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Gen surg > Urology > Flashcards

Urology Flashcards

1
Q

What is epididymo-orchitis

A

Clinical syndrome consisting of pain, swelling and inflammation of epididymis, with or without inflammation of the testes

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2
Q

What is orchitis

A

Infection limited to the testis

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3
Q

Most common cause of epididymo-orchitis in men under 35 yrs old

A

Sexually transmitted pathogen such as chalmydia trachomatis and neisseria gonorrhoeae

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4
Q

Most common cause of epididymo-orchitis in men over 35 years old

A

Non-sexually transmitted gram neg enteric organism such as escherichia coli, pseudomonas spp etc

Risk factors include recent instrumentation or catheterisation

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5
Q

Aetiology of acute orchitis

A

Viral: Mumps, coxsackie A, varicella

Bactieral: E. coli

Granulomatous: Syphilis, TB

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6
Q

Presentation of epididymo-orchitis

A

Unilateral scrotal pain and swelling(acute)

Symptoms of urethritis or urethral discharge

Symptoms of underlying cause(mumps, TB)

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7
Q

IX for epididymo-orchitis

A

Gram-stained urethral smear

MSU

HIV testing

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8
Q

General advice for epididymo-orchitis

A

Rest, analgesia and scrotal support

NSAIDs

Avoidance of sexual partner until completion of treatment

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9
Q

Medical management of epididymo-orchitis

A

If epididymo-orchitis is thought to be due any sexually transmitted organism, including gonorrhoea:
Treat without waiting for test results with ceftriaxone 1g intramuscular (IM) injection plus doxycycline

If epididymo-orchitis is thought to be due to chlamydia or other non-gonococcal organism:
Treat orally with doxycycline or ofloxacin

If epididymitis is thought to be due to sexually transmitted chlamydia and gonorrhoea and/or enteric organisms:
Consider treating with 1g ceftriaxone IM plus ofloxacin 200 mg orally twice daily for 10 days.

If epididymo-orchitis is thought to be due to an enteric organism (for example, Escherichia coli):
Treat without waiting for test results with ofloxacin levofloxacin

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10
Q

Complications of epididymo-orchitis

A

Reactive hydrocele

Abscess formation and infarction of the testicle

Infertility

Testicular atrophy in mumps

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11
Q

Causes of AUR in men

A

BPH
Meatal stenosis
Paraphimosis and phimosis
Prostate cancer
Infections such as balanitis and prostatic abscess

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12
Q

Causes of AUR in women

A

Prolapse(cystocele, rectocele)
Pelvic mass(malignancy, fibroid, ovarian cyst)
Acute vulvovaginitis

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13
Q

Drug-related causes of AUR

A

Anticholinergics(antipsychotics, antidepressants)
Opioids
Alpha agonists
Benzodiazepines
NSAIDs

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14
Q

Which precipitants should be considered in AUR

A

Alcohol consumption
Recent surgery
UTI
Constipation
Large fluid intake
Cold exposure or prolonged travel
PMH
Meds

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15
Q

Appropriate imaging ix for AUR

A

Ultrasound - can provide a measure of post-void residual urine
CT scan

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16
Q

Initial management of AUR

A

Immediate and complete bladder decompression(immediate catheterisation for men)

Alpha-blocker should be offered before removal of catheter

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17
Q

Pharmacological treatment for post-op retention

A

Cholinergics
Intravesicle prostaglandin

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18
Q

Secondary management of AUR

A

Prostatic surgery
Trial without catheter(TWOC) for men with BPH and AUR
Alpha-blocker is prescribed before commencing TWOC

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19
Q

Complications of AUR

A

UTIs
AKI
Post-obstructive diuresis
Post-retention haematuria

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20
Q

Prevention of AUR in men with BPH

A

Long-term medical treatment(5-reductase inhibitors alone or in combination with alpha-blockers)

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21
Q

What does chronic urinary retention refer to

A

Painless inability to pass urine
Significant bladder distension due to long standing retention resulting in bladder desensitisation

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22
Q

Most common cause of chronic urinary retention in men

A

Benign prostate hyperplasia (BPH)

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23
Q

Most common cause of chronic urinary retention in women

A

Pelvic prolapse or pelvic masses

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24
Q

Clinical features of chronic urinary retention

A

Painless urinary retention
Associated voiding LUTS(weak stream and hesitancy)
Reduced functional capacity(ability of bladder to store urine)
Overflow incontinence may also be present
Nocturnal enuresis

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25
Q

IX for chronic urinary retention

A

Post-void bedside bladder scan

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26
Q

What is high-pressure urinary retention

A

Refers to urinary retention causing such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and backs up into upper renal tract

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27
Q

what does high-pressure urinary retention lead to

A

Hydroureter and hydronephrosis

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28
Q

What is low pressure urinary retention

A

Occurs in patients with retention with the upper renal tract unaffected due to competent urethral valves or reduced detrusor muscle contractility/complete detrusor failure

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29
Q

What is post-obstructive diuresis

A

Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to the loss of their medullary concentration gradient, which can take time to re-equilibrate

Over-diuresis can lead to worsening AKI

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30
Q

Mx of chronic urinary retention

A

Patients with high post-void volumes or high pressure should be catheterised long-term

Should not undergo a TWOC due to concerns of repeat renal injury

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31
Q

What is an option for chronic urinary retention if patients do not wish for a long term cath

A

Intermittent self catheterisation

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32
Q

Complications of chronic urinary retention

A

UTIs
Bladder calculi
Chronic kidney disease

33
Q

What is vesicoureteral reflux(VUR)

A

Refers to urine refluxing from the bladder back into the ureters

34
Q

Presentation of upper urinary tract obstruction

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, such as vomiting

Impaired renal function on blood tests (i.e. raised creatinine)

35
Q

Presentation of lower urinary tract obstruction

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)

36
Q

Common causes of upper urinary tract obstruction

A

Kidney stones
Tumours pressing on the ureters
Ureter strictures
Retroperitoneal fibrosis
Bladder cancer
Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)

37
Q

Common 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

38
Q

what does neurogenic bladder refer to

A

Refers to 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.

39
Q

Key causes of neurogenic bladder

A

Multiple sclerosis
Diabetes
Stroke
Parkinson’s disease
Brain or spinal cord injury
Spina bifida

40
Q

Consequences of neurogenic bladder

A

Urge incontinence
Increased bladder pressure
Obstructive uropathy

41
Q

Management of obstructive uropathy

A

Nephrostomy

Urethral or Suprapubic catheter

42
Q

What is a nephrostomy

A

A nephrostomy may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone).

A nephrostomy involves surgically inserting a thin tube through the skin at the back, through the kidney and into the ureter. This tube allows urine to drain out of the body, into a bag.

43
Q

Complications of obstructive uropathy

A

Pain
AKI(post-renal)
CKD
Infection
Hydronephrosis
Urinary retention
Overflow incontinence of urine

44
Q

What is idiopathic hydronephrosis as a result of

A

Result of a narrowing at the pelviureteric junction (PUJ) – the site where the renal pelvis becomes the ureter. This narrowing may be congenital or develop later.

45
Q

Mx of idiopathic hydronephrosis

A

It can be treated with an operation to correct the narrowing and restructure the renal pelvis (pyeloplasty).

46
Q

Typical features of hydronephrosis

A

Vague renal angle pain and a mass in the kidney area

47
Q

Imaging ix for hydronephrosis

A

Ultrasound
CT KUB or iV urogram

48
Q

Treatment of hydronephrosis

A

Treat underlying cause
Percutaneous nephrostomy
Antegrade ureteric stent

49
Q

Where do cancers in the bladder arise from

A

Cancer in the bladder arises from the endothelial lining (urothelium). The majority are superficial (not invading the muscle) at presentation.

50
Q

Risk factors for bladder cancer

A

Smoking
Age
Aromatic amines(dye and rubber industries)
Schistosomiasis(SCC of bladder)

51
Q

What type of bladder cancer do factory workers in industries such as dye and rubber tend to get

A

Transitional cell carcinoma of the bladder

52
Q

Types of bladder cancer

A

Transitional cell carcinoma (90%)
Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma

53
Q

Presentation of bladder cancer

A

Painless macroscopic haematuria

54
Q

When do NICE recommend two week wait referral for suspected bladder cancer

A

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

Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count

55
Q

Diagnosis of bladder cancer

A

Cystoscopy (a camera through the urethra into the bladder) can be used to visualise bladder cancers. The cystoscope can be rigid or flexible. Cystoscopy can be performed under local or general anaesthetic.

56
Q

Staging of bladder cancer

A

TNM
There is a clear distinction between:

Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
Muscle-invasive bladder cancer (invading the muscle and beyond)

57
Q

Mx of bladder cancer

A

Transurethral resection of bladder tumour(TURBT)
Intravesical chemotherapy
Intravesical BCG vaccine
Radical cystectomy

Radiotherapy may also be used

58
Q

What is TURBT

A

Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.

59
Q

When is intravesical chemotherapy used

A

Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.

60
Q

Use of BCG in bladder cancer treatment

A

Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.

61
Q

Options for drainage of urine following a radical cystectomy

A

Urostomy with an ileal conduit (most common)
Continent urinary diversion
Neobladder reconstruction
Ureterosigmoidostomy

62
Q

What type of cancers are most prostate cancers

A

Adenocarcinomas that grow in the peripheral zone of the prostate

63
Q

Key risk factors for prostate cancer

A

Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids

64
Q

Presentation of prostate cancer

A

Asymptomatic
LUTS(similar to BPH)
Hesitancy, frequency, weak flow, terminal dribbling and nocturia
Haematuria
Erectile dysfunction
Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)

65
Q

Above what age can men request PSA

A

Men over 50

66
Q

Common causes of raised PSA

A

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

67
Q

How might a cancerous prostate feel on palpation

A

A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation.

In primary care, these findings require a two week wait urgent cancer referral to urology.

68
Q

1st line ix for prostate cancer

A

Multiparametric MRI of prostate

69
Q

2nd line ix for prostate cancer

A

Prostate biopsy - Transrectal ultrasound-guided biopsy(TRUS), transperineal biopsy

70
Q

Main risks of prostate biopsy

A

Pain (particularly lower abdominal, rectal or perineal pain)
Bleeding (blood in the stools, urine or semen)
Infection
Urinary retention due to short term swelling of the prostate
Erectile dysfunction (rare)

71
Q

Grading prostate cancer

A

Gleason grading system based on histology from prostate biopsies

72
Q

Mx of prostate cancer

A

Depending on the grade and stage of prostate cancer, treatment can involve:

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

73
Q

what is a key complication of external beam radiotherapy

A

A key complication of external beam radiotherapy is proctitis (inflammation in the rectum) caused by radiation affecting the rectum.

Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.

74
Q

What is brachytherapy

A

Involves implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis).

Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

75
Q

Purpose of hormone therapy in prostate cancer mx

A

Aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:

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

76
Q

Side effects of hormone therapy in prostate cancer mx

A

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

77
Q

Key complications of radical prostatectomy

A

erectile dysfunction urinary incontinence

78
Q

Which type of rta causes nephrolithiasis

A

Type 1 RTA

Gen surg (24 decks)

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