Deck 3 - GU

Question 1

Q. Describe the epithelium of the prostate

Answer 1

A. Secretory = pseudostratified, columnar cells and basal cells
B. Epithelium is highly variable with areas of low cuboidal or squamous cells – with transitional epithelium in the distal regions of the longer ducts

Question 2

Q. Which zone of the prostate do most prostate cancers occur in? In which zone do the most aggressive cancers occur?

Answer 2

A. 70-80% of prostate cancers occur in the peripheral zone
B. 2.5% of prostate cancers occur in the central zone surrounding the ejaculatory ducts, these tend to be more aggressive and invade the seminal vesicles
C. (10-20% occur in the TZ)

Question 3

Q. In which region of the prostate does benign prostatic enlargement occur?

Answer 3

A. Transitional zone

Question 4

Q. What is transcoelomic metastatic spread?

Answer 4

A. Spread of a malignant neoplasm across a body cavity; such as pleural/pericardial/peritoneal

Question 5

Q. Metastatic spread of a malignant neoplasm can result in a range of symptoms. Describe two non-specific and two specific symptoms related to this condition, and two symptoms of paraneoplastic syndromes

Answer 5

A. Non-specific: weight loss, anorexia, fever, anaemia (normocytic)
B. Specific: hypercalcaemia (anorexia, thirst, confusion, collapse), marrow replacement (purpura, anaemia, immune suppression)
C. Paraneoplastic syndromes:
a. Endocrine: crushing’s disease (ectopic ACTH – secretion by tumour)
b. Neuro: dementia, cerebellar degeneration, peripheral neuropathy
c. Dermatological: acanthosis nigricans (hyperpigmentation found in body folds)
d. Haematological: erythrocytosis
D. Local: e.g. haematuria in bladder cancer

Question 6

Q. Name two biomarkers for prostate cancer

Answer 6

A. Serum: prostate-specific antigen (PSA), prostate-specific membrane antigen (PSMA)
B. Urine: PCA3

Question 7

Q. Which conditions may elevate serum PSA levels?

Answer 7

A. BPE/H, urinary tract infection, prostatitis

Question 8

Q. Name two ways to diagnose/investigate suspected prostate cancer

Answer 8

A. LUTS, PSA, transrectal ultrasound (TRUSS), prostate biopsy, prostate cancer grading (Gleason grading)

Question 9

Q. Describe the investigation of choice to stage prostate cancer

Answer 9

A. T stage: palpable tumour on DRE
B. N stage: MRI/CT
C. M stage: bone scan
D. Partin’s nomograms predict pathological T and N stage by combining clinical T stage, PSA and biopsy Gleason score

Question 10

Q. Describe three treatments for localised prostate cancer

Answer 10

A. Surgery: radical prostatectomy, open laparoscopic, robotic
B. Radio: external beam, brachytherapy
C. Observation: watchful waiting, active monitoring/surveillance
D. Focal therapy: high intensity u/s, photodynamic therapy (TOOKAD)

Question 11

Q. Give two arguments for and against prostate cancer screening (PSA)

Answer 11

A. For: early diagnosis of localised disease, early treatment of advanced disease, commonest cancer in men, responsible for 10,000 deaths per annum, 4th most common cause of cancer death, 3% of men will die of prostate cancer
B. Against: uncertain natural history, overtreatment, morbidity of treatment, high rate of false positives – patient anxiety, risk of over diagnosis of insignificant disease, harm caused by investigation/treatment

Question 12

Q. Describe two treatments for metastatic prostate cancer

Answer 12

A. Surgical castration (prolonged survival, reduced pain from bony metastases)
B. Surgical orchidectomy therapy (removal of testosterone producing part of testis)
C. Androgen deprivation therapy: GNrH analogues, LH antagonists (prevents release of LH from pituitary gland), peripheral androgen receptor antagonists

Question 13

Q. What is an urinary tract infection? Which organisms are most common in primary care?

Answer 13

A. The inflammatory response of the urothelium to bacterial invasion, usually associated with bacteriuria and pyuria
B. E.coli, coag neg staph spp, proteus sp, enterococci, klebsiella

Question 14

Q. Which type of bacterial pili/fimbriae are associated with lower tract UTIs? Which are associated with upper UTIs?

Answer 14

A. Type 1 pili: associated with lower UTIs

B. Type P pili: associated with upper UTIs

Question 15

Q. Why is an increase in UTI incidence associated with post menopause?

Answer 15

A. Pre-menopause vagina is heavily associate with lactobacilli, this mantains a low pH from the glycogen metabolism to lactate
B. Post-menopausal: pH rises, increased colonisation by colonic flora, reduction of vaginal mucus secretion, increased vaginal mucosal receptivity to UPEC

Question 16

Q. Name two bacterial factors

Answer 16

A. Enzyme production: e.g. proteus spp. secretes of urease

B. Toxins: E.coli releases cytokines which are directly toxic

Question 17

Q. Describe two host defence factors of the vagina

Answer 17

A. Antegrade flushing of the urine (reduced in – incomplete emptying, obstruction, reflux, pregnancy)
B. GAG layer
C. Low urine pH and high osmolarity
D. Commensal flora (may be changed by spermicides, oestrogen, pH and antibiotic use)
E. Urinary IgA

Question 18

Q. What is pyuria?

Answer 18

A. Presence of leucocytes in the urine, associated with infection

Question 19

Q. What occurs in asymptomatic bacteriuria?

Answer 19

A. High prevalence in over 70s, catheters are colonised within 7-32 days, high incidence in institutionalised elderly population

Question 20

Q. What area of the urinary tract is included in a) upper b) lower

Answer 20

A. Lower tract: cystitis, prostatitis, epididymitis, urethritis
B. Pyelonephritis, urethritis

Question 21

Q. Describe the classical clinical presentation of cystitis

Answer 21

A. F>M, Symptoms: dysuria, frequency, urgency +- SP pain, haematuria, cloudy urine
B. (in infants > incidence in males, symptoms harder to ascertain in non-verbal child)

Question 22

Q. What investigations can be used to diagnose UTIS?

Answer 22

A. Multistix (nitrates, leucocytes, blood, pH, SG, protein, glucose, ketones
B. Mid-stream specimen of urine

Question 23

Q. What is the standard treatment for uncomplicated UTI?

Answer 23

A. 3/7 trimethoprim or nitrofurantoin

B. Also: increase fluid intake, regular voiding, hygiene, avoidance of spermicides, void pre and post intercourse

Question 24

1. Q. Name two features that may constitute a complicated UTI case

Answer 24

A. If patient is: male, pregnant, a child, recurrent or persistent infection, immunocompromised, nosocomial infection (hospital acquired), known structural/functional abnormality (includes catheter, nephrostomy, stent), SIRS/urosepsis, associated urinary tract disease e.g stones, fistula

Question 25

1. Q. Describe the management of complicated UTI

Answer 25

A. Treat as simple but MSU mandated – longer course of Rx tailored to sensitivity
B. Investigate is recurrent/significant LUTS/haematuria: MSU, examination including DRE/PV, post-void bladder scan, USS scan of renal tract/pelvis
C. Possibly: XR KUB (kidney, ureters, bladder)/NCCT (non-contrast CT), CT if suggestive of stones, flexible cystoscopy
D. Also: increase fluid intake, regular voiding, hygiene, avoidance of spermicides, void pre and post intercourse

Question 26

Q. What constituents recurrent UTI?

Answer 26

A. > 2 episodes in 6 months, >3 episodes in 12 months

B. re-infection with same bacteria, bacterial persistence, unresolved infection

Question 27

Q. Describe the NIH/NIDDK classification of prostatitis, describe the presentation of each

Answer 27

A. I: Acute bacterial prostatitis

a. Systemically unwell: fevers, rigors, significant voiding LUTS, pelvic pain
b. External findings: boggy exquisitely tender prostate

B. II: Chronic bacterial prostatitis
a. Symptoms > 3 months, recurrent UTIs, pelvic pain, voiding LUTS, uropathogens in urine +- blood

C. III: Chronic pelvic pain syndrome (CPPS): chronic abacterial prostatitis
i. IIIA: Inflammatory CPPS: WBC in EPS, post-prostatic massage urine, or semen
ii. IIIB: Non-inflammatory CPPS: no WBC in EPS, post-prostatic massage urine, or semen
Presents with: chronic pelvic pain +- LUTS, +- UTIs

D. IV: Asymptomatic inflammatory prostatitis (histological prostatitis)

Question 28

Q. How should prostatitis be treated?

Answer 28

A. Type 1: refer to secondary care – IVABx: gent + CoAmox/Tazocin/Carbapenem and long course of 2-4 weeks Quinolone once well +- TRUSS-guided abscess drainage if < 1cm
Type 2: 4-6 weeks course Quinolone +- alpha blockers +- NSAID for 6wks-3mths
B. Complications: retention – severe sepsis may need HDU etc

Question 29

Q. What occurs in Epididymo-orchitis? Describe the classical presentation

Answer 29

A. Inflammation of testicle and epididymis
B. Acute presentation usually unilateral: Short duration of pain, sudden onset, associated nausea, abdo pain, prev short-duration orchalgia, high riding/bell clapper testis
C. Rule out torsion!
D. STI (younger men), UTI (+35 yrs), take a sexual history, elderly predominantly catheter related

Question 30

Describe the management of Epididymo-orchitis

Answer 30

A. Investigations: 1st void urine, CT/NG PCR +- urethral swab, MSU, +- USS to R/O abscess
B. Tx: refer to GUM if ?STI
C. Abx: Quinolone if >35 or not suspect STI
D. Doxycycline +- stat azithromycin if STi more likely (contact tracing!)
E. Supportive underwear, NSAIDS if required

Question 31

Q. What is the classic presentation of pyelonephritis? Who does it usually affect?

Answer 31

A. Classical triad: loin pain, fever, pyuria – may have severe headache
B. Predominantly affects females < 35yrs
C. Inflammation of the kidney tissue, calyces and renal pelvis, similar pathogenesis to lower UTI. Commonly caused by bacterial infection that has spread up the urinary tract or travelled through the blood steam to the kidneys.
D. Examination: tender loin, Urgent US

Question 32

Q. What is sepsis? What is septic shock?

Answer 32

A. 2 severe inflammatory response syndrome (SIRS) + confirmed or suspected infection
B. Septic shock: severe sepsis with persistent hypotension

Question 33

Q. What are the sepsis 6 (sepsis treatment)?

Answer 33

A. Give high-flow oxygen (via non-rebreathe bag)
B. Take blood cultures (and consider source control)
C. Give IV antibiotics (according to local protocol)
D. Start IV fluid resuscitation (Hartmann’s or equivalent)
E. Check lactate
F. Monitor hourly urine output (consider catheterisation within one hour ..plus Critical Care support to complete Early Goal Directed Therapy (EGDT))

Question 34

Q. Name two causes of raised pressure in the a) upper urinary tract b) lower urinary tract

Answer 34

A. UUT: Lumen: stone, sloughed papilla, Wall: tumour, stricture, PUJ obstruction, latrogenic, Outside the wall: tumour, retroperitoneal fibrosis
B. LLT: Outflow obstruction: BPH, tumour, stricture, stone
C. Bladder dysfunction: poor compliance with raised outlet resistance

Question 35

Q. Name 5 causes of colonisation (UTI/LUT specific)

Answer 35

A. Immunosuppression, diabetes, renal failure, steroids, chemotherapy
B. Neuropathic, chronic retention
C. Indwelling, intermittent catheterisation

Question 36

Q. How should catheter associated UTIs be treated?

Answer 36

A. Not pathological: Only if patient develops fever/sign of bacteraemia
B. Catheter specimen of urine – for sensitivities
C. Commence antibiotics, consider catheter on free drainage
D. Upper tract: US, CT stones, tumours, hydronephrosis
E. Lower tract: cystoscopy (flexible)

Question 37

Q. Name 3 ways the dysfunctional bladder can be managed

Answer 37

A. Intermittent self-catheterisation, suprapubic catheter, penile sheath collection, pads, continuous drainage catheter, valve controlled catheter
B. Reduce over activity: antimuscularinics, bot A tox

Question 38

Q. Name ten symptoms of LUTS

Answer 38

A. Storage: frequency, urgency, nocturia, incontinence
B. Voiding: slow stream, spitting or spraying, intermittency, hesitance, straining, terminal dribble
C. Post-micturition: dribble, feelings of incomplete emptying

Question 39

Q. Name 3 types of incontinence

Answer 39

A. Stress (sphincter weakness) incontinence: associated with cough, stress
B. Urge incontinence (overactive bladder): associated with an urgent desire to void which is difficult to defer
C. Mixed: mix of urge and stress
D. Overflow incontinence: occurs in the presence of a full bladder
E. Social incontinence: often occurs in patients with dementia

Question 40

Q. Name four management techniques for an overactive bladder (OAB)?

Answer 40

A. Behavioural: frequency volume chart, caffeine, alcohol, bladder drills
B. Anti-muscarinic agents: decrease parasympathetic activity by blocking M2/3 receptors but have S/E – dry mouth
C. B agonists: increase sympathetic activity at B3 receptor in bladder
D. Botox: blocks NMJ
E. Bladder augmentation: cystoplasty (small bowel, colon, stomach)

Question 41

Q. What type of incontinence may birth trauma cause? Why? Name four ways to manage this

Answer 41

A. Stress incontinence
B. Denervation of pelvic floor and urethral sphincter, weakening of fascial support of bladder and urethra
C. Pelvic floor physiotherapy, ?duloxetine (tightens sphincter –S/E), bladder diary (frequency/day/night, volume/day/night, nocturnal volume, functional capacity, incontinence/day)

Question 42

Q. What type of incontinence would detrusor underactivity cause? How could this be treated?

Answer 42

A. Non-obstructive

B. [Long term catheterisation – ISC, LTC, SPC