Urology Flashcards
Benign prostatic hyperplasia
- Tx:
- If not bothered by symptoms, expectant management and education is appropriate.
Urodynamic testing
- Proedure to determine how well the bladder empties urine on demand
- Manometry catheter is placed into the rectum, then bladder is slowly filled with warm watter and the patient reports when they develop the urge to urinate. Urinary flow is measured as the patient is asked to empty their bladder.
Abnormalities identified during prostate exam can be further worked up via. . .
. . . transrectal ultrasonography
Alpha blockers for BPH
- Alfuzosin
- Doxazosin
- Tamsulosin
- Terazosin
- Silodosin
5-alpha-reductase inhibitors for BPH
- Alfatradiol
- Dutasteride
- Epristeride
- Finasteride
Alpha blockers vs 5-alpha-reductase inhibitors in their use for BPH
Alpha blockers act within days and reduce the contraction of the prostate
5-alpha-reductase inhibitors take several months to start working and reduce the plasiticty of the prostate parenchyma. They also have the side effects of reduced libido, erectile dysfunction, and abnormal ejaculation.
Role of desmopressin in treatment of LUTS
- Induces water reabsorption and thus decreases volume of urine produced
- Useful for patients with persistent and bothersome nocturia
- Taken once at bedtime
Role of muscarinic receptor anatagonists in treatment of LUTS
- Mostly indicated for overactive bladder
- Reduce urinary urgency by reducing bladder contraction and bladder sensory threshold
- Side effects are dry mouth, constipation, micturition difficulty, dizziness
Combination therapy for BPH
- Many patients with moderate to severe BPH take both an alpha-1-blocker and a 5-alpha-reductase inhibitor
Factors that may indicate high risk of disease progression in BPH
- High prostate volume
- High PSA
- Advanced age
- These may be indicatons for combination BPH therapy in more mild cases to prevent progression, as this may avoid a surgical procedure at a later date.
Transurethral resection of the prostate
- Resection of the transition zone of the prostate
- Indicated for patients with severe bladder outlet obstruction secondary to a large prostate
Transurethral incision of the bladder neck
- Another option for severe BPH
- Small-sized, highly symptomatic BPH is the best candidate for this procedure
Complications of transurethral resection and incision procedures
Urinary incontinence
Bladder neck strictures
Retrograde ejaculation
Erectile dysfunction
Transurethral needle ablation
- Deliver of low-level radiofrequency energy through a needle inserted into the prostate through the urethra
- Produces controlled destruction of the prostate and relief of bladder outlet obstruction
- Has a higher risk of recurrence and need for retreatment than transurethral resection
Open prostatectomy
- Most invasive surgical operation for BPH, but also more effective and durable than the rest
- Patient selection is key to balance complications and long-term benefits
Transurethral laser vaporization of the prostate
- Laser energy delivery devices are introduced transurethrally to deliver laser energy to the prostate
- Short-term results very good, however this treatment is relatively new and long-term outcomes data are not yet available
Next step after detection of an elevated PSA
Transrectal ultrasound and prostate biopsy
If suspicious for cancer, a staging CT abdomen and pelvis is indicated
__ can artificially increase the PSA for a period of time
Digital prostate exam can artificially increase the PSA for a period of time
A nontender, non-transilluminating testicular mass in a man under 40 is ___ until proven otherwise.
A nontender, non-transilluminating testicular mass in a man under 40 is testicular cancer until proven otherwise.
Tumor markers for testicular cancer
AFP and beta-hCG
Workup of testicular mass
- Testicular exam
- Testicular ultrasound
- A solid, hypoechoic mass suggests malignancy
- Biopsy is contraindicated in suspected testicular cancer due to the risk of tumor contamination of the scrotum and alterations in lymphatic drainage of the region
- If symptomatic, CT of the thorax (lung involvement) or abdomen (back pain) is indicated for further staging at this time
- If suspicious for malignancy, first obtain beta hCG, AFP, LDH and then radical orchiectomy should be performed for pathology
- If pathology indicates cancer, retriperitoneal lymphadenectomy and full CT staging are indicated
Elevated ___ is correlated to high tumor burden in testicular cancer
Elevated LDH is correlated to high tumor burden in testicular cancer
It has been observed that individuals with testicular cancer have ___ fertility relative to their peers without cancer
It has been observed that individuals with testicular cancer have lower fertility relative to their peers without cancer
In general, the prognosis for early stage testicular cancers is. . .
. . . excellent
Even with relapse, “cure” rates are > 99%
This is one of the most treatable forms of cancer.
Virchow node
The last lymph node in the thoracic duct, receiving afferent lymphatic drainage from the left head and neck, as well as the entirety of the chest, abdomen, pelvis, and bilateral lower extremities.
Enlargement of this node may be seen in patients with intraabdominal malignancies. Identification of an enlarged virchow lymph node suggests that there is metastatic malignancy present somewhere in the body.
Seminomas are exquisitely sensitive to ___
Seminomas are exquisitely sensitive to radiation therapy
Therefore, any extratesticular sites of extension of seminoma can be treated reliably with external beam radiation
Breakdown of testicular cancers
- 90% germ cell tumors
- Half of these are seminomas
- A substantial number of germ cell tumors are mixed cell type
- 10% stromal cell tumors
Surgical management of undescended teste
- Cryptorchidism greatly increases the risk of germ cell tumor, even after the maldesecended testicle is repositioned
- Orchioplexy is still recommended prior to 13 years of age, but the RR for cancer is still 2x greater than for the baseline population
Family history and testicular cancer
- Brother with history of testicular cancer: 8-10 x baseline risk
- Father with testicular cancer: 4-6 x baseline risk
Tumor markers for non-seminomatous testicular cancer
AFP
beta-HCG
LDH
Patient presents with a firm, nontender testicular mass. What do you do?
This is cancer until proven otherwise, and the only way to prove it is to perform a radical orchiectomy. You should never to trans-scrotal biopsy or FNA for these as this will seed the tumor into the lymphatics – don’t fuck around.
Workup includes:
- Bilateral scrotal ultrasound
- Serum AFP, beta-hCG, LDH
- Radical inguinal orchiectomy
Testicular cancer is the most common cancer in males ages ___, and has its peak incidence at age ___.
Testicular cancer is the most common cancer in males ages 15-35, and has its peak incidence at age 35.
Approach to pediatric hematuria
How a voiding cystourethrogram works
You put dye into the bladder. You let the patient urinate.
Then, you image the urinary system to see if there is residual dye and where it is.
This is an excellent test for demonstration of vesico-ureteral reflux, since there will be dye in the ureters by the end of the study
In a pediatric patient, kidney ultrasound can tell you if someone has hydronephrosis or not. What are the two over-arching etiologies of hydronephrosis in pediatric patients?
- Obstruciton
- Reflux
You should never use ___ when you are trying to assess for kidney stones with imaging
You should never use contrast when you are trying to assess for kidney stones with imaging
You won’t be able to see your stones!
Posterior urethral valves
Way to remember hypo- vs epi-spadias
Which causes a kid to pee in his own face?
Epispadias
What is the only important thing to know about hypospadias/epispadias from a management standpoint?
You NEVER circumsize these kids.
They will need that tissue for the surgical repair.
Ureteropelvic vs ureterovesicular junction obstruction
- Ureteropelvic: Obstruction is at the renal pelvis
- Ureterovesicular: Obstruction is at the ureterovesicular junction
Patient is an 18 year old male who presents with five hours of colicky abdominal pain. Pain began after drinking a large volume of beer at their first college party. While waiting at the ER, the pain gradually and spontaneously resolves. Ultrasound shows hydronephrosis without hydroureter. Voiding cystourethrogram does not demonstrate reflux. What is the diagnosis and what is the appropriate treatment?
Dx: Ureteropelvix junction obstruction
Tx: Surgery +/- stenting
Note: This patient has probably had this obstruction for their whole life, it is congenital. However, at normal flow rates the obstruction was not sufficient to produce symptoms. Only when they took a large volume load (lots of beer) and a diuretic (EtOH) did their obstruction become flow-limiting and thereby symptomatic.
When XY embryos develop ectopic ureter, it will implant ___.
When XX embryos develop ectopic ureter, it will implant ___.
When XY embryos develop ectopic ureter, it will implant above the internal sphincter. – This means that they will be asymptomatic.
When XX embryos develop ectopic ureter, it will implant either below the internal sphincter OR into the vagina. – This means that it will be symptomatic, with a constant urine leak. These patients will present as being persistently incontinent of urine past normal potty-training age (~5 years old).
Dx: US to rule out hydronephrosis. Then, VCUG to rule out reflux. Then, radionuclide scan to visualize anatomy.
Tx: Reimplantation of ureter into bladder.
Vesicoureteral reflux
Which is a better way to biopsy prostate cancer: transrectal or transurethral?
Transrectal
Prostate cancer tends to grow out of the posterior prostate into the potential space of the rectum.
Analine dyes
- Used in old painting and dry-cleaning equipment
- Risk factor for bladder cancer
Risk factors for bladder cancer
1: Smoking
When do you actually remove the bladder in bladder cancer?
- If cancer is invasive
- If there are multiple recurrences in the bladder
These are pretty rare. Most bladder cancers can be locally resected with adjuvant therapy and without need for bladder resection.
You NEVER do a biopsy for suspected ___ cancer
You NEVER do a biopsy for suspected testicular cancer
You will seed the needle tract. Just cut it out.
Teratomas are often ___ in women but often ___ in men
Teratomas are often benign in women but often malignant in men
Prostate cancer
Bladder cancer
Biopsying renal cell carcinoma
Not done if malignancy is suspected. This will just cause bleeding
If there is a small cyst and you aren’t sure whether or not it is malignant, biopsying that is okay – it is less likely to cause a significant bleed.
Renal cell carcinoma
Note: Renal cell may secrete EPO and cause polycythemia as a paraneoplastic syndrome. However, it may also sequester blood and cause anemia.
Who do you screen for prostate cancer?
Only those who had a first-degree relative with prostate cancer
Otherwise, no screening, just diagnostic PSAs when patients present with symptoms or findings on exam
Testicular cancer overview
Preferred alpha blocker for BPH
Tamsulosin
It is the most bladder specific and has the least orthostatic hypotension as a side effect
Things NOT to order on someone with run-of-the-mill BPH
DO NOT order a prostate biopsy, DO NOT order a PSA
These are tests you would only ever order if you think they have cancer
Otherwise you are going to do more harm then good. Instead, your diagnostic test is a therapeutic trial for BPH. You should also order urinalysis and culture to rule out UTI, which can mimic BPH with LUTS.
Nighttime tunescence test for erectile dysfunction
Place a special tape or stamp over the penis at night. Men normally have erections at night – this will break the tape/stamp. This shows you that erectile dysfunction is psychological, not physiological, in origin.
Treating diagnosed organic erectile dysfunction
- First, control medical diseases that may contribute (smoking, obesity, diabetes)
- PDE-i (sildenafil) – first-line
- Pumps
- Prosthesis
When won’t phosphodiesterase inhibitors (like sildenafil) work for organic erectile dysfunction?
In the case of spinal trauma, radiation, or prostate surgery. Still try them first, but they are unlikely to work.
Never give __ with PDE inhibitors
Never give nitrates with PDE inhibitors
Causes an unsafe drop in blood pressure
Features specific to testicular torsion
- Spotaneous, unprovoked pain
- Horizontal lie of testicle
- Elevation of testicle produces severe pain
If someone has an episode of testicular torsion, they will need. . .
. . . bilateral testicular orchoplexy
Basically tie-down and secure the blood supply to the testicle so that it cannot twist on itself again. This is done bilaterally, since if it happens to one testicle the other one is also at risk.
Etiology of epididymitis by age
< 35 y.o. Gonorrhea, chlamydia
35-55 y.o. Gonorrhea, chlamydia, E. coli
> 55 y.o. E coli
Features specific to epididymitis
- Spontaneous scrotal pain which develops gradually
- Vertical lie of testicle
- Relief of pain on elevation of testicle
Testicular torsion vs epididymitis
Prostatitis
On the exam, they will have you differentiate between prostatitis and ___.
On the exam, they will have you differentiate between prostatitis and pyelonephritis.
They can actually look pretty similar. Patient will be sick as shit and appear to have pyelo but for no casts in UA and no CVA tenderness. Instead, they will have exquisite tenderness on DRE.
If you can’t get a CT scan to evaluate for kidney stones (like in a pregnant patient), then use __ instead.
If you can’t get a CT scan to evaluate for kidney stones (like in a pregnant patient), then use ultrasound instead.
Kidney stone therapy by size of stone
- < 0.5 cm – pain control only
- 0.5 - 0.7 cm – CCB or alpha blocker to facilitate clearance
- 0.7 - 1.5 cm – stenting or lithotrypsy
- > 1.5 cm – surgery
- Any significant size with infection/sepsis: Nephrostomy tube for drainage, figure out the stone later
Prehn’s sign
Positive: Pain relief upon elevation of the testes (suggests epididymitis)
Negative: No pain relief upon elevation of the testes (suggests torsion)
Struvite stones almost always require. . .
. . . surgery
Kidney stone management
- For imaging tests:
- Non-contrast CT – preferred
- Ultrasound – if patient is pregnant, better for proximal stones
- KUB: Can be used to track known/diagnosed kidney stones
Optimal conditions for uric acid stone formation
-
Risk factors:
- Gout
- Obesity
- Diabetes
- Chronic diarrhea (due to associated urine acidity)
-
Conditions:
- Acidic pH
- High uric acid urinary excretion
- Concentrated urine
Urethral strictures
- Often idiopathic
- Relatively common
Varicocele
Relationship between malabsorption and kidney stones
When fat is malabsorbed, more oxalate is absorbed from the GI lumen
With more oxalate absorption, you are more prone to kidney stones.
So, those with IBD, Celiac’s, or post-bariatric surgery are at increased risk.
