An introduction to urology Flashcards
What are some of the key characteristics of the uro-epithelium?
3-5 layers thick
Impervious to urine - beneficial because otherwise we would suffer ammonia toxicity
From the calyx to tip of penis
What factors increase the risk of developing a UTI?
stagnation, reflux and contamination
- urine is sterile and therefore shouldn’t get infections
What is the normal flow rate of urine production?
20ml/min
What are the 7 steps involved in urology diagnoses?
History Physical exam Basic investigations Specialist investigations Imaging Endoscopy Biopsy
What are the lower urinary tract symptoms (irritative/storage)?
Day frequency - up to 7 times - filter 2L of urine a day and void 300ml each time
Night frequency
Urgency
Incontinence - urge, stress, overflow, anatomical
What are the lower urinary tract symptoms (obstructive/voiding)?
Hesitancy
Poor stream
Terminal dribbling
Post micturition dribbling
What are the basic principles of the micturition cycle?
During bladder filling the detrusor muscles are relaxed, however once the bladder contracts and the sphincter relaxes urine is voided
- both autonomic and voluntary nerves innervate the sphincters
What are the essential investigations and the optional ones when assessing LUTS?
Essential
- symptom score
- MSU
- PSA - normal =50
- bladder scan
- flow rate
- freq/vol chart - small amounts means the pathology is in the bladder, whereas large amounts more frequently is indicative of diabetes insipidus, cardiac failure
Optional
- plain X-ray KUB
- USS renal tract / CT
- urodynamics
- cystoscopy
What are the normal flow rates?
> 15ml/sec= normal
10-15ml/sec = equivocal
<10ml/sec = obstructed
Max and mean flow rates decrease with age
Flow rates between 10-15 may be normal for people over 70 years
What are the differential diagnoses for voiding dysfunction ?
Overactive bladder bladder outlet obstruction UTI bladder cancer prostate cancer gynaecological problem bladder stones fistula
What are the complications of not treating benign prostatic hyperplasia?
lead to bladder stagnation and bladder stones which can lead to diverticula formation and renal failure
Every man >40 will have signs of BPH but only about 30% will require symptomatic relief
What is the management plant for LUTS?
Conservative= fluid levels advised
Medical therapy - alpha blocker, 5 alpha reductase inhibitor (acts on the size of the prostate gland), anticholinergics
Surgical - Transurethral resection of the prostate, laser prostatectomy, open prostatectomy
What are the different types of incontinence?
Overflow: Urethral blockage, bladder unable to empty properly
Stress: relaxed pelvic floor, increased abdominal pressure - common in females because the urethra extends below the sphincter therefore cough causes incontinence
Urge: bladder oversensitivity from infection, neurological disorder
What are the causes of urinary incontinence?
1) genuine stress incontinence: congenital weakness of the bladder neck, denervation of sphincter mechanism of pelvic floor (during labour), oestrogen deficiency in menopause
2) detrusor instability
3) retention with overflow incontinence
4) urogenital fistula
5) temporary - UTI, drugs alpha blockers
6) Urethral diverticulum
What is cystometry?
put a catheter into the bladder and a measuring line in the rectum to measure the pressure and then fill the bladder up to determine voiding pressure
How do you manage urinary incontinence?
conservative - fluid levels advised
urethral catheter for overflow incontinence
anti-cholinergic for urge incontinence
surgical for significant stress incontinence- bulking agents, tapes, mesh, artifical urinary sphincter, or correction of anatomical cause
What are the different types of haematuria?
visual
Non-visual: symptomatic or asymptomatic
What investigations are carried out for haematuria?
FBC / U&Es, MSU = essential
Endoscopy = essential if you suspect a tumour
Imaging - CT urogram is the most important, US, Retrograde pylogram, MRI
Rarely biopsy
What are the different classifications of bladder cancer?
pTa - G1-4
- G1-2= LOW RISK<3CM
- G3-4 = high risk and will become muscle invasive if not treated
pT1 - G1-4
- G1-2 = medium risk
- G3-4 = high risk
pT2, pT3 and pT4 are all muscle invasive
- 2 = superficial muscle
- 3 = deep muscle
- 4 = surrounding are
What are the outcomes for bladder cancer?
superficial
- 70% remain superficial and have excellent outcome
- 30% can become invasive and their outcome depends on treatment offered
Invasive
- surgery at 6-% 5 yr survival
- radiotherapy at 40% 5 yr survival
How is renal cancer often diagnosed and what are the different types?
Often an incidental finding on US or CT scans as it doesn’t necessarily present with haematuria
Tumour types:
- renal parenchyma (renal cell carcinoma = most common)
- collecting system (ICC)
- other rare types
What are the important things to consider when there is a renal mass?
is the mass solid or cystic - if solid = tumour - if cystic need to define whether its simple or complex is renal function normal is the other kidney normal is there metastatic disease
What is PSA and when is it raised?
Prostate specific antigen
-protease enzyme secreted in the seminal fluid
Raised in the blood if:
- enlarged prostate
- prostatitis
- Ca prostate
However all these conditions can have normal PSA
What are the normal levels of PSA and if its raised what are the risks of cancer?
0-2 ng/ml -1% probability of cancer
2-4 ng/ml - 15% probability of cancer
4-10ng/ml - 25% probability of cancer
>10ng/ml ->50% probability of cancer
What are the age specific ranges for PSA?
40-49 year olds = 2.5
50-59 year olds = 3.5
60-69 year olds = 4.5
70 and > = 6.5
Where do most prostate cancers occur?
in the outer most layer, the inner most layer is usually benign
What are some of the key symptoms of prostate cancer?
sometimes asymptomatic but may have raised PSA / abnormal DRE
lower urinary tract symptoms
backache
On autopsy 80% of men have prostate cancer but didn’t died
How can prostate cancer be diagnosed and what techniques can help to stage it?
Diagnosis: PSA levels, TRUS (transrectal ultrasound) biopsy, TURP
Staging: DRE, bone scan, CT/MRI
Gleeson scoring = 5 grades
- 1 = well differentiated (hyperchromatic nuclei, no loss of polarity)
- 2-4 = moderately differentiated
- 5 = poorly differentiated
Relevant stages: localised, locally advanced, metastatic
If the prostate cancer is localised what is the management plan?
Watchful/waiting
Radical prostectomy
DXT - deep x-ray
If the prostate cancer is locally advanced what is the management plan?
hormone therapy treatment
If the prostate cancer is metastatic what is the management plan?
hormonal manipulation= increases lifespan by about 42 months
hormonal escapedDs
palliative
What are the differences between acute and chronic urine retention
Acute - painful, usually vol <1000ml, relief on catheterisation
Chronic - usually painless, vol >1000ml, 2 types: low pressure and high pressure (backpressure effects on the kidney
What is the management plan for urine retention?
check bloods before catheterisation Type and size of catheter record residual vol of urine if its chronic renal failure need to closely monitor urinary output plan twoc or definitive surgery
