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Urology Flashcards

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1
Q

Describe the histopathology of BPH (which cells are involved etc

A

There is nodular and diffuse proliferation (hyperplasia) of the glandular epithelial and stromal (musculofibrous) layers around the prostate - this occurs in the
TRANSITIONAL ZONE

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2
Q

Pathophysiology of BPH

A

testosterone –> 5 alpha reductase –> dihydrotestosterone - which acts on the glandular and stromal cells of the prostate –> hyperplasia

Static component - increased tissue bulk –> narrowing of lumen

Dynamic component - increase in prostatic smooth muscle tone

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3
Q

Aetiology of BPH

A

Age

  • Hyperactivity of receptors (for dihydrotestosterone)
  • Increased oestrogen –> primes androgen receptors
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4
Q

Presentation of BPH

A

Frequency
Urgency
Nocturia

Hesitancy
Straining
Poor stream 
Post void dribbling
incomplete emptying
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5
Q

Investigations for BPH

A

Triad - what is this hypertrophy from

  • DRE
  • PSA
  • TRUSS
Others 
Freq/vol chart 
MSU - rule out UTI
KUB USS 
Scoring system - IPSS (dont forget this one)
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6
Q

Management of BPH

A 
1) Behavioural 
Avoid triggers (caffeine, alcohol etc), void twice, limit fluid intake

Mild - watch and wait

Moderate (symptoms bother them)
alpha blocker - tamsulosin or doxazocin
5 alpha reductase inhibitor - finasteride

Severe
Surgery
<80g TURP/ TUVP
>80g open prostatectomy

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7
Q

Side effects of alpha blocker

A

Sexual dysfunction eg ED

Dizziness 
Postural hypotension 
Dry mouth 
Depression 
EXTRA-PYRAMIDAL SIGNS
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8
Q

Side effects of 5 alpha reductase

A

Remember symptoms may not improve for 6 months

Gynaecomastia
Sexual dysfunction - ED, reduced libido, ejaculation problems

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9
Q

Indications for surgery in BPH

A 
RUSHES 
Retention
UTIs 
Stones 
Haematuria
Elevated creatinine
Symptom severity ^
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10
Q

Complications of TURP

A

Short term
Bleeding, sepsis

Long term 
Retrograde ejaculation 
ED 
TURPT syndrome 
Strictures 
Incontinence
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11
Q

Complications of BPH

A 
UTIs 
Retention 
TURPT syndrome 
Hydronephrosis 
Stones
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12
Q

What is the underlying pathophysiology of TURP syndrome

A

There is absorption of irrigating fluids (during TURP surgery) into the prostatic venous sinuses

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13
Q

Presentation of TURP syndrome

A

FLUID OVERLOAD
Hyponatraemia
Hypothermia
Hypertension

N+V+headache/ confusion

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14
Q

Risk factors for TURP syndrome

A 
>60g resected 
High volumes of fluids for irrigation 
Surgery >1hr 
Perforation 
Large blood loss
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15
Q

Manage TURP syndrome

A

Supportive
O2
Correct hyponatraemia
Monitor BP

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16
Q

epidemiology of acute urinary retention

A

1/3 in 5 years for males over 80

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17
Q

Causes of urinary retention

A

Obstruction

  • BPH
  • Prostate cancer
  • Stones
  • Strictures
  • Surrounding malignancy - remember ovarian, important ∆∆

Neurological

  • MS
  • SCC
  • DM
  • GB
  • Parkinson’s

Drugs

  • Anticholinergics
  • Antihistamine
  • TCAs
  • NSAIDS
  • Opioids
  • Benzos

Gynae

  • Post partum
  • Prolapse
  • Ovarian cyst
  • Uterine fibroids

Infections

  • Prostatitis
  • Balantitis
  • Cystitis
  • Vaginitis
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18
Q

Presentation of
- Acute
- Chronic
Urinary retention

A

Acute
PAIN
Inability to pass urine

Chronic
Painless
May have overflow

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19
Q

Investigations for acute urinary retention

A

Just give em a catheter

MC+S + urinalysis

U+E + check creatinine!!! for AKI

FBC, CRP - infection?

PSA (?cause) - useless as is raised in retention!

USS later to find cause/ >300ml = retention

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20
Q

Management of acute urinary retention

A

CATHETER
*men should be offered alpha blocker before this

measure over 15 mins
<200ml - no retention
>400 defs retention

Secondary management:
TWOC
Prostate surgery

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21
Q

Complications of urinary retention

A

AKI

UTI

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22
Q

Pathophysiology of prostate cancer

A

80% adenocarcinoma
Malignant disease of the glandular origin - occurs in the
PERIPHERAL ZONE

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23
Q

What are the different types of spread of prostate cancer

A

Local - through the capsule
Haematogenous
Lymphatic

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24
Q

Aetiology of prostate cancer

A

Familial
Genetic
- BRCA
- HPC-1

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25
Presentation of prostate cancer
LUTS Haematuria B symptoms Bone pain if spread Palpable lymph nodes
26
Investigations for prostate cancer
PSA >4 TRUSS + biopsy DRE - hard and irregular MRI + CT staging Bone isotope scan for mets Testosterone PCA3 - urine PSMA - serum
27
Lymph spread in prostate cancer
Obturator
28
Staging of prostate cancer
T1 - not palpable or visible on imaging T2 - palpable/visible on imaging T3 - through the capsule (b, to the seminal vesicle) T4 - beyond the seminal vesicle N1 - local LN M1 - other LNs/ other sites - bone. lung. liver
29
Grading system for prostate
Level of differentiation - the management plan is determined on this
30
Management of prostate cancer
Very low risk Watch and wait Brachy Low/intermediate risk Radio/brachy High risk Radical prostatectomy Radiotherapy ``` Metastatic disease 80% are androgen sensitive Castration: - Orchidectomy - LHRH - Anti androgens (Gosrelin) - Cyproterone acetate ```
31
Complications of prostate cancer
ED Hormone induced gynaecomastia hormone induced hot flush radiation induced LUTS Surgery - incontinence - infertility - ED
32
Histopathology of bladder cancer
Transitional cell carcinoma Squamous cell carcinoma (schistosomiasis) Transitional cell papilloma Adenocarcinoma
33
RFs for bladder cancer
``` Smoking Schistosomiasis (SCC) Azo dyes Paints Pelvic radiation HNPCC - upper tract urolithial cancers M:F Cyclophosphamide ```
34
Presentation of bladder cancer
Painless haematuria (micro or macro) Bone pain Weight loss Symptoms of pressure eg LUTS
35
Investigations for bladder cancer
``` Urine dip - haematuria (micro or macro) KUB USS Flexi cystoscopy - with biopsy TURBT U+E CT staging +/- Urinary cystology ``` FBC - mild anaemia
36
Staging and management of bladder cancer
T1 - into lamina propria TURBT + intravesicle chemo - mitomycin C T2 - into muscle Radical/partial cystectomy with pelvic LN dissection +/- chemo + urinary diversion into internal resevoiur (via ileum) with drainage via urethra T3 - into fat - same T4 - pelvic organs eg vagina, ureter - Chemo N1 - ONE LN in the true pelvic region N2 - >1 LN in the true pelvic region N3 - outer eg common iliac
37
Complications of bladder cancer
Hydronephrosis Urinary retention Recurrence
38
Causes of haematuria
``` Obstruction - stones Trauma Cancers UTI Prostatitis BPH Coagulopathies Warfarin stuff ``` Pseudo - Rifampicin - Menstruation - Beetroot - Haemolytic anaemias - myoglobulinuria - rhabdo
39
Investigations for haematuria
``` MC+S Urine dip DRE PSA FBC - CLOTTING U+Es ``` KUB - USS Flexi cyst non contrast CT for stones
40
Timing of haematuria in the stream
Total - bladder/ upper tract Initial/terminal - lower (up to the bladder neck)
41
Pathogens causing UTI
E Coli - 70-95% Staph Saprophyticus 5-20% Enterobacter - Klebsilla - hospital - stones* - Proteus - hospital - stones* - Enterococci - GBC ** Struvite stones - these are phosphate stones
42
What counts as a complicated UTI?
Patient features: - Male - Pregnant - Immunocompromised - Children Recurrent (>2 in 6m or 3 in 12m) Decreased renal function Shit in the way: Stones Structural abnormality Indwelling catheter
43
RF for UTI
``` Immunocompromised Sex Female Structural abnormality Obstruction (eg stones) Poor hygiene Catheter Spermicide ```
44
Abx for UTIs
Trimethoprim - 3 days Nitro - 7 days Males/ab resistance - cipro Complicated - Outpatient - nitro/ Cephalxin - Inpatient - IV gentamycin
45
What is bacteruria
presence of bacteria in the urine - with or without symptoms
46
What is pyuria
Presence of leukocytes in the urine associated with infection
47
What is sterile pyuria and give example
Presence of elevated leukocytes in urine but unable to culture - Fastidious organism - Chlamydia - Recently treated UTI
48
Investigations for UTI
Urine dip MC+S of MSU = GOLD STANDARD FBC/ WCC/ ESR/CRP/ U+Es Blood cultures KUB USS - other cause
49
∆∆ in females for UTI
Its abdominal pain so if you haven't thought about ectopic pregnancy then srsly don't bother turning up to the exam Alice xo ``` Stones STI Overactive bladder Urolithial cancer Atypical infection ```
50
Complications of UTI
Sepsis Worsening of confusion RENAL ABSCESS
51
Common pathogens causing prostatitis
E. Coli is the main dude Enterococci Pseudomonas
52
RF for prostatitis
RECENT UTI - main dude Others: messin around with the prostate: UROGEN instrumentation Recent prostate biopsy Intermittent bladder catheterisation
53
Presentation of prostatitis
Haematuria Painful ejaculation Abdo pain Rectal and perianal pain O/E - warm, soft boggy prostate
54
O/E findings of prostatitis
warm, soft, boggy prostate
55
Investigations for prostatitis
PSA DRE TRUSS - check for abscess U+E FBC ESR/CRP Blood cultures STI screen MC+S of MSU Culture of prostatic secretions
56
Management of prostatitis
Abx No sepsis - oral cipro + NSAID relief + drainage if abscess Sepsis? - IV taz and gent Chronic - 4/6 weeks cipro + alpha blocker + NSAID
57
Complications of urethritis
Reactive arthritis Meningitis Endocarditis
58
Aetiology of epididymo-orchitis
<35 - STI >35 - UTI Elderly - catheter
59
Pathophysiology of epididymo-orchitis
retrograde ascent of urinary pathogens
60
Presentation of epididymo-orchitis
Testicular pain and swelling (over days, unlike testicular torsion which is V important to rule out!!!) Fever Urethral discharge LUTS
61
Investigations for epididymo-orchitis
NAAT/ urine sample for STI U+E Blood cultures MC+S Colour doppler USS - enlarged hyperaemic epididymis
62
Management
STI related? - Ceftriaxone IM 1 dose and oral doxy for 2 weeks UTI related? Levofloxacin
63
What is a hydrocoele
collection of excessive fluid in the tunica vaginalis
64
Types of hydrocoele
Communicating - There is a patent process vaginalis which connects the tunica vaginalis with the peritoneum (common in infants) Non- communicating abnormal collection of fluid in the tunica vaginalis (eg from infection etc)
65
Aetiology of hydrocoele
Communicating: Patient process vaginalis ``` Non- communicating: Epididymo-orchitis Tumour Cyst Torsion ```
66
Presentation of hydrocoele
soft non-tender swelling of the hemi-scrotum anterior and below the testicle O/E You can get 'above' the swelling Transilluminate Enlargement post - activity
67
Investigations for hydrocoele
Can be a clinical diagnosis but if unsure - USS
68
Management of hydrocoele
Supportive If it doesn't spontaneously resolve, can aspirate or surgical repair
69
Pathophysiology of varicocoele
There is venous congestion in the panpiniform plexus 90% occur in the LEFT as Left --> left renal artery Right --> IVC There is also testosterone pooling
70
Aetiology of varicocoele
Idiopathic - Incompetent valves in renal vein/ increased hydrostatic venous pressure Secondary - Pelvic or renal tumour - Nutcracker syndrome - SMA compresses the left renal vein
71
Complications of varicocoele (and how)
Infertility Increase in temperature --> testicular atrophy --> infertility BPH (due to pooling of testosterone if the blood goes via the prostate via communicating vessels) Hydrocoele - literally no fucking clue why x
72
Presentation of varicocoele
BAG O' WORMZ Dull ache Commonly presents as subfertility
73
Investigations for varicocoele
Doppler USS
74
Management of varicocoele
Supportive | Surgery if ongoing pain
75
Presentation of epididymal cyst
Extra-testicular mass (can separate from the body of the testes) found POSTERIOR Can transilluminate
76
Conditions associated with epididymal cyst
CF VHL PKD
77
Investigations of epididymal cyst
USS
78
Management of epididymal cyst
Supportive | Surgical removal
79
Aetiology of testicular torsion
Trauma | Bell clapper deformity
80
What is testicular torsion
twisting of the testicle on the spermatic cord
81
Presentation of testicular torsion
severe, sudden onset testicular pain --> referred to lower abdomen N+V Redness/ heat Transverse lie Loss of cremasteric reflex Lifting of the testes does NOT relieve the pain
82
Management of testicular torsion
Surgery | - May fix both testes as bell clapper is often bilateral
83
Histopathology of testicular cancer
``` Germ cell (95%) - Seminomas (55%) - Non- seminomas Teratoma (5-10%) Choriocarcinoma Yolk sac Embryonal ``` Non-germ cell - Leydig - Sarcoma
84
Aetiology of testicular cancer
Fam Hx Cryptochiridism Kleinfelter Mumps
85
Presentation of testicular cancer
Painless lump (but can be painful) Haemospermia Hydrocoele/ varicocoele Gynaecomastia
86
Why do you get gynaecomastia in testicular cancer
Bc of the raised b-HCG
87
Investigations for testicular cancer
Blood tings: - LDH - AFP (teratoma, yolk sac, embryonal but not in seminomas) - b-HCG (choriocarcinoma and seminomas) USS - gold stanny CT - abdo-pelvis
88
Where does testicular cancer spread to (LN)
Retroperitoneal | Para-aortic
89
Management of testicular cancer
Depends on stage + seminoma or non-seminoma Orchidectomy Early sem - radio/carboplatin chemo Early non-sem - RPLND Late stage either - BEP chemo
90
Complications of testicular cancer
Infertility
91
Staging of testicular cancer
A - confined to testes B - regional LN C - beyond regional LNs
92
Aetiology of erectile dysfunction
Psych - depression/ relationship problems Neuro - MS/ stroke CVS - diabetes, obesity, HTN Drugs - SSRI, BB, any antipsychotics rly, alcohol Surgical - PROSTATE! Hormonal - hyperprolaccy, hypothyroid Age
93
Investigations for erectile dysfunction
Testosterone Prolactin TSH FSH/LH BP HbA1c/ fasting glucose Cholesterol
94
Management of erectile dysfunction
Modify risk factors etc etc etc Sildenafil (CI in hypotension, SE facial flushing, headahces) Alprostadil Physical - Vacuum - Rings - Kegel Psychological - CBT - Psychodynamic - Couples therapy - Mixed therapy
95
Types of renal stones + RF for each
``` Calcium - Calcium oxylate Rhubarb, tea, chocolate, nuts - Calcium phosphate Hyperparathyroidism ``` Uric acid - gout related shit - obesity MAP - Struvite - Kelb + proteus UTIs Crystine - Inherent disorder of metab
96
Common locations for renal stones
Srsly pelv-ureter passing over internal iliac VUJ
97
Investigations for renal stones
NCCT - gold stannid U+E+Cr FBC - wcc infection MC+S on MSU
98
Presentation of renal stones
Loin to groin pain (colic) N+V Microscopic haematuria LUTS depending on site of stone
99
Management of renal stones
Housekeeping - Fluids Fluids Fluids - Morphine - Odansetron Depends on - Size - Obstructive vs non-obstructive <5mm + no obstruction - hydration and will pass ``` Non-obstructive <10mm alpha blocker, CCB - nifedipine 10-15 Shock wave lithotripsy >15mm - perc ureteroscopy >20mm - perc nephrolithotomy ``` Obstructive - as above + surgical decompression
100
Complications of renal stones
Obstruction -> hydronephrosis Infection --> pyelonephritis --> SEPSIS Pressure necrosis
101
Prevention of renal stones
- Hydration - Low animal protein, low salt - Thiazide diuretics

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