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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
Q

3 Ix in prostate Ca

A

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

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26
Q

Active surveillance is an option for very low risk prostate Ca.
What other Mx could you do for low risk?

A

brachytherapy (radioactive source to prostate)

external beam radiotherapy

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27
Q

Mx of high risk prostate Ca ? ( T3/4, PSA > 20, Gleason 8-10)

A

Radical prostatectomy plus pelvic LN dissection

External beam radiotherapy (every day M:F 7-8W) + brachytherapy/androgen deprivation (shrinks tumour)

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28
Q

Mx of mets in prostate Ca

A

They are usually androgen sensitive:

Androgen deprivation therapy

chemical castration

Surgical castration

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29
Q

Drug used for chemical castration

A

Goserelin (GnRH analogue -

[stimulates then inhibits pituitary gonadotrophin so symptoms may get worse, offer an anti-androgen e.g. flutamide]

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30
Q

Main comp in surgical castration

A

risk of impotence if cut cavernous nerve of penis

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31
Q

Mx if prostate mets are castration resistant?

A

Bisphosphonates - reduce pain

palliative radiotherapy

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32
Q

Name 3 comps of prostate Ca mx

A

Erectile dysfunction - radiation, surgery, androgen deprivation

Hormone induced gynaecomastia

Hormone induced hot flush

Radiation induced LUTS for a few weeks + haematuria + bowel bleeding

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33
Q

How to prevent hormone induced gynaecomastia

A

tamoxifen

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34
Q

Usual Ca in bladder? what if schisto?

A

Transitional cell carcinoma (90%)

Squamous

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35
Q

Name 3 RFs for bladder Ca ? genetic cause?

A

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

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36
Q

Bladder Ca stage

A

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

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37
Q

Where does bladder Ca spread?

A

Lymphatic: Pelvic

Haematogenous: liver and lungs

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38
Q

How does bladder Ca present?

A

Painless haematuria (frank or microscopic), dysuria, abdominal mass, RFs,

systemic weight loss + bone pain

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39
Q

Name 4 Ix in bladder Ca

A

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…..

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40
Q

3 Comps of bladder Ca

A

Hydronephrosis
Upper tract TCC
Prostatic urethral TCC
Urinary retention
Recurrence

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41
Q

Most bladder Ca presents with low-grade non muscle invasiion.

Mx?

A

Transurethral Resection of Bladder Tumour

+intravesical chemo (direct into bladder through catheter)

+intravesical BCG (bacille Calmette-Guerin) immunotherapy)

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42
Q

Mx of invasive bladder Ca?

mets?

A

cystectomy with pelvic LN dissection + chemo

mets = chemo

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43
Q

Other than haematuria give 2 causes of discoloured red(ish) urine

A

myoglobinuria (rhabdomyolysis or muscle destruction),

haemoglobinuria (haemolytic anaemias)

beeturia (beetroot),

rifampicin = pseudohematuria

44
Q

Total haematuria -> bladder or upper tract (kidney/ureter)

What if the haematuria is at the start/end of voiding?

A

urethra, prostate, seminal vesicles or bladder neck.

45
Q

3 causes of haematuria

A

Medical
UTI
Warfarin/clopidogrel etc
Coagulopathies
Menstruation contamination (pseudohaematuria)
Acute pyelonephritis
Trauma/instrumentation

Surgical
Stones
Urological malignancy - renal, bladder, ureter, prostate
BPH

46
Q

4 Ix for haematuria

A

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
Q

3 times you might use a catheter

A

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
Q

2 pros and 2 cons of a suprapubic catheter vs normal foley

A

SPC more comfortable, more convenient change, better self-image, better sexual function

SPC increased risk cellulitis, leakage, prolapse through urethra, surgical procedure

49
Q

3 complications of catheters

A

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
Q

3 Rfs for UTI

A

Female, sex, spermicide (decrease lactobacilli), pregnancy, decreased host defense (immunosuppression, DM), obstruction, stones, catheter, malformation

51
Q

2 Most common cause of uncomplicated UTI / how to differentiate?

A

E.coli - 70-95%

Staph saprophyticus 5-20% (coagulase -ve)

52
Q

Which bacteria are cause of some hospital (12%) UTIs? What added complication do you get?

A

Proteus mirabilis
Klebsiella

-> increased risk of stones
[secrete urease -> raise pH -> Stones (Struvite)]

53
Q

Abx in UTIs? If pregnant? men?

A

Trimethoprim 3 days (in uncomplicated)

Nitrofurantoin 7 days (in pregnancy as trimethoprim is teratogenic)

Men -> ciprofloxacin

54
Q

2 forms of host defence against UTIs

A

Antegrade urine flush (lost in stasis, reflux, preg),
low urine pH,
Tamm-Horsfall protein (mucopolysaccharide), urinary IgA

55
Q

Usually no mx for aSx bacteruria. Why do you treat if pregnant?

A

high risk pyelonephritis

56
Q

What is pyuria

A

leucocytes in urine associated with infection

57
Q

Name 2 things that would classify UTI as complicated

A

Functional impairment
Structural impairment
Kidney involvement
UTI in pregnancy
Indwelling catheter
Immunosuppressed

58
Q

What might you suspect in UTI if Costovertebral angle tenderness + fever

A

pyelonephritis

59
Q

3 Ix of urine in UTI

A

Urine dipstick,
microscopic urinalysis (bacteria, WBC, RBC),

*urine culture +s of MSU

60
Q

give 2 DDx of UTI

A

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
Q

Mx if known/suspected ABx resistant UTI

A

ciprofloxacin

62
Q

Mx of complicated and hospital admission UTI

A

IV gent

63
Q

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?

A

Dipstick
Urine microscopy
Urine culture (>10^2)

IMAGING
CT renal tract (perirenal abscess, urinary calculi, tumour)

KUB USS (stone, abscess)

64
Q

Usual cause of prostatitis?

A

e.coli (80%)
[+ enterococcus/pseudomonas]

65
Q

O/E prostatitis

A

warm or soft, exquisitely boggy prostate

66
Q

How does E coli get to the prostate

A

intraprostatic reflux (urine into prostatic duct)

67
Q

4 ix in prostatitis

A

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
Q

Prostatitis Mx (no sepsis - as then just BUFALO)

A

ciprofloxacin

+ NSAID + relief of obstruction + drainage of abscess

69
Q

What Sx if gonococcal urethritis is untreated and disseminates?

A

reactive arthritis, meningitis, endocarditis

70
Q

key DDx in epididymo-orchitis

A

torsion

71
Q

3 Ix in epididymo-orchitis

A

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
Q

epididymo-orchitis Mx if liekly STI? UTI?

A

sti - single dose ceftriaxone IM + doxycycline PO

UTI - levofloxacin

73
Q

Where are the most common locations of Nephrolithiasis/renal calculi

Nephrolithiasis = stones

A

Pelviureteric junction

Pelvic brim/cross internal iliac artery

Vesicoureteric junction

74
Q

3RFs for stones

A

Chronic dehydration, diet, obesity, positive family history, specific medicines

75
Q

Most common type of renal stone

A

calcium (oxalate)

76
Q

2 comps of stones

A

Pressure necrosis

Obstruction -> hydronephrosis

Infection -> pyelonephritis, SEPSIS

77
Q

Give 3 DDx of renal stones a

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
Q

4 Ix for Nephrolithiasis

A

*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
Q

Symtomatic Mx acute Nephrolithiasis

A

Pain control - Diclofenac (or morphone + ondansetron)

Hydration

80
Q

Mx of stone without obstruction

A

Medical expulsive therapy - alpha blocker (tamsulosin) or CCB (nifedipine)

If large:
ESWL (extracorporeal shock wave lithotripsy)

81
Q

Mx of big ass stones >15mm / with obstruction

A

Percutaneous ureteroscopy / nephrostolithotomy

+surgical decompression

82
Q

General prevention of stones

A

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
Q

Prevention of specific causes of stones

Hypercalciuria -

Hyperuricosuria -

Hyeroxaluria-

Cystinuria -

Struvite stones -

A

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
Q

Epididymal cyst:

Pres?
Ix?
Condition associated?
Mx?

A

Small painless cysts, bilateral

USS for confirmation - will transluminate, aspiration (milky fluid = spermatocele)

CF

Benign and need no mx

85
Q

What is a varicocele ?
Where?

A

Abnormal dilatation of internal spermatic veins and pampiniform plexus that drains the testes

90% on left side

86
Q

varicocele presentation?
Ix?
Mx?
Comp of mx?

A

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
Q

What is a hydrocele

A

Collection of serous fluid between layers of the tunica vaginalis or along the spermatic cord

88
Q

Mx hydrocele

A

Observation if no discomfort or infection (once underlying pathology ruled out)

Surgery or aspiration if discomfort (recurrence and pain is complication)

89
Q

Testie ca presents as hard, painless nodule on one testicle. Dx?

A

USS of testicle is 90-95% accurate in diagnosis

90
Q

2 main types of testie ca and ages

A

seminoma - 30-65 year olds, 25% metastasise

teratoma - 20-30 year olds, 50% metastasise

91
Q

Ix in testie tumour (first 3 are essential)

A

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
Q

Main comps of mx of testie tumour

A

Infertility

Treatment related neutropenia, nausea, pulmonary toxicity requires CXR for monitoring (bleomycin), renal failure (cisplatin)

93
Q

tesie Ca mx

A

Radical orchiectomy + chemo / radio

94
Q

What is erectile dysfunction

A

difficulty in attaining, maintaining an erection or a marked decrease in rigidity

95
Q

What 3 qs might you ask about erectile dysfunction

A

Early morning erections?
Foreplay?
Masturbation?

96
Q

name 3 causes of ED

A

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
Q

Bar treating underlying condition give 2 pharma and 2 non pharma Mx of ED

A

PDE5 inhibitor (sildenafil) - headache, facial flushing, CI: hypotension

Alprostadil (PGE1)

Vacuum pump

Constriction ring

Penile implant

Psychosexual therapy

98
Q

Mx of stress incontinence

A

pelvic floor, physio, surgery, sling (TVT, TOT)

M: artificial sphincter, male sling

99
Q

Mx of urge incontinence

A

Behavioural: F/V chart, caffeine, alcohol

Drugs: anticholinergics (oxybutinin), B3 agonists (mirabegron), botulinum toxin

Bladder augmentation: detrusor myectomy/*cystoplasty (small bowel)

100
Q

What causes a Flaccid (hypotonic) neurogenic bladder?
What does this lead to?

A

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
Q

What causes a spastic bladder? sx?

A

Brain damage or spinal cord damage above T12

Involuntary urination/defecation

102
Q

2 Comps of neurogenic bladder

A

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
Q

Sx of autonomic dysreflexia

A

Life threatening
Malignant hypertension
Brady/tachycardia
Headache
Piloerection
Sweating

104
Q

Aims of mx for neurogenic bladder

A

Bladder safety (an unsafe bladder may damage the kidneys) -> *protect the kidneys

Continence/symptom control

Prevent AUTONOMIC DYSREFLEXIA

Preserve body image and sexuality

105
Q

Usual type of incontince in neurogenic

A

Overflow incontinence (both flaccid and spastic) due to retained urine and dribbling

106
Q

3 ix in neurogenic bladder

A

Serum creatinine (kidney function)

+ renal ultrasound (hydronephrosis)

Post-void residual volume (normal < 100 ml)

Urodynamics if considdering surgery

107
Q

Bubbly urine 2 DDx

A

Gas producing UTI
Fistula - Eg in malignancy

Phase 4 - Katherine (26 decks)

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