Urology Flashcards by B M

Describe the epidemiology of urinary tract calculi

Very common (10%)
M > F
More common in hot, dry climates

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Describe the types of urinary tract calculi and risk factors

Calcium stones (oxalate, phos): 80%
- ^ in Crohn’s disease, thiazides, hypercalcaemia
Uric acid stones: 10%
- RF: gout
Triple stones/struvite (Mg ammonia phos)
- Assoc w Proteus UTI
Cystine: amino acid

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Describe the presentation of urinary tract calculi

Renal colic: intermittent, severe, loin->groin pain, agitation
N+V, anorexia
Haematuria

Complications: UTI, obstruction, sepsis

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Describe the investigations for urinary tract calculi

-Urine: dip, UPT, 24-hour-collection (rare)
-Bloods: FBC, CRP, U+Es and chemistry, pregnancy, VBG and culture (sepsis)
-Imaging: non-contrast CT-KUB (1st line)/ USS (<16/pregnant)
Extra tests: IVU, stone analysis

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Describe the management of urinary tract calculi

Acute management: analgesia (NSAIDs -> IV paracetamol, opioids), fluids

Conservative:

<5mm in lower 1/3 ureter: discharge and wait
Chronic: hydration, reduce salt/mod protein

Medical:

Acute: medical expulsive therapy (MET) if 5-10mm eg. tamsulosin. Most pass in 48hrs
Chronic: stop precipitating meds, oral alkinisation therapy (K citrate), thiazides (Ca stones)

Surgical: stones <10mm not passing/infection, >10mm

Shock wave lithotripsy (SWL), ureteroscopy, percutaneous nephrolithotomy (PCNL)
Stone >20mm: PCNL

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Describe the prognosis of urinary tract calculi

50% will have recurrence within 10 years

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Describe the classic features of a hydrocoele

Testicular mass: smooth, fluctuant, painless, one with testis, transilluminates

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Describe the classic features of a varicocoele

‘Bag of worms’- soft, nontender, lumpy, separate to testis
May have dull ache
More common in the L testicle because drains into the L renal vein (compared with R, which drains into IVC)

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Describe the classic features of epididymo-orchitis + causes

Painful testicular swelling +/- urethritis (dysuria etc)
Fever, sweating
O/E: tender, red, swollen, hot- esp on back side of testis (epididymis). Pain relief on lifting testis.
Causes: STIs (gonorrhoea, chlamydia), E coli, mumps

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Describe the investigations for epididymo-orchitis

Urine: dip, MC&S, NAAT (STI)
Swab (STI screen)

Can also consider:
Bloods: FBC, CRP, U+Es
USS to exclude abscess

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Describe the management of epididymo-orchitis

Drink lots of fluids

- PO ABx: doxycycline or cipro

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Describe the classic features of prostatitis

Back pain, rectal pain, pain on ejaculation
Dysuria
Haematuria
Fevers, sweating
O/E: swollen, boggy, tender prostate on PR

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Describe the investigations and management of prostatitis

Ix: urine dip + MC&S, STI screen
Mx: ciprofloxacin 14 days

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Describe the classic features of testicular torsion

Sudden onset severe pain in testes +/- abdo pain
N+V

O/E: extremely tender testes, riding high and transverse. Loss of cremasteric reflex

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Describe the differentials for testicular torsion and how these are different

Torsion of Hydatid of Morgagni: small blue dot visible on scrotum, less painful

Epididymo-orchitis: not quite so sudden onset, less painful, assoc with fever + dysuria

Strangulated hernia: history of lump/swelling

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Describe the investigations and management of testicular torsion

Ix: if suspected, do not delay treatment for Ix
-USS useful, detects absent blood flow

Mx: surgical emergency. Time is testicle.

Call urologists ASAP
Make NBM, get IV access for bloods, fluids + analgesia
Detort and bilateral orchidopexy +/- orchidectomy

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Describe the complications of undescended testes

Subfertility
Malignancy (x10), some risk even with surgery
Torsion
Hernias (patent processus vaginalis)

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Describe the management of hydrocoele and varicocoele

Hydrocoele:

Conservative: allow resolution
Surgical: aspiration (risk of recurrence), repair (2 types)

Varicocoele:

Conservative: scrotal support
Surgical: clipping of testicular vein

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Describe the epidemiology and risk factors for testicular cancer

Commonest cancer in younger men (<45)

RFs: undescended testes, family history

Describe the types of testicular cancer

Widely split into germ cell, sex-cord stromal and lymphoma:

1) Germ cell (95%): can be seminomas (40%) or non-seminomatous (60%)
Seminomas: commonest single subtype. Young M. May have raised bHCG
Non-seminomas:
-Teratoma: malignant in adults. Secrete bHCG and AFP
-Yolk sac: commonest in children
-Choriocarcinoma: very rare.

2) Sex cord stromal tumours
- Leydig cell: may secrete testosterone
- Sertoli cell

3) Lymphomas/leukemia:
- NHL: common in elderly
- ALL: common in very young children

Describe the investigations for testicular lumps

Bloods: FBC, CRP, U+Es, LDH, bHCG, AFP
Imaging: USS (CT CAP also if suspected cancer, but do not delay surgery for this)

*NO biopsy

Describe the management of testicular cancer

Medical:

Radiotherapy (used in early seminomas)
Chemotherapy (used in higher stage disease)

Surgical: mainstay for every stage
-Orchidectomy with groin approach

Describe the classic features of benign prostatic hypertrophy

Increasingly common with older age- 90% at 80 years
Presents with LUTS:
-Hesitancy and intermittency 
-Incomplete voiding 
-Poor stream 
-Straining 
Frequent UTIs

Describe the investigations for BPH

DRE
Urine: dip
Bloods: FBC, CRP, U+Es, PSA
Imaging: transrectal US

Describe the management of BPH

Conservative: -Reduce caffeine + alcohol intake Medical: - A blockers: tamsulosin, doxazosin - 5a reductase inhibitors: finasteride Surgical: multiple options - TURP - Laser or open prostatectomy

Describe some side effects of alpha-blockers and 5a reductase inhibitors used in BPH

Alpha-blockers: - Hypotension - Drowsiness 5a reductase inhibitors: -ED

Describe some complications of TURP

Immediate: - TURP syndrome - Haemorrhage (very vascular organ) Early: - Infection - Clot retention -> bladder irrigation w 3 way catheter Late: - Retrograde ejaculation (common) - ED - Incontinence - Stricture - Recurrence

What is TURP syndrome?

A rare but very serious complication of TURP. Occurs due to absorption of large volumes of hypotonic solution used to flush bladder during procedure -> hyponatraemia, ECG changes, confusion, coma etc

Describe the management of TURP syndrome

Stop procedure Monitor plasma Na and osm IV diuretics if overloaded IV hypertonic saline in severe cases

Describe the presentation of prostate cancer

LUTS eg. hesitancy, incomplete voiding, poor stream Systemic symptoms: weight loss, fatigue Mets: back pain O/E: hard, craggy, enlarged, asymmetrical prostate

Describe the investigations for prostate cancer

Urine: dip Bloods: FBC, U+Es, LFTs, bone profile, PSA Imaging: transrectal US -> staging scans eg CT CAP Biopsy

Describe the grading of prostate cancer

Gleason grade | Take 2 samples from worst affected areas, each is given Gleason score 1-5, total out of 10

Describe the management of prostate cancer

Conservative: -Active monitoring- suitable for lower grade in elderly Medical: - Brachytherapy - Endocrine therapy: LHRH analogues (goserelin), anti-androgens (bicalutamide) Surgical: only for younger patients -Radical prostatectomy

Describe the types of bladder cancer and RFs

Transitional cell carcinoma: 90% SCC: assoc with schistosomiasis Adenocarcinoma RFs: smoking, dye exposure, rubber workers, radiotherapy

Describe the classic features of bladder cancer

Older males Painless haematuria is classic presentation +/- storage symptoms: frequency, urgency, nocturia Retention

Describe the investigations for bladder cancer

Urine: dip, cytology Bloods Imaging: cystoscopy + biopsy is diagnostic -> CT/MRI for staging

Describe the management of bladder cancer

Medical: - Radiotherapy - Chemotherapy: may be intravesical Surgical: - 80% are superficial -> transurethral resection of bladder tumour (TURBT) - Invasive: radical cystectomy + ileal conduit **Important to follow up because recurrence is common

Describe the classic features of renal cancer

``` Often found incidentally Triad of: -Microscopic haematuria -Back/loin pain -Abdominal mass Systemic symptoms: weight loss, anorexia Paraneoplastic syndromes: EPO, PTHrP, ACTH ```

Describe the common types of renal cancer

Children: nephroblastoma/Wilm's Adults: -Renal cell carcinoma: clear cell, papillary, chromophobe -Transitional cell carcinoma

Describe the risk factors for renal cancer

- Older age - Male - Smoking - Obesity - Dialysis - Genetic syndrome eg. VHL

Describe the investigations for renal cancer

Bloods: Urine Imaging: CXR, USS, IVU, CT/MRI

Describe the management of renal cancer

Medical: chemotherapy Surgical: radical nephrectomy

Describe the causes of hydronephrosis

``` Obstruction: Intra-luminal: Urolithiasis, clots Mural: strictures Extra-luminal: -Malignancy: prostate, intra-abdo -BPH ```

Describe the management of hydronephrosis

``` Treat cause of obstruction Temporary measures: -Nephrostomy -Ureteric stent -Catheterisation: suprapubic or urethral ```

What are some complications of catheterisation?

``` Trauma eg. to prostate Pain Infection Haematuria Post-obstruction diuresis ```