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Urology Flashcards

1
Q

Differentiate between the different types of hematuria

A 
Pre-renal
- coagulopathy
- sickle cell disease
- thromboembolism
Renal
- trauma
- renal carcinoma
- infection
- glomerulonephritis 
Post-Renal (TITS)
- Trauma: foreign body, catheritization, radiation
- Infection
- Tumour: bladder cancer, prostate hypertrophy
- Stone: renal calculi
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2
Q

Differentiate between renal and post-renal hematuria

A 
Renal
- tea colored urine with no clots
- high creatinine and BUN
- dysmorphic RBC, RBC casts
- proteinuria
Post-Renal
- red with some clots
- normal creatinine
- normal shaped RBC with no proteinuria
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3
Q

Discuss the presentation and management of renal cell carcinoma

A 
Risk Factors
- smoking
- hypertension
- obesity
- kidney anomaly
Presentation
- asymptomatic with incidental finding on imaging
- Triad of gross hematuria, flank pain, and palpable mass
- paraneoplastic syndromes (hypercalcemia, anemia, erythrocytosis, hypertension)
Investigation
- CT
- biopsy
Management
- partial or radical nephrectomy 
- radiotherapy
- anti-angiogenesis factors, mTOR, IL-2 for advanced disease
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4
Q

Discuss the presentation and management of bladder cancer

A 
- transitional cell carcinoma
Risk Factors
- smoking
- chemical exposure
- cyclophosphamide
- radiation to pelvis
- chronic bladder irritation
Presentation
- gross hematuria 
- pain
- clot retention
- FUNSHED
Investigation
- NMP-22, BTA, immunocyt and FDP are bladder tumour markers
- cystoscopy with bladder washing
Management
- surperficial: transurethral resection of bladder tumour
- invasive: cystectomy with chemo-radiation adjuvant (mitomycin)
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5
Q

Differentiate the different causes of failure to store

A

Urge Incontinence (detrusor overactivity or decreased compliance)
- detrusor overactivity from CNS lesion, inflammation, bladder neck obstruction
- decreased bladder compliance: fibrosis of bladder or non-functioning neck
Stress Incontinence (urethral hypermobility or instrinsic sphincter deficiency)
- urethral hypermobility: weakened pelvic floor from childbirth, pelvic surgery, age
- instrinsic sphincter weakness: aging, hypo-estrogen, pelvic surgery
Overflow Incontinence (due to failure to void)

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6
Q

Discuss the medications associated with incontinence

A
  • anti-histamine
  • anticholinergic
  • ACE inhibitor
  • Diuretic
  • alpha agonist
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7
Q

Discuss the investigations and management of the types of incontinence

A

Urge
- diagnosis from urgency on history and urodynamics
- lifestyle modification and bladder habit training
- anti-cholinergics
- botox
Stress
- diagnosis past on history and positive stress test
- lifestyle modification with pelvic floor therapy
- pessary for females
- surgical sling, or sphincter
Overflow
- diagnosis from post-void residual of >200cc
- lifestyle management
- catheterization
- removal of obstruction

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8
Q

Differentiate the causes of urinary retention

A 
Outflow Obstruction
- urethra: stricture
- bladder neck: stone, foreign body, neoplasm
- prostate: BPH, cancer
- external obstruction
Neurogenic bladder
- stroke, Parkinson's
- spinal injury, MS
- diabetic neuropathy
Urinary Tract Irritation
- UTI
Medications
- anticholinergics
- narcotics
- ephedrine
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9
Q

Discuss the urinary questions

A

FUNSHED

  • Frequency
  • Urgency
  • Nocturia
  • Straining
  • Hesitancy
  • Dysuria
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10
Q

Describe the 3 zones of the prostate

A

Peripheral zone
- 70% of volume and most common site of cancer (adenocarcinoma)
Central Zone
- 25% of volume and surround ejaculatory ducts
Peri-urethral transitional zone
- 5% and is site of BPH

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11
Q

Discuss the physiology and histology of the prostate gland

A

Physiology
- secrete thin, milky fluid which aids in sperm viability and motility
- prostate growth stimulated by andreogens (testosterone and dihydrotestosterone)
Histology
- formed by tubuloalveolar glands surrounded by fibromuscular strom
- line with simple columnar epithelium
- have corpora amylacea in prostatic gland

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12
Q

List the risk factors for prostate cancer

A
  • African descent
  • family history
  • high dietary fat
  • cigarette smoking
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13
Q

Discuss the presentation and management of prostate cancer

A

Presentation
- asymptomatic early so detected by DRE and PSA
- FUNSHED
- erectile dysfunction
- incontinence
- DRE demonstrate hard, irregular node or diffuse induration
- metastasis to bone (osteoblastic) in axial skeleton
Investigations
- PSA
- biopsy with tans-rectal ultrasound
- CT abdomen
Management
- watchful waiting for short life expectancy
- active surveillance for low grade disease
- brachytherapy for low risk disease
- external beam for locally advanced in older patients
- radical prostatectomy for young patients with high risk disease
- metastasis treat with antiandrogens

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14
Q

Discuss PSA screening

A

Elevation in PSA
- prostate cancer
- BPH
- prostatitis
- trauma from DRE, catheterization
PSA
- <10% free PSA than high risk for cancer
- >0.75ng/mL/yr velocity than increased risk of cancer
- >0.15ng/mL/g density than increased risk
- <4ug/L is normal (but varies with age and race)

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15
Q

Discuss the presentation and management of benign prostate hyperplasia

A

Presentation
- FUNSHED
- DRE demonstrate symmetrically enlarged, smooth prostate
Investigation
- post-void residual and urodynamics
Management
- mild symptoms have lifestyle changes of fluid restriction
- moderate use alpha-adrenergic antagonist to reduce stroma smooth muscle tone (tamsulosin (flomax)
- 5-alpha reductase inhibitor to inhibit conversion of testosterone to DHT (finasteride)
- Surgery TURP for renal failure, recurrant UTI/hematuria, urinary retention

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16
Q

Discuss the presentation and management of prostatitis

A
  • most common urologic disease in men <50
  • infection with PEEAKS bacteria
    Risk Factors
  • BPH
  • recent instrumentation of urinary tract
    Presentation
  • FUNSHED with hematuria
  • fever
  • rectal, perineal pain
  • DRE show tender, warm prostate
    Investigation
  • 4 specimen urine culture
    Management
  • septra PO for 4-6 weeks
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17
Q

List the risk factors for renal calculi

A
  • dehydration
  • obesity
  • thiazide
  • UTI
  • gout
  • cystinuria, xanthinuria, oxaluria
18
Q

Discuss the pathophysiology of renal calculi

A
  • predisposition to supersaturation of salt from urinary stasis or low flow, increased solute, low urine pH
  • supersaturation of salt leads to formation of crystals where can obstruct urinary tract
19
Q

List the 4 different types of stones

A 
Calcium
- radiopaque on KUB
Uric acid
- low urine pH, diet rich in purines, gout
- radiolucent
Struvite
- infection with urea splitting organism (Proteus, pseudomonas, klebsiella, mycosplasma)
- staghorn calculi in renal pelvis
- radio-opaque
Cystine
- autosomal recessive disorder lead to reduced absorption of cystine
- radiolucent
20
Q

List the most common locations for stones

A
  • Uteropelvic junction
  • pelvic brim
  • under vas deferens/broad ligament
  • uretero-vesical junction
21
Q

Discuss the presentation and management of renal calculi

A 
Presentation
- constantly uncomfortable
- nausea, vomiting
- flank pain that is severe and radiate to grown
- hematuria
Investigation
- urinalysis and culture
- KUB x-ray
- CT scan without contrast
Management
- high likelihood stone will pass if <=5mm
- treat with PO fluids, ketorolac, alpha-blockers (flomax)
22
Q

Discuss the criteria for admission with renal calculi

A 
Urosepsis
- urine stasis lead to ascending infection
Acute Renal Failure
- can be obstructing leading to hydronephrosis and failure
High Risk Patient/Stone
- solitary kidney
- bilateral stones
Symptoms
- intractable nausea/vomiting
23
Q

Discuss the surgical intervention for renal calculi

A

Kidney Stones
- stone <2.5cm possible stent and then extra-corporeal shock wave lithotripsy
- >2cm then percutaneous nephrolithotomy
Uteral Stones
- ESWL and uterosopy to retrieve stone
- if infected stone then place stent and begin antibiotics (amp and gentamicin)

24
Q

Discuss the prevention measures for stone formation

A

Dietary Modification

  • increase fluid intake >2L
  • potassium and citrate intke
  • reduce animal protein
  • high dose vit C supplementation
  • do not decrease calcium intake
25
Discuss the presentation and management of testicular torsion
``` Risk Factors - cryptochordism - bell clapper deformity - trauma - intravaginal where twist in tunica vaginalis which occur in puberty (extravaginal occur in neonates) Presentation - acute, severe scrotal pain radiating to groin or abdomen - nausea and vomiting - tender, erythematous that can be high riding or transverse lie - no cremasteric reflex - negative Phren's sign Investigation - urgent go direct to OR - trans-scrotal ultrasound with doppler Treatment - surgical derotation with bilateral orchiopexy, possible orchiectomy ```
26
Discuss the presentation and management of epididymitis/orchitis
Risk Factors - sexual activity and risk factors for STI - recent instrumentation of urinary tract Pathogenesis - <35 most common is e coli, gonorrheae or chlamydia - >35 infection by e coli Presentation - insidious onset of pain associated with dysuria, frequency, nocturia - fever - diffuse tenderness - erythematous, warm, swollen testes with possible discharge - normal cremasteric reflex and Phren sign Investigation - leukocyte - urine culture and urethral swab Management - bed rest with scrotal elevation - NSAID - gonorrhea get ceftriaxone, chlamydia get azithromycin, and e coli get ciprofloxacin
27
Discuss the presentation and management of a hematocele
``` Presentation - history of trauma with painful scrotal mass - bruising and diffuse tenderness Investigation - ultrasound to visualize blood collection Management - pain control - surgical for fracture of testes ```
28
Discuss the presentation and management of hydrocele
Pathogenesis - collection of serous fluid in the tunica vaginalis - secondary have testicular pathology that irritate tunica - defect in tunica from patent processus vaginalis Presentation - painless large scrotal mass - transilluminating mass - mass not isolated from testis - palpable spermatic cord Investigation - ultrasound show cystic fluid Management - most resolve spontaneously - surgical management for symptomatic, cosmesis, or underlying pathology
29
Discuss the presentation and management of spermatocele
Pathogenesis - obstruction of distal duct leading to fluid filled sperm collection in epididymis Presentation - non-tender cystic mass in epididymis that transillumintes - palpate testis seperate from amss Investigation - ultrasound show cystic mass Management - operate only if symptomatic or cosmesis
30
Discuss the presentation and management of varicocele
Pathogenesis - dilatation and tortuosity of pampiniform venous plexus of spermatic cord - most commonly on left side due to gonadal vein entrance into renal vein - right side concerning for cancer Presentation - infertility - bag of worms scrotal mass Investigation - ultrasound Management - operative if infertility, ipsilateral testicular atrophy, symptomatic or cosmesis
31
Discuss the presentation and management of testicular cancer
Risk Factors - age <10, 15-35 and >60 - maternal exposure to androgen in pregnancy - cryptochordism Presentation - painless testicular enlargement - gynecomastia, Investigation - scrotal ultrasound showing hypoechoic mass with irregular borders and heterogeneity - bHCG: risk for seminioma, embryonal, choriocarcinoma - AFP: increased in non-seminoma - LDH Management - radial orchiectomy for painless mass in right age group with ultrasound suspicion - Pathology and CT afterwards to determine stage and treatment
32
List the different types of testicular cancers
``` Seminoma (35%) - germinal cell - epithelium - stage 1 get surveillance - stage 2 and 3 get radiation an chemotherapy Non-seminoma - Teratoma - embryonal - mixed cell type - yolk sac - chorio - stage 1 get surveillance - stage 2 and 3 get lymph node dissection and chemotherapy ```
33
Discuss the lymph node metastasis for testicular cancers
Right Testicle - medial, para-caval, anterior and lateral lymph nodes Left testicle - left lateral and anterior para-aortic lymph nodes
34
List the most common bacteria for a urinary tract infection
PPEEEAKS - proteus - pseudomonas - e coli - enterobacter - enterococcus - acinobacter - kliebsiella - staphyloccocus saprophyticus
35
List the risk factors for a UTI
``` Urine stasis - obstruction - functional urinary retention Foreign body - catheter Immune Compromise - diabetes - malignancy Other - female - trauma ```
36
Discuss the presentation and management of a UTI
Presentation - frequency, urgency, dysuria, hematuria - suprapubic tenderness - costavertebral tenderness Investigations - dipstick: positive leukocytes and nitrites - urine microscopy 5 WBC/HPF - culture >100CFU/mL Management - Uncomplicated: septra PO for 3 days 1st line or cipro for 3 days as second line - in men require longer course as most likely obstructive - pyelonephritis require cirpro for 7-14 days or septra for 7 days - asymptomatic treat only if pregnant or have manipulation
37
Differentiate between the different causes of recurrent urinary tract infections
Relapse - recurrence of same infection within 2 weeks after discontinuation of antibiotics - must consider anatomy or abnormal voiding - check resistances Reinfection - recurrence of UTI with new organism
38
Discuss the presentation and management of bladder trauma
Pathophysiology - contusion have no rupture of bladder - intra-peritoneal have bladder dome rupture into intra-peritoneal cavity - extra-peritoneal have anterior or lateral wall rupture Presentation - bladder trauma associated with pelvic fracture - abdominal tenderness with peritoneal signs - inability to void Investigation - CT Cystogram Management - Foley - extra-peritoneal can follow with CT cystograms - intra-peritoneal require suprapubic catheter and surgery
39
Discuss the presentation and management of kidney trauma
Presentation - associated with lower rib or vertebral transverse process fracture - upper abdominal/flank injury Investigation - abdominal and pelvic CT with contrast Management - gross hematuria with contusion require hsopitalization with bedrest
40
List the classification system for renal trauma
Stage 1 - renal contusion Stage 2 - <1cm laceration without urinary extravation - >1cm laceration without urinary extravation - urinary extravation - shattered kidney

Surgery (14 decks)

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