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Phase 4 - Katherine > Urology > Flashcards

Urology Flashcards

1
Q

What is BPH? Which areas enlarge?

A

Benign, nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate.

Enlargement of the inner transitional zone

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2
Q

The lower urinary tract Sx from BPH come from outlet obstruction. What are the 2 components of this?

A

Static component - increasing tissue bulk leads to narrowing urethral lumen

Dynamic component - increase in prostatic smooth muscle tone mediated by alpha adrenergic receptors

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3
Q

Name 3 Sx of BPH

A

Storage symptoms:
FUN -
frequency, urgency, nocturia

Voiding symptoms:
HIIPP -
hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling

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4
Q

Name 3 Ix in BPH + 1 to rule out other cause of Sx

A

DRE
TRUSS ± biopsy
PSA - increased may indicate prostate cancer or prostatitis

Urinalysis
MSU/urine dip to rule out pyuria and complicated UTI

Volume chart

USS KUB
To rule out hydronephrosis, urolithiasis, mass

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5
Q

What is the scoring system for BPH ?

A

IPSS - International Prostate Symptom Score (0-35)
also includes quality of life

[Mild = 0-7, Mod = 8-19, Severe = 20+]

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6
Q

3 parts of behavioural Mx for BPH

A

Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids

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7
Q

Most common Mx for BPH

A

watch and wait

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8
Q

Pharma Mx for BPH

A

Mild (bother)
FIRST LINE: Alpha blocker (tamsulosin or doxazosin)

or 5-alpha reductase inhibitor (finasteride)

[or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)]

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9
Q

How do alpha blockers work for BPH ? SEs?

A

Smooth muscle relaxation in prostate and bladder neck:

SE: postural hypotension, dry mouth

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10
Q

How do 5-a reductase inhibitors work for BPH

A

Reduced conversion of testosterone to dihydrotestosterone

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11
Q

Mx of abnormal DRE / PSA ?

A

Surgical referral

Prostate < 80g - TURP or TUVP (transurethral resection/vaporisation)

Prostate > 80g - Open prostatectomy

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12
Q

Name 2 comps of BPH

A

Progression - reduced by alpha blockers

Sexual dysfunction - due to alpha blockers, 5-alpha reductase inhibitors or surgical management

Acute urinary retention (roughly 2.5% over 5 years)

TURP syndrome

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13
Q

What is TUPR syndrome? Sx?

A

Consequence of absorption of irrigating fluids into prostatic venous sinuses - basically goes into blood stream and fucks your system

Fluid overload, disturbed electrolyte balance, hyponatraemia and hypothermia (bladder source of heat loss)
i.e. hypertension + reflex bradycardia, restless, headache, N + V, confusion

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14
Q

Mx of TUPR syndrome

A

ABCDE

Supportive
100% O2 non-rebreather,
monitor BP with arterial line,
correct hyponatraemia

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15
Q

Name 3 causes of acute urinary retention ? 2 for women only?
1 drug?

A

BPH / Ca

Bladder/urethral calculi, bladder cancer, faecal impaction
Infective

Women - Prolapse, pelvic mass

Drugs
ANTICHOLINERGICS + ALCOHOL

Neuro
Autonomic neuropathy (DM), spinal cord damage (disc disease, MS, spinal stenosis, cauda equina, cord compression), pelvic surgery

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16
Q

3 Ix in acute urinary retention?

A

USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities

Urinalysis - infection, haematuria, proteinuria, glucosuria

MSU - infection

[Blood tests
FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)

CT abdo pelvis - looking for mass causing bladder neck compression
MRI spine - disc prolapse, cauda equina, spinal cord compression MS]

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17
Q

Mx of acute urinary retention

A

Immediate bladder decompression with catheter

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18
Q

What should men be offered prior to removal of catheter in acute retention

A

alpha blocker

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19
Q

Type of Ca are prostate?

A

adenocarcinoma

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20
Q

Spread of prostate Ca? 1 is muy important

A

Haematogenous - *bone sclerotic (90%), lung (50%) and liver

[Local - through capsule to seminal vesicles, bladder, rectum

Lymphatic - pelvic LNs]

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21
Q

What is used to grade prostate cA

A

Gleason - level of differentiation

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22
Q

Who is screened for prostate Ca and how?

A

?PSA + DRE

(40s 2.5, 50s 3, 60s 4, 70s 5)

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23
Q

1 argument for and 1 against prostate screening

A

For: commonest cancer in men, 3% men die of PC

Against: uncertain natural history, PSA not specific

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24
Q

Name 2 Sx of pres for prostate Ca and 2 features that would indicate advanced metastatic

A

LUTS: fill and void
Haematuria

Advanced metastatic:
Weight loss/anorexia/lethargy
Bone pain
Palpable LNs

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25
3 Ix in prostate Ca
PSA (protease responsible for liquefaction of semen - prostate specific not prostate cancer specific) Normal = 0-4 ng/ml DRE - hard and irregular prostate TRUSS + biopsy (infection 1pc serious, bleed, retention, fp) Abnormal cells in 2 different samples MRI + CT for staging Isotope bone scan for metastasis (If PSA > *20) Testosterone (baseline if considering androgen deprivation) FBC/LFT - normal
26
Active surveillance is an option for very low risk prostate Ca. What other Mx could you do for low risk?
brachytherapy (radioactive source to prostate) external beam radiotherapy
27
Mx of high risk prostate Ca ? ( T3/4, PSA > 20, Gleason 8-10)
Radical prostatectomy plus pelvic LN dissection External beam radiotherapy (every day M:F 7-8W) + brachytherapy/androgen deprivation (shrinks tumour)
28
Mx of mets in prostate Ca
They are usually androgen sensitive: Androgen deprivation therapy chemical castration Surgical castration
29
Drug used for chemical castration
Goserelin (GnRH analogue - [stimulates then inhibits pituitary gonadotrophin so symptoms may get worse, offer an anti-androgen e.g. flutamide]
30
Main comp in surgical castration
risk of impotence if cut cavernous nerve of penis
31
Mx if prostate mets are castration resistant?
Bisphosphonates - reduce pain palliative radiotherapy
32
Name 3 comps of prostate Ca mx
Erectile dysfunction - radiation, surgery, androgen deprivation Hormone induced gynaecomastia Hormone induced hot flush Radiation induced LUTS for a few weeks + haematuria + bowel bleeding
33
How to prevent hormone induced gynaecomastia
tamoxifen
34
Usual Ca in bladder? what if schisto?
Transitional cell carcinoma (90%) Squamous
35
Name 3 RFs for bladder Ca ? genetic cause?
Smoking (50%) Occupational: aromatic amines (rubber + dye), polycyclic aromatic hydrocarbons (aluminum and coal) Age, 70% > 65 Pelvic radiation (prostate Ca) Men > Women HNPCC for upper tract urothelial cancers Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma
36
Bladder Ca stage
Ta - non-invasive papillary carcinoma T1 - tumour invades subepithelial connective tissue (lamina propria) Not felt T2 - tumour invades superficial muscle (detrusor or muscularis propria) Rubbery thickening T3 - tumour invades perivesical tissue Mobile mass T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall Fixed mass
37
Where does bladder Ca spread?
Lymphatic: Pelvic Haematogenous: liver and lungs
38
How does bladder Ca present?
Painless haematuria (frank or microscopic), dysuria, abdominal mass, RFs, systemic weight loss + bone pain
39
Name 4 Ix in bladder Ca
Urine dip Haematuria (80% of patients) ± pyuria Urine MC + S - cancers may cause sterile pyuria KUB USS Bimanual EUA for staging *Flexible cystoscopy with biopsy TURBT CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour or obstruction Urinary cytology - abnormal cells FBC - mild anaemia CXR, isotope bone scan, alkaline phosphatase etc…..
40
3 Comps of bladder Ca
Hydronephrosis Upper tract TCC Prostatic urethral TCC Urinary retention Recurrence
41
Most bladder Ca presents with low-grade non muscle invasiion. Mx?
Transurethral Resection of Bladder Tumour +intravesical chemo (direct into bladder through catheter) +intravesical BCG (bacille Calmette-Guerin) immunotherapy)
42
Mx of invasive bladder Ca? mets?
cystectomy with pelvic LN dissection + chemo mets = chemo
43
Other than haematuria give 2 causes of discoloured red(ish) urine
myoglobinuria (rhabdomyolysis or muscle destruction), haemoglobinuria (haemolytic anaemias) beeturia (beetroot), rifampicin = pseudohematuria
44
Total haematuria -> bladder or upper tract (kidney/ureter) What if the haematuria is at the start/end of voiding?
urethra, prostate, seminal vesicles or bladder neck.
45
3 causes of haematuria
Medical UTI Warfarin/clopidogrel etc Coagulopathies Menstruation contamination (pseudohaematuria) Acute pyelonephritis Trauma/instrumentation Surgical Stones Urological malignancy - renal, bladder, ureter, prostate BPH
46
4 Ix for haematuria
Urine dip - protein implies renal Culture - infection DRE - prostate Bloods FBC: Hb/pt Clotting/coagulation studies/INR WCC (infx) PSA Nephrological - eGFR, Cr Imaging USS KUB Flexible cystoscopy Non-contrast CT - stone Contrast CT urogram - excreting for malignancy
47
3 times you might use a catheter
Acute urinary retention Pre-op prophylactic emptying Monitoring urine output in critically ill patients Chronic urinary retention (bladder outlet obs) Management of incontinence (MS, terminal)
48
2 pros and 2 cons of a suprapubic catheter vs normal foley
SPC more comfortable, more convenient change, better self-image, better sexual function SPC increased risk cellulitis, leakage, prolapse through urethra, surgical procedure
49
3 complications of catheters
Failure e.g. phimosis, BPH (try a larger catheter) Create false passages Urethral strictures/perforation/bleeding Infection (E.coli) bacteriuria is inevitable 5% per day, 50% in one week 100% in one month
50
3 Rfs for UTI
Female, sex, spermicide (decrease lactobacilli), pregnancy, decreased host defense (immunosuppression, DM), obstruction, stones, catheter, malformation
51
2 Most common cause of uncomplicated UTI / how to differentiate?
E.coli - 70-95% Staph saprophyticus 5-20% (coagulase -ve)
52
Which bacteria are cause of some hospital (12%) UTIs? What added complication do you get?
Proteus mirabilis Klebsiella -> increased risk of stones [secrete urease -> raise pH -> Stones (Struvite)]
53
Abx in UTIs? If pregnant? men?
Trimethoprim 3 days (in uncomplicated) Nitrofurantoin 7 days (in pregnancy as trimethoprim is teratogenic) Men -> ciprofloxacin
54
2 forms of host defence against UTIs
Antegrade urine flush (lost in stasis, reflux, preg), low urine pH, Tamm-Horsfall protein (mucopolysaccharide), urinary IgA
55
Usually no mx for aSx bacteruria. Why do you treat if pregnant?
high risk pyelonephritis
56
What is pyuria
leucocytes in urine associated with infection
57
Name 2 things that would classify UTI as complicated
Functional impairment Structural impairment Kidney involvement UTI in pregnancy Indwelling catheter Immunosuppressed
58
What might you suspect in UTI if Costovertebral angle tenderness + fever
pyelonephritis
59
3 Ix of urine in UTI
Urine dipstick, microscopic urinalysis (bacteria, WBC, RBC), *urine culture +s of MSU
60
give 2 DDx of UTI
Overactive bladder (-ve dipstick) Urothelial Ca (positive urine cytology) Non-infectious urethritis (dysuria in absence of UTI) STI (discharge) - -ve urine dipstick, analysis and MC+S Interstitial cystitis - painful bladder syndrome, pain associated with bladder filling + urgency and frequency in absence of UTI Atypical infx (fungal, adenovirus, TB) may present with recurrent voiding - symptom of sterile pyuria
61
Mx if known/suspected ABx resistant UTI
ciprofloxacin
62
Mx of complicated and hospital admission UTI
IV gent
63
UTIs in men are uncommon = complicated Usually either due to klebsiella + proteus Or Abnormal function or structure of urinary tract Therefore what Ix do you do?
Dipstick Urine microscopy Urine culture (>10^2) IMAGING CT renal tract (perirenal abscess, urinary calculi, tumour) KUB USS (stone, abscess)
64
Usual cause of prostatitis?
e.coli (80%) [+ enterococcus/pseudomonas]
65
O/E prostatitis
warm or soft, exquisitely boggy prostate
66
How does E coli get to the prostate
intraprostatic reflux (urine into prostatic duct)
67
4 ix in prostatitis
Urinalysis (microscopy - leukocytes, bacteria), urine culture (MSU, MC+S) Culture of prostatic secretions (by massage) Blood cultures (important in acute + febrile) Serum PSA (may be elevated) STI screen TRUSS (?prostatic abscess)
68
Prostatitis Mx (no sepsis - as then just BUFALO)
ciprofloxacin + NSAID + relief of obstruction + drainage of abscess
69
What Sx if gonococcal urethritis is untreated and disseminates?
reactive arthritis, meningitis, endocarditis
70
key DDx in epididymo-orchitis
torsion
71
3 Ix in epididymo-orchitis
Colour duplex USS - enlarged hyperaemic epididymis First catch urine or NAAT for chlam/gon Gram stain urethral secretions - intracellular gram neg diplocococci Urine dip - +ve leucocyte esterase Urine microscopy (first void) - > 10 WBC per high power field Urine culture If suspect torsion -> surgical exploration
72
epididymo-orchitis Mx if liekly STI? UTI?
sti - single dose ceftriaxone IM + doxycycline PO UTI - levofloxacin
73
Where are the most common locations of Nephrolithiasis/renal calculi Nephrolithiasis = stones
Pelviureteric junction Pelvic brim/cross internal iliac artery Vesicoureteric junction
74
3RFs for stones
Chronic dehydration, diet, obesity, positive family history, specific medicines
75
Most common type of renal stone
calcium (oxalate)
76
2 comps of stones
Pressure necrosis Obstruction -> hydronephrosis Infection -> pyelonephritis, SEPSIS
77
Give 3 DDx of renal stones a
Acute appendicitis - -ve urine and NCCT Ectopic pregnancy: preg test +ve and raised HCG Ovarian cyst: AUSS - cystic adnexal lesions Diverticular disease - NCCT shows absence of renal stones *AAA or UTI - USS/CT abdomen shows presence of AAAConsider this for 50+ until proven otherwise
78
4 Ix for Nephrolithiasis
*NCCT (Gold-standard) - 99% sensitive - stones (white) in collecting system, ureter ± hydropehrosis Urinalysis - urine dip and MC+S Microhaematuria, ± leukocytes, nitrates FBC - raised WCC -> infection U+E+Cr- hypercalcaemia (PTH), hyperuricaemia (gout) Pregnancy test KUB USS
79
Symtomatic Mx acute Nephrolithiasis
Pain control - Diclofenac (or morphone + ondansetron) Hydration
80
Mx of stone without obstruction
Medical expulsive therapy - alpha blocker (tamsulosin) or CCB (nifedipine) If large: ESWL (extracorporeal shock wave lithotripsy)
81
Mx of big ass stones >15mm / with obstruction
Percutaneous ureteroscopy / nephrostolithotomy +surgical decompression
82
General prevention of stones
Overhydration (2.5-3 l) Decreased sodium, protein, oxalate, weight Increased citrate Normal calcium (restriction may lead to decreased oxalate binding in GI -> increased excretion)
83
Prevention of specific causes of stones Hypercalciuria - Hyperuricosuria - Hyeroxaluria- Cystinuria - Struvite stones -
Hypercalciuria - thiazide diuretics + potassium citrate (to counter low potassium + cit) Hyperuricosuria - allopurinol or potassium citrate (urinary alkalisation) Hyeroxaluria- calcium carbonate (binds oxalate) Cystinuria - potassium citrate (alkalisation), penicillamine (cysteine binder) Struvite stones - treat infection, urease inhibitor
84
Epididymal cyst: Pres? Ix? Condition associated? Mx?
Small painless cysts, bilateral USS for confirmation - will transluminate, aspiration (milky fluid = spermatocele) CF Benign and need no mx
85
What is a varicocele ? Where?
Abnormal dilatation of internal spermatic veins and pampiniform plexus that drains the testes 90% on left side
86
varicocele presentation? Ix? Mx? Comp of mx?
Painless scrotal mass Dull ache Feels like bad of worms Examination of testicles Scrotal USS with doppler Reassure large -> surgery -> likely hydrocele Can be secondary to compression of the renal vein!!!!! At the nutcracker angle - so always keep in mind the RCC
87
What is a hydrocele
Collection of serous fluid between layers of the tunica vaginalis or along the spermatic cord
88
Mx hydrocele
Observation if no discomfort or infection (once underlying pathology ruled out) Surgery or aspiration if discomfort (recurrence and pain is complication)
89
Testie ca presents as hard, painless nodule on one testicle. Dx?
USS of testicle is 90-95% accurate in diagnosis
90
2 main types of testie ca and ages
seminoma - 30-65 year olds, 25% metastasise teratoma - 20-30 year olds, 50% metastasise
91
Ix in testie tumour (first 3 are essential)
BALUC - [like bollock] (b-hcg, afp, ldh) USS (95% sensitive) CT abdomen and pelvis (LNs) CXR: mediastinal and lung mets (haematogenous spread) [Raised alpha-fetoprotein (AFP) - teratocarcinoma, yolk sac, embryonal (not seminoma) Raised B-HCG (choriocarcinoma and 5-10% of seminoma) Serum LDH (50% raised, only elevated marker in 10% of non-seminomas)]
92
Main comps of mx of testie tumour
Infertility Treatment related neutropenia, nausea, pulmonary toxicity requires CXR for monitoring (bleomycin), renal failure (cisplatin)
93
tesie Ca mx
Radical orchiectomy + chemo / radio
94
What is erectile dysfunction
difficulty in attaining, maintaining an erection or a marked decrease in rigidity
95
What 3 qs might you ask about erectile dysfunction
Early morning erections? Foreplay? Masturbation?
96
name 3 causes of ED
Age Pain Vascular HTN, CHD, diabetes, smoking, obesity Neurological MS, spinal cord injury Hormonal Decreased androgens, increased prolactin, hypothyroidism Psychological Anxiety, depression, substance misuse Surgical Prostate Drugs SSRI, beta-blockers, alcohol, all psych drugs
97
Bar treating underlying condition give 2 pharma and 2 non pharma Mx of ED
PDE5 inhibitor (sildenafil) - headache, facial flushing, CI: hypotension Alprostadil (PGE1) Vacuum pump Constriction ring Penile implant Psychosexual therapy
98
Mx of stress incontinence
pelvic floor, physio, surgery, sling (TVT, TOT) M: artificial sphincter, male sling
99
Mx of urge incontinence
Behavioural: F/V chart, caffeine, alcohol Drugs: anticholinergics (oxybutinin), B3 agonists (mirabegron), botulinum toxin Bladder augmentation: detrusor myectomy/*cystoplasty (small bowel)
100
What causes a Flaccid (hypotonic) neurogenic bladder? What does this lead to?
Conus or below destroyed or non-functioning -> AREFLEXIC BLADDER/BOWEL Peripheral nerve or spinal nerve damage at S2-4 High residual volume predisposes to infection and overflow
101
What causes a spastic bladder? sx?
Brain damage or spinal cord damage above T12 Involuntary urination/defecation
102
2 Comps of neurogenic bladder
Reduced quality of life and embarrassment Increased UTI and calculi Hydronephrosis with VUR High thoracic or cervical spinal cord lesions are at risk of autonomic disreflexia
103
Sx of autonomic dysreflexia
Life threatening Malignant hypertension Brady/tachycardia Headache Piloerection Sweating
104
Aims of mx for neurogenic bladder
Bladder safety (an unsafe bladder may damage the kidneys) -> *protect the kidneys Continence/symptom control Prevent AUTONOMIC DYSREFLEXIA Preserve body image and sexuality
105
Usual type of incontince in neurogenic
Overflow incontinence (both flaccid and spastic) due to retained urine and dribbling
106
3 ix in neurogenic bladder
Serum creatinine (kidney function) + renal ultrasound (hydronephrosis) Post-void residual volume (normal < 100 ml) Urodynamics if considdering surgery
107
Bubbly urine 2 DDx
Gas producing UTI Fistula - Eg in malignancy

Phase 4 - Katherine (26 decks)

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