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
Which type of urinary tract stone is most common? A Magnesium ammonium phosphate B Calcium oxalate C Cysteine D Urate E Hydroxyapatite
B Calcium oxalate
A 13-year-old boy is brought to A&E with sudden-onset pain and swelling in his scrotum, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to vomit. On examination, his right hemiscrotum is red and swollen. What is the most appropriate first step in his management? A Doppler ultrasound of the testes B CT Scan C Exploratory surgery D Empirical antibiotics E Abdominal X-ray
C Exploratory surgery
Urinary Tract Calculi Definition and types (4)
Crystal deposition within the urinary tract. AKA nephrolithiasis.
Types:
- CALCIUM OXALATE – most common
- Magnesium ammonium phosphate (Struvite)
- Urate
- Cysteine
Urinary Tract Calculi
Epidemiology and causes/RF
3 x more common in MEN
Causes
- Idiopathic
- Metabolic (e.g. hypercalcaemia, hyperuricaemia)
Risk Factors
- Low fluid intake
- Structural urinary tract abnormalities
Urinary Tract Calculi Symptoms and Signs
- Often asymptomatic
- SEVERE loin to groin pain (writhing in pain)
- Nausea and vomiting
NOTE: consider leaking AAA (especially in the elderly)
Urinary Tract Calculi Investigations
Urine dipstick (microscopic haematuria)
Non-contrast CT-KUB – GOLD STANDARD
Ultrasound
U&Es – check renal function
Urinary Tract Calculi Management
ANALGESIA
Advise to increase fluid intake
< 5 mm diameter – allow to pass spontaneously (retain –> sent off for analysis)
> 5 mm diameter – SURGERY
EMERGENCY: any signs of an obstructed and infected kidney requires urgent surgery to relieve the obstruction is necessarily
3 Types of Surgery for Urinary Tract Calculi
Ureteroscopic lithotripsy: scope is passed through urethra and bladder into ureter –> visualise stone. Lasers/fine tweezers break down + dislodge the stone. If the stone cannot be removed, a ‘JJ stent’ can be inserted to allow the passage of urine.
Extracorporeal Shockwave Lithotripsy (ESWL) - (non-invasive): electromagnetic shockwave focused onto the calculus –> break into smaller fragments –> pass spontaneously.
Percutaneous Nephrolithotomy (PCNL) - (for large, complex stones e.g staghorm calculus). Make a nephrostomy tract --> nephroscope is inserted --> disintegration and removal of stones.
Testicular Torsion Definition and DDx
Epidemiology
Definition: twisting or torsion of the spermatic cord results in disruption of the blood supply to the testicle. A SURGICAL EMERGENCY.
Differential Diagnosis
Epididymo-orchitis
Strangulated inguinal hernia
Epidemiology
Boys and young men
Testicular Torsion Symptoms and Signs
Sudden-onset severe hemiscrotal pain
Nausea and vomiting
Swollen and erythematous scrotum
Testicular Torsion Mx
EXPLORATORY SURGERY (within 6 hours)
Both testicles are fixed in place
Necrotic tissue may need removal
Duplex Ultrasound
A 50-year-old man has developed a swollen scrotum that has been bothering him for the past 2 weeks. The swelling is uncomfortable but not painful. On examination, the left hemiscrotum is enlarged, fluctuant and non-tender. It is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis? A Varicocoele B Hydrocoele C Testicular tumour D Epididymal cyst E Indirect inguinal hernia
B Hydrocoele
A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘bag of worms’, and is uncomfortable but not painful. On examination, the patient’s scrotum looks normal when lying down, however, the left hemiscrotum becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis? A Indirect inguinal hernia B Direct inguinal hernia C Hydrocoele D Varicocoele E Epididymal cyst
D Varicocoele
A 21-year-old man visits his GP complaining that his scrotum feels ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with orchidopexy. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to? A Inguinal B Femoral C Para-aortic D Iliac E Mesenteric
C Para-aortic
Hydrocoele definition, epidemiology and causes
Definition: an excessive collection of serous fluid in the tunica vaginalis.
Epidemiology
Very young boys (< 1 yr)
Older men
Causes Idiopathic Infection Trauma Tumour
Hydrocoele Symptoms and Signs
Usually asymptomatic swelling
Can get above the swelling
Transilluminates
Swelling cannot be separated from testicle
Hydrocoele Investigations
Ultrasound - exclude tumour
Testicular tumour markers
Urine dipstick/MSU – check for infection
Varicocoele definition
Which side is is more common on and why?
Definition: dilated veins of the pampiniform plexus forming a scrotal mass.
More common on the LEFT (80-90%)
- Angle at which the left testicular vein meets the left renal vein
- Lack of effective valves between the left testicular vein and the left renal vein
- Increased reflux from compression of the left renal vein
Associated with infertility
Varicocoele Symptoms and Signs
Usually asymptomatic
Scrotum feels like a ‘bag of worms’
Swelling may reduce when lying down
Epididymitis and Orchitis definition, epidemiology and causes
Definition: inflammation of the epididymis or testes.
Epidemiology
Most common in 20-30 yr olds
Causes
< 35 yrs: Chlamydia and Gonococcus
> 35 yrs: Coliforms (e.g. Enterobacter, Klebsiella)
Others: mumps, Candida
Epididymitis and Orchitis Symptoms and Signs
Painful, swollen and tender testis/epididymis NOTE: less acute onset than torsion Penile discharge (if STI) Fever Enquire about sexual history
Epididymitis and Orchitis Investigations
Urine dipstick
Urine MC&S
Bloods (FBC, CRP)
Testicular Cancer epidemiology and RF
Commonest malignancy in males between 20-40 yrs
Risk Factors: maldescended testes
Testicular Cancer Types
Seminomas and Non-Seminomas both arise from germ cells (cells that give rise to gametes).
They are categorised based on the histological appearance of the tumour.
Seminoma (like tissues of seminiferous tubules) - 50%
Non-Seminoma (e.g. teratoma) appears v. diff. from testicular tissue – 30%
Others: Sertoli and Leydig cell tumours
Symptoms of Testicular Cancer
- Painless, hard testicular mass
- Testicular swelling/discomfort
- Backache (metastasis to para-aortic nodes)
Testicular Cancer Investigations
Tumour Markers
- a-fetoprotein
- b-hCG
- Lactate Dehydrogenase
Testicular Ultrasound
CT – allows staging
Testicular cancers are NOT usually biopsied because it may risk spreading the cancer.
A 32-year-old man presents with a 2-week history of frequent urination and excessive thirst. He has also noticed that he feels much weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient? A Tented T waves B Absent P waves C ST elevation D J waves E U waves
E: U waves
This patient has Conn’s syndrome – a condition in which an aldosterone-secreting adenoma leads to inappropriately elevated aldosterone levels. The excessive sodium reabsorption and potassium excretion caused by the high aldosterone leads to hypertension and hypokalaemia. Hypokalaemia induces nephrogenic diabetes insipidus, which, consequently, leads to polyuria and polydipsia. Furthermore, muscle weakness is another feature of hypokalaemia. The main ECG features of hypokalaemia are U waves, ST depression, flattened T waves and prolonged PR interval. In any young patient presenting with hypertension, consider secondary causes such as Conn’s syndrome, coarctation of the aorta and renal artery stenosis.
Tented T waves are a feature of hyperkalaemia. Absent P waves can be seen in several different conditions, most notably atrial fibrillation and supraventricular tachycardia. J waves (sometimes referred to as Osborn waves) are see in hypothermia.
