Urology Flashcards
BPH presentation
Storage and voiding symptoms
BPH diagnosis
History, DRE, urinalysis, PSA
Where is BPH most common
Transition zone of prostate around the urethra (why LUTS presents sooner than in cancer)
BPH treatment options
alpha blockers - eg tamsulosin, decrease smooth muscle tone of prostate and bladder, First line
5-alpha reductase inhibitors eg finasteride, reduce DHT production
Surgical treatment- Transurethral resection of prostate (TURP)
Type of cancer and location of prostate cancer
Adenocarcinoma and peripheral zone of prostate
Risk factors of prostate cancer
Age, obesity, anabolic steroids, black origin, family history- BRCA2 and Lynch
Prostate cancer presentation
LUTS similar to BPH, haematuria, erectile dysfunction. generalised symptoms of advanced met cancer
Prostate cancer diagnosis
PSA, prostate exam, multiparametric MRI (first line for suspected prostate cancer), prostate biopsy (depends on MRI results eg Likert 3 or above and clinical suspicion)
Prostate cancer scoring system
Gleason score. Made up of adding 2 numbers. Score of 6 is low risk, 7 is intermediate risk, 8 is high risk.
Localised prostate cancer management
watchful waiting
radical prostatectomy if it’s low grade
external beam radiotherapy (can cause proctitis though)
2 WW referral for prostate cancer
PSA > 4 ng/mL
abnormal DRE
Bladder cancer risk factors
Smoking
Occupational carcinogens (dye, rubber, cable factory work)
Schistomiasis - most common cause of squamous cell carcinoma in countries w/ a high prevalence of the infection
Bladder cancer risk factors
Smoking
Occupational carcinogens (dye, rubber, paint, cable factory work)- working w/ aromatic amines
Schistosomiasis - most common cause of squamous cell carcinoma in countries w/ a high prevalence of the infection
Age
Male
Caucasians
Types of bladder cancer
95% transitional cell carcinoma
5% squamous cell carcinoma- higher in areas of schistosomiasis
Presentation of bladder cancer
Painless haematuria
Voiding symptoms
Or recurrent UTI which doesn’t clear w/ Abx
Diagnosis of bladder cancer
Flexible cystoscopy + biopsy
management of bladder cancer
trans urethral resection of bladder tumour (TURBT) in non muscle invasive bladder cancer
intravesical chemotherapy is used after TURBT to reduce recurrence risk, eg mitomycin
high risk: TURBt + intravesical BCG
Detrusor muscle involved- radical cystectomy, often use a urostomy for urine drainage after
schistosomiasis presentation
fever, urticaria/angioedmea (rash on skin), arthralgia/myalgia
schistosomiasis risk factors
contact w/ fresh water, activies eg swimming , fishing etc
increased cancer risk of which type if schistosomiasis
squamous cell carcinoma
what is schistosomiasis
parasitic flatworms attacking UT/IT
Renal cell carcinoma- type of cancer?
adenocarcinoma
renal cell carcinoma subtypes?
80% Clear cell
15% Papillary
5% Chromophobe
renal cell carcinoma risk factors
Age, male, smoking, hypertension, Acquired cystic disease of the kidney, chronic paracetamol use, Von Hippel Lindau Disease
renal cell carcinoma presentation
painful haematuria
flank pain
palpable mass
non-specific cancer symptoms
renal cell carcinoma 2 week wait referral criteria
Aged over 45 w/ unexplained visible haematuria, either w/o a UTI or persisting after treatment for a UTI
renal cell carcinoma diagnosis
CT contrast abdomen +/- MRI and image guided biopsy
how do we classify/stage renal cell carcinoma
TNM staging
Bosniak classification
Paraneoplastic features of renal cell carcinoma
Polycythaemia- high RBCs due to secretion of unregulated EPO
Hypercalcaemia - due to secretion of a hormone that mimics the action of parathyroid hormone
HTN- due to increased renin
Stauffer’s syndrome- abnormal LFTs (raised ALT, AST, ALP and bilirubin) w/o liver metastases
renal cell carcinoma management
surgery is first line- may involve partial nephrectomy or radical nephrectomy. nephrectomy is recommended even in metastatic disease.
When unsuitable for surgery- can use arterial embolisation, percutaneous cryotherapy, radiofrequency ablation
Kidney stones common formation points
Ureteropelvic junction (ureter coming into the renal pelvis)
Pelvic brim
Vesico-ureteric junction
kidney stones causes:
Hypercalcaemia
High salt intake
Dehydration
male
white ancestry
eating anything brown/red (tea/coffee/coke/rhubarb/strawberries/radish)
Hyperparatyhroid
kidney stones presentation
Colicky pain
Loin to groin
N/V
Haematuria
Reduced urine output
symptoms of infection
Diagnosis of kidney stones
Non contrast CT KUB is first line and gold standard
USS if pregnant or hydronephrosis
AXR shows calcium based stones
urine dipticks will show haematuria
U&Es- reduced eGFR, inflammatory markers
Management of kidney stones
Analgesia- NSAIDs eg IM diclofenac, ibuprofen. IV paracetamol
Symptom control- antiemetics eg metoclopramide, antibiotics
Watchful waiting in stones less than 5mm
Surgical intervention required in larger stones, stones that don’t pass spontaneously or where there’s complete obstruction or infection- eg Extracorporeal shockwave lithotripsy, Ureteroscopy + laser lithotripsy, Percutaneous nephrolithotomy, open surgery
types of kidney stone?
Calcium oxalate (85%) on CT is radiopaque + spiky, can reduce risk by low protein/salt diet/ thiazide diuretics
Calcium phosphate - CT is radiopaque and white/smooth. risk factor is alkaline urine.
Uric acid - CT is radiolucent + brown/smooth. Not visible on x ray. Caused by excess tissue breakdown.
Struvite- produced by bacteria so associated w/ infection. CT - slightly radiopaque, staghorn calculus
Management of localised advanced prostate cancer
hormonal therapy
radical prostatectomy
radiotherapy- external beam and brachytherapy
Management of metastatic prostate cancer
hormonal therapy- reduce androgen therapy
give synthetic GnRH agonist eg Goserelin. Initially cover this w/ an anti androgen to prevent a rise in testosterone eg, bicalutamide, cyproterone acetate
abiraterone
bilateral orchidectomy
chemotherapy w/ docetaxel
Management of recurrent kidney stones
increase oral fluid intake (2.5-3 litres daily)
add fresh lemon juice to water
avoid carbonated drinks
reduce salt intake
maintain normal calcium intake
potassium citrate in patients w/ calcium oxalate stones
thiazide diuretics eg indapamide in pts w/ calcium oxalate stones
UTI is more common among?
Females due to shorter urethra
most common UTI bacteria
E. Coli
UTI Symptoms
Increased frequency and urgency
Dysuria (pain when passing urine), burning
suprapubic pain
maybe haematuria
UTI diagnosis
urine dip:
leukocyte esterase
Nitrites- gram negative bacteria like e coli break down nitrates to nitrites.
RBCs show haematuria
Presence of nitrites or leukocytes + RBCs = patient likely to have UTI
nitrites + leuocytes = requires UTI treatment
only nitrites are present- treat for UTI
UTI management
3 days of Abx for a simple lower UTI in women - Trimethoprim or Nitrofurantoin
5-10 days for immunosuppressed women, w/ abnormal anatomy or impaired kidney function
7 days of Abx for men, pregnant women or catheter related UTIs:
for men - trimethoprim or nitrofurantoin offered first line under prostatitis is suspected. for pregnant women: first line- nitrofurantoin (avoid in 3rd trimester), second line - amoxicillin or cefalexin
Haematuria differentials
Bladder cancer (usually painless)
Renal cancer
UTI
Stones
Nephrological disease eg glomerulonephritis
Prostate disease
Systemic disease eg SLE, GPA
2 week wait referral criteria for haematuria
45+ w/
a) unexplained visible haematuria w/o UTI - RCC
b) visible haematuria persisting/recurring after UTI treatment - bladder cancer
c) 60+ w/ unexplained non-visible haematuria and dysuria or raised WCC - bladder cancer
d) non urgent referral for bladder cancer if 60+ w/ recurrent or persistent unexplained UTI
testicular torsion risk factors
10-30 y/o
Bell Clapper Deformity- testicle not attached to tunica vaginalis at posterior, higher chance of torsion.
testicular torsion presentation
sudden sharp unilateral testicular pain
abdo pain
N&V
testicular torsion signs
firm swollen testicle
retracted upwards (elevated)
loss of cremasteric reflex
abnormal testicular lie (often horizontal)
Rotation of epididymis
Can diagnose based on clinical signs, on USS whirlpool sign tho
testicular torsion management
analgesia
orchidopexy - fixation of testicle within scrotum, usually bilateral.
Orchidectomy if delayed surgery/ presence of necrosis
testicular cancer risk factors
20-30 year old male
Infertility
Undescended testes
family history
Klinefelters
testicular cancer types
Germ cell (produce gametes) - 95%; Seminoma, Non-seminoma (embryonic, yolk sac, teratomas)
Non-Germ Cell - 5%; Leydig Cell Carcinoma, Sarcoma
testicular cancer presentation
painless testicular lump
Hard + irregular
Non Translucent
Gynaecomastia in Leydig Cell cancer
Testicular cancer investigation first line
Scrotal USS
testicular cancer markers
AFP: raised in teratomas
Beta-HCG raised in teratomas + seminomas
Lactate dehydrogenase : non specific tumour marker
testicular cancer staging
Royal Marsden Staging
testicular cancer management
depends on whether seminoma or non-seminoma
Orchidectomy
Chemotherapy
Radiotherapy
Sperm banking
Prognosis of testicular cancer
seminomas have a slightly better prognosis, both over 95% 5 year survival.
Testicular cancer long term side effects
infertility, hypogonadism, peripheral neuropathy, hearing loss
hydrocele presentation
painless
soft scrotal swelling
palpable testicle
transilluminable
no bowel sounds
varicocele- what is it?
pampiniform plexus veins become swollen, most common on the left due to increased resistance in the left testicular vein. left sided varicocele can indicate an obstruction of the left testicular vein caused by a RCC. Can cause impaired fertility due to raising temperature, testicular atrophy
varicocele presentation
dragging sensation
throbbing/dull pain, worse on standing
sub/infertility
varicocele signs
scrotal mass feels like a bag of worms
more prominent on standing
disappears when lying down, if not then raises concerns about retroperitoneal tumours obstructing drainage of the renal vein
epididymal cysts what are they
occur at head of epididymis. fluid filled sac. v common around 30% incidence. usually harmless and not associated w/ infertility or cancer
epididymal cysts- symptoms
may be asymptomatic, or painless swelling in upper testicle
epididymal cysts signs
soft fluctuant mass separate to testicle, typically at the top
may be able to transilluminate large cysts
indirect inguinal hernia what is it
bowel herniates thru the inguinal canal and into the scrum
indirect inguinal hernia symptoms
soft fluctunat bulge in the scrotum. painless swelling in upper testicle
