GENITOURINARY (5%)

Question 1

TESTICULAR TORSION

Answer 1

Testicular torsion occurs when the spermatic cord twists, cutting off the testicle’s blood supply, leading to ischemia.

Usually occurs in young males

= ** TRUE UROLOGIC EMERGENCY **

• 65% occur in teenagers (10-20 y/o)

CAUSE
MC underlying cause in adolescents and neonates = congenital malformation known as a “bell-clapper deformity” wherein the testis is inadequately affixed to the scrotum allowing it to move freely on its axis and susceptible to induced twisting of the cord and its vessels.

“Bell-Clapper Deformity” = Inappropriately high attachment of the tunica vaginalis
- tunica vaginalis = serous covering of the testis

Adolescents usually suffer from intra-tunica vaginalis testicular torsion.

Neonates usually suffer from extra-tunica vaginalis testicular torsion.

MC Etiology in Adults = Testicular malignancy

** More common in patients with a history of cryptorchidism **

SYMPTOMS
⦁ principal symptom = rapid onset of testicular pain
⦁ erythematous and swollen scrotum
⦁ ** negative cremasteric reflex **
⦁ may have nausea + vomiting
⦁ Negative prehn’s sign = Lifting of testicle does NOT relieve pain

• patient won’t have fever and pyuria with torsion the way they would with epididymitis
• negative cremasteric reflex + negative prehn’s sign = testicular torsion
• positive cremasteric reflex + positive prehn’s sign = epididymitis
• patient presents with SEVERE DISTRESS WITHIN HOURS of onset (epididymitis = more gradual)
• often accompanied with NAUSEA + VOMITING
• large, firm and tender testes
• pain radiates to inguinal area
• testicle is often high in the scrotum and in an abnormal orientation (lies horizontally)
• if NAUSEA + VOMITING is present = suspect torsion **
• N/V = usually absent in epididymitis
• CREMASTERIC REFLEX = ABSENT*
• *** NEGATIVE PREHN’S SIGN **
• degree of swelling + redness depends on the duration of symptoms

The cremasteric reflex is a superficial reflex found in human males that is elicited when the inner part of the thigh is stroked. Stroking of the skin causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal

Appearance = high-riding testicle, edematous, inflamed

• as the torsion continues = will continue to elevate the testicle

Due to coiling, epididymis becomes more horizontal than vertical, and testicle is elevated

husky blue dot hue to that testicle due to lack of blood supply = indicative of APPENDICEAL TORSION (torsion of appendix of testis)

DIAGNOSIS
⦁ Clinical
⦁ Doppler US - shows absence of the blood flow to the testicle = best initial test

⦁ if US unable to exclude torsion = Emergency surgical exploration***

⦁ Radionuclide scan = not used as frequently

Testicular torsion is a surgical emergency and diagnosis is often made clinically. A doppler ultrasound can be utilized to assess testicular blood flow but should only be done in cases where diagnosis is unclear.

Doppler Ultrasound - must be done right away

• see decreased blood flow, or avascular testicle
• refer to urology! have a 4-6 hour window; the sooner the better

TREATMENT
⦁ Manual detorsion - twist out like opening a book = NOT LIKELY due to extreme pain

• can attempt manual detorsion - using pain relief as the guide for successful detorsion
• similar to “opening a book” - always twist outward / laterally because most torsions twist inwards and towards mid-line
• manual detorsion often doesn’t work, but should try; often won’t be able to do in clinic, especially due to pain; if caught early and hasn’t spun much, may able to succeed with manual detorsion

⦁ surgical detorsion urgently performed to prevent necrosis of the testicle and possible subfertility.

Surgical detorsion = treatment of choice

Surgical treatment of testicular torsion should be performed within 6 hours of the onset of symptoms to avoid testicular necrosis.

⦁ Orchiopexy = to prevent future recurrence = permanently fix the testis in the scrotum and prevent the recurrence of testicular torsion. Usually done to other side as well

o Surgery
⦁ *******surgical detorsion + Orchiopexy (fixation of testicle); usually prophylactic fixation of opposite testicle is performed

⦁ Orchiectomy = done when testis is deemed nonviable after surgical detorsion; salvage rates are directly related to duration of torsion; usually prophylactic fixation of opposite testicle is performed

< 6 hours will bring about the best results (> 90% salvage rate). There is a < 10% chance of salvaging the testicle after 24 hours.

** If young male who is not sexually active is having these symptoms (8-12 y/o) and has a “BLUE DOT SIGN” at the upper pole = torsion of testicular appendix

Question 2

EPIDIDYMITIS

Answer 2

Epididymitis is inflammation of the epididymis

Epididymitis can be characterized as either acute or chronic. Acute epididymitis is characterized by a swollen and erythematous scrotum with testicular pain, especially upon palpation of the spermatic cord.

Epididymis = a curved structure at the back of the testicle in which sperm matures and is stored, and is then transported to vas deferens

CAUSE
- bacteria from urethra travels to epididymis

• 2 major types
  ⦁ STIs
  ⦁ non-STI infections

STIs
- associated with urethritis
- associated with young men
⦁	gonorrhea -  gram-negative intracellular diplococci
⦁	chlamydia - gram negative

PRIMARY NON-SEXUALLY TRANSMITTED INFECTIONS
- Associated with UTIs and Prostatitis
- associated with men > 35
⦁	E. coli
⦁	Pseudomonas
⦁	Gram-positive Cocci

• could also occur post-vasectomy
• or due to trauma

*most cases of epididymitis = caused by bacterial pathogens (infection)

epididymitis = inflammation of the epididymis, doesn’t necessarily mean infection; but most of the time, it is

Chlamydia trachomatis and Neisseriagonorrhea are the most common bacterial causes of epididymitis.

⦁ STD (gonorrhea or chlamydia) > urethritis > sets up shop in epididymis→ inflammation

⦁ non-STI = UTIs/prostatitis (E-coli, pseudomonas, some gram positives)

SIGNS / SYMPTOMS
⦁ swollen / erythematous scrotum
⦁ testicular pain, especially upon PALPATION OF SPERMATIC CORD
⦁ pain develops over days
⦁ positive cremasteric reflex (unlike torsion)
⦁ low-lying testicle*****
⦁ A positive prehn’s sign = relief of pain with lifting of the testicle.
⦁ fever / chills

Epididymitis is an infection of the epididymis that is characterized by testicular pain, inflammation, redness and warmth of the scrotum.

• ** POSITIVE CREMASTERIC REFLEX ***
• ** POSITIVE PREHN’S SIGN ***
• unilateral pain + swelling in the epididymis over a period of days (not acute onset like torsion)
• erythema + edema of overlying scrotal skin - can become extremely large (reactive hydrocele)
• tenderness over the groin or in the lower abdomen
• fever
• dysuria - burning with urination
• could have urethral discharge if gonococcal

Epididymitis can often times be confused with testicular torsion. Differentiating between these two conditions is important as testicular torsion is a medical emergency in which surgical intervention within 6 hours of symptom onset is indicated to save the testicle. Unlike testicular torsion, epididymitis is more chronic and can develop over days.

DIAGNOSIS
** UA + CULTURE **

⦁ Ultrasound - to rule out testicular torsion

Classic ultrasound findings for epididymitis include an enlarged epididymis greater than 17 mm and INCREASED blood flow.

LABS
⦁ CBC (elevated WBCs - left shift)
⦁ UA + culture - positive leukocyte esterases
⦁ urethral culture (or urine NAAT) - GC + chlamydia
⦁ gram stain on urethral discharge

The definitive diagnostic tool of the causative agent of epididymitis is urine culture.

Leukocyte esterase (LE) is an esterase (a type of enzyme) produced by leukocytes (white blood cells).

TREATMENT
⦁ Scrotal elevation and support (Phren’s sign = pain relief with scrotal elevation)
⦁ Antibiotics appropriate to age, physical findings, urinalysis, cultures or gram’s stain, sexual history
⦁ Oral analgesics and antipyretics
⦁ Sexual activity or physical strain should be avoided until symptoms resolve

SYMPTOMATIC TREATMENT
⦁ NSAIDS
⦁ Scrotal elevation
⦁ Ice

o Patients < 35
⦁ Ceftriaxone (Rocephin) 250mg IM + Doxycycline 100mg BID x 10 days or Azithro 1g once (250mg x 4)

o Patients > 35
⦁ Fluoroqinolones- Cipro* or Levo
- Levaquin 500mg qd x 10 days
- don’t use Macrobid - only for uncomplicated cystitis

Question 3

CYSTITIS

Answer 3

Cystitis = inflammation of the bladder

CAUSES OF CYSTITIS
⦁	*** MC = bacterial infection ***
⦁	Fungal infection
⦁	chemical irritants
⦁	foreign bodies (kidney stones)
⦁	trauma

UTI (urinary tract infection) = any infection of the upper [kidneys, ureters] or lower [bladder, urethra] urinary tract

Cystitis = lower UTI

Lower UTIs = almost always caused by an ascending infection
- bacteria usually moves from the rectal area to the urethra, and then migrates up to the bladder

Rare, but possible = a descending infection, where bacteria spreads from blood or lymph to the kidneys, and then spreads downwards to bladder / urethra

PATHOPHYSIOLOGY

• Urine is normally sterile = bacteria doesn’t live there
• urine = High urea, low pH = helps keep bacteria out
• the unidirectional flow of urine and the process of urination helps flush out any bacteria / prevents bacteria from invading urethra + bladder

CAUSES OF BACTERIAL INFECTION
o Gram Negative
⦁	*** MC = E. COLI ***
⦁	Klebsiella
⦁	Proteus
⦁	Enterobacter
⦁	Citrobacter

o Gram Positive
⦁ ** Staph Saprophyticus = 2nd MC after E. Coli ** - particularly affects young, sexually active women
⦁ Enterococcus

RISK FACTORS
⦁ Sex (bacteria introduced into urethra)
⦁ Female gender (shorter urethra)
⦁ Post-menopausal women - decreased estrogen –> loss of protective vaginal flora –> increased risk of UTI
⦁ Foley catheter
⦁ Diabetes Mellitus** (due to hyperglycemia)
⦁ Uncircumcised infants (slightly higher risk due to foreskin)
⦁ Impaired bladder emptying –> urinary stasis –> longer time for bacteria to colonize in bladder

SYMPTOMS
⦁ Suprapubic pain
⦁ Dysuria - painful or difficulty urinating
⦁ Increased Frequency - have to pee a lot
⦁ Increased Urgency - have to go ASAP!
⦁ Urine voids are small in volume
⦁ may have cloudy appearing urine / may smell different

SYMPTOMS VARY BY AGE
o Infants
⦁	fever
⦁	fussy
⦁	feed poorly

o Elderly
⦁ fatigue
⦁ incontinence
⦁ delirium

SYMPTOMS THAT ARE TYPICALLY NOT PRESENT
= systemic symptoms
⦁	fever
⦁	N / V
⦁	CVA tenderness
- these more suggest an upper UTI (kidneys / ureters)

DIAGNOSIS
⦁ ** Urine Culture = gold standard **
- positive if > 100,000 CFUs / mL - colony forming units / mL
-
⦁ UA
- pyuria - WBCs in urine
( > 5 WBC / hpf or > 10 WBC / mL)
- presence of Leukocyte esterase (enzyme created by leukocytes (WBCs))
- may have presence of Nitrites (gram negative bacteria, such as E. coli, convert nitrates into nitrites

” Sterile Pyuria = pyuria in UA, but urine culture does not reveal bacteria = suggests URETHRITIS
⦁ MC chlamydia or gonorrhea

IMAGING
⦁ VCUG (voiding cystourethrogram) = detects VUR = backwards movement of urine from bladder to ureters / kidneys

TREATMENT
o Antibiotics
⦁ Macrobid (Nitrofurantoin) 100mg bid x 5-7 days
⦁ Cipro 250mg bid x 3 days
⦁ Bactrim bid x 3 days
⦁ pain medication - NSAIDS

o Prevention
⦁ drink lots of fluids - flush out bacteria
⦁ frequent urination / urinate with urge - especially after sex
⦁ good hygiene = wiping from urethra to rectum, not other way around!

COMPLICATED CYSTITIS = symptoms > 7 days, pregnancy, diabetics, immunosuppression, indwelling catheter, anatomic abnormality, elderly, males
⦁ Fluoroquinolones PO or IV x 7-10 days
⦁ Aminoglycosides x 7-10 days

Question 4

PYELONEPHRITIS

Answer 4

pyelo = pelvis
nephro = kidney

pyelonephritis = inflammation of the renal pelvis of kidney

Renal pelvis = funnel-like structure of kidney that drains into the ureter

ACUTE PYELONEPHRITIS = inflammation of the kidney that develops quite quickly, usually due to bacterial infection

Pyelonephritis is defined as inflammation (usually due to infection) of the kidney with neutrophilic infiltrate in the interstitium.

UTI = infection of any portion of the urinary tract: upper = kidneys + ureter, lower = bladder + urethra

So Acute Pyelonephritis = type of Upper UTI

CAUSE OF PYELONEPHRITIS
⦁ *** MC cause = ascending bacterial infection
- initially starts as a lower UTI and then travels up ureter to kidney

RISK FACTORS (same as for lower UTI)
⦁ female sex
⦁ sexual intercourse
⦁ indwelling catheters
⦁ DM
⦁ urinary tract obstruction / urinary stasis
⦁ pregnancy: progesterone + estrogen cause ureter dilation –> inhibit bladder peristalsis

• ** VUR = Vesicoureteral Reflux = where urine is moving backwards up the urinary tract, from bladder back up ureters to kidneys
• due to failure of the Vesicoureteral Orifice = one-way valve at UVJ (between ureters and bladder) that prevents backflow

VUR = can be due to primary congenital defect or by bladder outflow obstruction, which increases pressure of the bladder and distorts the valve

Obstruction leads to Urinary Stasis - makes it easier for bacteria to adhere and colonize the urinary tract

MC BACTERIA INVOLVED IN UTI / PYELO
⦁    *** E. COLI ***
⦁    Proteus
⦁    Enterobacter
- all 3 commonly found in bowel flora

Xanthogranulomatous pyelonephritis is associated with Proteus sp. infection.

Hematogenous infection can also lead to pyelonephritis, but is much less common
- occurs due to septicemia or bacteremia, or infective endocarditis
⦁ Staph
⦁ E. coli

PATHOPHYSIOLOGY

• bacteria adhere to renal epithelium of tubules –> inflammatory response
• chemokines attract neutrophils to renal interstitium and affect mainly the cortex
• typically glomeruli and vessels of the kidney are spared (unlike in chronic pyelo / glomerulonephritis)
• as neutrophils infiltrate and die off, they are excreted in the urine –> WBCs in the urine
• Sometimes the neutrophils form a cluster in the tubule, or a CAST in the shape of the tubule => may therefore find WBC CASTS in the urine

SIGNS / SYMPTOMS
⦁    usually unilateral (affects only 1 kidney)
⦁    fever
⦁    chills
⦁    nausea / vomiting
⦁    tachycardia
⦁    flank pain / CVA tenderness

THESE SYSTEMIC SYMPTOMS HELP DIFFERENTIATE AN UPPER UTI FROM A LOWER UTI

Also may have symptoms of (similar to lower UTI)
⦁    dysuria
⦁    increased urgency / frequency
⦁    hematuria
⦁    suprapubic pain

DIAGNOSIS
o UA
⦁    WBCs in urine / pyuria = > 5 WBC / hpf, espec if > 10
⦁    + leukocyte esterase
⦁    + nitrites
⦁    WBC casts***
⦁    hematuria

cystitis is associated with WBCs in urine, but not WBC casts

o Urine Culture = ** definitive diagnosis **
⦁ > 100,000

o CBC: leukocytosis (elevated WBC count)
- normal WBC = 4,500 - 11,000

TREATMENT
o Antibiotics
⦁    1ST LINE = ** FLUOROQUINOLONES ** 
- cipro 500mg BID x 7 days
- levo 750mg BID x 5 days

⦁ PREGNANT = Rocephin / Ceftriaxone IV or IM + hospitalization

⦁ Ampicillin or Gentamicin

o stay well hydrated - fluid promotion will increase urine production, helping to flush bacteria out of urinary tract

o NSAIDS for pain

COMPLICATIONS
⦁ formation of renal abscess
⦁ chronic pyelonephritis
⦁ papillary necrosis - death of renal papilla tissue

• WBC casts = acute pyelonephritis
• RBC casts = nephritic syndrome: post-streptococcal glomerulonephritis, IgA nephropathy, and rapidly progressive glomerulonephritis. They are also associated with malignant hypertension.
• eosinophilic casts = chronic pyelonephritis
• waxy casts = chronic renal failure, ESRD
• hyaline casts = can be normal
• granular casts = acute tubular necrosis (ATN)
• ATN is the most common cause of acute renal failure in hospitalized patients. ATN is an intrinsic renal failure that can be due to any of the following; persistent hypovolemia, shock, sepsis, severe hemolysis, rhabdomyolysis, amino glycosides, and amphotericin B

Question 5

NEPHROLITHIASIS (KIDNEY STONE)

Answer 5

Nephrolithiasis = Kidney stone = Renal calculi = Urolithiasis

Kidney stones form when solutes in the urine precipitate out and crystallize

MC form in the kidneys
- but can also form in the ureters, bladder or urethra

URINE
⦁ water = solvent
⦁ particles = solute
- when certain solutes become too concentrated in solvent, they become supersaturated and precipitate out to form crystals

NIDUS = crystal formation that allows more particles to easily attach and enlarge the crystalline structure

CAUSE OF KIDNEY STONES
⦁ decrease in solvent (dehydration)
⦁ increase in solutes

** MAGNESIUM + CITRATE = inhibit crystal formation, preventing kidney stones from forming in first place **

men affected more often than women
initial presentation = 30s - 50s
prevalence increases with age

5 major stone types
⦁	calcium oxalate = most common***
⦁	calcium phosphate
⦁	struvite (form staghorn calculi)
⦁	urice acid
⦁	cystine (genetic)

MOST COMMON STONE TYPE = CALCIUM OXALATE

CALCIUM OXALATE STONES
⦁ MC stone
⦁ black / dark brown stone
⦁ microscopy = looks like envelope or box with X inside
⦁ RADIOPAQUE = appears white on xray
⦁ more likely to form in ACIDIC urine
⦁ avoid grapefruit juice (makes calcium oxalate stones worse)

CALCIUM PHOSPHATE STONES
⦁ dirty white color
⦁ microscopy = looks like fortress of solitude
⦁ RADIOPAQUE = appears white on xray
⦁ more likely to form in ALKALINE urine (like struvite)

RISK FACTORS FOR CALCIUM STONES
⦁ hypercalcemia (increased GI absorption of Ca+)
⦁ hypercalciuria (decreased renal absorption of Ca+)
⦁ hyperparathyroidism
⦁ hyperoxaluria - genetic defect that decreases oxalate excretion
⦁ diet heavy in oxalate rich foods = rhubarb, spinach, chocolate, nuts, beer

URIC ACID STONES
⦁ red-brown in color
⦁ Radiolucent = transparent on xrays = don’t usually show up
⦁ uric acid –> urate ion + Na –> monosodium urate crystals
⦁ uric acid is a breakdown product of purines, so diet high in purine-rich foods = shellfish, anchovies, red meat…seafood, meat, cheese, alcohol
⦁ can cause gout / gouty arthritis = deposit of uric acid crystals in 1st MCP joint (podagra) = negatively birefringent crystals
⦁ microscope = looks like tear drops or needles

STRUVITE STONES
⦁ “Infection stones”
⦁ MIX of Magnesium + Ammonium + Phosphate
⦁ forms when BACTERIA (such as proteus mirabilis) use enzyme urease to split urea into CO2 + Ammonia
⦁ Associated with chronic UTI with Klebsiella and Proteus species
⦁ Ammonia makes urine more ALKALINE*** - which favors the precipitation of Mg + Ammonia + Phosphate into jagged crystals called (like calcium phosphate)
⦁ STAGHORN CALCULI - because they often branch into several renal calyces
⦁ dirty white in color (like calcium phosphate)
⦁ look like rectangle with line inside - looks like Hershey’s 3D chocolate - tomb shape
⦁ RADIOPAQUE = appear white on xray (like calcium stones)
⦁ Risk Factors
- UTIs
- VUR
- Obstructive uropathies

CYSTINE STONES (amino acid)
⦁	yellow or light pink stone
⦁	rare
⦁	genetic
⦁	ex: young boy with kidney stones
⦁	radiolucent = transparent on xray - wont show up
⦁	microscopy = HEXAGON

XANTHINE STONES
- also a byproduct of purine breakdown (along with uric acid)
⦁ also red-brown in color
⦁ radiolucent on xray

85% of patients with kidney stones form CALCIUM STONES (either phosphate or oxalate)
- uric acid stones also often have a calcium component

only CALCIUM + STRUVITE stones appear on KUB - are radiopaque

• stone formation thought to be from supersaturation of calcium
• stones form in interstitium; get extruded at renal papilla

Same patients may have more than one stone type at the same time

SIGNS / SYMPTOMS OF KIDNEY STONES
⦁ dull or localized flank pain - radiates to lower back
⦁ renal colic (sharp cramping pain) - more constant
⦁ N / V
⦁ CVA tenderness
⦁ hematuria
⦁ increased urgency / frequency with decreased urine volume from obstruction
⦁ colicky flank pain radiating to groin

⦁ Stones in the proximal ureter are more likely to have flank pain and CVAT
⦁ Stones in the mid-ureter cause more mid-abdominal pain
⦁ Stones in the distal ureter are more likely to cause pain that radiates to the groin

• Pain is caused by dilation / stretching / spasm of ureter
• Most painful location = UVJ (ureterovesicular junction) = narrowest point of ureter (between ureter and bladder)
• another location where stones can get stuck = UPJ (ureteropelvic junction) = between kidney and ureter

RISK FACTORS FOR STONES
⦁	Areas of high humidity
⦁	Elevated temperatures
⦁	Incidence greater in the summer months
⦁	Sedentary lifestyle
⦁	High protein and salt intake
⦁	Genetic factors –particularly with calcium stones

**but most common risk factor for kidney stones = decreased fluid intake

Citrate lowers calcium levels. so for calcium stones = have hypercalcuria, hyperoxaluria, and hypocitraturia

• UA with culture = may have microscopic or gross hematuria (Most pts experience hematuria); but could still be a stone with no hematuria present
• Urine pH (normal = 5.8-5.9)
  ⦁ pH < 5.5 = uric acid or cystine stone
  ⦁ pH 5.5-6.8 = calcium oxalate stone
  ⦁ pH > 7.2 = struvite or calcium phosphate stone
• Pregnancy test
• CBC
• CMP

METABOLIC EVALUATION OF STONES
- strain urine to catch stones for analysis
- complete metabolic evaluation required for recurrent stone formers (or family hx)
⦁ serum PTH, calcium, uric acid, phosphate, electrolytes, creatinine, BUN
⦁ 24 hour urine collection = volume, pH, calcium, uric acid, oxalate, phosphate, sodium, citrate

Stones < 5 mm = usually passed within hours

DIAGNOSIS OF KIDNEY STONES
⦁ hx + pe
⦁ Ultrasound = initial test - may see stone + hydronephrosis
⦁ CT without contrast = ** definitive diagnosis **
⦁ UA = may show microscopic or gross hematuria (RBCs)
⦁ pain may shift in location as stone travels

• CT scan / Ultrasound = both can detect presence of stone, obstruction, and hydronephrosis
• KUB can only detect large radiopaque stones (calcium + struvite stones), will miss radiolucent stones, and does not detect obstruction
• MRI = rarely used
• IV pyelography = determines extent of obstruction and severity (used to be gold standard, not anymore)

Gold standard = CT - noncontrast abdomen/pelvic**

most painful part of kidney stone passage = ureter

TREATMENT FOR KIDNEY STONES
- ACUTE THERAPY-
⦁ IV hydration
⦁ Pain Meds = Ketorolac/Toradol, or Morphine IV
⦁ Antiemetic = Metoclopramide/Reglan IV or Zofran
⦁ give strainer - cannot determine type of stone from UA, so give strainer to catch urine and bring in for analysis

⦁ can give alpha-1 blocker (Tamsulosin/Flomax - alpha 1 blocker - causes dilation) to help pass stone

• if the pain is under control, stable, and there are no signs of infection, the patient can be discharged and followed-up as an outpatient**

Stones < 5 mm = likely to pass with hydration / flomax
IF STONE IS 5mm+ = NEED SURGERY = lithotripsy

WHEN KIDNEY STONES BECOME A MEDICAL EMERGENCY
= any obstructing stone with an associated infection***

Outpatient management is appropriate for most patients

WHEN TO ADMIT THE PATIENT WITH KIDNEY STONES
⦁ intractable nausea/vomiting or pain that is not controlled with medications
⦁ obstructing stone with signs of infection (emergency!)
⦁ patients with only 1 kidney
⦁ renal colic with UTI or renal colic with fever

REASONS FOR UROLOGICAL CONSULT FOR KIDNEY STONES
⦁ evidence of urinary obstruction*
⦁ urinary stone with associated flank pain*
⦁ anatomic abnormalities or solitary kidney**
⦁ concomitant pyelonephritis or recurrent infection

THERAPEUTIC INTERVENTION IS NEEDED WHEN:
⦁ failure to pass stone in 4 weeks
⦁ fever, intolerable pain, persistent nausea or vomiting

SURGICAL TREATMENT
⦁ ESWL = extracorporeal shock wave lithotripsy
(> 5-10)
⦁ Percutaneous Nephrolithotomy (PNL) = only if in kidney, and is primary tx for struvite stones
⦁ Ureteroscopy with stent placement

PREVENTION OF KIDNEY STONE FORMATION
⦁ increase fluid intake** (most important)
⦁ avoid sodium and protein
⦁ reduce animal protein consumption
⦁ limit foods high in oxalate (beer, tea, coffee)

allopurinol = reduces amount of uric acid produced by body (helps with gout and when chemo increases uric acid levels)

Question 6

ORCHITIS

Answer 6

Orchitis = inflammation + infection of the testicle

Orchitis = unilateral infection of the testes, typically with mumps virus

Orchitis = acute inflammatory reaction of the testes secondary to infection

Orchitis develops in 20 to 25% of males with mumps
80% of cases occur in children < 10

CAUSES = usually VIRAL
⦁	MUMPS = MC
⦁	coxsackie
⦁	rubella
⦁	echovirus
⦁	parvovirus

MC complication of mumps = orchitis
MC neurological complication of mumps = ** aseptic meningitis***

• bacterial orchitis = quite rare, and usually associated with concurrent epididymitis

Orchitis in adults = usually bacterial
Orchitis without epididymitis = uncommon in adults
MC bacterial causes = E.coli + Pseudomonas

• 1/3 of post-pubertal men with mumps have concomitant orchitis (unilateral)
• Mumps parotitis precedes the onset of orchitis by 3-10 days

SYMPTOMS
⦁	Gradual onset of scrotal pain / tenderness
⦁	70% of mumps orchitis = unilateral
⦁	testicular enlargement
⦁	erythema
⦁	swelling

SYSTEMIC SYMPTOMS
⦁	may have associated fever
⦁	chills
⦁	headache
⦁	myalgia
⦁	irritative voiding symptoms

** POSITIVE PHREN’S SIGN **
** positive cremasteric reflex **
(torsion = negative cremasteric / negative prehn)
(epididymitis = positive cremasteric / positive prehn)

• symptoms may follow acute strain
  o sex
  o lifting
  o exercise

DIAGNOSIS
⦁ clinical
⦁ may do ultrasound to r/o torsion / abscess / tumor
⦁ UA - pyuria / bacteriuria if bacterial

TREATMENT
- symptomatic treatment = 
⦁	bed rest
⦁	scrotal elevation
⦁	cool compresses
⦁	analgesics (NSAIDS)

• abx if infectious etiology is bacterial
  o Age <35 or sexually active postpubertal males (cover for GC/Chlamydia)
  ⦁ Ceftriaxone 250 mg IM + doxycycline 100 mg PO BID for 10 days or Azithro 1g PO (4 250mg pills)

o Age >35
⦁ levofloxacin 500 mg/d PO x 10 days

Patient will present as → a 31-year-old male complaining of unilateral scrotal swelling with pain radiating to the ipsilateral groin. Examination reveals a tender swollen testicle, scrotal edema with erythema and shininess of the overlying skin.

Question 7

PHIMOSIS

Answer 7

Phimosis – foreskin in normal position and cannot be retracted

Not emergent

o PHYSIOLOGIC PHIMOSIS
- is normal in uncircumcised children, and typically resolves by age 5

• a normal condition in which children are born with a tight foreskin, and if uncircumcised, separation occurs during childhood / early adolescence.
• Children are born with tight foreskin at birth and separation occurs naturally over time. Phimosis is normal for the uncircumcised infant/child and usually resolves around 5-7 years of age, however the child may be older.

Physiologic phimosis is present at birth and resolves without intervention. Most children will not have a fully retractable foreskin at birth, but do so as they get older with the majority having a fully retractable foreskin by early adolescence.

o PATHOLOGIC PHIMOSIS

• happens due to infection, inflammation, or scarring
• usually found in uncircumcised adult men

COMPLICATIONS
- can cause BALANITIS due to phimosis making it difficult to clean the head of the penis

SYMPTOMS
⦁	difficulty urinating
⦁	painful urinating
⦁	painful erection
⦁	paraphimosis

If there is ballooning of the foreskin during urination, difficulty with urination, or infection, then treatment may be warranted.

DIAGNOSIS = clinical

TREATMENT
- may include
⦁	gentle daily manual retraction
⦁	topical corticosteroid ointment application
⦁	circumcision

STEROIDS
The most common corticosteroids used are hydrocortisone 2.5%, betamethasone 0.05%, triamcinolone 0.01%, and fluticasone propionate 0.05%.

• These topical ointments are used to help soften the tight foreskin around the penis, so the foreskin may be easily retracted.

The ointment is massaged into the affected areas twice daily for 6-8 weeks along with manual stretching/retraction twice daily. Once the foreskin can be fully retracted, the ointment is discontinued and manual daily retraction (during warm baths and urination) will prevent phimosis from reoccurring

Treatment is not required if there are no complications such as balanitis, UTIs, urinary outlet obstruction, unresponsive dermatologic disease, or suspicion of carcinoma.

If conservative measures are ineffective, preferred surgical option = ** CIRCUMCISION **

In adults, phimosis may result from balanoposthitis (inflammation of both the penis head and the foreskin) or prolonged irritation.

In adults = usually due to poor hygiene and bacterial causes

Broad-spectrum antibiotics to clear any infection that may have caused phimosis, then go to circumcision

Risk of UTI, penile cancer, HIV, and sexually transmitted diseases is increased with phimosis.

THE USUAL FINAL TREATMENT = CIRCUMCISION

Patient will present with → foreskin in normal position that cannot be retracted

Question 8

PARAPHIMOSIS

Answer 8

Paraphimosis = The foreskin gets TRAPPED behind the corona of the glans, and forms a TIGHT BAND, constricting penile tissues

The foreskin cannot be pulled forward

The entrapment of the foreskin in the retracted position; it is a medical emergency.

The tight band of tissue impairs blood + lymphatic flow –> causes gangrene + auto-amputation (takes days to weeks)

PARAPHIMOSIS = UROLOGIC EMERGENCY!!!!

Paraphimosis can occur when the foreskin is left retracted (behind the glans penis).

Retraction may occur during catheterization or physical examination.

If the retracted foreskin is somewhat tight, it functions as a tourniquet, causing the glans to swell, both blocking the foreskin from returning to its normal position and worsening the constriction.

Always remember to reduce the foreskin after urethral catheterization!!!

SYMPTOMS
⦁ enlarged, painful glans with constricting band of foreskin behind the glans

should be regarded as an emergency, because constriction leads quickly to vascular compromise and necrosis of the glans penis

TREATMENT
⦁ Manual reduction
- restore original position of the foreskin
- reduce edema with cool compresses or pressure dressing, then gentle pressure to restore the foreskin to its normal position

⦁ Pharm therapy

• granulated sugar
• injection of hyaluronidase (disperses edema)
• incision = dorsal slit followed by circumcision

Firm circumferential compression of the glans with the hand may relieve edema sufficiently to allow the foreskin to be restored to its normal position. If this technique is ineffective, a dorsal slit done using a local anesthetic relieves the condition temporarily. Circumcision is then done when edema has resolved.

Patient will present with → entrapment of the foreskin in the retracted position