Urology Flashcards
Differential for a retired dye factory worker with painless haematuria
Bladder cancer (transitional cell carcinoma).
What type of cancer is a renal cell carcinoma?
Adenocarcinoma arising from renal tubules.
What is the most common kidney cancer in children < 5 years old?
Wilms’ tumour.
What are the types of renal cell carcinoma?
Clear cell, papillary and chromophobe.
Name the main risk factors for renal cell carcinoma
Polycystic kidney disease, FHx, age, smoking, obesity, hypertension, end stage renal failure and long-term dialysis.
What are cannonball metastases?
Spread of renal cell carcinoma to the lungs.
What are the triad of clinical features in renal cell carcinoma?
Haematuria, loin pain and palpable mass.
What is the treatment for renal cell carcinoma?
Nephrectomy, cryotherapy, radiofrequency ablation, receptor tyrosine kinase inhibitors and mTOR inhibitors.
What are the risk factors for bladder cancer?
Smoking, age, aromatic amines (dye and rubber industries), schistomiasis, recurrent UTIs.
What is the main type of bladder cancer?
Transitional cell carcinoma.
What is the clinical presentation for bladder cancer?
Painless haematuria, dysuria, urgency and frequency.
Describe the management of bladder cancer
Transurethral resection of bladder tumour (TURBT), intravesical chemotherapy, intravesical BCG, radical cystectomy, radiotherapy and chemotherapy (cisplatin).
What is the most common cancer in men?
Prostate cancer.
Which zone does prostate cancer occur in?
Peripheral zone.
What are the risk factors for prostate cancer?
Age, FHx and ethnicity (black African/Caribbean).
What are the symptoms of prostate cancer?
Asymptomatic, lower urinary tract symptoms, haematuria.
What are the common causes for a rise in PSA?
Prostate cancer, BPH, prostatitis, UTI, vigorous exercise and recent ejaculation.
Does PSA test have a high or low sensitivity?
Low.
Describe the findings of DRE for prostate cancer
Hard, asymmetrical, irregular, nodules with loss of central sulcus.
Describe the management of prostate cancer
Surveillance, external beam radiotherapy, brachytherapy, anti-androgens, GnRH agonists, radical prostatectomy, chemotherapy (metastatic disease).
What are the side effects of hormone therapy for prostate cancer treatment?
Hot flushes, sexual dysfunction, gynaecomastia, fatigue, osteoporosis.
What are the types of testicular cancer?
Seminomas and non-seminomas (teratomas).
What is the main presentation of testicular cancer?
Painless lump on testicle.
How would you manage a patient with testicular cancer?
Radical orchidectomy.
What are the complications of renal stones?
Obstruction —> AKI
Infection —> obstructive pyelonephritis
What is the most common type of renal stone?
Calcium oxalate.
A staghorn calculus is indicative of which type of stone and why?
Struvite because recurrent upper UTIs cause bacteria to hydrolyse the urea in urine into ammonia leading to this type of stone.
What are the 3 sites of ureter obstruction?
Pelvi-ureteric junction (PUJ).
Pelvic brim.
Vesico-ureteric junction (VUJ).
What are the main symptoms of renal stones?
Renal colic - loin to groin pain, colicky.
Nausea and vomiting.
What is the first line investigation for renal stones?
Non contrast CT of kidneys, ureter and bladder (CT KUB).
What is the management for renal stones?
NSAIDs, anti-emetics, antibiotics, watchful waiting, tamsulosin and surgery (>10mm, doesn’t pass spontaneously or if there’s an obstruction/infection).
What is an uncomplicated UTI?
Occurring in healthy, non-pregnant adult women.
What is a complicated UTI?
Presence of factors that increase risk of treatment failure e.g. diabetes, structural abnormalities, catheter and all UTIs in men.
What is the most common bacteria to cause a UTI?
E.coli.
What are the 2 routes of infection in an UTI?
Ascending and haematogenous.
Name one bacterial virulence factor in UTI
Fimbriae —> adherence.
What are the most common risk factors for a UTI?
Women, recent sexual intercourse, catheters.
What are the symptoms of a lower UTI?
Dysuria, suprapubic pain, frequency, urgency, incontinence, confusion (elderly).
What 2 things confirm a UTI in a urine dipstick?
Leukocyte esterase and nitrites.
How long is antibiotic duration for men, pregnant women and catheter-associated UTIs?
7 days.
What is antibiotic duration for uncomplicated UTIs?
3 days.
Which antibiotics are commonly indicated in UTIs?
Trimethoprim and nitrofurantoin.
Why should nitrofurantoin be avoided in the 3rd trimester of pregnancy?
Haemolytic anaemia in the newborn.
Why should trimethoprim be avoided in the 1st trimester of pregnancy?
Anti-folate effects impacts of embryogenesis.
What is the first line treatment for UTIs in pregnancy?
Nitrofurantoin.
Which zone of the prostate does BPH occur in?
Transitional zone.
Describe lower urinary tract symptoms
Hesitancy, weak flow, urgency, frequency, intermittency, straining, terminal dribbling, incomplete emptying, nocturia.
What does BPH feel like on a DRE?
Smooth, symmetrical, soft and maintenance central sulcus.
What is the main side effect of alpha blockers?
Postural hypotension.
How long do 5 alpha reductase inhibitors take to work?
6 months.
What is the main side effect of 5 alpha reductase inhibitors?
Sexual dysfunction.
What are the main complications of BPH?
Urinary retention and infection.
A women has the sudden urge to pass urine, having to rush to the toilet and not arriving in time. What type of incontinence?
Urge incontinence.
A women complains of involuntary urine leakage when she laughs, coughs and sneezes. What type of incontinence?
Stress incontinence.
What is the cause of urge incontinence?
Overactivity of the detrusor muscle.
What is the cause of stress incontinence?
Weakness of the pelvic floor and sphincter muscles.
Overflow incontinence is secondary to…
Chronic urinary retention.
What are the risk factors for urinary incontinence?
Increasing age, obesity, previous pregnancies and vaginal deliveries, pelvic organ prolapse, neurological conditions e.g. MS, cognitive impairment and dementia.
How would you investigate for urinary incontinence?
Bladder diary, urine dipstick, post-void residual bladder volume, urodynamic testing.
Management for stress incontinence?
Pelvic floor exercises, urethral sling, supporting bladder neck, urethral bulking, duloxetine.
Management for urge incontinence?
Bladder retraining, anti-cholinergics e.g. oxybutynin, beta 3 adrenergic agonists e.g. mirabegron, percutaneous sacral nerve stimulation.
What are the side effects of anti-cholinergics?
Dry mouth, dry eyes, urinary retention, constipation, postural hypotension, worsening dementia.
What are beta 3 adrenergic agonists contraindicated in?
Uncontrolled hypertension.
Management of urinary retention?
Catheter.
Risk factors for testicular cancer?
Undescended testes, FHx, Klinefelter’s syndrome, mumps orchitis, infertility.
What is a hydrocele?
Fluid-filled sac present within the scrotum. Typically not painful. Can’t get above scrotal mass and may transilluminate.
How would you confirm diagnosis of acute urinary retention?
Bladder scan
Is chronic urinary retention painful or painless?
Painless
Non-seminoma germ cell testicular tumours (e.g. teratomas) are associated with which tumour markers?
hCG and AFP
Why does gynaecomastia occur in testicular cancer?
Do to increase in oestrogen:androgen ratio.
What is the first-line investigation for suspected testicular cancer?
Testicular ultrasound scan.
What is used for the acute management of renal colic?
IM diclofenac
A 20-year-old complains of severe pain and swelling of the scrotum after a cystoscopy. He had mumps as a child. The testis is tender. The urine dipstick is positive for leucocytes.
Epididymo-orchitis
A 20-year-old complains of severe pain in the right scrotal area after jumping onto his moped. He has also noticed discomfort in this area over the past few months. On examination there is a swollen, painful testis that is drawn up into the groin.
Testicular torsion
An 8-year-old presents with scrotal swelling. He has just recovered from an acute viral illness with swelling of the parotid glands. On examination both testes are tender and slightly swollen.
Orchitis
Nephroblastoma is also called…
Wilm’s tumour
What are the first line investigations for suspected epididymo-orchitis?
Sexually active younger adults: NAAT for STIs
Older adults with a low-risk sexual history: MSSU
What is the main contraindication for circumcision?
Hypospadias - as the foreskin may be used in surgical repair.
Urinary problems in a man with a history of gonorrhoea may be due what?
Urinary stricture
Which sided do varicoceles most commonly occur?
Left
What is the most important risk factor for bladder cancer?
Smoking
Schistosomiasis is a risk factor for what type of bladder cancer?
Squamous cell carcinoma
What are the first and second line pharmacological treatments for an overactive bladder?
First-line: oxybutynin.
Second-line: mirabegron.
What are you concerned about with an unresolving left varicocoele?
Renal cell cancer.
What is the first-line investigation for suspected prostate cancer?
Multiparametric MRI.
True or false - renal cell carcinoma is usually resistant to radiotherapy or chemotherapy
True
What is the first-line management for renal cell carcinoma?
Radical nephrectomy.
Epididymo-orchitis is commonly caused by what organism in young males?
Chlamydia
An 28-year-old man presents with pain in the testis and scrotum. It began 10 hours previously and has worsened during that time. On examination he is pyrexial, the testis is swollen and tender and there is an associated hydrocele.
Acute infective epididymo-orchitis
A 15-year-old boy develops sudden onset of pain in the left hemiscrotum. He has no other urinary symptoms. On examination the superior pole of the testis is tender and the cremasteric reflex is particularly marked.
Torsion of testicular appendage.
A 14-year-old boy develops sudden onset severe pain in the left testicle radiating to the left groin. He is distressed and vomits. On examination the testis is very tender and the cremasteric reflex is absent.
Torsion of the spermatic cord.
What drug can be used for the prophylaxis of calcium stones?
Thiazide diuretics.
What drug can be used for the prophylaxis of oxalate stones?
Cholestyramine or pyridoxine.
What drug can be used for the prophylaxis of uric acid stones?
Allopurinol or urinary alkalinization e.g. oral bicarbonate.
List the risk factors for erectile dysfunction
CVD risk factors, alcohol, drugs e.g. SSRIs and beta blockers.
How would you treat erectile dysfunction?
PDE-5 inhibitors (such as sildenafil, ‘Viagra’).
How would you investigate erectile dysfunction?
Calculate QRISK and measure morning testosterone levels.
A 32-year-old male presents to the GP with a painless lump in his testicle. On examination, it is possible to get above the lump, the testicle does not transilluminate and is found on the posterior side of the testicle and is separate from the body of the testicle.
Epididymal cyst.
What is the management for patients with obstructive urinary calculi and signs of infection (complicated urinary calculi)?
Urgent renal decompression via a ureteric stent or percutaneous nephrostomy and antibiotics.
Internal urethral sphincter vs external urethral sphincter
- Internal urethral sphincter: smooth muscle under autonomic control.
- External urethral sphincter: skeletal muscle under voluntary control.
What are the 2 types of catheter?
- Urethral catheter: tube inserted through the urethra, into the bladder.
- Suprapubic catheter: tube inserted through the skin just above the pubic bone, directly into the bladder.
What is hydronephrosis and how is it caused?
- Swelling of the renal pelvis and calyces in the kidney.
- This occurs due to obstruction of the urinary tract, leading to back-pressure into the kidneys.
Define idiopathic hydronephrosis
Narrowing at the pelviureteric junction (PUJ) causing hydronephrosis.
Describe the treatment for hydronephrosis
- Percutaneous nephrostomy.
- Antegrade ureteric stent.
Describe the clinical features of chronic prostatitis
At least 3 months of:
- Pelvic pain.
- Lower urinary tract symptoms.
- Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia.
- Pain with bowel movements.
- Tender and enlarged prostate on examination.
Describe the clinical presentation of acute bacterial prostatitis and investigations
- Similar symptoms to chronic prostatitis, along with fever, myalgia, nausea, fatigue and sepsis.
- Investigations: urine dipstick, urine microscopy culture and sensitivity, chlamydia and gonorrhoea NAAT testing (if STI considered).
Describe the management plan for acute bacterial prostatitis
Hospital admission and IV antibiotics if septic.
Oral antibiotics for 2-4 weeks.
Analgesia.
Laxatives for pain during bowel movements.
Describe the management plan for chronic prostatitis
Alpha blockers.
Analgesia.
Antibiotics if infection present.
Laxatives for pain during bowel movements.
What are the 2 types of biopsy for prostate cancer?
Transrectal ultrasound-guided biopsy (TRUS).
Transperineal biopsy.
Define interstitial cystitis
Chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. AKA bladder pain syndrome and hypersensitive bladder syndrome.
Name a finding seen on cystoscopy that would indicate interstitial cystitis
Hunner lesions (red, inflamed patches of the bladder mucosa).
Congenial hydrocele management
Reassurance and surgical repair if it doesn’t resolve within 1-2 years.
A positive Prehn’s test is characteristic of …
Acute epididymitis
Loss of cremasteric reflex is characteristic of …
Testicular torsion
Investigation for priapism?
Cavernosal blood gas analysis
Is circumcision available on NHS for religious reasons?
No - only available for medical reasons.
Describe the medical benefits of circumcision
Reduces risk of penile cancer, UTIs and acquiring STIs including HIV.
Describe the initial investigation for suspected renal cell carcinoma
CT abdomen and pelvis
Non-seminoma germ cell testicular tumours (e.g. teratomas) are associated with a rise in which tumour markers?
hCG and AFP
Treatment of testicular torsion?
Emergency surgical exploration.
Shockwave lithotripsy vs ureteroscopy
Shockwave lithotripsy for smaller stones and ureteroscopy for larger stones.
During the first stages of treatment, goserelin may cause a transient increase in symptoms of prostatic cancer. This is known as the ‘flare effect’ and is caused by an initial increase in luteinizing hormone production prior to receptor down-regulation. What drug can be given to prevent this effect?
Flutamide (synthetic antiandrogen).
Outline the 2 week wait referral criteria for bladder cancer
Patient >= 60 with unexplained non-visible haematuria and either dysuria or a raised WCC.
Describe the features of testicular cancer
- Painless lump is the most common presenting symptom.
- Pain may also be present in a minority of men.
- Hydrocele.
- Gynaecomastia.
Which tumour marker may be elevated in seminomas testicular tumours?
hCG
Ongoing loin pain, haematuria and pyrexia of unknown origin …
Renal cell carcinoma
What are the first and second line medications for BPH?
- First-line: Tamsulosin (alpha antagonist - SM relaxation of prostate).
- Second-line: Finasteride (5 alpha-reductase inhibitor - block the conversion of testosterone to dihydrotestosterone, reducing prostate volume). Takes 6 months to work.
Describe the features of BPH
- Voiding symptoms (obstructive): weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying.
- Storage symptoms (irritative): urgency, frequency, urgency incontinence, nocturia.
- Post-micturition: dribbling.
- Complications: UTIs, retention, obstructive uropathy.
Name one side effect of tamsulosin
Postural hypotension
What are the side effects of finasteride?
Erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia.
What is the most common form of prostate cancer?
Adenocarcinoma
10% of pelvic fractures are associated with what?
Urethral or bladder injuries
Name two causes of urethral injury
- Bulbar rupture: most common, due to straddle type injury e.g. bicycles.
- Membranous rupture: commonly due to pelvic fracture.
Both managed with suprapubic catheter.
Remi is a 58-year-old man who comes to see you worried about prostate cancer. You request a PSA which shows a level of 1 ng/ml (normal age-appropriate range is 3ng/ml) and then you perform a digital rectal examination which shows an irregular, hard and craggy prostate. What would be the most appropriate management?
Two week wait referral to urology - if a hard, irregular prostate typical of a prostate carcinoma is felt on rectal examination, then the patient should be referred urgently.
A 33-year-old man presents with a two day history of the gradual onset of pain and swelling in the right testicle. The pain is described as 5/10 on the pain scale. Around four weeks ago he returned from a holiday in Spain but reports no dysuria or urethral discharge. On examination he has a tender, swollen right testicle. On examination the heart rate is 84/min and his temperature is 36.8ºC. What is the most likely underlying diagnosis?
Epididymo-orchitis
Name one side effect of radiotherapy for prostate cancer
Proctitis
What is a common complication of a radical prostatectomy?
Erectile dysfunction
An 8-year-old presents with scrotal swelling. He has just recovered from an acute viral illness with swelling of the parotid glands. On examination both testes are tender and slightly swollen.
Orchitis
A 23-year-old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis.
Percutaneous nephrostomy
A 23-year-old man is admitted with left sided loin pain that radiates to his groin. His investigations demonstrate a 1cm left sided ureteric calculus with no associated hydronephrosis.
Extra corporeal shock wave lithotripsy
A 30-year-old male presents with left sided loin pain. His investigations demonstrate a large left sided staghorn calculus that measures 2.3cm in diameter.
Percutaneous nephrolithotomy
Outline management of renal stones
- Stone <5mm = expectant treatment
- Stone <2cm = lithotripsy (wave to break stone)
- Stone <2cm + pregnant = uteroscopy
- Stone complex = nephrolithotomy (invasive)
- Hydronephrosis/infection = nephrostomy
NICE advise that, as PSA levels may be increased, testing should not be done within at least:
- 6 weeks of a prostate biopsy
- 4 weeks following a proven urinary infection
- 1 week of digital rectal examination
- 48 hours of vigorous exercise
- 48 hours of ejaculation
A 65-year-old man with a background of benign prostatic hyperplasia attends his GP with a 6-month history of increased urinary frequency and urgency. In addition, he has a feeling of incomplete emptying after urinating. He takes both tamsulosin and finasteride as part of his routine medications and has been listed for a transurethral resection of the prostate (TURP).
What would be appropriate to help alleviate his symptoms while waiting for his operation?
Add oxybutynin (for overactive bladder)
What is the most common organic cause of erectile dysfunction?
Vascular causes
What is the most common causative organism in acute prostatitis?
E.coli
Describe features of acute prostatitis
- The pain of prostatitis may be referred to a variety of areas including the perineum, penis, rectum or back.
- Obstructive voiding symptoms may be present.
- Fever and rigors may be present.
- Digital rectal examination: tender, boggy prostate gland.
Define testicular torsion
Twisting of the spermatic cord resulting in testicular ischaemia and necrosis.
Describe features of testicular torsion
- Testicular pain is usually unilateral, severe and of sudden onset.
- Pain may be referred to the lower abdomen.
- Nausea and vomiting.
- Swollen, tender testis retracted upwards. The skin may be reddened.
- Cremasteric reflex is lost.
- Elevation of the testis does not ease the pain (Prehn’s sign).
- Abnormal testicular lie (often horizontal).
- Rotation, so that epididymis is not in normal posterior position.
What is testicular torsion usually triggered by?
Playing sports
Which condition can predispose a patient to testicular torsion?
Bell clapper deformity
A whirlpool sign on scrotal US is a sign of what?
Testicular torsion
What are the 2 surgical treatments for testicular torsion?
- Bilateral orchiopexy (correcting the position of the testicles and fixing them in place).
- Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis.
If NSAIDs are contraindicated in renal colic, which analgesia is used instead?
IV paracetamol
What is the most common cause of epididymo-orchitis in individuals with a low STI risk?
E.coli
What is the most common renal tumour?
Adenocarcinoma
Contraceptive advice after vasectomy
- Vasectomy isn’t an immediate form of contraception; semen analysis must be performed and azoospermia confirmed before used as contraception.
- Use additional contraception until a semen analysis confirms azoospermia.
Management of epididymo-orchitis with STI most likely agent but organism unknown
- Ceftriaxone 500mg IM single dose
- Doxycycline 100mg twice daily for 10-14 days
Management of epididymo-orchitis if enteric organism is the most likely cause
- Send MSU sample
- Treating empirically with an oral quinolone for 2 weeks (e.g. ofloxacin)
Name 2 side effects of quinolone Abx
- Tendon damage and tendon rupture, notably in the Achilles tendon
- Lower seizure threshold (caution in patients with epilepsy)
Efferent nerve of cremasteric reflex
Genitofemoral nerve
MOA of goserelin
Synthetic GnRH agonist
Management of obstructive urinary calculi and signs of infection
Urgent renal decompression and IV antibiotics due to the risk of sepsis
Management of hydrocele
Adult patients with a hydrocele require an ultrasound to exclude underlying causes such as a tumour.
Period of hypotension followed by renal impairment with urinary casts
Acute tubular necrosis
