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Urology Flashcards

1
Q

Kidney Stones

aka

A

renal stones
renal calculi
urolithiasis
nephrolithiasis

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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

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3
Q

Kidney Stones

where do they commonly get stuck

A

at the vesico-ureteric junction

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4
Q

Kidney Stones

what are 2 key complications

A
  • obstruction –> AKI

- infection with obstructive pyelonephritis

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5
Q

Kidney Stones

what are key risk factors for calcium collecting into a stone (2)

A
  • hypercalcaemia

- low urine output

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6
Q

Kidney Stones

what are the 2 types of calcium stones

A
  • calcium oxolate

- calcium phosphate

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7
Q

Kidney Stones

name some non-calcium stones

A

uric acid
struvite
cystine

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8
Q

Kidney Stones

name a key features of uric acid stones

A

not visible on x-ray

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9
Q

Kidney Stones

name a key feature of struvite stones

A

produced by bacteria therefore associated with infection

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10
Q

Kidney Stones

name a key feature of cystine stones

A

associated with cystinuria, an autosomal recessive disease

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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

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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

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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
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14
Q

Kidney Stones

presentation

A
  • renal colic
  • haematuria
  • N+V
  • reduced urine output
  • sepsis sx
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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
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16
Q

Kidney Stones

what is the initial inx of choice for diagnosing

A

non contrast CT KUB

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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

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18
Q

Kidney Stones

non surgical mnx

A
  • NSAIDs: IM diclofenac
  • Antiemetics
  • Abx
  • watchful waiting if stones are <5mm
  • Tamsulosin: may aid spontaneous passage
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19
Q

Kidney Stones

when is surgical intervention required

A

in large stones >10mm

stones that don’t pass spontaneously

complete obstruction of infection

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20
Q

Kidney Stones

surgical interventions (4)

A
  • Extracorporeal shock wave lithotripsy (ESWL)
  • Ureteroscopy and laser lithotripsy
  • Percutaneous nephrolithotomy (PCNL)
  • Open surgery
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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

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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

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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
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24
Q

Kidney Stones

why does adding lemon juice to water help

A

citric acid binds to urinary Ca, reducing the formation of stones

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25
Q

Kidney Stones

why should you avoid carbonated drinks

A

cola drinks contain phosphoric acid which promotes calcium oxolate formation

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26
Q

Kidney Stones

recommendations for calcium stones

A

reduce the intake of oxalate-rich foods (e.g., spinach, beetroot, nuts, rhubarb and black tea)

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27
Q

Kidney Stones

recommendations for uric acid stones

A

reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)

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28
Q

Kidney Stones

name 2 medications that may reduce the risk of recurrence

A
  • 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

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29
Q

Kidney Stones

mnx for confirmed stone + septic once stabilised

A

urgent decompression by either nephrostomy or retrograde stent insertion

to ensure the blocked system is relieved, and that urine can drain from the kidney.

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30
Q

Renal Cell Carcinoma

what is it

A

the most common type of kidney tumour

type of adenocarcinoma that arises from the renal tubules

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31
Q

Renal Cell Carcinoma

what is the classic triad of presentation

A
  1. haematuria
  2. flank pain
  3. palpable mass
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32
Q

Renal Cell Carcinoma

what are the 3 most common types of RCC

A
  • clear cell (80%)
  • papillary (15%)
  • chromophobe (5%)
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33
Q

Renal Cell Carcinoma

what is Wilms’ tumour

A

a specific type of tumour affecting the kidney in children, typically <5y

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34
Q

Renal Cell Carcinoma

RFs

A
  • smoking
  • obesity
  • HTN
  • end stage renal failure
  • Von Hippel-Lindau Disease
  • Tuberous sclerosis
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35
Q

Renal Cell Carcinoma

presentation

A

may be asymptomatic

  • haematuria
  • vague loin pain
  • palpable mass
  • non specific sx of cancer: weight loss, fatigue, anorexia, night sweats
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36
Q

Renal Cell Carcinoma

what does NICE advise for a 2 week referral

A

> 45years

with unexplained visible haematuria

either without a UTI or persisting after trx for a UTI

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37
Q

Renal Cell Carcinoma

where is it spread

A

to the tissues around the kidney, within Gerota’s fascia

often spreads to the renal vein, then to the inferior vena cava

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38
Q

Renal Cell Carcinoma

what is a classic feature of metastatic RCC

A

Cannonball metastases in the lungs

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39
Q

Renal Cell Carcinoma

how do cannonball metastases present

A

clearly-defined circular opacities scattered throughout the lung fields on a CXR

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40
Q

Renal Cell Carcinoma

what other cancers can cannonball metastases present

A

choriocarcinoma (cancer in the placenta)

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41
Q

Renal Cell Carcinoma

what paraneoplastic syndromes is RCC associated with

A
  • polycythaemia
  • hypercalcaemia
  • hypertension
  • Stauffer’s syndrome
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42
Q

Renal Cell Carcinoma

paraneoplastic features: why is polycythaemia a feature

A

due to secretion of unregulated erythropoietin

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43
Q

Renal Cell Carcinoma

paraneoplastic features: why is hypercalcaemia a feature

A

due to secretion of a hormone that mimics the action of PTH

and bony metastases

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44
Q

Renal Cell Carcinoma

paraneoplastic features: why is hypertension a feature

A

due to increased renin secretion, polycythaemia and physical compression

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45
Q

Renal Cell Carcinoma

paraneoplastic features: what is Stauffer’s syndrome

A

abnormal LFTs (raised ALT, AST, ALP + biliruibin) without liver metastasis

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46
Q

Renal Cell Carcinoma

what inx is used to stage the cancer

A

CT thorax, abdo + pelvis

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47
Q

Renal Cell Carcinoma

what is the most common staging system

A

TNM staging system

there’s also a number staging system

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48
Q

Renal Cell Carcinoma

Number staging system: stage 1

A

<7cm and confined to the kidney

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49
Q

Renal Cell Carcinoma

Number staging system: stage 2

A

> 7cm but confined to the kidney

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50
Q

Renal Cell Carcinoma

Number staging system: stage 3

A

local spread to nearby tissues or veins, but not beyond Gerota’s fascia

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51
Q

Renal Cell Carcinoma

Number staging system: stage 4

A

spread beyond Gerota’s fascia, including metastasis

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52
Q

Renal Cell Carcinoma

1st line mnx

A

surgery to remove tumour:

  • partial nephrectomy
  • radical nephrectomy
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53
Q

Renal Cell Carcinoma

non-surgical mnx

A
  • arterial embolisation
  • percutaneous cryotherapy
  • radiofrequency ablation
  • chemo + radio
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54
Q

Renal Cell Carcinoma

what is the definitive test for diagnosis and staging

A

contrast enhanced CT scan of abdo

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55
Q

what are the key causes of scrotal or testicular lumps

A
  • hydrocele
  • varicocele
  • Epididymal cyst
  • testicular cancer
  • epididymo-orchitis
  • inguinal hernia
  • testicular torsion
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56
Q

Hydrocele

what is it

A

a collection of fluid within the tunica vaginalis surrounding the testes

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57
Q

Hydrocele

sx

A

painless

soft scrotal swellings

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58
Q

Hydrocele

examination findings

A
  • transilluminated (testicle floats within the fluid)
  • irreducible and has no bowel sounds
  • soft, fluctuant and may be large
  • testicle is palpable within the hydrocele
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59
Q

Hydrocele

how to distinguish it from a hernia

A

hydroceles are irreducible and has no bowel sounds

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60
Q

Hydrocele

cause

A
  • idiopathic
  • testicular cancer
  • testicular torsion
  • epididymo-orchitis
  • trauma
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61
Q

Hydrocele

mnx

A
  • exclude serious causes (e.g. cancer)
  • idiopathic: manage conservatively
  • large or symptomatic: surgery, aspiration or sclerotherapy
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62
Q

Varicocele

what is it

A

when the veins in the pampiniform plexus become swollen

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63
Q

Varicocele

how come it can cause infertility

A

probs due to disrupting the temp in the affected testicle

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64
Q

Varicocele

what may it result in

A

testicular atrophy, reducing the size and function of the testicle

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65
Q

Varicocele

what is the pampiniform plexus

A

a venous plexus found in the spermatic cord and drains the testes

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66
Q

Varicocele

where does the pampiniform plexus drain into

A

the testicular vein

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67
Q

Varicocele

what is the role of the pampiniform plexus

A

regulates the temp of blood entering the testes by absorbing heat from the nearby testicular artery

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68
Q

Varicocele

pathophysiology

A

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

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69
Q

Varicocele

where does the right testicular vein drain directly into

A

the inferior vena cava

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70
Q

Varicocele

where does the left testicular vein drain into

A

the left renal vein

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71
Q

Varicocele

why do most occur on the left

A

due to increased resistance in the left testicular vein

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72
Q

Varicocele

what can a left-sided varicocele indicate

A

an obstruction of the left testicular vein caused by a renal cell carcinoma

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73
Q

Varicocele

presentation (3)

A
  • throbbing/dull pain or discomfort, worse on standing
  • a dragging sensation
  • sub-fertility or infertility
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74
Q

Varicocele

examination findings

A
  • 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
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75
Q

Varicocele

when should an urgent referral to urology be made

A

varicoceles that do not disappear when lying down as could be a retroperitoneal tumour obstructing the drainage of the renal vein

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76
Q

Varicocele

confirmation of dx

A

US with Doppler imaging

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77
Q

Varicocele

inx if concerns about fertility

A

semen analysis

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78
Q

Varicocele

inx if there are concerns about function

A

hormonal tests (e.g. FSH + testosterone)

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79
Q

Varicocele

mnx if uncomplicated

A

manage conservatively

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80
Q

Varicocele

mnx if pain, testicular atrophy or infertility

A

surgery or endovascular embolization

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81
Q

Epididymal Cysts

where do they occur

A

at the head of the epididymis (at the top of the testicle)

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82
Q

Epididymal Cysts

what is a spermatocele

A

an epididymal cyst that contains sperm

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83
Q

Epididymal Cysts

sx

A

pt felt a lump

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84
Q

Epididymal Cysts

examination findings

A
  • soft round lump
  • typically at the top of the testicle
  • associated with the epididymis
  • separate from the testicle
  • large cysts: may be transilluminated
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85
Q

Epididymal Cysts

worst case

A

torsion of cysts causing acute pain and swelling

usually entirely harmless

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86
Q

Testicular Cancer

where does testicular cancer arise from

A

germ cells in the testes

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87
Q

Testicular Cancer

what do germ cells produce

A

gametes (sperm in males)

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88
Q

Testicular Cancer

what age group has the highest incidence

A

15-35 years

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89
Q

Testicular Cancer

what 2 types can it be divided into

A
  • Seminomas

- Non- seminomas (mostly teratomas)

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90
Q

Testicular Cancer

RFs (4)

A
  • undescended testes
  • male infertility
  • FH
  • increased height
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91
Q

Testicular Cancer

typical presentation

A

painless lump on testicle

occasionally it can present with testicular pain

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92
Q

Testicular Cancer

describe the lump

A
  • non-tender (or even reduced sensation)
  • arising from testicle
  • hard
  • irregular
  • non fluctuant
  • no transillumination
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93
Q

Testicular Cancer

Leydig cell tumour is rare. What can it present with

A

gynaecomastia

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94
Q

Testicular Cancer

initial inx to confirm dx

A

scrotal US

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95
Q

Testicular Cancer

what tumour marker may be raised in teratomas (not in pure seminomas)

A

alpha-fetoprotein

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96
Q

Testicular Cancer

what tumour marker may be raised in both teratomas and seminomas

A

Beta-hCG

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97
Q

Testicular Cancer

what is a very non-specific tumour marker

A

lactate dehydrogenase (LDH)

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98
Q

Testicular Cancer

what can be used to look for areas of spread and to stage the cancer

A

a staging CT scan

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99
Q

Testicular Cancer

what is the staging system called

A

Royal Marsden Staging System

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100
Q

Testicular Cancer

Royal Marsden Staging System: Stage 1

A

isolated to the testicle

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101
Q

Testicular Cancer

Royal Marsden Staging System: Stage 2

A

spread to the retroperitoneal lymph nodes

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102
Q

Testicular Cancer

Royal Marsden Staging System: Stage 3

A

spread to the lymph nodes above the diaphragm

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103
Q

Testicular Cancer

Royal Marsden Staging System: Stage 4

A

metastasised to other organs

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104
Q

Testicular Cancer

where are common places for testicular cancer to metastasis to (4)

A
  • lymphatics
  • Lungs
  • Liver
  • Brain
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105
Q

Testicular Cancer

mnx

A
  • surgery (radical orchidectomy)
  • chemo
  • radio
  • sperm banking
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106
Q

Testicular Cancer

mnx: what is sperm banking

A

saving sperm for future use as trx may cause infertility

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107
Q

Testicular Cancer

SEs of trx (radical orchidectomy, chemo, radio)

A
  • infertility
  • hypogonadism (testosterone may be needed)
  • peripheral neuropathy
  • hearing loss
  • lasting kidney, liver or heart damage
  • increased risk of cancer in the future
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108
Q

Testicular Cancer

prognosis

A

> 90% cure rate

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109
Q

Testicular Cancer

which type has a better prognosis

A

seminomas have a slightly better prognosis than non-seminomas

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110
Q

Testicular Cancer

what does follow up involve

A
  • monitoring tumour markers

- CT scans or CXRs

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111
Q

Epididymo-orchitis

what is it

A

Epididymitis: inflammation of the epididymis

orchitis: inflammation of the testicle

Epididymo-orchitis: result of infection in the epididymis and testicle on one side

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112
Q

Epididymo-orchitis

describe the path of sperm

A
  • 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
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113
Q

Epididymo-orchitis

causes (4)

A
  • E.coli
  • Chlamydia trachomatis
  • Neisseria gonorrhoea
  • Mumps
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114
Q

pt with parotid gland swelling and orchitis and pancreatitis. What is it

A

mumps

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115
Q

Epididymo-orchitis

describe the onset

A

gradual over minutes to hours

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116
Q

Epididymo-orchitis

presentation

A
  • testicular pain
  • dragging or heavy sensation
  • swelling of testicle and epididymis
  • tenderness on palpation
  • urethral discharge
  • fever, sepsis?
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117
Q

Epididymo-orchitis

unilateral or bilateral?

A

unilateral

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118
Q

Epididymo-orchitis

key Ddx

A

testicular torsion

if there is any doubt, trx as testicular torsion until proven otherwise

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119
Q

Epididymo-orchitis

what features make it a STI more than E.coli

A
  • age <35
  • increased number of sexual partners in the last 12m
  • discharge from urethra
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120
Q

Epididymo-orchitis

inx to help establish dx

A
  • urine MC&S
  • NAAT testing on first pass urine
  • charcoal swab of purulent urethral discharge
  • saliva swab (mumps)
  • serum antibodies (mumps)
  • US (torsion, tumours)
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121
Q

Epididymo-orchitis

mnx for very unwell or septic

A

admit to hospital for trx (IV abx)

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122
Q

Epididymo-orchitis

mnx for pts with a high risk of STI

A

referred urgently to GUM

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123
Q

Epididymo-orchitis

for pts that are at a low risk of STI, what is the typical ab of choice

A

1st line: Ofloxacin for 14d

alternatives:

  • levofloxacin/ciprofloxacin
  • doxycycline
  • co-amoxiclav
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124
Q

Epididymo-orchitis

additional measures for mnx apart from abx

A
  • analgesia
  • supportive underwear
  • reduce physical activity
  • abstain from intercourse
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125
Q

Epididymo-orchitis

what are quinolone abx (ofloxacin, levofloxacin and ciprofloxacin)

A

powerful broad-spectrum abx, often used for UTIs. pyelonephritis, epididymo-orchitis and prostatitis.

excellent gram -ve cover

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126
Q

Epididymo-orchitis

2 critical SEs of Quinolone abx (ofloxacin, levofloxacin and ciprofloxacin)

A
  • tendon damage + rupture (Achilles)

- lower seizure threshold (caution in pts with epilepsy)

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127
Q

Epididymo-orchitis

complications (5)

A
  • chronic pain
  • chronic epididymitis
  • testicular atrophy
  • sub-fertility or infertility
  • scrotal abscess
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128
Q

pt with sepsis and kidney stones. what is the best mnx?

A

nephrostomy: urgent decompression

129
Q

Bladder Cancer

where does cancer in the bladder arise from

A

the endothelial lining (urothelium)

130
Q

Bladder Cancer

what are the 2 main risk factors for bladder cancer

A
  • smoking

- increased age

131
Q

Bladder Cancer

what carcinogen causes bladder cancer

A

aromatic amines (found in dye and rubber and cigarette smoke)

132
Q

Bladder Cancer

what causes squamous cell carcinoma of the bladder

A

Schistosomiasis esp in countries with a high prevalence of the infection

133
Q

pt is a retired dye factory worker with painless haematuria. What does he have

A

transitional cell carcinoma of the bladder

134
Q

Bladder Cancer

what are the types

A
  • Transitional cell carcinoma (90%)
  • Squamous cell carcinoma (5%)
  • adenocarcinoma (2%), sarcoma, small-cell carcinoma
135
Q

Bladder Cancer

The symptom to remember for exams

A

PAINLESS HAEMATURIA

136
Q

Bladder Cancer

Mnx: Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

A

2 week wait referral

137
Q

Bladder Cancer

Mnx: Aged over 60 with microscopic haematuria PLUS dysuria or raised WBCs

A

2 week wait referral

138
Q

Bladder Cancer

Mnx: >60 years with recurrent unexplained UTIs

A

consider a non-urgent referral

139
Q

Bladder Cancer

diagnostic inx

140
Q

Bladder Cancer

what is cystosocopy

A

camera through the urethra into the bladder

rigid or flexible

141
Q

Bladder Cancer

what staging system is used

142
Q

Bladder Cancer

TNM: what are the non-muscle-invasive bladder cancers

A
  • Tis/carcinoma in situ
  • Ta
  • T1
143
Q

Bladder Cancer

TNM: what is Tis/carcinoma in situ

A

cancer cells only affect the urotherlium and are flat

144
Q

Bladder Cancer

TNM: what is Ta

A

cancer only affecting the urotherlium and projecting into the bladder

145
Q

Bladder Cancer

TNM: what is T1

A

cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer

146
Q

Bladder Cancer

TNM: what does invasive bladder cancer include

A

T2-T4 and any lymph node or metastatic spread

147
Q

Bladder Cancer

mnx for non-muscle-invasive bladder cancer

A

TURBT (transurethral resection of bladder tumour)

148
Q

Bladder Cancer

mnx: what is TURBT

A

transurethral resection of bladder tumour

removing bladder tumour during cytoscopy

149
Q

Bladder Cancer

mnx: what is used after TURBT to reduce risk of recurrence

A

intravesical chemotherapy

150
Q

Bladder Cancer

mnx: what is intravesical chemo

A

chemo given into the bladder through a catheter

151
Q

Bladder Cancer

mnx: what may be used as a form of immunotherapy

A

Intravesical Bacillus Calmette-Guérin (BCG)

152
Q

Bladder Cancer

mnx: how would the BCG vaccine work

A

(the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours

153
Q

Bladder Cancer

mnx to remove entire bladder

A

radical cystectomy

154
Q

Bladder Cancer

what options are available for draining urine (following a radical cystectomy)

A
  • urostomy w/ an ileal conduit (most common)
  • continent urinary diversion
  • neobladder reconstruction
  • ureterosigmoidostomy
155
Q

Bladder Cancer

can chemo and radio be used for mnx

156
Q

Bladder Cancer

what is urostomy

A

used to drain urine from the kidney, bypassing the ureters, bladder and urethra

157
Q

Bladder Cancer

urostomy: what is an ilieal conduit

A

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
Q

Bladder Cancer

what is Continent Urinary Diversion

A

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
Q

Bladder Cancer

what is neobladder reconstruction

A

creating a new bladder from a section of the ileum.

160
Q

Bladder Cancer

what is Ureterosigmoidostomy

A

attaching the ureters directly to the sigmoid colon.

161
Q

what is the best pain relief for renal colic which presents acutely

A

IM diclofenac

162
Q

BPH

what is it caused by

A

hyperplasia of the stromal and epithelial cells of the prostate

163
Q

BPH

what are the lower urinary tract symptoms

A
  • hesitancy
  • weak flow
  • urgency
  • frequency
  • intermittency
  • straining
  • terminal dribbling
  • incomplete emptying
  • nocturia
164
Q

BPH

what scoring system is used to assess the severity of lower urinary tract symptoms

A

international prostate symptom score (IPSS)

165
Q

BPH

initial assessment of men presenting with LUTS

A
  • DRE
  • abdo exam
  • urinary freq volume chart
  • urine dipstick
  • PSA
166
Q

BPH

common causes of a raised PSA

A
  • prostate cancer
  • BPH
  • prostatitis
  • UTIs
  • vigorous exercise (notably cycling)
  • recent ejaculation or prostate stimulation
167
Q

BPH

what may a benign prostate feel like

A

smooth, symmetrical and slightly soft, with a maintained central sulcus

168
Q

BPH

what may a cancerous prostate feel like

A

firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus

169
Q

BPH

medical mnx

A

tamsulosin

finasteride

170
Q

BPH

how does tamsulosin work

A

alpha blocker

relaxes smooth muscle

with rapid improvement in symptoms

171
Q

BPH

how does finasteride work

A

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
Q

BPH

surgical options

A
  • 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
Q

BPH

SE of tamsulosin (alpha bloker)

A

postural hypotension

174
Q

BPH

SE of finasteride

A

sexual dysfunction (due to reduced testosterone)

175
Q

what reflex may be absent in testicular torsion

A

cremasteric reflex: contraction of the cremasteric muscle upon stroking of the inner thigh

176
Q

indications for finasteride

A
  • BPH

- Androgenetic alopecia in men

177
Q

important safety info for finasteride

A

cases of depression and, in rare cases, suicidal thoughts

male breast cancer

178
Q

Obstructive Uropathy

presentation of an upper urinary tract obstruction (e.g. ureters)

A
  • 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
Q

Obstructive Uropathy

presentation of a lower urinary tract obstruction (e.g. bladder or urethra)

A
  • 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
Q

Obstructive Uropathy

what is the costovertebral angle

A

the angle formed by the 12th rib and vertebral column at the back.

Tenderness in the renal angle suggests kidney pathology.

181
Q

Obstructive Uropathy

causes of upper urinary tract obstruction

A
  • 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
Q

Obstructive Uropathy

causes of lower urinary tract obstruction

A
  • 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
Q

Obstructive Uropathy

what is neurogenic bladder

A

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
Q

Obstructive Uropathy

causes of neurogenic bladder

A
  • Multiple sclerosis
  • Diabetes
  • Stroke
  • Parkinson’s disease
  • Brain or spinal cord injury
  • Spina bifida
185
Q

Obstructive Uropathy

what can neurogenic bladder result in

A
  • Urge incontinence
  • Increased bladder pressure
  • Obstructive uropathy
186
Q

Obstructive Uropathy

mnx to bypass an obstruction in the upper urinary tract (e.g. ureteral stone)

A

nephrostomy:
- insert thin tube through skin, kidney and ureter.
- allows urine to drain out of the body, into a bag.

187
Q

Obstructive Uropathy

mnx to bypass an obstruction in the lower urinary tract (e.g. urethral stricture or prostatic hyperplasia)

A

A urethral or suprapubic catheter

188
Q

Obstructive Uropathy

complications

A
  • Pain
  • AKI (post-renal)
  • CKD
  • Infection
  • Hydronephrosis
  • Urinary retention and bladder distention
  • Overflow incontinence of urine
189
Q

Obstructive Uropathy

what is hydronephrosis

A

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
Q

Obstructive Uropathy

what is idiopathic hydronephrosis

A

the result of a narrowing at the pelviureteric junction (PUJ)

can be congenital or develop later

191
Q

Obstructive Uropathy

trx of idiopathic hydronephrosis

A

pyeloplasty: surgery to correct the narrowing + restructure the renal pelvis

192
Q

Obstructive Uropathy

presentation of hydronephrosis

A

vague renal angle pain and a mass in the kidney area

193
Q

Obstructive Uropathy

imaging for hydronephrosis

A
  • US
  • CT scan
  • IV urogram (x-ray with IV contrast collecting in the urinary tract)
194
Q

Obstructive Uropathy

trx for hydronephrosis

A

treat underlying cause. If required, pressure can be relieved with either:

  • Percutaneous nephrostomy
  • Antegrade ureteric stent
195
Q

Prostatitis

what is it

A

inflammation of the prostate

196
Q

Prostatitis

how can it be classed

A

Acute bacterial prostatitis

Chronic prostatitis

197
Q

Prostatitis

how long must sx last for it to be chronic

198
Q

Prostatitis

what can chronic prostatitis be further sub-divided into

A
  • Chronic prostatitis or chronic pelvic pain syndrome (no infection)
  • Chronic bacterial prostatitis (infection)
199
Q

Prostatitis

chronic prostatitis presentation

A

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
Q

Prostatitis

acute prostatitis presentation

A

acute presentation of:
- pelvic pain, LUTS, sexual dysfunction, pain with bowel movements, tender enlarged prostate

  • fever, myalgia, nausea, fatigue, sepsis
201
Q

Prostatitis

how to assess the severity of the symptoms and their impact on QoL for chronic prostatitis

A

National Institute of Health Chronic Prostatitis Symptom Index

202
Q

Prostatitis

inx

A
  • urine dipstick
  • urine MC&S
  • chlamydia + gonorrhoea NAAT testing
203
Q

Prostatitis

mnx for acute bacterial prostatitis

A
  • admit if systemically unwell
  • PO abx for 2-4w (ciprofloxacin)
  • paracetamol/ NSAIDs
  • laxatives for pain during bowel movements
204
Q

Prostatitis

mnx for chronic bacterial prostatitis

A
  • 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
Q

Prostatitis

complications of acute bacterial prostatitis

A
  • Sepsis
  • Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
  • Acute urinary retention
  • Chronic prostatitis
206
Q

Testicular Torsion

what is it

A

urological emergency

twisting of the spermatic cord with rotation of the testicle

207
Q

Testicular Torsion

what is a common trigger

A

playing sport

208
Q

Testicular Torsion

sx

A
  • unilateral testicular pain
  • abdo pain
  • vomiting
209
Q

Testicular Torsion

examination findings

A
  • firm swollen testicle
  • elevated (retracted) testicle)
  • absent cremasteric reflex
  • abnormal testicular lie (often horizontal)
  • rotation (epididymis is not in normal posterior position)
210
Q

Testicular Torsion

what is Bell-Clapper Deformity

A

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
Q

Testicular Torsion

presentation of Bell-Clapper Deformity on examination

A

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
Q

Testicular Torsion

mnx

A
  • nil by mouth (for surgery)
  • analgesia
  • urgent senior urology assessment
  • surgical exploration of the scrotum
  • orchiopexy
  • orchidectomy
213
Q

Testicular Torsion

what is orchiopexy

A

correcting the position of the testicles and fixing them in place

214
Q

Testicular Torsion

when would you do an orchidectomy

A

if the surgery is delayed or there is necrosis

215
Q

Testicular Torsion

inx to confirm dx

A

scrotal US

but don’t delay for surgery

216
Q

Testicular Torsion

what will show on US

A

whirlpool sign: a spiral appearance to the spermatic cord and blood vessels

217
Q

Lower Urinary Tract Infection

why is it more common in women

A

he urethra is much shorter, making it easy for bacteria to get into the bladder

218
Q

Lower Urinary Tract Infection

what can contribute to UTIs

A
  • incontinence
  • poor hygiene
  • sexual activity
  • urinary catheters
219
Q

Lower Urinary Tract Infection

presentation

A
  • Dysuria (pain, stinging or burning when passing urine)
  • Suprapubic pain or discomfort
  • Frequency
  • Urgency
  • Incontinence
  • Haematuria
  • Cloudy or foul smelling urine
220
Q

Lower Urinary Tract Infection

what is commonly the only symptom in older and frail patients

A

Confusion is commonly the only symptom in older and frail patients

221
Q

Lower Urinary Tract Infection

what sx should you suspect pyelonephritis

A
  • Fever
  • Loin/back pain
  • Nausea/vomiting
  • Renal angle tenderness on examination
222
Q

Lower Urinary Tract Infection

which is a better indication of infection on urine dipstick?

A

nitrates rather than leukocytes

223
Q

Lower Urinary Tract Infection

why are nitrites present on urine dipstick

A

gram-negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites

224
Q

Lower Urinary Tract Infection

should pt be treated if only leukocytes are present

A

not as a UTI unless there is clinical evidence of one

225
Q

Lower Urinary Tract Infection

what may urine dipstick show

A
  • raised nitrites
  • raised leukocytes
  • haematuria
226
Q

Lower Urinary Tract Infection

when should you send a midstream urine sample for microscopy

A
  • pregnant
  • recurrent UTIs
  • atypical sx
  • when sx do not improve with abx
227
Q

Lower Urinary Tract Infection

what is the most common cause of UTIs

A

e.coli

other:

  • Klebsiella pneumoniae
  • Enterococcus
  • Pseudomonas aeruginosa
  • Staphylococcus saprophyticus
  • Candida albicans
228
Q

Lower Urinary Tract Infection

what kind of bacteria is e.coli

A

gram-negative, anaerobic, rod-shaped bacteria

229
Q

Lower Urinary Tract Infection

what would an appropriate initial antibiotic in the community be?

A
  • trimethoprim

- nitrofurantoin

230
Q

Lower Urinary Tract Infection

which patients should avoid nitrofurantoin

A

patients with an eGFR <45

231
Q

Lower Urinary Tract Infection

duration of abx for simple lower urinary tract infections in women

232
Q

Lower Urinary Tract Infection

duration of abx for immunosuppressed women, abnormal anatomy or impaired kidney function

233
Q

Lower Urinary Tract Infection

duration of abx for men, pregnant women or catheter-related UTIs

234
Q

Lower Urinary Tract Infection

trx for catheter-related UTI

A

abx for 7d

and change the catheter

235
Q

Lower Urinary Tract Infection

what does it increase the risk in pregnancy

A
  • pyelonephritis
  • premature rupture of membranes
  • pre-term labour
236
Q

Lower Urinary Tract Infection

abx options for pregnant women

A
  • Nitrofurantoin (avoid in the third trimester)
  • Amoxicillin (only after sensitivities are known)
  • Cefalexin
237
Q

Lower Urinary Tract Infection

why does nitrofurantoin need to be avoided in the 3rd trimester

A

neonatal haemolysis (destruction of the neonatal red blood cells).

238
Q

Lower Urinary Tract Infection

why does trimethoprim need to be avoided in the 1st trimester

A

it’s a folate antagonist

Folate is essential in early pregnancy for the normal development of the fetus

239
Q

Lower Urinary Tract Infection

what can trimethoprim cause in early pregnancy

A

congenital malformations, particularly neural tube defects (e.g., spina bifida)

240
Q

Pyelonephritis

RFs (4)

A
  • female
  • structural urological abnormalities
  • vesico-ureteric reflux
  • diabetes
241
Q

Pyelonephritis

what is vesico-ureteric reflux

A

urine refluxing from the bladder to the ureters – usually in children

242
Q

Pyelonephritis

what is the most common cause

A

Escherichia coli

243
Q

Pyelonephritis

what type of bacteria is e.coli

A

gram-negative, anaerobic, rod-shaped bacteria

244
Q

Pyelonephritis

other causes apart from e.coli

A
  • Klebsiella pneumoniae (gram-negative anaerobic rod)
  • Enterococcus
  • Pseudomonas aeruginosa
  • Staphylococcus saprophyticus
  • Candida albicans (fungal)
245
Q

Pyelonephritis

presentation

A

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
Q

Pyelonephritis

inx

A
  • urine dipstick
  • midstream urine for MC+S
  • CRP + WCC
  • US or CT scan to exclude other pathologies
247
Q

Pyelonephritis

mnx in the community

A

1st line abx for 7-10d:

  • Cefalexin
  • co-amoxiclav, trimethoprim (if culture results are available)
  • ciprofloxacin
248
Q

Pyelonephritis

when should you admit

A

features of sepsis or if it is not safe to manage them in the community.

249
Q

Pyelonephritis

mnx in hospital

A

sepsis 6

  1. lactate
  2. blood cultures
  3. urine output
  4. O2
  5. IV abx
  6. IV fluids
250
Q

Pyelonephritis

Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment

A
  1. renal abscess

2. kidney stone obstructing the ureter, causing pyelonephritis

251
Q

Pyelonephritis

how does chronic pyelonephritis present

A

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
Q

Pyelonephritis

what scan in used in recurrent pyelonephritis to assess for renal damage

A

Dimercaptosuccinic acid (DMSA) scan

injecting radiolabelled DMSA. Damage in areas that do not take up the DMSA

253
Q

Interstitial Cystitis

aka?

A

bladder pain syndrome and hypersensitive bladder syndrome

254
Q

Interstitial Cystitis

what is it

A

a chronic condition causing inflammation in the bladder, resulting in LUTS and suprapubic pain

255
Q

Interstitial Cystitis

pathophysiology?

A

likely a complex combination of dysfunction of the blood vessels, nerves, immune system and epithelium

256
Q

Interstitial Cystitis

who is it more common in

257
Q

Interstitial Cystitis

presentation

A

> 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
Q

Interstitial Cystitis

what inx would you do to exclude other causes

A
  • urinalysis: UTIs
  • swabs: STIs
  • cystoscopy: bladder cancer
  • prostate examination: prostatitis, hypertrophy or cancer
259
Q

Interstitial Cystitis

what may be seen on cystoscopy patients with interstitial cystitis

A

Hunner lesions
- red, inflamed patches of the bladder mucosa associated with small blood vessels

Granulations
- tiny haemorrhages on the bladder wall

260
Q

Interstitial Cystitis

supportive mnx

A
  • avoid alcohol, caffeine and tomatoes
  • stop smoking
  • pelvic floor exercises
  • bladder retraining
  • CBT
  • transcutaneous electrical nerve stimulation (TENS)
261
Q

Interstitial Cystitis

oral medications that may be helpful

A
  • analgesia
  • antihistamines
  • anticholinergics (oxybutynin or solifenacin)
  • mirebegron
  • cimetidine
  • pentosan polysulfate sodium
  • ciclosporin
262
Q

Interstitial Cystitis

what kind of drug is mirebegron

A

beta-3-adrenergic-receptor agonist

263
Q

Interstitial Cystitis

what kind of drug is Cimetidine

A

histamine-2-receptor antagonist

264
Q

Interstitial Cystitis

what intravesical medication may be helpful

A
  • Lidocaine
  • Pentosan polysulfate sodium
  • Hyaluronic acid
  • Chondroitin sulphate
265
Q

Interstitial Cystitis

what is hydrodistension

A

filling the bladder with water, to high pressure, during a cystoscopy

requires GA

This can give a temporary (3-6 month) improvement

266
Q

Interstitial Cystitis

what surgical procedures may be used in mnx

A
  • 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
Q

‘warm and boggy’ prostate . what could this be

A

prostatits

268
Q

when should you refer a boy with undescended testes

269
Q

what is paraphimosis

A

typically caused by not replacing a retracted foreskin

270
Q

mnx of paraphimosis

A

reducing the oedema to the glans by applying pressure over a period of time

if not, dorsal slit to cut foreskin

271
Q

what is phimosis

A

the foreskin is tight and cannot be retracted over the glans

272
Q

causes of phimosis in adults

A
  • STIs
  • Eczema
  • Psoriasis
  • Lichen planus
  • Lichen sclerosis
  • Balanitis
273
Q

trx of phimosis

A

steroid creams or circumcision

274
Q

what is a complication of TURP

A

TURP syndrome:

Hyponatraemia due to absorption of irrigation fluids intra-operatively

275
Q

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

A

bladder calculi

276
Q

undescended bilateral testes at birth, what do u do

A

refer immediately as could be CAH

277
Q

Prostate Cancer

key RFs (5)

A
  • increasing age
  • FH
  • black african or carribbean
  • tall
  • anabolic steroids
278
Q

Prostate Cancer

presentation

A
  • asymptomatic
  • LUTS
  • haematuria
  • erectile dysfunction
  • weight loss, bone pain, cauda equina
279
Q

Prostate Cancer

which cells produce prostate-specific antigen (PSA)

A

The epithelial cells of the prostate

280
Q

Prostate Cancer

what is PSA

A

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
Q

Prostate Cancer

can a patient request a PSA

A

yes if man is >50

282
Q

Prostate Cancer

common causes of raised PSA

A
  • prostate cancer
  • BPH
  • prostatitis
  • UTIs
  • vigorous exercise (notably exercise)
  • recent ejaculation or prostate stimulation
283
Q

Prostate Cancer

why is PSA testing unreliable

A

high rate of false positives and false negatives

284
Q

Prostate Cancer

first line examination

285
Q

Prostate Cancer

what does a benign prostate feel like

A

smooth, symmetrical and slightly soft, with a maintained central sulcus

may be generalised enlargement in prostatic hyperplasia

286
Q

Prostate Cancer

what will an infected or inflamed prostate (prostatitis) feel like

A

enlarged, tender and warm

287
Q

Prostate Cancer

what may a cancerous prostate feel like

A
  • firm or hard - asymmetrical
  • craggy or irregular
  • loss of the central sulcus
  • may have a hard nodule
288
Q

Prostate Cancer

suspected prostate cancer on DRE in GP< what now?

A

2 week wait urgent cancer referral to urology

289
Q

Prostate Cancer

1st line inx for suspected prostate cancer

A

Multiparametric MRI of the prostate

reported on a Linkert scale 1-5, 5 being definite cancer

290
Q

Prostate Cancer

what inx to establishing diagnosis

A

prostate biopsy

291
Q

Prostate Cancer

what are the 2 options for prostate biopsy

A
  • Transrectal ultrasound-guided biopsy (TRUS)

- Transperineal biopsy

292
Q

Prostate Cancer

what does transperineal biopsy involve

A

needles inserted through the perineum

293
Q

Prostate Cancer

main risks of prostate biopsy

A
  • pain
  • bleeding
  • infection
  • urinary retention
  • erectile dysfunction
294
Q

Prostate Cancer

what inx to look for bony metastasis

A

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
Q

Prostate Cancer

what scoring system is used to determine what trx is appropriate

A

The Gleason grading system

based on the histology from the prostate biopsies

296
Q

Prostate Cancer

what is the first number in the gleason score

A

the grade of the most prevalent pattern in the biopsy

graded 1-5

297
Q

Prostate Cancer

what is the second number in the gleason score

A

the grade of the second most prevalent pattern in the biopsy

graded 1-5

298
Q

Prostate Cancer

what does a gleason score of 6 indicate

299
Q

Prostate Cancer

what does a gleason score of 7 indicate

A

intermediate risk

300
Q

Prostate Cancer

what does a gleason score of 8 or above indicate

301
Q

Prostate Cancer

what system is used to stage it

302
Q

Prostate Cancer

trx

A
  • Surveillance or watchful waiting in early prostate cancer
  • External beam radiotherapy directed at the prostate
  • Brachytherapy
  • Hormone therapy
  • Surgery
303
Q

Prostate Cancer

what is a key complication of external beam radiotherapy

A

proctitis (inflammation in the rectum) caused by radiation affecting the rectum

304
Q

Prostate Cancer

presentation of proctitis

A

pain, altered bowel habit, rectal bleeding and discharge

305
Q

Prostate Cancer

mnx of proctitis

A

Prednisolone suppositories can help reduce inflammation.

306
Q

Prostate Cancer

what does brachytherapy involve

A

implanting radioactive metal “seeds” into the prostate

which delivers continuous, targeted radiotherapy

307
Q

Prostate Cancer

SEs of brachytherapy

A
  • cystitis, proctitis
  • erectile dysfunction
  • incontinence
  • increased risk of bladder or rectal cancer
308
Q

Prostate Cancer

when is hormone therapy used

A

in combo w. radiotherapy or alone in advanced disease where cure is not possible

309
Q

Prostate Cancer

what is the aim of hormonal therapy

A

to reduce the level of androgens e.g. testosterone that stimulate the cancer to grow

310
Q

Prostate Cancer

options of hormonal therapy

A
  • Androgen-receptor blockers such as bicalutamide
  • GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
  • Bilateral orchidectomy to remove the testicles (rarely used)
311
Q

Prostate Cancer

SEs of hormone therapy (5)

A
  • hot flushes
  • sexual dysfunction
  • gynaecomastia
  • fatigue
  • osteoporosis
312
Q

Prostate Cancer

surgical mnx

A

radical prostatectomy

313
Q

Prostate Cancer

complications of prostatectomy

A

erectile dysfunction and urinary incontinence

314
Q

Non-seminoma testicular tumours are more common in what age group

315
Q

Seminomas are more common in what age group

316
Q

common side effect of radiotherapy to the prostate region

A

mucositis in the rectum called proctitis.

This can lead to diarrhoea and the presence of blood in the stool.

317
Q

what is Prehn’s sign

A

to distinguish between epididymo-orchitis and testicular torsion

lifting half of the scrotum up relieves pain –> epidymo-orchitis

318
Q

2 signs of testicular torsion which distinguishes it from epididymo orchitis

A
  • absent cremasteric reflex

- testicle is high and lying transversely

319
Q

2 signs of epididymo orchitis which distinguishes it from testicular torsion

A
  • Prehn’s sign

- retrotesticular pain

Finals (47 decks)

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