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Flashcards in Deck 3 - GU Deck (42)
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1

Q. Describe the epithelium of the prostate

A. Secretory = pseudostratified, columnar cells and basal cells
B. Epithelium is highly variable with areas of low cuboidal or squamous cells – with transitional epithelium in the distal regions of the longer ducts

2

Q. Which zone of the prostate do most prostate cancers occur in? In which zone do the most aggressive cancers occur?

A. 70-80% of prostate cancers occur in the peripheral zone
B. 2.5% of prostate cancers occur in the central zone surrounding the ejaculatory ducts, these tend to be more aggressive and invade the seminal vesicles
C. (10-20% occur in the TZ)

3

Q. In which region of the prostate does benign prostatic enlargement occur?

A. Transitional zone

4

Q. What is transcoelomic metastatic spread?

A. Spread of a malignant neoplasm across a body cavity; such as pleural/pericardial/peritoneal

5

Q. Metastatic spread of a malignant neoplasm can result in a range of symptoms. Describe two non-specific and two specific symptoms related to this condition, and two symptoms of paraneoplastic syndromes

A. Non-specific: weight loss, anorexia, fever, anaemia (normocytic)
B. Specific: hypercalcaemia (anorexia, thirst, confusion, collapse), marrow replacement (purpura, anaemia, immune suppression)
C. Paraneoplastic syndromes:
a. Endocrine: crushing’s disease (ectopic ACTH – secretion by tumour)
b. Neuro: dementia, cerebellar degeneration, peripheral neuropathy
c. Dermatological: acanthosis nigricans (hyperpigmentation found in body folds)
d. Haematological: erythrocytosis
D. Local: e.g. haematuria in bladder cancer

6

Q. Name two biomarkers for prostate cancer

A. Serum: prostate-specific antigen (PSA), prostate-specific membrane antigen (PSMA)
B. Urine: PCA3

7

Q. Which conditions may elevate serum PSA levels?

A. BPE/H, urinary tract infection, prostatitis

8

Q. Name two ways to diagnose/investigate suspected prostate cancer

A. LUTS, PSA, transrectal ultrasound (TRUSS), prostate biopsy, prostate cancer grading (Gleason grading)

9

Q. Describe the investigation of choice to stage prostate cancer

A. T stage: palpable tumour on DRE
B. N stage: MRI/CT
C. M stage: bone scan
D. Partin’s nomograms predict pathological T and N stage by combining clinical T stage, PSA and biopsy Gleason score

10

Q. Describe three treatments for localised prostate cancer

A. Surgery: radical prostatectomy, open laparoscopic, robotic
B. Radio: external beam, brachytherapy
C. Observation: watchful waiting, active monitoring/surveillance
D. Focal therapy: high intensity u/s, photodynamic therapy (TOOKAD)

11

Q. Give two arguments for and against prostate cancer screening (PSA)

A. For: early diagnosis of localised disease, early treatment of advanced disease, commonest cancer in men, responsible for 10,000 deaths per annum, 4th most common cause of cancer death, 3% of men will die of prostate cancer
B. Against: uncertain natural history, overtreatment, morbidity of treatment, high rate of false positives – patient anxiety, risk of over diagnosis of insignificant disease, harm caused by investigation/treatment

12

Q. Describe two treatments for metastatic prostate cancer

A. Surgical castration (prolonged survival, reduced pain from bony metastases)
B. Surgical orchidectomy therapy (removal of testosterone producing part of testis)
C. Androgen deprivation therapy: GNrH analogues, LH antagonists (prevents release of LH from pituitary gland), peripheral androgen receptor antagonists

13

Q. What is an urinary tract infection? Which organisms are most common in primary care?

A. The inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria and pyuria
B. E.coli, coag neg staph spp, proteus sp, enterococci, klebsiella

14

Q. Which type of bacterial pili/fimbriae are associated with lower tract UTIs? Which are associated with upper UTIs?

A. Type 1 pili: associated with lower UTIs
B. Type P pili: associated with upper UTIs

15

Q. Why is an increase in UTI incidence associated with post menopause?

A. Pre-menopause vagina is heavily associate with lactobacilli, this mantains a low pH from the glycogen metabolism to lactate
B. Post-menopausal: pH rises, increased colonisation by colonic flora, reduction of vaginal mucus secretion, increased vaginal mucosal receptivity to UPEC

16

Q. Name two bacterial factors

A. Enzyme production: e.g. proteus spp. secretes of urease
B. Toxins: E.coli releases cytokines which are directly toxic

17

Q. Describe two host defence factors of the vagina

A. Antegrade flushing of the urine (reduced in – incomplete emptying, obstruction, reflux, pregnancy)
B. GAG layer
C. Low urine pH and high osmolarity
D. Commensal flora (may be changed by spermicides, oestrogen, pH and antibiotic use)
E. Urinary IgA

18

Q. What is pyuria?

A. Presence of leucocytes in the urine, associated with infection

19

Q. What occurs in asymptomatic bacteriuria?

A. High prevalence in over 70s, catheters are colonised within 7-32 days, high incidence in institutionalised elderly population

20

Q. What area of the urinary tract is included in a) upper b) lower

A. Lower tract: cystitis, prostatitis, epididymitis, urethritis
B. Pyelonephritis, urethritis

21

Q. Describe the classical clinical presentation of cystitis

A. F>M, Symptoms: dysuria, frequency, urgency +- SP pain, haematuria, cloudy urine
B. (in infants > incidence in males, symptoms harder to ascertain in non-verbal child)

22

Q. What investigations can be used to diagnose UTIS?

A. Multistix (nitrates, leucocytes, blood, pH, SG, protein, glucose, ketones
B. Mid-stream specimen of urine

23

Q. What is the standard treatment for uncomplicated UTI?

A. 3/7 trimethoprim or nitrofurantoin
B. Also: increase fluid intake, regular voiding, hygiene, avoidance of spermicides, void pre and post intercourse

24

1. Q. Name two features that may constitute a complicated UTI case

A. If patient is: male, pregnant, a child, recurrent or persistent infection, immunocompromised, nosocomial infection (hospital acquired), known structural/functional abnormality (includes catheter, nephrostomy, stent), SIRS/urosepsis, associated urinary tract disease e.g stones, fistula

25

1. Q. Describe the management of complicated UTI

A. Treat as simple but MSU mandated – longer course of Rx tailored to sensitivity
B. Investigate is recurrent/significant LUTS/haematuria: MSU, examination including DRE/PV, post-void bladder scan, USS scan of renal tract/pelvis
C. Possibly: XR KUB (kidney, ureters, bladder)/NCCT (non-contrast CT), CT if suggestive of stones, flexible cystoscopy
D. Also: increase fluid intake, regular voiding, hygiene, avoidance of spermicides, void pre and post intercourse

26

Q. What constituents recurrent UTI?

A. > 2 episodes in 6 months, >3 episodes in 12 months
B. re-infection with same bacteria, bacterial persistence, unresolved infection

27

Q. Describe the NIH/NIDDK classification of prostatitis, describe the presentation of each

A. I: Acute bacterial prostatitis
a. Systemically unwell: fevers, rigors, significant voiding LUTS, pelvic pain
b. External findings: boggy exquisitely tender prostate

B. II: Chronic bacterial prostatitis
a. Symptoms > 3 months, recurrent UTIs, pelvic pain, voiding LUTS, uropathogens in urine +- blood

C. III: Chronic pelvic pain syndrome (CPPS): chronic abacterial prostatitis
i. IIIA: Inflammatory CPPS: WBC in EPS, post-prostatic massage urine, or semen
ii. IIIB: Non-inflammatory CPPS: no WBC in EPS, post-prostatic massage urine, or semen
Presents with: chronic pelvic pain +- LUTS, +- UTIs

D. IV: Asymptomatic inflammatory prostatitis (histological prostatitis)

28

Q. How should prostatitis be treated?

A. Type 1: refer to secondary care – IVABx: gent + CoAmox/Tazocin/Carbapenem and long course of 2-4 weeks Quinolone once well +- TRUSS-guided abscess drainage if < 1cm
Type 2: 4-6 weeks course Quinolone +- alpha blockers +- NSAID for 6wks-3mths
B. Complications: retention – severe sepsis may need HDU etc

29

Q. What occurs in Epididymo-orchitis? Describe the classical presentation

A. Inflammation of testicle and epididymis
B. Acute presentation usually unilateral: Short duration of pain, sudden onset, associated nausea, abdo pain, prev short-duration orchalgia, high riding/bell clapper testis
C. Rule out torsion!
D. STI (younger men), UTI (+35 yrs), take a sexual history, elderly predominantly catheter related

30

Describe the management of Epididymo-orchitis

A. Investigations: 1st void urine, CT/NG PCR +- urethral swab, MSU, +- USS to R/O abscess
B. Tx: refer to GUM if ?STI
C. Abx: Quinolone if >35 or not suspect STI
D. Doxycycline +- stat azithromycin if STi more likely (contact tracing!)
E. Supportive underwear, NSAIDS if required