Urology Flashcards

Question

Peri-aortitis ass/ Presentations

Answer 1

Ass/  Drugs: β-B, bromocriptine, methysergide, methyldopa  AI disease: thyroiditis, SLE, ANCA+ vasculitis  Smoking  Asbestos ``` Presentation  Middle–aged male  Vague loin, back or abdo pain  ↑ BP  Chronic urinary tract obstruction ```

Answer 2

Ix  Blood: ↑U and Cr, ↑ESR/CRP, ↓Hb  US: bilateral hydronephrosis + medial ureteric deviation CT/MRI: peri-aortic mass  Biopsy: exclude Ca Rx  Relieve obstruction: retrograde stent placement  Ureterolysis: dissection of ureters from retroperitoneal tissue.  ± immunosuppression

Answer 3

 ↑ concentration of urinary solute  ↓ urine volume  Urinary stasis ``` Common anatomical sites  Pelviureteric junction  Crossing the iliac vessels at the pelvic brim  Under the vas or uterine artery  Vesicoureteric junction ```

Answer 4

Calcium oxalate: 75%  ↑ risk in Crohn’s Triple phosphate (struvite): 15%  Ca Mg NH4 – phosphate  May form staghorn calculi  Assoc. c¯ proteus infection Urate: 5% (radiolucent)  Double if confirmed gout Cystine: 1% (faint)  Assoc. c¯ Fanconi Syn

Answer 5

 Dehydration  Hypercalcaemia: primary HPT, immobilisation  ↑ oxalate excretion: tea, strawberries  UTIs  Hyperuricaemia: e.g. gout  Urinary tract abnormalities: e.g. bladder diverticulae  Drugs: frusemide, thiazides

Answer 6

Ureteric colic (severe loin to groin pain, n/v, pt cannot lie still) Bladder or Urethral Obstruction  Bladder irritability: frequency, dysuria, haematuria  Strangury: painful urinary tenesmus  Suprapubic pain radiating → tip of penis or in labia  Pain and haematuria worse at the end of micturition ``` Other features  UTI  Haematuria  Sterile pyuria  Anuria ```

Answer 7

Urine  Dip: haematuria  MC+S Blood  FBC, U+E, Ca, PO4, urate Imaging KUB XR  90% of stones radio-opaque  Urate stones are radiolucent, cysteine stones are faint USS: hydronephrosis Spiral non-contrast CT-KUB  99% of stones visible  Gold standard IVU  600x radiation dose of KUB  IV contrast injected and control, immediate and serial films taken until contrast @ level of obstruction >Abnormal findings  Failure of flow to the bladder  Standing column of contrast  Clubbing of the calyces: back pressure  Delayed, dense nephrogram: no flow from kidney C/I - Contrast allergy, Severe asthma, Metformin, Pregnancy

Answer 8

 DMSA: dimercaptosuccinic acid  DTPA: diethylenetriamene penta-acetic acid  MAG-3

Answer 9

 Drink plenty  Treat UTIs rapidly  ↓ oxalate intake: chocolate, tea, strawberries

Answer 10

<5mm and lower 1/3 - conservative Medical - stone 5-10mm - Nifedipine or tamsulosin +/- prednisolone Active stone >10mm, persistent, renal insufficiency, infection Extracorporeal shockwave lithotripsy Ureteronoscopy + dormier basket removal Percutaneous Lap or open surgery rare

Answer 11

surgical emergency percutaneous nephrostomy or ureteric stent IV abx - cefuroxime 1.5g IV TDS

Answer 12

```  Obesity  Smoking  HTN  Dialysis (15% of pts. develop RCC)  4% heritable: e.g. VHL syndrome ```

Answer 13

Adenocarcinoma from proximal renal tubular epithelium (90%) ``` Subtypes  Clear Cell (glycogen): 70-80%  Papillary: 15%  Chromophobe: 5%  Collecting duct: 1% ```

Answer 14

50% incidental finding Triad: Haematuria, loin pain, loin mass Systemic: anorexia, malaise, wt. loss, PUO Clot retention Invasion of L renal vein → varicocele (1%) Cannonball mets → SOB

Answer 15

```  EPO → polycythaemia  PTHrP → ↑ Ca  Renin → HTN  ACTH → Cushing’s syn.  Amyloidosis ```

Answer 16

Spread  Direct: renal vein  Lymph  Haematogenous: bone, liver and lung Ix  Blood: polycythaemia, ESR, U+E, ALP, Ca  Urine: dip, cytology ``` Imaging  CXR: cannonball mets  US: mass  IVU: filling defect  CT/MRI ```

Answer 17

Renal Cell Carcinoma 1. Confined to kidney 2. Involves perinephric fat, but not Garota’s fascia 3. Spread into renal vein 4. Spread to adjacent / distant organs

Answer 18

Medical  Reserved for pts. c¯ poor prognosis  Temsirolimus (mTOR inhibitor) Surgical  Radical nephrectomy  Consider partial if small tumour or 1 kidney

Answer 19

assw chronic staghorn calucli

Answer 20

RF Smoking, amine exposure, cyclophosphamdie Highly malignant locations - bladder 50%, ureter, renal pelvis Ix - urine cytology - CT/MRI - IVU - pelviceal filling defect Mx - nephrourectomy - regular f/up - 50% develop bladder tumours

Answer 21

Childhood tumour of primitive renal tubules and mesenchymal cells  May be assoc. c¯ Chr 11 mutation  May be assoc. c¯ WAGR syndrome  Wilms, Aniridia, GU abnormalities, Retardation ``` Presentation  2-5yrs  5-10% bilat  Abdo mass (doesn’t cross the midline)  Haematuria  Abdo pain  HTN ```

Answer 22

Painless Haematuria Voiding irritability (dysuria, frequency, urgency Recurrent UTI Retention + obstructive renal failure

Answer 23

``` Smoking Amine exposure (rubber industry) Previous renal TCC Chronic cystitis Schistosomiasis (SCC) ``` Urechal remnants (adenocarcinomas)  Embryological remnant of communication between umbilicus and bladder Pelvic irradiation

Answer 24

```  Urine: dip (sterile pyuria), cytology  IVU: filling defects  Cystoscopy c¯ biopsy: diagnostic  Bimanual EUA: helps to assess spread  CT/MRI: helps stage ```

Answer 25

TIS, Ta and T1 (Superficial)  80% of all pts.  Diathermy via transurethral cystoscopy / Transurethral Resection of Bladder Tumour (TURBT)  Intravesicular chemo: mitomycin C  Intravesicular immunotherapy: Bacille Calmette-Guérin T2, T3 (Invasive)  Radical cystectomy w ileal conduit is gold standard  Radiotherapy: worse 5ys but preserves bladder  Salvage cystectomy can be performed  Adjuvant chemo: e.g. M-VAC  Neoadjuvant chemo may have a role T4  Palliative chemo / radiotherapy  Long-term catheterisation  Urinary diversions Complications  Massive bladder haemorrhage  Cystectomy → Sexual and urinary malfunct

Answer 26

 Up to 70% of bladder tumours recur therefore intensive f/up is required.  History, examination and regular cystoscopy  High-risk tumours: every 3mo for 2yrs, then every 6mo  Low-risk tumours: @ 9mo, then yrly

Answer 27

Benign nodular or diffuse hyperplasia of stromal and epithelial cells ``` Affects inner (transitional) layer of prostate (cf. Ca)  → urethral compression ``` DHT produced from testosterone in stromal cells by 5α-reducatase enzyme. DHT-induced GFs → ↑ stromal cells and ↓ epithelial cell death.

Answer 28

``` Storage Sx  Nocturia  Frequency  Urgency  Overflow incontinence ``` ``` Voiding Sx  Hesitancy  Straining  Poor stream/flow + terminal dribbling  Strangury (urinary tenesmus)  Incomplete emptying: pis en deux ``` Bladder stones and UTI (2ndary to stasis)

Answer 29

PR  Smoothly enlarged prostate  Definable median sulcus Bladder not usually palpable unless acute-on-chronic obstruction ``` Ix Blood: U+E, PSA (after PR)  Urine: dip, MC+S  Imaging (Transrectal US ± biopsy)  Urodynamics: pressure / flow cystometry  Voiding diary ```

Answer 30

Conservative  ↓ caffeine, EtOH  Double voiding  Bladder training: hold on → ↑ time between voiding Medical  Useful in mild disease and while awaiting TURP ``` 1st: α-blockers  Tamsulosin, doxazosin  Relax prostate smooth muscle  SE: drowsiness, ↓BP, depression, EF, wt. ↑, extra-pyramidal signs ``` 2nd: 5α-reductase inhibitors  Finasteride  Inhibit conversion of testosterone → DHT  Preferred if significantly enlarged prostate.  SE: excreted in semen (use condoms), ED

Answer 31

Indications  Symptoms affect QoL  Complications of BPH TURP  Cystoscopic resection of lateral and middle lobes  ≤14% become impotent Transurethral incision of prostate (TUIP)  < destruction → ↓ risk to sexual function  Similar benefits to TURP if small prostate (<30g) Tranurethral ElectroVaporisation of Prostate  Electric current → tissue vaporisation Laser prostatectomy  ↓ ED and retrograde ejaculation  Similar efficacy as TURP Open retropubic prostatectomy  Used for very large prostates (>100g)

Answer 32

Immediate  TUR syndrome - Absorption of large quantity of fluids → ↓Na  Haemorrhage Early  Haemorrhage  Infection  Clot retention: requires bladder irrigation ``` Late  Retrograde ejaculation: common  ED: ~10%  Incontinence: ≤10%  Urethral stricture  Recurrence ```

Answer 33

Adenocarcinoma Peripheral Zone of prostate ``` Presentation  Usually asymptomatic  Urinary: nocturia, frequency, hesitancy, poor stream, terminal dribbling, obstruction  Systemic: wt. loss, fatigue  Mets: bone pain ```

Answer 34

Examination  Hard irregular prostate on PR  Loss of midline sulcus Spread  Local: seminal vesicles, bladder, rectum  Lymph: para-aortic nodes  Haem: sclerotic bony lesions

Answer 35

Bloods: PSA, U+E, acid and alk phos, Ca ``` Imaging  XR chest and spine  Transrectal US + biopsy  Bone scan  Staging MRI >Contrast enhancing magnetic nanoparticles ↑s detection of affected nodes. ```

Answer 36

Proteolytic enzyme used in liquefaction of ejaculate Not specific for prostate Ca  ↑ ¯c age, PR, TURP, and prostatitis >4ng/ml: 40-90% sensitivity, 60-90% specificity  Only 1-in-3 will have Ca Normal in 30% of small cancers

Answer 37

 Score two worst affected areas |  Sum is inversely proportional to prognosis

Answer 38

TIS Carcinoma in situ T1 Incidental finding on TURP or ↑PSA T2 Intracapsular tumour c¯ deformation of prostate T3 Extra-prostatic extension T4 Fixed to pelvis + invading neighbouring structures N1-4 1 or more lymph nodes involved M1 Distant mets, e.g. spine

Answer 39

``` Help determine whether to pursue radical Rx Age Pre-Rx PSA Tumour stage Tumour grade ```

Answer 40

Conservative: Active Monitoring  Close monitoring c¯ DRE and PSA Radical Therapy Radical prostatectomy (+ goserelin if node +ve)  Performed laparoscopicaly w robot  Only improves survival vs. active monitoring if <75yrs Brachytherapy: implantation of palladium seeds SEs: ED, urinary incontinence, death (0.2-0.5%)

Answer 41

Medical Used for metastatic or node +ve disease LHRH analogues  E.g. goserelin  Inhibit pituitary gonadotrophins → ↓ testosterone Anti-androgens  E.g. cyproterone acetate, flutamide

Answer 42

 TURP for obstruction  Analgesia  Radiotherapy for bone mets / cord compression

Answer 43

Aetiology  S. faecalis  E. coli  Chlamydia ``` Presentation  Usually >35yrs  UTI / dysuria  Pain (Low backache/on ejaculation)  Haematospermia  Fever and rigors  Retention  Malaise ``` Examination  Pyrexia  Swollen / boggy / tender prostate on PR  Examine testes to exclude epididymo-orchitis Ix  Blood: FBC, U+E, CRP  Urine: dip, MC+S Rx  Analgesia  Levofloxacin 500mg/d for 28d

Answer 44

Usually caused by prostatic enlargement  Urge incontinence or dribbling may result from partial retention.  Retention may → overflow (palpable bladder after voiding) TURP and pelvic surgery may weaken external urethral sphincter.

Answer 45

 Leakage from incompetent sphincter when IAP ↑  Loss of small amounts of urine when coughing  Pelvic floor weakness

Answer 46

 Can’t hold urine for any length of time  May have precipitant: arriving home, running water, coffee Dx: urodynamic studies

Answer 47

Check  PR: faecal impaction  Palpable bladder after voiding: retention c¯ overflow  UTI  DM  CNS: MS, Parkinson’s stroke, spinal trauma  Diuretics ``` Stress Incontinence  Pelvic floor exercises  Ring pessary  Duloxetine  Surgery: tension-free vaginal tape ``` Urge Incontinence  Bladder training  Wt. loss  Anti-AChM: tolterodine, imipramine

Answer 48

Surgical: Orchidopexy by Dartos Pouch Procedure  Perform before 2yrs  Mobilisation of testis and cord  Removal of patent processus  Testicle brought through a hole made in the dartos muscle to lie in a subcutaneous pouch.  Dartos prevents retraction. Hormonal  β-HCG may be tried if testis is in inguinal canal

Answer 49

Occurs because testicle doesn’t have a large “bare area” to attach to scrotal wall.  Tunica vaginalis invests whole of testicle  Free-hanging “clapper bell” testicle can twist on its mesentery. usually 2ndary to exertion or minor trauma

Answer 50

 Usually 10-25yrs  Sudden onset severe pain in one testis  May have lower abdominal pain (testis supplied by T10)  Assoc. c¯ n/v  May be Hx of previous testicular pain or torsion

Answer 51

 Inflam of one testis: hot, swollen, extremely tender  Testis rides high and lies transversely Ix Doppler US -may demonstrate absence of flow > MUST NOT DELAY SURGICAL EXPLORATION

Answer 52

Surgical emergency  4-6h window from onset of pain to salvage testis Inform senior NBM IV access  Analgesia  Bloods: FBC, U+E, G+S, clotting Surgery  Consent for possible orchidectomy  Bilateral orchidopexy: suture testes to scrotum If no torsion found and epididymo-orchitis Dx, take fluid sample from scrotum for bacteriology and Rx c¯ Abx.

Answer 53

Epididymo-orchitis  Older pt.  UTI symptoms  More gradual onset ``` Torted Hydatid of Morgagni  Remnant of Mullerian duct  Younger pt.  Less pain  Tiny blue dot visible on scrotum ```  Tumour  Trauma  Strangulated hernia  Appendicitis

Answer 54

 Can’t get above: inguinoscrotal hernia  Separate, cystic: epididymal cyst  Separate, solid: varicocele, sperm granuloma, epididymitis  Testicular, cystic: hydrocele  Testicular, solid: tumour, orchitis, haematocele

Answer 55

Develop in adulthood contain clear or milky (spermatocele) fluid Lie above and behind testis Remove if Sx

Answer 56

Dilated veins of pampiniform plexus ``` Presentation  Feel like bag of worms in the scrotum  May be visible dilated veins  ↓ size on lying down  Pt. may c/o dull ache  May → oligospermia (↓ fertility) ``` Pathology  1O: Left side commoner: drain into left renal vein  2O: left renal tumour has tracked down renal vein → testicular vein obstruction. Mx  Conservative: scrotal support  Surgical: clipping the testicular vein (open or lap)

Answer 57

Painful lump of extravasated sperm after vasectomy

Answer 58

Collection of serous fluid w/i tunica vaginalis Primary  assoc. w patent processus vaginalis  Commoner, larger, tense, younger men Secondary  Tumour, trauma, infection  Smaller, less tense Ix - US testicle to exclude tumour Mx May resolve spontaneously ``` Surgery  Lord’s Repair: plication of the sac  Jaboulay’s Repair: eversion of the sac Aspiration  Usually recur so not 1st line.  Send fluid for cytology and MC+S ```

Answer 59

 Blood in the tunica vaginalis  Hx of trauma  May need drainage or excision

Answer 60

 STI: Chlamydia, gonorrhoea  Ascending UTI: e. coli  Mumps Features  Sudden onset tender swelling  Dysuria  Sweats, fever ``` Examination  Tender, red, warm, swollen testis and epididymis  Elevating testicle may relieve pain  Secondary hydrocele  Urethral discharge ```

Answer 61

``` Ix  Blood: FBC, CRP  Urine: dip, MC+S (fist catch may be best)  Urethral swab and STI screen  US: may be needed to exclude abscess ``` Complications  May → infertility ``` Mx  Bed rest  Analgesia  Scrotal support  Abx: doxycycline or cipro  Drain abscess if present ```

Answer 62

Acute inflammation of the foreskin and glans Cause: Strep, staph infection, Candida (DM) RFs: DM, young children c¯ tight foreskin Rx: hygiene advice, Abx, circumcision

Answer 63

Foeskin occludes the meatus Children Pres: recurrent balanitis and ballooning  Mx: Gentle retraction, steroid creams, circumcision Adult Pres dyspareunia, infection  Mx: circumcision  Assoc. c¯ balanitis xerotica obliterans: thickening of foreskin and glans → phimosis + meatal narrowing

Answer 64

Tight foreskin retracted becomes irreplaceable ↓ venous return → oedema and swelling of the glans  Can rarely → glans ischaemia Causes: catheterisation, masturbation, intercourse Mx:  Manual reduction: use ice and lignocaine jelly  May require glans aspiration or dorsal slit

Answer 65

Developmental abnormality of the position of the urethral opening  Hypospadia: opens on ventral surface of penis  Epispadia: opens on dorsal surface

Urology Flashcards

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