MET3 Revision: Urology I Flashcards
State the male LUTS from BPH that can be split into voiding [5], storage [4] and post micturition symptoms [1].
Voiding:
SHITE
- Straining
- Hesitancy
- Intermittant stream
- Terminal dribbling
- (incomplete) emptying
Storage:
- Urgency
- Frequency
- Incontinence
- Nocturia
Post mic:
- Dribbling (more delayed than terminal dribbling)
Investigations for BPH? [5]
- Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
- Abdominal examination to assess for a palpable bladder and other abnormalities
- Urinary frequency volume chart, recording 3 days of fluid intake and output
- Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
- Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
- IPSS
What is the max flow rate score that is suggestive of bladder outflow obstruction due to BPH? [1]
Max flow rate < 10ml per second is suggestive of bladder outflow obstruction due to BPH
State two complications of not treating BPH [2]
Renal failure: post-renal AKI
Severe UTI leading to sepsis
What are the drug treatment options & order for BPH w/ bothersome symptoms but no indications for surgery? [4]
FIRST LINE: for moderate to severe LUTS
- Alpha 1 antagonists e.g. ORAL TAMSULOSIN
- 5-alpha-reductase inhibitor e.g. ORAL FINASTERIDE / DUTASTERIDE
- phosphodiesterase-5 (PDE-5) inhibitor: tadalafil
- anticholinergics: oxybutynin; tolterodine; solifenacin
Second line:
- Combine alpha 1 antagonist and 5-alpha reductase inhibitor
LUTS + what size prostate [1] or PSA score [1] would you move to second line treatment for BPH? [1]
- Prostate larger than 30g
- PSA > 1.4
BPH Treatment:
The general idea is that [] are used to treat immediate symptoms, and [] are used to treat enlargement of the prostate.
They may be used together where patients have significant symptoms and enlargement of the prostate.
The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate.
They may be used together where patients have significant symptoms and enlargement of the prostate.
Describe the MoA of finasteride [4]
5-alpha-reductase inhibitor:
* Blocks conversion of testosterone to DHT;
* DHT is considered to be the primary androgen playing a role in the development and enlargement of the prostate gland. It serves as the hormonal mediator for the hyperplasia upon accumulation within the prostate gland
Describe the MoA of tamulosin [3]
Alpha blocker:
* Blockade of α1-adrenergic receptors in prostate, urethra, bladder neck and detrusor muscle
* Relaxation of smooth muscle resulting in improved urinary flow
What is the most common congenital male reproductive disorder?
Testicular torsion
Cryptorchidism
Hydrocoele
Peyronie disease
What is the most common congenital male reproductive disorder?
Testicular torsion
Cryptorchidism
Hydrocoele
Peyronie disease
Which of the following statements correctly defines priapism?
Inability to void the bladder
Abnormal curvature of the penis
Cyst due to a dilated testicular duct
Painful erection lasting more than 4 hours
Which of the following statements correctly defines priapism?
Inability to void the bladder
Abnormal curvature of the penis
Cyst due to a dilated testicular duct
Painful erection lasting more than 4 hours
A patient presents with symptoms of an overactive bladder.
What is the first choice drug treatment? [1]
What treatment is offered if the first choice is contrindicated? [1]
First choice: Oxybutynin
Second choice: Mirabegron
What is a positive Prehn’s sign? [1]
Which two pathologies does it help to distinguish between? [2]
+ve Prehn’s sign:
- the relief of pain on elevation of the testis
- Positive: indicates epididymo-orchitis
- Negative (i.e. the pain is not relieved) in cases of testicular torsion.
TOM TIP:
The notable side effect of tamsulosin is [].
The most common side effect of finasteride is [] (due to reduced []).
TOM TIP: The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure.
The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
1.
Describe surgical treatment for BPH [5]
Transurethral resection of prostate (TURP):
* GOLD STANDARD
* Less than 14% impotent, 1% incontinent & 10% erectile
dysfunction
Transurethral incision of prostate (TUIP):
* Less destruction than TURP and less risk to sexual function, best for smaller prostate
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Holmium laser enucleation of the prostate (HoLEP)
- also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
Open prostatectomy via an abdominal or perineal incision
Name two anti-cholinergics used for storage symptoms? [2]
- Oxybutynin
- Tolterodine
Describe the MoA of Oxybutynin, Tolterodine [3]
Competitively inhibits acetylcholine, blocking the muscarinic receptors and
promoting bladder relaxation to increase capacity
This reduces urgency and frequency of urination
These muscarinics are selective for M3 receptor which is the main receptor in the bladder
How do you manage acute urinary retention? [4]
- Immediately catheterise;
- Provide alpha blocker (e.g. tamulosin);
- Wait 24hr and remove catheter;
- (If still can’t urinate - schedule for TURP)
Describe the pathophysiology of TURP syndrome? [3]
How serious is it? [1]
It is caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection
This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
TURP syndrome is a rare and life-threatening complication
Desribe the early presentation [2] and late presentation [5]of TURP syndrome [2
TURP syndrome typically presents with CNS, respiratory and systemic symptoms:
Early features
* mild cases may go unrecognised
* restlessness, headache, and tachypnoea, or a burning sensation in the face and hands
Features of greater severity
* respiratory distress, hypoxia, pulmonary oedema
* nausea, vomiting
* visual disturbance (e.g. blindness, fixed pupils)
* confusion, convulsions, and coma
* haemolysis
* acute renal failure
* reflex bradycardia from fluid absorption
Pneumonic for TURP complications? [4]
Complications of Transurethral Resection: TURP
T urp syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
TURP presents classically as a triad of? [3]
The triad of features are:
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity
How long does finasteride need to be given for results to be seen? [1]
Finasteride treatment of BPH may take 6 months before results are seen
Name two side effects of tamulosin for treating BPH [2]
Dizziness
Postural hypotension
[] is the most effective management option in renal cell carcinoma? [1]
Radical nephrectomy is the most effective management option in renal cell carcinoma - RCC is usually resistant to radiotherapy or chemotherapy
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Signs and symptoms of:
Early stage prostate cancer? [6]
Late stage prostate cancer? [3]
Early stage:
* Often asymptomatic
* Urinary frequency
* Poor flow
* Nocturia
* Dribbling
* Renal obstruction
* Haematuria / Haematospermia
* Nodular hard craggy prostate on DRE
If metastised:
* Weight loss
* Bone pain
* Anaemia
What investigations should you conduct for prostate cancer:
- Indication of cancer? [2]
- For diagnosis? [2]
- For staging? [1]
- To investigate metastasis? [1]
PSA (raised) & hard, irregular DRE: indicates cancer
Multiparametric MRI is now commonly the first line investigation in the diagnosis of prostate cancer.
Transrectal US & biopsy: for diagnosis
Bone scan: for metastasis
CT: for staging
What levels normal PSA? [1]
What is the upper limit of normal PSA:
- under age of 50 [1]
- over the age of 70 [1]
Normal range varies w/ age, but generally < 4 ng/ml
Upper limit of normal PSA:
< 2.7 ng/ml if under 50;
< 7.2 over 70
Name this form of prostate biopsy [1]
Trans-rectal ultrasound: OUT OF USE due to high infection rate and limited number of biopsies able to take
Name this form of taking prostate biopsies [1]
Why is it better than trans rectal biopsy? [1]
Template / transperineal biopsy (BP)
Less infections; more biopsies can be taken
Which histological scoring system is used to grade prostate cancers? [1]
Describe how you use this scoring system [2]
Gleason score [1-5]
Because prostate cancers are heterogenous; Gleason score is a score made from:
The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy
A guided biopsy is offered to patients with a Likert score of [] or greater
A guided biopsy is offered to patients with a Likert score of 3 or greater
3 = Chance of clinically significant cancer is equivocal
4 = Clinically significant cancer is likely to be present
5 = Clinically significant cancer is highly likely to be present
What are well, moderately and poorly differentiated Gleason scores? [3]
Well differentiated: Score 2-4
Moderately differentiated: Score 5-7
Poorly differentiated: Score 8-10
Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a [] scale.
Describe the differences in results given from this scale. [5]
The results are reported on a Likert / PIRADS scale
1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer
Describe the treatment types for localised prostate cancer [4]
Radical prostatectomy (if < 75 and fit): can be open, laparoscopic or robotic surgery
Focal therapy:
- Brachytherapy (radioactive seeds)
- Cryotherapy
- HIFU (High frequency focused ultrasound)
Radiotherapy
Radiotherapy & androgen deprivation (stops stimulating the cancer to grow):
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Name two differentials for prostate cancer [2]
How would you investigate to differentiate between them and prostate cancer? [3]
BPH: positive prostate biopsy
Chronic prostatitis: leukocytes
indicative of inflammation
What are the prognostic factors in prostate cancer? [3]
- Pre-treatment PSA levels
- Tumour stage (TNM)
- Tumour grade (Gleason)
Explain how a GnRH agonist works to treat prostate cancer [3]
Gonadotropin-releasing hormone (GnRH) agonist: cause a ‘chemical castration’.
GnRH (also called luteinising hormone-releasing hormone or LHRH) is the hormone that stimulates LH/FSH release from the anterior pituitary.
Initially it causes an increase in LH/FSH release.
However, the persistent presence of an agonist causes downregulation of receptors on the pituitary gland leading to reduced LH/FSH release.
Goserelin is a commonly used GnRH agonist (brand name Zoladex).
Describe the treatment types and mechanisms for metastasied prostatic cancer [7]
Anti-androgen therapy:
- Synthetic GnRH agonist: Goserelin; causes lower LH levels by causing overstimulation; causes testosterone levels to initially rise then fall after 2/3 weeks
- GnRH antagonists: Degarelix; suppress testosterone without flare
- Non-steroidal anti-androgen: Bicalutamide: blocks androgen receptor
Steroidal anti-androgen: cytoproterone acetate
Androgen synthesis inhibitor: abiraterone
Bilateral orchidectomy: rapidly decreases testosterone levels
Chemotherapy with docetaxel
Where is the most common cause of prostatic metastasis? [1]
Why is this clinically significant? [2]
Bone; can cause skull and spinal cord compression: urological emergency
Management of Cord Compression due to prostatic cancer? [3]
(mainly) Radiotherapy
Rest and dexamethasone
Neurosurgery (if urgent decompression required)
What does an infected / inflamed prostate feel like? [1]
An infected or inflamed prostate (prostatitis) may be enlarged, tender and warm.
What does a cancerous prostate feel like? [2]
A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule
Describe the two forms of prostate biospy [2]
There are two options for prostate biopsy:
Transrectal ultrasound-guided biopsy (TRUS):
- ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.
Transperineal biopsy
- involves needles inserted through the perineum. It is usually under local anaesthetic.
A 70-year-old patient with prostate cancer is commenced on goserelin therapy. A week after starting treatment, he attends a local emergency department complaining of worsened lower urinary tract symptoms and new onset back pain.
Which treatment may have helped avoid this deterioration? [1]
Flutamide, a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.
What is proctitis? [1]
Name three causes of proctitis [3]
Proctitis is inflammation of the lining of the rectum.
Causes:
- radiotherapy
- inflammatory bowel disease
- infection.
How long after ejaculation and vigorous exercise should you wait before measuring PSA? [1]
How long after protastitis and UTI exercise should you wait before measuring PSA? [1]
ejaculation and vigorous exercise: wait 48hrs
protastitis and UTI: wait 1 month
What is an aide for memorising upper age limit of PSA levels? [1]
(Age-20) / 10
What is the purpose of cyproterone acetate?
Directly reducing the growth of prostate cancer
Increase luteinizing hormone secretion
Increase testosterone levels
Prevent paradoxical increase in symptoms with GnRH agonists
Reduce dose of GnRH agonists required for the intended effect
What is the purpose of cyproterone acetate?
Directly reducing the growth of prostate cancer
Increase luteinizing hormone secretion
Increase testosterone levels
Prevent paradoxical increase in symptoms with GnRH agonists
Reduce dose of GnRH agonists required for the intended effect
Prostate cancer: GnRH agonists may cause ‘tumour flare’ when started, resulting in bone pain, bladder obstruction and other symptoms
Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes?
Cytoproterone acetate - steroidal anti-androgen
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
What is Fanconi syndrome and why does it occur? [1]
Fanconi syndrome arises from an underlying dysfunction in the proximal convoluted tubule (PCT), resulting in a broad impairment of reabsorption.
What electrolyte disturbance does Fanconi syndrome present with? [2]
Which other disease state is Fanconi syndrome associated with? [1]
Hypophosphatemia, and hypokalemia
Associated with Wilson’s disease
