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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
Q

Investigations for a UTI

A

MSU dip and urinalysis for cultures and sensitivities
If concerned- CT urogram

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26
Q

Management of UTI

A

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

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27
Q

Trimethoprim

A

Men, non pregnant women, 2nd and 3rd trimester

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28
Q

Nitrofurantoin

A

1st and 2nd semester

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29
Q

Obstructive uropathy symptoms

A

Flank pain, fever, LUTS, distended abdomen, anuria, reduced renal function

30
Q

Investigations for obstructive uropathy

A

Urine dip and urinalysis
FBC UE PSA
Renal USS

31
Q

Obstructive uropathy complications

A

Hyperkalaemia
Metabolic acidosis
Post obstructive diuresis (eg. 250ml/hour after catheterisation, causes confusion and AKI)
Infection
Electrolyte disturbance

32
Q

When to wait for a PSA

A

2 weeks- urinary retention
4 weeks- infection

33
Q

Contraindications to urethral catheterisation

A

Urethral trauma, recent urethral surgery, acute bacterial prostatitis

34
Q

Management of renal stones

A

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
Q

Lifestyle management to prevent renal stones (at increased risk after one episode)

A

Increase fluids
Reduce dietary salt
Limit protein
Reduce oxalate- spinach nuts rhubarb tea
Reduce urate- kidney liver sardines

NB- normal calcium diet however!!!

36
Q

Referral to nephrology or urology for haematuria

A

Below 40- nephrology
Above 40- urology

37
Q

Features of an upper UTI

A

Typically pyelonephritis

Fever, rigors, loin pain, vomiting white cell casts in urine, renal angle tenderness

38
Q

Management of an upper UTI eg. Pyelonephritis

A

Hospital admission
Broad spectrum cephalosporin (cef-) for 10-14 days
May require drainage

39
Q

When to send a urine culture in suspected UTI

A

65+
Haematuria (visible or non visible)
Pregnant women

40
Q

First line ABX in pregnancy

A

Nitrofurantoin (avoid in 3rd trimester, near term)
Trimethoprim is teratogenic so avoid in 1st and 2nd trimesters

41
Q

Asymptomatic bacteriuria in pregnant women

A

Urine culture at first antenatal visit
Antibiotic prescription
Send urine again to test if treatment has been effective

42
Q

Catheterised patients

A

Do not treat asymptomatic bacteriuria
Look for signs and symptoms such as delirium, pyrexia, tachypnoea, tachycardia, painful bladder on palpation, hameaturia etc.

43
Q

Features of a UTI in children

A

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
Q

Management of UTI in children

A

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
Q

Features of BPH

A

LUTS

Voiding (obstructive)- weak or intermittent stream, straining, hesitancy, terminal dribbling, incomplete emptying

Storage (irritative)- urgency, frequency, nocturia, urgency incontinence

Dribbling, UTI, retention

46
Q

Management of BPH

A

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
Q

Tamsulosin

A

Alpha 1 antagonist

Decreases smooth muscle tone of prostate and bladder
Considers first line

Dizziness, postural hypotension, dry mouth, depression

48
Q

Finasteride

A

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
Q

Nephroblastoma

A

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
Q

Post prostatectomy syndromes (TURP)

A

Haemorrhage
Urosepsis
Retrograde ejaculation
Electrolyte disturbance

51
Q

Priapism

A

Persistent penile erection (4 hours+)

52
Q

Causes of priapism

A

Idiopathic
Sickle cell disease/haemaglobinopathies
Erectile dysfunction medication (sildenafil)
Anti HTN, anticoagulants, antidepressants, recreational drugs eg. Cocaine, cannabis, ecstasy
Trauma

53
Q

Features of priapism

A

Persistent erection
Pain localised to penis

54
Q

Investigations and management of priapism

A

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
Q

Upper PSA limits

A

50-59 3

59-69 4

70+ 5

56
Q

Contraindications to urethral catheterisation

A

Urethral trauma
Recent urethral surgery
Acute bacterial prostatitis

57
Q

Bladder cancer referral

A

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
Q

Trospium chloride

A

Antimuscarinic
Urinary incontinence

59
Q

Pelvic fracture and highly displaced prostate

A

Membranous urethral rupture

60
Q

Most common renal stone

A

Calcium oxalate

61
Q

Calcium oxalate stones

A

most common
radio opaque
variable urinary pH

62
Q

Uric acid stones

A

children with inborn errors of metabolism
adults with excess tissue breakdown eg. malignancy
radiolucent
acidic urinary pH

63
Q

Calcium phosphate

A

renal tubular acidosis
radio opaque
normal-alkaline urinary pH

64
Q

Styruvite (triple phosphate) stones

A

composed of magnesium, ammonium, and phosphate
chronic infections
staghorn calculi (Proteus mirabilis)
radio opaque
alkaline urinary pH

65
Q

Xanthine stones

A

radiolucent

66
Q

Xanthine stones

A

radiolucent

67
Q

Radiolucent stones

A

Uric acid
Xanthine

68
Q

Radio opaque stones

A

Calcium oxalate
Cystine
Calcium phosphate
Styruvite

69
Q

Risk factors for renal stones

A

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
Q

Prevention of renal stones

A

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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