Urology T1-16 COPY Flashcards
(355 cards)
1
Q
- What are the three initial embryological components of the human kidney?
A
Pronephros, Mesonephros, Metanephros.
2
Q
From where do the three embryological components of the kidney arise?
A
They arise from the intermediate mesoderm on the dorsal body wall.
3
Q
Which of the three initial embryological kidneys develops into the adult kidney?
A
The metanephros develops into the adult kidney.
4
Q
When does the pronephros arise during pregnancy?
A
The pronephros arises on day 22 of pregnancy.
5
Q
What is the pronephros composed of?
A
The pronephros is composed of a small group of nephrotomes (segmented division of the mesoderm).
6
Q
What do nephrotomes contribute to in the pronephros?
A
Nephrotomes are needed for the development of the pronephric duct from the intermediate mesoderm.
7
Q
When does the pronephric duct reach the cloacal wall, and what is it called at this stage?
A
The duct reaches the cloacal wall on day 26 and is referred to as the Wolffian (mesonephric) duct.
8
Q
What arises from the Wolffian (mesonephric) duct?
A
The mesonephric tubules arise from the Wolffian duct.
9
Q
What happens to the nephrotomes and pronephric part of the duct later on?
A
They involute completely later on.
10
Q
From what does the mesonephros arise?
A
The mesonephros arises from the mesonephric duct and adjacent mesonephric tubules.
11
Q
What transformation occurs to form the mesonephric tubules?
A
The tubules form via a mesenchymal to epithelial transformation.
12
Q
What structures do the segments of mesonephric tubules later contribute to?
A
They contribute to the formation of the metanephric glomeruli and proximal and distal tubules.
13
Q
Does the mesonephros produce urine, and if so, how is it drained?
A
Yes, the mesonephros produces small amounts of urine, which drains via the Wolffian duct.
14
Q
What happens to the mesonephros by the end of the first trimester?
A
Most of the mesonephros has involuted.
15
Q
What do the remnants of the caudal mesonephric tubules become in males?
A
They become part of the epididymis, seminal vesicle, and ejaculatory duct.
16
Q
What are the two cell types that initially compose the metanephros?
A
Epithelial cells of the ureteric bud and mesenchymal cells of the metanephric mesenchyme.
17
Q
From where and when does the ureteric bud arise?
A
The ureteric bud arises from the Wolffian duct around day 28.
18
Q
What happens to the ureteric bud by day 32?
A
The bud grows and its tip (ampulla) penetrates the metanephric blastema.
19
Q
What interactions occur between the ureteric bud and mesenchymal cells of the metanephros?
A
Epithelial-mesenchymal interactions occur, triggering the ureteric bud to branch and form the ureter, renal pelvis, calyces, and collecting tubules.
20
Q
What process occurs in the mesenchyme at the same time as the ureteric bud branching?
A
The mesenchyme undergoes epithelial conversion to form nephrons (nephrogenesis).
21
Q
What structures make up each nephron?
A
Each nephron is composed of a glomerulus, proximal convoluted tubule, Loop of Henle, and a distal convoluted tubule.
22
Q
What forms the capillary meshwork in the glomerular tufts to supply each nephron?
A
Branches from the internal iliac artery form the capillary meshwork in the glomerular tufts.
23
Q
During what weeks does the embryonic kidney ascend, and from where?
A
The kidney ascends from its pelvic position during weeks 6-9.
24
Q
What happens to the kidney’s vasculature as it reaches its final lumbar position?
A
The vasculature reorganizes to form a definitive renal artery.
25
By what week does the fetal kidney start producing urine?
Fetal urine is produced by week 10.
26
What is the cloaca, and how is it initially closed off?
The cloaca is the common end of the rectal tube and the urogenital tract, closed by the cloacal membrane.
27
What septum forms around day 28, and what is its function?
The uro-rectal septum forms and divides the cloaca into a primitive urogenital sinus (anterior) and rectum (posterior).
28
How does the cloacal membrane divide?
The cloacal membrane divides into an anterior urogenital membrane and a posterior anal membrane.
29
When does the urogenital membrane break, and what does it result in?
The urogenital membrane breaks in week 7, creating an open connection between the developing urinary tract and the amniotic cavity.
30
What is the vesico-urethral canal, and what does it become?
The vesico-urethral canal is the upper part of the primitive urogenital sinus and will eventually form the bladder.
31
What happens to the allantois as it remains attached to the apex of the fetal bladder?
The allantois loses its patency and persists as the urachal remnant (median umbilical ligament).
32
What do the mesonephric ducts fuse to form in the bladder?
The mesonephric ducts fuse to form the trigone of the bladder.
33
What happens to the ureters as the kidneys ascend?
The ureters rapidly elongate to compensate for the ascent of the kidneys.
34
What will the distal part of the primitive urogenital sinus form?
It will form the definitive urogenital sinus.
35
In females, what does the definitive urogenital sinus give rise to?
It gives rise to the entire urethra and the vestibule of the vagina.
36
In males, what does the definitive urogenital sinus give rise to?
It gives rise to the posterior urethra (the anterior urethra is formed from the closure of the urethral folds).
37
2. Where are the kidneys located in the body?
The kidneys are retroperitoneal organs situated at the back of the abdominal cavity in the lumbar region, extending from the 11th rib to the iliac crest.
38
Why is the right kidney lower than the left?
The right kidney is lower due to the presence of the liver.
39
What surrounds the kidneys and helps suspend their position?
The kidneys are surrounded by peri-renal fat, which helps suspend their position.
40
What glands are located on top of the kidneys?
The adrenal glands are located on top of the kidneys.
41
What structure enters the hilum of the kidney, and where is it located relative to the renal vein?
The renal artery enters the hilum of the kidney and is located posterior to the renal vein.
42
Where do the renal lymphatics drain?
The renal lymphatics drain into the right and left lumbar (caval and aortic) lymph nodes.
43
What type of fibers are found in the renal nerve plexus, and what does it innervate?
The renal nerve plexus contains both sympathetic and parasympathetic fibers and serves to innervate the kidney.
44
Approximately how many nephrons are in a mature kidney?
A mature kidney has around 1 million nephrons.
45
What are the components of a nephron?
Each nephron is composed of a glomerulus, proximal tubule, Loop of Henle, and distal tubule.
46
To what are the nephrons connected in the kidney?
Nephrons are connected to a collecting duct system.
47
What are the primary functions of the kidneys?
The kidneys regulate the secretion of nitrogenous waste products, maintain homeostasis of water, electrolytes, and acid-base, and produce hormones such as renin.
48
What is the function of the lower urinary tract?
The lower urinary tract forms a low-pressure area for urinary storage.
49
3. What is the most common examination used for the urinary tract?
Ultrasound (US).
50
What frequencies are used for urological ultrasound imaging?
3.5 MHz is used for urology, and 5 MHz is used for testes and penile imaging.
51
Which urological organs can be imaged using ultrasound?
Kidneys, adrenal glands, bladder, prostate, seminal vesicles, scrotal organs, urethra, and penis.
52
Which urological organ cannot be imaged using ultrasound?
The ureter.
53
What can be determined about the kidneys using ultrasound?
Ultrasound can determine the size, location, shape, and number of kidneys.
54
How is prostate imaging performed using ultrasound?
The prostate can be examined via supravesical imaging or with a 5 MHz transrectal probe.
55
How do we calculate the volume of the prostate using ultrasound?
We measure the dimensions of the prostate and divide by 2.
56
What is the normal volume of the prostate?
The normal volume of the prostate is between 20-25 cm³.
57
How is the seminal vesicle visualized in ultrasound?
The seminal vesicles can only be seen transrectally.
58
What is the best use of transrectal ultrasound of the prostate?
It is best used to accurately guide a biopsy needle.
59
What probe frequency is used to examine the testes via ultrasound?
A small 5 MHz probe is used to examine the testes.
60
What are the most frequent testicular disorders seen with ultrasound?
Small tumors, epididymitis, testicular torsion, infarct, or cyst.
61
What intra-scrotal pathologies can be seen with ultrasound?
Hydrocele, varicocele, hematocele, and intra-scrotal hernia.
62
What is a hydrocele testis?
An accumulation of serous fluid in the tunica vaginalis of the testis.
63
What is a hematocele?
An accumulation of blood in the tunica vaginalis of the testis.
64
What is a varicocele?
An abnormal enlargement of the pampiniform venous plexus of the testis.
65
What can X-rays be used to visualize in urology?
Calcium-containing stones, foreign bodies, and different bone diseases (such as metastasis).
66
What can a KUB (Kidney, Ureter, Bladder) or IVP (Intravenous pyelography) with contrast show?
They can show the duration and intensity of urinary excretion.
67
What does retrograde pyelography reveal, and how is it performed?
Retrograde pyelography can reveal obstructions or ureteric strictures, using a cystoscope with a tube to introduce contrast medium and visualized with fluoroscopy.
68
How is antegrade pyelography performed?
It is done via a percutaneous nephrostomy where dye is injected directly into the collecting system for visualization.
69
What is cystography, and when is it indicated?
Cystography is when the bladder is filled with a urinary catheter and X-rays are used for visualization. It is indicated if a bladder perforation is suspected.
70
What is urethrography used for, and how is it done?
Urethrography introduces radio-contrast into the urethra (usually via catheter) and X-rays are taken to locate and measure the length of a urethral stricture.
71
What can CT imaging be used to detect in urology?
CT is used to image urological tumors, lymph nodes, stones, kidney abscesses, emergencies, and congenital diseases.
72
What is MRI particularly good for in urology?
MRI is very good for functional imaging but is typically used as a last resort after other imaging techniques.
73
When is isotope scintigraphy indicated, and which isotope is used?
Isotope scintigraphy, using MAG3 Tc-99m, is indicated in prostate, bladder, or renal cancers to prove or exclude bone metastases. It is also used to determine the individual function of each kidney.
74
What should be analyzed in urine samples during lab examination?
Urine volume, color, smell, pH, RBC and WBC count, fungi, trichomonas, crystals, creatinine, carbamide, Na, and K levels should be analyzed.
75
What are the normal amounts of RBCs and WBCs in urine?
Normal RBCs: 0-1 cells/field. Normal WBCs: 2-4 cells/field.
76
What additional tests should be done besides urine analysis?
A full blood count, liver function test, and the measurement of creatinine and carbamide concentrations as well as Na and K levels should be performed.
77
What is the tumor marker for prostate cancer?
The tumor marker for prostate cancer is PSA (Prostate-Specific Antigen).
78
What are the tumor markers for testicular cancer?
The tumor markers for testicular cancer are Beta-hCG, Alpha-fetoprotein, and NSE (neuron-specific enolase).
79
4. What are simple cysts in the kidney?
Simple cysts can be within the kidney or on its surface, lined with cuboidal epithelium and filled with clear, serous fluid.
80
How do kidney cysts form?
Kidney cysts form congenitally due to unregulated epidermal growth factor mitogens needed for nephrogenesis.
81
What percentage of fetuses can have simple kidney cysts?
Simple kidney cysts can occur in 1-50% of fetuses.
82
How are simple kidney cysts diagnosed and treated?
Diagnosed with ultrasound (US); treatment (if needed) includes unroofing or percutaneous aspiration of the fluid.
83
What characterizes polycystic kidney disease?
Polycystic kidney disease is an autosomal recessive disease affecting both kidneys, with tubules filled with cysts.
84
How common is polycystic kidney disease in fetuses, and what is a major complication?
It occurs in 0.01% of fetuses and can lead to oligohydramnios, resulting in pulmonary hypoplasia.
85
What is the only definite solution for polycystic kidney disease?
The only definite solution is a renal transplantation.
86
What is multi-cystic kidney disease?
It is a congenital condition affecting one kidney (unilateral) with variably sized and communicating cysts.
87
What is the most common renal cystic disease and the most common cause of an abdominal mass in infants?
Multi-cystic kidney disease.
88
What are the symptoms of multi-cystic kidney disease, and how is it diagnosed?
Symptoms include abdominal pain, hematuria, and hypertension. Diagnosis is via ultrasound or IV pyelography with Tc-99m-DMSA for difficult cases.
89
What is the treatment for severe multi-cystic kidney disease?
Treatment involves a nephrectomy for severe symptoms.
90
What is medullary sponge kidney?
Medullary sponge kidney is characterized by small medullary cysts and dilated intra-papillary collecting ducts, giving a sponge-like appearance on radiology.
91
What are the symptoms and occurrence rate of medullary sponge kidney?
Symptoms include renal colic, UTIs, hematuria, or formation of stones. It occurs in 0.02% of pregnancies.
92
How is medullary sponge kidney diagnosed?
Diagnosed with IV urography, which shows enlarged kidneys with calcifications (mainly in papillae), elongated papillary tubules that fill with contrast, and persistent medullary opacity.
93
What is the treatment for medullary sponge kidney?
Symptomatic treatment.
94
What is renal agenesis?
Renal agenesis is the absence of one or both kidneys, which can be unilateral or bilateral.
95
What causes renal agenesis?
It is caused by the absence of a nephrogenic ridge or failure of the ureteral bud to develop from the Wolffian duct.
96
How common is renal agenesis in pregnancies?
It occurs in 0.025% of pregnancies.
97
What is the prognosis for unilateral renal agenesis?
Individuals can have normal lives if the solitary kidney functions correctly, as it undergoes compensatory enlargement.
98
What happens in cases of bilateral renal agenesis?
Bilateral renal agenesis leads to oligohydramnios, causing pulmonary hypoplasia, and results in death within 2 days of birth.
99
How can renal agenesis be diagnosed?
It can be diagnosed with any imaging technique.
100
Is there any treatment for renal agenesis?
No, there are no treatments for renal agenesis.
101
What is a duplex kidney?
A condition where a patient has two separate pelvicalyceal systems and ureters.
102
What causes a duplex kidney?
It occurs when two separate ureteric buds develop from a Wolffian duct.
103
What structures develop in a duplex kidney due to the presence of two ureteric buds?
Two completely separate renal units, collecting systems, ureters, and ureteral orifices develop.
104
What does the Weigert-Meyer law describe in relation to duplex kidneys?
It describes the relationship of the upper and lower renal moieties in duplex kidneys, where the upper pole ureter drains inferomedial to the normal lower moiety ureter.
105
Why does the upper pole moiety ureter drain inferomedial in duplex kidneys?
Because the lower pole ureter separates earlier from the Wolffian duct, it migrates superiorly, while maintaining its original embryologic relationship during drainage.
106
What is a ureterocele and how is it related to duplex kidneys?
A ureterocele is a congenital dilation of the distal ureter, often associated with ectopic insertion, and can obstruct its own collecting system in duplex kidneys.
107
How is a duplex kidney with ectopic ureter diagnosed and treated?
Primarily diagnosed with IV urography. Treatment can include a heminephrectomy or ureterectomy if the upper moiety is non-functional, or a ureteroneocystostomy if renal function is normal.
108
What is renal ectopia?
A congenital condition where a kidney is located in an abnormal position, such as pelvic, iliac, abdominal, thoracic, or contralateral (crossed ectopia).
109
What causes renal ectopia?
It occurs when the nephrogenic tissue migrates abnormally during embryonic elongation, or is prevented from moving properly into the true pelvis.
110
What are the common characteristics and risks of an ectopic kidney?
The ectopic kidney is usually smaller and abnormally shaped. It may lead to a higher chance of UTIs, calculus formation, or secondary hypertension.
111
What is the treatment for renal ectopia?
Symptomatic treatment for UTIs, stones, or hypertension. A nephrectomy may be performed if the other kidney functions well.
112
What is a horse-shoe kidney?
A congenital condition where the two kidneys are fused at their lower poles, forming a U-shaped structure.
113
How does a horse-shoe kidney develop?
It occurs when the two metanephric masses are too close, allowing cells to migrate between them and form an isthmus connecting the lower poles.
114
What are the symptoms and complications of a horse-shoe kidney?
Symptoms include hydronephrosis, infections, or calculus formation due to ureteropelvic obstruction. However, 30% of cases are asymptomatic.
115
How is a horse-shoe kidney diagnosed and treated?
Diagnosed with ultrasound (US), but CT or retrograde pyelography is more definitive. Treatment is symptomatic.
116
What is an ectopic ureter?
An ectopic ureter is when the ureter has its orifice in an abnormal position, not in its usual location on the bladder. This occurs when the ureteral orifice remains on the caudal Wolffian duct and is not absorbed into the bladder.
117
Where can the ureteral orifice of an ectopic ureter be located?
The ureteral orifice may be in the bladder neck, proximal urethra, or outside of the urinary sphincter area.
In males, it can drain into the bladder neck, prostatic urethra, or Wolffian duct structures such as the seminal vesicles, vas deferens, or epididymis, while still being upstream of the external sphincter.
118
Why is an ectopic ureter a common cause of urinary incontinence in females?
In females, the ectopic ureter often drains outside the control area of the urinary sphincter, leading to urinary incontinence.
119
What are the complications associated with an ectopic ureter?
Complications of an ectopic ureter include a higher chance of urinary tract infections (UTIs) and, in females, urinary incontinence.
120
What are the treatment options for an ectopic ureter?
Treatment for an ectopic ureter includes ureteral re-implantation or ureteropyelostomy, which creates a new communication between the ureter and the renal pelvis.
121
What is a ureterocele?
A ureterocele is a cystic dilation of the terminal ureter, caused by incomplete dissolution of the membrane dividing the ureteric bud from the urogenital sinus or abnormal muscular development.
122
What complications can a ureterocele cause?
A large ureterocele can obstruct the bladder neck or contralateral ureteral orifice, leading to hydronephrosis, increased UTI risk, and potential incontinence due to interference with normal sphincter function.
123
How is a ureterocele diagnosed?
A ureterocele is diagnosed via ultrasound (US) or intravenous pyelography (IVP).
124
What are the treatment options for a ureterocele?
Treatment for a ureterocele involves preserving renal function and eliminating infection, obstruction, or reflux. Surgical options include resecting the ureterocele or performing a partial ureterectomy.
125
What is uretero-pelvic junction (UPJ) obstruction?
UPJ obstruction is a stricture at the uretero-pelvic junction, which can be caused by defective development of circular musculature or mechanical obstruction from an aberrant vessel near the junction.
126
How is uretero-pelvic junction obstruction diagnosed?
UPJ obstruction is diagnosed with ultrasound (US).
127
What symptoms can uretero-pelvic junction obstruction present?
UPJ obstruction is usually asymptomatic but can present with urinary tract infections (UTIs), pain, and hematuria.
128
What is the treatment for uretero-pelvic junction obstruction?
Treatment for UPJ obstruction is the Anderson-Hynes pyeloplasty, a surgical procedure to correct the obstruction by reshaping the UPJ.
129
What is hydronephrotic pyelum, and how is it treated?
Hydronephrotic pyelum involves a dilated renal pelvis due to obstruction. The treatment includes resecting the hydronephrotic pyelum and the stenotic part of the ureter, then stitching the remaining parts back together.
130
What is vesico-ureteral reflux?
Vesico-ureteral reflux is the retrograde flow of urine from the bladder back into the upper urinary tract. It occurs due to a deficiency in the longitudinal muscle of the ureter, leading to an inadequate valvular mechanism.
131
What are the symptoms of vesico-ureteral reflux?
Symptoms of vesico-ureteral reflux can include urinary tract infections (UTIs), abdominal pain, hydronephrosis, and calculus formations. It is usually asymptomatic.
132
What are the grades of vesico-ureteral reflux and their characteristics?
Grade 1: Flow remains in the ureter; the ureter is not dilated.
Grade 2: Urine refluxes into the pelvis and calyces without dilation.
Grade 3: Mild dilation of the ureter, pelvis, and calyces.
Grade 4: Moderate ureteral tortuosity and dilation of the pelvis and calyces.
Grade 5: Massive dilation of the ureter, pelvis, and calyces with papillae losing shape and significant ureter tortuosity.
133
How is vesico-ureteral reflux treated?
Low-grade vesico-ureteral reflux may resolve spontaneously. High-grade reflux usually requires ureteral re-implantation surgery.
134
What is megaureter?
Megaureter is a condition characterized by a dilated or large ureter. It can be due to primary obstructive causes, such as an aperistaltic ureteral juxtavesical segment, or secondary obstructive causes like infra-vesical obstructions.
135
What are the types of megaureter and their causes?
Primary obstructive megaureter: Due to abnormal musculature development in the ureter.
Secondary obstructive megaureter: Due to infra-vesical obstructions, such as a posterior urethral valve.
Non-obstructive, non-refluxing megaureter: Resulting from inflammation and toxins inhibiting normal ureteral peristalsis.
136
How is megaureter diagnosed and treated?
Megaureter is diagnosed using urography. Treatment involves surgical remodeling of the ureter and re-implantation into the bladder.
137
5. Where does the ureter normally traverse before opening into the bladder?
The ureter normally traverses through the base of the bladder, traveling through the ureteral hiatus. It courses between the detrusor muscle and the bladder mucosa before opening into the bladder.
138
What is the usual developmental sequence of the bladder and surrounding structures?
Normally, the bladder separates from the rectum, and the anterior abdominal muscles develop before the cloacal membrane regresses.
This results in the bladder and hindgut being distinct structures in the abdomen before the regression of the cloacal membrane.
139
What does the distal end of the Wolffian duct become?
The distal end of the Wolffian duct becomes the ejaculatory duct.
140
What is a peri-ureteral diverticulum?
A peri-ureteral diverticulum occurs when the ureteral hiatus is large enough that the distal ureter and surrounding bladder mucosa herniate through the detrusor muscle during micturition.
141
What is bladder exstrophy?
Bladder exstrophy occurs when the cloacal membrane ruptures before the mesoderm has separated the anterior bladder from the abdominal wall, resulting in the bladder being exposed on the abdominal surface.
142
What is cloacal exstrophy?
Cloacal exstrophy occurs before the bladder is separated from the hindgut by the uro-rectal septum, leading to a complex exposure of both the bladder and hindgut.
143
What is a patent urachus and what problems can it cause?
A patent urachus occurs if the cranial end of the developing bladder fails to fuse and close, allowing urine to drain out of the bladder at the umbilicus. It can lead to infections and is a fibrous remnant of the allantois.
144
What are posterior urethral "valves" and their potential effects?
Posterior urethral "valves" are flaps of tissue resulting from the persistence of the Wolffian duct in boys, which can obstruct urinary flow.
This condition can be life-threatening as it can lead to oligohydramnios and pulmonary hypoplasia due to back-flow of fetal urine.
145
What is hypospadias and its variations?
Hypospadias occurs when fusion of the urethral folds stops short of the tip of the glans. Variations include:
Abnormal ventral opening of the urethral meatus anywhere on the ventral aspect of the glans to the perineum.
Abnormal ventral curvature of the penis (chordee).
Abnormal distribution of foreskin with a dorsally present head and a ventrally deficient foreskin.
146
What can cause hypospadias in terms of testosterone production?
Hypospadias can result if the testes fail to produce adequate amounts of testosterone.
147
What is phimosis and how does it typically resolve in infants?
Phimosis is the inability to retract the foreskin. At birth, it is a normal physiological condition due to natural adhesions between the prepuce and glans.
As the penis grows and smegma accumulates, the foreskin begins to separate from the glans.
By age 3, 90% of boys can retract the foreskin, and less than 1% have phimosis by age 17. Treatment may include topical steroid cream to loosen the phimotic ring.
148
What are the implications of failure of testicular development?
Early failure of testicular development results in the absence of the testis and Wolffian structures on the affected side.
Late failure may show an absent testis but with a present vas deferens. A non-palpable testis might still be present if it failed to descend into the vaginal process.
The vaginal process is an embryological outpouching of the peritoneum that precedes testicular descent and closes to form the tunica vaginalis.
149
What is cryptorchidism?
Cryptorchidism is the failure of the migration and descent of the testis.
150
What causes a hydrocele, and how is it treated if persistent?
A hydrocele occurs when the vaginal process fails to close, allowing fluid from the peritoneal cavity to accumulate. If the hydrocele is very large or persists beyond 12 months, surgery is required to close the vaginal process.
151
What is an indirect inguinal hernia and how is it treated?
An indirect inguinal hernia usually results from a persistent, patent vaginal process. It can cause a portion of the bowel to herniate into the inguinal canal.
This type of hernia does not spontaneously resolve and requires emergency surgery to prevent ischemia of the trapped bowel.
152
What is a varicocele?
A varicocele is the enlargement of the pampiniform venous plexus, a group of veins responsible for draining the testis.
153
What causes a varicocele, and why is it most commonly found on the left side?
A varicocele occurs when the valves of the veins along the spermatic cord do not function properly, similar to varicose veins.
It is most commonly found on the left side because the left testicular vein runs mostly vertical and drains into the renal vein, which can lead to increased pressure and valve failure.
Symptoms may include aching pain in the scrotum, infertility, a visible or palpable enlarged vein, and a feeling of a heavy testicle. It is usually seen in teens and young adults.
154
What is epispadias?
Epispadias is a congenital condition where the urethra ends in an opening on the upper part (dorsum) of the penis.
It can range from mild cases to more severe forms that result in complete incontinence in both males and females.
155
What is a webbed penis and how does it differ from a concealed penis?
A webbed penis is a congenital malformation where the scrotal skin extends onto the ventral aspect of the penis, creating a web-like appearance.
A concealed, buried, or hidden penis is a condition where a normally developed penis is hidden underneath the suprapubic fat pad.
156
What is urethra duplex and how does it present?
Urethra duplex is a rare malformation primarily occurring in males, characterized by an extra urethral opening on the penis. The extra opening can be:
Ventral (hypospadias-like) — most frequent
Dorsal (epispadias-like)
Perineal form
157
What is the approach for treating urethra duplex if the extra urethra does not impinge on the lumen of the real urethra?
If the extra urethra in a urethra duplex does not impinge on the lumen of the real urethra, no treatment is typically required.
If the extra urethra does affect the lumen, the wall between the two tubes is surgically cut to resolve the issue.
158
What is megalourethra, and how is it typically treated?
Megalourethra is a condition characterized by the dilation of the urethra without stenosis. One cause of megalourethra is a lack of the corpus cavernosum. Surgical treatment is necessary to address the condition.
159
6. What are some common causes of abdominal pain in urological diseases?
Common causes of abdominal pain in urological diseases include UTIs, obstruction of the pelvic-ureteric junction, and uretero-vesical stenosis. Other causes can include constipation, nephrolithiasis, renal tumors, and spermatic cord torsion.
160
What is pyuria and what is it most likely caused by?
Pyuria is the presence of pus in the urine, and it is most likely caused by a UTI. However, UTIs can occur without pyuria and pyuria can occur without a UTI.
161
What is obstructive mega-ureter, and what can cause it?
Obstructive mega-ureter is characterized by a dilated ureter. It can be caused by obstructive factors (e.g., uretero-vesical stenosis) or non-obstructive factors (e.g., vesico-ureteral reflux). Urinary tract dilation can extend to the kidneys.
162
What is a ureterocele and what is it commonly associated with?
A ureterocele is a cystic enlargement of the distal portion of the ureter. Most cases are associated with a duplex kidney.
163
What is the common cause of infravesical obstruction in pediatric patients?
Infravesical obstruction is usually due to posterior urethral valves. Severe forms of this obstruction can lead to renal failure.
164
What causes vesico-ureteral reflux and what does it result in?
Vesico-ureteral reflux can be caused by anatomical or functional obstruction or block, leading to urinary stasis and subsequent backflow.
165
Where does Wilms' tumor (nephroblastoma) typically arise, and what is its common presentation?
Wilms' tumor arises anywhere in the renal parenchyma and is typically found as an incidental, palpable mass. Hematuria occurs in only 25% of patients.
166
What is Rhabdomyosarcoma, where is it commonly seen, and what is the treatment approach?
Rhabdomyosarcoma is usually seen in the prostate, bladder, and paratestis (epididymis, tunica albuginea, spermatic cord). It has three variants: embryonal, alveolar, and pleomorphic.
Treatment includes radical inguinal orchiectomy followed by post-operative chemotherapy.
167
How do testicular tumors present in childhood and what types can they be?
Testicular tumors in childhood typically present as a painless testicular mass. They can be either non-germ cell or germ-cell tumors.
168
7. What causes tuberculosis of the genito-urinary tract?
Tuberculosis of the genito-urinary tract is caused by Mycobacterium tuberculosis. It causes chronic granulomatous inflammation and typically reaches these organs hematogenously from the lungs.
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Which genito-urinary organs are most commonly affected by tuberculosis?
The kidney and prostate are the most common primary sites of tuberculosis infection in the genito-urinary tract.
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How does tuberculosis affect the kidney over time?
Tuberculosis destroys the normal renal parenchyma over a very long period (10-20 years), causing cells to undergo caseous necrosis. The infection can lead to fibrosis of the ureter and result in hydronephrosis.
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What are common presentations of tuberculosis infection of the bladder?
Tuberculosis infection of the bladder typically presents with bladder irritability. Vesico-ureteral reflux is also fairly common in these cases.
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What should be suspected if a patient has chronic cystitis unresponsive to therapy, hematuria, and a non-tender, enlarged epididymis?
Tuberculosis should be suspected. Additional signs include a chronic draining scrotal sinus and routine urinalysis showing "sterile pyuria".
173
What are the primary and secondary agents used in the treatment of tuberculosis?
Primary agents: Isoniazid, Rifampicin, Streptomycin, Pyrazinamide.
Secondary agents: Ethambutol, Cycloserine.
174
What is schistosomiasis and what causes it?
Schistosomiasis is a parasitic infection caused by Schistosoma hematobium. It progresses through several stages including swimmer's itch, acute schistosomiasis (Katayama fever), and chronic urinary schistosomiasis.
175
What are the clinical features of acute schistosomiasis?
Acute schistosomiasis, or Katayama fever, is associated with egg-laying and features hematuria and terminal dysuria.
176
How does chronic urinary schistosomiasis affect the bladder and ureters?
Chronic urinary schistosomiasis causes inflammatory destruction of the bladder, leading to metaplasia and potential squamous cell carcinoma formation. Ureters typically show obstructive uropathy.
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What is the treatment for schistosomiasis?
Schistosomiasis is treated with praziquantel, which targets and kills the entire family of schistosomes.
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8. What is pyelonephritis?
Pyelonephritis is the most common renal disease, characterized by an infection of the renal parenchyma and collecting system, usually due to an ascending UTI.
179
What are the symptoms of acute uncomplicated pyelonephritis?
Symptoms include shaking, flank pain, fever, dysuria, increased urinary frequency or urgency, nocturia, and cloudy urine color. GI symptoms such as nausea and vomiting may also be present.
180
What is the most common cause of acute uncomplicated pyelonephritis?
E. coli causes about 85% of infections in patients with no previous medical history.
181
How is acute uncomplicated pyelonephritis typically diagnosed and treated?
It is diagnosed with CT and treated with a 2-3 week course of antibiotics such as ciprofloxacin, augmentin, or 3rd generation cephalosporins.
182
What distinguishes acute complicated pyelonephritis from uncomplicated pyelonephritis?
Acute complicated pyelonephritis is associated with anatomical anomalies (like vesico-ureteral reflux), cancer, stones, surgery, diabetes, immunodeficiency, or pregnancy.
It features general symptoms such as high fever, shaking, nausea, vomiting, flank pain, and dry and red tongue.
183
How is acute complicated pyelonephritis diagnosed and treated?
It is diagnosed with US, which can show renal abscesses. Treatment involves broad-spectrum IV antibiotics and drainage of any abscesses in the collecting system.
184
What is chronic pyelonephritis and what causes it?
Chronic pyelonephritis is characterized by a small, atrophic, or very scarred kidney due to bacterial infection, either from hematogenous spread or ascending UTI. It often involves vesico-ureteral reflux or recurrent UTIs.
185
What imaging study is useful for diagnosing chronic pyelonephritis, especially in children?
A voiding cystourethrogram is useful for showing vesico-ureteral reflux and diagnosing chronic pyelonephritis.
186
What is the approach to treating chronic pyelonephritis?
Treatment focuses on eliminating any reflux, obstruction, or ongoing UTI to prevent further renal damage. Once damage occurs, it is generally irreversible.
187
What is xanthogranulomatous pyelonephritis?
Xanthogranulomatous pyelonephritis is a rare, severe, chronic inflammatory disorder that usually affects one kidney, leading to a non-functioning and enlarged kidney. It involves obstruction, UTI, and nephrolithiasis.
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How is xanthogranulomatous pyelonephritis best diagnosed?
CT imaging is best for diagnosing xanthogranulomatous pyelonephritis, as it can show a large mass with the renal pelvis tightly surrounding a central calcification but without pelvic dilation.
189
What is papillary necrosis in the context of pyelonephritis?
Papillary necrosis involves ischemic necrosis of the papillae in the medulla of the kidney.
190
What are the characteristics of papillary necrosis?
Papillary necrosis involves ischemic necrosis of the papillae in the medulla and can be localized or diffuse, unilateral or bilateral. It is predisposing factors include diabetes mellitus (DM), UTI, sickle cell anemia, and liver cirrhosis. Treatment typically involves antibiotics.
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What is emphysematous pyelonephritis?
Emphysematous pyelonephritis is a life-threatening, fulminant, necrotizing UTI associated with gas in the kidney and/or perinephric space. It features multiple renal abscesses and is associated with diabetes mellitus, stones, and calyceal stenosis.
192
How is emphysematous pyelonephritis diagnosed and treated?
CT imaging is used to identify pockets of air. Treatment involves antibiotics, drainage of abscesses, or even nephrectomy in severe cases.
193
What is pyonephrosis?
Pyonephrosis is infected, purulent urine in an obstructed collecting system. It can result from a UTI or hematogenous infection and may present with severe symptoms like high fever, chills, and flank pain.
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How is pyonephrosis diagnosed and treated?
Ultrasound (US) is the best imaging method for diagnosing pyonephrosis, with retrograde pyelogram as a second option. Treatment involves antimicrobial drugs once a pathogen is identified and drainage of the infected pelvis using nephrostomy or retrograde stent.
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9. What is cystitis and who does it most commonly affect?
Cystitis is inflammation of the bladder, which can be acute (uncomplicated) or complicated. It most commonly affects women and is the most common infection in women.
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What are the characteristics of acute uncomplicated cystitis in pre-menopausal, non-pregnant women?
Acute uncomplicated cystitis is usually caused by E. coli and has a 30% chance of recurrence. Risk factors for relapse include gynecological infections like vaginitis or adnexitis, frequent sexual activity, and use of spermicide, drugs, or beta-lactam antibiotics.
Symptoms include suprapubic pain, tenderness, and urgency. Treatment typically involves trimethoprim + sulfamethoxazole.
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What defines recurrent uncomplicated cystitis in women and its risk factors?
Recurrent uncomplicated cystitis is defined as having 3 episodes in the last 12 months or two episodes in the last 6 months. Risk factors include frequent sexual activity and use of spermicide.
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What are the characteristics of UTIs in post-menopausal women?
In post-menopausal women, E. coli causes 50% of UTIs, with Klebsiella pneumoniae and Enterococcus making up the rest. Symptoms include pain, tenderness, and urgency.
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What are the common causative agents of acute bacterial prostatitis?
The common causative agents include E. coli, Klebsiella, Proteus mirabilis, Pseudomonas aeruginosa, and Enterococcus faecalis.
200
What symptoms are associated with acute bacterial prostatitis?
Symptoms include weak stream or difficult urination, urgency, prostate or scrotal pain, and urinary retention.
201
What findings are noted during a digital rectal exam in acute bacterial prostatitis?
The digital rectal exam is very painful, and the prostate is enlarged and soft to the touch.
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What are the treatment options for acute bacterial prostatitis?
Acute cases are treated with broad-spectrum penicillins, fluoroquinolones, or 3rd generation cephalosporins. Chronic cases can be treated with fluoroquinolones.
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What is the treatment for abacterial cases of prostatitis?
Abacterial cases are treated with NSAIDs to reduce inflammation and pain.
204
What surgical treatments are available for acute bacterial prostatitis?
Surgical treatments include draining the bladder with an epicystotomy tube or localizing and draining a prostate abscess. Instrumental examinations (e.g., cystoscopy) are generally avoided in acute cases due to the risk of exacerbating inflammation.
205
What causes urethritis?
Urethritis can be primary (due to an STD) or secondary (due to urological interventions or other non-pathological causes). Primary urethritis is typically caused by Neisseria gonorrhea, often with coexisting chlamydia.
206
What are the symptoms of urethritis?
Symptoms include milky or pus-like penile discharge, burning or stinging during urination or ejaculation. Many cases are asymptomatic.
207
How is urethritis diagnosed?
Diagnosis involves inserting a swab deep into the urethra to collect a sample for testing.
208
What is the treatment for urethritis caused by gonorrhea?
The treatment includes ceftriaxone and ciprofloxacin (cephalosporins and fluoroquinolones).
209
What is epididymitis, and what does it usually involve?
Epididymitis is an acute inflammation of the epididymis, usually unilateral. If it involves the testis, it is called epididymo-orchitis.
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What are the initial symptoms of acute epididymitis or epididymo-orchitis?
Initial symptoms include local pain, tenderness, swelling, redness of the affected side, fever, and possibly urethral discharge.
211
What common causes of epididymitis include?
Epididymitis is often caused by retrograde extension from the vas deferens. It can also follow mumps infection (epididymo-orchitis) or be an initial presentation of urogenital TB.
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How is epididymitis diagnosed?
Diagnosis can involve a testicular ultrasound, which may reveal an abscess.
213
What antibiotics are used in the treatment of acute bacterial prostatitis?
Antibiotics include ofloxacin (especially for risk of chlamydia), levofloxacin, cephalosporins, aminopenicillin, and aminoglycosides.
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What supportive therapy should be given alongside antibiotics for acute bacterial prostatitis?
Anti-pyretics should be given to manage fever and provide symptomatic relief.
215
What is balanitis?
Balanitis is the inflammation of the glans penis.
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What is balanoposthitis?
Balanoposthitis is the inflammation of both the glans penis and the foreskin.
217
10. What is the most frequent urological disease in males?
Benign Prostatic Hyperplasia (BPH) is the most frequent urological disease.
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What is Benign Prostatic Hyperplasia (BPH)?
BPH is a benign proliferation of epithelial and fibro-muscular cells in the transitional zone of the prostate.
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At what age does Benign Prostatic Hyperplasia (BPH) commonly occur?
BPH commonly occurs in males aged 60-70 years, although only 30-50% of these individuals are symptomatic.
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What are obstructive symptoms of Benign Prostatic Hyperplasia (BPH)?
Obstructive symptoms include decreased urine flow, difficulty starting urination, dribbling, residual urine in the bladder, and the need for abdominal pressure to empty the bladder.
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What are irritative symptoms of Benign Prostatic Hyperplasia (BPH)?
Irritative symptoms include urgency, nocturia (voiding at night), pollakisuria (frequency), and alguria (painful urination).
222
How does a recto-digital exam help diagnose Benign Prostatic Hyperplasia (BPH)?
The exam shows a slightly harder than normal prostate gland, with potential tenderness or pain.
223
What is the best imaging technique for diagnosing Benign Prostatic Hyperplasia (BPH)?
Ultrasound (US) is the best imaging technique to visualize BPH.
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What are some differential diagnoses for Benign Prostatic Hyperplasia (BPH)?
Differential diagnoses include prostate cancer, sphinctersclerosis, bladder cancer, urethral stricture, and atonic bladder.
225
What treatments are available for Benign Prostatic Hyperplasia (BPH)?
Treatments include:
Alpha blockers: Relax the internal sphincter to increase urinary flow and decrease residual urine.
Symptoms return rapidly if stopped.
Endocrine treatment: 5-alpha-reductase inhibitors to reduce prostate volume.
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How long does the treatment for Benign Prostatic Hyperplasia (BPH) last?
The treatment for BPH typically lasts about 3 months.
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What is the benefit of combination therapy for Benign Prostatic Hyperplasia (BPH)?
Combination of alpha blockers and endocrine treatment can lead to better urination.
228
What is the surgical approach for Benign Prostatic Hyperplasia (BPH)?
Surgery involves resection of deeper tissues, but the capsules and seminal vesicles remain untouched.
229
What does TURP stand for?
TURP stands for Trans-Urethral Resection of Prostate.
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What is a potential complication of TURP?
A life-threatening complication of TURP is TURP syndrome, caused by fluid over-hydration during prolonged operations.
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What can cause TURP syndrome?
TURP syndrome can be caused by the use of warm sterile water or glycine solution for bladder irrigation, leading to fluid overload.
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What are the symptoms of TURP syndrome?
Symptoms include confusion, coma, arrhythmias, heart failure, pulmonary edema, hyperkalemia (due to hemolysis), and hypoxemia.
233
What physiological imbalances are associated with TURP syndrome?
TURP syndrome can lead to hypervolemia, hyperammonemia, hyponatremia, and hypothermia.
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11. What are the two functional phases of the bladder?
The two functional phases are the Storage phase and the Voiding phase.
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What happens during the bladder Storage phase?
During the Storage phase, the bladder passively fills with urine. The sphincters should be closed, and there should be no urinary leakage.
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What does bladder compliance refer to?
Bladder compliance describes how the bladder accommodates extra volume without a significant increase in bladder pressure.
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What occurs during the Voiding phase of the bladder?
During the Voiding phase, the detrusor muscles contract, and the urethral sphincter and pelvic floor muscles relax. There should be no straining and no urine remaining in the bladder.
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How is bladder pressure managed during the Voiding phase?
Bladder pressure during voiding should not cause damage to the upper urinary tract.
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Which nervous system controls the Storage phase of bladder function?
The Storage phase is mainly under sympathetic control.
240
What role does the hypogastric nerve play in bladder function?
The hypogastric nerve carries sympathetic fibers that relax the detrusor muscle and contract the smooth muscle of involuntary sphincters during the Storage phase.
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Which nervous system controls the Voiding phase of bladder function?
The Voiding phase is mainly under parasympathetic control.
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What role does the pelvic nerve play in bladder function?
The pelvic nerve carries parasympathetic fibers that cause contraction of the detrusor muscle and relaxation of the involuntary sphincters during the Voiding phase.
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Which nerves are involved in sensory (afferent) control of the bladder?
Sensory (afferent) control occurs along the hypogastric, pelvic, and pudendal nerves.
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What is the role of involuntary reflexes in bladder function?
Involuntary reflexes transmit information on bladder fullness and the presence of any noxious stimuli.
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What does the pudendal nerve do in relation to bladder function?
The pudendal nerve is a somatic nerve that causes contraction of the striated external sphincter muscles and pelvic floor muscles.
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How do involuntary storage reflexes affect bladder function?
Involuntary storage reflexes increase sympathetic activity, inhibit parasympathetic activity, and activate the pudendal nerve to prolong storage.
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What happens when the bladder fills and stretch receptors are activated?
Stretch receptors activate the pelvic nerve, which carries information to the peri-aqueductal gray area in the midbrain.
This signals are transferred to the pontine micturition center and then to the supra-pontine areas responsible for delaying micturition.
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Which brain areas are involved in delaying micturition?
The supra-pontine areas involved in delaying micturition include the frontal cortex, hypothalamus, para-central lobule, limbic system, and cingulate gyrus.
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How does voluntary control of voiding work?
The pontine micturition center (PMC) coordinates voluntary control. If the bladder is full but the person does not want to urinate, the PMC sends signals to increase sympathetic and decrease parasympathetic activities. If the person wants to urinate, the PMC does the opposite.
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What signals does the pontine micturition center (PMC) send when a person wants to urinate?
When the person wants to urinate, the PMC sends signals to decrease sympathetic activity and increase parasympathetic activity to facilitate voiding.
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What is neurogenic dysfunction of the bladder?
Neurogenic dysfunction of the bladder can alter bladder and urethral function, causing issues with storing or voiding urine, or both.
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What are the types of lesions or affected areas that impact urination in neurogenic dysfunction?
The types of lesions or affected areas are divided into four anatomical regions:
Supra-pontine
Pontine (brainstem)
Supra-sacral spinal cord
Sacral-subsacral (peripheral nerves and cauda equina)
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What are the typical lesions affecting the supra-pontine area and their impact on urination?
Typical lesions include strokes, brain tumors, head injury, dementia, and cerebral palsy. These can lead to neurogenic detrusor overactivity during the storage phase due to reduced cortical inhibition. Detrusor and sphincter function coordination is preserved.
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What disorders are associated with the pontine (brainstem) area, and what are their effects on bladder function?
Disorders include Parkinson's, Multiple Sclerosis, and Multiple System Atrophy.
The brainstem contains both the pontine micturition center and the pontine storage center, leading to a loss of coordination between the detrusor and sphincters.
Possible conditions include neurogenic detrusor overactivity, detrusor underactivity, urethral overactivity, or urethral incompetence.
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What are the effects of lesions in the supra-sacral spinal cord on bladder function?
Lesions in the supra-sacral spinal cord, such as those from spinal cord injury or Multiple Sclerosis, result in loss of high detrusor inhibition and coordination.
Patients may experience neurogenic detrusor overactivity with urethral overactivity, known as detrusor-sphincter dyssynergia, leading to dangerous pressure build-up due to the detrusor contracting against a closed sphincter.
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What are the effects of sacral-subsacral (peripheral nerves and cauda equina) lesions on bladder function?
Lesions from spina bifida, MS, DM, or surgery can lead to a non-contracting detrusor, incompetent urethra, and loss of bladder sensation.
Lumbo-sacral lesions result in an overactive detrusor and an incompetent urethra. Most lesions are incomplete, causing variable symptoms.
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What diagnostic tests are used for neurogenic bladder dysfunction?
Urodynamic pressure-flow investigations and electromyography (EMG) are used. EMG examines the pelvic floor muscles, urethral sphincter, and anal sphincter and can be done separately or during a urodynamic investigation.
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What is the primary aim of treatment for neurogenic bladder dysfunction?
The primary aim is to protect the upper urinary tract by maintaining low bladder pressures and low residual urine. Secondary aims include improving quality of life.
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What are the types of dysfunction associated with failure of storage in neurogenic bladder dysfunction?
Failure of storage can involve conditions like neurogenic detrusor overactivity and loss of bladder sensation, which impair the bladder's ability to store urine effectively.
260
What is neurogenic detrusor overactivity and how is it treated?
Neurogenic detrusor overactivity involves excessive contraction of the bladder. Treatments include:
Bladder Training: Helps improve bladder control.
Oral Anti-cholinergics: Reduce bladder contractions.
Intra-detrusor Injection of Botulinum Toxin: Blocks the release of acetylcholine at the motor end-plate, reducing bladder contractions.
Catheterization: For managing symptoms and reducing pressure.
Augmentation Enterocystoplasty: Involves suturing a bowel segment to the bladder to increase bladder volume and lower intra-vesical pressures.
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How is an incompetent sphincter treated in neurogenic bladder dysfunction?
Incompetent Sphincter treatments include:
Physiotherapy: Strengthens pelvic floor muscles.
Artificial Urinary Sphincters: Devices implanted to help control urination.
Catheterization: For managing symptoms.
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What are the management strategies for failure of voiding?
Failure of Voiding can be due to:
Detrusor Underactivity:
Bladder Maneuvers: Techniques to aid in bladder emptying.
Clean Intermittent Self-Catheterization (CISC): Recommended for patients with spinal cord injuries and good hand-eye coordination.
Overactive Sphincter:
CISC: Helps with bladder emptying.
Oral Spasmolytics: Medications to reduce sphincter spasms.
Botulinum Toxin Injections into the Sphincter: Reduces sphincter activity.
Blockade of Pudendal Nerve: Reduces sphincter tone.
Intra-urethral Stents: Help keep the urethra open.
Sphincterotomy: Surgical procedure to cut the sphincter muscle.
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What is autonomic dysreflexia and what are its features?
Autonomic Dysreflexia is an exaggerated sympathetic response to a noxious stimulus in patients with spinal cord injuries above T6. Features include:
Hypertension: Elevated blood pressure.
Bradycardia: Slow heart rate.
Intense Sweating: Excessive sweating.
Flushing: Redness of the skin.
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What can trigger autonomic dysreflexia and how should it be managed?
Triggers can include bladder over-distention, high detrusor pressures, or pressure-flow urodynamic studies. Management includes:
Stop Filling the Bladder: Begin emptying the bladder immediately.
Sit Patient Up: Helps reduce blood pressure.
Administer Nifedipine: To lower blood pressure and manage symptoms.
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12. What are the types of urinary incontinence?
Stress Urinary Incontinence
Urge Urinary Incontinence
Mixed Urinary Incontinence
Neuropathic Incontinence
Overflow Incontinence
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Stress Urinary Incontinence
Leakage when intra-vesical pressure exceeds urethral limits (e.g., coughing, lifting). Most common in females; due to pelvic floor support loss or sphincter weakness. In males, often iatrogenic (e.g., after radical prostatectomy).
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Urge Urinary Incontinence
Involuntary urination with a strong sense of urgency, often without increased abdominal pressure. Associated with polyuria, nocturia, bladder lesions, or idiopathic causes.
268
Mixed Urinary Incontinence
Combination of stress and urge incontinence
269
Neuropathic Incontinence
Due to central or peripheral neurological lesions (e.g., MS, stroke).
Two forms:
Active: Detrusor overactivity with involuntary leakage.
Passive: Less common, with less clear symptoms
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Overflow Incontinence
Leakage due to bladder being too full, often from bladder outlet obstruction or poor detrusor contractility.
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What can cause stress urinary incontinence in females?
Loss of Pelvic Floor Support: Resulting in bladder neck or proximal urethra descent during stress.
Urethra Hypermobility: Excessive movement of the urethra.
Weak Sphincters: Poor sphincter function.
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What are common causes of urge urinary incontinence?
Bladder Lesions: Damaging bladder function.
Lower Urinary Tract Obstruction: Impeding normal bladder emptying.
Post-Menopausal Urogenital Atrophy: Due to estrogen deficiency.
Idiopathic Origin: No clear cause.
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What is the difference between active and passive neuropathic incontinence?
Active Neuropathic Incontinence: Features detrusor overactivity, leading to involuntary leakage without urge.
Passive Neuropathic Incontinence: Less common, with different or less pronounced symptoms.
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What is overflow incontinence?
Occurs when the bladder becomes too full, leading to leakage due to high pressure.
Often due to bladder outlet obstruction or poor detrusor contractility.
275
What are some transient causes of urinary incontinence?
Post-childbirth changes.
Temporary factors that resolve spontaneously.
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What is the initial step in diagnosing urinary incontinence?
Detailed History: Get a comprehensive history of previous urinations and current problems with urination.
Physical Examination: Note any anomalies and perform a urinary stress test (positive if urine leakage is observed when the patient coughs).
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What should be included in the neurological examination for urinary incontinence?
Anal Sphincter Tone: Measure tone to assess function.
Bulbocavernosus Reflex: Check for reflexive contraction of the anal sphincter when the glans penis is squeezed (S2-S4 reflex).
Spinal Shock Assessment: Look for signs of loss of neurological reflex activity below the level of a spinal cord injury.
Anocutaneous Reflex: Observe for reflexive contraction of the anal sphincter upon stroking the anal skin (S2-S4 reflex).
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What is uroflowmetry?
Procedure: Measures urine flow rate and residual urine in the bladder using ultrasound.
Normal Flow Rates:
Males: 15-25 mL/sec
Females: 20-30 mL/sec
Purpose: Useful for screening bladder outlet obstruction.
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What does cystometry measure?
Procedure: Measures bladder pressure during filling and intra-abdominal pressures with a two-way catheter.
Information Provided:
Bladder sensation and stability.
Differentiates between stress urinary
incontinence (normal sensation and capacity, no detrusor contraction) and urge urinary incontinence (increased urgency and/or detrusor contraction).
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What is a pressure-flow study (voiding cystometry)?
Procedure: Bladder is filled with fluid via a two-way catheter, and the patient then urinates the fluid out.
Purpose: Most sensitive method for detecting bladder outlet obstructions. Provides information about bladder contractility and outlet obstruction.
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How can you differentiate between stress and urge urinary incontinence using cystometry?
Stress Incontinence: No detrusor contraction; normal sensation and bladder capacity.
Urge Incontinence: Increased urgency and/or detrusor contraction observed.
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13. What are conservative treatments for Stress Urinary Incontinence?
Lifestyle Interventions: Weight loss, smoking cessation, reduced fluid intake.
Pelvic Floor Muscle Training: Effective for strengthening pelvic muscles and improving control.
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What are the three types of surgical treatments for Stress Urinary Incontinence?
Sub-Urethral Bulking Agents:
Agents: Fat, collagen, or silicone.
Procedure: Injected into peri-urethral tissue around the bladder neck to increase urethral resistance.
Sub-Urethral Sling:
Indications: Intrinsic sphincter deficiency and urethral hypermobility.
Procedure: Material loops under the urethra to prevent descent during stress.
Open/Laparoscopic Colposuspension:
Indication: Urethral hypermobility.
Procedure: Lift and fix the vaginal wall and bladder neck to the pubic bone with permanent stitches.
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What are the conservative and pharmacological treatments for Urge Urinary Incontinence?
Conservative Treatment:
Lifestyle Interventions: Useful for symptom management.
Pharmacological Treatment:
Anti-Muscarinics: Increase bladder capacity, decrease contractility, and reduce involuntary contractions, urgency, and frequency.
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What are the surgical treatments for Urge Urinary Incontinence?
Botulinum Toxin Intradetrusor Injection: Reduces involuntary contractions by blocking acetylcholine release.
Sacral Neuromodulation: Electrical stimulation of sacral nerves to improve bladder control.
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How should Mixed Urinary Incontinence be managed?
Treat Predominant Condition First: Focus on whether urge or stress incontinence is more prominent.
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What is the approach to managing Overflow Incontinence?
Empty the Bladder: Use catheterization to relieve immediate symptoms.
Investigate Cause:
Obstruction: Treat with alpha blockers, TURP, internal urethrotomy, etc.
Detrusor Problem: Limited treatment options for hypo or non-contractility.
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What is the management strategy for Neuropathic Incontinence?
Detrusor Hyperreflexia:
Treatment: Anti-cholinergics and clean intermittent catheterization if urinary retention is present.
Sphincter Atony:
Treatment: Artificial sphincter implants to improve control.
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14. What is oliguria, and how is it defined?
Oliguria: Reduced urine volume.
Definition: Less than 500 mL of urine produced in a day
290
What is anuria, and how is it defined?
Anuria: Extremely low urine output.
Definition: Less than 100 mL of urine produced in a day.
291
What is acute renal failure and its main causes?
Acute Renal Failure: Sudden reduction in glomerular filtration leading to retention of urea, creatinine, potassium, phosphate, and sulfate.
Causes:
Pre-Renal: Dehydration, sepsis, decreased cardiac output.
Intra-Renal: Glomerulonephritis, acute tubular necrosis.
Post-Renal: Kidney stones, bilateral ureteral obstruction.
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What are the symptoms and diagnostic approach for acute renal failure?
Symptoms: Inability to urinate, lack of desire to urinate, kidney pain, vomiting.
Diagnostic Approach:
Ultrasound (US): Check for dilated pelvis to rule out post-renal obstruction.
Therapy: Control electrolyte concentrations; extreme cases may require hemodialysis.
For Post-Renal Obstruction: Ureteral catheterization or nephrostomy.
Infection Signs: Wide-spectrum antibiotics.
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What causes urinary retention and how is it managed?
Causes: Bladder outlet obstruction (e.g., BPH, prostate tumor, urethral stone).
Symptoms: Inability to urinate unless bladder is full, strong desire to void, bladder pain.
Diagnosis: Palpate and percuss full bladder.
Management:
Transurethral Catheterization: Insert catheter through the urethra.
Percutaneous Suprapubic Catheterization: Insert catheter through the abdominal wall.
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What are the causes and diagnostic steps for gross hematuria?
Causes: Cancer, stone, or inflammatory processes.
Diagnostic Steps:
Visual Inspection: Bloody urine observable with the naked eye.
Physical Examination: Examine urethral meatus, palpate prostate.
Imaging: Ultrasound (US), cystoscopy, IV pyelography, CT for upper urinary tract bleeding.
Treatment:
Large Catheter: Remove potential blood clots using cystoscope.
Transurethral Electrocoagulation: For hemorrhage not treated conservatively.
Infection: Administer antibiotics.
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What are the causes of kidney colic and how is it treated?
Causes: Ureteral stones, ureteral strictures, or tumors.
Treatment: Focus on addressing the underlying cause, which may involve pain management, stone removal, or treating strictures/tumors.
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What are the symptoms and management options for kidney colic?
Symptoms:
Strong kidney pain radiating down towards the gonadal region.
Urgency and vomiting may occur.
Fever may be present.
Management:
Without Fever: IV painkillers, spasmolytics, and fluid replacement.
With Fever:
Perform catheterization to drain urine.
Administer antibiotics.
Conduct blood count and urinalysis.
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What is testicular torsion and how is it managed?
Definition: Torsion of the spermatic cord compresses the blood supply to the testis.
Commonly Seen: In adolescent males, often during sleep.
Risk Factors: Cryptorchidism, recent trauma.
Symptoms:
Sudden severe pain in the testicle.
Swelling, redness, vomiting.
Diagnosis:
Doppler Ultrasound: Shows poor blood flow to the testes.
Management:
Immediate Surgery: Required to prevent testicular atrophy (occurs within 6 hours).
Manual De-torsion: Can be attempted before surgery; if successful, surgical fixation is still needed.
If Testicle is Dead: Removal is necessary.
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What is paraphimosis and how is it treated?
Definition: Foreskin is retracted over the glans penis and cannot return to its normal position.
Pathophysiology:
Phimotic ring causes venous congestion, leading to edema and enlargement of the glans, potentially resulting in necrosis.
Symptoms:
Swollen prepuce over the glans.
Strong pain.
Management:
Manual Reposition: Attempt to restore foreskin to its normal position.
Surgical Intervention: If manual reposition fails, perform a surgical incision of the constricting ring.
Post-Inflammation: Circumcision is recommended after inflammation resolves.
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What is priapism, its types, and how is it managed?
Definition: Prolonged erection lasting more than 6 hours.
Common Causes: Drugs for impotence, leukemia, pelvic tumors, pelvic infections. 60% are idiopathic.
Types:
High Flow: Due to perineal trauma leading to injury of central penile arteries and loss of penile blood flow regulation.
Low Flow: Venous drainage obstruction causes blood build-up in the corpora cavernosa.
Symptoms:
Painful erection without sexual desire.
Management:
High Flow: May resolve spontaneously; supportive care.
Low Flow: Requires medical intervention to reduce blood flow and relieve obstruction
-Glans penis and corpus spongiosum are soft.
-Corpora cavernosa is tense due to congested blood and is tender as well
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15. What are the three major classifications of renal trauma?
Minor Renal Trauma
Major Renal Trauma
Vascular Injury
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What defines Minor Renal Trauma?
Definition: Contusions or bruising of renal parenchyma.
Incidence: 84% of cases.
Symptoms: May show subcapsular hematomas.
Management: Rarely needs surgery; managed conservatively.
Grades:
Grade 1-3: Includes injuries with lacerations deeper than 1cm but no urinary extravasation.
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What defines Major Renal Trauma?
Definition: Deep lacerations extending into the collecting system with urinary leakage into the peri-renal space.
Incidence: 15% of cases.
Symptoms: Large retroperitoneal and peri-renal hematomas; potential for complete kidney destruction.
Grades:
Grade 4: Severe injuries with collecting system involvement.
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What defines Vascular Injury in renal trauma?
Definition: Total or partial avulsion of renal artery or vein; stretch can lead to thrombosis.
Incidence: 1% of cases.
Symptoms: Can cause total kidney destruction.
Grades:
Grade 5: Severe vascular injuries.
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What are the initial clinical signs of renal injuries?
Initial Signs: Hypotension and hemorrhagic shock.
Pain: Localized to the flank or entire abdomen.
Hematoma: Large hematomas may be palpable.
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How does microscopic hematuria indicate the severity of renal injuries?
With Hypotension: Indicates significant renal injuries.
Without Hypotension: Indicates mild renal injuries.
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What diagnostic methods are used for renal injuries?
Ultrasound (US): Reveals hematomas but not parenchymal lacerations.
CT Scan: Best for identifying renal trauma and assessing the extent of injury.
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How is minor renal trauma typically managed?
Non-Surgical: Most minor injuries do not require surgery.
Care: Monitor closely and provide rest.
Urinary Extravasation: May require Double J catheter placement or percutaneous drainage.
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When is surgery indicated for renal injuries?
Persistent Renal Bleeding: Requires surgical intervention.
Massive Urinary Extravasation: Requires surgical management.
Segmental Arterial Injury: Requires surgical repair.
Penetrating Injuries: Requires surgical exploration (e.g., bullet or stab wounds).
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What are the causes of ureter injuries?
Blunt Trauma: Injuries from blunt trauma.
Penetrating Trauma: Injuries from penetrating trauma.
Iatrogenic Causes: More commonly occur during surgical procedures.
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How are ureter injuries managed?
Diagnosis and Treatment: Based on the type and severity of the injury; may involve surgical exploration and repair.
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What are the initial symptoms of ureter injuries?
Initial Symptoms: Often asymptomatic except for hematuria (microscopic or macroscopic) in about 70% of cases.
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What are the later features of ureter injuries?
Later Features: Fever, flank or abdominal pain, vomiting, and sometimes paralytic ileus.
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What is the most accurate diagnostic tool for ureter injuries?
Most Accurate Diagnostic Tool: CT scan.
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How are partial and segmental ureter injuries managed?
Management:
Ureteric Stent: Placement for a few weeks.
Percutaneous Nephrostomy: For decompression if stenting is inadequate
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What is the treatment for complete ureteral rupture?
Surgical Options:
Ureteroureterostomy: End-to-end anastomosis.
Pyeloplasty: Anastomosis between the ureter and renal pelvis for very high lesions.
Transureteroureterostomy: End-to-side anastomosis with the other ureter.
Ureteroneocystostomy: Re-implantation of the ureter into the bladder for low ureter injuries.
Bladder Tube Flap: For short ureter segments.
Bowel Segment Replacement: For extensive ureter damage or loss.
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16. How common are bladder injuries and what factors contribute to their rarity?
Frequency: Bladder injuries are relatively rare.
Reason: Due to the bladder's deep location within the pelvis.
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What types of bladder injuries exist?
Types of Ruptures:
Extraperitoneal Bladder Rupture: Extravasation into the infraperitoneum.
Intraperitoneal Bladder Rupture: Extravasation into the intra or retraperitoneum.
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What factors make a bladder injury more likely?
Full Bladder: More likely to be damaged compared to an empty bladder due to its proximity to the surface.
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What causes blunt bladder trauma?
Causes: Typically caused by a blow to the lower abdomen when the bladder is full.
Associated Injuries: 80% of bladder injuries are associated with pelvic fractures.
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What are the types and features of blunt bladder trauma?
Types: Can range from small contusions with intramural hematomas to extensive intra or extraperitoneal bladder wall lacerations.
Typical Presentation:
Extraperitoneal Ruptures: Common with pelvic fractures.
Intraperitoneal Ruptures: Usually occur when the bladder is full.
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What are the symptoms of bladder injuries?
Symptoms: Low abdominal pain, urinary retention, and gross hematuria (in 95% of cases).
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What diagnostic tool is used for suspected bladder injuries?
Diagnostic Tool: Cystography.
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What is the treatment for large or intra-abdominal bladder ruptures?
Treatment: Requires open surgical repair
324
How common are female urethral injuries and what causes them?
Frequency: Very rare.
Causes: Usually due to gynecological or urological operations.
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How are male urethral injuries classified?
Classification:
Anterior Urethral Injuries: Associated with direct trauma.
Posterior Urethral Injuries: Associated with pelvic fractures.
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What are common signs of urethral injuries in both males and females?
Common Signs:
Males: Bleeding from the urethral meatus, inability to pass urine.
Females: Vulvar edema, blood at the vaginal opening.
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What diagnostic tool should be used for urethral injuries?
Diagnostic Tool: Urethrography.
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How are minor urethral injuries treated?
Treatment: Urethral catheterization.
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What is the surgical approach for ruptured urethral injuries?
Surgical Repair: Required for ruptures.
330
What is the most common penile injury and its typical cause?
Common Injury: Penile fracture.
Typical Cause: Excessive bending force, often during sexual activity.
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Where along the penile shaft do fractures typically occur?
Location: Most are distal to the suspensory ligament.
332
Is urethral rupture always present with penile fractures?
Urethral Rupture: May or may not be present.
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What sound do patients typically describe with a penile fracture?
Cracking or popping as the tunica tears.
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What are the common symptoms following a penile fracture?
Symptoms:
Massive pain
Rapid detumescence (subsiding of sexual arousal)
Discoloration and swelling of the penile shaft
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How is a penile fracture diagnosed?
Diagnosis: Primarily based on clinical presentation.
Atypical Cases: MRI may be used for further evaluation.
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What is the treatment for a penile fracture?
Treatment:
Surgical repair is necessary.
Exploration for other lesions.
Broad-spectrum antibiotics are prescribed.
337
What is the first step in managing a penile amputation?
First Step: Isolate the amputated segment in clean gauze, place it in a sterile bag, and then put the bag in a container filled with ice.
338
What is the treatment for penile strangulation?
Treatment:
Remove the strangulation device urgently.
Long-lasting strangulation may require a necrectomy.
339
What is the primary cause of testicular injury?
Cause: Blunt trauma (e.g., sports, car accidents).
340
What symptoms are associated with testicular injury?
Symptoms:
Severe scrotal pain
Nausea
Scrotal hemorrhage
Hematocele
341
How is testicular injury assessed and treated?
Assessment: Ultrasound to evaluate testicular integrity.
Treatment:
Surgery for tunica albuginea reconstruction, bleeding control, or vessel management.
Broad-spectrum antibiotics if surgery is performed.
342
What is Fournier's gangrene?
Definition: A life-threatening necrotizing fasciitis in the genital region caused by multiple pathogens.
Main cause of genital skin loss.
343
What are the predisposing factors for Fournier's gangrene?
Predisposing Factors:
Diabetes mellitus (DM)
Poor hygiene
Immunosuppression
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What are the clinical features of Fournier's gangrene?
Symptoms:
Sepsis
Edema
Erythema
Skin ischemia
Strong odor
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How is Fournier's gangrene diagnosed?
Diagnosis: Usually based on physical examination due to clear clinical signs.
346
What are the key treatment steps for Fournier's gangrene?
Initial Treatment:
Debridement
Drainage
Necrectomy (until infection stops)
347
What is the role of antibiotics in Fournier's gangrene?
Antibiotics:
Start with broad-spectrum antibiotics.
Adjust based on isolated pathogens after cultures.
348
What additional therapy is used to promote wound healing in Fournier's gangrene?
Therapy: Hyperbaric oxygen treatment helps with wound healing.
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What is done after the infection and necrosis stop in Fournier's gangrene?
Next Step: Transplant skin flaps to cover the wounded area.
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351
What is a common cause of uretero-pelvic junction obstruction in pediatric patients?
Uretero-pelvic junction obstruction is commonly caused by intrinsic/congenital stenosis or by an aperistaltic segment (functional stenosis).
352
What are some causes of dysfunctional voiding, enuresis, and incontinence?
Causes include Hinman's syndrome (functional obstruction during voiding leading to urinary retention and bladder damage), constipation, phimosis, meatal stenosis, previous urethral surgery, hematometrocolpos due to hymenal atresia, and labial synechia (labia minora sealed in the mid-line).
353
What can cause abdominal mass in urological conditions?
Abdominal mass can be caused by large hydronephrosis, a filled bladder, Wilms' tumor (palpable mass), or any retroperitoneal masses which may move the kidneys forward, making them palpable.
354
What is the difference between microscopic and macroscopic hematuria?
Microscopic hematuria is usually benign and occurs in children as a random event.
Macroscopic hematuria can be caused by several pathologies such as UTI, urethral prolapse, trauma, coagulation problems, nephrolithiasis, Wilms' tumor, acute glomerulonephritis, cystitis hemorrhagica, or a foreign body.
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What symptoms might be seen in newborns and young infants with urological diseases?
In newborns and young infants, symptoms of urological diseases can include abdominal distension, loss of appetite, vomiting, anemia, and failure to thrive (dystrophy or atrophy).
