Urology Flashcards

Question

Renal stones - state the following: - Pathophysiology and main complications - Composition of 2 main types of stone - Risk factors (for calcium based) - Presentation - Investigations - Management

Answer 1

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)

Answer 2

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

Answer 3

- 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

Answer 4

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

Answer 5

- 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

Answer 6

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

Answer 7

Simple investigations: Urinalysis - check for an infective cause of haematuria Baseline bloods (FBC, U&Es, and clotting) - check general condition and kidney function DRE and PSA testing - if prostate malignancy is suspected Surgical investigations: Lower urinary tract imaging - Flexible cystoscopy Upper urinary tract imaging - CT urogram or USS

Answer 8

Urinary tract infection (UTI) Renal stones BPH Cancer: Renal cancer Bladder cancer Prostate cancer

Answer 9

Distant systemic effects that are unrelated to symptoms

Answer 10

Polycythaemia - secretion of unregulated EPO Hypercalcaemia - secretion of hormone that mimics PTH Hypertension - various factors including increased renin secretion, polycythaemia and physical compression Stauffer's syndrome - abdominal LFTs without liver metastasis

Answer 11

Pathophysiology: - Transitional Cell Carcinoma of the renal pelvis and ureter Presentation: - Haematuria - Palpable pelvic mass - Hydronephrosis - Strangury Investigations: - Ureteroscopy - CT urography Management: - Radical nephroureterectomy

Answer 12

Both used to investigate the kidneys, ureters and bladder CT urogram - contrast technique - Helps to illustrate the urinary tract - Can be used to investigate upper tract tumours, strictures and kidney function CT KUB - non-contrast technique - First line investigation for renal calculi

Answer 13

Non-muscle invasive bladder cancer: - Requires local treatment only e.g. intravesicle BCG - May require repetitive treatments due to high rate of recurrence Muscle invasive bladder cancer: - Requires multimodal treatment strategies e.g. radical cystectomy, chemotherapy (neoadjuvant and adjuvant), radiotherapy

Answer 14

Risks: - False positive test results (man has an abnormal PSA test but does not have prostate cancer), can lead to unnecessary tests and anxiety - Individual may never die from their prostate cancer Benefits: - Finding prostate cancers that may be at high risk of spreading, so that they can be treated earlier before they spread which may lower deaths - Some men prefer to know if they have prostate cancer

Answer 15

- Pathologist looks at how the cancer cells are arranged in the prostate - Assigns a score on a scale of 3 to 5 from 2 different locations 3 = cancer cells that look similar to healthy cells 5 = cancer cells that look more aggressive Scores are added together (between 6 and 10) 6 = low-grade cancer 7 = medium-grade cancer 8-10 = high-grade cancer Score helps to guide treatment

Answer 16

Active surveillance: more aggressive - Agreement not to treat cancer straight away - Actively monitor to determine if the cancer is growing or getting more aggressive - Monitor using PSA, DRE, imaging and biopsies - Curative - Best for men with small, low-risk tumours without symptoms . Watchful waiting: less aggressive for older/less medically fit patients - No regular biopsies or other frequent testing - Palliative - Best for men with prostate cancer who do not want or cannot have treatment therapies

Answer 17

- All hormone therapy treatments aim to reduce levels of testosterone that normally stimulate the cancer - This can be done by suppressing the HPA axis at various points along the axis Hormone treatments: - GnRH agonists to suppress the HPA axis, leading to reduced testosterone production - Androgen receptor blockers - Rarely: bilateral orchidectomy to reduce endogenous testosterone production

Answer 18

AFP - Protein secreted by the fetal yolk sac, liver and gastrointestinal tract - Teratomas (NOT seminomas) beta-HCG - In germ cell tumours, cancerous cells can transform into syncytiotrophoblasts and secrete bHCG - Teratomas and seminomas Lactate dehydrogenase: - Expressed on chromosome 12p, which is often amplified in testis cancer cells - Non-specific

Answer 19

- Lymphatics from the testes drain into the para-aortic lymph nodes - Therefore during surgery, retroperitoneal lymph node removal is important

Answer 20

Penile cancer metastasises in a predictable pattern 1. Sentinel lymph node (often superficial lymph nodes) 2. Metastases to deep inguinal lymph nodes 3. Metastases to pelvic lymph nodes 4. Widespread metastasis to LLBB (lungs, liver, bones, brain)

Answer 21

- Renal obstruction including stones and blood clots - Pyelonephritis - Gall bladder disease - Liver disease - Muscular pain - Ectopic pregnancy - Aortic dissection

Answer 22

Start with NSAIDs: IM or PR Diclofenac Escalation to IV Paracetamol Escalation further to opioids

Answer 23

Internal system - A thin, flexible plastic tube which is curled at both ends - The ends are in the bladder and the affected side's kidney - Cystoscope through the bladder is used to guide the stent into the ureter opening (interventional radiologist) - Stent must be changed every 3-6 months

Answer 24

External system - A thin plastic tube which is passed from the back through the skin and then through to the renal pelvis - USS or x-ray guided - Temporarily drains urine (allows the kidney to function) - Can be removed once the because of the obstruction has been resolved

Answer 25

UTI - symptomatic infection of the urinary tract with bacteria - Requires treatment with antibiotics Asymptomatic bacteriuria - colonisation of urinary tract WITHOUT symptoms - Not appropriate to treat with antibiotics - More common in elderly (over 65) and patients with catheters How this affects management: - Studies have found that prescribing antibiotics for people without UTI symptoms offers no benefits in women or men and increases risk of C.diff infection and antibiotic resistance - Treat as soon as patient becomes symptomatic

Answer 26

‘Multi-drug resistant Gram-negative bacteria’ are bacteria exhibiting resistance to multiple classes of antimicrobial agents, - Includes E coli and others (doesn't include MRSA) - Most commonly detected in the urine, but can be present in respiratory tract or wounds Management: - Discussion with a Microbiologist to advise on appropriate therapy - If catheter associated, remove catheter

Answer 27

Non-antibiotic based: - Advise about behavioural and personal hygiene measures - Increase daily fluid in take - Wipe from front to back - Avoid long intervals between urination - Urination after intercourse - Suggest Cranberry products (evidence uncertain) - Consider vaginal oestrogen in post-menopausal women - D-mannose (non-pregnant women) Antibiotic based: - Consider single / daily dose antibiotic prophylaxis - First line: Nitrofurantoin or Trimethoprim - Second line: Amoxicillin or Cefalexin

Answer 28

Pyelonephritis: - Inflammation of the kidney parenchyma and the renal pelvis - Typically occurs due to bacterial infection Presents with: fever, dysuria, abdominal pain and vomiting Pyonephrosis: - Infection of the kidneys' collecting system, where pus collects in the renal pelvis which causes distension of the kidney - Can occur as a complication of kidney stones (source of persisting infection), complication of hydronephrosis or pyelonephritis or spontaneously Presents with: fever and chills, flank pain, with a previous history of infection, stones or surgery

Answer 29

Prostatitis is inflammation of the prostate gland Acute bacterial prostatitis: - Most cases are caused by ascending urethral infection or sometimes direct or lymphatic spread - Presents with: LUTS, perineal or suprapubic pain, urethral discharge or features of systemic infection - Management: prolonged antibiotic treatment Chronic bacterial prostatitis: - Infection of the prostate with or without prostatitis symptoms - Thought to be the sequelae of inadequately treated acute prostatitis - Presents with: pelvic pain or discomfort > 3 months alongside LUTS - Management: can be difficult

Answer 30

Epididymo-orchitis: - Testes in normal position - Positive Prehn's sign (pain relieved by lifting the testicle) - Intact cremasteric reflex Testicular torsion: - Testes in high riding position and may be horizontal - Negative Prehn's sign (pain NOT relieved by lifting the testicle) - Absent cremasteric reflex - Occurs most commonly in younger males

Answer 31

Bladder outflow obstruction: - A blockage at the base of the bladder, leading to reduced flow of urine into the urethra Symptoms include - Abdo pain - Increased urinary frequency - Feeling of a full bladder - Urinary hesitancy - Dysuria - Straining / spraying urine Overactive bladder syndrome: - Combination of symptoms that may cause you to urinate more frequently with additional urgency - Feel a sudden urge to urinate that's difficult to control - Urgency incontinence - Increased urinary frequency - Nocturia Distinguish between: - BOO is more of an obstructive pattern, whereas OAB is more of an urgency/frequency pattern

Answer 32

Causes of nocturia: - Bladder pathology e.g. OAB, lower UTI, interstitial cystitis - Prostate pathology e.g. BPH, prostate cancer - Poor sleeping patterns e.g. sleep apnoea - Excessive urine production e.g. diabetes, diabetes insipidus, diuretic medication, excessive fluid intake, excessive caffeine intake Management: - Correct the underlying because Conservative: reduce fluid intake, reduce caffeine intake, increase general exercise Medical: Anticholinergics, Desmopressin

Answer 33

- Patient should attend with a full bladder and bladder diary (without any UTI symptoms) - Explain that the tests are there to reproduce urinary symptoms and so not to be embbarrased about any leakage Uroflowmetry: - Patient voids into commode which measure urine volume and flow rate FiIlling cystometry (storage capacity of bladder): - Insert filling catheter and pressure sensor into bladder (at same time, pressure sensor in vagina or rectum to measure intra-abdominal pressure) - Measure post-void residual volume Voiding cystometry (mechanics of weeing): - Patient voids normally - Pressure and flow is measured, to give pressure-flow graph - Can suggest a cause is fast/slow flow

Answer 34

Conservative: - Bladder retraining - Alter drinking habits - Manage weight - Maintain bowel regularity Medical: - Anticholinergics - Beta 3 agonists Surgical: - Botox injections - Sacral nerve stimulation - Augmentation cystoplasty - Urinary diversion

Answer 35

Acute retention: **Acute urinary retention is a medical emergency** - Characterised by a sudden inability to pass urine - Painful / suprapubic tenderness - High but not that high residual volume - Palpable distended bladder Chronic retention: - Characterised by a gradual inability to empty the bladder completely - Painless - Very high residual volume - Palpable distended bladder

Answer 36

Obstructive: - BPH or prostate cancer - Bladder calculi - Bladder cancer or compressive tumour - Strictures - Constipation - Pelvic organ prolapse Infectious and inflammatory: - Prostatitis - Cystitis Other: - Neurogenic bladder e.g. Guillain-Barré syndrome - Iatrogenic / medications - Fowler's syndrome - Trauma

Answer 37

Residual volume: defined as the amount of urine left in the bladder at the end of micturition Measured by catheterisation (gold standard) or non-invasively by ultrasonography (bladder scan) < 50 mL = normal > 200 mL = abnormal (urinary retention)

Answer 38

Treatment depends on the underlying condition - Catheterisation is used to relieve acute painful urinary retention or when no cause can be found - Before the catheter is removed an alpha-adrenoceptor blocker should be given for 2 days **Need urine output monitored for post-obstructive diuresis** - Surgical procedures or dilatation are often used to correct underlying mechanical outflow obstructions

Answer 39

The terms “low” and “high” refer to the bladder pressure at the end of voiding Low pressure chronic retention (LPCR): - More common, less serious - Upper renal tract unaffected due competent urethral valves or reduced detrusor muscle contractility / complete detrusor failure - Normal kidney function and normal kidneys High pressure chronic retention (HPCR) - Less common, more serious - High bladder pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract - Leads to hydroureter and hydronephrosis (checked on USS and bloods)

Answer 40

- A long term urethral or a suprapubic catheter - Definitive management depends on underlying because **Beware of post-obstructive diuresis**

Answer 41

Should not undergo a TWOC due to concerns of repeat renal injury (risk of going back into high-pressure retention)

Answer 42

Possible causes: - Psychological e.g. anxiety or stress - Heart disease - Atherosclerosis - Hypercholesterolaemia - Hypertension - Diabetes - Obesity - Metabolic syndrome - Parkinson's disease - Multiple sclerosis - Medications - Peyronie's disease — development of scar tissue inside the penis - Alcoholism / substance abuse - Treatments for prostate cancer or enlarged prostate - Surgeries or injuries that affect the pelvic area or spinal cord - Low testosterone Importance of assessing cardiovascular risk in men with ED: - Many of the causes of erectile dysfunction are cardiovascular in nature such as hypercholesterolaemia or hypertension - Further investigation is required to assess cardiovascular risk Common medications used in management: - Sildenafil - Inhibits phosphodiesterase enzyme, which is normally responsible for degradation of cGMP - By inhibiting degradation of cGMP, it enhances the effects of nitric oxide = smooth muscle relaxation and improves blood flow - Requires an erection in the first place in order to work

Answer 43

Phimosis is when the foreskin cannot be retracted Physiological phimosis: - Pliant and unscarred foreskin, occurs due to early developmental stage - Common in male patients < 3 yrs, but often extends into older age groups - At birth, there are adhesions between the prepuce (foreskin) and the glans of the penis - Over time these gradually break down True pathological phimosis: - Secondary to distal scarring of the foreskin (often appears as a contracted white fibrous ring around orifice)

Answer 44

- Inability to pull forward a retracted foreskin over the glans penis - Often due to the presence of a tight constricting band - If it continues, glans becomes increasingly oedematous due to reduced venous return, leading to vascular engorgement of the distal penis and further oedema - If untreated this may lead to penile ischaemia and worsening infection - Urological emergency and in worst case, can develop into Fournier’s Gangrene

Answer 45

Pathophysiology: - A form of necrotising fasciitis that specifically affects the perineum - Very high mortality rate 20-40% Risk factors: - Diabetes mellitus - Excess alcohol intake - Poor nutritional state - Excess steroid use - Haematological malignancies - Recent trauma to region Importance of prompt surgical debridement: - Debridement should be urgent and is often extensive - Requires adequate removal of all necrotic tissue is key - Patient started on broad-spectrum antibiotics

Answer 46

Peyronie’s Disease - condition characterised by an acquired curvature of the penis due to fibrosis of the tunica albuginea - Acute inflammatory phase followed by a chronic stable phase. - Most prevalent in middle aged men but can affect men of any age - Generally a progressive condition

Answer 47

Indirect inguinoscrotal hernia (not incarcerated): - Can't get above lump - Worse on coughing - May disappear on lying flat Hydrocele: - Transilluminates - Can't feel testes through Epididymal cyst: - Smooth, fluctuant and round - Transilluminates Testicular cancer: - Can't separate from testicles - Painless Varicocele: - Disappear on lying flat - More common on left side - Bag of worms

Answer 48

- Urinary retention e.g. obstruction - Neurogenic bladder - Peri-operatively - Close urine output monitoring e.g. in sepsis - Bladder irrigation - Chemotherapy administration

Answer 49

Para-aortic lymph nodes

Answer 50

Superficial inguinal lymph nodes

Answer 51

- Erectile dysfunction - Retrograde ejaculation - Urethral strictures - Dysuria / incontinence - Electrolyte abnormalities e.g. hypernatraemia - Failure to resolve symptoms - Bleeding - Infection - Damage to local structures e.g. bladder neck

Answer 52

- Urine dipstick - Urine MC&S - DRE - Bladder scan - USS KUB - Bladder diary - Urodynamics (best)

Answer 53

- Aspiration of the blood within the corpus cavernosa - Irrigation of the corpus cavernosa with saline water - Intracavernosal alpha agonists can be used e.g. Adrenaline or Phenylephrine

Urology Flashcards

(77 cards)