Clinical (Week 3) Flashcards
(213 cards)
1
Q
What are the types of urethral incontinence?
A
Overflow
Urge
Stress
Mixed
2
Q
What are the types of extraurethral incontinence?
A
Ectopic ureter
Fistula
3
Q
A huge palpable bladder, often wet at night and renal impairment suggest what kind of incontinence?
A
Overflow
4
Q
Frequency, urgency provoked by standing up/coughing/laughing and enuresis suggest what kind of incontinece?
A
Urge
5
Q
What causes urge incontinence?
A
Detrusor overactivity:
- Contracting during inhibition of voiding
6
Q
How can we diagnose urge incontinence?
A
Urodynamics
7
Q
How can pelvic surgery or fractures result in urge incontinence?
A
- PNS nerves damaged
- Residual urine
- Infection
- Bladder irritation
- Overstimulation
8
Q
What causes stress incontinence?
A
Increased intra-abdominal pressure without detrusor contraction
9
Q
What causes stress incontinence?
A
Damage to the following during childbirth:
- Pelvic floor - Urethral function
10
Q
How does the bladder appear on abdominal exam in a patient with urinary retention?
A
Painless Palpable Arises in pelvis Cannot 'get below' it Dull to percussion
11
Q
How do we treat overflow incontinence?
A
Assess renal function Treat obstruction -> Catheterise Rehabilitate bladder (Teach self-catheterisation)
12
Q
What dietary advice in urge incontinence?
A
Caffeine
13
Q
What medical therapy can be used to treat urge incontinence?
A
Antimuscarinics:
- Oxybutynin
- Tolterodine
β3-adrenergics:
- Mirabegran
14
Q
What are some alternative treatments to treating urge incontinence? (Apart from medication)
A
Botox (unlicensed)
Neuromodulation
Enterocytoplasty
15
Q
What lifestyle advice is given to assist in the treatment of stress incontinence?
A
Weight loss
Stop smoking
16
Q
What is the first line treatment for stress incontinence?
A
Physiotherapy
17
Q
What pharmacology treatment is available for stress incontinence?
A
Duloxetine (SSRI-5HT inhibitor)
Norepinephrin reuptake inhibitor
18
Q
What surgery is available for stress incontinence?
A
Colposuspension
Minimally invasive ‘tape’ procedures
19
Q
What can cause a vesico-vaginal fistula?
A
Prolonged obstructed labour
20
Q
How do we define haematuria?
A
Presence of >=5 RBCs per high-field power
In 3/3 consecutive centrifuged samples
>=1 week apart
21
Q
A patient with microscopic haematuria due to a lower urinary tract pathology are likely to have what symptoms?
A
Hesitancy
Frequency
Urgency
Dysuria
22
Q
Symptomatic, microscopic haematuria from an upper urinary tract pathology usually presents with what symptom?
A
Renal colic
23
Q
If there is profound haematuria what might you suspect?
A
Malignancy
24
Q
How much blood much be present in 100ml of urine to be seen?
A
1ml
25
What are some non-pathological causes of red urine?
Menstruation
| Food (Beetroot, blackberries, rhubarb)
26
How can myoglobin end up in the urine?
Rhabdomyolysis
McArdle syndrome
Bywaters/Crush syndrome
27
Which of the following drugs does not cause red urine:
- Doxyrubicine
- Furosemide
- Chlorqine
- Rifampicin
- Nitrofurantoin
- Senna
Furosemide
28
What toxins can cause red urine?
Lead
| Mercury
29
What can cause brown urine?
```
Urobillinogen:
- Haemolysis
- Icterus
- Liver dysfunction
Porphyria
```
30
Patients over what age are at an increased risk of malignancy if they present with microscopic haematuria?
40 years
31
What past medical history might increase the risk of malignancy in a patient presenting with microscopic haematuria?
Urological disorder
Irritative voiding
UTI
32
Why is it important to drain a distended bladder slowly?
To prevent decompression haematuria
33
How do renal stones cause haematuria?
Scratch mucosa
34
What causes pneumaturia?
Connection between bowel and bladder
35
In regard to haematuria, what do the following indicate:
- Fresh red blood
- Dark blood with clots
- Vermiform (wormlike) clots
1. Active bleed
2. Resolving bleed
3. Kidney/UUT bleed -> Clot forms in ureter -> Frank pain
36
If blood is present in 1st voiding, where is the bleeding likely to be coming from?
Urethra
| Prostate
37
Ingestion of Aristolochia increases the risk of what in what country?
Transitional cell cancer in China
38
Schistosomiasis is common in what country and what does it lead to an increased risk of?
Egypt
| Squamous cell bladder cancer
39
When taking a history in a patient with haematuria, what cancer is a patient's family history is very relevant?
Prostate
40
What can phenacetin abuse cause?
Renal epithelial cancer
41
What features of urinalysis may suggest a UTI?
Leukocytes
Protein
Nitrites
Blood
42
What is the definitive diagnostic method for UTI?
Urine culture (Send in Boricon container, must be received within 24 hours)
43
What is the gold standard investigation into haematuria (and renal problems)?
CT urogram (with IV contrast)
44
What is the first line investigation into haematuria in the case of trauma?
CT
45
How can we best view the bladder?
Cytoscopy/Urethrocytoscopy
46
What is acute urinary retention?
Anuria with increasing pain
47
What can precipitate BPH?
```
Surgery/Anaesthesia
Catheterisation
Medications:
- Sympathomimetics
- Anticholinergics
```
48
If a patient has painful retention with
Alpha blocker before a trial without catheter:
- Alfusozin
- Tamsulosin
49
Which of the following is not associated with post-obstructive diuresis after chronic obstruction:
- Uraemia
- BPH
- Oedema
- CCF
- Hypertension
BPH
50
What causes post-obstructive diuresis?
```
Solute diuresis; Retained:
- Urea
- Na+
- Water
Defect in kidney's concentrating ability
```
51
When should we suspect post-obstructive diuresis?
If urine output is >200ml/hr
52
How do we treat severe post-obstructive diuresis?
IV fluids
| Na+ replacement
53
How long does a mild post-obstructive diuresis take to resolve on its own?
24-48 hours
54
What mediates the pain felt in ureteric colic?
Prostaglandins
55
How do we treat ureteric colic due to calculi?
NSAID +/- opiate
| Tamsulosin for small stones expected to pass
56
What is the chance of a renal calculi passing if its diameter is
80%
57
When would we intervene in assisting the passage of a renal stone?
If not resolved in a month
58
Which of the following is not an indication for emergency treatment of a renal stone:
- Pain unrelieved
- Pyrexia
- Persistent nausea/vomiting
- Reduced urine output
- High grade obstruction
Reduced urine output
59
What is the first line emergency treatment for a renal calculus?
Ureteric stent
60
If there is no infection, how could we treat a renal calculus?
Stone fragmentation or removal
61
When would we carry out a percutaneous nephrostomy in the treatment of a renal calculus?
If infected hydronephrosis
62
How do we induce clot retention in frank haematuria?
Use a 3-way irrigating haematuria catheter
63
What is the first line investigation for frank haematuria?
CT urogram
64
What is the second line investigation for frank haematuria?
Cytoscopy
65
A 16 year old boy presents with acute onset pain in his suprapubic area. He tells you it came on while he was playing rugby. He has vomited a number of times. On examination, the left testis appears high in the scrotum and there is absence of the cremasteric reflex
Spermatic cord torsion
66
What can obliterate landmarks in a scrotal/testicular examination?
Acute hydrocoele and oedema
67
What investigation can be useful for scrotum pathology?
Doppler USS
68
How can we resolve spermatic cord torsion?
2 or 3 point fixation with fine, non-absorbable sutures or removal of the necrotic testis
69
What is the most common anatomical precipitant of spermatic cord torsion?
Bell-Clapper deformity:
| - Testis is inadequately affixed to the scrotum
70
A 18 year old boy presents with tenderness on the upper pole of his left testis. On examination, the testis is still mobile and the cremaster reflex is present. You notice a 'blue dot' sign
Torsion of testicular appendage
71
What are the common presenting symptoms of epididymitis?
Dysuria
| Pyrexia
72
What can predispose to epididymitis?
UTI
Urethritis
Catheterisation
73
Which of the following is not present on investigation of a patient with epididymitis:
- Present cremasteric reflex
- Pyuria
- Elevated testis
Elevated testis
74
On doppler USS of a patient with epididymitis, what would you expect to see?
Swollen epididymis
| Increased blood flow
75
What is the appropriate management of epididymitis?
Analgesia
Ofloxacin:
- 400mg/day
- For 2 weeks
76
If we take a urine sample in a patient with epididymitis, what would we ask microbiology to do?
Culture
| Chlamydia PCR
77
A patient presents with a mildly tender and itchy testis. On examination there is no fever and the testes are only very slightly tender.
Idiopathic Scrotal Oedema
78
What can precipitate paraphimosis?
Catheterisation
| Cytoscopy
79
What is paraphimosis?
Painful swelling of foreskin distal to the phimatic ring
80
Which of these is not a recommended treatment for paraphimosis:
- Iced glove
- Granulated sugar for 1-2hours
- Punctures in oedematous skin
- Manual glans compression with distal foreskin traction
- Dorsal slit
- Emergency circumcision
Emergency circumcision:
| Circumcision is often carried out after it resolves to prevent future episodes
81
What is priapism?
Prolonged erection (>4hrs)
82
True of false; priapism is most often associated with sexual arousal?
False
83
Which of the following is not a recognised cause of priapism:
- Intracorporeal papaverine for ED (vasodilator)
- Trauma
- Paraphimosis
- Sickle cell anaemia
- Neurological conditions
- Idiopathic
Paraphimosis
84
What causes ischaemic priapism and what is the pathophysiology?
Veno-occlusion or low-flow;
- Vascular stasis
- > Reduced venous outflow
85
How do the corpora cavernosum appear in ischaemic priapism?
Rigid and tender
86
What causes non-ischaemic priapism? How does this result in the condition?
Traumatic disruption of penile vasculature:
- Unregulated blood entry/corpora filling
- > ie. Arterial or high-flow priapism
87
A fistula can also cause non-ischaemic priapism. What is the pathophysiology of this cause?
Fistula forms between cavernous artery and lacunar spaces:
| - Blood bypasses normal helicine arteriolar bed
88
In ischaemic priapism, how does aspirated blood from the corpus cavernosum appear?
Dark
| Low oxygen/High carbon dioxide
89
In non-ischaemic priapism, how does aspirated blood from the corpus cavernosum appear?
Normal
90
Colour duplex USS can also be used to aid in the diagnosis of priapism; how will the flow appear in:
1. The cavernosal arteries
2. Non-ischaemic
1. Minimal/Absent
| 2. Normal/High flow
91
What is the initial management of ischaemic priapism?
Aspiration +/- saline irrigation
92
What medical treatment can be given in ischaemic priapism?
α antagonist:
- 100-200μg every 5-10mins
- Max 1000μg
93
When would surgical shunting be carried out in ischaemic priapism?
If in 2-3 days there is no response to intracavernosal therapy
94
If response is very delayed in ischaemic priapism, what might have to occur?
Penile prosthesis
95
What is Fournier's Gangrene and what does it involved?
Necrotising fasciitis of male genitalia:
- Skin
- Urethra
- Rectum
96
Which of the following is not a risk factor for Fournier's Gangrene:
- DM
- UTI
- Local trauma
- Periurethral extravasation
- Perianal infection
UTI
97
How does the scrotum appear in Fournier's Gangrene?
Swollen
| Crepitus on examination
98
How do we confirm that there is gas present in Fournier's Gangrene?
X-ray
| USS
99
How do we treat Fournier's Gangrene?
Antibiotics
| Debridement
100
In what individuals is there an increased mortality in Fournier's Gangrene?
Diabetics
| Alcoholics
101
What is Emphysema Pyelonephritis?
Acute necrotising fasciitis of:
- Parenchyma
- Perianal area
102
What causes Emphysema Pyelonephritis?
Gas-forming uropathogens:
| - Usually E. coli
103
What patients usually get Emphysema Pyelonephritis?
Diabetics with ureteric obstructions
104
What is often required in the treatment of Emphysema Pyelonephritis?
Nephrectomy
105
What are the two most common causes of a perinephric abscess?
Rupture of acute cortical abscess into perinephric space
OR
Haematogenous spread
106
True or false; almost all patients with a perinephric abscess present pyrexic?
False:
| - 33% are apyrexial
107
True or false; 50% of patients with a perinephric abscess have a flank mass on examination?
True
108
On serum and urinary investigations, what would you expect?
High WCC
High serum creatinine
Pyuria
109
What imaging modality is most useful in a suspected perinephric abscess?
CT
110
How do we treat a perinephric abscess?
Antibiotics
| Percutaneous/Surgical drainage
111
On investigation there is a renal haematoma that is entirely subcapsular. There is no expansion and no parenchymal laceration. What class of renal trauma would this fall under?
1
112
A kidney has a laceration >1cm in depth, but there is no collecting system rupture or extravasation. What class of renal trauma would this fall under?
3
113
There is a laceration through the kidney's cortex, medulla and collecting system. There is a contained haemorrhage. What class of renal trauma would this fall under?
4
114
On investigation, the right kidney is shattered. There is evidence of hilum avulsion and a devascularised kidney. What class of renal trauma would this fall under?
5
115
Which of the following is not an indication for imaging:
- Frank haematuria in an adult
- Frank/Occult haematuria in a child
- Occult haematuria and shock (Systolic BP 5hrs
- Penetrating injury with haematuria
Acute urinary retention >5hrs
116
How do we investigate haematuria?
CT urogram
117
After haematuria, what treatment do most patients receive?
Non-operative
118
When would surgery be indicated as a treatment for haematuria?
```
Persistent renal bleeding
Expanding perineal haematoma
Pulsatile perirenal haematoma
Urinary extravasation
Non-viable tissue
Incomplete staging
```
119
What is a bladder injury most often due to?
Pelvic fracture
120
What two symptoms suggest a bladder injury?
Suprapubic/Abdominal pain
| Inability to void
121
Which of the following is not a sign of a bladder injury:
- Suprapubic tenderness
- Overflow incontinence
- Lower abdominal bruising
- Guarding/Rigidity
- Reduced bowel sounds
Overflow incontinence
122
If blood was present as the external meatus or the catheter doesn't pass easily?
Retrograde urethrogram
123
What is the main imaging modality for investigating a bladder injury>
CT cystography
124
Flame-shaped collection of contrast in the pelvis suggests what injury?
Extraperitoneal injury
125
How do we treat a traumatic bladder injury?
Large bore catheter
Antibiotics
Repeat cystogram in 14 days
126
A pubic rami fracture will damage what aspect of the urethra?
Posterior
127
Where is the posterior urethra fixed?
Urogenital diaphragm and puboprostatic ligaments
128
What is the most vulnerable part of the urethra to trauma?
Bulbomembranous junction
129
Which of the following is not an examination feature of a urethral injury:
- Blood at meatus
- Inability to urinate (Palpably full bladder)
- High riding prostate
- Suprapubic pain
- Butterfly perineal haematoma
Suprapubic pain
130
How do we investigate urethral trauma?
Retrograde urethrogram
131
How can a urethral injury be treated?
Suprapubic catheter
| Delayed reconstruction after >=3 months
132
What typically causes a penile fracture and what kind of injury is it?
Intercourse:
| - Buckling injury -> Penis slips out and strikes pubis
133
Which of the following is not a symptom of a penile fracture:
- Cracking/Poping
- Pain
- Rapid detumescence
- Discolouration
- Swelling
- Suprapubic bruising
- Frank haematuria (20%)
Suprapubic bruising
134
On USS investigation of a testicular injury, what must be assessed?
Integrity
| Vascularity
135
How is a penile fracture treated?
Prompt exploration and repair
Circumcision:
- Deglove penis
-> Expose all 3 compartments
136
Early repair of a testicular injury can help improve what outcomes?
Improves testicular salvage
Reduces convalescence
Better preserves fertility an hormonal function
137
What is the approximate weight of the prostate?
20g
138
What is the inferior portion of the prostate called and what is it continuous with?
Apex
| Continuous with striated sphincter
139
What is the superior portion of the prostate called and what is it continuous with?
Base
| Continuous with bladder neck
140
What covers the prostatic urethra?
Transitional epithelium
141
What is the verumontanum?
Landmark near the entrance of the seminal vesicles
142
Where is the verumonatum?
Just distal to the urethral angulation
143
What forms the ejaculatory ducts?
Union of seminal vesicles and each vas deferens
144
Where do the ejaculatory ducts?
Drain to each side of the prostatic urethra
145
Where is the transitional zone of the prostate?
Surrounding the prostatic urethra
146
Where is the transitional zone of the prostate in relation to the verumonatum?
Proximal
147
How much of the prostate does the transitional zone make up?
10%
148
What percentage of prostate cancers arise in the transitional zone?
20%
149
What shape is the central zone of the prostate and what does it surround?
Cone-shaped
| Surrounding ejaculatory ducts
150
How much of the prostate does the central zone make up?
20%
151
What percentage of prostate cancers arise in the central zone?
1-5%
152
Where does the peripheral zone of the prostate lie?
Posterolaterally
153
How much of the prostate does the peripheral zone make up?
85-90%
154
What percentage of prostate cancers arise in the peripheral zone? What type of cancers most commonly arise here?
70% of prostate adenocarcinomas
155
What is the peak age for prostate cancers?
70-74 years old
156
What regions have the highest incidence rates of prostate cancer?
Scandinavia
| North America
157
What region has the lowest incidence rate of prostate cancer?
Asia
158
What race is has the highest incidence of prostate cancer?
Black men
159
If a patient has one first degree relative who had prostate cancer, what is the risk increase?
2 times
160
If a patient has one two degree relatives who had prostate cancer, what is the risk increase?
4 times
161
Chromosomal mutations on what chromosomal arms can increase the risk of prostate cancer?
1q
8p
Xp
162
What gene mutations can increase the risk of prostate cancer?
BRCA2
163
Which of the following is not a typical presentation of prostate cancer:
- Mostly asymptomatic
- Suprapubic pain
- Haematuria/Haematospermia
- Bone pain
- Weight loss
Suprapubic pain
164
On PR exam of a prostate cancer, how will it feel?
Asymmetiric
Nodule
Fixed craggy mass
165
What is PSA?
A glycoprotein (Kallikren-like Serine Protease) enzyme
166
Where is PSA produced?
Secretory epithelium in prostate
167
What is PSA involved in?
Liquefaction of semen
168
In a normal individual, what levels should seminal and serum PSA be?
Seminal -> High
| Serum -> Low
169
What is the sensitivity and specificity of PSA for prostate cancer?
Sensitivity -> 90%
| Specificity -> 40%
170
Which of the following does not routinely raise PSA:
- BPH
- Prostatitis
- Retention
- Catheterisation
- PR exam
PR exam
171
What is the main indication for testing PSA?
Symptomatic patients
172
WHat are indications for carrying out a trans-renal USS-guided prostate biopsy?
Men with abnormal:
- DRE
- PSA
Previous biopsies showing:
- rostatic Intraepithelial Neoplasia (PIN)
- Atypical Small Acinar Proliferation (ASAP)
Rising PSA
173
How many biopsies are taken in a trans-renal USS-guided prostate biopsy?
5 from ech lobe (10 in total)
174
What are some complications of a trans-renal USS-guided prostate biopsy?
Sepsis (0.5%)
Bleeding (0.5%)
Vasovagal fainting
Haematosperma/Haematuria for 2-3 weeks
175
95% of prostate cancers are of this histological type?
Adenocarcinoma
176
Put the following sites of prostatic cancer growth in order of which is invaded first to fifth:
- Bladder base
- Local extension
- Seminal vesicle
- Perineural invasion along ANS nerves
- Urethra
1. Local extension
2. Urethra
3. Bladder base
4. Seminal vesicle
5. Perineural invasion along ANS nerves
177
What are the two most common sites for prostate cancer metastasize to?
Pelvic lymph nodes
| Bones (sclerotic lesions)
178
What is Gleason's scoring?
Score based on microscopic architectual appearance of glands
179
What is the initial Gleason score?
Less of basement membrane
180
As the Gleason score increases, what happens microscopically?
Loss of structure
| Replaced by disorganised cell growth
181
How is the Gleason score calculated?
Two most abundant cell patterns assessed and added together:
| - Score between 2 + 10
182
A T3 prostate cancer extends through what?
Prostate capsule
183
An organ-confined prostate tumour will have what TMN stage?
T1-2, N0, M0
184
A locally advanced prostate tumour will have what TMN stage?
T3-4, N0, Mo
185
A metastatic prostate tumour will have what TMN stage?
T1-4, N0-1, M1
186
When would an organ-confined prostate cancer be treated?
If it worsens
187
What radical surgery can cure an organ-confined prostate cancer?
Prostatectomy
188
What are some side effects of prostatectomies?
Erectile dysfunction
Incontinence
Bladder neck stenosis
189
What methods of radical radiotherapy can treat organ-confined prostate cancer?
External Beam Radiation Therapy (EBRT)
| Brachytherapy
190
What are some side effects of radical radiotherapy?
Irritative lower urinary tract symptoms
| Haematuria
191
What are the two mainstay treatments of locally advanced prostate cancer?
Radiotherapy and hormonal therapy
192
When would watchful waiting be appropriate in a locally advanced prostate cancer?
If:
- Asymptomatic
- Well differentiated tumour
- Life expectancy
193
How can we carry out androgen deprivation in order to treat metastatic prostate cancer?
```
Hormonal therapy:
- LNRH analogues
- Anti-androgens
Bilateral subcapsular orchidectomy
MAximum androgen blockade
```
194
What non-steroidal oestrogen acts as an endocrine disruptor in metastatic prostate cancer?
Diethylstilbesterol
195
How do LNRH agonists work?
Down-regulate LNRH receptors which causes suppression of LH/FSH/Testosterone secretion
196
What happens initially on LNRH agonist therapy?
LNRH analogues initially increase LH/FSH secretion which increases testosterone production
197
If a patient on LNRH agonist therapy has a flare up, what can 20% of patients suffer?
Catastrophic spinal cord compression
198
How can we prevent an initial flare up of LNRH agonist therapy?
Anti-androgen cover:
- 1 week before 1st dose
- 2 weeks after 1st dose
199
What are two examples of LNRH agonists?
Goserelin
| Triptorelin
200
Which of the following is not a side effect of LNRH agonists:
- Reduced libido
- Hot flushes
- Weight gain
- Gynaecomastia
- Anaemia
- Galactorrhoea
- Osteoporosis
Galactorrhoea
201
How do anti-androgens work?
Compete with testosterone and DHT:
- On prostate cell nucleus
- Promote apoptosis
- Reduced CaP growth
202
Give an example of a steroidal anti-androgen?
Cyproterone acetate
203
What are some side effects of steroidal anti-androgens?
Reduced libido
Gynaecomastia
CVS toxicity
Hepatotoxicity
204
Give some examples of non-steroidal anti-androgens?
Bicalutamide
Nilutamide
Flutamide
205
What is the most common type of uroepithelial tumour?
Transitional cell
206
What is the second most common type of uroepithelial tumour?
Squamous
207
What is the most common type of transitional cell uroepithelial tumour?
Papillary (80%)
208
True or false; 50% of non-papillary type uroepithelial tumours are malignant?
False - All are malignant
209
How can transitional cell tumours appear?
```
Single lesion:
- Small and papillary
- Bulky and sessile
Multiple discrete lesions
Diffuse, confluent lesions
```
210
What do transitional cell tumours tend to be?
Multicentric
| Bilateral
211
What is the M:F ratio of urinary bladder cancer?
4:1
212
What is the gold standard investigation for urinary bladder cancer and what sign appears?
CT urogram:
| - Halo sign
213
Put the following types of urinary bladder cancer in order of likelihood to calcify:
- Squamous
- Urachal
- Transitional
1. Transitional
2. Squamous
3. Urachal
