Urology Flashcards
Types - Bladder Cancer
Transitional cell (90%)
Squamous (3-5%)
Adenocarcinoma (2-3%)
Risk factors - Bladder Ca
age SMOKING occupation - dyes, rubber pelvic rt cyclophosphamide recurrent utis Schistosomiasis - SCC
Clinical features - Bladder Ca
HAEMATURIA - visible or non visible urinary frequency urgency dysuria later sx: anorexia, W/L, bone pain, flank pain
2WW Criteria - Bladder Ca
Aged 45 or over w/ visible haematuria w/o UTI
Aged 45 or over w/ visible haematuria which persists/recurs after successful tx of UTI
Aged 60 or over w/ non-visible haematuria + dysuria or raised WCC on FBC
Investigations - Bladder Ca
urinalysis - C&S, microscopy, dipstick
bloods - fbc, u&es, lfts
cystoscopy - visualise & biopsy
imaging - uss/ct/mri (can be useful for staging or other causes)
Management options - bladder cancer
TMN staging - dependent
TUBRT - Transurethral resection of bladder tumour (1st line for non-invasive bladder tumours)
Intravesical chemotherapy (often used after TURBT to reduce risk of recurrence)
Intravesical BCG (immunotherapy)
Radical cystectomy (used in cancers which have invaded muscle, requires urinary diversion)
Chemo + RT
Presentation - Prostate Cancer
• Frequency • Hesitancy • Nocturia • Weak stream • Incomplete emptying • Intermittency • Straining • Terminal dribbling • Haematuria ED
Or can p/w symptoms of advanced disease or metastasis e.g. weight loss, bone pain, cauda equina syndrome
Investigations - Prostate Cancer
Bedside
• Urinalysis - dipstick, C&S (r/o UTI?)
• Examination (DRE) - prostate may feel enlarged craggy, hard, irregular mass, loss of midline sulcus
Bloods • FBC • U&Es • PSA (prostate specific antigen) ○ Valves are age related & it is non-specific, can be raised during infection, in BPH, following catheter • LFTs • Bone profile
Imaging
• Multiparametric MRI - now commonly first line investigation in dx of prostate cancer
• Imaged guided prostate biopsy (+ Trans-rectal ultrasound)
• Bone isotope scan/CT/MRI - can all be considered for staging
2WW Criteria - Suspected Prostate Ca
2WW CRITERIA
• Abnormal prostate on DRE (‘‘feels malignant’’)
• PSA elevated above age specific range
Management options - Prostate Ca
Active surveillance
• Option in low risk patients
• Watchful waiting & PSA monitoring
Radical prostatectomy
• For tumours localised to gland
Radical radiotherapy
• External beam radiotherapy (EBRT) and brachytherapy
Medical androgen-depravation therapy
• GnRH agonist; persistent presence of an agonist causes downregulation of receptors on the pituitary gland leading to reduced LH/FSH release. Goserelin is a commonly used GnRH agonist (brand name Zoladex).
Docetaxel chemotherapy
• used in non-metastatic high-risk disease as well as locally advanced and metastatic prostate cancer.
How does BPH present?>
Lower urinary tract symptoms
• Hesitancy – difficult starting and maintaining the flow of urine
• Weak flow
• Urgency – a sudden pressing urge to pass urine
• Frequency – needing to pass urine often, usually with small amounts
• Intermittency – flow that starts, stops and varies in rate
• Straining to pass urine
• Terminal dribbling – dribbling after finishing urination
• Incomplete emptying – not being able to fully empty the bladder, with chronic retention
Nocturia – having to wake to pass urine multiple times at night
Assessment of BPH
Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
Abdominal examination to assess for a palpable bladder and other abnormalities
Urinary frequency volume chart, recording 3 days of fluid intake and output
Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference
Management of BPH
Conservative – watch & wait, long term catheter
Medical – 𝛼 blockers (Tamsulosin), 5𝛼 reductase inhibitors (Finasteride)
• Alpha blockers relax smooth muscle, with rapid improvement in symptoms
• 5𝛼 reductase inhibitors - gradually reduce size of prostate
Surgical - TURP
Differentials of Scrotal Swellings
Hydrocele - fluid around testis (communicating e.g. due to PPV or non-communicating)
Varicocele - dilated veins in pampiform plexus
Inguinal hernia - part of an organ that protrudes outside the walls of its usual cavity. (direct or indirect - via deep inguinal ring)
Hydrocele - risk factors, clinical features, investigations & management
Trauma, infection, torsion, congenital (PPV), testicular ca
Non-tender scrotal swelling, smooth, non-reducible & transilluminates
Testicular USS
Observations or surgical repair
Varicocele - risk factors, clinical features, investigations & management
Most commonly occurs in adolescent boys
Strongly associated with infertility - 40% of men undergoing fertility investigations found to have varicocele
increased pressure in plexus - can be due to incompetent or absent valves
Can also be a sign/due to renal malignancy
Scrotal swelling - on examination ‘‘bag of worms’’, frequently asymptomatic, may reduce while lying down & occasionally can be painful, cause dragging sensation
Clinical dx - refer in symptomatic
Observation in adolescence w/ yearly examination
Refer those that are symptomatic or develop testicular asymmetry (can cause atrophy)
Surgical options
Inguinal Hernia - risk factors, clinical features, investigations & management
Protrusions in the inguinal or scrotal region, can be direct (through posterior wall of inguinal canal) or indirect (through deep inguinal ring - most common)
Risk factors
- Chronic cough
- Constipation
- Pregnancy
- Older age
Bulge, dragging sensation in groin, reducible or non-reducible
Investigations: observations, bloods,
Imaging - USS: if there is diagnostic uncertainty, USS normally confirms or excludes the presence of a hernia, CT: may be used for diagnosis, more commonly completed in patients presenting with complications (e.g. obstruction, strangulation), MRI: normally used to investigate for other causes of symptoms e.g. ‘sports hernia’.
• Observation - with education on signs of obstruction/strangulation • Surgical Open or laproscopic
Peyrone’s Disease - definition & management
Build up of scar tissue on the side of the penis which leads to curative & painful erections
Usually painful erections, 3-6mths later curative noticed & erections become more painful, can be a/w ED
Clinical course of 12-24mths
No routine investigations needed
13% resolve, of the remainder 50% progress & 50% stabilise
Management
○ Reassurance & explanation to patient
○ Stretching - vacuum & traction devices
○ Medical - collegenase injections (break down plaques)
○ Surgical (last resort) - wait 24mths
Premature ejaculation - causes, management
premature ejaculation occurs when a man ejaculates sooner during sexual intercourse than he or his partner would like
• Causes (debatable)
○ Psychological – early sexual experiences, abuse, body image
○ Erectile dysfunction
○ Relationship problems
○ Biological causes – hormones, inflammation, hereditary
○ Some evidence that life long is related to central 5-HT receptor sensitivity
○ Some evidence that acquired is related to anxiety
• Treatment
○ Combined approach
○ Psychosexual support – pelvic floor exercises / squeeze technique
○ Condoms / Topical anaesthetics – reduce sensation
○ Oral medications – drugs such as Dapoxetine that have the side effect of delaying ejaculation
○ If ED is a problem address that too
Erectile Dysfunction - history & clues to cause
○ Onset (sudden - psychogenic, gradual - organic)
○ Situational (psychogenic) vs Always (organic)
○ Morning/Night time erections - psychogenic
○ Libido
○ PMHx inc medications, drug use, trauma
○ RFs for CVD inc FHx
Erectile Dysfunction - Causes
• vascular (CVD) • neurogenic; spinal cord injuries, DM, MS • drugs; SSRIs, alcohol, weed • endocrine psychogenic
Erectile Dysfunction - Investigations & Management
Investigations • important to screen for CV risks, good opportunity for intervention ○ CV risk; BMI, BP, lipids, HbA1c ○ Secondary sexual characteristics ○ Lower limb pulses
Management • Lifestyle Modification ○ weight loss, exercise, stop smoking • Phosphodiesterase inhibitors (PDE5i) ○ Sildenafil • Alprostadil preparations • Vacuum devices/pumps • Testosterone replacement
• Considerations for treatment ○ Contraindications -Unfit for sexual activity, recent MI, angina, uncontrolled HTN, hypotension or uncontrolled hypertension ○ Side Effects – all fairly common, Facial flushing and headache, masal congestion, dizziness due to low blood pressure
