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Surgery > Urology > Flashcards

Urology Flashcards

1
Q

whats obstructive uropathy

A

blockage–> build up of urine and back pressure into kidneys- impairs renal function

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2
Q

internal urethral spincheter
external urethral sphincter
whats their innervcation

A

internal= ans- smooth muscle
external- voluntary- skeletal muscle

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3
Q

whats vesicoureteral reflux

A

urine refluxing from bladder into ureters

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4
Q

presenrtation of upper urinary tract obstruction

A

loin to groin pain/ flank
no/decreased urinary output
non specific systemic symptoms = vomiting
impaired renal function- raised creatitnine
tenderness in renal angle

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5
Q

presentaiton lower urinary tract obstruction

A

investigations for urinary obstruction diff / inability pass urine - poor flow, diff initiating, terminal dribbling

urinary retention- increased full bladder
impaired renal fucntion - raised creatitine
tenderness in renal angle

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6
Q

investigations of obstructive uropathy

A

us of bladder,kidneys, ureters

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7
Q

casues upper urinary tract obstruction

A

kindey stones
bladder cancer obsturcting ureteral opening
tumours pressing on ureters
ureteral strictures
retroperitoneal fibrosis
ureterocele = ballooning of distal portion of ureter- usulaly congential

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8
Q

casues lower urinary tract obstruction

A

benign prostatic hyperplasia
prostate cancer
bladder cancer blocking urethral opening
urethral strcitures
neurogenic bladder

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9
Q

whats neruogenic bladder and causes and result in

A

abnormal functioning of nerves innervating bladder and urethra

will result in over/under activity of detrusor muslce and spihincter urethra

casues of this are:
MS, diabtetes, stroke, parkinsons, spia bifida, spinal cord/brain injury

results in:
obstructive uropathy, urge incontinence, increase in bladder pressure

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10
Q

magangement of obstructive uropathy

A

need remove/ bypass obstruction

can do nephrostomy for upper tract

suprapubic/ urethral catheter for lower obstruction

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11
Q

complciations of obstructive uropathy

A

pain
aki
ckd
hydronepthrosis
urinary retnetion and bladder distenntion
overflow incontinenc eof urine

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12
Q

whats hydronephrosis and what can casue it and how treat

A

swlling of renal pelivs and calcyes
due to obstruction which casues bakc pressure

ca be due to idiopathic hydronephrosis = narrowing at pelviureteric junction = treat with pyeloplasty to correct narrowing

treatment other casues : treat cause and may need percuatneous nephrostomy/ anterograder uteric stent

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13
Q

presentation hydronephrosis

A

vague renal angle pain
mass in kidney area
may be seen on US/CT scan / iv urogram (xray with contrast)

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14
Q

indications for urinary catheter

A

urinary retnetion due to lower urinary tract obstruction
neurogenic bladde- eg. intermittent use in ms
surgery- before/after
outout monitoring
bladder irrigation
deleiver medication- chemo drugs

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15
Q

patient with enlarge proastate has acute urinary retnetion. insert a catheter. what meds start and the se

A

tamsulosin - alpha blocker
then twoc

se tamsulosin:
postrual hypotention –> dizzy on stnading and falls

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16
Q

how to sample urine from catfher

A

directly from catheter or from sample port using aseptic technique

not from bag

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17
Q

treat catheter associated uti

A

if symmtpoms antibioitcs 7 days
chage catheter soon as can

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18
Q

whats BPH

A

usually men over 50
hyperplasia of epithelial and stromal cells of prostate

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19
Q

presentation of bengin prostate hyperplasia

A

LUTS-
hesitancy
straining
weak flow
urgency
frequency
intermittency- flow start/stop and varies rate
terminal dribbling
incomplete emptyig- chronic retention
nocturia

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20
Q

investigations for bph

A

digital rectal exam
urine dipstick
PSA
abdo exam- palpate bladder?
urinary frequency volume chart - 3 days assess input and output

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21
Q

benign/cancer prostate on digital rectal exam

A

benign- smooth, round, regular, slightly soft, feel midline sulcus, symmetri cal

cancerous - firm/hard, asymetircla, craggt, irregulr, loss central sulcus

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22
Q

causes of rasied PSA

A

high rate of fasle posititves- 75%
false negatives 15%

rasied wih
prostate cnacer
BPH
prostatitis
vigorous exercise- esp cycling
ejaculation/prostate stimulation-anal sex
prsotate biopsy
uti
urinary catheter insertion

no ejactualtion/ vigorous exercise = 48 hrs before

after biopsy prostate/catheter inseertion- wait 6 weeks for psa test

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23
Q

management of bengin prostatic hyperplasia

A

non if mild/manageble
alpha blockers- Tamsulosin - rapid improvement symtpoms
se= postural ht

5-alpha reductase inhibitors - Finasteride - inhibits the 5 alpha reductase that converts tesoterone to DHT (stronger androgen) so helps shirnk prostate - 6 months for impromement of symtpoms se= erectile dysfunction

can use both meds together

surgery-
transurethral resection of the prostate
transurethral electrovcaporisation of the prostate
holmium laser enucleation of the prostate
open prostatectomy - abdo/perineal incision

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24
Q

complicaitons of surgery if bph

A

bleeding
infection
urinary incontience

erectile dysducntion
retrograde ejacualtion
urethral stricutres
may not reolse symtokms

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25
Q

male 60 patient comes in getting dixxy when stand up

what need chack

A

is he on tamsulosin = se is postrual hypotension as relaxes smooth muscle
check supine and standing bp

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26
Q

side effect of finasteride

A

sexual dysfucntion - reduced androgens
- loss libido
ejaculaiton issues
ed
etc

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27
Q

classes of prostatitis

A

acute bacterial prostatitis
chronic prostaitits (symtoms at least 3 months) = two categories for this :
chronic prostiatits/ chronic pelivc pain syndrome (cause may be due to intially infection then inflammation not resolve)

chronic bacterial prostatitis

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28
Q

presentation of prostatitis

A

LUTS - dysuria, frequency, retention, hestitancy
pelivc pain- can be sctorum, perineum, testicular, penis, rectum, lower back, groin, suprapubic pain
sexual dysfunction- ed, haematospemia, pain on ejaculation
pain on bowel movement
tneder/enlarged prostate- could be normla though

acute bacterial prostotos have more rapid onset symtpoms and aslo sytemic symtooms - fever, mylagia, sepsis, nasuea, fatigue

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29
Q

investigations for prostitis

A

urine dipstick- psotive in acute, may be postive with chronic bacterial but may not show unless got acute uti. use urine microscopy, culture, sneeitivity- psotive in chronic and acute bacterial prostaittis
digial rectal exam
abdo exam- bladder, genital exam
chlamydia, conhorrea NAAT testing if suspet sti
psa for chronic to rule out prsitate cancer

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30
Q

management acute bacterial prosatitis

A

hosp admission if systemically unwell - bloods. iv antibiotcs
oral antibiotcs 4-6 weeks first line: ciprofloxacin/ofloxacin (if not use these then trimethorprim)
anaglesia- nsaids/ paracetamol
laxatives to help pain on bowel movement

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31
Q

management of chronic prostatits

A

alpha blockers if signs of LUTS - tamsulosin -4-6 weeks= gives rapid improvmenet
anaglesia- paracetamol/nsaids
psycholgicxal- cbt/ anti depressants
abx if had less than 6 moths of symtpomd or if had hisotry of an infection = trimethoprim/doxycycline 4-6 weeks
laxatives if pain on bowel movement- lactulose/ docusate

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32
Q

where prostate cacer metasise to

A

lymph nodes
bones

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33
Q

featyrs of prostate cancer - where it growa, tyoe

A

almost always androgen dependant
most are adenocarcinomas and grow in peripheral zone

balance betqeen wanting to find cacner early but not pick up cancers that wouldnt be concerning - die before have prostate cancer symtpoms

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34
Q

risk factors prostate cancer

A

increased age
fam hist
black african/carribean
tall
anabolic steroids
obesity

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35
Q

presentation of prostate cancedr

A

can be asymtpomatic
may have luts same as BPH-
hestiacnt, frequency, weak flow, terminal dribbling, nocturia
haematuria
Erectile dysfunction
sighs of progressed cacer/metases- weight loss, bone pain, cauda equina

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36
Q

investigations
prostate cancer

A

pr exam- irregular, craggy, nodular, hard/firm, asymemetrocial, loss central sulcus = any these 2ww

firs tline after thayt is Multiparametric MRI of the prostate - do if susepcted localsied cancer
this gives likert scale 1 is v low suspicion 5 is definite cancer

then based on likert scale 3 or more/clinical suspicion do prosate biopsy

isotope bone scan - bony metasteses

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37
Q

prostat ebiopsy score used

A

gleason grading system -
1 closes to normal histology
use two number for the two most common cells

6 low risk
7 mid risk
8 or above high risk

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38
Q

risk biopsy

A

infection
pain- perineal, rectal, lower abdo
bleeding- in stool, urine, semen
urinary retention short term due to prosate swelling

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39
Q

mangement of prostate cancer

A

watch an wait
external beam radiotherapy
brachytherapy- insert radioactive metal seeds in prostate
hormone therpay
surgery- prostectomy

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40
Q

complications of external beam radioatherpy and how treat that complcation

A

can casue proctitis
= pain, altered bowel habit, rectal bleeding, discharge from rectum

treat with predinisolone suppository

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41
Q

complciation of brachytherapy

A

the radioactive can cause inflammation of other organs nearby- proctitis, cysittis
can casue ed and incontiencne. can in crease risk of bladder and rectal cancer

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42
Q

complication of prostatectomy

A

ed
urinary inconeitnce

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43
Q

hormone therpay treatment for prostate cancer
and se

A

aim reducde androgen
GnRH agonist - goserelin/ leuprorelin
androgen receptor blockers- bicalutamide
bilateral orchidectomy - rare to do but removing testicles

SE
hot flushes
fatigue
osteoporosis
gynaecomastia
sexual dysfucntion

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44
Q

what age can a man request a psa

A

over 50

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45
Q

wheres sperm stored and mature

A

epididmyis

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46
Q

causes of epididymo-orchirtis

A

e coli
chlamydia trachomatis
neisseria gonorrhea
mumps

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47
Q

pt has parotid gland swelling and orchtitis
what casue

A

mumps
if got parotid gland swelling and orchitits then suspect mumps

mumps tends to spare the epidiymius

mumps can also casue pacnreatitis

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48
Q

presetation of epididymoorchitits

A

relatively acute onset- mins to hrs
usulally unilateral
testicalu pain
tenderness on palpation - esp over epididmyis
dragging/ heavy sensation
swelling of testicle+/epididymis
urethral discharge - chlamydia/gonorrhea
systenic symptoms- n and v, fever, sepsus

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49
Q

what differential diagnosis for epididymoorchitis

A

testicular torsion- if unsure treat as this until proven diff

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50
Q

investigfations for epididymoorchitits

A

need to distinguish if sexually transmitted organism or if enteric organsim (e.coli)
urine microscopy, sensitivity and culutre
gonorrhea and chlamyida naat testing on first pass urine if suspect sti casue
charcoal swab of purulent urethral discharge for gonorrhea culture and sensitivities
saliva swab for pcr if mumps suspected
serum antibodies for mumps if suspected- IgM= acute infection, IgG= previous infection/vaccinated
ultrasound to asses torsion/tumour

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51
Q

when would you suspect sti the casue of epididymoorchitits

A

under 35
high number of sexual partnes in last 12 months
urethral discharge

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52
Q

management of epididymo orchitits

A

if v unwell/ sepsis- hosp for iv antibiotics

if risk of sti refer to GUM

if low risk sti casue then give ofloxacin 14 days - frist line

or levofloxacin 10 days
or if quinolones contraindicated give co amoxiclav

can give doxycycline

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53
Q

when are quinolones used - good for

A

broad spectrum abx
v good for gram negative
used for uti, pyeloneprhittis, epididymo orchitits, prostitis

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54
Q

se of quinolones

A

tendon damage/ rupture- esp achilles tendon
lower thresholf ofr seizures- be careful in epipleptic patients
qt interval prolongation
fungal infection

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55
Q

complications that epididymo orchitits can casue

A

chronic pain
chronic epididymitits
testicular atrophy
subfertility/infertitlity
scrotal abscess

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56
Q

whats testicular torsion

A

urological emergency
spermatic cord twists with the roation of the testicle- cuts of blood supply to testicle

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57
Q

male comes in with abdominal pain
what need to examine

A

testicles o exclude testicular torsion

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58
Q

causes of testicular torsion

A

often triggered by acittivty eg. playing sports
bell clapper deformity - testicle and tunica vaginalis not fixated together like normally should-> testicle hangs more horizontally and can rotate within the tunica vaginalis and twist the spermatic cord

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59
Q

presentation of testicular torsion

A

acute onset unilateral testicular pain
may have abdo pain and vomiting
!sometimes abdo pain is only symptom in boys!

o/e
swollen frim testicle
elevated/retracted testicle
absent cremasteric reflex
abnormla testicular lie- more horizontal instead of more vertical
rotation- epididymis not at usual posterior position

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60
Q

investigation for testicualr torsion

A

dont really
if examination and history suspect go straight to treatment as any delay can increase ishcemia and increase chance of necrosisi

can do scrotal us and see whirlpool sign = spiral appearance to spermatic cord and bv

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61
Q

management of testicualr torsion

A

urgent treatment
nil by mouth- ready fir surgery
analgesia
surgical exploration of scrotum
orchiopexy= correct postitioning of testicle and fixathion in place
orchidectomy- remove testicle if surgery is delayed/necrosis

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62
Q

when taking hisotry of testicualr pain what need ask

A

when did the pain start - testicualr torsion normally during activity
had it before - can have reoccurence where have intermittend testicualr torsion

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63
Q

causes of scrotal/testicular lump

A

testicular cancer
epididymo-orchitits
hydrocele
varicocele
epididymal cyst
inguinal hernia
tesiticular torsion

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64
Q

whats a hydrocele

A

collection of fluid in the tunica vaginalis

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65
Q

presentation of hydrocele

A

usually painless
soft scrotal swelling
transilluminated and see testicle floating
testicel palpable
soft, fluctuant and may be large
irreducible and no bowel sounds- differentiate from inguinal hernia

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66
Q

cause of hydroele

A

idiopathic
secodnary to:
testicular cancer
epididymo-orchitits
trauma

67
Q

management of hydrocele

A

exclude serious cause
idiopathic- mangage conservcatively
if symptomatic/large= surgery/ aspiration/ sclerotherapy

68
Q

whats varicocele in a testicle
and cause

A

veins in the pampiniform plexus that drains the testicle are swollen

pampiniform plexus drains the testicles and this plexus is in the spermatic cord. it helps regualte temp of testis as lies next to the testicular artery and so abosrbs heat from blood going into the testicle.
pampiniform plexus drains into the testicular vein

R testicualr vein drains into the IVC

L testicular vein drains into the L
renal vein

if theres increased resitance in the testicualr vein then have varicocele as blood cant exit the paminiform plexus/ if the valves in the testicualr vein are incompetant then blood flow back into the paminifrom plexus

69
Q

which side is most comon for vcaricocele

A

left side varicoele are most common -90%

70
Q

left sided varicoele can indicate what

A

renal cell carcinoma -

the left testicualt vein drains into the left renal vein. if theres an obstruction in the left testicualr vein that can be casued by renal cell carcinoma then back pressure and pampiniform plexus cant drain so varicocele

71
Q

complications of varicoele

A

subfertility/inferitliy- temp not regualted
testicular atrophy- reduced size and function

72
Q

presentation of testicualr varciocele

A

throbbing/dull pain worse on standing- gravity
dragging sensation
subfertility/infertility present with

o/e=
scrotal mass feels like bag of worms
more promintent on standing
disappears when liw down- if dont then concern for retroperitoneal tumour blocking the drainage of the renal vein L
asymmetry of testicle sizeaffected by growth

73
Q

why if the scortal swelling of a testicular varicocele doesnt disparea on stadning be for concern

A

if its left then this suggest that theres retroperitoneal tumour blocking the drainage of the renal vein (l testicular vein drain into the l renal vein)

74
Q

management of testicualr varciocele

A

conservativielt
surgery/endovascualr embolisation if pain/testricualr atrophy/ inferitltiy

75
Q

investigfations for testicualr vcaricocele

A

us doppler for confrim dx
semen analysis if concern fertilit
hormonal test- fsh and testosterone if concern testicle function

76
Q

whats an epididymal cyst

A

fluid filled sac on epididymis

77
Q

whats a spermatocele

A

cysts containing semen on epeididymis - same mangaemt of epididmal cysts

78
Q

presentaiton of epidiymal cyst

A

very common
mmost asyptomatic just feel lump
soft round lump
may be transillinate large cysts
normaly at head of epididymis (top of testicle)
associated with epididymis
seperate from testicle
can have torsion of cysts so acute pain and swelling but v rare

79
Q

treatment epididymal cysts

A

usually harmless
if pain / discomfrot then reoval

80
Q

what cells does most testicular cancer arise from

A

germ cells- make gametes
are other rarer ones and metasteses

81
Q

types of testicular cancer

A

seminomas
non seminomas= mostly teratomas

82
Q

risk factors of testicualr cacner

A

most common in young men 15-35 yrs old
undescended testes
male infertility
tall height
fam hist

83
Q

presentation of testicualr cancer

A

painless lump
can have testicular pain
lumps is :
non tender may eve have decreased sesation
non fluctuant
irregular
non transillumination
hard

rarely can have gynaecomastia - esp in leydig cell tumour

84
Q

investifations for testicualr cancer

A

scrotal us - first line for diangosis
tumour markers-
alpha fetoprotein= may be raised in teratomas
beta hCG - may be rasied in teratomas and seminomas
LDH(lactate dehydrogenase) = non specific tumour marer

staging CT

85
Q

what staging system is used for testicualr cacner

A

royal marsden staging system
1= isolated to tesicle
2= lymoh nodes retroperitoneal
3=lymph nodes under diagphrgm
4= metasitise to other organs

86
Q

where are the common palces testicualr cancer can metastisie to

A

brain
liver
lungs
lymphatics

87
Q

managemnt of testicualr cacner

A

surgery- orchidectomy - can have prosthetis
chemo
radiotherpy
sperm banking- rx may casue infertility

88
Q

long term side effects of testicualr cancer treatment

A

big impact as men young and expected to live long after treatment

hearing loss
peripheral neuropathy
infertility
renal lung and heart damage
increase risk of cancer in furtutre
hypogonadism= may need testosterone replacmeent

89
Q

prognosis and what to do once treated with testicualr cancer

A

good prognosis for testicualr cacner esp if eaerly 90% cure. even metastatic is curable. seminomas slightly better prognosis

monitor for reoccurenace- ct, tumour markers, cxr

90
Q

whats a lower urinary tract infection

A

infection of bladder casuing cystitis
can spread up to kidneys and cause pyelonephritits

91
Q

risk factors lower uti

A

Sex
woman
poor hygiene
incontinence
urinary catheter

92
Q

casues of lower uti

A

e coli!!! = gram negative, anerobic, rod shaped

klebsiella pneumonia
pseudomonas aerguinosa
staphylcoccus saprophyticus
candida albicans- fungal

93
Q

resentation of lower uti

A

dysuria- pain, burning, stinging on passing urine
frequency
urgency
incontinece
cloudy/foul smelling urine
suprapubic pain/discomfort
haematuria
confusion! - esp aelderly frail only symtpoms sometimes

94
Q

hpw to know difference to lower uti and pyelonephritis

A

pyeloneprhtitis susepct if :
fever
loin/ back pain
renal angle tenderness on examaintion
nausea and vomiting

95
Q

investigations for lower uti

A

urine dipstick
mid stream sample for microscopy, sensitivity and culutre if :
pregnant
pt with recurrent uti
atypical symtoms
not improing after abx

96
Q

nitrites

A

uti treat
gram negfative bacteira convert nitrates to nitrites

97
Q

leucoytes

A

treat uti if got clinical signs

98
Q

leukocytes and rbc

A

treat uti

99
Q

nititires and lekocytes

A

treat uti

100
Q

rbc in urine mean

A

uti
bladder cancer
nephritits

101
Q

leukocytes in urine mean

A

infection
other cause of inflammation-

102
Q

treat uti with

A

nitrofurantoin - not if eGFR under 45

trimethorpim

other:
pivmecillinam
amoxicillin
ciprofloxin

3 days if simple uti women
5-10 days if immunosupressed woman, abnormal anatomy, impaired renal funnction

7 days man, pregant woman, catheter uti = and change catheter

103
Q

treatment for pregnant women uti

A

uti increase ris of pyelonephrotits, premature rupture of membranes, pre term labour

do MSU for cutlure and microscopy and sensititivites

7 days abx: nitrofurantoin (not 3rd trimester as casue neonatal haemolysis)
amoxicillin if senstivies say
cefalexin

try an avoid trimethoprim most times but defo dont give it in forst trimester as its a folate antagonist so will casue congenital malformations - spina bfidia

104
Q

lady
immunsupressed
uti

treatment

A

5-10 days antibiotcs
nitrofurantoin
trimethoprim

pivmecillinam
amoxicillin
cefalexin

105
Q

pregnat lady
2nd trimester
uti

treamtnet

A

nitrofurantoin can be given as not in 3rd trimester
7 days
msu for culture and microscopy and sensitivties

106
Q

when not to give nitrofurantoin to pregnant lady for uti

A

not in 3rd trimester as causes neonatal haemolysis

107
Q

when to not give trimethoprim to pregnant lady with uti

A

not in frist trimester as casue congential malformation as folate antagonist - spina bfida

try to not give it at all though

108
Q

whats pyelonephritits

A

inflammation of the kidney die to bacterial infection that casues inflammation of the renal pelvis and parenchyma

109
Q

risk factors of pyelonephritits

A

pregancy
diabetes
female
structural urological abnormalities
vesico-ureteric reflux= usually childrne

110
Q

casues of pyelonephritits

A

e.coli- gram negative , rod shaped anerobic

klebsiella pneumoniae
staphylcoccus saprophyticus
psuedomonas aeurogniosa
enterococcus
candida albicans= fungal

111
Q

dysuria
suprapubic disconfort
fever
vomiting
loin pain

what is this

A

pyeloneprhtitis

112
Q

presentation of pyeloneprhtitis

A

luts-
dysuira, suprapubic disomfort, increased frequency
plus triad of:
fever
n/v
loin/back pain- unilateral/bilateral

can also have:

systemic illness
loss appepties
haemoaturia
renal angle tenderness o/e

113
Q

investigfations for pyelonepthritits

A

urine dipstick=nitrites, leukocytes, blood
msu for microscopy, sentivies and culture
bloods- raised wbc and crp
us/ct scan for other pathologies= kidneys stones/abscess

114
Q

management of peylonephritits

A

hosp if sepsitis features

antibiotics 7-10 days
cefalexin
co-amoxiclav - if culture results available
trimethorpim- if culture resutls available
ciprofloxacin= se are tnedon damage and lower threshold seizures

if sepstic:
sepsis 6
- blood lactate
- blood culture
- monitor urine output
- give oxygen sats aim 94-98% (88-92% copd)
- iv fluids
-iv broad spectrum abx

115
Q

if patient on abx for peylonepthritis not improving consider what

A

renal abscess
kidneys stone obstructing ureter causing pyelonepthritis

116
Q

whats chronic peylonepthritis

A

recurtrent epidosdes of pyelonephritits
–>
recurrent infections causes scaring of parenchyma –> cks–> end stage renal fialure

117
Q

what investifation do for chronic pyelonephritits

A

DMSA scan (dimercaptosuccinic acid)
inject radiolabeled DMSA
healthy kidney takes it up- scarred/ damage areas dont take it up
can see gamma camera areas of scarring

118
Q

whats interstitial cystitis

A

also called hypersentive bladder syndrome / bladder pain syndrome

chronic condition causing inlfammation of bladder resulting in LUTS and suprapubic pain

119
Q

presentation of interstitial cystits

A

more common in women
similar to lower UTI but more persitiant
usually over 6 weeks of: suprapubic pain- can be worse on full bladder and relived on emptying frequency
urgency
symtoms may be worse during menstruating

120
Q

inverstivations interstital cystitis

A

exclude other casues
urinalysis - uti
cystosctopy= bladder cancer
swabs - sti
prostate exam- cancer, prostatits, bph

121
Q

what see on cystoscopy in interstital cystitis

A

hunner lesions = red, inflammed pathces of bladder mucosa 5-20% have
granulations- tiny haemorrhages on bladder wal

122
Q

management of interstital cystitis

A

supportive:
diet - no alcohol, caffeine and tomatoes
stop smoking
cbt
retrain bladder
pelivc floor exercises
TENS

meds:
analgesia
antihistamine
anti cholinergics- solefenacin, oxybutynin
mirebegron= beta 3 adrenergic agonsit
cimetidine- histamine 2 r antagonist
pentosan polysulfate sodium
ciclosporin- immunsupressant

intrevesical meds- directly to bladder:
lidocaine
pentosan polysulfate sodium
hyaluronic acid
chondroitin sulphate

hydrodistention- GA fill bladder with water to high pressure - temorary improve symtoms 3-6months

surgical:
cauterisation of hunner lesions - cystoscopy
butulinum toxin injections during cystoscopy
neruomodulation with implanted electrical stimulator
augmentation of bladder using section of iluem to increase capacity= ileocystoplasty
cystectomy

123
Q

patient presents with lUTS

differentials

A

lower UTI
pyelonephritits
interstital cystitis

124
Q

where does bladder cancer arise from

A

urothelium- epithelial cellsof bladder

125
Q

risk factors bladder cancer

A

increased age
smoking
aromatic amines- in rubber and dye now bannned/regulated - in cigarettes too = its a carcinomgen for bladder cancer
schistosomiasis= casues squamous cell carinoma in countries of high prevelance of infection

126
Q

patient painless hameaturia and worked in rubber facotry

A

bladder cnacer

127
Q

types of bladder ancer

A

transistional cell carcinoma=90%
squamous cell carcinoma= 5% but higher in areas of schistosomasis

tohers:
small cell carcinoma, adenocarcioma, sarcoma

128
Q

preentation bladder cancer
when do 2 ww

A

painless haematuria]

over 45 and unexplained macroscopic haematuria without uti / uti presisting after rx

over 60 and microscopic haematuria and dysuria/ raised wbc on fbc

129
Q

over 60 with recurrent unexplained uti

A

non urgent referal to check bladder cancer

130
Q

diangosis of bladder cancer

A

cycstoscopy

staging:
non invasive muscle bladder cancer = Tis (cancer cells in urothelium and flat)
ta= urothelium and proturde into bladder
t1= into the connective tissue but not muscle

invasive bladder cxancer- T2-4

131
Q

treatment of bvladder cancer

A

chemo / radiothepry
transurethral resection of bladder tumour - for non muslce invasive cancer - during cystoscopy

intravesical chemo

intravescial BCG(same vaccine TB) - stimulates immunsystem to attack bladder caner

radical cystectomy

132
Q

whats the ways urine can drain out once had a cystectomy

A

urostomy with ileal conduit = most common- use secion of the ileum (anastamose the bowel back together). anatsamose the urethers to the ileal section and then the ileum forms a stoma on the skin draining into a urostomy bag - bag needs be away from skin as urine irritate and damage the skin

continet urinary divcersion- use ileum as above but no urostomy bag so doesnt drain freely have to insert catheter intermittently into stoma to drain the urine fromthe ileal pouch

neobladder reconstruction- use section of ileum and connect urethers and urethra to it - may need washouts to clear the ileal secretion

uretersigmoidostomy - ureters into sigmoid and create a rectosigmoid puch for urine to stay in and then open bowels and urine will aslo come out - not used much now as electroylte imbalance, infection of kidneys and secondary cacer at the uether and sigmoid anastamoses

133
Q

names for kidney stones

A

renal calculiculi
urolithiasis
nephrolithiasis

134
Q

key complications of kidney stones

A

obstruction leading to aki
infection with obstructive pyelonephrittis

135
Q

common place kideys stones get stuc

A

vesicouteric junction

136
Q

types kidneys sotnes

A

calcium based= most common
- calcium oxalate - more common
- calcium phosphate

uric acid - not seen on xray
struvite- produced bby bacteria = assocaited with infection
cystine - associated with cystinuria - autosomal recessive disease

137
Q

whats staghorn calciculi and common stone made of

A

form in shape of renal pelvis
may be seen on xray
most commonly occurs with struvite stones

occur in reccurent upper uti as bacteria hydroylse the urea to amonia

138
Q

presentation of kidney stones

A

can be asymptomatic and cause no priblesm but if symtpomatic :

renal colic:
- unilateral loin to groin pain and can be excruiciating
- colicky pain- fluctating severity as stone moves

can also have :
reseltess moving due to pain
haematuria
nausea and vomiting
decreased urine output
symptos of sepsis if present

139
Q

investigfations for renal stones

A

first line: non contrast CT of bladder, ureters and kidneys - try do within 24 hrs of presentation

urine dipsick may show haematuriea- if normal doesnt exclude stone

bloods- serum ca, raised infpam if infection, see kidney funciton

abdo xray - see ca based stones

us - less effective but good if children/ pregant women

140
Q

managemen tof renal stones

A

nsaids- rectal/oral diclofenac
antiemetics- metoclopramide, cyclozine, prochlorperazine

abx if infection
watch and wait if less than 5mm - can use tamulosin to help (alpha blocker )
surgical intervention if larrge 10mm or more or if not passing or if complete obstruction

surgical interventions:
extracorporeal shock wave lithotripsy
ureteroscopy and laser lithotripsy
percutaneous nephrolithotripsy - done under GA
open surgery

141
Q

what can you do for patientshtat have recurrent stones

A

adivse:
increas fluid oral intake 2.5-3l/day
fresh lemon juisce to water as helps bind to ca in urine
avoid carbonated drinks - promotes oxalate formation
decrease salt intake
maintain normal ca intake - low ca can actually promote ca stones
limit diet protein

ca stones:
reduce oxalate rich foods= beetroot, nuts, spinahc, rhubarb, black tea

uric acid stones:
reduce purine rich foods=
liver,kidneys, spinach, anchovies, sardines

meds to reduce recurrence:
thiazide dieuretics (indapomide) = forpatients with ca oxalate stones and high urine ca
potassium citrate = ssame as above

142
Q

risk facotrs of ca stones

A

hypercacliumea
low urine output

143
Q

casue sof ca stones

A

high ca:
hyperparathryoidsim
ca supplementation
cancer

144
Q

types of renal cell carcinoma

A

renal cell carcinoma is a type of adenocarcinoma
renal cell carcinoma is the most common type of kideny tumour

types of renal cell adenocarcioms:
clear cell- 80%
papillary-15%
chromophobe -5%

wilms tumour is a specific type of tumour seen in childrentypicallt under 5

145
Q

risk factors renal cell carcinoma

A

obesity
smoking
hypertension
end stage renal failure
con hippel lindau disease
tuberous sclerosis

146
Q

haematuria
flank pain
palpable mass of kideny on oe

A

renal cell carcinoma

147
Q

presentation of renal cell carcinoma

A

haematuria
flank pain/ vague loin pain
palpable mass o/e
can be asymptomtic
weight loss
dec apeptie
night sweats
fatigue

can also get paraneoplastic features

148
Q

when do 2 ww for renal cell carcinoma

A

over 45 with visible haematuria without uti/presitant uti depsite rx

149
Q

where does renal cell carinoma spread to

A

tissues around kidney and withi in the gerotas fascia

renal vein to ivc

150
Q

feature of renal cell carinoma on cxr of lungs

A

cannonball metastases
= cleary defined circular opacities scattered throughout lung fields in cxr

151
Q

whats cannonball metases in lungs a featre of

A

renal cell carcinoma

can also be a feature of choriocarcinoma (placental cacner)
and less commonly in prostate, bladder and endometrial cancer

152
Q

whats the paraneoplastic features that can be associated with renal cell carcinoma

A

hypercalcaemia - hormone secreted similar to PTH - can also be due to bony metastes

hypertension- physical compression, increased secretion of renin, polycythaemia

polycythamia = due to increased unregulated secretion of erythropoeitin= increased risk thrombosis

stauffers syndrome - raised LFTs- raised alt, ast, alp, billirubin without liver metastases

153
Q

satging renal cell carcinoma how to

A

ct thorax abdo and pelivs

154
Q

management of renal cell caricnoma

A

partial nephrectomy
radical nephrectomy

if not suitable for surgferu:
arterial embolisation- cut off blood supply to affected kidney

percutaenous cryotherpay- liquid nitrogen injected to freeze and kill tumour cells

radiofrequency ablation

chemo/radiotherpay

155
Q

patient has renal failure
has suspected pe
investigation

A

vq scan - not ctPA cus that has contrast in

156
Q

posotives of renal transplant

A

adds 10 years life compared to dialysis
improves q of l

157
Q

donot matching for renal transplant

A

match HLA on chr 6
if donor alive can desensitise pt to their hla
doesnt have to match perfect, but better match the better chance working and no rekection

158
Q

pt had renal transplasnt
what can you see on them in an examination

A

brachio-cephalic av fistual - left in for dialysis if needed again
hockey stick scar in iliac fossa area
may be able to palpate kidney in iliac fossa
if ballot the pt own kidneys if enlarge may feel them if their pathology casues them to be
seborrheic warts = due to immunosupressants
skin cancer/scxar from skin cacner removeal= due to immunosupressant s
gum hypertrophy- due to cyclosporine - option of immunsupressant
cushing syndrome - due to steroids
tremor- due to tacrolimus

159
Q

procedure of renal transplant

A

leave kideys in place
put new kideny in iliac fossa with hockey stick incsiion
connect donor kidney bv to pelivic vessels- external iliac vessels
ureter of kidey anatstamosed to bladder

160
Q

treatment for after renal transplant

A

immunosuprresants life long :
tacrolimus
prednisolone
mycophenolate
= usual regime
others:
cyclosporine
azathioprine
sirolimus

161
Q

se of the immunosuprresants on for rneal transplant

A

tacrolimus= tremor
immuosuppresants= seborrheic warts, skin cancer (esp squamous cell carcinoma)
predinosolone= chsuhings syndrome
cyclosporine = gum hypertrophy

162
Q

complications of renal transplant

A

transplant:
rejection- hyperacute, acute, chronic
failure
electroylte imbalance

immuosupressants :
ifection- more likely, more severe, unusal
skin cancer- squamous cell carcinoma
non-hodgkin lymphoma
ischemic heart disease
type 2 diabetes- due to steroids reducing bodys senstivity to insulin (cant take up glucose into cells so need more insulin= insulin resistance)

infections secondary to immunosupresants

163
Q

what infections are secondary to immunosupressants esp i renal treansplant

A

cmv= cytomegalovirus
pcp/pjp= pneumocytits jiroveci pneumoniaE
TB

Surgery (7 decks)

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