General Surgery Flashcards
1
Q
Which type of ulcer is worse after eating?
A
Gastric ulcers
2
Q
Which type of ulcer is better after eating?
A
Duodenal
3
Q
Failure rate of vasectomy
A
1 in 2,000
4
Q
Follow up investigations from vasectomy
A
Semen analysis at 16 and 20 weeks
5
Q
Complications from vasectomy
A
Bruising
Haematoma
Infection
Sperm granuloma
Chronic testicular pain in 5%
6
Q
Success rate of vasectomy reversal
A
up to 55% within 10 years
25% over 10 years
7
Q
Which type of varicocele requires urgent referral to urology?
A
Solitary right sided
8
Q
Which side do 90% of varicoceles occur on?
A
Left side
9
Q
Treatment of non-specific dermatitis causing balanitis
A
topical hydrocortisone 1%
Imidazole cream
10
Q
At which BMI should you refer for bariatric surgery?
A
With risk factors >35
Without risk factors >40
11
Q
When should women stop taking combined oral contraception or HRT prior to surgery?
A
4 weeks before surgery
12
Q
Benefits of circumcision
A
Reduced penile cancer
Reduced UTI
Reduced STI
13
Q
Medical indications for circumcision
A
Phimosis
Recurrent balanitis
Balanitis xerotica obliterans
Paraphimosis
14
Q
What percentage of patients with a positive FIT test have bowel cancer at colonoscopy?
A
10%
15
Q
How is bowel cancer screened for?
A
Faecal immunochemical test
Every 2 years
Between ages 60 and 74
16
Q
At what ABPI can compression stockings be used?
A
ABPI ≥ 0.8
17
Q
Can patients over 74 have bowel screening?
A
They can self refer for faecal immunochemical testing
18
Q
What is erythroplasia of Queyrat?
A
Insitu squamous cell carcinoma found on the penis
19
Q
What scoring system is used to predict prognosis in prostate cancer?
A
Gleason score
20
Q
What is the range of the Gleason score?
A
2 to 10
gives grade from 1 to 5
21
Q
How to interpret the Gleason score
A
Higher the gleason score the worse the prognosis
22
Q
What does the Gleason score predict?
A
Prognosis in prostate cancer
23
Q
Complication of radial prostatectomy
A
Erectile dysfunction
24
Q
Side effect of radiotherapy for prostate cancer
A
Increased risk of bladder, colon and rectal cancer
25
Management of cyclical mastalgia
```
Supportive bra
Oral analgesia
Flaxseed oil
Evening primrose oil
Refer if affecting QoL
```
26
How many breastfeeding women are affected by mastitis?
1 in 10
27
Management of mastitis
Continue breastfeeding
| Fluclox for 10-14 days
28
Which BMI should prompt considering batriatric surgery as first line treatment?
50
29
Treatment for hot flushes in men undergoing hormonal treatment for prostate cancer
Cyproterone acetate
30
What medication should be co-prescribed for the first three weeks when starting gonadorelin for prostate cancer?
Anti-androgen treatment e.g. cyproterone acetate
Start 3 days before
31
Most common organism causing mastitis
Staphylococcus aureus
32
Antibiotic choice in mastitis
Flucloxacillin
If pen allergic: erythromycin
33
What percentage of boys/men will get a varicocele?
15%
34
For which symptoms should we offer PSA + PR?
```
Erectile dysfunction
Haematuria
Lower back pain
Bone pain
Weight loss
```
35
What simple test should be done prior to PSA?
Urine dipstick to exclude UTI
36
How long should you wait after UTI before doing PSA testing?
1 month
37
Contraindication to circumcision
Hypospadias as foreskin is used in the repair
38
Removal time for non-absorbable sutures on the face
3-5 days
39
Removal time for non-absorbable sutures on the scalp, limb or chest
7-10 days
40
Removal time for non-absorbable sutures on the hand, foot or back
10-14 days
41
Maximum safe dose of local anaesthetic
3mg/kg
Max 200mg
Or max 500mg if contains adrenaline
42
Features of acute epididymo-orchitis
Dysuria, urethral discharge
| Tender testicular swelling
43
Main cause of acute epididymo-orchitis
Chlamydia
44
Which ABPI suggests calcified, stiff arteries?
>1.2
45
What is a normal ABPI?
1.0-1.2
46
What is an acceptable ABPI?
0.9-1.0
47
What ABPI suggests peripheral arterial disease?
What ABPI suggests severe peripheral arterial disease?
<0.9
<0.5 = severe disease
48
Post procedure VTE prophylaxis in elective hip replacement
LMWH for 10 days then aspirin for 28 days
OR LMWH for 28 days
OR rivaroxaban
49
Post procedure VTE prophylaxis in elective knee replacement
Aspirin for 14 days
OR LMWH for 14 days
OR rivaroxaban
50
Post procedure VTE prophylaxis for fragility fractures of the pelvis, hip and proximal femure
28 days with LMWH or fondaparinux
51
Head injury - who needs immediate CT head?
GCS <13 initial assessment
GCS <15 2 hours post injury
Suspected open or depressed skull fracture
Any sign of basal skull fracture
Post traumatic seizure
Focal neuro deficit
>1 episode vomiting
52
Head injury - who needs a CT within 8 hours?
Age 65+
History of bleeding or clotting disorders
Dangerous mechanism of injury
More than 30 minutes retrograde amnesia of events before injury
Warfarin
53
Side effects of sildenafil
Chest pain
Prolonged painful erections
Postural hypotension
Headaches
Hot flushes
Colour tinge to vision
Blurred vision
54
Infrapatellar bursitis - typical history
Kneeling
55
Prepatella bursitis - typical history
Upright kneeling
56
Features of anterior cruciate ligament injury
Twisting injury
Popping noise
Rapid onset effusion
Positive draw test
57
Posterior cruciate ligament injury typical history
Anterior force applied to proximal tibia
e.g. knee hitting dashboard during RTA
58
Erb-Duchenne palsy - where is damaged?
Upper trunk of brachial plexus
C5, C6
59
Erb-Duchenne palsy - what is the cause?
Shoulder dystocia
60
Erb-Duchenne palsy - features
Arm hangs by side, internally rotated, elbow extended
61
Klumpke injury - where is damaged?
Lower trunk of brachial plexus
| C8, T1
62
Klumpke injury - what is the cause?
Shoulder dystocia
| Sudden upward jerk of the hand
63
Peripheral arterial disease - features
```
Intermittent claudication
Ischaemic rest pain in severe disease
Leg is cold, pale, lack of hair
Weak or absent pulses
Poorly healing wounds
Ulcers
```
64
Peripheral arterial disease - investigations
Full cardiovascular assessment
ABPI
Doppler ultrasound
CT/MRI aniography
65
Peripheral arterial disease - when to refer
Any doubt re: diagnosis
Severe uncontrolled symptoms
Concerns about critical limb ischaemia
Otherwise healthy young adults
66
Peripheral arterial disease - management
Optimise risk factors
Exercise programme
Naftidrofuryl oxialate
Angioplasty/bypass
67
Medication that can be used in peripheral arterial disease
Naftidrofuryl oxialate
68
Chronic pancreatitis - causes
```
Alcohol
Smoking
Genetic
Biliary tract disease
Iatrogenic - ERCP
Abdominal radiotherapy
```
69
Chronic pancreatitis - features
Epigastric pain radiating to back
Nausea and vomiting
Malabsorption, weight loss
Diabetes
70
Chronic pancreatitis - investigations
Normal amylase
Secretin stimulation test
CT/MRI/MRCP
Pancreatic biopsy
71
Chronic pancreatitis - management
Analgesia
Pancreatic enzymes for malabsorption
Stop alcohol
Surgery
72
Renal stones - initial management
IM diclofenac
73
Renal stones - initial investigations
Urine dipstick and culture
U+E
Non contrast CT KUB
74
Renal stones - management if <5mm
Pass spontaneously
75
Renal stones - management of ureteric obstruction
Nephrostomy
| Ureteric stent
76
Renal stones - management if stone burden <2cm
Shockwave lithotripsy
77
Renal stones - management if stone burden <2cm and pregnant
Ureteroscopy
78
Renal stones - management if complex renal calculi or staghorn calculi
Percutaneous nephrolithostomy
79
Prevention of calcium renal stones
Lots of fluids
Low animal protein, low salt
Thiazide diuretics
80
Prevention of oxalate renal stones
Cholestyramine
| Pyridoxine
81
Prevention of uric acid stones
Allopurinol
82
Acute pancreatitis - causes
Alcohol
Gallstones
post ERCP
Mumps
Drugs:
- steroids
- azathioprine
- mesalazine
- sodium valproate
- bendroflumethiazide
83
Acute pancreatitis - drug causes
```
Steroids
Azathioprine
Mesalazine
Sodium valproate
Bendroflumethiazide
```
84
Acute pancreatitis - features
Severe epigastric pain radiating to the back
Vomiting
Cullen's sign (umbilicus)
Grey Turner's sign (flanks)
85
Acute pancreatitis - investigations
Amylase 3x upper limit of normal
86
Acute pancreatitis - management
Analgesia, antiemetics
IV fluids
Severe cases in ITU
87
Types of colorectal cancer
1) Sporadic - 95%
2) Hereditary non-polyposis colorectal cancer - 5%
3) Familial adenomatous polyposis - <1%
88
What is the screening for colorectal cancer?
Faecal immunochemical test = FIT
| a type of faecal occult blood test
89
When do people get screened for colorectal cancer?
Age 60-74 in England
Age 50-74 in Scotland
Over 74 can request screening
90
How regularly do people get screened for colorectal cancer?
Every 2 years
91
What is the outcome at colonoscopy for people called from the screening programme?
IE how many are normal, how many have polyps and how many have cancer
5/10 normal
4/10 polyps
1/10 cancer
92
When to urgently refer for suspected colorectal cancer?
≥40 + weight loss + abdo pain
≥50 + unexplained rectal bleeding
≥60 + IDA OR change in bowel habit
Tests show occult blood in faeces
93
When to consider urgent referral for suspected colorectal cancer?
Rectal or abdominal mass
Unexplained anal mass or ulcer
<50 years + rectal bleeding + one of:
- abdo pain,
- change in bowel habit,
- weight loss,
- IDA
94
What test should you do for people with new symptoms concerning for colorectal cancer who don't meet urgent referral criteria?
FIT testing
95
Causes of spontaneous SAH
Intracranial aneurysm
AVM
Pituitary apoplexy
Arterial dissection
96
Medication used in SAH
Nimodipine to prevent vasospasm
97
Voiding symptoms (urinary)
Hesitancy
Poor flow
Straining
Incomplete emptying
Terminal dribbling
98
Storage symptoms (urinary)
Urgency
Frequency
Nocturia
Urinary incontinence
99
Lower urinary tract symptoms in men - examination
Urinalysis - infection, haematuria
PR
PSA
100
Lower urinary tract symptoms in men - what questionnaires should you ask them to do?
Urinary frequency-volume chart
International prostate symptom score
101
Conservative management of voiding symptoms in men
Pelvic floor muscle training
Bladder training
Moderate fluid intake
102
Medical management of voiding symptoms in men
Alpha blocker - tamsulosin
If enlarged prostate then 5-alpha reductase inhibitor - finasteride
103
What type of medication is tamsulosin?
Alpha blocker
104
Give an example of an alpha blocker
Tamsulosin
105
What type of medication is finasteride?
5-alpha reductase inhibitor
106
Give an example of a 5-alpha reductase inhibitor
Finasteride
107
Medical management of mixed voiding and overactive bladder symptoms in men
Antimuscarinic - oxybutynin
108
Give an example of an antimuscarinic
Oxybutynin
109
What type of medication is oxybutynin?
Antimuscarinic
110
Management of nocturia in men
Moderate fluid intake at night
Furosemide 40mg in afternoon
Desmopressin
111
Management of overactive bladder symptoms in men
Moderate fluid intake
Bladder training
Antimuscarinic - oxybutynine
112
What is Scheurmann's disease?
Epiphysitis of vertebral joints
113
Scheurmann's disease - presentation
Adolescents
Back pain
Stiffness
Progressive kyphosis
114
Scheurmann's disease - xrays
Epiphyseal plate disturbance
| Anterior wedging
115
Scheurmann's disease - management
PT
Analgesia
Surgery/bracing if severe
116
What is spondylolisthesis?
One vertebrae is displaced
117
Management of spondylolisthesis
Conservative
| If severe = spinal decompression and stabilisation
118
Nipple discharge - features suggesting carcinoma
Blood stained
| Underlying mass or axillary lymphadenopathy
119
Nipple discharge - features in intraductal papilloma
Younger patients
Blood stained discharge
No palpable lump
120
Nipple discharge - features in mammary duct ectasia
Menopausal women
| Thick green discharge
121
Management of mammary duct ectasia
Stop smoking
| Total duct excision if severe
122
Causes of proctitis
Crohn's
UC
Clostridium difficile
123
Bacterial causes of anorectal abscess
E coli
| Staph aureus
124
Most common anal neoplasm
Squamous cell carcinoma
125
What is solitary rectal ulcer associated with?
Chronic straining and constipation
126
Causes of pruritis ani in children
worms
127
Causes of pruritis ani in adults
Idiopathic
| Haemorrhoids
128
Features of inguinal hernias
Above and medial to pubic tubercle
| Strangulation rare
129
When can you return to work after inguinal hernia repair?
Open and lap
Open - 2 to 3 weeks
| Lap - 1 to 2 weeks
130
Who gets femoral hernias?
Mulliparous women
131
Who gets inguinal hernias?
What % of men will get inguinal hernias?
Men
| Will affect 25% of men
132
Where is a femoral hernia found?
Below and lateral to pubic tubercle
133
Management of femoral hernia
Surgical repair as high strangulation risk
134
Management of congenital inguinal hernia
Repair when identified due to incarceration risk
135
Who gets congenital inguinal hernias?
1% term babies
| more common in boys and prems
136
Who gets infantile umbilical hernias?
Prems
| Africo-Caribbean
137
When do infantile umbilical hernias typically resolve by?
4-5 years
138
What is the screening for AAA?
Single abdo ultrasound age 65
139
<3cm aortic diameter
Normal
| no further action
140
3 - 4.4cm aortic diameter
Small aneurysm
| Scan every 12 months
141
4.5 - 5.4cm aortic diameter
Medium aneurysm
| Scan every 3 months
142
>5.4cm aortic diameter
Large aneurysm
| Urgent 2 week referral to vascular
143
Features of AAA with low rupture risk
Asymptomatic
| Size <5.5cm
144
Management of AAA with low rupture risk
Ultrasound surveillance
| Optimise cardiovascular risk factors
145
Features of AAA with high rupture risk
Symptomatic
Size ≥5.5cm
Rapidly enlarging >1cm per year
146
Management of AAA with high rupture risk
2 week vascular referral
| Elective endovascular repair or open surgery
147
Risk factors for AAA
```
Smoking
HTN
Syphilis
Ehlers Danlos type 1
Marfans
```
148
Acute bacterial prostatitis - cause
Escherichia coli
149
Acute bacterial prostatitis - risk factors
Recent UTI
Urogenital instrumentation
Intermittent catheterisation
Recent prostate biopsy
150
Acute bacterial prostatitis - features
Pain - perineum, penis, rectum, back
Obstructive voiding symptoms
Fever, rigors
151
Acute bacterial prostatitis - PR findings
Tender boggy prostate
152
Acute bacterial prostatitis - management
14 days of ciprofloxacin
| Screen for STIs
153
Epididymal cysts - features
Separate to body of testicle
| Posterior to testicle
154
What is the most common scrotal swelling in primary care?
Epididymal cysts
155
Epididymal cysts - associations
Polycystic kidney disease
Cystic fibrosis
von Hippel-Lindau syndrome
156
Epididymal cysts - diagnosis
Ultrasound
157
Epididymal cysts - management
Supportive
| Surgical removal/sclerotherapy if large and symptomatic
158
What is a hydrocele?
Accumulation of fluid within tunica vaginalis
159
Causes of hydrocele
Epididymo-orchitis
Testicular torsion
Testicular tumours
160
Features of hydrocele
Soft non-tender swelling of hemi-scrotum
Confined to scrotum, can "get above" swelling
Transilluminates
161
Diagnosis of hydrocele
Clinical
| Ultrasound
162
Management of hydrocele in infants
Repair if doesn't resolve by 1-2 years
163
Management of hydrocele in adults
Conservative
| Repair if severe
164
Features of fibroadenoma
Young women
| Discrete non-tender mobile lumps
165
Features of fibroadenosis
Middle aged women
Lumpy breasts, may be painful
Symptoms worse prior to menstruation
166
Features of breast cancer on examination
Hard, irregular lump
Nipple inversion
Skin tethering
167
Features of paget's disease of the nipple
Redding and thickening of the nipple
| Looks like ecsema
168
Features of duct papilloma
blood stained discharge
169
Features of mammary duct ectasia
Around menopause
Tender lump around nipple
Green nipple discharge
170
Features of fat necrosis in the breast
Obese women
Trivial or unnoticed trauma
Firm and hard lesion causing hard, irregular breast lump
171
Two main categories of testicular cancers
1) Germ cell tumours - 95%
| 2) Non-germ cell tumours
172
Types of germ cell testicular tumours
1) Seminomas
| 2) Non-seminomas
173
Types of non-seminoma testicular tumours
Embryonal
Yolk sac
Teratoma
Choriocarcinoma
174
Types of non-germ cell testicular tumours
Sarcomas
| Leydig cell tumours
175
Presentation of testicular tumours
Painless lump
May have pain
Hydrocele
Gynaecomastia
176
Tumour markers in testicular cancer
HCG (in seminomas and non-seminomas)
AFP (in non-seminomas)
LDH (in germ cell tumours)
177
Diagnosis of testicular tumours
Ultrasound
178
Prognosis of testicular tumours
Seminomas 95% 5 year if stage 1
Teratomas 85% 5 year if stage 1
179
Management of testicular tumours
Orchidectomy
| Chemo/radiotherapy
180
Peak incidence of teratomas
25 years
181
Peak incidence of seminomas
35 years
182
Risk factors for testicular tumours
```
Infertility
Cryptorchidism
FHx
Klinefelter's syndrome
Mumps orchitis
```
183
Who to refer urgently for suspected breast cancer?
Age >30 + unexplained lump, with or without pain
| Age >50 + nipple discharge, nipple retraction or skin changes
184
Who to consider referring urgently for suspected breast cancer?
Skin changes
| Age >30 + axillary lump
185
Who to refer routinely to the breast clinic?
Age <30 + unexplained breast lump, without or without pain
186
Biological treatment for HER2 positive breast cancer
Herceptin (trastuzumab)
187
When is herceptin used?
HER2 positive breast cancer
188
Contraindications of herceptin
heart disorders
189
Hormonal therapy for hormone receptor positive breast cancer in pre and perimenopausal women
Tamoxifen
190
How long to prescribe tamoxifen in pre and perimenopausal women?
5 years
191
Side effects of tamoxifen
Increased endometrial cancer
VTE
Menopausal symptoms
Reduced bone mineral density
192
Hormonal therapy for hormone receptor positive breast cancer in post menopausal women
Anastrozole - an aromatase inhibitor
193
Who gets screened for breast cancer?
Age 47-73 years
Every 3 years
Can ask for appointment if age over 70
194
Which features in the history should prompt referral to breast clinic in a person with one 1st/2nd degree relative?
```
Diagnosis <40
Bilateral
Male
Ovarian ca
Jewish ancestry
Sarcoma in relative <45
Glioma or childhood adrenal cortical ca
Complicated pattern of multiple cancers at young age
2+ relatives on fathers side
```
195
Which relatives affected by breast cancer should prompt referral to breast clinic?
1st degree female <40
1st degree male any age
1st degree bilateral breast ca with first <50
2x 1st degree or 1st degree + 2nd degree
1st degree + 2nd degree with ovarian ca at any age
3x 1st degree or 3x 2nd degree
196
Grade 1 haemorrhoids
Do not prolapse
197
Grade 2 haemorrhoids
Prolapse on defecation but reduce spontaneously
198
Grade 3 haemorrhoids
Can be manually reduced
199
Grade 4 haemorrhoids
Can't be reduced
200
Features of haemorrhoids
Painless rectal bleeding
Can be painful
Pruritis
201
Management of haemorrhoids
Soften stool
Topical anaesthetics + steroids
Rubber band ligation
Surgery
202
Thrombosed haemorrhoids - presentation
Significant pain and tender lump
| Purple oedematous subcutaneous perianal mass
203
Thrombosed haemorrhoids - management
within 72 hours can refer for excision
Stool softeners
Ice packs
Analagesia
204
Superficial thrombophlebitis - risk factors
```
Varicose veins
Thrombophilia
IV cannulation
Pregnancy
Cancer
```
205
Superficial thrombophlebitis - features
Pain, itchy, erythema of skin
Hardening of surrounding soft tissue
Pigmentation changes
206
Superficial thrombophlebitis - investigations
Doppler US to exclude DVT
207
Superficial thrombophlebitis - management
NSAIDs
Compression stockings - ABPI first
LMWH for 30 days or fondaparinux for 45 days
If affecting saphenofemoral junction then anticoagulate for 6-12 weeks
208
Balanitis - general treatment
Gentile saline washes
Wash under foreskin
1% hydrocortisone
209
Candida balanitis - features
Itchy
| White discharge
210
Candida balanitis - management
14 days of topical clotrimazole
211
Contact/allergic dermatitis balanitis - features
Itchy, painful
| Clear discharge
212
Contact/allergic dermatitis balanitis - management
Mild potency topical steroids - hydrocortisone
213
Anaerobic balanitis - features
Very offensive yellow discharge
214
Anaerobic balanitis - management
Saline washes
| Oral/topical metronidazole
215
Bacterial balanitis - features
Painful
| Yellow discharge
216
Bacterial balanitis - main cause
Staph
217
Bacterial balanitis - management
Oral flucloxacillin
| Clarithromycin if penicillin allergic
218
Lichen planus balanitis - features
Itchy
Wickham's striae
Violaceous papules
219
Plasma cell balanitis of zoon - features
Middle aged/old men
Not itchy
Clearly circumscribed areas of inflammation
220
Plasma cell balanitis of zoon - management
High potency steroids - clobetasol
Circumcision
CO2 laser therapy
221
What is another name of lichen sclerosus balanitis?
Balanitis xerotica obliterans
222
What is balanitis xerotica obliterans also known as?
lichen sclerosus balanitis
223
Balanitis xerotica obliterans - features
Itchy
White patches
Scarring
224
Balanitis xerotica obliterans - management
High potency topical steroids - clobetasol
| Circumcision
225
Circinate balanitis - features
Painless erosions
| Associated with reactive arthritis
226
Circinate balanitis - management
Mild potency steroids - hydrocortisone
227
Bladder cancer - risk factors
Smoking
Exposure to hydrocarbons
Schistosomiasis
228
Bladder cancer - types
Transitional cell carcinoma (90%)
Squamous cell carcinoma (higher rate in areas with schistosomiasis)
Adenocarcinoma
229
Bladder cancer - presentation
Painless macroscopic haematuria
| Incidental microscopic haematuria
230
Bladder cancer - investigations
```
Cytoscopy
Biopsy
TURBT
Pelvic MRI for local spread
CT for distant spread
```
231
Bladder cancer - management
Superficial lesions managed with TURBT
Intravesical chemotherapy
Radical cystectomy + ileal conduit
Radiotherapy
232
What is priapism?
Persistent penile erection >4 hours not associated with sexual stimulation
233
Types of priapism
Ischaemic - impaired vasorelaxation, trapped deoxygenated blood in corpus cavernosa
Non-ischaemic - typically fistula due to trauma or congenital causing high arterial inflow
234
Priapism - causes
Idiopathic
Sickle cell
Erectile dysfunction medication
Cocaine, ecstasy, cannabis
Trauma
235
Priapism - management
Aspiration of blood
Intercavernosal injection of vasoconstrictor
Surgery if all else fails
236
Prostate cancer - risk factors
Increasing age
Obesity
Afro-Caribbean
Family history
237
Prostate cancer - features
Asymptomatic if localised
Bladder outlet obstruction = hesitany, urinary retention
Haematuria, haematospermia
Back, perineal or tesitcular pain
238
Prostate cancer - PR findings
Asymmetrical, hard, nodular enlargement
| Loss of median sulcus
239
Prostate cancer - investigations
Multiparametric MRI first line
If Linkert score ≥3 then prostate biopsy
If Linkert score 1-2 then discuss pros/cons of biopsy
240
Side effects of transrectal US guided prostate biopsy
Sepsis
Pain for more than 2 weeks in 15%, severe in 7%
Fever
Haematuria and rectal bleeding
241
Prostate cancer - management
Localised = monitor, radical prostatectomy, radiotherapy
| Localised advanced = hormone therapy, radical prostatectomy, radiotherapy
242
Prostate cancer - hormone therapy options
Anti-androgen therapy
- synthetic GnRH agonist e.g. goserelin
- bilateral orchidectomy
243
What percentage of people with a PSA rise have prostate cancer?
PSA 4-10 then 33%
| PSA 10-20 then 60%
244
What percentage of people with prostate ca have normal PSA?
20%
245
Age adjusted limits for PSA
50-59 years = 3.0
60-69 years = 4.0
70+ years = 5.0
246
When do NICE say to refer urgently for suspected prostate ca?
Men 50-69 with PSA ≥3.0
Or abnormal PR exam
247
Causes of raised PSA
Prostate ca
BPH
Prostatitis and UTI
Ejaculation
Vigorous exercise
Urinary retention
Instrumentation of urinary tract
248
How long to wait after prostatitis or UTI before testing PSA?
1 month
249
How long to wait after ejaculation before testing PSA?
48 hours
250
How long to wait after vigorous exercise before testing PSA?
48 hours
251
Varicocele - features
'bag of worms'
| Subfertility
252
Varicocele - what percentage are left sided?
90%
253
Variocele - diagnosis
ultrasound
254
Varicocele - management
Conservative
Surgery if lots of pain
Refer if isolated right sided varicocele
255
Varicocele - does surgery improve chances of pregnancy?
No
256
Erectile dysfunction - factors favouring organic cause
Gradual onset
Lack of engorgement
Normal libido
257
Erectile dysfunction - factors favouring psychogenic cause
```
Sudden onset
Decreased libido
Good spontaneous or self stimulated erections
Major life events
Problems/changes in relationships
Previous psychological problems
History of premature ejaculation
```
258
Erectile dysfunction - drug causes
SSRIs
| beta blockers
259
Erectile dysfunction - investigations
Calculate 10 year cardiovascular risk - so need to test lipids and fasting glucose
Free testosterone - if abnormal then recheck free testosterone with FSH, LH and prolactin
260
Erectile dysfunction - what bloods?
Lipids, fasting glucose, free testosterone
261
Erectile dysfunction - management
Sildenafil (viagra)
Vacuum erection devices
Refer to urology if ALWAYS had problems
Don't cycle more than 3 hours per week
262
What type of drug is sildenafil?
PDE-5 inhibitor
263
Anal fissure - features
Painful, bright red rectal bleeding
90% in posterior midline
Consider sinister underlying cause if located elsewhere
264
Anal fissure - when does it become chronic?
>6 weeks
265
Anal fissure - risk factors
```
Constipation
Inflammatory bowel disease
HIV
Syphilis
Herpes
```
266
Anal fissure - acute management
Soften stool - high fibre diet, high fluid, bulk forming laxatives (fybogel)
Lube before defecation
Topical anaesthetics
Analgesia
267
Anal fissure - chronic management
Topical GTN
| Refer to secondary care if topical GTN not effective after 8 weeks for surgery or botox
268
Varicose veins - risk factors
Increasing age
Female
Pregnancy
Obesity
269
Varicose veins - features
```
Aching, itching
Varicose eczema
Lipodermatosclerosis
Haemosiderin deposition
Bleeding
Superficial thrombophlebitis
Venous ulcers
DVT
```
270
Varicose veins - management
Conservative = elevate leg, weight loss, graduated compression stocks
In secondary care = endothermal ablation, foam slcerotherapy, surgery
271
Varicose veins - when to refer
```
Significant symptoms
Bleeding
Skin changes
Superficial thrombophlebitis
Active or healing venous leg ulcers
```
272
What percentage of men have BPH?
50% at age 50
| 80% at age 80
273
BPH features
Lower urinary tract symptoms
Voiding (obstructive) = weak flow, straining, hesitancy, terminal dribbling
Storage (irritative) = urgency, frequency, incontinenace, nocturia
Post-micturation dribbling
274
BPH complications
UTI
Urinary retention
Obstructive uropathy
275
BPH - management
Watchful waiting
Alpha-1 antagonists = tamsulosin
5-alpha reductase inhibitors = finasteride
Surgery (TURP)
276
What is an example of an alpha-1 antagonist?
Tamsulosin
277
What type of drug is tamsulosin?
Alpha-1 antagonist
278
What is an example of a 5 alpha reductase inhibitor?
Finasteride
279
How does tamsulosin work?
Reduces smooth muscle tone
280
1st line medication for BPH
Tamsulosin (alpha-1 antagonist), reduces smooth muscle tone
Improvement in 70%
281
Side effects of tamsulosin
Dizziness
Postural hypotension
Dry mouth
Depression
282
How does finasteride work?
Reduces prostate volume, slows disease progression
283
How long does finasteride take to work?
6 months
284
Side effects of finasteride
Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia
285
Effect of finasteride on PSA
Reduces PSA
