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PBLs > Week 16 - Urology > Flashcards

Week 16 - Urology Flashcards

1
Q

What are the 4 zones of the prostate?

A

peripheral
fibromuscular
central
transitional

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2
Q

What vessels supply the prostate?

A

inferior vesical, middle rectal and internal pudendal arteries

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3
Q

What vessels drain the prostate?

A

prostatic venous plexus draining into the internal iliac veins

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4
Q

What nerve sympathetically innervates the prostate?

A

Hypogastric

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5
Q

What nerve parasympathetically innervates the prostate?

A

pelvic

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6
Q

what is the function of the prostate?

A

secretes proteolytic enzymes into the semen, which act to break down clotting factors in the ejaculate.

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7
Q

how do proteolytic enzymes leave the prostate?

A

via the prostate ducts
open into the prostatic portion of the urethra

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8
Q

what are the 4 features of the bladder?

A

apex
body
fundus
neck

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9
Q

how does urine enter and leave the bladder?

A

enters via left and right ureters
exits via urethra

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10
Q

what is the trigone in the bladder?

A

area located within the fundus marked by the 2 ureters and urethra
has smooth walls

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11
Q

what muscles in the bladder help it contract during micturition?

A

detrusor muscles

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11
Q

what are the 2 sphincters in the urethra and what are their functions?

A

Internal urethral sphincter:
Male – consists of circular smooth fibres, which are under autonomic control. It is thought to prevent seminal regurgitation during ejaculation.
Females – thought to be a functional sphincter (i.e. no sphincteric muscle present). It is formed by the anatomy of the bladder neck and proximal urethra.

External urethral sphincter – has the same structure in both sexes.
It is skeletal muscle, and under voluntary control.

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11
Q

what vessels supply the bladder?

A

superior vesical branch from internal iliac artery
Males = supplemented by inferior vesical artery
Females = supplemented by vaginal arteries

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12
Q

what vessels drain the bladder?

A

drained by vesical venous plexus emptying into internal iliac veins

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13
Q

what is the lymphatic drainage of the bladder?

A

Superolateral aspect = drains to external iliac lymph nodes
Neck + fundus = drain to internal iliac, sacral and common iliac nodes

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14
Q

What nerve supplies the sympathetic innervation to the bladder and what does it cause?

A

hypogastric nerve (causes relaxation of detrusor muscle .: urine retention)

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15
Q

what nerve supplies parasympathetic innervation to the bladder and what does it cause?

A

pelvic nerve (contraction of detrusor muscle .: micturition

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16
Q

what nerves supply the somatic innervation to the bladder and what do they cause?

A

pudendal nerve (external urethral sphincter providing voluntary control of micturition) + sensory (afferent) nerves

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17
Q

What are the 2 main functions of the bladder?

A

Temporary storage of urine – the bladder is a hollow organ with distensible walls. It has a folded internal lining (known as rugae), which allows it to accommodate up to 400-600ml of urine in healthy adults.

Assists in the expulsion of urine – the musculature of the bladder contracts during micturition, with concomitant relaxation of the sphincters.

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18
Q

what is the max amount of urine that can be held in the bladder?

A

400-600ml

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19
Q

what is the bladder stretch reflex? When is it seen?

A
  1. Bladder fills with urine, and the bladder walls stretch.
    1. Sensory nerves detect stretch and transmit this information to the spinal cord.
    2. Interneurons within the spinal cord relay the signal to the parasympathetic efferents (the pelvic nerve).
      The pelvic nerve acts to contract the detrusor muscle, and stimulate micturition.

infants before potty training
spinal injuries
neurodegenerative diseases

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20
Q

what are the 2 phases of micturition?

A

storage
voiding

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21
Q

what innervation is sent to the bladder during the storage phase of micturition?

A

sympathetic = hypogastric nerve causes relaxation of detrusor muscles by stimulation of B3-adrenoreceptors and constriction of the IUS via stimulation of A1-adrenoreceptors

somatic = pudendal nerve acts on cholinergic receptors to contract EUS

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22
Q

what innervation is sent to the bladder in the voiding stage of micturition?

A

parasympathetic - pelvic nerve stimulates muscarinic receptors causing contraction of detrusor muscles

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23
what is BPH?
benign prostatic hyperplasia caused by hyperplasia of the stromal and epithelial cells of the prostate, presents with lower urinary tract symptoms (LUTS)
24
when is BPH most common?
men over 50
25
what re the symptoms of BPH?
Hesitancy Weak flow Urgency Frequency Intermittency Straining Terminal dribbling Incomplete emptying Nocturia - significant usually if waking up twice or more *IPSS - scoring system used to assess severity of LUTS
26
what investigations are done to test for BPH?
Digital rectal exam - assess size, shape and characteristics of prostate Abdo exam - palpable bladder or other abnormalities Urinary frequency volume chart - recording 3 days of fluid intake and output Urine dipstick - assess for infection, haematuria etc PSA - prostate cancer
27
what management is given to those with BPH with mild symptoms?
alpha blockers (tamsulosin) - relax smooth muscle, improve symptoms 5-alpha reductase inhibitors (finasteride) - reduce size of prostate
28
what surgical options are available in BPH with severe symptoms?
Transurethral resection of the prostate (TURP) Removal of part of the prostate from inside the urethra Transurethral electrovaporisation of the prostate (TEVAP/TUVP) Rollerball electrode rolled across prostate, vaporising prostate tissue and creating more expansive space for urine flow Holmium laser enucleation of the prostate (HoLEP) Laser used to remove prostate tissue, creating more expansive space for urine flow Open prostatectomy via abdo or perineal incision Open procedure to remove prostate
29
what is the most common cause of acute urinary retention?
BPH
30
what is acute urinary retention?
new onset inability to pass urine leading to pain and discomfort, with significant residual volumes.
31
what are some causes of acute urinary retention?
· UTI - cause urethral sphincter to close, especially in BPH individuals · Constipation - through compression on the urethra · Severe pain - medications e.g. anti-muscarinics, spinal/epidural anaesthesia can affect innervation to the bladder Neurological - peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, multiple sclerosis, Parkinson's, DSD
32
what are some symptoms of acute urinary retention?
· Acute suprapubic pain · Inability to micturate · UTI infection LUTS symptoms as above
33
what investigations are done to test for acute urinary retention?
· Bedside bladder scan - volume of retained urine · Routine bloods - FBC, CRP, U&Es, catherised specimen of urine (CSU) · Ultrasound of urinary tract - if high pressure retention, assess presence of hydronephrosis
34
what is the management of acute urinary retention?
Immediate urethral catheterisation - measure volume drained post-catheterisation Treat underlying cause - e.g. tamsulosin, finasteride started if appropriate · Check CSU - evidence of infection? Treat with Abx · Review medications - potential contributing causes? Treat constipation if present Large retention volume (>1000ml) Need to be monitored post-catheterisation for evidence of post-obstructive diuresis No evidence of renal impairment - TWOC All men with a history of chronic LUTS or a palpably large prostate should be started on tamsulosin. Can have their TWOC >72hrs after commencement. If TWOC unsuccessful - recatheterise Further TWOCs attempted (after longer interval in a specialist TWOC clinic) Failed attempts --> long-term catheter
35
between what spinal levels are the kidneys found?
T12-L3
36
what are the 2 main structures of the kidney?
outer cortex inner medulla
37
what are some causes of a urinary tract obstruction?
Benign prostatic hyperplasia Scar tissue in the ureter → makes it hard to micturate Tumours or cysts in the abdominal area that press on the ureter Vascular disease and blood clots GI issues → Crohn's disease, diverticulitis or a swollen appendix Ureteral stones Ureteropelvic junction obstruction → blockage of the ureter at its connection to the kidney Ectopic ureter → ureter connects to the wrong place in the body Ureterocele → birth condition that causes swelling in the ureter Pregnancy, endometriosis or uterine prolapse
38
what are the symptoms of a urinary tract obstruction?
Pain in the abdomen, lower back or flank pain Fever, nausea or vomiting Difficulty urinarting or emptying the bladder Frequent urination Recurring UTIs Haematuria Cloudy urine Swollen legs
39
what is hydronephrosis?
when obstruction causes urine to backflow up to the kidneys causing an increase in pressure on internal structures in the kidney kidney distention loss of kidney function
40
what method is commonly used to obtain images of urinary tract stones, swellings and masses?
ultrasonography
41
what cells produce PSA?
epithelial cells of the prostate
42
what is PSA?
a glycoproteins secreted into the semen to help thin the thick semen into a liquid consistency
43
what is the average PSA levels?
0-4 nanograms/ml
44
what could PSA be used as a screening tool for?
prostate cancer
45
why is PSA not readily used as a screening tool for prostate cancer?
high rate of false positve and false negatives
46
what are some common causes of raised PSA?
1. Prostate cancer 2. Benign prostatic hyperplasia 3. Prostatitis 4. UTI 5. Vigorous exercise (notably cycling) 6. Recent ejaculation or prostate stimulation
47
what should a patient not do before a PSA test?
* An active urinary infection or within previous 6 weeks * Ejaculated in previous 48 hours * Exercised vigorously, for example cycling, in the previous 48 hours. Had a urological intervention such as prostate biopsy in previous 6 weeks
48
what is next after a raised PSA leads to suspected prostate cancer?
* A prostate biopsy - to confirm or exclude the diagnosis. Imaging - to assess the stage of the prostate cancer.
49
what is the most common organism to cause UTIs?
e.coli
50
what is the presentation of a lower UTI?
* Dysuria (pain, stinging or burning when passing urine) * Suprapubic pain or discomfort * Frequency * Urgency * Incontinence * Haematuria * Cloudy or foul-smelling urine * Confusion is commonly the only symptom in older and frail patients
51
what triad of symptoms are seen in pyelonephritis in addition to symptoms of lower UTI?
Fever Loin or back pain (bilateral or unilateral) Nausea or vomiting
52
what type of bacteria breaks down nitrates to nitrites?
gram -ve
53
what 2 signs on a urine dipstick indicate a UTI?
nitrites leukocytes
54
what is the difference between microscopic and macropscopic haemateuria?
Microscopic haematuria is where blood is seen on a urine dipstick but not seen when looking at the sample. Macroscopic haematuria is where blood is visible in the urine. Haematuria is a common sign of infection but can also be present with other causes, such as bladder cancer or nephritis.
55
at what age should urine dipsticks no longer be routinely preformed?
65
56
what type of bacteria is e.coli?
gram -ve anaerobic rod-shaped
57
what organisms can cause UTIs?
e.coli Klebsiella pneumoniae Enterococcus Pseudomonas aeruginosa Staphylococcus saprophyticus Candida albicans (fungal)
58
what type of bacteria is klebsiella pneumoniae?
gram -ve anaeurobic rod-shaped
59
what 2 drugs are most common in the management of UTIs?
nitrofurantoin trimethoprim
60
when should nitrofurantoin be avoided?
in patients with eGFR <45
61
what is the typical duration of abx in uncomplicated UTI in women?
3 days
62
what is the typical duration of abx in immunosuppressed women, abnormal anatomy or impaired kidney function?
5-10 days
63
what is the typical duration of abx in men, pregnant women or catheter related UTIs?
7 days
64
what abx should be used 1st line in pyelonephritis in the community and how long for?
* Cefalexin * Co-amoxiclav (if culture results are available) * Trimethoprim (if culture results are available) Ciprofloxacin (keep tendon damage and lower seizure threshold in mind) 7-10 days
65
what should you keep in mind for patients with pyelonephritis who have significant symptoms or dont respond well to treatment?
renal abscess kidney stones
66
how long should abx given in UTIs in pregnancy?
7 days
67
what antibiotic options are there to treat UTIs in pregnancy?
Nitrofurantoin (avoided in the third trimester) Amoxicillin (only after sensitivities are known) Cefalexin (the typical choice)
68
when should nitrofurantoin be avoided in pregnancy? why?
3rd trimester risk of neonatal haemolysis
69
why is trimethoprim avoided in pregnancy?
its a folate antagonist .: can cause congenital malformations e.g. spina bifida
70
what does sensitivity mean?
Sensitivity is the proportion of people WITH Disease X that have a POSITIVE blood test. A test that is 100% sensitive means all diseased individuals are correctly identified as diseased i.e. there are no false negatives. Importantly, as the calculation involves all patients with the disease, it is not affected by the prevalence of the disease
71
what does specificity mean?
Specificity is the proportion of people WITHOUT Disease X that have a NEGATIVE blood test. A test that is 100% specific means all healthy individuals are correctly identified as healthy, i.e. there are no false positives
72
what is a false positive?
A false positive is when a scientist determines something is true when it is actually false (also called a type I error). A false positive is a “false alarm.
73
what is a false negative?
A false negative is saying something is false when it is actually true (also called a type II error).
74
what are positive and negative predictive values?
Positive predictive value reflects the proportion of subjects with a positive test result who truly have the outcome of interest. Negative predictive value reflects the proportion of subjects with a negative test result who truly do not have the outcome of interest.
75
what are positive and negative likelihood ratios?
Likelihood ratios compare the probability that someone with the disease has a particular test result as compared to someone without the disease. These are represented as the likelihood ratio for a positive test result (LR+) and the likelihood ratio for a LR−. LR+ = Probability that a person with the disease tested positive/probability that a person without the disease tested positive. i.e., LR+ = true positive/false positive LR− = Probability that a person with the disease tested negative/probability that a person without the disease tested negative. i.e., LR− = false negative/true negative Calculation: LR+ = sensitivity/(1 − specificity) LR− = (1 − sensitivity)/specificity.
76
what are the 4 stages of the cell cycle?
1) The cell increases in size (gap 1, or G1, stage) 2) Copies its DNA (synthesis, or S, stage) 3) Prepares to divide (gap 2, or G2, stage) 4) and divides (mitosis, or M, stage).
77
what is a tumour supressor gene?
Tumor suppressor genes represent the opposite side of cell growth control, normally acting to inhibit cell proliferation and tumor development. p53
78
what is an oncogene?
An oncogene is a mutated gene that has the potential to cause cancer. Before an oncogene becomes mutated, it is called a proto-oncogene, and it plays a role in regulating normal cell division. The protooncogenes that turn into oncogenes are HER2, BRCA1, and BRCA2.
79
what are the 4 stages of carcinogenesis?
1. Tumour initiation with several mutations 2. Tumour promotion 3. Malignant conversion 4. Tumour progression
80
what are the 6 steps of metastasis?
1) Local invasion 2) Intravasation (invasion of cancer cells through the basement membrane into a blood or lymphatic vessel) 3) Survival in the circulation 4) Extravasation (exit of tumor cells from the circulation to host tissue) 5) Micrometastases formation 6) Metastatic colonization
81
what ethnicities have a higher risk of prostate cancer?
balck-african
82
how is prostate cancer graded?
TNM score gleason score
83
what ilicit drug can cause interstitial cystitis and ulceration of the bladder?
ketamine
84
what is the tumour marker for ovarian cancer?
ca125
85
what is ca125 a tumour marker for?
ovarian cancer
86
what is the function of carcinoembryonic antigen?
check how well treatment is going for certain types of cancer e.g. bowel
87
what is the tumour marker for testicular cancer?
Alpha feto-protein
88
what is the tumor marker for liver cancer?
Alpha feto-protein
89
when is Alpha feto-protein raised?
liver, ovarian and testicular cancer
90
what is the tumor marker for pancreatic cancer?
ca19-9
91
when is ca19-9 raised?
pancreatic cancer
92
what is peyronies disease?
penis curves and is painful
93
what is priapsim?
prolonged erection
94
what is paraphimosis and when is it most commonly seen?
swollen foreskin after catheterisation
95
what is phimosis?
tight foreskin
96
what is paruresis?
difficult or impossible to wee when others are around
97
what investigations should be performed in recurrent UTIs?
MSU USS KUB
98
what are the treatment options for recurrent UTIs?
- Prophylactic antibiotics - Nitrofurantoin 100 mg twice daily orally for 5 to 7 days - Trimethoprim-sulfamethoxazole 160/800 mg twice daily orally for three days - Fosfomycin, as a single oral dose of 3 grams. - Pivmecillinam

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