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Urology Flashcards

(48 cards)

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1
Q

Definition of benign prostatic hyperplasia

A

Nonmalignant proliferation of the epithelial and stromal cells of the prostate gland. It is a gradually progressive histologic change primarily in the transitional zone of the prostate, which leads to enlargement of the prostate especially in older men and causes lower urinary tract symptoms

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2
Q

Risk factors for developing BPH

A 
Advanced age
Obesity
Reduced physical activity
Diabetes
Fatty diet
Diet high in beef
Systemic HTN

Protective factors:
Alcohol, liver cirrhosis (high oestrogen relative to androgen)

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3
Q

Clinical features of BPH

A 
gradual onset and progression
Lower urinary tract symptoms
- inc frequency
- nocturia
- hesitancy
- urgency
- weak urinary stream
- incomplete voiding
- incontinence
- +/- haematuria
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4
Q

Complications of BPH

A

Acute urinary retention
Recurrent UTIs
Hydronephrosis
Renal failure

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5
Q

BPH on DRE

A

firm, symmetrical enlargement
Non-tender
Normal sphincter tone
No saddle anaesthesia

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6
Q

Grading of BPH

A 
IPSS (international prostate symptom score)
Score of 0-5 for the following topics:
- incomplete emptying
- frequency
- intermittency
- urgency
- weak stream
- straining

0-7 without bother: non-pharmacological
0-7 + bothered about symptoms: nonpharmacological therapies + alpha blocker
9-35: nonpharmacological + alpha blocker and/or 5a-reductase inhibitor

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7
Q

Non-pharmacological management of BPH

A 
Watchful waiting
Life-style modification
- reduce fluid intake
- bladder training exercises
- double voiding
- reduced caffeine and alcohol intake
- monitoring of symptoms for progression
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8
Q

Pharmacological therapies for BPH

A

Alpha-blockers (e.g. prazosin)
- onset of action 1 week
- red. smooth muscle tone, red. prostatic and bladder neck contraction - reduced symptoms
5a-reductase inhibitors
- e.g. finasteride/dutasteride
- onset of action 3-6m
- reduced conversion of testosterone to DHT - reduced stimulation of prostate tissue - reduced progression of hypertrophy

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9
Q

Side effects of alpha blockers used in BPH e.g. prazosin

A

Orthostatic hypotension
1st dose syncope
Nasal congestion
tachycardia

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10
Q

Side effects of 5a-reductase inhibitors (e.g. finasteride used in BPH)

A

Reduced libido
Erectile dysfunction
Breast tenderness

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11
Q

Surgical therapies for BPH

A 
Minimally invasive:
- TUNA (transurethral needle ablation)
- TUMT (transurethral microwave therapy)
Standard surgical therapies:
- TURP (transurethral resection of the prostate)
- laser prostatectomy
- open prostatectomy
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12
Q

Indications for TURP

A
  • Symptoms of BPH unresponsive to medical therapy
  • Persistent haematuria (other causes excluded)
  • Renal failure
  • Bladder stones
  • recurrent UTI
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13
Q

When to refer man with BPH to urologist

A

No improvement within 6 weeks of treatment with best pharmacological regime

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14
Q

Risk factors for prostate cancer

A

Africa background
high dietary fat
Family history: one 1st degree - 2x risk, two 1st degree - 5x risk

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15
Q

Most common types and sites of prostate cancer

A 
Adenocarcinoma (over 95%)
Urothelial carcinoma (4.5% associated with TCC of bladder, not hormone-responsive)

70% arise from peripheral zone (classically posterior)
20% arise in transition zone
10% arise in central zone

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16
Q

Clinical features of prostate cancer

A 
Obstructive voiding symptoms (reflects locally advanced disease into bladder neck or urethra)
- hesitancy
- intermittent urinary stream
- reduced force of stream
Locally advanced tumours:
- haematuria
- haematospermia
- painful ejaculation
Spread to regional LN:
- LL oedema
- discomfort in pelvic/perineal areas
Bony mets:
- severe unremitting pain
- pathological fractures
- spinal cord compression
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17
Q

Diagnosis of Prostate cancer

A

Made by DRE, PSA and TRUS biopsy

PSA not useful for diagnosis, used to monitor treatment and relapse

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18
Q

Histology of prostate adenocarcinoma

A

Smaller glands lined by single uniform layer of cuboidal or low columnar epithelium
More crowded glands than normal
Lack branching and papillary infolding
Absent basal cell layer typical of benign glands!

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19
Q

Procedure of transrectal ultrasound guided biopsy

A 
Local anaesthetic (lignocaine)
lie in lateral position
US probe inserted into rectum
Take 10-12 core specimens (target peripheral zone, try to avoid transitional zone {BPH} at least on first biopsy)
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20
Q

Complications/risks of transrectal US guided biopsy

Study These Flashcards
A

Bleeding (rarely serious)
Infection - give prophylactic antibiotics in periprocedural time
Missed diagnosis (may require 2nd or 3rd biopsies)

21
Q

Grading and staging of prostate cancer

Study These Flashcards
A

Staging by TNM score
Grading by Gleason’s score:
- score our of 10
- addition of the 2 most predominant patterns

1 - 5 from well differentiated to poorly differentiated (higher score = worse prognosis)

22
Q

management of prostate cancer

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A

Watchful waiting:

  • if PCa is slow growing and unlikely to cause problems
  • treat with palliative intent when symptoms arise

Active surveillance:

  • younger men who are candidates for definitive treatment
  • delay curative treatment until evidence of progression
  • Frequent PSA review and biopsy

Radical prostatectomy

Radiotherapy (localised cancer with curative intent - local ductal seeds, external beam)

Hormonal therapy: non-curative intent for metastatic disease
- 3-monthly injection of GnRH agonist

23
Q

Complications of prostatectomy

Study These Flashcards
A

Similar in robotic v laparoscopic v open

  • erectile dysfunction 40% (may be able to manage with viagra, penile injections or vacuum pumps)
  • dry orgasm
  • incontinence
24
Q

Complications of hormonal therapy for prostate cancer

Study These Flashcards
A

GnRH agonist

  • flushes
  • reduced libido
  • DM
  • reduced body fat
  • osteoporosis
  • anaemia
  • muscle atrophy
25
Staging of bladder cancer
T1: superficial T2: into muscle T3: into perivesicular fat T4: invasion into another organ
26
Risk factors for bladder cancer
``` Age Smoking Family history (esp. young) Occupational carcinogens: dyeing, rubber, printing, metal industries Chronic indwelling foreign body Chronic cystitis Chronic analgesic use Pelvic irradiation ```
27
Types of bladder cancer
Over 90% transitional cell carcinoma | Some squamous cell carcinomas and adenocarcinomas
28
Clinical features of bladder cancer
Painless haematuria - may be intermittent - passing clots MAY BE PAINFUL - needs admission, 3-way catheter for washout Often associated with UTI/cystitis (irritative symptoms)
29
Investigations in bladder cancer
``` Cystoscopy and biopsy Urine cytology (very specific but low sensitivity) ```
30
Management of bladder cancer
Carcinoma in situ: - high-grade and invasive in bladder cancer - CTx or Immunotherapy (mitomycin) - cystectomy if young - BCG (tuberculosis) - causes huge immune response - reduces recurrence and progression to deeper layer) Ta: superficial, can burn off TURBT Muscle-invasive: - radical cystectomy - radiotherapy or combined treatments
31
What does a radical cystectomy involve
In males: bladder and prostate In females: bladder, urethra, uterus, most of vagina, ovaries, fallopian tubes Reconstruction: ileal conduit (ureters - bit of bowel) Use lots of ileum to reconstruct neobladder (absorbs toxins as urine sits waiting to void)
32
Causes of haematuria
``` Bladder cancer Renal cancer Prostate cancer Renal calculi (painful) BPH Ureteric cancer Infection Trauma (e.g. catheter) Renal (glomerular disease, polycystic kidney) Papillary necrosis Bleeding disorders or anticoagulants ```
33
Kidney tumours
Renal cell carcinomas - arise from renal cortex (85%) Transitional cell carcinomas - arise from renal pelvis (8%) Secondary tumours usually clinically insignificant and discovered post-mortem
34
Risk factors for renal cell carcinoma
Cigarette smoking HTN Obesity Acquired cystic disease of the kidney
35
Most common histological group of renal cell carcinoma
Clear cell carcinoma | Notoriously resistant to chemotherapy
36
Classic triad of renal cell carcinoma
Flank pain, haematuria and palpable abdominal mass (less than 10% of patients, only occurs when locally advanced)
37
Flank pain, haematuria and palpable abdominal mass is the classic triad of what
Renal cell carcinoma
38
Symptoms and signs of renal cell carcinoma
``` Related to invasion of adjacent structures or distant mets - haematuria - abdo or flank mass - scrotal varicoceles (mainly L sided) - IVC involvement - pitting oedema, ascites, hepatic dysfunction Paraneoplastic syndromes: - anaemia - hepatic dysfunction - hypercalcaemia - cachexia - erythrocytosis - secondary amyloidosis - thrombocytosis - polymyalgia rheumatica ```
39
Investigations for unexplained haematuria
Abdo USS Abdo CT MRI
40
Management of renal cell carcinoma
Localised (stage I-III): - Radical nephrectomy - Renal sparing (partial nephrectomy or ablative techniques) - -tumours less than 4cm, solitary kidneys, bilateral renal cancer - Acute surveillance in elderly or not fit for surgery Advanced disease: generally unresectable - medical therapy (molecularly targeted) - - bevacizumab (humanised VEGF neutralising monoclonal antibody) - - tyrosine kinase inhibitors
41
Why does renal cell carcinoma respond poorly to chemotherapy
Proximal tubule multiresistance
42
Risk factors of nephrolithiasis
``` History of nephrolithiasis Gout - uric acid stones Hypercalcaemia Low fluid intake Occupational exposure to continual high temperature Obesity HTN Diabetes Excessive physical activity IBD/bariatric surgery (inc. enteric absorption of oxalate) ```
43
Types of stones in nephrolithiasis
Clacareous stones (calcium containing) - 80% - Calcium oxalate (70%) - Calcium phosphate (5-10%) - Radiopaque on plain film Noncalcareous Stones: - struvite/infection (15-20%) - uric acid (10%) - Cysteine stones (less than 1%) - associated with autosomal recessive cystinuria - all are radiolucent on plain film, can be seen on CT
44
Struvite stones: composition and cause
Magnesium, ammonium and calcium phosphate Leading cause of staghorn stones (occupying entire renal pelvis) Cause by urea-splitting bacteria - alkalisation of the urine - Klebsiella - proteus - mirabilis
45
Clinical features of nephrolithiasis
- intermittent crampy loin-groin pain - paroxysms of severe pain 20-60min - passage of stone or gravel - haematuria - nausea, vomiting - dysuria, urgency - costovertebral or flank tenderness
46
indications for conservative management of nephrolithiasis
- small stones (under 7mm) - no signs of sepsis - normal renal function (with 2 kidneys) - no ISS ``` Hydration Analgesia (indomethacin) Medical expulsive therapy (relax ureter) - prazocin, nifedipine Repeat imaging in 2-3w to ensure pasasge ``` Stones under 5mm will pass up to 98% of the time, over 5mm will pass less than 50%
47
Indications for urgent urological consultation in nephrolithiasis
- single kidney - bilateral calculi - pre-existing renal impairment - obstructed infected kidney - pregnancy (increases risk of miscarriage) - ongoing pain with simple analgesia - severe sepsis
48
Definitive management of nephrolithiasis
If systemically unwell: urgent renal compression (percutaneous nephrostomy, cystoscopy with ureteric stent placement) Medical: for uric acid stones - allopurinol/ural Surgical: - extracorporeal shock wave lithotripsy - ureteroscopy/laser - percutaneous nephrolithotomy for larger stones

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