Urology

Question 1

What is the most common bladder cancer (89-90%) & renal cancer (85%)?

Answer 1

Transitional cell carcinoma - bladder

Renal cell carcinoma (adenocarcinoma) - kidneys

Question 2

4 layers of the bladder wall

Answer 2

Inner lining - transitional epithelium/ urothelium

2nd - CT lamina propria

3rd - muscularis propria

4th - fatty CT

(Trigone with internal urethral orifice & ureter orifices)

Question 3

How does bladder cancer present?

Answer 3

Painless haematuria
(Visible/ non)

Recurrent UTIs/ LUTS

May ureteric obstruction

Locally advanced - pelvic pain
Metastatic - systemic

Question 4

How do we stage bladder can ear?

Answer 4

TNM

Tis - in situ
T1 - lamina propria
T2 - muscularis propria
T3 - perivesical tissues
T4 - adjacent local structures 

N0 - no nodal involvement
N1 - single node <2cm
N2 - single node 2-5cm/ multiple
N3 - 1+ nodes >5cm

M0 - no metastases
M1

Question 5

Investigations for bladder cancer

Answer 5

Urgent flexible cystoscope
Suspicious lesion -> rigid cystoscope (GA)

Tumours identified - biopsy, transurethral resection of bladder tumour (TURBT)

Muscle invasive - CT staging
May initially have US/ CT

Question 6

Management of bladder cancer

Answer 6

T1 - TURBT

Higher risk - intravesical therapy (BCG/ Mitomycin C), radical cystectomy

70% recurrence 3yrs - regular cytology & cystoscopy

Muscle invasive: radical cystectomy, neoadjuvant chemoT (cisplatin) -> urinary diversion (ileal conduit formation, bladder reconstruction segment SB) - regular CT, bloods, B12, folate

Locally advanced/ metastatic - otherwise well ChemoT (cisplatin/ carboplatin)

Question 7

Investigations BPH

Answer 7

Urinary frequency & volume chart
Urinalysis 
Post void bladder scan 
DRE
PSA
USS renal tract 
Urodynamic studies

Question 8

Medical & main surgical management BPH

Answer 8

Alpha-adrenoreceptor antagonist e.g. tamsulosin (relax SM)
❌postural hypotension, asthenia, rhinitis, retrograde ejaculation

5alpha- Reductase inhibitors e.g. Finasteride
Prevent conversion testosterone-> DHT (decrease prostatic volume)

Surgery:
TURP
❌TURP syndrome - fluid overload & hyponatremia (confusion, N, agitation, visual changes)

Question 9

What are prostate cancers >95% & which zone do they occur? How can it be categorised?

Answer 9

Adenocarcinomas
75% peripheral zone

Acinar adenocarcinoma - most common
Ductal adenocarcinoma - metastases faster

Question 10

Gleason grading of prostate cancer

Answer 10

1 - small, uniform glands
->
5 - only occasional gland formation

Most common growth pattern + 2nd most common
Lowest with cancer = 3+3

Question 11

Watchful waiting vs active surveillance

Answer 11

WW - symptom guided, definitive therapy deferred & hormonal therapy initiated if symptoms
Generally older with lower life expectancy

AS - low risk disease, monitoring 3 monthly PSA, 6 month-annual DRE, re biopsy 1-3 yearly intervals
Intervening when appropriate

Question 12

Treatment prostate cancer

Answer 12

Radical prostatectomy

External beam radioT
BrachyT - radioactive seeds

ChemoT - metastatic
Chemo drugs: docetaxel, cabazitaxel

Androgen deprative therapies: LHRH agonists (goserelin), GnRH R agonists (degarelix)

Question 13

Types of prostatitis

Answer 13

Acute bacterial
Chronic bacterial
Non bacterial
Prostatodynia

Question 14

Pathophysiology of prostatitis

Answer 14

Ascending urethral infection/ lymphatic spread from rectum/ haematogenous bacterial sepsis

E.coli most common
Enterobacter
Serratia

STIs rare causes

Chronic - inadequately treated acute

Question 15

Investigations prostatitis

Answer 15

DRE - tender & boggy
Inguinal lymphadenopathy

Urine culture
STI screen
Routine bloods
PSA

Initial therapy failed (quinolone prolonged) - TRUS
Transrectal prostatic USS / CT

Question 16

A sign for epididymitis

Answer 16

Prehn’s sign - supine, scrotum elevated by examiner

Pain relieved by elevation +ve

Question 17

What is bell-clapper deformity & what does it put you at risk of?

Answer 17

Horizontal lie, lack normal attachment to tunica vaginalis

Testicular torsion (twisting of spermatic cord within tunica vaginalis)

Question 18

Clinical features testicular torsion

Answer 18

Sudden onset severe unilateral testicular pain

N&V secondary to pain

Referred abdo pain

Testis high position with horizontal lie

Swollen
Tender

Cremasteric reflex absent
Pain despite elevation of testis (-ve prehn’s sign)

Question 19

What’s a bilateral orchidopexy & when is it done?

Answer 19

Cord & testis untwisted & both testicals fixed to the scrotum

Prevent testicular torsion (within 4-6hrs)

Question 20

How are primary testicular tumours categorised?

Answer 20

Germ cell tumours 95%
- seminoma (localised until late)
- non-seminomatous (yolk sac tumours, choriocarcinoma, embryonal carcinoma, teratoma - metastasise early)
Usually malignant

Non-germ cell tumours 5%
- leydig cell tumours -> androgens
- Sertoli cell tumours -> oestrogen
Usually benign

Question 21

Investigations testicular cancer

Answer 21

Tumour markers:
BetaHcG elevated 60% NSGCTs & 15% seminoma

AFP raised some NSGCTs

LDH tumour volume

Scrotal USS
CT with contrast Chest-abdo-pelvis

No biopsy as could cause seeding of cancer

Question 22

How can urethritis be classified?

Answer 22

Gonococcal - caused by N.gonorrhoeae
✅ceftriaxone + azithromycin

Non-gonococcal - most often C.trachomatis, M.genitalium, T.vaginalis
✅doxycycline or azithromycin

Question 23

Urethritis symptoms & investigations

Answer 23

Dysuria
Penile irritation
Discharge

Epididymitis
Reactive arthritis

Gram stain - urethral swabs
First void urine - NA
Mid stream urine dipstick

Sti screening

Question 24

What is paraphimosis? What causes it & what can it lead to?

Answer 24

Inability to pull forward a retracted foreskin over glans penis -

often due tight constricting band as part of foreskin -> glans oedematous

• > vascular engorgement
• > ischaemia/ infection (Fournier’s gangrene)

✅urgent reduction

Question 25

What is priapism? Pathophysiology? What can it lead to?

Answer 25

Unwanted painful erection not associated with sexual desire >4 hrs Low flow/ Ischaemic priapism - blood stays within corpus cavernosa, prolonged venous stasis, veno-occlusive - associated intracavernosal drug therapy, SCD, haematological disorders, pelvic malignancy - painful & rigid High flow/ non-ischaemic - unregulated cavernous arterial inflow (more quickly than can be drained) - associated trauma, can triggered stimulation - painless & not fully rigid Can lead to fibrosis & impotence

Question 26

Management of priapism

Answer 26

Corporeal aspiration - alleviates 30% Also obtains corporeal blood gas sample If no response - intracavernosal injection of sympathomimetic agent e.g. phenylephrine trialled Surgical: shunt between corpus cavernosa & glans - 70% (can lead to erectile dysfunction)

Question 27

What is a penile fracture?

Answer 27

Traumatic rupture of corpus cavernosa & tunica albuginea in erect penis Caused blunt trauma (penis violently deviated away from axis) Popping sensation Penile swelling & discolouration - aubergine sign - deviation May firm immobile haematoma shaft - rolling sign

Question 28

Investigations & management penile fracture

Answer 28

``` Clinical diagnosis Bloods Cavernosography- identify rupture site Ultrasonography Urethral injury - retrograde urethography ``` ✅surgical exploration & repair - sutures, haematoma evacuated Abstinence 6-8weeks

Question 29

What is Fournier’s gangrene? Signs & management?

Answer 29

Necrotising fasciitis (rapidly spreading necrosis)affects perineum, mortality 20-40% Monomicrobial/ polymicrobial - Group A streptococcus, C. Perfringes & E.coli Severe pain out of proportion to signs or pyrexia -> crepitus, skin necrosis, haemorrhagic bullae-> sepsis ✅ Immediate surgical exploration, bloods, CT -> surgical debridement +/- partial/ total orchiectomy, broad ABs, fluid

Question 30

Define pyelonephritis, what causes it?

Answer 30

Inflammation of the kidney parenchyma & renal pelvis typically due bacterial infection (ascending UTI, blood stream, lymphatics) Uncomplicated - structurally/ functionally normal urinary tract, non-immunocompromised 80% Escherichia coli Klebsiella, proteus Enterococcus faecalis - catheters

Question 31

Symptoms of pyelonephritis

Answer 31

Classic triad: fever, unilateral loin pain, N&V Typically over24-48hrs UTI Symptoms Haematuria Costovertebral angle tenderness - renal USS - CT non contrast if obstruction suspected

Question 32

What are urinary tract stones made from?

Answer 32

``` 80% calcium Calcium oxalate 35% Ca phosphate 10% Mixed 35% Struvite Urate (radiolucent) - ⬆️purine red meats/ haematological disorder Cystine - hypocystinuria ``` Over saturation urine

Question 33

Where do ureteric stones typically impact?

Answer 33

3 narrowed points - pelviureteric junction - crossing pelvic brim where iliac vessels travel across ureter - vesicoureteric junction

Question 34

Clinical features of renal tract calculi & investigations

Answer 34

Ureteric colic Loin to groin N&V Haematuria 90%, typically non visible Urine dip Bloods (urate, Ca) Retrieval stone - analysis ⭐️non contrast CT KUB USS - hydronephrosis

Question 35

Management renal tract calculi

Answer 35

Majority pass spontaneously Infection - IV ABs Obstructive nephropathy/ significant infection - stent insertion/ nephrostomy Stones do not pass: Extracorporeal shock wave lithotripsy Percutaneous nephrolithotomy Flexible uretero-renoscopy ``` Recurrent: Stay hydrated Oxalate - avoid high purine foods Ca - PTH levels Urate - avoid high purine Cystine - genetic testing ```

Question 36

Types of renal malignancies

Answer 36

Renal cell carcinoma - 85% (adenocarcinoma) TCC Nephroblastoma children (Wilm’s tumour) Squamous CC

Question 37

Risk factors for renal cancer

Answer 37

``` Smoking doubles Industrial exposure carinogens Dialysis 30X Hypertension Obesity Anatomical abnormalities (polycystic kidneys, horseshoe kidneys) Genetic disorders ```

Question 38

Clinical features of renal cancer

Answer 38

Haematuria - most common presenting complaint Flank pain Flank mass Weight loss Lethargy 50% incidental on abdo imaging (compression left testicular vein as joins renal vein) Left masses - left varicocele Paraneoplastic syndromes - secretions of hormones -> polycthaemia, hypercalcaemia, hypertension, pyrexia Triad 15% haematuria, flank pain, mass 25% metastases at presentation

Question 39

Simple vs complex renal cysts

Answer 39

Simple - well defined outline, homogenous, older pts, from renal tubule epithelium Complex - thick walls/ septations/ calcification/ heterogenous enhancement on imaging, all risk malignancy

Question 40

Risk factors for renal cysts & clinical features

Answer 40

``` Older Smoking Hypertension Male Genetic conditions - PKD, tuberous sclerosis ``` ``` Often found incidentally abdo imagin Usually asymptomatic Flank pain Haematuria Uncontrolled hypertension - PKD Flank mass - PKD ``` Ct/ mri IV contrast

Question 41

Storage vs voiding symptoms LUTs

Answer 41

Storage - when bladder should otherwise be storing urine Urgency, frequency, nocturia, urgency incontinence Voiding - bladder outlet obstruction Hesitancy, intermittency, straining, terminal dribbling, incomplete emptying

Question 42

Pharmacological management of LUTs

Answer 42

Conservative insufficient Anticholinergics e.g. oxybutynin, tolterodine OAB Alpha blockers e.g. alfuzosin. Tamsulosin 5 alpha reductase inhibitors e.g. finasteride BPH Loop diuretics, desmopressin Prevent nocturia

Question 43

6 Ss for describing a scrotal lump & acronym for palpating

Answer 43

``` Site Size Shape Symmetry Skin changes Scars ``` ``` CAMPFIRE Consistency Attachments Mobility Pulsation Fluctuation Irreducibility Regional LNs Edge (Temp, transillumination, tenderness) ```

Question 44

Differentials for scrotal lumps

Answer 44

Extra-testicular: Hydrocoele - collection peritoneal fluid between parietal & visceral layers of tunica vaginalis Painless, transilluminate, fluctuant Varicocele - abnormal dilation pampiniform plexus May disappear lie flat, 90% left (renal vein) Epididymal cysts - smooth, fluctuant nodule, transilluminate Epididymitis- pain, swelling, erythematous, fever Inguinal hernia Testicular: Tumours - cancer firm, irregular, painless Orchitis - inflammation testis, mumps Torsion - severe pain, N&V Benign lesions - leydig cell tumours, Sertoli cell tumours, lipomas, fibromas, lysts

Question 45

Causes of acute & chronic urinary retention

Answer 45

``` BPH Urethral strictures Prostate cancer UTIs -> urethral sphincter close Constipation Severe pain Meds (anti-muscarinics, spinal/ epidural anaesthesia) Neurological (peripheral neuropathy, iatrogenic nerve damage pelvic surgery, UMNd, bladder sphincter dysinergy) ``` ``` Chronic: BPH Urethra strictures Prostate cancer Pelvic prolapse (cystocele, rectocele, uterine prolapse) Pelvic masses (large fibroids) Neurological ```

Question 46

What is high pressure urinary retention? As well as a post void bedside bladder scan, routine bloods & CSU (catheterised specimen of urine) what other investigation is required for high pressure cases? Treatment?

Answer 46

Urinary retention causing high intra-vesicular pressures that anti reflux mechanism of bladder & ureters is overcome & backs up into upper renal tract -> hydroureter & hydronephrosis (Impairing kidneys clearance levels) Confirmed USS - assess hydronephrosis Follow up subsequent weeks ✅keep catheters in situ until definitive management can be arranged due risk further episodes leading AKI -> renal scaring & CKD - no evidence renal impairment TWOC

Question 47

What do patients with large retention volume (>1000mls - only seen acute on chronic) need to be monitored post catheterisation for?

Answer 47

Post obstructive diuresis Kidneys can often over diurese due to loss of medullary conc grad -> worsening AKI Monitor Urine output over following 24hrs >200mls/ hr - should have 50% of urine output replaced IV fluids

Question 48

Which major vessel provides the arterial supply to the bladder?

Answer 48

Internal iliac artery

Question 49

Causes of haematuria

Answer 49

``` Urological UTI Urothelial carcinoma Stone disease Adenocarcinoma prostate BPH Trauma/ recent surgery Radiation cystitis Parasitic - schistosomiasis ``` Non-urological: Medical (cyclophosphamide, naproxen, nitrofurantoin) Pseudohaematuria

Question 50

Urological referral criteria for haematuria

Answer 50

For specialist haematuria investigation: Aged >45yrs with any - unexplained visible H without UTI - visible H persists or recurs after successful treatment UTI Aged >60yrs with any - unexplained non visible H & dysuria or raised WCC Asymptomatic Non visible H 2/3 tests

Question 51

Causes of urinary incontinence & treatment options

Answer 51

Stress ✅PFMT -> duloxetine (serotonin- NA reuptake inhibitor), tension free vaginal tape, open colposuspension, intramural bulking agents, artificial urinary sphincter Urge (OAB/ detrusor hyperactivity - neurogenic/ infection/ malignancy/ idiopathic/ cholinesterase inhibitors) ✅anti muscarinics e.g. oxybutynin/ tolterodine, bladder training, botulinum toxin A injections, percutaneous sacral N stimulation, augmentation cystoplasty, urinary diversion via ileal conduit Mixed (stress & urge) Overflow (complication chronic urinary retention) Continuous (constant leaking - anatomical abnormality e.g. ectopic ureter/ bladder fistulae severe overflow IC)