urology Flashcards
(88 cards)
1
Q
calcium stones
A
Majority of stones 75% • Calcium oxalate are the most common o due to hypercalciuria o hard and dark stones o acidic urine o Urinalysis: colorless tetrahedral (envelope shape), oval or dumbbell shape, polarizable o Seen in ethylene glycol poisoning • Calcium phosphate: less common, softer and paler stones in alkaline urine
2
Q
struvite stones
A
- Struvite (triple phosphate): magnesium ammonium phosphate—15%
- Due to urea splitting bacteria (proteus, staph, providencia)
- Staghorn caliculi
- Urine is alkaline
- Urinalysis: colorless rectangles, coffin lid shaped crystals
3
Q
uric acid stones
A
- Uric acid: 6%
- Due to hyperuricemia
- Radiolucent stones
- Acidic urine
- Urinalysis: rhomboid crystals
4
Q
cysteine stones
A
- Cysteine: rare—1% of stones
- due to genetic defects in cystine transport
- Aut Rec
- Stones are yellow-brown and radioopaque
- Acidic urine
- Urinalysis: flat hexagonal crystals “stop sign”
5
Q
etiologies of infectious cystitis
A
o Culture negative cystitis: ureaplasm urealyticum, Chlamydia, mycoplasma hominis
o Bacterial cystitis: E coli, Staph saprophyticus, klebsiella
• Tuberculous cystitis by mycobacterium tuberculosis
o Fungal cystitis: candida
o Parasite cystitis: schistosomiasis
o Viral cystitis: adenovirus (type 11), HSV2
• Hemorrhagic cystitis: Present as viral cystitis bone marrow transplant recipients (also caused by cyclophosphamide)
6
Q
interstitial cystitis
A
“painful bladder syndrome”
o Persistent cystitis with pelvic pain and irritative voiding symptoms
o Females
o Multifactorial
o Cytoscopy: punctate hemorrhage of “hunner ulcer”
o Diagnosis of exclusion
o Vs overactive bladder—urgency of urination, pain is not the key feature but urine leakage is
7
Q
malakoplakia
A
inflammatory d/o w/ accumulation of macrophages in GU tract (esp. bladder)
o Older females, immunosuppressed, chronic infection, cancer
o Assoc. w/ UTI caused by E. coli
o Soft yellow plaques on surface of bladder
o Michaelis-Gutman bodies (engorged lysosomes containing bacteria)
8
Q
hypospadia
A
urethra opens on underside of penis; more common; easier to repair
9
Q
epispadia
A
urethra opens on upper side of penis; less common; harder to repair
10
Q
phimosis
A
narrowing of prepuce orifice; impairs retraction over glans; can strangulate glans and predisposes to infection/cancer
11
Q
paraphimosis
A
strangulation of glans; usually due to recurrent infection/trauma; circumcision is cure
12
Q
hydrocele
A
o Hydrocele: serous fluid in scrotal sac b/t 2 layers of tunica vaginalis;
• Comgenital: most common cause of scrotal swelling in infants; assoc. w/ inguinal hernia
• Acquired: occurs in adults 2/2 infection, tumor or trauma; if long standing can cause testicular atrophym compression epididymus, or fluid can become infected (periorchitis)
13
Q
hematocele
A
blood b/t layers of tunica vaginalis; results from trauma, hemorrhage into hydrocele, tumors, infection
14
Q
spermatocele
A
o Spermatocele: cyst from protrusion of widened efferent ducts of rete testis or epididymus
• Hilar paratesticular nodule or fluctuating mass filled with milky fluid
• Cyst lined by cuboidal epithelium containing spermatozoa
15
Q
varicocele
A
o Varicocele: “bag of worms”
• Dilation of testicular veins and appears as nodularity on lateral side of scrotum
• Common cause of infertility; pts usually asymptomatic
16
Q
genital herpes
A
o Genital herpes: painful, grouped vesicles that ulcerate and transform into crusts
• Cluster of vesicles on a red base
• Microscopically: viral nuclear inclusions, multinucleation, nuclear molding; skin separation with vesicle formation
17
Q
syphilis
A
- Treponema pallidum
- Solitary, ulcer “chancre” with hard edges
- Painless
- Screen test VDRL, RPR
- Confirmatory test: FTA-ABS, treponema hemagglutination assay
18
Q
chancroid
A
o Chancroid: haemophilus ducreyi (gram negatuve coccobacillus)
• Painful papule, pustule and shallow ulcers on glans or shaft
• Chancroid ulcer has pus and soft edges
• Painful suppurative inguinal lymphadenitis
19
Q
granuloma inguinale
A
o Granuloma inguinale: Klebsiella granulomatis
• Donovan bodies (rod shaped bacteria within histiocytes)
• Tropical disease
• Raised painless red ulcer with copious chronic inflammatory exudate and granulation tissue
• Ulcers enlarge and heal very slowly
20
Q
lymphogranuloma venereum
A
o Lymphogranuloma venereum: Chlamydia trachomatis
• Painless, small, innocuous vesicle that ulcerates
• Swollen groin (inguinal) LN
• Sinuses draining ous from nodes into skin
21
Q
condyloma acuminatum
A
o Condyloma acuminata: HPV 6 and 11
• Flat topped warts on shaft, small polyps on glans and urethral meatus, or large cauliflower-like tumors
22
Q
balanitis
A
inflammation of glans, due to poor hygiene
• Balanoposthitis: glans and foreskin caused by bacteria, fungi, or virus
• Complications: meatal stricture, phimosis, paraphimosis
23
Q
balanitis xerotica obliterans
A
- Balanitis xerotica obliterans: chronic inflammatory condition
- Fibrosis and sclerosis or subepithelial connective tissue
- Affected glans becomes white and indurated
- Fibrosis can cause phimosis
24
Q
circinate balanitis
A
- Circinate balanitis: circular, linear or confluent plaque-like discoloration of glans
- Assoc. w/ superficial ulcerations
- Seen in reiter syndrome: HLA-B27 autoimmune condition with arthritis, inflammation of eye, urethritis
25
plasma cell balanitis
* Plasma cell balanitis: aka Zoon balanitis
* Macular discoloration or painless papules of the glans
* Connective tissue shows infiltrates of plasma cells and lymphocytes; overlying epithelium is thickened
26
peyronie disease
* Peyronie disease: fibrous induration of penis
* Focal, asymmetric fibrosis of penile shaft with ill-defined induration and normal overlying skin
* “penile strabismus”: loss of penile curvature and painful erections
* young and middle aged men
* dense fibrosis with sparse chronic inflammation
27
sexually transmitted urethritis
o Sexually transmitted urethritis: most common manifestation of STDs in men
• Purulent and greenish yellow urethral or vaginal discharge
• Pain or tingling at meatus, pain on urination
• Gonorrhea
• Chlamydia trachomatis, ureaplasma urealyticum
28
non-specific infectious urethritis
o Non-specific infectious urethritis: E coli and pseudomonas; assoc. w/ cystitis
• Urgency and burning on urination
• Usually no discharge
• Men can express milky fluid by milking the urethra
29
urethral caruncles
o Urethral caruncles: polypoid inflammatory lesions near female urethral meatus that produce pain and bleeding
• Post-menopausal women with exophytic, ulcerated, polypoid mass at or near urethral meatus
• M: inflammation, blood vessel granulation tissue, ulceration, urothelial or squamous epithelium hyperplasia
• Does not lead to cancer
tx is surgical excision
30
reiter syndrome
o Reiter syndrome: urethritis, conjunctivitis, and arthritis of weight bearing joints
• Circinate balanitis, cervicitis, skin eruptions
• Young adults, HLA-B27
• Sx appear after urethritis or enteric infection
• Sx resolve in 3-6months
31
cryptorchidism
• Cyptorchidism: congenital undescended testis
o Bilateral in 30%; Prevalence of 1%
o Most common urologic condition requiring surgery in infants
o Location: abdominal, inguinal, upper scrotal
o Increases infertility and germ cell neoplasia
o Orchiopexy: 6months-1year to prevent infertility; but does not reduce cancer risk
32
infertility--possible findings on testicular biopsy
* Immature seminiferous tubules (hyogonadotrophic hypogonadism 2/2 hypothalamic-pituitary disease)
* M: seminiferous tubules w/o spermatic differentiation resembling prepubertal testes
* Decreased spermatogenesis (cryptorchid testes, malnutrition, AIDS)
* Germ cell maturation arrest (idiopathic)
* Germ cell aplasia (sertoli cell only syndrome)
* Orchitis
* Peritubular and tubular fibrosis (cryptorchdism, infection, ischemia, radiation)
33
bacterial epididymitis
young men with gonorrhea of chlamdyia; older men and children with E. coli
• Intrascrotal pain w/ or w/o fever and infertility
34
tuberculous epididymitis
assoc. w/ tuberculosis and caseating granulomas
35
spermatic granuloma
from sperm extravasation due to traumatic rupture
• M: mixed inflammatory cell infiltrate with numerous extravasated sperm fragments and phagocytosis by macrophages; later=fibrosis and ductal obstruction
36
spermatic cord torsion
o Twisting of the spermatic cord with compromise of testicular blood supply
o Results from abnormal fixation of testis and spermatic cord
o Seen in children and young adults during vigorous activity
o Presents as abrupt onset of pain and swelling
o Can cause testicular infarct
37
orchitis
inflammation of the testis
o Gram-neg bacterial orchitis is the most common form; 2/2 UTI
o Syphilitic orchitis
o Mumps orchitis: unilateral!
o Granulomatous orchitis: type IV cell-mediated hypersensitivity reaction and tuberculosis
• Non-caseating granulomas
o Malakoplakia
38
BPH
o Enlargement of prostate and urinary tract outflow obstruction
• Decreased vigor or urinary stream
• Increasing frequency
• Post-urinary dripping
• Hydroureter, hydronephrosis, and renal failure
o Blacks>whites>Asians
o Older men
o DRE: firm, enlarged nodular prostate
o Tx: transurethral resection prostate (TURP), suprapubic enucleation
39
urothelial papilloma
* Benign
* Exophytic or inverted
* M: papillary fronds lined by normal urothelium
* Single lesion, 2-5cm in diameter
40
bladder inverted papilloma
rare, nodular mucosal lesions, trigone area
| • M: cords of urothelium descend into lamina propria covered by normal urothelium
41
urothelial carcinoma
* Present with Hematuria
* 15% have mets at presentation
* Tx: transurethral resection for T0, T1 and non-muscle invading tumors; radical cystectomy for others
42
non-urothelial bladder cancer
rare!
• Squamous cell carcinoma: schistosomiasis
• Adenocarcinoma: urachal remnants in bladder dome
• Neuroendocrine: like small cell lung cancer
• Rhabdomyosarcoma: children, sarcoma botryoides
43
urethral carcinoma
o Elderly women
o Distal urethral squamous cell carcinoma
o Proximal urethra: urothelial carcinoma
o Most tumors have spread at presentation
44
penis carcinoma
uncircumcised men, 60yo, uncommon
o HPV 16, 18
o Phimosis and smegma
o SCC
45
bowen disease of the penis
shaft; solitary, sharply demarcated, red or white plaque
| penile intraepithelial neoplasia
46
eryhroplasia of queyrat
glans and foreskin; solitary of multiple shiny, soft red plaques
o Both of these are carcinoma w/o invasion of the dermis; 10% progress to invasive carcinoma
penile intraepithelial neoplasia
47
bowenoid papulosis of the penis
not a carcinoma!
o young sexually active men, HPV type 17; multiple brownish or violet papules
o lesions regress spontaneously and do not progress to invasive carcinoma
48
invasive SCC of penis
o Ulcer, crater, friable hemorrhagic mass
o Exophytic, fungating
o Glans or prepuce and less commonly shaft
o M: well differentiated, focally keratinizing, SCC;
• Invasive tumors have dense chronic inflammation of dermis
49
verrucous carcinoma of the penis
low grade SCC
o slow growing, exophytic, locally aggressive but rarely mets
o not related to HPV
o surgical removal is cure
Must differentiate from giant condyloma acuminata of Buschke and Lowenstein
• Benign condyloma in anogenital area assoc. w/ HPV 6 and 11 and overexpression p53
• Locally destructive but doesn’t met
• Men <50
• Most common on glans
• Recurs
50
scrotal cancer
: SCC affecting older men; pts show invasion of scrotal contents and mets to regional LN; tx is surgical excision
51
prostatic intraepithelial neoplasia
o Noninvasive neoplastic transformation of lining of prostatic epithelium
o Low grade and high grade
o Precedes invasive cancer by 20years
o M: dilated branching glands with intraluminal papillary projections; lined by crowded enlarged cells with prominent nucleoli
52
prostate adenocarcinoma
malignant glands
o Multicentric on the peripheral zone
o Irregulary, yellow-white indurated nodules
o M: glands with conspicuous “nucleoli” that infiltrate stroma; lacks architectural organization
o Gleason grading pattern: based on tumor architecture
• Score of 2-10
• Lower score=better prognosis
o Blastic bony mets (vertebrae, ribs, pelvis); painful (positive PSAP on IHC confirms prostate origin)
o Usually detected by PSA and DRE
o Pts do not usually present with bladder probs (vs BPH)
53
nephroblastoma/Wilm's tumor
o Most common pediatric renal tumor!
o Chr11, WT1/2 genes are overexpressed
o Mean age is 3-4years
o Present w/ abdominal mass (rarely with hematuria, pain, HTN)
o Assoc. w/:
• Wilms-Aniridia-genital anomaly-retardation syndrome
• Beckwith-Weideman syndrome: abdominal wall defect, macroglossia, macrosomia
o M: blasema (small blue cells in solid nests), hypocellular stroma with myxoid spindle cells, epithelial arranged in tubules
o Excellent prognosis!
54
congential mesoblastic nephroma
hamartoma
o Translocation 12;15, ETV6-NTRK3 fusion gene
o Most are benign
o 5-10% recurrences and mets
o solitarym tranb, bulgy soft mass (like leiomyoma)
o M: spindle cells with mitosis on cellular pattern
55
clear cell sarcoma of the kidney
: “bone metastatizing tumor” aggressive malignant sarcoma; late recurrence and bad prognosis
o Located in medulla
o M: epitheloid with clear cytoplasm and nucleus arranged in sheets with arbozing blood vessels in myxoid stroma
56
rhabdoid tumor
highly malignant seen in first 2 years of life
o Deletion/mutation of IN11 gene on chr 22q
o Does not have muscle differentiation
o Assoc. w/ brain tumor (atypical rhabdoid teratoid tumor)
57
oncocytoma
benign adult renal tumor
• Central scar
• Mahogany brown mass with a central scar
• M: eosinophilic cells w/ abundant cytoplasm, round nucleus with prominent nucleoli arranged in nests, cords, tubules or cysts
58
metanephric adenoma
benign renal tumor
• Epithelial nephroblastic cells
• Women, 40s, polycythemia
• Presents with hematuria and flank pain
• Gray-tan tumor, unencapsulated 5cm
• Metanephric adenofibroma: younger age, equally common in males, 80% have polycythemia
• Trisomy 7 and 17 with loss of Y or X (sim to papillary)
59
papillary adenoma
```
benign renal tumor
: most common renal neoplasm!!
• Asymptomatic or hematuria
• Gray-tan <0.5cm
• Psammoma bodies
• Genetics: +7, +17, -Y
```
60
angiomyolipoma
benign renal cell tumor
• Derived from perivascular epithelioid cells
• Females
• Tuberous sclerosis (mutation in TSC1 and TSC2)
• Co-express melanocytic and muscle markers
• Presents with flank pain
• HMB45+ on IHC
61
clinical presentation of malignant renal cancer
```
• Hematuria
• Triad: hematuria, flank pain, palpable mass
• Metastasis
• Paraneoplastic syndrome:
• Hypercalcemia: PTHrP; sx of lethargy, nausea, fatigue, weakness, decreased DTR
• Hypertension
• Polycythemia (inc. EPO)
• Incidental finding
o Risk factor=tobacco!
```
62
renal clear cell carcinoma
* Elderly, male predominant
* Sporadic
* VHL: multifocal, bilateral RCC, inactivation tumor suppressor on chr3
* Well-circumscribed, golden yellow, cystic solid, hemhorrhagic, necrosis
* Fuhrman grades 1-4
* Sarcomatoid RCC=worse prognosis
63
papillary renal cell carcinoma
2nd most common RCC
• Multifocal, tan-white nodules >0.5cm
• Genetics: +7, +17, -Y
• Type 1: small cells, pale cytoplasm; foamy macrophages
• Type 2: large cells, eosinophilic cytoplasm; younger pts, and pts with end-stage renal disease
64
chromophobe renal cell carcinoma
* From intercalating cell of collecting duct
* Multiple chromosomal losses (1, Y, 6, 10, 13, 17) and hypodiploidy
* DDX is oncocytoma (can also have central scar)
* Hale’s colloidal iron stain + (vs oncocytoma is negative)
65
renal collecting duct carcinoma
collecting ducts of bellini
• Adenocarcinoma with high grade cytology
• Poor prognosis
• Ulex europaeus lectin reactivity (differentiates from papillary RCC)
66
medullary renal cell carcinoma
* Sickle cell trait, sickle cell disease, SC disease
* Aggressive (most pts have mets at diagnosis)
* Young black males
* Poor prognosis
67
renal carcinoma assoc w/ Xp11.2/TFE gene fusion
* Children and young adults
* Presents at advanced stage but has an indolent clinical course
* Papillary architecture and psamomma bodies
68
multilocular cystic renal cell carcinoma
* Multi-cystic with small clusters of clear cells
| * Excellent prognosis
69
Germ cell tumors of the testicles epidemiology
• Germ cell tumors: 95% of testicular tumors
o Most common in men between 15-34; Whites>Blacks
o Risk factors: cyrptorchidism, gonadal dysgenesis, family hixostyr, isochromosome 12
70
testicular seminomas
radiosensitive and present at an early age
• Homogenous mass with no hemorrhage and necrosis
• Most common adult testicular tumor
• Painless mass in 4th decade
• Non-hemorrhagic tumor
• IHC: PLAP+, CD117+, OCT ¾+
• Can be bHCG positive
71
Spermatic seminoma
* Pts >55
* 3 sizes of cells in sheets w/o fibrovascular septa
* excellent prognosis
72
embryonal testicular carcinoma
o Non-seminomas: relatively radiosensitive, more aggressive, usually mixed
-hemorrhagic mass with necrosis (vs seminoma)
• Embryonal carcinoma:
• Aggressive, arises from primitive cells
• 30s-40s
• usually mixed
• pts present with mets
• pain is common sign
• poorly demarcated, variegated with foci of hemorrhage and necrosis
• IHC: CD30, cytokeratins, PLAP, OCT3/4, CD117
73
testicular teratoma
non-seminoma--relatively radiosensitive, more aggressive, usually mixed
contains all 3 germ layers (endoderm, mesoderm ectoderm)
• kids < 2
• in adults, teratomas are malignant
74
yolk sac tumors
•non-seminoma
Pure form in kids < 4
• Mixed GCT in adults as rapidly growing painless mass
• Schiller duval bodies
• AFP is marker (found in tissue in hyaline globules)
75
choriocarcinoma
non-seminoma
rare malignant tumor
• Marked increase in bHCG
• Aggressive with hematogenous spread to lungs, liver, GI, brain
• can present as gynecomastia and hyperthryoidism
• can be hemorrhagic or burn out scar
• syncytiotrophoblasts and cytotrophoblasts
76
mixed germ cell tumor of testicles
• Mixed germ cell tumors: 2 or more germ cell tumor types
o Elevated AFP (yolk sac) and HCG (choriocarcinoma) are common
o Presents as painless mass
o Tumor is variegated soft, firm, cystic with hemorrhage and necrosis
o Metastasis is via lymphatics to retroperitoneal lymph nodes
o Teratocarcinoma= teratoma + embyronal carcinoma
77
• Intratubular Germ cell neoplasia, Unclassified:
o Malignant transformation of primordial germ cell
o Precursor of all invasive germ cell tumors except spermatocytic seminoma
o Higher incidence in cryptorchid testes and prior GCT
o Prophylactic orchiectomy recommended
o IHC: PLAP+
78
leydig cell tumors
* hormonally active and secrete androgens, estrogens, and corticosteroids
* can have precocious puberty, gynecomastia etc
* Present with testicular swelling
* Bimodal age peaks
* Reinke crystals
* IHC: inhibin+
79
sertoli cell tumor
* No hormonal sx!
* Testicular mass < age of 40
* Small nodules
* Large cell calcifying sertoli cell tumor is subtype assoc. w/ Peutz-Jeghers syndrome and carney’s complex
80
metastasis to testicles
o Testicular lymphoma is most common testicular neoplasm in men >60
• Diffuse large B cell lymphoma
o Mets from prostate, large intestine, bladder
81
most significant cause of bladder cancer
cigarette smoking
82
major risk factors assoc. w/ bladder cancer
- carcinogens--aryl amines, benzidine, naphthylamines, phenacetin,
- cyclophosphadmide
- infection (schistosomiasis)
- chronic inflammation
83
treatment of early stage bladder cancer
BCG
84
Von Hippel-Lindau syndrome
-30% pts get kidney cancer
85
kidney cancer
chemoresistant
| never perform a percutaneous biopsy (risk spread)
86
testicular cancer (clinical)_
- most common malignancy men 15-35
- never perform a transcrotal biopsy in testicular mass (risk spread)
- metastatic testicular cancer is curable with chemotherapy +/- radiation in 90% pts
87
PSA and DRE
screening for prostate cancer in men >50 (but not proven to reduce mortality)
-PSA is helpful in assessing follow-up of pts with PSA secreting tumors that were treated
88
recurrent prostate cancer
progress and become hormone refractory
| -hormone refractory prostate cancer should be treated with systemic chemo (improves overall survival)
