MET3 Revision: Urology III Flashcards
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
A 34-year-old female presents to her General Practitioner after noticing sudden-onset hair growth, particularly in the facial region. She is becoming increasingly embarrassed by this. She is keen to have the problem sorted. Blood tests were performed, with the only abnormality being a testosterone level of 10.4 nmol/l l (reference range 0.8–3.1 nmol/l).
What is the next step in her management? [1]
A 34-year-old female presents to her General Practitioner after noticing sudden-onset hair growth, particularly in the facial region. She is becoming increasingly embarrassed by this. She is keen to have the problem sorted. Blood tests were performed, with the only abnormality being a testosterone level of 10.4 nmol/l l (reference range 0.8–3.1 nmol/l).
Refer to Endocrinology as a suspected cancer referral
This patient’s history of sudden-onset hair growth and her raised testosterone level necessitates an urgent referral for suspected malignancy.
A 38-year-old male arrives at the Emergency Department complaining of intense left flank pain that extends to the groin area. The presence of blood in the urine, as indicated by urinalysis, raises suspicion of a renal stone. An ultrasound scan of the kidneys, ureters, and bladder (KUB) reveals a likely stone in the left ureter.
What is the most appropriate imaging modality to visualise a ureteric renal stone?
Non-contrast computed tomography (CT) KUB
Micturating cystourethrogram
Magnetic resonance imaging (MRI) KUB
Plain radiography KUB
Intravenous urography (IVU)
A 38-year-old male arrives at the Emergency Department complaining of intense left flank pain that extends to the groin area. The presence of blood in the urine, as indicated by urinalysis, raises suspicion of a renal stone. An ultrasound scan of the kidneys, ureters, and bladder (KUB) reveals a likely stone in the left ureter.
What is the most appropriate imaging modality to visualise a ureteric renal stone?
Non-contrast computed tomography (CT) KUB
Micturating cystourethrogram
Magnetic resonance imaging (MRI) KUB
Plain radiography KUB
Intravenous urography (IVU)
A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis.
What is the most appropriate treatment?
Put it into the scrotum surgically (orchidopexy)
Remove it (orchidectomy)
Remove it along with the opposite testis (bilateral orchidectomy)
Start the patient on testosterone
Perform a chromosome analysis
A 30-year-old male has a right inguinal mass. On examination, the left testis is palpated in the scrotum and is of normal size, but the right testis cannot be palpated in the scrotum. An ultrasound scan shows that the inguinal mass is consistent with a cryptorchid testis.
What is the most appropriate treatment?
Remove it (orchidectomy)
Orchidectomy of the undescended testis is the most appropriate option since it eliminates the risk of subsequent development of seminoma
Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as smooth, can be large and radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as smooth, brown & radiolucent on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as smooth, brown & radiolucent on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as a spiky & radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which of the following stone type appears as a spiky & radio-opaque on x-ray?
Urate
Magnesium ammonium phosphate
Calcium oxalate
Calcium phosphate
Cystine
Which drug classes increase the chance of urinary tract calculi? [5]
allopurinol (treat gout)
loop-diuretics
antacids
acetazolamide
corticosteroids
aspirin
What causes an increased risk of infection from urinary tract calculi? [1]
If voiding impaired
How does pain present in urinary tract calculi?
How does pain presentation differ if the stone is
- Obstructing the kidney [2]
- Obstructing mid ureter [1]
- Obstructing lower ureter [2]
- Obstructing bladder or urethra [3]
Obstructing the kidney:
- felt in loin;
- between rib 12 and lateral edge of lumbar muscles
Obstructing mid ureter:
- mimics appendicitis / diverticulitis
Obstructing lower ureter
- may lead to symptoms of bladder iritability and pain in scrotum, penile tip or labia
Obstructing bladder or urethra:
- pelvic pain
- dysuria
- strangury
What differential will CT-KUB help to exclude? [1]
Ruptured AA
How does pain present in urinary tract calculi?
Excruciating pain that spreads from loin to groin that can cause nausea and vomiting in colicky fashion
Describe the analgesic therapy offered for urinary tract calculi [1]
IM diclofenac
IV paracetamol 2nd line
Describe the treatment algorithim for a patient who has a confirmed obstructed kidney stone? [2]
1.urgent decompression:
- ureteric stent past the obstruction and achieve drainage.
- a percutaneous nephrostomy tube can be placed by interventional radiology.
- urgent antibiotics
Calcium phosphate stones are commonly found in which structure? [1]
Bladder - found with urinary stasis
Calcium phosphate stones are clinically associated with which 3 conditions? [3]
Hyperparathyroidism
Medullary Sponge Kidney (MSK)
Distal Renal Tubular Acidosis (Type 1)
How are urate stones formed? [1]
How do they appear? [1]
Yellow
Acidic urine forms stones; uric acid entering urine
Struvite stones are associated with what type of infection? [1]
Bacterial infection; (form when bacteria meet a surface and make urine more alkali; Mg binds and builds up): UTI
When lasering a kidney stone is smells of egg. Which type of renal stone is this? [1]
Cysteine
Describe the free theory of stone formation [4]
Free theory:
- Unsaturated urine increases in concentration; goes beyond the solubility product, at which point the urine becomes saturated
- Above this level, the urine is saturated but crystals are prevent from forming by inhibitors
- Above the formation product, crystals form spontaneously
- Stone formers sit at both the metastable and spontaneous regions; they have less inhibitors
Describe the formation of stones via fixed theory [2]
Normally, need high energy to form crystal lattice
But, if have rough surface, e.g. from urate crystals, then energy required to form lattice is lower
Describe how uric acid stones are formed [2]
Urate stones are formed from both theories:
Free theory:
- Urate has pK value of 5.4 (crystals will form when pH meets pK value); urate crystal formation is pH dependent
Fixed theory:
- Prescence of urate crystals forming acts as a nidus for stone formation
What is a Randall’s plaque? [1]
Where do they form? [1]
Wn attachment site over which calcium oxalate stones form, begins in the basement membranes of thin limbs of the loop of Henle.
Label A
What is a Duct of Bellini? [1]
How are stones formed here? [2]
The duct of Bellini represents the most distal portion of the collecting duct.
- Stones formed within the tubules
- Duct of Bellini narrows
- Stones gets “stuck” at papillary surface
Name a stone inhibitor [1] and how it works [1]
Tamm Horfshall Protein (aka uromodulin)
Bind to crystal structures and prevent from binding to renal epithelial cells
How do you differentiate between a bowel colic and uteric colic [1]
Ureteric colic pain
- usually comes and goes with a background of pain completely between bouts
Bowel colic
- pain comes and goes, going away completely between bouts
State reasons why hypercalciuria [4] and hyperoxaluria [3] may be occurring and thus causing calcium stones
Hypercalciuria:
- Hyperparathyroidism
- Excess Ca2+ intake
- Increased Ca2+ gut absorption
- Poylcystic ovaries or medullary sponge disease
Hyperoxaluria:
- High diet in oxalates
- Low dietary Ca2+ (leading to decreased binding to oxalate)
- Increased intestinal resorption (e.g Crohns)
Name 3 foods high in oxalate [3]
spinach
tea
rhubarb
Important differential diagnoses? [6]
AAA: older patients
Bilary colic (presents more with RUQ pain)
Ectopic pregnancy
Pyelonephritis
MI
Pneumonia
Describe the treatment plan for a renal stone < 10 mm that fails to pass despite initial conservative management [3]
Offer shock wave lithotripsy (SWL)
Consider ureteroscopy if SWL is contraindicated, fails, or is not indicated because of anatomical reasons
Consider percutaneous nephrolithotomy (PCNL) if SWL and ureteroscopy are not suitable options or have failed.
What is the first line treatment for pregnant person with stone? [1]
If the patient has no evidence of infection, the specialist will arrange ureteroscopy. Ureteroscopy has been demonstrated to be safe in pregnancy.[74]
Describe the treatment plan for a renal stone > 20 mm [1]
Percutaneous nephrolithotomy
