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Yr 3 - Surgery > Urology > Flashcards

Urology Flashcards

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1
Q

What are renal tract calculi?

A

Renal tract calculi/renal stones/urolithiasis are hard masses that form in the urinary tract.

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2
Q

How common are renal tract calculi?

A

Very common - affect 2-3% of population

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3
Q

Pathophysiology of renal stones?

A

Over-saturation of urine with certain products.

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4
Q

What are the 4 renal stone types?

A
  1. Calcium oxalate & calcium phosphate
  2. Struvite
  3. Urate
  4. Cystine
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5
Q

What are struvite stones formed of?

A

Magnesium, ammonium and phosphate

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6
Q

What type of renal stone is the most common?

A

Calcium (80%)

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7
Q

What is the cause of calcium oxalate or calcium phosphate renal stones?

A

Dietary factors (high purine, high Na, low K), high doses of vitamin D, intestinal bypass surgery and several metabolic disorders can increase the concentration of calcium or oxalate in urine.

Calcium phosphate stones are more common in metabolic conditions, such as renal tubular acidosis.

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8
Q

Describe the appearance of calcium stones on an xray

A

Spiky, smooth, opaque

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9
Q

What is the most common metabolic abnormality?

A

Hypercalciuria

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10
Q

Give some risk factors for renal stones

A
  • Low fluid intake
  • Urinary tract malformations e.g. horseshoe kidney
  • UTIs
  • Cystinuria (congenital)
  • Hypercalciuria (most common metabolic abnormality)
  • Hyperoxaluria
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11
Q

Give some causes of hypercalciuria

A
  • High sodium intake
  • 1ary hyperparathyroidism
  • Hypervitaminosis D
  • Cushing’s syndrome
  • Sarcoidosis
  • Milk-alkali syndrome
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12
Q

What is the most common presenting feature of renal stones?

A

Ureteric colic pain (when stone has passed from kidney to ureters).

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13
Q

What causes ureteric colic pain in renal stones?

A

Caused by increased peristalsis around the site of obstruction

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14
Q

How does ureteric colic pain present?

A

Sudden onset, severe and radiates from ‘loin to groin’.

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15
Q

Where may the patient be tender on examination in renal stones?

A

Tender in the flank region

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16
Q

Haematuria, nausea & vomiting may also be present in renal stones. Is the haematuria visible or microscopic?

A

90% microscopic

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17
Q

There are 3 naturally narrow parts of the ureter. What are they?

A
  1. Pelvicoureteric junction (PUJ) → Where the renal pelvis becomes the ureter
  2. Crossing the pelvic brim → Iliac vessels cross the ureters
  3. Vesicoureteric junction (VUJ) → where the ureters enter the bladder
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18
Q

What must you rule out if a male >65 presents with abdominal/flank pain?

A

AAA

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19
Q

What is the triad of symptoms in an AAA?

A

Hypotension, syncope and back pain

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20
Q

Give some differentials for renal stone presentation

A
  • AAA
  • Gallstones
  • Ectopic pregnancy
  • Pyelonephritis
  • Renal infarcts
  • Hydronephrosis
  • Renal tract malignancy
  • MSK
  • Shingles

Can use Vitamin D surgical sieve:

Vascular – AAA, renal artery, vein thrombus, mesenteric ischaemia

Infective/Inflammatory – pyelonephritis, colitis, shingles

Trauma – muscle pain, splenic rupture

Autoimmune

Metabolic/Endocrine – renal stones

Iatrogenic/Idiopathic

Neoplasm – renal cancer, bowel cancer

Degenerative – osteoarthritis

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21
Q

What bedside investigations would you perform in suspected renal stones?

A
  • Urinalysis
  • Obs
  • Pregnancy test (women)
  • ECG (rule out cardiac)
  • Bedside USS (FAST)
  • Glucose
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22
Q

What bloods would you request in suspected renal stones?

A
  • FBC
  • U&Es
  • LFTs
  • CRP
  • Renal specific:
    • Bone profile
    • Magnesium
    • Urate
    • Thinking AAA:
      • Clotting
      • G&S/crossmatch
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23
Q

What is the 1st line imaging tool in suspected renal stones (not including women <40)?

A

CT KUB (no contrast)

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24
Q

Likely blood test results in renal stones:

A
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25
CT KUP scan showing right sided hydronephrosis
26
Likely urine dip in renal stones:
27
Abdominal XR of renal stone and staghorn calculi
28
What is the cause of struvite renal stones?
UTIs → ammonia produced as waste product by bacteria can make urine more alkaline, leading to struvite stones (proteus → urate producing)
29
How do struvite stones appear on x-rays?
Staghorn calcifications, radio-opaque
30
Which type of renal stones appear in a ‘staghorn' shape on x-rays?
Struvite
31
What is the least common type of renal stone?
Cystine
32
What is the cause of urate renal stones?
Hyperuricaemia e.g. diet rich in purine, alcohol, gout, CKD
33
How do urate renal stones appear on x-rays?
Smooth, brown, radiolucent
34
Cause of cystine renal stones?
Renal tubular defects
35
How do cystine renal stones appear on x-rays?
Yellow, semi-opaque
36
What is given for **initial management** of renal stones?
* **Analgesia +/- antiemetic** * May need IV fluids * Any signs of infection → antibiotics
37
Which type of analgesia is most effective at managing renal stone pain?
PR diclofenac
38
Give some admission criteria for renal stones
Any of the following: * Renal function deranged (AKI) * Pain uncontrolled with simple analgesia (requiring morphine) * Evidence of an infection * Large stones (\>5mm) * Solitary kidney/previous renal transplant * Bilateral renal calculi
39
What is the most common **conservative management** plan in renal stones _if the stones are \<5mm_?
Stones that are \<5mm in diameter have a **95% chance** of passing spontaneously (this is only used if there is no evidence of hydronephrosis or renal damage). GIVE ANALGESIA.
40
What is the name of the interventional radiology used in the treatment of renal stones?
**Extracorporeal shock wave lithotripsy (ESWL)**
41
What does ESWL involve?
* Using shockwaves guided by US to break up the stones into smaller fragments * Must be \<2cm
42
Who can ESWL not be used on?
Pregnant women Where the stone is on a bony landmark
43
If there is evidence of significant hydronephrosis and renal damage in renal stones, what may be put in?
Nephrostomy
44
What are lower urinary tract symptoms (LUTS)?
A group of key symptoms that are often experienced with urinary tract pathology.
45
What are the 3 broad classifications of LUTS?
Voiding, storage & associated symptoms
46
Give some **storage** LUTS
* Increased urinary frequency * Nocturia * Urgency * Incontinence: * Urge (e.g. in young children) * Stress (e.g. after childbirth)
47
Give some **voiding** LUTS
* Hesitancy/straining * Poor flow * Terminal dribble * Feeling of incomplete emptying
48
Give some **associated** LUTS
* Haematuria * Suprapubic pain * Colicky pain
49
What is the most common cause of LUTS in men?
Benign prostate hypertrophy
50
What is the most common cause of LUTS in women?
UTIs
51
Give some differential diagnoses for LUTS
* **Prostate:** * **Benign prostate hypertrophy (BPH)** * Acute/chronic prostatitis * Prostate cancer * **Bladder:** * **UTIs** * Bladder cancer * Detrusor muscle weakness/instability * Neurological disease (MS, spinal cord injury) * Polyuria * **Urethra:** * Urethral stricture * Malignancy * **External:** * Menopause * External compression (e.g. pelvic tumour, faecal impaction)
52
What bedside investigations would you do in LUTS?
* Pre & post void bladder scan * Urine dip * PT * DRE * Blood glucose
53
What bloods would you do in LUTS?
* FBC * U&Es * LFTs * CRP * HbA1c * PSA * VBG * G&S * Clotting
54
What imaging would you most likely do in LUTS?
US or CT KUB
55
What is PSA?
Prostate specific antigen → a protein secreted by **normal prostatic epithelial cells** and **cancerous prostate cells**
56
What is the function of PSA?
To **liquefy** **semen** allowing spermatozoa to move more freely
57
What can PSA blood levels indicate?
* Small amounts of PSA are present in the blood * As a result of altered prostate architecture in prostate cancer/BPH, more PSA leaks out and increases the levels in the blood
58
What is the aim of a PSA test?
Early detection of prostate cancers
59
Which signs & symptoms may indicate the need for a potential PSA test?
* LUTS e.g. nocturia, frequency, hesitancy, urgency or retention * Erectile dysfunction * Visible haematuria (painless, visible haematuria is cancer until proven otherwise) * Unexplained symptoms that could be due to advanced prostate cancer e.g. lower back pain, bone pain, weight loss
60
What are some other factors that can cause a raised PSA?
BPH, UTI, vigorous exercise (cycling), ejaculation and recent prostate examination
61
Why are PSA tests not always the best test?
* Other factors can cause a raised PSA * False negatives - 15% of men with a negative PSA may have prostate cancer * False positives - 75% of men with a positive PSA will go on to have a negative prostate biopsy
62
What % of men with a positive PSA will go on to have a negative prostate biopsy?
75%
63
What are some conservative management options for LUTS?
* Regulating fluid intake * Urethral milking/double voiding * Pelvic floor exercises * Bladder training
64
What are the 2 most common medications used in the treatment of LUTS in BPH?
1. Alpha blockers 2. 5a-reductase inhibitors
65
What is an example of an alpha blocker?
Tamsulosin
66
What is an example of a 5a-reductase inhibitor?
Finasteride
67
What is the function of alpha blockers?
Relax prostatic muscle to aid urination
68
What is the function of 5a-reductase inhibitors?
Reduce testosterone production in order to shrink prostate
69
How can anticholinergics be used in the treatment of LUTS?
Help in urinary incontinence (overactive bladder) by relaxing the detrusor muscle.
70
Potential complication of BPH?
* Renal and bladder calculi due to stagnation of urine * Chronic obstruction → bladder wall hypertrophy/distension → overflow incontinence/bilateral hydronephrosis → renal failure * Acute urinary retention may also occur
71
Define acute urinary retention
A new inability to pass urine with significant residual volumes (usually \<500ml). This leads to pain and discomfort, with significant post-void residual volumes.
72
Who is acute urinary retention most common in?
Most prevalent in **older male** patients, due to enlarged prostate leading to bladder outflow obstruction, however there are a wide array of potential causes.
73
What is the immediate management of acute urinary retention?
Catheterisation
74
What are the 2 major complications of acute urinary retention?
1. AKI 2. Post-obstructive diuresis
75
What is post-obstructive diuresis?
The condition of **prolonged** **urine** **production** of at least 200ml for at least **two** **consecutive** **hours** immediately following the **relief of urinary retention** or similar obstructive uropathy.
76
What type of tumour are most prostate cancers?
Adenocarcinomas
77
What staging system is used in prostate cancer?
TNM (tumour, node, metastasis)
78
What grading system is used in prostate cancer?
Gleason scale
79
Risk factors for prostate cancer?
* Age * Ethnicity → men of Black African or Caribbean ethnicity are 2x more likely (1 in 4) * Family history
80
Which genes are implicated in prostate cancer?
BRCA1 or BRCA2
81
What **zone** do over 75% of prostate adenocarcinomas arise from?
Peripheral zone (20% in transitional zone, 5% in central zone)
82
What type of cells do prostate cancers arise from?
Acinar (glandular) or ductal cells
83
Are LUTS an early or late sign of BPH? Of prostate cancer?
BPH → early sign Prostate cancer → late sign
84
What **zone** does BPH arise from?
It is a generalised enlargement of the transitional zone
85
What is a tumour grade?
**Tumour grade** is the description of a ***tumour*** based on how abnormal the ***tumour*** cells and the ***tumour*** tissue look under a microscope
86
What makes up the Gleason score?
**Sum of the most common growth pattern + Second most common growth pattern seen on biopsy**
87
What does a higher Gleason score indicate?
Poorer prognosis
88
What is the lowest Gleason score that can be assigned to prostate cancer?
3 + 3

Yr 3 - Surgery (3 decks)

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