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Year 3 OSCE > Case 14- Bladder Cancer > Flashcards

Case 14- Bladder Cancer Flashcards

1
Q

Investigations for haematuria

A

Urinalysis, urine cytology and urine cultures
FBC UE LFT clotting
Cystoscopy with biopsy
CT KUB- gives more of an overview of the whole renal tract
Renal and bladder ultrasound- if CT contraindicated

NB- if history fits more with an infection- think of urine microscopy. If microscopic haematuria (found on dip stick) and under 45- don’t need urological investigation

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2
Q

Prostate cancer

A

Usually adenocarcinoma in the peripheral zone

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3
Q

Common organisms causing UTI

A

E. coli- most common
Klebsiella pneumoniae
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans

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4
Q

BPH

A

Growth occurs in the transitional zone

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5
Q

Complications post obstructive uropathy

A

Hyperkalaemia
Metabolic acidosis
Post obstructive diuresis (delirium)
Sodium and bicarbonate loss
Infection

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6
Q

Investigations for renal colic/ suspected nephrolithiasis

A

Urinalysis, Urine culture
Pregnancy test- exclude ectopic
Palpate abdomen for AAA- expansile mass
FBC UE - WCC if infection and maybe hypercalcaemia/ hyperuricaemia
non contrast CT KUB- gold standard for diagnosing stones

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7
Q

Bladder cancer differentials

A

BPH (male), haemorrhagic cystitis, prostatitis (male), renal cell carcinoma, nephrotlithiasis, pelvic cancer (vulval for women), radiation cystitis (if recent radiation treatment)

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8
Q

Prostate cancer Sx

A

FUNWISE

Frequency, Urgency, Nocturia, Weak stream, Intermittency, Straining, Emptying incomplete

Exam and tests- abnormal DRE, elevated PSA

Advanced disease- haematuria, weight loss, bone pain, palpable lymph nodes

NB- normal PSA doesn’t exclude prostate cancer

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9
Q

Investigations for suspected prostate cancer

A

Urinalysis
Bloods- PSA (refer if above 3, cancer is usually 4+), FBC, UE, bone profile, CRP (inflammation), LFT (whether androgen deprivation possible and ALP levels (bony metastasis)), testosterone (see if androgen deprivation possible)
DRE- after PSA taken
Miltiparametric MRI is now first line
2nd line- Trans rectal USS guided Prostate biopsy with Gleason score calculated
Bone scan- if signs of advanced disease

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10
Q

Increased PSA levels

A

Cancer, BPH, UTI, prostatitis, trauma, DRE, ejaculation, cycling

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11
Q

BPH investigations

A

Urinalysis (exclude infection), urine culture, urinary output chart
Bloods- PSA (pre-DRE), UE (bladder outlet obstruction), LFT (ALP)
DRE
IPSS score

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12
Q

Management of UTI

A

Non pregnant women- 3 days of trimethoprim, nitrofurantoin, cirpofloxacin

Pregnant women- avoid trimethoprim and cirpofloxacin in 1st trimester, and nitrofurantoin in the 3rd trimester. Local guidelines

Men- 7 days of trimethoprim and nitrofurantoin

NB- trimethoprim or cephalosporins (not in penicillin allergy) post-partum when breastfeeding (nitrofurantoin/ciprofloxacin should be avoided when breastfeeding)

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13
Q

Obstructive uropathy causes

A

Mechanical- BPH, urethral stricture, bladder calculi, phimosis, pelvic tumour

Functional- MS, anticholinergics eg. tricyclic antidepressants, diabetic autonomic neuropathy (NOT NEPHROPATHY), opioids

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14
Q

Obstructive uropathy vs renal colic/ pyelonephritis

A

Same Sx- will be able to pass urine in the latter 2 conditions

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15
Q

Management of obstructive uropathy

A

Treat underlying cause
Analgesia
Fluids- post obstructive diuresis
Catheter- not in upper obstruction (if more than 400cc, keep catheter in)

If upper- ureteric stent or nephrostomy

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16
Q

Acute urinary retention vs chronic urinary retention

A

Sudden onset vs slower progression
Painful inability to void vs painless
Patient is restless and distressed vs nocturnal incontinence or nocturnal enuresis

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17
Q

Nephrolithiasis vs pyelonephritis

A

Same Sx but fever in pyelonephritis

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18
Q

Nephrostomy vs urinary stoma

A

Nephrostomy- between skin and kidney

Urinary stoma- between skin and either bowel (kidney diversion) or ureters

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19
Q

Investigations for bladder cancer

A

Urinalysis with cytology
FBC UE LFT
Cystoscopy with biopsy
CT urogram

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20
Q

Differentials for prostate cancer

A

BPH, prostatitis, bladder cancer

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21
Q

Treatment of prostate cancer

A

Watchful waiting
Radio or brachy therapy
Hormonal therapy eg. Bilateral orchidectomy, goserelin (GnRH agonist- works to reduce sex hormone levels over time, be wary of initial tumour flare (initial increase in sex hormones)), bicalutamide (blocks androgen receptor)
Total prostatectomy last resort

NB- GnRH ANTagonists are being investigated

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22
Q

Castration resistant prostate cancer

A

Requires anti androgen therapy (bicalutamide) and chemotherapy

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23
Q

Features of a lower UTI

A

Dysuria, frequency, haematuria, flank pain, costovertebral angle tenderness, suprapubic pain, delirium (elderly)

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24
Q

Differentials for a UTI

A

BPH, urinary tract stones, pyelonephritis, bladder cancer, renal cancer, prostate cancer, STI

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25
Investigations for a UTI
MSU dip and urinalysis for cultures and sensitivities If concerned- CT urogram
26
Management of UTI
Fluids, analgesia (not ibuprofen or aspirin), rest etc. ABX; -3 days if simple in women -5-10 days in immunocompromised women, abnormal anatomy, impaired kidney function -7 days for men, pregnant women or catheter related UTI Men and non pregnant women- either trimethoprim or nitrofurantoin
27
Trimethoprim
Men, non pregnant women, 2nd and 3rd trimester
28
Nitrofurantoin
1st and 2nd semester
29
Obstructive uropathy symptoms
Flank pain, fever, LUTS, distended abdomen, anuria, reduced renal function
30
Investigations for obstructive uropathy
Urine dip and urinalysis FBC UE PSA Renal USS
31
Obstructive uropathy complications
Hyperkalaemia Metabolic acidosis Post obstructive diuresis (eg. 250ml/hour after catheterisation, causes confusion and AKI) Infection Electrolyte disturbance
32
When to wait for a PSA
2 weeks- urinary retention 4 weeks- infection
33
Contraindications to urethral catheterisation
Urethral trauma, recent urethral surgery, acute bacterial prostatitis
34
Management of renal stones
Conservative- Stones less than 5mm should pass naturally Medical- NSAID antiemetic fluids (if they need admission- give IM diclofenac), thiazide diuretics for calcium stones Surgical; Ureteric obstruction with signs of infection eg. Fever, systemic compromise- decompression (nephrostomy, ureteric catheters, ureteric stents) Less than 2cm- extracorporeal shockwave lithotripsy Less than 2cm and pregnant- ureteroscopy Complex renal calculi and staghorn calculi- percutaneous nephrolithotomy
35
Lifestyle management to prevent renal stones (at increased risk after one episode)
Increase fluids Reduce dietary salt Limit protein Reduce oxalate- spinach nuts rhubarb tea Reduce urate- kidney liver sardines NB- normal calcium diet however!!!
36
Referral to nephrology or urology for haematuria
Below 40- nephrology Above 40- urology
37
Features of an upper UTI
Typically pyelonephritis Fever, rigors, loin pain, vomiting white cell casts in urine, renal angle tenderness
38
Management of an upper UTI eg. Pyelonephritis
Hospital admission Broad spectrum cephalosporin (cef-) for 10-14 days May require drainage
39
When to send a urine culture in suspected UTI
65+ Haematuria (visible or non visible) Pregnant women
40
First line ABX in pregnancy
Nitrofurantoin (avoid in 3rd trimester, near term) Trimethoprim is teratogenic so avoid in 1st and 2nd trimesters
41
Asymptomatic bacteriuria in pregnant women
Urine culture at first antenatal visit Antibiotic prescription Send urine again to test if treatment has been effective
42
Catheterised patients
Do not treat asymptomatic bacteriuria Look for signs and symptoms such as delirium, pyrexia, tachypnoea, tachycardia, painful bladder on palpation, hameaturia etc.
43
Features of a UTI in children
Infants- poor feeding, vomiting, irritability Young children- abdominal pain, fever, dysuria Older children- dysuria, frequency, hameaturia NB- upper UTI (fever, loin pain, regal angle tenderness)
44
Management of UTI in children
Less than 3 months- urgent referral to paediatrician Upper UTI- consider admission to hospital Over 3 months- trimethoprim or nitrofurantoin for 3 days (bring back if they remain unwell after 24-48 hours) Prophylaxis given for recurrent UTI’s NB- if below 6 months may require a follow up USS in a few weeks to assess anatomy
45
Features of BPH
LUTS Voiding (obstructive)- weak or intermittent stream, straining, hesitancy, terminal dribbling, incomplete emptying Storage (irritative)- urgency, frequency, nocturia, urgency incontinence Dribbling, UTI, retention
46
Management of BPH
Watchful waiting Supportive measures- less caffeine, pads, don’t drink too late at night, bladder training, void in a sitting position, double voiding etc. medication- tamsulosin (troubling symptoms), finasteride (enlarged prostate), combination therapy if voiding symptoms and prostatic enlargement, if these don’t work try anticholinergic (antimuscarinic) such as oxybutinin or tolterodine Surgery- TURP (destroys transitional zone, but peripheral zone still present so may still get cancer- although BPH is not a risk factor for cancer development)
47
Tamsulosin
Alpha 1 antagonist Decreases smooth muscle tone of prostate and bladder Considers first line Dizziness, postural hypotension, dry mouth, depression
48
Finasteride
5 alpha reductase inhibitors Block conversion of testosterone to dihydrotestosterone Indicated if patient has enlarged prostate and is considered high risk of progression (but symptoms may not improve for 6 months) SE’s- erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
49
Nephroblastoma
First 4 years of life Mass associated with haematuria (pyrexia in 50%) Often mestasise early (usually to lung) Treated by nephrectomy Younger children have a better prognosis
50
Post prostatectomy syndromes (TURP)
Haemorrhage Urosepsis Retrograde ejaculation Electrolyte disturbance
51
Priapism
Persistent penile erection (4 hours+)
52
Causes of priapism
Idiopathic Sickle cell disease/haemaglobinopathies Erectile dysfunction medication (sildenafil) Anti HTN, anticoagulants, antidepressants, recreational drugs eg. Cocaine, cannabis, ecstasy Trauma
53
Features of priapism
Persistent erection Pain localised to penis
54
Investigations and management of priapism
Cavernosal blood gas- differentiate between ischaemic and non ischaemic (ischaemic- pO2 and pH reduced, whilst pCO2 increased) Doppler USS FBC toxicology screen If ischaemic- aspiration of blood from cavernosa, flush with saline, if this fails, phenylephrine injections, then surgery If non ischaemic- observation
55
Upper PSA limits
50-59 3 59-69 4 70+ 5
56
Contraindications to urethral catheterisation
Urethral trauma Recent urethral surgery Acute bacterial prostatitis
57
Bladder cancer referral
A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should be referred using the suspected cancer pathway (within 2 weeks) to exclude bladder cancer
58
Trospium chloride
Antimuscarinic Urinary incontinence
59
Pelvic fracture and highly displaced prostate
Membranous urethral rupture
60
Most common renal stone
Calcium oxalate
61
Calcium oxalate stones
most common radio opaque variable urinary pH
62
Uric acid stones
children with inborn errors of metabolism adults with excess tissue breakdown eg. malignancy radiolucent acidic urinary pH
63
Calcium phosphate
renal tubular acidosis radio opaque normal-alkaline urinary pH
64
Styruvite (triple phosphate) stones
composed of magnesium, ammonium, and phosphate chronic infections staghorn calculi (Proteus mirabilis) radio opaque alkaline urinary pH
65
Xanthine stones
radiolucent
66
Xanthine stones
radiolucent
67
Radiolucent stones
Uric acid Xanthine
68
Radio opaque stones
Calcium oxalate Cystine Calcium phosphate Styruvite
69
Risk factors for renal stones
dehydration hypercalciuria, hyperparathyroidism, hypercalcaemia cystinuria high dietary oxalate renal tubular acidosis medullary sponge kidney, polycystic kidney disease beryllium or cadmium exposure Risk factors for urate stones -gout -ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid Drug causes -drugs that promote calcium stones: loop diuretics, steroids, acetazolamide, theophylline -thiazides can prevent calcium stones (increase distal tubular calcium resorption)
70
Prevention of renal stones
Calcium stones -high fluid intake -low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet) -thiazides diuretics (increase distal tubular calcium resorption) Oxalate stones -cholestyramine reduces urinary oxalate secretion -pyridoxine reduces urinary oxalate secretion Uric acid stones -allopurinol -urinary alkalinization e.g. oral bicarbonate

Year 3 OSCE (61 decks)

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