1
Q
What is an epidymal cyst?
A
-Most common cause of scrotal swelling seen in primary care
2
Q
What are the features of an epididymal cyst?
A
- Lump
- Separate from the body of the testicle
- Found posterior to the testical
3
Q
Which conditions are associated with epididymal cysts?
A
- PCKD
- CF
- Von Hippel-Lindau syndrome
4
Q
How is epididymal cysts diagnosed?
A
-USS
5
Q
How is an epididymal cyst managed?
A
- Supportive therapy
- Surgical removal or sclerotherapy for larger symptomatic cysts
6
Q
What is a hydrocele?
A
-Abnormal collection of fluid between the 2 layers of the tunica vaginalis
7
Q
What are the causes of hydroceles?
A
- Non-communicating/simple hydrocele: Overproduction of fluid within the tunica vaginalis
- Communicating hydrocele: processus vaginalis fails to close allowing peritoneal fluid to communicate with scrotal portion
- Hydrocele of the cord: processus vaginalis closes segmentally, trapping fluid with the spermatic cord
8
Q
Which conditions may hydroveles develop secondary to?
A
- Epididymo-orchitis
- Testicular torsion
- Testicular tumours
- Trauma
- Generalised oedema
9
Q
How do hydroceles present?
A
- Scrotal enlargement with a soft non-tender swelling
- Painless
- Lies anterior to and below the testes
- Transluminates with pen torch
- Testes can be difficult to palpate if hydrocele is large
10
Q
Investigations for hydroceles?
A
- Simple: none
- USS
- Duplex sonography
- Serum alpha fetoprotein and HCG levels to exclude malignant teratomas
11
Q
Treatment for hydroceles?
A
-Many of infancy resolve spontaneously before 2years
-Conservative approach depending on severity in adults
>Exclusion of malignancy
-Scrotal support
-Therapeutic aspiration
-Surgical removal (in some cases)
12
Q
What is a varicocele?
A
- Anbnormal dilatation of testicular veins in the pampiniform venous plexus, caused by venous reflux
- Usually asymptomatic but associated with infertility
13
Q
What is an important cause of varicocele that must be excluded?
A
-Renal cell carcinoma
14
Q
Causes of varicoceles?
A
- Reflux (from renal vein->testicular veins:Usually the left)
- Vein incompetence
- Swollen testicles could be caused by kidney cancer
15
Q
Why does varicoceles usually occur on the left?
A
- Left testicular vein drains into the left renal vein. Increased chance of becoming obstructed.
- Right testicular vein drains in the the IVC
16
Q
What is the epidemiology of a varicocele?
A
- Unusual in boys under 10
- Incidence increases after puberty
- Cause of infertility
17
Q
Clinical presentation of a varicocele?
A
- Usually asymptomatic
- Scrotum described as feeling like a ‘bag of worms’
- Scrotal heaviness
- Incidentally when having infertility investigations
- Lower scrotum on varicocele side
18
Q
Investigations and varicoceles?
A
- Sperm count
- US colour doppler studies
- Venography, CT
- Serum FSH, LH and LHRH (relate to sperm production)
19
Q
What is the treatment for varicoceles?
A
-Surgical repair when there is pain, possible infertility consequences and possible testicular atrophy
20
Q
What are the main differential diagnoses for scrotal swelling?
A
- Inguinal hernia
- Testicular tumour
- Acute epididymo-orchitis
- Epididymal cysts
- Hydrocele
- Testicular torsion
- Varicocele
21
Q
Define testicular torsion?
A
-Twisting of the spermatic cord resulting in testicular iscahemia and necrosis
22
Q
Aetiology of testicular torsion?
A
- Occlusion of the testicular blood vessels
- Usually following sport or physical activity
23
Q
Pathophysiology of testicular torsion
A
- Blood vessel occlusion leads to ischaemia of the testicle
- Acute inflammation causes pain and swelling to try and block the occlusion
24
Q
Epidemiology of testicular torsion?
A
- Mainly affects males between 10-30 (commonly 13-15)
- Can occur in new borns
- Most likely left side affected
- Bilateral cases are rare
25
Clinical presentation of testicular torsion?
- Acute swelling of the scrotum
- Pain: sudden and severe
- Lower abdo pain
- Nausea and vomiting
- Reddening of scrotal skin
- Swollen tender testes (retracting upwards)
- Cremasteric reflex lost
26
Investigations for testicular torsion?
- Urinalysis to exclude infection
| - Doppler USS: shows reduced blood flow
27
Treatment for testicular torsion?
- Surgery (within 6 hours to keep the testicle)
| - if torted tesis -> both testes should be fixed to treat bell clapper testis (bilateral)
28
What is BPH?
- Benign prostatic hyperplasia
- Enlarged prostate gland without malignancy
- Common in older men
29
What is the cause of BPH?
-May be due to failure of apoptosis but cause is unknown
30
What are the risk factors for BPH?
- Increasing age
| - Ethnicity: black men > white men > asian men
31
Which zone of the prostate gland does BPH occur in?
-Transitional zone
| >hyperplasia of both glandular and connective tissue elements within the gland
32
How does BPH present?
-LUTS
>Voiding symptoms (obstructive): weak/intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
>Storage symptoms (irritative): urgency, frequency, urgency incontinence, nocturia
>Post micturition: dribbling
>Complications: UTI, retention, obstructive uropathy
33
Investigations ofr BPH?
- PR: smooth enlarged prostate
- U&Es and renal USS
- Rule out malignancy
- Serum PSA
34
What is the treatment for BPH?
- Watchful waiting
- Alpha blockers
- 5-alpha-reductase inhibitors
- Urethral or suprapubic catheterisation
- Prostatectomy/TURP
35
What are some example alpha blockers/a1 receptor antagonists? How do they work?
- Tamsulosin
- Alfuzosin
- Relax smooth muscle in the bladder neck and prostate
36
What are some examples of 5 alpha reductase inhibitors and how do they work?
- Finasteride
- Blocks conversion of testosterone to dihydrotestosterone (cause of prostate growth)
- Can slow disease progression
37
What are the adverse effects of alpha 1 antagonists ie tamsulosin?
- Dizziness
- Postural hypotension
- Dry mouth
- Depression
38
What are the adverse effects of 5 alpha reductase inhibitors?
- Erectile dysfunction
- Reduced labido
- Ejaculation problems
- Gynaecomastia
39
What are some complications of BPH?
- Symptom progression leading to bladder obstruction or progression to malignancy
- Infections
- Stones
- Haematuria
- Acute retention
- Chronic retention
- Interactive obstructive uropathy
40
What is the most common type of bladder cancer?
-Transitional cell carcinomas
41
What are the risk factors for transitional cell carcinoma of the bladder?
- Smoking
- Exposure to aniline dyes in the printing/textile industry
- Rubber manufacture
- Cyclophosphamide
- Pelvic irradiation
42
What are the risk factors for squamous cell carcinoma of the bladder?
- Schistosomiasis
- BCG treatment
- Smoking
43
What is the link between schistosomiasis and bladder cancer?
-Schistosomiasis = parasite that causes chronic inflammation of the UT
>leads to SCC
>20 year lag
44
What layers form the bladder wall?
- Transitional epithelium
- Lamina propria
- Submucosa
- Detrusor muscle
- Adventitia
45
What is the epidemiology of bladder cancer?
- 50% worldwide: schistosomiasis
| - 50% UK: smoking
46
What are the 2 categories of LUTS?
- Storage symptoms
| - Voiding symptoms
47
What are storage symptoms?
- Frequency
- Urgency
- Incontinence
- Painful micturition or reduced bladder senstation
- Nocturia
48
What are examples of Voiding symptoms
- Intermittent stream
- Hesitancy
- Straining
- Dribbling
- Feeling of incomplete emptying
49
What are red flags of LUTS?
- Haematuria
| - Dysuria
50
What is the clinical presentation of bladder cancer?
- Painless haematuria
- Recurrent UTIs
- Voiding irritability
- LUTS
- Dysuria
- Abdo pain
- Weight loss/bone pain
51
Investigations for bladder cancer?
- Urine dipstick (non-visible haematuria)
- Blood tests (FBC, U&E, LFTs)
- Flexible cystoscopy with biopsy
- Ct urogram: provides staging
52
What is the treatment for bladder cancer in situ (non muscle invasive bladder ca)?
-Resection +/- intravesicle chemo
| >Mitomycin and BCG vaccine
53
How is localised bladder cancer managed?
-Depends on pts fitness
>Radical surgery: cyctectomy +/- prostatectomy +/- urethrectomy +/- neoadjuvant chemo
>Radical radiotherapy if not fit/unwilling to have cystectomy
54
How do you treat locally advance bladder cancer?
- Radical surgery +/- chemo
| - Radical radiotherapy
55
How do you treat metastatic bladder cancer?
- Combination chemo
- Poor survival
- Urinary diversion for severe symptoms if unfit for radical surgery. Create urostomy
56
What is the 2WW criteria for suspected urological malignancy?
-PSA above normal levels
>45 with any:
-Unexplained visible haematuria without UTI
-Persistent visible haematuria after treatment of UTI
>60 with any:
-Unexplained non-visible haematuria with either,
>raised WCC, dysuria
57
What is the role of the prostate gland?
-Produces seminal fluid that nourishes the sperm
>Production of fluid is triggered by
dihydrotestoerone
-Located below male bladder and surrounds the urethra
58
What zone of the prostate is affected by malignant cancer?
-Peripheral zone
(compared to BPH affecting the transitional zone)
-Presents later than BPH because peripheral zone is further away from the urethra
59
What type of cancer is most commonly found in the prostate?
- Adenocarcinoma
| - Usually multifocal
60
Why should prostate cancer be considered as 2 different diseases?
- Localised and advanced disease
| - Both have different symptoms, outcomes and treatments
61
What are causes/risk factors for prostate cancer?
- Age
- Obesity
- Afro-caribbean ethnicity
- Family history
- Mutations in androgen receptor genes
62
What is the epidemiology of prostate cancer?
- Disease of the elderly
| - Most men die with prostate cancer rather than from it
63
What is the most common presenting complaint for prostate cancer?
-Can be asymptomatic or mimic BPH
>increased frequency, nocturia, urinary hesitancy, post-void dribbling
-Pain (back, perineal, testicular)
-Haematuria or haematospermia
64
What are the non-urinary symptoms of prostate cancer?
-Non-specific: weight loss, anorexia, fever, anaemia
-Hypercalcaemia: due to bone mets causing increased bone breakdwon: anorexia, thirst, confusion, collapse
-Marrow replacement: purpura, anaemia, immune suppression
-Paraneoplastic:
>Cushing's
>Dementia
>Peripheral neuropathy
>Erythrocytosis
>Acanthosis nigricans
65
Which lymph nodes does prostate cancer metastasise to initially?
- Obturator nodes
| - Also commonly spreads to bone
66
What are the investigations for prostate cancer?
- PSA
- Prostate specific membrane antigen
- Urine test for PCA3
- Transrectal ultrasound scan
- Prostate biopsy
- MRI/CT and bone scanning
67
What is considered normal for the upper limit of PSA?
Age: 50-59 = 3ng/ml
Age: 60-69 = 4ng/ml
Age: 70+ = 5ng/ml
68
When should someone be referred due to a raised PSA?
-Men aged: 50-69 with PSA >3 or abnormal DRE
69
What are some causes of false +ve raised PSA?
- Prostatitis
- UTI
- BPH
- Vigorous DRE
- Vigorous exercise
- Ejaculation
- Urinary retention
- Instrumentation of the Urinary tract
70
How must a PSA test be timed in order to obtain an accurate result?
- 6 weeks following prostate bipsy
- 4 weeks following proven UTI
- 1 month following prostatitis
- 1 week following DRE
- 48hrs post vigorous exercise/ejaculation
71
What is the most important physical examination to perform in someone with ?prostate cancer?
```
-DRE
>Asymmetrical
>hard
>Nodular enlargement (craggy)
>loss of median sulcus
```
72
Which grading system is used for grading prostate cancer?
-Gleason grading system
73
What is the treatment for localised prostate cancer?
- Radical prostatecomy + radiotherapy
- Focal therapy (high intensity USS)
- Watchful waiting in the elderly, multiple co-morbidities
74
What is the difference between watchful waiting and active surveillance?
- Watchful waiting: less invasive form of monitoring. Treatment is guided by symptoms
- Active surveillance: follow up for physical examinations, measurement of PSA level and treatment depends on those factors
75
What are the risks for radical prostatectomy?
- Incontinence
| - Sexual dysfunction
76
Arguements for radical treatment of localised prostate cancer?
- Curative
- Prostate cancer cells killed
- Reduces pt anxiety
77
Arguements against radical surgery for localised prostate cancer?
- Disease of the elderly
- Cause of death
- Adverse effects of Rx
78
Arguments for screening for prostate cancer?
- Commonest cancer in men
| - Men die from it
79
Arguments against prostate cancer
- Uncertain natural history
- Morbidity of treatment
- False +ves
- Pts can be treated when they'd never develop symptoms
80
How do you treat locally advanced prostate cancer?
- Radiotherapy +/- radical prostatectomy
| - Brachytherapy (radiotherapy inserted into prostate using device)
81
What are some complications of radiotherapy for prostate?
- Bowel cancer
- Bladder cancer
- Increased frequency of urination
- Fibrosis
- Urethral strictures
- Skin changes/inflammation
82
How is metastatic prostate cancer treated?
-Androgen deprivation essential
>surgical castration or medical castration if pt refuses surgery
>stops action of dihydrotestosterone
83
What is surgical castration?
-Removal of testes to get rid of testosterone level to reduce symptoms and improve survival
84
Explain how medical castration works?
-GNRH analogues
>-ve feedback on testosterone
-LH antagnoists (block testosterone production from Leydig cells)
-Peripheral androgen receptor antagnosists
85
What are some examples of GNRH analogues?
- Buserelin
- Goserelin (Zoladex)
- Lueprorelin
- Triptorelin
86
Which medication should be co-prescribed for someone starting on a GNRH analogue?
-Anti-androgen treatment ie cyproterone
>used to reduce the risk of tumour flare
>start cyproterone 3/7 before GNRH
87
What is castration-resistant prostate cancer and how is it treated?
-Disease continues to progress despite castration
>abiraterone =2nd line hormonal therapy
>cytotoxic chemotherapy: docetaxel, carbazitaxel
-Bisphosphonates to protect bones
88
What is the main complication of TURP?
-Transurethral resection of the prostate syndrome
| >Venous destruction and absorption of the irrigation fluid occurs
89
What are the risk factors of TURP syndrome?
-Surgical time >1hr
-Height of bag >70cm
-Resected >60g
-Large blood loss
>Perforation of the bladder
>Large amount of fluid used
-Poorly controlled CHF
90
What are the features of TURP syndrome?
-Early features: restless, headache, tachypnoea, burning sensation in face and hands
-Greater severity features:
>resp distress, hypoxia, pulmonary oedema
>N+V
>visual disturbance
>Confusion
>Haemolysis
>Acute renal failure
91
What investigations should be done for TURP?
- Hyponatraemia (from the large volume of fluid absorbed)
| - Metabolic acidosis
92
How is TURP syndrome managed?
- ABCDE + resus +02
| - Fluid overload management
93
Which cells in the testicles produce a) testosterone, b) sperm
a) Leydig cells in the presence of LH
| b) sertoli cells
94
What are the causes of testicular cancer?
- Unknown (majority of cases)
- Larger risk factors in those with undescended testicles
- FH
- Genetic factors: chromosome 12 abnormalities
95
What are the risk factors for testicular cancer?
- For teratomas and seminomas (25-35years)
- Cryptorchidism (undescended testes)
- Infertility
- Family hx
- Klinefelter's syndrome
- Mumps orchitis
96
What are the main types of cancer in the testicles?
-Mainly arise from the germ cells: Seminomas, teratomas
97
What is the epidemiology of testicular cancer?
-Most common cancer in young men
98
How does testicular cancer present?
- Painless lump
- Testicular +/- abdo pain
- Dragging sensation in the testicles
- Hydrocele
- Gynaecomastia from B-HCG production
- Mets in lungs: cough/dyspnoea
- Mets in para-aortic lymph nodes: back pain
99
Investigations for testicular cancer?
-USS: helps differentiate between masses in the testes and other intra-scrotal
swellings
-Serum conc. of tumour markers: alpha fetoprotein, Beta-HCG
-Tumour staging with CT CAP
100
Treatment of testicular cancer?
- Orchidectomy
- Radiotherapy (seminomas mets below the diaphragm)
- Chemotherapy (widespread tumours from teratoma mets)
- Sperm banking
101
Define urinary tract infection?
-Inflammatory response of the urothelium to bacterial invasion usually associated with bacteriuria and pyuria
102
How can UTIs be classified?
- Upper vs lower
- Clinical risk ie uncomplicated vs complicated
- Timing: single/isolated vs unresolved, acute vs chronic
103
What are the 5 main pathogens responsible for causing UTIs seen in primary care?
- E. coli
- Coagulation negative staph species (ie staph epidermidis)
- Proteus spp. (gram -ve bacillus)
- Enterococci (gram +ve cocci)
- Klebsiella species (gram -ve bacillus)
104
What kind of urinary tract abnormalities encourage bladder infections?
- Urinary obstruction or stasis
- Previous damage to the bladder epithelium ie previous infections
- Bladder stones
- Poor bladder emptying ie neuro problems
105
Describe the most common pathway to a UTI?
-Colonic flora exists naturally
-Which colonise the vagina and then the urethral meatus
-Ascent of bacteria up the urethra = bacteriuria
=UTI
106
What are some bacterial factors that increase the likelihood of UTI?
-Fimbriae/pili allow strong adheretion to the urothelium, vaginal epithelium, vaginal mucous
-Ability to avoid host defences
>capsule resistant to phagocytosis
>toxin release
>enzyme production ie secreation of urease
>abx resistance
107
What is the function of urease enzyme in UTIs?
- Produced by infecting bacteria
- Increases the risk of stone formation (calcium phosphate)
- Increase pH >7.2 through production of ammonium = dispruption of normal commensal bacteria which are usually protective against infection
108
Examples of bacteria that produce urease:
a) gram -ve?
b) gram +ve?
Gram -ve: Proteus, klebsiella, pseudomonas, providencia
| Gram +ve: Staph, mycoplasma
109
What host factors increase the risk of UTI?
- Oestrogen depletion (causes pH to rise = less acidic protection)
- Incomplete bladder emptying/outlet obstruction
- Reflux of the urine within the urinary tract
- Pregnancy
- Lowered levels of Tamm-Horsfall protein
- Lowered levels of commensal flora
- Raised urinary pH
110
Epidemiology of UTIs?
- More common in women
- UTIs in men indicates underlying UT abnormality
- Most common cause: E.coli (from pts own urine)
111
Why are UTIs more common in women?
- Shorter urethra
- Closer proximity to anus
- Ease of transmission of bacteria from anal region to vagina/urethra
112
Clinical presentation of Lower UTI?
- Increased frequency of micturition
- Dysuria (painful urination)
- Suprapubic pain and tenderness
- Haematuria
- Smelly urine
113
Symptoms of acute pyelonephritis?
- Loin pain and tenderness
- Nausea and vomiting
- Fever/rigors
- Be aware of elderly: they may be generally unwell
114
Investigations for UTI?
-Symptoms + urinalysis
>MS+C of MSSU
>Shows leucocytes, blood, raised pH, nitrites
115
What's the difference between a complicated and an uncomplicated UTI?
Complicated if:
- Male
- Pregnant
- Children
- Recurrent/persistent infection
- Immunocomprimised pt
- Infection that occurs in hospital
- Presence of a UT abnormality
- SIRS or urosepsis
- Associated urinary tract disease ie stones
116
How is recurrent UTI defined?
- >2 episodes in 6/12
- >3 episodes in 12/12
- Reinfection with same bacteria
- Bacterial persistence
- Unresolved infection
117
Investigation of recurrent or complicated UTI?
- MSSU
- Examination: DRE, pV (check for fistulae)
- Post void bladder scan
- USS of renal tract
- KUB XR or NCCT KUB to rule out stones (Only CT if symptoms suggest stones)
- Flexible cystoscopy
118
Treatment of uncomplicated UTI?
-Treat on basis of symptoms
-3/7 course of Trimethoprim or nitrofurantoin
>increase fluid intake
>regular voiding
>void before and after intercourse
>hygeine
>OCP advice if abx interfere
119
Treatment of complicated UTI?
- Trimethorpim, amoxicillin or nitrofurantoin
- MSSU
- Longer course of abx to the sensitivity of the bacteria
- Investigate further for recurrent UTIs
120
How are pregnant women treated for UTI?
- Culture
| - Nitrofurantoin
121
Treatment of recurrent UTIs?
- Increase fluid intake
- Regular voiding and double voiding
- Voiding before and after sex
- Vaginal oestrogen replacement
- Avoid spermacides and perfumed soaps
- Cranberry juice
- Self-start abx if at risk
122
How is acute pyelonephritis treated?
- Hospital admission should be considered
| - Broad spec cephalosporin or quinolone for 10-14 days
123
Define bacteriuria?
- Presence of bacteria in the urine: can be asymptomatic or symptomatic
- Asymptomatic bacteriuria without pyuria is rarely a concern
- Prevalence of asymptomatic bacteriruira increases with age and in pregnancy
124
When does bacteriuria need treating?
- In pregnant pts (high risk of pyelonephritis and pre-term labour)
- If causing symptoms
125
Define pyuria?
- Presence of leucocytes in the urine
| - Can be ass. with infection or sterile causes (bladder cancer)
126
Causes of bacterial colonisation or urine?
- Immunosuppression
- Disease ie DM, renal failure
- Steroids and chemo
- Urolithiasis
- Tumour
- Fistula with the bowel
- Neuropathic bladder/chronic retention
- Indwelling catheter
- Intermittent self catheterisation
- Paraplegic pts
127
Causes of raised pressure in the urinary tract? (ass with increased risk of colonisation)
- In the lumen: stones, sloughed papillae
- In the wall: tumour, stricture, PUJ obstruction, iatrogenic
- Outside the wall: tumour, retroperitoneal fibrosis
- Inability to effectively empty the bladder ie neuro causes
128
Where are the main origins of sepsis in the body in order of likelihood?
- Urinary tract
- Respiratory tract
- GI tract
- Hepatobiliiary
- Other
- Skin/soft tissue
129
What are the stages of sepsis?
- Systemic inflammatory response syndrome
- Sepsis
- Severe sepsis
- Septic shock
130
What is the criteria for diagnosis of SIRS?
```
-2 of the following:
>temp >38 or <36
>Hr >90
>RR >20
>pCO2 <4.3kPa
>Wcc >12000 or <4000
```
131
Criteria for diagnosis of sepsis and severe sepsis?
```
-Sepsis:
>2 SIRS criteria
>confirmed or suspected infection
-Severe sepsis:
>sepsis
>signs of end organ damage ie SBP<90 OR LACTATE >2
>septic shock + persistent hypotension
```
132
Diagnosing a UTI in a pt known to have colonised urine?
- Fever
| - Pain
133
What are the investigations for sepsis?
-Sepsis screening tool ie BUFALO, FABULOS
134
What is the treatment of urosepsis?
```
-Given in 1 hour:
>high flow o2
>blood cultures
>iv abx
>iv fluids
>lactate
>monitor urine output hourly
-Manage systemic factors ie diabetes, immune system supports
-Relieve pressure: catheter, nephrostomy
```
135
What are some important key points about urosepsis regarding drainage, colonised urine and catheters?
- Drainage is important treatment in urosepsis
- Colonised urine is ofthen a mutlisystem disorder that does not need treating, but is a risk factor for urosepsis
- Catheters: consider a suprapubic catheter in pts requiring long term catheterisation
136
Define pyelonephritis
- Infection of the renal parenchyma and soft tissues of the renal pelvis/upper ureter
- Acute pyelonephritis is ass. with neutrophil infiltration of the renal parenchyma
137
Which bacteria is the most common of pyelonephritis?
-E.coli
>known as UPEVC (uropathogenic E.coli)
>have P pili on their surface to allow ureteral ascent
138
Pathogenesis of pyelonephritis?
- Bacteria from the colon ascending the urinary tract
| - Can progress from lower urinary tract infections that have not resolved
139
What is emphysematous pyelonephritis and which type of pt is it most common in?
- Rare life threatening kidney infection (fulminant onset - needs fast recognition)
- Gas forming organisms ie E perfingens (gas builds up in the renal parenchyma)
- May need an emergency nephrectomy
- More common in diabetics
140
What is pyelonephritis in children most commonly associated with?
-Vesico-ureteric reflux
>incompetent valve between the bladder and ureter
>allows reflux of urine up the ureter during bladder contraction
-Chronic reflux and repeated infections = significant renal compromise
-Typically ass with multiple structural/functional abnormalities
141
What is the clinical presentation of pyelonephritis?
- Classic triad: loin pain, fever, pyuria
- Ass. w/ systemic upset and rigors
- May have severe headaches
- Often fluid deplete O/A
142
Investigations for pyelonephritis?
- Regular observation (watch for decompensation)
- Ex: shows tender loin area
- PV: rule out vaginal/ovarian/appendix pathology
- Bloods (inc. cultures)
- Urgent USS: rule out obstruction of upper tracts
143
Treatment of pyelonephritis?
- IV infusion (to replace fluid losses
- IV abx: gent/augmentin
- HDU if required
- Drain obstructed kidney
- Catheter
- Analgesia
- Convert to PO abx when getting better
- 10-14 days of treatment
144
What is cystitis and what causes it?
- UTI in the bladder
| - Mainly caused by uropathogenic E.coli
145
How does cyctitis present?
- Dysuria
- Increased frequency of urination
- Urgency
- Sharp pain on urination
- Haematuria
- Offensive smelling/cloudy urine
146
Investigations for cystitis?
-Hx + examination = diagnosis
-Dipstick:
>urinary nitrites (bacteria break down nitrates >nitrites)
>leucocyte elastase
>pyuria
-Urinary MS+c plus susceptibility for testing of pathogens
147
Treatment of cystits?
- Trimethoprim or amoxicillin or nitrofurantoin
| - High fluid intake during and after treatment for a few weeks
148
Define prostatitis
- Inflammation of the prostate
- Variable symptoms
- hard to treat
- Associated LUTs
149
Which organism is most commonly associated with acute bacterial prostatits?
-E.coli
| >gram -ve bacteria enter the prostate gland via the urethra
150
What are the risk factors for acute bacterial prostatitis?
- Recent UTI
- Urogenital instrumentation
- Intermittent bladder cathererisation
- Recent prostate biopsy
151
Presentation of acute bacterial prostatitis?
```
-Systemically unwell
>fevers
>rigors
>significant voiding LUTS
>pelvic pain
-Tender prostate on DRE
```
152
Presentation of chronic bacterial prostatitis?
- Symptoms >3/12, recurrent UTIs
- Pelvic pain, voiding LUTs
- Uropathogens in urine/ blood
153
What is chronic pelvic pain syndrome?
- Chronic abacterial prostatitis
- Inflammation of the prostate without presence of infection
- Chronic pelvic pain +/- LUTs +/- UTIs
154
Epidemiology of prostatitis?
- Common in men of all ages
| - Most common type of urinary tract problem in men <50
155
Investigations for prostatitis?
- Urinalysis and MSSU
- Urine and semen cultures (presence of coliforms)
- Blood tests for presence of infection ie wcc
- STI screen
- Urodynamic tests if predominant LUTs
- Imaging (transrectal urethral US +/- abdo/pelvis CT)
156
What is the treatment of acute prostatitis?
- IV abx (gentamycin and co-amoxiclav/tazocin/carbapenam)
- Long course (2-4/52 of quinolone once well)
- +/- TRUSS-guided abscess drainage if >1cm
157
What is the treatment for chronic prostatitis?
- 4-6 week course of quinolone
| - Alpha blockers and NSAIDs for 6weeks-3months if needed)
158
Complications of prostatitis?
-Retention
>if prostate becomes really inflamed = obstruction of bladder outflow as it surrounds the urethra (may need a suprapubic catheter
-Severe sepsis
159
What is urethritis and what is it most commonly cause by?
- Inflammation of the urethra
- -Urethral pain/dysuria +/- discharge
- Predominantly STI related
- Best managed by GUM
160
Define epididymo-orchitis
- Infection of the epipdidymis and/or testes
- Painful swelling
- Commonly spread locally from infections from the genital tract (chlamydia/gonorrhoea) or the bladder
161
What are the causes of epididymo-orchitis?
-Pathogenesis depends on age and lifestyle
> age<35: STI>UTI
> age>35: UTI>STI
-Always take a sexual hx
-can be caused following urological intervention ie cystoscopy
-Elderly: catheter related
162
Clinical presentation of epididyo-orchitis?
- Acute presentation: unilateral testicular pain and swelling
- Urethral discharge (can be asymptomatic)
- Must rule out testicular torsion
163
What features are suggestive of testicular torsion?
- Age <20
- Short duration of pain, sudden onset
- Associated nausea and abdo pain
- Previous short-duration orchalgia
- High riding/bell-clapper testis
164
Investigtions of epididymo-orchitis?
- Void urine and then perform CT +/- urethral swab
- MSSU
- US to rule out abscess
- Sexual history
165
Treatment of epididymo-orchitis?
-If STI suspected: refer to GUM
-Abx:
>Quinolone if >35/suspecting UTI
>Doxycycline +/- stat azithromycin if STI more likely (contact tracing)
-If organism is unknown: IM CEFTRIAXONE SINGLE DOSE + DOXYCYLCINE 100MG BD 10-14/7
-Supportive underwear
-NSAIDs if required
166
What is dialysis and how does it work?
- Removal or uraemic toxins from the blood by the process of diffusion across a semipermeable membrane towards the low concentration present in the dialysis fluid
- Gradient maintained by replacing the used dialysis fluid with fresh solution
167
What's the differene between haemodialysis and peritoneal dialysis?
- Haemodilaysis: blood is removed from the circulation and expose to dialysis fluid across an artificial semi-permeable membrane
- Peritoneal dialysis- peritoneum is used as the semi-permeable membrane and dialysis fluid is instilled into the peritoneal cavity
168
Why do pts need anticoagulating if they're undergoing haemodialysis?
-Blood undergoes contact with foreign surfaces which activates the clotting cascade
>heparin is usually used
169
WHat else do pts need before receiving haemodialysis?
-AV fistula
170
What are some possible complications of an AV fistula?
- Infection
- Thrombosis
- Stenosis
- Steal syndrome (ichaemia)
171
What is the most common acute complication of haemodialysis?
-Hypotension
| >excessive removal of extracellular fluid
172
What is the most common serious complication of peritoneal dialysis?
-Bacterial peritonitis caused by staph epidermidis
173
Which pts are more likely to choose haemodialysis?
- Elderly/live alone
- Those who are afraid to operate the peritoneal dialysis machine
- If unsuitable for peritoneal dialysis ie prev abdo sx, abdo disease/hernia, recurrent PD peritonitis
174
Which pts are more likely to choose peritoneal dialysis?
Young/full time work
- Wanting control over own care
- Lack of suitable haemodialysis
175
What is haemofiltration adn what is it used for?
- Removal of plasma water and dissolved constituents and replacing it with a solution of desired biochemical composition
- Commonly used in the management of AKI on ITU
176
Difference between haemodialysis and haemofiltration?
- Haemodialysis: semipermeable membrane allowing only small solutes to pass through it
- Haemofiltration: highly permeable membrane > larger solutes also able to pass through. More expensive
177
What are the leading causes of death in all long term dialysis pts?
- CV disease (results from atheroma - dialysis can lead to hyperlipidaemia
- Sepsis: peritonitis (staph aureus)
178
Why are kidney transplants better than long term dialysis?
- Better survival
- Better quality of life
- Economic advantage
- Enable successful pregnancy in younger pts
179
Indications for dialysis in AKI?
- Hyperkalaemia
- Metabolic acidosis
- Pulmonary oedema
- Uraemic pericarditis
- Severe uraemia
180
Complications of dialysis?
- Hypotension
- Arrhythmias (disruption of normal electrolyte balance)
- Dialysis disequillibiration syndrome: occurence of neuro signs and symptoms attributed to cerebral oedema
181
How is continence maintained between episodes of bladder emptying?
-Detrusor muscle is relaxed during storage
-Sphincter mechanisms of the bladder neck and urethral muscles remain contracted during storage
>under sympathetic control (storage)
-On voiding the sphincter relaxes and detrusor contracts
>parasympathetic (pissing)
182
What are the neural roots that control the Lower urinary tract?
- Parasympathetic: (cholinergic) S3-S5. Detrusor contraction during voiding
- Sympathetic: (noradrenergic) T10-L2. Urethral contraction and inhibition of detrusor contraction
183
Define incontinence?
-Involuntary/uncontrolled leakage or urine
184
What are risk factors for urinary incontinence?
- Advancing age
- Previous pregnancy and childbirth
- High BMI
- Hysterectomy
- Family history
185
What are the 4 classifications of incontinence?
- Stress incontinence (sphincter weakness)
- Urge incontinence (overactive bladder - detrusor overactivity
- Overflow incontinence
- Mixed incontinence
186
Causes of stress incontinence?
-Result of sphincter weakness
-In women:
>usually secondary to birth trauma, neurogenic, congenital, gynae prolapse
-In men:
>Most commonly iatrogenic nerve damage from a prostatectomy, neurogenic
187
Causes of urge incontinence?
- Strong desire to void, pt may be unable to hold their urine
- Usually caused by detrusor overactivity
- Less commonly called by bladder hypersensitivity fro local pathology ie UTI, stones, tumours
- Causes: idiopathic
188
Causes of overflow incontinence?
- Most often seen in men with prostatic hypertrophy (causing outflow obstruction and therefore leakage)
- Will have a hx of inability to pass urine
189
Name some neurological causes of incontinence?
- Brainstem damage: incoordination of detrusor muscle activity and sphincter relaxation
- Paraplegia/tetraplegia
- Autonmic neuropathy ie diabetics
- MS
- Elderly people ie dementia, immobility
190
Presentation of stress incontinence?
```
-Small leak when intra-abdominal pressure rises
>coughing
>laughing
>standing up
>sneezing
```
191
Presentation of urge incontinence/overactive bladder?
- Ass. w/ urgency
- Pathology: detrusor overactivity. Rise of detrusor pressure on filling (normal should keep pressure same on filling and stay relaxed)
192
Presentation of overflow incontinence?
- Leakage of small amounts of urine
- Pain
- Distended bladder felt rising out of the pelvis on abdo examination
193
What will be the main consequence of not treating overflow incontinence?
- Bladder is v full
- if Obstruction is not relieved with a catheter, renal damage will develop
- Urine will back up ureters and cause hydronephrosis
194
Epidemiology of incontinence?
- More common in women
- Overflow incontinence (common in men with BPH)
- Increases with age
195
Investigation for incontinence?
- History is most diagnostic tool
- Bladder diaries (for >3 days)
- Vaginal examination (to exclude pelvic organ prolapse and to assess kegel exercises
- Urine dip and culture
196
Treatment of stress incontinence?
- Pelvic floor exercises (8 contract 3x day for 3/12)
- Duloxetine
- Surgery: sling or colposuspension
197
Treatment of urge incontinence/overactive bladder?
- Bladder retraining
- Anticholinergic agents ie oxybutynin, tolterodine
- Beta 3 adrenergic agonists ie mirabegron
- Intravesicle botox
- Detrusor myomectomy
- Cystoplasty
198
How do anticholinergic agents work to treat urge incontinence?
- Oxybutynin, tolterodine are anti-muscarinic specifically
| - Block ACh and therefore parasympathetic stimulation which can reduce the activity of the overactive bladder
199
How do beta 3 adrenergic agonists work?
-Triggers sympathetic nervous system and therefore storage
200
How do you treat overflow incontinence?
-Relieve the urine build up with a catheter initially
-Treat the underlying cause
ie BPH: 5 alpha reductase inhibitor
201
Where abouts in the urinary tract can obstructions occur?
- Any point between the kidney and urethral meatus
| - Results in dilation of the tract proximal to the obstruction
202
Define hydronephrosis?
-Dilation of the renal pelvis or calyces as a result of obstruction of the outflow of urine distal to the renal pelvis
203
What's the mneumonic to remember the causes of hydronephrosis?
- SUPER PACT
- Super: bilateral causes
- Pact: unilateral
204
What are the bilateral causes of hydronephrosis?
- Stenosis of the urethra
- Urethral valve dysfunction
- Prostatic enlargement
- Extensive bladder tumour
- Retroperitoneal fibrosis
205
What are the unilateral causes of hydronephrosis?
- Pelvic-ureteric obstruction (congenital or acquired)
- Abnormal renal vessels
- Calculi
- Tumours of the renal pelvis
206
How is hydronephrosis investigated?
- USS
- IV urogram (assess the postion of the obstruction)
- Antegrade or retrograde pyelography
- CT scan for renal colic if suspected
207
How id hydronephrosis managed?
- Remove the obstruction and drain the urine
- Acute upper urinary truct obstruction - nephrostomy tube
- Chronic upper urinary tract obstruction - ureteric stent of pyeloplasty
208
Define obstructive uropathy?
- Functional or anatomical obstruction of urine flow at any level of the urinary tract
- Can be supravesicle or infravesicle
209
Renal causes of urinary tract obstructions?
- Congenital ie cysts in PKD
- Neoplastic: Wilm's tumour, RCC, Multiple myeloma
- Inflammatory: TB
- Metabolic: kidney stones
- Misc: sloughed papillae, trauma
210
Ureter causes of urinary tract obstruction?
- Congenital: strictures, ectopic kidney
- Neoplastic: TCC of the ureter, mets
- Inflammatory: TB, schistosomiasis
- Misc: retroperitoneal fibrosis, pregnancy
- Kidney stones
211
Bladder and urethra causes of urinary tract obstruction?
- congenital: phimosis (narrow foreskin), vaginal distention
- Neoplastic: bladder cancer, prostate cancer
- Inflammatory: prostatitis
- Misc: BPH, overflow incontinence
212
What are the 3 simple reasons that cause urinary obstruction?
- Proximal dilatation
- Hydronephrosis
- Detrusor muscle is trabeculated
213
What are the permanent changes that occur to the kidneys after obstruction has occurred?
- Tubulointerstitial fibrosis
- Tubular atrophy and apoptosis
- Interstitial inflammation
214
What are the phases of renal recovery after obstruction?
- Tubular function recovery
| - GRF recovery
215
What is the clinical presentation of upper urinary tract obstruction?
- Dull ache in the flank or loin
- Complete anuria: suggests bilateral obstruction
- Polyuria: suggestive of partial obstruction as a result of tubular damage and impairment of concentrating mechanisms
216
Clinical presentation of bladder outlet obstruction?
- Urinary hesitancy/difficulty urinating
- Poor stream
- Terminal dribbling/sense of incomplete emptying
217
Investigations for urinary tract obstructions?
- Imaging: USS, CT
- Serum creatinine (assesses function of affected kidney)
- Blood tests: FBC, U&E, Coag, ABG, serum Cr
- Urine dipstick: MC&S to rule out infection
218
Treatment of urinary tract obstruction?
-ABCDE
-Fluid resus
-Pain management
-Abx and diagnosis
-Goal: re-establish urinary flow
>catheter
>manage post obstructive diuresis
219
What is acute urinary retention?
- Sudden (<6 hours) inability to voluntarily pass urine
- Painful
- Most common urological emergency
- 600ml-1L can not be cleared
- Catheter! and alpha blockers
220
What are the causes of acute urinary retention?
- Most common cause: BPH
- Other urethral obstructions: strictures, calculi, constipation, masses
- Medications: anticholinergics,opioids, benzos
- Neuro: cauda equina
- Post op
- Post partum
221
How does acute urinary retention present?
-Subacute onset of:
>inability to pass urine
>lower abdo discomfort
>considerable pain/distress
222
What are the signs of acute urinary retention?
- Palpable distended urinary bladder
| - Lower abdo tenderness
223
How is acute urinary retention investigated?
- Rectal and neuro exam
- Pelvic examination
- Urine sample
- U&E and Cr: ?kidney injury
- FBC & CRP: ?infection
- Bladder USS: volume >300ml
224
How is acute urinary retention managed?
-Decompression of the bladder via catheterisation
-Find the underlying cause
>UTI
>BPH
>neuro - refer
>gynae
>urology - if no obv cause found
225
What is the chronic urinary retention?
- Incomplete bladder emptying
- Often a comlpication of BPH
- Increases risk of infections and stones
- Painless (unlike acute retention)
226
How might acute on chronic retention present?
-As overflow incontinence
227
What causes chronic urinary retention?
- BPH
- Prostate cancer
- Drugs: antispasmodics, antihistamines, anticholinergics, BOTOX
- Iatrogenic: surgery
- Urethral strictures
- Neuro: MS,diabetic neuropathy, stroke
228
What are the symptoms of chronic urinary retention?
- Frequency, urgency hesitancy
- Poor urinary stream
- Post-micturition dribbling
- Nocturia
- Urinary incontinence
- Painless inability to pass urine
229
What are some important differentials to exclude in someone with urinary retention?
- Spinal cord injury
- Pelvic/sacral fracture
- Herniated disc
- Infections
- MS
- Myogenic failure to due to chronic detrusor over distension
230
How should chronic retention be investigated?
- Urinalysis
- MSSU
- Bloods: U&Es
- Bladder diary
- Imaging of urinary tract
231
Hoow is chronic retention managed?
-Offer ISC
-Offer indwelling catheter
-Stop any participating/aggravating meds
-Alpha blockers/sx for BPH
-Lifestyle measures
>regulate fluid intake, avoid evening drinking
>reducing alcohol intake
>reducing tea and coffee
232
What are the possible complications of chronic urinary retention?
- Acute on chronic retention: painful
- Hypertrophy of detrusor muscle and formation of bladder diverticula
- Hydronephrosis
- Urinary incontinence due to overflow
233
What is interactive obstructive uropathy?
- Very obstructed urinary tract
- Nocturnal enuresis is an indicator
- Residular volume can be up to 4L
- Check U&Es
- Lying/standing BPs may be affected
- Long term options; TURP or indwelling catheter
234
Indications for surgery for bladder retention problems?
```
-RUSHES:
>Retention
>UTIs
>Stones
>Haematuria
>Elevated Cr due to bladder outlet obstruction
>Symptom deterioration
```
235
What are the surgical options for bladder outflow problems?
- Bladder neck incision
- TURP
- Laser therapy
236
Complications of TURP?
- Immediate: sepsis, haemorrhage, TURP syndrome
- Early: sepsis, haemorrhage, clot retention
- Late: retrograde ejaculation, ED, urethral stricture, bladder neck stenosis, urinary incontinence
237
Which compartment of the penis fills with blood in erection?
-Corpus cavernosa
238
What is the nerve supply to the penis?
- PSNS: S2,3,4 (Point)
- SNS: T11-L2 (shoot)
- cavernous nerve carries both fibres and passes posterolaterally to the prostate = high damage in prostatectomy
239
How does an erection occur?
- Inflow of blood to the corpora cavernosum
- Trabecular smooth muscle relaxation and arteriolar dilation
- NO is the main mediator of the smooth muscle relaxation
240
What are the endocrine role in erections?
-Testosterone required for normal erectile function
-Acquired low test = ED.
>Primary: pituitary, hypothalamus
>Secondary: testes (tumour, injury, drugs ie beta blockers)
>congenital syndromes: Klinefelters, Noonans
241
How does the penis return to its flacccid state?
-Phosphodiesterase
242
Define ED?
-Inability to attain and maintain an erection sufficient for satisfactory sexual performance
243
Risk factors for ED?
- Lack of exercise
- Obesity
- Smoking
- Hypercholesterolaemia
- HTN
- Metabolis syndrome
- DM
244
Causes of ED?
- Vascular
- Neurogenic
- Hormonal
- Anatomical
- Drug induced
- Pscyhogenic
245
What are some vascular causes of ED?
- CVD
- Atherosclerosis
- Hypertension
- DM
- Hyperlipidaemia
- Smoking
- Iatrogenic
- Trauma
246
What are some central neuro causes of ED?
- Parkinsons, stroke
- MS
- Tumours
- Traumatic brain injury- hypothalamic-pituitary def
- CVA
- Intervertebral disc disease
247
What are some peripheral neuro causes of ED?
-Polyneuropathy
-Peripheral neuropathy
DM
-Alcoholism
-Uraemia
-Surgery
248
What are some hormonal causes of ED?
- Hypogonadism
- Hyperprolactinaemia
- Thyroid disease
- Cushing's
249
What are some anatomic causes of ED?
- Peyronie's disease (penis bends when it gets an erection due to fibrous growth
- Micropenis and other penile anomalies
250
What are some durg causes of ED?
- Beta blockers
- Antidepressants: SSRIs and TCAs
- Antihypertensives
- Recreational drugs
- H2 antagonists ie ranitidine
251
What are some psychosexual causes of ED?
- General: disorders of sexual intimacy, lack of arousal
| - SItuation: partner, performance/stress
252
What are some psych illness causes of ED?
- Generalised anxiety disorders
- Depression
- Psychosis
- Alocholism
253
What lab tests would be done for someone with ED?
- Fasting glucose
- Lipid profile
- Morning testosterone
- Usually all normal
254
Treatment for hormonal or psychological causes of ED?
- Testosterone replacement (Contra-indicated in hx of prostate cancer)
- Psychosexual counselling
255
Medical treatment for ED?
-Phosphodiesterase (PDE5) inhibitors)
| >prevent smooth muscle from relaxing
256
Mechanism of action of PDE5 inhibitors?
-Blocks phosphodiesterase = stops the erection from returning to a flaccid state
=increased arterial blood flow, vasodilation and erection maintenance
-Action on nitric oxide: erectile chemical
257
Examples of phospodiesterase inhibitors?
- Sildenafil
- Tadalafil
- Vardenafil
258
Common side effecots of phosphdiesterase inhibitors?
- Headache
- FLushing
- Dyspepsia
- Nasal congestion
- Dizziness
- VIsual disturbance
259
Contraindications of phosphodiesterase inhibitors?
- Someone already taking nitrates
| - Someone taking alpha blockers
260
What is priapism?
-Prolonged erection
>4 hours = risk of permanent ischaemic damage to the corpora
>needs aspiration with a 19 gauge needle or inject phenylephrine
261
Define haematuria?
-Presence of blood in the urine
| >can be visible, non-visible, symptomatic or asymptomatic
262
What are the causes of transient non-visible haematuria?
- UTI
- Menstruation
- Vigorius exercise
- Sex
263
Causes of persistent non-visible haematuria?
- Cancer: renal, bladder, prostate
- Stones
- BPH
- Prostatits
- Urethritis
- Renal causes ie IGA nephropathy
