Urinary problems

Question 1

Pathophysiology of testicular torsion (TT)

Answer 1

When the spermatic cord (blood flow to the testicle) rotates + becomes twisted
This causes testicular ischaemia

Question 2

What is the most common age for TT

Answer 2

<30 years

Peak age is 13 years

Question 3

What is bell-clapper deformity? (TT)

Answer 3

Caused by abnormal fixation of the tunica vaginalis to the testicle - so the testicle can rotate freely in the tunica vagninalis

Question 4

Presentation of TT

Answer 4

Acute onset testicular pain
Abdo pain (+/- vomiting)
PAINFUL TO WALK!!

Question 5

How may the testical appear in TT?

Answer 5

Red, swollen, tender hemi-scrotum

Affected testis is higher + transverse

Question 6

What reflex is absent in TT?

Answer 6

Cremasteric reflex is absent in TT

Question 7

Initial managment of TT

Answer 7

Analgesia (?anti-emetic)

KEEP FASTED!! they will need surgical intervention

Question 8

Should you image in suspected TT?

Answer 8

NO! this will delay treatment

Question 9

Surgical managment of TT

Answer 9

Orchidopexy (detorsion + fixation with suture) of BOTH SIDES!! the other testis is at increased risk of torsion

Question 10

What is the most common cause of scrotal pain in men?

Answer 10

Epididymitis

Question 11

How does epididymitis differ from torsion?

Think onset, symptoms, management etc

Answer 11

Epididymitis:
Usually more gradual onset
Can progress to testis
Usually urinary symptoms too 
Treated with antibiotics

Question 12

What are the most common causes of epididymitis in older men, sexually-active men and pre-pubescent boys

Answer 12

Old: usually enteric (e. coli)

Sexually active men: usually STI (chlamydia/ gonorrhoea)

Pre-pubescent: usually non-infective cause

Question 13

What is another infective cause of epididymitis?

Answer 13

Mumps

Question 14

How is epididymitis managed?

Answer 14

Treat the underlying cause!

e.g. treat STI with ceftriaxone + doxycycline

Question 15

What is the most common type of renal stones?

What are these associated with?

Answer 15

Calcium oxalate (60%)

Associated with:
low urine volume, raised urine pH (alkalotic)

Question 16

Give 4 other type of renal stones

Answer 16

Calcium phosphate (20%)
Struvite (stag horn calculi)
Uric acid (gout)
Cysteine (genetic disorders)

Question 17

What are the 3 most common sites of renal stone obstruction?

Answer 17

Pelvi-uteric junction (PUJ)
Mid-ureter
Vesico-uteric junction (VUJ)

Question 18

Renal stone obstruction leads to vasodilation and ureteric smooth muscle spasm - how do these present?

Answer 18

Vasodilation: leads to diuresis (increased urine production)

Muscle contraction: colicky pain

Question 19

Give 4 risk factors for renal stones

Answer 19

Dehydration
Poor diet
Obesity
Gout

Question 20

What analgesic is recommended for renal colic?

Answer 20

75mg Diclofenac (PR or IM)

Question 21

What other immediate management is there for renal colic?

Answer 21

Anti-emetic (e.g. metaclopramide IM)
IV fluids
Antibiotics if co-existing infection

Question 22

Investigations in suspected renal colic

Answer 22

Urine dip and MSU

Us+Es, creatinine, glucose, calcium phosphate + urate levels

Imaging

Question 23

If renal stone is small enough to pass naturally, what should you tell the patient to do

Answer 23

Try and catch the stone in a sieve so it can be sent for analysis

Question 24

If hospital admission is not required, what analgesia can be prescribed

Answer 24

NSAID

Question 25

How big do stones have to be for interventional management (usually)

Answer 25

> 5mm diameter

Question 26

What is MET and what drugs can be used for it?

Answer 26

Medical expulsive therapy

Alpha blocker or CCB - when stones are <10mm

Question 27

With MET, how long should it take for stones to apss?

Answer 27

within 48 hours

Question 28

If a patient with renal stones is unsuitable for medical management, what surgical options are there?

Answer 28

ESWL (extracorporeal shock wave lithotripsy) - outpatient

Percutaneous nephrolithotomy - stone fragmentation through a neohroscope

Question 29

In renal colic, what are 3 indications for early intervention and admission?

Answer 29

Infection + obstruction (ureteric stent may be required)
Urosepsis
Impending AKI

Question 30

What foods (oxalate rich) would you advise reduced consumption of in someone who has had renal stones?

Answer 30

Rhubarb, spinach, cocoa, tea leaves, nuts, soy, strawberries, wheat bran

Question 31

General advice to someone who has had renal stones

Answer 31

Increase fluid intake (to produce 2-3L of urine a day, or to maintain colourless urine)

Balanced diet - reduce salt intake

Maintain a healthy weight