Urology Flashcards
BPH/ prostate cancer. Hydrocele/ epididymitis/ orchitis/ testicular cancer (tumour markers). Haematuria, renal tract tumours and stones. Testicular torsion. (49 cards)
What is benign prostatic hyperplasia?
A histological diagnosis.
Benign enlargement of prostate.
Common.
May be associated with urinary symptoms.
What are the different types of lower urinary tract symptoms?
Poor flow- BOO (BPH). Voiding symptoms (obstructive): hesitancy, weak stream, intermittency, incomplete emptying.
Strong flow- detrusor overactivity. Storage symptoms (irritative): frequency, urgency, nocutia.
Define lower urinary tract symptoms (LUTS).
Non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding).
Define benign prostatic enlargement (BPE).
The clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia.
Define bladder outflow obstruction (BOO).
Bladder outlet obstruction caused by benign prostatic enlargement (clinical finding).
Define benign prostatic hyperplasia (BPH).
Properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction.
What are the risk factors for BPH?
Age Androgens Functional androgen receptors Obesity Diabetes (& elevated fasting glucose) Dyslipidaemia Genetic Afro-Caribbean
What are the important aspects of a BPH history and examination?
LUTS.
IPSS questionnaire.
Frequency volume chart.
Haematuria, dysuria.
Full medical history (co-morbidities, drug history and family history).
Examination of abdomen (is bladder palpable?).
DRE.
What are the important investigations to order for BPH?
Urine dipstick (exclude infection).
Flow rate + post void residual bladder scan in clinic.
Blood tests (U&E, PSA, need to counsel patient).
? Renal tract ultrasound.
? Flexible cystoscopy.
What is the management plan for patients with voiding symptoms/ BPH?
Conservative management: reassure; fluid intake advice (reduce evening fluid intake).
Medical management: alpha blockers (tamsulosin, alfuzosin); 5-alpha-reductase inhibitors (finasteride, dutasteride).
Surgical management: TURP (transurethral resection of prostate); alternatives include laser surgery, rezum/steam, urolift, embolisation, catheter options.
What is the treatment for overactive bladder/ storage symptoms?
Conservative management: reassure (& treat triggering UTI); dietary advice; bladder retraining exercises (NICE recommended).
Medical management: anticholinergics (oxybutinin, detrusitol, solifenacin).
Surgical management: intravesical botox injection; bladder augmentation; urinary diversion/conduit.
Case 1:
70y/o man presents with inability to pass urine for 10hrs.
Previous history of BPH (on tamsulosin and finasteride).
Pain.
How do you assess and manage this patient?
a) give analgesia
b) advise the patient to drink less, especially in evening
c) start an alpha blocker
d) catheterise patient
e) advise TURP surgery
Catheterise patient.
How should you proceed in the case of a patient with urinary retention?
Catheterise. Dipstick/CSU. FBC, U&E. Measure residual urine. Neurological examination if necessary. Prescribe: antibiotics, laxatives, alpha blocker if necessary.
What are the different types of urinary retention?
Acute retention (AUR) = painful. Chronic retention (CUR) = postvoid residual >800mL. Acute on chronic.
How is low pressure urinary retention (LPR) managed?
Normal U and Cr, no hydronephrosis.
Consider starting alpha blockers.
Trial without catheter (TWOC).
How is high pressure urinary retention (HPR) managed?
Raised U & Cr, bilateral hydronephrosis. Measure UO, BP, body weight. Only 10% need fluid replacement. Never TWOC. BOO surgery or longterm catheter.
Case 2: 67y/o male. Urgency, frequency, poor flow. DRE 40g BPE. PSA 1.2 MSU -ve. US normal, postovoid residual 40mL. What do you prescribe? a) alpha blocker b) 5-alpha-reductase inhibitor c) anticholinergic
Alpha blocker.
Anticholinergic can be added later to address urgency.
What are the presenting symptoms of prostate cancer?
Asymptomatic; raised PSA. LUTS. Urinary retention/ renal failure. (Pain). Haematuria. Bone pain/ weight loss/ spinal cord compression (metastases).
What are the risk factors for prostate cancer?
Age
Race (Afro-Caribbean)
Family history (2 1st degree relatives).
BRCA 2 gene.
What are the causes of raised PSA (prostate specific antigen)?
BPH. Urinary retention. Urinary infection. Catheterisation/ instrumentation of urethra. Prostate cancer. DRE is not a significant risk factor.
How do you assess a patient with suspected prostate cancer?
Counselling.
History: LUTS? bone pain? weight loss? blood in urine?
Family history.
Examination.
DRE!
Check PSA.
MRI: can differentiate between high risk and low risk prostate cancer; PIRADS classification 1-5.
TRUS biopsy (can also do transperineal, template, or saturation biopsy).
How is prostate cancer histologically analysed?
Grading: Gleason score. Low risk 3+3, high risk 5+5.
Staging: TNM.
Case 3:
70y/o man referred by GP with PSA 18ug/L (upper limit 7.2).
How are you going to assess? Pick 2.
a) repeat PSA and check MSU
b) organise MRI prostate and TRUS biopsies
c) explain likely diagnosis of prostate cancer
d) advise radical prostatectomy or radiotherapy
Repeat PSA and check MSU.
Organise MRI prostate and TRUS biopsies.
What is the management plan for a patient with prostate cancer?
Staging- MRI/ bone scan.
MDT discussion and breaking news to patient.
Active surveillance (low risk low volume disease).
Surgery: radical prostatectomy (robotic or laparoscopic).
Radical radiotherapy.
Watchful waiting (elderly/comorbid patient).
Hormones.
Chemotherapy.
