Clinical (Week 3) Flashcards Preview

Year 2 - Renal (DP) > Clinical (Week 3) > Flashcards

Flashcards in Clinical (Week 3) Deck (213):
1

What are the types of urethral incontinence?

Overflow
Urge
Stress
Mixed

2

What are the types of extraurethral incontinence?

Ectopic ureter
Fistula

3

A huge palpable bladder, often wet at night and renal impairment suggest what kind of incontinence?

Overflow

4

Frequency, urgency provoked by standing up/coughing/laughing and enuresis suggest what kind of incontinece?

Urge

5

What causes urge incontinence?

Detrusor overactivity:
- Contracting during inhibition of voiding

6

How can we diagnose urge incontinence?

Urodynamics

7

How can pelvic surgery or fractures result in urge incontinence?

1. PNS nerves damaged
2. Residual urine
3. Infection
4. Bladder irritation
5. Overstimulation

8

What causes stress incontinence?

Increased intra-abdominal pressure without detrusor contraction

9

What causes stress incontinence?

Damage to the following during childbirth:
- Pelvic floor
- Urethral function

10

How does the bladder appear on abdominal exam in a patient with urinary retention?

Painless
Palpable
Arises in pelvis
Cannot 'get below' it
Dull to percussion

11

How do we treat overflow incontinence?

Assess renal function
Treat obstruction -> Catheterise
Rehabilitate bladder (Teach self-catheterisation)

12

What dietary advice in urge incontinence?

Caffeine

13

What medical therapy can be used to treat urge incontinence?

Antimuscarinics:
- Oxybutynin
- Tolterodine
β3-adrenergics:
- Mirabegran

14

What are some alternative treatments to treating urge incontinence? (Apart from medication)

Botox (unlicensed)
Neuromodulation
Enterocytoplasty

15

What lifestyle advice is given to assist in the treatment of stress incontinence?

Weight loss
Stop smoking

16

What is the first line treatment for stress incontinence?

Physiotherapy

17

What pharmacology treatment is available for stress incontinence?

Duloxetine (SSRI-5HT inhibitor)
Norepinephrin reuptake inhibitor

18

What surgery is available for stress incontinence?

Colposuspension
Minimally invasive 'tape' procedures

19

What can cause a vesico-vaginal fistula?

Prolonged obstructed labour

20

How do we define haematuria?

Presence of >=5 RBCs per high-field power
In 3/3 consecutive centrifuged samples
>=1 week apart

21

A patient with microscopic haematuria due to a lower urinary tract pathology are likely to have what symptoms?

Hesitancy
Frequency
Urgency
Dysuria

22

Symptomatic, microscopic haematuria from an upper urinary tract pathology usually presents with what symptom?

Renal colic

23

If there is profound haematuria what might you suspect?

Malignancy

24

How much blood much be present in 100ml of urine to be seen?

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