GU top tier Flashcards
renal colic epidemiology
- age
- gender
- commonness
- recurrence
- 30-50 (young) but rare in children
m>f
common
recurrent often
risk factors for renal colic
anatomical abnormalities
- congenital (eg shape or duplex kidney (two ureters)
- aquired (trauma, obstruction, reflux)
urinary factors
- hypercalciuria (hypercalcaemia /primary hyperparathyroidism)
- hyperoxaluria
- hyperuricaemia
- cystine in urine
- dehydration ** = most common factor
infection
prevention of renal colic. name 5
- Hydration
- Low calcium diet
- low salt (na) diet (lowers ca)
- Normal dairy intake
- Low protein diet
- Reduced BMI
- active lifestyle
renal colic cause
made from
renal stones form when solute concentrations exceed saturation + trigger
Most = calcium oxalate and second most = calcium phosphate. Also stones made of uric acid/ cystine
name some high oxalate foods
spinach
rhubarb
choc
tea
stones in the urinary tract (renal colic)
- where
- which in where
UUT>LUT
most form in collecting ducts of kidney and may be deposited anywhere
UUT - renal stones (most) / ureteric
LUT - bladder stones (most)
may cause obstruction
hydronephrosis vs pyonephrosis
both result from renal colic stone obstruction
kidney swells, unable to drain
hydro= water; pyo = pus (= infected!!)
presentation of renal colic
- most= asymptomatic
- recurrent UTIs
- pain
- – radiates: loin to groin; to ipsilateral testis/labia
- – colic (waves, with peristalsis)
- – rapid onset
- – severe
- restless/writhing
- naus/vom
renal colic investigations
urine dipstick - haematuria
NCCT - KUB (non contrast (=safe!) CT)- diagnostic, first line, gold standatd. stones= bright white
Xray (KUBXR) - see stone. not too sensitive so not 1st line but maybe ok if you know where to look (previous stones)
ultrasound (less good for ureteric )
bloods
renal colic management
conservative (small- pass spontaneously, safe, asymptomatic, comorbidities)
- analgesia
- observe for sepsis
- anti-emetics
surgery
- ESWL - (extracorporeal shockwave lithotripsy) = Ultrasound fragments, shock waves break into smaller pieces from many directions
- endoscopy/ureteroscopy – laser/basket
- PCNL (percutaneous nephrolithotomy) =keyhole surgery for large/multiple/complex stones– break up and fish out
Through kidney tissue, so higher risk
infected obstructed kidney- sepsis
- =?
- prognosis
- presentation
- treatment
v bad- fatal/quick
pyonephrosis
systemic sepsis signs (tachy, febrile, low BP, high RR, malaise)
IV antibiotics
Oxygen
Drainage - nephrostomy (percutaneous) / ureteric stent
can –> gangrene
kidney cancer
- gender
- age
- commonness
- race
m>f
Age related - commonly presents late 50s, peak 80-85
Common
Czech republic
kidney cancer risk factors
smoking Obesity Environmental : leather, petroleum, asbestos Hormonal estrogen level high Genetic Von hippel lindau (VHL) mutation Hypertension Renal failure + hemodialysis Polycystic kidneys
upper tract TCC=
treatment
- Upper tract TCC (transitional cell carcinoma)
- Transitional cells = urinary tract down to bladder
- Malignancy in urinary tract
- Not curable if gone beyond kidney
- Nephroureterectomy = get rid of whole urinary tract lining (removes kidney and ureter )
kidney cancer presentation
- classic triad (3)
- signs (4)
- symptoms (5)
Classic triad (for more advanced, most don’t have this)
- Mass in abdomen
- Haematuria
- Pain
- Fever
- Hypertension
- Polycythaemia (if kidney cancer cells make EPO)
- or anaemia !
- Pain
- Can be asymptomatic - often found incidentally
- Symptoms of metastatic disease (often metastases on presentation)
- Paraneoplastic syndrome (= consequence of cancer)-PTH, erythropoietin, prolactin = related hormones
- – Stones, groans, bones, moans (hyperCa)
- Varicocele (rare)- enlargement of veins in scrotum (Slow drain of gonadal vein, compression of vein → varicole. If on R, you worry more – Cancer may potentially invade into IVC)
kidney cancer investigations
- Often found incidentally
- Fbc
- – Polycythaemia and anaemia due to EPO decrease
- – ESR may be raised
- –liver tests may be abnormal
- BP
- ultrasound/ CT/ MRI
- – if simple cyst : discharge
- – if small risk of malignancy, follow up
- – if medium/high/ already malignant : treat (bosniak classsification)
- Biopsy
- – Histology
- –Different types of renal carcinoma, distinguished with histology
- – = different cell types
- – Different levels of aggression
- –Looking for loss of architecture, = loss of function
- Bone scan
kidney cancer management
Surveillance
- Old
- Low aggression cancer
surgery
- Radical nephrectomy (remove one whole kidney – Aims to cure
- Partial nephrectomy– If small tumour / bilateral involvement
- Ablative techniques (For comorbidities - can’t tolerate surgery )
- – Radiofrequency ablation
- – Cryotherapy
- Tyrosine kinase inhibitors
- Interleukin 2 and interferon alpha
- Angio-genesis targeted therapy (Sunitinib, bevacizumab, sorafenib)
Palliative care
bladder cancer
- age
- gender
- commonness
Increased risk with age. Incidence peaks in 80s
Male
Common
bladder cancer risk factors
- Smoking
- Exposure to carcinogens (eg industrialized regions)
- – Benzidine, azo dyes, petroleum, chemical, cable, rubber
- Chronic inflammation of urinary tract
- –Schistosomiasis (worms infection)
- –Indwelling catheter
- Chronic HPV in immunocomprimised
- Pelvic irradiation
- Age - above 40
- Male
- Family history
what type of cancer is bladder cancer
transitional cell carcinoma
- most common TCC
bladder cancer symptoms
Painless!! Haematuria = most common symptoms
- Painless as no stimulus. Blood just from shed/ popped cancer cells
- May be pain due to clot retention
Recurrent UTIs
-Void irritability/ irritable LUTS
Symptoms of metastases (uncommon but worrying)
- Flank pain + tenderness
- Lower limb oedema
- Pelvic mass
- Weight loss
- Bone pain
bladder cancer investigations
Cystoscopy (bladder endoscopy ) + Biopsy = best diagnostic
Urine microscopy /cytology
– Sterile pyuria = pus in urine
CT urogram , = diagnostic
–Staging of cancer
MRI/CT/lymphangiography - show pelvic involvement
bladder cancer management
- non -muscle invasive (Ta/T1)
- localised muscle invasion (T2)
- metastatic
- +… for aggressive cancer
Non- muscle invasive Ta/T1
- Surgical resection,
- Resect endoscopically
- +/- chemo to reduce recurrence
Localised muscle invasion - T2
- Radical cystectomy (bladder removal) = gold standard, advised (some do not want)
- Post op chemo
- Radical radiotherapy - if not fit for surgery
- Chemotherapy
Metastatic
- Palliative chemotherapy and radiotherapy
Intravesical Immunotherapy (BCG)
- Aggressive cancer, not surgery
- Toxic, hard to tolerate for entire course
bladder cancer metastases, via different routes
Local → pelvic structures
Lymphatic → to iliac and para-aortic nodes
Haematogenous → to liver and lungs
testicular cancer
- prognosis
- age
- gender
Most common cancer in young males (20-44)
- Rare below 15
- Rare over 60
Nicely curable
men, silly!!
testicular cancer risk factors
Previous testicular cancer Undescended testis (10% of testis cancer is in this) = cryptorchidism Infant hernia Infertility Family history HIV Maternal oestogen exposure
testicular cancer causes and thus types
Vast majority arise from germ cells
- Seminomas (older adults in range adult) - slow growing
- Teratomas (younger adults in range) - fast growing /metastases
Small number arise from non-germ cells
- Leydig cells
- Sertoli cells
- sarcomas
testicular torsion=
twisting of spermatic cord, which supplies blood to testis
testicular cancer signs and symptoms
- Hydrocele = swollen scrotum (secondary)
- abdominal mass
- Painless lump in testicle/scrotum =Hard, non- tender
- Testicular/scrotal pain,
- Abdominal pain
- Cough, dyspnoea (indicative of lung metastases)
- Back pain (indicative of para-aortic lymph node metastases - where testicle drains into!)
testicular cancer investigations
US : Differentiate between intrascrotal swelling and testes masses
Biopsy and histology
Serum tumour markers
- AFP = alpha fetoprotein
- B-hCG : beta subunit of human chorionic gonadotropin
- Which are raised is different depending on type (see causes)
- –Teratomas - both raised
- –Seminomas - b-hcg sometimes raised, but not afp
- LDH
CXR/CT CAP (chest, abdo, pelvis) -to assess tumour staging
testicular cancer management
- Radical orchiectomy (testes removal)
- Seminomas with metastases below diaphragm = radiotherapy
- Widespread tumour = chemo
- Teratomas = chemotherapy
- Sperm storage (sterility)
testicular cancer metastases and routes
- Lymphatic → paroaortic nodes intitially
- Local → epididymis, spermatic cord. Scrotal wall, then on to pelvic and inguinal nodes
- Distant (lungs, liver, bones) , once tunica albuginea breached
prostate cancer
- commonness
- age
- gender
- race
- common
- M>F (skene gland referred to as female prostate)
- Peak incidence in 80s
- More common: A-c /black (higher testosterone)
- Less common : far east
prostate cancer risk factors
- Age
- Family history - 2/3x risk
- Ethnicity
- – More common: A-c /black (higher testosterone)
- – Less common : far east
- Genetic
- –More common in younger patients than older
- –BRCA2
- –HOXB13
- Obesity
type of cancer in prostate cancer
where is it
Majority = adenocarcinoma
Majority on outside - peripheral zone (also transitional zone, central zone). these are easier to detect DRexam
prostate cancer symptoms
Most prostate cancers are diagnosed at an asymptomatic stage
History - if these things are picked up - more likely advanced disease
- Specific/local = urinary problems - due to pressing on urethra- obstruction mainly!! – LUTS
if cancer invades up to ureters…
- Uraemic symptoms –confusion
- kidney failure
Symptoms at site of metastasis
- Bony pain
- Lower extremity pain
- Oedema
- Neurological deficits from spinal cord compression
general systemic cancer symptoms
prostate cancer investigations
PSA testing - prostate specific antigen
- Not specific to prostate cancer
- You risk picking up someone who would have been otherwise asymptomatic/fine but then they are exposed to the side effects of treatment
DRE - Feel prostate
- Hard
- Nodules
- Irregularity
- Asymmetry
- Bogginess
- anal tone and anal sensation (May be spinal compression → paralysis )
Neurological examination - Inc external anal sphincter tone
MRI
- Between examination/PSA and biopsy
- Good for target lesions for biopsy (rather than random sites, local staging (local invasion, metastases)
Biopsy
- If suspicious MRI/ palpable DRE / PSA high
- With ultrasound
Transrectal (TRUS) / transperineal (better). Both ways probe goes up bum, needle goes in via bum to prostate or past outer skin to bum - can reach anterior too
- Histopathology
may check other organs for metastases (kidney function, lymph node oedema)
gleason grading system
for prostate cancer histology
- Patterns can be categorised 1-5
- The two most prominent/common patterns seen are summed. This grade (2-10) indicates level of differentiation
- 2= most differentiated
- 10 = least differentiated.
- Higher = more serious. 6 and below in general are unlikely to spread
prostate cancer staging
not gleason
gives idea of prognosis
T = tumour itself
- T1 - cant feel, incidental finding on biopsy
- T2 - can feel
- T3 - invade through prostate capsule
- T4 - invade to adjacent structures
N = nodes
- N1 - metastases in regional lymph nodes
M = metastases
- M1 distant metastases – Can be categorized as to where - a/b/c
prostate cancer metastases- and route
Direct spread (local surroundings)
- Rest of prostate — intrinsic
- Upward =Bladder , ureter
- back/up = Seminal vesicles
- Downward = urethra
- Forward = pubic bone
- Laterally = sciatic nerve , iliac blood vessels
- Backward = rectum – late, and rare
- Not testes (outside- scrotum)
Lymphatics
- External, internal iliac and presacral nodes. Obturator nodes = ext iliac?
- Occasionally thoracic duct → supraclavicular nodes
Haematogenous
- Bone = most common
- Lung
- Liver
- Kidneys
- Late in disease
prostate cancer treatment
Activity surveillance
- Low risk patients / old
- No treatment (reduce toxicity), close monitoring until see features of invasion/aggression
surgery
- radical prostatectomy
- TURP (resection)
- nephrostomies (for ureteric obstruction – drains kidneys to urine bag to prevent renal failure (palliative))
radiotherapy (localised / locally advanced)
hormone therapy (locally advanced/ metastatic) =block testosterone
- remove testicles (orchiectomy)
- LHRH agonist (goserelin, leuproelin) - overload pit (transient flare) then it stops
- antiandrogens (bicalutamide) - block testosterone at testes receptor level
- hormone resistance can occur, so a temporary delay
chemo - once hormone-resistant
bisphosphonates - reduce osteoclast activity (bone pain reduced)
radiotherapy - palliative for bone pain
BPH
- commonnes
- age
- race
- castration?
Common
Increases with age
A-C
castration is protective as testosterone needed (although not the cause)
bph vs. bpe
BPH- benign prostatic hyperplasia (histological)
BPE - benign prostatic enlargement (DRE)
BPE= benign enlargement (found on DRE) that isnt cancerous (histological) and isnt hyperplasia. cause is unknown
??? or maybe the same thing??
bph pathophysiology
- Increase in prostate size without presence of malignancy
- The transitional zone enlarges (rather than outer peripheral zone that gets bigger in prostate cancer)
- Increase in epithelial and stromal cells : Increase in cell number and/or decrease in cell apoptosis
- Prostate gland surrounds the urethra so an causes obstruction to lower urinary tract as its size gets bigger → outflow obstruction (BOO= bladder outflow obstruction), causing LUTS (benign prostatic obstruction)
bph symptoms
= LUTS Nocturia Frequency Post-micturition dribbling Hesitancy Overflow incontinence Haematuria Bladder stone Incomplete emptying of bladder
bph investigations
- DRE= Enlarged but SMOOTH
- Raised PSA (prostate specific antigen) - not specific
- Imaging (US/MRI)
- Biopsy (rule out cancer)
- Endoscopy
- Renal biochemistry/urinalysis / renal ultrasound/electrolytes
- – to rule out kidney cause
- – Mid stream urine sample - to exclude infection
- Flow rates (pee on to weight/spinning disk) – BPH has lower peak and longer peak in rate
- Residual volume (scan after weeing)
- Frequency-volume chart / bladder diary
bph conservative management
- Fluid intake - Less in evening, Less alcohol, caffeine, sweeteners, fizzy drinks
- Regular bladder emptying
- —Double voiding - aids emptying
- –Wear pads/sheath
- –Bladder training /bladder drill
- Weight loss
- Exercise
- Urethral milking
- Diet - Fruit and fibre
- Relax when voiding
main 2 pharmacological bph treatments
Alpha blocker (tamsulosin, alfuzosin )
- Vasodilate outflow
- Relax prostate and base of bladder (smooth muscle)
- quicker action
- symptoms improved but no effect on actual prostate hyperplasia
- s/e: drowsy, dizzy, depression, ejaculatory failure (vasodilator), wight increase, nasal congestion
- Avoid in postural hypertension (a vasodilator)
5-ARI (5 alpha reductase inhibitors) (finasteride, dutasteride)
- Shrink prostate, by blocking conversion of testosterone → dihydrotestosterone
- effects progrression, reduces size and maintains it
- s/e: impotence, decreased libido
combination therapy = good
other (non main) pharmacological bph treatment
PDE5 inhibitor
- Relaxes bladder neck
Anticholinergic
- Relax bladder muscle (good for overactive detrusor)
Hormone replacement therapy
- Orchiectomy = remove testical
- LHRH antagonist: Overload pituitary gland so LH stops being produced (transient flare up of cancer)
- Antiandrogens - Block testosterone at testes receptor level
Diuretics
- Speed up urine production so more done in day and less in night
Desmopressins
- Slow urine production down → less produced at night
surgical/mechanical bph interventions
catheters
surgery
- TURP (gold standard)
- prostatectomy (all removed) - s/e - haemorrhage, sepsis, erectile dysfunction, retrograde ejaculation, infertility, urethral stricture
- TUIP (incision rather than resection- good for smaller prostates, less destruction and less s/e
- Prostatic urethral lift - prostate held away from urethra to stop blockage
- Cystoplasty = bladder size increased
- Urinary diversion
indications for bph surgery
RUSHES Retention UTIs Stones Haematuria Elevated creatinine due to BOO (bladder outflow obstruction) Symptom deterioration
complications of bph
inc what is NOT a complication
- Infections
- Bladder stones = bladder calculi (Can’t crush -too hard)
- Symptoms worsen
- Haematuria
- Acute retention AUR = cannot void - Pain, Relieved with catheter, alpha blockers
- Chronic retention CUR. Less pain, infection, stones risk
- Interactive obstructive uropathy
Nocturnal enuresis = bladder spontaneously contracts
Collecting duct insensitive to ADH → more urine
NOT infertility
NOT erection problems
NOT prostate cancer
syphillis pathogen
treponema pallidum
