1
Q
What are epididymis cysts?
A
Epididymis cysts are the most common cause of scrotal swelling sein in primary care.
Features:
- Separate from body of testicle
- Found posterior to testicle
Associated with PCKD, Cystic Fibrosis and Von Hippel-Lindau syndrome.
Management is usually supportive, but can be surgical if large.
2
Q
What is a hydrocoele?
A
A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating:
- communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
- non-communicating: caused by excessive fluid production within the tunica vaginalis, e.g. 2° to epididimo-orchitis or testicular cancer.
Clinical features include:
- soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
- the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
- transilluminates with a pen torch
- the testis may be difficult to palpate if the hydrocele is large
3
Q
What is a varicocoele?
A
A varicocoele is an abnormal enlargement of the testicular veins.
These are usually asymptomatic but may be important as they are associated with infertility.
4
Q
What is the first line investigations in suspected prostate cancer?
A
The first line investigation for suspected prostate cancer is multiparametric MRI.
5
Q
What do you need to counsel about that wants a vasectomy?
A
- doesn’t work immediately
- semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
- complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)
- the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
6
Q
How long can it take for finasteride to benefit a patient with BPH?
A
This takes time and symptoms may not improve for 6 months.
7
Q
What are the risk factors for BPH?
A
- Age: around 50% of men at 50 will have evidence of PBH. Around 80% of 80 year olds will have BPH
- Ethnicity: black > white > Asian
8
Q
What are the symptoms of BPH?
A
BPH typically presents with lower urinary tract symptoms (LUTS), which may be categorised into:
- voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying
- storage symptoms (irritative) urgency, frequency, urgency incontinence and nocturia
- post-micturition: dribbling
- complications: urinary tract infection, retention, obstructive uropathy
9
Q
Summarise the management options for BPH.
A
Conservative:
- Watchful waiting. Advise on lifestyle:
- Avoid caffeine/tea/alcohol
- Don’t drink at night
Medical:
- Alpha-1-antagonists (e.g. tamsulosin, alfazuosin)
- Decrease smooth muscle tone of ureter/prostate
- First-line
- Side effect: postural hypotension, dry mouth, depression
- 5-alpha reductase inhibitors
- Block conversion of testosterone into di hydro testosterone
Surgical:
- TURP
- Uro-lift (see image - potentially better outcomes)
10
Q
What is a normal post-void volume in <65 and >65 year old?
A
- <65: <50 mL
- >65: <100 mL
11
Q
What is the definition of chronic urinary retention in terms of post-void volume?
A
Chronic urinary retention (CUR) is defined by the International Continence Society as ‘a non-painful bladder, which remains palpable or percussable after the patient has passed urine.`
Most commonly, a post-void residual volume of 300 mL is cited as diagnostic.
12
Q
What are the most common causative organisms of epididymo-orchitis?
A
Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia
trachomatis and Neisseria gonorrhoeae) or the bladder.
13
Q
What is Prehn’s Sign, and what is its significance?
A
Elevation of the testis does not ease the pain (Prehn’s sign).
This indicates a testicular torsion.
14
Q
What are the clinical features of epididimo-orchitis?
A
- Unilateral testicular pain and swelling
- Unilateral discharge may be present
- Absence of factors that would point towards torsion:
- Age < 20
- Severe pain
- Acute onset
15
Q
What is the most effective analgesia in acute renal colic?
A
Diclofenac IM (usually 75 mg) is recommended first line.
16
Q
What are the initial investigations you would like to perform in someon with a suspected renal stone?
A
- urine dipstick and culture
- serum creatinine and electrolytes: check renal function
- FBC / CRP: look for associated infection
- calcium/urate: look for underlying causes
- also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis
17
Q
Summarise the management of renal stones.
A
Conservative:
- Stones < 5mm will usually pass by themselves (within 4 weeks)
- Provide analgesia, and consider alpha blockers (although not recommended by BAUS)
Medical:
- As mentioned above, analgesia and alpha-blockers may be indicated
Surgical:
- In the non-emergency setting:
- extra-corporeal shock wave lithotripsy
- Percutaneous nephrolithiotimy
- Ureteroscopy
- Open surgery remains an option in some cases, especially if sever complications or failure of other methods
18
Q
What can be done to prevent renal stones?
A
Calcium stones:
- High fluid intake
- Low animal protein, Low salt diet
- Thiazide diuretics (increase calcium reabsoption and therefore decrease urinary excretion)
Oxalate stones:
- Cholestyramine and pyridoxine reduces oxalate secretion
Urin acid stones:
- Allopurinol
- Alkalizing agents
19
Q
What is the most common type of renal tumour?
A
Renal adenocarcinoma are the most common renal tumours.
They can be subdivided into:
- Clear Cell (75%)
- Papillary (10%)
- Chromophobe (5%)
Note: renal adenocarcinomas may produce cannon ball metastases in the lung, which can cause haemoptysis.
20
Q
What are common causes of urethral strictures?
A
- Iatrogenic (e..g traumatic catheter insertion)
- Sexually transmitted infections
- Hypospadias
- Lichen Sclerosus
21
Q
Summarised the management for STI related epididmo-orchitis.
A
BASHH guidelines:
- If organism unknown: ceftriaxone 500mg IM stat + Doxycycline 100 mg by mouth bd for 10-14 days
- Do futher investigations to rule out underlying structureal abnormalities
22
Q
What organism are staghorn calculi associated with?
What is the likely composition of staghorn calculi?
A
Associated with Proteus infection.
Composition: struvate (ammonium magnesium phosphate, triple phosphate).
23
Q
What is the MoA of goserelin?
A
Goserelin is a GnRH agonist, therefore leading to loss of the pulsatile stimulation of the pituitary required for sustained LH/FSH release. This causes chemical castration.
24
Q
What medication should be co-prescribed when starting goserelin?
A
Goserelin is a GnRH agonist. As this initially leads to hyperstimulation of the axis before suppressing it, an anti-androgen has to be co-prescribed for the first 3 weeks of treatment.
25
What is testicular torsion?
Also summarise clinical features and management.
Testicular torsion is the twisting of the spermatic cord resulting in testicular ischaemia and necrosis (if not fixed quickly enough).
This is most common in males aged 10-30.
Features:
* Sudden onset severe testicular pain
* Pain refers to lower abdomen
* N&V may be present
* Testicle is swollen and reddended, and often retracted upwards.
* Cremasteric reflex is lost
* Elevation of testis does **not** ease pain
Management:
* Surgical exploration with detorsion and **bilateral** fixation of the testis as bell clapper testis is bilateral
26
What is bell clapper deformity of the testis?
The bell clapper deformity allows the testis to move more freely inside the scrotum.
The abnormality is an inappropriately high attachment of the tunica vaginalis, as well as abnormal fixation to the muscle and fascial coverings of the spermatic cord. This causes the testicle to be orientated transversly as opposed to cephalocaudally.
27
What is a varicocoele?
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
28
Why are varcocoeles more common in the left testicle?
More than 80% of varicocoeles occur on the left side.
This is as the left gonadal vein drains into the left renal vein at a right angle, which can easier lead to backpressure (the right drains at a steeper angle directly into the IVC)
29
How are varicocoeles diagnosed?
USS with Doppler studies.
30
How are varicocoeles managed?
In adult males with sublinical or mild varicocoeles, reassurance and observation is the appropriate management.
With more symptomatic varicocoeles, offer semen analysis every year to ensure fertility isn't impacted.
If symptomatic or there are abnormal semen parameters, offer surgery.
31
How is prostate cancer scored?
Prostate cancer is scored using the Gleason Scoring system.
2 grades are awarded: one for the most dominant grade, and one for the second most dominant grade. They are added together (2 best prognosis, 10 worst).
32
What type of bladder cancer is schistosomiasis a risk factor for?
Schistosomiasis is a risk factor for squamous cell carcinoma. This is thought to be due to chronic inflammation of the bladder lining.
33
What is the peak incidence of testicular cancer?
Summaruse the risk factors for testicular cancer.
Testicular cancers have a peak incidence of 25 years (teratomas) and 35 years (seminomas).
Risk factors include:
* Infertility
* cryptorchidism
* family history
* Klinefelter's syndrome
* Mumps orchitis
34
What are the symptoms of testicular cancer.?
* Painless lump (in a minority of men pain is present)
* Hydrocoele and ganaecomastia may be present
* Elevated AFP (60%)
* Elevated LDH (40%)
* Elevated hCG (20%)
35
In pregnant women, what is the preferred method of treating renal stones?
The surgical management for pregnant women mentions ureteroscopy as first line.
36
Which type of bladder cancer are patients at risk of following neobladder reconstruction?
Adenocarcinoma
37
What is the best investigation for hydro nephronsis?
USS of the renal tract
38
How does the survival compare between seminomas and teratomas?
Both have very good prognosis, however, seminomas are slightly better
39
What is TURP syndrome?
TURP syndrome occurs when the irrigation fluid used during TURP enters the systemic circulation. The triad of symptoms includes:
* Hyponatraemia (dilutional)
* Fluid overload
* Glycine toxicity
40
In what patients do you see **cysteine stones**?
Cysteine stones are commonly seen in inherited metabolic disorders of transmembrane cysteine transport leading to decreased absorption of cysteine from intestine and renal tubule.
On X-ray, these stones are radiodense.
Of all renal stones, these make up \<1%.
41
What are struvite stones made of, and in what patients do these commonly occur?
Struvite stones are **triple stones** from magnesium, ammonium and phosphate.
They result from urease producing bacteria (i.e. associated with chronic UTI).
42
What is a useful investigation in a boy with priapism?
Priapism is a persistent penile erection not associated with sexual stimulation (typically seen in sickle cell disease, also idiopathic or medication related).
**Cavernosla blood gas analysis** is essential to differentiate between ischaemic and non-ischaemic propiapism.
**Doppler US** to assess blood flow may also be useful to assess blood flow in the penis.
43
Summarise the management of priapism.
Priapism is considered **a medical emergency**.
If the priapism has lasted longer than 4 hours, first-line managment is **aspiration of blood from the cavernosa**.
If this fails, **intracavernosal injection of vasoconstrictive agent** (e.g. phenylephrine).
Finally, surgical options are considered.
44
What is the first-line investigation of testicular cancer?
**Ultrasound** is the important first-line diagnosis.
45
Describe the pathological division of testicular cancer.
Germ cell tumours (95%):
* Seminomas (peak at 35)
* Non-seminomas:
* embryonal
* Yolk sac
* Teratoma (peak at 25)
* Chorioncarcinoma
Non-Germ Cells (5%):
* Leydig cell
* Sarcomas
46
What are risk factors for testicular cancer?
* Infertility
* Cryptorchidism
* Family history
* Kilnefelter's syndrome
* Mumps orchitis
47
What are the clinical features of testicular cancer?
The clinical features include:
* Painless lump (though pain may be present in a minority of patients)
* Hydrocoele and gynaecomastia
Tumour marker:
* AFP is elevated in around 60% of germ cell tumours
* LDH is elevated in around 40% of germ cell tumours
* hCG may be elevated in around 20% of seminomas
48
Where do testicular cancers commonly metastasise to?
Lung and lymph nodes
49
What medical condition is a contraindication to circumcision?
Hypospadias.
This is because in the surgery, the foreskin may be used in surgical repair
50
What are medical indications for circumcision?
* Phimosis
* Recurrent balanitis
* Balanitis xerotica as obliterans (male lichen sclerosus)
* Paraphimosis
51
What are medical benefits of circumcision?
* Reduces risk of penile cancer
* Reduces risk of UTI
* Reduces risk of STIs including HIV
52
What can be given to reduce the initial flare in symptoms observed with goserelin in prostate cancer?
Pretreatment with **flutanide**, an **antiandrogen** (synthetic) can be used to counteract the initial flare observed with goserelin.
53
Which virus is most commonly implicated in post-transplant infections?
**CMV**.
This infection in the presence of immunosuppression can lead to widespread organ infection, as well as graft failure.
Treatment is with **Ganciclovir**.
54
What is reflux nephropathy?
What is the investigation of choice for reflux nephropathy?
Reflux nephropathy is a term used to describe chronic pyelonephritis secondary to vesico-uretic reflux.
It can lead to scarring of the kideneys.
Investiagted with **micturating cystography** - this can show up to which level the urine refluxes to.
55
What would disproportionately raised urea vs creatinine indicate?
Dehydration, as urea is actively reabsorbed in dehydration.
56
What drug can be used for the treatment of nephrogenic diabetes insipidus?
Thiazide diuretics - this may seem paradoxical, but in simple terms DI leads to the production of vast amounts of dilute urine which is dehydrating and raises the plasma osmolarity, stimulating thirst. The effect of the thiazide causes **more sodium to be released into the urine**. This lowers the serum osmolarity which helps to **break the polyuria-polydipsia cycle.**
57
How long after insertion is an AV fistula for RRT usable?
It takes ~6-8 weeks for a fistula to work.
58
What should be given prohphylactically in a patient with nephrotic syndrome and why?
LMWHE - in nephrotic syndrome, antithrombin III is lost in the urine, leading to increased clotting risk.
59
What id Liddle's syndrome?
Liddle's syndrome is an autosomal **dominant mutation of the ENaC in the collecting duct**, **preventing** its **degradation**.
Usually this channel is increased in response to aldosterone.
Therefore, in Liddle's syndrome, there is increased sodium (and therefore water) retention, leading to hypertension. **Aldosterone** and **renin are** **suppressed**.
60
What is the appropriate screening tool for a patient with a family member affected by APKD?
USS of abdomen - genetic testing is NOT indicated.
61
What size would you expect kidney to be in chronic renal failure?
Usually the kidney shrink in chronic renal failure.
Exceptions are:
* Autosomal dominant PKD
* Diabetic nephropathy (produces a proliferative response)
* Amyloidosis (infiltrative disease leading to larger kidneys)
* HIV-associated nephropathy
62
What are primary causes of nephrotic syndrome?
And what are systemic causes?
Primary causes:
* **Minimal Change disease** (mainly seen in **children**)
* **Membranous glomerulonephritis** (diffuse membrane thickening, subepithelial deposists -\> spikey appearance)
* **Focal Segmental Glomerulosclerosis**
Systemic causes are diabetes (causing diffuse GBM thickening and Kimmelstiel Wilson nodules) and Amyloidosis.
63
What could be a cuase of bilateral RAS in a young females?
Fibromuscular dysplasia.
It is a disease with abnormal growth of the endothelium of arteries.
64
What causes of CKD lead to enlarged rather than shrunken kidneys?
* ADPKD
* Diabetic nephropathy
* Amyloidosis
* HIV-assocaited nephropathy
65
When do you see hyaline casts?
Hylaine casts are Tamm-Horsfall protein, secreted by distal convulated tubule.#
They are seen in **normal urine, after exercise, during fever** or with **loop diuretics**.
66
When do you see muddy casts?
These are seen in Acute tubular necrosis.
This is caused by:
* Pre-renal (**ischamic**): hypovolaemia leading to ischaemia of the tubular cells
* Renal (**nephrotoxic**):
* Drugs: aminoglycosides, vancomycin, NSAIDs, Contrast nephropathy
* Myoglobin/rhabdomyolysis
67
What causes red cell casts?
**Nephritic syndrome**. This is seen in:
* Rapidly progressive GN:
* Goodpasture's (anit-GBM)
* ANCA positive vasculitis
* IgA nephropathy
* Alport Syndrome (& Thin basement membrane syndrome)
Mixed mephritic/ephrotic disease include:
* Diffuse proliferative GN:
* Post-sterptococcal
* SLE-renal disease
* Membranoproliferative GN:
* Cryoglobulinaemia and Hepatitis C related
* Partial lipodystrophy
68
Define AV fistulas.
AV fistulars are a direct connection between arteries and veins. They may occur pathologically, but are generally formed surgically to allow access for haemodialysis.
69
What are potential complications of AV fistulas?
* Infection
* Thrombosis (absence of bruit)
* Stenosis (acute limb pain)
* Steal syndrome
70
Which variables are required for the calculation of eGFR?
CAGE
Creatinine, Age, Gender, Ethnicity
Passmed Surgery
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