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Year 4 > Surgery - Urology > Flashcards

Surgery - Urology Flashcards

1
Q

Describe acute urinary retention and its presentation

A

SUDDEN inability to pass urine

complete obstruction
lower abdominal pain
medical emergency
palpable bladder (dull to percuss)
BPH on DRE
May see phimosis on external genitalia examination
suprapubic tenderness
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2
Q

Describe chronic urinary retention and its presentation

A

PERSISTENT inability to completely empty the bladder

there is increased post-void residual volume
insidious onset
partial obstruction
painless
Associated LUTS
usually painless 
?lower abdominal pass
UTIs associated +/- renal failure
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3
Q

Describe complications of acute urinary retention

A

infection
AKI
post-retention haematuria

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4
Q

Describe complications of chronic urinary retention

A

hydronephrosis
CKD
bladder detrusor hypertrophy
acute on chronic retention

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5
Q

What are the causes of urinary retention?

A

POMN!
Post-op (iatrogenic)
Obstructive - BPH, constipation, stones, strictures, phimosis, infection
Medications (TCA’s opioids, antihistamines)
Myogenic (increased alcohol/anaesthesia)
Neurological - DM, stroke, GB syndrome, cauda equine syndrome

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6
Q

What are the investigations for urinary retention?

A

urine - dipstick and microscopy, culture and sensitivity
Bloods - FBC, U&E, PSA (can be falsely + in AUR)
renal USS
bladder USS
urinary catheterisation
CT (?tumour)
voiding cystourethrogram

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7
Q

How is acute urinary retention managed?

A

conservative:

  • analgesia
  • privacy, running water…
  • walking/movement

catheter:

  • urethral/suprapubic
  • antibiotic cover

drugs:
alpha-1-receptor blocker (relax the internal urethral sphincter) e.g. doxazocin, tamsulosin

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8
Q

How is chronic urinary retention managed?

A 
catheterise
treat the cause e.g. TURP
nephrostomy
ureteric stent
catheter (urethral/suprapubic)
antibiotics
5-a-reductase inhibitors (finasteride)
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9
Q

Describe the risk factors for UTI development

A

infancy
increased bacterial inoculation (sex, constipation, incontinence)
anatomy (females)
reduced urine flow (incomplete bladder emptying)
increased bacterial growth (DM)

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10
Q

Describe how an upper UTI may present

A

upper = pyelonephritis (kidneys)

- systemic symptoms (fever, rigors)…

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11
Q

Describe how a lower UTI may present

A

lower causes = cystitis, prostatitis, orchitis, epididymitis

Present with LUTS but no systemic symptoms

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12
Q

What is urosepsis?

A

life threatening UTI

high WCC, RR, HR and temperature

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13
Q

What organisms commonly cause UTI’s?

A

E.coli
Klebsiella pneumoniae
Proteus mirablis
Enterococcus faecalis

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14
Q

Describe LUTS and possible systemic urinary symptoms (which you would get in an UPPER UTI)

A

increased frequency
dysuria
urgency
polyuria

systemic = rigors, chills, fever, flank pain

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15
Q

What antibiotics are used to treat an upper UTI?

A

IV amox and gent

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16
Q

What antibiotics are used to treat a lower UTI?

A

trimethoprim

nitrofurantoin

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17
Q

What are the investigations of a UTI?

A

Bloods - FBC, U&E, CRP, ?BM, blood cultures
Urinalysis - microscopy and culture and sensitivuty
dipstick - + nitrates and + leukocytes
Imaging - USS (cyst/drainage issues?), micturating urethrogram

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18
Q

What are complications of recurrent UTIs

A

in children, may be underlying structural abnormalities

Risk of scarring/CKD

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19
Q

What is the definition of haematuria?

A

presence of blood in the urine

>3RBC/HPF in 2 successive samples

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20
Q

What are the causes of true haematuria?

A

Glomerular (kidney)
- infarct, trauma, stones, infection, cancer, GN, IgA nephropathy, polycystic kidney

Ureter
- stones, tumour

Bladder
-infection, stones, tumour, exercise

Prostate
- BPH, prostatitis, tumour

Urethra
- infection, stones, trauma, tumour

INFECTION IS THE MOST COMMON CAUSE!

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21
Q

What are the causes of false haematuria?

A

beetroot
rifampicin
PV bleed
porphyuria

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22
Q

What S/Sx may present with haematuria?

A 
LUTS
Blood might be frank or microscopic
'clots' suggest extra-glomerular source
infective/inflammatory signs:
- frequency
- dysuria
- urgency
- discharge
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23
Q

How is haematuria investigated?

A 
Bloods - FBC, U&E, clotting
Urine culture - exclude infection
Urine dipstick - MC&S, cytology
PR exam
Imaging...
-> renal USS for upper tracts
flexible cystoscopy +/-biopsy for lower tracts
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24
Q

How are large bleeds (haematuria) managed?

A 
Fluids
Catheterise
All bloods (FBC, U&E, G&S, clotting)
Transfusions?
Start Abx?
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25
Q

Describe testicular cancer types and their presentation

A

commonest male malignancy
5X>in caucasians than black ethnicity
excellent prognosis

3 types:

1) Germ cell = 80%
- seminoma = normal AFP/b-HCG, men 25-30 (older)
- teratoma = raised AFP/b-HCG, men 20-35yrs
2) Stromal cell = 10%
- leydig
- sertoli
3) Other e.g. lymphoma =10%

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26
Q

What are the risk factors for testicular cancer?

A 
un/maldescended testes (cryptorchidism)
atrophic testes
previous testicular cancer
infertility
HIV
infant hernia
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27
Q

What are the S/Sx of testicular cancer?

A 
painless testicular mass (firm, irregular, does not transilluminate)
para-aortic lymphadenopathy
B symptoms
haematospermia
secondary hydrocoele
gynaeomastia (with leydig cell tumours)
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28
Q

What are the differentials for a testicular lump?

A 
hydrocoele
scrotal hernia
testicular torsion
spermatocoele
benign cyst
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29
Q

How is a testicular lump investigated

A 
scrotal US
tumour markers (AFP, b-HCG, LDH)
CT (staging)
consider sperm storage
regular self-examination advised
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30
Q

What is the management of testicular cancer?

A

cryopreserve sperm if both testes abnormal
surgical -> radical orchidectomy
para-aortic node RTx
retroperitoneal LN dissection

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31
Q

Describe bladder cancer and its types

A 
2nd most common uro malignancy
3M:1F
average age 73yrs
Types:
90% transitional cell (MIBC/NMIBC) - can affect any part of urinary system
5% squamous
2% adenocarcinoma
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32
Q

What are the risk factors for bladder cancer

A 
male
occupation 
smoker
chronic inflammation (stones/infection)
drugs (cyclophosphamide)
race
pelvic irradiation
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33
Q

What are the S/Sx for bladder cancer?

A 
80% = painless frank haematuria
20% dipstick + haematuria
LUTS
recurrent UTIs
retention
obstructive renal failure
anorexia
confusion
lower limb swelling
?abdo/DRE mass
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34
Q

What are the differentials for bladder cancer?

A 
BPH
haemorrgahic cystitis
nephrolithiasis
RCC
UTI
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35
Q

How is bladder cancer investigated?

A

CT urethrogram
CT-KUB
USS renal tract
cystoscopy + cytology -> allows TNM staging

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36
Q

How is bladder cancer managed?

A 
Surgery = TURBT, cystectomy...
Chemotherapy = intravesicle mitomycin
RTx
Immunotherapy (BCG = bacille calmette guerin)
37
Q

What are the complications of bladder cancer?

A

Bladder haemorrhage

Sexual/urinary malfunction after cystectomy

38
Q

Describe prostate cancer and its risk factors

A

commonest urological malignancy
in 80% of 80yr old men (most die with it than of it)
> in black ethnicity
RFX: age, family history

39
Q

What zone of the prostate does prostate cancer most commonly affect?

And what is the most common type of prostate cancer?

A

peripheral zone

adenocarcinoma is the most common

40
Q

What are the S/Sx of prostate cancer?

A 
often asymptomatic 
raised PSA
LUTS
ureteric obstruction (if advanced)
if metastatic: -> bone pain, PSA, renal failure
41
Q

How is prostate cancer investigated?

A

TRIAD: DRE, PSA, TRUS biopsy
Bloods: FBC, PSA, U&E, LFT, calcium
Imaging: MRI, CXR/spinal XR (?mets), TRUS (+ biopsy), isotope bone scan

42
Q

How is prostate cancer staged?

A

Gleason score (2 x TRUS biopsies, each gets a score out of 5, then added together and the higher the total score the worse the prognosis)

43
Q

What is the management of prostate cancer

A
  • Conservative (close monitoring, watch and wait)
  • Radical therapy (prostatectomy)
  • Surgery (prostatectomy, robot assisted laparoscopic radical prostatectomy = RALRP)
  • Medical (androgen deprivation therapy) = LHRH antag/agonists, radiotherapy (external beam or brachytherapy)
44
Q

What is PSA and what can cause it to be raised?

A 
A proteolytic enzyme (a glycoprotein) used to liquefy ejaculate
half life is 2-3 days
Screening is NOT recommended as can be raised with:
- age
- PR exam
- sex
- TURP
- prostatitis
45
Q

What are the causes of testicular torsion?

A

Can be primary but normally secondary to exertion/minor trauma
Due to an anatomical variant of testicular anatomy (tunica vaginalis invests the whole testes rather than having a bare area, this is called a ‘bell clapper’ testicle)
Means the testes can twist on its mesentery

46
Q

How is testicular torsion treated (and what are the important timings?)

A

SURGERY - try to untwist but consent for possible orchidectomy
4-6hr salvageable window
Carry out orchidopexy on the opposite testes
IV access
Bloods (FBC, U&E, G&S, clotting)

47
Q

What are the risk factors for renal stones?

A 
male
20-40yrs
caucasian
dehydrated
hypercalcaemia
tea, chocolate, strawberries (high in oxalate)
UTI
gout
diuretics (furosemide, thiazide)
48
Q

What are the three causative factors of renal stones

A

1) Infection (proteus mirablis -> has urease enzyme and increases formation of struvite stones e.g. Ca/Mg/NH3 components)
2) Abnormal urine (high oxalate, low citrate, dehydration)
3) Urinary obstruction (congenital (PUJ) or acquired obstructions (e.g. strictures))

49
Q

What are the 5 types of renal stones?

A

CatSlidUptheColourfulXylophone

Calcium stones (e.g. calcium oxalate, calcium phosphate)
-increased risk in Crohn's disease

Struvite stones (ass. with proteus mirablis infection) - triple stones: Ca/Mg/NH3 components

Uric acid/urate stones (common in gout, radiolucent)

Cysteine stones (associated with Fanconi syndrome)

Xanthine stones (radiolucent)

50
Q

What are the S/Sx of renal stones?

A 
colicky pain, loin -> groin
associated N&V
patient CANNOT LIE STILL
LUTS
UTI
haematuria
fever
pyuria
urinalysis
?anuria
51
Q

What are the three common sites where stones can become stuck?

A

PUJ
pelvic brim
VUJ

52
Q

What are the differentials of renal stones?

A 
UTI
gynae pathology
pyelonephritis
lower lobe pneumonia
acute abdomen
testicular torsion
radicular pain (shingles, sciatica)
53
Q

What investigations would you carry out for renal stones?

A

Hx and Ex
Urine -> dipstick, MC&S, pH (alkaline - infection stone, acidic = uric acid stone), B-HCG!!!
Bloods -> FBC, U&E, CRP, Ca, PO4, urate
Imaging: CT-KUB, X-ray, USS (?hydronephrosis), IV urogram, functional scans (DMSA)

54
Q

What is the normal diameter of the ureter?

A

5-7mm

55
Q

What is the management of renal stones?

A 
Analgesia (diclofenac, morphine)
Fluids and Abx
1) Conservative and leave to pass
2) Medical expulsive therapy:
- nifedipine (relaxes smooth muscle)
- tamsulosin (alpha 1 blocker)
3) temporary relief
- nephrostomy
- stents
4) active stone removal
- ESWL
- ureteroscopy +/- laser, pneumatics, electrohydraulics
- cystoscopy
- PNL (percutaneous nephrolithotomy)
- open/lap (nephrolithotomy, ureterolithotomy, cystolithotomy)
56
Q

How can renal stones be prevented?

A

hydration
treat UTIs rapidly
low oxalate (less strawbs, chocolate and tea)
urine alkalisation (sodium bicarbonate)
thuazide diuretics (for idiopathic hypercalcaemia)

57
Q

What is BPH and its two components?

A

BPH = LUTS caused by bladder outlet obstruction due to BPH
2 components:
- static: increased mass of benign prostatic tissue which narrows urethral lumen
- increased prostatic smooth muscle tone (due to stimulation of a-adrenergic receptors)

Pathophysiology: testes, prostate and seminal vesicles make 5-a-reductase which converts testosterone -> DHT (DHT is more potent and induces growth of prostate)

58
Q

What zone of the prostate does BPH most commonly involve?

A

transitional zone

59
Q

What are the signs/symptoms of BPH

A

Storage symptoms: nocturia, frequency, urgency, overflow incontinence

Voiding symptoms: hesitancy, straining, poor flow, strangulatory (urinary tenesmus)

2o to urinary stasis: UTI, bladder stones

60
Q

What are the differentials for BPH?

A 
Prostate cancer
prostatitis
UTI
Overactive bladder
Bladder cancer
Neurogenic bladder
Urethral stricture
61
Q

What investigations should be carried out for BPH?

A 
Bloods: PSA, U&E
Urine: dipstick, MC&S
Imaging: TRUS and biopsy
Urodynamics -> pressure flow cytometry
Voiding diary
62
Q

What is the management of BPH?

A

Conservative: less caffeine and alcohol, bladder training, double voiding
Medical: useful for mild disease when awaiting TURP
- alpha-blocker (tamsulosin)
- finasteride (5-a-reductase inhibitor) = takes 6/12 to work
Surgical: TURP, laser prostatectomy, open prostatectomy

63
Q

What are complications of TURP?

A 
bleeding
infection
retrograde ejaculation
ED
incontinence
urethral stricture
BPH recurrence
64
Q

Define erectile dysfunction

A

inability to achieve/maintain an erection which is satisfactory for sexual intercourse

65
Q

Describe causes of erectile dysfunction:

A

Drugs - antihypertensives, alcohol, recreational drugs
Psychological - anxiety, depression
Vascular - hypercholesterolaemia, atheroma, DM
Penile - cavernositis, previous priapism, peyronies disease
Endocrine - hyperthyroid, DM, hypogonadism…
Neurological - parkinson’s, spinal injury autonomic neuropathies

66
Q

How is erectile dysfunction investigated?

A 
Questionnaires -> international index of erectile dysfunction
BP
glucose
lipids
serum electrolytes
hormones
TFTs
67
Q

Describe renal cell carcinoma and the two main types

A

Any cancer affecting the kidneys
Due to imaging advances, the number of cancers being diagnosed incidentally is increasing!
1) renal cell carcinoma = 80% (5 subtypes)
2) transitional cell carcinoma = 20%

68
Q

What are the S/Sx of renal cancer?

A

Usually asymptomatic and picked up on imaging!

  • haematuria
  • palpable abdominal mass
  • flank pain
69
Q

What is the link between varicocoeles and renal cancer?

A

Often a renal cancer can cause gonadal vein compression and so anyone presenting with varicocoele gets a kidney scan

70
Q

Where do the L and R renal veins drain into?

A

L gonadal vein -> L renal vein

R gonadal vein -> straight into IVC

71
Q

How is renal cancer investigated?

A

Bloods: FBC, LDH, U&E, a+, LFT
Urine: dipstick and MCS
Examination: abdo mass/lymphadenopathy/varicocoele/lower limb oedema
Imaging: pelvic USS, CT/MTI, bone scan, biopsy, PET scan
Flexible cystoscopy

72
Q

How is renal cancer treated?

A

Medical - temsirolismus (mTOR inhibitor)
Surgery - radical nephrectomy, partial nephrectomy, nephron-sparing surgery
Chemo/immunotherapy (usually very angiogenic so respond well to VEGF inhibitors)
Palliative if mets

73
Q

What is the definition of prostatitis/orchitis/epididymo-orchitis?

A

Epididymitis = inflammation of the epididymis, causing pain and swelling (usually unilateral, develops over a few days and lasts ~6 weeks)

Orchiditis = inflammation of the testes

Acute epididymo-orchiditis = inflammation of both (most commonly used term!)

74
Q

What is the cause of epididymo-orchiditis and its pathophysiology

A

Usually BACTERIAL
Younger men = chlamydia, gonorrhoea
Older men = enteric pathogens e.g. E.coli

Retrograde ascent of pathogens from urethra/bladder via ejaculatory ducts and vans deferens which colonise the epididymis leading to infection

75
Q

What are the risk factors for epididymo-orchiditis

A

Sex (STDs)
Anal intercourse (enteric organism infection)
UTIs
Bladder outlet obstruction

76
Q

What are the S/Sx of epididymo-orchiditis

A 
Urethral discharge
Fever
LUTs
Unilateral scrotal swelling and pain
Tenderness
Hot, erythematous, swollen hemiscrotum
77
Q

What are the differentials of epididymo-orchiditis

A 
Torsion
scrotal oedema
infected hydrocoele
strangulated inguinal hernia
testicular tumour
78
Q

How is epididymo-orchiditis investigated?

A 
Urethral swab
urine dipstick
urine microscopy
urine culture and sensitivity
NAAT test of urethral discharge (for chlamydia/gonorrhoea)
79
Q

How is epididymo-orchiditis treated?

A

Supportive measures

Antibiotics

80
Q

What are the causes of urethral strictures?

A

Trauma (surgery, instruments)
Infection (STIs)
Chemotehrapy
Balantitis xerotica obliterans

81
Q

What are the complications of urethral strictures

A

voiding difficulties: hesitancy, strangury, poor stream, terminal dribbling, pis en deux (need to pee immediately after peeing)

82
Q

What is the treatment of urethral strictures?

A

Internal urethrotomy (surgery to remove a narrowed section of the urethra)
Stent
Dilatation

83
Q

What is the definition of a hernia and what are its contents?

A

protrusion of viscus beyond the coverings of the viscus in which it is contained
Contents: sac, covering and contents

84
Q

Name 5 types of hernia

Which one is most likely to strangulate?

A 
epigastric
incisional
umbilical
inguinal (direct and indirect)
femoral -> more likely to strangulate as borders are 70% none
85
Q

What is the pathophysiology of a hernia?

A

Increased intra-abdominal pressure (exercise, coughing, straining, sneezing)
+
weakened abdominal wall (older age, malnutrition, muscle/nerve paralysis)

86
Q

How are hernias investigated?

A

Examination -> reducible?, N&V (obstructed?), severe pain (strangulated?)
Hernigram (CT + contrast)
USS (used with scrotal lumps to exclude hydrocoeles)

87
Q

What is the difference between an incarcerated and strangulated hernia>

A

Incarcerated - a hernia that is irreducible but not strangulated

  • The lumen of the hernia has become obstructed but the blood supply is intact
  • Can cause bowel obstruction

Strangulation - the blood supply to the hernia contents are cut off

  • Tissue undergoes ischaemic necrosis
  • Perforation and septic shock can result
88
Q

What are the 9 layers of the abdominal wall?

A 
skin
subcut fat
fascia -> campers and scarpas
external oblique
internal oblique

Year 4 (28 decks)

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