Urology

Question 1

Viral pleuritis

Answer 1

Viral pleuritis is a viral infection of the pleurae.
Viral pleuritis is most commonly caused by infection with coxsackie B virus. Occasionally, echovirus causes a rare condition known as epidemic pleurodynia (Bornholm pleurodynia), manifesting as pleuritis, fever, and chest muscle spasms. The condition occurs in the late summer and affects adolescents and young adults.

The primary symptom of viral pleuritis is pleuritic pain; pleural friction rub may be a sign.

Diagnosis is suspected in patients with pleuritic chest pain with or without systemic symptoms of viral infection. Chest x-ray is usually done. Other causes of pleuritic chest pain, such as pulmonary emboli and pneumonia, need to be considered and sometimes ruled out with testing.

Treatment is symptomatic with oral nonsteroidal anti-inflammatory drugs (NSAIDs) or a short course of oral opioids if needed.

Question 2

Pulmonary embolism

Answer 2

Pulmonary embolism (PE) is a blockage of an artery in the lungs by a substance that has moved from elsewhere in the body through the bloodstream (embolism). Symptoms of a PE may include shortness of breath, chest pain particularly upon breathing in, and coughing up blood. Symptoms of a blood clot in the leg may also be present, such as a red, warm, swollen, and painful leg. Signs of a PE include low blood oxygen levels, rapid breathing, rapid heart rate, and sometimes a mild fever. Severe cases can lead to passing out, abnormally low blood pressure, obstructive shock, and sudden death.

PE usually results from a blood clot in the leg that travels to the lung. The risk of blood clots is increased by cancer, prolonged bed rest, smoking, stroke, certain genetic conditions, oestrogen-based medication, pregnancy, obesity, and after some types of surgery. A small proportion of cases are due to the embolization of air, fat, or amniotic fluid. Diagnosis is based on signs and symptoms in combination with test results. If the risk is low, a blood test known as a D-dimer may rule out the condition. Otherwise, a CT pulmonary angiography, lung ventilation/perfusion scan, or ultrasound of the legs may confirm the diagnosis. Together, deep vein thrombosis and PE are known as venous thromboembolism (VTE).

Question 3

Pulmonary embolism treatment

Answer 3

Pharmacological treatment options for confirmed pulmonary embolism (PE) include:
Low molecular weight heparin (LMWH).
Fondaparinux.
Unfractionated heparin.
Oral anticoagulant treatment (warfarin, apixaban, or rivaroxaban).
LMWH followed by an oral anticoagulant (dabigatran or edoxaban).
Mechanical (or physical) interventions may be considered in some cases.
Inferior vena cava (IVC) filters are designed to trap fragmented thromboemboli from the deep leg veins en route to the pulmonary circulation (whilst preserving blood flow in the IVC filter).
Various filters are available and can be placed in the IVC filter on either a temporary basis (for example in people with PE who cannot have anticoagulation treatment) or a permanent basis (for example in people with recurrent PE despite adequate anticoagulation treatment after alternative treatments have been considered).
Thrombolytic therapy may be used to remove the embolic material from the pulmonary arteries by promoting lysis of blood clots.
The thrombolytic agent can either be given into a peripheral vein (systemic thrombolysis) or directly into the pulmonary arteries via a catheter (catheter-directed thrombolysis). It can also be combined with attempts to break up the thrombus by using mechanical devices inserted via a catheter into the major pulmonary arteries or attempting to aspirate the clot (pharmacomechanical thrombolysis).
Pharmacological thrombolytics that have been used in the treatment of PE include streptokinase, urokinase, and rt-PA. These plasminogen activators stimulate the fibrinolytic system, leading to the lysis of blood clots. However, their mechanisms of action differ slightly: rt-PA is a fibrin-specific agent, preferentially activating plasminogen on the clot surface, whilst streptokinase and urokinase are non-selective agents.
Open pulmonary embolectomy (surgical removal of clots in the pulmonary arteries) is an alternative used less commonly in modern practice.

Question 4

Benign prostatic hyperplasia

Answer 4

40% of men in their 50s. More common in afroamericans + high testosterone. Shows urinary frequency, urgency, hesitancy, poor stream, post-micturition dribble, incomplete voiding -> strain -> syncope.

PSA cut-offs: 40-49 = 2.5mcg/L, 50-59= 3.5, 60-69 = 4.5, 70-79= 6.5.

What needs immediate referral- AKI, acute retention, inc PSA, In two weeks for haematuria, dysuria wi/o bacteria, night time incontinence.

Question 5

Treating BPH

Answer 5

Tamsulosin and other alpha blockers like doxazocin, terazosin. Tamsulosin has inc risk of intraoperative floppy iris syndrome.

Can also consider 5-alpha reductase inhibitors- blocks testosterone eg finasteride. Takes some months to work but helps retention- give if LUTs, 30g+, or PSA= 1.4ng/ml. Can combine with alphas if not responding to alphas alone. But alpha blockers are contraindicated with postural hypotension and micturition syncope. Surgery includes prostatectomy or TURP.

Question 6

Prostate cancer

Answer 6

Signs of locally invasive prostate cancer- haematuria, LUTs, haematospermia, perineal +suprapubic pain, tenesmus, lethargy, weight loss.

DRE might show hard, irregular prostate gland, nodular, induration, adhesion to surrounding tissue. Palpable seminal vesicles.

Question 7

Treatment for prostate cancer

Answer 7

Offer PSA= DRE to anyone with LUTs, erectile dysfunction, visible haematuria. Options are radical prostatectomy , external beam radiotherapy.

Brachytherapy- ADT/ androgen deprivation eg LHRH goserelin, triptorelin.

Or anti androgens cyproterone acetate (steroid) or bicalutamide (not).

If cancer is hormone sensitive, give apalutamide+ ADT if docetaxel chemo x suitable or relapsing with risk of metastasis- eg PSA doubles. 2nd line= prednisone + cabazitaxel or prednisolone.

Enzalutamide is given before chemo, after failed ADT+metastasises.

Question 8

Prostatis

Answer 8

Ciprofloxacin is 1st choice treatment. 2nd line is levofloxacin or cotrimoxazole. If prostatis is chronic = trimethoprim or doxycycline. If abacterial, give NSAIDs.

Question 9

Bladder cancer

Answer 9

90% of bladder cancers are transitional cell carcinomas, rest are squamous mostly. 1/2 of bladder cancers are caused by smoking. Hardware manufacturing also impacts. Cyclophosphamide is also a risk. Squamous cell is more likely following chronic inflammation from renal stones or catheters. Main symptoms - gas haematuria, painless. Adenocarcinoma can come from embryological remnants.

Referral guideline- +45, visible haematuria wi/o infection or reoccurs after successful UTI treatment. Over 60 w/ microhaematuria and dysuria or raised white cells.

Question 10

Bladder cancer treatments

Answer 10

TURBT alone if in the superficial muscle with intravesical mitomycin C. If high risk, give immunotherapy w/ BCG or cystectomy. If invasive- cisplatin chemo+ radical cystectomy. If lymph nodes, follow up with neoadjuvant cisplatin. If metastatic, give cisplatin combo or carboplatin and gemcitabine.

Question 11

Renal cancer

Answer 11

80% renal cell carcinoma. Most common in 60s. Risk factors- classic lifestyle, long term dialysis, tuberous sclerosis, renal transplant recipients.

Presentations= asymptomatic or fatigue, weight loss, macroscopic haematuria, varicocele, oedema, HTN.

25% show metastasis- haemoptysis, bone pain or fracture. Paraneoplastic symptoms= neuromyopathy, anaemia, polycythaemia, amyloidosis, hypercalcaemia.

Can also locally invade adrenals, liver, spleen, colon, pancreas, renal vein -> vena cava.

Question 12

Renal cancer treatments

Answer 12

1st line is partial nephrectomy if under 7cm. Can do a complete + IFN-alpha or IL-2 or sunitinib.

Question 13

Schistosomiasis

Answer 13

Tropical flatworm that causes abdominal pain, diarrhoea, bloody stool, haematuria, urinary retention, cercarial dermatitis that looks like scabies. From freshwater snails and also prawns. It’s common in children who swim in their waters or those who ingest them. Commonly treated with praziquantel.

Acute reaction = katayama fever, 2-8 wekks after infection. Affects lungs and liver. Usually self-resolves but can be given prednisone and praziquantel.

Question 14

Pseudohaematuria causes

Answer 14

Rifampicin, methyldopa, hyperbilirubinuria, myoglobulinuria, beetroot and rhubarb.

Question 15

Treating urinary retention

Answer 15

Acute = catheterise, give 2+ days doxazosin or another alpha blocker, then remove.

Chronic- intermittent catheter offered before indwelling +/- alpha blocker is still symptomatic. Also the options of surgery.

Question 16

Pivmecillinam

Answer 16

Pivmecillinam or amdinocillin pivoxil is an orally active prodrug of mecillinam, an extended-spectrum penicillin antibiotic. Pivmecillinam hydrochloride is used to treat infections of the bladder (cystitis) in adults.

Question 17

Meropenem

Answer 17

Meropenem injection is used to treat skin and abdominal (stomach area) infections caused by bacteria and meningitis.

Question 18

Phimosis

Answer 18

Phimosis is a condition where the foreskin is too tight to be pulled back over the head of the penis (glans). Phimosis is normal in babies and toddlers, but in older children it may be the result of a skin condition that has caused scarring.

Question 19

Balanitis Xerotica Obliterans

Answer 19

BXO is a penile skin condition which affects the foreskin, glans and/or urethra. In BXO there is chronic balanitis. Patches appear on the affected skin causing an abnormally dry appearance (referred to as xerotica) with white, thickened plaques. Lesions start in the foreskin but can extend to the surface of the skin on the glans penis and cause the involved areas of skin to fuse together. As a result, the foreskin can become firmly adhered to the glans so retracting the foreskin becomes painful.

Concerns for circumcision include:

Poor stream of urine (may be described as a fine stream)
Stream of urine which deviates rather than flowing in a straight line
Spraying during passing of urine
Pain when passing urine
Risk of meatal stenosis or urethral stricture.

Question 20

Rheumatic fever

Answer 20

Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a streptococcal throat infection.

Signs and symptoms include fever, multiple painful joints, involuntary muscle movements, and occasionally a characteristic non-itchy rash known as erythema marginatum. The heart is involved in about half of the cases. Damage to the heart valves, known as rheumatic heart disease (RHD), usually occurs after repeated attacks but can sometimes occur after one. The damaged valves may result in heart failure, atrial fibrillation and infection of the valves.

Give aspirin, nsaids or corticosteroids.

Question 21

Fournier’s gangrene

Answer 21

Fournier’s gangrene is a type of necrotizing fasciitis (flesh-eating disease) that affects your scrotum, penis or perineum. Fever, malaise, severe pain and swelling in the genital and anal areas, followed by rankness and smell/fetid suppuration leading to fulminating gangrene.

Weakened immune system: Even minor infections can lead to gangrene in individuals with weakened health status (for example, from such causes as diabetes, cancer, infectious diseases, alcoholism/drug abuse, older age).

Question 22

Myelodysplastic syndrome

Answer 22

Myelodysplastic syndrome makes immature blast cells. These die in the marrow or soon after entering the bloodstream, resulting in too few healthy blood cells and low blood counts.

Signs:
Easy bruising
Fatigue
Weight loss, loss of appetite
Petechiae (tiny red spots just under the skin)
Fever
Frequent infections
Weakness
Shortness of breath

In its mildest form, MDS may be anaemia, low platelets or low white blood count, but about 10% to 20% of diagnosed cases progress to acute myeloid leukaemia (AML).

Risk factors:
60+
Smoking tobacco
Long-term exposure to chemicals, including benzene or other chemicals used in the petroleum and rubber industries
Exposure to high levels of radiation, such a nuclear reactor accident or atomic bomb
Prior chemotherapy or radiation therapy
Inherited disorders, including:
Fanconi anaemia
Shwachman-Diamond syndromes
Familial platelet disorder
Severe congenital neutropenia

Question 23

Necrotising fasciitis

Answer 23

Necrotising fasciitis is a very serious bacterial infection of the soft tissue and fascia. The bacteria multiply and release toxins and enzymes that result in thrombosis in the blood vessels. The result is the destruction of the soft tissues and fascia.

The main types of necrotising fasciitis are:

Type I (polymicrobial)
Type II (due to haemolytic group A streptococcus, and/or staphylococci including methicillin-resistant strains/MRSA)
Type III (gas gangrene eg, due to clostridium)
Other: marine organisms or fungi

Risks for necrotising fasciitis include:

Aspirin and non-steroidal anti-inflammatory drugs
Advanced age
Diabetes mellitus
Immune suppression
Obesity
Drug abuse
Severe chronic illness
Malignancy

Question 24

Presentation of necrotising fascitis

Answer 24

The most common site of infection is the lower leg. Necrotising fasciitis may also affect upper limb, perineum, buttocks, trunk, head and neck.
Symptoms appear usually within 24 hours of a minor injury.
Pain is often very severe at presentation and worsens over time.
There may be flu-like symptoms, such as nausea, fever, diarrhoea, dizziness and general malaise.
Intense thirst develops as the body becomes dehydrated.

Clinical features after 3 to 4 days
The affected area starts to swell and may show a purplish rash
Large dark marks form that turn into blisters filled with dark fluid
The wound starts to die and area becomes blackened (necrosis)
Oedema is common
A fine crackling sensation under the skin (crepitus) is due to gas in the tissues
Severe pain continues until necrosis/gangrene destroys peripheral nerves when the pain subsides
The infection may not improve when antibiotics are given

By about days 4–5, the patient is very ill with dangerously low blood pressure and high temperature. The infection has spread into the bloodstream and the body goes into toxic shock. The patient may have altered levels of consciousness.

Metastatic abscesses can develop in liver, lung, spleen, brain, pericardium, and rarely, in the skin.

Question 25

Notable tumour markers

Answer 25

Tumour markers are most suitable when a mass is found. CA27,29 = breast cancer. CEA= colorectal. CA19-9 = pancreatic and biliary tract. AFP = hepatocellular carcinoma, non seminoma testicular cancer, gestational trophoblastic disease. CA125 = ovarian cancer. PSA = prostate cancer.