Urological Conditions In Adults Flashcards
What is the commonest histologicall classification of prostate carcinoma?
Adenocarcinoma
What is the difference between grading and staging of of a malignancy?
Grade = How well/poorly differentiated tumour cells are
Stage = How far the cancer has spread
Haematogenous metastases of prostate ca usually occurs first to which area?
Axial skeleton
What are the causes of a raised PSA
Prostate Ca
BPH
Prostitis
Prostate biopsy/surgery
Rectal exam
In what part of the prostate does prostate cancer usually start?
Peripheral zone
How is prostate Ca diagnosed?
Rectal examination
Prostate biopsy
Serum PSA
What are the possible complications of a trans-rectal prostate biopsy?
Rectal bleeding
Bacteraemia
Septicaemia
Prostatitis
Cystitis
Epididymo-orchitis
Urinary retention
Haematuria
Haematospermia
How can the complications of prostate biopsy be prevented?
Administer prophylactic antibiotics
Monitor for 24hrs for septicaemia
What is the best, first option of treatment in a patient who presents with severe back pain due to metastatic prostate cancer?
Hormonal treatment - suppress testosterone:
- Bilateral orchidectomy
- Oestrogen
- Anti-androgens - Ketaconazole
- LHRH-agonists (GnRH-agoniste) - Buserelin
What are the possible complications and side-effects of bilateral orchidectomy for prostatic carcinoma?
Bleeding
Wound sepsis
Psychological trauma of castration
Loss of libido and potency
Hot flushes
What is the treatment of organ confined prostate carcinoma for a patient with >10 years life expectancy?
Depends on stage of disease
Radical prostatectomy
External beam radiotherapy
Brachytherapy
How would you treat an older patient with organ confined prostate carcinoma (e.i <10 years life expectancy)?
Depends on stage of disease
Conservative management
Watchful waiting
What are the complications of a radical prostatectomy?
Intra-operative haemorrhage
Erectile dysfunction
Incontinence
Name 5 possible complications of advanced prostate carcinoma
LUTS
- Hesitancy
- Weak stream
- Interrupted stream
- Feeling of incomplete voiding
- Post-micturation dribbling
Urinary retention
UTI
Haematuria
Pain
With regard to prostate cancer: In which age group does it occur most commonly?
> 45 - 50 years
What are the findings on rectal examination for organ-confined prostate carcinoma?
Enlarged prostate with nodule or hard area palpable in 1 or both lobes
What are the findings on rectal examination for advanced prostate carcinoma?
Enlarged, hard irregular prostate
Poorly defined edges of prostate
Overlying rectal mucosa is intact
Describe the pathogenesis of BPH
Arises from transitional zone
>>Enlarged prostate > increased urine outflow obstruction > detrusor hypertrophy > decompensation > increased residual volume post micturation > chronic retention > hydronephrosis > renal failure
What are the symptoms of BPH?
50% asymptomatic
LUTS
How is BPH diagnosed?
Symptom scoring
* IPSS - 7 Q’s - <7 = Mild and >20 = Severe
Rectal examination
* Smooth, non-tender enlarged prostate
Urine flow rate
- Low flow = <10ml/sec
- (N) = Bell shaped curve
Bloods
* Serum PSA
How would you manage BPH with a symptom score of <7? Explain your answer
IPSS <7 = Mild
Watchful waiting
Because…
50% will remain unchanged
25% will improve
25% will get worse
How would you manage a patient with symptomatic uncomplicated BPH?
Medical management
Flowmax (alpha a1 adrenergic blocker)
* Causes smooth muscle relaxation of the prostate
Proscar (5 alpha-reductase inhibitor)
- Causes shrinkage of the prostate
- Decreases PSA
- Secreted in semen and can cause hypospadias in a fetus
What are the indications for surgery in BPH?
Complications of bladder outflow obstruction
Recurrent haematuria due to BPH
Failed/contraindicated medical treatment
Previous prostate surgery
What are the surgical options for management of BPH?
TURP
Open prostatectomy
What are the complications of TURP?
TUR-syndrome
* Fluid overload + hyponatraema (esp. when using sterile water)
Secondary Haemorrhage
Septicaemia
Retrograde ejaculation
Incontinence
Urethral stricture
How would you managed a patient with TUR-syndrome?
Stop procedure
Furoscemide 40mg IV
What is the most common type of bladder cancer?
Transitional cell carcinoma
What is the etiology of TCC of the bladder?
Smoking
Exposure to aromatic amines
Analgesic abuse
Cyclophosphamide
Pelvic Irradiation
What is the clinical presentation of a TCC of the bladder?
Painless macroscopic haematuria (70-90%)
Microscopic haematuria
Irritative voiding symptoms
Suprapubic pain
Lower abdominal mass
Metastases
- Dyspnoea
- Bone pain
What special investigations would you do for a TCC of the bladder?
FBC
Renal function test
* Creatinine raised
Urine cytology
- Urothelium cells
- Presence of malignant cells
Cystoscopy
- visualization of lesion
- Can do a TURBT/biopsy of lesion
Ultrasound
- Bladder mass
- Presence/absence of hydronephrosis
Excretory urethrogram
- Ureteric obstruction
- Hydronephrosis
- Filling defect on cystogram phase
CT scan
* Staging
List the causes of a filling defect
Bladder tumour
Bladder stone
Blood clot
Prostate middle lobe
Foley catheter balloon
Overlying bowel gas
Foreign body
Fungus Ball
How would you manage a carcinoma is situ (CIS) of the bladder?
Intravesicular immunotherapy
* BCG weekly for 6 weeks
If successful:
* BCG every 3 months for 3 years
If unsuccessful:
* radical cystectomy
How would you manage a superficial papillary lesion of the bladder?
Complete TURBT
Follow-up cystoscopy every 3 months
Repeat TURBT if needed
(Prognosis = 75-95% 5-year survival)
What are the indications for a cystectomy?
Unsuccessful intravesical immunotherapy of CIS
Extensive multiple recurrent tumours
Evidence of muscle invasion
List to types of Renal calculi
Radio-opaque
- Calcium oxalate
- Struvite (infection) - Staghorn
- Cystine
Non-opaque
- Uric acid
- Indinavir
Discuss calcium stones
Most common renal calculi (75%)
May be associated with metabolic abnormalities
- Hypercalcaemia
- Hypercalciuria
- Hyperoxaluria
- Hyperuricosuria
- Low magnesium / citrate
Discuss struvite (infection) stones
20% of renal calculi
Pathogenesis
- UTI caused by urease producing organisms - Proteus, pseudomonas, klebsiella
- Urea is then broken down into ammonia which causes the urine to become alkalinic
- This leads to precipitation of various proteins in urine + pus cells + organisms which makes up the matrix of the stone
- The crystalline part of the stone is made up of calcium, magnesium, ammonium and phosphate (CAMP)
Rapid stone growth leads to a staghorn configuration
* Fills/partially fills the renal pelvis + 2 or more renal calyces
What are the factors associated with uric acid stone formation?
Low urine output - Dehydration
Low urine pH
High red meat intake
Chronic diarrhoea - dehydration
Hyperuricosuria - Gout
What are the complications of renal calculi?
UTIs
Obstruction
- Hydronephrosis
- Renal failure
Chronic irritation
- Leukoplakia
- SCC of renal pelvis
What is the presentation of a patient with a renal calculi?
Haematuria
Pain
- Renal colic
- Renal pain
Complications
Asymptomatic - Infection stones
How would you investigate a patient with suspected renal calculi?
Urine dipstick
* Haematuria
Urine MCS
AXR
- Able to visualize an radio-opaque stone
- Calcium - Round, irregular border
- Struvite - Staghorn
- Cystine - Ground glass appearence
IVP
- site of stone
- degree of obstruction
- kidney function
Metabolic evaluation
- Primary hyperparathyroidism - serum levels
- 24 hour urine - recurrent stone formers
Stone analysis
What is the surgical treatment of a renal calculi?
General measures
- High fluid intake
- low salt, low red meat diet
- do not restrict calcium intake
Surgical Treatment
- PCNL
- ESWL - small stones <2cm
- Pyelolithomy - removed from renal pelvis
- Nephrolithotomy - removed through renal parenchyma
- Combined treatment
- Chemolysis
- Nephrectomy
Long term follow up
What is the etiology of bladder calculi?
Primary
* Children
Secondary
- Bladder outflow obstruction
- Foreign bodies
- Stasis and infection - neuropathic bladder/ bladder diverticulum
- Stone from upper tract
- Primary hyperparathyroidism
What is the clinical presentation of a patient with a bladder calculi?
Suprapubic pain
Dysuria
Haematuria
Intermittent interruption of bladder stream
Symptoms of bladder outflow obstruction
Irritative symptoms
How do you diagnose a patient with a bladder calculi?
US
AXR
* 50% non-opaque
Cystoscopy
* Usually done for bladder outflow obstruction
What is the treatment of a patient with a bladder calculi?
Endoscopic cystolithopaxy
Open cystolithopaxy
- Multiple stones
- If open prostatectomy needed
TURP
* For treatment of bladder outflow obstruction if present
What are the components of the posterior urethra?
Prostatic urethra
Membranous urethra
What are the components of the anterior urethra?
Penile urethra
Bulbar urethra
Glanular urethra
What are the inflammatory causes of Urethral strictures in males?
Gonorrhoea urethritis - Most common cause in SA
Chlamydial urethritis
Balanitis xerotica obliterans (lichen sclerosis)
Discuss how a catheter can cause a urethral stricture in a male
- Previous indwelling urethral catheter
- Premature inflation of catheter balloon in the urethra
- Submeatal/Bulbar stricture
What are the clinical features of urethral strictures?
Previous history…
- Urethritis
- Catheterisation
- Perineal trauma
- Pelvic radiotherapy
- Urinary difficulty - thin stream/spraying
Examination…
- Meatal/submeatal stricture
- Palpable bulbar urethra thickening
- Palpable urethral mass - carcinoma
Local complications
- peri-urethral abscess
- necrotising fasciitis
Complications of bladder outflow obstruction
- urinary retention
- epididymitis
- chronic renal failure
How would you investigate a patient with a urethral stricture?
Urine dipstick
Urine MCS
Ascending Retrograde Urethrogram
- Foleys catheter inserted through the EUM and balloon inflated just enough to prevent leakage
- Contrast injected upwards through the EUM under x-ray screening
- Info about penile and bulbar urethra
Descending retrograde urethrogram
- Patient already has a suprapubic catheter in place
- Bladder is filled with contrast via surprapubic catheter
- Patient voids under x-ray screening
What is the managemnet of urethral strictures in males?
Inital - Suprapubic catheterization
Dilation of urethra
Optical Urethrotomy
- short <2cm strictures in bulbar urethra
- Cystoscope with small knife at tip
- indwelling transurethral catheter 1-3 days
Intermittent self dilatation
* Used with urethral dilatation and optical urethrotomy coz of stricture recurrencce
Urethral stent
* Expensive
Urethroplasty - Treatment of choice
- Excision and end to end urethroplasty - <2cm
- Substitution urethroplasty
What are the treatment complications of urethral strictures?
Periurethral abscess
Necrotising fasciitis of perineum
Urethrocutaneous fistula
Proximal diversion
