Urology Flashcards
Types of haematuria?
Visible - pink/red/brown urine
Symptomatic Non-Visible - Blood on urinalysis/ microscopy with associated symptoms
Asymptomatic Non-Visible - Blood on urinalysis/microscopy with no associated symptoms
Common causes of haematuria?
UTI
Renal Cancer
Bladder Cancer
Renal Calculi
Prostate Cancer
BPH
Medical causes of haematuria?
Glomerulonephritis
Thin basement membrane disease
Haemolytic uraemic syndrome
HSP
What can cause pseudohaematuria?
Rifampicin
Methyldopa
Hyperbilirubinuria
Myoglobinuria
Beetroot
Rhubarb
Important points for haematuria history taking?
Degree of haematuria
Presence of clots
Timing in stream
Associated symptoms
Drug history
Smoking status
Industrial carcinogen exposure
Foreign travel
What initial investigations for haematuria?
Urinalysis
Baseline bloods (FBC, U&E, Clotting)
PSA
What is the Gold Standard investigation for the lower urinary tract?
Flexible cystoscopy
What are the urgent referral criteria for haematuria?
Aged >45 with either unexplained visible haematuria without UTI or persistent haematuria after successful UTI treatment
Aged 60 with unexplained non-visible haematuria with dysuria or raised WCC
Most common cause of LUTS in men?
Benign prostatic hyperplasia
Most common cause of LUTS in women?
UTI
Causes of LUTS?
Bladder cancer
Prostate cancer
Detrusor muscle weakness
Pelvic floor dysfunction
Chronic Prostatitis
Urethral stricture
Pelvic tumour
MS
What can exacerbate LUTS?
Drinking fluids late at night
Excess alcohol
Excess caffeine
Diabetes mellitus
Diuretics
LUTS: Storage symptoms
Frequency
Nocturia
Urgency
Urge incontinence
LUTS: Voiding
Hesitancy
Straining
Poor flow
Terminal dribble
Incomplete emptying
LUTS: Important history features
Visible haematuria
Suprapubic discomfort
Colicky pain
Medications (anticholinergics, antihistamines, bronchodilators)
LUTS: Initial investigations
Urinalysis
Bladder diary
Routine bloods
PSA
Post void bladder scan/flow rate
What is gold standard investigation for LUTS?
Cystoscopy
What are the management options for LUTS?
Treat underling pathology
Regulate fluid intake
Double voiding
Pelvic floor exercises
Bladder training
Anticholinergics for overactive bladder (oxybutynin, tolterodine)
Alpha blockers for BPH (tamsulosin)
What are complications associated with LUTS?
Infection
Renal & bladder calculi
Bladder wall hypertrophy/distension
Renal failure
Bilateral hydronephrosis
What is acute urinary retention?
New onset inability to pass urine which leads to pain and discomfort with significant residual volumes
What are the causes of acute urinary retention?
BPH
Urethral strictures
Prostate cancer
UTI
Constipation
Anti-muscarinics
Bladder sphincter dysinergy
UMN disease (MS, Parkinsons)
Peripheral neuropathy
What are the clinical features of acute urinary retention?
Acute suprapubic pain
Inability to micturate
Palpable bladder distension
What are the investigations for acute urinary retention?
Routine bloods (FBC, CRP, U&E)
Post-void bladder scan
Urinary tract ultrasound scan
What is high pressure urinary retention?
Urinary retention which causes such high intra-vesicular pressures that the anti-reflux mechanism is overcome causing urine to back up into the upper urinary tract
How would you manage acute urinary retention?
Immediate urethral catheterisation
Treat underlying cause
Medication review
High pressure retention - Catheter remains in-situ, TWOC after 24hrs
What are potential complications of acute urinary retention?
AKI
Renal scarring
UTI
Renal stones
What is post-obstructive diuresis?
Following retention resolution, kidneys often over-diurese due to loss of medullary concentration gradient. This leads to worsening AKI. Patients may require fluid replacement
What is Chronic Urinary Retention?
The longstanding, painless, inability to pass urine
What are common causes of Chronic Urinary Retention in men?
BPH
Urethral strictures
Prostate cancer
What are common causes of Chronic Urinary Retention in women?
Pelvic prolapse
Fibroids
Ovarian/endometrial cancer
What are some neurological causes of Chronic Urinary Retention?
Peripheral neuropathies
Multiple Sclerosis
Parkinson’s disease
What are the clinical features associated with Chronic Urinary Retention?
Painless
Weak stream
Hesitancy
Overflow incontinence
Nocturnal enuresis
Palpable distended bladder
How would you investigate Chronic Urinary Retention?
Routine bloods (FBC, CRP, U&E)
Post-void bladder scan
Urinary tract US (high pressure retention)
Management of Chronic Urinary Retention?
Treat underlying cause
Long-term catheter if high pressure retention
Who is suitable for Intermittent Self Catheterisation?
Patients with chronic retention who wish to avoid having a long term catheter
Good manual dexterity
Compliant patients
Possible complications of Chronic Urinary Retention?
UTI
Bladder calculi
Chronic kidney disease
How would you investigate someone presenting with acute scrotal pain?
Urine dip
Urethral swab
Routine bloods (FBC, CRP, U&E)
Scrotal US
What are the differential diagnoses of acute scrotal pain?
Testicular torsion
Epididymitis
Testicular cancer
Henoch-Schoenlein purpura
Viral Orchitis
Torsion of testicular/epididymal appendages
What should be looked for when inspecting a scrotal lump?
Site
Size
Shape
Symmetry
Skin changes
Scars
What should be looked for on palpation of a scrotal lump?
Tenderness
Temperature
Transillumination
Consistency
Attachments
Mobility
Pulsation
Fluctuation
Irreducibility
Regional lymph nodes
Edge
What are the differential diagnoses of an Extra-testicular scrotal lump?
Hydrocoele
Varicocoele
Epididymal cyst
Epididymitis
Inguinal hernia
What are the differential diagnoses of a testicular scrotal lump?
Testicular tumour
Testicular torsion
Benign lesion (sertoli cell tumour. leydig cell tumour, lipoma, fibroma)
Orchitis
What are the types of renal stones?
Calcium oxalate
Calcium Phosphate
Struvite
Urate
Cystine
What is the most common type of renal stone?
Calcium oxalate
Which type of renal stone is the most common cause of staghorn calculi?
Struvite
Which type of renal stone is radiolucent?
Urate
Which type of renal stone is associated with familial metabolic disorders?
Cystine
Where are the 3 most common areas of renal stone impaction?
Pelviuretric junction (PUJ)
Pelvic brim
Vesicoureteric junction (VUJ)
What are the typical clinical features of renal stones?
Sudden onset pain (colicky)
Loin to groin pain distribution
Nausea & vomiting
Haematuria
What are the differential diagnoses of flank pain?
Pyelonephritis
Ruptured AAA
Biliary pathology
Bowel obstruction
Lower lobe pneumonia
MSK pain
How do you investigate renal stones?
Urine dip
Routine bloods (FBC, U&E, CRP)
Urate & calcium levels
US renal tract
CT KUB
What is the gold standard investigation for diagnosis of renal stones?
Non-contrast CT KUB
What is the management of renal stones?
Encourage oral fluid intake
IV fluids if required
Analgesia
Majority of stones pass spontaneously
Retrograde stent insertion
Nephrostomy
Extracorporeal Shock Wave Lithotripsy (ESWL)
Percutaneous nephrolithotomy
Which patients with renal stones will be offered ESWL?
Small stones <2mm (not spontaneously passed)
Which patients with renal stones will be offered percutaneous nephrolithotomy?
Large stones (not spontaneously passed)
Staghorn calculi
What are the indications to admit a patient with renal stones?
Post-obstructive AKI
Pain not controlled by simple analgesia
Infection
Large stones >5mm
What are the complications of renal stones?
Infection
AKI
Renal scarring
Loss of kidney function
How do you manage recurrent oxalate stone formers?
Avoidance of high purine or high oxalate foods such as nuts, rhubarb & sesame
How do you manage recurrent calcium stone formers?
Check PTH to exclude hyperparathyroidism
Avoid excess dietary salt
How do you manage recurrent urate stone formers?
Avoid high purine foods such as red meat & shellfish
Allopurinol
How do you manage recurrent cystine stone formers?
Genetic testing for underlying familial disease
What is Pyelonephritis?
Inflammation of the kidney parenchyma and the renal pelvis
What is the most common organism causing pyelonephritis?
E. coli
What are some risk factors for developing pyelonephritis?
Urinary tract obstruction
Spinal cord injury
Female
Catheter
Vesico-ureteric reflux
Diabetes
Corticosteroid use
HIV
Sexual intercourse
Renal calculi
Menopause
What are the clinical features of pyelonephritis?
Fever
Loin pain (usually unilateral)
Nausea & vomiting
Frequency
Urgency
Dysuria
Differential diagnoses of pyelonephritis?
Ruptured AAA
Renal calculi
Acute cholecystitis
Ectopic pregnancy
PID
Diverticulitis
How can you investigate pyelonephritis?
Urinalysis
Urine culture
Routine bloods (FBC, U&E, CRP)
Renal US
Non-contrast CT KUB
In which cases should you consider admitting a patient with pyelonephritis?
Clinically unstable
Significant dehydration
Immunocompromised pt
Co-morbid conditions
What are possible complications of pyelonephritis?
Sepsis
Multi organ failure
Renal scarring
CKD
Pyonephrosis
Preterm labour
What is the most common type of renal cancer?
Renal cell carcinoma
How can renal cell carcinomas spread?
Via lymphatic system to pre-aortic and hilar nodes
Haematogenous spread to bones, liver, brain & lungs
What are risk factors for renal cancer?
Smoking
Industrial carcinogens
Dialysis
Hypertension
Obesity
Polycystic kidneys
Horseshoe kidney
von-Hippel-Lindau
What are the clinical features of renal cancer?
Haematuria
Flank pain
Flank mass
Left varicocoele (left sided)
Paraneoplastic syndrome
Often incidental finding
How do you investigate renal cancer?
Routine bloods (FBC, CRP, U&E, Calcium, LFT)
Urinalysis
CT Abdo-pelvis (pre & post contrast)
Biopsy
How do you stage renal cancer?
TMN
What is the management for localised renal cancer?
Partial nephrectomy (small tumours)
Radical nephrectomy (larger tumours)
Percutaneous radiofrequency ablation
Surveillance
What is the management for metastatic renal cancer?
Nephrectomy + immunotherapy
Biologics
What is a simple renal cyst?
Cysts developing from the renal tubule epithelium with well-defined outlines and homogenous features
What is a complex renal cyst?
Cysts with more complicated structures including thick walls, septations, calcifications or heterogenous enhancement. They all have a risk of malignancy.
What classification system is used for complex renal cysts?
Bosniak classifcation
What are the risk factors for developing complex renal cysts?
Increasing age
Smoking
Hypertension
Male
Polycystic kidney disease
Tuberous sclerosis
Von Hippel-Lindau disease
What is the definitive diagnostic investigation for renal cysts?
CT with IV contrast
How would you manage a Bosniak IIF renal cyst?
CT scan at 3,6 & 12 months
How would you manage a Bosniak III renal cyst?
Surveillance or surgical excision
How would you manage a Bosniak IV renal cyst?
Surgical excision
How can you manage a symptomatic simple renal cyst?
Analgesia
Needle aspiration
Surgical deroofing
What are the types of urinary incontinence?
Stress incontinence
Urge incontinence
Mixed incontinence
Overflow incontinence
Continuous incontinence
What are risk factors for stress incontinence?
Childbirth
Constipation
Obesity
Menopause
Pelvic surgery
What are risk factors for urge incontinence?
Previous stroke
Pelvic malignancy
Infections
Cholinesterase inhibitors
What is the most common cause of overflow incontinence?
Prostatic hyperplasia
What can cause continuous incontinence?
Ectopic ureter
Bladder fistulae
How do you investigate urinary incontinence?
Bladder diary
QOL questionnaire
Midstream urine dipstick
Post-void bladder scan
Urodynamic assessment
Outflow urodynamics
Cystoscopy
How would you manage stress incontinence?
Supervised pelvic floor muscle training
Duloxetine
Tension-free vaginal tape
Intramural bulking agents
How would you manage urge incontinence?
6 weeks bladder training
Oxybutynin/tolterodine
Botulinum toxin A injections
What is the most common type of bladder cancer?
Transitional cell carcinoma
What are the 4 layers of the bladder wall?
Fatty connective tissue
Muscularis propria
Lamina propria
Transitional epithelium
Risk factors for bladder cancer?
Smoking
Increasing age
Aromatic hydrocarbons (dyes)
Schistosomiasis
Clinical features of bladder cancer?
Painless haematuria
Recurrent UTIs
LUTS
Weight loss
Lethargy
How is bladder cancer staged?
TMN
How do you investigate suspected bladder cancer?
Urgent cystoscopy (flexible)
Biopsy via TURBT
CT CAP
Management of a Non invasive bladder cancer?
Resected via TURBT
Adjuvant intravesical therapy (BCG or Mitomycin C)
Radical cystectomy
Regular surveillance
Management of a Muscle-invasive bladder cancer?
Radical cystectomy
Neoadjuvant chemotherapy
Ileal conduit formation
Regular follow up with CT
Management of locally advanced/metastatic bladder cancer?
Chemotherapy
MDT input
Palliative input
What are the risk factors for BPH?
Increasing age
Family history
Afro-caribbean ethnicity
Obesity
Clinical features of BPH?
Hesitancy
Weak stream
Terminal dribbling
Incomplete emptying
Frequency
Nocturia
Differentials of BPH?
Prostate cancer
UTI
Overactive bladder
Bladder cancer
How do you investigate suspected BPH?
Frequency & volume chart
Urinalysis
PSA
DRE
Post void bladder scan
US renal tract
Medical management options for BPH?
Tamsulosin (alpha blocker)
Finasteride (5 alpha reductase inhibitor)
Surgical management for BPH?
TURP
Simple prostatectomy
Prostate artery embolism
Possible complications of TURP for BPH?
TURP syndrome
Haemorrhage
Sexual dysfunction
Retrograde ejaculation
Urethral stricture
Where do the majority of prostate cancers arise?
Peripheral zone
What is the most common cancer subtype of prostate cancer?
Adenocarcinoma
Risk factors for prostate cancer?
Increasing age
Afro-caribbean ethnicity
Family history
BRCA1/BRCA2 genes
Obesity
DIabetes
Smoking
Clinical features of prostate cancer?
Weak urinary stream
Increased urinary frequency
Urgency
Haematuria
Haematospermia
Dysuria
What features on DRE would be suspicious of prostate cancer?
Asymmetry
Nodularity
Fixed irregular mass
What are differentials of prostate cancer?
BPH
Prostatitis
Bladder cancer
Urinary stones
What investigations should be done for suspected prostate cancer?
PSA
MRI prostate
TRUS biopsy
CT CAP
What can cause raised PSA/
Prostate cancer
BPH
Prostatitis
UTI
Recent urological surgery
Retention
Ejactulation
What scoring system is used for prostate cancer?
Gleason score
How would you manage low risk prostate cancer?
MDT input
Active surveillance
How would you manage intermediate & high risk prostate cancer?
MDT input
Radiotherapy
Radical prostatectomy
How would you manage metastatic prostate cancer?
Chemotherapy (Docetaxel)
Androgen deprivation therapy (Goserelin, Degarelix)
What is the most common causative agent of Prostatitis?
E. Coli
Risk factors for acute bacterial prostatitis?
Indwelling catheters
Phimosis
Urethral stricture
Recent surgery
immunocompromised
Risk factors for chronic prostatitis?
Intraprostatic ductal reflex
Neuroendocrine dysfunction
Dysfunctional bladder
Clinical features of prostatitis?
LUTS
Pyrexia
Suprapubic/perineal pain
Urethral discharge
Tender, boggy prostate
What investigations for suspected prostatitis?
Urine culture
STI screen
Routine bloods (FBC, CRP, U&E)
TRUS
Management of acute bacterial prostatitis?
Prolonged antibiotic treatment
Analgesia
Alpha blockers
Management of chronic prostatitis?
Alpha blockers
Analgesia
Chronic pain specialist referral
What are risk factors for epididymitis?
MSM
Multiple sexual partners
Recent instrumentation
Bladder outlet obstruction
Immunocompromised
Clinical features of epididymitis?
Unilateral scrotal pain & swelling
Fever
Dysuria
Intact cremasteric reflex
Prehn’s sign
Differentials of epididymitis?
Testicular torsion
Testicular abscess
Epididymal cyst
Hydrocoele
Investigations for suspected epididymitis?
Urine dipstick
NAAT
US testes
Management of epididymitis?
Analgesia
Bed rest
Antibiotics
Abstinence from sexual activity
Epididymitis complications?
Reactive hydrocoele
Abscess formation
Testicular infarction
Define testicular torsion
When the spermatic cord twists within the tunica vaginalis
Risk factors for testicular torsion?
Aged 12-25
Previous testicular torsion
Family history
Undescended testes
Clinical features of testicular torsion?
Sudden onset severe unilateral testicular pain
High horizontal lie
Absent cremasteric reflex
Management of testicular torsion?
Urgent surgical exploration within 4-6 hours
Bilateral orchidopexy
What is the most common type of testicular cancer?
Seminoma
What are some non-germ cell testicular tumours/
Leydig cell tumour
Sertoli cell tumour
Risk factors for testicular cancer?
Cryptorchidism
Previous testicular malignancy
Family history
Caucasian ethnicity
Kleinfelter’s syndrome
Clinical features of testicular cancer?
Unilateral painless testicular lump
No transillumination
Irregular, firm, fixed lump
Weight loss
what tumour markers are relevant for testicular cancer?
beta HCG
AFP
LDH
What staging system is used for testicular cancer?
Royal Marsden classification
How would you manage a Non-seminomatous germ cell tumour?
MDT discussion
Orchidectomy
Adjuvant chemotherapy
Surveillance CT imaging
Surveillance tumour markers
How would you manage seminomas?
MDT discussion
Orchidectomy
Surveillance monitoring
Chemotherapy if metastatic
