MLA Urology Flashcards
What differentiates between acute urinary retention and chronic urinary retention?
Acute = pain and a palpable/percussible bladder
What is the volume threshold for urinary retention post-void?
> 200 mL
What is the volume threshold on bladder scan for acute retention?
> 500 mL
What is the first line management for acute urinary retention?
Immediate catheterisation
What drug should be prescribed prior to the removal of the catheter?
Alpha-adrenoreceptor blocker e.g., doxazosin
Following urinary retention, what is a common complication that requires monitoring?
Post-obstructive diuresis (assess renal function)
Benign prostatic enlargement anatomically affects which zone?
Transitional zone
Which scoring system is indicated to assess for BPH?
International Prostate Symptom Score
What is the first line medical therapy for BPH?
Alpha-1 antagonists e.g., tamsulosin, alfuzosin (if IPSS >7)
What are the adverse effects associated with alpha-1 antagonists?
Dizziness, postural hypotension, dry mouth, depression
What is the 2nd line medical therapy for BPH?
: 5-alpha-reductase inhibitors e.g., finasteride
5-alpha reductase inhibitors reduce the conversion of testosterone to what?
DHT
What are the adverse effects associated with 5-alpha reductase inhibitors?
Erectile dysfunction, reduced libido, ejaculation problems, gynecomastia
What is the surgical intervention for BPH?
Transurethral resection of the prostate
What is a common complication associated with Transurethral resection of the prostate ?
TURP syndrome - results in dilutional hyponatraemia
What is the major risk factor for squamous cell bladder carcinoma?
Endemic urinary schistosomiasis
What is the most common type of bladder cancer?
Transitional cell
What are the main risk factors for transitional cell bladder cancer?
Aromatic amines e.g., industrial paint processing, dye, rubber and textiles
What is the main clinical presentation associated with bladder cancer?
Frank painless haematuria
What are the NICE 2ww referral criteria for a >45 year for suspected bladder cancer?
Aged >45 years with unexplained visible haematuria in the absence of a UTI
NICE 2ww referral criteria for >60 years for suspected bladder cancer?
Aged >60 years with microscopic haematuria AND
Dysuria
or
Raised WCC on FBC
What the first line investigation following urine dipstick for suspected bladder cancer?
Cystoscopy
Which investigation provides a histological diagnosis for bladder cancer?
transurethral resection of bladder tumour
What is the management for low-risk non muscle invasive bladder cancer?
Discharge to primary care
What is the management for intermediate-risk non-muscle invasive bladder cancer?
Cytoscopic follow-up at 3, 9 and 18 months, and once a year thereafter – consider TURBT.
What is the management for high risk non-muscle invasive bladder cancer?
Intravesical BCG or radical cystectomy or TURBT + chemotherapy
What is the definitive management for muscle invasive bladder cancer?
cisplatin combination AND radical cystectomy/radiotherapy
What is the most common histological subtype of renal cell carcinoma?
Clear cell carcinoma
What are the risk factors associated with renal cell carcinoma?
Smoking, hypertension, obesity, long-term dialysis, genetic syndromes (VHL).
What are the three most common histological subtypes of renal cell carcinoma?
- Clear cell renal carcinomas - 70%
- Papillary renal carcinoma - 15%
- Chromophobe - 5%
What is the classic triad of symptoms associated with renal cell carcinoma?
- Visible haematuria
- Flank pain
- Palpable abdominal mass
Renal cell carcinoma commonly metastasises where?
Lungs - results in cannonball metastases
What are the three endocrine effects associated with renal cell carcinoma?
- Secrete erythropoietin (polycythaemia)
- Parathyroid hormone-related protein (hypercalcaemia), renin
- ACTH
Which side are varicocele most commonly found in renal cell carcinomas?
left side
What is the investigation of choice to diagnose renal cell carcinoma?
CT thorax, abdomen and pelvis
What is the first line investigation for suspected renal cell carcinoma?
Urinalysis
Which large vessel does renal cell carcinoma tend to spread to via the Gerota’s fascia?
Inferior vena cava
What is the tumour size threshold for a partial nephrectomy in a renal cell carcinoma?
<7 cm
A T2 tumour > x cm = radical nephrectomy?
> 7 cm
What is the most common histological subtype for prostate cancer?
Adenocarcinoma (95%)
What is the strongest risk factor for prostate cancer?
Increasing age >50 years
What are the clinical features of prostate cancer?
Early prostate cancer is associated with an asymptomatic presentation.
* Lower back pain
* LUTS
* Lethargy
* Weight loss/anorexia
* Visible haematuria
* Erectile dysfunction
* Bone pain (metastatic disease)
On DRE, what are the findings consistent with prostate cancer?
Hard, asymmetric, craggy, hard nodular prostate.
What is the normal PSA range?
0-4 ng/mL
What can lead to falsely raised PSA?
BPE, prostatitis, recent DRE, urinary tract instrumentations and recent ejaculation
Ejaculation in the previous _ hours is a contraindication to PSA testing?
48 hours
Active UTI in the previous _ weeks is a contraindication to PSA testing?
6 weeks
Urological intervention in the previous _ weeks is a contraindication to PSA testing?
6 weeks
What two activities are are contraindications to PSA testing 48 hours before testing?
Ejaculation
Vigorous exercise
What is the first line diagnostic investigation of choice for suspected prostate cancer?
Multiparametric MRI
How frequently should PSA be monitored for prostate cancer?
Every 6 weeks for 6 months for 2 years
A PSA level > ng/mL in patients aged 50-69 years warrants a 2ww referral?
> 3.0
What is the management for low risk localised prostate cancer?
Active surveillance
PSA every 6-12 months
Prostate re-biopsy at 12 months
What do the two numbers mean in the Gleason score?
There are two grades: 1 for the most dominant grade 1-5, and 2 for the second most dominant grade.
2 is the best prognosis
10 is the worst
What scoring system is used to assess the extent of prostate cancer?
Gleason score
What is the definitive management option of choice for intermediate-risk prostate cancer?
Radical prostatectomy
When should a re-biopsy be performed for low risk prostate cancer?
12 months
Which androgen deprivation therapy agent is associated with the management of intermediate risk prostate cancer?
(LHRH agonist e.g., goserelin) or GnRH antagonist e.g., degarelix.
What is the acute complication associated with the use of GnRH agonists in the management of prostate cancer?
Causes tumour flare - use an anti-androgen to prevent a rise in testosterone e.g., bicalutamide
What is the management of a tumour flare in prostate cancer?
Medroxyprogesterone acetate or cyproterone acetate.
How is erectile dysfunction managed in the management of prostate cancer?
PDE-5 inhibitors
Which drugs are associated with overflow incontinence?
ACEi, antidepressants, antimuscarinics, and antiparkinsonian drugs
Which test is used to assess bladder compliance in patients with urinary incontinence?
Urodynamic tests
What is the first line management for urge incontinence?
6-week trial of bladder retraining
What is the 2nd line management for urge incontinence?
Oxybutynin
What is the third line management for urge incontinence?
Botulinum A toxin or percutaneous sacral/posterior tibial nerve stimulation.
What is the most common cause of prostatitis?
E. coli (~50%); pseudomonas aeruginosa
What are the risk factors associated with prostatitis?
Urethral instrumentation, trauma, bladder, outflow obstruction or dissemination of infection.
What is the first line antibiotic for the management of prostatitis?
Ciprofloxacin
What class of antibiotic is Ciprofloxacin ?
fluoroquinolones
What are the adverse effects associated with fluoroquinolones?
Tendonitis, tendon rupture, muscle pain, joint swelling, peripheral neuropathy
What type of priapism is caused by sickle cell disease?
Low flow ischaemic (veno-occlusive)
A prolonged erection by x > hours defines priapism?
4 hours
Rigidity of what penile structure is implicated in the pathogenesis of priapism?
rigidity of the corpora cavernosa
Ischaemic priapism is classically associated with what presentation?
progressive penile pain and erection is rigid + SOFT glans penis.
What is the first line investigation for priapism?
Aspiration of blood from the corpora cavernosa to perform a cavernosal blood gas analysis (perform an ultrasound prior to aspiration).
How does a Cavernosal blood gas differentiate between ischaemic versus non ischaemic priapism?
- Results: Dark ischaemic blood – differentiates ischaemic and non-ischaemic priapism.
o pO2 <30 | pCO2 >60 | pH <7.25
Penile Doppler US findings in ischaemic priapism?
Sluggish non-existent blood flow (low-flow)
What is the first line management of priapism?
Aspiration and irrigation with 0.9% saline solution
What is the second line management of priapism?
Intracavernosal therapy with phenylephrine
What is the third line management of priapism?
Surgical shunting
Rupture of which structure is associated with a penile fracture?
tunica albuginea (during an erection)
What eponymous sign is associated with a penile fracture?
- Aubergine sign or Eggplant sign.
What fascia is breached for there to be extensive haematoma into the perineum following a penile fracture?
Buck’s fascia
What is the first line investigation of choice for a penile fracture?
Ultrasonography of the penis
What is the immediate management for a penile fracture?
Urgent exploration and repair of the tunica albuginea (within 24 hours of presentation).
What is the most common organism implicated in Balanitis?
o Candida albicans
What is the characteristic clinical finding observed in Zoon’s balanitis?
Cayenne pepper spots (symmetrical orange0red lesions with pinpoint red spots)
What is the first line management of candidal balanitis?
Clotrimazole cream 1%
What is the first line management for anaerobic balanitis?
metronidazole
What drug is the first line management for lichen sclerosus?
Clobetasol propionate - potent topical steroid
What further investigation is indicated in a patient with Zoon’s balanitis?
Refer for penile biopsy to exclude penile intraepithelial neoplasia.
What is the most common type of testicular cancer?
- Seminomas
What are the four most common non-seminoma germ cell testicular cancer?
- Embryonal carcinoma
- Yolk sac
- Choriocarcinoma
- Post-pubertal teratoma
What are the common non-germ cell testicular cancers?
sex cord-stromal tumours e.g., Leydig/Sertoli/granulosa cell tumours.
What are the risk factors associated with testicular cancer?
- Cryptorchidism
- Hypospadias
- Decreased spermatogenesis and impaired fertility
- Klinefelter’s syndrome
- Mumps orchitis
What is the clinical presentation of testicular cancer?
Present as a painless testicular mass or as an incidental finding on ultrasound.
Which tumour cell marker is raised in a seminoma?
hCG
Which two tumour cell markers are raised in a non-seminoma?
AFP or beta-hCG
What is the first line investigation of choice for suspected testicular cancer?
Testicular ultrasound
What is the first line management for testicular cancer?
Orchidectomy + division of the spermatic cord at the internal inguinal ring.
Which deformity is associated with increasing the risk of testicular torsion?
Bell-clapper deformity
Which reflex is absent in testicular torsion?
cremasteric reflex
Which sign refers to sustained pain upon elevation of the testes?
Phren’s sign
Is Phren’s sign positive or negative in testicular torsion?
Negative
Which scoring system is used to indicate whether an immediate scrotal exploration is required in a patient with suspected testicular torsion?
TWIST Score
What is the immediate management for testicular torsion?
Immediate scrotal exploration
What is the definitive management of testicular torsion?
- Bilateral orchidopexy (viable) – fix both testicles.
Which two organisms are the most common cause of Epidiymo-orchitis in young males?
chlamydia trachomatis and Neisseria gonorrhoeae
Which organism is the most common cause of Epidiymo-orchitis in older adults with a low sexual history?
E. coli
What test is indicated in a young male with Epidiymo-orchitis?
NAAT testing
What test is indicated in an older adult with a low sex history with suspected Epidiymo-orchitis?
Mid-steam urine sample and urine dipstick
What is the management of Epidiymo-orchitis in a sexually active adult?
Ceftriaxone 1 g IM AND oral doxycycline 100 mg BDS for 10-14 days
What is the antibiotic of choice for Epidiymo-orchitis (with a low sex history)?
Oral ofloxacin 200 mg BDS for 14 days or oral levofloxacin 500 mg OD for 10 days
What is the first line of management of hydrocele in an infant?
Reassurance for 1-2 years - refer to paediatric surgeon is present after 12 months
Which scrotal pathology transilluminates and confined to the scrotum (cannot get above the mass on examination)?
Hydrocele
What is the conservative management for a hydrocele in an adult?
scrotal support e.g., supportive underwear
Which plexus is enlarged in a patient with a varicocele?
pampiniform plexus
Which vein is most implicated in the pathogenesis of a varicocele?
left testicular vein
What is the clinical presentation of a varicocele?
- Throbbing/dull pain or discomfort, worse on standing.
- A dragging sensation
- A ‘bag of worms’ sensation
- Disappears when lying down
- Asymmetry in testicular size
- Sub-fertility or infertility
What investigation is preferred as first line to confirm the diagnosis of a varicocele?
Doppler imaging
Which bacteria is associated with Fournier Gangrene?
Group A streptococci
Which drug increases the risk of Fournier gangrene?
- SGLT-2 inhibitor
What is the most common pre-existing condition associated with Fournier Gangrene?
Diabetes mellitus
What is the definitive management for Fournier Gangrene?
- Urgent surgical referral debridement and intravenous antibiotics
What is the most common cause of erectile dysfunction?
- Vasculogenic (most common):
- Cardiovascular disease e.g., hypertension, peripheral arterial disease, hyperlipidaemia, type ½ diabetes mellitus, metabolic syndrome, smoking, obesity, major pelvic surgery.
Which drugs are associated with erectile dysfunction?
- Antihypertensives e.g., beta-blockers, verapamil, methyldopa, and clonidine.
- Diuretics e.g., spironolactone and thiazides.
- Antidepressants e.g., SSRIs, lithium
What should be calculated in all patients with erectile dysfunction?
10-year cardiovascular risk
What is the first line of investigation for patients with erectile dysfunction?
Serum testosterone level (taken between 9-11 am
What is the first line of management for a young person with ED?
Referral to a urologist specialist.
What drug is indicated in patients with ED?
Phosphodiesterase inhibitors (not for high cardiac risk):
* E.g., sildenafil and tadalafil – 50 mg tablets can be purchased over the counter,
What is the first line analgesia for renal stones?
IM/rectal diclofenac, ibuprofen
What is the second line analgesia if IM diclofenac is ineffective in renal stone management?
IV paracetamol
What is the management of renal stones measuring 5-10 mm?
Shockwave lithotripsy
What is the management of renal stones measuring >20 mm?
Percutaneous nephrolithotomy
What is the investigation of choice for renal stones?
- Non-contrast CT KUB
