Urology Flashcards
When during urination does blood appear, indicates what?
Initial - diseased urethra, distal to UG diaphragm
Terminal - disease near bladder neck, prostatic urethra
Throughout - disease in bladder or upper urinary tract
What are lower urinary tract symptoms? [FUN DISSH]
storage: frequency, urgency, nocturia
voiding: terminal dribbling, intermittency, poor stream, straining, hesitancy
others: polyuria, oliguria, urethral discharge
What causes storage problems?
UTI, stones, bladder tumour
What causes voiding problems?
BPH, prostate cancer, urethral stricture
Upper urinary tract symptoms
Loin pain/tenderness
Severe loin pain w radiation to iliac fossa, groin, genitalia
What causes upper urinary tract symptoms?
Renal infection, infarction, obstruction, glomerulonephritis
radiating pain caused by acute obstruction of renal pelvis/ureter by calculus/blood clots
Hallmark of malignancy in urology
Painless gross haematuria in patient >35 years old
Urine characteristics of glomerular bleeding
Frothy - proteinuria
Blood - smoky brown, “coca-cola”
no clots
some RBCs are dysmorphic
RBC cast may be present
Urine characteristics of extraglomerular bleeding
Red or pink blood
Blood clots may be present
Non frothy - no proteinuria
Normal RBC
RBC casts absent
Presence of RBC casts diagnostic of?
Glomerulonephritis / vasculitis
Different aetiologies for post-renal haematuria
Trauma
Infection
Stones
Tumours
BPH
Renal causes of haematuria usually present
microscopically
Risk factors for RCC
Smoking
Industrial exposure
Prior kidney irradiation
Family history - VHL, tuberous sclerosis
Acquired polycystic kidney disease - secondary to chronic dialysis
Types of RCC and which part of collecting duct system they arise from (3)
clear cell RCC - proximal tubule epithelium
Papillary RCC - distal tubule
Chromophobe RCC - collecting ducts
Prognosis of each type of RCC
clear cell - resistent to chemo & radio
papillary - type 1 good, type 2 poor
chromophobe - excellent
Ddx for renal masses
(split benign and malignant)
Benign:
- angiomyolipoma (most common benign)
- renal cysts
- renal abscess
- pyelonephritis
- renal oncocytoma
Malignant:
- RCC
- Wilm’s tumour (nephroblastoma) more common in kids
- Metastases
- Sarcoma
Triad of presenting symptoms for advanced renal tumours
Painless haematuria, flank pain, palpable flank mass
Common regional symptom of RCC
Left testicular varicocele
Tumour invades into left renal vein, blocks drainage of left testicular vein that empties
Paraneoplastic syndromes of RCC
Hypertension - renin overproduction
Hypercalcaemia - production of PTH-related peptide, acts like PTH, bone resorption
Polycythaemia - EPO production
Cushing’s, feminisation/masculinisation
Kidney tumour limited to kidney is stage ___, progression to stage ___ occurs when ___
2
3 - when tumour invades major vessels/adrenal gland
Difference between total and radical nephrectomy
Total: remove kidney
Radical: ligate renal artery/vein + remove kidney + Gerota’s fascia +/- adrenal gland
What is milk-alkali syndrome?
Repeated calcium & alkali ingestion leading to
hypercalcaemia + metabolic alkalosis + AKI
predisposes to stone formation
Non-modifiable risk factors for urolithiasis
Age
Gender (M)
Cystinuria
Inborn error of purine metab
Crohn’s - hyperoxaluria
HyperPTH - hypercalciuria
Gout - hyperuricosuria
Points of constriction of the ureter
Pelvic-ureteric junction (where pelvis of kidney meets ureter)
Pelvic brim (near common iliac artery bifurcation)
Vesico-ureteric junction (entry to bladder)
What stones are radiopaque on X ray?
Calcium oxolate
Calcium phosphate
Struvite (magnesium, ammonium, phosphate)
What stones are radiolucent on X ray?
Urate
Cystine
Struvite stones are formed due to?
Infection with urease positive bacteria (Proteus, Staph. sapro, kleb)
Hydrolyse urea to ammonia, make urine alkali -> Staghorn calculi form
Causes of stone formation (3)
Supersaturation
Infection
Drugs
Ureteric stone presentation
Ureteric colic pain - severe, intermittent loin to groin (+- ipsilateral testis/labia)
Haematuria
Upper UT infection - fever
Stone at VUJ - frequency, urgency, dysuria
Renal stones presentation
Asymptomatic unless block PUJ -> hydronephrosis -> infection -> pyonephrosis
Vague flank pain
Large staghorn calculi can completely fill kidney pelvis + calyces -> chronic renal failure
Bladder stone symptoms
Storage LUTS - frequency, urgency
Dysuria
Haematuria
Drugs that increase risk of stone formation
Acyclovir
Antacids
Salicylic acid
When is a stone unlikely to pass with conservative management?
> 1 month, probably too large to pass on its own
Complications of stone
Blocks urine flow -> UTI
Damage renal tissue
Bleeding
Increase in size
Types of bladder cancer
Transitional cell carcinoma (most common)
Squamous cell carcinoma
Rhabdomyosarcoma (children)
Risk factors for bladder cancer
Industrial exposure: rubber workers, textile/printing industries
Non-industrial:
smoking
analgesia abuse
chronic parasite infection - schistosoma (causes SCC)
chemo, chronic cystitis from radiation
LUTS in relation to bladder cancer
Storage problems - carcinoma in situ
Voiding problems - cancer at neck of bladder/prostatic urethra
Dysuria, pyuria
Where can bladder tumour invade and what does it cause?
Colon (vesico-colic fistula) - pneumaturia
Vagina (vesico-vaginal fistula) - incontinence
Aetiologies of acute urinary retention
Mechanical:
- BPH
- Stricture - STD, instrumentation
- Stones
Functional:
- Drugs - anticholinergics
- UTI
- Spinal cord compression
- Neurogenic bladder
Bladder is percussible when containing ___ of urine, palpable when more than ___
150mL
200mLs
DDx classification for ARU
Mechanical - extraluminal, mural, luminal
Functional - infection, neurologic impairment, drugs, others
Extraluminal causes of ARU
BPH
prostate cancer
constipation
pelvic masses
pelvic organ prolapse
Mural causes of ARU
TCC of bladder neck
Strictures
Urethritis
Luminal causes of ARU
Stones
Strictures
Foreign body
Blood clot
Functional causes of ARU
neuro - cord compression (Cauda equina syndrome)
infection
drugs - anticholinergic, sympathomimetic, cardiac meds, pain meds, psychiatric meds
others - post anaesthesia, pain
AdenoCA of prostate commonly occurs in ___ zone
peripheral zone
*palpable on DRE
Symptoms of prostate cancer
symptoms of BPH (DISH) + haematuria + dysuria
BPH commonly occurs in ___ zone
central
Major stimulus of prostate hyperplasia
dihydrotestosterone
produced by testosterone via 5-alpha reductase
BPH cardinal features
- voiding LUTS
- storage LUTS (complication of urine retention - UTI, stones)
- haematuria
- ARU
- overflow incontinence
Complications of BPH
- hydroureter
- hydronephrosis
- pyonephrosis
- pyelonephritis
- hernia
Enlarged prostate: ___ on DRE
> 3 finger breadth
intact median sulcus
no nodule
firm
smooth rectal mucosa, not attached to prostate
Questions to differentiate testicular swellings (4)
1) Whether can get over testis
2) Whether can differentiate testis from epididymis
3) Whether transilluminable
4) Whether tender
Testicular torsion happens in ___
peri-pubertal age group (12-18 yrs)
How to differentiate torsion from epididymitis
Prehn sign
-ve in torsion: lifting testis does not relief pain
+ve in epididymitis
What is Fournier gangrene
Necrotising fasciitis of the perineum & genital region frequently due to synergistic polymicrobial infection
Risk factors of fournier gangrene
Diabetes, alcoholics, immunocompromised
Scrotal varicocele commonly occurs on the ___. Why?
Left hemi-scrotum
Left spermatic vein enters left renal vein at perpendicular angle. Intravascular pressure in left renal vein higher than right (compressed between aorta and SMA). Higher backpressure -> varicocele.
Risk factors for testicular tumour
Cryptorchidism - failure of testicle to descend
HIV
gonadal dysgenesis
Most common type of testicular tumour
Germ cell tumours - especially seminomatous
Seminoma prognosis
Excellent prognosis
Highly responsive to radiotherapy
Metastasize late
Non-seminomatous germ cell tumour prognosis
Variable response
sensitive to chemo
metastasize early
Testicular torsion causes irreversible damage after ___
12 hours
Clinical presentation of testicular torsion
Acute abdomen (T10 innervation)
Nausea + vomiting
No voiding complaints, dysuria, fever, STD exposure
