Urology Flashcards
1
Q
What symptoms should you specifically ask about when taking a renal history?
A
Dyspnoea (ET, triggers, diurnal variation, orthopnea, PND, relieving factors)
Leg swelling (site, severity, time of onset, amount of fluid intake)
Nausea /& Vommiting
Upper airway symptoms
Constitutional symptoms (fever, joint pains, muscle aches, weight changes, lethargy, night sweats, puritis)
LUTs (dysuria, frequency, qunaitity of urine, colour of urine, frothieness, heamaturia)
Flank Pain (durayion, radiation, associated symptoms, intensity, aggravating/relieveing factors)
ENT symptoms (nasal secretions, sinusitis, epistaxis, haemoptysis, sore throat, visual disturbances, hearing loss)
2
Q
What should you be sure to clarify in dialysis patients?
A
Mode of RRT (APD/CAPD/Asissted PD/UHD/HHM)
What access?
When was the last dialysis?
3
Q
Relevant PMH and SHx in renal patients?
A
Previous AKI Requiring dialysis CKD stage Cause of CKD/ESRF CVD risk factors: DM, HTN, Hypercholestorolaemia UTIs CHildhood infections Surgery Cancer
4
Q
What OTC drug is often associated with renal insult?
A
NSAIDs - ibuprofen
5
Q
What family history should be specifically asked for in renal patients?
A
Renal disease Cardiac disease DM HTN Genetic conditions
6
Q
Is chronic retention painful?
A
Not usually
7
Q
What kind of retention is nocturnal enuresis suggestive of?
A
Chronic
8
Q
What volume of urine to patients with chronic retention generally have in their bladders?
A
> 1L in bladders
9
Q
What should you be suspicious of in painful haematuria in a patient over 65? What is the most common diagnosis?
A
Bladder cancer until proven otherwise
Transitional cell carcinoma is the most common type of bladder cancer
10
Q
What may be seen on X-ray of a patient with metastatic prostate cancer?
A
Sclerotic lesions (bone mets)
11
Q
How is testicular torsion managed?
A
Surgical exploration with orchiopexy fixation
12
Q
What is the most commonly found renal stone composition?
A
Calcium oxolate
13
Q
What type of kidney stone will not be seen on X-ray (raidoopaque)?
A
Uric acidic
14
Q
What kind of renal stones cause acidic urine?
A
Uric acid
Struvite stones
15
Q
What size renal stone can be managed conservatively?
A
<5mm
16
Q
When would a JJ stent be used in renal stones?
A
Sepsis, renal failure
17
Q
What might be used to prevent uric acid stones?
A
Allopurinol
18
Q
Management options for renal stones?
A
Active surveillance
Lithotripsy
Uretoscopy
Percutatinoeus lithotomoy
19
Q
Most common renal stone compositions?
A
Calcium oxolate
Uric acid
Struvite
20
Q
Gold standard investigation for renal stones?
A
CT-KUB without contrast
21
Q
What examination of the affected testi show in testicular torsion?
A
Transverse lie and no movement of the testis when the ipsilateral inner thigh is stroked
22
Q
Whats Phren’s sign?
When will it be positive?
A
Elevation of the testicle reveals pain
Positive in epididymitis, negative in testicular torsion
23
Q
Risk factor for Fournier’s gangrene?
A
DM
ETOH
Steroid therapy
Obesity
24
Q
What is paraphimosis?
A
When the foreskin gets retracted behind the glans and can’t be put back
Occludes blood supply leading to ischemia
Put the foreskin back after catheterisation
25
What may be felt on DRE of a patient with prostate cancer?
Hard and craggy
26
What is used to score prostate cancer?
Gleason score
27
What makes up the gleason score?
most prodominent cell type + second most prodominent cell type
e.g. highest is 4+3
28
What is active survelance for prostate cancer?
Continue investigations to monitor disease with the aim of curative treatment
29
What are the most common complications of radical-prostectomy?
Erectile dysfunction
Cancer recurrence
Urinary incontinence
30
What should patients be advised about raised PSA levels?
Could be raised in BPH, prostatitis, UTI, recent medical procedure
Used as a marker for early prostate cancer detection and treatment
75% false positive as marker for prostate cancer (negative biopsy)
31
Gold standard investigation for prostate cancer?
Transrectal ultrasound prostate biopsy
| USS guided biopsy takes 10-12 cores
32
Risk factors for prostate cancer?
```
Age
BRACA1/BRACA2 genes
Lynch syndromes/hereditery non-polyposis colorectal cancer
Black african or carribean
Obesity
```
33
How can GnRH receptor agonists such as leuprolide, bruserelin and goserelintreat prostate cancer?
GnRH receptor agonists decrease circulating androgens by negative feedback
Falters the cancer growth as prostate cancer is stimulated by androgens
34
Risk factors for bladder cancer?
```
Smoking
Exposure to dyes/textiles/paints (aromatic amines)
Chronic cystitis
Intermittent self catheterisation
Longterm catheterisation
Schostosomiasis
Radiotherapy to the pelvis
```
35
Triad of investigations for haematuria?
Urine cytology - abnormal cells in urine
USS KUB - anatomical changes
Flexible cytoscopy - visualise abnormal growths in bladder
36
What is the most common type of bladder cancer?
Transitonal cell carcinoma
37
What type of bladder cancer is associated with schistosomiasis?
Squamous cell carcinoma (rare)
38
What is the only curative option for T2 bladder cancer?
Radical cystectomy (+ illeal conduit)
39
When is TURBT a suitable curative treatment for bladder cancer?
T1 bladder cancers
40
Most common causative organism in UTI?
E coli
41
First line treament for pyelonephritis?
co-amoxiclav
42
How many UTIs a year warrent an US-KUB in a girl under 16?
3 or more
43
Voiding LUTS?
```
Haematuria+/- dysuria
Hesitancy
Poor flow
Terminal dribbling
Incomplete voiding
```
44
Storage LUTS?
```
Frequency
Urgency
Urge incontinence
Noctura
Bedwetting (due to high pressure chronic retention)
```
45
How is urinary retention diagnosed?
Post-void bladder scan
46
What complication should be monitored for post drainage of a patient with urinary retention?
AKI
Kidney had adapted to fluid overload
Massive diuresis
Kidney cannot compensate
47
Classifcations of haematuria?
Visable
Symptomatic non visable
Asymptomatic non visable
Pseudohaematuria (brown urine not secondary to the presence oof haemoglobin)
48
Causes of pseudohaematuria?
```
Rifampicin
Methydopa
Hyperbilirubinuria
Myoglobinuria
Foods such a beetroot or rhubarb
```
49
Most common cause of haematuria?
```
UTI
Prostatitis
Pyelnoephritis
Urothelial carcinoma
Stone disease
Trauma or recent surgery
Radiation cystitis
Parasitic (schistosomiasis)
Adneocarcinoma of the prostate
BPH
```
50
What symptoms may be associated with haemturia?
```
Suprapubic pain
Renal colic
LUTs
Fevers
Rigors
Weight loss
```
51
What does total haematuria suggest?
Bladder or upper tract source
52
What does terminal haematuria suggest?
Potential severe bladder irritation
53
Initial investigations when a patient presents with haematuria?
```
Urinalysis (true haematuria? nitrites + leukocytes = infection)
Baseline bloods (FBC U&E clotting)
PSA after appropriate counselling where prostatic pathology considered
Urinary protein levels (albumin:creatinine or protein creatinine) if derranged renal function or suspected nephrological cause
```
54
What level of blood on dipstick constitutes haematuria?
1+ blood
| NOT TRACE
55
What is the criteria for urgent referal in haematuria in a patient 45 or older?
Unexplained visible haematuria without UTI
| Visible haematuria that persists or recurrs after sucsessful treatment or UTI
56
When should patients with asymptomatic haematuria be reffered for further investigations?
non-visable haematuria present on two out of three tests
57
When should a patient with haematuria who is over 60 be referred urgently to an adult urological service?
Unexplained non-visable haematuria and either dysuria or a raised WCC on blood test
58
What is the gold standar investigation for lUT?
Flexible cystoscopy
| Performed under local anesthetic
59
What, more commonly used in follow up of patients with proven mallignancy, may be sent in an initial assement of haematuria?
Urine cytology
60
Upper urinary tract imaging that may be used in haematuria?
US KUB - non visable
| CT urogram - visable
61
Which is more likely to be malignancy: non visable or visable haematuria?
Visable (20% of presenting patients vs 5%)
62
Most common urinary tract stones in order?
Calcium oxolate
Mixed calcium oxolate and phosphate
Calcium phosphate
Struvite, urate, cystine
63
Which stones are often large and soft, the most common cause of ''staghorn calcuili' whereby the stone will fil the renal pelvis?
Struvite stones (magnesium ammonium phosphate)
64
What is the only renal tract stone composition that is radiolucent?
Urate
65
Basis for formulation of urinary tract stones?
Over-saturation of urine
i.e. urate stones - high levels of purine in the blood, resulting in increas of urate formation and subsequent crystalisation in the urine
66
What causes urate stones?
High levels of purine in the blood from:
- Diet, red meats
- Haematological disorders such as myeloproliferative disease
67
What are cystine stones associated with and how are they formed?
Homocystinuria
Inherited defect that affects the absorption and transport of cystine in the bowel and kindeys,
As citrate is a stone inhibitor, hypocitrauria from the condition can predispose affected individuals to recurrent stone formation
68
Where are ureteric stones likely to impact?
Pelviureteric junction, where the renal pelvis becomes the ureter
Crossing the pelvic brim, where the illiac vessels travel across the ureter in the pelvis
Vesicoureteric junction, where the ureter enters the bladder
69
Most common presenting symptoms of ureteric stones?
Ureteric colic, associated with N&V
Haematuria
Tenderness in affected flank
70
Describe renal/ureteric colic and why it occurs?
Sudden onset
Severe
Radiated from flank to pelvis (loin to groin)
Occurs from increased peristalsis around site of obstruction
71
Differentials for flank pain?
```
Ureteric stones
Pyelonephritis
Ruptured AAA
Billary patholgy
Bowel obstruction
Lower lobe pneumonia
MSK pain
```
72
What is the gold standard for diagnosis of renal stones?
Non-contrast CT KUB
73
How might renal colic be investigated?
Urine dip (microscopic haemturia, evidence of infection) +/- urine culture
Routine bloods (FBC and CRP, evidence of infection, U&Es to asses renal function)
Urate and calcium levels (aid assesment of stone analysis)
Retrival of the stone to send for analysis
non contrast CT KUB
74
When might USS of the renal tract be used in renal colic?
Use concurrently in cases of known stone disease to assess for any hydronephrosis
75
What stones can USS KUB detect and which can they not?
Can detect renal stones
| Cannot detect ureteric stones
76
What is hyrdronephrosis (also known as obstructive uropathy)
A condition of excess urine accumulation in the kidney causing welling of the kidney
Can cause pain during urination
Nausea
Vommiting
77
Initial management of renal stones?
Adequate fluid resussitation as required due to dehydration secondary to reduced oral intake and or vommiting
Sufficient anlgesia - opiate and NSAID
IVABx therapy and urgent referal to urology if evidence of signficiant infection or sepsis
78
Criteria for inpatient admission in renal stones?
Post-obstructive acute kidney injury
Uncontrollable pain from simple analgesia
Evidence of infected stone(s)
Large stones > 5mm
79
How does a retrograde stent insertion help treat renal stones?
Stent is placed in the ureter, approaching from distal to proximal via cystocopy, keeping the ureter patent and temporarily releiving the obstruction
80
How can a nephrostomy treat renal stones?
A nephrostomy is a tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally (Fig. 5). If required, an anterograde stent can subsequently be passed via the same tract made.
81
What is the definetive treatment of retained renal or ureteric stones that do not pass spontaneously, and what does each treatment involve?
```
Extracorporeal Shock Wave Lithotrispy (ESWL) involves targetd sonice waves to break up the stone, to then be passed sponatneously.
Percutaneous nephrolithotomy (PCNL) involves percutaneous access to the kidney being performed, with a nephrocope passed into the renal pelvis. Stone are fragmented using various forms of lithrotripsy
Flexible utero-renoscopy (URS) involved passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser lithotripsy.
```
82
What is extracorporeal show wave therapy (ESWL) reserved for?
Small stones <2cm, that are retained or do not pass spontaneously
83
What is percutaneous nephrolithotomy (PCNL) reserved for?
Large renal stones only, including staghorn calculi
84
Complications of ureteric stones?
Infection
| Post-renal AKI
85
Complications of recurrent renal stones?
Renal scarring, loss of kidney function
86
How are recurrent stone formers managed?
Advised to stay hydrated
Ask patient to retrive any passed stones or check calcium and serum urate
Specific advice as per stone composition
87
How can oxalate stones be prevented?
Avoid high purine foods and oxalate foods, including:
Nuts
Rhubarb
Sesame
88
How can calcium stones be prevented?
Check PTH levels to exclude primary hyperparathyroidsim (and treat if present)
Avoid excess salt in diet
89
What should urate stone formers be advised?
Avoid high purine foods: red meat, shellfish
| Consider urate-lowering medications: allopurinol
90
What should cystine stone formers be tested for?
Genetic testing for underlying familial disease (homocystinuria)
91
In what cases are bladder stones often seen?
Chronic urinary retention (cause urinary stasis)
Secondary to schistosomiasis
Passes ureteric stone
92
Defintive management of bladder stones?
Cystocopy, allowing the stones to drain for fragmenting them through lithotrispy if required
93
What can recurrent bladder stones predispose patients to?
Development of SCC bladder cancer due to chronic irritation of the bladder epithelium
94
How do bladder stones present?
LUTS
95
What is SUI?
Involuntary leakage of urine occuring when the inra-abdominal pressure exceeds the urethral pressure (laughing, coughing, sneezing), secondary to weakness of the pelvic floor muscles, impairing urethral support.
96
Risk factors for SUI?
```
Post-partam
Consitpation (recurrent strainig)
Obesity
Postmenopause
Pelvic surgery such as TURP, damaging the external sphincter
```
97
What is UUI?
Involuntary leakage of urine due to detrusor hyperactivity, leading to uninhibited bladder contraction, leading to a rise in intravesical pressure and subsequent leakage of urine.
98
What may cause UUI?
```
Neurogenic (previous stroke)
Infection
Malignancy
Medications such as cholinesterase inhibitors (Donepezil)
Idiopathic
```
99
What is Mixed UI?
Urge incontinence and stress incontinence
100
What is overflow UI?
Involuntary constant dribbeling of urine
Progressive stretching of the bladder wall (ie. chronic urinary retention),
damage to the efferent fibers of the sacral reflex and
loss of bladder sensation.
As the bladder fills with urine it becomes grossly distended
Intravesicular pressure builds
101
Causes of overflow UI?
BPH
Spinal cord injury
Congenital defects
102
What is Continuous UI?
Constant involuntary leakage or urine, typicall due to an anatomical abnormality such as an ectopic ureter or bladder fistulae (e.g. vesicovaginal fistula) however may also be due to severe overflow incontience.
103
What can aid diagnosis of the underlying cause of UI?
Bladder diarys
Enquiery about other symptoms (dysuria, haematuria), precipitating factors, PMHx, PSHx, DHx
Examination: enlarged prostate, prolapse, fistula openinig
104
What can be used to determine the severity of UI?
Qol questionaires such as
ICIQ
BFLUTS
I-QOL
105
How might a patient with incontinence be investigated?
Midstream urine dipstick performed (infection/haematuria)
Post-void bladder scans - especially for overflow UI
Urodynamic assessments' (measure intravesicular and intra-abdominal pressures are measured, allowing detrusor muscle activity against urine flow rate)
Outflow urodynamics can then also be performed, to measure detrusor muscle activity against urine flow rate.
Cystoscopy/IV urogram/vaginal speculum investigation
106
When will urodynamic testing be performed in a patient with UI?
Considered in those weith suspected detrusor over-activity, symptoms suggestive of voiding dysfunction, or had previous surgery for stress UI
107
What does presence of high intra-vesicular pressure with poor urine flow on outflow urodynamic studies suggest?
Overflow UI
108
What would bladder wall hyperactivity on urodynamic assesment suggest?
Urge UI
109
Lifestyle advise regarding UI?
```
Weight loss
Avoid excessive fluid
Reducing caffeine intake
Avoid drinking excessive fluid volumes each day
Smoking cessation
```
110
Conservative management of stress or mixxed UI?
Pelvic floor muscle training (3 months)
| Limited response, trial of duloxetine (works to cause stronger urethral contractions)
111
Conservative management of urge/mixed UI?
Anti-muscarinic drugs can be trialled such as oxybutynin or tolterodine, inhbiting detrusor contraction
Bladder training should be offered, ensure the patient continues this for a minimum of 6 weeks
112
Surgical options to treat urge UI?
Botulinum toxin A injections
Percutaneous sacral nerve stimulation
Augmentation cystoplasty
Urinary diversion via ileal conduit
113
Surgical options to treat stress UI?
Tension-free vaginal tape,
Open colposuspension (elevation of the bladder neck and urethra through a lower abdomincal incision)
Intramural bulking agents
An artificial urinary sphincter
114
What clinical features should be considered in the presentation of a scrotal lump?
```
Time of onset
Associated symptoms - especially pain
Previous episodes
Inspection: (6 S's)
Site
Size
Shame
Symmetry
Skin changes
Scars
Palpation: (TTT CAMPFIRE)
Tenderness
Temperature
Transilumination
Consistency
Attachments
Mobility
Pulsation
Fluctutation
Irreducibility
Regional lymph nodes
Edge
```
115
Why isn't biopsy used in the diagnosis of testicular cancer? How is it diagnosed?
Risk of seeding,
Diagnosis made purely on clinical features, USS, histopathological examination of testis following orchidectomy
Blood tests for tumour markers
116
What testicular tumour markers may be sent for in suspected testicular cancer?
```
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (AFP)
Beta-human chorionic gonadotrophin (beta-hCG)
```
117
Extra-testicular causes of scrotal lump?
```
Hydrocele
Varicocele
Epididymal cysts
Epdidymitis
Inguinal hernia
```
118
Testicular causes of scrotal lumps?
Testicular tumour
Testicular torsion
Benign testicular lesions (include benign leydig cell tumours, sertoli cell tumours, lipomas, fibromas)
Orchitis
119
What is a hydrocoele?
Abnormal collection of peritoneal fluids between the parietal and visceral layers of the tunica vaginalis enveloping the testis.
120
How do hydrocoeles typically present?
Painless fluctuant swelling that will transilluminate,
Unilateral or bilateral,
Occasionally they can grow very large and cause discomfort when sitting and walking necessitating surgical management
121
By what point do congenital hydroceles, regress spontaneously?
By two years
122
If a patent processus vaginalis causes a hydrocele what treament may be needed?
Ligation to stop recurrence
123
How should patients presenting with a hydrocele between 20 and 40 years old be managed?
Urgent ultrasound scan?
124
What may cause hydroceles in an older male?
Primary (idiopathic)
| Secondary due to trauma, infection, or malignancy.
125
Which testicular masses will transilluminate?
Hydrocele
| Epididymal cyst
126
What is a varicocele?
Abnormal dilation of the pampinform venous plexus within the spermatic cord.
127
How might a varicocele present?
Testicular lump
Feel like a bag of worms/dragging sensation
Disappear on lying flat
Examine patient lying down, standing up and while performing a valsalva manouvere
128
Which side are varicocoeles typically found on and why?
Left side
| Spermatic vein drains directly into the left renal vein, as opposed to the inferior vena cava on the right
129
What complications can variocoeles cause?
Increase in intra-scrotal temperature, leading to:
Infertility (if this is the case patient should undergo semen analysis with referal to urology if abnormal)
Testicular atrophy
130
Red flag signs with a varicocoele, that warrent urgent investigation?
Acute onset
Right sided
Remain when lying flat
131
What management may be offered in varicocele and when?
If symptomatic or with red flag signs (acute onset, remains on lying flat, right sided)
Embolization by an interventional radiologist
Ligation of the spermatic veins (open or laproscopic)
132
Why, in a patient with a varicocoele, should the abdomen always be examined?
Exclude renal tumour as the cause (although this is rare)
133
What is an epididymal cyst/spermatocele?
Benign fluid-filled sac arising from the epidiymis
134
How might an epididymal cyst present?
Smooth, fluctuant nodule,
found above and seperate from the testes
transilluminates
often multiple
135
Which patients are epididymal cysts most commonly seen in?
Middle-aged men
136
How are epididymal cysts managed?
Usually no treatment as no association to mallignancy, rarely cause symptoms
Can be surgically managed if large and painful but this can cause infertility
137
What is epididymitis?
Inflammation of the epididymis
| One of the most common causes of scrotal pain in adults
138
How does epididymitis typicall present?
```
Unilateral acute onset scrotal pain
+/- associated swelling
Erythematous underlying skin
Systemic symptoms - fever
Tender
Pain may be relieved on elevation of the tesis - phren's sign
```
139
What bacteria typically cause epididymitis?
STI-related organisms - sexually active younger patients
| Enteric ogranisims - older males
140
How is epididymitis managed?
Oral abx and analgesia
141
How will testicular tumours present?
Painless lump arising from the testis (5% painful)
Firm irregular mass
Do not transilluminate
142
How are testicular tumours managed?
Radical inguinal orchidectomy
| Chemotherapy following this
143
What is testicular torsion?
Testicular torsion is a twisting of the testis on the spermatic cord, leading to ischemia, surgical emergency
144
How does testicular torsion present?
Sudden onset severe unilateral scrotal pain
Associate nausea vommiting
?'Bell clapper' deformity (high attachment of tunica vaginalis allowing rotation)
Testis affected is extremely tender, raised and swollen
Loss of cremasteric reflex
145
How is testicular torsion managed and within what time frame?
Surgically: scrotal exploration and fixation of both testes, to prevent irreversable testicular damage
Salvage rates decline after 6 hours following the onset of pain
146
Examples of benign testicular lesions?
Leydig cell tumours
Sertoli cell tumours
Lipomas
Fibromas
147
What is orchitis?
Inflammation of the testis - rare in isolation
148
What is orchitis often proceeded by and why?
Main cause is mumps virus so preceded by a history of parotid swelling
149
What is the treatment of orchitis?
Rest, analgesia
| If intra-testicular abscess may warrent surgical drainage and occasionally orchidectomy
150
What is urethritis and what causes it most commonly?
Inflammation of the urethra, most commonly due to infection.
151
How can urethritis be classified?
Gonococcal urethritis - caused by N. gonorrhoeae
| Non-gonococcal urethritis - c. trachomatis, m. genitalium, t. vagininalis
152
Risk factors for urethritis?
```
<25 years
MSM
Previous STI
Recent new sexual partner
Multiple sexual partners in the last year
```
153
Symptoms of urethritis?
Dysuria
Penile irritation
Discharge from the urethral meatus
154
Complications of urethritis?
Epididymitis
| Reactive arthritis
155
How is urethritis investigated?
Urethral swabs for urethral gram stain under microscopy (puss cells, gram negative diplococci)
First void urine for NAAT (gold standard) for N. gonorrhoeae, C. trachomatis, M. genitalium
MSU dipstick
Triple site testing for culture in the case of gonococcal infection
Further STI testing, HIV and syphillis serology
156
First line analgesia for renal colic?
IM diclofenac in the acute management of renal colic
157
What is the only cure for transitional cell muscle invasive bladder cancer?
Total cystectomy
158
Why is non-contrast spiral CT scan the best diagnostic investigation for renal colic?
Reveals radiolucent stones
| Rules out important differentials such as AAA
159
What is the treatment for BPH with failed medical management, given the patient has normal detrouser activity?
TURP
160
Why might tamsulosin (alpha 1 blocker) cause dizziness?
Associated with pre-syncopal symptoms and postural hypotension
161
Urinary retention post-pelvic fracture suggests likely urethral injury, how should it be managed?
Suprapubic catheter - urethral catheter is contraindicated
162
What abx should be used in women with G6PD def for uti?
Cefalexin
163
Management of prostitis?
Prostatitis - quinolone for 14 days e.g. ciprofloxacin
