Urology Flashcards

Question

medical management kidney stones

Answer 1

``` Indications • Stone 5-10mm • Stone expected to pass Drugs • Nifedipine or tamsulosin • ± prednisolone • Most pass w/i 48h, 80% w/i 30d ```

Answer 2

initial - pain relief, IV fluids, abx if obs off if expected to pass but 5-10mm -> nifedipine or tamsulosin +/- pred if not expected to pass, can do extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy or ureterorenoscopy

Answer 3

Indications • Low likelihood of spontaneous passage: e.g. >10mm • Persistent obstruction • Renal insufficiency • Infection Extracorporeal Shockwave Lithotripsy (SWL) • Stones <20mm in kidney or proximal ureter • SE: renal injury may → ↑BP • CI: pregnancy, AAA, bleeding diathesis Ureterorenoscopy (URS) + Dormier Basket Removal • Stone >10mm in distal ureter or if SWL failed • Stone >20mm in renal pelvis Percutaneous Nephrolithotomy (PNL) • Stone >20mm in renal pelvis • E.g. staghorn calculi: do DMSA first

Answer 4

Febrile + Renal Obstruction • Surgical emergency • Percutaneous nephrostomy or ureteric stent • IV Abx: e.g. cefuroxime 1.5g IV TDS Rx Summary • Conservative: stone <5mm in distal ureter • MET: stone 5-10mm and expected to pass • Active: stones >10mm, persistent pain, renal insufficiency

Answer 5

main RF obestiy, smoing ``` Adenocarcinoma from proximal renal tubular epithelium • Subtypes § Clear Cell (glycogen): 70-80% § Papillary: 15% § Chromophobe: 5% § Collecting duct: 1% ```

Answer 6

* 50% incidental finding * Triad: Haematuria, loin pain, loin mass * Systemic: anorexia, malaise, wt. loss, PUO * Clot retention * Invasion of L renal vein → varicocele (1%) * Cannonball mets → SOB paraneoplastic features

Answer 7

``` Paraneoplastic Features • EPO → polycythaemia • PTHrP → ↑ Ca • Renin → HTN • ACTH → Cushing’s syn. • Amyloidosis Spread • Direct: renal vein • Lymph • Haematogenous: bone, liver and lung ```

Answer 8

``` • Blood: polycythaemia, ESR, U+E, ALP, Ca • Urine: dip, cytology • Imaging § CXR: cannonball mets § US: mass § IVU: filling defect § CT/MRI ```

Answer 9

``` Robson Staging • Confined to kidney • Involves perinephric fat, but not Gerota’s fascia • Spread into renal vein • Spread to adjacent / distant organs ```

Answer 10

``` Mx • Medical § Reserved for pts. ¯c poor prognosis § Temsirolimus (mTOR inhibitor) • Surgical § Radical nephrectomy § Consider partial if small tumour or 1 kidney Prognosis: 45% 5ys ```

Answer 11

``` Risk Factors • Smoking • Amine exposure (rubber industry) • Cyclophosphamide Pathology • Highly malignant • Locations § Bladder: 50% § Ureter § Renal pelvis ```

Answer 12

``` Painless haematuria • Frequency, urgency, dysuria • Urinary tract obstruction Ix • Urine cytology • CT/MRI • IVU: pelviceal filling defect Mx • Nephrouretectomy • Regular f/up: 50% develop bladder tumours ```

Answer 13

``` • Childhood tumour of primitive renal tubules and mesenchymal cells • May be assoc. ¯c Chr 11 mutation • May be assoc. ¯c WAGR syndrome § Wilms, Aniridia, GU abnormalities, Retardation Presentation • 2-5yrs • 5-10% bilat • Abdo mass (doesn’t cross the midline) • Haematuria • Abdo p ```

Answer 14

Benign • Cysts: very common • Renal papillary adenomas • Oncocytoma: eosinophilic cells ¯c numerous mitochondria • Angiomyolipoma: seen in tuberous sclerosis Malignant • SCC: assoc. ¯c chronic infected staghorn calculi NB. Benign tumours commonly require nephrectomy to exclude malignancy

Answer 15

``` Smoking • Amine exposure (rubber industry) • Previous renal TCC • Chronic cystitis • Schistosomiasis (SCC) • Urechal remnants (adenocarcinomas) § Embryological remnant of communication between umbilicus and bladder • Pelvic irradiation ```

Answer 16

``` • Painless haematuria • Voiding irritability: dysuria, frequency, urgency • Recurrent UTIs • Retention and obstructive renal failure Examination • Anaemia • Palpable bladder mass • Palpable liver ```

Answer 17

TNM Staging • 80% confined to mucosa • 20% penetrate muscle (↑ mortality) ``` Spread • Local → pelvic structures • Lymph → iliac and para-aortic nodes • Haem → bones, liver and lungs Histological Classification • Grade 1: well differentiated • Grade 2: intermediate • Grade 3: poorly differentiated ```

Answer 18

``` Urine: dip (sterile pyuria), cytology • IVU: filling defects • Cystoscopy c¯ biopsy: diagnostic • Bimanual EUA: helps to assess spread • CT/MRI: helps stage Mx superficial - 80% -diathermy in cystoscopy or TURBT, intravesicular chemotherapy/ immunoT ``` invasive - cystectomy, radioT, chemoT v advanced - catheter and palliate

Answer 19

Complications • Massive bladder haemorrhage • Cystectomy → Sexual and urinary malfunction Follow-Up • Up to 70% of bladder tumours recur therefore intensive f/up is required. • History, examination and regular cystoscopy • High-risk tumours: every 3mo for 2yrs, then every 6mo • Low-risk tumours: @ 9mo, then yrly

Answer 20

90% menover 80 yrs Benign nodular or diffuse hyperplasia of stromal and epithelial cells • Affects inner (transitional) layer of prostate (cf. Ca) § → urethral compression • DHT produced from testosterone in stromal cells by 5α-reducatase enzyme. • DHT-induced GFs → ↑ stromal cells and ↓ epithelial cell death.

Answer 21

``` Storage Symptoms § Nocturia § Frequency § Urgency § Overflow incontinence ``` ``` • Voiding Symptoms § Hesitancy § Straining § Poor stream/flow + terminal dribbling § Strangury (urinary tenesmus) § Incomplete emptying: pis en deux ``` * Bladder stones (2O to stasis) * UTI (2O to stasis)

Answer 22

``` Examination • PR § Smoothly enlarged prostate § Definable median sulcus • Bladder not usually palpable unless acute-on-chronic obstruction ``` ``` Ix • Blood: U+E, PSA (after PR) • Urine: dip, MC+S • Imaging § Transrectal US ± biopsy • Urodynamics: pressure / flow cystometry • Voiding diary ```

Answer 23

Conservative • ↓ caffeine, EtOH • Double voiding • Bladder training: hold on → ↑ time between voiding Medical tamsulosin, doxazosin, (SE SE: drowsiness, ↓BP, depression, EF, wt. ↑, extra-pyramidal signs) finasteride (SE SE: excreted in semen (use condoms), ED) Surgical TURP transurethral incision of prostate better SE profile

Answer 24

``` Immediate • TUR syndrome § Absorption of large quantity of fluids → ↓Na • Haemorrhage Early • Haemorrhage • Infection • Clot retention: requires bladder irrigation Late • Retrograde ejaculation: common • ED: ~10% • Incontinence: ≤10% • Urethral stricture • Recurrence ```

Answer 25

``` Epidemiology • Commonest male Ca • 3rd commonest cause of male Ca death • Prevalence: 80% of men >80yrs • Race: ↑ in Blacks Pathology • Adenocarcinoma • Peripheral zone of prostate Presentation • Usually asymptomatic • Urinary: nocturia, frequency, hesitancy, poor stream, terminal dribbling, obstruction • Systemic: wt. loss, fatigue • Mets: bone pain Examination • Hard irregular prostate on PR • Loss of midline sulcus ```

Answer 26

``` Spread • Local: seminal vesicles, bladder, rectum • Lymph: para-aortic nodes • Haem: sclerotic bony lesions Ix • Bloods: PSA, U+E, acid and alk phos, Ca • Imaging § XR chest and spine § Transrectal US + biopsy § Bone scan § Staging MRI - Contrast enhancing magnetic nanoparticles ↑s detection of affected nodes. ```

Answer 27

Gleason Grade | • Score two worst affected areas

Answer 28

conservative - especially if elderly, may be more prudent to monitor radical prostatectomy if under 75 improves survival but poor SE profile meds - goserelin

Answer 29

``` Prostatitis Aetiology • S. faecalis • E. coli • Chlamydia Presentation • Usually >35yrs • UTI / dysuria • Pain § Low backache § Pain on ejaculation • Haematospermia • Fever and rigors • Retention • Malaise ```

Answer 30

``` Examination • Pyrexia • Swollen / boggy / tender prostate on PR • Examine testes to exclude epididymo-orchitis Ix • Blood: FBC, U+E, CRP • Urine: dip, MC+S Rx • Analgesia • Levofloxacin 500mg/d for 28d ```

Answer 31

Male • Usually caused by prostatic enlargement § Urge incontinence or dribbling may result from partial retention. § Retention may → overflow (palpable bladder after voiding) • TURP and pelvic surgery may weaken external urethral sphincter.

Answer 32

Women • Stress Incontinence § Leakage from incompetent sphincter when IAP ↑ § Loss of small amounts of urine when coughing § Pelvic floor weakness • Urge Incontinence / Overactive Bladder § Can’t hold urine for any length of time § May have precipitant: arriving home, running water, coffee § Dx: urodynamic studies

Answer 33

``` Mx • Check § PR: faecal impaction § Palpable bladder after voiding: retention ¯c overflow § UTI § DM § CNS: MS, Parkinson’s stroke, spinal trauma § Diuretics • Stress Incontinence § Pelvic floor exercises § Ring pessary § Duloxetine § Surgery: tension-free vaginal tape • Urge Incontinence § Bladder training § Wt. loss § Anti-AChM: tolterodine, imipramine ```

Answer 34

Cryptorchidism • Complete absence of testis from scrotum • Anorchism = absence of both testes Retractile Testis • Normal development but excessive cremasteric reflex • Testicle often found at external inguinal ring • Will descend: no Rx required Maldescended Testis • Found anywhere along normal path of descent • Testis and scrotum are usually under-developed • Often assoc. ¯c patent processus vaginalis Ectopic Testis • Found outside line of descent • Usually in sup. inguinal pouch (ant. to external oblique aponeurosis) • Abdominal, perineal, penile, femoral triangle

Answer 35

Complications • Infertility • 10x ↑ risk of malignancy (remains after surgery) • ↑ risk of trauma • ↑ risk of torsion • Assoc. ¯c hernias (90%) or urinary tract abnormalities

Answer 36

Mx • Restores potential for spermatogenesis • Makes Ca easier to Dx Surgical: Orchidopexy by Dartos Pouch Procedure • Perform before 2yrs β-HCG may be tried if testis is in inguinal canal.

Answer 37

Usually 2O to some exertion or minor trauma • Occurs because testicle doesn’t have a large “bare area” to attach to scrotal wall. § Tunica vaginalis invests whole of testicle § Free-hanging “clapper bell” testicle can twist on its mesentery. Presentation • Usually 10-25yrs • Sudden onset severe pain in one testis • May have lower abdominal pain (testis supplied by T10) • Assoc. ¯c n/v • May be Hx of previous testicular pain or torsion

Answer 38

Examination • Inflam of one testis: hot, swollen, extremely tender • Testis rides high and lies transversely Ix • Doppler US may demonstrate absence of flow § Must not delay surgical exploration

Answer 39

``` Differential • Epididymo-orchitis § Older pt. § UTI symptoms § More gradual onset • Torted Hydatid of Morgagni § Remnant of Mullerian duct § Younger pt. § Less pain § Tiny blue dot visible on scrotum • Tumour • Trauma • Strangulated hernia • Appendicitis ```

Answer 40

Mx • Surgical emergency § 4-6h window from onset of pain to salvage testis • Inform senior • NBM • IV access § Analgesia § Bloods: FBC, U+E, G+S, clotting • Surgery § Consent for possible orchidectomy § Bilateral orchidopexy: suture testes to scrotum • If no torsion found and epididymo-orchitis Dx, take fluid sample from scrotum for bacteriology and Rx ¯c Abx.

Answer 41

Differential • Can’t get above: inguinoscrotal hernia • Separate, cystic: epididymal cyst • Separate, solid: varicocele, sperm granuloma, epididymitis • Testicular, cystic: hydrocele • Testicular, solid: tumour, orchitis, haematocele

Answer 42

Develop in adulthood • Contain clear or milky (spermatocele) fluid • Lie above and behind testis • Remove if symptomatic

Answer 43

``` Dilated veins of pampiniform plexus • Presentation § Feel like bag of worms in the scrotum § May be visible dilated veins § ↓ size on lying down § Pt. may c/o dull ache § May → oligospermia (↓ fertility) • Pathology § 1O: Left side commoner: drain into left renal vein § 2O: left renal tumour has tracked down renal vein → testicular vein obstruction. • Mx § Conservative: scrotal support § Surgical: clipping the testicular vein (open or lap) ```

Answer 44

``` Hydrocele • Collection of serous fluid w/i tunica vaginalis • Primary § assoc. ¯c patent processus vaginalis § Commoner, larger, tense, younger men • Secondary § Tumour, trauma, infection § Smaller, less tense • Ix § US testicle to exclude tumour • Mx § May resolve spontaneously § Surgery - Lord’s Repair: plication of the sac - Jaboulay’s Repair: eversion of the sac § Aspiration - Usually recur so not 1st line. - Send fluid for cytology and MC+S ```

Answer 45

``` Aetiology • STI: Chlamydia, gonorrhoea • Ascending UTI: E. coli • Mumps Features • Sudden onset tender swelling • Dysuria • Sweats, fever Examination • Tender, red, warm, swollen testis and epididymis § Elevating testicle may relieve pain • Secondary hydrocele • Urethral discharge ```

Answer 46

``` Ix • Blood: FBC, CRP • Urine: dip, MC+S (fist catch may be best) • Urethral swab and STI screen • US: may be needed to exclude abscess Complications • May → infertility Mx • Bed rest • Analgesia • Scrotal support • Abx: doxycycline or cipro • Drain abscess if present ```

Answer 47

``` Commonest male malignancies from 15-44yrs • Whites > Blacks = 5:1 Presentation • Painless testicular lump § Often noticed after trauma • Haematospermia • 2O hydrocele • Mets: SOB from lung mets • Abdo mass: para-aortic lymphadenopathy • Hormones: gynaecomastia, virilisation • Contralateral tumour in 5% Risk Factors • Undescended testis § 10% occur in undescended testes • Infant hernia • Infertility ```

Answer 48

<5 ALL germ cell tumour (seminoma or non seminoma 95%, otherwise sex cord stromal) >65 NHL

Answer 49

``` Staging: Royal Marsden Classification • Disease only in testis • Para-aortic nodes involved (below diaphragm) • Supra- and infra-diaphragmatic LNs involved • Extra-lymphatic spread: lungs, liver Ix • Tumour markers § Useful for monitoring § ↑AFP and ↑hCG in 90% of teratomas § ↑hCG in 15% of seminomas § Normal AFP in pure seminomas • Scrotum US • Staging § CXR § CT NB. Percutaneous biopsy should not be performed as it may → seeding along needle tract ``` Mx • If both testes are abnormal, semen can be cryopreserved seminomas = orchidectomy + radiotherapy (stage1/2) + chemotherapy stage3/4 Close f/up to detect relapse • Typically w/i 18-24mo • Repeat CT scanning and tumour markers

Answer 50

Acute inflammation of the foreskin and glans • Cause: Strep, Staph infection, Candida (DM) • RFs: DM, young children ¯c tight foreskin • Rx: hygiene advice, Abx, circumcision

Answer 51

``` Foreskin occludes the meatus • Children § Pres: recurrent balanitis and ballooning § Mx: Gentle retraction, steroid creams, circumcision ``` • Adults § Pres: dyspareunia, infection § Mx: circumcision § Assoc. ¯c balanitis xerotica obliterans: thickening of foreskin and glans → phimosis + meatal narrowing

Answer 52

Tight foreskin is retracted and becomes irreplaceable. • ↓ venous return → oedema and swelling of the glans § Can rarely → glans ischaemia • Causes: catheterisation, masturbation, intercourse • Mx: § Manual reduction: use ice and lignocaine jelly § May require glans aspiration or dorsal slit

Answer 53

Hypo- / epi-spadias • Developmental abnormality of the position of the urethral opening • Hypospadia: opens on ventral surface of penis • Epispadia: opens on dorsal surface

Answer 54

pretty rare compared to others entation • Chronic fungating ulcer • Bloody / purulent discharge • 50% have inguinal nodes at presentation Mx • Medical § Early growths ¯c no urethral involvement § DXT and iridium wires • Surgical § Amputation required if urethral involvement § Lymph node dissection

Urology Flashcards

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