UROLOGY Flashcards by Eira Hegarty

3 types of urinary retention:

Chronic
Acute
Drug induced

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Types of chronic urinary retention, and their differentiating factors?

High Pressure: impaired renal function, bilateral hydronephrosis usually due to bladder outflow obstruction

Low Pressure: normal renal function, no hydronephrosis

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What can occur post-catheterisation for chronic retention, and what is the treatment?

Decompression haematuria due to rapid decrease in pressure.

No treatment required.

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Acute urinary retention is the most common urological emergency, coming on over hours or less. Classical patient script of someone presenting with acute urinary retention:

Man over 60, history of e.g. BPH.
Lower abdominal pain / tenderness / causing distress has come on over a few hours.
Inability to pass urine, ?confusion in elderly.

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Clinical examinations indicated in acute urinary retention:

Rectal +/- abdominal

Neurological

Pelvic if female

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Most common cause of acute urinary retention in men is BPH. Give some other causes.

Obstructive e.g. calculi, strictures, cystocele, constipation, mass

Medications e.g. anticholinergics, TCA, antihistamines, opioids, benzos

Neurological cause

Can occur postpartum

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Investigations in acute urinary retention and management:

Urinalysis with microscopy and culture

U+Es to check renal function, eGFR, creatinine
FBC and CRP for infection

PSA is NOT indicated, as it typically elevated in urinary retention

US bladder >300 cc = Catheterise!

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Complication of acute urinary retention and how is this managed?

Post obstructive diuresis

Loss of medullary concentration gradient, can lead to volume depletion and worsening of AKI

?IV fluids to correct the temporary fluid loss

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Discuss LUTS, splitting them into 3 groups of voiding, storage and post-micturition, and give 3 examination / investigations to go alongside these symptoms.

Voiding: incomplete bladder emptying, hesitancy, poor stream / dribbling, straining

Storage: urgency, frequency, nocturia, incontinence

Post-micturition: feeling of incompleteness

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What can you get from the patient who is presenting with LUTS to assess impact on life and to guide management?

Urine frequency / volume chart - distinguishes between frequency, polyuria, nocturia and nocturnal polyuria.

IPSS (International Prostate Symptom Score) - assesses impact of Sx on life, categorised into mild mod and severe

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Management of predominantly voiding symptoms:

Pelvic floor / bladder training, prudent lifestyle advice inc reduced fluid intakes.

If moderate to severe = alpha blocker e.g. tamsulosin

If large prostate / high risk of progression, give 5-alpha reductase inhibitor as well = finasteride

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Management of predominantly overactive bladder:

Bladder retraining

Oxybutynin, tolterodine, darifenacin first line options.

Mirabegron 2nd line.

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Urine dipsticks should NOT be used for the diagnosis in 3 different groups:

Catheter
Women >65
Men

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When should urine culture be sent in confirmed / suspected UTI?

Men
Women >65
Pregnancy
Recurrent UTI (2 episodes in 6 months / 3 in 12)
Haematuria

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Management of symptomatic and asx UTI in pregnancy:

Nitrofurantoin 7 days

Also send test of cure urine cultures

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Who should get 7 day courses of antibiotics for a UTI?

Men
Pregnant women
Catheterised with symptoms

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Signs / symptoms and treatment of acute pyelonephritis:

Fever, rigor
Loin pain
Nausea and vomiting
Dysuria
Urinary frequency

MSU sent before commencing antibiotics. Can be managed in community if stable. Ceftriaxone or cipro

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Malignant causes of haematuria:

Renal cell carcinoma
Bladder cancer - TCC, squamous, adenoma
Prostate carcinoma
Penile cancer

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Structural abnormalities that can cause haematuria:

BPH due to hypervascularisation of the gland
PKD
Renal vein thrombosis in RCC

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Non visible haematuria can be found as a one off cause or it can be more persistent. Give causes that would fit into each of these two groups.

One off findings:
UTI
Vigorous exercise
Menstruation
Sexual intercourse

Persistent:
Malignancy
Stones
BPH
Prostatitis
IgA nephropathy
Chlamydia urethritis

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When should an urgent referral be made in the context of haematuria?

45 or over + unexplained visible haematuria without a UTI OR visible haematuria that persists or returns even after treatment

60 or over with unexplained non-visible haematuria + dysuria OR raised white cell count

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When should a non-urgent referral be made in the context of haematuria?

Over 60 with recurrent or persistent UTI

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Investigations when haematuria is present:

Urine dipstick (persistent non-visible is diagnosed twice 2-3 weeks apart)

U+Es, eGFR

Albumin creatinine or protein creatinine ratio

Urine microscopy

Blood pressure!

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Who do you NOT need to refer in the context of haematuria?

<40, normal renal function, no proteinuria and BP normal

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Risk factors for testicular cancer:

Cryptorchidism Infertility Klinefelter syndrome Family history Mumps orchitis

First line investigation in suspected testicular cancer:

Ultrasound

Discuss the different types of testicular cancer. 95% are germ cell tumours.

95% germ cell (Other type is Leydig cell) Germ cell is split into seminoma and non-seminoma. Non-seminomas are further split into embryonal, yolk sac, teratoma and choriocarcinoma

Tumour marker in seminomas?

hCG in 20%

Tumour marker for germ cell tumours in general?

Raised lactate dehydrogenase

Tumour markers for all non-seminomas?

AFP + bhCG

Why does gynaecomastia occur in germ-cell tumours and Leydig cell tumours respectively?

Germ cell = hCG is raised, causing leydig cell dysfunction, increases oestradiol and testosterone, but more oest. Leydig = directly secretes more oestradiol and converts additional androgen precursors to oestrogens.

What is the most common organism that causes acute epididymo-orchitis?

Chlamydia

There are 2 types of bladder cancer, what are they and which is the most common?

1 = Uroepithelial carcinoma / Transitional cell carcinoma Squamous cell

Risk factors for squamous cell carcinoma of the bladder:

Smoking Shistosomiasis (endemic in e.g. African origin)

Risk factors for transitional cell carcinoma of the bladder:

Smoking Rubber factory Aniline dyes e.g. printing and textiles industry Cyclophosphamide *Current or previous smokers of the last 20 years have a 2-5x increased risk of bladder cancer

Most common presenting complaint for bladder cancer:

Painless visible haematuria

Regional lymph nodes around the bladder that a bladder cancer would metastasise to first (single = N1, multiple = N2):

Hypogastric Obturator External iliac Pre-sacral

Describe the structures that are invaded in T4, T4a and T4b bladder cancer:

T4 - prostatic stroma, seminal vesicles, uterus, vagina T4a - uterus, prostate, bowel T4b - pelvic sidewall or abdominal wall

A bladder cancer has invaded into the perivesicular fat. What stage is it?

Ta in bladder cancer refers to non-invasive papillary carcinoma. What invasion does T1, T2a and T2b describe?

Ta = non-invasive papillary T1 = subepithelial connective tissue T2a = superficial muscularis propria T2b = deep muscularis propria

Investigations in suspected bladder cancer:

Cystoscopy Biopsies

Management options for bladder cancer:

TURBT Recurrence / higher grade or risk = intravesical chemotherapy. ?Intravesical BCG vaccine = thought to stimulate the immune system. Radical cystectomy with urostomy and ileal conduit

4 surgical options for draining urine post radical cystectomy:

Urostomy - drains urine directly from kidney, bypassing ureter, bladder and urethra. Ileal conduit created. Continent urinary diversion - pouch created inside abdomen from a section of the ileum with the ureters connected. Intermittent catheterisation done by the patient. Neobladder reconstruction - new bladder from section of ileum. May require intermittent catheterisation and washout. Uterosigmoidostomy - ureters drain directly into sigmoid colon. Rarely done.

Which types of TCC's will have a worse prognosis and why?

70% of TCCs have a papillary growth pattern and are more superficial. Those with a mixed pattern / solid only pattern are more prone to invasion, may be of a higher grade / worse prognosis.

Investigation of suspected prostate cancer:

PSA DRE Multi-parametric MRI is first line ?Bone scan for staging

What type of cancer are 95% of prostate cancers?

Prostatic adenoma

What is the name of the system used to grade prostate cancer, and describe how to use it?

Gleason Multiple biopsies taken. Grades of a) most prevalent cell types and b) most prevalent cell type are assessed. Grades added together e.g. 3+4 = 7 6 = low risk 7 = moderate 8 = high

Which nodes will prostate cancer first spread to via lymphatics?

Obturator

4 causes of false positive PSA result:

Vigorous DRE Ejaculation Acute urinary retention BPH UTI Prostatitis

Who should the watch and wait option be for in prostate cancer?

Elderly Multiple comorbidities Low Gleason score

External radiotherapy is both potentially curative and palliative. Give 2 complications.

Rectal malignancy Radiation proctitis

Standard treatment for localised disease of the prostate +1 common side effect:

Radical prostatectomy + obturator node excision Erectile dysfunction is a common side effect

Testosterone stimulates prostate tissue and prostate cancers usually show some degree of testosterone dependence. As 95% of testosterone is derived from the testis, which operation could reduce the testosterone and therefore cause regression of the prostate cancer?

Bilateral orchidopexy

Multi-parametric MRI of the prostate is now the first line investigation for suspected cancer. What scale are the results reported on and what do they mean?

Likert scale 5 points 1-2 = discuss pros and cons of biopsy >3 = offer MRI influence biopsy

Anti-androgen therapy is key in treating metastatic prostate cancer. What kind of drug is Goserelin, and how does it work?

GnRH agonist Causes overstimulation of the pituitary, disrupting normal endogenous feedback systems, resulting in paradoxically low LH eventually. Testosterone rises initially for 2-3 weeks before falling to castration level.

When is hormone therapy considered in prostate cancer?

Advanced metastatic cancer

What type of drug is bicalutamide and when is it used in prostate cancer?

Non-steroidal anti-androgen / androgen receptor blocker Metastatic disease

Peak incidence of testicular torsion, and what actually happens?

10-13 years Twisting of the spermatic cord, can result in ischaemia and necrosis

Symptoms and clinical examination findings of testicular torsion:

Severe, sudden onset pain Can be referred to the abdomen Prehn's sign - pain NOT alleviated by elevation of the testes Testis will be retracted, may be red Nausea and vomiting Loss of cremasteric reflex Often triggered by playing sport

Management of suspected testicular torsion:

Urgent surgical exploration under anaesthesia, immediate. <6 hours is time frame where least incidence of testes loss Fix both - orchidopexy

What is meant by a bell-clapper deformity?

Normally the testis is tethered posteriorly to the tunica vaginalis, but in bell clapper this is not the case / not fixed. Testis sits more horizontally. Is bilateral. Able to rotate = this is why there is twisting of the cord.

What is an arbitrary window of time from symptom onset that surgery should be done in in testicular torsion?

? 6 hours

UROLOGY Flashcards

(62 cards)