Urology

Question 1

LUTS sx in men

Answer 1

Storage/irritative:
- F requency
- U rgency
- N octuria
- D ysuria

Voiding/obstructive
- H esistancy
- I complete emptying
- P oor stream
- S training
- Other = terminal dribbling, overflow incontinence

Question 2

Compare signs and sx of BPH and prostate cancer

Answer 2

Both:
FUND HIPS
Severe pain if acute urinary retention

BPH:
DRE => smoothly enlarged porstate w/ palpable midline groove

Prostate cancer:
DRE => asymmetrical hard nodule prostate
Malignancy sx => bone pain, cord compression, FLAWS, paraneoplastic (hypercalcaemia)

Question 3

Ix for BPH

Answer 3

U&Es: check for any decrease in kidney function
USS urinary tract

Question 4

Mx for BPH

Answer 4

Conservative
- watchful waiting; typically if pts are older

Medical
- 5-alpha-reductase inhibitor (finasteride)
- alpha-blockers (tamsulosin to relax smooth muscles)

Surgery
- transurethral resection of prostate (TURP)
- open prostatectomy

Emergency
- urinary retention => catheterise!!

Question 5

Ix for prostate cancer

Answer 5

PSA (low specificity)
MRI (first line)
Transrectal ultrasound-guided biopsy
LFTs/bone profile; mets

Question 6

RFs for bladder cancer

Answer 6

Dye stuffs
Pelvic irradiation
Smoking
Chronic UTIs
Schistosomiasis (‘developing’ countries)

Question 7

Sx and ix for bladder cancer

Answer 7

Sx: FLAWS, FUND (no HIPS), painless macroscopic haematuria (main PC)

Ix: cytoscopy w/ biopsy (majority are transitional cell carcinomas, few are squamous cell), CT/MRI (for staging)

Question 8

What are the different types of urinary incontinence?

Answer 8

Stress
=> physical movement/activity places stress on the bladder, poor closure of bladder during childbirth is RF
Urge
=> urine leaks as you feel sudden intense urge to pee, detrusor overactivity
Functional
=> aware of need to pee but unable to go due to physical/mental reasons
Overflow
=> involuntary release of urine from full bladder, in absence of any need to urinate

Question 9

What types of kidney stones can you get?

Answer 9

Calcium oxalate (most common)
Magnesium ammonium phosphate; struvite (renal horn calculus)
Urate (infectons)
Cysteine (cystinuria)

Question 10

Sx and signs of nephrolithiasis

Answer 10

Often asymptomatic
Severe loin to groin pain (writhing in bed)
Nausea and vomiting
Consider leaking AAA, especially in elderly

Question 11

Ix for nephrolithiasis

Answer 11

Urine dipstick
- microscopic haematuria
U&Es
- check renal function, can cause AKI
USS
Non-contrast CT-KUB
- GOLD-STANDARD

Question 12

Mx for nephrolithiasis

Answer 12

<5mm
- allow to pass spontaneously
- increased fluid intake (dehydration risk factor)
- keep stone for analysis (determine cause)

> 5mm
=> Surgey
- ureteroscopic lithotripsy
- extracorporeal shockwave lithotripsy (non-invasive)
- percutaneous nephrolithotomy (staghorn calculus)

Emergency
- signs of obstructed/infected kidneys => urgent nephrostomy to relieve obstruction

Question 13

Sx + signs of testicular torsion

Answer 13

Swollen + erythematous scrotum
Nausea + vomiting
Sudden-onset severe hemi-scrotal pain
Typically occurs in boys and young men

Question 14

Mx for testicular torsion

Answer 14

Duplex ultrasound
Exploratory surgery within 6 hours
Necrotic tissue may need removal
Both testicles fixed in place

Question 15

Ddx of swollen + erythematous scrotum

Answer 15

Testicular torsion
Epididymo-orchitis
Strangulated inguinal hernia

Question 16

Scrotal mass ddx

Answer 16

Hydrocele
Epididymitis + orchitis
Varicocele
Testicular cancer

Question 17

Hydrocele summary card

Answer 17

Baby or old men, idiopathic, infection, trauma, tumour causing excessive collection of serous fluid in tunica vaginalis
- transilluminates, asymptomatic swelling, can get above swelling, swelling cannot be separated from testicle

Question 18

Epididymitis + orchitis summary card

Answer 18

< 35 (Chlymadia/Gonococcus), > 35 (Coliforms, i.e. ENterobacter, Klebsiella), mumps, Candida can cause inflammation of epididymitis or testes
- fever, penile discharge (if STI), less acute onset than torsion, painful, swollen and tender testis/epididymitis

Question 19

Varicocele summary card

Answer 19

Dilated veins of pampiniform plexus, more common on left, associated with infertility
- usually asymptomatic, swelling may reduce when lying down, scrotum feels like ‘a bag of worms’

Question 20

Testicular cancer summary card

Answer 20

Commonest malignancy in 20-40 yo males
Painless hard testicular mass, testicular swelling/discomfort, backache (mets via para-aortic nodes)
- seminoma
- non-seminoma (teratoma)
- sertoli/leydig cell tumours

Question 21

Testicular cancer tumour markers

Answer 21

Raised AFP
- yolk sac tumour, embryonomal caricnoma
- NOT a seminoma

Raised beta-hCG
- most testicular cancers

Raised LDH
- most testicular cancers

*Teratoma, no markers

Question 22

Ix for scrotal masses

Answer 22

Check for infection
- urine dipstick, MSU, sexual health hx if indicated
- bloods: FBC, CRP
O/E
- can you get above the mass? (if not = inguinal hernia)
- does it transilluminate? (if yes = fluid)
- is it reducible?

Question 23

Ix for testicular cancer

Answer 23

Tumour markers (AFP, beta-hCG, LDH)
Testicular USS
CT to allow for staging

Question 24

Why are varicoceles more common on the left testes?

Answer 24

Left testicular vein connects to the left renal vein at 90 degrees so increased reflux from compression of the left renal vein or a lack of effective valves is more likely to present with a varicocele > right testes

Question 25

A 67-year-old man has been urinating around 12-14 times per day over the past 6 months. His stream is ‘weak’ and often takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him?

A Oxybutynin
B Solifenacin
C Tamsulosin
D Nitrofurantoin
E Co-trimoxazole

Answer 25

C Tamsulosin

Question 26

A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost some weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis?

A Pyelonephritis
B Glomerulonephritis
C Bladder Cancer
D Prostate Cancer
E Ureteric Stone

Answer 26

C Bladder Cancer

Question 27

An 80-year-old man has had considerable difficulty urinating. He goes about 10-12 times per day, including at night, and has described his stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which first-line investigation should be used to confirm the diagnosis?

A PSA
B Acid phosphatase
C MRI Scan
D Transrectal ultrasound guided biopsy
E Isotope bone scan

Answer 27

C MRI Scan

Question 28

A 43-year-old woman presents to her GP having wet herself several times since the birth of her third child, 4 months ago. Whenever she laughs or coughs, a little bit of urine leaks out without her control. Which type of incontinence does she have?

A Functional incontinence
B Stress incontinence
C Urge incontinence
D Overflow incontinence
E Double incontinence

Answer 28

B Stress incontinence

Question 29

A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become overwhelmed by the feeling of needing to urinate. Before she can even think about finding a toilet, she has wet herself. Which type of incontinence is this?

A Functional incontinence
B Stress incontinence
C Urge incontinence
D Overflow incontinence
E Double incontinence

Answer 29

C Urge incontinence

Question 30

A 42-year-old man presents with severe pain in his right flank. He adds that the pain moves towards his right groin. Although he is writhing around in pain, no abnormalities are detected on abdominal examination.
Urine Dipstick: + blood
Which investigation would you do next?

A Renal ultrasound
B Cystoscopy
C CT-KUB
D MRI
E Urine MC&S

Answer 30

C CT-KUB

Question 31

Which type of urinary tract stone is most common?

A Magnesium ammonium phosphate
B Calcium oxalate
C Cysteine
D Urate
E Hydroxyapatite

Answer 31

B Calcium oxalate

Question 32

A 13-year-old boy is brought to A&E with sudden-onset pain and swelling in his scrotum, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to vomit. On examination, his right hemiscrotum is red and swollen. What is the most appropriate first step in his management?

A Doppler ultrasound of the testes
B CT Scan
C Exploratory surgery
D Empirical antibiotics
E Abdominal X-ray

Answer 32

C Exploratory surgery

Question 33

A 50-year-old man has developed a swollen scrotum that has been bothering him for the past 2 weeks. The swelling is uncomfortable but not painful. On examination, the left hemiscrotum is enlarged, fluctuant and non-tender. It is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis?

A Varicocoele
B Hydrocoele
C Testicular tumour
D Epididymal cyst
E Indirect inguinal hernia

Answer 33

B Hydrocoele

Question 34

A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘bag of worms’, and is uncomfortable but not painful. On examination, the patient’s scrotum looks normal when lying down, however, the left hemiscrotum becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis?

A Indirect inguinal hernia
B Direct inguinal hernia
C Hydrocoele
D Varicocoele
E Epididymal cyst

Answer 34

D Varicocoele

Question 35

A 21-year-old man visits his GP complaining that his scrotum feels ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with orchidopexy. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to?

A Inguinal
B Femoral
C Para-aortic
D Iliac
E Mesenteric

Answer 35

C Para-aortic

Question 36

A 32-year-old man presents with a 2-week history of frequent urination and excessive thirst. He has also noticed that he feels much weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient?

A Tented T waves
B Absent P waves
C ST elevation
D J waves
E U waves

Answer 36

E U waves

Pt has Conn’s syndrome => hypokalaemia, which induces nephrogenic diabetes insipidus, which, consequently, leads to polyuria and polydipsia. Furthermore, muscle weakness is another feature of hypokalaemia. The main ECG features of hypokalaemia are U waves, ST depression, flattened T waves and prolonged PR interval.