Urology Flashcards by Himani Jayasinghe

What are the risk factors for prostate cancer?

Increasing age
FH
Black ethnicity
Anabolic steroids

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Where in the prostate do most prostate cancers occur in?

Peripheral zone

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Where does prostate cancer most commonly metastasise to?

Lymph nodes

Bone

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What are the symptoms of prostate cancer?

Asymptomatic
Back pain
Nocturia
Hesitancy
Poor stream
Terminal dribbling 
Haematuria
Erectile dysfunction
Weight loss

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Which cells produce prostate-specific antigen (PSA)?

Epithelial cells

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What can cause a raised PSA?

Prostate cancer
BPH
Prostatitis 
UTIs
Exercise
Recent ejaculation

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How would a benign prostate feel on DRE?

Smooth, soft and central sulcus

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How would prostatitis feel on DRE?

Enlarged, tender, warm

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How would a cancerous prostate feel on DRE?

Firm, craggy and loss of central sulcus

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What is the referral wait time if you suspect prostate cancer?

2 weeks

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What investigations can you do to confirm diagnosis of prostate cancer?

Multiparametric MRI
Prostate biopsy
Isotope bone scan

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What are the risks of a prostate biopsy?

Pain
Bleeding 
Infection
Urinary retention
Erectile dysfunction

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Which system is used to grade prostate biopsies?

Gleason - the greater the score, the poorly differentiated the tumour is and worse the prognosis is

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Which system is used to stage prostate cancer?

TNM staging

tumour, lymph nodes and mets

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How would you manage localized prostate cancer?

Radical prostatectomy
Radical radiotherapy
Hormone therapy - androgen receptor blockers
Watchful waiting

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How would you manage metastatic prostate cancer?

Androgen deprivation: GNrH analogues + LH antagonists

Radiotherapy

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How would you manage castration resistant prostate cancer?

2nd line hormone therapy e.g. enzalutamide
Chemo e.g. docetaxel
Bisphosphonates

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What is the key complication of radiotherapy?

Proctitis = inflammation in rectum

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What are the key complications of radical prostatectomy?

Erectile dysfunction

Urinary incontinence

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Which cells does testicular cancer arise from?

Germ cells

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Name the types of testicular cancer

Seminoma
Non-seminoma
Mixed

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What are the risk factors of testicular cancer?

Undescended testis
Previous testicular tumour  
FH
Infertility
Infant hernia

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What are the signs of testicular cancer?

Painless lump on testicle

Gynaecomastia

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Which type of tumour causes gynaecomastia?

Leydig cell

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How does a testicular cancer lump appear?

``` Non tender Arise from testicle Hard Irregular Not fluctuant No transillumination ```

What scans would you do to diagnose testicular cancer?

Scrotal USS | CT

What are the tumour markers for testicular cancer?

Alpha-fetoprotein Beta-hCG Lactate dehydrogenase (LDH)

How would you manage testicular cancer?

Radical orchidectomy - testis and spermatic cord are removed Radiotherapy Chemo Sperm banking - treatment can cause infertility

How does an epididymal cyst appear?

Cyst on epididymis (top of testicle) which contains clear or milky fluid

A hydrocele is a collection of fluid where?

Tunica vaginalis

What are the clinical features of a hydrocele?

``` Testicle is palpable within hydrocele Soft Irreducible No bowel sounds (separate from hernia) Transilluminated ```

What is hydrocele secondary to?

Testicular cancer Testicular torsion Epididymo-orchitis Trauma

A varicocele is dilated veins of what structure?

Pampiniform plexus The pampiniform plexus is a venous plexus, which is found in the spermatic cord and drains the testes. The pampiniform plexus drains into the testicular vein. It plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery. The testicles need to be at an optimum temperature for producing sperm.

What are the complications of a varicocele?

Testicular atrophy | Impaired fertility

Varicoceles are the result of increased resistance in the testicular vein. Where do the right and left testicular veins drain into?

Right testicular vein ---> inferior vena cava Left testicular vein ---> Left renal vein

Which side do varicoceles most commonly occur in and why?

Left, due to increased resistance in left testicular vein

A left-sided varicocele can indicate an obstruction of the left testicular vein caused by what?

Renal cell carcinoma

What are the symptoms of a varicocele?

Dull pain | Infertility

What are the signs of a varicocele?

Scrotal mass that feels like a bag of worms More prominent on standing Disappears when lying down

Which conditions can cause erectile dysfunction?

``` MS Hypogonadism Hyperthyroidism Cord lesions Pelvic surgery ```

Which drugs can cause erectile dysfunction?

Beta blockers Diuretics Anti-psychotics Anti-depressants

Which hormones are needed to produce an erection?

Testosterone | Nitric oxide

Which hormone returns penis to flaccid state?

Phosphodiesterase

What are the signs of erectile dysfunction?

Fibrous plaque and deviated penis - Peyronies disease Prostatic enlargement Small testes - hypogonadism

Which investigations can you do to determine cause of erectile dysfunction?

Morning testosterone - if this is low, measure prolactin, FSH + LH Nocturnal penile tumescence Arteriography

How would you conservatively manage erectile dysfunction?

Counselling Stop smoking and reduce alcohol Penile ring

Which medications can you give for erectile dysfunction?

Oral phosphodiesterase inhibitors e.g. sildenafil Intracavernous injections Prostheses

What is a prolonged erection called?

Priapism

What are the symptoms of chlamydia in a male?

Dysuria | Urethral discharge

What are the complications of chlamydia in a male?

Epididymo-orchitis | Reactive arthritis

Which investigation is done in males for chlamydia?

First void urine sample

How would you treat chlamydia?

Doxycycline for 7 days

What are the symptoms of gonorrhoea in a male?

Urethral discharge Dysuria Tenesmus Proctitis

What are the complications of gonorrhoea in a male?

Prostatitis Sepsis Reactive arthritis Infective endocarditis

Which investigation is done in males for gonorrhoea?

Male urethra sample

What kind of bacteria is gonorrhoea?

Gram -ve diplococci

How would you treat gonorrhoea?

1g ceftriaxone IM

What are the symptoms of primary syphilis?

Non tender ulcers on genitals

What are the symptoms of secondary syphilis?

``` Skin rash Mucous membrane lesions Lymphadenopathy Fever Headache Fatigue Weight loss ```

What are the symptoms of tertiary syphilis?

Focal neurological deficits Seizures Skin granulomata

Which investigation is done in males for syphilis?

Blood test

How would you treat syphilis?

Parenteral benzylpenicillin

What are the symptoms of genital herpes?

``` Flu like prodrome Papule lesions burst into ulcers around genitals Urethral discharge Dysuria Urinary retention ```

How would you treat genital herpes?

Analgesia Topical lidocaine Antivirals

What are the risk factors for UTI?

Catheter Sexual intercourse Pregnancy

What are the symptoms of UTI?

``` Dysuria Suprapubic pain Frequency Urgency Incontinence Haematuria Cloudy urina Confusion - elderly ```

How would a UTI appear on a urine dipstick?

Nitrites Leukocytes Red blood cells NICE guidelines: UTI is likely with presence of nitrites OR leukocytes, AND red blood cells

A midstream urine (MSU) sample sent for microscopy, culture and sensitivity testing will determine the infective organism and the antibiotics that will be effective in treatment. Which patients would you not do a MSU in?

Prgenant women Patients with recurrent UTIs Atypical symptoms Symptoms do not improve after antibiotics

Which organism most commonly causes UTI?

E. coli (gram -ve, rod shaped)

Name the two first line antibiotics for UTI

Trimethoprim | Nitrofurantoin

When can you not give nitrofurantoin?

In patients with eGFR <45

How long is an antibiotic course for men with UTI?

7 days

What are the causes of upper urinary tract obstruction?

Kidney stones Tumour Ureter stricture Ureterocele

What are the causes of lower urinary tract obstruction?

BPH Prostate cancer Urethral strictures Neurogenic bladder

Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. What are the symptoms of this?

``` Hesitancy Weak flow Urgency Frequency Intermittency Straining Terminal dribbling Nocturia ```

What is used to score severity of lower urinary tract symptoms?

International prostate symptom score (IPSS)

How would you investigate BPH?

PSA DRE Urine dipstick Urinary frequency volume chart

Which zone of the prostate does BPH affect?

Inner transitional zone

Which drugs would you give to treat BPH?

Alpha blockers e.g. tamsulosin | 5-alpha reductase inhibitor e.g. finasteride

Which surgery can you do for BPH?

Transurethral resection of the prostate (TURP) Transurethral electrovaporisation of the prostate (TEVAP/TUVP) Prostatectomy

What is the main side effect of alpha blockers?

Postural hypotension

What is the main side effect of finasteride and why?

Sexual dysfunction due to reduced testosterone