Urology

Question 1

Risk factors for bladder cancer

Answer 1

• Smoking
• Occupation: aromatic amine, aniline dyes,polycyclic aromatic hydrocarbons,paint, hair dye, textilem rubber, motor , leather and pesticide industries
• drugs – phenacetin, cyclophosphamide
• pelvic irradiation
• Caucasian
• chronic urinary tract infection (squamous cell carcinoma)
  *long term catherisation (squamous cell carcinoma)
• Schistosomiasis in Middle East (squamous cell carcinoma)

Question 2

Types of bladder cancer

Answer 2

• 90-95% are transitional cell carcinomas (TCC)
• 3-4% are squamous cell carcinomas ( in middle east, this one is more common)
• 1-2% are adenocarcinomas

Question 3

Clinical presenation of bladder cancer

Answer 3

• haematuria
• irritative lower urinary tract symptoms (frequency, urgency)
• recurrent UTI (SCC)
• hydronephrosis
• pelvic pain
• lower limb/genital oedema from pelvic lymphadenopathy

Question 4

2ww bladder cancer referral

Answer 4

if they are aged 45 and over and have:
Unexplained visible haematuria without urinary tract infection or
Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
or

if they are aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test.

Question 5

Ix bladder cancer

Answer 5

urine dip
CT urogram
Ultrasound and flexible cystoscopy
CT / MRI for staging

Question 6

Tx Bladder cancer

Answer 6

transurethral resection of bladder tumour (“TURBT”)
Moderate/high grade non-muscle invasive (including carcinoma-in-situ) →Intravesical chemotherapy (Mitomycin C) or intravesical immunotherapy (BCG) + Cystoscopic surveillance
Muscle-invasive disease → Radical cystectomy with ileal conduit or radiotherapy ± neoadjuvant Cisplatin-based systemic chemotherapy

Question 7

Epidemiology renal stones

Answer 7

M
40-60 years in males and late 20’s in females

Question 8

Features of Calcium oxalate stones

Answer 8

85% of stones, radiopaque. Hypercalciuria is major risk factor.

Question 9

Features of Calcium phosphate stones

Answer 9

10% of stones, radiopaque. Occurs in renal tubular acidosis type 1 & 3, where high urine pH increases supersaturation of urine with calcium and phosphate.

Question 10

Features of Cystine stones

Answer 10

1% of stones. Semi opaque “ground glass” appearance. Inherited recessive inborn errors of metabolism. Leads to disruption of cystine transport and decreased absorption from renal tubule.stones at a younger age.

Question 11

Features of uric acid stones

Answer 11

5-10% of stones. Radiolucent. Acid produced as product of purine metabolism. Precipitated with urinary pH is low. Can be caused by diseases which result in extensive tissue breakdown.high urinary concentration of uric acid. proportion of uric acid stones is higher in hot, dry climates

Question 12

Features of Struvite stones

Answer 12

2-20% of stones. Radio opaque. Formed from magnesium, ammonium and phosphate. Occur as a result of urease producing bacteria, associated with chronic UTIs (ureaplasma, proteus). Tend to form staghorn calculi.

Question 13

Management renal stones

Answer 13

NSAIDS
Antiemetic if nausea and vomiting (e.g. ondansetron or cyclizine)
Fluids
Abx if infection
Medical expulsive therapy – Tamsulosin,doxazocin ( alpha blocker)
Surgical Interventions in large stones or stones that do not pass
Extra corporeal shockwave lithotripsy (ESWL)
Ureteroscopy

Question 14

Epidemiology UTI

Answer 14

more common in women where the urethra is much shorter

Question 15

Duration of antibiotics in UTI

Answer 15

3 days for a simple lower urinary tract infection in women
5-10 days of antibiotics for women that are immunosuppressed, have abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter related UTIs

Question 16

Hydroceles may develop secondary to

Answer 16

epididymo-orchitis, testicular torsion, testicular tumours

Question 17

Features of hydrocele

Answer 17

soft, fluctuant and may be large non-tender swelling
Usually anterior to and below the testicle
the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
It is irreducible and has no bowel sounds
Scrotum Transilluminated by shining torch into the fluid

Question 18

Hydrocele

Answer 18

collection of fluid around the testicle

Question 19

Mx hydrocele

Answer 19

Most spontaneously resolve by 12 months
May indicate underlying testicular cancer
May require surgical intervention
there is a significantly increased risk of an indirect inguinal hernia

Question 20

Varicocele

Answer 20

abnormal enlargement of the testicular veins
more common on the left side
associated with infertility
Swollen pampiniform venous plexus (testicular veins)
Can cause dragging or soreness
ultrasound with Doppler studies to diagnose
Usually harmless
Usually conservative, occasionally surgery if pain

Question 21

Epididymal cyst/spermatocele

Answer 21

A cyst (sac of fluid)
Usually occur over 40 years of age
the most common cause of scrotal swellings seen in primary care.
often post to testicle
Usually harmless
Associated conditions: PCKD, CF, von hippel-lindau syndrome
Diagnosis confirmed by US
Epididymal cysts can be excised using a scrotal approach

Question 22

Features of Epididymo-orchitis

Answer 22

gradual onset
presents as acute scrotal pain 
often unilateral
Dragging / heavy sensation
Urethral discharge
Swelling of testicle and epididymis
Erythema to scrotum

Question 23

Testicular torsion

Answer 23

occurs when the spermatic cord and its contents twists within the tunica vaginalis, compromising the blood supply to the testicle.
urgent surgical emergency

Question 24

Testicular torsion epidemiology

Answer 24

peak incidence is in neonates and adolescents between the ages of 12-25yrs.

Question 25

Testicular torsion presentation

Answer 25

Acute/sudden onset of unilateral testicular pain
Often triggered by activity (e.g. playing sports)
“6 hour window” after onset before damage from ischaemia is irreversible
nausea and vomiting secondary to pain

Question 26

Cremasteric reflex

Answer 26

inner part of the thigh is stroked. This causes the cremaster muscle to contract and pull up the ipsilateral testicle toward the inguinal canal.
in torsion the cremasteric reflex is absent and pain continues despite elevation of the testicle, termed a negative Prehn’s sign

Question 27

Lower Urinary Tract Symptoms

Answer 27

Storage symptoms ( cant keep urine in the bladder) 
•Urgency
•Daytime Frequency
•Nocturia
Voiding symptoms ( difficulty emptying bladder) 
•Poor flow
• Straining to void 
•Incomplete emptying sensation
•Hesitancy
• Terminal dribbling

Question 28

Ix for LUTS

Answer 28

Urine dipstick (exclude infection)
PSA done prior to rectal examination 
Rectal exam to assess prostate size, shape and characteristics- smoothly enlarged 
IPSS - international prostate score
Can image further if unsure with USS,MRI and biopsy to exclude malignancy

Question 29

Treatment Benign prostatic hyperplasia

Answer 29

Conservative: Reassurance and monitoring if manageable symptoms
Medical:
Relax smooth muscle through alpha 1 selective blockers
Finasteride tablet 5a reductase inhibitors to reduce conversion of testosterone into dihydrotestosterone to reduce size of prostate
Surgical includes: Transurethral resection of the prostate (TURP),little bits and remove the bits
Prostatic artery embolisation,Open prostatectomy

Question 30

Paraphimosis

Answer 30

typically caused by not replacing a retracted foreskin retracted foreskin can impair venous return to the glans penis, resulting in oedema. If left uncorrected, it may compromise the blood supply to the glans penis and lead to ischaemia.

Question 31

Paraphimosis Mx

Answer 31

involves reducing the oedema to the glans by applying pressure over a period of time.
If conservative measures fail, a dorsal slit is used to cut the foreskin.

Question 32

Phimosis

Answer 32

foreskin is tight and cannot be retracted over the glans.
It’s normal in babies and young children but over time it resolves.
In adults it may present with painful intercourse, recurrent infection and ulceration. In young males, recurrent balanitis and ballooning is common.

Question 33

Phimosis Mx

Answer 33

Treatment involves steroid creams, or circumcision.

Question 34

Balanoposthitis

Answer 34

inflammation of the glans penis and prepuce, most commonly caused by infection,
but can occur in dermatological conditions or pre-malignant/malignant conditions.
Take swab for culture, any infection tx with abx
avoid irritants such as soap, and keep the area clean. If doesn’t resolve, skin biopsy may be required for a diagnosis.

Question 35

Priapism

Answer 35

prolonged and often painful erection which persists for more than 2 hours after sexual activity. Priapism carries a risk of permanent damage to the penis and requires prompt treatment. Sickle cell is a risk factor for ischaemic priapism.

Question 36

Priapism mx

Answer 36

First line treatment is with aspiration of the blood within the corpus cavernosa and irrigation with normal saline. Intracavernosal alpha agonists such as Adrenaline or Phenylephrine may also be used.

Question 37

Erectile dysfunction

Answer 37

•Oral therapy (PDE5is) eg viagra-sildenail

If this doesn’t work, can try vacuum pump , injectable devices

Question 38

Peyronie’s Disease

Answer 38

Bend in penis
; age 18-80
Present with pain and deformity on erection, a palpable penile plaque, and, in many cases, erectile dysfunction
Associated with Dupuytren’s contracture and a history of penile trauma

Question 39

Torsion of Hydatid of Morgagni

Answer 39

blue dot sign especially in caucasian patients

Question 40

Causes of urinary retention

Answer 40

Neurological
Obstructive
Infectious
Drugs - anticholinergic,alpha agonist.alcohol
Post-operative