Urology Flashcards
(125 cards)
1
Q
How do renal stones present
A
severe loin to groin pain
nausea and vomiting
urinary urgency, frequency, retention
haematuria
2
Q
what are most common types of renal stones
A
Calcium oxalate (85%)
calcium phosphate
Struvite (from proteus mirabilis)
Uric acid, xanthine (radio-lucent)
3
Q
what is a risk factor for calcium oxalate stones
A
Metabolic (hypercalciuria, hyperurcaema, hypercysturia)
Low fluid intake
Structural abnormality
4
Q
What are ssx of kidney stones
A
NOT peritonitic
Loi to groin tenderness
5
Q
What is main differential ddx for kidney stones
A
Ruptured AAA
6
Q
What basic bedside and blood ix do you need for kidney stones
A
Urine dip + MCS
Blood (FBC, CRP, UE; calcium, urate, phosphate)
7
Q
What is the definitive ix for kidney stones
and what are the findings
A
CT-KUB (non contrast)
stone or peri-ureteric fat stranding
8
Q
what clinical pictures can kidney stones present as
A
Renal colic
Pyelonephrosis (EMERGENCY)
9
Q
When should you admit kidney stones
A
pain not controlled impaired renal function single kidney pysexia / sepsis stone >5mm
10
Q
How should you manage a renal colic prior to referral to UROLOGY
A
Mx sepsis (sepsis &)
Mx pain (PR/IM diclofenac or diamorphine + antiemetic)
Check UE
Get CT KUB to confirm stone (Urology otherwise will not accept - could be a AAA)
11
Q
How do urology manage renal stones (renal colic - not emergency)
A
<5mm = will likely pass spontaneously. Treat expectantily, consider alpha blocker (tamlosulin) or CCB
<2cm = lithotrypsy (Extracorporeal Shockwave Lithotripsy
Complex stone e.g. staghorne = NEPHROLIITHOTOMY
12
Q
How do you manage hydronephrosis / pyelonephrosis ( infection
A
aggressive fluid resus
broad spec abx
urgent de-obstruction with PERCUTANEOUS NEPHROSTOMY
13
Q
What do you do for renal colic patient who is discharged home (i.e. pt is well, pain is mild and well controlled)
A
outpatient visit in 4 weeks with CT-KUB (may need lithotripsy or surgical removal)
safety net
encourage high fluid intake
14
Q
how common is BPH
A
very common, 70% of men over 70 years old
although only about half have sx
15
Q
Sx of BPH
A
Frequency
Urgency
Urge incontinence
Nocturia
Hesistancy
Incomplete voiding
Poor stream
16
Q
Examination findings BPH
A
on DRE: prostate is smoothly enlarged with palpable midline groove
17
Q
Ix BPH
A
urine dip and MCS
Bloods: UE, PSA
Bladder scan (if retention)
18
Q
Management of BPH
A
- Watchful waiting
- Medical:
- Alpha 1 ANTAGONIST (tamlosulin)
- 5alpha reductase inhibitor (finasteride) - Surgical - TURP
19
Q
how does tamlosulin work
A
decreases smoooth muscle tone of prostate and bladder
20
Q
How does finasteride work
A
blocks conversion of testosterone to dihydrotestosterone
causes reduction of prostate volume, but takes time to work (approx 6months)
21
Q
what are risks with TURP (Complications)
A
TURP
TURP syndrome: OVER-IRRIGATION –> leakage into circulation–> hyponatraemia, fluid overloading, glycine toxicity (confusion, coma, N+V)
Urethral stricture/ UTI
Retrograde ejaculation (ejaculate up into your bladder because the internal urinary sphincter is relaxed) - common
Perforation of the prostate
others: incontinence, erectile dysfunction, haemorrhage, prostatitis
this causes
22
Q
Prostate cancer ix
A
- PSA testing
- Multi-parametric MRI (if +ve PSA + high index clin suspition)
- TRUS guided biopsy
23
Q
When should you NOT do a PSA
A
48 hours of vigorous exercise / ejaculation
1 week of DRE
4 weeks of proven UTI / prostatitis
if 6 weeks from prostate biopsy
24
Q
how do you manage prostate cancer
A
radical prostatectomy
radiotherapy
hormonal therapy if appropriate
25
what is the most common malignant cause of abdominal mass in children 2-5 years old
Wilms tumour
26
differentials for haematuria
Cancer:
- renal cancer
- bladder cancer
- prostate cancer
```
Urinary tract calcili
Renal calculi
Radiation cystitis
Trauma
Infection: UTI, infection, schistosomiasis, TB
```
27
what is the MAJOR CAUSE of PAINLESS VISIBLE HAEMATURIA
BLADDER CANCER
28
bladder cancer symptoms
* PAINLESS MACROSCOPIC (VISIBLE) HAEMATURIA
* Irritative/storage symptoms (FUND not hips)
**Frequency, Urgency, Nocturia, Dysuria**
* Suprapubic pain
* Recurrent UTIs
*** FLAWS**
29
how do you investigate visible haematuria (sus bladder cancer)
* urine dip, urine cytology (MCS)
* FBC, CRP
if suspecting bladder cancer:
Refer to urology for urgent **Flexible cystoscopy** + **CT urogram** (to look at upper urinary tract)
30
how do urology investigate non-visible haematuria
Flex cystoscopy + US KUB (instead of CT urogram)
31
How do you manage bladder cancer
* non-muscle-invasive bladder cancer: **Transurethral resection of bladder tumour**
* Muscle-invasive bladder cancer: **Radical cystectomy + Neoadjuvant chemotherapy **
* metastatic: **chemotherapy or immunotherapy **
| 3 way catheter, keep in overnight (TURBT)
ileal conduit made after cyste
32
bladder cancer complications
Hydronephrosis
Urinary retention
33
Risk factors for TCC bladder cancer
- smoking
- dyes (aromatic amines ~benzidine and napthylamines)
- cyclophosphamides
34
Risk factors for SCC bladder cancer
- long term catheterisation
- smoking
- schistosomiasis
35
Testicular cancers types
SEMINOMA (around 40yo)
| NON-SEMINOMA (teratoma, yolk sac)
36
what age group do teratomas occur in
20-35
37
What age group do Yolk sac tumours occur iin
10 year old
38
RF for testicular cancer
cryptorchidism (failed descent of testis in scrotum)
orchidopexy as chld
mumps orchitis
infertility
39
S/S testicular cancer
painless lump
rapidly growing, feels craggy and irrecular
gynaecomastia
40
tumour markers for testicular cancer
AFP == elevated in NON SEMINOMA
hCG = elevated in both
LDH = elevated in SEMNOMA
41
what are tumour markers very useful for in testicular cancer? especially which one and why
useful for monitoring response to treaatment
| LDH is especially useful as t measures level of tumour necrosis
42
Ix for testicular cancer
urine dip, MCS (exclude infection)
USS + tumour markers (AFP, hCG, LDH)
Consider CT
43
Mx testicular cancer
orchidectomy + chemotherapy (BEP) +- radiotherapy
| offer sperm banking
44
what approach do you need to take for orchidectomy
INGUINAL APPROACH (as this follows the lymphatic drainage of testes >> it avoids risk of spread)
45
How is epididymitis different to testicular cancer on exaMINATION
epididimytis is posterior, feels separate from testis
46
What is testicular torsion
twisting of spermatic cord > venous outflow obstruction > arterial occlusion > testicilar infarct
47
RF testicular tosion
trauma
imperfectly descended testes
bell clapper deformitiy
48
sx testicular torsion
sudden severe hemiscrotal pain
no pain relief on scrotal elevation (-ve Prehn sign)
abdo pain and vomiting
49
Which TWO SIGNS Occur in testicular torsion
Prehn sign NEGATIVE (no pain relief on scrotal elevation )
| Cremasteriic reflex ABSENT (stroking innner part of thigh fails to pull scrotum ipsilaterallhy=
50
How do you clinically differentiate testic torsion from hydradid of Morgani
hydradid of Morgani:
- superior pole pain
- cremasteric reflex +ve
51
How do you ix testic torsion
Doppler USS (only if it doesnt delay tx)
52
mx testic torsion
surgical exploration + bilateral orchidopexy within 6 hours!!!!!
53
What are organic (not psychological) differentials for ED
atherosclerosis (do QRisk score, which includes CV risk factors)
abnormla endocrine picture (check testosterone )
54
manageement of ED
Sildenafil
second line: vacuum devices
55
what is a vasectomy
cutting of vas deferens
| better contraception than female (failure rate only 1 in 2000)
56
how invasive is a vasectomy -- how soon can you go home
under LA
| Go home wiithin hours
57
when does a vasectomy start working
NOT immedate
| semen analysis needs to be done at 16 weeks and 20 weeks before unprotected sex
58
what is vasectomy reversal success rate
55% within 10 years
59
Abx for uncomplicated UTI in women
Trimethoprim or nitrofurantoin
| 3 days
60
Abx for UTI in pregnancy
Nitrofurantoin 7 days (avoid near term)
OR
Amoxiicilliin 7 days
61
Abx for UTI in men or catheterised patients
Trimethoprim or nitrofurantoin 7 days
62
when to send a urine culture in uti
if
* aged > 65 years
* visible or non-visible haematuria
* pregnant
* immunosuppressed
63
acute pyelonephritis symptoms
high fever +/- rigors
flank pain
vomiting
64
treatment for pyelonephritis
abcde
sepsis 6
monitor renal function
**oral ciproflaxacin**
65
what is a Hydrocoele
collection of fluid in the tunnica vaginalis, in the testis
66
sx of hydrocoele
asymptomatic scrotal swelling
scrotum larger in evening or after exercise (due to change in abdominal pressures)
transilluminates
cannot be separated from testcles
67
ix of hydrocoele
urine dip, MSU (exclude infection)
USS testis (exclude lump)
TRANSILLUMINATES
68
Management hydrocoele
watchful waiting
Aspiration for symptomatic relief
Surgical repair
69
2 possible causes of hydrocoele
* Non-communicating hydrocele: tumour, infection, trauma, testicular torsion, epididimytis
* Communicating hydrocele: increased intra-abdo fluid/pressure (e.g. shunt, ascites)
70
what is varicocoele
scrotal swelling due to dilated veins in pampiniform plexus of spermatic cord, forming a scrotal mass
71
epidemiology of varcicoele
15 % male population, so very common
| incidence highest after puberty
72
what is the biggest complication of varicocele
INFERTILITY
73
where is varicocele most likely to occur
on the LEFT
as the left testicular vein drains at 90 degree angle, is longer than the right, lacks terminal valve to prevent backflow
74
ix for varicocoele
doppler USS
75
presentation of varicocele
asymptomatic
bag of worms on palpation
dragging/ heavy sensation
dull ache
76
Examiination findings in varicocele
sidee with varicocele hangs low
| swelling reduces with lying down
77
mx varicocele
generally conservative
| ooccasional surgery
78
differential for scrotal mass (always split anatomically!)
SCROTAL SKIN: sebaceous cyst, melanoma
INTRA-VAGINAL (within processus vaginalis): hydrocele, epidydimal cyst, epididimits, torted hydratid
INTRA TESTICULAR: ooschitis, testicular abscess, testicular cancer, lymphoma
OTHER: inguinal hernia
79
what is the most common organism to cause prostatitis
E coli
80
RF prostatitis
recent UTI
urogenitaal instumentation
intermittent catheterisatiion
recent prostate biopsy
81
sx prostatitis
referred pain
obstructive voiding sx
fevers, rigors
82
Ix prostatitis
DRE: tender boggy prostate
83
mx prostatitis
Quinolone e.g. ciprofloxacin 14 days
84
which organisms are involved with the formation of staghorn calculi
Ureaplasma urealyticum and Proteus infections
85
what score do you use for prostate cancer and how does it work
Grade 1-5 for two worse slices
| sum up the grades
86
how do you manage localised prostate cancer
conservative: active monitoring, watchful waiting (if low gleason score or elderly)
radical prostatectomy: surgical removal of prostate and obturator nodes
radiotherapy (external beam and brbachytherapy)
87
is circumcision available on NHS
NO
88
What are medical indications for circumcision on NHS
phimosis
recurrent balanitis
balanitis xerotica obliterans
paraphimosis
89
what must you exclude before circumcision
hypospadias
as foreskin would be needed for surgical repair
90
what is first line ix for testicular cancer?
USS
91
what must you NEVER do in testicular cancer
NEVER do a biopsy / FNA
because you risk spreading the cancer
92
what ix are necessary for all ED
lipids, glucose (Qrisk)
Free morning testosterone
93
what iix are necessary in ED if testosterone is low
do FSH, LH, prolactin
if these are low, then refer to endocrinology
94
what routes can you give diclofenac in for stones and why?
IM if very severe pain
| PR/PO otherwise
95
when do you refer a man with uncomplicated UTI
at the SECOND UTI
96
when do you need to treat a cathheterised pt with UTI?
only if symptomatic!
do not treat if asymptomatic bacteriuria
97
what is stress incontinence due to
weakened or damaged muscles (pelvic floor / urethral sphincter) leading to small loss incontinence
98
what is urge incontinence due to
detrusor overactvity
99
what is functional incontinence due to
inability to get to the toilet in time (due to mobility)
100
ix for incontinence
speculum (if F - exclude pelvic organ prolapse)
Valsalva maneuvre to check for fluid leakage
Urine dip / MCS (exclude DM or UTI)
1. Bladder diaries (min 3 days)
2. Urodynamic testinig (if mixed - measures pressures inside bladder and urethra)
101
mx stress incontinence
Conservative:
- lifestyle
- WL (if BMI >30)
- pelvic floor exercisies
Medical/ surgical
- offer Burch colposuspension or SNRI duloxetiine
102
risk factors for stress incontinence
```
age
children
traumatic delivery
pelvic surgery
obesity
```
103
mx urge incontinence
COnservative:
- lifestyle advice (avoid fizzy drink)
- bladder training for 6 weeks (hold off going to toilet)
Mediical:
1
- antimuscarinic (oxybutinin, tolterodine)
- ADH analogue (desmopressin)
2.
- Mirabegron
3. Surgical
- Botox injection, sacral nerve stimulation
104
commonest type of pancreatic cancer
adenocarcinoma
105
how does epididimo orchitis present
| signs and symptoms
symptoms:
* unilateral : **painful swollen** testis/epididymis
* **fever**
* **dysuria**
* **urethral discharge**
signs:
* **pyrexia**
* **walking is painful**
* scrotum may be **oedematous and erythematous**
* **cremasteric** reflex = painful but **intact**
* **prehn sign + ve** = patient supine, **pain relieved by elevation**
## Footnote
cremaster reflex = stroking inner thigh --> cremaster muscle contracts and pulls up the ipsilateral testicle toward the inguinal canal
106
what is the commonest cause of epididimo orchitis
If **< 35** yrs: **Chlamydia and Gonococcus**
If **> 35** yrs: **E coli** (**recent UTI**)
107
investigations for Epididymitis and Orchitis
Urine:
o **Dipstick**, **MC&S**, First-void urine for **NAAT** (for N gonorrhoea, C trachomatis and M genitalum)
Bloods
o **FBC** - high WCC, **High CRP, U&Es, IgM/IgG mumps** serology if suspected
Imaging
o **Increased blood flow on duplex examination**
o **Rule out testicular abscess**
108
management of epididimo orchitis
Medical
Antibiotics:
* If **< 35 years or suspected STI organisms** --> referral to a local specialist sexual health clinic
* **Ceftriaxone** 500mg IM single dose
* **doxycycline** (covers chlamydia)
* **azithromycin** (if gonorrhoea likely)
* Treat sexual partners
* **If > 35 years or suspected enteric organism**
* **Ofloxacin** 200mg PO bd for 14 days
* If no improvement: **discuss with micro**
**Analgesia + scrotal support/elevation + bed-rest**
o **Abstain from sexual activity** until antibiotics completed and symptoms resolve
o Counsel on** barrier contraception**
o **Safety-net for non-resolving symptoms or deterioration**
o Typically symptoms r**esolve within 48 hours of starting abx**
* Isolation and notify Public Health if mumps orchitis
Surgical
* Exploration of testicles if testicular torsion cannot be excluded clinically
* Required if an abscess develops – abscess drainage
109
what is MoA of Goserelin
GnRH agonist >> so it decreases LH levels by overstimulating the pituitary > decreases testosterone levels
110
What must you co-prescribe Goserelin with
3 week cover of anti androgen e.g. FLUTAMIDE; CYPROTERONE ACETATE
these prevent the initial rise in testosterone(due to initiial increased LH and FSH, due to GnRH agonisst >> which is later desensitised)
111
what is a complication of acute urinary retention
**post-obstructive diuresis**
-prolonged poluruia bcos kidneys have lost their medullary concentration gradient.
- it **takes time re-equilibrate** >> this can lead to **volume depletion and worsening of any AKI**
- may require **IV fluids to correct this temporary over-diuresis**
112
what is balanitis
inflammatino of the glans penis
113
cause of balanitis
STI
dermatitis
bacterial
fungaal infection (esp if immunocompromised or diabetes)
114
how do you manage recurrent balanitis
circumcision
115
how do you detect an inguinal hernia on examination in the testis
if you CANNOT GET ABOVE IT
| + separate to the testis
116
what does hydronephrosis mean in the context of ureteric stone
that the ureter is almosst completely occluded by the stone > very bad
117
what is hydronephrosis
kidneys become stretched and swollen due to build up of urine inside them
118
what is the general cause of hydronephrosis
OBSTRUCTION of renal / ureteric tracts
so kidneys can no longer drain
| uni = kidney stones, blood clot, scar tissue
bi = bph, pregnancy
119
clinical features of hydronephrosis
* Symptoms
o **Flank or back pain** (dull ache)
o Urinary **frequency**
o **Dysuria**
o **Haematuria**
o **Incontinence**
* Signs
o **Palpable enlarged bladder**
o **Enlarged prostate**
o **Neurological signs** (cauda equina)
120
hydronephrosis investigations
bedside: **urine dipstick**
bloods: **FBC, U+E**
imaging: **renal ultrasound** (1st line)
121
how do you manage hydronephrosis
*Obstruction due to calculi*
- Small stones (<10mm): **Observe, analgesia (Ketorolac IM) and rehydration. Tamsulosin (to support passage of stone)**
- Large stones (>10mm): Analgesia and rehydration. **Nephrostomy or ureteric stent**
*Obstruction NOT due to calculi*
- Unilateral: **Ureteric stent , Analgesia, Treat cause**
- Bilateral: **Urethral catheter, Treat cause**
122
complications of radical prostatectomy
erectyle dysfunction
| incontinence
123
key ix with hydronephrosis
renal USS
124
how do you manage RCC
nephrectomy
it is often non responsive to chemo or radiotherapy
125
how does urethritis cause urinary retention?
by causing urethral oedema
this may occur for instance with UTI /STI
