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Surgery > Urology > Flashcards

Urology Flashcards

1
Q

Differentiate between the different types of hematuria

A 
Pre-renal
- coagulopathy
- sickle cell disease
- thromboembolism
Renal
- trauma
- renal carcinoma
- infection
- glomerulonephritis 
Post-Renal (TITS)
- Trauma: foreign body, catheritization, radiation
- Infection
- Tumour: bladder cancer, prostate hypertrophy
- Stone: renal calculi
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2
Q

Differentiate between renal and post-renal hematuria

A 
Renal
- tea colored urine with no clots
- high creatinine and BUN
- dysmorphic RBC, RBC casts
- proteinuria
Post-Renal
- red with some clots
- normal creatinine
- normal shaped RBC with no proteinuria
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3
Q

Discuss the presentation and management of renal cell carcinoma

A 
Risk Factors
- smoking
- hypertension
- obesity
- kidney anomaly
Presentation
- asymptomatic with incidental finding on imaging
- Triad of gross hematuria, flank pain, and palpable mass
- paraneoplastic syndromes (hypercalcemia, anemia, erythrocytosis, hypertension)
Investigation
- CT
- biopsy
Management
- partial or radical nephrectomy 
- radiotherapy
- anti-angiogenesis factors, mTOR, IL-2 for advanced disease
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4
Q

Discuss the presentation and management of bladder cancer

A 
- transitional cell carcinoma
Risk Factors
- smoking
- chemical exposure
- cyclophosphamide
- radiation to pelvis
- chronic bladder irritation
Presentation
- gross hematuria 
- pain
- clot retention
- FUNSHED
Investigation
- NMP-22, BTA, immunocyt and FDP are bladder tumour markers
- cystoscopy with bladder washing
Management
- surperficial: transurethral resection of bladder tumour
- invasive: cystectomy with chemo-radiation adjuvant (mitomycin)
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5
Q

Differentiate the different causes of failure to store

A

Urge Incontinence (detrusor overactivity or decreased compliance)
- detrusor overactivity from CNS lesion, inflammation, bladder neck obstruction
- decreased bladder compliance: fibrosis of bladder or non-functioning neck
Stress Incontinence (urethral hypermobility or instrinsic sphincter deficiency)
- urethral hypermobility: weakened pelvic floor from childbirth, pelvic surgery, age
- instrinsic sphincter weakness: aging, hypo-estrogen, pelvic surgery
Overflow Incontinence (due to failure to void)

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6
Q

Discuss the medications associated with incontinence

A
  • anti-histamine
  • anticholinergic
  • ACE inhibitor
  • Diuretic
  • alpha agonist
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7
Q

Discuss the investigations and management of the types of incontinence

A

Urge
- diagnosis from urgency on history and urodynamics
- lifestyle modification and bladder habit training
- anti-cholinergics
- botox
Stress
- diagnosis past on history and positive stress test
- lifestyle modification with pelvic floor therapy
- pessary for females
- surgical sling, or sphincter
Overflow
- diagnosis from post-void residual of >200cc
- lifestyle management
- catheterization
- removal of obstruction

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8
Q

Differentiate the causes of urinary retention

A 
Outflow Obstruction
- urethra: stricture
- bladder neck: stone, foreign body, neoplasm
- prostate: BPH, cancer
- external obstruction
Neurogenic bladder
- stroke, Parkinson's
- spinal injury, MS
- diabetic neuropathy
Urinary Tract Irritation
- UTI
Medications
- anticholinergics
- narcotics
- ephedrine
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9
Q

Discuss the urinary questions

A

FUNSHED

  • Frequency
  • Urgency
  • Nocturia
  • Straining
  • Hesitancy
  • Dysuria
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10
Q

Describe the 3 zones of the prostate

A

Peripheral zone
- 70% of volume and most common site of cancer (adenocarcinoma)
Central Zone
- 25% of volume and surround ejaculatory ducts
Peri-urethral transitional zone
- 5% and is site of BPH

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11
Q

Discuss the physiology and histology of the prostate gland

A

Physiology
- secrete thin, milky fluid which aids in sperm viability and motility
- prostate growth stimulated by andreogens (testosterone and dihydrotestosterone)
Histology
- formed by tubuloalveolar glands surrounded by fibromuscular strom
- line with simple columnar epithelium
- have corpora amylacea in prostatic gland

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12
Q

List the risk factors for prostate cancer

A
  • African descent
  • family history
  • high dietary fat
  • cigarette smoking
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13
Q

Discuss the presentation and management of prostate cancer

A

Presentation
- asymptomatic early so detected by DRE and PSA
- FUNSHED
- erectile dysfunction
- incontinence
- DRE demonstrate hard, irregular node or diffuse induration
- metastasis to bone (osteoblastic) in axial skeleton
Investigations
- PSA
- biopsy with tans-rectal ultrasound
- CT abdomen
Management
- watchful waiting for short life expectancy
- active surveillance for low grade disease
- brachytherapy for low risk disease
- external beam for locally advanced in older patients
- radical prostatectomy for young patients with high risk disease
- metastasis treat with antiandrogens

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14
Q

Discuss PSA screening

A

Elevation in PSA
- prostate cancer
- BPH
- prostatitis
- trauma from DRE, catheterization
PSA
- <10% free PSA than high risk for cancer
- >0.75ng/mL/yr velocity than increased risk of cancer
- >0.15ng/mL/g density than increased risk
- <4ug/L is normal (but varies with age and race)

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15
Q

Discuss the presentation and management of benign prostate hyperplasia

A

Presentation
- FUNSHED
- DRE demonstrate symmetrically enlarged, smooth prostate
Investigation
- post-void residual and urodynamics
Management
- mild symptoms have lifestyle changes of fluid restriction
- moderate use alpha-adrenergic antagonist to reduce stroma smooth muscle tone (tamsulosin (flomax)
- 5-alpha reductase inhibitor to inhibit conversion of testosterone to DHT (finasteride)
- Surgery TURP for renal failure, recurrant UTI/hematuria, urinary retention

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16
Q

Discuss the presentation and management of prostatitis

A
  • most common urologic disease in men <50
  • infection with PEEAKS bacteria
    Risk Factors
  • BPH
  • recent instrumentation of urinary tract
    Presentation
  • FUNSHED with hematuria
  • fever
  • rectal, perineal pain
  • DRE show tender, warm prostate
    Investigation
  • 4 specimen urine culture
    Management
  • septra PO for 4-6 weeks
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17
Q

List the risk factors for renal calculi

A
  • dehydration
  • obesity
  • thiazide
  • UTI
  • gout
  • cystinuria, xanthinuria, oxaluria
18
Q

Discuss the pathophysiology of renal calculi

A
  • predisposition to supersaturation of salt from urinary stasis or low flow, increased solute, low urine pH
  • supersaturation of salt leads to formation of crystals where can obstruct urinary tract
19
Q

List the 4 different types of stones

A 
Calcium
- radiopaque on KUB
Uric acid
- low urine pH, diet rich in purines, gout
- radiolucent
Struvite
- infection with urea splitting organism (Proteus, pseudomonas, klebsiella, mycosplasma)
- staghorn calculi in renal pelvis
- radio-opaque
Cystine
- autosomal recessive disorder lead to reduced absorption of cystine
- radiolucent
20
Q

List the most common locations for stones

A
  • Uteropelvic junction
  • pelvic brim
  • under vas deferens/broad ligament
  • uretero-vesical junction
21
Q

Discuss the presentation and management of renal calculi

A 
Presentation
- constantly uncomfortable
- nausea, vomiting
- flank pain that is severe and radiate to grown
- hematuria
Investigation
- urinalysis and culture
- KUB x-ray
- CT scan without contrast
Management
- high likelihood stone will pass if <=5mm
- treat with PO fluids, ketorolac, alpha-blockers (flomax)
22
Q

Discuss the criteria for admission with renal calculi

A 
Urosepsis
- urine stasis lead to ascending infection
Acute Renal Failure
- can be obstructing leading to hydronephrosis and failure
High Risk Patient/Stone
- solitary kidney
- bilateral stones
Symptoms
- intractable nausea/vomiting
23
Q

Discuss the surgical intervention for renal calculi

A

Kidney Stones
- stone <2.5cm possible stent and then extra-corporeal shock wave lithotripsy
- >2cm then percutaneous nephrolithotomy
Uteral Stones
- ESWL and uterosopy to retrieve stone
- if infected stone then place stent and begin antibiotics (amp and gentamicin)

24
Q

Discuss the prevention measures for stone formation

A

Dietary Modification

  • increase fluid intake >2L
  • potassium and citrate intke
  • reduce animal protein
  • high dose vit C supplementation
  • do not decrease calcium intake
25
Q

Discuss the presentation and management of testicular torsion

A 
Risk Factors
- cryptochordism
- bell clapper deformity
- trauma 
- intravaginal where twist in tunica vaginalis which occur in puberty (extravaginal occur in neonates)
Presentation
- acute, severe scrotal pain radiating to groin or abdomen
- nausea and vomiting
- tender, erythematous that can be high riding or transverse lie
- no cremasteric reflex
- negative Phren's sign
Investigation
- urgent go direct to OR
- trans-scrotal ultrasound with doppler
Treatment
- surgical derotation with bilateral orchiopexy, possible orchiectomy
26
Q

Discuss the presentation and management of epididymitis/orchitis

A

Risk Factors
- sexual activity and risk factors for STI
- recent instrumentation of urinary tract
Pathogenesis
- <35 most common is e coli, gonorrheae or chlamydia
- >35 infection by e coli
Presentation
- insidious onset of pain associated with dysuria, frequency, nocturia
- fever
- diffuse tenderness
- erythematous, warm, swollen testes with possible discharge
- normal cremasteric reflex and Phren sign
Investigation
- leukocyte
- urine culture and urethral swab
Management
- bed rest with scrotal elevation
- NSAID
- gonorrhea get ceftriaxone, chlamydia get azithromycin, and e coli get ciprofloxacin

27
Q

Discuss the presentation and management of a hematocele

A 
Presentation
- history of trauma with painful scrotal mass
- bruising and diffuse tenderness
Investigation
- ultrasound to visualize blood collection
Management
- pain control
- surgical for fracture of testes
28
Q

Discuss the presentation and management of hydrocele

A

Pathogenesis
- collection of serous fluid in the tunica vaginalis
- secondary have testicular pathology that irritate tunica
- defect in tunica from patent processus vaginalis
Presentation
- painless large scrotal mass
- transilluminating mass
- mass not isolated from testis
- palpable spermatic cord
Investigation
- ultrasound show cystic fluid
Management
- most resolve spontaneously
- surgical management for symptomatic, cosmesis, or underlying pathology

29
Q

Discuss the presentation and management of spermatocele

A

Pathogenesis
- obstruction of distal duct leading to fluid filled sperm collection in epididymis
Presentation
- non-tender cystic mass in epididymis that transillumintes
- palpate testis seperate from amss
Investigation
- ultrasound show cystic mass
Management
- operate only if symptomatic or cosmesis

30
Q

Discuss the presentation and management of varicocele

A

Pathogenesis
- dilatation and tortuosity of pampiniform venous plexus of spermatic cord
- most commonly on left side due to gonadal vein entrance into renal vein
- right side concerning for cancer
Presentation
- infertility
- bag of worms scrotal mass
Investigation
- ultrasound
Management
- operative if infertility, ipsilateral testicular atrophy, symptomatic or cosmesis

31
Q

Discuss the presentation and management of testicular cancer

A

Risk Factors
- age <10, 15-35 and >60
- maternal exposure to androgen in pregnancy
- cryptochordism
Presentation
- painless testicular enlargement
- gynecomastia,
Investigation
- scrotal ultrasound showing hypoechoic mass with irregular borders and heterogeneity
- bHCG: risk for seminioma, embryonal, choriocarcinoma
- AFP: increased in non-seminoma
- LDH
Management
- radial orchiectomy for painless mass in right age group with ultrasound suspicion
- Pathology and CT afterwards to determine stage and treatment

32
Q

List the different types of testicular cancers

A 
Seminoma (35%)
- germinal cell
- epithelium 
- stage 1 get surveillance
- stage 2 and 3 get radiation an chemotherapy
Non-seminoma
- Teratoma
- embryonal
- mixed cell type
- yolk sac
- chorio
- stage 1 get surveillance
- stage 2 and 3 get lymph node dissection and chemotherapy
33
Q

Discuss the lymph node metastasis for testicular cancers

A

Right Testicle
- medial, para-caval, anterior and lateral lymph nodes
Left testicle
- left lateral and anterior para-aortic lymph nodes

34
Q

List the most common bacteria for a urinary tract infection

A

PPEEEAKS

  • proteus
  • pseudomonas
  • e coli
  • enterobacter
  • enterococcus
  • acinobacter
  • kliebsiella
  • staphyloccocus saprophyticus
35
Q

List the risk factors for a UTI

A 
Urine stasis
- obstruction
- functional urinary retention
Foreign body
- catheter
Immune Compromise
- diabetes
- malignancy
Other
- female
- trauma
36
Q

Discuss the presentation and management of a UTI

A

Presentation
- frequency, urgency, dysuria, hematuria
- suprapubic tenderness
- costavertebral tenderness
Investigations
- dipstick: positive leukocytes and nitrites
- urine microscopy 5 WBC/HPF
- culture >100CFU/mL
Management
- Uncomplicated: septra PO for 3 days 1st line or cipro for 3 days as second line
- in men require longer course as most likely obstructive
- pyelonephritis require cirpro for 7-14 days or septra for 7 days
- asymptomatic treat only if pregnant or have manipulation

37
Q

Differentiate between the different causes of recurrent urinary tract infections

A

Relapse
- recurrence of same infection within 2 weeks after discontinuation of antibiotics
- must consider anatomy or abnormal voiding
- check resistances
Reinfection
- recurrence of UTI with new organism

38
Q

Discuss the presentation and management of bladder trauma

A

Pathophysiology
- contusion have no rupture of bladder
- intra-peritoneal have bladder dome rupture into intra-peritoneal cavity
- extra-peritoneal have anterior or lateral wall rupture
Presentation
- bladder trauma associated with pelvic fracture
- abdominal tenderness with peritoneal signs
- inability to void
Investigation
- CT Cystogram
Management
- Foley
- extra-peritoneal can follow with CT cystograms
- intra-peritoneal require suprapubic catheter and surgery

39
Q

Discuss the presentation and management of kidney trauma

A

Presentation
- associated with lower rib or vertebral transverse process fracture
- upper abdominal/flank injury
Investigation
- abdominal and pelvic CT with contrast
Management
- gross hematuria with contusion require hsopitalization with bedrest

40
Q

List the classification system for renal trauma

A

Stage 1
- renal contusion
Stage 2
- <1cm laceration without urinary extravation
- >1cm laceration without urinary extravation
- urinary extravation
- shattered kidney

Surgery (14 decks)

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