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urology Flashcards

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1
Q

what is varicocele?

A

dilation of testicular vein and pampiniform plexus

  • predominantly occurs on Left side
  • typically asymptomatic (sometimes dull ache)
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2
Q

PE findings for varicocele?

A

“bag of worms” - often found on ultrasound

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3
Q

is varicocele associated with male-factor infertility?

A

yes but not all men with varicoceles are infertile (impaired spermatogenesis from elevated temperatures)

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4
Q

varicocele grades

A

subliclinical (only detected by US, veins > 3 mm)

grade I - small, palpable with valsalva only

grade II- easily palpable at rest without valsalva

grade III- grosly palpable

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5
Q

how is varicocele treated?

A

subclinical is not treated

treated with syptoms or with infertility or impaired testicular growth. surgical-inbuinal, subinguinal microscopic, laparoscopic varicocelectomy

*abnormal semen analysis/infertility can be reversed with varicocelectomy

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6
Q

collections of fluid in the epididymis (epididymal cysts). PE is smooth, painless, transilluminate

A

spermatocele - tx rarely needed

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7
Q

twisting of the testis around the cord causing ischemia

A

testicular torsion

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8
Q

what is a risk of testicular torsion?

A

bell-clapper deformity - congenital malformation where tunical vaginalis attaches high/improperly on cord **surgical emergency

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9
Q

what is the presentation of testicular torsion?

A

sudden/acute testicular/scrotal pain, swelling

PE: **absent cremasteric reflex, anormal testicular lie

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10
Q

treatment of testicular torsion

A

surgery - manual detorsion “open the book” - physician stands at patient’s feet and manually rotates affected testicle away from midline

ischemia/pain 24 hours - 10% salvage

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11
Q

inflammation of the epididymis/testicle, very common in age 20-35

A

epididymitis/orchitis - can be bacterial (mostly), viral, fungal, idiopathic

Sexually active males 35 yrs think E. Coli

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12
Q

presentation of epididymitis/orchitis

A

pain and swelling over several days, also fever, scrotal erythema, testicular pain, dysuria. can mimic testicular torsion

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13
Q

risk factors for epididymitis/orchitis

A

sexual activity, bladder outlet obstruction, urologic surgery

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14
Q

tx for epididymitis/orchitis

A

males 35 yrs old:
Levofloxacin 500 mg PO daily for 10 days OR Ofloxacin 300 mg PO BID for 10 days

Also, analgesics, scrotal elevation, ice PRN

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15
Q

fluid collection between layers of tunic vaginalis

A

hydrocele

Communicating: Patent processus vaginalis allows fluid to pass from peritoneum to scrotum

Non-Communicating: No connection

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16
Q

difference between communicating and non-communicating hydrocele

A

Non-communicating:
Lymphatic or venous obstruction from trauma or infection
Develop slowly
Most common hydrocele in adults

Communicating:
Present at birth or first year of life
Most will resolve by age 2

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17
Q

how do you diagnose hydrocele?

A

scrotal mass that transilluminates. treat with surgical excision and observation

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18
Q

risk factors for ED

A 
shared with CV disease: 
Smoking
Obesity
Hypercholesterolemia
Metabolic Syndrome
Physical inactivity

ED is a risk factor for CV disease**

prostate cancer treatments

hypogonadism (low testosterone)

Peyronie’s Disease

neurologic conditions (MS, strokes)

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19
Q

prescription drugs that are a risk factor for ED

A

antihypertensives (diuretics, HCTZ, metoprolol)

antidepressants/antianxiety (sertraline, fluoxetine, lorazepam) - SSRIs are prescribed for premature ejaculation

antiandrogens, etc, (lueprolide, bicalutimide)

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20
Q

first line treatment for ED

A

PDE5I

Inhibit PDE5 –> smooth muscle relaxation –> incr blood flow –>veno-occlusive mechanism

-Tadalafil (cialis) has longest half life and also helps BPH

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21
Q

lower urinary tract symptomes (LUTS) of BPH

A 
frequency
nocturia
hesitancy, weak/slow stream
post-void dribbling
incomplete bladder emptying

Static component- direct bladder outlet obstruction from enlarged tissue
Dynamic phase- increased smooth muscle tone and resistance within the enlarged gland

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22
Q

digital rectal exam (DRE) for BPH

A

typically smooth enlargement, rubbery (Pca can be firm, hard, irregular)

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23
Q

Treatment of BPH

A

Surveillance (if mild symptoms, if symptoms are moderate/severe but patient has little or no bother, no complications) - monitor annually

Medical therapy- alpha blockers, alpha reductase inhibitors (decrease PSA by 50%)**have been shown to decrease risk of prostate cancer, combo therapies, phosphodiesterase inhibitors(cialis, MOA not well known)

Minimally invasive therapies

  1. transurethral needle ablation of prostate- TUNA and transurethral microwave thermotherapy-TUMT
    - done outpatient without general anesthesia
  2. Urolift system - trans-prostatic urethral implant that lifts and compresses prostate tissue

Surgical therapies

  • transurethral resection of prostate
  • laser vaporization of prostate ( *gold standard)/photoselective vaporization of prostate –>shorter hospital stay, no risk of TUR syndrome, decreased bleeding
  • simple prostatectomy - more “invasive”, typically done in patients with larger prostates (>100-120 cc) or with large bladder stones
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24
Q

most common urologic diagnosis in males

A

prostatitis - inflammation or infection of prostate that presents as several syndromes with varying clinical features

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25
acute bacterial prostatitis and chronic bacterial prostatitis pathogens
80% E coli 10-15% psuedomonas, klebsiella, proteus 5-10% enterococcus
26
category I - acute bacterial prostatitis presentation and treatment
presents with dysuria, frequency, perineal pain, back pain, fever/chills DRE- enlarged, boggy, tender prostate labs: elevated WBC, UA - pyuria, bacteria tx: antibiotics (IV cipro for in patient,, PO levofloxacin for outpatient), antipyretics, IVF, suprapubic catheter drainage
27
category II - chronic bacterial prostatitis presentation and treatment
Presentation-acute episodes of dysuria, perineal pain, frequency with culture-documented UTI (same organism each time) asymptomatic in between * can be ruled out if no culture-documented UTI present tx: TMP-SMX and fluoroquinolones (penetrate prostate) x 4-6 weks
28
Category III: Chronic prostatitis and chronic pelvic pain syndrome (CPPS) presentation and tx
Chronic/recurring episodes perineal, pelvic, testicular, penile pain, sometimes assoc with voiding dysfunction in absence of infection Causes-a primary event leading to immunologic stimulation followed by inflammatory response with persistent stimulation and neuropathic damage No infectious pathogens Treatments-?? Empiric ABX, sitz baths, NSAIDs, alpha blockers, etc Poorly understood and challenging synrome=Many frustrated patients
29
Category IV | Asymptomatic Inflammatory Prostatitis presentation and tx
Can be found incidentally on prostate biopsy | No treatment indicated
30
risk factors for prostate cancer
increasing age (more than 80% are diagnosed in men older than 65 years of age) family history (first degree relatives - two to three X greater risk) race (AA 1.6 more likely to get and also higher mortality) dietary factors (high animal fat) exposures (agent orange)
31
T or F: prior vasectomy and benign prostatic hypertrophy (BPH) increase risk of prostate cancer
false
32
prostate cancer development
develops in epithelium (possibly from basal cell later) requires androgens (testosterone) increased cell proliferation and decreased apoptosis
33
more than 95% or primary prostate cancers are what?
adenocarcinomas
34
who should be screened for prostate cancer?
* *do not screen younger than 40 - individualized screening fro men between 40-54 years - men 55-69 shared decision making
35
clinical manifestations of prostate cancer
can be asymptomatic and picked up by PSA >4 obstructive voiding symptoms (hesitancy, intermittent urinary stream, decreased force of stream) - typically indistinguishable from BPH ***hematuria and hematospermia edema of lower extremities or discomfort in pelvic and perineal areas
36
most common mets for prostate cancer
bone - can result in pathologic fractures of the long bones or spinal cord compression
37
what should prompt a biopsy for Prostate cancer?
a palpable nodule on digital rectal exam
38
what is the PSA threshold for prostate cancer?
4 ng/mL- 70-80% or tumors are detected ``` **age adjusted values 40-49: 0-2.5 50-59: 0-3.5 60-69: 0-4.5 70-79: 0-6.5 ```
39
what is a genomic prostate score (GPS)?
assesses prostate biopsy tissue, assigns a score based on 17 genes to predict the likelihood of high grade or advanced stage disease (T3)
40
prostate biopsy
only a snap shot. advanced imaging with 3T MIR dedicated to the prostate can help determine extent of disease. can also help to guide treatment choice
41
where does prostate cancer develop?
in the peripheral zone of the prostate (so biopsies directed towards here)
42
what is a gleason score?
sum of the two most common histologic patterns seen on each tissue specimen - very predictive of metastases and outcome
43
prostate cancer treatments
- watchful waiting - active surveillance - hormone therapy - androgen deprivation with lutenizing hormone releasing hormone - surgery (robotic is most preferred) - radiation - cryotherapy
44
what is PCA 3?
simple urine test. for men with life expectancy of greater than or equal to 10 years and 1 or more negative biopsies, and PSA of 3 or more
45
most common subtypes of renal cell carcinoma
clear cell (75-85%)-proximal tubule origin, abnormalities in chromosome 3p paillary (15%) - 85% of these are dx as stage I tumors, also proximal tubule in origin
46
epidemiology of renal cell carcinoma
male predominance, highest incidence between age 60-80
47
classic triad and presentation of renal cell carcinoma presentaiton
flank pain, hematuria, palpable abdominal mass hematuria present in 40% of patients- often with clots (non-glomerular)
48
how do you diagnose renal cell carcinoma?
ultrasound : solid vs. cystic lesions contrast CT: test of choice to evaluate tumor size, location, lymph node involvement
49
75-86% of RCC is what type?
clear cell
50
differences in RCC staging
TNM staging system Stage I-III: localized disease I: tumor 7 cm- 5 yr survival 88% III: tumor in major veins or adrenal gland, tumor within gerota's fascia, or 1 regional lymph node involvement yr survival 59% Stage IV: advanced, metastatic disease
51
poor prognostic indications for RCC
poor performance status, anemia, hypercalcemia, and elevated LDH
52
localized RCC treatment
radical nephrectomy is gold standard (open or laparoscopic depending on size and experience) - no role for adjuvant therapy except under investigational protocol cytoreductive nephrectomy in patients with good performance status
53
advanced RCC treatment
primary treatments are systemic therapy with molecularly targeted therapy or immunotherapy
54
what are immunotherapy treatments for advanced RC?
IL-2, sorafenib, sunitinib, and temsirolimus
55
does chemo work with RCC?
only minimally responsive (overall response 6%)
56
epidemiology of bladder CA
older persons (median age is 65) 3 times more common in men (women have worse prognosis) more prevelant in white persons
57
best known behavioral risk factor for bladder cancer
cigarette smoking
58
parasitic infection that is a risk factor for bladder cancer
schistosoma haematobium (schistosomiasis) - not common in US but is endemic in africa and middle east
59
most common and classic presentation of bladder cancer
Frank hematuria. **painless gross hematuria (consider all patients with gross hematuria to have bladder cancer until proven otherwise)
60
noninvasive test for the diagnosis of bladder cancer
voided urine cytology - used to identify high-grade tumors and monitor patients for persistent or recurrent disease following treatment
61
mainstay for diagnosis and surveillance of bladder cancer
cystoscopy - provides info about tumor size, location, appearance, and size (direct visualization of the bladder)
62
if a lesion is detected on cystoscopy, what is the next step for bladder cancer?
transurethral resection of bladder tumor - under general anesthesia ***if a patient has a positive voided cytology, move straight to the TUR**
63
all patients with bladder cancer need what?
to evaluate the upper urinary tract -renal ultrasonography, CT with and without IV contrast (urography), MRI
64
treatment for bladder cancer
non-muscle invasive tumors: transurethral resection, followed by close observation or intravesical chemotherapy or immunotherapy *high rate of disease recurrence and progression in non-muscle invasive bladder cancer muscle invasive disease: radical cystectomy with pelvic lymphadenectomy
65
indications for urine culture
pyelonephritis children, pregnant women patients with structural abnormalities of the urinary tract recurrent UTI
66
diagnostic criteria for UTI
historically 100,000 colonies/mL of single organism.. lower colony count of 1,000 colonies is accepted now
67
Urine for GC/chlamydia
should be first voided urine, needs to be processed as quickly as possible
68
what is the diagnostic procedure to visualize into the bladder?
cystoscopy- assess for stone, tumor, cystitis, diverticula
69
indications for diagnostic imaging/evaluation
fever after 3 days of antibiotics proteus in urine if ph > 8 (think struvite stones) hematuria, suspected obstruction, diabetes, stone disease
70
TMP/SMX treatment
Inhibits bacterial synthesis, therefore growth; useful except with P aeruginosa Dosing: 160 mg TMP/800mg SMX po q 12 hours UTI 3- 7 days Uncomplicated pyelonephritis 10-14 days May use with/without SMX

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