Infection, Inflammation and Genitourinary Tuberculosis
Core concepts
Infection questions reward syndrome recognition and the correct specimen.
UTI: distinguish uncomplicated from complicated, and know when imaging is indicated (recurrent, pyelonephritis with failure to respond, suspected obstruction, or in men). Trap: treating asymptomatic bacteriuria in most patients - it should not be treated except in pregnancy and before urological instrumentation.
Pyelonephritis and sepsis: an obstructed infected system is an emergency requiring decompression.
Prostatitis: acute bacterial (fever, tender prostate, do not massage), chronic bacterial, and chronic pelvic pain syndrome. Trap: massaging the prostate in acute prostatitis.
Epididymo-orchitis: in young men consider chlamydia/gonorrhoea; in older men consider obstruction and Gram-negative organisms.
Fournier's gangrene: necrotising fasciitis of the perineum; a surgical emergency requiring debridement, broad-spectrum antibiotics and critical care. Trap: delaying surgery for imaging.
Genitourinary tuberculosis: presents with sterile pyuria, frequency, dysuria, and a "putty kidney" or strictured ureter. Diagnosis requires early morning urine samples for culture. Trap: treating a patient with sterile pyuria as a simple UTI; and forgetting that TB can cause ureteric strictures and a contracted bladder.
Worked rule of thumb
Sterile pyuria with frequency and a strictured ureter: think TB - the trap answer is "recurrent UTI, give another antibiotic". Send three early morning urines for TB culture.
Exam traps
- Treating asymptomatic bacteriuria outside pregnancy and instrumentation.
- Massaging the prostate in acute prostatitis.
- Delaying debridement in Fournier's gangrene.
- Missing genitourinary TB in sterile pyuria.
Basic Sciences Applied to Urology
Core concepts
Basic science questions are usually applied, so link each fact to a clinical consequence.
Anatomy: the course of the ureter and its three anatomical narrow points (pelviureteric junction, crossing the iliac vessels, vesicoureteric junction) explain where stones lodge. The blood supply of the ureter is segmental, which explains why mobilisation causes ischaemia. Know the fascial planes of the prostate and the neurovascular bundles, and the lymphatic drainage of the testis (para-aortic) versus the scrotum (superficial inguinal) - a classic trap.
Physiology: glomerular filtration, tubular handling, acid-base regulation, and the micturition reflex. Know the roles of the sympathetic (storage) and parasympathetic (voiding) systems and the somatic pudendal control of the external sphincter.
Pathology: urothelial carcinoma field change, the difference between low- and high-grade urothelial lesions, and the significance of carcinoma in situ.
Pharmacology: antimuscarinics, alpha-blockers (orthostatic hypotension, intraoperative floppy iris), PDE5 inhibitors, and antibiotics.
Embryology: the mesonephric and paramesonephric ducts, renal ascent, and the origin of duplication anomalies and hypospadias.
Worked rule of thumb
A testicular tumour metastasises to para-aortic nodes, not inguinal nodes, because the testis descends with its blood supply from the abdomen. The trap answer is "superficial inguinal nodes" - that is scrotal skin drainage.
Exam traps
- Confusing testicular and scrotal lymphatic drainage.
- Forgetting the three anatomical narrow points of the ureter.
- Missing the autonomic control of storage versus voiding.
- Overlooking the alpha-blocker iris syndrome.
Emergency Urology, Critical Care and Perioperative Management
Core concepts
This domain tests triage and the first ten minutes, plus safe perioperative practice.
Emergencies: testicular torsion, Fournier's gangrene, obstructed infected kidney, priapism, renal trauma with instability, and acute urinary retention. For each, know the single time-critical action. Trap: ordering imaging before decompression in an obstructed infected system, or before exploration in torsion.
Acute urinary retention: distinguish acute from chronic, and know that high-pressure chronic retention with renal impairment requires controlled decompression and monitoring for post-obstructive diuresis.
Critical care: sepsis bundles, fluid resuscitation, vasopressors, and the recognition that urosepsis is a common cause of ICU admission. Know the principles of perioperative risk assessment, VTE prophylaxis, and antibiotic prophylaxis.
Perioperative: antiplatelet and anticoagulant management, the patient on alpha-blockers, and enhanced recovery principles. Trap: stopping necessary antiplatelets without a plan, or forgetting VTE prophylaxis in pelvic surgery.
Metabolic and electrolyte: know the consequences of obstructive uropathy, and the fact that relief of obstruction can cause significant post-obstructive diuresis requiring fluid replacement.
Worked rule of thumb
A patient with an obstructed infected kidney and hypotension: resuscitate and decompress with a nephrostomy or stent, and take to theatre only after stabilisation. The trap answer is "definitive stone surgery now" - source control, not stone clearance, is the emergency.
Exam traps
- Delaying decompression in obstructed infection.
- Missing post-obstructive diuresis.
- Ignoring VTE prophylaxis.
- Stopping antiplatelets without a plan.