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Year 3 - TCD > Case 14 - Urological Disease > Flashcards

Case 14 - Urological Disease Flashcards

1
Q

What is included in lower UTI?

A
  • Cystitis

- Prostatitis

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2
Q

What is included in upper UTI?

A

Pyelonephritis

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3
Q

What are the risk factors of UTI?

A
  • Sexual activity
  • Menopause
  • Pregnancy
  • Dehydration
  • Birth control
  • Personal hygiene
  • Chronic health conditions - DM, immunosuppression, obstruction, stones, catheter,
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4
Q

What are the symptoms of lower UTI?

A
  • Dysuria (pain, stinging or burning when passing urine)
  • Suprapubic pain or discomfort
  • Frequency
  • Urgency
  • Incontinence
  • Gross haematuria
  • Polyuria
  • Confusion is commonly the only symptom in older more frail patients
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5
Q

What are the symptoms of upper UTI?

A
  • Fever is a more prominent
  • Loin, suprapubic or back pain.
  • Looking and feeling generally unwell
  • Vomiting
  • Rigor
  • Loss of appetite
  • Haematuria
  • Costovertebral angle pain
  • Septic like symptoms
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6
Q

What are the differential diagnosis for UTI?

A

Look unwell with loin pain:

  • Appendicitis
  • Pelvic inflammatory disease
  • Ruptured AAA
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7
Q

What invetigations are done in UTI?

A
  • MSU dipstick: nitrates confirm infection diagnosis
  • MSU dipstick: positive leukocyte esterase (enzyme produced by WBC)
  • MSU microscopy: More accurate
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8
Q

Which bacteria is more likely to cause UTI?

A

E.coli

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9
Q

What is complicated UTI?

A

UTI in the presence of a structural/functional abnormality of genitourinary tract, e.g. obstruction, catheter, stones, neurogenic bladder, renal transplant.

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10
Q

What is an uncomplicated UTI?

A

Normal renal tract structure and function

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11
Q

What are the symptoms of prostatitis?

A
  • Perineal/rectal/scrotal/penis/bladder/lower back pain
  • Fever
  • Malaise
  • Nausea
  • Swollen/tender on PR exam
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12
Q
  • What is the treatment for lower UTI?

- How long should it be taken?

A

Trimethoprim or Nitrofurantoin

  • 3 days for non-pregnant women
  • 5-10 days for non-pregnant women with complicated infection
  • 7 days for men
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13
Q

What is classified as recurrent UTI?

A

> 3/year

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14
Q
  • What is the treatment for lower UTI in pregnant women?
  • How long should it be taken?
  • What should be avoided?
A
  • First line: nitrofurantoin
  • Second line: cefalexin or amoxicillin
  • 7 days in pregnant women
  • Avoid ciprofloxacin and trimethoprim in 1st trimester, and nitrofurantoin in 3rd trimester.
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15
Q

What is the treatment for pyelonephritis?

A
  • Ciprofloxacin for 7 days for Non-pregnant women, men and people with in-dwelling catheters
  • Cefalexin for 10-14 days for pregnant women who do not require admission
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16
Q

What is the pathogenesis of BPH?

A

It is caused by hyperplasia of the stromal and epithelial cells of the transitional zone of the prostate.

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17
Q

What are the symptoms of BPH?

A
  • LUTS

- Gross haematuria: due to increase in vascularity `

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18
Q

What are the storage symptoms of LUTS?

A
  • Urinary frequency
  • Urinary urgency and urge incontinence
  • Nocturia
  • Dysuria
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19
Q

What are the voiding symptoms of LUTS?

A
  • Hesitancy: difficulty to initiate micturition. Delayed onset of urination.
  • Straining to urinate
  • Poor and/or intermittent stream (not continuous)
  • Prolonged terminal dribbling
  • Sensation of incomplete voiding
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20
Q

What investigations are conducted in BPH?

A
  • Urine dipstick (exclude infection)
  • PSA: raised in prostatitis or prostate cancer
  • Rectal exam to assess prostate size, shape and characteristics
  • IPS score
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21
Q

What is the IPS score?

A
  • Max 35 points, 7 questions
  • Combination of obstructive and irritative symptoms
  • > 1-7: mild symptoms
  • > 8-19: moderate symptoms
  • > ≥20: severe symptoms
  • Important QoL due to symptoms question at the end – Ranked out of 6.
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22
Q

How to treat BPH for IPS score 0-7?

A

Watchful waiting: monitor fluid intake, reduce alchol intake and ensure bladder emptying.

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23
Q

What is the medical therapy for BPH?

A

1st - Alpha blockers (relax smooth muscle, inhibits a1 receptors, reduced symptoms)
2nd - 5-alpha reductase inhibitors (block testosterone to DNT conversion and actually help reduce the size of the prostate)
- Phosphodiesterase type 5 inhibitors

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24
Q

What are the side effects of Tamsulosin (alpha blockers)?

A
  • Postural hypotension
  • Retrograde ejaculation
  • Headaches
  • Drowsiness
  • Sexual dysfunction
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25
Q

What are the side effects of Finasteride (5-alpha reductase inhibitors)?

A
  • Sexual dysfunction: erectile dysfunction, decreased libido, ejaculatory dysfunction
  • Gynecomastia
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26
Q

What is tadalafil?

When is it given?

A
  • Phosphodiesterase type 5 inhibitors

- Mild/moderate BPH symptoms and erectile dysfunction

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27
Q

What are the surgical interventions for BPH if prostate <80g?

A
  • Transurethral resection of the prostate (TURP) – resection of the hyperplastic prostatic tissue. If prostate
  • Transurethral incision of the prostate (TUIP) – less invasive, no resection of prostate, only neck widened.
28
Q

What are the surgical interventions for BPH if prostate >80g?

A

Open prostatectomy - (HoLEP)

29
Q

What is the most common type of prostate cancer?

Where in the prostate is it more likely to occur in?

A
  • Adenocarcinoma

- Peripheral zone (posterior zone)

30
Q

What are the risk factors for prostate cancer?

A
  • Older males
  • African Americans
  • Tall males
  • Males who use anabolic steroids
  • Obese
  • High fat diet
  • Genetic: BRCA 2, Lynch
31
Q

What are the symptoms of bladder cancer?

A
  • Fatigue
  • Loss of appetite, weight loss
  • Urinary symptoms: Nocturia, urinary frequency, urinary hesitancy, dysuria, haematuria
  • Bone pain
  • Palpable lymph nodes
32
Q

What investigations are done in prostate cancer?

A
  • DRE: Irregular and nodular prostate (suspect malignancy)
  • PSA: >4 mcg, done prior to DRE
  • Biopsy: confirm diagnosis
  • MRI: metastasis
33
Q

What are the 2 different types of biopsies that can be taken for prostate cancer?

A
  • Trans-rectal ultrasound (TURS) guided needle biopsy: 12 prostate samples, quicker
  • Transperineal biopsy – takes 35 samples, more sensitive
34
Q

What is Gleasons score?

A

Grading system used to define aggressiveness of the cancer

35
Q

What is the result of the Gleasons?

A
  • Score of 3-5 are considered cancerous but score 1 -2 are not cancer.
  • Addition of 2 most common scores
  • The lowest is 6 and highest is 10.
36
Q

What is the ISUP grading for prostate cancer?

A
  • Grade 1: Gleason 6
  • Grade 2: Gleason 3+4
  • Grade 3: Gleason 4+3
  • Grade 4: Gleason 8
  • Grade 5: Gleason 9/10
37
Q

What is the treatment for localised prostate cancer?

A
  • Radiation therapy: external beam therapy or brachytherapy (implantation of radioactive seeds, iodine 125)
  • Prostatectomy
38
Q

What is the treatment for high grade/metastatic prostate cancer?

A
  • GnRH/LHRH agonists (Leuprolide and Goserelin) -
    bicalutamide/flutamide (Anti-androgen therapy) given 3 days before LHRH agonists and continued for a week after.
    -GnRH/LHRH antagonist (Degarelix) - reduction in circulating LH and ↓ synthesis of testosterone.
39
Q
  • What is the most common type of bladder cancer?
A
  • Transitional cell carcinoma

- Non muscle invasive

40
Q

What are the risk factors for bladder cancer?

A
  • Age >55y
  • Male gender
  • Family history
  • Smoking
  • Occupational exposure e.g. Dye industry, rubber manufacturing
  • Exposure to 2-Naphthylamine
  • Pelvic radiation
  • Systemic chemotherapy
  • Chronic bladder inflammation: schistosomiasis
41
Q

What are the symptoms of bladder cancer?

A
  • Painless gross haematuria throughout micturition
  • Irritative voiding symptoms: dysuria, urinary frequency, urgency
  • Dysuria is typical of carcinoma in situ,
  • UTIs that do not resolve despite antibiotic treatment.
42
Q

Where does bladder cancer arise from?

A

Endothelial lining (urothelium)

43
Q

What investigations are done in bladder cancer?

A
  • MSU dipstick and culture: rule out infection

- Cystoscopy and biopsy: confirms diagnosis

44
Q

What is the treatment for non invasive bladder cancer?

A
  • Low risk (below Stage T1): transurethral resection of bladder tumour (TURBT) + immediate post-operative intravesical chemotherapy (mitomycin)
  • High risk (Stage T1 or Grade 3): TURBT and BCG vaccine into the bladder.
45
Q

What is the treatment for invasive bladder cancer?

A
  • Stage T2 and above: cystectomy with pelvic lymph node dissection.
  • Neo-adjuvant chemotherapy: CMV (cisplatin, methotrexate and vinblastine)
  • Adjuvant chemotherapy: M-VAC (methotrexate, vinblastine, Adriamycin and cisplatin)
46
Q

What is macroscopic/Gross/Frank haematuria?

A

Blood in urine visible to the eye

47
Q

What is microscopic haematuria?

A

Blood in urine not visible to the eye.

48
Q

What investigations can be done in haematuria?

A

1st - Urine dipstick: +ve for blood, then do
2nd - Microscopy: confirms presence of RBC
3rd - Imaging: required to identify bleeding source

49
Q

What are the different causes of haematuria?

A
  • Trauma
  • No known cause
  • Nephrolithiasis
  • Polycystic kidney disease
  • Kidney tumours
  • Glomerular haematuria
50
Q

What is nephrolithiasis?

A

Stones usually form in the collecting ducts of kidneys but may be deposited along the entire urogenital tract from renal pelvis to the urethra.

51
Q

What are the symptoms of nephrolithiasis?

A
  • Severe unilateral and colicky flank pain (renal colic) – loin to groin pain
  • Radiates anteriorly to the lower abdomen, groin, labia, testes or perineum
  • Haematuria
  • Dysuraia, frequency and urgency
52
Q

Who is likely to present with nephrolithiasis?

A
  • Often present 30-50y

- Male > female

53
Q

What are the causes of nephrolithiasis?

A
  • Metabolic disturbances (hyperparathyroidism)
  • Outflow obstruction/stasis
  • Infection
  • Immobilisation: reabsorption of bone occurs during immobilisation
54
Q

What are the different types of stones?

A
  • 75% calcium oxalate
  • 10% struvite - staghorn calculi associated with recurrent bacterial infections.
  • 10% urate – appear radiolucent on X-ray, requires other imaging such as USS or CT.
  • Calcium phosphaste
  • Cystine
55
Q

What is the treatment for renal colic?

A
  • ↑fluid intake
  • Treat any bacterial infections with trimethoprim
  • Alkalinise urine for urate stones
  • Analgesics
  • Specific for stone size
56
Q

What are benign kidney tumours?

What is the risk if they grow in size?

A
  • Angiomyolipomas
  • oncocytoma
  • Risk of bleeding
57
Q

What are 2 types of malignant kidney tumours?

A
  • Renal cell carcinoma (80%)

- Transitional cell carcinoma

58
Q
  • What is the clinical triad of renal cell carcinoma?

- How to treat?

A
  • Haematuria, pain, palpable mass

- Surgical or medical immunotherapy

59
Q
  • How does transitional cell carcinoma present?
  • What are the risk factors?
  • How to treat?
A
  • Haematuria, pain and LUTS
  • smoking, infections due to schistosomiases, radiotherapy, occupational exposure
  • Surgical resection
60
Q

What are the cause of raised PSA?

How long to wait before doing PSA again?

A
  • BPH
  • UTI
  • Prostitis
  • Trauma
  • 4 weeks
61
Q

What are the different types of bladder cancer types?

A
  • Transitional cell carcinoma
  • Squamous cell carcinoma
  • Adenoma
62
Q

What is the most common cause of squamous cell carcinoma?

A

Schistosomiasis

63
Q

What is the treatment for renal stones <5mm?

A

Lower ureter, no obstruction:

  • Analgesia’s
  • Fluid intake
  • Anti-emetics
  • Medical expulsion therapy: alpha adrenergic blockers (tamsulosin) and CCB
64
Q

What is the treatment for renal stones >8mm?

A
  • Extracorporeal shock wave lithotripsy
  • Uteroscopy (if present in ureters or bladder)
  • Percutaneous nephrolithotomy - laparoscopic surgical stone removal for >20mm and complicated stones)
65
Q

What is used to treat bacterial infections in renal colic?

A

Trimethoprim

66
Q
  • What are the different diagnostic tests done for renal colic?
  • What is the gold standard test?
A
  • Urine dipstick (haematuria in stones but also exclude infection)
  • Bloods for infection and kidney function
  • Non contrast CT KUB is gold standard

Year 3 - TCD (17 decks)

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