Renal, Urology, Gynae, Breast Flashcards
Which testosterone blood test should be done for ED?
Free testosterone
Testosterone bound to SHBG which increases with age so poor correlation with total testone and symptoms
What is the definition of recurrent UTI?
Two or more UTI’s within 6 months
Name 3 possible reasons to consider a referral for bladder ca?
Unexplained haematuria over age 45 (no UTI or persisting after UTI)
NVH over 60 WITH dysuria or raised WCC
(Both 2ww)
Non-urgent referral for anyone over 60 with recurrent or persistent UTI’s (2 or more in 6 months)
How is interstital cystitis managed? (Name 3 steps)
Simple (paracetamol + nsaid)
2) + Oxybutynin
3) + Amitriptyline (off label, with specialist)
Name 4 groups of drugs which can cause ED?
Antidepressant
Antihypertensive
Diuretics
Ranitidine
Cardiac drugs
Recreational drugs
What are the PSA cut offs for prostate cancer?
40-49- > 2.5
50-59 - > 3.5
60-69 - > 4.5
70-79 - > 6.5
If above this refer on 2ww for cancer
Who should PSA be offered to and what should not be done before testing?
Suspected prostate Ca/ anyone over 50 who requests one
No UTI or urology intervention in last 6 weeks
No vigorous exercise or ejactualation in last 48hrs
Acute prostatitis:
a) Classic presentation
b) Management
a) Fever, dysuria, low back and perineal pain
b) Ciprofloxacin or ofloxacin for 14 days (send MSU also)
How may radiation induced enteropathy present? How is it investigated?
Common complication of prostate cancer treated with radiotherapy.
Presents diarrhoea, urgency, steatorrhoea, bloating, rectal pain
Investigate with sigmoidoscopy
A 28-year-old lady has a positive leucocyte esterase and nitrites on a routine urine dipstick test. She is asymptomatic.
What is the SINGLE MOST appropriate management option?
Send urine MCS
- Delay starting antibiotics til results available
(If symptomatic and either leuk or nitrates then treat straight away - here not treated as asymptomatic)
How should symptomatic, partially retractile phimosis be managed?
1st: Mod to potent steroid with regular gentle retraction in the bath or shower
2nd - Circumcision if this fails
What is the biggest cancer risk following external beam radiotherapy for prostate ca?
New primary rectal Ca
Also radiation induced enteropathy
What tumour markers are associated with non-seminomatous germ cell tumour?
AFP
hCG
What tumour markers are associated with testicular seminoma’s?
None
(AFP and hCG are associated with non-seminomatous)
What potential risk should you be aware of for patients on metformin when considering contrast requiring investigation?
Lactic acidosis
What is the gold standard test to confirm nephrotic syndrome?
24 hour urine collection for protein: creatinine ratio
A spot test for protein:creatinine ratio provides a reasonable level of confirmation and is practical to request in primary care. However, a 24-hour urine collection for protein:creatinine ratio remains the gold standard.
In the context of UTI’s in children, name 3 indications for renal tract USS?
- When should the USS be performed
Typical infection in under 6 month olds (to be performed within 6 weeks)
All children over 6m with recurrent UTI’s (performed within 6 weeks)
All children with atypical infection (performed during current illness)
- Raised creatanine/ sepsis/ poor flow
- Any non e.coli infection
- Any doesn’t respond within 48 hours
What is the definition of recurrent UTI in children?
3 or more UTI’s during childhood
2 or more UTI’s if one or more of them were upper/ pyelonephritis
What are the indications for a DMSA in children with UTI’s?
All children aged under 3 years with atypical or recurrent UTI.
All children aged 3 years or over with recurrent UTI.
(Usually after USS renal tract and only done in secondary care)
Alkalinising agents (such as potassium citrate) can reduce the effectiveness of which SINGLE antibiotic?
Nitrofurantoin
(Advise women to avoid)
What is the blood pressure target for patients with polycystic kidney disease? When may this be lower?
Which agent is used first line?
130/80 mm Hg
- Lower if proteinuria (>1g/day)
ACEI are first line
Given two examples of anticholinergics which may be used to control urinary symptoms?
Oxybutanin
Tolterodine
Intersistial cystitis:
a) 3 presenting symptoms
b) Classic cystoscopy finding?
a) Abdominal pain + urgency + frequency
b) Hunner lesions
A patient is being started on goserelin (GnRH antagonist) - what is the most concerning initial side effect and what is done to prevent this?
Tumour flare up (initial 1-2 week lack of testosterone can make the tumour swell - concern RE spinal cord compression etc)
Anti-androgen treatment (cyproterone) is started 3 days before until 3 weeks after to mitigate this
How does IgA nephropathy usually present?
Gross haematuria, usually with an upper respiratory tract infection or, less often, gastroenteritis.
According to current evidence, what PERCENTAGE of men who have a normal prostate specific antigen (PSA) test are subsequently found to have prostate cancer (false negative result)?
The false negative rate for PSA testing is 15% (men who have a PSA in the normal range but are subsequently diagnosed with prostate cancer).
How is acute epididymitis treated?
Ceftriaxone 1g intramuscular injection plus doxycycline 100 mg twice daily for 10-14 days.
(As most caused by chlamydia or gonorrhoea)
If caused by enteric organism can be treated with just doxycycline, ofloxacin or ciprofloxacin for 10-14 days.
What are the SLS (selected list scheme) rules on prescriptions for viagra?
Generic sildenafil can now be prescribed to all men with erectile dysfunction. Patients who are prescribed avanafil (Spedra®), tadalafil (Cialis®), vardenafil (Levitra®) or the Viagra® brand must still meet the SLS criteria and the prescription must be endorsed ‘SLS’ by the prescriber.
A 44-year-old man has had intermittent pelvic discomfort, dysuria, and frequency for six months. Urine dipstick and cultures have been negative. A four-week trial of ciprofloxacin did not help.
What is the SINGLE MOST appropriate NEXT treatment?
Tamulosin
If a bacterial cause is excluded, and there is no improvement after antibiotic therapy, a different treatment modality (or referral) should be considered. Alpha-blockers have a modest effect on urinary symptoms, pain, and quality of life, and are an initial treatment option.
How do you define baseline serum creatinine in the context of AKI?
Baseline serum creatinine is assumed to be the lowest value over the previous 3 months or if no recent value available, the median value over the year is used.
What are the 8 domains of the IPPS?
Incomplete emptying
Frequency
Intermittency
Urgency
Weak Stream
Straining
Nocturia
Quality of life
(All on a scale of 0-5, so total score out of 35)
A 42-year-old lady comes to see you for follow up regarding her urinary incontinence. Her incontinence is mainly when coughing, sneezing or laughing. She has tried losing weight but her symptoms have persisted.
What is first line management?
Guided pelvic floor muscle training with a specialist women’s health physiotherapist
(NO evidence to support self directed pelvic floor exercises)
What is the Hb target for patients with CKD4/5?
Anaemia in CKD - aim for 10-12 g/dl
What is the management of cyclical mastalgia?
Supportive bra and simple analgesia
- First line is topical NSAID
No role for COCP or POP
What is the USS criteria for a diagnosis of ADPKD in patients with a +ve FHx?
Ultrasound diagnostic criteria (in patients with positive family history)
two cysts, unilateral or bilateral, if aged < 30 years
two cysts in both kidneys if aged 30-59 years
four cysts in both kidneys if aged > 60 years
What medication can be used in the management of polycystic kidneys, what is the criteria?
Tolvaptan (vasopressin receptor 2 antagonist) may be an option if:
- CKD 2 or 3 at the start of treatment
- Evidence of rapidly progressing disease and
- Company provides it with the discount agreed in the patient access scheme.
What should happen to PSA levels following prostatectomy?
Following a complete prostatectomy, the PSA level should be ‘undetectable’ which is defined usually as a value less than 0.2ng/ml.
Anything over this after surgery requires referral to oncology team for review
A patient is started on finasteride for the treatment of benign prostatic hyperplasia. How long should the patient be told that treatment may take to be effective?
How does finasteride work?
Up to 6 months
Finasteride works by inhibiting the conversion of testosterone into dihydrotestosterone (DHT), which contributes to prostate enlargement (hence it takes so long to work)
How do you distinguish anatomically between a femoral and inguinal hernia?
What about in the history?
Femoral: Below and lateral to the pubic tubercle
Inguinal hernias usually present as a lump above and medial to the pubic tubercle.
What percentage of men with a raised PSA will go on to have cancer?
1 in 3
(Not very specific, so 2/3 with raised PSA will not have cancer)
A breast cancer is found to be ER+, what adjuvant therapy may be offered if the woman is:
a) Pre or peri menopausal
b) Post menopausal
a) Tamoxifen (usually for 5 years)
b) Aromotase inhibitors (anastrozole)
- Most oestrogen in post menopausal women produced by aromatisation
Name 3 important side effects of tamoxifen?
Increased risk of endometrial cancer
Venous thromboembolism
Menopausal symptoms.
How may mammary duct ectasia present?
Dilatation of the large breast ducts
- Around the menopause
- Tender lump around the areola +/- a green nipple discharge
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
What is a duct papilloma and how may it present?
Local areas of epithelial proliferation in large mammary ducts
Hyperplastic lesions rather than malignant or premalignant
Presents with blood stained nipple discharge
Who is most at risk of fat necrosis of breast and how may it present?
More common in obese women with large breasts
May follow trivial or unnoticed trauma
Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
- May mimmic breast cancer so investigation is always needed
According to the NICE guidelines, above which age threshold does starting hormone replacement therapy INCREASE a woman’s cardiovascular disease (CVD) risk?
60
Does not increase risk when started before this
What is a rectocele? How does it present?
How may you distinguish between that and a cystocele?
Proplapse of rectal wall between that and the vagina
- Deep dyspareunia, feeling of incomplete emptying bowels. - O/E: VE- posterior wall bulge which increases in size on straining
Cystocele or urethrocele would give anterior wall buldge on VE
What is the only drug licenced for stress incontinence, in what context should it be used?
Duloxetine
- Used in combination with pelvic floor exercises only
Name 3 indications to go for surgical management in the context of vaginal prolapse?
Stage 2 prolapse
Significant symptoms
Voiding or defecation problems
Ulceration/ irreducible prolapse
No improvement/ declines conservative tx
What are 4 options for management of vaginal prolpase?
Lifestyle changes (weight loss, cough control)
Pelvic floor exercises
Vaginal hormone tx
Vaginal pessary
Surgery
What are the first line treatments for OAB (overactive bladder)?
Oxybutynin
Tolterodine
Darifenacin
Which group should not be offered oxybutynin for OAB?
What other drug can be considered for nocturia associated with OAB?
Frail older women should not be offered oxybutynin
- Mirabegron is a good alternative
Desmopression can be considered if OAB and nocturia
How long post partum should a woman wait before having cervical screening?
Wait 3 months post partum
Not advised during pregnancy
- Can be exceptions if lesion or abnormalities identifed
What age group are eligable for breast screening?
How often is it offered?
Offered to women aged 50 up to their 71st birthday
Every 3 years
The presence of clue cells on HVS suggests what diagnosis?
How is it treated?
Bacterial vaginosis
Tx metronidazole 400mg BD for 7/7
- Can use single 2g dose of metronidazole in NON pregnant if adherance an issue
How long can low dose vaginal oestrogen be used for?
Indefinitely
(With annual review)
Name 3 drugs which could cause breast pain?
Spironolactone (also gynocomastia in men)
COCP or HRT
Antidepressants
Methyldopa
Digoxin
Some diuretics
COCP
a) Which cancers are increased risks?
b) Which cancers are decreased risks?
a) Breast and cervical
b) Endometrial and ovarian
What are the classic presenting features of bacterial vaginosis?
What percentage of women are asymptomatic?
Fishy smelling, thin white discharge
- No itch or soreness
Around 50% women are asymptomatic
Name 3 risk factors for endometriosis?
Early menarche/ late menopause/ nulliparity/ delayed childbearing (All extra oestrogen)
FHx
White/ low BMI
Autoimmune disorders
Smoking
Late first sexual encounter
When should endometriosis be suspected? (5 syx)
Chronic (>6mths) pelvic pain (cyclical or continuous)
Dysmenorrhoea affecting daily life
Period/ cyclical GI symptoms - i.e. painful bowel movement
Period/ cyclical urinary symptoms - i.e. dysuria or haematuria
Infertility with 1 or more of above
First 2 steps of endometriosis management?
1) Simple (paracetamol and NSAID) analgesia
2) COCP or POP, depot, implant or IUS
How do you manage men with voiding symptoms?
a) If very mild
b) Mod-severe
Conservative (pelvic floor, bladder training, fluid intake, lifestyle tx constipation etc)
Mod/ severe - IPPS over 8
- Alpha blocker (tamulosin etc)
- If enlarged prostate or high risk or not settling + 5-alpha reductase inhibitor (dulasteride or finasteride)
(Higher risk = older men, poor urine flow, higher IPPS scores)
Your patient on tamulosin and finasteride also has some storage symptoms - how do you manage?
Add antimuscarinic (oxybutynin) OD in combination
- Do not give oxybutanin to older frail men (causes impaired function and confusion)
What drug may be used in men with retention when removing a catheter?
Alfuzosin 10mg OD
- Licenced for 2-3 days during catheterisation and 1 day after removal
How should I manage a man with post micturition dribble not due to urinary obstruction
Advise the man that he can reduce the post micturition dribbling by ‘milking’ his urethra after urinating.
Name 3 groups of patients with CKD that should be referred to a specialist?
- 4 antihypertensives and BP not controlled
- ACR over 70 (and not diabetic)
- ACR over 30 with haematuria
- Decrease eGFR 25% or more or 15mls min or more in 12 months
- Suspected genetic cause or renal artery stenosis
Name 3 storage and 3 voiding symptoms in men?
Storage - Urgency, frequency, nocturia, incontinence
Voiding - Hesitancy, weak stream, terminal dribbling, straining, splitting or spraying
A 9 year old boy has recurrent UTI’s and has been fully investigated - there is no underlying abnormality. What do you recommend to help reduce number of infections?
Increase fluid intake
(No role for starting propylactic ABx in primary care)
A well patient presents with abdo pain and foul smelling urine. You consider UTI. Dipstick is negative for blood, leuks and nitrites. Next step?
Consider other causes
(Don’t need MSU)
The negative predictive value when nitrites, leucocytes and blood are all negative is 76%, therefore other causes for her symptoms should be considered.
It is normal for boys to have a non-retractile foreskin up to what age?
10 years
- Topical steroids can be used to thin foreskin in older boys
What is suggested management for premature ejaculation?
Squeeze technique (compress glans), condoms to reduce sensation, pyschosexual counselling
SSRI’s can be useful, do not need to be taken continuously
What is the most common testicular tumour in:
a) Men over 50
b) Men under 50
a) Non-Hodgkin’s lymphoma
b) Seminoma’s are slightly more common than non-seminomatous
- Leydig cell and sertoli are rare non germ cell tumours
The parents bring their uncircumcised male child to see you, worried about a ‘pearly’ lump under his foreskin.
What is the SINGLE MOST likely diagnosis?
Smegma is a pearly lump beneath the foreskin in an uncircumcised child. It is the result of accumulation of desquamated epithelial cells under the foreskin.
What is:
a) Asthenozoospermia
b) Teratozoospermia
c) Oligozoospermia
a) Asthenozoospermia refers to a sample where less than 50% of the sperm are moving
b) Teratozoospermia is indicated by a semen analysis where less than 15% of sperm have normal morphology
c) Oligozoospermia is characterised by a sperm count of less than 20 million/ml
Which ethnic group are at highest risk of developing prostate cancer?
African decent
What is the acronym to remember COCP rules for 2 or more missed pills?
ECO rule for 2 missed pills COCP.
Week 1 - needs emergency contraception (E)
Week 2 is condoms (C) (but no emergency contraception needed)
Weeks 3 is omit pill free week (O)
Essentially if you take 7 pills in a row you are protected for the next 7 days (no missed pills affect the following days)
What is the relationship between IUD and ectopic pregnancies?
IUCD - the proportion of pregnancies that are ectopic is increased but the absolute number is decreased
What are options for emergency contraception?
Copper IUD - For upto 5 days after (120hrs) or 5 days after ovulation date.
Levongestrel 1.5mg - Has to be taken with 72 hours
Ulipristal 30mg (EllaOne) - Can be taken upto 5 days (120 hours). Mainly decreased ovulation so less effective after ovulation
If a patient vomits after taking emergency contraception what rules should be followed?
If vomiting occurs within 3 hours then the dose should be repeated
When can hormonal contraception be restarted after using Levonelle or EllaOne?
Levonogestrel - Immediately after
Ulipristal - Condoms for 5 days, start hormal contraception after this
What frequency of pelvic floor exercises do NICE recommended for stress incontinence?
NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
When do the FSRH recommended testing for STI’s after UPSI?
2 and 12 weeks following UPSI
What is the routine cervical screening programme?
Routine recall is every 3 years for patients aged 25-49 years
and
every 5 years for patients aged 50-64 years.
How do you manage a +ve HPV smear test?
If cytology abnormal - Colposcopy
If cytology normal:
- Rpt in 12 months
- If still abnormal rpt in further 12 (24 months)
- If still abnormal then refer for colposcopy
How do you manage an inadequate result in a smear test?
Repeat the sample in 3 months
If two consecutive inadequate samples then → colposcopy
At least how long should you advise your patient to wait after childbirth before conceiving again?
12 months
(Before this risk of preterm/ small babies)
How should gestational diabetes be managed?
Fasting glucose <7
- Start diet and lifestyle, maybe add metformin
Fasting glucose >7
- Start insulin
What are the cut off’s to diagnose gestational diabetes?
fasting glucose is >= 5.6 mmol/L
2-hour glucose is >= 7.8 mmol/L
What should women be advised about contraception efficacy of lactational ammenorrhoea?
98% effective providing the woman is fully breast-feeding (no supplementary feeds), amenorrhoeic and < 6 months post-partum
What screening tool is used for postnatal depression?
Edinburgh scale
What is the SINGLE MOST common gynaecological cancer in the United Kingdom?
Endometrial
(Vaginal is least common)
What are the management steps in lactational mastitis?
(incl pen allergy)
Effective milk removal (continue feed or express)
Fluclox if symptoms no better after 12-24 hours
- If not improving with 48 hours switch to broad spectrum (co-amox) for 10-14 days
If pen allergic - erythromycin or clarithromycin
What is the optimum point in a 28 day cycle to perform a smear?
It should be carried out on days 10–20 of a 28-day cycle. At this time there are few polymorphs and more mature endocervical cells. From day 21 of the cycle there is an increase in the number of polymorphs.
A 43-year-old woman has had amenorrhoea for six months, hot flushes and low mood. Her follicle-stimulating hormone (FSH) result from six weeks ago is 43 mIU/ml (normal < 30 mIU/ml).
When can FSH levels be used to diagnosis peri-menopause and when is a rpt needed?
40-45years with menopausal syx (i.e. no periods) - Single FSH over 30 is enough
If under 40 need to repeat at 4-6 weeks when diagnosing PROF
Name 3 indications for referral to gynae in a women with fibroids?
Fibroids 3 cm or more
Suspected submucosal fibroids
Heavy bleeding
Compressive bowel/ bladder syx
Rapid growth after menopause
Fertility issues
Treatment for Chlamydia?
Doxycycline 100 mg twice daily for 7 days
CI in pregnancy and breastfeeding
- Use 1g azithromycin 1 day and then 500g for 2 days (Or erythro or amox)
When is test of cure recommended for chlamydia?
When should retesting occur?
Test of cure not recommended other than for pregnancy women, suspected poor compliance or persistent symptoms
Resting (for new infection) should be done in those under 25 at 3-6 months
(Also older than 25 in high risk groups)
What should patients with chlamydia be advised with regard to:
a) Partner treatment
b) Resuming UPSI
a) Partners should be treated at same time
b) If doxy wait til treatment compeleted, if azithromycin then wait 7 days after tx completed
What percentage of patients with chlamydia are asymptomatic?
How does this compare to gonorrhoea?
Chlamydia is asymptomatic in:
70% women
50% men
Gonorrhoea is only asymptomatic in around 10% men, 50% in women
What is test of choice for chlamydia in:
a) Women
b) Men
a) Vulvovaginal or endocervical swabs or first catch urine if preferred
b) First catch urine is preference
Urethral swab second
How should gonorrhoea be managed?
If suceptibility is known - single dose ciprofloxacin 500 mg
If don’t know suceptibility - ceftriaxone 1 g intramuscular (IM) injection as a single dose
What is the most common STI worldwide?
Trichomonas vaginalis
How is trichomonas vaginalis treated?
For all- Oral metronidazole 400–500 mg twice a day for 5–7 days
If not pregnant/ breastfeeding - Can be offered single 2g dose oral metronidazole
What is the classic presentation of syphillis?
Solitary painless, indurated, genital ulcer
- Rash involving palms and soles
- Wart like lesions
- Patchy lesions on oral mucosa
How should syphillis be managed?
All in GUM/ secondary care
- Needs specialist testing to distinguish current/ past/ stage
- Treatments (like parenteral benzathine and procaine penicillin) are unlicenced
What are the contraindications to the HPV vaccine?
When is HPV vaccine given?
Pregnancy (but only due to lack of data)
Girls 12-13
- People who missed this are eligable to contact GP and request it up to 25th birthday
What is the duration you need to go back for partner notification with men who have urethral symptoms in STI’s?
Gonoccocal - Back 2 weeks
All others - Go back 4 weeks
A female patient is treated for chlamydia, what are the partner tracing recommendations?
If female index case, or male who is asymptomatic:
- Tracing for previous 6 months
What are come of the complications of chlamydia infection?
Ectopic pregnancy (40% caused by chlamydia)
PID - Untreated 40% women develop PID, 20% of these develop infertility
How should PID be managed?
Ceftriaxone 1 g as a single intramuscular (IM) dose, followed by oral doxycycline 100 mg twice daily plus oral metronidazole 400 mg twice daily for 14 days.
- STI testing ideally before starting treatment but not to delay start of treatment
A 26 year old female is diagnosed with PID. She has a coil in situ. She’s STI tested and started on ABx, what should you do regarding the coil?
If mild-moderate - If clinicially imroving after 2-3 days ABx, can keep coil in, otherwise remove
If severe syx - Remove
What is the definition of a high prevelance area with regard to HIV?
An area where there are more than 2/1000 suffering with HIV is considered a higHh prevalence area
How do you distinguish between an ulcer caused by syphillis and one caused by herpes or behcets disease for example?
Lesions in syphilis are typically painless. Behçets disease, herpes simplex, herpes zoster and lichen sclerosus can all cause painful genital ulceration
A 55-year-old man is human immunodeficiency virus (HIV) positive but is generally well and on antiretroviral therapy. He attends for a routine health check. There is no significant family history. His body mass index (BMI) is 26 kg/m2.
Which is the SINGLE MOST appropriate screening investigation out of?
(Lipid, U+E, LFT, glucose, TFT?
Lipids
People with HIV have a higher risk of cardiovascular disease and standard cardiovascular disease (CVD) risk scores tend to underestimate risk in people with HIV. Lipid abnormalities are common on antiretroviral therapy
What is the most common pathogen responsible for genital herpes?
How is it treated?
Herpes simplex virus type 2 (HSV2)
Tx- Aciclovir 200mg five times daily for 5 days
What are the smear recommendations for women with HIV?
Annual smears
(Higher risk of HPV infections and cervical cancer with HIV)
In what circumstances do you refer FGM to social services and when the police?
Police: FGM is disclosed (under 18) or visually confirmed
Social services - If you think the child is at risk (urgent)
Up to how many hours after exposure to human immunodeficiency virus (HIV) is post-exposure prophylaxis (PEP) considered to be effective?
72 hours
(Ideally within 24 hours though)
How should women be counselled RE IUD expulsion risk?
Intrauterine contraceptive devices: risk of expulsion is 1 in 20
Most commonly in the first 3 months
At what age are women advised to stop COCP
Age 50 if no other contraindications
