Urology Flashcards
State the differences between upper and lower urinary obstructions in terms of:
- Presentation
- Management
Presentation:
- UO presents with ‘loin to groin’ pain, reduced urine output and non-specific symptoms e.g. vomiting
- Whereas LO presents with difficulty passing urine instead and urinary retention (swollen bladder)
- Both have impaired renal function on blood tests
Management:
- UO managed with a nephrostomy to bypass an upper blockage
- Whereas LO is managed with either a urethral or suprapubic catheter
Upper obstructive nephropathy - state the following:
- Pathology
- Presentation
- Common causes
- Management
- Complications if not treated
Pathology:
- Obstruction of the upper urinary tract (i.e. ureters)
Presentation:
- ‘Loin to groin’ pain
- Reduced urine output
- Non-specific symptoms e.g. vomiting
- Reduced renal function on blood tests
Common causes:
- Renal calculi
- Tumour pressing on ureters
- Ureteric strictures
- Retroperitoneal fibrosis
- Bladder cancer blocking entrance of ureters
- Uterocoele (congenital)
Management:
- Nephrostomy
- Involves inserting tube through skin, through kidney and into ureters to drain into catheter bag
Complications if not treated:
- Pain
- Post-renal AKI
- CKD
- Infection
- Hydronephrosis
- Urinary retention and bladder distension
- Overflow incontinence
Lower obstructive nephropathy - state the following:
- Pathology
- Presentation
- Common causes
- Management
- Complications if not treated
Pathology:
- Obstruction of the lower urinary tract (i.e. bladder or urethra)
Presentation:
- Difficulty passing urine
- Urinary retention and distended bladder
- Reduced renal function on blood tests
Common causes:
- BPH
- Prostate cancer
- Bladder cancer
- Urethral strictures
- Neuropathic bladder
Management:
- Urethral catheter
- Suprapubic catheter
Complications if not treated:
- Pain
- Post-renal AKI
- CKD
- Infection
- Hydronephrosis
- Urinary retention and bladder distension
- Overflow incontinence
Neuropathic bladder - state the following:
- Pathology
- Key causes
- Management
- Complications if not treated
Pathology:
- Abnormal functioning of the nerves innervating the bladder and urethra
- Can lead to either under/over activity of the urethral sphincter muscles or detrusor muscle of bladder
Key causes:
- Diabetes
- Spinal cord / brainstem injury
- Stroke
- Multiple sclerosis
- Parkinson’s disease
- Spina bidifa
Management:
- Depending on cause, manage as with upper/lower obstruction
Complications if not treated:
- Urge incontinence
- Distended bladder
- Obstructive uropathy (complications as seen in upper/lower obstruction)
Benign prostatic hyperplasia (BPH) - state the following:
- Pathophysiology and demographic it commonly affects
- Symptoms
- Assessment
- Management
Pathophysiology and demographic it commonly affects:
- Hyperplasia of the epithelial and stomal cells of the prostate
- Commonly affects men over the age of 50
Symptoms:
General lower urinary tract symptoms:
- Difficulty initiating urination
- Spitting or spraying of urine
- Urinary retention / incomplete bladder emptying
- Straining
- Increased urinary frequency
- Nocturia
- Urgency
Assessment:
- Digital rectal examination
- Abdominal examination
- PSA blood test
- Urinary frequency test
- Urine dipstick
Management:
Conservative
- Reduce oral fluid intake, reduce caffeine/alcohol intake
Medical
- Alpha receptor blockers e.g. Tamulosin
- 5-alpha reductase inhibitors e.g. Finesteride
Surgical
- TURP
- TEVAP
- HoLEP
- Open prostatectomy
Prostate specific antigen (PSA) - state common causes of raised PSA
- BPH / general enlarged prostate
- Prostatitis
- Urinary tract infection
- Vigorous exercise especially cycling
- Recent prostate stimulation / ejaculation
- Prostate cancer
List major complications of TURP (transurethral resection of prostate)
- Infection
- Bleeding
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation
- Urethral strictures
- Failure to resolve symptoms
Prostate cancer - state the following:
- Key risk factors
- Presentation
- Investigation (order of events)
- Management
Key risk factors:
- Increasing age
- Family history
- Black
- Tall stature
- Anabolic steroids
Presentation:
- May be asymptomatic
- Haematuria
- LUTS
- Erectile dysfunction
- Systemic cancer signs e.g. weight loss
Investigation (order of events):
- DRE / PSA blood test
- Multiparameteric MRI
- Biopsies (either transrectal or transperineal)
- Isotope bone scan
Management:
- Watchful waiting
- Radiotherapy
- Radical prostectomy
- Hormone therapy e.g. androgren-receptor blockers, GnRH agonists
Prostatitis - state the following:
- Pathophysiology
- General categories of prostatitis
- Presentation for the 2 main types
- Investigation
- Management
- Complications of acute prostatitis
Pathophysiology:
- Inflammation of the prostate, either acute and bacterial or chronic inflammation
General categories of prostatitis:
1. Acute bacterial
2. Chronic bacterial
3. Chronic non-bacterial
Presentation:
Chronic
- Pelvic pain
- LUTS
- Sexual dysfunction
- Pain on bowel movements
Acute bacterial is as above, but with these additional symptoms
- UTI symptoms
- Fever
- Nausea
- Fatigue
- Myalgia
Investigation:
- Urine dipstick
- Urine microscopy
- STI testing
Management:
Acute
- Antibiotics
- Analgesia
- Laxatives
Chronic
- Alpha blockers
- Analgesia
- Psychological therapy
- Antibiotics
- Laxatives
Outline some complications of acute prostatitis
- Sepsis
- Prostate abscess
- Acute urinary retention
- Chronic prostatitis
Epididymo-orchitis - state the following:
- Key causative organisms
- Presentation
- Investigation
- Management
- Long term complications
Key causative organisms:
- E Coli
- Chlamydia
- Gonorrhoea
- Mumps
Presentation:
Unilateral and gradual onset (mins to hrs)
- Scrotal swelling
- Testicular pain
- Dragging sensation
- Systemic infection symptoms e.g. fever
- Urethral discharge if STI cause suspected
Investigation:
- MC&S to elicit likely organism
- STI testing
- Ultrasound to rule out other causes
Management:
- Antibiotics to treat underlying infection
- May refer to GUM if STI cause
- Analgesia
- Reduce physical activity / sexual activity
Long term complications:
- Chronic testicular pain
- Chronic epididymitis
- Reduced fertility
- Scrotal abscess
Testicular torsion - state the following:
- Pathophysiology and demographic
- Presentation
- Examination findings / investigations
- Management
Pathophysiology:
- Twisting of the spermatic cord with rotation of the testicle
- Typically teenage boys, but can occur at any age
Presentation:
- Sudden onset of unilateral testicular pain
- May have associated abdominal pain and nausea/vomitting
Examination findings / investigations:
- Elevated testicle / horizontal testicle
- Firm testicular swelling
- Absent cremasteric reflex
Management:
- Analgesia
- Surgical exploration leading to orchidoplexy or orchidoectomy (depending on situation)
List some causes of scrotal lumps
- Hydrocoele
- Varicoele
- Epididymal cyst
- Inguinal hernia
- Epididymo-orchitis
- Testicular torsion
- Testicular cancer
Hydrocoele - state the following:
- Pathophysiology
- Presentation
- Examination findings / investigations
- Management
Pathophysiology:
- Collection of fluid within the tunica vaginalis that surrounds the testes
- Can be idiopathic or secondary to cancer, torsion etc.
Presentation:
- Scrotal lump
Examination findings / investigations:
- Soft, fluctuant swelling
- Can feel the testicle through
- Irreducible with no bowel sounds
- Transilluminates
Management:
- Exclude more serious causes
- Conservative if idiopathic
- Surgery / aspiration if large/symptomatic
Varicocele - state the following:
- Pathophysiology
- Presentation
- Examination findings
- Investigations
- Management
Pathophysiology:
- Swelling of the veins forming the pampiniform venous plexus
- Can result from either increased resistance in the testicular vein or incompetent valves
Presentation:
- Scrotal lump
- Dragging sensation
- Throbbing/dull pain
- Fertility issues
Examination findings:
- Bag of worms texture
- Worse on standing/disappears on sitting down
- Asymmetry in testicular size if atrophy has occurred
If doesn’t disappear on lying down, suspect more sinister cause
Investigation:
- Colour doppler ultrasound for diagnosis
- May do sperm analysis if fertility is a concern/issue
Management:
Reassurance if minimal
- Surgery
- Endovascular embolisation to prevent abnormal flow
Epididymal cyst - state the following:
- Pathophysiology and epidemiology
- Presentation
- Examination findings
- Investigations
- Management
Pathophysiology:
- Fluid filled swellings, most commonly in the head of the epididymis
- Commonly in men (up to 30% of men)
Presentation:
- Scrotal lump but this can be an incidental finding
- Mostly asymptomatic
Examination findings:
- Soft, round lump associated with the epididymis
- Separate from the testicle
- Transilluminates
Management:
- Mostly entirely harmless so may be left
- Removal may be considered if causing pain or discomfort
Testicular cancer - state the following:
- Pathophysiology including the 2 types
- Risk factors
- Presentation
- Examination findings
- Investigation
- Staging system for testicular cancer
- Management
- Prognosis
Pathophysiology:
- Most arise as germ cell tumours in the testes (from cells that produce sperm)
- Rarely can be non-germ cell or secondary mets
2 main types
1. Seminomas
2. Non-seminonas (mostly teratomas)
Risk factors:
- Undescended testes
- Male infertility
- Family history
- Previous testicular cancer
Presentation:
- Painless lump on the testicle
- May be testicular pain
Examination findings:
- Firm / craggy / irregular mass
- Non-tender
- Can’t separate from testicle
Investigation:
- Ultrasound
- Tumour markers (alpha-feta protein, beta-hCG, LDH)
- Can stage with CT scan
Staging system for testicular cancer:
- Royal Marsden staging system
- Classic TNM staging with focus on whether spread above or below the diaphragm
Management:
- Surgical to remove testicle
- Radiotherapy
- Chemotherapy
+ sperm banking
Patients require monitoring follow ups with imaging and tumour markers
Prognosis:
- Mostly good if early with 90% cure rate
- Metastatic can also be curative
Common sites for testicular cancer metastasis
LLLB
Lung
Lymphatics
Liver
Brain
List some side effects of testicular cancer management
- Sub-fertility or infertility
- Hypogonadism
- Hearing loss
- Peripheral neuropathy
- Lasting kidney/liver/heart damage
- Risk of cancer in the future
Lower UTI (cystitis) - state the following:
- Pathophysiology
- Risk factors
- Presentation including additional symptoms for pyelonephritis
- Investigation
- Management including medication duration
Pathophysiology:
- Tracking of bacteria from the anus to the urethral opening, then up to the bladder
- Most commonly of E Coli
Risk factors:
- Female
- Sexual activity (spreads it)
- Incontinence
- Poor hygiene
Presentation:
- Dysuria
- Increased frequency / nocturia
- Cloudy / foul smelling urine
- Suprapubic pain
- Haematuria
- Urgency
- Confusion in the elderly
ADDITIONAL SYMPTOMS FOR PYELONEPHRITIS
- Loin/groin pain
- Fever
- Nausea and vomiting
Investigations:
- Urine dipstick (likely show positive for nitrites and leukocytes)
- Midstream urine sample (in pregnancy, recurrent UTIs, atypical symptoms and if antibiotics are ineffective)
Management:
Give Nitrofurantoin or Trimethoprim
- Uncomplicated: 3 day course
- Complicated (e.g. immunocompromised or abnormal anatomy): 5 day course
- Men/pregnancy/catheter related: 7 day course
Upper UTI (pyelonephritis) - state the following:
- Pathophysiology
- Risk factors
- Presentation
- Investigation
- Management
Pathophysiology:
- Inflammation of the kidneys (parenchyma or renal pelvis)
- Results from tracking of bacteria from the anus to the urethral opening, then up to the bladder and further up to the kidneys
- Most commonly of E Coli
Risk factors:
- Female
- Pregnancy
- Diabetes
- Vesico-ureteric reflux
- Structural abnormalities (urological)
Presentation:
- Dysuria
- Increased frequency / nocturia
- Cloudy / foul smelling urine
- Suprapubic pain
- Haematuria
- Urgency
- Confusion in the elderly
PLUS
- Loin/groin pain
- Fever
- Nausea and vomiting
May also have
- Systemic illness
- Haematuria
- Loss of appetitie
- Renal angle tenderness
Investigations:
- Urine dipstick (likely show positive for nitrites and leukocytes)
- Midstream urine sample (in pregnancy, recurrent UTIs, atypical symptoms and if antibiotics are ineffective)
- Blood tests (looking for raised inflammatory markers or WBCs)
- Imaging (USS or CT) may help to investigate the cause
Management:
- Give Cefalexin 7 day course (also consider giving Co-Amoxiclav or Trimethoprim, if have culture results)
- Consider sepsis!
Explain how lower UTIs can affect pregnancy and how management changes in pregnancy
Lower UTIs in pregnancy can cause premature rupture of foetal membranes and pre-term labour
Management:
- 7 days of antibiotics (rather than the normal 3 days)
- Avoid Trimethoprim in the 1st semester as it’s a folate antagonist (risk of spina bifida)
- Avoid Nitrofurantoin in the 3rd trimester (risk of neonatal haemolysis)
Interstitial cystitis - state the following:
- Pathophysiology
- Presentation
- Investigation
- Management
Pathophysiology:
- Chronic condition causing inflammation of the bladder
- Results in LUTS symptoms and suprapubic pain
- Complex pathophysiology
Presentation:
- LUTS symptoms that persist for more than 6 weeks, specifically suprapubic pain, frequency and urgency
Investigations:
No diagnostic criteria - diagnosis of exclusion
- Urine dipstick
- Swabs (check STI)
- Cystoscopy (may see Hunner lesions or granulations)
- DRE in males
Management:
- Can be challenging, but options include
- Lifestyle changes
- CBT / pelvic floor exercise / TENS machine
- Medications (oral and intravesicle)
- Hydrodistension
- Surgical procedures
Bladder cancer - state the following:
- Pathophysiology
- Main types of bladder cancer
- Risk factors
- Presentation
- Diagnosis
- Key stages of bladder cancer
- Management
Pathophysiology:
- Cancer arising from the endothelial lining
- Majority of cancers at superficial at time of presentation
Main types of bladder cancer:
- Transitional cell carcinoma
- Squamous cell carcinoma
Risk factors:
- Age
- Smoking
- Aromatic amines (factory dye)
- Schistosomiasis
Presentation:
- Painless haematuria (important to remember!)
Diagnosis:
- Cystoscopy (rigid or flexible)
Key stages of bladder cancer:
- TNM staging
- Non-muscle invasive (in situ, Ta and T1)
- Muscle invasive (T2-T4)
Management:
- MDT management
Surgical options
- Transurethral resection of the bladder
- Intra-vesicle chemo or BCG
- Chemotherapy
- Radiotherapy
- Radical cystectomy (would need: urostomy which is most popular, continent urinary diversion, neobladder reconstruction)
Renal stones - state the following:
- Pathophysiology and main complications
- Composition of 2 main types of stone
- Risk factors (for calcium based)
- Presentation
- Investigations
- Management
Pathophysiology and main complications:
- Formation of hard stones in the renal pelvis
- Complications include obstruction (leading to AKI) and infection
Composition of 2 main types of stone:
- Calcium oxalate (more common)
- Calcium phosphate
Risk factors (for calcium based)
- Hypercalcaemia
- Low urine output
- Previous renal stones
Presentation:
- Generally only become symptomatic when they get stuck in the ureters (commonly at the vesico-ureteric junction)
- Unilateral loin to groin pain
- Colicky pain
- Restlessness (can’t get comfortable)
May also be
- Haematuria
- Nauseas/vomiting
- Reduced urine output
- Systemic infection symptoms
Investigations:
- Urine dipstick
- Blood tests
- Non-contrast CT (CT KUB)
- Ultrasound (more useful in pregnancy or children)
Management:
- Analgesia (IM or PR Diclofenac)
- Anti-emetics
- Antibiotics (if infection present)
- Watchful waiting?
- Tamsulosin
- Surgical intervention (shock wave lithotripsy, laser lithotripsy or nephrolithotomy)
Outline the management options for renal stones (based on their size)
All patients = PR diclofenac and strong opiates e.g. Codeine
Stones < 5mm with no signs of obstruction:
- Watchful waiting
If stones < 5 mm in the distal ureter:
- Medical expulsive therapy e.g. tamsulosin
If > 5mm
- Extracorporeal shock wave lithotripsy
- Ureteroscopy = treatment of choice for pregnant women
If > 20mm, signs of obstruction, infection or stones not spontaneously passing:
- Percutaneous nephrolithotomy (under GA)
- Open surgery
Outline lifestyle modifications for preventing recurrent kidney stones
- Increase oral fluid intake
- Add fresh lemon juice to water (citric acid binds calcium)
- Avoid carbonated drinks
- Reduce salt intake
- Maintain calcium intake
Calcium stones specifically - reduce oxalate-rich foods
Uric acid stones specifically - reduce purine-rich foods
Renal cell carcinoma - state the following:
- Pathophysiology
- Main types of renal cancer
- Risk factors
- Presentation and spread of metastasis
- Diagnosis
- Management
Pathophysiology:
- Adenocarcinoma of the renal tubules
Main types of renal cancer:
- Clear cell
- Papillary
- Chromophobe
- Wilm’s tumour (affects children <5 yrs)
Risk factors:
- Smoking
- Obesity
- Hypertension
- End-stage renal failure
Presentation and spread of metastasis:
- Triad of symptoms: haematuria, flank pain and palpable mass
- Non-specific cancer symptoms
- First presentation could be varicoceles
- Commonly spreads to surrounding fascia
- If spreads to lungs, forms cannonball metastasis (also comes from placenta cancer)
Diagnosis:
- CT
- TNM system
Management:
- Partial nephrectomy
- Radical nephrectomy
- Other less invasive procedures
- Chemotherapy or radiotherapy
Explain how a renal transplantation is done including post-transplant treatment
- Leave old kidney in-situ
- Hockey stick incision
- Place kidney anteriorly in the iliac fossa on affected side
- Anastomose donor kidney vessels to the pelvic vessels
- Anastomose donor ureter to bladder
Post-transplant:
- Requires life long immunosuppressants
- Tacrolimus
- Presnisolone
- Mycophenolate
State the different types of complications post-renal transplant (transplant complications and immunosuppressant complications)
Transplant complications:
- Transplant rejection
- Transplant failure
- Electrolyte disturbances
Immunosuppressant complications:
- Skin cancer
- T2DM
- Ischaemic heart disease
- Increased likelihood of infections, including atypical and rare infections
