Genitourinary: Part 5 Flashcards
6 Indications for LUTS
- Retention
- UTIs
- Stones
- Haematuria
- Elevated creatinine du eto bladder outflow obstruction
- Symptoms deteriorating
What defines benign prostatic hyperplasia
Increase in size of prostate without present of malignancy
What proportion of volume of seminal fluid is contributed to by the prostate
70%
What age does BPH effect
Over 60
What ethnicity does BPH effect
Afro-caribbeans more than men (higher levels of testosterone)
Risk factors for BPH
Age
What is a protective measure for preventing BPH
CASTRATION (removal of testicales)
Does Testosterone cause BPH
No, it is a requirement for BPH but doesn’t cause it
When should castration occur for BPH to not manifest
Castration prior to puberty or genetic disease inhibiting androgen production
What layers over-proliferate in the prostate in BPH
Musculofibrous and glandular layers
BPH vs prostate CARCINOMA histologically
Transitional (inner) zone enlarges in contrast to peripheral layer expansion seen in prostate carcinoma
Pathophysiology of BPH
Enlarged prostate can block the urethra
Clinical presentation of LUTS
- Nocturne
- Frequency
- Urgency
- Post-micturition dribbling
- Poor stream/flow
- Hesitancy
- Overflow incontinence
- Haematuria
- Bladder stones
- Delay in initiation of micturition
- Incomplete emptying
Diagnosis of LUTS
- AXR
- Digital rectal exam
- FBC
- ULTRASOUND
- BIOPSY and ENDOSCOPY
- MID-stream urine sample
- Flow rate and residual volume
- Frequency volume chart
What would AXR show in LUTS
Enlarged BLADDER
What would digital rectla exam accomplish in LUTS
Feel prostate is enlarged but SMOOTH
Why is ultrasound done in LUTS
- Exclude renal damage by obstruction
2. Transrectal ultrasound - size of prostate
What would FBC show in LUTS
Serum electrolytes - excludes renal damage
PSA raised
What max flow rate indicates bladder outflow obstruction due to BPH
Less than 10ml per second is suggestive
What is the frequency volume chart
Measures volume voided and time over MINIMUM 3 days
Why is frequency volume chart important
Can indicate if nocturne is present
If symptoms are minimal for BPH what do we do
Watchful waiting
Lifestyle changes in BPH
- Avoid caffeine and alcohol to reduce urgency and nocturne
- Relax when voiding
- Void twice in a row to aid emptying
First line drug treatment of BPH
ORAL TAMSULOSIN
ORAL FINASTERIDE (alternatief(
How does TAMSULOSIN work
- Relaxes smooth muscle in bladder neck and prostate thereby producing increase in urinary flow rate and improvement in obstructive symptoms
Side-effects of Tamsulosin
DDDEE
D - Drowsy D - Dizzy D - Depression E - Ejactulatory failure E - Extra-pyramidal signs
also:
Weight gain and nasal congestion
When do we avoid tamsulosin
Postural hypotension
Role of ORAL FINESTERIDE
Bolocks conversion of testosterone to dihydrotestosterone - androgen responsible for prostate enlargement
Side-Effects of ORAL FINESTERIDE
- Decreased Libido
2. Impotence
Surgical intervention for BPH
- TURP - Transurethral resection of prostate (MAIN)
2. TUIP - Transurethral incision of prostate
When is surgery done for BPH
When prostate is too large and isn’t being improved
Indications for BPH
- Recurrent haematuria
- Acute urinary retention
- Failed voiding trials
- Renal insufficiency
- Failure of medical treatment
Complications of BPH if left untreated
- Bladder calculi
- UTI
- HAEMATURIA
- ACUTE retention
What part of the kidney is effected by RENAL CELL CARCINOMA
PCT epithelium
In what gender is renal cell carcinoma caused in
Males over females
Average age of renal cell carcinoma presentation
55
Risk factors for renal cell carcinoma
- Smoking
- Obesity
- Hypertension
- Renal failure + haemodialysis
- Polycystic kidneys
- Von Hippel Lindau syndrome
Genetic pattern of Von Hippel Lindau syndrome
Autosomal dominant
What gene causes VHL syndrome
Mutation of chromosome 3 on p arm
Causes loss of both copies of tumour suppressor genes
Characteristic of RCC caused by VHL syndrome
Bilateral and multifocal
Where do malignancies spread to in RCC caused by VHL syndrome
Renal, pancreatic and cerebellar
How does RCC spread
- Renal vein
2. Lymph or haematogenous (bone, liver and lung)
Clinical presentation of RCC
- Asymptomatic and discovered incidentally
- Haematuria, loin/flank pain and abdo mass
- Anorexia, malaise and weight loss
- Invasion of left renal vein - testicaulr vein compression causing varicocele in left testicular vein
- Polycythaemia
- Hypertension due to renin secretion
- Anaemia due to depression of erythropoietin
- Fever
Differential diagnosis of RCC
- Transitional cell carcinoma
- WILM’s tumour
- Renal oncocytoma
- Leiomyosarcoma
Diagnostics of RCC
- ULTRASOUND
- CT and abdo contrast
- MRI
- BP
- FBC
- RENAL BIOPSY
- Bone scan
Role of ultrasound in RCC
Distinguish simple cyst to complex cyst or tumour
Role of CT chest and abdo with contrast in RCC
- Detects renal mass, involvement of renal vein of inferior vena cava
- Kidney function seen by contrast (should be taken up and excreted by wet functioning kidney)
Role of MRI in RCC
Tumour staging
FBC results in RCC
- Polycythaemia and anaemia as EPO decreased
- ESR raised
- Liver biochemistry may be abnormal
Role of Renal biopsy in RCC
- Get histology to identify tumour
When is bone scan done for RCC
Only if there are signs of raised serum ca
Treatment of RCC
- Nephrectomy unless TUMOURS ARE BILATERAL (partial nephrectomy if bilateral)
- Ablative techniques
- IL-2 and INF-alpha for remission
- — 2nd line—-
4. Sunitinib, BEVACIZUMAB and SORAFENIIB
5. TEMSIROLIMUS - mTOR inhibitor (more effective than INF-alpha)
What is WILMS’ tumour
Childhood tumour of primitive renal tubules and mesenchymal cells
When is WILM’s tumour seen
First 3 years of life
Clinical presentation of WILMS’ tumour
ABdo mass and haematuria
Diagnostics of WILMS’ tumour
ULTRASOUND, CT and MRI
How is WILMS’ tumour treated
Nephrectomy, radiotherapy and chemotherapy
What carcinoma is bladder ancer
Transitional cell carcinoma
What structures are lined by transitional epithelium
Calyces Renal pelvis Ureter Bladder Urethra
What gender is TTC more common in
Men than female
Risk factors for TTC
- Smoking
- Exposure to carcinogens
- Exposure to drugs
- Chronic inflammation of urinary tract
- Greater than 40
- Male
- Family history
What causes chronic inflammation of the urinary tract
Schistomiasis - squamous carcinoma
Indwelling catheter
What carcinogens can increase risk of bladder cancer
- Beta-napthylamine, benzidine, azo dyes
2. Workers in PETROLEUM, chemical, cable and rubber industries
What drugs can cause bladder cancer
CYCLOPHOSPHAMIDE
PHENACETIN
Where does bladder cancer spread locally
Pelvic structure
Lymphatic spread of bladder cancer
Iliac, para-aortic nodes
Haematogenous spread of bladder cancer
Liver and lungs
Clinical presentation of bladder cancer
- PAINLESS HAEMATURIA - pain in clot retention
- Any patient over 40 with haematuria presumed tumour
- Recurrent UTIs
- Voiding irritability
Differential diagnosis of TTC
- Haemorrhagic cystitis
- Renal cancer
- UTI
- Urethral trauma
How is TTC diagnosed
- Cystoscopy (bladder endoscopy) and biopsy - DIAGNOSTIC
- Urine microscopy - STERILE PYURIA (pus in urine) caused in cancer
- CT urogram - staging and DIAGNOSTIC
- Urinary tumour markers
- MRI/Lymphangiogrpahy for pelvic lymph nodes
- CT/MRI of pelvis
Treatment of TTC
- ——-(non-muscle invasive bladder cancer)———-
1. SURGICAL RESECTION
2. CHEMOTHERAPY (with surgery) - ——– (localised muscle invasive disease)————-
3. RADICAL CYSTECOMY (GOLD STANDARD)
4. RADICAL RADIOTHERAPY (if not fit for surgery)
5. CHEMOTHERAPY
Non-muscle invasive bladder cancer chemotherapy
MITOMYCIN
DOXORUBICIN
CISPLATIN - reduces recurrence
Post-op chemotherapy after radical cystectomy in Localised muscle invasive disease
- METHOTREXATE
- VINBLASTINE
- ADRIAMYCIN + CISPLATIN
Chemotherapy in localised muscle invasive disease
- METHOTREXATE
- VINBLASTINE
- CISPLATIN
Treatment of metastatic bladder cancer
Palliative chemotherapy and radiotherapy
IN what layer of the prostate is prostatic carcinoma found in
Peripheral zone
Common metastasis in prostatic carcinoma
Bone and lymph
What gender is prostatic cancer common
Men
Why is prostatic cancer more common in black people
More testosterone
Family history of prostatic cancer
- 3 or more affected relatives
2. 2 relatives who have developed early onset
What gene predisposes you to prostatic cancers
- HOXb13
2. BRCA2 confers a 5-7 times higher risk
Local spread of prostatic cancer
Seminal vesicles, bladder and rectum
Haematological spread of prostatic cancer
Bone (sclerotic bony lesions), brain, liver and lung
Clinical presentation of prostatic cancer
Signs for LUTS:
- Nocturne
- Haematuria
- Poor stream
- Terminal dribbling
- Obstruction - bladder outflow problems similar to BPH
Presentation of metastatic prostatic cancer
- Weight loss
- Bone pain
- Anaemia
Differential diagnosis of prostatic cancer
- BPH
- Prostatitis
- Bladder tumours
Diagnostics of prostatic cancer
- Digital rectal exam
- Trans-rectal ultrasound + biopsy - DIAGNOSTICS
- Urine biomarkers
- Endorectal coli MRI
Urine biomarkers for prostatic cancer
PCA3 or gene fusion protein
Why is an endorectal coli MRI done for prostatic cancer
Locally stage tumour
Results of DRE in prostatic cancer
- Hard, irregular prostate
2. Raised PSA (over 16 ng/ml)
Treatment of prostatic cancer if disease is confined to prostate
- Radical prostatectomy (over 70)
- Radiotherapy + hormone therapy
- Brachytherapy
- Hormone therapy temporarily delays tumour progression
- Active surveillance (over 70 and low risk)
What is brachytherapy
Implantation of radioactive material targeted at tumour
Metatstic prostatic carcinoma treatment
NOTE: BINDING AT THE ANDROGEN RECEPTOR STIMULATES TUMOUR GROWTH
- Orchidectomy (remove testes)
- LH receptor hormon agnost:
- Androgen receptor blocker
Name two LH receptor hormone agonist
- GOSERELIN
2. SC LEUPRORELIN
How do LH hormone receptor hormone
- Stimulate then inhibit testosterone release from pituitary
How is initial surge of pituitary testosterone medicated
- ORAL CYPROTERONE ACETATE
Name an androgen receptor blockers
BICALUTAMIDE
Side effects of BICALUTAMIDE
- Weakness
- Nausea
- Hot flushes
- Weight change
How are symptoms of Prostatic cancer treated
- ANALGESIA
- HYPERCALCAEMIA
RADIOTHERAPY - bone metastases/spinal cord compression
Why should Tamsulosin not be given in postural hypotension
It is an alpha-1 antagonist: alpha-1 receptors cause contraction of smooth vascular muscles so if we give during hypotension then BP would get even worse
