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Medical School Finals > Speciality: Urology > Flashcards

Speciality: Urology Flashcards

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USMLE® Step 1 flashcards
1
Q

Patient - Patient aged mid 50’s. Haematuria, loin pain and palpable mass.

A

Renal cell carcinoma.

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2
Q

RCC Aetiology

A
  • 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.
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3
Q

RCC Presentation

A
  • 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.
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4
Q

RCC Ix

A

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

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5
Q

RCC Rx

A

1) nephrectomy - CI in BL disease and compromised contralateral kidney.
2) Mets - Immunotherapy w/ interferon alpha
3) Other options are as yet unfounded.

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6
Q

Patient - aged 40 and over, painless haematuria

A

Bladder cancer until proven otherwise

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7
Q

Urothelial Ca Aetiology/pathology

A
  • 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
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8
Q

Urothelial Ca Presentation

A
  • 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.
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9
Q

Urothelial Ca Ix

A

1) Cytological Ix of urine for malignant cells.
2) renal imaging USS and CT KUB
3) Cystoscopy +/- biopsy to rule out bladder Ca.

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10
Q

Urothelial Ca Rx

A

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.)

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11
Q

Patient - female, pain on urination, suprapubic tenderness, haematuria, foul smelling urine, increased frequency.

A

UTI

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12
Q

UTI Aetiology

A
  • E.coli is most common
  • Proteus mirabilis (males) predisposes to stone formation
  • Klebsiella
  • Staph saprophyticus
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13
Q

UTI Pathology

A
  • 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)
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14
Q

UTI Presentation

A
  • LUTS - Frequency, pain, nocturia, suprapubic tenderness, haematuria, foul smelling urine.
  • Upper Sx suggesting pyelonephritis; loin pain, fever, systemic upset.
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15
Q

UTI Ix

A

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.

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16
Q

UTI Rx

A

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.

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17
Q

Patient - Male, Lower urinary tract symptoms; prostate normal however large on DRE

A

BPH

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18
Q

BPH Aetiology

A
  • UK
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19
Q

BPH Pathology

A
  • 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.
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20
Q

BPH Presentation

A
  • Frequency
  • Nocturia
  • Hesitancy
  • Dribbling
  • Reduced stream force
  • LUTS
  • ACUTE URINARY RETENTION
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21
Q

BPH Ix

A

1) Abdominal examination for distended bladder.
2) DRE - large smooth prostate
3) Bloods - raised PSA

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22
Q

BPH Rx

A

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.

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23
Q

Patient - Male, LUTS w/ craggy enlarged prostate on DRE. High serum PSA.

A
  • Prostate cancer
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24
Q

Prostate CA aetiology and pathology

A
  • 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.
25
Q

Prostate Ca Presentation

A

1) LUTS
2) Back pain, weight loss anaemia - mets and general cancer Sx.
3) Often found incidentally on DRE

26
Q

Prostate Ca Ix

A

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

27
Q

Prostate CA Rx

A

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.

28
Q

Patient - Middle aged. Loin to groin pain. Unable to lie still. Haematuria.

A

Renal colic and urolithiasis

29
Q

Renal colic Aetiology

A
  • 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.
30
Q

Renal colic pathology

A
  • 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.
31
Q

Urolithiasis presentation

A
  • 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.
32
Q

Renal colic Ix

A

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.

33
Q

Renal colic Rx

A

1) Analgesia = diclofenac 75mg IM
2) Stone lithotripsy
3) Prevention of further stone formation, hydration and avoid infection etc.
4) Acute obstruction - nephrostomy

34
Q

Patient - Young male, recurrent UTI + sensation of complete emptying post void.

A
  • VUR
35
Q

VUR/reflux nephropathy aetiology/pathology

A
  • 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
36
Q

VUR presentation

A
  • Recurrent UTI
  • sensation of incomplete void
  • Asymptomatic
37
Q

VUR Ix

A

1) CT KUB - irregular renal outlines, enlarged pelvis and calyces.

38
Q

VUR Rx

A

1) Continuous ABx to prevent UTI halting progression of nephropathy

39
Q

Patient - 15-20. lump in testicle. Painful or painless. Irregular hard mass.

A
  • Testicular Ca
40
Q

Testicular CA Aetiology and Pathology

A
  • Seminoma - Raised LDH, normal HCG, raised AFP, no mets
  • Non-seminoma - Raised HCG, mets nodes, spine.
  • RF = cryptorchidism, klinefelter’s syn, male infertility, height.
41
Q

Testicular Ca presentation

A

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

42
Q

Testicular Ca Ix

A

1) USS is first line
2) Assay of tumour markers; AFP, HCG, LDH
3) CT/MRI/PET for mets.

43
Q

Testicular Ca Rx

A

1) Orchidectomy and node removal if required

2) +/- adjuvant chemo/radio

44
Q

Acute epididymo-orchitis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Chlamydia or STI
    - Underlying structural abnormality
    - UTI
    - Mumps (parotid swelling)
  2. Dysuria
    - Urethral discharge
    - Tenderness
    - Pain relieved on testicle elevation !!!!!!
    - Unilateral swelling
  3. STI Ix
  4. Rule out torsion.
    - Ceftriaxone 250mg IM + doxy 100mg PO BD 10-14 days.
    - Analgesia + rest
45
Q

Epidydimal cyst

A
  • Trans illuminates
  • Painless
  • Lie above or behind balls.
  • Rx w/ surgery
46
Q

Hydrocele

A
  • Non painful
  • Fluctuant
  • Soft
  • Trans illuminates
  • Rx w/ surgery
47
Q

Testicular Torsion

A
  • 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.
48
Q

Varicocele

A
  • 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.
49
Q

Alpha blockers (Tamsulosin)

  1. MOA
  2. SE
A
  1. Decreases smooth muscle tone in the bladder and prostate

2. Dizziness, Postural hypotension, Dry mouth, depression

50
Q

5-alpha reductase inhibitors (finasteride)

  1. MOA
  2. SE
A
  1. Block conversion of testosterone to dihydrotestosterone.
    - Reduces prostate volume over 6 months.
  2. ED, reduced libido, ejaculation problems, man boobs.
51
Q

Balanitis

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. Inflammation of the glans penis.
    - STI
    - Dermatitis
    - Candida
    - Bacteria.
    - Often seen in DM.
  2. Swollen, tender and red glans penis.
    - Unable to retract foreskin.
    - Pain on urination.
  3. Clinical
    - Swabs MC&S
    - STI testing
  4. STI = Empirical
    - Dermatitis = topical hydrocortisone
    - Candida = topical clotrimzole, nystatin, miconazole. Recurrent - circumcise.
    - Bacteria = Fluclox or erythromycin.
52
Q

Medical indication for circumcision

A
  • Phimosis
  • Recurrent balanitis
  • Paraphimosis
53
Q

CI for circumcision

A
  • Hypospadias

- The skin needs to be used for hypospadias repair.

54
Q

Cancer type following neobladder reconstruction from the bowel.

A

Adenocarcinoma.

55
Q

Which drug should be started alongside Goserrelin (zoladex) for prostate Ca management

A
  • Cyptoterone acetate
  • Reduces risk of tumour flare due to LH release from the Pit.
  • Increased LH increases testosterone.
56
Q

Erectile dysfunction

  1. Causes
  2. Presentation
  3. Ix
  4. Rx
A
  1. 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.
  2. Simple
  3. Qrisk score.
    - Testosterone; if low or borderline repeat w/ LH and FSH and Prolactin.
    - If these are abnormal refer to endocrinology.
  4. Viagra (PDE-5 inhibitors)
    - Vacuums
    - Injections etc.
57
Q

Unilateral Hydronephrosis causes

A

PACT

  • Pelvic-ureteric obstruction
  • Aberrant renal vessels
  • Calculi
  • Tumours
58
Q

Bilateral hydronephrosis causes

A

SUPER

  • Stenosis of the urethra
  • Urethral valve issues
  • BPH
  • Extensive bladder tumour
  • Retro-peritoneal fibrosis.

Medical School Finals (24 decks)

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