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Urology Flashcards

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1
Q

What are the possible differentials for acute urinary retention?

A 
prostatic obstruction e.g. BPH, tumour
urethral stricture
constipation 
neurological e.g. cauda equina 
alcohol 
infection (UTI)
post op
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2
Q

How should acute urinary retention be assessed?

A
  1. abdominal exam
  2. DRE
  3. test for perineal sensation (cauda equina)
  4. MSU, PSA
  5. lower limb neurological exam - weakness
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3
Q

How should acute urinary retention be managed initially?

A
  • encourage voiding e.g. to sound of running water, standing when voiding
  • analgesia
  • privacy on the ward
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4
Q

If your initial conservative treatment is unsuccessful, how should acute urinary retention be managed?

A

catheterisation (drain <1.5L)

alpha blocker e.g. tamulosin

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5
Q

List the differentials for obstruction of the urinary tract

A

IN THE LUMEN - stone, blood clot, foreign body, congenital valve

IN THE WALL - tumour, stricture, BPH, trauma

PRESSURE FROM OUTSIDE - fibroids, pregnancy, constipation , diverticulitis , crohns, tumour

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6
Q

Where does BPH occur in the prostate and how?

A

in the INNER (TRANSITIONAL) zone

= benign proliferation of the connective tissue and glandular layers of the prostate with failure of apoptosis

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7
Q

List the lower urinary tract symptoms

A

STORAGE SYMPTOMS - urgency, increased frequency, nocturia, urinary incontinence

VOIDING SYMPTOMS- hesitancy, weak stream, terminal dribbling, incomplete emptying

POST MICTURITION SYMPTOMS - post void dribble, incomplete emptying

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8
Q

How is BPH investigated?

A
  1. assess how affecting QOL with the “international prostate scoring system”
  2. PR exam - enlarged smooth prostate
  3. MSU - may show infection indicating prostatitis
  4. complete a “urinary frequency volume” chart
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9
Q

List the differentials for LUTS in men?

A 
BPH 
infection 
diabetic neuropathy
dementia 
drugs e.g. diuretics, anti muscarinics
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10
Q

How is BPH managed conservatively, medically and surgically?

A 
CONSERVATIVE 
dietary advice (avoid alcohol, caffeine, spicy foods), avoid constipation, voiding routine (void twice in row, relax), bladder retraining (try holding on, pelvic floor exercises)

MEDICAL
1st line = alpha adrenergic receptors e.g. tamsulosin, doxazosin
2nd line = 5 alpha reductase inhibitors e.g. finasteride

SURGICAL
Transurethral resection of prostate (TURP)
Transurethral incision of prostate (TUIP)

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11
Q

Describe mechanism and SE of alpha 1 adrenergic blockers?

A

e.g. tamsulosin, doxazosin

block alpha adrenergic receptors in the prostate and bladder -> relax the smooth muscle -> increase flow of urine

SE: drowsiness, dizziness, reduce BP, dry mouth, weight gain

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12
Q

Describe the mechanism and SE of 5 alpha reductase inhibitors?

A

e.g. finasteride

decrease testosterone conversion to dihydrotestosterone so shrink the size of the prostate

SE: decrease libido, impotence, take 4-6 months for effect

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13
Q

What are the complications of TURP?

A

general: bleeding, infection

at risk: sexual dysfunction, urinary continence

complications of surgery: TURP syndrome (glycine irrigation fluid enters intravascular space and expands causing fluid overload and hyponatraemia -> seizures, SOB), retrograde ejaculation, retention, clotting

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14
Q

What are the causes and risk factors of prostatitis?

A

S. faecalis, E.coli, chlamydia

RF: STI, UTI, indwelling catheter, post procedures, diabetics

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15
Q

What are the symptoms/ signs of prostatitis?

A

UTI
retention
haematospermia
swollen/boggy prostate on DRE

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16
Q

How is prostatitis treated?

A

analgesia
admit to hospital
levofloxacin for 28 days

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17
Q

What type of prostate cancer is the most common and where?

A

adenocarcinoma 95% in the peripheral zone of the prostate

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18
Q

How does prostate cancer present?

A

asymptomatic and found with elevated PSA
LUTS - retention, increased urgency, frequency, haematuria, weak stream
weight loss , fatigue, fever

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19
Q

How might locally advanced prostate cancer present?

A

impotence - due to infiltration of neuromuscular bundle
haematospermia
bone mets - pain, fracture, spinal cord compression , malignancy hypercalcaemia

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20
Q

How would you investigate possible prostatic cancer?

A
  1. DRE - hard craggy irregular NODULAR prostate
  2. serum PSA >4mg/L -> indicates a biopsy
  3. transrectal ultrasound and biopsy (4 core biopsies from each lobe)
  4. MRI - to stage
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21
Q

How is prostate cancer graded?

A

GLEASON SCALE

6 = low grade cancers = slow growing, confined to prostate
8-10 = high grade cancers = fast growing, invade through prostate capsule
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22
Q

How is prostate cancer treated?

A
  1. watch and wait/ active surveillance = regularly monitor PSA to assess if disease progressed
  2. surgery (prostatectomy) and radiotherapy - if localised or local spread
  3. if metastatic- hormonal treatments = GnRH agonists e.g. goserelin (-ve feedback to anterior pituitary to stop testosterone), LH antagonists
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23
Q

How can haematuria be classified?

A
  1. Visible - frank, macroscopic

2. non visible - found on dipstick or microscopy

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24
Q

What is the most sensitive test for blood in the urine?

A

** urine dipstick **

MSU has a high false -ve rate

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25
List the differentials for haematuria?
Transient - UTI, trauma, vigorous exercise, menstruation Bladder cancer - urgent 2 week referral infection stones drugs e.g. anti coagulants, furosemide, ACE-I, cephalosporins TITS: Trauma, Infection, Tumour, Stones
26
List the risk factors for an UTI
``` female catheter sexual intercourse urinary tract obstruction e.g. stones pregnancy recurrent UTIs menopause catheter ```
27
Define recurrent UTIs
= >2 UTI in the past 6 months
28
What are the main pathogens causing UTIs
E.COLI (gram -ve bacillus)****** + klebsiella, proteus, staphylococcus saprophyticus
29
Describe the symptoms of a lower urinary tract infection
``` dysuria increased frequency, urgency fever haematuria suprapubic pain foul smelling urine delirium * ```
30
How should a possible UTI be investigated?
1. urine dipstick - positive leukocytes or nitrates (treat whilst waiting for MCandS) 2. Mid stream urine for MCandS - > 10^5 organisms per ml is diagnostic - mandatory if complicated UTI
31
How should you investigate if possible Urosepsis?
``` FBC UandE blood cultures CRP monitor urine output and urinanalysis ABG - lactate ```
32
what is defined as a complicated UTI? how is the management different?
if children, men, fail to respond to abx, recurrent UTI, impaired renal function, abnormal organism , pregnancy need to do imaging e.g. CT KUB, cystoscopy or urodynamics
33
How is an uncomplicated UTI treated?
conservative - plenty of fluids, analgesia, void often, void after intercourse trimethoprim or nitrofurantoin (if pregnancy = nitrofurantoin) for 3 days
34
What are the possible complications of a UTI?
``` recurrent UTI Urosepsis impaired renal function pyelonephritis pre term pregnancy or small birthweight ```
35
How are renal stones formed?
stones form in the collecting duct from urine due to high concentration of the particular precipitate in the urine
36
What are the most common composite of renal stones?
1. CALCIUM OXALATE** (75%) or calcium phosphate 2. struvate 3. uric acid
37
Where do ureteric stones often get stuck if >5mm?
1. pelvi-ureteric junction 2. pelvic brim 3. vesico-ureteric junction
38
List the predisposing factors for renal/ ureteric stones?
``` diet - high in nuts, chocolate, spinach dehydration obesity men 40-65 y/o drugs e.g. calcium and vitamins D supplements, diuretics, corticosteroids, allopurinolol recurrent UTIs metabolic conditions e.g. hypercalcaemia, hyperparathyroidism, Addisons, bushings catheters ```
39
How do ureteric stones present?
``` asymptomatic renal colic ** (pain referred as visceral nerve supply to ureter and kidney follows similar course to somatic nerve supply to gonads and flanks) + nausea and vomiting haematuria +/- UTI ```
40
Describe renal colic
excruciating "worst ever" pain from loin to groin associated with nausea and vomiting lasts for mins-hours occurs in spasms - with no pain or dull ache in between (pain comes in waves as peristalsis pushes on obstruction and causes ischaemia) associated with nausea and vomiting
41
How are renal stones investigated?
1. urine dipstick - for blood or signs of infection 2. urine microscopy and culture 3. KUB x-ray 4. non contrast CT KUB **- best for visualising stones
42
How are renal stones managed conservatively?
1. analgesia (NSAIDs - IM diclofenac ) + anti -emetic 2. encourage lots of fluids, IV fluids and admit if dehydrated/ can't keep fluids down 3. most pass spontaneously (if <5mm) within 4 weeks 5. calcium channel blocker (nimodipine)
43
What are the possible differentials for renal stones?
RENAL- pyelonephritis, acute renal infarction GYNAE- ectopic, endometriosis, ovarian cyst, PID GI- appendicitis, diverticulitis, biliary colid CARDIO- ruptured aortic aneurysm
44
how are renal stones managed surgically?
1st line = extracorporeal shock wave lithotripsy SE: HTN, diabetes, haematuria, steinstrasse 2nd line = uteroscope (laser) 3rd line = percutaneous nephrolithotomy (large stones) if hydronephrosis/ obstruction = percutaneous nephrostomy
45
List the risk factors for bladder cancer (transitional cell carcinoma)?
smoking ** occupational exposure e.g. aromatic amines in rubber and dye industry, gas works, textile printing, sewage works schistosomiasis (causes squamous cell ca) pelvic radiotherapy
46
How does bladder cancer present?
painless frank haematuria | irritative bladder symptoms e.g. frequency, dysuria , recurrent UTIs
47
How should non/visible haematuria in >60 y/o be managed?
2 week referral wait!!! | cystoscopy and biopsy
48
How are bladder tumours managed?
superficial tumours/ carcinoma in situ: transurethral resection of superficial lesions Invasive tumours into muscle: radical cystectomy or radical radiotherapy
49
what is a hydrocele?
excess fluid within the tunica vaginalis
50
How is a hydrocele caused?
PRIMARY- in <1 y/o with a patent vaginalis SECONDARY - to trauma, tumour or infection
51
How is a hydrocele treated?
1. aspirated | 2. surgery (lords repair)
52
What are the possible causes of epididymo-orchitis?
Chlamydia ** (<35 y/o) Gonorrhoea E.coli Mumps
53
How does epididymo orchitis present?
``` sudden onset of a tender swelling dysuria fever/ sweats urethral discharge Prehns sign - lifting testis relieves pain ```
54
How should epididymo- orchitis be investigated?
1. first catch urine sample 2. STI screen - NAAT for chlamydia/ gonorrhoea 3. sexual history
55
How is epididymo- orchitis treated?
1. antibiotics - doxycycline for chlamydia, ceftriaxone if gonorrhoea, ciprofloxacin if >35 y/o 2. analgesia (NSAIDs) 3. contact tracing 4. supportive underwear
56
What is testicular torsion?
when the spermatic cord to a testicle twists and cuts off the blood supply to the testis which causes testicular ischaemia and necrosis
57
What is contained within the spermatic cord?
testicular artery, cremasteric artery cremasteric nerve, sympathetic nerve pampinform plexus of veins, vas deferens, lymphatic drainage starts at deep inguinal ring and enters scrotum at the superficial inguinal ring
58
List the RF for testicular torsion
``` <30 y/o bell clapper deformity (free floating in testis in the scrotum) undescended testis large size testis most common in neonate or adolescents ```
59
How does testicular torsion present?
unilateral sudden onset pain, tender (can radiate to groin and abdomen) nausea and vomiting acute swelling, redness, erythema
60
What are the signs of testicular torsion on examination?
testis lying transverse and high tender, hot, swollen testis loss of cremasteric reflex
61
List the differentials of a swollen, inflamed testis
``` epididymo orchitis - prehn sign +ve (-ve in testicular torsion) testicular torsion tumour trauma acute hydrocele idiopathic scrotal oedema ```
62
How is testicular torsion managed?
clinical diagnosis and requires surgery within 6 hours (orchidectomy and bilateral fixation) - do both sides to ensure doesn't happen to other testis complications: psychological impact, decreased fertility, tissue loss ** doppler USS diagnoses**
63
list possible causes of testicular cancer?
``` undescended testis (10%) FH klinefelters sydnrome previous testicular cancer mumps orchitis infertility ```
64
What are the most common types of testicular cancer?
95% are germ cell in origin which can be divided into: 1. seminoma - peak incidence 30-40 y/o 2. non seminoma/ teratoma - peak incidence 20-30 y/o (tumour markers) 3. mixed germ cell
65
Where does testicular tumours commonly spread to?
lymph nodes: para aortic and supra diaphragmatic lymph nodes lumbar bone lung mets (25% of seminomas and 50% of non seminomas metastasised at presentation)
66
How does testicular cancer present?
hard painless testicular lump (warrants 2 week referral) +/- dragging sensation, abdominal pain + gynaecomastia (due to high levels of HCG), secondary hydrocele, haemospermia, abdo mass
67
How is testicular cancer diagnosed?
1st line = ultrasound of both testes 2nd = tumour markers (alpha fetoprotein and human chorionic gonadotropin) + CT/ PET + CXR for staging
68
how is testicular cancer managed?
1. low dose radiotherapy 2. radical orchidectomy - good prognosis! + chemo if mets/widespread
69
List sites where transitional cell carcinoma can occur?
bladder urethra ureter renal pelvis
70
List lymph nodes that drain the bladder
obturator external and internal iliac common iliac
71
Where does the blood supply to the bladder come from?
vesical arteries (branch of the internal iliac arteries)
72
what are the complications of BPH?
urinary retention urinary tract infection obstructive uropathy
73
what is the gold standard investigation to diagnose testicular torsion?
doppler ultrasound !! | *but usually clinical diagnosis as do not delay surgical exploration
74
which drugs increase the risk of renal stones?
``` loop diuretics calcium and vit D supplements steroids theophylline acetalozomide ```
75
what are the risk factors for urate kidney stones?
gout hyperuricaemia myeloproliferative disorders ileostomy patients
76
where is testosterone produced?
in the leydig cells by LH
77
where is sperm produced?
Sertoli cells
78
list examples of non germ cell tumours?
lymphoma leydig cell tumours sarcoma
79
What are the complications of prostate cancer?
spread to OBTURATOR lymph nodes spinal cord compression hypercalcaemia bone mets - fracture, pain
80
when does PSA increase?
``` prostate cancer BPH vigorous exercise ejaculation - wait 48hrs after to do test prostatitis, UTI ```
81
where do bladder cancers spread to?
para aortic and common / external/ iliac lymph nodes pelvic structures locally via blood: lungs, bone, liver
82
how are renal stones and obstruction / signs of sepsis managed?
1. urgent decompression via ureteric stent or nephrostomy | 2. IV abx
83
how is hydronephrosis diagnosed?
USS = dilatation of renal pelvis | can be caused by renal obstruction
84
what is the difference between acute and chronic urinary retention?
``` acute = painful, <1.5L retention chronic = painless, >1.5L drained ```
85
what are the risks with acute urinary retention?
post obstructive diuresis - ensure hourly UO monitoring and replace with IV fluids
86
how can you tell O/E if there is a renal mass?
mass palpable on bimanual palpation moves up and down with respiration able to get above mass
87
what are the causes of urethral strictures?
long term catheter pelvic truama foreign bodies lichen sclerosis
88
what are the complications of urethral strictures?
calculus | prostatitis
89
how are urethral strictures managed?
internal uthrostomy

3b Specialities (7 decks)

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