Urology Flashcards
What is the best form of imaging for kidney stones?
CT KUB
Recall the 4 main types of kidney stone in order of highest to lowest radiointensity
Calcium phosphate
Calcium oxalate
Triple (struvite) stones
Uric acid (radiolucent)
Which type of kidney stone is associated with urease bacteria?
Triple (struvate) stones
Which type of kidney stone is associated with hypercalciuria?
Calcium oxalate
How should kidney stone pain be managed?
PR/IM diclofenac
Recall one contra-indication to diclofenac
CVS disease
How should kidney stones be managed depending on size?
<0.5cm: expectant treatment +/- tamsulosin
<2cm: lithotripsy
<2cm and pregnant: uteroscopy
> 2cm (eg staghorn calculi): nephrolithotomy
If hydronephrosis/infection: percutaneous nephrostomy and antibiotics
Recall 2 options for medically managing BPH and some side effects of each
- alpha-1 antagonists (tamsulosin): postural hypotension, dry mouth
- 5 alpha reductase inhibitors (finasteride): ED, reduced libido, gynaecomastia, ejaculation problems
What is the main way in which BPH can be surgically managed?
TURP (transurethral resection of the prostate)
What is the main complication of TURP to be aware of?
TURP syndrome
Hyponatraemia, fluid overload and glycine toxicity caused by over-irrigation
When can PSA levels not be done?
Within:
- 6 weeks of a prostate biopsy
- 1 week of DRE
- 4w following a proven UTI/prostatitis
- 48 hours of vigorous exercise and/or ejaculation
When would a multi-parametric MRI be used to investigate possible prostate cancer?
If PSA is inappropriate or if high chance of Ca
What is the gold-standard investigation for prostate cancer?
TRUS-guided biopsy
Recall 3 options for managing localised prostate cancer (T1/T2)
- Conservative with active monitoring
- Radical prostatectomy
- Radiotherapy (external beam and brachytherapy)
Recall 3 options for managing localised advaced prostate Ca
- Hormonal therapy
- Radical prostatectomy
- Radiotherapy
How should metastatic prostate cancer disease be managed?
Hormonal therapy only
What are the options for hormone therapy in prostate cancer?
Synthetic GnRH agonist + 3w cover of anti-androgen
Recall 2 types of benign epithelial renal tumour
Papillary adenoma
Renal oncocytoma
What sort of tumour is an angiomyolipoma?
Benign mesenchymal renal tumour composed of thick-walled blood vessels, smooth muscle and fat
What is the maximum size for a papillary adenoma?
15mm
If more than this = malignant papillary renal cell carcinoma
What type of renal tumour can be seen in Birt-Hogg-Dube syndrome?
Renal oncocytoma
What type of renal tumour can be seen in tuberous sclerosis?
Angiomyolipoma
Which genetic syndrome predisposes to renal cell carcinoma?
Von Hippel Lindau
What are the 3 main subtypes of renal cell carcinoma, and which is most common
Clear cell (70%)
Papillary
Chromophobe
Which tumours are people with Von-Hippel-Lindau predisposed to?
Phaeochromocytoma
Neuroendocrine pancreatic
Clear cell renal
Which type of renal cell tumour is associated with loss of 3p?
Clear cell renal
Which type of renal tumour is associated with long-term dialysis?
Papillary renal cell carcinoma
What is Wilm’s tumour?
Nephroblastoma
How should high-grade transitional cell carcinomas be managed?
1st: intravesical immunotherapy
2nd: radical cystectomy
How should traumatic urethral injuries be investigated and managed?
Ix: ascending urethrogram
Mx: suprapubic catheter
How should traumatic bladder injuries be investigated and managed?
Ix: Intravenous urogram or cystogram
Mx: laparotomy if intraperitoneal, conservative if extraperitoneal
What proportion of testicular tumours are germ cell tumours?
95%
What are the subtypes of germ cell testicular tumours?
Seminomas (50%)
Non-seminoma (embryonal, yolk sac, teratoma an choriocarcinoma)
What is the biggest risk factor for testicular seminoma?
Cryptochidism
What are the signs and symptoms of testicular cancer?
Painless lump +/- hydrocele, gynaecomastia
How should testicular cancer be investigated?
1st = USS
2nd = AFP, hCG, LDH
3rd = CT TAP
NO biopsy
How can testicular cancer be managed?
Orchidectomy +/- chemotherapy +/- radiotherapy
Is the cremasteric reflex pos or neg in testicular torsion?
Neg
What is the cremasteric reflex?
Stroking of the skin of the inner thigh causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal
What is Prehn’s test?
Elevating scrotum and assessing for difference of pain - positive if pain is relieved
Is Prehn’s test pos or neg in testicular torsion?
Neg
What condition is Prehn’s test positive in?
Epididymitis
How should testicular torsion be managed?
Surgical exploration + BL orchidopexy
What is an orchidopexy
Surgical procedure that moves undescended testicle into the scrotum
What are the main RFs for ED?
EtOH
Drugs (beta-blockers, SSRI)
CVD RFs (metabolic syndrome, hyperlipidaemia etc)
How should ED be investigated?
QRisk score Free testosterone (9-11am) --> if low, FSH, LH, prolactin --> if abnormal, refer to endo
How can ED be managed?
1st: PDE4 inhibitors (sildenafil)
2nd line: vacuum devices
How should pregnant women with asymptomatic bacteriuria? UTI be managed?
MC&S –> Abx
7 days nitrofurantoin 100mg BD (AVOID AT TERM )
OR
Amoxicillin/cephalexin
How should UTIs in men be managed?
7 days trimethoprim/nitrufurantoin
When should men be referred to urology for UTI?
If 2 or more uncomplicated UTIs
How should catheterised patients with asymptomatic bacteriuria be managed?
No treatment needed
How should catheterised patients with symptomatic UTI be managed?
7 days trimethoprim/nitrofurantoin
What is the causative organism in 95% of cases of prostatitis?
E coli
What are the signs and symptoms of prostatitis?
Referred pain
Obstructive voiding symptoms
Fever and rigors may be present
How should prostatitis be investigated?
DRE –> tender, boggy prostate gland
How should prostatitis be managed?
Quinolone 14/7
STI screening
How should urinary incontinence be investigated?
1st: speculum - exclude prolapse
2nd: Urine dip and MC&S (rule out DM and UTI)
3rd: Bladder diaries (minimum 3 days) - if inconclusive –>
4th: Urodynamic testing (if mixed incontinence)
What is measured by urodynamic testing?
3 pressures measured from inside rectum and urethra:
- bladder
- detrusor
- IAP
How should stress incontinence be managed?
1st line: lifestyle advice, WL if BMI>30, pelvic floor exercises
2nd line: duloxetine or surgical treatment
How should pelvic floor exercises be done for stress incontinence?
8 contractions, TDS, 3 months
Recall some options for sugical management of stress incontinence
- Burch colposuspension
- Autologous rectus fascial sling
- Bulking agents
Recall some RFs for stress vs urge incontinence
Stress: age, children, traumatic delivery, pelvic surgery, obesity
Urge: age, obesity, smoking, FHx, DM
What is the normal post-void volume for <65 vs >65ys?
<65 = <50mLs >65 = <100mLs
How should urge incontinence be managed?
1st line: lifestyle advice, bladder training, avoid fizzy drinks, DM control
2nd line: oxybutynin/tolterodine or desmopressin
3rd line: mirabegron (beta-3 agonist)
4th line: surgical
Recall an important side effect of oxybutynin and an alternative option if there is concern
Falls
Can give mirabegron instead
How can urge incontinence be managed surgically?
Botox injection, sacral nerve stimulation, urinary diversion
How should overflow incontinence be managed?
Refer to specialist urogynaecologist
1st line = timed voiding
How should hydrocele be managed?
- Watch and wait
- Aspiration for symptomatic relief
- Surgical = Lloyd’s repair/ Jaboulay’s repair
Why does varicocele affect the LHS more than the RHS?
Left testicular vein:
- drains into renal vein at 90 degree angle
- is longer than right
- often lacks a terminal valve to prevent backflow
- can be compressed by renal and bowel pathology
What is the best investigation for varicocele?
Doppler USS
If varicocele has a sudden onset, what must be considered?
Renal cell carcinoma
How should varicocele be managed?
Conservative (scrotal support) or surgical (radiological embolisation or operation to expose and ligate vein)
