Urology Flashcards
1
Q
Kidney Stones
aka
A
renal stones
renal calculi
urolithiasis
nephrolithiasis
2
Q
Kidney Stones
what are they
A
hard stones that form in the renal pelvis, where the urine collects before travelling down the ureters
3
Q
Kidney Stones
where do they commonly get stuck
A
at the vesico-ureteric junction
4
Q
Kidney Stones
what are 2 key complications
A
- obstruction –> AKI
- infection with obstructive pyelonephritis
5
Q
Kidney Stones
what are key risk factors for calcium collecting into a stone (2)
A
- hypercalcaemia
- low urine output
6
Q
Kidney Stones
what are the 2 types of calcium stones
A
- calcium oxolate
- calcium phosphate
7
Q
Kidney Stones
name some non-calcium stones
A
uric acid
struvite
cystine
8
Q
Kidney Stones
name a key features of uric acid stones
A
not visible on x-ray
9
Q
Kidney Stones
name a key feature of struvite stones
A
produced by bacteria therefore associated with infection
10
Q
Kidney Stones
name a key feature of cystine stones
A
associated with cystinuria, an autosomal recessive disease
11
Q
Kidney Stones
what is staghorn calculus
A
where the stone forms in the shape of the renal pelvis, giving it a similar appearance to the antlers of a deer stag
The body sits in the renal pelvis with horns extending into the renal calyces
most common in struvite stones
12
Q
Kidney Stones
why is staghorn calculus more common in struvite stones
A
in recurrent UTIs the bacteria can hydrolyse the urea to ammonia, creating solid struvite
13
Q
Kidney Stones
presenting complaint
A
RENAL COLIC:
- unilateral loin to groin pain that can be excruciating
- colicky (fluctuating in severity) as the stones moves and settles
14
Q
Kidney Stones
presentation
A
- renal colic
- haematuria
- N+V
- reduced urine output
- sepsis sx
15
Q
Kidney Stones
inx
A
- urine dipstick: haematuria
- blood tests: infection + kidney function + Ca
- abdo X-ray: calcium based stones
- non contrast CT KUB
16
Q
Kidney Stones
what is the initial inx of choice for diagnosing
A
non contrast CT KUB
17
Q
Kidney Stones
what is a cause of kidney stones
A
hypercalcaemia:
renal stones, painful bones, abdominal groans and psychiatric moans
caused by Ca supplementation, hyperparathyroidism + cancer
18
Q
Kidney Stones
non surgical mnx
A
- NSAIDs: IM diclofenac
- Antiemetics
- Abx
- watchful waiting if stones are <5mm
- Tamsulosin: may aid spontaneous passage
19
Q
Kidney Stones
when is surgical intervention required
A
in large stones >10mm
stones that don’t pass spontaneously
complete obstruction of infection
20
Q
Kidney Stones
surgical interventions (4)
A
- Extracorporeal shock wave lithotripsy (ESWL)
- Ureteroscopy and laser lithotripsy
- Percutaneous nephrolithotomy (PCNL)
- Open surgery
21
Q
Kidney Stones
what is Percutaneous nephrolithotomy (PCNL):
A
under GA
nephroscope inserted to back and a scope is inserted through kidney to assess ureter
stones can be broken into smaller pieces and removed
22
Q
Kidney Stones
what is Ureteroscopy and laser lithotripsy
A
A camera is inserted via the urethra, bladder and ureter, and the stone is identified.
broken up using targeted lasers
23
Q
Kidney Stones
what do NICE recommend to prevent further episodes
A
- increase oral intake
- add lemon juice to water
- avoid carbonated drinks
- reduce salt intake
- maintain a normal Ca intake
24
Q
Kidney Stones
why does adding lemon juice to water help
A
citric acid binds to urinary Ca, reducing the formation of stones
25
Kidney Stones
why should you avoid carbonated drinks
cola drinks contain phosphoric acid which promotes calcium oxolate formation
26
Kidney Stones
recommendations for calcium stones
reduce the intake of oxalate-rich foods (e.g., spinach, beetroot, nuts, rhubarb and black tea)
27
Kidney Stones
recommendations for uric acid stones
reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)
28
Kidney Stones
name 2 medications that may reduce the risk of recurrence
- Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium
29
Kidney Stones
mnx for confirmed stone + septic once stabilised
urgent decompression by either nephrostomy or retrograde stent insertion
to ensure the blocked system is relieved, and that urine can drain from the kidney.
30
Renal Cell Carcinoma
what is it
the most common type of kidney tumour
type of adenocarcinoma that arises from the renal tubules
31
Renal Cell Carcinoma
what is the classic triad of presentation
1. haematuria
2. flank pain
3. palpable mass
32
Renal Cell Carcinoma
what are the 3 most common types of RCC
- clear cell (80%)
- papillary (15%)
- chromophobe (5%)
33
Renal Cell Carcinoma
what is Wilms' tumour
a specific type of tumour affecting the kidney in children, typically <5y
34
Renal Cell Carcinoma
RFs
- smoking
- obesity
- HTN
- end stage renal failure
- Von Hippel-Lindau Disease
- Tuberous sclerosis
35
Renal Cell Carcinoma
presentation
may be asymptomatic
- haematuria
- vague loin pain
- palpable mass
- non specific sx of cancer: weight loss, fatigue, anorexia, night sweats
36
Renal Cell Carcinoma
what does NICE advise for a 2 week referral
>45years
with unexplained visible haematuria
either without a UTI or persisting after trx for a UTI
37
Renal Cell Carcinoma
where is it spread
to the tissues around the kidney, within Gerota's fascia
often spreads to the renal vein, then to the inferior vena cava
38
Renal Cell Carcinoma
what is a classic feature of metastatic RCC
Cannonball metastases in the lungs
39
Renal Cell Carcinoma
| how do cannonball metastases present
clearly-defined circular opacities scattered throughout the lung fields on a CXR
40
Renal Cell Carcinoma
what other cancers can cannonball metastases present
choriocarcinoma (cancer in the placenta)
41
Renal Cell Carcinoma
what paraneoplastic syndromes is RCC associated with
- polycythaemia
- hypercalcaemia
- hypertension
- Stauffer's syndrome
42
Renal Cell Carcinoma
paraneoplastic features: why is polycythaemia a feature
due to secretion of unregulated erythropoietin
43
Renal Cell Carcinoma
paraneoplastic features: why is hypercalcaemia a feature
due to secretion of a hormone that mimics the action of PTH
and bony metastases
44
Renal Cell Carcinoma
paraneoplastic features: why is hypertension a feature
due to increased renin secretion, polycythaemia and physical compression
45
Renal Cell Carcinoma
paraneoplastic features: what is Stauffer's syndrome
abnormal LFTs (raised ALT, AST, ALP + biliruibin) without liver metastasis
46
Renal Cell Carcinoma
what inx is used to stage the cancer
CT thorax, abdo + pelvis
47
Renal Cell Carcinoma
what is the most common staging system
TNM staging system
| there's also a number staging system
48
Renal Cell Carcinoma
Number staging system: stage 1
<7cm and confined to the kidney
49
Renal Cell Carcinoma
Number staging system: stage 2
>7cm but confined to the kidney
50
Renal Cell Carcinoma
Number staging system: stage 3
local spread to nearby tissues or veins, but not beyond Gerota's fascia
51
Renal Cell Carcinoma
Number staging system: stage 4
spread beyond Gerota's fascia, including metastasis
52
Renal Cell Carcinoma
1st line mnx
surgery to remove tumour:
- partial nephrectomy
- radical nephrectomy
53
Renal Cell Carcinoma
non-surgical mnx
- arterial embolisation
- percutaneous cryotherapy
- radiofrequency ablation
- chemo + radio
54
Renal Cell Carcinoma
what is the definitive test for diagnosis and staging
contrast enhanced CT scan of abdo
55
what are the key causes of scrotal or testicular lumps
- hydrocele
- varicocele
- Epididymal cyst
- testicular cancer
- epididymo-orchitis
- inguinal hernia
- testicular torsion
56
Hydrocele
what is it
a collection of fluid within the tunica vaginalis surrounding the testes
57
Hydrocele
sx
painless
soft scrotal swellings
58
Hydrocele
examination findings
- transilluminated (testicle floats within the fluid)
- irreducible and has no bowel sounds
- soft, fluctuant and may be large
- testicle is palpable within the hydrocele
59
Hydrocele
how to distinguish it from a hernia
hydroceles are irreducible and has no bowel sounds
60
Hydrocele
cause
- idiopathic
- testicular cancer
- testicular torsion
- epididymo-orchitis
- trauma
61
Hydrocele
mnx
- exclude serious causes (e.g. cancer)
- idiopathic: manage conservatively
- large or symptomatic: surgery, aspiration or sclerotherapy
62
Varicocele
what is it
when the veins in the pampiniform plexus become swollen
63
Varicocele
how come it can cause infertility
probs due to disrupting the temp in the affected testicle
64
Varicocele
what may it result in
testicular atrophy, reducing the size and function of the testicle
65
Varicocele
what is the pampiniform plexus
a venous plexus found in the spermatic cord and drains the testes
66
Varicocele
where does the pampiniform plexus drain into
the testicular vein
67
Varicocele
what is the role of the pampiniform plexus
regulates the temp of blood entering the testes by absorbing heat from the nearby testicular artery
68
Varicocele
pathophysiology
the result of increased resistance in the testicular vein
incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus
69
Varicocele
where does the right testicular vein drain directly into
the inferior vena cava
70
Varicocele
where does the left testicular vein drain into
the left renal vein
71
Varicocele
why do most occur on the left
due to increased resistance in the left testicular vein
72
Varicocele
what can a left-sided varicocele indicate
an obstruction of the left testicular vein caused by a renal cell carcinoma
73
Varicocele
presentation (3)
- throbbing/dull pain or discomfort, worse on standing
- a dragging sensation
- sub-fertility or infertility
74
Varicocele
examination findings
- scrotal mass that feels like a 'bag of worms'
- more prominent on standing
- disappears when lying down
- asymmetry in testicular size if the varicocele has affected the growth of the testicle
75
Varicocele
when should an urgent referral to urology be made
varicoceles that do not disappear when lying down as could be a retroperitoneal tumour obstructing the drainage of the renal vein
76
Varicocele
confirmation of dx
US with Doppler imaging
77
Varicocele
inx if concerns about fertility
semen analysis
78
Varicocele
inx if there are concerns about function
hormonal tests (e.g. FSH + testosterone)
79
Varicocele
mnx if uncomplicated
manage conservatively
80
Varicocele
mnx if pain, testicular atrophy or infertility
surgery or endovascular embolization
81
Epididymal Cysts
where do they occur
at the head of the epididymis (at the top of the testicle)
82
Epididymal Cysts
what is a spermatocele
an epididymal cyst that contains sperm
83
Epididymal Cysts
sx
pt felt a lump
84
Epididymal Cysts
examination findings
- soft round lump
- typically at the top of the testicle
- associated with the epididymis
- separate from the testicle
- large cysts: may be transilluminated
85
Epididymal Cysts
worst case
torsion of cysts causing acute pain and swelling
usually entirely harmless
86
Testicular Cancer
where does testicular cancer arise from
germ cells in the testes
87
Testicular Cancer
what do germ cells produce
gametes (sperm in males)
88
Testicular Cancer
what age group has the highest incidence
15-35 years
89
Testicular Cancer
what 2 types can it be divided into
- Seminomas
| - Non- seminomas (mostly teratomas)
90
Testicular Cancer
RFs (4)
- undescended testes
- male infertility
- FH
- increased height
91
Testicular Cancer
typical presentation
painless lump on testicle
occasionally it can present with testicular pain
92
Testicular Cancer
describe the lump
- non-tender (or even reduced sensation)
- arising from testicle
- hard
- irregular
- non fluctuant
- no transillumination
93
Testicular Cancer
Leydig cell tumour is rare. What can it present with
gynaecomastia
94
Testicular Cancer
initial inx to confirm dx
scrotal US
95
Testicular Cancer
what tumour marker may be raised in teratomas (not in pure seminomas)
alpha-fetoprotein
96
Testicular Cancer
what tumour marker may be raised in both teratomas and seminomas
Beta-hCG
97
Testicular Cancer
what is a very non-specific tumour marker
lactate dehydrogenase (LDH)
98
Testicular Cancer
what can be used to look for areas of spread and to stage the cancer
a staging CT scan
99
Testicular Cancer
what is the staging system called
Royal Marsden Staging System
100
Testicular Cancer
Royal Marsden Staging System: Stage 1
isolated to the testicle
101
Testicular Cancer
Royal Marsden Staging System: Stage 2
spread to the retroperitoneal lymph nodes
102
Testicular Cancer
Royal Marsden Staging System: Stage 3
spread to the lymph nodes above the diaphragm
103
Testicular Cancer
Royal Marsden Staging System: Stage 4
metastasised to other organs
104
Testicular Cancer
where are common places for testicular cancer to metastasis to (4)
- lymphatics
- Lungs
- Liver
- Brain
105
Testicular Cancer
mnx
- surgery (radical orchidectomy)
- chemo
- radio
- sperm banking
106
Testicular Cancer
mnx: what is sperm banking
saving sperm for future use as trx may cause infertility
107
Testicular Cancer
SEs of trx (radical orchidectomy, chemo, radio)
- infertility
- hypogonadism (testosterone may be needed)
- peripheral neuropathy
- hearing loss
- lasting kidney, liver or heart damage
- increased risk of cancer in the future
108
Testicular Cancer
prognosis
>90% cure rate
109
Testicular Cancer
which type has a better prognosis
seminomas have a slightly better prognosis than non-seminomas
110
Testicular Cancer
what does follow up involve
- monitoring tumour markers
| - CT scans or CXRs
111
Epididymo-orchitis
what is it
Epididymitis: inflammation of the epididymis
orchitis: inflammation of the testicle
Epididymo-orchitis: result of infection in the epididymis and testicle on one side
112
Epididymo-orchitis
describe the path of sperm
- released from testicle into the head of the epididymis
- sperm travels through head, then body then tail of the epididymis
- sperm mature and stored in the epididymis
- the epididymis drains into the vas deferens
113
Epididymo-orchitis
causes (4)
- E.coli
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Mumps
114
pt with parotid gland swelling and orchitis and pancreatitis. What is it
mumps
115
Epididymo-orchitis
describe the onset
gradual over minutes to hours
116
Epididymo-orchitis
presentation
- testicular pain
- dragging or heavy sensation
- swelling of testicle and epididymis
- tenderness on palpation
- urethral discharge
- fever, sepsis?
117
Epididymo-orchitis
unilateral or bilateral?
unilateral
118
Epididymo-orchitis
key Ddx
testicular torsion
| if there is any doubt, trx as testicular torsion until proven otherwise
119
Epididymo-orchitis
what features make it a STI more than E.coli
- age <35
- increased number of sexual partners in the last 12m
- discharge from urethra
120
Epididymo-orchitis
inx to help establish dx
- urine MC&S
- NAAT testing on first pass urine
- charcoal swab of purulent urethral discharge
- saliva swab (mumps)
- serum antibodies (mumps)
- US (torsion, tumours)
121
Epididymo-orchitis
mnx for very unwell or septic
admit to hospital for trx (IV abx)
122
Epididymo-orchitis
mnx for pts with a high risk of STI
referred urgently to GUM
123
Epididymo-orchitis
for pts that are at a low risk of STI, what is the typical ab of choice
1st line: Ofloxacin for 14d
alternatives:
- levofloxacin/ciprofloxacin
- doxycycline
- co-amoxiclav
124
Epididymo-orchitis
additional measures for mnx apart from abx
- analgesia
- supportive underwear
- reduce physical activity
- abstain from intercourse
125
Epididymo-orchitis
what are quinolone abx (ofloxacin, levofloxacin and ciprofloxacin)
powerful broad-spectrum abx, often used for UTIs. pyelonephritis, epididymo-orchitis and prostatitis.
excellent gram -ve cover
126
Epididymo-orchitis
2 critical SEs of Quinolone abx (ofloxacin, levofloxacin and ciprofloxacin)
- tendon damage + rupture (Achilles)
| - lower seizure threshold (caution in pts with epilepsy)
127
Epididymo-orchitis
complications (5)
- chronic pain
- chronic epididymitis
- testicular atrophy
- sub-fertility or infertility
- scrotal abscess
128
pt with sepsis and kidney stones. what is the best mnx?
nephrostomy: urgent decompression
129
Bladder Cancer
where does cancer in the bladder arise from
the endothelial lining (urothelium)
130
Bladder Cancer
what are the 2 main risk factors for bladder cancer
- smoking
| - increased age
131
Bladder Cancer
what carcinogen causes bladder cancer
aromatic amines (found in dye and rubber and cigarette smoke)
132
Bladder Cancer
what causes squamous cell carcinoma of the bladder
Schistosomiasis esp in countries with a high prevalence of the infection
133
pt is a retired dye factory worker with painless haematuria. What does he have
transitional cell carcinoma of the bladder
134
Bladder Cancer
what are the types
- Transitional cell carcinoma (90%)
- Squamous cell carcinoma (5%)
- adenocarcinoma (2%), sarcoma, small-cell carcinoma
135
Bladder Cancer
The symptom to remember for exams
PAINLESS HAEMATURIA
136
Bladder Cancer
Mnx: Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
2 week wait referral
137
Bladder Cancer
Mnx: Aged over 60 with microscopic haematuria PLUS dysuria or raised WBCs
2 week wait referral
138
Bladder Cancer
Mnx: >60 years with recurrent unexplained UTIs
consider a non-urgent referral
139
Bladder Cancer
diagnostic inx
Cytoscopy
140
Bladder Cancer
what is cystosocopy
camera through the urethra into the bladder
rigid or flexible
141
Bladder Cancer
what staging system is used
TNM
142
Bladder Cancer
TNM: what are the non-muscle-invasive bladder cancers
- Tis/carcinoma in situ
- Ta
- T1
143
Bladder Cancer
TNM: what is Tis/carcinoma in situ
cancer cells only affect the urotherlium and are flat
144
Bladder Cancer
TNM: what is Ta
cancer only affecting the urotherlium and projecting into the bladder
145
Bladder Cancer
TNM: what is T1
cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer
146
Bladder Cancer
TNM: what does invasive bladder cancer include
T2-T4 and any lymph node or metastatic spread
147
Bladder Cancer
mnx for non-muscle-invasive bladder cancer
TURBT (transurethral resection of bladder tumour)
148
Bladder Cancer
mnx: what is TURBT
transurethral resection of bladder tumour
removing bladder tumour during cytoscopy
149
Bladder Cancer
mnx: what is used after TURBT to reduce risk of recurrence
intravesical chemotherapy
150
Bladder Cancer
mnx: what is intravesical chemo
chemo given into the bladder through a catheter
151
Bladder Cancer
mnx: what may be used as a form of immunotherapy
Intravesical Bacillus Calmette-Guérin (BCG)
152
Bladder Cancer
mnx: how would the BCG vaccine work
(the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours
153
Bladder Cancer
mnx to remove entire bladder
radical cystectomy
154
Bladder Cancer
what options are available for draining urine (following a radical cystectomy)
- urostomy w/ an ileal conduit (most common)
- continent urinary diversion
- neobladder reconstruction
- ureterosigmoidostomy
155
Bladder Cancer
can chemo and radio be used for mnx
yes
156
Bladder Cancer
what is urostomy
used to drain urine from the kidney, bypassing the ureters, bladder and urethra
157
Bladder Cancer
urostomy: what is an ilieal conduit
section of ilelum removed
end-to-end anastomosis is created so that the bowel is continuous.
end of ureters are anastomsed to the separate section of the ileum
other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag.
Urine drains from the kidneys to the ureters, then the separated section of ileum (the conduit), then out of the urostomy.
158
Bladder Cancer
what is Continent Urinary Diversion
creating a pouch inside the abdomen from a section of the ileum
with the ureters connected. This pouch fills with urine. A thin tube is connected between a stoma on the skin and the internal pouch. Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.
159
Bladder Cancer
what is neobladder reconstruction
creating a new bladder from a section of the ileum.
160
Bladder Cancer
what is Ureterosigmoidostomy
attaching the ureters directly to the sigmoid colon.
161
what is the best pain relief for renal colic which presents acutely
IM diclofenac
162
BPH
what is it caused by
hyperplasia of the stromal and epithelial cells of the prostate
163
BPH
what are the lower urinary tract symptoms
- hesitancy
- weak flow
- urgency
- frequency
- intermittency
- straining
- terminal dribbling
- incomplete emptying
- nocturia
164
BPH
what scoring system is used to assess the severity of lower urinary tract symptoms
international prostate symptom score (IPSS)
165
BPH
initial assessment of men presenting with LUTS
- DRE
- abdo exam
- urinary freq volume chart
- urine dipstick
- PSA
166
BPH
common causes of a raised PSA
- prostate cancer
- BPH
- prostatitis
- UTIs
- vigorous exercise (notably cycling)
- recent ejaculation or prostate stimulation
167
BPH
what may a benign prostate feel like
smooth, symmetrical and slightly soft, with a maintained central sulcus
168
BPH
what may a cancerous prostate feel like
firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
169
BPH
medical mnx
tamsulosin
| finasteride
170
BPH
how does tamsulosin work
alpha blocker
relaxes smooth muscle
with rapid improvement in symptoms
171
BPH
how does finasteride work
5-alpha reductase inhibitor
5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone
gradually reduce the size of the prostate
172
BPH
surgical options
- Transurethral resection of the prostate (TURP)
- Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- Holmium laser enucleation of the prostate (HoLEP)
- Open prostatectomy via an abdominal or perineal incision
173
BPH
SE of tamsulosin (alpha bloker)
postural hypotension
174
BPH
SE of finasteride
sexual dysfunction (due to reduced testosterone)
175
what reflex may be absent in testicular torsion
cremasteric reflex: contraction of the cremasteric muscle upon stroking of the inner thigh
176
indications for finasteride
- BPH
| - Androgenetic alopecia in men
177
important safety info for finasteride
cases of depression and, in rare cases, suicidal thoughts
male breast cancer
178
Obstructive Uropathy
presentation of an upper urinary tract obstruction (e.g. ureters)
- Loin to groin or flank pain on the affected side (due to stretching and irritation of ureter and kidney)
- Reduced or no urine output
- Non-specific systemic symptoms: vomiting
- Impaired renal function on blood tests (i.e. raised creatinine)
179
Obstructive Uropathy
presentation of a lower urinary tract obstruction (e.g. bladder or urethra)
- Difficulty or inability to pass urine (e.g. poor flow, difficulty initiating urination or terminal dribbling)
- Urinary retention, with an increasingly full bladder
- Impaired renal function on blood tests (i.e. raised creatinine)
180
Obstructive Uropathy
what is the costovertebral angle
the angle formed by the 12th rib and vertebral column at the back.
Tenderness in the renal angle suggests kidney pathology.
181
Obstructive Uropathy
causes of upper urinary tract obstruction
- Kidney stones
- Tumours pressing on the ureters
- Ureter strictures (due to scar tissue narrowing the tube)
- Retroperitoneal fibrosis (the development of scar tissue in the retroperitoneal space)
- Bladder cancer (blocking the ureteral openings to the bladder)
- Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)
182
Obstructive Uropathy
causes of lower urinary tract obstruction
- Benign prostatic hyperplasia (benign enlarged prostate)
- Prostate cancer
- Bladder cancer (blocking the neck of the bladder)
- Urethral strictures (due to scar tissue)
- Neurogenic bladder
183
Obstructive Uropathy
what is neurogenic bladder
abnormal function of the nerves innervating the bladder and urethra
It can result in overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra.
184
Obstructive Uropathy
causes of neurogenic bladder
- Multiple sclerosis
- Diabetes
- Stroke
- Parkinson’s disease
- Brain or spinal cord injury
- Spina bifida
185
Obstructive Uropathy
what can neurogenic bladder result in
- Urge incontinence
- Increased bladder pressure
- Obstructive uropathy
186
Obstructive Uropathy
mnx to bypass an obstruction in the upper urinary tract (e.g. ureteral stone)
nephrostomy:
- insert thin tube through skin, kidney and ureter.
- allows urine to drain out of the body, into a bag.
187
Obstructive Uropathy
mnx to bypass an obstruction in the lower urinary tract (e.g. urethral stricture or prostatic hyperplasia)
A urethral or suprapubic catheter
188
Obstructive Uropathy
complications
- Pain
- AKI (post-renal)
- CKD
- Infection
- Hydronephrosis
- Urinary retention and bladder distention
- Overflow incontinence of urine
189
Obstructive Uropathy
what is hydronephrosis
swelling of the renal pelvis and calyces in the kidney
due to obstruction of the urinary tract, leading to back-pressure into the kidneys.
190
Obstructive Uropathy
what is idiopathic hydronephrosis
the result of a narrowing at the pelviureteric junction (PUJ)
can be congenital or develop later
191
Obstructive Uropathy
trx of idiopathic hydronephrosis
pyeloplasty: surgery to correct the narrowing + restructure the renal pelvis
192
Obstructive Uropathy
presentation of hydronephrosis
vague renal angle pain and a mass in the kidney area
193
Obstructive Uropathy
imaging for hydronephrosis
- US
- CT scan
- IV urogram (x-ray with IV contrast collecting in the urinary tract)
194
Obstructive Uropathy
trx for hydronephrosis
treat underlying cause. If required, pressure can be relieved with either:
- Percutaneous nephrostomy
- Antegrade ureteric stent
195
Prostatitis
what is it
inflammation of the prostate
196
Prostatitis
how can it be classed
Acute bacterial prostatitis
Chronic prostatitis
197
Prostatitis
how long must sx last for it to be chronic
3m
198
Prostatitis
what can chronic prostatitis be further sub-divided into
- Chronic prostatitis or chronic pelvic pain syndrome (no infection)
- Chronic bacterial prostatitis (infection)
199
Prostatitis
chronic prostatitis presentation
at least 3m of:
- pelvic pain: perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area
- LUTS: dysuria, hesitancy, freq, retention
- sexual dysfunction: erectile dysfunction, pain on ejaculation, haematospermia
- pain with bowel movements
- tender + enlarged prostate
200
Prostatitis
acute prostatitis presentation
acute presentation of:
- pelvic pain, LUTS, sexual dysfunction, pain with bowel movements, tender enlarged prostate
- fever, myalgia, nausea, fatigue, sepsis
201
Prostatitis
how to assess the severity of the symptoms and their impact on QoL for chronic prostatitis
National Institute of Health Chronic Prostatitis Symptom Index
202
Prostatitis
inx
- urine dipstick
- urine MC&S
- chlamydia + gonorrhoea NAAT testing
203
Prostatitis
mnx for acute bacterial prostatitis
- admit if systemically unwell
- PO abx for 2-4w (ciprofloxacin)
- paracetamol/ NSAIDs
- laxatives for pain during bowel movements
204
Prostatitis
mnx for chronic bacterial prostatitis
- Alpha-blockers (e.g., tamsulosin)
- paracetamol or NSAIDs
- CBT/ antidepressants
- Abx if <6m of sx or a history of infection (e.g. trimethoprim or doxycycline for 4-6 weeks)
- Laxatives for pain during bowel movements
205
Prostatitis
complications of acute bacterial prostatitis
- Sepsis
- Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
- Acute urinary retention
- Chronic prostatitis
206
Testicular Torsion
what is it
urological emergency
twisting of the spermatic cord with rotation of the testicle
207
Testicular Torsion
what is a common trigger
playing sport
208
Testicular Torsion
sx
- unilateral testicular pain
- abdo pain
- vomiting
209
Testicular Torsion
examination findings
- firm swollen testicle
- elevated (retracted) testicle)
- absent cremasteric reflex
- abnormal testicular lie (often horizontal)
- rotation (epididymis is not in normal posterior position)
210
Testicular Torsion
what is Bell-Clapper Deformity
Normally, the testicle is fixed posteriorly to the tunica vaginalis
Bell-Clapper Deformity is when fixation between the testicle and the tunica vaginalis is absent.
one of the causes of testicular torsion
211
Testicular Torsion
presentation of Bell-Clapper Deformity on examination
testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position
able to rotate within the tunica vaginalis, twisting at the spermatic cord.
it cuts off the blood supply.
212
Testicular Torsion
mnx
- nil by mouth (for surgery)
- analgesia
- urgent senior urology assessment
- surgical exploration of the scrotum
- orchiopexy
- orchidectomy
213
Testicular Torsion
what is orchiopexy
correcting the position of the testicles and fixing them in place
214
Testicular Torsion
when would you do an orchidectomy
if the surgery is delayed or there is necrosis
215
Testicular Torsion
inx to confirm dx
scrotal US
but don't delay for surgery
216
Testicular Torsion
what will show on US
whirlpool sign: a spiral appearance to the spermatic cord and blood vessels
217
Lower Urinary Tract Infection
why is it more common in women
he urethra is much shorter, making it easy for bacteria to get into the bladder
218
Lower Urinary Tract Infection
what can contribute to UTIs
- incontinence
- poor hygiene
- sexual activity
- urinary catheters
219
Lower Urinary Tract Infection
presentation
- Dysuria (pain, stinging or burning when passing urine)
- Suprapubic pain or discomfort
- Frequency
- Urgency
- Incontinence
- Haematuria
- Cloudy or foul smelling urine
220
Lower Urinary Tract Infection
what is commonly the only symptom in older and frail patients
Confusion is commonly the only symptom in older and frail patients
221
Lower Urinary Tract Infection
what sx should you suspect pyelonephritis
- Fever
- Loin/back pain
- Nausea/vomiting
- Renal angle tenderness on examination
222
Lower Urinary Tract Infection
which is a better indication of infection on urine dipstick?
nitrates rather than leukocytes
223
Lower Urinary Tract Infection
why are nitrites present on urine dipstick
gram-negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites
224
Lower Urinary Tract Infection
should pt be treated if only leukocytes are present
not as a UTI unless there is clinical evidence of one
225
Lower Urinary Tract Infection
what may urine dipstick show
- raised nitrites
- raised leukocytes
- haematuria
226
Lower Urinary Tract Infection
when should you send a midstream urine sample for microscopy
- pregnant
- recurrent UTIs
- atypical sx
- when sx do not improve with abx
227
Lower Urinary Tract Infection
what is the most common cause of UTIs
e.coli
other:
- Klebsiella pneumoniae
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Candida albicans
228
Lower Urinary Tract Infection
what kind of bacteria is e.coli
gram-negative, anaerobic, rod-shaped bacteria
229
Lower Urinary Tract Infection
what would an appropriate initial antibiotic in the community be?
- trimethoprim
| - nitrofurantoin
230
Lower Urinary Tract Infection
which patients should avoid nitrofurantoin
patients with an eGFR <45
231
Lower Urinary Tract Infection
duration of abx for simple lower urinary tract infections in women
3d
232
Lower Urinary Tract Infection
duration of abx for immunosuppressed women, abnormal anatomy or impaired kidney function
5-10d
233
Lower Urinary Tract Infection
duration of abx for men, pregnant women or catheter-related UTIs
7d
234
Lower Urinary Tract Infection
trx for catheter-related UTI
abx for 7d
and change the catheter
235
Lower Urinary Tract Infection
what does it increase the risk in pregnancy
- pyelonephritis
- premature rupture of membranes
- pre-term labour
236
Lower Urinary Tract Infection
abx options for pregnant women
- Nitrofurantoin (avoid in the third trimester)
- Amoxicillin (only after sensitivities are known)
- Cefalexin
237
Lower Urinary Tract Infection
why does nitrofurantoin need to be avoided in the 3rd trimester
neonatal haemolysis (destruction of the neonatal red blood cells).
238
Lower Urinary Tract Infection
why does trimethoprim need to be avoided in the 1st trimester
it's a folate antagonist
Folate is essential in early pregnancy for the normal development of the fetus
239
Lower Urinary Tract Infection
what can trimethoprim cause in early pregnancy
congenital malformations, particularly neural tube defects (e.g., spina bifida)
240
Pyelonephritis
RFs (4)
- female
- structural urological abnormalities
- vesico-ureteric reflux
- diabetes
241
Pyelonephritis
what is vesico-ureteric reflux
urine refluxing from the bladder to the ureters – usually in children
242
Pyelonephritis
what is the most common cause
Escherichia coli
243
Pyelonephritis
what type of bacteria is e.coli
gram-negative, anaerobic, rod-shaped bacteria
244
Pyelonephritis
other causes apart from e.coli
- Klebsiella pneumoniae (gram-negative anaerobic rod)
- Enterococcus
- Pseudomonas aeruginosa
- Staphylococcus saprophyticus
- Candida albicans (fungal)
245
Pyelonephritis
presentation
similar to lower UTI (dysuria, suprapubic discomfort and increased frequency)
PLUS
1. fever
2. loin or back pain
3. N or V
may have:
- systemic illness
- loss of appetite
- haematuria
- renal angle tenderness on examination
246
Pyelonephritis
inx
- urine dipstick
- midstream urine for MC+S
- CRP + WCC
- US or CT scan to exclude other pathologies
247
Pyelonephritis
mnx in the community
1st line abx for 7-10d:
- Cefalexin
- co-amoxiclav, trimethoprim (if culture results are available)
- ciprofloxacin
248
Pyelonephritis
when should you admit
features of sepsis or if it is not safe to manage them in the community.
249
Pyelonephritis
mnx in hospital
sepsis 6
1. lactate
2. blood cultures
3. urine output
4. O2
5. IV abx
6. IV fluids
250
Pyelonephritis
Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment
1. renal abscess
| 2. kidney stone obstructing the ureter, causing pyelonephritis
251
Pyelonephritis
how does chronic pyelonephritis present
recurrent episodes of infection in the kidneys
which lead to scarring of the renal parenchyma
leading to CKD
and progress to end stage renal failure
252
Pyelonephritis
what scan in used in recurrent pyelonephritis to assess for renal damage
Dimercaptosuccinic acid (DMSA) scan
| injecting radiolabelled DMSA. Damage in areas that do not take up the DMSA
253
Interstitial Cystitis
aka?
bladder pain syndrome and hypersensitive bladder syndrome
254
Interstitial Cystitis
what is it
a chronic condition causing inflammation in the bladder, resulting in LUTS and suprapubic pain
255
Interstitial Cystitis
pathophysiology?
likely a complex combination of dysfunction of the blood vessels, nerves, immune system and epithelium
256
Interstitial Cystitis
who is it more common in
women
257
Interstitial Cystitis
presentation
>6w of:
- suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
- frequency
- urgency
- sx ,ay be worse during menstruation
258
Interstitial Cystitis
what inx would you do to exclude other causes
- urinalysis: UTIs
- swabs: STIs
- cystoscopy: bladder cancer
- prostate examination: prostatitis, hypertrophy or cancer
259
Interstitial Cystitis
what may be seen on cystoscopy patients with interstitial cystitis
Hunner lesions
- red, inflamed patches of the bladder mucosa associated with small blood vessels
Granulations
- tiny haemorrhages on the bladder wall
260
Interstitial Cystitis
supportive mnx
- avoid alcohol, caffeine and tomatoes
- stop smoking
- pelvic floor exercises
- bladder retraining
- CBT
- transcutaneous electrical nerve stimulation (TENS)
261
Interstitial Cystitis
oral medications that may be helpful
- analgesia
- antihistamines
- anticholinergics (oxybutynin or solifenacin)
- mirebegron
- cimetidine
- pentosan polysulfate sodium
- ciclosporin
262
Interstitial Cystitis
what kind of drug is mirebegron
beta-3-adrenergic-receptor agonist
263
Interstitial Cystitis
what kind of drug is Cimetidine
histamine-2-receptor antagonist
264
Interstitial Cystitis
what intravesical medication may be helpful
- Lidocaine
- Pentosan polysulfate sodium
- Hyaluronic acid
- Chondroitin sulphate
265
Interstitial Cystitis
what is hydrodistension
filling the bladder with water, to high pressure, during a cystoscopy
requires GA
This can give a temporary (3-6 month) improvement
266
Interstitial Cystitis
what surgical procedures may be used in mnx
- Cauterisation of Hunner lesions during cystoscopy
- Butulinum toxin injections during cystoscopy
- Neuromodulation with an implanted electrical nerve stimulator
- Augmentation of the bladder, using a section of ileum, to increase the capacity (ileocystoplasty)
- Cystectomy (removal of the bladder)
267
'warm and boggy' prostate . what could this be
prostatits
268
when should you refer a boy with undescended testes
6 months
269
what is paraphimosis
typically caused by not replacing a retracted foreskin
270
mnx of paraphimosis
reducing the oedema to the glans by applying pressure over a period of time
if not, dorsal slit to cut foreskin
271
what is phimosis
the foreskin is tight and cannot be retracted over the glans
272
causes of phimosis in adults
- STIs
- Eczema
- Psoriasis
- Lichen planus
- Lichen sclerosis
- Balanitis
273
trx of phimosis
steroid creams or circumcision
274
what is a complication of TURP
TURP syndrome:
| Hyponatraemia due to absorption of irrigation fluids intra-operatively
275
PMH: catheter balloon popped whilst in situ
PC: visible haematuria. blood towards the end of voiding which is often associated with referred pain to the end of his penis
what could this be
bladder calculi
276
undescended bilateral testes at birth, what do u do
refer immediately as could be CAH
277
Prostate Cancer
key RFs (5)
- increasing age
- FH
- black african or carribbean
- tall
- anabolic steroids
278
Prostate Cancer
presentation
- asymptomatic
- LUTS
- haematuria
- erectile dysfunction
- weight loss, bone pain, cauda equina
279
Prostate Cancer
which cells produce prostate-specific antigen (PSA)
The epithelial cells of the prostate
280
Prostate Cancer
what is PSA
a glycoprotein that is secreted in the semen, with a small amount entering the blood
Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation
281
Prostate Cancer
can a patient request a PSA
yes if man is >50
282
Prostate Cancer
common causes of raised PSA
- prostate cancer
- BPH
- prostatitis
- UTIs
- vigorous exercise (notably exercise)
- recent ejaculation or prostate stimulation
283
Prostate Cancer
why is PSA testing unreliable
high rate of false positives and false negatives
284
Prostate Cancer
first line examination
DRE
285
Prostate Cancer
what does a benign prostate feel like
smooth, symmetrical and slightly soft, with a maintained central sulcus
may be generalised enlargement in prostatic hyperplasia
286
Prostate Cancer
what will an infected or inflamed prostate (prostatitis) feel like
enlarged, tender and warm
287
Prostate Cancer
what may a cancerous prostate feel like
- firm or hard - asymmetrical
- craggy or irregular
- loss of the central sulcus
- may have a hard nodule
288
Prostate Cancer
suspected prostate cancer on DRE in GP< what now?
2 week wait urgent cancer referral to urology
289
Prostate Cancer
1st line inx for suspected prostate cancer
Multiparametric MRI of the prostate
reported on a Linkert scale 1-5, 5 being definite cancer
290
Prostate Cancer
what inx to establishing diagnosis
prostate biopsy
291
Prostate Cancer
what are the 2 options for prostate biopsy
- Transrectal ultrasound-guided biopsy (TRUS)
| - Transperineal biopsy
292
Prostate Cancer
what does transperineal biopsy involve
needles inserted through the perineum
293
Prostate Cancer
main risks of prostate biopsy
- pain
- bleeding
- infection
- urinary retention
- erectile dysfunction
294
Prostate Cancer
what inx to look for bony metastasis
isotope bone scan
aka radionuclide scan or bone scintigraphy
Metastatic bone lesions take up more of the isotope, making them stand out on the scan.
295
Prostate Cancer
what scoring system is used to determine what trx is appropriate
The Gleason grading system
based on the histology from the prostate biopsies
296
Prostate Cancer
what is the first number in the gleason score
the grade of the most prevalent pattern in the biopsy
graded 1-5
297
Prostate Cancer
what is the second number in the gleason score
the grade of the second most prevalent pattern in the biopsy
graded 1-5
298
Prostate Cancer
what does a gleason score of 6 indicate
low risk
299
Prostate Cancer
what does a gleason score of 7 indicate
intermediate risk
300
Prostate Cancer
what does a gleason score of 8 or above indicate
high risk
301
Prostate Cancer
what system is used to stage it
TNM
302
Prostate Cancer
trx
- Surveillance or watchful waiting in early prostate cancer
- External beam radiotherapy directed at the prostate
- Brachytherapy
- Hormone therapy
- Surgery
303
Prostate Cancer
what is a key complication of external beam radiotherapy
proctitis (inflammation in the rectum) caused by radiation affecting the rectum
304
Prostate Cancer
presentation of proctitis
pain, altered bowel habit, rectal bleeding and discharge
305
Prostate Cancer
mnx of proctitis
Prednisolone suppositories can help reduce inflammation.
306
Prostate Cancer
what does brachytherapy involve
implanting radioactive metal “seeds” into the prostate
which delivers continuous, targeted radiotherapy
307
Prostate Cancer
SEs of brachytherapy
- cystitis, proctitis
- erectile dysfunction
- incontinence
- increased risk of bladder or rectal cancer
308
Prostate Cancer
when is hormone therapy used
in combo w. radiotherapy or alone in advanced disease where cure is not possible
309
Prostate Cancer
what is the aim of hormonal therapy
to reduce the level of androgens e.g. testosterone that stimulate the cancer to grow
310
Prostate Cancer
options of hormonal therapy
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
- Bilateral orchidectomy to remove the testicles (rarely used)
311
Prostate Cancer
SEs of hormone therapy (5)
- hot flushes
- sexual dysfunction
- gynaecomastia
- fatigue
- osteoporosis
312
Prostate Cancer
surgical mnx
radical prostatectomy
313
Prostate Cancer
complications of prostatectomy
erectile dysfunction and urinary incontinence
314
Non-seminoma testicular tumours are more common in what age group
25 ish
315
Seminomas are more common in what age group
30-50
316
common side effect of radiotherapy to the prostate region
mucositis in the rectum called proctitis.
This can lead to diarrhoea and the presence of blood in the stool.
317
what is Prehn’s sign
to distinguish between epididymo-orchitis and testicular torsion
lifting half of the scrotum up relieves pain --> epidymo-orchitis
318
2 signs of testicular torsion which distinguishes it from epididymo orchitis
- absent cremasteric reflex
| - testicle is high and lying transversely
319
2 signs of epididymo orchitis which distinguishes it from testicular torsion
- Prehn's sign
| - retrotesticular pain
