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DPD 2019 > Urology (x4) > Flashcards

Urology (x4) Flashcards

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1
Q

Outline the areas of the prostate

A

Central zone (wraps around the urethra)

Transition zone (area that increases in size during the life of a man, and causes obstruction of the urethra in a benign way)

Anterior fibromuscular zone

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2
Q

T/F prostate size correlates to cancer risk

A

F

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3
Q

What kind of diagnosis of BPH

A

Histological diagnosis

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4
Q

What are voiding symptoms and what are they due to

A

Poor flow, due to bladder outflow obstruction such as BPH/strictures

VOIDING SYMPTOMS
Incl. Hesitancy
Weak stream
Intermittency
Incomplete emptying
Post-void dribbling
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5
Q

What are storage symptoms and what are they due to

A

Strong flow, detrusor overactivity due to incorrect brain signals causing bladder to contract

STORAGE SYMPTOMS
Frequency,
urgency,
nocutia

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6
Q

What happens to bladder and detrusor in bladder outflow obstruction leading to voiding symptoms

A

In order to generate the increased pressures required to void, the bladder detrusor muscle initially becomes hypertrophied, which leads to trabeculation. In the longer term replacement of muscle fibres with collagen results in loss of detrusor efficacy

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7
Q

Define lower urinary tract symptoms (LUTS)

A

Lower Urinary Tract Symptoms (LUTS) is a non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding)

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8
Q

Define Benign Prostatic Enlargement (BPE)

A

the clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia

a histological diagnosis

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9
Q

Define Bladder Outflow Obstruction (BOO)

A

bladder outlet obstruction caused by benign prostatic enlargement (clinical finding)

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10
Q

Define Benign Prostatic Hyperplasia (BPH)

A

Benign Prostatic Hyperplasia (BPH) properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction

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11
Q

Outline the international scoring system

What is it used for

A

The IPSS is a widely used, validated questionnaire covering the range of storage and voiding symptoms
Patients score each item from 0 to 5 according to the frequency with which the particular symptom is experienced
Total score will range from 0 to 35
The patients IPSS score should be re-evaluated over time to monitor disease progression and response to treatment

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12
Q

How is QoL assessed for prostate

A

The Bother score

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13
Q

Risk factors for BPH

A 
Age
Androgens
Functional androgen receptors
Obesity
Diabetes (& elevated fasting glucose)
Dyslipidaemia
Genetic
Afro-Caribbean
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14
Q

When taking a prostate history/examination?

A 
LUTS
IPSS questionnaire
Frequency Volume chart
Haematuria; Dysuria
Full medical history (co-morbidities, drug history and family history)
Examine abdomen – is bladder palpable? 
DRE!!!!
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15
Q

Which investigations for prostate

A

Urine dipstick (exclude infection)
Flow rate + POSTVOID RESIDUAL BLADDER SCAN in clinic
Blood tests (U&E, PSA – but need to counsel patient)
?Renal tract ultrasound
? Flexible cystoscopy

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16
Q

Common size compairsons to help assess prostate size

improve

A

Walnut

Ping pong

Golf

Clementine

Tennis

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17
Q

Obstructued flow is considered to be lower than what flow on urine flow measurements

A

<12ml per second

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18
Q

Treatment of voiding symptoms (i.e. BOO)

A

Conservative:
Reassure
Fluid intake advice (reduce evening fluid intake)

Medical management: 
Alpha blockers (Tamsulosin, Alfuzosin)

5 alpha-reductase inhibitors (Finasteride, Dutasteride)

Surgical management:
TURP (transurethral resection of the prostate)

(alternatively, rezum/steam, urolift (=staples), lazer surgery)

Possibly an anticholinergic if storage symptoms too but DON’T start with this (as it may relax the bladder too much on top of the already present voiding issues, causing acute urinary retention)

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19
Q

Why are 5a-reductase inhibitors give for prostate

improve

A

Inhibit testosterone production to shrink prostate

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20
Q

Management of storage problems (i.e. can’t store, i.e. detrusor overactivity)

A

Conservative management:
Reassure (& treat triggering UTI)
Dietary advice
Bladder Retraining Exercises (NICE recommended)

Medical management:
Anticholinergics (Oxybutinin, Detrusitol, Solifenacin)
Betmiga

Surgical management:
Intravesical Botox injection, (improve- but lasts for 6 months so you might need to catheterise for up to this time if surgery isn’t great)

(Bladder augmentation; urinary diversion/conduit)

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21
Q

Management of urinary retention

A

Catheterise

Dipstick/CSU

FBC, U & E (if they’ve been in high pressure retention then the pressure on the kidneys might have put them into renal failure, and they may then have an episode of diuresis)

Measure Residual Urine

Neurological examination if necessary

Prescribe - Antibiotics,

Laxatives, Alpha blocker if necessary

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22
Q

Types of short term and long term catheters

A 
Simplastic (short term )
PTFE coated (short term 
Hydrogel coated (long term)
Silicone (long term)
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23
Q

When would a 3 way catheter be used

A

To wash out any clots (it can be used to irrigate)

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24
Q

Differentiate acute and chronic urinary retention

Why is it important to check U&E in acute retention

A

Acute Retention (AUR) = painful

Chronic Retention (CUR)= postvoid residual >800ml

Chronic occurs over months or years

So both acute and chronic retention can be high or low pressure.

If the U&Es are affected, ti indicates there was high pressure retention which has caused renal failure.

Patients who have acute urinary retention with renal failure can have a large diuresis so need to be admitted, as they may need fluids

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25
What is the management of low pressure retention (and how do you know it's low pressure)
Normal U &Cr , no hydronephrosis Consider starting alpha blockers and Trial Without Catheter (TWOC) 1 week later
26
What is the management of high pressure retention (and how do you know it's low pressure)
Raised U & Cr Bilateral hydronephrosis. ADMIT THEM Measure urinary output, BP, body weight They may need fluids if they have a large diuresis Only < 10 % need fluid replacement NEVER TWOC! BOO Surgery or Longterm Catheter will be needed
27
What might you give for urgency in a voiding patient (even though urgency is a storage issue)
You might want to give anticholingergic for urgency
28
What is the most common cancer in males
Prostate cancer
29
Presenting symptoms of prostate cancer
Asymptomatic; raised PSA LUTS Urinary retention / renal failure (Pain) Haematuria Bone pain/weight loss/ spinal cord compression (Mets)
30
Prostate caner risk factors
Age Race (afro-caribbean heritage) Family history BRCA 2 gene
31
T/F PSA increases with age
T
32
Does PSA meet screening criteria?
PSA does not meet screening criteria – testing is informed decision process with GP or other clinician
33
Causes of raised PSA
BPH Urinary Retention Urine infection Catheterisation / instrumentation of urethra Prostate cancer
34
T/F DRE can significantly raise PSA
Digital rectal examination is not significant. Don't worry about doing DRE then sending for PSA blood test
35
Assessment of prostate cancer
Counselling History – LUTS? Bone pain? Weight loss? Blood in urine? Family history Examination DRE! Check PSA (if high, then you should check urine to make sure it's not a urine infection) MRI scan (to differentiate high and low risk prostate cancer) TRUS Biopsy
36
What can MRI scan add to the investigation of prostate cancer?
Can differentiate between high risk and low risk prostate cancer Grade using PIRADS
37
A prostate cancer is identified as high risk using PIRADS scoring. What is the next step in the investigations
Then go onto have a biopsy to have a tissue diagnosis
38
A prostate cancer is identified as low risk using PIRADS scoring. What is the next step in the investigations
They can be reassured, they don't need to have a biopsy. They just need to have their PSA monitored
39
How is a biopsy taken from the prostate what is the risk
Transrectal ultrasound guided biopsy (TRUS). But there is clearly a significant risk of sepsis as you're going throuhg the rectum (1% end up hospitalised due to infection) New techniques include transperineal biopsy
40
What happens to the biopsy
It is graded according to the gleason score
41
Outline the grading of prostate cancers according to gleason score What about staging
Grading: Gleason score Low riks 3+3 High risk 5+5 Staging: TNM
42
Where does prostate cancer metastasize to ---------------- Asymptomatic older male patient with raised PSA. How to manage.
Lymph nodes and bone --------------------------- 1. Repeat PSA and check MSU (they may have a urine infection, which is a common cause of raised PSA, and the PSA may fall when the infection is resolved) IF the PSA doesn't come down, 2. Send for MRI prostate and TRUS biopsy if necessary
43
Management of prostate cancer So the patient has now had a biopsy and there is prostate cancer
Staging – MRI / Bone scan. Managed by the MDT. ``` Options: Active surveillance (low risk low volume disease, but monitoring for increased disease) ``` Surgery – radical prostatectomy (robotic or laparoscopic) Radical Radiotherapy Watchful waiting (elderly / co-morbid patients) Hormones (given LHRH agonist to shrink the prostate before radiotherapy) Chemotherapy
44
When are hormone treatments most useful
In metastases
45
More minimally invasive treatments for prostate cancer
Surgery: laparoscopic, robotic Radiotherapy Brachytherapy HIFU Cryotherapy
46
Why has surgery for prostate cancer become unpopular
More bleeding higher incontinence Likely erectile dysfunction May not die anyway
47
Hormonal therapy examples
Can be used in conjunction with radiotherapy or alone LHRH agonist (e.g. Zoladex) (there is initially a rise in testosterone before it falls) Anitandrogen
48
What is the risk with hormonal therapy
Beware tumour flare (a metastasis could become unstable) This is because the testosterone actually increases at the beginning of LHRH agonist injections, so you give antiandrogen therapy in advance The LHRH could actually cause the tumour to cause spinal cord compression during this time
49
Name of LHRH agonist
Zoladex
50
What causes spinal cord compression in prostate cancer
Due to vertebral bone metastases
51
Management of spinal cord compression
Start steroids (dexamethasone iv) Urgent MRI Suppress testosterone Decompress cord with spinal surgery or radiotherapy (if you don't decompress within 12 hrs they will end up in a wheelchair)
52
How is RRP followed up
PSA as followup post RRP <0.01 in 6/52 Failure initial PSA >0.2 Early rapid rise indicates disease beyond prostate Later slow rise local recurrance Biopsy to confirm Restage- bone scan /MRI
53
What do you do if there is a PS failure post RT
Nadir +2 Consider HIFU or salvage surgery Hormones
54
What is the active surveillance
Gleeson 6 (?7) Less than 2 cores PSA <10 T1c or T2 PSA FU 3 monthly MRI scan anually Rebiopsy year 1,3 & 7
55
When should you treat prostate cancer on active surveillance
``` PSA >10 PSA dt <3 years Grade progression on rebiopsy Clinical progression Patient choice ```
56
Where can PSA monitoryong be done
Post radical treatment- radiotherapy/surgery On Hormones Cancer- watchful waiting Raised PSA after MRI and/or biopsies Active surveillance – in secondary care as requires regular MRI and re-biopsy
57
What s a hydrocele
Fluid within Tunica vaginalis Can get above it Transilluminates!
58
Treatment of hydrocele
Surgical repair if large
59
What is epididymitis (orchitis) and what are the causes
Infection of epididymis or testis or both Causes STIs UTIs Post-operative
60
Who does testicular affect
Younger men
61
Types of testicular cancer
Germ Cell - Seminomatous - Non-seminomatous Non-Germ Cell
62
Why is sperm banking done before surgery for testicular cancer
testicular cancer likely to affect the single testicle, but subsequent chemo/radio can affect fertility
63
What operation is done in testicular cancer
Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?)
64
Post op care for radical inguinal orchitectomy
Surveillance +- chemotherapy (BEP) +- Radiotherapy +-RPLND
65
Causes of haematuria
``` Infection Cancer Medical Trauma (kidney stones) ```
66
What does a three way catheter help with in haematuria
Irrigate the bladder and filter out the clots (stops the catheter being blocked by clots in the bladder)
67
What is the management of haematuria
``` Resuscitate incl. transfusion 3 way catheter Hx Ex Bloods incl. Clotting and G&S; KUB MSU ```
68
Why are you going to be caustious about putting suprapublic catheter in with haematuria
Could spread a bladder cancer into the abdminal wall
69
Criteria for admission in haematuria
Frank haematuria with clots Drop in Hb Social circumstance
70
Role of haematuria clinic
2 week rule | One-stop
71
Haematuria- irrigation and theatre?
``` ivi Transfuse if necessary Thorough bladder washout Continuous irrigation May need clot evacuation in theatre Monitor closely and review regularly ```
72
Investigations for haematuria
FBC, clotting, U&E MSU MC&S Urine cytology / NMP22 ? CT Urogram or KUB, U/S Flexible cystoscopy (will show a bladder tumour)
73
What type of cancers are bladder cancers
90% are adenocarcinoma, 10% are transition cell cancer
74
Follow up issues for haematura
Blocked catheters Persistant haematuria UTI / Antibiotics
75
Who are renal stones most common in
More common in caucasian men
76
What should you consider for family history for renal stones
CYSTINURIA
77
What predisposes you to renal stones
Anatomical and biochemical Factors
78
Why are renal stones important
Obstruction can lead to hydronephrosis and renal impairment Painful Infection (life threatening gram -ve sepsis) Can indicate underlying metabolic problem Underlying anatomical problems
79
What underlying metabolic problems might lead to kidney stones
Hyperparathyroidism, gout, cysteinuria
80
Underlying anatomical problems leading to renal stones
(eg. PUJ-o, MSK, Horseshoe kidney, ureteric stricture)
81
Classification of stones
Size, location, xray characteristics, stone composition
82
Outline classification of stones by size
<5mm; 5-20mm; >20mm; staghorn
83
Outline classification of stones by location
Renal (calyceal, pelvic, diverticular); Ureteric
84
Outline classification of stones by x-ray characteristics
radiolucent; radioopaque
85
Outline classification of stones by stone composition
CaOx, CaP, Uric acid, cysteine, indinavir; Infection MAP/Struvite
86
Diagnosis of renal stones
Hx Ex (will be a soft abdomen) Bloods, Urine dip (RBC, WBC, Nitrites, pH) & MSU Imaging: KUB (gold standard) / US (won't pick up uteric stones)/ CT-KUB / IVU
87
When do you need immediate imaging for renal stones
Fever solitary kidney diagnosis unclear
88
Presentation of uteric colic
Loin pain, Soft abdo, Mic haem 85%
89
When is uteric colic an emergency
SEPSIS
90
Causes of uteric colic
Stones, TCC, blood clot, RPF, ?BPH/CaP
91
Differential diagnosis for uteric colic
``` AAA Testicular torsion Perforated PU Appendicitis Ruptured ectopic MI Diverticulitis Prostatitis ```
92
Uteric colic in a&e
1. Analgesia: 5-10mg Morphine iv +/- antiemetic (Diclofenac if creatinine normal)  2. Basic Investigations: FBC/U+E, Ca, Urate, Urine dipstick, ßHCG (♀)  3. Radiological Investigations: plain both KUB and CT KUB
93
Drug for helping passing stone
A blocker (controversial)
94
General advice for renal stones
High fluid intake – urine champagne colour Normal diet – do not cut out dairy products (milk can bind oxalate in the gut)
95
When to attend a&e with renal stones
Pain not controlled by analgesia | PYREXIA
96
Treatment of stones
Conservative Medical / Metabolic ESWL Ureteroscopy PCNL
97
When can a stone be dissolved
Uric acid (with potassium citrate)
98
Outline conservative renal stone management
Observe asymptomatic non-obstructive renal stones in selected patients incl. Metabolic screen
99
Outline medical renal stone management
Alkalinise / acidify urine Treat / prevent UTIs Allopurinol?
100
Outline surgical renal stone management
Uretero-renoscopy +- laser ESWL PCNL (Lap / Open)
101
What is ESWL lithotripter
....
102
When would you do a PCNL: percutaneous nephrolithotomy
If the stone is in the kidney and more than 2cm
103
Follow up issues with renal stones
Renal deterioration after 2-6 weeks if complete obstruction: danger in losing kidney JJ stent encrustation <6 months in stone formers! 50% patients will have recurrent stones: fluid intake advice 40% of conservatively managed renal stones will enlarge – monitor by imaging & RF
104
What is obstructive pyelonephrosis Why is it dangerous
= Obstruction + infection Risk of fatal GRAM –ve sepsis
105
How to manage obstructive pyonephrosis
``` Immediate resuscitation + iv antibiotics Culture Urgent imaging (KUB & U/S) Discuss with urology SpR Consider urgent nephrostomy (or JJ stent) Monitor closely (HDU) ```
106
Futher treatment of obstructive pyonephrosis
``` Imaging to determine cause CT KUB Nephrostogram Antegrade stent Plan ureteroscopy / ESWL / PCNL ``` May need drainage if perinephric abscess May need nephrectomy if XGP or EPN
107
DDx testiscular torsion
Torted appendix testis, epididymitis, viral orchitis, bleed into testicular tumour With torted appendix testis... usually cannot distinguish from testicular torsion Blue dot sign Manage conservatively only if confident of diagnosis
108
When is testicular torsion rare beyond
Rare beyond 35y of age
109
What underlying deformity predisposes testicular torsion
Underlying deformity: | extension of tunica vaginalis behind testicle  clapper bell
110
Presentation of testicular torsion
Sudden onset Ex: swollen, tender, high riding (contralat horiz) Loss of cremateric reflex in children
111
Investigation for testicular torsion
: MSU (urgent microscopy if Sy suggest UTI/epididymitis)

DPD 2019 (30 decks)

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