GP Flashcards
Lower Urinary Tract Symptoms
FUUN SHIPP
STORAGE :
FUUN
Frequency
Urgency
Urgency incontinence
Nocturia
VOIDING :
SHIPP
Straining
Hesitancy
Incomplete emptying
Poor/Intermittent stream
Post-micturition dribbling
BPH Tx
1st line - alpha blocker e.g. Tamsulosin
2nd line - 5a-reductase inhibitor e.g. Finasteride
If severe, GS = SURGERY
TURP - trans-rectal resection of prostate
TUIP - Trans-urethral incision of prostate
S/E of Tamsulosin
+ Mechanisms
Postural hypotension - bc ↑vasodilation of capacitance vessels
Retrograde ejaculation - Over-relaxation of bladder
(also a comp of TURP)
Intra-operative floppy iris syndrome (IFIS) - seen in cataracts surgery, mostly calm but make sure surgeon knows!
Alpha-Blocker mechanism for BPH
Relaxes detrusor muscles of bladder neck
5a-Reductase Inhibitor mechanism for BPH
↓ Conversion of testosterone to dihydrotestosterone
Why would one choose Tamsulosin over Doxasozin?
Bc Tamsulosin has less side effects
Why is PSA not reliable?
Elevated in a lot of situations
Not v accurate
Can be falsely positive
idk if this is a good enough answer
Causes of Incontinence
MEN : Mostly prostate enlargement
Pelvis surgery
WOMEN : Stress incontinence - pregnancy, after giving birth
Brain damage - stroke, Parkinson’s
UTI, DM, urethritis
When can PSA be raised?
BMI < 25
Black Africans
Taller men
Recent ejaculation
Recent rectal examination
Prostatitis
BPH
Prostate cancer
UTI
What is the MC cancer in males ages 15-44 years?
TESTICULAR CANCER
Types of Testicular cancer
GERM CELLS - 96%!!
Seminomas - MC! 25-40 yrs and 60yrs
Teratomas - infancy
Non-germ cells - 4%
Leydig cell tumours
Sertoli cell tumours
Sarcomas
RF Testicular cancer
Undescended testis (cryptorchidism)
Prev testicular malignancy
Infertility
FHx
Signs / Symptoms Testicular cancer
Painless/Painful lump in testicle
Testicular/Abdo pain +/- mass
Haematospermia
Hydrocele
Cough +/- Dyspnoea - indicates lung mets
Back pain - indicates para-aortic lymph nodes mets
DDx Testicular cancer
Testicular torsion
Lymphoma
Hydrocele
Epididymal cyst
Ix Testicular cancer
US - to differentiate between mass in body of testes and other intra-scrotal swellings
GS!! Biopsy and histology
Seminoma - “fried egg cells”
Serum tumour markers
AFP - not raised if pure seminoma
∴ if Normal AFP = seminoma
B-hCG - if AFP is also raised, = teratoma
Lactate dehydrogenase (LDH)
CXR, CT - staging
Describe testicular cancer staging
- No mets
- Para-aortic - infradiaphragmatic
- Supra-diaphragmatic
- Spread to lungs!
Tx Testicular cancer
Radical orchidectomy via inguinal approach
Radiotherapy - for seminomas w mets BELOW diaphragm (ONLY radio, no chemo)
Chemo - for more widespread tumours and teratomas
Sperm storage
Prognosis Testicular cancer
Very treatable!!
Stage 1 = 99% survival rate
What is Renal cancer assoc with?
Von Hippel-Lindau syndrome
PKD
Renal cancer classic triad
Loin/flank pain
Haematuria
Abdo mass
RF Bladder cancer
Males!
Most occur after 40 years old
Smoking
Bladder stones
Paraplegia - long term catheter use
Occupation - exposure to carcinogens (Aromatic dyes! beta-napthylamine, benzidine, azo dyes)
Workers in petroleum, chemical, cable, rubber industries !
Exposure to drugs - phenacetin, cyclophosphamide
Chronic inflam of urinary tracts e.g. schistosomiasis, bladder stones or indwelling catheters
Pelvic irradiation
FHx
Spread of Bladder cancer
Local - to pelvic structure
Lymphatic - to iliac and para-aortic nodes
Haematogenous - to liver and lungs
Types of bladder cancer
Urothelial (transitional) cell carcinoma - > 90% !!!!!!
Squamous cell carcinoma - recurrent UTI, kidney stones
Adenocarcinoma - freq mets
Signs / Symptoms Bladder cancer
Painless haematuria - vis or non vis
Mucusuria
Abdo mass
Back pain
Cancer B Sx
UTI Sx - in absence of bacteriuria
Voiding irritability
Change in bladder habits
Pain from clot retention
DDx Bladder cancer
Haemorrhagic cystitis
Renal cancer
UTI
Urethral Trauma
Ix Bladder cancer
Cystoscopy and biopsy - GS!!
CT urogram - staging, also GS!!
Urine dipstick and microscopy
Urinary tumour markers
CT/MRI pelvis
Tx Bladder cancer
Non-muscle invading (Ta or T1) :
> Trans-urethral resection of bladder (TURB) - must include some muscle to stage
> Mitomycin (chemo) - to reduce recurrence
> BCG
Muscle invasion (T2 - T3) :
> Radical cystectomy - GS!
post op chemo = M-VAC (methotrexate, vinblastine, adriamycin, cisplatin)
> Radical radiotherapy +/- chemo - if not fit for surgery
T4 - palliative chemo and radiotherapy
Most Common transitional cell carcinoma
Bladder tumour
Types of kidney cysts
Simple - MC, benign
Polycystic - multiple cysts
Hydronephrosis - when ureter is blocked, kidneys dilate and get bigger
Dysplasia - not formed properly
Medullary sponge - dilation of collecting ducts
go look at a diagram
What is polycystic kidney disease?
Mostly inherited
Genetic disorder in which kidney is covered w cysts (sacs of fluid)
Types of inherited PKD
- Autosomal dominant PKD
- Autosomal recessive PKD
Big diff between ADPKD and ARPKD
ADPKD = adult
ARPKD = infancy or before birth
When are cysts usually found?
Found incidentally on US exam
Often asymptomatic
(but can present!)
Causes PKD
Simple - develop over time
Acquired - CKD
Drugs - lithium!
Genetics
Syndromic - Tuberous sclerosis
When is lithium used sometimes?
To treat depression
RF PKD
FHx
HTN
Describe the inheritance of ADPKD
If one parent = 50% of transmission
If both parents = 50% of being affected, 25% normal, 25% homozygous but these babies will die in womb
When do people start to present with ADPKD?
20 years onwards
Causes ADPKD
Mutation in PKD1 gene (85%) on chromosome 16 - more severe, earlier onset
Mutation in PKD2 gene (15%) on chromosome 4
Signs / Symptoms ADPKD
Acute loin pain! - cyst haemorrhage or infection, or urinary tract stone formation
Abdo discomfort - renal enlargement
Nocturia
Haematuria
Renal colic - bc clots
HTN
Bilateral kidney enlargement
UTI - pyelonephritis
Extra-renal manifestations!
Sub-arachnoid haemorrhage
Liver cysts
Mitral valve prolapse
Tx Generalised seizures
Sodium Valproate
Unless female 15-45 years - Lamotrogine
Tx Partial/Focal seizures
Carbamazepine
In particular, what drug does Carbamazepine affect?
How?
∴ What do doctors recommend to patients?
Combined contraceptive pill
Induces CYP450 ∴ faster metabolism
∴ advised to use other forms of contraception
If pregnant, do you keep taking Carbamazepine?
YES
Epilepsy damage is greater then potential foetal risk
To compensate, high dose folate supplements
S/E Sodium Valproate
Weight gain
Hair loss
Liver failure
S/E Lamotrogine
Maculopapular rash
Blurred vision
Vomiting
S/E Carbamazepine
Leukopenia, Thrombocytopenia
Hyponatraemia
Hepatic impairment
Diplopia
Rash
Impaired balance
Drowsiness
How can you differentiate an epileptic seizure from a non-epileptic seizure?
EPILEPTIC :
Tongue biting
Head turning
Muscle pain
Incontinence
Cyanosis
Post-ictal syndrome
NON-EPILEPTIC :
Situational
Longer duration
Mouth/eyes closed during tonic-clonic movement
Pelvis thrusting
Ictal crying +/- speaking
MOA NSAIDs (Naproxen)
Inhibits COX-1 (normal cells) AND COX-2 (inflamm cells)
CI NSAIDs
Recurrent GI bleeds
Active ulceration
Previous NSAID-induced ulceration
Severe HF
Aspirin allergy
Renal failure
Caution of use of NSAIDs in :
CVD
Cerebrovascular disease
Elderly
Crohn’s + UC
Impaired renal function
Asthma
Allergy Hx
S/E NSAIDs
Depend on ratio of COX-1 : COX-2 inhibition
Causes BRONCHOCONSTRICTION in 8-20% - ∴ maybe fatal in asthmatics
Could cause acute interstitial nephritis after many months of use
Step 1 WHO Analgesic Ladder
NON-OPIOIDS
e.g. NSAIDs or paracetamol
+/- adjuvants
Step 2 WHO Analgesic Ladder
WEAK OPIOIDS
e.g codeine, dihydrocodeine, tramadol
+/- adjuvants
Step 3 WHO Analgesic Ladder
STRONG OPIOIDS
e.g. morphine, oxycodone, methadone, fentanyl
AND non-opioids
+/- adjuvants
5 Key Principles of the WHO Analgesic Ladder
- Oral meds whenever possible
- Taken at regular intervals w/ dose and duration matching Px pain
- Pain should be judged by patient, not clinician
- Start at lowest dose/duration and adapt
- Consistently administer for effective pain management
