Urology PA

DRE

Mandatory at end of clinical exam

Patient prep - r lat decubitus, knee-chest, standing, gyno

  • flexed thigh if hard to mobilize patient

Sphincter tone

  • low tone - neuro disease

  • increased/spastic - neurological or inflammatory disease

Palpation

  • Douglas sac - painful in peritonitis, nodules in peritoneal metastases

  • Men - prostate thru ant rectal wall → chestnut sized, 2 lat lobes by median sulcus, smooth, firm

    • difficult to palpate in fibrosis, nodules from tb or prostatitis, stones

    • cancer nodules - don’t protrude, smooth, hard, peripheral, no secretion, T2 if multiple, whole prostate big + hard, t4 if adherent

    • nut bag sign → multiple stones, crackling sound

    • sensitivity - increased in acute prostatitis, + hot in abscess

  • Women - for suppleness, cervical cancer, sensitivity

Clinical Exam

Personal History

  • Nephropathy → scarlet fever

  • Infertility → endemic mumps

Kidneys

  • perinephritic abscess - lumbosacral edema, hyperemia

  • abd collateral circ - malignancy

  • Palpation

    • Guyon - balloting, Israel method

  • Percussion - Giordano maneuver

  • Auscultation - paraumbilical systolic murmur if renal a stenosis

Ureters

  • palpated only by vaginal touch

  • Bazy upper ureteral point → pelvis + pyeloureteral jxn

  • Halle middle ureteral point → painful in lumbar + iliac ureter disease

  • Pasteau lower ureteral point → inguinal orifice

    Bladder

  • able to be investigated >300ml

  • palpation → gyno position

  • percussion in chronic retention

  • auscultation in vesico-colic communications

    Urethra

  • Inspection - meatus

    Penis

  • phimosis - difficult to perform

  • paraphimosis - blockage of foreskin

  • Peyronie’s - curvature, plaques on corpora cavernosa

    Scrotum

  • varicocele - hypertrophic and on left, if right → kidney tumour

  • atrophic testicle - by torsion, orchitis

    Catheterization

    Indications

  • Therapeutic - retention, macroscopic hematuria, surgery, bladder injury, chemo

  • Diagnostic - PVR, intravesical p, retrograde cystography

  • Diuresis

    COs - acute prostatitis, fournier syndrome, urethral rupture, urethral stricture

Accidents - lesions, inflation in prostatic area, paraphimosis (roll foreskin back), prostatitis, hematuria ex vacuo (quick emptying)

Prostate biopsy

Etiology - BRCA, metabolic syndromes

Clinical diagnosis - PSA, DRE

Technique - lithotripsy position, atb prophylaxis, transrectal prostate US, puncture from apex → base as lat + post as possible

Lab

Creatinine - increased in RF, not influenced by protein intake

Urea - increased in failure to eliminate/retention, increased protein catabolism

Uric acid - increased early in RF, uric lithiasis, sepsis, metabolic disease

Urine test

  • Colour - red in hematoporphyrinuria, brown in icterus, black in alkaptonuria

  • Substances

    • proteinuria - GN

    • glycosuria - DM only if w/ hyperglycemia

    • ketone - DKA

  • Sediment - valuable for stones

  • Erythrocytes - deformed if from kidneys

  • Epithelial cells

    • cylinders - hyaline in congestion or jaundice, granular if nephropathy, epithelial if inflammation of parenchyma, hematic if GN

  • Culture

    • Interpretation

      • Leukocyturia - repeat, then definite infection

      • Corynebacterium urealyticum - cause of UTI if prolonged atb

      • candida - in dm

  • PSA - increased in cancer, BPH, prostatitis, interventions

  • afp, bhcg, ldh - testicular tumour markers

Stamey test - for diagnosis prostatitis/urethritis

US

Prep - no voiding before, administration gas adsorbents

Valsava maneuver

KIDNEYS

Malformations - postnatal or fetal US

  • Renal duplications, horseshoe, PUJ syndrome

Cysts

  • Simple (cortical)

  • Parapelvic - central, multiple → hydronephrosis

  • PCKD - bilateral multiple cysts, big kidney, no parenchyma

  • Chronic pyelonephritis - asymmetrical kidney, irregular contour, small calcifications

  • Perirenal absess - thick septa, loss kidney mobility

  • Pyonephrosis - no parenchyma (only distinguish from hydronephrosis), distended intrarenal cavities, bubbles

  • Renal TB - ‘period of status’ shows dilatations, cavern, calcifications, late stage shows tuberculoma, diffuse damage, cortical calcifications

Tumours

  • renal carcinoma - changes kidney architecture, Doppler shows vasc

  • angiomyolipoma - well delimited tumour in women

  • clear cell carcinoma - badly delimited, infiltration perirenal fat

  • transitional cell carcinoma - mass in pelvis/calyx ± hydronephrosis, multifocal

Tumours >3cm show

  1. hemorrhage

  2. necrosis

  3. infection (clinical)

  4. rear shadow cone, calcifications or hyperechoic areas

Injury

  • subcapsular hematoma - hypoechoic structure that changes renal contour

URETERS

  • ureterohydronephrosis - dilatation calyx + pelvis, US shows level obstruction

  • hydronephrosis

    1. intraspinal fluid dilation, communication w/ calyx stems, dilated pelvis

    2. dilation pelvis + calyx

    3. expansion pelvis + calyx, thin parenchyma

    4. expansion pelvis + calyx, no parenchyma

    5. megaureter - dilated ureter w/ sinuous/tortuous trajectory

    6. ureterocele - cystic dilatation of intramural ureter

BLADDER - must be full

  • Tumours - hypoechoic masses adherent to wall

  • Lithiasis - mobile

  • Diverticula - round thing attached to bladder

  • prostate hyperplasia - hypertrophied middle lobe protrudes into bladder, transrectal US

Male genitalia

  • Hydrocele - transonic structure w/ flakes

  • Varicocele - dilatations of veins of papilliform plexus

Urodynamic investigations

Storage dysfxns - symptoms during filling phase → pollakiuria, nocturia, urgency

Urinary incontinence

  • Stress - loss from increased intrabd p

  • urgency - detrusor contraction

  • mixed

  • overflow - from retention

Uroflowmetry - measure flow rate of voided urine, quantifies level micturition

  • Indication - diagnosis bladder obstruction or detrusor dysfxn

  • Results - prolonged curve → BPH

    • plateau → urethral stricture

    • discontinuous curve → dysfxn detrusor

Filling cystometry - invasive, investigates detrusor

Pressure-flow study - measures detrusor p during micturition relative to micturition flowrate, in 2 phases (filling + voiding)

  • Values - intravesical p, intrabd p, detrusor p, flow curve

Findings:

  • detrusor sphincter dyssynergia - increased detrusor p in voiding

IVU

Indications - obstruction, trauma, congenital, tumour, lesions

Prep - empty intestines, antihistamines, creatinine

CO - contrast allergy, renal insufficiency, pregnancy, asthma

Complications - v administration, nephrotoxicity, anaphylactic shock

Results:

  • Urinary lithiasis - obstruction, stasis, hydronephrosis

CT/MRI-SB/K

CT

Indications - trauma, tumour, lithiasis, vasc patho

CO - pregnancy, contrast allergy, metal implants

Endoscopy

Urethral strictures:

  1. Urethral meatus stenosis - must be treated as first intervention, incision by urethrotome

  2. Urethral stricture - ‘cold’ incisions by urethrotome

Prostate enlargements, bladder tumours:

  • Requires deobstruction by resectoscope

Bladder lithiasis:

  • fragmented w/ Punch lithotripter

Ureteral lithiasis:

  • ureteroscope fragments in situ, extracted w/ clamp

Kidney lithiasis:

  • percutaneous nephrolithotomy

Open Surgery

Pyelolithotomy

Indications - anatomical abnormalities, failed endoscopy, last resort

Complications - intraop lesions (pleura, peritoneum, vessels)

Pyeloplasty

Indications - reconstruction pyelo-ureteral jxn, association w/ lithiasis, failed endoscopy

Simple lumbar nephrectomy

Indications - traumas that don’t need reconstruction, kidney dyfxn w/ htn + stones, infections that can’t be treated w/ meds

Complications - injuries intrabd or pleura

Intermittent autocatheterization

Used in patients w/ chronic urinary + RSV, w/o subvesical obstruction

Indications - neuro pathos, dm

CO - urethritis, ureteral stricture, bph, prostatitis

Self-catheterization techniques - clean catheter technique OR no touch (needs more skill)

Complications - uretroragia, uti, urethral strictures, false pathways