Urology Flashcards
What is the commonest type of bladder cancer?
transitional cell / urothelial bladder cancer
what subtype of bladder cancer does schistosomiasis predispose you to?
SCC
What predisposes you to SCC bladder cancer?
Carcinogens
- tobacco
Infection: chronic inflammation of the urinary tract that can lead to the transformation of urothelial cells into squamous epithelial cells (squamous metaplasia)
- schistosomiasis
- recurrent / persistent UTIs
- chronic nephrolithiasis and bladder calculi
What are the different types of bladder cancer that you can get?
transitional cell (=urothelial) cancer - most common 90%
SCC
adenocarcinoma (rare)
Management of bladder cancer
Surgery + neoadjuvant chemotherapy +/- radiotherapy
1st line:
- radical cystectomy
- neoadjuvant chemotherapy
If ineligible for cystectomy or wishing to retain bladder:
- chemotherapy and radiotherapy
Source: Amboss
Investigations in ?bladder cancer
Urine dip
- haematuria (may be micro- or macroscopic)
Urinalysis with microscopy
- some features (e.g. red cell casts, proteinuria may indicate glomerular causes of
Cystoscopy
- mass
CT / CT urography
- mass
- +/- metastatic disease
Bloods
- FBC may show anaemia
Symptoms and signs of bladder cancer
Symptoms:
- haematuria
- SOB/fatigue (due to anaemia)
- voiding sx (dysuria, urinary frequency, urgency)
- bladder outlet obstruction (rare)
- suprapubic/perineal/rectal pain
- FLAWS (fever, weight loss, malaise, lymphadenopathy, night sweats)
Signs:
- features of anaemia
- rarely a mass may be palpable
RF for testicular torsion
age 12-25
bell clapper deformity (more horizontal lie to testis, increased mobility)
personal or FHx
cryptorchidism
What is cryptochidism
undescended testicle
sx of testicular torsion
sudden onset testicular pain
can radiate to abdomen (around umbilicus/groin)
can cause N&V
Signs of testicular torsion
- testicular swelling
- testicular tenderness (particularly at the top where the cord is)
- loss of cremasteric reflex (stroke anteromedial thigh, scrotum should elevate - L1 and L2)
- high riding testis (testicular elevation in comparison to contralateral side)
- pain not relieved by lifting the testicle
ddx for TT
epidydimoorchitis
incarcerated inguinal hernia
torsion of hydatid of Morgagni (remnant of obliterated Mullein duct, blue dot sign)
Ix for testicular torsion
-> immediately to theatre for scrotal exploration
(have 6h to save the testicle)
low clinical suspicion
-> USS with doppler
-> urinalysis ?infective cause
->bloods -?infective cause
Prognosis for TT
potential for reduced fertility
chronic pain
one more
epidydimoorchitis definition
inflammation of the epididymis and testicle
epidydimorchitis causes
UTI or STI
(only orchitis: can also be Mumps)
orchitis in the absence of epididymitis - what can cause this?
mumps
RF for epididymorchitis
UTI: BPH, diabetes, recent catheter, imunosuppression
STI: MSM, unprotected sex, multiple partners, anal sex
sx of epididymoorchitis
scrotal pain (typically unilateral)
slower onset than torsion, typically worsening over 24h
scrotal swelling (reactive hydrocele)
fever (rigors if septic)
symptoms related to origin of infection (UTI: dysuria, foul smelling urine; STI: dysuria, discharge)
Mx of testicular torsion
urgent surgical exploration
+/- reduction (untwisting)
+/- orchidectomy (only if the testis is grossly necrotic or non-viable)
+/- bilateral orchidopexy
signs in epididymoorchitis
erythema
swelling (can develop reactive hydrocele)
tender
cremasteric reflex should be intact
Prehn’s sign positive (raising testicle improves the pain)
Ix for epididymoorhcitis
bloods (IFM)
urinalysis
urine culture
clean catch urine NAAT for STI
blood cultures if septic
imaging?
treatment of epididymoorchitis
analgesia and abx as per trust guidelines
NICE:
- if any STI, ceftriaxone 1g IM single dose plus 100 mg doxycycline BD for 10-14days
- if no RF for gonorrhoea, then just the doxy or ofloxacin 200 mg BD for 14d
at what locations do stones cause obstruction?
PUJ
pelvic brim
VUJ
RF for renal calculi
(depend on type of stone)
dehydration
high levels of meat in the diet
obesity
hyperparathyroidism
drugs: HIV ART, furosemide
presentation of renal stones
renal colic, loin to groin pain (due to ureteric peristalsis)
N&V
O/E flank tenderness, pain in renal angle
Ix for renal calculi
urinalysis
U + E ?creatitine rise due to obstruction
uric acid and calcium levels (won’t change management)
CT KUB (unless very young and want to avoid radiation)
best analgesia for renal calculi
diclofenac suppository
mx of renal calculi
analgesia (diclofenac suppository)
fluids
if evidence of obstructive nephropathy:
- stent insertion (retrograde)
- nephrostomy
definite mx:
- PCNL for very large stones (percutanoes access to kidney, then laser)
- ESWL (sonic waves for small stones)
- ureteroscopy (scope into urether, then…)
what is a nephrostomy
a tube put in the kidney by IR with US (this gives an alternate route for urine to pass, reduces the risk of AKI, relieves the hydronephrosis)
antegrade stent put a few days later
then get treatment for stone
Infection in renal calculi
- renal calculi become more complicated with a superimposed infection
- higher risk of sepsis
- becomes severe very quickly
additional clinical features are rigors, fever 40+… -? sepsis 6 them (most need amino glycoside + other broad spectrum0
Fournier’s gangrene
necrotising fasciitis of the scrotum/genitals/perineum
usually polymicrobial
can be lethal or very debilitating, requires a lot of debridement
RF
- older men
- diabetes
- immunocompromised
- obesity
- smoking
presentation of Fournier’s gangrene
- scrotal pain, swelling, ulceration
- erythema
- fever
- sc gas -> crepitus when pressing on skin
- pain in excess of clinical appearance
Ix in Fournier’s gangrene
primarily a clinical dx
Bloods (IFM)
CT scan - aid in surgical planning, extent of disease, confirms dx
blood cultures and swabs
plain radiograph may show free air
management of Fournier’s gangrene
urgent surgical debridement
plastics will do reconstruction and grafting
antibiotics
ITU
paraphimosis - definition
inability to pull a retracted foreskin back over the glans
part of the prepuce acts as tight band which reduces venous return causing oedema, ischaemia, necrosis, infection / Fournier’s gangrene
RF for paraphimosis
catheter
phimosis
forgetting to put foreskin back in place after intercourse
Paraphimosis -
- Foreskin cannot be returned to its original position
- Edema and pain of the glans penis
paraphimosis - management
emergency
needs urgent reduction!
analgesia (can be a penile nerve block, LA injected into the base of the penis)
Reduction techniques:
- principle: need to recuse oedema in glans to size that can fit through the tight band
- manual pressure to glans using dextrose soaked gauze
- hypodermic needle puncture of glans to remove oedema (?clinicaly?
if ineffective:
-> insert
Varicocoele signs and symptoms
- aching, dragging pain
- may see visible, dilated veins
-> caused by dilatation of the pampiniform plexus
what can right sided varicocele be associated with?
renal cancer
if suspicious -> CT AP with contrast
management of small urinary stones
can discharge home with analgesia +/- tamsulosin
(e.g. 2mm )
if you are manually detorting a testicle, which direction do you do it in?
turn laterally
What happens in testicular torsion and why is it an emergency?
the spermatic cord twists on itself within the scrotum
there is a risk of ischaemia and possible infarction of the testis
What is the most important differential of epididymoorchitis?
testicular torsion
What is the Prehn sign? give a condition where it is +ve and -ve
it is when there is reduced pain when the affected hemiscrotum is liften
+ve in epididymitis (reduced pain)
-ve in testicular torsion (still have pain)
What are possible complications of epididymitis?
epidydimal abscess
testicular infarction
infertility
Why would you go for a nephrostomy rather than a ureteric stent first line for hydronephrosis due to ureteric stent?
- easy to put in
- does not require GA
you would then place a stent later down the line and remove it about 2/12 later›››
no difference in outcome according to studies
if you have access to a theatre right away you could also go for a nephrostomy
Ddx for renal colic pain
kidney stones
AAA
non-specific abdominal pain
therefore urologists often won’t accept a patient without a scan
What is the 1st line ix for ?prostate ca?
multiparametric MRI
What is the best pain relief for renal colic? (incl doe and route)
IM diclofenac 75 mg
What are the medical indications for a circumcision?
- phimosis
- recurrent balanitis
- balanitis xerotica obliterans
- paraphimosis
2nd line pain relief for renal colic
IV paracetamol
Renal colic: if NSAIDs are contraindicated or not giving sufficiency pain relief NICE recommend IV paracetamol
Which type of renal cancer is associated with exposure to chemicals?
renal transitional cell cancer
TCC is a rare form of renal cancer, accounting for approximately 7% of all renal tumours. Risk factors include exposure to chemicals in the textile, plastic and rubber industry.
most common renal tumour in children?
Wilm’s tumour / nephroblastoma
Which renal mass is tuberous sclerosis associated with?
Is it benign or malignant?
angiomyolipoma (benign)
renal angiomyolipoma - which condition is it associated with?
Is it benign or malignant?
tuberous sclerosis
angiomyolipoma is usually benign
What cancer would you suspect in a testicular mass in >60yo?
lymphoma a
What are the causes of haematuria?
- Infection (UTI, schistooomiasis)
- trauma
- nephritic syndrome
- urothelial cancer
… - abx/beetroot - fake
How can you differentiate between a stoma and an ileal conduit?
look at the contents
stool -> stoma
urine -> ileal conduit
common causes of LUTS
Is BPH hyperplasia or hypertrophy
which drugs cause retrograde ejaculation?
finasteride
tamsulosin
Surgical management of prostate cancer
reasons to admit pt with renal colic
- pain not controlled
- significantly impaired renal function
- single kidney
- pyrexia/sepsis
- stone >5mm
Pain mx in renal colic and AKI?
not NSAID
-> IV paracetamol, WHO pain ladder
Contraindications for lithotripsy
- aneurysm
- infection
- anticoagulation
How are stag horn stones managed?
PCNL
(if the kidney I functioning well. may need multiple attempts)
staghorn calculi can be very damaging to the kidneys
The indications for antibiotics with a catheter
change include neutrophils 1 x 109/L, multiple attempts or traumatic insertion, post
trans-urethral urological surgery, previous episode of catheter change related sepsis,
frank pus at the urethral meatus or in critical care patients.
