16. Urology Flashcards
A 67-year-old man has been urinating around 12-14 times per day over the past 6 months. His stream is ‘weak’ and often takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him? A Oxybutynin B Solifenacin C Tamsulosin D Nitrofurantoin E Co-trimoxazole
C Tamsulosin
A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost some weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis? A Pyelonephritis B Glomerulonephritis C Bladder Cancer D Prostate Cancer E Ureteric Stone
C Bladder Cancer
An 80-year-old man has had considerable difficulty urinating. He goes about 10-12 times per day, including at night, and has described his stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which investigation is most likely to provide a definitive diagnosis?
A PSA
B Acid phosphatase
C CT Scan
D Transrectal ultrasound guided biopsy
E Isotope bone scan
D Transrectal ultrasound guided biopsy
Lower Urinary Tract Symptoms Definition, Categories and MNEMONIC
Definition: a group of symptoms involving the bladder, urinary sphincter, urethra and prostate gland (in men).
Storage/Irritative: FUND
Voiding/Obstructive: HIPS
LUTS (8)
Storage/Irritative
- Frequency
- Urgency
- Nocturia
- Dysuria
Voiding/Obstructive - Hesitancy - Incomplete emptying - Poor stream - Straining (Others: terminal dribbling, overflow incontinence)
Benign Prostatic Hyperplasia Definition and Epidemiology
Definition: slowly progressive hyperplasia of the periurethral (transitional) zone of the prostate gland.
Epidemiology:
VERY COMMON – most common cause of LUTS in men
Benign Prostatic Hyperplasia Symptoms, Signs, Invx
- FUND HIPS
- Severe pain (if ACUTE retention)
- DRE - smoothly enlarged prostate with a palpable midline groove
Investigations
- Usually unnecessary
- U&Es – check for ↓ renal function
- Ultrasound of urinary tract
Benign Prostatic Hyperplasia - Management
EMERGENCY (acute urinary retention): CATHETERISE!
Conservative (if mild): Watchful waiting (because patients are old)
Medical
- a-blockers (e.g. tamsulosin)
- 5a-reductase inhibitors (e.g. finasteride
Surgical
- Transurethral resection of the prostate (TURP)
- Open prostatectomy
How does Medical Tx of BPH work?
Alpha-blockers (e.g. tamsulosin) relax the smooth muscle of the internal urinary sphincter and prostate capsule, thereby reducing the resistance to urinary outflow
5a-reductase inhibitors (e.g. finasteride) inhibits the conversion of testosterone to dihydrotestosterone (which is a more potent androgen) – this can lead to a dramatic decrease in prostate size
Prostate Cancer Symptoms and Signs
FUND HIPS Symptoms of malignancy - Bone pain - Cord compression - FLAWS - Paraneoplastic (e.g. hypercalcaemia) DRE – asymmetrical hard nodular prostate
Prostate Cancer Investigations
PSA – low specificity
Transrectal Ultrasound-guided Biopsy – GOLD STANDARD
CT/MRI – assess local invasion and metastasis
LFTs/bone profile – check for metastatic effects
Bladder Cancer RF and most common type
Most = transitional cell carcinomas
Rarely, they can be squamous cell carcinomas
Risk Factors: Dye stuffs Pelvic irradiation Smoking Chronic UTIs Schistosomiasis
Bladder Cancer symptoms and investigations
Symptoms
Painless macroscopic haematuria
FUND (not HIPS)
FLAWS
Investigations
Cystoscopy with biopsy
CT/MRI for staging
A 43-year-old woman presents to her GP having wet herself several times since the birth of her third child, 4 months ago. Whenever she laughs or coughs, a little bit of urine leaks out without her control. Which type of incontinence does she have? A Functional incontinence B Stress incontinence C Urge incontinence D Overflow incontinence E Double incontinence
B Stress incontinence
A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become overwhelmed by the feeling of needing to urinate. Before she can even think about finding a toilet, she has wet herself. Which type of incontinence is this? A Functional incontinence B Stress incontinence C Urge incontinence D Overflow incontinence E Double incontinence
C Urge incontinence
Urinary Incontinence Definition and types
Definition: the unintentional loss of urine.
STRESS
- Physical movement/activity (e.g. coughing, laughing) places a ‘stress’ on the bladder
- Due to poor closure of the bladder
- RF: Childbirth is a risk factor
URGE
- Urine leaks as you feel a sudden, intense urge to urinate
- Due to detrusor overactivity
Functional – aware of the need to urinate, but unable to get to the bathroom in time (physical/mental reasons)
Overflow – over full bladder leaks, in the absence of any need to urinate
Niche Causes of Incontinence
Normal pressure hydrocephalus
Cord compression
A 42-year-old man presents with severe pain in his right flank. He adds that the pain moves towards his right groin. Although he is writhing around in pain, no abnormalities are detected on abdominal examination. Urine Dipstick: + blood Which investigation would you do next? A Renal ultrasound B Cystoscopy C CT-KUB D MRI E Urine MC&S
C CT-KUB
