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Urology Flashcards

1
Q

BPH

A

benign increase in size of prostate

inner (transitional) zone enlarges

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2
Q

BPH Px

A

LUTS
Storage
- frequency
- urgency, urgency incontinence
- nocturia
SHIPP
- straining
- hesitancy
- incomplete emptying
- poor / intermittent stream
- post-micturition dribbling
- also overflow incontinence

  • enlarged bladder on abdo exam
  • UTI sx, bladder stone
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3
Q

BPH Ix

A
  • urine dip
  • DRE - smooth, enlarged
  • U/E
  • urinary freq/vol chart
  • transrectal US - not routine
  • PSA
  • International Prostate Symptom Score
  • US / CT / cystoscopy
  • post-void bladder scan
  • urodynamic studies if dx unsure
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4
Q

BPH Mx

A
  • avoid caffeine, alcohol

Medical
- tamsulosin
- finasteride
- consider tolterodine / darifenacin

Surgical
- transurethral resection of prostate (TURP)
- transurethral incision of prostate (TUIP)
- Transurethral electrovaporisation of prostate (TEVAP/TUVP)
- Holmium laser enucleation of prostate (HoLEP)
- Open prostatectomy

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5
Q

BPH indications for surgery

A

RUSHES
- Retention
- UTIs
- Stones
- Haematuria
- Elevated creatinine due to bladder outlet obstruction (BOO)
- Sx deterioration

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6
Q

LUTS Ix

A
  • bladder diary
  • post-void bladder scan
  • urinalysis
  • DRE
  • urinary freq/vol chart
  • IPSS
  • bloods
  • urodynamic studies
  • cystoscopy / US / CT
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7
Q

LUTS Mx

A

Voiding sx
- pelvic flood muscle training, bladder training
- tamsulosin / finasteride

Overactive bladder
- bladder retraining
- oxybutynin, tolterodine, darifenacin
- mirabegron

Nocturia
- furosemide in late afternoon
- desmopressin may help

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8
Q

Prostatitis

A

inflammation of prostate

E coli most commonly

RFs
recent UTI, intermittent catheterisation, recent biopsy

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9
Q

Prostatitis Px

A
  • pelvic pain, genital pain
  • LUTS
  • fever, rigors, N+V
  • sexual dysfunction
  • pain with bowel movts
  • inguinal lymphadenopathy
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10
Q

Prostatitis Ix

A
  • DRE - tender, boggy
  • STI screen
  • urine dip, MC+S
  • FBC, blood cultures
  • National Institute of Health Chronic Prostatitis Sx index
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11
Q

Prostatitis Mx

A

Acute
- 14d ciprofloxacin
- admit if unwell

Chronic
- tamsulosin, analgesia

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12
Q

Prostate cancer

A

growth of peripheral zone of prostate - adenocarcinoma

RFs
- older, FHx, black ethnicity, tall, anabolic steroids

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13
Q

Prostate cancer Px

A
  • asym
  • LUTS
  • haematuria
  • erectile dysfunction
  • wt loss, bone pain, cauda equina
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14
Q

Prostrate cancer Ix

A
  • PSA - 50-69yo refer if PSA >3 OR abnormal DRE
  • DRE - firm, craggy, irregular
  • multiparametric MRI
  • Biopsy - transrectal / transperineal - Gleason Grading for severity
  • isotope bone scan
  • CT / MRI for mets
  • TNM staging
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15
Q

Prostate cancer Mx

A
  • surveillance / W+W
  • external beam radiotherapy
  • brachytherapy

Hormone therapy
- androgen-receptor blockers - bicalutamide
- GnRH agonists - goserelin, leuprorelin (Prostap)

  • chemo
  • radical prostatectomy
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16
Q

Bladder cancer - definition and RFx

A

cancer of urothelium of bladder (endothelium) - transitional cell carcinoma

RFs
- smoking
- hydrocarbon exposure - 2-naphthylamine
- Schistosomiasis causing chronic bladder inflammation

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17
Q

Bladder cancer Px

A
  • painless, macroscopic haematuria
  • LUTS
  • wt loss, bone pain etc
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18
Q

Bladder cancer Ix

A

2ww if
- >45yo, unexplained visible haematuria
- >60yo, microscopic haematuria + dysuria / raised WCC
- non urgent referral if >60yo, recurrent unexplained UTIs

  • cystoscopy, biopsy (flexible then rigid)
  • CT / MRI / PET
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19
Q

Bladder cancer Mx

A
  • TURBT - transurethral resection of bladder tumour
  • intravesical chemo
  • BCG vaccine
  • radical cystectomy (+ urostomy + ileal conduit)
  • chemo / radio
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20
Q

Renal cell carcinoma (& RFx)

A
  • adenocarcinoma of kidney - from PCT, majority clear cell type
  • Wilms tumour in paeds

Paraneoplastic
- polycythaemia - EPO
- hypercalcaemia - PTH mimic
- HTN - renin
- Stauffers syndrome

RFs
- smoking, obesity, HTN, ESRF, tuberous sclerosis, von Hippel-Lindau, industrial exposure, dialysis

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21
Q

RCC Px

A
  • asym
  • haematuria
  • loin pain
  • wt loss, fatigue, anorexia, night sweats
  • renal mass
  • PUO
  • varicocele
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22
Q

RCC Ix

A
  • FBC, U/E, LFTs, bone profile, PTH
  • urinalysis, cytology
  • US kidney
  • CXR - cannonball mets
  • CT chest, abdo, pelvis
  • ?biopsy
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23
Q

RCC Mx

A
  • nephrectomy - partial / radical
  • arterial embolisation
  • percutaneous cryotherapy
  • radiofrequency ablation
  • chemo / radio
  • biological tx
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24
Q

Testicular cancer (& RFx)

A

commonly germ cells (produce gametes)

Mets to lymphatics, lungs, liver, brain

RFs
- undescended, infertility, FHx, taller

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25
Testicular cancer Px
- lump +/- pain - hard, irregular - non-fluctuant - no transillumination - gynaecomastia - Leydig cell tumour
26
Testicular cancer Ix
- scrotal US - Tumour markers - alpha-fetoprotein, bhCG, LDH - staging CT - Royal Marsden staging
27
Testicular cancer Mx
- radical orchidectomy - chemo / radio - sperm banking
28
Epididymo-orchitis (& causes)
infection of epididymis +/- testes Causes - genital tract - chlamydia, gonorrhoea - bladder - E coli - mumps
29
Epididymo- orchitis Px
- unilateral testicular pain + swelling - dragging - tender on palpation - urethral discharge - fever, LUTS - Prehn's positive - elevation of scrotum eases pain
30
Epididymo-orchitis Ix
- STI screen - first pass urine, charcoal swab of discharge - MSU - dip + MC+S - saliva swab / serum ABs - mumps - ?US testes
31
Epididymo-orchitis Mx
- GUM referral Organism unknown - ceftriaxone 1g IM + doxycycline 100mg oral BD 10-14d Enteric organism likely - ofloxacin / co-amox
32
Testicular torsion (& RFx)
twisting of spermatic cord --> testicular ischaemia / necrosis in 4-6hrs RFs - FHx, undescended, age - often sports related
33
Testicular torsion Px
- severe, sudden onset pain - referred lower abdo pain - N+V - loss of cremasteric reflex - Prehn's sign negative - horizontal testicular lie - rotation - epididymis not in normal position
34
Testicular torsion Ix
- clinical dx - USS - whirlpool sign - urine dip - r/o infection
35
Testicular torsion Mx
- NBM - analgesia - surgical exploration - for dx - orchidopexy - orchidectomy - if necrosis
36
Hydrocele (& causes)
- collection of fluid within tunica vaginalis that surrounds testes - communicating - patent processus vaginalis - non-communicating - excessive fluid production Causes - idiopathic, cancer, torsion, epididymo-orchitis, trauma
37
Hydrocele Px
- painless - soft scrotal swelling - fluctuant - testicle palpable within hydrocele - irreducible, no bowel sounds - transilluminates
38
Hydrocele Ix
- US
39
Hydrocele Mx
- conservative - surgery / aspiration
40
Varicocele (& causes)
- swelling of veins in pampiniform plexus Causes - incompetent valves - L>R - drains into L renal vein - higher resistance - RCC - left
41
Varicocele Px
- throbbing, dull pain, worse standing - dragging sensation - sub/infertility - bag of worms scrotal mass, worse standing - red flags - acute onset, R side, remains whilst flat -> urology referral
42
Varicocele Ix
- US - semen analysis - fertility - hormone tests - FSH, test - if concern about function
43
Varicocele Mx
- conservative - surgery / endovascular embolisation if painful / testicular atrophy / infertility
44
Epididymal cyst
- fluid filled cyst at head of epididymis - PKD, CF, von Hippel Lindau associations
45
Epididymal cyst Px
- asym - soft, round lump - at top of testicle - transilluminates - can get above lump
46
Epididymal cyst Ix
US
47
Epididymal cyst Mx
- conservative - surgical removal - if pain / discomfort
48
Scrotal lumps DDx
hydrocele varicocele epididymal cyst testicular cancer epididymo-orchitis inguinal hernia testicular torsion
49
Renal stones: definition and pathophysiology
stones form in renal pelvis, get stuck in ureters obstruction -> AKI infection -> obstructive pyelonephritis get stuck at - PUJ, pelvic brim, VUJ Types - calcium oxalate - Uric acid, - Struvite - Cystine
50
Risk factors for renal stones
- dehydration - hypercalciuria, hyperparathyroidism, hypercalcaemia - cystinuria - high dietary oxalate - renal tubular acidosis - medullary sponge kidney, PKD - gout - drugs - loop diuretics, steroids, acetazolamide, theophylline
51
Renal stones Px
- renal colic - loin/groin pain - haematuria - dysuria - N+V - reduced UO - sepsis sx
52
Renal stones Ix
- urine dip - blood +/- infection - Bloods - FBC, U/E, Ca, CRP, coag - NCCT KUB - AXR - US KUB - pregnancy / children
53
Renal stones Mx
- analgesia, antiemetics - Abx if infection - stones <5mm - W+W - tamsulosin admit if: - AKI, uncontrollable pain, infected, large >5mm stones >10mm - extracorporeal shock wave lithotripsy (ESWL) - ureteroscopy + laser lithotripsy - percutaneous nephrolithotomy (PCNL) - open surgery infection / AKI - stent / nephrostomy - decompress - prevent hydronephrosis
54
Tips for prevention of renal stones?
- increase fluids - lemon juice, avoid carbonated drinks, reduce salt, normal Ca intake, reduce oxalate/purine rich foods, limit dietary protein - potassium citrate / thiazide diuretics
55
Bladder stones (Px, Ix and Mx)
- from stasis of urine in bladder - chronic urinary retention / schistosomiasis Px - LUTS Ix - as for renal stones Mx - cystoscopy, fragment with lithotripsy
56
Acute urinary retention
- acute inability to pass urine
57
Causes of acute urinary retention
- BPH - urethral strictures, calculi, cystocele, constipation, masses - meds - anticholinergics, TCAs, antihistamines, opioids, benzos - neuro cause - post-op, post-partum
58
Acute urinary retention Px
- no UO - lower abdo discomfort, distension - acutely confused - pain, distress
59
Acute urinary retention Ix
- MSU for MC+S - bloods - U/E, FBC, CRP - DRE - bladder scan - >300mls, also check post-void residual volume
60
Acute urinary retention Mx
- catheter - if >1000mls - US kidneys to r/o high-pressure chronic retention / hydronephrosis - Ix / Tx cause - TWOC after tx cause - IV fluids for post-obstructive diuresis
61
Chronic urinary retention
- chronic inability to pass urine - bladder desensitised - high-pressure - impaired renal function, bl hydronephrosis, bladder outflow obstruction - low-pressure - normal renal function, no hydronephrosis
62
Causes of chronic urinary retention
- BPH - pelvic prolapse - pelvic masses - fibroids - neuro - peripheral neuropathies, MS, Parkinson's
63
Chronic urinary retention Px
- painless urinary retention - LUTS - weak stream, hesitancy - overflow incontinence - palpable distended bladder
64
Chronic urinary retention Ix
- post-void bladder scan - bloods - FBC, CRP, U/E - USS urinary tract
65
Chronic urinary retention Mx
- catheter - long-term / intermittent self-catheterisation
66
Neurogenic bladder
Abnormal function of nerves innervating bladder / urethra Causes - MS, DM, stroke, Parkinson's, brain / spinal cord injury, spina bifida Results in - urge incontinence - increased bladder pressure - obstructive uropathy
67
Hydronephrosis
Swelling of renal pelvis + calyces in kidney
68
Causes of hydronephrosis
Unilateral - PACT - Pelvic-ureteric obstruction (congenital or acquired) - Aberrant renal vessels - Calculi - Tumours of renal pelvis Bilateral - SUPER - Stenosis of the urethra - Urethral valve - Prostatic enlargement - Extensive bladder tumour - Retro-peritoneal fibrosis
69
Hydronephrosis Px
- vague renal angle tenderness - mass
70
Hydronephrosis Ix
- USS - CT - IV urogram - XR with IV contrast in urinary tract
71
Hydronephrosis Mx
- tx cause - nephrostomy - antegrade ureteric stent
72
Lower UTI: uncomplicated?
infection of bladder (can spread to kidneys = pyelonephritis) Uncomplicated - normal renal tract structure / function
73
what is a complicated UTI?
increased likelihood of complications due to anatomical, functional or pharmacological factors predisposing to recurrence e.g. stones, obstruction, DM, male
74
Causative organisms of lower UTI
KEEPS - klebsiella - e coli - most common - enterococcus - pseudomonas - staph (coagulase negative - candida - catheters
75
what 4 things might make you suspect pyelonephritis?
Fever Loin/back pain Nausea/vomiting Renal angle tenderness on examination
76
Lower UTI Px
- dysuria - suprapubic pain / discomfort - frequency, urgency, incontinence - haematuria - cloudy / foul-smelling urine - confusion
77
Lower UTI Ix
Urine dip - Nitrites / leucocytes, blood - NB if only leukocytes then don't treat as UTI unless other clinical reasons MSU to MC+S - if pregnant, recurrent, atypical sx, no resolution with abx, men, haematuria
78
Lower UTI Mx for males and non pregnant females? how longer would you treat for?
Non pregnant women - nitrofurantoin or trimethoprim for 3 days Men - nitro or trimethoprim for 7 days NB avoid nitro if eGFRv <45
79
lower UTI treatment for pregnant women? how long?
7 days of ABx Nitrofurantoin (avoid in the third trimester) Amoxicillin (only after sensitivities are known) Cefalexin
80
Lower UTI: which ABx need to be avoided in which trimester?
nitro - avoid in 3rd trimester (risk of haemolysis) trimethoprim - avoid in 1st trimester (folate antagonist - can cause congenital malformations)
81
What is pyelonephritis?
inflammation of the kidney resulting from bacterial infection - affects renal pelvis and parenchyma Causes: same as lower UTI, typically e coli
82
risk factors for pyelonephritis?
Female sex Structural urological abnormalities Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children) Diabetes
83
Pyelonephritis Px
key triad: - fever - loin/back pain - n+v other: Lower UTI sx e.g. dysuria Systemic illness Loss of appetite Haematuria Renal angle tenderness
84
Pyelonephritis Ix
- Urine dip - MSU for MC+S - bloods - raised WCC and CRP - USS / CT to exclude other pathology e.g. stones
85
Pyelonephritis Mx
1. Cefalexin 2. Co-amoxiclav (if culture results are available) 3. Trimethoprim (if culture results are available) 4. Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
86
patient is admitted with sepsis following pyelonephritis: what is the sepsis 6?
Three tests: Blood lactate level Blood cultures Urine output Three treatments: Oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD) Empirical broad-spectrum IV antibiotics (according to local guidelines) IV fluids
87
what is chronic pyelonephritis?
- recurrent infections leading to scarring of parenchyma and CKD (possible ESRF) - DMSA scan to assess damage
88
Interstitial cystitis
chronic inflammation of bladder complex causes, various dysfunction
89
Interstitial cystitis Px
- LUTS - suprapubic pain, worse with full bladder, relieved on emptying - >6wks
90
Interstitial cystitis Ix
- urinalysis - ?UTIs - swabs - ?STIs - cystoscopy - ?bladder Ca - may see Hunner lesions, granulations - DRE - prostate
91
Interstitial cystitis Mx
- supportive - meds - surgery
92
Circumcision
- in Jewish and Islamic faiths - reduces risk of penile cancer, UTI, HIV Medical indications - phimosis - recurrent balanitis - BXO - paraphimosis - exclude hypospadias first
93
Balanitis
- inflammation of glans penis - various causes Ix - clinical dx - swab if needed - biopsy if doubt on cause / extensive skin change Mx - gentle saline washes - 1% hydrocortisone - irritation / dermatitis - topical clotrimazole - candida - oral fluclox / clari - staph / strep infection - metronidazole - anaerobic balanitis - clobetasol / circumcision - lichen sclerosus
94
Erectile dysfunction ( + causes and RFx)
- inability to maintain erection sufficient for satisfactory sexual performance Causes Organic - gradual sx onset, normal libido Psychogenic - sudden onset, decreased libido, good quality spontaneous erections, major life events, psych problems Mixed RFs - older age, CVD (obesity, DM, lipids, HTN, smoking), alcohol, SSRIs, BBs
95
Erectile dysfunction Ix
- QRISK - free testosterone level (9-11am) - if low, rpt with FSH, LH, prolactin
96
Erectile dysfunction Mx
- PDE-5 inhibitors - sildenafil - if young and always had problem - refer to urology - if pt cycles >3hrs/wk - stop
97
Urethral injury
- blood in meatus - bulbar rupture - straddle injury, urinary retention, perineal haematoma - membranous rupture - penile/perineal haematoma, prostate displaced upwards Ix - ascending urethrogram Mx - suprapubic catheter
98
Bladder injury
- haematuria, suprapubic pain, inability to void Ix - IVU / cystogram Mx - laparotomy / conservative
99
Penile fracture
- traumatic rupture of corpus cavernosa and tunica albuginea in erect penis Px - snap / popping - immediate pain / swelling - Aubergine sign - firm immobile haematoma Ix - clinical dx - US - retrograde urethrography if ?urethral injury Mx - surgical repair - no sex for 6-8wks
100
Urethral stricture
- narrowing of urethra Causes - iatrogenic (catheter) - STIs - gonorrhoea - penile fracture - hypospadias - lichen sclerosus Px - decreased stream, incomplete bladder emptying, spraying of stream, dysuria Ix - uroflowmetry - US postvoid residual (PVR) measurement Mx - dilatation - endoscopic urethrotomy
101
Vasectomy
- under LA - semen analysis 2x post-op before sex Cx bruising, haematoma, infection, sperm granuloma, chronic testicular pain
102
Priapism
- persistent penile erection >4hrs, not associated with sexual stimulation Patho - ischaemic - due to impaired vasorelaxation, reduced outflow - non-ischaemic - high arterial inflow - eg fistula formation Causes - sickle cell, sildenafil, drugs (anti-HTN, anticoagulants, antidepressants...), trauma
103
Priapism Px
- erection >4hrs - pain in penis - if not painful / fully rigid - more so non-ischaemic
104
Priapism Ix
- cavernosal blood gas - ischaemic pO2 / pH reduced, pCO2 increased - doppler / duplex US - FBC, tox screen
105
Priapism Ix
- cavernosal blood gas - ischaemic pO2 / pH reduced, pCO2 increased - doppler / duplex US - FBC, tox screen
106
Priapism Mx
- ischaemic - emergency - aspirate blood - inject phenylephrine, rpt 5 mins - consider surgery - shunt
107
Haematuria
- blood in urine - non/visible, a/symptomatic Causes - UTI, renal cancer, bladder cancer, renal calculi, prostate cancer, BPH, trauma, schistosomiasis, glomerulonephritis, HSP - pseudo - eg rifampicin, beetroot, methyldopa
108
Haematuria Hx
- ask about urine colour, clots, timing in stream - LUTS, fever, rigors, flank pain etc - recent trauma - smoking, occupational exposures
109
Haematuria Ix
- DRE, examine external genitalia - urinalysis - FBC, U/E, clotting, PSA - flexible cystoscopy - USS / CT urogram
110
Haematuria 2 WW
>45yo with - unexplained visible haematuria w/o UTI - visible haematuria after UTI Ix >60yo - unexplained non-visible haematuria + dysuria / raised WCC
111
Haematuria Mx
- Tx cause - if clot retention - 3 way catheter - washout / irrigation - to control bleed - rigid cystoscopy
112
Stress incontinence
- urine leakage with increased intra-abdo pressure - coughing / straining - weakness of pelvic floor muscle - post-partum, constipation, obesity, post-menopausal, pelvic surgery
113
Urge incontinence
- overactive bladder - detrusor hyperactivity - eg stroke, infection, malignancy, cholinesterase inhibitors
114
Overflow incontinence
- from chronic urinary retention - stretching of bladder -> loss of bladder sensation, urine overflows - BPH, spinal cord injury, congenital defects
115
Continuous incontinence
- constant leakage of urine - anatomical abnormality - ectopic ureter, bladder fistulae
116
Urinary incontinence Px
- involuntary leakage of urine - ask about other urinary sx
117
Urinary incontinence Ix
- bladder diaries - QoL questionnaire - examine prostate, prolapse, ?fistula - urine dip - post-void bladder scan - urodynamic studies - cystoscopy, IV urogram, MRI
118
Urinary incontinence Mx
- wt loss, reduce caffeine, stop smoking Stress - pelvic floor muscle training - duloxetine - surgery - tension-free vaginal tape.... Urge - bladder retraining - oxybutynin, tolterodine - mirabegron - botox injections, ....
119
Urethritis (& RFx)
- inflammation / infection of urethra - gonococcal - N gonorrhoeae - Non-gonococcal - chlamydia, mycoplasma genitalium... RFs - MSM - <25yo - previous STIs - new sexual partner - >1 partner in last yr
120
Urethritis Px
- dysuria - penile irritation - discharge - sx of epididymitis / ReA
121
Urethritis Ix
- urethral swab / STI screen / first-void urine / MSU
122
Urethritis Mx
gonococcal - ceftriaxone 1g IM + azithromycin 1g oral Non-gonococcal - oral doxy 7d / single dose oral azithromycin contact tracing etc
123
Fourniers gangrene
- nec fasc that affects perineum - eg GAS, e coli... RFs - DM, alcohol, poor nutrition, steroids, trauma... Px - severe pain, fever, unwel - crepitus, skin necrosis, haemorrhagic bullae Ix - clinical dx - FBC, U/E, CRP, LFT, coag, cultures - CT - tissue / pus to MC+S Mx - broad spec abx - surgical debridement - skin grafts
124
Paraphimosis
- inability to replace retracted foreskin -> glans swells, reduced venous return -> penile ischaemia, infection RFs - phimosis, catheter, poor hygiene, prior occurrence Px - pain, swelling Mx - analgesia - manual pressure - dextrose soaked gauze - needle punctures into glans penis, drain swelling - Dundee technique - dorsal slit / emergency circumcision
125
Penile cancer
- rare urological cancer - mostly SCC - HPV 6,16,18 association RFs - HPV, phimosis, smoking, lichen sclerosis, untreated HIV - circumcision protective Px - ulcerating lesion on glans - +/- pain, - discharge / bleeding - inguinal lymphadenopathy Ix - penile biopsy - CT TAP, PET - TNM staging Mx - surgical removal - radio / chemo

finals (19 decks)

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