Speciality: Urology Flashcards
Patient - Patient aged mid 50’s. Haematuria, loin pain and palpable mass.
Renal cell carcinoma.
RCC Aetiology
- Association w/ Von hippel-lindau; AD inherited w/ BL RCC and cysts.
- Deletion on the short arm of chromosome 3 is the most consistent genetic finding.
- vascular tumours w/ large cells containing clear cytoplasm.
RCC Presentation
- Asymptomatic
- Haematuria + loin pain + palpable mass
- in 30% malaise, anorexia and weight loss occur
- 30% have HTN due to tumour secretion of renin and anaemia due to EPO suppression.
- LHS RCC can be associated with a LHS varicoceole due to obstruction of the L testicular vein drainage.
RCC Ix
1) USS to demonstrate mass and patency of the renal vein and IVC
2) CT
3) MRI TNM Stage
4) Bloods; ESR raised and LFT abnormal
RCC Rx
1) nephrectomy - CI in BL disease and compromised contralateral kidney.
2) Mets - Immunotherapy w/ interferon alpha
3) Other options are as yet unfounded.
Patient - aged 40 and over, painless haematuria
Bladder cancer until proven otherwise
Urothelial Ca Aetiology/pathology
- Renal calyces, pelvis, ureters, bladder and urethra are all lined with urothelium (transitional epithelium)
- Bladder Ca is most common
- Risks include; smoking, exposure to azo dyes, exposure to cyclophosphamide, chronic inflammation such as Schistosomiasis - often associated w/ Squamous cell carcinoma
Urothelial Ca Presentation
- Bladder = often painless haematuria, may be painful owing to clot retention.
- Consider in patient w/ UTI over 40 w/ no bacteria.
- Ureter and renal pelvis Ca may present w/ flank pain owing to obstruction.
Urothelial Ca Ix
1) Cytological Ix of urine for malignant cells.
2) renal imaging USS and CT KUB
3) Cystoscopy +/- biopsy to rule out bladder Ca.
Urothelial Ca Rx
1) Renal pelvis and ureteric tumours are resected w/ nephrectomy.
2) Bladder - superficial is resected.
3) Bladder Ca recurrence Rx w/ BCG, Doxorubicin and mitomycin
4) Agressive Bladder CA <70 radical cystectomy, >70 w/ radical radio.
5) Neo-adjuvant chemo (cisplatin and 5FU to shrink.)
Patient - female, pain on urination, suprapubic tenderness, haematuria, foul smelling urine, increased frequency.
UTI
UTI Aetiology
- E.coli is most common
- Proteus mirabilis (males) predisposes to stone formation
- Klebsiella
- Staph saprophyticus
UTI Pathology
- Often patients own bowel flora
- Direct extension up the urethra
- More common in women due to short urethra.
- Predisposed in those w/ DM, sickle cell.
- Often an isolated event, however can be recurrent - consider underlying pathology (stones, reflux, tumour, PKD)
UTI Presentation
- LUTS - Frequency, pain, nocturia, suprapubic tenderness, haematuria, foul smelling urine.
- Upper Sx suggesting pyelonephritis; loin pain, fever, systemic upset.
UTI Ix
1) MC&S of midstream urine. Pyuria and most Gram -ve produce nitrates (E.coli)
2) Special Ix in those who need;
- USS in those w/ suspected pyelonephritis
- CT KUB
- MRI if allergic to contrast.
UTI Rx
Single isolated attack
1) Nitrofurantoin 100mg BD for 3 days or Trimethroprim 200mg BD 3 days
Recurrent infection
1) Prophylaxis w/ lots of fluids, regular voiding, post-coital voiding. + Trimethroprim 200mg single dose when exposed to trigger or 100mg od. or 50-100mg nitrofurantoin OD.
Patient - Male, Lower urinary tract symptoms; prostate normal however large on DRE
BPH
BPH Aetiology
- UK
BPH Pathology
- Hyperplasia of the glandular and connective tissue in the prostate in response to testosterone
- This causes gland enlargement which presses and obstructs the urethra leading to Sx.
BPH Presentation
- Frequency
- Nocturia
- Hesitancy
- Dribbling
- Reduced stream force
- LUTS
- ACUTE URINARY RETENTION
BPH Ix
1) Abdominal examination for distended bladder.
2) DRE - large smooth prostate
3) Bloods - raised PSA
BPH Rx
1) Mild to mod = watchful wait
2) Moderate = alpha blockers - tamsulosin or 5a reductase inhibitor - finasteride (reduces testosterone - takes 6 months to work)
3) Severe = debulking surgery
4) Retention = urinary catheter relieves pain and pressure. Suprapubic if required.
Patient - Male, LUTS w/ craggy enlarged prostate on DRE. High serum PSA.
- Prostate cancer
Prostate CA aetiology and pathology
- Adenocarcinoma
- Rf’s = Age, FHx, HOXB13 gene, BRCA2
- Malignant growth results in external pressure on the urethra leading to LUTS.
- Commonly mets to the spine.
Prostate Ca Presentation
1) LUTS
2) Back pain, weight loss anaemia - mets and general cancer Sx.
3) Often found incidentally on DRE
Prostate Ca Ix
1) PSA (leaked by leaky cancer cells - level is not proportional to cancer) - >4ng/ml is abnormal.
Levels between 4-10 can be due to BPH or cancer
Levels >10 are most likely Ca.
- No exercise or wanking 48hrs previous
2) TRUS + Biopsy - gleason scoring from histology - higher score is worse
3) MRI
Prostate CA Rx
1) Localised disease = radical prostatectomy or external bean radiation
2) Androgen deprivation therapy - goserelin (GnRH agonist) or orchidectomy.
3) Advanced disease - radio + androgen therapy and palliate.
Patient - Middle aged. Loin to groin pain. Unable to lie still. Haematuria.
Renal colic and urolithiasis
Renal colic Aetiology
- Stone formation
- Most stones are calcium oxalate and phosphate - more common in men.
- Infective stones are more common in women.
- RF’s = Dehydration, hypercalcaemia, hypercalcuira, hyperoxaluria, infection (proteus - creates an alkaline environment which aids stone formation), PKD, drugs.
Renal colic pathology
- Stones from in the upper urinary tract and w/ urinary peristalsis cause pain and obstruction.
- Inhibitors of stone formation are present in the urine, however in some people the concentration of stone forming chemicals overtakes this.
Urolithiasis presentation
- Mostly asymptomatic
- Renal colic - from spasms, loin to groin, unable to sit still.
- Obstruction can occur, fluid intake worsens sx
- Exertion may allow the stone to move causing pain or haematuria.
Renal colic Ix
1) Urine dip (occult haematuria, protein and glucose)
2) Chemical analysis of any passed stones.
3) MSU
4) Kidney function
5) USS
6) CT KUB - uric acid stones are radiolucent. Peri-ureteric fat stranding demonstrating inflammation.
Renal colic Rx
1) Analgesia = diclofenac 75mg IM
2) Stone lithotripsy
3) Prevention of further stone formation, hydration and avoid infection etc.
4) Acute obstruction - nephrostomy
Patient - Young male, recurrent UTI + sensation of complete emptying post void.
- VUR
VUR/reflux nephropathy aetiology/pathology
- Progressive damage and fibrosis due to faulty VUJ and reflux.
- VUJ is a one way valve, reflux back into the ureter from the bladder. Refluxed urine returns to the bladder post void. Sensation of incomplete empty
VUR presentation
- Recurrent UTI
- sensation of incomplete void
- Asymptomatic
VUR Ix
1) CT KUB - irregular renal outlines, enlarged pelvis and calyces.
VUR Rx
1) Continuous ABx to prevent UTI halting progression of nephropathy
Patient - 15-20. lump in testicle. Painful or painless. Irregular hard mass.
- Testicular Ca
Testicular CA Aetiology and Pathology
- Seminoma - Raised LDH, normal HCG, raised AFP, no mets
- Non-seminoma - Raised HCG, mets nodes, spine.
- RF = cryptorchidism, klinefelter’s syn, male infertility, height.
Testicular Ca presentation
1) Mass, hard irregular, doesn’t transilluminate. Painless
2) Sx of mets, backspin, para-aortic nodes, sob from lung mets
3) Man boobs from HCG in non-seminoma.
4) Blood in sperm
Testicular Ca Ix
1) USS is first line
2) Assay of tumour markers; AFP, HCG, LDH
3) CT/MRI/PET for mets.
Testicular Ca Rx
1) Orchidectomy and node removal if required
2) +/- adjuvant chemo/radio
Acute epididymo-orchitis
- Causes
- Presentation
- Ix
- Rx
- Chlamydia or STI
- Underlying structural abnormality
- UTI
- Mumps (parotid swelling) - Dysuria
- Urethral discharge
- Tenderness
- Pain relieved on testicle elevation !!!!!!
- Unilateral swelling - STI Ix
- Rule out torsion.
- Ceftriaxone 250mg IM + doxy 100mg PO BD 10-14 days.
- Analgesia + rest
Epidydimal cyst
- Trans illuminates
- Painless
- Lie above or behind balls.
- Rx w/ surgery
Hydrocele
- Non painful
- Fluctuant
- Soft
- Trans illuminates
- Rx w/ surgery
Testicular Torsion
- SEVERE sudden onset pain
- Due to spermatic cord twisting and testicle ischaemia.
- RF include abnormal testicle lie.
- Tender and pain not eased with elevation !!!!!!!!!!
- Urgent surgical exploration and fixation.
Varicocele
- Pampiniform plexus
- Bag of worms
- Occurs on the L due to testicular drainage to the renal vein.
- Dx w/ USS
- RCC presentation.
- Can affect fertility.
- Conservative management.
Alpha blockers (Tamsulosin)
- MOA
- SE
- Decreases smooth muscle tone in the bladder and prostate
2. Dizziness, Postural hypotension, Dry mouth, depression
5-alpha reductase inhibitors (finasteride)
- MOA
- SE
- Block conversion of testosterone to dihydrotestosterone.
- Reduces prostate volume over 6 months. - ED, reduced libido, ejaculation problems, man boobs.
Balanitis
- Causes
- Presentation
- Ix
- Rx
- Inflammation of the glans penis.
- STI
- Dermatitis
- Candida
- Bacteria.
- Often seen in DM. - Swollen, tender and red glans penis.
- Unable to retract foreskin.
- Pain on urination. - Clinical
- Swabs MC&S
- STI testing - STI = Empirical
- Dermatitis = topical hydrocortisone
- Candida = topical clotrimzole, nystatin, miconazole. Recurrent - circumcise.
- Bacteria = Fluclox or erythromycin.
Medical indication for circumcision
- Phimosis
- Recurrent balanitis
- Paraphimosis
CI for circumcision
- Hypospadias
- The skin needs to be used for hypospadias repair.
Cancer type following neobladder reconstruction from the bowel.
Adenocarcinoma.
Which drug should be started alongside Goserrelin (zoladex) for prostate Ca management
- Cyptoterone acetate
- Reduces risk of tumour flare due to LH release from the Pit.
- Increased LH increases testosterone.
Erectile dysfunction
- Causes
- Presentation
- Ix
- Rx
- Often psychogenic.
- Organic = Vascular (most common organic) , neurogenic, structural or hormonal.
- Think organic when; gradual onset, lack of boners, normal libido.
- Think psycho when; sudden, boners, decreased libido, problems, affect disorders. - Simple
- Qrisk score.
- Testosterone; if low or borderline repeat w/ LH and FSH and Prolactin.
- If these are abnormal refer to endocrinology. - Viagra (PDE-5 inhibitors)
- Vacuums
- Injections etc.
Unilateral Hydronephrosis causes
PACT
- Pelvic-ureteric obstruction
- Aberrant renal vessels
- Calculi
- Tumours
Bilateral hydronephrosis causes
SUPER
- Stenosis of the urethra
- Urethral valve issues
- BPH
- Extensive bladder tumour
- Retro-peritoneal fibrosis.
