uro Flashcards
definition of obstructive uropathy
problem passing urine as a result of an obstruction along the urinary tract
presentation of upper urinary tract obstruction (ureters)
- loin to groin/flank pain on affected side
- reduced/no urine output
- non-specific symptoms such as vomiting
- reduced renal function on bloods
presentation of lower urinary tract obstruction (bladder/urethra)
- acute urinary retention
- lower urinary tract symptoms: poor flow, difficulty initiating urination, terminal dribbling)
- reduced renal function on bloods
3 causes of upper urinary tract obstruction
- kidney stones
- local cancer masses pressing on ureters
- ureter strictures
4 causes of lower urinary tract obstruction
- BPH
- prostate cancer
- urethra strictures
- neurogenic bladder
definition of neurogenic bladder
no neurological signal to the bladder telling it to contract
5 complications of obstructive uropathy
- AKI (post-renal)
- CKD
- infection due to pooling of urine and retrograde infection
- dilated kidney, ureters or bladder
- pain
what is the most common type of kidney tumour
renal cell carcinoma
typical metastasis of renal cell carcinoma
cannon ball metastases in the lungs
presentation of renal cell carcinoma
- often asymptomatic
- haematuria
- vague loin pain
- non-specific cancer symptoms: weight loss, fatigue, anorexia, night sweats, lethargy
2 most common types of renal cell carcinoma and prevalence + common renal tumour in children
- clear cell (75-90%)
- papillary (10%)
Wilms tumor in children <5yo
5 risk factors for renal cell carcinoma
- smoking
- obesity
- hypertension
- long-term dialysis
- Von Hippel-Lindau disease
management approach for renal cell carcinoma
first-line = surgery (partial nephrectomy)
+/- radiotherapy and chemotherapy
3 paraneoplastic features of renal cell carcinoma and pathophysiology
- polycythaemia - RCC secretes unregulated erythropoietin
- hypercalcaemia - RCC secretes hormone which mimics PTH
- Stauffer syndrome - abnormal LFTs demonstrating obstructive jaundice but no localised liver or biliary metastasis
5 types of bladder cancer and prevalence
- transitional cell carcinoma (90%)
- squamous cell carcinoma (10%)
RARE: - adenocarcinoma
- sarcoma
- small cell carcinoma
investigations for diagnosis of bladder cancer
cystoscopy and biopsy
typical presentation of bladder cancer
painless haematuria
risk factors/associations for bladder cancer
- smoking
- carcinogens found in hair dyes, industrial paint, rubber, motor, leather
risk factor for squamous cell bladder cancer
schistosomiasis (in countries with high prevalence)
treatment for bladder cancer which is not invading the muscle
transurethral resection of a bladder tumour = TURBT
chemo after surgery
BCG vaccine injection into bladder via catheter:
- weekly treatments for 6 weeks
- then every six months for 3 years
treatment for bladder cancer which has invaded the muscle
- radical cystectomy with ileal conduit
- radiotherapy
- IV chemotherapy
pathophysiology of benign prostatic hyperplasia
hyperplasia (more cells not bigger cells) of the stromal and epithelial cells of the prostate
presentation of BPH
lower urinary tract symptoms (LUTS)
- hesitancy
- frequency
- urgency
- intermittency
- straining to void
- terminal dribbling
- incomplete emptying
investigations/assessments for BPH
- urine dipstick - exclude infection
- PSA - done PRIOR to rectal exam (falsely elevates result) to exclude cancer
- rectal exam - assess size, shape and characteristics
management of BPH (mild symptoms)
reassurance and monitoring
2 medical management options for BPH
- alpha-blockers to relax smooth muscle e.g. Tamsulosin 400mcg OD
- 5-alpha reductase inhibitors to block testosterone and reduce prostate size e.g. finasteride
4 options for surgical management of BPH
- transurethral resection of the prostate (TURP)
- transurethral electrovaporisation of the prostate (TUVP)
- holmium laser enucleation of the prostate (HoLEP)
- open prostatectomy via abdo or perineal incision
what is a TURP procedure
transurethral resection of the prostate (TURP)
accessing the prostate through the urethra and ‘shaving’ prostate tissue using diathermy to create a wider space for urine to flow
complications of a TURP procedure and mnemonic
FIRES
- failure to resolve symptoms
- incontinence
- retrograde ejaculation
- erectile dysfunction
- strictures
risk factors for prostate cancer
- increasing age
- FHx
- Black
- tall
- use of anabolic steroids
presentation of prostate cancer
lower urinary tract symptoms (LUTS) - hesitancy - frequency - urgency - intermittency - straining to void - terminal dribbling - incomplete emptying also haematuria, erectile dysfunction, signs of cancer (FLAWS)
use of PSA in prostate cancer
not very sensitive or specific (false positives and false negatives)
useful in monitoring progression of disease and success of treatment
feeling of prostate on PR: benign vs cancerous
- benign: smooth, symmetrical, slightly soft, maintained central sulcus
- cancerous: firm/hard, asymmetrical, craggy, irregular, loss of central sulcus
investigations for suspected prostate cancer
- PR, PSA
- prostate biopsy (multiple needle biopsies required)
2 types of prostate biopsy
- transrectal ultrasound-guided biopsy (TRUS):
- US inserted into rectum and needle biopsy taken through rectal wall
- ~10 biopsies taken - transperineal biopsy:
- more biopsies taken (~35)
- higher sensitivity than TRUS but takes longer and requires GA
what grading system is used in prostate cancer and overview
Gleason - helps determine what tx is most appropriate
relating to histological appearance, higher grade = worse prognosis
from grade 1 = well differentiated to grade 5 = anaplastic (poorly differentiated)
5 types of tx for prostate cancer
- watchful waiting
- radiotherapy
- brachytherapy
- hormonal tx (antiandrogen)
- surgical
what is brachytherapy
- radioactive seeds implanted into prostate
- delivers continuous, targeted radiotherapy to prostate
mechanism of hormone therapy in prostate cancer
block androgens (e.g. testosterone) to slow/stop growth of cancer
options for hormone therapy in prostate cancer
- bilateral orchidectomy
- LHRH agonists (e.g. goserelin) cause chemical castration
- androgen receptor blockers (e.g. bicalutamide)
surgical tx of prostate cancer
prostatectomy
side effects of hormone therapy for prostate cancer
- hot flushes
- sexual dysfunction
- gynaecomastia
- fatigue
- osteoporosis
4 complications of prostatectomy/radiotherapy tx
- erectile dysfunction
- urinary incontinence
- radiation-induced enteropathy (GI symptoms such as PR bleeding, pain, incontinence)
- urethral strictures
definition of epididymo-orchitis
inflammation/infection of the epididymis and teste
4 causes of epididymo-orchitis
- e. coli
- chlamydia trachomatis
- neisseria gonorrhoea
- mumps
presentation of epididymo-orchitis
- (usually) unilateral testicular pain and tenderness of gradual onset (mins) with dragging/heavy sensation
- urethral discharge (chlamydia/gonorrhoea)
- tender on palpation
- swelling and erythema
management of epididymo-orchitis
- admit and treat sepsis if indicated, otherwise as OP
- abx e.g. ciprofloxacin for 2/52
- tight underwear for scrotal support
- abstain from intercourse
investigation for epididymo-orchitis
confirm with US - exclude torsion and tumour
typical presentation of testicular torsion
- teenage boy
- acute/sudden onset unilateral testicular pain
- triggered by playing sport/activity
complication of testicular torsion
subfertility/infertility
what is the window for testicular torsion and how long is it
time after onset before the damage from ischaemia is irreversible
6 hours
examination findings in testicular torsion
- acutely tender testicle
- may be too tender to examine
- firm testicle
- absent cremasteric reflex
- abnormal lie: horizontal, rotated, elevated/retracted
what anatomical variant is associated with testicular torsion
bell-clapper deformity
- testicle normally fixed posteriorly to tunica vaginalis
- in bell-clapper deformity this fixation is absent
- allows testicle to rotate within tunica vaginalis which can twist vessels and cut off blood supply
management of testicular torsion
urgent urology assessment immediate surgical intervention - untwist - fix both testicles into correct position (orchiopexy) - possible orchidectomy if necrotic
7 differentials for testicular lump
- testicular cancer
- hydrocoele
- varicocoele
- epidydimal cyst
- epididymo-orchitis
- inguinal hernia
- testicular torsion
definition of hydrocoele
fluid build-up within the tunica vaginalis membrane
examination findings in hydrocoele
- transilluminated by shining torch into fluid
- soft, fluctuant, may be large
- irreducible, no bowel sounds
definition of varicocoele
swollen pampiniform venous plexus (testicular veins)
examination findings in varicocoele
- soft, ‘bag of worms’
- may cause dragging or soreness
definition of epididymal cyst
sac of fluid at the epididymis
examination findings in epididymal cyst
- soft, fluctuant lump at the top of the testicle
examination findings in inguinal hernia
- separate from testicle
- soft
- bowel sounds
- reducible
anatomy of the testicular veins
- R testicular vein arises from IVC
- L testicular vein arises from L renal vein
what to consider in unilateral varicocoele
if unilateral left sided varicocoele, can indicate obstruction of L testicular vein (from L renal vein) e.g. caused by renal cell carcinoma
2 main types of testicular cancer
germ cell cancer:
- seminoma
- teratoma
tumor markers in testicular cancer
- alpha-fetoprotein (raised in teratomas)
- beta-hCG (raised in teratomas > seminomas_
- lactate dehydrogenase
4 sites of metastasis for testicular cancer
- lymphatics
- lungs
- liver
- brain
prognosis for testicular cancer
good prognosis unless metastatic
seminomas have slightly better prognosis
treatment for testicular cancer
- orchidectomy (+ testicular prosthesis)
- chemo / radiotherapy depending on staging
- monitor post-tx with tumour markers and imaging
definition of pyelonephritis
infection in the renal pelvis (join between kidney and ureter) and parenchyma
risk factors for pyelonephritis
- female
- structural urological abnormalities
- diabetes
4 most common causative organisms for pyelonephritis
- E. coli
- klebsiella
- enterococcus
- pseudomonas
presentation of pyelonephritis
- high fever and rigors
- loin to groin pain
- dysuria, urinary frequency
- haematuria
- non-specific symptoms e.g. vomiting
- pain on bimanual palpation of the renal angle
urine dipstick results in pyelonephritis
- blood
- protein
- leucocyte esterase (produced by neutrophils)
- nitrites (gram-neg organisms metabolise nitrates -> nitrites)
investigations in pyelonephritis
- CT to confirm dx
- USS in children
- DMSA scans to indicate level of scarring in recurrent pyelonephritis
management of pyelonephritis
- blood and urine culture
- broad-spectrum abx (co-amoxiclav) until culture + sensitivities back
- admit if systemically unwell
- IV rehydration
- analgesia
- antipyretics
complications of chronic pyelonephritis
- scarring of renal parenchyma
- CKD
- abscess/pus in or around kidney
4 types of renal stones
- calcium oxalate (80%)
- calcium phosphate
- uric acid
- struvite (magnesium ammonium phosphate) - can be staghorn
what is a staghorn calculus
renal calculus which forms the shape of a staghorn - body sits in renal pelvis with horns extending into renal calyxes
usually struvite
how is a staghorn calculus formed
recurrent upper UTI -> bacteria hydrolyse urea in urine to ammonia, creating solid struvite
presentation of renal stones
- may be asymptomatic
- renal colic
- excruciating loin to groin pain
- colicky as stones move and settle
- haematuria, nausea, vomiting, oliguria
- may be septic
investigations to diagnose renal stones
- urine dipstick (haematuria +/- exclude infection)
- bloods: FBC, CRP, U&E
- AXR but may not be visible
- CT KUB gold standard (non-contrast CT)
management of renal stones
- NSAIDs e.g. PR diclofenac
- antiemetic if needed
- fluids
- abx if infection
- smaller stones (<6mm) may pass spontaneously
- tamsulosin (alpha-blocker) to aid passage
- surgical intervention if needed
4 surgical intervention options for renal stones
- extracorporeal shock wave lithotripsy (x-ray guided breaking up of stones by shock waves)
- ureteroscopy and laser lithotripsy (stone broken up by lasers, guided via camera through urethra/bladder/ureter)
- percutaneous nephrolithotomy (small incision in back, stones removed or broken up)
- open surgery
advice to prevent recurrent renal stones
- increase oral fluids
- reduce dietary salt intake
- reduce intake of oxalate-rich foods e.g. spinach, nuts, rhubarb, tea
- reduce intake of urate-rich foods e.g. kidney, liver, sardines
- limit dietary protein
prophylaxis for calcium renal stones
thiazide
risk factors for erectile dysfunction
- increasing age
- CVD risk factors: obesity, DM, dyslipidaemia, metabolic syndrome, HTN, smoking
- alcohol
- drugs: SSRIs, beta-blockers
investigations for erectile dysfunction
- calculate QRISK score for CVD (measure lipid and fasting glucose)
- free testosterone measured between 9-11am
- repeat testosterone with FSH/LH/prolactin levels if low or borderline
most important risk factor for testicular cancer
infertility -> 3x more likely to develop testicular ca if infertile
histological appearance of clear cell carcinoma
variegated, septated interior (different colours and separate compartments e.g. solid and liquid)
triad for renal cancer sx
flank pain
mass
haematuria
how does gynaecomastia occur in testicular cancer
increased oestrogen:androgen ratio
what is a nephroblastoma
wilm’s tumour
renal cancer usually presents in first 4 years of life
presents as a mass associated with haematuria (+/- pyrexia)
tumour markers in testicular cancer patterns
AFP (alpha-fetoprotein) and HCG +/- lactate dehydrogenase (LDH)
raised in teratomas and yolk sac tumours, normal in seminomas
causes of hydronephrosis: unilateral vs bilateral
unilateral: - pelvic-ureteric obstruction - renal vessel abnormality - calculi - tumours of renal pelvis bilateral: - urethral stenosis - urethral valve - prostatic enlargement - extensive bladder tumor - retro-peritoneal fibrosis
investigations for hydronephrosis
USS
IV urogram
antegrade/retrograde pyelography
CT (non-contrast) if renal colic suspected
management of hydronephrosis
remove obstruction and drain urine
- nephrostomy if acute upper urinary tract obstruction
- ureteric stent or pyeloplasty if chronic obstruction
causative organisms of epididymo-orchitis and epidemiology
sexually active <35yo = chlamydia trachomatis
>35yo = e. coli
criteria for doing a PSA test
at least:
- 6 weeks after prostate biopsy
- 4 weeks after UTI
- 1 week after PR
- 48 hours after vigorous exercise
- 48 hours after ejaculation
main findings on examination of epidydimal cyst
can palpate above the swelling
non-tender
above and behind testis
main findings on examination of hydrocoele
transilluminates
soft, fluctuant
3 main things to assess with a scrotal swelling
- involving testicle or not
- trans-illumination
- able to palpate above the swelling
main findings on examination of inguinal hernia
cannot get above it
may be reducible
main findings on examination of epididymo-orchitis
tender, eased by elevating testis
hx of dysuria and discharge
main findings on examination of varicocoele
LHS > RHS (testicular vein drains into renal vein)
treatment of prostatitis
14 day course of quinolone (ciprofloxacin)
