Urology Flashcards
1
Q
What are the two types of haematuria?
A
Visible and non-visible
2
Q
What drugs can cause haematuria?
A
- Nitrofurantoin
- Rifampicin
- Ibuprofen/ Naproxen
- Levodopa/ Methyldopa
- Quinine/ Chlorquine
- Senna
3
Q
What is pseudohaematruia?
A
Red/ Brown urine without Hb
Caused by medications (rifampicin/ methydopa), hyperbilirubinuria, myoglobinuria and certain foods e.g beetroot/ rhubarb
4
Q
What are the most common causes of haematuria?
A
- UTI (pylonephritis)
- Urothelial carcinoma
- Stone disease
- Adenocarcinoma of prostate
- BPH
5
Q
What are some of the urological causes of haematuria?
A
- Infection (pyelonehpritis, cystitis, prostatitis)
- Renal calculi
- Malignancy
- Parasitic infection (schistosomiasis)
- Radiation cystitis
- Trauma or recent surgery
6
Q
What are the main risk factors for bladder cancer?
A
- Cigarette smoking
- Industrial carcinogens especially aramatic hydrocarbons e.g. leather factory/ dye worker
- Schistosomiasis infection
- Previous radiation to the pelvis
7
Q
What initial investigations would you do for a patient presenting with haematuria?
A
- Urinalysis (dipstick)- check from nitrities and leukocytes as infection may be underlying cause
- Baseline bloods - FBC, U&E, clotting
8
Q
What secondary investigations can you do for a patient presenting with haematuria?
A
- CT Urogram
- CT KUB
- US KUB
- Urine cytology
- Flexible cystoscopy (gold standard)
9
Q
What is ‘terminal’ haematuria?
A
Passage of clear urine with blood or blood stained urine at the end of the urine stream
10
Q
What is haematospermia and what are some of the causes?
A
Blood in the semen
Common causes:
- Infection
- Stone in ejaculatory duct
- Rare complaint of prostatic carcinoma in older patients
11
Q
What are some of the causes of acute urinary retention?
A
- Most common cause in men: BPH
- Urethral stricture or prostate cancer
- UTI
- Constipation (through compression of urethra)
- Severe pain cause patients to enter retention
- Neurological causes: MS, Parkinson’s disease, sacral nerve injury
- Drugs
12
Q
Which drugs can cause someone to go into urinary retention?
A
- Anticholinergics: e.g. oxybutynin
- Antimuscarinics
- Antihistamines
- Duloxetine
- alpha agonists
13
Q
What are the clinical features of acute urinary retention?
A
- Acute suprapubic pain
- Inability ot micturate
- Palpable distended bladder
- Associated fevers/rigors suggest infective cause
14
Q
What investigations should be done if suspecting urinary retention?
A
- Post void bladder scan - helps confirm diagnosis
- Routine bloods: FBC, CRP, U+Es
- Post catheterisation CSU (Catheterised specimen of urine) should be sent to assess for presence of infection
15
Q
What is the management of acute urinary retention?
A
- Immediate urethral catheterisation
- measure volume drained
- Underlying cause then treated accordingly
16
Q
What is high pressure urinary retention?
A
- Urinary retention that causes high intra vesicular pressure so anti-reflux mechanism of ureters is overcome leading to hydroureter and hydronephrosis
- Causes deranged renal function
- Pressure in bladder is ~20cm water (in normal bladders it is 0cm)
- Creatinine and K+ are significantly raised
17
Q
Should a patient with high pressure urinary retention be TWOC before going home?
A
No!
Leave the catheter in until definitive management can be arranged due to increased risk of further retention or AKI
18
Q
What is the best pain relief for renal stone pain?
A
Diclofenac PR
19
Q
Why should patients who have a large retention volume (>1,000 ml) be monitored post catheterisation?
A
At risk of Post obstructive diuresis
After catheterisation the kidney’s can over diurise due to loss of medullary concentration → it takes time to re-quiilibriate
Over diuresis can worsen AKI
20
Q
How should patients producing >200ml/hr urine output be managed?
A
Replace ~50% of urine output with IV fluids to avoid worsening AKI
21
Q
What is chronic urinary retention?
A
The painless inability to pass urine
In long standing retention there is significant bladder distension which causes bladder desensitisation which is why it is painless
22
Q
What are the common causes of chronic urinary retention?
A
-
Most common in men: BPH
- Other causes urethral stricture or prostate cancer
- Women: pelvic prolapse (cystocele, rectocele or uterine prolapse) or other pelvic masses e.g. large fibroids
- Neurological cause: peripheral neuropathies or MS or Parkinson’s
23
Q
How can chronic urinary retention patients be managed outside of hospital until the underlying cause can be treated?
A
Taught intermittent self catheterisation (catheterise themselves every 4-6hrs) but not suitable for everyone as requires good manual dexterity and patient complicance
Long term catheter is the alternative
24
Q
What is TURP syndrome?
A
Rare but potentially life threatening complication after TURP
Hyposmolar irrigation (Glycin 1.5%) during procedure can cause significant fluid overload and hyponatraemia
Present with: confusion, nausea, agitation and visual changes
25
What are the different compositions of urinary tract stone?
* Calcium oxalate (35% of stones)
* Calcium phosphate (10%)
* Mixed oxalate and phosphate (35%)
* Uric Acid
* Struvite
* Cystine
26
What is the gold standard for diagnosis of renal stones?
Non-contrast CT scan
27
What are some of the risk factors for developing stone disease?
* Poor water intake
* Meat consumption
* Drugs: corticosteroids, chemotherpeutic agents
* UTI
* Immobile patients (common in care home residents)
28
Where are the 3 common places that renal calculi can impact?
1. Pelviureteric Junction
2. Crossing of pelvic brim (under the iliac vessels)
3. Vesicoureteric Junction
29
What are the clinical features of renal stones?
* Pain (ureteric colic) - sudden onset, severe, from loin to groin
* Associated N+V
* Haematuria (typically non-visible)
* Examination: typically unremarkable but may have some flank pain)
30
What should be on your differentials list if you're suspecting renal stones?
1. Pyelonephritis
2. Ruptured AAA
3. Biliary pathology
4. Bowel obstruction
5. Lower lobe pneumonia
6. Ovarian torsion/ ectopic pregnancy
31
Which diseases are associated with stone formation?
1. Hyperparathyroidism
2. Metabolic syndrome
3. Nephrocalcinosis
4. GI disease
5. Sarcoidosis
32
How do you examine a patient with suspected renal stones?
Full examination
* Chest, abdomen, testicles to rule out other causes of pain
* Check for masses: pulsatile and expanding
* Check vitals: temp, pulse, BP, urine output
33
Which types of stones are radiopaque vs radiolucent?
**Radiopaque**: The calcium stones
**Radiolucent:** uric acid, ammonirum urate, xanthine
34
What changes occur in the renal tract during pregnancy and why?
Significant **dilatation** of the pelvicalyceal system and ureters dur to **progresterone** increasing smooth muscle relaxation
Physiological hydronephrosis occurs in 90% of pregnant women
Pelvicalyceal dilation up to 2cm is regarded as normal
35
What investigations should you do if suspecting renal stones?
* Urine dip
* Routine bloods: FBC, U&E, CRP
* Urate and calcium levels
* Retrieval of stone if passed during micturition and send for analysis
* **non-contrast CT KUB** gold standard
* USS can be useful in assessing of hydronephrosis
* can detect renal stones but **not** ureteric stones
36
What should be your initial management of a patient presenting with urinary stones?
* **Ensure adequare fluids**: likely dehydrated secondary to reduced oral intake +/- vomiting
* **Sufficient analgesia** (NSAIDs per rectum most effective)
* Most stones pass spontaneously if \<5mm
* Any evidence of sepsis warrants IV abx
* Tamsulosin only beneficial if stone is at lower pole of the ureter
37
What is the criteria for inpatient admission in a patient presenting with renal stones?
* Post obstructive acute kidney injury
* Uncontrollable pain from simple analgesics
* Evidence of infected stones
* Large stones \>5mm
38
What are the **temporary** surgical options for a patient with renal stones?
* **JJ stent insertion** - allows ureter to be kept patent to temporarily relieve the obstruction
* **Nephrostomy -** relieves obstruction proximally
39
What are the **definitive** surgical options for renal/ureteric stones?
* **ESWL** - extracorpreal shock wave therapy
* **Percutanous nephrolithomy** - (PCNL)
* **Flexible ureto-renoscopy**
40
What is ESWL?
Give some contraindicationsn to the procedure
* Targetted sonic waves to break up the stone so it can be passed spontaneously
* Typically for smaller stones
* **Contraindications:** pregnancy or stone positioned over a bony landmark
41
What is **Percutaneous nephrolithotomy**?
Method used for **renal** stones only, preferred method for **large** stones including **staghorn calculus**
The kidney is accessed percutanously and stones fragmented using various forms of lithotripsy
42
What are the main complications of kidney stones?
* Infection
* post renal AKI
* recurrent renal stones can cause **scaring** and loss of kidney function
43
How can reccurent stone formers be managed?
(changes dependent on the type of stone)
* Advise to stay hydrated
* Oxalate stone formers: avoid high purine foods and high oxalate foods e.g. nuts, rhubarb, sesame
* Calcium stone formers: check PTH levels and avoid excess salt
* Urate stone formers: avoid high purine foods (red meat, shellfish) and consider for urate lowering medicine (e.g. allopurinol)
* Cysteine stone formers may warrant genetic testing
44
What causes bladder stones?
Typically formed from **urine stasis** therefore commonly seen in **chronic urinary retention**
or secondary to infections e.g. schistosomiasis
45
What are the types of bladder cancer?
* Transitional cell carcinoma (80-90%)
* Squamous cell carcinoma - rare
* Adenocarincoma - rare
* Sarcoma -rare
46
What are the 4 layers of the bladder wall?
* Inner lining - urothelium (transitional cell)
* Connective tissue lining - lamina propria
* Muscular layer - muscularis propria
* Outer fatty layer
47
What are the symptoms of bladder cancer?
* **Painless haematuria** - most common
* recurrent UTI/ LUTs
* If presenting with advanced disease may have localised symptoms e.g. pelvic pain
* Metastatic disease present with systemic symptoms: lethargy or weight loss
48
What is a hydrocele?
An abnormal collection of **peritoneal fluid** between the paritetal and visceral layers of the **tunica vaginalis**
49
How do patients with hydrocele typically present?
* Painless fluctuant swelling
* Either bilateral or unilateral
* Transilluminates
* Can cause discomfort on sitting and walking if very larger
50
What are the causes of hydrocele?
* **Primary** - idiopathic
* **Secondary** -
* trauma
* infection
* malignancy
* Those presenting between **20-40yrs** should undergo **urgent ultrasound** incase of malignancy
51
What is a varicocele?
**Abnormal dilatation** of the **pampiniform venous plexus**
52
How do patients with varicocele present?
* Lump
* Feels like a 'bag of worms'
* 'dragging sensation'
* 90% are left sided
53
What are 'red flag' symptoms for varicoceles?
* acute onset
* right sided
* remain when lying flat
* Should be investigated urgently
54
How are varicoceles managed?
* **Asymptomatic** : generally need no treatment
* **Surgical:** embolisation or open/lapropscopic ligation of the spermatic veins
55
What are epididymal cysts? How do they present?
Benign fluid filled sacs arising from the epididymis
Present as a smooth fluctuant nodules, transilluminate, feel 'separate' from the testis
56
How are epididymal cysts usually manaeged?
* Most do not need treatment
* May need surgery if very large or painful
* can cause infertility so best avoided in younger men
57
What is epididymitis and how does it present?
Inflammation of the epididymis
* Acute onset scrotal pain
* +/- swelling
* +/- erythematous overlying skin
* +/- systemic symptoms e.g. fever
* Pain my be relieved no **elevation** of testes (Phren's sign)
58
What is the most common cause of epididymitis and how is it treated?
* **Bacterial origin** - either STI related or enteric oragnisms
* Mostly treated by antibiotics and analgesia
59
What deformity is associated with testicular torsion?
**Bell Clapper** deformity
High attachment of the tunica vaginalis allowing rotation
60
How does testicular torsion present?
* Sudden onset, severe unilateral scrotal pain
* Associated N+V
* Typically a pre-pubescent boy
* Extremely tender and swollen
* Loss of cremasteric reflex
61
How should testicular torion be managed?
Surgical emergency with scrotal exploration and **fixation** of both testes
62
What is orchitis?
What is the main cause
Inflamation of the testis
Rare in isolation - main cause is **mumps,** often preceded by history of parotid swelling
63
What types of testicular tumours are benign?
* Leydig cell tumours
* Sertoli cell tumours
* Lipomas
* Fibromas
64
Which enzyme does the prostate use to convert testosterone to dihydrotestosterone?
5alpha-reductast
65
Give some risk factors for developing BPH?
* Increasing age (most common)
* FHx (1st degree relative)
* Afro Caribbean ethnicity
* Obesity
66
How does BPH present?
* LUTS
* **voiding symptoms:** hesitancy, weak stream, terminal dribble, incomplete emptying
* **storage symptoms:** urinary frequency, nocturia, nocturnal enuresis, urge incontinence
67
How are LUTS (lower urinary tract symptoms) evaluated?
The **Internaltional Prostate Symptom Score**
68
How is a possible BPH investigated?
* Urinary frequency and bolume charts
* Bedside urinalysis (excluding UTI)
* Post void bladder scan
* PSA (marginally elevated)
* USS of renal tract can calculate the **volume** of the prostate (\>**30ml** is enlarged)
* Urodynamic studies
69
How are patients with BPH managed?
* Keep symptom diary
* Medication review
* Lifestyle advice (moderate caffeine and alcohol intake)
* **alpha adrenoreceptor antagonis** e.g. **tamsulosin** (relaxes smooth muscle of prostate)
* can add **5alpha-reductase inhibitors** e.g. **finasteride** if no success with tamsulosin
70
What is the most common way to manage BPH surgically?
**TURP** (Trans urethral resection of the prostate)
71
Give some complications of TURP?
* Haemorrhage
* Sexual dysnfunction
* Retrograde ejaculation
* Urethral stricture
* TURP syndrome
72
What is TURP syndrome?
* Rare but portentially life threatening complication of TURPs using **monopolar** energy as this uses **hypoosmolar irrigation**
* Can cause significant **fluid overload** and **hyponatraemia**
* Presents as:
* confision
* nausea
* agitation
* visual changes
