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Urology > Urological Conditions In Adults > Flashcards

Urological Conditions In Adults Flashcards

1
Q

What is the commonest histologicall classification of prostate carcinoma?

A

Adenocarcinoma

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2
Q

What is the difference between grading and staging of of a malignancy?

A

Grade = How well/poorly differentiated tumour cells are

Stage = How far the cancer has spread

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3
Q

Haematogenous metastases of prostate ca usually occurs first to which area?

A

Axial skeleton

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4
Q

What are the causes of a raised PSA

A

Prostate Ca

BPH

Prostitis

Prostate biopsy/surgery

Rectal exam

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5
Q

In what part of the prostate does prostate cancer usually start?

A

Peripheral zone

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6
Q

How is prostate Ca diagnosed?

A

Rectal examination

Prostate biopsy

Serum PSA

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7
Q

What are the possible complications of a trans-rectal prostate biopsy?

A

Rectal bleeding

Bacteraemia

Septicaemia

Prostatitis

Cystitis

Epididymo-orchitis

Urinary retention

Haematuria

Haematospermia

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8
Q

How can the complications of prostate biopsy be prevented?

A

Administer prophylactic antibiotics

Monitor for 24hrs for septicaemia

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9
Q

What is the best, first option of treatment in a patient who presents with severe back pain due to metastatic prostate cancer?

A

Hormonal treatment - suppress testosterone:

  • Bilateral orchidectomy
  • Oestrogen
  • Anti-androgens - Ketaconazole
  • LHRH-agonists (GnRH-agoniste) - Buserelin
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10
Q

What are the possible complications and side-effects of bilateral orchidectomy for prostatic carcinoma?

A

Bleeding

Wound sepsis

Psychological trauma of castration

Loss of libido and potency

Hot flushes

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11
Q

What is the treatment of organ confined prostate carcinoma for a patient with >10 years life expectancy?

A

Depends on stage of disease

Radical prostatectomy

External beam radiotherapy

Brachytherapy

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12
Q

How would you treat an older patient with organ confined prostate carcinoma (e.i <10 years life expectancy)?

A

Depends on stage of disease

Conservative management

Watchful waiting

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13
Q

What are the complications of a radical prostatectomy?

A

Intra-operative haemorrhage

Erectile dysfunction

Incontinence

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14
Q

Name 5 possible complications of advanced prostate carcinoma

A

LUTS

  • Hesitancy
  • Weak stream
  • Interrupted stream
  • Feeling of incomplete voiding
  • Post-micturation dribbling

Urinary retention

UTI

Haematuria

Pain

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15
Q

With regard to prostate cancer: In which age group does it occur most commonly?

A

> 45 - 50 years

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16
Q

What are the findings on rectal examination for organ-confined prostate carcinoma?

A

Enlarged prostate with nodule or hard area palpable in 1 or both lobes

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17
Q

What are the findings on rectal examination for advanced prostate carcinoma?

A

Enlarged, hard irregular prostate

Poorly defined edges of prostate

Overlying rectal mucosa is intact

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18
Q

Describe the pathogenesis of BPH

A

Arises from transitional zone

>>Enlarged prostate
> increased urine outflow obstruction
> detrusor hypertrophy
> decompensation
> increased residual volume post micturation
> chronic retention
> hydronephrosis
> renal failure
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19
Q

What are the symptoms of BPH?

A

50% asymptomatic

LUTS

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20
Q

How is BPH diagnosed?

A

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

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21
Q

How would you manage BPH with a symptom score of <7? Explain your answer

A

IPSS <7 = Mild

Watchful waiting

Because…
50% will remain unchanged
25% will improve
25% will get worse

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22
Q

How would you manage a patient with symptomatic uncomplicated BPH?

A

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
23
Q

What are the indications for surgery in BPH?

A

Complications of bladder outflow obstruction

Recurrent haematuria due to BPH

Failed/contraindicated medical treatment

Previous prostate surgery

24
Q

What are the surgical options for management of BPH?

A

TURP

Open prostatectomy

25
Q

What are the complications of TURP?

A

TUR-syndrome
* Fluid overload + hyponatraema (esp. when using sterile water)

Secondary Haemorrhage

Septicaemia

Retrograde ejaculation

Incontinence

Urethral stricture

26
Q

How would you managed a patient with TUR-syndrome?

A

Stop procedure

Furoscemide 40mg IV

27
Q

What is the most common type of bladder cancer?

A

Transitional cell carcinoma

28
Q

What is the etiology of TCC of the bladder?

A

Smoking

Exposure to aromatic amines

Analgesic abuse

Cyclophosphamide

Pelvic Irradiation

29
Q

What is the clinical presentation of a TCC of the bladder?

A

Painless macroscopic haematuria (70-90%)

Microscopic haematuria

Irritative voiding symptoms

Suprapubic pain

Lower abdominal mass

Metastases

  • Dyspnoea
  • Bone pain
30
Q

What special investigations would you do for a TCC of the bladder?

A

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

31
Q

List the causes of a filling defect

A

Bladder tumour

Bladder stone

Blood clot

Prostate middle lobe

Foley catheter balloon

Overlying bowel gas

Foreign body

Fungus Ball

32
Q

How would you manage a carcinoma is situ (CIS) of the bladder?

A

Intravesicular immunotherapy
* BCG weekly for 6 weeks

If successful:
* BCG every 3 months for 3 years

If unsuccessful:
* radical cystectomy

33
Q

How would you manage a superficial papillary lesion of the bladder?

A

Complete TURBT

Follow-up cystoscopy every 3 months

Repeat TURBT if needed

(Prognosis = 75-95% 5-year survival)

34
Q

What are the indications for a cystectomy?

A

Unsuccessful intravesical immunotherapy of CIS

Extensive multiple recurrent tumours

Evidence of muscle invasion

35
Q

List to types of Renal calculi

A

Radio-opaque

  • Calcium oxalate
  • Struvite (infection) - Staghorn
  • Cystine

Non-opaque

  • Uric acid
  • Indinavir
36
Q

Discuss calcium stones

A

Most common renal calculi (75%)

May be associated with metabolic abnormalities

  • Hypercalcaemia
  • Hypercalciuria
  • Hyperoxaluria
  • Hyperuricosuria
  • Low magnesium / citrate
37
Q

Discuss struvite (infection) stones

A

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

38
Q

What are the factors associated with uric acid stone formation?

A

Low urine output - Dehydration

Low urine pH

High red meat intake

Chronic diarrhoea - dehydration

Hyperuricosuria - Gout

39
Q

What are the complications of renal calculi?

A

UTIs

Obstruction

  • Hydronephrosis
  • Renal failure

Chronic irritation

  • Leukoplakia
  • SCC of renal pelvis
40
Q

What is the presentation of a patient with a renal calculi?

A

Haematuria

Pain

  • Renal colic
  • Renal pain

Complications

Asymptomatic - Infection stones

41
Q

How would you investigate a patient with suspected renal calculi?

A

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

42
Q

What is the surgical treatment of a renal calculi?

A

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

43
Q

What is the etiology of bladder calculi?

A

Primary
* Children

Secondary

  • Bladder outflow obstruction
  • Foreign bodies
  • Stasis and infection - neuropathic bladder/ bladder diverticulum
  • Stone from upper tract
  • Primary hyperparathyroidism
44
Q

What is the clinical presentation of a patient with a bladder calculi?

A

Suprapubic pain

Dysuria

Haematuria

Intermittent interruption of bladder stream

Symptoms of bladder outflow obstruction

Irritative symptoms

45
Q

How do you diagnose a patient with a bladder calculi?

A

US

AXR
* 50% non-opaque

Cystoscopy
* Usually done for bladder outflow obstruction

46
Q

What is the treatment of a patient with a bladder calculi?

A

Endoscopic cystolithopaxy

Open cystolithopaxy

  • Multiple stones
  • If open prostatectomy needed

TURP
* For treatment of bladder outflow obstruction if present

47
Q

What are the components of the posterior urethra?

A

Prostatic urethra

Membranous urethra

48
Q

What are the components of the anterior urethra?

A

Penile urethra

Bulbar urethra

Glanular urethra

49
Q

What are the inflammatory causes of Urethral strictures in males?

A

Gonorrhoea urethritis - Most common cause in SA

Chlamydial urethritis

Balanitis xerotica obliterans (lichen sclerosis)

50
Q

Discuss how a catheter can cause a urethral stricture in a male

A
  1. Previous indwelling urethral catheter
  2. Premature inflation of catheter balloon in the urethra
  3. Submeatal/Bulbar stricture
51
Q

What are the clinical features of urethral strictures?

A

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
52
Q

How would you investigate a patient with a urethral stricture?

A

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
53
Q

What is the managemnet of urethral strictures in males?

A

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
54
Q

What are the treatment complications of urethral strictures?

A

Periurethral abscess

Necrotising fasciitis of perineum

Urethrocutaneous fistula

Proximal diversion

Urology (5 decks)

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