Urology Flashcards
1
Q
What is renal colic?
A
a presenting complaint associated with kidney stones.
Renal colic- unilateral loin to groin pain
Colicky- fluctuating in severity as the stone settles
2
Q
What is the most common renal stone composition?
A
Calcium- calcium oxalate
3
Q
What are struvite stones associated with?
A
Infection
4
Q
What are the symptoms of renal stones?
A
Restless movement
Haematuria
Nausea and vomiting
Reduced urine output
Symptoms of sepsis if there is an infection
5
Q
What non imaging investigations would you do for a patient presenting with renal colic?
A
Urine dipstick- for any haemturia
Blood tests- show any infection and kidney function. Also calcium and urate can aid stone analysis
6
Q
What is the gold standard imaging for kidney stones?
A
Non- contrast CT scan KUB
7
Q
A 46 male patient comes in with intense pain in the left lower loin, he has not passed urine 8 hours, and has vomited 4 times, what are your differentials?
A
Ruptured AAA, appendicitis, kidney stone, AKI due to obstruction?
8
Q
What is the most common type of bladder cancer?
A
Transitional cell carcinoma
9
Q
What are the clinical features of bladder cancer?
A
Visible haematuria IS bladder cancer unless proven otherwise?
Other symptoms incl painless haematuria, UTIs and hydronephrosis, neuropathic pain on medial thigh
Systemic- weight loss, night sweats
10
Q
What is stress incontinence?
A
Leaking of urine when intra-abdominal pressure is raised, putting pressure on bladder
11
Q
What are triggers of stress incontinence?
A
coughing, laughing, sneezing
12
Q
what are the RF for stress incontinence?
A
childbirth and hysterectomy, female, pregnant, chronic cough, smoker, weak pelvic floor
13
Q
What are the complications associated with an undescended testes?
A
Increased chance of a testicular tumour being diagnosed late, as it is harder to feel a testicular lump when it is in the inguinal region
14
Q
What are the RF for prostate cancer?
A
Non-modifiable:
African ethnicity
BRCA mutation
Fhx
Increasing age
Modifiable:
Obesity
Smoking
Diet
15
Q
How does prostate cancer present?
A
Early stages- no signs and symptoms
Late- problems urinating, poor stream of urine, blood in semen, discomfort in the pelvic area, bone pain and ED
16
Q
What is acute urinary retention?
A
Medical emergency characterised by the abrupt development of the inability to pass urine
17
Q
What investigations would you do for acute urinary retention?
A
Bedside : DRE, Urinanlysis
Bladder scan, post void residue.
May also want to do USS kidney for any hydronephrosis.
18
Q
Name a tumour marker you may ask for, for suspected testicular cancer
A
HCG, AFP, LDH (less specific)
19
Q
Name a presenting feature of testicular cancer that is not found in the testis/scrotal area.
A
Gynaecomastia
20
Q
Define a varicocele
A
Abnormal enlargement of the testicular veins. Usually asymptomatic
21
Q
What is a distinguishing feature of an epididymal cyst, on examination of the testis?
A
Palpated as separate from the body of the testicle
22
Q
Name a condition that can predispose a patient to epididymal cysts
A
von Hippel-Lindau syndrome - where you get multiple tumours and cysts around the body.
polycystic kidney disease
cystic fibrosis
23
Q
What is the likely diagnosis of a scrotal swelling that you can not get above (i.e has no superior border), feels separate to the testicle but does not transilluminate?
A
Inguinal hernia - a scrotal swelling you can’t get above!!!
24
Q
Define urinary incontinence
A
Involuntary leakage of urine
25
Name some general risk factors for urinary incontinence
Age, obesity, multiparty, vaginal birth, FHx, being female, PMH of stroke, DM, depression.
26
What is the PERFECT mnemonic used for pelvic floor examination?
P= Power, E = Endurance, R = Repetition, Fast contraction, ECT = Every Contraction Timed
27
How does stress incontinence present?
Urine leaks when increase intra abdo pressure e.g cough, sneeze, laugh, exercise, lift.
Woman. Older age. Smoker. Chronic cough may be present. Pregnant or childbirth. Pelvic or prostate surgery. Overweight/high BMI. Hysterectomy.
28
Describe the pathophysiology of stress incontinence
Intra abdominal pressure exceeds the urethral pressure. Also have weak pelvic floor muscles
29
What investigations may you do for suspected stress incontinence?
Ask pt to keep bladder diary.
Midstream urine dip.
Examine rectum (for prostate) and bladder.
Urodynamic assessment for detrusor muscle.
Outflow urodynamics. Cystoscopy.
30
How is stress incontinence managed if pt has visible haematuria or non-visible haematuria?
Urgent 2ww.
31
What lifestyle advice might you recommend to a pt with stress UI or urge UI?
Reduce caffeine intake, lose weight, advise on fluid intake, stop smoking.
32
What surgical options are available for stress UI?
Colpususpension, sling surgery, vaginal mesh surgery, urethral bulking agents, artificial urinary sphincter.
33
How does urge UI present?
High BMI pt, drinks caffeinated drinks. Has PMH of UTIs. Sudden intense urge to pee, followed by involuntary loss of wee. Nocturia. Pass urine during sex, when reaching orgasm.
34
What is the pathophysiology of urge UI?
Overactive bladder leads to uninhibited bladder contractions. This increases intravesical pressure, causing urine to leak.
35
How is urge UI managed (non-surgical)?
1)Need to exclude overflow UI. 2) Bladder training. 3) Prescribe antimuscarinic e.g. oxybutynin.
36
How can urge UI be managed surgically?
Botox injections. Sacral nerve stimulation. Posterior tibial nerve stimulation. Augmentation cystoplasty. Urinary diversion.
37
Define mixed UI
Stress and urge incontinence
38
How does overflow incontinence present?
Small trickles of wee. Feel bladder is never empty. Can not empty when try to go. PMh of BPH.
39
What is pathophysiology of overflow UI?
A complication of chronic urinary retention. Progressive stretching of bladder leads to damage of sacral reflex efferent fibres. Lose sensation of bladder. Bladder fills with urine and becomes distended. Intravesicular pressure builds, so get dribbling of urine out.
40
What specific investigation may you want to do for suspected overflow UI?
Bladder scans pre and post voiding.
41
What are surgical options for overflow UI?
Indwelling catheter, Clean intermittent catheter.
42
How does continuous incontinence present?
Constant dribbling/leaking, needing to wear a pad. Affect daily life.
43
Describe pathophysiology for continuous UI
Anatomical abnormality (e.g. ectopic ureter) or bladder fistula.
44
What are complications of using botox to manage urge UI?
May need catheter to drain bladder
45
Name a complication of a long term catheter?
UTIs!!!
46
Define renal colic
Unilateral loin to groin pain that is excruciating.
47
If a pt has "colicky" pain due to renal stones, what does this mean?
Pain fluctuates in severity as the stone moves and settles.
48
Where do renal stones most commonly get stuck?
Vesico-ureteric junction
49
Name the most common type of renal stone?
Calcium oxalate.
50
What are risk factors for getting calcium oxalate renal stones?
Hypercalcaemia, low urine output
51
Name three types of renal stones?
Calcium oxalate, calcium phosphate, uric acid, struvite, cystine.
52
Where can renal stones be found in the urinary system?
Pelvi-ureteric junction, crossing the pelvic brim and vesicoureteric junction.
53
How do renal stones present?
Pt moving restlessly due to pain. Haematuria. N&V, reduced urine output, Sx of sepsis if infected.
54
Name 2 differentials for renal stones presentation
Ectopic pregnancy, pyelonephritis, ruptured AAA, biliary pathology, appendicitis.
55
Name a complication of renal stones
Obstruction —> lead to AKI. Infection can result with obstructive pyelonephritis.
56
What investigations would you do for suspected renal stones?
Urine dip - helps exclude infection, and may show haematuria. Blood tests - FBC, U+Es, calcium levels, eGFR. Abdo XR. CT
57
What is the gold standard for suspected renal stones?
Non-contrast CT scan KUB within 24hours.!!
58
What initial management may be part of your plan after confirming a pt with renal stones?
1) Pt is dehydrated - may need fluid resuscitation. 2) Analgesia - IM or rectal diclofenac (or IV para if NSAIDs not tolerated). 3)Anti-emetic if nauseas/vomiting. 4) Abx if infection or septic signs. 5) Tamsulosin may help pass stone. 6) If stone is in lower ureter or <5mm, may pass.
59
What surgical management would you think about for renal stones?
Extracorporeal shock wave lithotripsy if smaller than 2mm.
Percutaneous nephrolithotomy.
Ureteroscopy and laser lithotripsy.
Stent insertion or nephrostomy.
60
What advice would you give a patient about recurrent renal stones?
They can happen! Need to: 1) increase oral intake - add fresh lemon, avoid carbonated drinks, reduce salt, maintain normal Ca2+ intake.
61
A patient has calcium oxalate stones. What would you tell them to avoid in their diet?
Oxalate rich foods - spinach, beetroot, nuts, rhubarb, black tea.
62
A pt has uric acid stones. What should they avoid in their diet?
Kidney, liver, anchovies, spinach, sardines.
63
Define a testicular lump
Scrotal lump - abnormal mass or swelling in scrotum
64
Where can testicular lump present?
In testis, or extra-testicular.
65
What should you ask about in Hx taking of testicular lump?
Pain??? Onset of Sx, previous Sx.
66
What are the 6 S's involved in inspection of testicles?
Size, Shape, Site, Skin changes, Symmetry, Scars.
67
When palpating testis in scrotal exam, what are you checking for?
Tender, Transilluminates, Temperature. Consistency, Attachments, Pulsations, Fluctuations, Regional LN, Irreducibility, the Edge (3Ts (by the) CAMPFIRE)
68
How does hydrocele present?
Soft swollen large testicle, painless usually, unilateral usually. Pain on walking or sitting.
69
What may be present in PMH of pt presenting with hydrocele?
Trauma, testicualr torsion, testicualr cancer, epidimo-orchitis.
70
What are RF for hydrocele?
Premature babies, infection, STI, inflammation, trauma
71
What is the pathophysiology of a hydrocele?
Collection of fluid in the tunica vaginalis.
72
What investigations would you do in pt with suspected hydrocele?
Scrotal USS, Exclude cancers, Bloods - AFP (teratomas), B-HCG (teratoma and seminomas)
73
How is hydrocele managed?
Conservatively if idiopathic. If v large or symptomatic - surgery, aspiration, scleropathy.
74
What are Ddx for hydrocele?
Testicular cancer, hernia
75
Between what age group is a hydrocele a red flag?
Between 20-40.
76
How does varicocele present?
Bag of worms - visible enlarged veins. 90% on L side. Dull throbbing pain worse on standing. Ache at end of day. Swollen scrotal mass, may be hot to touch. Dragging sensation. Sub fertility.
77
What is pathophysiology of varicocele?
Abnormal dilatation of pampiniform venous plexus. This usually drains into testicular vein. Get either increased resistance or incompetent valves = get back flow at testicular vein.
More common on left side as:
left pampiniform plexus is subjected to increased hydrostatic pressures due to the right-angle insertion of the left internal spermatic vein into the left renal vein. Whereas, the right internal spermatic vein joins the inferior vena cava at an oblique angle.The left internal spermatic vein is also 8 to 10 cm longer, resulting in increased hydrostatic pressure transmission
78
Why is there reduced fertility with varicocele?
Increased heat = testicular atrophy and reduced fertility. Usually, testicuar vein removes heat from blood from artery - in varicocele, can not do this.
79
What are the 3 ways to examine pt with suspected varicocele?
1. standing up = prominent. 2. lying down = disappears. 3. valsava manoeuvre - when feel scrotum, feel bag of worms.
80
How is varicocele diagnosis confirmed?
USS w/ Doppler imaging.
81
How is varicocele surgically managed?
Open or laproscopic surgery to ligate spermatic veins.
82
What red flags are associated to varicocele?
If does not reduce when lying down OR onset is acute OR is R sided = need urgent referral.
A L sided varicocele can be a sign of TCC obstructing L testicular vein
83
How does epididymal cyst present?
Soft, round, fluctuant lump. Lump SEPARATE to testicle. At top of testicle. Painless usually. Middle aged men.
84
What are RF for epididymal cyst?
CF, Polycystic kidney disease, von Hippel-Lindau syndrome
85
What is the pathophysiology of epididymal cysts?
Fluid filled cysts.
86
Investigation for epididymal cyst?
USS
87
How are epididymal cysts managed?
Rare to be symptomatic, small painless etc.
Often reassurance as no link to malignancy
Surgery only if v rare there was pain / symptoms but best to avoid as can lead to infertility in men
Large or painful cysts can be surgically removed or treated by aspiration and injection of a substance to shrink and seal the cyst.
88
What are Ddx for epididymal cyst
Lipoma, hydrocele, varicocele
89
How does testicular cancer present?
Typically painless
Non tender
Arise from testes
Hard
Irregular
No fluctuation
No transillumination
V rare = gynaecomastia (often in rare ones like Leydig cell tumours)
90
Who most commonly has testicualr cancer?
age 20-40
91
What are RF for testicular cancer?
Undescended testes, FHx, being tall, male infertility, Klinefelter's syndrome, HIV/AIDS
92
Which type of cell do testicular cancers most likely arise from?
germ cells.
93
What are the two germ cell tumour groups?
Seminoma and non-seminoma
94
What is felt on examination of testis with testicular cancer?
No transillumination, hard, irregular, no fluctuation.
95
Name some investigations for suspected testicular cancer
Initial investigation : Ultrasound definitive to diagnose
Tumour markers:
Alpha-fetoprotein (raised in teratomas)
Beta-hCG (raised in teratomas and seminomas)
lactate dehydrogenase (non specific tumour marker
Staging
A Staging CT- spread / stage
Royal Marsden Staging system
1) isolated to testes
2) Regional lymph node invovlement
3) Diagphram lymph node
4) mets to other organs
Common mets: Lymphatics, Lungs, Liver, Brain
96
How is testicular cancer managed by surgery?
Radical orchidectomy - curative if not spread yet.
97
What are ddx for testicular cancer?
Hydrocele, epididymal cyst.
98
What is Fournier’s gangrene?
Necrotising fasciitis of the perineum - see erythema around sacrum and perineum, black skin in perineum
99
Why is Fournier’s gangrene a surgical emergency?
Can cause rapid uncontrollable necrosis of tissue, can lead for death by overwhelming sepsis if not treated promptly.
100
Which organism most commonly causes acute epididymo-orchitis in men?
Chlamydia trachomatis
101
What are Sx of BPH?
Nocturia, hesitancy, terminal dribble, intermittency, straining, incomplete emptying, frequency, urgency, weak flow
102
What would be in your initial assessment of man with LUTsx ?
DRE for prostate, Abdo exam for palpable bladder? Urinary frequency volume chart, urine dipstick, PSA
103
What is a common side effect of tamsulosin?
Postural Hypotension
104
What is a common side effect of finasteride?
Sexual dysfunction due to reduced androgen activity
105
How does Acute urinary retention present?
Painful! Acute suprapubic pain, unable to urinate, PMH of uti, change in meds or worsening LUT sx. Pt has a palpable distended bladder and tenderness suprapubically on examination
106
How does Chronic urinary retention present?
Painless!! Has voiding LUT sx - weak stream, hesitancy, overflow incontinence that is worse at night. Pt has palpable distended bladder but no/minimal suprapubic tenderness.
107
What investigations would you do for urinary retention?
PR exam - enlarged prostate or constipation. Post-void bladder scan. Need to do routine bloods. Take specimen of urine from catheter to check for infection. Do an USS for any associated hydronephrosis
108
How is acute urinary retention managed?
Immediate catheter needed. Measure volume post catheterisation. Monitor for post-obstructive diuresis.
109
What are complications of acute urinary retention?
AKI - can lead to CKD. Risk of UTI and stones due to stasis of urine.
110
How is chronic urinary retention managed?
Long term catheter and/or self catheter if an option. Monitor for post-obstructive diuresis.
111
What are complications of chronic urinary retention?
UTI, stones in bladder, CKD
112
How does obstructive uropathy present if in upper UT?
Loin to groin or flank pain on the side of obstruction. Reduced or no urine output. Non-specific Sx - vomiting. High creatinine on bloods.
113
How does obstructive uropathy present if in lower UT?
Hard to pass urine. Urinary retention with increasingly full bladder. High creatinine on bloods.
114
How is obstructive uropathy in the upper UT managed?
Nephrostomy
115
How is obstructive uropathy in the lower UT managed?
Urethral or suprapubic catheter.
116
What are complications of obstructive uropathy?
Hydronephrosis, pain, post renal AKI, CKD, infection, urinary retention and bladder distention, overflow incontinence of urine.
117
What is hydronephrosis?
Swelling of the renal pelvis and calyces in the kidney, caused by obstructed UT - leads to back pressure into the kidneys.
118
How does hydronephrosis present?
Vague renal angle pain. Mass in the area the kidneys are.
119
What investigations would you do for hydronephrosis?
USS, CT, IV urogram
120
How is hydronephrosis treated?
Treat underlying cause. Relieve the pressure: percutaneous nephrostomy and antegrade ureteric stent.
121
How do you distinguish between visible haematuria, non-visible haematuria and pseudohaematuria?
Visible = urine is coloured pink, red, brown
Non-visible = id with urine dip stick. May be asyptomatic/symptomatic. Pseudohaematuria = red/brown urine which is not secondary to Hb in the urine. It can be due to other causes - meds, hyperbilirubinuria, myoglobinuria, beetroot, rhubarb
122
What are 2 urological causes of haematuria?
UTI, urothelial carcinoma, renal calculi, trauma, radiation cystitis, prostate cancer, BPH
123
How may patient present, if they have haematuria?
Secondary symptoms - LUTs, fever, flank pain. Trauma, surgical Hx, co-morbidities, taking anticoagulants, smoker.
124
What investigations might you want to do in pt presenting w haematuria?
Urinanalysis - nitrates, leukocytes. MSSU, FBC, U+Es, coat screen, PSA, albumin:creatinine
125
What imaging might you order for pt with haematuria?
USS, CT KUB. Cytoscopy
126
In which patients would you want to Admit and catheterise with 3 way, order urgent US/CT KUB and consider abx?
If pt is 1) in retention 2) bloods are abnormal 3) heavy haematuria 4) history or renal trauma
127
A 50 yr old pt presents in ED with hameaturia but on questioning, you find out that they have no voiding problems. Bloods are normal. Urine is light red. What is your management?
Urgent 2 week wait referral
As >45 years and unexplained visible haematuria without urinary tract infection or visible haematuria that persists after successfully treating UTI
128
What is the Royal Marsden Staging system?
Testicular Cancer:
1) isolated to testes
2) Regional lymph node invovlement
3) Diagphram lymph node
4) mets to other organs
129
What are common mets for testicular cancer?
Common mets: Lymphatics, Lungs, Liver, Brain
130
What is hypospadias?
Birth defect in boys
Opening of urethra located along shaft of penis and not the tip
131
Analgesia for renal colic as per guidelines?
IM diclofenac
132
Causes of painless haematuria?
Malignancies - bladder cancer
Pseudohaematuria: Beetrot, rifampicin, myoglobin (if you have rhabdomyalsis), porphyrin
133
Risk factors for testicular cancer?
Family history
Klienefelters syndrome
Infertility
Cryptochism
Mumps orchitis
134
Causes of acute urinary retention ?
In men: BPH
Urethral strictures, constipation, masses, UTI, neuro causes
Anti-cholinergic medication, antihistamines, opioids, post-partum in women
135
What is post obstructive diuresis?
Kidney's increase diuresis due to loss of medullary conc gradient in urinary retention- may take time to re-equiliberate
Volume depletion and worsening of AKI
136
What is Prehn's sign?
Testicular torsion- Elevation of testes does not ease the pain
137
Features of epidimo-orchitis?
Unilateral testicular pain and swelling
Uretheral discharge (possible)
Not as acute or severe as testicular torsion
138
Presentation/ clinical features of prostatitis?
Acute onset
Pain in perianal area, prostatic pain, rectal pain, lower back pain, or pain on ejaculation
Systemic symtoms - fever, rigors, tachycardia
Voiding symptoms - weak stream, haematuria, straining, dysuria, urgency, frequency
DRE - prostate gland is tender, "boggy", swollen, warm
139
Causative organism in prostatitis?
Escherichia coli
(Neisseria gonnorhoea can also cause it!)
140
RF for prostatitis?
UTI
Intermittent bladder catheter
Epididymitis
Recent prostate biopsy
Urethral surgery
Prostate stone
141
Examination to do for prostatitis and what is found?
DRE - tender, boggy, swollen, warm prostate gland
142
Investigations for prostatitis?
DRE
MSSU
Screen for STI - gonorrhoea in particular
143
How to manage prostatitis?
Abx - 14 days of quinolone w.g ciprofloxacin
Analgesia - paracetamol
Treat urinary retention if present
Advise to drink fluids to avoid dehydration
144
Ddx for prostatitis?
BPH
UTI
Epididymo-orchitis
Prostate cancer
145
RF for renal colic
Non-modifiable:
- Previous stone disease. The risk of developing a second stone is 30-40% over 5 years.
- Anatomical abnormalities of the collecting system
- Family history
- Underlying medical conditions. These include:
Hyperparathyroidism
Renal tubular acidosis
Myeloproliferative disorders
All chronic diarrhoeal conditions
Modifiable:
- Obesity
- Dehydration
- Diet
146
Blood test investigations for renal colic?
FBC - for inflammation and infection
CRP - inflammation
U+Es - impaired renal function which needs management
Calcium and uric acid - ID any underlying metabolic condition which is causing stone formation
147
Bedside investigations for renal colic?
Urinalysis - will likely show the presence of blood in the urine, and may help with stone identification and subsequent follow up in stone clinic.
148
Radiological investigations for renal colic?
Non-contrast helical CT KUB
XR - useful for planning management if CT confirms stone. XR is also needed for ESWL (extracorporeal shockwave lithotripsy)
149
Infection and organism most commonly linked to struvite calculi in renal colic?
Recurrent UTIs with Proteus spp.
150
Presentation of erectile dysfunction by organic cause (I.e. not psychological) ?
Gradual onset of symptoms
Lack of tumescence - hardening and enlargement of the penis
Normal libido
151
Presentation of erectile dysfunction with a psychogenic cause?
Sudden onset of symptoms
Decrease libido
Good quality spontaneous or self stimulated erections
Major life events
Problem or changes in a relationship
Previous psychological problems
History of premature ejaculation
152
Risk factors for erectile dysfunction?
Increasing age
Cardiovascular disease risk factors: obesity, DM, dyslipidaemia, metabolic syndrome, hypertension, smoking
Alcohol use
Drugs: SSRI, beta blockers
153
Investigations to do for erectile dysfunction?
Q risk – measure lipid and fasting glucose serum levels
Free testosterone (9 to 11 a.m.)
LH, FSH, prolactin levels – to be measured if free testosterone is low

154
How is erectile dysfunction managed?
PDE – 5 inhibitors - sildenafil/Viagra
If cannot take this, can use vacuum direction devices
If young and has always had difficulty achieving an erection, refer to urology
