Flashcards in Clinical (Week 3) Deck (213):
What are the types of urethral incontinence?
What are the types of extraurethral incontinence?
A huge palpable bladder, often wet at night and renal impairment suggest what kind of incontinence?
Frequency, urgency provoked by standing up/coughing/laughing and enuresis suggest what kind of incontinece?
What causes urge incontinence?
- Contracting during inhibition of voiding
How can we diagnose urge incontinence?
How can pelvic surgery or fractures result in urge incontinence?
1. PNS nerves damaged
2. Residual urine
4. Bladder irritation
What causes stress incontinence?
Increased intra-abdominal pressure without detrusor contraction
What causes stress incontinence?
Damage to the following during childbirth:
- Pelvic floor
- Urethral function
How does the bladder appear on abdominal exam in a patient with urinary retention?
Arises in pelvis
Cannot 'get below' it
Dull to percussion
How do we treat overflow incontinence?
Assess renal function
Treat obstruction -> Catheterise
Rehabilitate bladder (Teach self-catheterisation)
What dietary advice in urge incontinence?
What medical therapy can be used to treat urge incontinence?
What are some alternative treatments to treating urge incontinence? (Apart from medication)
What lifestyle advice is given to assist in the treatment of stress incontinence?
What is the first line treatment for stress incontinence?
What pharmacology treatment is available for stress incontinence?
Duloxetine (SSRI-5HT inhibitor)
Norepinephrin reuptake inhibitor
What surgery is available for stress incontinence?
Minimally invasive 'tape' procedures
What can cause a vesico-vaginal fistula?
Prolonged obstructed labour
How do we define haematuria?
Presence of >=5 RBCs per high-field power
In 3/3 consecutive centrifuged samples
>=1 week apart
A patient with microscopic haematuria due to a lower urinary tract pathology are likely to have what symptoms?
Symptomatic, microscopic haematuria from an upper urinary tract pathology usually presents with what symptom?
If there is profound haematuria what might you suspect?
How much blood much be present in 100ml of urine to be seen?
What are some non-pathological causes of red urine?
Food (Beetroot, blackberries, rhubarb)
How can myoglobin end up in the urine?
Which of the following drugs does not cause red urine:
What toxins can cause red urine?
What can cause brown urine?
- Liver dysfunction
Patients over what age are at an increased risk of malignancy if they present with microscopic haematuria?
What past medical history might increase the risk of malignancy in a patient presenting with microscopic haematuria?
Why is it important to drain a distended bladder slowly?
To prevent decompression haematuria
How do renal stones cause haematuria?
What causes pneumaturia?
Connection between bowel and bladder
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
If blood is present in 1st voiding, where is the bleeding likely to be coming from?
Ingestion of Aristolochia increases the risk of what in what country?
Transitional cell cancer in China
Schistosomiasis is common in what country and what does it lead to an increased risk of?
Squamous cell bladder cancer
When taking a history in a patient with haematuria, what cancer is a patient's family history is very relevant?
What can phenacetin abuse cause?
Renal epithelial cancer
What features of urinalysis may suggest a UTI?
What is the definitive diagnostic method for UTI?
Urine culture (Send in Boricon container, must be received within 24 hours)
What is the gold standard investigation into haematuria (and renal problems)?
CT urogram (with IV contrast)
What is the first line investigation into haematuria in the case of trauma?
How can we best view the bladder?
What is acute urinary retention?
Anuria with increasing pain
What can precipitate BPH?
If a patient has painful retention with
Alpha blocker before a trial without catheter:
Which of the following is not associated with post-obstructive diuresis after chronic obstruction:
What causes post-obstructive diuresis?
Solute diuresis; Retained:
Defect in kidney's concentrating ability
When should we suspect post-obstructive diuresis?
If urine output is >200ml/hr
How do we treat severe post-obstructive diuresis?
How long does a mild post-obstructive diuresis take to resolve on its own?
What mediates the pain felt in ureteric colic?
How do we treat ureteric colic due to calculi?
NSAID +/- opiate
Tamsulosin for small stones expected to pass
What is the chance of a renal calculi passing if its diameter is
When would we intervene in assisting the passage of a renal stone?
If not resolved in a month
Which of the following is not an indication for emergency treatment of a renal stone:
- Pain unrelieved
- Persistent nausea/vomiting
- Reduced urine output
- High grade obstruction
Reduced urine output
What is the first line emergency treatment for a renal calculus?
If there is no infection, how could we treat a renal calculus?
Stone fragmentation or removal
When would we carry out a percutaneous nephrostomy in the treatment of a renal calculus?
If infected hydronephrosis
How do we induce clot retention in frank haematuria?
Use a 3-way irrigating haematuria catheter
What is the first line investigation for frank haematuria?
What is the second line investigation for frank haematuria?
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
What can obliterate landmarks in a scrotal/testicular examination?
Acute hydrocoele and oedema
What investigation can be useful for scrotum pathology?
How can we resolve spermatic cord torsion?
2 or 3 point fixation with fine, non-absorbable sutures or removal of the necrotic testis
What is the most common anatomical precipitant of spermatic cord torsion?
- Testis is inadequately affixed to the scrotum
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
What are the common presenting symptoms of epididymitis?
What can predispose to epididymitis?
Which of the following is not present on investigation of a patient with epididymitis:
- Present cremasteric reflex
- Elevated testis
On doppler USS of a patient with epididymitis, what would you expect to see?
Increased blood flow
What is the appropriate management of epididymitis?
- For 2 weeks
If we take a urine sample in a patient with epididymitis, what would we ask microbiology to do?
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
What can precipitate paraphimosis?
What is paraphimosis?
Painful swelling of foreskin distal to the phimatic ring
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
Circumcision is often carried out after it resolves to prevent future episodes
What is priapism?
Prolonged erection (>4hrs)
True of false; priapism is most often associated with sexual arousal?
Which of the following is not a recognised cause of priapism:
- Intracorporeal papaverine for ED (vasodilator)
- Sickle cell anaemia
- Neurological conditions
What causes ischaemic priapism and what is the pathophysiology?
Veno-occlusion or low-flow;
- Vascular stasis
-> Reduced venous outflow
How do the corpora cavernosum appear in ischaemic priapism?
Rigid and tender
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
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
In ischaemic priapism, how does aspirated blood from the corpus cavernosum appear?
Low oxygen/High carbon dioxide
In non-ischaemic priapism, how does aspirated blood from the corpus cavernosum appear?
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. Normal/High flow
What is the initial management of ischaemic priapism?
Aspiration +/- saline irrigation
What medical treatment can be given in ischaemic priapism?
- 100-200μg every 5-10mins
- Max 1000μg
When would surgical shunting be carried out in ischaemic priapism?
If in 2-3 days there is no response to intracavernosal therapy
If response is very delayed in ischaemic priapism, what might have to occur?
What is Fournier's Gangrene and what does it involved?
Necrotising fasciitis of male genitalia:
Which of the following is not a risk factor for Fournier's Gangrene:
- Local trauma
- Periurethral extravasation
- Perianal infection
How does the scrotum appear in Fournier's Gangrene?
Crepitus on examination
How do we confirm that there is gas present in Fournier's Gangrene?
How do we treat Fournier's Gangrene?
In what individuals is there an increased mortality in Fournier's Gangrene?
What is Emphysema Pyelonephritis?
Acute necrotising fasciitis of:
- Perianal area
What causes Emphysema Pyelonephritis?
- Usually E. coli
What patients usually get Emphysema Pyelonephritis?
Diabetics with ureteric obstructions
What is often required in the treatment of Emphysema Pyelonephritis?
What are the two most common causes of a perinephric abscess?
Rupture of acute cortical abscess into perinephric space
True or false; almost all patients with a perinephric abscess present pyrexic?
- 33% are apyrexial
True or false; 50% of patients with a perinephric abscess have a flank mass on examination?
On serum and urinary investigations, what would you expect?
High serum creatinine
What imaging modality is most useful in a suspected perinephric abscess?
How do we treat a perinephric abscess?
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?
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?
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?
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?
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
How do we investigate haematuria?
After haematuria, what treatment do most patients receive?
When would surgery be indicated as a treatment for haematuria?
Persistent renal bleeding
Expanding perineal haematoma
Pulsatile perirenal haematoma
What is a bladder injury most often due to?
What two symptoms suggest a bladder injury?
Inability to void
Which of the following is not a sign of a bladder injury:
- Suprapubic tenderness
- Overflow incontinence
- Lower abdominal bruising
- Reduced bowel sounds
If blood was present as the external meatus or the catheter doesn't pass easily?
What is the main imaging modality for investigating a bladder injury>
Flame-shaped collection of contrast in the pelvis suggests what injury?
How do we treat a traumatic bladder injury?
Large bore catheter
Repeat cystogram in 14 days
A pubic rami fracture will damage what aspect of the urethra?
Where is the posterior urethra fixed?
Urogenital diaphragm and puboprostatic ligaments
What is the most vulnerable part of the urethra to trauma?
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
How do we investigate urethral trauma?
How can a urethral injury be treated?
Delayed reconstruction after >=3 months
What typically causes a penile fracture and what kind of injury is it?
- Buckling injury -> Penis slips out and strikes pubis
Which of the following is not a symptom of a penile fracture:
- Rapid detumescence
- Suprapubic bruising
- Frank haematuria (20%)
On USS investigation of a testicular injury, what must be assessed?
How is a penile fracture treated?
Prompt exploration and repair
- Deglove penis
-> Expose all 3 compartments
Early repair of a testicular injury can help improve what outcomes?
Improves testicular salvage
Better preserves fertility an hormonal function
What is the approximate weight of the prostate?
What is the inferior portion of the prostate called and what is it continuous with?
Continuous with striated sphincter
What is the superior portion of the prostate called and what is it continuous with?
Continuous with bladder neck
What covers the prostatic urethra?
What is the verumontanum?
Landmark near the entrance of the seminal vesicles
Where is the verumonatum?
Just distal to the urethral angulation
What forms the ejaculatory ducts?
Union of seminal vesicles and each vas deferens
Where do the ejaculatory ducts?
Drain to each side of the prostatic urethra
Where is the transitional zone of the prostate?
Surrounding the prostatic urethra
Where is the transitional zone of the prostate in relation to the verumonatum?
How much of the prostate does the transitional zone make up?
What percentage of prostate cancers arise in the transitional zone?
What shape is the central zone of the prostate and what does it surround?
Surrounding ejaculatory ducts
How much of the prostate does the central zone make up?
What percentage of prostate cancers arise in the central zone?
Where does the peripheral zone of the prostate lie?
How much of the prostate does the peripheral zone make up?
What percentage of prostate cancers arise in the peripheral zone? What type of cancers most commonly arise here?
70% of prostate adenocarcinomas
What is the peak age for prostate cancers?
70-74 years old
What regions have the highest incidence rates of prostate cancer?
What region has the lowest incidence rate of prostate cancer?
What race is has the highest incidence of prostate cancer?
If a patient has one first degree relative who had prostate cancer, what is the risk increase?
If a patient has one two degree relatives who had prostate cancer, what is the risk increase?
Chromosomal mutations on what chromosomal arms can increase the risk of prostate cancer?
What gene mutations can increase the risk of prostate cancer?
Which of the following is not a typical presentation of prostate cancer:
- Mostly asymptomatic
- Suprapubic pain
- Bone pain
- Weight loss
On PR exam of a prostate cancer, how will it feel?
Fixed craggy mass
What is PSA?
A glycoprotein (Kallikren-like Serine Protease) enzyme
Where is PSA produced?
Secretory epithelium in prostate
What is PSA involved in?
Liquefaction of semen
In a normal individual, what levels should seminal and serum PSA be?
Seminal -> High
Serum -> Low
What is the sensitivity and specificity of PSA for prostate cancer?
Sensitivity -> 90%
Specificity -> 40%
Which of the following does not routinely raise PSA:
- PR exam
What is the main indication for testing PSA?
WHat are indications for carrying out a trans-renal USS-guided prostate biopsy?
Men with abnormal:
Previous biopsies showing:
- rostatic Intraepithelial Neoplasia (PIN)
- Atypical Small Acinar Proliferation (ASAP)
How many biopsies are taken in a trans-renal USS-guided prostate biopsy?
5 from ech lobe (10 in total)
What are some complications of a trans-renal USS-guided prostate biopsy?
Haematosperma/Haematuria for 2-3 weeks
95% of prostate cancers are of this histological type?
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
1. Local extension
3. Bladder base
4. Seminal vesicle
5. Perineural invasion along ANS nerves
What are the two most common sites for prostate cancer metastasize to?
Pelvic lymph nodes
Bones (sclerotic lesions)
What is Gleason's scoring?
Score based on microscopic architectual appearance of glands
What is the initial Gleason score?
Less of basement membrane
As the Gleason score increases, what happens microscopically?
Loss of structure
Replaced by disorganised cell growth
How is the Gleason score calculated?
Two most abundant cell patterns assessed and added together:
- Score between 2 + 10
A T3 prostate cancer extends through what?
An organ-confined prostate tumour will have what TMN stage?
T1-2, N0, M0
A locally advanced prostate tumour will have what TMN stage?
T3-4, N0, Mo
A metastatic prostate tumour will have what TMN stage?
T1-4, N0-1, M1
When would an organ-confined prostate cancer be treated?
If it worsens
What radical surgery can cure an organ-confined prostate cancer?
What are some side effects of prostatectomies?
Bladder neck stenosis
What methods of radical radiotherapy can treat organ-confined prostate cancer?
External Beam Radiation Therapy (EBRT)
What are some side effects of radical radiotherapy?
Irritative lower urinary tract symptoms
What are the two mainstay treatments of locally advanced prostate cancer?
Radiotherapy and hormonal therapy
When would watchful waiting be appropriate in a locally advanced prostate cancer?
- Well differentiated tumour
- Life expectancy
How can we carry out androgen deprivation in order to treat metastatic prostate cancer?
- LNRH analogues
Bilateral subcapsular orchidectomy
MAximum androgen blockade
What non-steroidal oestrogen acts as an endocrine disruptor in metastatic prostate cancer?
How do LNRH agonists work?
Down-regulate LNRH receptors which causes suppression of LH/FSH/Testosterone secretion
What happens initially on LNRH agonist therapy?
LNRH analogues initially increase LH/FSH secretion which increases testosterone production
If a patient on LNRH agonist therapy has a flare up, what can 20% of patients suffer?
Catastrophic spinal cord compression
How can we prevent an initial flare up of LNRH agonist therapy?
- 1 week before 1st dose
- 2 weeks after 1st dose
What are two examples of LNRH agonists?
Which of the following is not a side effect of LNRH agonists:
- Reduced libido
- Hot flushes
- Weight gain
How do anti-androgens work?
Compete with testosterone and DHT:
- On prostate cell nucleus
- Promote apoptosis
- Reduced CaP growth
Give an example of a steroidal anti-androgen?
What are some side effects of steroidal anti-androgens?
Give some examples of non-steroidal anti-androgens?
What is the most common type of uroepithelial tumour?
What is the second most common type of uroepithelial tumour?
What is the most common type of transitional cell uroepithelial tumour?
True or false; 50% of non-papillary type uroepithelial tumours are malignant?
False - All are malignant
How can transitional cell tumours appear?
- Small and papillary
- Bulky and sessile
Multiple discrete lesions
Diffuse, confluent lesions
What do transitional cell tumours tend to be?
What is the M:F ratio of urinary bladder cancer?
What is the gold standard investigation for urinary bladder cancer and what sign appears?
- Halo sign