Urology Flashcards
Causes of upper urinary tract obstruction
- Kidney stones
- Tumours pressing on the ureters
- Ureter strictures (due to scar tissue narrowing the tube)
- Retroperitoneal fibrosis (the development of scar tissue in the retroperitoneal space)
- Bladder cancer (blocking the ureteral openings to the bladder)
- Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)
Causes of lower urinary tract obstruction
- Benign prostatic hyperplasia (benign enlarged prostate)
- Prostate cancer
- Bladder cancer (blocking the neck of the bladder)
- Urethral strictures (due to scar tissue)
- Neurogenic bladder
6 causes of a neurogenic bladder, and what is it
- MS
- DM
- Stroke
- Parkinson’s disease
- Brain or spinal cord injury
- Spina bifida
What can be done to bypass an upper urinary tact obstruction ?
-> Nephrostomy : insering a thin tube through the skin at the back, through the kidney and into the ureter.
What can be done to bypass a lower urinary tract obstruction ?
-> Urethral or suprapubic catheter
Key SE of tamulosin
- Postural hypOtension = leading to dizziness on standing or falls
How long do people require antibiotics for catheter associated infections ?
7 days
Symptoms seen in BPH
-> Hesitancy
-> Weak flow
-> Urgency
-> Frequency
-> Intermittency
-> Straining to pass urine
-> Terminal dribbling
-> Incomplete emptying
-> Nocturia
causes of a raised PSA
- Prostate cancer
- BPH
- Prostatitis
- Urinary tract infections
- Vigorous exercise
- Recent ejaculation or prostate stimulation
Cancerous prostate on DRE
Firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus
Medical management options of BPH
- Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
- 5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate
How do 5-alpha reductase inhibitors work ?
- Converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone.
- By inhibiting it, there is less DHT = reduction in prostate size
Four surgical treatment options for BPH
- Transurethral resection of the prostate (TURP)
Most common SE of finasteride
Sexual dysfunction (due to reduced testosterone)
2 classifications of prostatitis
- Acute bacterial prostatitis – acute infection in the prostate, presenting with a more rapid onset of symptoms
- Chronic prostatitis – symptoms lasting for at least 3 months
How can chronic prostatitis be classified ?
- Chronic prostatitis or chronic pelvic pain syndrome (no infection)
- Chronic bacterial prostatitis (infection)
Presentation of acute bacterial prostatitis
- More acute onset of pelvic pain, LUTs, sexual dysfunction, pain with bowel movements and tender/enlarged prostate
- Fever, myalgia, nausea, fatigue, sepsis
Presentation of chronic prostatitis
- Pelvic pain
- LUTs : dysuria, hesitancy, frequency and retention
- Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen)
- Pain with bowel movements
- Tender and enlarged prostate on examination (although examination may be normal)
Management of acute prostatitis
- Admission if systemically unwell
- 14 oral quinolone (e.g ciprofloxacin)
- Analgesia
- Laxatives
Management of chronic prostatitis
- Alpha blockers
- Analgesia
- CBT
- Laxatives
- Abx (if indicated)
5 RF for prostate cancer
Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids
If not asymptomatic, how can prostate cancer present ?
- LUTs
- Haematuria
- Erectile dysfunction
First line investigation for suspected prostate cancer
- Multiparametric MRI (reported on a Likert scale)
- > =3 prostate biopsy
How is prostate cancer diagnosed ?
Prostate biopsy
- Transrectal ultrasound guided biopsy (TRUS)
- Transperineal biopsy
(Risks : pain, bleeding, infection, urinary retention and ED)
How do you assess for bone metastasis in prostate cancer ?
- Isotope bone scan
How is prostate cancer graded
- Gleason grading system : the greater the score = the more poorly differentiated the tumour
How is prostate cancer staged ?
TNM staging
Management options for prostate cancer
- Surveillance or watchful waiting in early prostate cancer
- External beam radiotherapy directed at the prostate
- Brachytherapy
- Hormone therapy
- Surgery
Key complication of external beam radiotherapy for prostate cancer
Proctitis (inflammation in the rectum)
Side effects of brachytherapy
- Cystitis and proctitis
- Erectile dysfunction, incontinence and increased risk of bladder or rectal cancer
Hormone therapies used in prostate cancer
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
SE of hormone therapy used in prostate cancer
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
Key complication of radical prostatectomy done for prostate cancer
Erectile dysfunction and urinary incontinence
- Soft, PAINLESS scrotal swelling anterior to and below testicle
- Palpable testicle
- Irreducible
- TRANSILLUMINATED
Hydrocele
- Scrotal mass than feels like a bag of worms
- More prominant on standing, disappears on lying
- Dragging sensation
- Sub/infertility
Varicocele
what is a varicocele
- Swelling of veins in the pampiniform plexus
what could be an underlying cause of a left sided varicocele ?
- Renal cell carcinoma obstructing the left testicular vein
- The left testicular vein drains into the left renal vein
Soft, round lump
Typically at the top of the testicle
Associated with the epididymis
Separate from the testicle
Epididymal cyst
Causes of epididymo-orchitis
Escherichia coli (E. coli)
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
Parotid gland swelling and orchitis
MUMPS (spares the epididymis)
Presentation of epididymo-orchitis
Gradual onset (mins-hrs) - Unilateral :
- Testicular pain and swelling
- Pain relieved on elevation of tesicle
Key differential for epididymo-orchitis
Testicular torsion
what makes an STI the more likely underlying cause of epididymo-orchitis over an enteric organism like E.coli ?
- Age under 35
- Increased number of sexual partners in the last 12 months
- Discharge from the urethra
Management of epidiymo-orchitis caused by an enteric organism
- Ofloxacin for 14 days
- Send MSU
Two important SE of quinolone Abx (e.g ciprofloxacin)
- Tendon damage and rupture (esp achilles tendon)
- Lowers seizure theshold (caution in pts with epilepsy)
5 complications of epididymo-orchitis
Chronic pain
Chronic epididymitis
Testicular atrophy
Sub-fertility or infertility
Scrotal abscess
- Teenage boy with sudden onset unilateral testicular pain, triggered whilst playing sport
Testicular torsion
Examination findings in testicular torsion
- Firm swollen testicle
- Elevated (retracted) testicle
- Absent cremasteric reflex
- Abnormal testicular lie (often horizontal)
-Rotation, so that epididymis is not in normal posterior position
what is one underlying cause of testicular torsion
Bell-clapper deformity
- Fixation between testicle and tunica vaginalis is absent and so testicle hangs in horizontal position
Management of testicular torsion
- Nil by mouth, in preparation for surgery
- Analgesia as required
- Urgent senior urology assessment
- Surgical exploration of the scrotum
- Orchiopexy (correcting the position of the testicles and fixing them in place)
what can be seen on USS in testicular torsion ?
Whirlpool sign -> spiral appearance to spermatic cord and blood vessels
4 RF for testicular cancer
Undescended testes
Male infertility
Family history
Increased height
Common presentation of testicular cancer
- Typically = painless lump
Arises frm the testicle
Hard
Irregular
Not fluctuant
No transillumination
What is a rare presentation of testicular cancer
- Gynaecomastia
- Particularly = leydig cell tumour
Tumour markers for testicular cancer
- Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)
- Beta-hCG – may be raised in both teratomas and seminomas
- Lactate dehydrogenase (LDH) is a very non-specific tumour marker
Diagnosis of testicular cancer
Scrotal USS
Staging system for testicular cancer
Royal Marsden Staging System
- Stage 1 – isolated to the testicle
- Stage 2 – spread to the retroperitoneal lymph nodes
- Stage 3 – spread to the lymph nodes above the diaphragm
- Stage 4 – metastasised to other organs
Common places for testicular cancer to metastasise to
Lymphatics
Lungs
Liver
Brain
Course of antibiotics for UTI in men
7 days
Complete contraindication to mitrofurantoin
METHOTRXATE USE
4 RF for pyelonephritis
- Female sex
- Structural urological abnormalities
- Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
- Diabetes
Presentation of pyelonephritis
- Same Sx as lower UTI +
- Fever
- Loin or back pain
- N&V
Management of pyelonephritis
7-10 days of Abx
- Cefalexin
- Co-amoxiclav (if culture results are available)
-Trimethoprim (if culture results are available) - Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
Possible causes of significant symptoms of pyelonephritis or those that don’t respond well to treatment
- Renal abscess
- Kidney stone obstructing the ureter, causing pyelonephritis
How does interstitial cystitis present ?
- Persistent symptoms of a lower urinary tract infection (>6 wks)
- suprapubic pain -> worse with a full bladder, relieved by emptying
- Frequency
- Urgency
what is seen on cystoscopy in 5-20% with interstitial cystitis
Hunner lesions : red, inflamed patches of the bladder mucosa associated with small blood vessels
RF for bladder cancer
Increased age
Smoking
Aromatic amines in dye / rubber
what kind of cancer does schistosomiasis cause
squamous cell carcinoma of the bladder
Most common type of bladder cancer
Transitional cell carcinoma
how does bladder cancer present ?
Painless haematuria
when is a two week wait for bladder cancer advised ?
- Aged over 45 with unexplained visible haematuria
- Aged over 60 with microscopic haematuria PLUS:
Dysuria or;
Raised white blood cells on a full blood count
how is a bladder cancer diagnosed
cystoscopy
staging system for bladder cancer
TMN
Most common type of kidney stone
- Calcium based (oxalate or phosphate)
RF for calcium based renal stones
- Hypercalcaemia (calcium supplementation, hyperparathyroidism and cancer)
- Low urine output
Give 3 other type of renal stone
- Uric acid : not visible on x-ray
- Struvite : produced by bacteria, therefore, associated with infection
- Cystine : associated with cystinuria, an autosomal recessive disease
what is a staghorn calculus
- The stone forms in the shape of the renal pelvis
- Most commonly occurs with struvite stones
Presentation of renal stones
- Renal colic (unilateral loin-groin pain, colicky)
- Haematuria
- N&V
- Reduced urine outpur
- Sepsis if infection present
Investigation of choice for diagnosing kidney stones
- Non contrast CT of kidneys, ureters and bladders ( CT KUB)
Management of kidney stones
- <5mm and asymptomatic = watchful waiting
- 5-10mm = shockwave lithotripsy
- 10-20mm shockwave lithotripsy or uteroscopy
- > 20mm = percutaneous nephrolithotomy
what 2 medications can be given to reduce the risk of recurrence of kideny stones
- Potassium citrate with calcium oxalate stones
- Thiazide diuretics
Classic traid of renal cell carcinoma
Haematuria
Flank pain
Palpable mass
Sub types of renal cdell adenocarcinoma
Clear cell (80%)
Papillary
Chromophobe
Wilm’s tumour (children <5)
RF for renal cell carcinoma
- Smoking
- Obesity
- Hypertension
- End-stage renal failure
- Von Hippel-Lindau Disease
- Tuberous sclerosis
Classic feature of metastatic renal cell carcinoma seen on X-ray
Cannonball metastases
what paraneoplastic syndromes are seen in renal cell carcinomas
- Polycythaemia – due to secretion of unregulated erythropoietin
- Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
- Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
- Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis
what is the specific number staging system used in renal cell carcinoma
-> Stage 1: Less than 7cm and confined to the kidney
-> Stage 2: Bigger than 7cm but confined to the kidney
-> Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia
-> Stage 4: Spread beyond Gerota’s fascia, including metastasis
1st line management of renal cell carcinoma
Surgery
- Partial nephrectomy (removing part of the kidney)
- Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland)
In pts not suitable for surgery, how can renal cell carcinomas be managed
-> Arterial embolisation, cutting off the blood supply to the affected kidney
-> Percutaneous cryotherapy, injecting liquid nitrogen to freeze and kill the tumour cells
-> Radiofrequency ablation, putting a needle in the tumour and using an electrical current to kill the tumour cells
what monoclonal antibody is given post renal transplant to prevent acute infection ?
Basiliximab : targets interleukin-2 receptor on T cells
what is used as immunosuppression following renal transplant
- Tacrolimus
- Mycophenolate
- Ciclosporin
- Azathioprine
- Prednisolone
Give the common SE of certain immunosuppressant agents given post renal transplants
- Immunosuppressants cause seborrhoeic warts and skin cancers (look for scars from skin cancer removal)
- Tacrolimus causes a tremor
- Cyclosporine causes gum hypertrophy
St4. eroids cause features of Cushing’s syndrom
What Abx used in bladder ifnections is unhelpful in pyelonephritis
Nitrofurantoin
Scrotal swelling commonly seen i nrenal cell caner
Left sided varicocele
