Urology Exam 1

Priaprism

Sustained erection lasting more than 4 hours

Penile erection pathophys

Relaxation of smooth muscle of cavernosal arteries and tissues- increased inflow, decreased venous outflow

Ischemic priapism

Low-flow, anoxic, or veno-occlusive priapism- blood not properly draining from penis due to impaired relaxation and paralysis of cavernosal smooth muscle

Non-ischemic priapism

High-flow, arterial, or congenital priapism

Non-ischemic priapism results fro

a fistula between the cavernosal artery and corpus cavernosum- commonly due to penile or perineal trauma

Common causes of priapism

Alcohol or drug abuse

drugs

spinal cord issues

gential trauma

anesthesia

penile injection therapy

hematologic disease

Ischemic priapism treatment

Intracavernosal injection of sympathomimetic drug (phenylephrine), aspiration with or without irrigation, surgical shunt creation

Non ischemic priapism treatment

observation, arteriography with fistula embolization

Peyronies Disease

An acquired localized fibrotic disorder of the tunica albuginea- a fibrous plaque lesion with excessive collagen

Management Peyronie’s

Medical management- Pentoxifylline for moderate curvature

Observation for mild

Management Peyronie’s >12 months, refractory to medical management, or deformity compromising sexual function

Surgery- remove plaque with skin graft

Balantitis

Inflammation of glans penis

Balanposthitis

Inflammation of glans and foreskin

Cause of Balantitis

Inadequate hygeine in uncircumcised males- usually candidal infection

Balantitis can be first sign of

Diabetes

Management of balantitis

Local hygeine measures, empiric candidal infection, trial or hydrocortisone if no response to antifungals

Phimosis

tight foreskin that cannot be retracted to form glans penis. Normal in young children, abnormal in adults

Phimosis treatment

Manual stretching of the foreskin after application of topical medicine, circumcision, preputioplasty (slit to widen foreskin)

Paraphimosis

Retracted foreskin in an uncircumcised or partially circumcised male that cannot return to normal- foreskin entrapped behind coronal sulcus

Paraphimosis results in

venous engorgement of the glans penis with swelling. If untreated can lead to necrosis

Causes of paraphimosis

Failure to return foreskin to normal position, penile trauma, sexual activity

Treatment of paraphimosis

Adjuncts to reduce swelling - manual reduction, squeeze/compression, Surgical dorsal slit/circumcision

Hydrocele

A collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis

Hydrocele cause

Imbalance of secretion and reabsorption in tunica vaginalis- most idiopathic

Exam for hydrocele

Physical exam with transillumination, confirmed with ultrasound

Hydrocele treatment

Only when painful, embarrassing, or causing ischemia to penis- observation, needle aspiration, hydrocelectomy

Varicocele

Dilatation of the pampiniform plexus of spermatic veins, typically left sided

Varicoele seen most commonly in

15-20 year old post-pubertal males

Varicocele causes

Incompetent or absent valves within spermatic veins

perpendicular drainage of left internal spermatic vein

Increased pressure in left side due to nutcracker effect

Varicocele on exam

Scrotal fullness

bag of worms

dull, achy, scrotal pain

Diagnosis varicocele

US- veins>3mm, reversal of flow with valsalva

exam

Tx varicocele

Medical: analgesics for pain

Surgical: open vs lap repair, percutaneous embolization

Observation: if no pain and no fertility concerns

Spermatocele

Painless cyst arising from the head of the epididymis>2cm

Causes of spermatocele

Trauma

Blockage of efferent ducts in epididymis

Spermatocele diagnosed by

Ultrasound

Tx spermatocele

Observation, spermatocelectomy

Epididymitis

Inflammation of the epididymis

Epididymitis onset

heavy lifting

trauma

sexual activity

Symptoms of epididymitis

Pain in scrotum

Scrotal swelling

fever

maybe urethritis or cystitis symptoms

Infectious causes of epidiymitis

GC or chlamydia (often)

Infectious cause of epididymitis >40

Enteric bacteria (often, could still be STD)

Diagnosis of epididymitis

Symptoms: redness, warmth, swelling, tenderness to posterior testicle

Prehn’s sign

US if unclear

Prehn’s sign

Relief of pain with elevating the testicle in epididymitis, not reliable

Tx epididymitis

Oral abx, nsaids, local application of ice, scrotal elevation

Epididymitis Abx

Testicular torsion

twisting of the testicle on the spermatic cord causing ischemia from reduced arterial

Causes of testicular torsion

inadequate fixation of the lower pole of the testis to the tunica vaginalis

Irreversible damage from testicular torsion after

12 hours

Testicular torsion exam

Diffuse tenderness and swelling of testis

Negative cremasteric reflex

High riding testis with long axis oriented transversely (Bell Clapper deformity)

Testicular torsion management

Manual detorsion (no surgery w/in 2 hours)

Surgery- also for contralateral, detorsion and fixation

Gross hematuria with clots infers

lower urinary tract source

Microscopic hematuria defined as

3 or more RBCs per HPF

False positive dipsticks for microscopic hematuria

Semen in urine

Alkaline urine

Presence of myglobinuria or hemoglobinuria

Free urinary hemoglobin indicates

Intravascular hemolysis

Free urinary myoglobin indicates

rhabdomyolysis

With presence of unilateral flank pain you should

consider imaging with CT or US for nephrolithiasis

Gross hematuria with clots present you should

CT abdomen and pelvis (w&w/o contrast)

Urgent **urology** referral for cystoscopy and workup

Gross hematuria without clots you should

look for evidence of glomerular bleeding

urgent **nephrology** referral for further workup

Urinalysis and microscopy should be repeated in 6 weeks if (3)

Urine collected during womens menses

urine collected after vigorous exercise

urine collected after acute trauma

Evidence of glomerular bleeding

Albuminuria

Acutely elevated serum creatinine

dysmorphic RBCs

RBC casts

WBC casts

New or worsening HTN

New or worsening edema

Evidence of glomerular bleeding requires

Urgent nephrology referral

Risk factors for malignancy with microscopic hematuria

Age >35

History of smoking

prior macroscopic hematuria

occupational exposure to benezenes or aromatic amines

If concerned for malignancy you should

CT abdomen and pelvis with and without contrast

Urgent urology referral for cystoscopy and workup

Concurrent pyuria and dysuria + hematuria could indicate

UTI

Recent URI + hematuria could indicate

post infectious glomerulonephritis

positive family hx & hematuria possibilities

hereditary nephritis, PCKD, SCD

Unilateral flank pain and hematuria could indicate

Nephrolithiasis

Symptoms of prostatic obstruction + hematuria could indicate

BPH

Recent vigorous exercise + hematuria

exercise induced hematuria

Cyclic hematuria during menses could indicate

endometriosis of urinary tract

Hematuria + positive travel history could indicate

Schistosoma or tuberculosos

Glomerular bleeding can be accompanied by

leakage of protein (>500mg/day) through injured site - high urine albumin-to-protein ratio

Signs of glomerular bleeding

RBC casts

Dysmorphic appearing RBCS

Brown cola colored urine

Red to pink urine usually indicates

non-glomerular source of bleeding

Blood clots usually indicate

Nonglomerular source

Indications for renal biopsy

Presence of glomerular hematuria (casts, dysmorphic RBCs)

Risk factors for progressive disease (proteinuria, elevated sCR, systemic manifestations)

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Imaging recommended for patients with unexplained hematuria

CT urography

Non-contrast CT urography used for

Nephrolithiasis and hydronephrosis

Contrast CT urography used for

renal and urothelial abnormalities

Exceptions to CT urography for hematuria

Young patients with non-con showing kidney stone

Pregnant women (US)

patient with decreased renal function

patients with iodinated contrast reactions

MRI urography can be used for

Localize anatomic site of hydronephrosis seen on US

Retrograde pyelography

Fluorscopic exam

ureters cannulated during cystoscopy

Iodinated contrast injected retrograde into the ureters

Reasonable option for patients unable to have IV contrast

Benefits of cystoscopy

Entire bladder can be visualized

\-malignancy/abnormalities

\-may help identify source of gross hematuria

only modality to permit visualization of prostate and urethra

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Cystoscopy indicated for (2)

Patients with gross hematuria

Patients with microscopic hematuria (no evidence of glomerular disease, no evidence of infection, no recent vigorous exercise)

Transient hematuria follow up with negative initial evaluation

If 1 episode and high risk for malignancy

\-yearly urinalysis (x2 negative)

\-If gross hematuria- full eval

Persistent hematuria follow up if initial evaluation is negative

Yearly urinalysis

persistent for 3-5 years, repeat intial workup

Calcium stones

80%

Composed of calcium oxalate or calcium phosphate

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Styruvite stones

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composed of magnesium ammonium phosphate

occur when ammonia production increases and pH is elevated

ONLY occurs when urease producing bacteria is present in the urine

Most common in women due to UTI

Uric acid stones

Caused by high urine uric acid concentration and acidic urine

Seen more commonly in hot, arid climates

Cystine stones

Genetic cause of kidney stones - cystinuria

defect in amino acid transporter - decreased reabsorption - high urinary excretion of insoluble cystine

Risk factors for stones (4 highs, 1 low)

Higher urine calcium

higher urine oxalate

higher pH

persistently acidic urine

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LOW urine citrate

Classic kidney stone presentation

Acute onset of severe flank pain

colic pain

nausea and vomiting

dehydrated

pain radiating to lower abdomen, groin, scrotum

hematuria/dysuria

Most common symptom of kidney stone

Pain

waxes and wains due to urinary obstruction and distention of the renal capsule

Upper ureteral obstruction causes

flank pain

Lower ureteral obstruction causes

abdominal pain or pain radiating to ipsiliateral testicle or labium

Single most discriminating predictor of kidney stone in patients with unilateral flank pain

hematuria

Gold standard imaging for detection of kidney stone

Non-con CT scan of abdomen and pelvis

Ultrasound reliably detects

Hydronephrosis

Initial imaging modality for pregnant patients with suspected kidney stone

Ultrasound

Intravenous pyelography

Radiographic imaging of the kidneys, ureters, and bladder

performed before and after administration of IV contrast

reliably detects hydronephrosis