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Junior surgery > Urology > Flashcards

Urology Flashcards

1
Q

What are the two types of haematuria?

A

Visible and non-visible

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2
Q

What drugs can cause haematuria?

A
  • Nitrofurantoin
  • Rifampicin
  • Ibuprofen/ Naproxen
  • Levodopa/ Methyldopa
  • Quinine/ Chlorquine
  • Senna
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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

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4
Q

What are the most common causes of haematuria?

A
  • UTI (pylonephritis)
  • Urothelial carcinoma
  • Stone disease
  • Adenocarcinoma of prostate
  • BPH
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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
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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
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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
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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)
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9
Q

What is ‘terminal’ haematuria?

A

Passage of clear urine with blood or blood stained urine at the end of the urine stream

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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
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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
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12
Q

Which drugs can cause someone to go into urinary retention?

A
  • Anticholinergics: e.g. oxybutynin
  • Antimuscarinics
  • Antihistamines
  • Duloxetine
  • alpha agonists
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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
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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
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15
Q

What is the management of acute urinary retention?

A
  • Immediate urethral catheterisation
    • measure volume drained
  • Underlying cause then treated accordingly
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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
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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

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18
Q

What is the best pain relief for renal stone pain?

A

Diclofenac PR

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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

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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

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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

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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
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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

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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

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25
Q

What are the different compositions of urinary tract stone?

A
  • Calcium oxalate (35% of stones)
  • Calcium phosphate (10%)
  • Mixed oxalate and phosphate (35%)
  • Uric Acid
  • Struvite
  • Cystine
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26
Q

What is the gold standard for diagnosis of renal stones?

A

Non-contrast CT scan

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27
Q

What are some of the risk factors for developing stone disease?

A
  • Poor water intake
  • Meat consumption
  • Drugs: corticosteroids, chemotherpeutic agents
  • UTI
  • Immobile patients (common in care home residents)
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28
Q

Where are the 3 common places that renal calculi can impact?

A
  1. Pelviureteric Junction
  2. Crossing of pelvic brim (under the iliac vessels)
  3. Vesicoureteric Junction
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29
Q

What are the clinical features of renal stones?

A
  • 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
Q

What should be on your differentials list if you’re suspecting renal stones?

A
  1. Pyelonephritis
  2. Ruptured AAA
  3. Biliary pathology
  4. Bowel obstruction
  5. Lower lobe pneumonia
  6. Ovarian torsion/ ectopic pregnancy
31
Q

Which diseases are associated with stone formation?

A
  1. Hyperparathyroidism
  2. Metabolic syndrome
  3. Nephrocalcinosis
  4. GI disease
  5. Sarcoidosis
32
Q

How do you examine a patient with suspected renal stones?

A

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
Q

Which types of stones are radiopaque vs radiolucent?

A

Radiopaque: The calcium stones

Radiolucent: uric acid, ammonirum urate, xanthine

34
Q

What changes occur in the renal tract during pregnancy and why?

A

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
Q

What investigations should you do if suspecting renal stones?

A
  • 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
Q

What should be your initial management of a patient presenting with urinary stones?

A
  • 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
Q

What is the criteria for inpatient admission in a patient presenting with renal stones?

A
  • Post obstructive acute kidney injury
  • Uncontrollable pain from simple analgesics
  • Evidence of infected stones
  • Large stones >5mm
38
Q

What are the temporary surgical options for a patient with renal stones?

A
  • JJ stent insertion - allows ureter to be kept patent to temporarily relieve the obstruction
  • Nephrostomy - relieves obstruction proximally
39
Q

What are the definitive surgical options for renal/ureteric stones?

A
  • ESWL - extracorpreal shock wave therapy
  • Percutanous nephrolithomy - (PCNL)
  • Flexible ureto-renoscopy
40
Q

What is ESWL?

Give some contraindicationsn to the procedure

A
  • 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
Q

What is Percutaneous nephrolithotomy?

A

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
Q

What are the main complications of kidney stones?

A
  • Infection
  • post renal AKI
  • recurrent renal stones can cause scaring and loss of kidney function
43
Q

How can reccurent stone formers be managed?

(changes dependent on the type of stone)

A
  • 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
Q

What causes bladder stones?

A

Typically formed from urine stasis therefore commonly seen in chronic urinary retention

or secondary to infections e.g. schistosomiasis

45
Q

What are the types of bladder cancer?

A
  • Transitional cell carcinoma (80-90%)
  • Squamous cell carcinoma - rare
  • Adenocarincoma - rare
  • Sarcoma -rare
46
Q

What are the 4 layers of the bladder wall?

A
  • Inner lining - urothelium (transitional cell)
  • Connective tissue lining - lamina propria
  • Muscular layer - muscularis propria
  • Outer fatty layer
47
Q

What are the symptoms of bladder cancer?

A
  • 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
Q

What is a hydrocele?

A

An abnormal collection of peritoneal fluid between the paritetal and visceral layers of the tunica vaginalis

49
Q

How do patients with hydrocele typically present?

A
  • Painless fluctuant swelling
  • Either bilateral or unilateral
  • Transilluminates
  • Can cause discomfort on sitting and walking if very larger
50
Q

What are the causes of hydrocele?

A
  • Primary - idiopathic
  • Secondary -
    • trauma
    • infection
    • malignancy
    • Those presenting between 20-40yrs should undergo urgent ultrasound incase of malignancy
51
Q

What is a varicocele?

A

Abnormal dilatation of the pampiniform venous plexus

52
Q

How do patients with varicocele present?

A
  • Lump
  • Feels like a ‘bag of worms’
  • ‘dragging sensation’
  • 90% are left sided
53
Q

What are ‘red flag’ symptoms for varicoceles?

A
  • acute onset
  • right sided
  • remain when lying flat
  • Should be investigated urgently
54
Q

How are varicoceles managed?

A
  • Asymptomatic : generally need no treatment
  • Surgical: embolisation or open/lapropscopic ligation of the spermatic veins
55
Q

What are epididymal cysts? How do they present?

A

Benign fluid filled sacs arising from the epididymis

Present as a smooth fluctuant nodules, transilluminate, feel ‘separate’ from the testis

56
Q

How are epididymal cysts usually manaeged?

A
  • Most do not need treatment
  • May need surgery if very large or painful
    • can cause infertility so best avoided in younger men
57
Q

What is epididymitis and how does it present?

A

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
Q

What is the most common cause of epididymitis and how is it treated?

A
  • Bacterial origin - either STI related or enteric oragnisms
  • Mostly treated by antibiotics and analgesia
59
Q

What deformity is associated with testicular torsion?

A

Bell Clapper deformity

High attachment of the tunica vaginalis allowing rotation

60
Q

How does testicular torsion present?

A
  • Sudden onset, severe unilateral scrotal pain
  • Associated N+V
  • Typically a pre-pubescent boy
  • Extremely tender and swollen
  • Loss of cremasteric reflex
61
Q

How should testicular torion be managed?

A

Surgical emergency with scrotal exploration and fixation of both testes

62
Q

What is orchitis?

What is the main cause

A

Inflamation of the testis

Rare in isolation - main cause is mumps, often preceded by history of parotid swelling

63
Q

What types of testicular tumours are benign?

A
  • Leydig cell tumours
  • Sertoli cell tumours
  • Lipomas
  • Fibromas
64
Q

Which enzyme does the prostate use to convert testosterone to dihydrotestosterone?

A

5alpha-reductast

65
Q

Give some risk factors for developing BPH?

A
  • Increasing age (most common)
  • FHx (1st degree relative)
  • Afro Caribbean ethnicity
  • Obesity
66
Q

How does BPH present?

A
  • LUTS
  • voiding symptoms: hesitancy, weak stream, terminal dribble, incomplete emptying
  • storage symptoms: urinary frequency, nocturia, nocturnal enuresis, urge incontinence
67
Q

How are LUTS (lower urinary tract symptoms) evaluated?

A

The Internaltional Prostate Symptom Score

68
Q

How is a possible BPH investigated?

A
  • 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
Q

How are patients with BPH managed?

A
  • 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
Q

What is the most common way to manage BPH surgically?

A

TURP (Trans urethral resection of the prostate)

71
Q

Give some complications of TURP?

A
  • Haemorrhage
  • Sexual dysnfunction
  • Retrograde ejaculation
  • Urethral stricture
  • TURP syndrome
72
Q

What is TURP syndrome?

A
  • 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

Junior surgery (8 decks)

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