Urology Flashcards
How are lower urinary tract symptoms in men investigated?
Digital rectal examination
Abdominal examination (palpable bladder?)
Urinary frequency volume chart
Urine dipstick
PSA - depending on patient preference
What are causes of a raised PSA?
Prostrate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infection
Vigorous exercise (notably cycling)
Recent ejaculation/prostate stimulation
How long after having prostatitis can PSA be checked?
Need to wait at least 1 month
What are management options for benign prostatic hyperplasia?
Medical options:
Alpha blockers (e.g. Tamsulosin) - rapid improvement in symptoms
5-alpha reductase inhibitors (e.g. Finasteride) - gradually reduces size of prostate
Surgical options
TURP
Open prostectomy
What are side effects of Tamsulosin (alpha blocker)?
Postural hypotension
Dry mouth
Dizziness
What are side effects of Finasteride?
Erectile dysfunction
Reduced libido
Ejaculation difficulty
What are lower urinary tract symptoms?
Urgency
Hesitancy
Weak flow
Straining
Dribbling
Incomplete emptying
How does chronic prostatitis present and what is seen on DRE?
Pelvic pain, LUTS, sexual dysfunction
Pain on bowel movement
DRE shows tender enlarged prostate
What is the most common cause of acute bacterial prostatitis?
E. coli
What are risk factors for acute bacterial prostatitis?
Recent UTI
Intermittent bladder catheterisation
Recent prostate biopsy
How does acute bacterial prostatitis present?
Fever
LUTS
How is acute bacterial prostatitis managed?
14 day course of Ciprofloxacin
Screen for STIs
What is the most common type of prostate cancer?
Adenocarcinoma
What are features of prostate cancer?
Prostate cancer is often asymptomatic
May be obstructive symptoms - hesitancy, retention, dribbling
May be haematuria
What investigations are used for prostate cancer?
First DRE/PSA
If findings suggestive of prostate cancer..
First line investigation for suspected prostate cancer = Multi-parametric MRI
Then prostate biopsy
Either transrectal or transperineal
What is the criteria for 2WW for prostate cancer?
Man 50-69 with raised PSA or DRE suggestive of prostate cancer
What is found on DRE in prostate cancer?
Asymmetrical, hard, Nodular prostate
However may be normal
How is prostate cancer managed?
Watchful waiting
External beam radiotherapy
Brachytherapy
Hormone therapy (if metastatic)
Surgery (if localised)
What are side effects of a prostatectomy?
Erectile dysfunction
Urinary incontinence
Where does a prostate cancer most commonly metastasise to? How can we look for these metastases?
Lymph nodes and bones
Bony mets can be found with an isotope bone scan
What are indications for conducting a PSA?
Abnormal DRE
Symptoms of malignancy + LUTS
If over 50 - can be done on request
If over 45 and family history/black ethnicity - can be done on request
What is TURP syndrome and how does it present?
Rare life threatening complication of transurethral prostate resection
Caused by irrigation with large volumes of glycine
Due to irrigation with glycine
Leads to fluid overload
Severe Hyponatraemia
Nausea
Headache
Can lead to respiratory distress
What is the most common scrotal swelling and how does it present?
Epididymal cyst
Separate and posterior to testes, possible to get above lump
Scrotal swelling: separate from testes, posterior to testicle, possible to get above the lump?
Epididymal cyst
Scrotal swelling: non-tender soft swelling which transilluminates?
Hydrocele
Congenital hydrocele usually resolves in a few months
In adults - urgent referral is needed
Scrotal swelling: feels like bag of worms, usually on the left?
Varicocele
Enlargement of the testicular veins
Associated with infertility and renal cell carcinoma
Which side is a varicocele usually on?
Left
What scrotal swelling is associated with renal cell carcinoma?
Varicocele
What cancer is associated with a Varicocele?
Renal cell carcinoma
Scrotal swelling: sudden severe onset testicular pain which is NOT eased on elevation? Absent cremasteric reflex
Diagnosis + management?
Testicular torsion
Urgent surgical exploration needed for detorsion and BILATERAL fixation
Nil by mouth prior to surgery
Provide analgesia
What are risk factors for testicular torsion?
Abnormal testicle lie
Bell-Clapper deformity
What does a loss of cremasteric reflex indicate?
Testicular torsion
Scrotal swelling: dysuria, urethral discharge, testicular pain eased on elevation?
Acute Epididymo-orchitis
Usually due to Chlamydia
Management is as for Chlamydia (Doxycycline)
In older men can be caused by E coli
What is priapism and what are causes? How is it investigated? How is it managed?
Persistent penile erection
Causes:idiopathic, sickle cell crisis, erectile dysfunction medication
Investigation: Cavernosal blood gas analysis
Management:
If ischaemic - aspiration
If non ischaemic - observe
What is the most common type of testicular cancer?
Germ cell tumour
What are risk factors for testicular cancer?
Infertility
Family history
Klinefelter’s
Undescended testes
What are features of testicular cancer?
Painless testicular lump - hard, irregular, not fluctuant, no trans illumination
May be a hydrocele
May be gynaecomastia (particularly in Leydig cell tumour)
What tumour markers may be raised in testicular cancer? Which type are they associated with?
If it’s a seminoma - HCG may be elevated
Non-seminoma - HCG / Alpha feto-protein
Which type of testicular cancer is associated with gynaecomastia?
Leydig cell tumour
What is the definitive diagnosis for testicular cancer?
Scrotal ultrasound
What are the most common places for testicular cancer to metastasise?
Lymph nodes
Lungs
Liver
Brain
Which type of testicular cancer has a better prognosis?
Seminoma
What to differentiate between organic and psychogenic causes of erectile dysfunction?
Organic - gradual onset, normal libido, lack of spontaneous erections
Psychogenic - sudden onset, decreased libido, normal spontaneous erections, problems in relationship
Which medications can cause erectile dysfunction?
SSRIs
Beta blockers
Alcohol
Finasteride
How is erectile dysfunction investigated?
Measure free testosterone between 9am and 11am
How is erectile dysfunction managed?
Sildenafil
Phosphodiesterase type V inhibitors
What are causes of haematuria?
Infection - UTI/Pyelonephritis
Vigorous exercise
Cancer - bladder/renal/prostate
Renal stones
BPH
Prostatitis
Renal causes - Glomerulonephritis
What is the 2WW criteria for upper urinary tract cancer?
45 or over with unexplained visible haematuria
What is the most common cause of UTI?
E. coli
How does a UTI present?
Dysuria, frequency, urgency
Cloudy or offensive smelling urine
Lower abdominal pain
Low grade fever
In the elderly - delirium
How are symptoms of a UTI investigated?
Urine dipstick - will show raised nitrites, raised leukocytes
MSU
Urine dipstick result - raised leukocytes but nitrites normal?
Do not treat unless in pregnancy
How is UTI treated?
Non-pregnant women = Nitrofurantoin/Trimethoprim
Pregnant women= Trimester 1/2 = Nitrofurantoin, at term = Trimethoprim (7 days)
Men = trimethoprim/Nitrofurantoin but longer course (7 days)
When should asymptomatic bacteriuria be treated?
In pregnant women
What is the most common cause of pyelonephritis?
E. coli
What are risk factors for pyelonephritis?
Female
Structural abnormalities
Versico-ureteric reflux
Diabetes
How does pyelonephritis present?
Triad
Loin pain
Fever
Nausea / vomiting
How is suspected pyelonephritis diagnosed?
Urine dipstick - raised leukocytes and nitrites, may be haematuria
MSU is essential for diagnosing bacteria
Imaging may be conducted to exclude other pathologies
What is the first line management for pyelonephritis (if no culture results available)?
Oral Cefalexin OR IV Co-Amoxiclav + IV Cephalosporin
What is the most common type of bladder cancer?
Transitional cell carcinoma
What are risk factors for bladder cancer?
Smoking
Aromatic amines (e.g. dye factory worker)
What is the classic presentation of bladder cancer?
Painless visible haematuria
Where do kidney stones most commonly get stuck?
Vesico-ureteric junction
What is the most common kidney stone and how are they seen on x-ray?
Calcium oxalate
Radio-opaque
What are causes of calcium oxalate kidney stones?
Dehydration
Hypercalcaemia
How do renal stones present?
Renal colic - unilateral loin to groin pain (colicky)
Haematuria
Nausea/vomiting
Reduced urine output (if obstructive)
May be symptoms of sepsis
How is renal colic investigated?
Urine dipstick usually shows haematuria
Non contrast CT-KUB = initial investigation of choice
Blood tests - calcium levels, U+Es, inflammatory markers
How are renal stones investigated in children and pregnant women?
Ultrasound KUB
How are renal stones initially managed?
IM Diclofenac for pain management
Anti-emetics if nausea is present
How is a renal stone measuring less than 5mm managed?
Watchful waiting
When can medical management be given for calculi and what is given?
Alpha blockers - if distal ureteric stone less than 10mm (Tamsulosin, Doxazosin)
If alpha blockers CI - Nifedipine
How are stones managed if they are…
1) <5mm
2) <2cm
3) >2cm/staghorn
4) causing obstruction
1) Watch and wait
2) Shockwave lithiotripsy (if pregnant - try uteroscopy as lithotripsy is CI)
3) Percutaneous Nephrolithiotomy
4) Nephrostomy
x
x
x
x
x
x
x
x
What is a stag-horn calculus?
Calculus made of struvite (magnesium ammonium phosphate)
Which types of renal calculi is radio-lucent (not seen on x-ray)?
Uric acid + Xanthine
How can renal stones be prevented?
Increase fluid intake
Low salt diet
Thiazide diuretic - will reduce calcium in urine by increasing calcium reabsorption
If uric acid stones - allopurinol
What medication can be given to reduce the risk of renal calculi?
Calcium oxalate stones - potassium citrate/thiazide diuretics
Uric acid stones - allopurinol
What is the most common type of renal cell carcinoma?
Adenocarcinoma - clear cell
How does renal cell carcinoma classically present?
Haematuria
Flank pain
Palpable mass
What is the most common occupational type of renal cell carcinoma?
Renal Transitional cell carcinoma
What are risk factors for renal cell carcinoma?
Smoking
Obesity
Hypertension
End-stage renal failure
Tuberous sclerosis
What paraneoplastic features are associated with renal cell carcinoma?
Polycythaemia - increased EPO production
Hypercalcaemia - secretion of PTH mimick
Hypertension - increased renin secretion
Stauffer’s syndrome - Abnormal LFTs without liver mets
Which medication can cause acute urinary retention?
Tricyclic antidepressants
Anticholinergics
Alpha agonist
Alcohol
What is hydronephrosis?
Kidneys become stretched/swollen due to build up of urine
What are causes of unilateral hydronephrosis?
PACT
Pelvo-ureteric onstructiom
Aberrant renal vessels
Calculi
Tumours of the renal pelvis
What are causes of bilateral hydronephrosis?
SUPER
Stenosis of urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
How do you treat a calculi which has caused hydronephrosis and obstruction?
Urgent decompression with nephrostomy
What medication can reduce the risk of calcium stones?
Thiazide diuretic e.g. bendroflumethiazide
How long must you wait after ejaculation/vigorous exercise to check PSA?
48 hours
How is bladder cancer investigated?
- urine dipstick
- CT Urogram + Flexible cystoscopy
- Biopsy
Why does varicocele occur in renal cell carcinoma?
Compression of the left renal vein leading to compression of the testicular vein
What is a Bell Clapper deformity?
The testes is not fixed to the tunica vaginalis - it hangs freely and therefore is able to rotate
What is the most important risk factor for bladder cancer?
Smoking
What is phimosis and paraphimosis?
Phimosis = foreskin is tight and cannot be retracted over the glans. Normal in babies + young children
Paraphimosis = foreskin cannot be returned to original position after being retracted. Usually following catheterisation
When is urgent decompression with nephrostomy required for calculi?
Sepsis
Obstruction
What infection is most associated with Staghorn calculi?
Proteus infections
What is the difference between low pressure and high pressure chronic urinary retention?
High pressure leads to complications such as hydronephrosis and renal impairment
Low pressure does not
How to manage hydrocele in an adult?
Urgent testicular ultrasound to rule out underlying tumour
When to refer an infant for undescended testes?
6 months
What is the upper limit for an acceptable post-void volume?
<65 years = 50ml
>65 years = 100ml
Which calculi are radio-opaque?
Calcium oxalate
Calcium phosphate
Which type of calculi is associated with an inherited disorder?
Cystine stones
What are medical indications for circumcision?
Phimosis
Recurrent balanitis
Balanitis xerotica obliterans
Paraphimosis
Scrotal swelling that you cannot get above?
Inguinoscrotal hernia