Wednesday, March 4, 2020

UROLOGY

ANATOMY

- two corpora cavernosa for erection

- corpus spongiosum for urethra

INFECTION

- Cystitis

• Three days of antibiotics

• for men, 7 days of antibiotics

• for complicated, 10 to 14 days of antibiotics

- Pyelonephritis

• acute: 7 to 14 days of antibiotic

• Nitrofurantoin should not be used as it does not penetrate renal parenchyma

- Prostatitis

• (4–6 weeks) of antibiotics

• Chronic bacterial prostatitis is also known as chronic pelvic pain syndrome

- Epididymoorchitis.

• generally arises over the course of 24–48 hours

• ceftriaxone and azithromycin

URINARY TRACT OBSTRUCTON

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- Urolithiasis

• calcium oxalate

• hyperoxaluria after small bowel resection, particularly the terminal ileum

- increase in unabsorbed fatty acids and bile salts which undergo saponification
by binding with calcium in the bowel

- alkaline milieu (pH >7) = infectious (struvite) stones

- α-Blockers = inhibit ureteral peristalsis

- ESWL

• particularly if <10 mm or non–lower-pole renal stones <2 cm

- Ureteroscopy

• middle or distal ureteral stones.

• >10-mm proximal ureteral stones and renal stones

• complications: ureteral injury or stricture

- PCNL

• stones larger than 2 cm

• or smaller stones located in the lower pole of the collecting system

- BPH

• α-Blockers = relaxing the smooth muscle of the prostate and bladder neck

• Five-α reductase inhibitors (5-ARIs) block testosterone to dihydrotestosterone

- Urethral stricture

• prostatic, membranous, bulbous and penile

- bulbar urethra = most common site of stricture

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TRAUMA

- mandate renal imaging include the presence of gross hematuria, microscopic

hematuria with hypotension, and mechanisms increasing the prevalence of renal
injury

- initial step in management of a urethral injury is bladder drainage to prevent urinoma

- excessive torqueing results in rupture of the tunica albuginea

EMERGENCIES

- Acute urinary retention

• inability to void or the presence of a postvoid residual over 200 mL is concerning

for development of another episode of AUR

• α-blocker such as tamsulosin for BPH

• finasteride and dutasteride (5α-reductase inhibitors) —> reduce the incidence of

urinary retention by 50%, they require several months to take effect and are most
beneficial in large prostates

- Torsion

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• blood supply to the testicle is compromised due to twisting of the spermatic cord
within the tunica vaginalis, resulting in ischemia to the epididymis and the testis

• contralateral testes also must be explored and fixed to the dartos fascia
- Priapism

• persistent erection for greater than 4 hours unrelated to sexual stimulation

• tx: injection of sympathomimetics (phenylephrine; diluted 100–500 mcg/mL and

given in 1 mL increments every 3–5 minutes for up to 1 hour before determining
failure). Insertion of a large-gauge needle (16–21 gauge) into the lateral aspect of
one corporal body allows thorough aspiration and irrigation of both corporal bodies

- Paraphimosis

• foreskin is retracted for prolonged periods, constriction of the glans penis

- Emphysematous pyelonephritis

• acute necrotizing infection of the kidney

• predominantly in diabetic patients

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• present with sepsis and ketoacidosis

• Escherichia coli

MALIGNANCIES

- bladder CA

• most common histology: urothelial carcinoma

• Intravesical immunotherapy using bacillus Calmette-Guérin (BCG)

- testicular CA

• Seminoma

• risk factors: cryptorchidism, family history of testis cancer, a personal history of

testis cancer, and intratubular germ cell neoplasia

• retroperitoneal lymphadenopathy in young men should be considered metastatic

testicular cancer

• serum tumor markers (α-fetoprotein, quantitative human chorionic gonadotropin,

and lactate dehydrogenase)

• Radical inguinal orchiectomy is the gold standard treatment for excision of the
primary tumor.

• Recurrence usually occurs within the first 2 years and in the retroperitoneum

• Pure seminoma is radiosensitive

- kidney CA

• Clear cell RCC most common

• Partial nephrectomy is most appropriate for patients with small tumors, solitary

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kidney, bilateral tumors, or familial RCC

- Prostate CA

• screening for high-risk disease for men between the ages of 55 and 69

• Radical prostatectomy and pelvic lymph node dissection (robotic, laparoscopic, or

open), image modulated radiation therapy (IMRT), and brachytherapy

• Once prostate cancer metastasizes, it is no longer curable

- Urethral CA

• risk factors: chronic inflammation from sexually transmitted diseases (HPV 16 and
18 in squamous cell carcinoma), chronic urethral stricture, and indwelling
catheterization

• Urothelial carcinoma is the most common histology

COMMON UROLOGIC CONDITIONS

- Erectile dysfunction

• due to endothelial dysfunction

• Nitric oxide is released —> increase in cyclic guanosine monophosphate (cGMP)

—> smooth muscle relaxation within the corpora cavernosa

• tx: phosphodiesterase type-5 inhibitors (PDE5i)

PEDIATRIC UROLOGY

- Hypospadias

• most common: mid to distal shaft or proximal glans

• chordee = with penile curvature

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- UTI

• infants less than 2 months of age with febrile infections should undergo both a
renal US and VCUG.

• Children between 2 months and 2 years who have their first documented infection
only need have a renal ultrasound performed

- VCUG is only needed if there are abnormalities detected on the ultrasound

• VCUG may also be performed if a child has recurrent infections despite empirical
treatment