Urology

Question 1

What is the commonest type of bladder cancer?

Answer 1

transitional cell / urothelial bladder cancer

Question 2

what subtype of bladder cancer does schistosomiasis predispose you to?

Answer 2

SCC

Question 3

What predisposes you to SCC bladder cancer?

Answer 3

Carcinogens
- tobacco

Infection: chronic inflammation of the urinary tract that can lead to the transformation of urothelial cells into squamous epithelial cells (squamous metaplasia)
- schistosomiasis
- recurrent / persistent UTIs
- chronic nephrolithiasis and bladder calculi

Question 4

What are the different types of bladder cancer that you can get?

Answer 4

transitional cell (=urothelial) cancer - most common 90%
SCC
adenocarcinoma (rare)

Question 5

Management of bladder cancer

Answer 5

Surgery + neoadjuvant chemotherapy +/- radiotherapy

1st line:

• radical cystectomy
• neoadjuvant chemotherapy

If ineligible for cystectomy or wishing to retain bladder:

• chemotherapy and radiotherapy

Source: Amboss

Question 5

Investigations in ?bladder cancer

Answer 5

Urine dip
- haematuria (may be micro- or macroscopic)

Urinalysis with microscopy
- some features (e.g. red cell casts, proteinuria may indicate glomerular causes of

Cystoscopy
- mass
CT / CT urography
- mass
- +/- metastatic disease

Bloods
- FBC may show anaemia

Question 6

Symptoms and signs of bladder cancer

Answer 6

Symptoms:

• haematuria
• SOB/fatigue (due to anaemia)
• voiding sx (dysuria, urinary frequency, urgency)
• bladder outlet obstruction (rare)
• suprapubic/perineal/rectal pain
• FLAWS (fever, weight loss, malaise, lymphadenopathy, night sweats)

Signs:

• features of anaemia
• rarely a mass may be palpable

Question 7

RF for testicular torsion

Answer 7

age 12-25
bell clapper deformity (more horizontal lie to testis, increased mobility)
personal or FHx
cryptorchidism

Question 8

What is cryptochidism

Answer 8

undescended testicle

Question 9

sx of testicular torsion

Answer 9

sudden onset testicular pain
can radiate to abdomen (around umbilicus/groin)
can cause N&V

Question 10

Signs of testicular torsion

Answer 10

• testicular swelling
• testicular tenderness (particularly at the top where the cord is)
• loss of cremasteric reflex (stroke anteromedial thigh, scrotum should elevate - L1 and L2)
• high riding testis (testicular elevation in comparison to contralateral side)
• pain not relieved by lifting the testicle

Question 11

ddx for TT

Answer 11

epidydimoorchitis
incarcerated inguinal hernia
torsion of hydatid of Morgagni (remnant of obliterated Mullein duct, blue dot sign)

Question 12

Ix for testicular torsion

Answer 12

-> immediately to theatre for scrotal exploration
(have 6h to save the testicle)

low clinical suspicion
-> USS with doppler
-> urinalysis ?infective cause
->bloods -?infective cause

Question 13

Prognosis for TT

Answer 13

potential for reduced fertility
chronic pain

one more

Question 14

epidydimoorchitis definition

Answer 14

inflammation of the epididymis and testicle

Question 15

epidydimorchitis causes

Answer 15

UTI or STI

(only orchitis: can also be Mumps)

Question 16

orchitis in the absence of epididymitis - what can cause this?

Answer 16

mumps

Question 17

RF for epididymorchitis

Answer 17

UTI: BPH, diabetes, recent catheter, imunosuppression

STI: MSM, unprotected sex, multiple partners, anal sex

Question 18

sx of epididymoorchitis

Answer 18

scrotal pain (typically unilateral)
slower onset than torsion, typically worsening over 24h
scrotal swelling (reactive hydrocele)
fever (rigors if septic)
symptoms related to origin of infection (UTI: dysuria, foul smelling urine; STI: dysuria, discharge)

Question 19

Mx of testicular torsion

Answer 19

urgent surgical exploration

+/- reduction (untwisting)
+/- orchidectomy (only if the testis is grossly necrotic or non-viable)
+/- bilateral orchidopexy

Question 20

signs in epididymoorchitis

Answer 20

erythema
swelling (can develop reactive hydrocele)
tender
cremasteric reflex should be intact
Prehn’s sign positive (raising testicle improves the pain)

Question 21

Ix for epididymoorhcitis

Answer 21

bloods (IFM)
urinalysis
urine culture
clean catch urine NAAT for STI
blood cultures if septic
imaging?

Question 22

treatment of epididymoorchitis

Answer 22

analgesia and abx as per trust guidelines

NICE:
- if any STI, ceftriaxone 1g IM single dose plus 100 mg doxycycline BD for 10-14days
- if no RF for gonorrhoea, then just the doxy or ofloxacin 200 mg BD for 14d

Question 23

at what locations do stones cause obstruction?

Answer 23

PUJ
pelvic brim
VUJ

Question 24

RF for renal calculi

Answer 24

(depend on type of stone) dehydration high levels of meat in the diet obesity hyperparathyroidism drugs: HIV ART, furosemide

Question 25

presentation of renal stones

Answer 25

renal colic, loin to groin pain (due to ureteric peristalsis) N&V O/E flank tenderness, pain in renal angle

Question 26

Ix for renal calculi

Answer 26

urinalysis U + E ?creatitine rise due to obstruction uric acid and calcium levels (won't change management) CT KUB (unless very young and want to avoid radiation)

Question 27

best analgesia for renal calculi

Answer 27

diclofenac suppository

Question 28

mx of renal calculi

Answer 28

analgesia (diclofenac suppository) fluids if evidence of obstructive nephropathy: - stent insertion (retrograde) - nephrostomy definite mx: - PCNL for very large stones (percutanoes access to kidney, then laser) - ESWL (sonic waves for small stones) - ureteroscopy (scope into urether, then...)

Question 29

what is a nephrostomy

Answer 29

a tube put in the kidney by IR with US (this gives an alternate route for urine to pass, reduces the risk of AKI, relieves the hydronephrosis) antegrade stent put a few days later then get treatment for stone

Question 30

Infection in renal calculi

Answer 30

- renal calculi become more complicated with a superimposed infection - higher risk of sepsis - becomes severe very quickly additional clinical features are rigors, fever 40+... -? sepsis 6 them (most need amino glycoside + other broad spectrum0

Question 31

Fournier's gangrene

Answer 31

necrotising fasciitis of the scrotum/genitals/perineum usually polymicrobial can be lethal or very debilitating, requires a lot of debridement

Question 32

RF

Answer 32

- older men - diabetes - immunocompromised - obesity - smoking

Question 33

presentation of Fournier's gangrene

Answer 33

- scrotal pain, swelling, ulceration - erythema - fever - sc gas -> crepitus when pressing on skin - pain in excess of clinical appearance

Question 34

Ix in Fournier's gangrene

Answer 34

primarily a clinical dx Bloods (IFM) CT scan - aid in surgical planning, extent of disease, confirms dx blood cultures and swabs plain radiograph may show free air

Question 35

management of Fournier's gangrene

Answer 35

urgent surgical debridement plastics will do reconstruction and grafting antibiotics ITU

Question 36

paraphimosis - definition

Answer 36

inability to pull a retracted foreskin back over the glans part of the prepuce acts as tight band which reduces venous return causing oedema, ischaemia, necrosis, infection / Fournier's gangrene

Question 37

RF for paraphimosis

Answer 37

catheter phimosis forgetting to put foreskin back in place after intercourse

Question 38

Paraphimosis -

Answer 38

- Foreskin cannot be returned to its original position - Edema and pain of the glans penis

Question 39

paraphimosis - management

Answer 39

emergency needs urgent reduction! analgesia (can be a penile nerve block, LA injected into the base of the penis) Reduction techniques: - principle: need to recuse oedema in glans to size that can fit through the tight band - manual pressure to glans using dextrose soaked gauze - hypodermic needle puncture of glans to remove oedema (?clinicaly? if ineffective: -> insert

Question 40

Varicocoele signs and symptoms

Answer 40

- aching, dragging pain - may see visible, dilated veins -> caused by dilatation of the pampiniform plexus

Question 41

what can right sided varicocele be associated with?

Answer 41

renal cancer if suspicious -> CT AP with contrast

Question 42

management of small urinary stones

Answer 42

can discharge home with analgesia +/- tamsulosin (e.g. 2mm )

Question 43

if you are manually detorting a testicle, which direction do you do it in?

Answer 43

turn laterally

Question 44

What happens in testicular torsion and why is it an emergency?

Answer 44

the spermatic cord twists on itself within the scrotum there is a risk of ischaemia and possible infarction of the testis

Question 45

What is the most important differential of epididymoorchitis?

Answer 45

testicular torsion

Question 46

What is the Prehn sign? give a condition where it is +ve and -ve

Answer 46

it is when there is reduced pain when the affected hemiscrotum is liften +ve in epididymitis (reduced pain) -ve in testicular torsion (still have pain)

Question 47

What are possible complications of epididymitis?

Answer 47

epidydimal abscess testicular infarction infertility

Question 48

Why would you go for a nephrostomy rather than a ureteric stent first line for hydronephrosis due to ureteric stent?

Answer 48

- easy to put in - does not require GA you would then place a stent later down the line and remove it about 2/12 later››› no difference in outcome according to studies if you have access to a theatre right away you could also go for a nephrostomy

Question 49

Ddx for renal colic pain

Answer 49

kidney stones AAA non-specific abdominal pain therefore urologists often won't accept a patient without a scan

Question 50

What is the 1st line ix for ?prostate ca?

Answer 50

multiparametric MRI

Question 51

What is the best pain relief for renal colic? (incl doe and route)

Answer 51

IM diclofenac 75 mg

Question 52

What are the medical indications for a circumcision?

Answer 52

- phimosis - recurrent balanitis - balanitis xerotica obliterans - paraphimosis

Question 53

2nd line pain relief for renal colic

Answer 53

IV paracetamol Renal colic: if NSAIDs are contraindicated or not giving sufficiency pain relief NICE recommend IV paracetamol

Question 54

Which type of renal cancer is associated with exposure to chemicals?

Answer 54

renal transitional cell cancer TCC is a rare form of renal cancer, accounting for approximately 7% of all renal tumours. Risk factors include exposure to chemicals in the textile, plastic and rubber industry.

Question 55

most common renal tumour in children?

Answer 55

Wilm's tumour / nephroblastoma

Question 56

Which renal mass is tuberous sclerosis associated with? Is it benign or malignant?

Answer 56

angiomyolipoma (benign)

Question 57

renal angiomyolipoma - which condition is it associated with? Is it benign or malignant?

Answer 57

tuberous sclerosis angiomyolipoma is usually benign

Question 58

What cancer would you suspect in a testicular mass in >60yo?

Answer 58

lymphoma a

Question 59

What are the causes of haematuria?

Answer 59

- Infection (UTI, schistooomiasis) - trauma - nephritic syndrome - urothelial cancer ... - abx/beetroot - fake

Question 60

How can you differentiate between a stoma and an ileal conduit?

Answer 60

look at the contents stool -> stoma urine -> ileal conduit

Question 61

common causes of LUTS

Question 62

Is BPH hyperplasia or hypertrophy

Question 63

which drugs cause retrograde ejaculation?

Answer 63

finasteride tamsulosin

Question 64

Surgical management of prostate cancer

Question 65

reasons to admit pt with renal colic

Answer 65

- pain not controlled - significantly impaired renal function - single kidney - pyrexia/sepsis - stone >5mm

Question 66

Pain mx in renal colic and AKI?

Answer 66

not NSAID -> IV paracetamol, WHO pain ladder

Question 67

Contraindications for lithotripsy

Answer 67

- aneurysm - infection - anticoagulation

Question 68

How are stag horn stones managed?

Answer 68

PCNL (if the kidney I functioning well. may need multiple attempts) staghorn calculi can be very damaging to the kidneys

Answer 69

The indications for antibiotics with a catheter change include neutrophils 1 x 109/L, multiple attempts or traumatic insertion, post trans-urethral urological surgery, previous episode of catheter change related sepsis, frank pus at the urethral meatus or in critical care patients.