Urology Summary

Nov 2014

Renal Colic
90% stones radio-opaque (25% gallstones)
70% Ca phosphate/Ca oxalate
10-15% infection stones (struvites; PO4, CaPO4, MgNH4PO4)
10% urate stones (radiolucent)
1% cysteine stones

4mm 90% passage rate

5mm 80%
5-8mm 15%
>8mm 5%

Admit urology if:

Obstructed solitary kidney or transplanted kidney
High grade obstruction
Decr renal function (Cr>200)
Persistent pain (despite 24hrs in SSU)
Large proximal stone >6mm

Imaging in renal colic

CT: sens 95%, spec 99%
Pros: fast, no contrast, detect other diagnoses, can measure stone size, can detect obstruction
Cons: radiation, higher cost
IVP: sens 60-90%, spec 90-100%
Pros: info re size/position of stone, measures renal function
Cons: contrast reaction, radiation, time-consuming, can’t rule out other diagnoses
KUB: sens 30-60%, spec 70-75%
Pros: readily available, fast, good for monitoring
Cons: low sens/spec, radiation
USS: sens 60-85%, spec 80-100%
Pros: non-invasive, no radiation, best in pregnancy, no contrast, will detect AA
Cons: may miss small stones, insensitive middle 1/3 ureter, operator dependent, not always available

Priapism
5-10yrs (sickle cell, Ca); 20-25yrs (idiopathic); >25yrs (impotence treatment)
Low flow (drugs, hypercoagulability - sickle cell/leukaemia, spinal cord injury)
painful = ischaemic = thrombotic: obstruction to outflow; most common
pH <7.25, pO2 <30, pCO2 >60, dark blood
High flow (trauma, AV fistula)
painless = non-ischaemic = non-thrombotic: uncommon
bright red blood
usually treated conservatively

Management Low Flow

Analgesia
Early urology consultation
Terbutaline 500mcg sc; Pseudoephedrine 120mg po
Intracavernosal aspiration or injection intracorporeal adrenaline/phenylephrine
SCD: IVF, O2, exchange blood transfusion

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 Phimosis: Inability to retract foreskin
Paraphimosis: Inability to replace retracted foreskin - venous obstruction and oedema; urological emergency
Balanitis: Candida, Staph aureus, gardnerella, anaerobes

Scrotal Emergencies
<10yrs: torsion of appendix testis
10-19yrs: testicular torsion; 20-40% torsion of appendix testis
20-29yrs: 75% epididymitis > 20% testicular torsion
>30yrs: nearly all epididymitis > hernia, referred pain

Testicular torsion
2 peaks: newborns (extravaginal), 12-16yrs (intravaginal)
USS 88% sens, 90% spec
100% salvage <4hrs 80-90% salvage <6hrs 20% salvage 10-24hrs 0% salvage >24hrs

Epididymitis
Pre-pubertal = coliforms
19-35yrs = 30-50% chlamydia > gonorrhoea > ureaplasma urealyticum
>40yrs = coliforms, E coli, klebsiella from urine; post-procedural
If STD: ceftriaxone 250mg IM stat + doxycycline 100mg BD 14/7 + roxithyromycin 300mg OD 14/7
If unwell: ampicillin 2g Q6h IV + gentamicin 4-6mg/kg OD

Fournier’s gangrene
Mixed aerobic/anaerobic necrotising subcutaneous infection of scrotum and perineum
Bacteroides and E coli most common; anaerobic Strep, G-ive rods, anaerobes
RF: obesity, immunocomp, DM in 20-70%, ETOH in 25-50%, chronic steroid use
Ceftriaxone 2g IV + metronidazole 500mg IV + gentamicin 4-6mg IV; OT

Testicular Cancer
Common metastatic sites: lumbar spine, inguinal/para-aortic LNs, lungs

Renal carcinoma
85% clear cell carcinoma (peaks 60s-70s), 10% papillary carcinoma

Bladder tumours
1. Transitional-cell: 90% bladder cancer; links: smoking, aniline dyes, artificial sweeteners, cyclophosphamide
2. Squamous-cell: <5% bladder cancer; links: schistosomiasis, chronic bladder irritation, long term IDC
3. Adenocarcinoma: <2%

Prostate Cancer
Can metastasize to bone - osteoblastic
>95% adenocarcinoma

UTI
E coli (70-80%)
Staph saprophyticus in sexually active women (5-15%)
5-20% other (proteus (suggested by high urinary pH), strep faecalis, enterobacter, pseudomonas)
<5% other (grp D strep, chlamydia, TB)
Klebsiella and staph aureus in neonates
LR’s: self diagnosis of UTI > haematuria > frequency > fever > dysuria > suprapubic pain

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 Pyelonephritis
Nitrites: 95% PPV, 70% NPV for UTI
Leucs: 70% PPV, 85% NPV for UTI

Paediatrics
84% E coli, 6% proteus, 5% klebsiella, 3.5% enterococcus; G+ives in older boys/underlying medical conditions
Always check BP
Nitrites: 60% sens (doesn’t develop with G+ives) 95-99% spec
WBC dipstick: 70-80% sens; Gram stain 80-97% sens 80-90% spec; sens decr if <2yrs
WBC: 50-90% sens 50-90% spec
Bacteria: 50-90% sens 10-90% spec
Renal USS: all children with 1st UTI, 3-6/52 after infection
DMSA scan: after 6/12 or at age 3-4yrs to look for scarring if required hospitalisation
MCU: <3/12 or if abnormal USS

Admit if:
<6/12
septic
underlying disease
urinary obstruction
pyelonephritis
failure to respond to PO’s

Prostatitis
<35yrs: usually STD
>35yrs or homosexual: usually E coli >80%; 20% other G –ives or haematogenous spread or post biopsy
Treat as per UTI; if <35yrs, treat as STD
If severe: systemic features/urinary retention: amp 2g IV QID + gent 4-6mg/kg OD for 14/7

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