Urology

Question 1

Kidney stones:

Answer 1

Anatomical factors-in form of blockage or obstruction. If stagnation of urine then this can lead to form of kidney stone

Biochemical-hyperthyroid, hypercalcaemia, gout

-Over 80% are calcium oxalate

Question 2

Why are they important?

Answer 2

• Gram neg sepsis is life threatening
• Kidney stones can lead to diagnosis of metabolic disorders like PUJ obstruction or strictures or horse shoe kidneys.

Question 3

Diagnosis:

Answer 3

Non visible haematuria-good positive but bad negative

WBC and nitrates to rule out infection that could be involved with kidney stone

CT KUB-no contrast, safe unless pregnant and short and gold standard for giving diagnosis. Do without contrast as stones are white on CT and so is contrast so would be hard to see

Question 4

Answer 4

Radioopaque shadow in left kidney. Plain KUB xray

Right-non contrast CT scan. White inside kidney is bilateral kidney stones

Question 5

Renal colic

Answer 5

Question 6

3 natural areas of stone impaction

Answer 6

Stones will form in kidney and once reach bladder they can be passed.

Less than 5mm can pass. 5-10mm will get stuck in natural narrowings

1. PUJ
2. ureter crosses iliac vessels
3. As ureter opens into bladder

Question 7

Renal colic management

Answer 7

• First line is NSAIDs then second is opiates
• In pregnant women, don’t do CT but do US and MRI if needed.

Question 8

Treatment:

Answer 8

• If non septic and no symptoms can manage conservatively
• Tamulosin-alpha blocker can help passage of small ureteric stone (less than 1cm). Alpha receptors are found in distal ureter so relaxes these when blocked improving chance of these stones coming out.
• ESWL-shock wave treatment

Question 9

Conservative

Answer 9

Question 10

ESWL

Answer 10

Bottom take x ray pics and once determined location of stone we can shoot shockwaves at stone and these bits can pass.

Usually for stones 1cm

No anaesthetic, done on outpatient

Question 11

GA needed

Answer 11

Designed for much bigger stones

Question 12

Haematuria-blood in the urine

Answer 12

• Cancer until proven otherwise but could be due to infection, trauma, urological procedure.
• Clot retention or can they pass urine?

Question 13

Management

Answer 13

• Encourage them to drink to flush out blood
• May have to admit if they have clot retention ie clots block bladder. So have to drain bladder using 3 way catheter and use third channel to flush bladder out and drain it.

Question 14

If still worried about cancer do 2 tests:

Answer 14

• On left can see tumour involving the left kidney
• Also in haematuria clinics do cystoscopy under local anaesthetic and can see bladder cancer here
• CT contrast-looks for cancer
• CT non contrast-looks for kidney stones

Question 15

Background of bladder cancer

Answer 15

Transitional cell carcinoma is the most common

Question 16

Management

Answer 16

• TNM classification
• Starts on inner lining and progresses into bladder wall
• Muscle layer determines what treatment. Superficial if not invading muscle and anything reaching muscle=muscle invading bladder cancer.
• T1 can be managed by TURBT-go with camera and shave inside and then continue flexible cystoscopy surveillance. May need to give intravesical chemo or immunotherapy to maintain. Immunotherapy is injecting BCG into bladder producing immune response there which basically fights the superficial bladder cancer
• If invades bladder muscle we have to do Radial cystectomy-remove bladder (and prostate in men) and divert urine using ileal conduit urinary diversion and also offer radiotherapy

Question 17

BPH and LUTS

Pushes urethra and narrows it causing urinary symptoms.

LUTS:

Answer 17

Bladder has 2 roles: storage of urine and passing of urine. Think Fundhips or for this FUN SHIPS

Question 18

Definitions

Answer 18

To be able to use terminology BPH you need histology. Better to say BPE for enlargement unless you have histology results.

BPH is prevalent more in elderly men

Question 19

Assessment:

Answer 19

Smooth-BPE

Craggy-cancer

Frequency volume chart-bladder diary to monitor fluid intake and output. Cut down on caffeine as this irritates the bladder and so this may be causing their issues.

Urine in bladder may cause back pressure on the kidneys

Question 20

Management

Answer 20

Cut down bladder irritants like caffeine

Most common medications are the first 2-tamsulosin and finasteride (blocks conversion of testosterone to dihydrotestosterone which is more active form and by blocking this you can shrink prostate)

Anticholingeric and beta 3 agonists are mainly for bladder storage issues. Doesn’t effect prostate

PDE5-in smaller doses can help with urinary trouble secondary to BPE eg viagra

Rezum-steam into prostate to shrink it down

PAE-beads in vessels supplying prostate to shrink it

Question 21

TURP

Answer 21

Go up urethra and core apple from inside to allow it to pass

Question 22

Urinary retention

Answer 22

Percuss bladder and will be dull not resonant as it should be.

Put probe on tummy and it will give reading of how much urine in bladder

If catheter doesn’t go in, may need to use suprapubic catheter and if this fails may need to do it guided with a camera.

Question 23

Management

Answer 23

Question 24

What catheter?

Answer 24

Question 25

Urinary sepsis: