Urology Flashcards
What is the pathophysiology of Benign Prostate Hyperplasia?
There is hyperplasia of a different set of cells first- the GLANDULAR EPITHELIAL CELLS and the STROMAL CELLS (connective tissue).
This increases the activity of the 5-ALPHA REDUCTASE enzymes
This enzyme produces high amounts of DIHYDROTESTOSTERONE (DHT) and OESTROGEN
DHT is what acts on ANDROGEN RECEPTORS in the prostate and causes HYPERPLASIA
What zone of the prostate is affected in Benign Prostate Hyperplasia?
The Transition Zone
What are the 4 risk factors for Benign Prostate Hyperplasia?
Being Black, then being White, then being Asian
Diabetes
Obesity
Increasing Age
What are the 3 signs of Benign Prostate Hyperplasia?
Lower UTI Symptoms- hesitancy, terminal dribbling, weak stream, straining or incomplete emptying
Lower abdominal tenderness and palpable bladder- indicates Acute Urinary Retention- Patient requires urgent BLADDER SCAN and URGENT CATHETERISATION
Smooth, Enlarged and Non-tender Prostate in Digital Rectal Examination
What 6 investigations should be conducted if Benign Prostate Hyperplasia is suspected?
Pyuria (indicates infection)
PSA (Prostate-Specific Antigen)- correlates to size of prostate
U&Es- if the obstruction is severe then it could cause renal failure
Transrectal Ultrasound- to estimate the size of the Prostate
Renal Tract Ultrasound- if acute urinary retention is suspected then this is done to check for Hydronephrosis
A flow rate <20
How do you manage Benign Prostate Hyperplasia?
(3 steps if symptoms are bothersome)
Surgery is considered in severe cases (covered in a separate card)
If the symptoms are bothersome- then give ALPHA BLOCKERS like TAMSULOSIN to relax the smooth muscles and 5-ALPHA REDUCTASE INHIBITORS like FINASTERIDE to inhibit the formation of DHT
Then for Second-line, just combine them both
Also give a PHOSPHODIESTERASE-5 INHIBITOR like SILDENAFIL
If the symptoms are not bothersome- treat the constipation, reduce caffeine and fluid intake
What are the 4 side effects of Tamsulosin and 3 side effects of Finasteride, which are given as treatment for Benign Prostate Hyperplasia?
Tamsulosin-
- Postural Hypertension
- Dizziness
- Dry mouth
- Depression
Finasteride-
- Reduced Libido
- Erectile Dysfunction and Reduced Ejaculate Volume
- Gynaecomastia
What are the indications for surgery in Benign Prostate Hyperplasia?
RUSHES
- Recurrent or Refractory Urinary Retention
- Recurrent UTI
- Bladder Stone
- Haematuria (not stopped by medication)
- Elevated Creatinine due to the bladder outflow obstruction
- Symptoms deteriorate despite medical therapy
What are the 3 surgeries considered for Benign Prostate Hyperplasia and the requirements for each one?
TUIP- if Prostate<30
TURP- if Prostate 30-80
Open Prostatectomy- if Prostate >80
What are the two main types of Bladder Cancer (one of them is 90% of the cases)
Transitional Cell Carcinoma (90% of cases)
Squamous Cell Carcinoma
What are the two main types of Transitional Cell Carcinoma (main type of Bladder Cancer)
What are 2 things about each type
Papillary- MAJORITY of the TCC cases
- Superficial cancer with FINGER-LIKE PROJECTIONS
- Often Non-invasive with a Better Prognosis
Flat-
- They lie flat against the bladder
- More prone to Invasion with a Poor Prognosis
What is Squamous Cell Carcinoma (the rare type of Bladder Cancer) associated with?
Chronic Cystitis- secondary to Schistosoma Haematobium
What are the 4 risk factors for Bladder Cancer?
Male
Smoking
Occupational Exposure (3)
- Aromatic Amines (rubber, dye and textile industries)
- Polycyclic Aromatic Hydrocarbons (aluminium, coal and roofing industries)
- Painters and Hairdressers
Risk factors for Squamous Cell Carcinoma
- Schistosoma Haematobium
What are the 6 signs of Bladder Cancer?
PAINLESS Haematuria
Dysuria
Frequency
Weight loss
Anaemia- Pallor if Chronic Bleeding is Present
Palpable Suprapubic Mass
What are the two main referral pathways for Bladder Cancer and the age ranges for each Patwhay?
45 Years Old and Above-
- Unexplained Haematuria Without UTI
- Haematuria that doesn’t go away after treatment of UTI
60 Years Old and Above-
- Unexplained Haematuria and either Dysuria OR a Raised WCC Count
What are the 8 investigations to be ordered if Bladder Cancer is suspected?
Flexible Cystoscopy is conducted to confirm the presence of the Bladder Cancer
CT Urogram- to image the Urinary Tract and visualise the Renal Parenchyma
PET-CT- if the CT is unclear
Haematuria
Assess Bone Profile- Hypercalcaemia and Raised ALP (seen in Bone Metastasis)
Bone Scan- if Bone Metastasis is suspected
LFTs and Coagulation- usually Deranged in Liver Metastasis
CT Abdomen and Pelvis- assesses for distant metastasis for High-Risk Patients or Suspected Muscle-Invasive Disease.
- This is not needed if the Patient is Low-Risk or has no risk of Muscle-Invasion
What are the 3 management pathways for Bladder Cancer (2 steps in each pathway)
If it is superficial and NOT Muscle-invasive-
- Trans-urethral Resection of Bladder Tumor- which is performed through Rigid Cystoscopy under general anaesthetic
- Give a post-operative dose of Mitomycin C
If it is Muscle-Invasive-
- Radical Cystectomy- with Neoadjuvant and Adjuvant Chemotherapy
- Radical Radiotherapy- with Neoadjuvant Chemotherapy
If it is Locally-advanced or Metastatic
- Chemotherapy- Cisplatin-based chemotherapy
- Palliative Treatment- Radiotherapy for bladder symptoms
Which microorganisms cause Epididymo-Orchitis through STI (3) and non-STI (2)?
STI
- Chlamydia trachomatis
- Neisseria gonorrhoea
- Mycoplasma genitalium
Non-STI
- E. Coli
- Proteus Sp.
What ae the 3 risk factors for Epididymo-Orchitis?
STI-related- Multiple Partners, Young, Unprotected Sex
Enteric-related- Elderly, Bladder Outflow Obstruction, Instrumentation of Urinary Tract
Tuberculosis (TB) can cause Epididymo-Orchitis
What are the 5 signs of Epididymo-Orchitis?
Lower UTI Symptoms- Like Dysuria, Hesitancy, Nocturia
Unilateral, Tender, Swollen Testicle
Present Prehn’s sign- relief when lifting the testicle (absent in Testicular Torsion)
Present Cremasteric reflex (absent in Testicular Torsion)
Pyrexia (but may not be present)
What 3 investigations should be ordered if Epididymo-Orchitis is suspected?
Urinalysis (remember Neisseria Gonorrhoea is Gram-Negative)
Nucleic Acid Amplification Test- detect the DNA/ RNA of the causative organism
Swab of urethral secretions- but this is less sensitive that NAAT
What is the first-line management for STI and enteric causes of Epididymo-Orchitis?
STI-
- Ceftriaxone and Doxycycline
Enteric-
- Fluoroquinolones such as Ofloxacin or Ciprofloxacin
What is the most common type of Prostate Cancer and which zone of the Prostate do they usually arise from?
Adenocarcinomas- they arise from the Peripheral Zone of the Prostate
What 2 genes are associated with Prostate Cancer?
BRCA1 and BRCA2
What are the three risk factors for Prostate Cancer?
Increasing Age
Afro-Caribbean Ethnicity
Cadmium Exposure (3)
- Cigarettes
- Battery
- Working in the welding industry
What are the 7 signs of Prostate Cancer?
Common Lower UTI Symptoms (4)
- Frequency
- Hesitancy
- Terminal Dribbling
- Nocturia
Less Common Lower UTI Symptoms (2)
- Haematuria
- Dysuria
Bone Pain (Lumbar Back Pain suggests a Metastatic Disease)
Asymmetrical Hard Nodular Prostate with a Loss of the Median Sulcus
Palpable Lymphadenopathy indicates Metastatic Disease
Urinary Retention (Lower Abdominal Pain and Tenderness, Inability to Urinate and Palpable Bladder)
Weight Loss
What 7 investigations should be ordered if Prostate Cancer is suspected?
Multiparametric MRI (is First Line)- conduct if >2 on the Likert Scale
Gleason Score is used to assess severity (8-10 is severe with low differentiation)
PSA (>2.5)
U&Es to assess for renal failure
Bone Profile- Hypercalcaemia and Raised ALP suggests Bone Metastasis
Bone Scan- if bone metastasis is suspected
Liver Profile to assess for Liver Metastasis
What are the treatment options for Low (3) and High (4) Risk Non-Metastatic Prostate Cancer?
Low-risk= PSA is 10 or lower, Gleason Score is 3+3, Cancer Stage is T1 or T2
Low-Intermediate Risk Non-Metastatic Prostate Cancer-
- Active Surveillance or Observation
- Radical Prostatectomy
- Radical Radiotherapy or Brachytherapy with or without AntiAndrogen Therapy
High Risk Non-Metastatic Prostate Cancer-
- Radical Prostatectomy
- Radical Radiotherapy with AntiAndrogen Therapy
- Radical Radiotherapy with Brachytherapy
- Docetaxel Chemotherapy with AntiAndrogen Therapy
What are the two options for the management of Metastatic Prostate Cancer?
Docetaxel Chemotherapy with AntiAndrogen Therapy
Bilateral Orchidectomy
What are the two types of AntiAndrogen Therapy offered in Prostate Cancer and which one should be offered before the other?
Anti-Androgens-
- Flutamide
LHRH Agonists-
- Goserelin
- Zoladex
Anti-Androgens should be given before LHRH Agonist
What type of carcinoma is Renal Cell Carcinoma and where does this type originate from?
Adenocarcinoma- arises from the Epithelium of the Proximal Convoluted Tubule (HYPERNEPHROMA)
What is the most common histological variant of Renal Cell Carcinoma?
Clear Cell Carcinoma
What gene is associated with Renal Cell Carcinoma and what 4 conditions is this gene associated with?
The Von-Hippel-Lindau Gene
It is associated with-
- Renal Cell Carcinoma
- Pheochromocytoma
- Cerebellar Hemangioblastoma
- Tuberous Sclerosis
What are the 4 endocrine associations of Renal Cell Carcinoma?
Erythropoeitin- Polycythaemia
Parathyroid Hormone-related Peptide- Hypercalcaemia
ACTH- Cushing’s
Renin
What are the 5 Histological Subtypes of Renal Cell Carcinoma? State a fact about each of them
Clear Cell- Most Common
Papillary- Second Most Common
Chromophobe- Large, Pale Cells and associated with an Excellent Prognosis
Multiocular Cystic- Associated with an Excellent Prognosis
Renal Medullary- VERY AGGRESSIVE, patients are often Metastatic at presentation
What are the 3 main risk factors for Renal Cell Carconoma?
Black
Male
Smoking
What are the 6 signs of Renal Cell Carcinoma?
Haematuria/ Flank Pain and Abdominal Pain (but only seen in 10% of patients)
Flank Mass
Asymptomatic in most cases- diagnosed incidentally
Left-sided Varicocele
Constitutional Symptoms (Weight loss, Fatigue, FEVER of unknown origin)
Evidence of Metastatic Disease (Shortness of Breath, Chronic Liver Disease, Bone Pain)
What 11 Investigation should be ordered in Renal Cell Carcinoma?
CT Abdomen and Pelvis- for a definitive diagnosis
Abdominal Ultrasound to help differentiate between benign and malignant lesions
CT Chest- if initial imaging suggests a malignancy
Assessment for Microscopic Haematuria and Proteinuria
FBC- Anaemia of Chronic Disease or Polycythaemia
U&Es- Check for Renal Dysfunction
LFTs and Coagulation- derangement suggests Liver Metastasis
Bone Profile- Elevated Calcium is a Poor Prognostic Marker and indicates Bone Metastasis
Bone Scan- if there is evidence of bone metastasis (pain or hypercalcaemia)
LDH- Elevated LDH is a poor prognostic marker
Renal Biopsy- risk of tumour spreading to surrounding structures
What are the 3 options for the treatment of Non-Metastatic Renal Cell Carcinoma?
Partial Nephrectomy- standard for T1 Tumours (7cm or less)
Radical Nephrectomy- standard for T2-T4 Tumours (more than 7cm)
- Consider Local Lymph Node Dissection and Adrenalectomy if these structures are involved
Minimally-invasive procedures such as Radiofrequency Ablation or Embolism are reserved for patients who are unfit for surgery
What are the 3 options for the treatment of Metastatic Renal Cell Carcinoma?
Molecular Therapy- Sunitinib and Pazopanib are first line agents (considered before Interferon Alpha)
Radiotherapy
Cytoreductive Surgery
What are the 5 complications of Renal Cell Carcinoma?
Metastasis
Polycythaemia (EPO)
Hypercalcaemia (PTHrP) (Parathyroid hormone-related peptide)
Cushing’s Syndrome
Stauffer Syndrome
- Paraneoplastic Nephrogenic HEPATOMEGALY
- RCC can result in HEPATOMEGALY, CHOLESTASIS and CHOLESTATIC JAUNDICE- secondary to an increased IL6
What are the majority of Renal Stones composed of?
Calcium Oxalate
What are the 8 risk factors for Renal Stones?
Male
Eating Stone-Forming Foods
Systemic Diseases- such as Crohn’s Disease
Metabolic Conditions (3)- Hypercalcaemia, Hyperparathyroidism, Hypercalciuria
Loop Diuretics and Acetazolamide cause Calcium Stones
Protease Inhibitors (HIV medication) causes Radiolucent Stones
Exposure to certain things- Cadmium and Beryllium
Gout and Ileostomies- causes Uric Acid Stones
What are the 5 signs of Renal Stones?
Acute, Severe Flank Pain (writhing around)
- Loin to Groin
Hypotension and Tachycardia indicates Urosepsis/ a Septic Stone
Fever- suggests Septic Stone
Nausea and Vomiting
Differentiate this from a Ruptured Abdominal Aortic Aneurysm- especially in elderly males with a new onset flank pain and no history of stones
What 4 investigations should be ordered if Renal Stones are suspected?
Non-Contrast CT Kidney, Ureter, Bladder is Gold Standard
Urinalysis- Microscopic Haematuria with Pyuria if Pyelonephritis is present
U&Es- raised Creatinine- check for AKI caused by Severe Obstruction
Bone Profile and Urate- Hypercalcaemia suggests Hyperparathyroidism
What is the Acute management for Renal Stones? (2)
IV Fluids and Anti-emetics
Analgesia (NSAIDs)
- PR Diclofenac
- or IV Paracetamol if NSAIDs are contraindicated
What is the Conservative management for Renal Stones? (2)
Watchful Waiting as stones<5mm should pass spontaneously
Ureteric stones 5-20mm- give them Tamsulosin
What is the Surgical management for Renal Stones? (5)
Ureteroscopy
Extracorpeal Shock Wave Lithrotripsy- Contraindicated in Pregnancy so use Ureteroscopy instead
Percutaneous Nephrolithotomy- access via Surgical Incision in the back
Ureteral Stenting- Insertion of a plastic tube to assist drainage
Percutaneous Nephrostomy- Insertion of rubber tube into kidney to drain urine
What are the 5 types of Renal Stones?
Calcium Oxalate (Majority)
Struvite
Calcium Phosphate
Uric Acid
Cysteine
What are 6 facts about Struvite Renal Stones?
UTI with Urease Producing Organisms (like Proteus mirabilis) can cause this
Consists of Magnesium, Phosphate and Ammonium
Coffin Lid-shaped stones
They can cause Staghorn Calculi
Mildly radiopaque
Caused by High Levels of Ammonium and Bicarbonate
What 2 conditions cause Calcium Phosphate Stones and are they radiopaque/ lucent?
Hypercalcaemia (like from Hyperparathyroidism
Hypercitraturia
They are very radiopaque- like bone
What 4 conditions can cause Uric Acid Stones? And are they radiopaque/lucent?
Gout
Hyperuricosuria
Dehydration
Hot Climates
They are radiolucent
What are 3 facts about Cysteine Renal Stones?
Caused by Cysteinuria
Hexagonal Shaped
They are SEMI-OPAQUE and have a Ground-Glass Appearance
What 2 type of tumours can be seen in Testicular Cancers?
Germ Cell Tumours- they arise from Haploid Germ Cells which take part in Spermatogenesis
Non-germ Cell Tumours- they arise from Diploid Sex-Cord Stroma Cells
What 2 types of tumours can Germ Cell Tumours (like Testicular Cancers) be divided into?
Seminomas and Non-Seminomas
What are the 5 types of Germ Cell Tumours (like Testicular Cancer) and state 1 fact about each?
Seminomas- these are the most common
Embryonal Carcinomas- these are aggressive and metastasise early
Teratomas- common in children- these are composed of tissue from a different germinal layer- like TEETH
Yolk-sac Tumours- common in children
Choriocarcinoma- rare but aggressive
What are the 2 types of Non-germ Cell Tumours (like Testicular Cancer) and state 1 fact about each?
Leydig Cell Tumour- Androgen-secreting- causes precocious puberty
Sertoli Cell Tumour- usually Clinically Silent
What are the 4 main risk factors for Testicular Cancer?
Cryptorchidism- Undescended Testes
Young Male>35 years old- Seminomas, <35 years old- Non-Seminomas
Caucasian
Intersex Conditions (Klinefelter’s)
What are the 5 signs of Testicular Cancer?
Painless testicular lump (firm and non-tender, does not transluminate)
Conditions related to Beta-HCG (2)- Hyperthyroidism (as Beta-HCG mimics TSH) and Gynaecomastia
Bone pain- indicates skeletal metastasis
Breathlessness indicates lung metastasis
Superior Lymphadenopathy
What are the 3 investigations to be ordered in Testicular Cancer+ name the 5 tumour markers?
First-line= ULTRASOUND Testicular Doppler
Do NOT DO- Fine Needle Aspiration- Do NOT
5 Tumour Markers-
- Seminoma- Beta hCG
- Embryonal Carcinoma- AFP
- Teratoma- AFP
- Yolk sac Tumour- AFP
- Choriocarcinoma- Beta hCG
What are the 3 management steps for Non-Metastatic Seminomas and Non-seminomas (Testicular Cancer)?
Seminoma-
- Radical Orchiectomy
- Then Post-Orchiectomy active surveillance if low-risk
- Or Post Radiotherapy or Chemotherapy with Carboplatin
Non-Seminoma-
- Radical Orchiectomy
- Then Post-Orchiectomy active surveillance if low-risk
- Post-Orchiectomy Combination Therapy
What is the 3 step management plan for Metastatic Testicular Cancer?
- Radical Orchiectomy
- Then for Seminoma- Adjuvant combination chemotherapy or radiotherapy
- For Non-Seminoma- Combination Chemotherapy
What is the pathophysiology of the Bell Clapper Abnormality, which is a risk factor for Testicular Torsion?
Bell Clapper Abnormality describes a HIGH RIDING TESTICLE with a HORIZONTAL LIE
A developing testicle typically descends down the inguinal canal and is covered in PERITONEUM as it does so
This layer of peritoneum is known as the TUNICA VAGINALIS- which goes on to attach onto the scrotum
The failure of the TUNICA VAGINALIS to properly attach onto the scrotum results in the Bell Clapper Abnormality
What is the Hydatid of Morgagni Torsion?
It is a torsion of the testicular appendage and mimics testicular torsion
The Hydratid of Morgagni is an embryonic remnant of the MULLERIAN DUCT and is present on the upper pole
Torsion of this can cause INTENSE PAIN and this characteristically causes a BLUE-DOT SIGN and is managed conservatively- be aware of this when looking for Testicular Torsion
What are the 3 risk factors for Testicular Torsion?
Cryptorchidism (Undescended Testicles)
Bell Clapper Abnormality
Trauma
What are the 6 signs of Testicular Torsion?
Sudden, unilateral, severe testicular pain
A swollen, high-riding, tender testicle where the skin may be erythematous and red
Nausea and Vomiting (not usually seen in Epididymo-Orchitis)
Lower Abdominal pain
Prehn’s sign is negative- no relief upon lifting the testicle
Absent Cremasteric Reflex- swiping the inner and superior part of the thigh does not pull the testicle up
What 3 investigations should be conducted if Testicular Torsion is suspected?
DO NOT DO THESE IF PHYSICAL EXAMINATION PROVES IT IS TORSION AS THIS IS AN EMERGENCY
Surgical exploration IMMEDIATELY
Urinalysis- make sure there is no leukocytes/ nitrites- urinalysis should be NORMAL
Testicular ultrasound- whirlpool sign suggests torsion
What is the management of a Viable and Non-Viable testicle in Testicular Torsion?
Viable Testicle-
- Bilateral Orchipexy- the contralateral testicle also needs to be fixed to avoid contralateral testicular torsion
Non-Viable Testicle-
- Ipsilateral Orchiectomy and Contralateral Orchipexy
- The removal of the affected testicle and fixing the contralateral testicle to prevent contralateral testicular torsion
What usually causes Lower UTI? What 2 other ways can bacteria enter the bladder?
Bacteria from the Gastrointestinal Tract ascend from the urethra into the bladder
Bacteria can also enter from the blood stream (especially if the patient is immunosuppressed) and directly through the insertion of a urinary catheter or through surgery
Which 4 organisms typically cause a Lower UTI?
E.Coli (most common)
Proteus Mirabilis (associated with renal tract abnormalities like Calculi (Staghorn Calculi- producing Struvite renal stones)
Klebsiella
Candida- they are a rare cause and are typically associated with indwelling catheters, immunosuppression and contamination from the genital tract
What are the risk factors for a Lower UTI in Pre-menopausal women (3) and Post-menopausal women (4)?
Pre-menopausal
- Intercourse
- Mother with a history of UTI
- History of UTI in childhood
Post-menopausal
- Atrophic vaginitis
- Cystocele
- UTI before menopause
- Urinary incontinence
What are the 8 signs of a Lower UTI?
Non-specific generalised clinical features- Delirium, Lethargy and Reduced Appetite
Delirium or Confusion
Dysuria
Frequency
Urgency
Changes in the urine appearance (Cloudy or Pungent Odour/ Haematuria)
Suprapubic Discomfort
Nocturia
What 3 symptoms would make a diagnosis of Pyelonephritis (Upper UTI) likely?
Fever
Loin Pain
Rigors
What 5 symptoms would make a diagnosis of Sepsis likely?
Loin pain
Rigors
Nausea
Vomiting
Altered Mental State
What 4 investigations should be considered if a Lower UTI is suspected?
Urine Dipstick- Positive Nitrites or Leukocytes and positive RBCs, although Negative can also mean UTI
Urine Microscopy, Culture and Sensitivity- Request this in ALL women with Positive Leukocytes. Bacteria, WBCs and RBCs are expected
If a Tumour, Bladder Stone or Diverticulum is suspected- a Cystoscopy must be considered
If a Kidney Stone, Hydronephrosis or Renal Abscess is suspected- a Renal Tract Ultrasound must be considered
What is the First (2) and Second line (3) options for the management of Lower UTI in Non-Pregnant Women?
First line-
- Nitrofurantoin (if eGFR is 45 or higher)
- Trimethoprim
Second line-
- Nitrofurantoin (if not used as first line and if eGFR is 45 or higher)
- Pivmecillinam
- Fosfomycin single-dose sachet
What is the First (1) and Second line (2) options for the management of Lower UTI in Pregnant Women and Men?
First line-
- Nitrofurantoin (if eGFR is 45 or higher)
Second line-
- Amoxicillin
- Cefalexin
What are the 4 complications of a Lower UTI?
An ascending infection
- Pyelonephritis
- Renal and Peri-renal Abscess
- Impaired Renal Function or Renal Failure
- Urosepsis
