

Question 38

Risk factors TURP syndrome:

Answer 38

- surgical time >1 hour - height of bag >70cm - resected >60g - large blood loss - perforation - large amount of fluid used - poorly controlled CHF

Question 39

Causes of urethral strictures:

Answer 39

- iatrogenic - STI - hypospadias - lichen sclerosus

Question 40

What is a varicocele?

Answer 40

- abnormal enlargement testicular veins - asymptomatic - infertility - more common left - bag of worms

Question 41

Diagnosis and management of varicoceles:

Answer 41

- ultrasound with doppler | - usually conservative, occasionally surgery if pain

Question 42

Vascectomy:

Answer 42

- more effective than female sterilisation - under LA, home within hours - doesnt work immediately - semen analysis twice after before sex (16 and 20 weeks) - bruising, haematoma, infection, sperm granuloma, chronic testicular pain - success rate reversal 55% if within 10 years