urology

Question 1

what are the 4 sections of the urethra - and which is the site at which most idiopathic strictures in men occur?

Answer 1

1. prostatic urethra
2. membranous
3. bulbar - where most idiopathic strictures in men occur
4. penile

Question 2

in which area does the hyperplasia of cells in BPH occur?

Answer 2

transition zone of the prostate

Question 3

list the symptoms associated with BPH. split them into two categories for ease

Answer 3

1. storage - urgency / frequency

2. weak or intermittent flow / straining / hesitancy / terminal dribbling / incomplete emptying

Question 4

outline the key investigations for suspected BPH

Answer 4

Bedside:
PR, urine dip
Bloods:
U&Es, maybe PSA if suspected PrCa and
Scans:
Bladder scan - to check for incomplete emptying
Plain abdo XR
USS of kidney - check for hydronephrosis 2y to bladder outflow obstruction

Question 5

outline the conservative, pharmacological and surgical management of BPH

Answer 5

conservative:
advise to limit caffeine intake
review medications: (swap antihypertensive diuretics for non-diuretics antiHTNs)
- tell patients on diuretics to take their tablets in the mornings NOT at night - lessen nocturia
-underwear pads for incontinence?
Medical:
- a-blockers - tamsulosin / doxazosin.
- 5-AR inhibitors
surgical:
TURP - coring out the middle of the prostate

Question 6

how do alpha-blockers work?

Answer 6

relax the smooth muscle of the prostate

reduce its constrictive effect on the prostatic urethra

Question 7

what side effects are associated with alpha blockers?

Answer 7

dizziness / postural hypotension / syncope

Question 8

give some cuases of acute urinary retention

Answer 8

PROSTATIC OBSTRUCTION
urethral strictures
anticholinergics (oxybutinin / tolterodine - for overactive bladder)
POST-OP (anaesthetics / pain / inflamm)
constipation / cauda equina / Ca

Question 9

give some cuases of chronic urinary retention

Answer 9

prostatic enlargement
pelvic Ca
CNS disease (S2-S4) eg. MS / transverse myelitis

Question 10

describe the TNM staging of prostate Ca

Answer 10

T1 - tumour found histologically only
t2 - tumour palpable - BUT not spread beyond confines of prostate capsule
t3 - tumour spread through capsule / to seminal vesicles
prostate still mobile
t4 - spread to pelvic organs / to pelvic wall
prostate fixed / non-mobile

Question 11

describe the two key types of bladder Ca - and their associated risk factors

Answer 11

general bladder Ca RFS:

• increasing age
• smnoking
• male sex

transitional cell carcinoma - Exposure to AROMATIC AMINES (aniline dyes) in the printing and textile industry / Rubber manufacture / Cyclophosphamide

squamous cell carcinoma - smoking / schisto.

(the three s’s)

Question 12

what findings on a dip test would suggest a UTI?

Answer 12

incraesed leuk - UTI
increased nitrites - gram -ve UTI eg. E coli
nb - should not use dipstick to Dx UTI if >70yrs - send urine for MC and S instead

Question 13

give some complications assoc with prostate surgery / radiotherapy

Answer 13

surgery: urinary incontinence (sphincter weakened)/ UTIs / haematuria / dysuria / ED / retrograde ejactulation
RT: bowel problems (constipation etc) - and the above..

Question 14

where does prostate cancer usually arise?

Answer 14

adenocarcinomatas - glandular cells (usually in the peripheral zone)

Question 15

what can cause a raised PSA?

Answer 15

uti / vigourous exercise / ejaculation / anal sex / BPH / prostatitis

Question 16

how would a metastatic prostate cancer feel on a dre?

Answer 16

hard and craggy

?mobile? if not - likely stage 4 TNM..

Question 17

if suspected advanced prCa what tests should you do..?

Answer 17

U&Es - renal fn - bladder outlow / ureteric obs
FBC - anaemia of cd
LFTs - liver mets
PSA - usually raised in PrCa - if raised - ?TURP - biopsies
needle biopsy of prostate - for Gleason score
CT / MRI
Bone scan

Question 18

outline the management of prostate Ca by reference to the tnm stages

Answer 18

T1-2 : active surveillance / radical prostatectomy / radiotherapy / brachytherapy (internal radiotherapy)
T3-4 : a combination of ADT / external beam radiotherapy / watchful waiting

Question 19

GnRH (LH releasing hormone) analogues can be used to manage metastatic prostate cancer.

1. where is GnRH produced normally and how does it work?
2. how do GnRH analogues work?
3. what do you need to do in the early stages of GnRH treatment
4. give an example of a GnRH analogue

Answer 19

1. hypothalamus - acts on ant pit to increase LH production
2. LHRH analogues work by flooding the endocrine system with lots of exogenous LH - causing downregulation of the LH receptors on the testes (so they produce less testosterone)
3. add in an antiandrogen to counter the initial rise in testosterone (before downregulation of receptors..) eg. flutamide
4. Goserelin

Question 20

how can pyelonephritis occur? (how can bacteria reach the kidney..)

Answer 20

haematogenous spread

ascending route

Question 21

which organisms commonly cause pyelonephritis?

Answer 21

E coli from LUT

(can be from haematogenous spread eg in sepsis

Question 22

describe the main prsenting sx of pyelonephritis

and the finding OE

Answer 22

loin pain
fever (high grade, swinging..)
rigors
nausea and vomiting 
OE:
febrile 
tenderness in renal angle 
oliguric...
signs of dehydration 2y to vomiting and sweating

Question 23

what are rigors often a sign of , and why do patients with pyelonephritis often develop them.?

Answer 23

bacterial infection

high fever

Question 24

where is the renal angle?

Answer 24

the angle between the 12th rib and the lateral border of the erector spinae muscle

Question 25

what investigations should you do if you suspect a patient to have pyelonephritis - and what are you looking for on each?

Answer 25

``` BEDSIDE: urinalysis (blood, protein, leukocytes urine culture (white cell casts) INVASIVE / BLOODS: bloods - raised WCC U+Es - renal Fn and which ABx blood cultures SCANS: US KUB - look for renal abnormalities eg. PKD / horsehoe - also looks for ureteric stones etc.. ```

Question 26

how should you manage a patient with suspected pyelonephritis eg. in GPland

Answer 26

abcde (sepsis) - ix as above admit to hospital iv ABx - Gent

Question 27

why gentamicin for pyelonephritis - and what 2 things need to be checked in someone on gent..?

Answer 27

1. aminoglycoside - good for gram -ves like e coli 2. a. gent levels 2. b. renal function (nephrotoxic - cant be used in pts with overly deranged renal fn)

Question 28

which factors predispose to pyelonephritis?

Answer 28

?UTI RFs? | pregnancy / female / new sexual activity / indwelling catheter / urinary tract stones / DM / dementia..

Question 29

what is meant by SIRS?

Answer 29

Systemic Inflammatory Response Syndrome (SIRS). This is characterised by body temperature outside 36 oC - 38 o C, HR >90 beats/min, respiratory rate >20/min, WBC count >12,000/mm3 or < 4,000/mm3. (sepsis = infection + 2 of these criteria..) Patients with infections and two or more elements of SIRS meet the diagnostic criteria for sepsis. Those with organ failure have severe sepsis and those with refractory hypotension -septic shock.

Question 30

how is pyonephrosis different to pyelonephritis?

Answer 30

PUS in pyonephrosis.

Question 31

what substances can renal stones be made from? - and which is most common?

Answer 31

calcium oxalate - 80% - sharp - cause Sx even if small calcium phosphate - urate - 10% - high uric acid levels in urine struvite -

Question 32

where do renal stones most commonly form? (3 places..)

Answer 32

PUJ where ureter passes over pelvic brim vesicoureteric junction

Question 33

describe the presentation of someone with Renal / ureteric calculi

Answer 33

``` intense loin to groin pain unable to get comfortable writhing around macroscopic haematuria fever / n&v - would suggest PYELONEPHRITIS / PYONEPHROSIS ```

Question 34

describe findings on examionation of someone with rrenal / ureteric stones

Answer 34

loin tenderness

Question 35

What would your investigations be if you suspected someone had a stone?

Answer 35

urinalysis - ALMOST ALWAYS have haematuria bloods: FBC (WCC raised in secondary pyonephrosis / pyelonephritis) CRP (?infection..) clotting screen if percutaneous intervention likely / planned U&Es - is renal fuinction impaired? Makes up your mind whether to site a nephrostomy or not (particular reference to creat + electrolytes) Calcium and urate levels - if raised - further suspicions of a stone. Guide Mx in preventing further stone formation AXR - 50% are radio-opaque. confiurm stone, allow further aXRs in follow up clinics Non contrast CT-KUB ON ALL PATIENTS W/INB 14HRS OF ADMISSION- radiolucent stones NB - Blood cultures if the patient is pyrexial >38°C, or has signs of systemic inflammatory response syndrome (SIRS) or sepsis

Question 36

what is colic/?

Answer 36

the pain created by peristalsis against a blockage?

Question 37

a) what is your immediate management of someone with a renal / ureteric stone? b) what size stone should be managed surgically? c) what surgical options are available for stones? d) which surgical option is best for which stone?

Answer 37

a. IMMEDIATE - give NSAIDs (diclofenac ibuprofen (nb - increased CV risk with these though..)) if requiring admission - IM diclofenac b) generally, stones less than 7mm in size are left for the pt to pass naturally w/ lots of analgesia stones larger than 7mm are managed surgically: c)lithotripsy - ultrasound waves- smallish stones litholapaxy - breaking up stones with laser / mechanical device under spinal / GA percutaneous nephrolithotomy - access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed. IF PREGANT - Ureteroscopy - A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure. d) Stone burden of less than 2cm in aggregate - Lithotripsy Stone burden of less than 2cm in pregnant females - Ureteroscopy Complex renal calculi and staghorn calculi - Percutaneous nephrolithotomy Ureteric calculi less than 5mm(7mm).. - Manage expectantly

Question 38

when should a non-contrast CT-KUB be performed immediately?

Answer 38

if a patient has a fever, a solitary kidney or when the diagnosis is uncertain (ie. exlcuding rupture AAAs etc) an immediate CT KUB should be performed

Question 39

outline the long term management / prevcention of renal calculi

Answer 39

Prevention of renal stones - DEPENDS ON THE STONE Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population. high fluid intake low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet) thiazides diuretics (increase distal tubular calcium resorption) Oxalate stones cholestyramine reduces urinary oxalate secretion pyridoxine reduces urinary oxalate secretion Uric acid stones allopurinol urinary alkalinization e.g. oral bicarbonate

Question 40

how would you manage hypercalcaemia (think of 2 principles..)

Answer 40

1. IV 0.9% saline 4-6L in 24hrs - volume expansion nb - MONITOR FOR FLUID OVERLOAD - may need loop diuretics if occurs (esp likely in elderly / renal impairment) 2. IV bisphosphonates - Zoledronic acid 4mg over 15 mins (inhibit osteoclasts - stop more Ca2+ being released, so it goes down BUT will be slow response - Monitor serum calcium response - will reach nadir at 2 to 4 days) care using bisphosph in renal failure (renally excreted) NB - if SEVERE RENAL FAILURE - use denosumab - RANK-L inhibitor - targets osteoclasts as wel; 3. Calcitonin - works faster than bisphosphonates - 12 to 48 hours (bisphosphonates 2-4days)# NB - if very severe renal failure / very high Ca2+ - may need dialysis..

Question 41

a) how would hypercalcaemia present? | b) what are the two most common causes?

Answer 41

bones, groans and psychic moans... Patients with mild hypercalcemia (calcium <12 mg/dL [3 mmol/L]) may be asymptomatic, or they may report nonspecific symptoms, such as constipation, fatigue, and depression A serum calcium of 12 to 14 mg/dL (3 to 3.5 mmol/L) may be well tolerated chronically, while an acute rise to these concentrations may cause marked symptoms: polyuria, polydipsia, dehydration, anorexia, nausea, muscle weakness, and sensory changes In patients with severe hypercalcemia (calcium >14 mg/dL [3.5 mmol/L]), there is often progression of these symptoms

Question 42

how does bladder ca present?

Answer 42

painless haematuria if pt is passing lots of clots - these may get stuck in the bladder neck / urethra - causing acute urinary retention.. NB - 15% ofpts present with urinary frequency (+/- haematuria) / suprapubliuc pain / dysuria

Question 43

what might be your findings examining a pt with bladder ca?

Answer 43

anaemia | pelvic / lower abdo mass

Question 44

what would be your ix for susp bladder Ca | *and what would you find

Answer 44

bloods - FBC - look for anaemia 2y to haematuria / anaemia oCD U&Es - ureteric obstruction (serum creatinine / electrolytes) MSU - Dx and treat any associate UTI Cystoscopy - look inside the bladder - with rigid or flexible cystoscope - visualise the tumour CT / MRI - image the bladder / stage the tumours

Question 45

outline the staging and grading system for bladder Ca:

Answer 45

stage: Ta: cancer confined to the mucosa T1: invades lamina propria BUT not muscle coat T2 - invaded the muscle layer of the bladder T3 - cancer has spread to the perivesical fat T4 - cancer has spread to the adj structures / pelvic side walls.. Grading: G1-2 = low grad G3-4 = high grade

Question 46

outline the management of bladder cancer

Answer 46

* Low-grade non-invasive cancers (G1-2 Ta-T1?? tumours): transurethral resection of the bladder tumour (TURBT) followed by intravesical chemotherapy. * High-grade invasive cancers (G3 T2-T3 tumours): radical cystectomy and lymphadenectomy, or radical radiotherapy with adjuvant or neoadjuvant systemic chemotherapy. * Metastatic bladder cancer (T4 tumours): management focuses on symptom control and palliation.

Question 47

what are your reconstructive options post rad-cystectomy?

Answer 47

Reconstructive options after a radical cystectomy 1. Bladder reconstruction (orthotopic bladder) 2. Ileal conduit with urinary diversion (see below) 3. Continent urinary diversion Forming an ileal conduit with urinary diversion involves plugging the ureters into a piece of isolated ileum, i.e. a piece of ileum which has been cut away from the rest of the bowel but which has its blood supply still intact. One end of the ileum is brought out through an opening in the anterolateral abdominal wall and a stoma bag is put over it. The stoma bag collects the patient’s urine.