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Surgery > Urology > Flashcards

Urology Flashcards

1
Q

State 5 causes of Nephrolithiasis.

A

• Hyperparathyroidism
• Hypercalcemia
• Hypercalcuria
• Hypomagnesemia
• Hyperoxaluria
• Hypervitaminosis D
• Hyperuricemia/Hyperuricosuria

• Infection
• Inadequate urinary drainage (urine stasis)
• Immobilisation
• Indinavir

• Diet (Vitamin A deficiency)
• Dehydration
• Decreased urine citrate
• Distal RTA
• Drugs: Loop diuretics; Thiazide diuretics; Indinavir

• Endocrine (metabolism error) -> Cysteinuria

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2
Q

Which drugs may cause Nephrolithiasis.

A

Loop diuretics

Thiazide Diuretics

Indinavir

Excess Vitamin D

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3
Q

Which 3 stones are radiolucent on XRA?

A

Indinavir

Cysteine

Uric Acid

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4
Q

What is the gold-standard investigation for Nephrolithiasis?

A

CT-KUB

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5
Q

How do you manage nephrolithiasis?

A

Supportive: Analgesia; Fluids

Medical: Tamsulosin; ESWL; ABX

Surgical: PCNL

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6
Q

A 57 y/o F patient presenting with abdominal pain in a loin-to-groin distribution. Pain comes and goes, nothing makes it better, 8/10. Urinalysis shows blood.

Likely diagnosis?

Gold-standard investigation?

Other investigations?

Causes (5) of this condition.

Treatment?

A

Nephrolithiasis

CT-KUB

Other: Urinalysis; FBC; U+E; Pregnancy test

Hypercalcaemia; Hyperoxaluria; Hypervitaminosis D; Infection; Indinavir; Inadequate drainage; Diet (vitamin A deficiency); Dehydration; Drugs (loop diuretics); Endocrine (cysteinuria)

Depends on size of stone (10mm) for ureteric stones; (5mm) for renal stones

Ureteric stones <10mm
- ESWL
+
- Tamsulosin

Ureteric stones >10mm
- PCNL

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7
Q

What shape are calcium oxalate stones?

A

Biconcave/ Bipyramidal envelopes

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8
Q

What shape are uric acid stones?

A

Rhomboid/ Needle-shaped

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9
Q

What shape are Struvite stones?

A

Staghorn; Coffin-lid

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10
Q

What shape are Calcium Phosphate stones?

A

Wedge-shaped prisms

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11
Q

What shape are Cystine stones?

A

Hexagon-shaped crystals

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12
Q

Define an AKI.

A

Sudden-onset reduction in renal function measured by SCr or Urine output occurring hours-days

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13
Q

Outline the criteria for a Stage 1 AKI.

A

SCr increase of 1.5-1.9x ; increase by 26umol/L

Urine output of <0.5mL/kg/hour for 6-12 hours

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14
Q

Outline Stage 2 AKI

A

SCr increase of 2-2.9x

Urine output reduction of <0.5mL/kg/hr for 12h

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15
Q

What is stage 3 AKI?

A

3x or >354umol/L or RRT

<0.3mL/kg/h (24h)3x or >354umol/L or RRT

<0.3mL/kg/h (24h)

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16
Q

How may an AKI be categorised by cause(s)?

A

Pre-renal

Renal

Post-renal

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17
Q

Outline the general management of an AKI?

A

Consider the cause

Pre-renal AKI:
- Fluid resuscitation: 500mL STAT (max 2L)

Renal:
- Biopsy and referral

Post-renal:
- Decompression

Other sequelae:

Acidosis:
- Sodium bicarbonate

Hyperkalaemia: (10:10:10)
- Calcium gluconate (10%) 10mL over 10 minutes
- IV Insulin 10U in 25g glucose (50% in 50mL)

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18
Q

State 3 Nephrotoxic drugs.

A

O-DAMN

Opiates
Diuretics
ACEi/ARBs
Metformin
NSAIDs

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19
Q

Describe CKD.

A

Abnormal structure or function ≥ 3/12 characterised by reduced eGFR

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20
Q

What measurable components are used in the criteria for CKD?

A

eGFR

Albumin excretion

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21
Q

An eGFR of 120mL/min/1.73 is stage…

A

G1

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22
Q

An eGFR of 88mL/min/1.73m is stage…

A

Stage 2

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23
Q

An eGFR of 68mL/min/1.73m is stage…

A

Stage 2

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24
Q

An eGFR of 58mL/min/1.73m is stage…

A

Stage 3a

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25
Q

An eGFR of 58mL/min/1.73m is stage…

A

Stage 3a

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26
Q

An eGFR of 48mL/min/1.73m is stage…

A

Stage 3

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27
Q

An eGFR of 38mL/min/1.73m is stage…

A

Stage 3b

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28
Q

An eGFR of 42mL/min/1.73m is stage…

A

G3b

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29
Q

An eGFR of 18mL/min/1.73m is stage…

A

G4

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30
Q

An eGFR of 28mL/min/1.73m is stage…

A

Stage 4

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31
Q

An eGFR of 8mL/min/1.73m is stage…

A

Stage 5

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32
Q

An eGFR of 12mL/min/1.73m is stage…

A

Stage 5

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33
Q

What are the 3 categories for CKD regarding Albumin excretion?

What are the 3 categories and their limits for CKD regarding ACR?

A

A1 = <30; <3

A2 = 30-300; 3-30

A3 = >300; >30

(Albumin; ACR)

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34
Q

What investigations may you order in a patient with a declining eGFR over time?

A
  • Urinalysis: protein/blood/ leukocytes
  • ACR
  • Electrophoresis
  • MSC: white casts/red casts/granular casts
  • FBC: derangements - ?Hb
  • U+Es: ∆s? - reduced Ca2+; elevated PO43- ; reduced EGFR; increased ACR
  • Hormones: increased PTH (renal osteodystrophy)
  • Abs
  • Bone profile
  • USS: size; corticomedullary differentiation
    -> Offer in visible haematuria or persistent microscopic haematuria
  • Renal biopsy
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35
Q

How would you treat CKD?

A
  • ACEi: Ramipril
    or
  • ARB + Statin: Candesartan + Simvastatin

Consider:
- Diuretics
- Vitamin D
- Bisphosphonates
- Calcium acetate
- Quinine
- Ferrous fumarate

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36
Q

At what level of Pi do you consider medical management?

A

Pi > 1.5mmol/L

Calcium acetate

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37
Q

How would you treat cramps associated with CKD?

A

Quinine

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38
Q

When do you refer to nephrology in CKD?

A
  • eGFR drop by 25% or drop by 15% over 12/12
  • G4+G5 (≈ eGFR <30)
  • Proteinuria = A3 (ACR >30) with haematuria
  • Malignant hypertension (≥4 antihypertensive)
  • Rare/genetic CKD cause
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39
Q

Compare and contrast the two types of RRT.

A

HD = blood via dialysis machine with dialysate on either side allowing diffusion
- 4-5 times a week
- AV fistula
- Anticoagulation required
- Risk of hypotension

PD = Tenckhoff catheter placed into peritoneal cavity in SC tunnel with dialysate connected to tunnel to push fluid into cavity
- 3-5 times a day
- Risk of infection

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40
Q

What opportunistic pathogen may enter via a Tenckhoff catheter?

A

S epidermidis

S aureus

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41
Q

State 3 complications of RRT

A

CVD: endothelial dysfunction; vascular stiffness

Renal bone disease

Infection (opportunistic; uraemia changes T cell and granulocyte function)

Amyloid accumulation

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42
Q

What are the donor options for a renal transplant?

A
  • Living donor
  • Donor after cardiac death (DCD)
  • Donor after brain death (DBD)
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43
Q

What drugs may be used in a kidney transplant?

A

Monoclonal antibodies: Daclizumab; Alemtizumab

Calcineurin inhibitors: Tacrolimus; Ciclosporin

Antimetabolites: Mycophenolate; Azathioprine

Glucocorticoids

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44
Q

Which drugs are given as inducers at the time of renal transplantation?

A

Monoclonal antibodies:

Daclizumab (CD25 T cell blocker)

Alemtuzumab (T and B cell)

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45
Q

What drug is given as first line for acute renal transplant rejection?

A

Prednisolone

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46
Q

Describe Glomerulonephritis.

A

Diseases caused by pathology to the filtration unit of the kidney causing CKD which presents with proteinuria and/or haematuria, diagnosed by renal biopsy or urinalysis and can progress to kidney failure.

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47
Q

Outline the broad structure of a glomerulus.

A
  • Afferent + Efferent arteriole
  • Capillary plexus
  • Fenestrated endothelium lines glomerular capillaries
  • Basement membrane (GBM) supports endothelium
  • Podocytes (foot processes) separated by filtration pores
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47
Q

Outline the broad structure of a glomerulus.

A
  • Afferent + Efferent arteriole
  • Capillary plexus
  • Fenestrated endothelium lines glomerular capillaries
  • Basement membrane (GBM) supports endothelium
  • Podocytes (foot processes) separated by filtration pores
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48
Q

What is the gold-standard investigation to diagnose a glomerulonephritis?

A
  • Renal biopsy
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49
Q

Which two syndromes may Glomerulonephritis be divided into?

Give the main features of each.

A

Nephrotic syndrome: hypoalbuminaemia + proteinuria + peripheral oedema

Nephritic syndrome: haematuria + oedema + hypertension

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50
Q

What 3 features are present in a nephrotic syndrome?

A

Hypoalbuminaemia (<30g/L)

Proteinuria (>3g/day)

Oedema

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51
Q

Give 3 examples of primary renal nephrotic syndrome and 3 examples of secondary renal nephrotic syndrome.

A

Primary:
- Minimal Change Disease
- Focal Segmental Glomerulosclerosis
- Membranoproliferative Glomerulonephritis

Secondary:
- Diabetes Mellitus
- SLE
- Myeloma
- Amyloid
- Pre-eclampsia

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52
Q

How would you manage a nephrotic syndrome?

A
  • Tx cause
    +
  • Renoprotection: reduce damage
    +
  • Reduce oedema: Diuretics
    -> Aim for 0.5-1kg weight loss/day
    +
  • Tx complications: infection; VTE; hyperlipidaemia; electrolyte disturbances; metabolic changes
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53
Q

How much weight loss per day do you aim for when treating nephrotic syndrome with diuretics?

A

0.5-1kg/day

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54
Q

Why is minimal change disease named this?

A

On microscopy, nothing is observed and electron microscopy shows fusion of podocytes.

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55
Q

An 4 y/o M presents with ankle oedema which has occurred recently. He is systemically well and there is nothing he sees his doctor for usually. FH is unremarkable.

Urinalysis shows protein ++, no blood and is frothy.

What investigations would you run?

Differential?

Treatment?

A

Urinalysis: Protein
MS+C: hyaline casts
eGFR: reduced
Renal biopsy: no change

DDx: Minimal Change Disease

Prednisolone 1mg/kg for 16 weeks

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56
Q

What other features may occur in patients with nephrotic syndrome?

A

Deranged lipids

Hypertension

Hypercoagulability

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57
Q

Which patient group is Focal Segmental Glomerulosclerosis most likely to occur in?

A

Black Patients

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58
Q

What is the definition of Focal Segmental Glomerulosclerosis?

A

Disease which may be primary or secondary which results in reduction of kidney mass, featuring scarring at specific points in the glomeruli covering <50% of glomerulus resulting in nephrotic syndrome.

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59
Q

How do you treat Focal Segmental Glomerulosclerosis?

A
  • Renoprotection: ARB/ACEi
    ± Primary (idiopathic)
  • Corticosteroids: 1mg/kg
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60
Q

The treatment of Wilson’s disease may cause which Glomerulonephritis?

Which drug is this?

A

Membranous Nephropathy

Penicillamine

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61
Q

What is membranous nephropathy?

A

Commonest cause of nephrotic syndrome in adults, usually idiopathic but may be secondary, resulting in IgG and C3 deposition along GBM resulting in resorption of deposits and structural change.

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62
Q

A patient is presenting with nephrotic syndrome. Upon biopsy, diffusely thickened GBM is identified, due to IgG deposits. Additionally, IgG is seen in the Ab screen.

Differential?

Treatment?

A

Membranous Nephropathy

  • Renoprotection: ACEi/ARB and Anti-hypertensives

Refractory to Tx for 6/12 or increased SCr by 30%
+ Ponticelli regimen (Pred + Cyclophosphamide)

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63
Q

What is Membranoproliferative Glomerulonephritis?

A

Nephrotic syndrome caused by deposition of IgG or C3 with increased cell numbers in the membrane of the glomerulus

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64
Q

What is the difference between Membranous Nephropathy and Membranoproliferative Glomerulonephritis?

A

In membranoproliferative disease, the mesangium and the GBM is affected

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65
Q

A patient presents with frothy urine showing protein and blood. On renal biopsy, there is C3 present and proliferation of the basement membrane and mesangium.

Differential?

A

Membranoprolierative Glomerulonephritis

  • Renoprotection: ACEi/ARB
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66
Q

Outline the key clinical features of nephritic syndrome.

A

Haematuria + Hypertension + Oedema

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67
Q

A 32 year old female presents with ankle oedema. She is usually well but has had a throat infection for the last 2 days. Urinalysis shows blood and protein.

A renal biopsy shows IgA deposited within the mesangium.

Differential?

Treatment?

A

IgA Nephropathy

  • Renoprotection: ACEi/ARB
    ± Persistent proteinuria (>1g following 3/12)
  • Corticosteroids: Prednisolone at 1mg/kg
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68
Q

A 15 year old presents with ankle oedema and a purpuric rash on the buttocks. Additionally, he has had some tummy pain.

Urinalysis shows blood ++ and protein ++. He his hypertensive. Furthermore, a renal biopsy shows IgA and C3 positive.

What is your diagnosis?

What is your treatment?

A

HSP

  • Renoprotection: ACEi/ARB
    ± Persistent proteinuria (>1g following 3/12)
  • Corticosteroids: Prednisolone at 1mg/kg
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69
Q

A patient presents with periorbital and ankle oedema, oliguria and darker urine. They are usually well but had a throat infection 2 weeks ago.

Their ASO is raised. Furthermore, urinalysis shows protein ++, blood ++.

What is your differential?

Wat other Antibody may be present?

What is your management?

A

Post-streptococcal Glomerulonephritis

Anti-DNAse B

  • Supportive: analgesia; antipyretics
    +
  • ABX: Penicillin
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70
Q

Which type of collagen are antibodies produced against in Anti-GBM Disease?

A

Type 4 collagen

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71
Q

A patient presents with haematuria, puffy ankles and productive cough in which blood is present.

Renal biopsy shows crescent formation with anti-GBM antibodies.

Differential?

Treatment?

A

Anti-GBM disease

  • Corticosteroids: Prednisolone
    +
  • Immunosuppressants: Cyclophosphamide
    +
  • Plasma exchange
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72
Q

What is rapidly progressive glomerulonephritis?

A

Any aggressive GN progressing to renal failure over days/weeks

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73
Q

What pathogen is the most common cause of Pyonephrosis?

Give 3 other potential pathogens.

A

E. coli

Proteus
Klebsiella
S. saprophyticus
S. aureus
Candida

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74
Q

A patient presents with nausea, high temperatures and fishy urine following a few hours of severe pain in the side of her tummy.

What investigations would you order?

Differentials?

Treatment?

A

• Urinalysis: Haematuria/Proteinuria/Leukocytes/WBCs
• Renal function: Hypercreatinemia/Reduced eGFR; Hyponatremia/Hyperkalemia/Acidosis (low bicarbonate)
• Urine culture: Positive or sterile
• FBC: Anaemia/Leukocytosis
• US-renal: small, irregular, scarred kidneys; echogenic parenchyma (pus); hydronephrosis; renal stones; peri-renal fluid collections
• XR-KUB: Renal calculi/kidney size

Pyelonephritis

Pyonephrosis

• ABX: Ciprofloxacin (500mg PO BDS 7-14/7)

If stones:
- PCNL

If complicated disease:
- Admit + Ceftriaxone

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75
Q

How may you categories UTIs?

A

Uncomplicated: UTI in healthy individual

Complicated: drug-resistant or structural impairment

Acute: infection

Recurrent: 2 episodes within 6 mo

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76
Q

State 3 RFs for a UTI

A

PMHx UTI
Age > 50
F
Instrumentation of renal tract
Renal tract obstruction / Structural differences

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77
Q

Which is the most common cause of a UTI?

A

E. coli

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78
Q

A 27 year old male presents with painful urination, increased trips to the toilet to pee and pain in his lower tummy.

He has no discharge or pruritus. He has recently had sexual intercourse with his partner of ten years and they use barrier contraception.

What investigations would you run?

Treatment?

A

Urinalysis: Nitrite, Leukocytes
FPU: Leukocytes
Culture

Could order a CT-KUB

Nitrofurantoin; Ciprofloxacin

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79
Q

A 28 year old male presents with painful urination, green discharge and pruritus at the end of his penis.

What investigations would you order?

Differentials?

Management?

A

FPU + NAAT: gram negative, diplococci

Urinalysis: Leukocytes

Urethritis secondary to Gonorrhoea

Ceftriaxone (1g IM) and Azithromycin (1g PO)
AND
Test of cure in 5 weeks

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80
Q

A 28 year old male presents with painful urination, discharge and pruritus at the end of his penis. He also has some eye pain and joint pain.

What investigations would you order?

Differentials?

Management?

A

Urinalysis: Leukocytes

FPU + Microscopy: rod-shaped, gram negative bacterium

Urethritis secondary to Chlamydia infection (Reiter’s Syndrome)

Ceftriaxone (1g) + Azithromycin (1g PO)

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81
Q

Which organism is the commonest cause of Prostatitis?

A

E. coli

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82
Q

Describe Urinary Incontinence

A

Involuntary expulsion of urine occurring due to strenuous physical activity (stress incontinence) or increased urge (urgency incontinence) or both (mixed incontinence) characterised by polyuria, nocturia, lower abdominal (suprapubic) distension and enuresis (if no physical cause found).

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83
Q

How may Urinary Incontinence be classified?

A

• Stress: Urination on physical activity (e.g. cough, strain ): IA pressure raised > Urethral P

• Urgency: Increased desire: Overflow UI = male outflow obstruction thus oliguria + bladder distension

• Mixed: ∑ (Stress + Urgency)

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84
Q

The external urethral sphincter is controlled by which nerves?

A

Pudendal N. (S2-4)

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85
Q

Outline the two phases of the micturition cycle.

A

Filling phase in which urine enters, stretch receptors are stimulated and bladder relaxes with sphincter contracting (L1-L3 hypogastric plexus)

Voiding phase in which the bladder is 75% full thus the detrusor contracts and sphincters relax (S2-S4) with intravesical P > urethral P

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86
Q

State 5 RFs for urinary incontinence.

A

Stroke
Obesity
Pregnancy
Ageing
Parkinson’s
Dementia
Multiple Sclerosis
Radiotherapy
Iatrogenic
Faecal incontinence

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87
Q

What is the difference between urgency and voiding symptoms?

A

Urgency is suggestive of storage incontinence, whereby the bladder is weaker or overactive thus increased desire to micturate

Voiding is suggestive of stress incontinence, whereby there is improper expulsion of urine

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88
Q

State the urgency and voiding symptoms.

A

Frequency
Urgency
Nocturia

Weak stream
Intermittency
Straining
Emptying incomplete

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89
Q

What investigations may you order in a case of suspected urinary incontinence?

A

• Bladder diary
• Empty supine stress test (Valsalva manoeuver in dorsal lithotomy position after voiding): Positive (urine leakage)

• Cough stress test (300mL filling + Valsalva manoeuvre in dorsal lithotomy): Urine leakage if positive

• Post-void residual measurement (US following voiding): Elevated if ≥100mL OR ≥ 50% void volume

• Urinalysis: May show leukocytosis; RBC casts; Infection; Nitrites
• US-KUB
• Cystourethroscopy (bladder scope): Fistula/Foreign body/Tumour/Interstitial cystitis/Urethritis

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90
Q

How do you manage a stress UI?

A

1st line is Pelvic floor training

• Conservative: Pelvic floor training; Weight loss; Smoking cessation; Modify fluid intake; Penile sheath (M)
±
• SNRIs: Duloxetine
± (Failed conservative + medical thus 3rd line)
• Surgery: Suburethral sling/ Urethral bulking agent (Si microparticles; Coaptite)

OR (Urethral hypermobility or displacement)

• Surgery: Burch colposuspension/ Artificial sphincter

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91
Q

How do you manage an urgency UI?

A

• Conservative: Bladder training/Pelvic floor training/ Modify fluid intake
±
• Pharmacotherapy: Oxybutynin (anticholinergic)/ Tolterodine (anticholinergic)/ Mirabegron (ß3 agonist)/ Topical Oestrogen/ Botulinum toxin (Ives.)
± (Failed conservative + medical)
• Surgery: Sacral nerve stimulation (Neuromodulation)/Clam ileocystoplasty/Urinary diversion

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92
Q

What class of drug is Duloxetine?

A

SNRI

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93
Q

What class of drug is Mirabegron?

A

ß3 agonist

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94
Q

What class of drug is Oxybutynin?

A

Anticholinergic

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95
Q

What class of drug is Tolterodine?

A

Anticholinergic

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96
Q

What are the side effects of Oxybutynin?

A

Oxybutynin is an anticholinergic thus SLUDGE side effects

Salivation
Lacrimation
Urination
Defaecation
GI upset
Emesis

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97
Q

A patient presents with painful urination, increased need to urinate and a fever. He has not passed urine like usual for the last day. He feels like he needs to go but cannot.

O/E he has a distended bladder. He has a PMHx of retroperitoneal fibrosis.

What investigations will you order?

What are your differentials?

How will you manage this?

A

Urinalysis: positive nitrites and blood
FBC: Normal
U+Es: Normal
US-Renal: Hydronephrosis
CT-Pyelogram: Pyonephrosis and fibrosis of the ureters causing extraluminal obstruction.

Urinary Obstruction secondary to Pyonephrosis tertiary to Retroperitoneal Fibrosis

Catheterise
Analgesia
Antibiotics
Stenting

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98
Q

A 62 year old male presents with increased need to go to the bathroom to pass urine, passing urine 2-3 times per night. He says when he goes, he has to wait to get going and then it stops then starts again. At the end a few drops come out and he mus wait.

What symptoms are he describing?

What investigations may you order?

O/E he has a smooth, nodular enlargement bilaterally of the prostate.

What are your differentials?

How may you manage this?

A

Frequency
Urgency
Nocturia

Waiting
Intermittency
Emptying incomplete (dribbling)

• Urinalysis: Normal (uncomplicated); Pyuria (Complicated); Haematuria (Ca)
• PSA: Elevated
• International Prostate Symptom Score (IPSS): Mild (0-7); Moderate (8-19); Severe (20-35)
• US: Hydronephrosis/Mass/Urolithiasis/Post-void residual
• CT-Abdo/Pelvis: Mass/Hydronephrosis/Urolithiasis

Benign Prostatic Hyperplasia

Want to rule out Prostate Adenocarcinoma

Medical: Tamsulosin or Finasteride

Volume >30g
Surgical: TURP

Volume >80g
Surgical: Open prostatectomy

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99
Q

How does Tamsulosin mediate its effects in BPH management?

A

alpha 1 antagonist thus smooth muscle relaxes in prostate and ureters with reduced resistance to urine flow

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100
Q

How does Tamsulosin mediate its effects in BPH management?

A

alpha 1 antagonist thus smooth muscle relaxes in prostate and ureters with reduced resistance to urine flow

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101
Q

What are the side effects of Tamsulosin?

A

Dizziness

Sexual dysfunction

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102
Q

What is the MOA of Finasteride in BPH?

A

5a reductase inhibitor therefore reduces production of testosterone which reduces the growth of the prostate

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103
Q

What is the main side effect of Finasteride?

A

Sexual dysfunction

Breast abnormalities

Skin reactions

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104
Q

Which grading system can be used for Prostate Cancer?

A

Gleason Score

TNM

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105
Q

How is a Gleason Score calculated?

A

Take the two biopsied areas with the most dysplasia and add the score up using the Gleason Pattern Scale (1-5) which gives a score from 2-10.

Low = <6

Intermediate = 7

High = 8

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106
Q

What DRE finding(s) may increase your suspicion of a Prostate Cancer?

A

Assymetrical, enlargement, rigid, nodular prostate

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107
Q

What is the PSA threshold which warrants further investigation?

A

> 4 ug/L

with LUTS and 50+ or FHx

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108
Q

Which cancers commonly metastasise to bone?

A

Prostate

Breast

Kidney

Lung

Thyroid

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109
Q

How do you manage prostate cancer?

A

Supportive: Active surveillance (6 mo. bloods; 12 mo. DRE); Smoking cessation; Diet

Medical: Brachytherapy; Radiotherapy; Bicalutamide/Flutamide + Gorserelin

Surgery: Radical prostatectomy

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110
Q

A 2 day old presents with frothy urine and clubbed feet. O/E he is breathing rapidly with shallow breaths, you note craniofacial abnormalities.

He was born by LUCS in a planned delivery. The mother reports that the health visitor said she had less amount of amniotic fluid than usual.

US-Kidney shows no kidneys present.

What is your differential?

What are the features of this disease?

How would you manage this?

A

Bilateral renal agenesis (Potters Syndrome)

Features:
Pulmonary Hypoplasia
Oligohydramnios
Twisted skin
Twisted face
Extremity Deformity
Renal agenesis

• RRT: Dialysis/Transplantation
• IV Fluids and electrolytes
• Diuretics: Thiazide diuretics (bendroflumethiazide/Indapamide); ARAs (Spironolactone/Eplerenone)

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111
Q

What is Polycystic Kidney Disease?

A

congenital disease which results in cysts developing in the kidneys, compromising renal function and predisposing to chronic renal disease

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112
Q

What are the associated extra-renal findings with PCKD?

A

Cerebral aneurysms

Pancreatic/Prostatic, Ovarian, Splenic, Hepatic (POSH) Cysts

Colonic diverticula

Cardiac valve disease (mitral regurgitation)

Aortic root dilatation

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113
Q

What are the associated extra-renal findings with PCKD?

A

Cerebral aneurysms

Pancreatic/Prostatic, Ovarian, Splenic, Hepatic (POSH) Cysts

Colonic diverticula

Cardiac valve disease (mitral regurgitation)

Aortic root dilatation

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114
Q

Which type of PCKD is more common?

A

Autosomal dominant (85%)

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115
Q

Where is PKD-1 found?

A

Chromosome 16

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116
Q

Where is the PKD-2 gene found?

A

Chromosome 4

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117
Q

Which form of PCKD is more dangerous/sever?

A

Autosomal recessive

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118
Q

What investigation would you order and what would it show in PCKD?

A

US - enlarged bilaterally with echoic and anechoic masses (liquid-filled cysts)

U+Es

Genetic testing

IV Pyelogram

Liver biopsy

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119
Q

How would you manage PCKD?

A

• Supportive (delay progression): Monitoring/Avoid nephrotoxic substances/Treat arterial hypertension/Treat UTIs
• Vasopressin receptor analogue: Tolvaptan
• Treat liver failure
• Genetic counselling
• RRT: Dialysis/Kidney transplantation

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120
Q

What is Wilm’s Tumour?

A

WT1 TS gene ∆ in children with oncology referral (surgery, radio + chemo)

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121
Q

How do you treat a Wilm’s tumour?

A

• Surgery: Radical nephrectomy
• Post-operative chemotherapy: Dactinomycin + Vincristine

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122
Q

What are the renal phakomatoses?

A

broad group of neurocutaneous syndromes

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123
Q

A 34 year old male presents to the GP with recent personality change. He says that his wife has gradually reported a more fluctuant mood in himself. Furthermore, he said he has had some recent headaches. He recently had a cough which has been present for 6 months and he says he is regularly SOB.

O.E you notice some areas of hypopigmentationw which are flat. Furthermore, on his lower back there are some skin lesions with an orange-peel texture. His chest is clear; S1+S2 are pure but he has an irregular heart rate.

PMHx - pneumothorax

What tests would you order?

What is your differential diagnosis?

What are the clinical features (both observed) and seen in this condition?

How would you manage this condition? (Give the 3 main ones, and 2 further examples)

A
  • FBC
  • U+E
  • PFTs
  • ECG
  • Echocardiogram
  • EEG
  • MRI-Brain
  • CT-CAP
  • Genetic testing: ∆TSC1/2
  • Colonoscopy
  • Renal biopsy

Tuberous Sclerosis

Ashleaf Spots
Shagreen’s patches
Heart rhabdomyomas

LAMs
Epilepsy
Angiomyolipoma
Facial angiofibroma

  • mTOR1 inhibitor: Evrolimus

± Seizures
- Anticonvulsant: Lamotragine

Note: Ketogenic diet may reveal metabolic disorders via diet, levels of organic acids and carnitine w/ ECG

± Subependymal giant cell astrocytoma
- Active surveillance: Periodic neuroimaging

or
- Surgical resection

± Angiofibroma/collagen plaque (Shagreen patch)
- Laser therapy (<2mm)

or
- Dermabrasion (>2mm)

± HTN
- Antihypertensives: Amlodipine

Note: Do not use ACEi if patients Tx with mTOR inhibitor

± Angiomyolipomata
- Active surveillance

If >3-6cm
- Embolisation or Nephrectomy

± Lymphangioleiomyomatosis (LAM)
- Active surveillance
+
- mTORi: Evrolimus
±
- Oxygen therapy

± Renal Cell Carcinoma
- Total Nephrectomy

± Intracranial aneurysm
- Surgery: Intra-arterial coiling/ Craniotomy/ Clipping

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124
Q

What type of diet may reveal metabolic disorders?

A

Ketogenic diet

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125
Q

What is Von-Hippel Lindau Syndrome?

A

Autosomal dominant inheritance disease due to ∆VHL causing ∆VHLp resulting in tumour and cyst development affecting multiple systems

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126
Q

What are the clinical features of Von-Hippel Lindau Syndrome?

A

Haemangiomas
Increased risk of RCC
Phaeochromocytoma
Pancreatic lesions
Eye Lesions

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127
Q

What would you expect the plasma catecholamines to come back as in VHL Syndrome?

A

Elevated due to Phaeochromocytoma

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128
Q

How would you manage a patient with known Von-Hippel Lindau Disease?

A

Supportive: Annual review (surveillance)

Surgical: Nephrectomy; Resection of adrenal medulla; Resection of haemangioblastoma

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129
Q

Describe Alport Syndrome.

A

Inherited disease of glomerular basement membrane abnormalities – type IV collagen resulting in sensorineural hearing loss, lenticonus, retinal abnormalities and renal problems.

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130
Q

A 4 year old child is brought into GP by his mother due to noticing blood in his urine. The urine is described as frothy. In addition to this, she says she has to speak louder to him when communicating and that he does not listen.

O/E he is SOB and has a cough. His chest is clear and S1+S2 are pure. He has swollen ankles. A Rinne’s and Weber’s test shows sensorineural hearing loss bilaterally.

Urinalysis shows blood++ and protein++.

What condition are you suspicious of?

What investigations would you wish to run?

How would you manage this?

A

Alport Syndrome

  • FBC: elliptocytosis; leykocytosis; anaemia
  • Metabolic panel: may suggest renal impairment
  • Urinalysis: haematuria/proteinuria
  • Fasting lipid panel: ?dyslipidaemia
  • Audiometry: High-tone sensorineural hearing loss
  • Ophthalmoscopy: corneal/retinal abnormalities/ lenticonus/ maculopathy/ cataracts
  • Renal ultrasound: Normal – exclude other renal tract pathology
  • Renal biopsy: loss of staining for type IV collagen
  • ECG: ? LV hypertrophy
  • Genetic testing: COL4A5
  • Supportive: Annual monitoring – FBC; U+Es; eGFR; lipids; uric acid; urinalysis

± Nephrotic Syndrome
- ACEi
+
ARB

Aim for < 130/80mmHg

± Chronic Renal Failure
- RRT

± Sensorineural deafness
- Audiologist referral

± Visual disturbance
- Ophthalmology referral

± Symptomatic leiomyomas
- Surgical excision

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131
Q

What is the target blood pressure for a patient with Alport Syndrome?

A

<130/80mmHg

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132
Q

Which gene is mutated in Alport Syndrome?

A

COL4A5

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133
Q

In Fabry Disease, which enzyme is deficient?

A

a-Galactosidase A

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134
Q

Deficiency of what results in accumulation of what substrate in Fabry Disease?

A

alpha Galactosidase A deficiency results in accumulation of Ceramide trihexoside

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135
Q

What are the clinical manifestations of Fabry Disease?

A

Foamy urine (Fabry nephropathy)
Anhidrosis/Angiokeratoma
Burning pain (dysaesthesia)
Really dry
CVD/ Corneal disease/ Cataracts

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136
Q

How do you manage a patient with Fabry Disease?

A
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137
Q

What is the gold standard test for a patient with suspected Cystinuria?

A
  • Urinary cyanide nitroprusside test: positive
    (Cyanide converts cystine to cysteine with nitroprusside binding to cause a purple hue which detects levels of cystine)
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138
Q

How do you manage cystinuria?

A
  • Supportive: IV fluids
    +
  • Alkalising agent: Potassium citrate; Acetazolamide
    +
  • Chelating agent: Penicillamine-D
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139
Q

Describe Cystinosis.

A

Inherited inborn error of metabolism of autosomal recessive nature that involves lysosomes improperly transporting cystine hence accumulation (lysosomal storage disease).

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140
Q

What is the diagnostic test for suspected Cystinosis?

A
  • WBC Cystine test: Elevated
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141
Q

How do you manage Cystinosis?

A
  • Supportive: IV Fluids; Electrolytes
    +
  • Cysteamine
    (binds to cystine to form cysteine which is transported)
    +
  • Renoprotection/RRT
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141
Q

How do you manage Cystinosis?

A
  • Supportive: IV Fluids; Electrolytes
    +
  • Cysteamine
    (binds to cystine to form cysteine which is transported)
    +
  • Renoprotection/RRT
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142
Q

What drug can be used to bind Cystine in Cystinosis?

A

Cysteamine

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143
Q

What is the most common form of Renal Cell Carcinoma?

A

Clear Cell (75%)

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144
Q

What syndrome describes hepatic dysfunction in the absence of metastasis with hepatic derangements seen in Renal Clear Cell Carcinoma?

A

Stauffer Syndrome

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145
Q

Describe Stauffer Syndrome.

A

paraneoplastic disorder associated with RCC resulting in hepatic dysfunction in the absence of metastasis with hepatic derangements seen

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146
Q

What is the 1st line imaging for a suspected Renal Cell Carcinoma?

A

US-Abdomen

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147
Q

Deranged LFTs in the presence of RCC with unremarkable US-Liver suggests…?

A

Stauffer Syndrome

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148
Q

How do you manage a Renal Cell Carcinoma?

A

Stage 1 or 2
- Surveillance
or
- Surgery

Stage 3
- Surgery: Radical nephrectomy
+
- Chemotherapy

Stage 4
- Chemotherapy
+
- Radiotherapy

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149
Q

What is the most common bladder cancer?

A

Urothelial (transitional)

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150
Q

What are the types of bladder cancer?

A
  • Urothelial (transitional = TCC) – derived from epithelium
  • Squamous Cell Carcinoma (SCC) – derived from bladder lining
  • Adenocarcinoma (derived from urachas; AC) – derived from glandular cells
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151
Q

Stae 3 RFs for bladder cancer.

A

• Smoking
• Age > 55 years
• Exposure to chemical carcinogens
• Pelvic radiation
• Systemic chemotherapy

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152
Q

What investigation is used to diagnose Bladder Cancer?

A

• CT-urogram: Bladder tumours
• Cystoscopy: Rough, erythematous patch in bladder (stain with Methylene Blue)

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153
Q

How is Bladder Cancer managed?

A

Non-invasive
• Surgery: Transurethral resection of Bladder tumour (TURBT)
• Chemotherapy: Intravesical chemotherapy

Locally invasive tumours (T1)
• Surgery: Radical/partial cystectomy with pelvic lymph node dissection
• Chemotherapy: Preoperative + postoperative chemotherapy

Metastatic Disease
• Chemotherapy
• Surgery/Radiotherapy
• Immunotherapy

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154
Q

What are the clinical features of Acute Epididymitis?

A

Unilateral scrotal pain
Unilateral scrotal swelling
Hot, erythematous hemiscrotum
Dysuria
Enlarged testes

Negative Prehn’s test

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155
Q

What clinical examination can be used to differentiate between Epidydimitis and Testicular Torsion?

A

Prehn’s Test

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156
Q

Give 5 aetiological factors for Epididymitis?

A

• C. trachomatis
• N. gonorrhea
• M. genitalium
• E. coli (anal sex + elderly patients)
• Proteus spp. (older men  urine stasis + outflow obstruction)

• Mumps (Viral epididymitis)
• Candida spp. (Fungal epididymitis)
• Amiodarone (reversible, sterile epididymitis)  Anti-amiodarone Abs attack epididymis at high [amiodarone]
• Vasculitides (Behcet’s; HSP)

• Idiopathic

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157
Q

How do you treat Epidydimitis caused by Gonorrhoea?

A

Ceftriaxone (250mg IM) + Azithromycin (1mg PO)

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158
Q

How do you treat Epidydimitis caused by Mumps?

A

Supportive: Paracetamol; Rest; Elevation

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159
Q

How do you treat Epididymitis occurring following commencing Amiodarone?

A

• Reduction/Discontinuation + Supportive measures

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160
Q

Describe Testicular Torsion

A

Urological emergency caused by twisting of spermatic cord, constricting vascular supply with resultant ischaemia and/or necrosis of testicular tissue characterised by severe onset pain, N+V and scrotal swelling.

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161
Q

What anatomical variation may increase risk of Testicular Torsion?

A

• Bell clapper deformity (testes rotate within tunica vaginalis)

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162
Q

A 19 year old male presents with pain in the scrotum, nausea and a high temperature. He said the pain began suddenly when he was watching TV.

O/E there is scrotal oedema and erythema. The stroking the medial thigh does not elicit a response. Elevation of the testes worsens the pain.

What is your differential?

What investigations should you order?

What are the examination special tests called?

What is the management?

A

Testicular torsion

None, its a clinical diagnosis

Cremasteric Reflex
Prehn’s Test

Supportive: Admission; IV Analgesia; Fluids

Surgery: Exploration and Orchidopexy/Orchiectomy

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163
Q

Describe a Varicocoele.

A

Enlargement of pampiniform plexus of scrotum causing low sperm production (hypospermia), reduced concentration (oligoospermia) and low sperm quality (tetrazoospermia/asthenozoospermia)

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164
Q

What is hypospermia?

A

Reduced volume (< 1.5ml)

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165
Q

What is Oligoospermia?

A

Low count (<15 million/ml)

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166
Q

What is Tetrazoospermia?

A

Abnormal morphology (< 4% normal)

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167
Q

What is Asthenozoospermia?

A

• Asthenozoospermia: Reduced motility (< 40% moving)

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168
Q

What is the primary clinical find of Varicocoele?

A

• Painless scrotal mass (bag of worms)*
• Asymmetrical testes*

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169
Q

What is the management of a Varicocoele?

A

• Supportive (reassurance and observation)
+
• Surgery

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170
Q

Describe a Hydrocoele.

A

Collection of serous fluid between tunica vaginalis or spermatic cord characterised by scrotal oedema that can undergo transillumination

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171
Q

What are the two types of Hydrocoele.

A

• Communicating: patent processus vaginalis connects peritoneal cavity and scrotum
• Non-Communicating (Simple): Processus vaginalis closed, fluid production > output (by tunica vaginalis)

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172
Q

What are the primary clinical features of a Hydrocoele?

A

• Scrotal mass/oedema
• Transillumination

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173
Q

How do you manage a Hydrocoele?

A

Child 2-11/Adolescent
• Surgery: Exploration + Repair

Adult: No bothersome Sx
• Observation

Adult: Discomfort
• Intervention: Surgery/Aspiration/Sclerotherapy

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174
Q

What is an Epididymal cyst?

A

smooth, spherical cyst in head of epididymis

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175
Q

What are the clinical features of an Epididymal Cyst?

A

• Testicular lump: well-defined, fluctuant, non-transilluminating
• Can get around the lump

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176
Q

How do you manage an Epididymal Cyst?

A

• Supportive, watch and wait

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177
Q

What are the two main types of testicular cancer?

A

Seminomas

Non-Seminomas

178
Q

How does a Testicular cancer present?

A

Painless lump - may cause testicular pain

Hard
Irregular
Non fluctuant

No transillumination

Gynaecomastia (in Leydig Cell Tumour)

179
Q

What specific testicular cancer may cause gynaecomastia?

A

Leydig Cell Tumour

180
Q

What is the first line investigation used to diagnose a Testicular Cancer?

A

US

181
Q

Which Tumour Markers are used in Testicular Cancer?

What are they suggestive of?

A

Alpha fetoprotein (teratomas)

ß-hCG (both teratoma and seminoma)

LDH (non-specific)

Mnemonic:
FeToprotein = TeraToma
Beta-hCG = Both

182
Q

What Staging System is used in Testicular Cancer?

A

Royal Marsden Staging System

Stage 1 = isolated to testicle

Stage 2 = retroperitoneal lymph nodes

Stage 3 = LN above diaphragm

Stage 4 = other organs

183
Q

Where are the most common sites of metastasis for a Testicular Cancer?

A

Lymphatics

Lungs

Liver

Brain

184
Q

How do you manage a Testicular cancer?

A

MDT decision

Sperm bank (for future)
+
Surgery: Radical orchidectomy
+
Chemotherapy
+
Radiotherapy

185
Q

Which type of testicular cancer has a better prognosis?

A

Semimomas

186
Q

What is a phimosis?

A

Tight foreskin

187
Q

What is a Paraphimosis?

A

Foreskin retraction

188
Q

What is a Hypospadias?

A

urethral opening below penis

189
Q

What is an Epispadias?

A

urethral opening above penis

190
Q

What is a buried penis?

A

penis present in dartos tissue

191
Q

What are the clinical features of a phimosis?

A

• Penile pain
• Erythema
• Glans oedema
• Voiding symptoms
• Black tissue on glans

192
Q

What are the clinical features of a Paraphimosis?

A

• Penile pain
• Erythema
• Glans oedema
• Cicatrix (sclerotic white ring at tip)

193
Q

What are the clinical features of a Hypospadias?

A

• Voiding symptoms: flow/direction
• Opening of urethra inferior to usual

194
Q

What are the clinical features of an Epispadias?

A

• Voiding symptoms: flow/direction
• Opening of urethra at superior to usual

195
Q

What are the clinical features of a buried penis?

A

• Voiding symptoms
• Prominent pre-pubic fat pad

196
Q

How do you manage a Phimosis?

A

• Surgery: Circumcision

197
Q

How do you manage a Paraphimosis?

A

• Medical: Paraphimosis reduction
OR
• Surgery: Surgical reduction (dorsal slit)

198
Q

How do you manage an Epispadias?

A

• Surgery: Urethroplasty

199
Q

How do you manage a Hypospadias?

A

• Surgery: Urethroplasty

200
Q

How do you manage a Buried Penis?

A

• Surgery: Phalloplasty

201
Q

A 35 year old man presents with an itchy glans of the penis. O/E there are erosions and erythematous patches.

What investigations would you order?

What is your differential?

What is the management?

A

• Swab + NAAT/PCR: May be positive for pathogen
• Skin Biopsy: Histopathological find for cause

Balanoposthitis

• Tx underlying cause

202
Q

What are the causes of Balanoposthitis?

A

• Inflammatory
• Infection
• Pre-cancerous

203
Q

Describe Erectile Dysfunction.

A

The consistent or recurrent inability to attain/maintain a penile erection sufficient for sexual intercourse

204
Q

State 10 RFs for Erectile Dysfunction

A
  • Advanced age
  • CAD
  • PAD
  • HTN
  • DM
  • Smoking
  • Hyperlipidemia
  • Drugs: Anti-depressants/Anti-hypertensives
  • Libido disorder
  • Obesity
  • SCI
  • Pelvic injury
  • Neurological disease
  • Peyronie’s Disease (fibrous nodules in tunica albuginea)
205
Q

What is the most common cause of Erectile Dysfunction?

A

• Vascular/Arteriogenic (40%)

206
Q

What are the clinical features of Erectile Dysfunction?

A

• Premature ejaculation
• Abnormal prostate exam/DRE
• Psychosocial stressors
• Penile abnormalities: Plaques/Deformities/Angulation
• Teste abnormalities: Cryptorchidism/ Microorchidism
• Lack of male pattern of hair

207
Q

What investigations may you order in a patient describing Erectile Dysfunction?

A

• International Index of Erectile Dysfunction (IIED): Abnormal
• FBG: Normal; Raised (DM)
• HbA1c: ≥ 48mmol/L (≥ 6.5%)
• Lipid panel: Normal; Raised (Hyperlipidemia)
• Sex hormones: Variation; Low = hypogonadotrophic hypogonadism; Normal = eugonadotrophic hypogonadism; Elevated = hypergonadotrophic hypogonadism
-> FSH + LH
• Prolactin: Normal; Elevated (hypogonadotrophic hypogonadism)
• Doppler-US: Normal

208
Q

How do you manage Erectile Dysfunction?

A

• Tx Underlying Condition
+
• Psychotherapy: CBT
+
PDE5 inhibitors: Sildenafil
± (Peyronie’s Disease/Trauma)

OR

• Surgery: Surgical correction/Prosthesis/Revascularisation

209
Q

Describe an Inguinal Hernia.

A

protrusion of abdominopelvic contents into inguinal canal via inguinal floor or internal inguinal ring

210
Q

What are the types of Inguinal Hernia?

A
  • Direct inguinal hernia: herniates via inguinal floor medial to inferior epigastric artery and deep inguinal hernia
  • Indirect inguinal hernia: herniates via deep inguinal ring, lateral to inferior epigastric artery
  • Reducible
  • Irreducible (incarcerated)
  • Strangulated (blood supply compromised thus ischaemia)
211
Q

What is the difference between an Incarcerated and a Strangulated hernia?

A

An incarcerated hernia is irreducible whilst a strangulated hernia has compromised blood supply with ischaemia

212
Q

What are the borders of Hesselbach’s Triangle?

A

Inguinal ligament (inferiorly)

Inferior epigastric vessels (laterally)

Lateral border of rectus abdominis muscle (medial)

213
Q

Where is the Inferior Epigastric Artery found?

A

Between the posterior wall of rectus abdominis and the transversalis fascia

214
Q

What are the clinical features of an inguinal hernia?

A
  • Groin pain: dull/heaviness/dragging
  • Groin bulge/mass: soft; pliable; ∆s when coughing; reducible?
  • N/V
  • Constipation
215
Q

What are the management options for an Inguinal Hernia?

A

Small, asymptomatic
- Watch and wait

Large/ Symptomatic
- Open/ Laparoscopic repair
±
- Prophylactic ABX

Strangulated hernia/incarcerated
- Open repair
±
- Prophylactic ABX

216
Q

What is the difference between an incarcerated and strangulated hernia?

A

Incarcerated hernias cannot be reduced into the proper position (irreducible), which may lead to an obstruction and strangulation.

Strangulation is where the hernia is non-reducible with the base of the hernia becoming so tight that the blood supply is reduced causing ischaemia. Bowel will undergo necrosis rapidly

217
Q

Describe a Richter’s Hernia?

A

This is where only part of the bowel wall and lumen herniate through the defect with the remainder remaining within the peritoneal cavity.

These can become strangulated and rapidly progress to ischaemia.

218
Q

Describe Maydl’s hernia?

A

This is where two different loops of bowel are contained within the hernia.

219
Q

How may hernias be managed?

A

Supportive: leave

Surgery:

Tension-free repair (mesh sutured to muscles and tissue either side)

Tension repair (suture muscle and tissue either side of defect back together

220
Q

What foetal remnant gives the route for a hernia to form?

What type of hernia is this?

A

Processus vaginalis

Indirect inguinal hernia

221
Q

What are the boundaries of Hesselbach’s Triangle?

A

Mnemonic: RIP

Rectus abdominis (medial border)

Inferior epigastric vessels (superolateral border)

Poupart’s Ligament (inferior border)

222
Q

Outline the boundaries of the femoral canal?

A

Mnemonic: FLIP

Femoral vein (lateral)

Lacunar ligament (medial)

Inguinal ligament (anteriorly)

Pectineal ligament (posteriorly)

223
Q

Outline the boundaries of the femoral triangle.

A

Mnemonic: SAIL

Sartorius (lateral)

Adductor longus (medial)

Inguinal Ligament (superior)

224
Q

What are the contents of the femoral triangle?

A

Mnemonic: NAVY-C

Nerve (Femoral)
Artery
Vein
Y fronts
Femoral Canal (lymphatic vessels and nodes)

225
Q

What is an incisional hernia?

A

Herniation occurring at the site of previous surgery due to muscle weakness

226
Q

What is an umbilical hernia?

A

Herniation due to defect in musculature around the umbilicus

227
Q

What is an epigastric hernia?

A

Herniation through the epigastric region of the abdomen

228
Q

What is a Spigelian Hernia?

What aids the diagnosis?

A

Hernia occurring at the site of Spigelian fascia, between rectus abdominis and linea semilunaris.

Imaging - US-Abdomen or CT-Abdomen

229
Q

What is Diastasis Recti?

What accentuates this?

A

Widening of the linea alba resulting in a larger gap between the rectus muscles.

Laying supine and lifting the head accentuates the bulge

230
Q

Describe an Obturator Hernia?

A

Herniation of abdominopelvic contents through the obturator foramen which may irritate the obturator nerve

231
Q

What is the term for the clinical examination find of pain when internally rotating the hip in an Obturator hernia?

Why is this occurring?

A

Howship-Romberg Sign

Internal rotation of the hip compresses the obturator nerve

232
Q

What is a hiatus hernia?

A

Herniation of the stomach through the diaphragm at the T10

233
Q

Outline the types of Hiatus Hernia?

A

Type 1: GO junction into thorax

Type 2: separate portion into thorax

Type 3: mixed

Type 4: large hernia with other IA organs into diaphragm

234
Q

How are hiatus hernias managed?

A

Conservative: treat reflux symptoms (PPI)

Surgical: Laparoscopic fundoplication

235
Q

How may you manage a hydrocoele?

A

Non-Operative: Aspiration

Operative: Hydrolectomy (incision in scrotum and drained via suction then close communication between canal and abdominal cavity and suture up)

236
Q

When do you refer a hydrocoele to Urology?

A

Painful

Cannot palpate testicle in scrotum (US-Testes)

237
Q

What are the layers you pierce through when doing an aspiration of the scrotum in a hydrocele?

A

Skin > Dartos Muscle > External spermatic fascia > Cremasteric muscle and fascia > Internal spermatic fascia

Other layers:
- Tunica Vaginalis
- Tunica albuginea

Mnemonic: Some Damn Englishman Called It The Testes

238
Q

What are the clinical features of bulbar urethra rupture?

A

Blood in meatus

Perineal oedema

Urinary retention

239
Q

What are the clinical features of membranous urethral rupture?

A

penile/perineal oedema

difficult to palpate on PR as prostate displaced superiorly

240
Q

How long does Finasteride take to work?

A

6-9 months

241
Q

What is the MOA of Bicalutamide?

A

Anti-androgen, blocking effect of testosterone to reduce tumour growth

242
Q

How long after a UTI can a PSA be done according to NICE?

A

4 weeks

243
Q

How long following a Prostate biopsy can a PSA be done?

A

6 weeks

244
Q

How long after vigorous exercise and ejaculation can a PSA be done?

A

48 hours

245
Q

How long after a DRE can a PSA be done?

A

1 week

246
Q

Which of the following is not a risk factor for Renal Cell Carcinoma?

A. Aniline Dye

B. Smoking

C. Rubber manufacture

D. Schistosomiasis

A

D - Schistosomiasis is a RF for squamous cell carcinoma of the bladder

247
Q

What is the MOA of Gorserelin?

A

GnRH agonist thus stimulates HPG axis to elevate LH which reduces endogenous secretion of testosterone. Testosterone rises for 2-3 weeks then depressed (chemical castration)

248
Q

What is the MOA of Degarelix?

What effect is different to Gorsorelin?

A

GnRH agonist however artificially depresses HPG axis without the initial 2-3 week elevation of Testosterone

249
Q

What is the MOA of Bicalutamide?

A

Non-steroidal anti-androgen, blocking the androgen receptor to depress testosterone secretion

250
Q

What is the MOA of abiraterone?

When is it indicated?

A

Androgen synthesis inhibitor

Metastatic prostate cancer in patients where androgen deprivation therapy has failed and before chemotherapy is indicated

251
Q

What is the MOA of crypoterone acetate?

A

Steroidal anti-androgen which prevents DHT binding from IC protein complexes.

Used as an adjunct with Gorsorelin at times to reduce prostate growth.

252
Q

What is the MOA of crypoterone acetate?

A

Steroidal anti-androgen which prevents DHT binding from IC protein complexes.

Used as an adjunct with Gorsorelin at times to reduce prostate growth.

253
Q

Give 5 causes of balanitis.

Outline the brief differences.

A

Candidiasis (itching; white, non-urethral discharge)

Dermatitis (itchy; painful; may have exudate/discharge and skin elsewhere affected)

Bacterial (painful; itchy; discharge)

Lichen planus (hexagonal, purple papules with Wickham’s striae)

Balanitis xerotica obliterans (itchy, white plaques and scarring)

Plasma cell balanitis of Zoon (no itch; areas of inflammation; plasma cell on biopsy)

254
Q

What is Priapism?

A

A penile erection lasting >4 hours which is not sexually stimulated

255
Q

Give 3 causes of Priapism.

A

Idiopathic

Haematological: Sickle cells; Thalassaemia; Lymphoma

Iatrogenic: PDE5i; SSRIs; Anti-hypertensives; Anticoagulants

Trauma

256
Q

What investigations may you conduct in a patient with Priapism?

A

Cavernosal blood gas analysis

Doppler-US

FBC

Toxicology screen

257
Q

What is urinary tract obstruction?

A

Mechanical or functional blockage stopping flow of urine

258
Q

State 5 causes of urinary tract obstruction.

A

Renal:
Nephrolithiasis
Carcinoma of renal pelvis
Renal papillary necrosis
UPJ obstruction

Ureteral
Intraluminal:
Nephrolithiasis
Blood clots

Intramural:
Strictures
Ureteric carcinoma
Surgical ligation

Extraluminal:
Pregnancy
Neoplasia
Aortic aneurysm
Iliac artery aneurysm
Tubo-ovarian masses (endometriosis; prolapse; haematoma)
GI masses (CD; diverticulitis)
Retroperitoneal fibrosis
Iatrogenic

Ectopic ureter
Ureterocele

Bladder:
Bladder carcinoma
Neurogenic bladder
Bladder calculi
Bladder neck dysfunction
Post-operative urinary retention

259
Q

What are the functions of the urinary system?

A

Excretion
Volume and solute regulation
Detoxification
Elimination
Endocrine (EPO; Vitamin D synthesis)
Acid-base regulation

Mnemonic: A WET BED
Acid-base regulation
Water balance
Electrolytes
Toxin removal

BP control
EPO synthesis
D Vitamin synthesis

260
Q

Where are the kidneys located?

A

Retroperitoneal structures located at T12-L3

261
Q

What 3 connective tissue layers surround the kidney?

A

Fibrous capsule
Perinephric fat
Renal fascia (Gerota’s fascia)

262
Q

What is the arterial supply to the kidney?

A

Renal artery (br. Abdominal aorta)

263
Q

What vertebral level does the renal artery branch from the aorta?

A

L1/L2

264
Q

Which vein drains the kidney?

A

Renal vein (into IVC)

265
Q

Which structures are present at the hilum of the kidney?

A

Mnemonic: VAD (both anterior and superior)

Vein
Artery
Duct

266
Q

At what vertebral level is the ureter visualised?

A

L2, the hilum of the kidney projects at this level, bearing the ureter.

267
Q

What is the potential space between the liver and right kidney called?

A

Hepatorenal pouch of Morison

268
Q

Which structure traverses the anterior concavity and the medical convexity of the right kidney?

A

Descending duodenum (L3)

269
Q

What is the relation to the lateral part of the inferior pole of the right kidney?

A

Hepatic flexure

And the SI (jejunum)

270
Q

What organ(s) contact the superior pole of the left kidney?

A

Peritoneum of stomach contacted medially and spleen laterally
Pancreas contacts just inferiorly

271
Q

What organ/structure contacts the inferior pole of the left kidney?

A

Splenic flexure
and peritoneum of the jejunum

272
Q

What are the posterior structures related to the kidneys?

A

Mnemonic: All Boys Need Muscles

Artery - Subcostal artery
Bones - 11th and 12th ribs
Nerves - subcostal, iliohypogastric and ilioinguinal nerves
Muscles - Diaphragm, Psoas major, quadratus lumborum, transversus abdominis

273
Q

What are the two parenchymal divisions of the kidneys?

A

Renal cortex and medulla

274
Q

What is the main unit of the renal medulla?

A

Renal pyramid

275
Q

What is the apical projection of the renal medulla called?

A

Renal papilla

276
Q

What is a papilla?

A

Small, rounded protuberance

277
Q

What does the renal papilla open into?

A

Minor calyx

278
Q

What do the minor calyces combine to form?

A

The major calyx

279
Q

What do the major calyces form?

A

The renal pelvis

280
Q

What is the union of the renal pelvis and ureter named?

A

PUJ
Pelvoureteric Junction

281
Q

What separates the renal pyramids?

A

Renal columns

282
Q

What are the functional regions of the nephron?

A

Renal corpuscle and renal tubule

283
Q

What are the features of the renal corpuscle?

A

Bowman’s (glomerular) capsule
Glomerulus

284
Q

What is the structure of the glomerular membrane?

A

Fenestrated endothelial cells
Glomerular basement membrane
Podocytes

Integrins link the cells to the BM via laminin

285
Q

What substances are not filtered into the urinary space at the glomerular membrane?

A

RBCs
Plasma protein

286
Q

What are the divisions of the renal artery?

A

Split into anterior and posterior branch of renal arteries

Anterior branch arborists into 5 segmental arteries which branch into interlobar arteries and then into arcuate arteries. Arcuate arteries branch into interlobular arteries which then go into afferent arterioles.

287
Q

What is nutcracker phenomenon?

A

Compression of L renal vein which passes between the aorta and SMA resulting in testicular infarction

288
Q

What is the lymphatic drainage of the kidney?

A

Lateral aortic lymph nodes

289
Q

What is the innervation of the kidney?

A

Renal plexus
Plexus gives input from: SNS (lower thoracic splanchnic nerves)
PSNS from Vagus nerve (CN X)
Sensory nerves from T10-T11

290
Q

Give 3 anatomical variations in renal structure

A

Third kidney
Renal agenesis
Horseshoe kidney

291
Q

What is the function of the ureters?

A

Urine transport from the kidneys to the urinary bladder

292
Q

What is the blood supply to the kidney?

A

Ureteric branches of renal artery
Ureteric branches of abdominal aorta and common iliac arteries
Ureteric branches of superior and inferior vesical and uterine arteries

293
Q

What is the innervation of the ureters?

A

Renal plexus and ganglia
Ureteric branches of intermesenteric plexus
Pelvic splanchnic nerves
Superior and inferior hypogastric plexuses

294
Q

What are the pelvic splanchnic nerves?

A

Preganglionic, parasympathetic nerve fibres from anterior rami of S2-S4

295
Q

What are the regions of the bladder?

A

Apex
Body
Fundus
Neck

296
Q

What are the surfaces of the bladder?

A

x1 superior surface
x2 inferolateral surfaces

297
Q

Upon cystoscopy, what landmark may be suggestive of the prostatic urethra?

A

Seminal colliculus - ejaculatory ducts distal to it; prostatic ducts proximal to it.

298
Q

What is the longest portion of the urethra?

A

Spongy; ≈15cm

299
Q

Which part of the urinary tract has the internal urethral sphincter?

A

Junction of bladder and urethra

300
Q

What is the term for the posterior elevation of the prostatic urethra?

A

Urethral crest, merging to form prostatic utricle

301
Q

Which ducts drain into the prostatic urethra?

A

Prostatic ducts superior to seminal colliculus

Ejaculatory ducts

302
Q

What exits via the ejaculatory ducts?

A

Seminal fluid and sperm

303
Q

What portion of the male urethra houses the external urethral sphincter?

A

Membranous urethra

304
Q

What are the two regions of the spongy urethra?

A

Bulbar urethra and pendulous urethra

305
Q

What are the two widened areas of the spongy urethra?

A

Ampulla of urethra
Navicular fossa of urethra

306
Q

Which glands drain into the spongy urethra in a male?

A

Bulbourethral glands (pre-ejaculate)

Urethral glans of Littre (mucous)

307
Q

What are the shapes of the pelvis determined by pelvic inlet shape?

A

Android (heart shaped; narrow apex; narrow pelvic outlet

Anthropoid (oval shaped; long and narrow sacrum; narrow pelvic outlet)

Gynecoid (oval in TR axis; broad sacrum; wide pelvic outlet 90-100)

Platypelloid (oval in TR axis; wide pelvic outlet; narrow sacrum and slightly curved)

308
Q

What cartilaginous feature deepens the acetabulum?

A

Acetabular labrum

309
Q

Which bones fuse to form the hip bone?

A

Ilium + Ischium + Pubic bone

310
Q

What are the two portions of the ilium?

A

Ala (wing)
Body

311
Q

What are the key bony landmarks of the ilium?

A

ASIS
AIIS
PSIS
PIIS

312
Q

Which feature of the ilium spans between the ASIS and the PSIS?

A

Iliac crest (with inner lip, outer lip and intermediate zone)

Houses the iliac tubercle

313
Q

Which ligaments help form the greater sciatic foramen?

A

Sacrotuberous and sacrospinous ligaments

314
Q

What are the contents of the greater sciatic foramen?

A

Sciatic nerve (L4-S3)
Sacral plexus branches: superior and inferior gluteal; pudendal; posterior femoral cutaneous; nerve to quadratus femoris; nerve to obturator internus

Superior gluteal art. ; Inferior gluteal art.; internal pudendal art.;

Piriformis muscle

315
Q

What 3 lines are present on the gluteal surface of the ilium?

A

Anterior gluteal line (oblique line from tubercle of iliac crest towards posterior gluteal line)

Posterior gluteal line (anterosuperior to greater sciatic notch)

Inferior gluteal line (superior to acetabular margin)

316
Q

What are the surfaces of the ilium?

A

Gluteal
Iliac (iliac crest to arcuate line)
Sacropelvic

317
Q

What are the causes for bladder cancer?

A

Mnemonic: ACTS
Aniline dye
Cyclophosphamide
Tobacco
Schistosomiasis

HPV
Chronic cystitis
Prolonged catheters
Pelvic radiation

318
Q

What is the most common renal malignancy in childhood?

A

Nephroblastoma

319
Q

Which genes may be responsible for Nephroblastoma development?

A

WT1 gene 11p13
WT2 gene 11p15

320
Q

Give 3 examples of conditions associated with Wilms’ tumours?

A

Beckwith-Wiedemann syndrome
Sotos syndrome
WAGR syndrome

321
Q

What is WAGR syndrome?

A

Syndrome featuring
Wilms tumour
Aniridia
Genitourinary abnormalities
Retardation

322
Q

Discuss the pre-malignant stage thought to be associated with Wilms’ tumour.

A

Nephrogenic rests of primitive blasternal renal elements (derived from renal stem cells) are found in the kidney

323
Q

What are the main clinical features of a nephroblastoma?

A

Abdominal pain
Haematuria
SOB
Anorexia
Fever

Abdominal mass
Pallor
Varicocele
Bone pain

324
Q

What is the initial imaging test ordered when suspecting a Wilm’s tumour?

A

US-Abdo

shows an evenly echogenic solid mass

325
Q

Why may LFTs be done when suspecting a Wilms’ tumour?

A

Cholestasis secondary to hepatic metastasis
Baseline value prior to hepatotoxic chemotherapy

326
Q

Why is it important to do coagulation studies in a patient with Wilms’ tumour?

A

can be a cause of acquired vWB disease;

Reduced endothelial adhesion, reduced factor 8 stabilisation and increased tendency to bleed

Should check APTT

327
Q

Outline the criteria for staging Nephroblastoma.

A

Stage 1 = kidney

Stage 2 = penetrates renal capsule

Stage 3 = microscopic abdominopelvic spread

Stage 4 = haematogenous mets

Stage 5 = bilateral renal involvement

328
Q

What are the management options for a nephroblastoma?

A

Surgery: radical nephrectomy
+
Chemotherapy

Stage 3 / 4
+ Radiotherapy

Stage 5 and ESRF
Consider Renal transplant

329
Q

What are the causes of RCC?

A

Smoking
High BMI
Hypertension

VHL syndrome
Birt-Hogg-Dubé syndrome
Tuberous sclerosis (mainly angiomyolipomas, but increases RCC risk)

330
Q

What is the size of a small renal mass?

A

<4cm

331
Q

What are the various types malignant renal neoplasms?

A

Clear cell
Papillary
Chromophobe
Medullary
Collecting duct

Neuroendocrine
Lymphoma
Nephroblastic

332
Q

Give an example of a benign renal cancer.

A

Renal adenoma
Oncocytoma
Angiomyolipoma
Neuroendocrine tumours

333
Q

What classification system may be used for cystic renal masses?

A

Bosniak classification

334
Q

Outline the Bosniak classification.

A

Mnemonic: F is for follow; Enhance means excise

3cm is the sweet spot

1 = thin wall, no septa, no calcifications; water density (-10 to 20 HU)

2 = fine calcifications; no enhancement

2F = multiple hair-line septa; calcification; >3cm

3 = irregularly thickened walls or septa; enhance

4 = enhancing tissue components

335
Q

How may a renal cell carcinoma present?

A

Asymptomatic (>50%)

Haematuria
Flank pain

Palpable abdominal mass

Cachexia/fever/weight loss/pallor/ sweats

Varicocele
Stauffer syndrome (nephrogenic hepatomegaly)
Endocrine: Polycythaemia / ACTH
Dermatological signs e.g. papules (Birt-Hogg-Dube)

Vision loss - VHL

336
Q

Why may a renal cell carcinoma present via a varicocele?

A

Tumour blocks renal vein, reducing drainage from the testicular vein thus varicocele

337
Q

How may RCC be categorised by tumour?

A

Use T categories

T1 = <7cm in kidney
T2 = >7cm in kidney
T3 = in major veins/tissues but not beyond Gerota’s fascia
T4 = Extends beyond Gerota’s fascia

338
Q

How may RCC be managed?

A

Surgery: RFA/ Cryoablation/Partial/Total nephrectomy
+
TKI immunotherapy: Sorafenib

339
Q

When might you consider RFA for a RCC?

A

Small Renal mass/RCC stage 1/2

340
Q

What is the most common histological subtype of ureteral cancer?

A

TCC (90%)

SCC (8%)

341
Q

How may Ureteral cancer present?

A

Haematuria
Storage symptoms
Dyspareunia

342
Q

What is the gold-standard investigation for ureteral cancer?

A

Ureteroscopy ± CT-Urogram

343
Q

How may Ureteral cancer be staged?

A

Stage 0is = CIS (flat on tissue lining)
/
Stage 0a = NI papillary carcinoma (thin protuberances from epithelia)

Stage 1 = invades lamina propria

Stage 2 = ureteric (smooth muscle)

Stage 3 = spread beyond muscle

Stage 4 = spread to surrounding organ

344
Q

How may bladder cancer present?

A

Haematuria
Dysuria
Storage symptoms

345
Q

What are the gold-standard methods for diagnosing bladder cancer?

A

Cystoscopy

CT-urogram

346
Q

A bladder cancer is found to be present only at the surface, flat and not extending beyond the epithelia. How would you classify it?

A

Urothelial cancer Tis

Cancer in situ

347
Q

A bladder cancer is found to be invading into the outer half of muscularis propria. Correctly stage this cancer.

A

T2b

348
Q

A bladder cancer is found to be invading into the inner half of muscularis propria. Correctly stage this cancer.

A

T2a

349
Q

How may you manage bladder cancer?

A

NMIBC
Surgery: TURBT
+
Intravesical chemotherapy
+
BCG Immunotherapy

Invasive
Surgery: Partial/Radical cystectomy
+
Chemotherapy

Metastatic
Chemotherapy
±
Radiotherapy

350
Q

How may a urethral cancer present?

A

Haematuria
Palpable mass
Voiding symptoms

351
Q

How can you manage a urethral cancer?

A

NI:
Transurethral resection
+
Intraurethral BCG

I:
Urethrectomy
+
Chemotherapy

352
Q

What are the risk factors for prostate cancer?

A

> 50 years old
Black ethnicity
FHx

353
Q

What are some potential risk factors for prostate cancer, currently under investigation?

A

Saturated fat
Red meat

Elevated androgens
Elevated IGF-1

354
Q

How may prostate cancer present?

A

Storage symptoms (FUN)
Voiding symptoms (WISE)
Haematuria
Weight loss
Bone pain

355
Q

What may cause an elevation in PSA?

A

BPH
DRE
Cycling
Sex/ejaculation
Prostatitis
Urinary retention
Instrumentation of urinary tract

356
Q

What is the gold-standard test for prostate cancer diagnosis?

A

Multi-parametric MRI

357
Q

What grading score can be used in prostate cancer?

A

Gleason score

2 samples of highest dysplasia and /10

358
Q

Why may the PSA test be described as poor?

A

Poor sensitivity with 60% of men with a PSA of 10-20ng/mL found to have prostate cancer

Around 20% of men with prostate cancer have a normal PSA

359
Q

Under what circumstances would you refer a patient for suspected prostate cancer?

A

PSA > 3ng/mL
OR
abnormal DRE

360
Q

A tumour with a Gleason score of 5 is classified as?

A

Low-grade

361
Q

A tumour with a Gleason score of 8 is classified as?

A

High-grade

362
Q

A tumour with a Gleason score of 7 is classified as?

A

Intermediate grade tumour

363
Q

What are the management options for a prostate cancer?

A

Very low risk (T1 disease/ PSA <10/<50% Ca in each core/ negative DRE)
Supportive: Observation (v low risk); active surveillance (yearly)

Radical prostatectomy
±
Brachytherapy
±
External beam radiotherapy

OR
Surgery/Androgen deprivation therapy/External beam radiotherapy

364
Q

What age does testicular cancer tend to occur?

A

20-30 years old

365
Q

What are the risk factors for testicular cancer?

A

Infertility
Cryptorchidism
FH
Klinefelter’s syndrome
Mumps

366
Q

Why may gynaecomastia occur in testicular cancer?

A

Either germ cell or non-germ cell tumours can contribute.

Germ-cell tumours can secrete hCG which alter Leydig cell function thus increasing oestradiol and T but oestradiol&raquo_space; T

Leydig cell tumour secretes more oestradiol thus high circulating oestrogens

367
Q

In which type of testicular tumour is LDH mostly raised in?

A

Germ cell tumours

368
Q

Which type of testicular tumour has AFP raised?

A

Non-seminomas

369
Q

Which type of testicular tumour has hCG raised?

A

Seminomas

370
Q

What is the first line investigation for a suspected testicular cancer?

A

US-Testes

371
Q

A prostate cancer which is not palpated on DRE but seen on imaging is classified as?

A

T1

372
Q

A prostate cancer which is palpated on DRE but seen on imaging in more than half of one lobe is classified as?

A

T2b

373
Q

A prostate cancer that is present in both lobes of the prostate is classified as?

A

T2c

374
Q

A prostate cancer that has spread to a seminal vesicle is classified as?

A

T3b

375
Q

Explain why BPH has both a dynamic and static aspect.

A

Static element is the increase in prostatic size reducing the urethral lumen

The dynamic element is the tone of the prostate mediated by alpha-1 adrenoceptors

Treatment modalities can address either

376
Q

How may BPH present?

A

Storage symptoms (FUN)

Voiding symptoms (WISE)

Urinary retention

377
Q

What is the greatest RF for BPH?

A

Age
50% of men by 50 years old

378
Q

What investigations should be done if suspecting BPH?

A

Urinalysis
U+Es
PSA

IPSS

Urodynamics

379
Q

What is the first line management for a patient with bothersome symptoms of BPH?

A

Alpha blocker: Tamsulosin

380
Q

How may BPH be managed?

A

Medical: Tamsulosin ± Finasteride

Surgery: 30g or 80g
>30g
TUIP/TURP/ PUL

> 80g
Prostatectomy

381
Q

How does PUL work in BPH treatment?

A

Prostatic urethral lift may be used when prostate volume 30-80g and wish to preserve ejaculatory and erectile function

T-shaped, spring-loaded device delivered via cystoscope and placed between prostatic capsule and in the urethral lumen.

382
Q

What is the normal weight of the prostate?

A

20-25g

383
Q

State 3 types of urinary incontinence.

A

Urge incontinence
Stress incontinence
Mixed incontinence
Overflow incontinence
Functional incontinence

384
Q

What investigations would you order in a patient with urinary incontinence?

A

Bladder diary
Urinalysis
Urine MC+S
Bloods
Urodynamic studies

385
Q

What urodynamic studies may you utilise?

A

Uroflowmetry - volume and rate

Postvoid residual measurement (<150mL normal)

Cystometric testing (catheter and manometer placement with retrograde filling until urgency noted, then recorded)

386
Q

What are the management options for stress urinary incontinence?

A

Supportive: Pelvic floor training

Medical: Duloxetine

Surgery: Retropubic mid-urethral tape; peri-urethral bulking

387
Q

What are the management options for urgency urinary incontinence?

A

Supportive: Bladder retraining

Medical: Oxybutynin; Tolterodine; Mirabegron

Surgical: Sacral nerve stimulation; botulinum toxin A

388
Q

What class of drug is tolterodine?

A

Anticholinergic, acting as an antagonist at the muscarinic receptors

389
Q

What class of drug is tolterodine?

A

Anticholinergic, acting as an antagonist at the muscarinic receptors

390
Q

What class of drug is mirabegron?

A

ß3 adrenoceptor agonist to relax the detrusor muscle in the bladder

391
Q

Outline the pathophysiology of renal colic.

A

Stones form on the basement membrane in the Loop of Henlé/Collecting duct which erode and anchor to nucleate and grow; these pass into the urinary system. The stone occludes the passage of urine which leads to a rise in intraluminal pressure proximal to the stone. The distension results in stretch and afferent feedback through T11-L2 dorsal nerve roots, yielding pain in those dermatomes.

392
Q

List 3 types of renal stone.

A

Calcium oxalate
Calcium phosphate

Uric acid
Cystine
Struvite

393
Q

Which pathogens may result in struvite stone development?

A

Proteus
Pseudomonas
Klebsiella

394
Q

Under what conditions do uric acid stones form?

A

pH <5.5

395
Q

What is the gold-standard investigation when suspecting renal stones in a non-pregnant individual?

A

Non-contrast CT-KUB within 14 hours of admission

396
Q

Which types of stones are radiolucent to XR-KUB?

A

Uric acid
Indinavir
Cystine (partially)

397
Q

How might you manage an acute presentation of renal stones?

A

Medical: IV fluids; diclofenac

Surgery: urgent decompression (nephrostomy/ureteric stent)

<5mm
Anyone: manage expectantly

<2cm
Non-pregnant: ESWL
Pregnant: Ureteroscopy

> 2cm
Non-pregnant: PCNL

398
Q

How would you advise a patient to prevent the risk of renal stones?

A

Increase fluid intake
Reduce salt
Reduce meat intake
TZD diuretics

Oxalate stones:
Pyridoxine / Cholestyramine (reduced urinary oxalate secretion)

Uric acid stones:
Allopurinol
Oral bicarbonate (urinary alkalinisation)

399
Q

Define a paraphimosis.

A

Foreskin is retracted, resulting in vascular engorgement and oedema of the distal glans

400
Q

How may a paraphimosis present?

A

Penile pain
Constricting band proximal to
gland engorgement
Swollen penis glans

401
Q

What are the risk factors for paraphimosis?

A

Not being circumcised
Urinary catheterisation
Poor hygiene
Tight foreskin
Previous phimosis
Bacterial infection
Lichen sclerosis
Diabetes
Haemangiomas
Penile piercing

402
Q

How does phimosis lead to paraphimosis?

A

A phimosis results in scarring which creates a white fibrous ring around the preputial orifice; this can result in physical obstruction and vascular engorgement contributing to a paraphimosis

403
Q

How is paraphimosis diagnosed?

A

Clinical diagnosis

404
Q

How can you manage a paraphimosis?

A

Depends on urgency - based on tissue compromise.

Without ischaemia and necrosis:
Manual manipulation (reduction with ice/compression/osmotic agent)

2nd: Puncture technique

Ischaemia and necrosis:
Debridement; dorsal slit

405
Q

What two types of hydrocele are there?

A

Communicating: patency of processus vaginalis

Non-communicating: excessive fluid production in tunica vaginalis

406
Q

What clinical features of a hydrocele are there?

A

Soft, fluctuant mass
Can get above the mass

Transilluminates pen torch

407
Q

How may you manage a hydrocele?

A

Infantile: repaired if not resolved by 1-2 years

Adult: watch-and-wait; aspiration;
surgical repair

408
Q

Why are varicoceles more common on the left side?

A

The left testicular vein drains into the left renal at a sharper angle than the right does, draining into the larger IVC

409
Q

What are the clinical features of a varicocele?

A

‘Bag of worms’

Infertility

410
Q

What is the management of a varicocele?

A

Supportive: watch-and-wait

Infertility/Pain
Surgery: Percutaneous occlusion; Surgical ligation

411
Q

What are the indications for an intervention of a varicocele?

A

Infertility
Hypogonadism
Scrotal pain
Testicular hypotrophy
Aesthetics

412
Q

What are the causes of orchitis?

A

Bacterial: C trachomatis; N gonorrhoea; M genitalium; E.coli; TB; Candida

Viral: Mumps

Drug: Amiodarone

Vasculitic: Behcet’s; HSP

Idiopathic

413
Q

What are the clinical features of orchitis?

A

Unilateral scrotal pain
Tender
Hot ,erythematous hemiscrotum

Frequency/Dysuria/ Discharge
Systemic symptoms

414
Q

What is the key difference between urinary retention and obstructive uropathy?

A

Obstructive uropathy occurs when kidney function is compromised

415
Q

What are some of the clinical features of obstructive uropathy?

A

Features dependent on cause…
Flank pain/ costovertebral angle tenderness
LUTS
Anuria/oliguria

Haematuria

UTIs
Pelvic mass
Weight loss/lymphadenopathy

416
Q

Which classes of medication may cause urinary retention?

A

Anti-cholinergics
Opioid analgesics
Alpha receptor agonists

417
Q

Which anatomical variation may predispose to a testicular torsion?

A

Bell Clapper deformity - tunica vaginalis attached superiorly, leaving inferior portion of testicle to rotate freely

418
Q

What types of testicular torsion are there?

A

Intra-vaginal (rotation within tunica vaginalis)

Extra-vaginal (occurs per-natally prior to attachment to posterior scrotal wall - spermatic cord twists)

Long mesorchium (CT tissue attaching efferent ductules of epididymis to posterolateral wall of testes. If longer, allows testicles to twist)

419
Q

What are the clinical features of a testicular torsion?

A

Sudden-onset testicular pain
Nausea/vomiting
Abdominal pain

Absence cremasteric reflex
Negative Prehn’s sign

Scrotal oedema

420
Q

What tissue is damaged in a ‘penile fracture’?

A

Tunica albuginea

421
Q

What are the clinical features of a penile fracture?

A

Popping/cracking sound
Significant pain
Swelling
Flaccidity
Skin haematoma

422
Q

How are penile fractures managed?

A

Surgical repair

423
Q

What are the potential complications of a penile fracture?

A

Erectile dysfunction
Peyronie’s disease
Urethral damage
Dyspareunia

424
Q

What may preoperative nephrectomy evaluation involve?

A

US-scan and CT-Kidney (contrast) to identify tumour

Renal function tests - assess contralateral renal function and fitness

CT-Chest (evaluate for pulmonary mets)

Bone scan and bone markers (if symptomatic)

425
Q

What is the relevance of the white line of Toldt?

A

Avascular plane for incision

This is the confluence of the colonic visceral peritoneum and parietal peritoneum of lateral abdominal wall

426
Q

What is meant by kocher manoeuvre in surgery?

A

Incision of peritoneum at R edge of duodenum with the organ being reflected to the left

427
Q

Which renal structure is divided first in a nephrectomy?

A

Renal artery divided first to prevent renal congestion

428
Q

Why is the separation of kidney from lateral abdominal wall done last?

A

Prevent specimen falling into operative field

429
Q

Which structure is a reliable landmark when identifying the ureter?

A

Psoas muscle

430
Q

Why use an Endobag in a nephrectomy?

A

Prevention of port site metastasis

431
Q

Give 2 examples of absorbable suture.

A

Monocryl
Vicryl
PDS

Collagen

432
Q

Outline the differences between Monocryl and Vicryl

A

Monocryl: monofilament
+ T1/2 of 7-14 days
+ 20-30% breaking strength at 2 weeks

Vicryl: polyfilament
+ Stronger
- Site reaction
- Infection

433
Q

Which types of uroenteric diversion are you aware of? Give examples.

A

Ileal conduit: 15-20cm segment of distal ileum connected to ureter with urostomy in RLQ

Continent cutaneous diversion: portion of bowel with reservoir and urostomy
E.g. Indiana pouch with caecum and ascending colon detubularised and urostomy

Orthotropic bladder: bladder in same position as before
E.g. Struder pouch with detubularised ileum connected to native urethra

434
Q

How is urine voided by a patient with a continent uroenteric diversion?

A

Credé manoeuvre - void by increasing abdominal pressure

435
Q

Which structures may be damaged by nephrostomy placement?

A

Pleura
Diaphragm
Colon
Spleen
Liver

436
Q

When placing a nephrostomy, what region of the kidney should be aimed for and why?

A

Posterolateral aspect of kidney, where anterior and posterior vascular territories meet; 20-30 degrees from sagittal plane.

The posterior calyx is usually aligned with the avascular zone thus enter along this 20-30 degree axis from the sagittal plane to reduce risk of vascular damage

437
Q

Outline the one-stick technique

A

One stick technique: US-kidney to visualise posterior calyces using long axis of US probe; 18 gauge Trocar needle inserted below 12th rib at 20-30 degrees axis to the sagittal plane. 0.035-inch guidewire can be added with nephrostomy tube placed directly over

Urine aspirated and equivalent volume of contrast used to opacify collecting system and confirm presence in posterior calyx; advance guide wire into proximal ureter

438
Q

Why should you be cautious regarding overdistension of the collecting system when injecting contrast during a nephrostomy?

A

May force infected urine into venous system, increasing the risk of sepsis

439
Q

What are the anterior and posterior renal fascia named?

A

Gerota’s fascia
Zuckerkandl’s fascia

440
Q

Give 3 indications for a TURP

A

Failed medical management
Obstructive nephropathy
Bladder outlet obstruction
Difficulty with clean intermittent catheterisation
Large prostate volume (>80g)

441
Q

Outline how a TURP procedure is undertaken.

A

Resectoscope inserted into urethra and visualise bladder with visual obturator

Channel made at 5 and 7 o’clock position down to the verumontanum - allows better visualisation via continuous irrigation during resection

Resection continues and laterally up to 3 and 9 o’clock positions

Use haemostasis, with minimal irrigation towards the end, allowing for assessment of venous bleeding

Bladder irrigation until light pink

442
Q

What are the potential complications of a TURP?

A

LUTS
Bladder perforation
Prostate perforation
Bleeding
Poor visualisation

Retrograde ejaculation
Infection
Urethral strictures

TURP syndrome

443
Q

What are the features of TURP syndrome?

A

Hypertension
Bradycardia
Mental status change

There will be CNS, respiratory and systemic symptoms

444
Q

Outline the pathophysiology of TURP syndrome.

A

Irrigation with large volumes of glycine results in absorption via prostatic venous sinuses. This causes hyponatraemia and glycine broken down into ammonia with hyperammonemia

445
Q

State 3 risk factors for TURP syndrome.

A

Surgical time >1 hour
Resected >60g
Large blood loss; Large fluid used
Perforation
Poorly controlled CHF/Renal failure

Surgery (10 decks)

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