Urology Flashcards
1
Q
What factors protect against infection in the urinary tract?
A
- Acidity of urine
- Increased osmolality
- Increased urea
- Antibacterial secretions (Tamm Hanstall in Loop of Henle, prostatic factor, immunoglobulins)
2
Q
What is epididymo-orchitis?
A
Acute testicular pain and swelling with UTI.
Epididymitis is more common and is usually bacterial (E.coli/STI).
Orchitis is more likely to be viral (Mumps or Coxackie)
3
Q
How do you manage epididymo-orchitis?
A
Doxycycline and Ciprofloxacin
4
Q
What are the features of Prostatitis?
A
Systemically unwell
Tender prostate
Outflow obstruction
Discharge
Pain on ejaculation
Haemospermia
5
Q
What is Fournier’s Gangrene?
A
Necrotising fasciitis of the external genitalia caused by mixed growth with psuedomonas, beta haemolytic strep, e.coli and clostridium.
It is a surgical emergency.
6
Q
What is the mortality rate of Fournier’s Gangrene?
A
10-75%
7
Q
What are the signs/symptoms of pylonephritis?
A
Acute: pyrexia, loin pain and rigors
Chronic: small contracted kidney, CKD and chronic UTI
8
Q
Where do the kidneys lie and what are the layers of surrounding tissue?
A
Retroperitoneal
T12-L3
Hilum sits at the transpyloric plane
Each kidney is surrounded by a renal capsule of fibrous tissue, which has perinephric fat which is then surrounded by the renal fascia (Gerotas fascia)
9
Q
Describe the internal structure of the kidneys?
A
The renal pelvis is formed by two or three major calyces, which are formed by confluence of several minor calyces. Each minor calyx has a renal papilla draining into it which is formed by the pyramids of the renal medulla.
The darker renal medulla is lined by the lighter coloured cortex
10
Q
What is the functional unit of the kidney called?
A
The nephron- consisting of a glomerulus and tubular system
11
Q
How do you manage pylonephritis?
A
Acute: amoxicillin and gentamicin for 14 days.
12
Q
What is a complication of pylonephritis?
A
Sepsis
Renal failure
Chronic pyelonephritis
Pyelonephrosis: pus in the renal collecting system requiring percutaneous nephrostomy for drainage.
Perineprhic abscess
13
Q
Can you name some examples of benign renal tumours?
A
Angiomyolipoma (associated with tuberous sclerosis and if over 4cm may require partial nephrectomy)
Oncocytoma (may mimic RCC)
Simple cysts
14
Q
Which benign renal tumour is associated with tuberous sclerosis?
A
Angiomyolipoma
15
Q
What are some examples of malignant renal tumours?
A
Adenocarcinoma
Nephroblastoma
Metastatic tumours (from lung, breast, stomach and pancreas)
Transitional cell (only in renal pelvis)
Sarcoma
Cystadenocarcinoma
16
Q
Where do adenocarcinomas of the kidneys typically arise from?
A
The proximal renal tubules?
17
Q
What are the typical characteristics of adenocarcinoma?
A
Well circumscribed with a pseudocapsule
Most commonly clear cell histopathologically
18
Q
How does RCC spread?
A
Haematogenous: lung, bone and brain (canonball mets/ hypervascular mets)
Local spread to perinephric fat, renal vein and IVC
19
Q
What are the risk factors for RCC?
A
Acquired cysts
Smoking
Dialysis
Exposure to cadmium and lead
Familial (Von Hippel, Pheochromocytoma, haemangioma)
20
Q
What are the management options for RCC?
A
Radical nephrectomy, or if small/frail then consider ablation.
Embolisation/ chemoradiotherapy for metastatic disease
Tyrosine kinase inhibitors
21
Q
What are the different compositions of renal stones?
A
Calcium oxaloate
Calcium phosphate
Struvate
Uric acid
Cystiene
22
Q
What are struvate stones associated with?
A
These are Mg-ammonium phosphate. They are soft, white and generally fill the renal pelvis.
They are associated with proteus infection.
23
Q
How would you manage renal stones?
A
Initial management: fluid resuscitation and analgesia.
If <5mm then typically will pass within 4 weeks.
If <10mm then ESWL
If 10-20mm then you may consider ESWL but likely need ureteroscopy
If >20mm then PCNL
24
Q
What is ESWL?
A
Extracorpeal shockwave therapy = shockwaves generated externally leading to stone fragmentation.
25
What are the risks and contraindications for ESWL for renal stones?
Risks: obstruction, solid organ injury.
Contraindications:
- pregnancy
- calcified vessels
- aneurysm
- urosepsis
26
What is ureteroscopy?
This is laser therapy via the urethra and bladder to fragment the stones which can then be retracted.
27
When may you consider admitting a patient with renal colic?
- AKI secondary to obstruction
- For analgesia requirement
- Evidence of infected stone
- Stones >5mm
28
What is the pathophysiology of renal stones?
The calcium oxalate/ phosphate are due to oversaturation of the urine. Calcium oxalate precipitates at lower saturations and therefore is the most common.
Struvate form due to alkali conditions due to urease secreting organisms such as proteus and klebsiella.
Urate stones are due to the increased levels of purine.
29
What are the causes of hydronephrosis?
Unilateral:
- pelvicoureteric obstruction
- aberrant renal vessels
- calculi
- tumour
Bilateral:
- Stenosis of urethra
- urethral valve
- prostate pathology
- extensive bladder tumour
- retroperitoneal fibrosis
30
How would you manage hydronephrosis?
Removal of obstruction
Nephrostomy tube
May require urethral stenting
31
Describe the path of the ureters?
They descend retroperitoneally down the psoas muscle. They are crossed lateral - medial by the gonadal vessels.
The ureter passes anterior to the common iliac artery lateral- medial.
It is crossed by the vas deferens/ broad ligament in females.
Enters the bladder at the trigone.
32
What is the blood supply to the ureters?
Proximal 1/3 = renal artery
Middle 1/3 = gonadal artery
Distal 1/3 = superior vesicular artery
33
Where is the lymphatic drainage to the ureters?
To the para-aortic and the pelvic nodes
34
What is the nerve supply to the ureters?
Sympathetic = T1-T12
Parasympathetic = S2-S4
35
Where are the areas of narrowing in the ureter?
- Pelvico-ureteric juntion
- Pelvic brim
- Vesicoureteric juntion
36
Describe the basic anatomy of the bladder
Extraperitoneal, hollow, smooth muscle lined organ that can hold approximately 500ml.
The detrusor muscle is a spiral shaped muscle.
The bladder has a midline fold (a remnant of the urachus) and 2 lateral folds each side (remnants of the umbilical arteries and the inferior epigastric vessels).
37
What are the anatomical relations to the bladder?
Superior: apex of the bladder is joined to the abdominal wall by the median umbilical ligament.
Inferolateral: pubic bones, obturator internus and levator ani
Base: in men it is the seminal vesicles which lie behind the base with the vas deferns.
The bladder is supported by the periprostatic ligament in men and the pubovesical ligament in women.
38
What is the blood supply to the bladder?
Superior and inferior vesicular arteries (branches of the IIA)
39
What is the venous drainage of the bladder?
Vesicular plexus - prostatic plex - IIV
40
What is the nervous supply to the bladder and the sphincters?
The parasympathetic supply to the bladder is S2-S4. Parasympathetic stimulation makes you pee.
The sympathetic supply to the bladder is via T10-L2.
This also supplies the internal sphincter (tonic contraction).
The external sphincter is made of skeletal muscle and is innervated by the pudendal nerve.
41
What is compliance and why is it important for the function of the bladder?
This is the ability of the bladder to increase in volume without increasing in pressure.
When the volume reaches a critical point the pressure rises sharply and causes the detrusor reflex (contraction).
42
How do we maintain urinary continance?
Neurologically the bladder control lies in the pontine micturition centre. To commence micturition, the sympathetic inhibitory stimulation is silenced and the parasympathetic nerve stimulation causes detrusor contraction.
43
What are some causes of neurological bladder dysfunction?
Cerebrovascular: normal co-ordination but detrusor hyperreflexia causing urge incontinance.
Spinal cord: interruption of fibres at the pontine centre causing loss of co-ordination between detrusor contraction and sphincter relaxation.
Cauda equina: paralysis of the detrusor muscle/ sphincter causing retention.
44
What are the different types of incontinence and how would you manage them?
Stress Incontinence: normally due to sphincter dysfunction (typically seen after obstetric damage).
Management = pelvis floor exercises, urethral sling, colosuspension procedure.
Urge incontinence: due to detrusor overactivity (often due to infection or cerebral causes).
Management: bladder retraining for at least 6 weeks, oxybutynin therapy/tolterodine, TCA or botox.
Overflow incontinence:
Due to retention, often occurs at night.
Management: treat underlying cause.
45
What are the indications for a USC referral when a patient is presenting with haematuria?
Macroscopic haematuria or microscopic in a patient over the age of 50.
46
What are some causes of haematuria?
- Trauma
- Inflammation: infection, stones, glomerulonephritis
- Radiotherapy
- Physiological: exercise
- Malignancy
- Coagulopathy
- Structural abnormalities: BPH, AVM
- Drugs (NSAIDs, penicillins, sulphonamide)
47
What is the gold standard investigation for haematuria?
Flexible cystoscopy
48
What drugs might cause haematuria? and what drugs may cause a pseudo-haematuria?
Chemotherapy/aminoglycosides (cause tubular necrosis)
Penicillins, NSAIDs and sulphonamides (cause interstitial nephritis)
Allopurinol or rifampicin may mimic haematuria
49
What is the most common histological subtype of bladder cancer?
The most common worldwide is SCC, but the most common in western world is TCC>
50
What are the risk factors for bladder cancer?
Smoking
Exposure to rubber/dye/textiles
Chronic inflammation
Congential abnormalities
51
How can bladder cancer be categorised, and how does this affect management?
Superficial: tumour invades the sub-epithelial tissue.
This can be managed by TURBT + intra-vesicular chemotherapy (mitomycin)/ immunotherapy (BCG).
Invasive bladder cancer: tumour invades into the detrusor muscle.
This needs radial cystectomy and bladder reconstruction (often done with small bowel).
And chemotherapy/radiotherapy.
52
What percentage of male pelvic fractures will have a urethral injury?
10%
53
What are the features and management of traumatic bladder rupture?
This may be intra- or extra-peritoneal.
It can give features of:
- haematoma
- suprapubic pain
- difficulty voiding
- inability to irrigate the bladder
Management:
- If intra then laparotomy
- If extra then conservative
54
How will a rupture of the membranous urethra present?
Normally due to a pelvic fracture.
Causes penile or perineal oedema and a non-palpable prostate.
55
How will traumatic rupture of the bulbar urethra present?
Normally a result of a straddle injury. Causes urinary retention, perineal haematoma and blood clot at the meatus.
56
Where is the anatomical location of the prostate?
The prostate sits below the bladder on the urogenital diaphragm, behind the pubic symphysis. It is connected to the pubic bones via the pubo-prostatic ligaments.
Devonvillier's fascia separates it from the rectum. Laterally to the prostate lie the pubococcygeal portions of the levator ani.
57
What separates the prostate from the rectum?
Devonvillier's fascia.
58
What is the blood supply to the prostate?
Arterial supply is via the inferior vesicular artery and the middle rectal artery (both from the internal iliac).
Venous drainage is via the prostatic plexus.
59
Where does the lymph drainage from the prostate go?
internal iliac nodes.
60
What is the affect of the sympathetic nervous supply to the prostate?
Sympathetic innervation is via alpha adrenergic receptors which cause contraction.
61
Describe the structure of the prostate gland.
70% is glandular, 30% is fibromuscular.
The transitional zone surrounds the urethra, proximal to the ejaculatory ducts.
The central zone surrounds the ejaculatory ducts and projects under the bladder protecting the seminal vesicles.
The peripheral zones are where cancers typically occur.
62
What is BPH?
Benign prostatic hyperplasia, occurs in the transitional zone.
63
What is the prevalence of BPH?
50% of over 50s
90% of over 90s
64
What is the pathophysiology of BPH?
Testosterone diffuses into prostatic and stromal cells. Some will bind with the androgen receptor, whilst some binds to the alpha-reductase II receptor on the nuclear membrane.
This enzyme converts it to dihydroxytestosterone which has a greater affinity for androgen receptor than testosterone.
This stimulates proliferation of the cells.
65
What are the features of BPH?
Hesitancy
Poor stream
Straining
Dribbling
Pain
Increased frequency
Nocturia
66
What is the management of BPH?
Alpha adrenergic antagonists (tamsulosin): blocks the action of noradrenaline on the prostatic smooth muscle.
5-alpha-reductase inhibitors (finasteride): inhibits the conversion of testosterone to DHT.
If conservative management fails then consider TURP or transurethral laser therapy.
If over 80g then open prostectomy.
67
What are some of the side effects of tamsulosin?
Postural hypotension and retrograde ejaculation
68
What are the complications of TURP?
Bleeding
Infection
Retrograde Ejaculation
Secondary Clot Retention
Stricture
Hypotonic bladder
Sphincter damage
Impotence (v. common)
TURP syndrome
69
What is TURP syndrome?
This occurs due to absorption of large volumes of irrigation via the prostatic plexus. It causes increase nitrogen levels, cerebral oedema and hyponatraemia.
You use glycine (if small operation) or saline irrigation fluid.
This subsequently leads to visual disturbance, nausea/vomiting, seizures, HTN and bradycardia.
70
How would you manage TURP syndrome?
They need diuretics, fluid restriction and consider high level are (HDU/ITU)
71
What is the most common histological subtype and location of prostate cancer?
Adenocarcinoma
Peripheral zone of the prostate.
72
How does prostate cancer spread?
Lymphatic to obturator nodes.
Also spreads to bone causing sclerotic lesions
73
What are the features of prostate cancer?
Normally asymptomatic but can cause LUTI Sx or bladder outflow obstruction.
Mets may present with spinal pain.
High PSA
74
What else may cause an elevated PSA?
BPH, UTI, Post catheter, Post exercise
75
How is prostate cancer diagnosed?
Transrectal USS and biopsy.
76
What is the gleason score?
2 predominant areas of tumour to get a combined grade.
Scores of 3-5 in two areas are added.
If 6 then low grade, 7 medium and 8-10 is high.
77
How is prostate cancer managed?
Locally advanced
- if elderly/frail or a low gleason score then can consider surveillance.
- Radical prostatectomy and re-anastomosis of the bladder neck and urethra +/- pelvic lymph node dissection.
- Brachytherapy
Advanced: palliative radiotherapy and hormone therapy.
78
How does hormone therapy work in prostate cancer?
This acts to prevent the action of testosterone. Initially there is a good response but then the tumour will become androgen independent.
79
What are the layers of the scrotum?
Skin, superficial fascia (containing the Dartos muscle), Colle's fascia (continuation of the abdominal Scarpa's fascia), external spermatic fascia, cremasteric spermatic fascia, internal spermatic fascia, tunica vaginalis, tunica albuginea
80
Where do the layers of the spermatic fascia originate from?
External: external oblique
Cremasteric: internal oblique
Internal: transversalis fascia
81
What is the embryological origin of the testes?
Derived from the retroperitoneal gonadal ridge, descending to the deep ring at 4 months. They then travel through the inguinal canal to the scrotum, guided by the gubernaculum.
82
What is the arterial supply to the testes?
The testicular artery (a direct branch of the aorta), travels via the inguinal canal and anastomoses with the epidiymal, cremasteric and vasal arteries
83
What is the venous drainage of the testes?
What is the clinical significance?
The venous drainage is via the pampiniform plexus
The left drains into the L renal, and the right directly into the IVC.
varicoceals are more common on the left and may be a sign of renal malignancy.
84
What is the lymphatic drainage or the testes and the scrotum and why is this clinically important?
Testes: L1 para-aortic nodes
Scrotum: superficial inguinal nodes.
This is why you shouldn't do a needle biopsy or take a scrotal approach to an orchidectomy in suspected testicular cancer.
85
What does the spermatic cord contain?
3 layers of fascia: external, cremasteric, internal
3 arteries: the testicular artery, the cremasteric artery and the artery to the vas
3 nerves: genital branch of the genitofemoral nerve, sympathetic and parasympathetic fibres
3 other: vas deferens, lymphatic vessels, pampiniform plexus
86
Describe the course of the vas deferens?
Starts at the tail of the epididymis and travels via the spermatic cord through the inguinal canal to enter the pelvis.
Moves down the lateral pelvic wall, close to the ischial spine.
It then turns medially to pass between the bladder and the ureter and travels down the posterior surface of the bladder where it joins with the duct from the seminal vesicle to form the ejaculatory duct.
87
What is the structure of the vas deferens?
Thick, muscular tube (smooth muscle). It has 3 layers: longitudinal, circular and longitudinal.
There is also microvilli which help the movement of spermatozoa through the tube.
88
What is the function of the epidydmis?
This is a 6m coiled tube that sits posterior to the testes. It stores and matures sperm, absorbing any excess fluid.
89
What is the anatomical location and function of the seminal vesicles?
These sit on the posterior surface of the bladder and produce nourishing secretions that are added to sperm for ejaculation.
Their ducts join medially to become the ejaculatory duct which pierce the prostate and enter the urethra.
90
What is the most common age of testicular cancer presentation?
15-35
91
What is the survival rates of testicular cancer?
90%
92
What are the risk factors for testicular cancer?
Mumps
Undescended testes
Kleifelters (XXY)
HIV
Radiotherapy
93
What investigations may you perform if a young male presented with a painless, testicular lump?
Full Hx and Examination.
Bloods including BHCG, AFP, LDH
Imaging: USS testes +/- staging CT TAP
94
What are the types of testicular cancer?
Germ cells tumours: seminoma and non-seminoma
Stromal cell tumours: sertoli cell and leydig cell
Lymphoma
95
What are the features of a seminomatous testicular tumour?
Tend to have a heterogenous appearance consisting of clear cell sheets. 3 subtypes (classic or lymphocysticostromal, anaplastic, spermatic)
They will have a normal AFP, BHCG may be raised in 10%.
High LDH
PLAP +ve in 65%
96
What are the features of a non-seminomatous testicular carcinoma?
Normally of mixed origin, but can be embryonal, teratoma, yolk sac, choriocarcinoma.
Investigations include:
High AFP, high BHCG, high LDG.
97
How would you manage a germ cell testicular carcinoma?
Both need discussion at MDT, patient counselling and staging.
They should have an orchidectomy via an inguinal approach and a lymph node dissection.
If high risk then should consider chemotherapy (carboplatin or bleomycin).
98
What are the steps of an orchidectomy?
1.Oblique incision
2. Dissect through the external oblique aponeurosis to locate the superficial ring.
3. Identify the ilioinguinal nerve.
4. Ligate the cord with a high clamp and dissect it out.
5. Withdraw the testes from the scrotum into the inguinal incision.
6. Divide as high as possible.
99
Describe the endocrine axis of the male reproductive system.
The hypothalamus releases LHRH which travels to the pituitary which releases LH. This travels to the Leydig cells in the testes to stimulate testosterone release.
The FSH acts on Sertoli cells to allow spermatogenesis in the seminiferous tubules.
100
How does parasympathetic stimulation lead to erection?
Parasympathetic fibres from S1-S4 travelling with the pudendal nerve cause release of NO and prostaglandins. This subsequently leads to increased cGMP and cAMP which cause smooth muscle relaxation and artery dilatation. This causes reduced venous outflow leading to an erection.
Phosphodiesterase leads to relaxation.
101
How does testicular torsion present?
Acute hemi-scrotal pain due to testes twisting on its cord and causing venous congestion and infarction. Typically ages 10-16.
The Cremasteric reflex is absent in approximately 85%.
Phrenns sign +ve: alleviation of the pain on elevation of the testes.
102
How would you manage a patient with signs of testicular torsion?
This is a surgical emergency.
Keep patient NBM, inform appropriate staff and consent patient.
Needs an urgent surgical exploration and orchidopexy.
103
What is torsion of the hyatid of Morgagni?
This is a torsion of a small appendicular attachment of the testes which may become twisted and gangrenous.
Diagnosis is made intra-operatively.
Can get a "blue dot" sign on the upper half of the hemiscrotum.
104
What is a varicocele and what are the different grades?
This is varicose dilation of the pampiniform veins.
Grade 1: subclinical and only detected on doppler.
Grade 2: palpable when standing
Grade 3: large and visible
105
How would you manage a varicoceal?
This needs further investigations including USS of the renal tract.
Veins can be ligated or managed by percutaneous ablation
106
What is a hydrocele and why does it occur?
This is a collection of fluid in the tunica vaginalis.
Presents as a painless scrotal swelling, trans-illuminates.
May be congenital due to a patent processes vaginalis or acquired (idiopathic, trauma, tumour or infection).
107
What are some differentials of a testicular mass?
Tumour
Cyst
Hydrocele
Infection
Varicocele
Superficial cyst
108
What is the perineum?
This is an anatomical area separated from the abdominal cavity by the pelvic diaphragm.
109
What is the pelvic diaphragm?
This is made by the two slings of the levator ani muscle (its iliococcygeus (posterior) and the pubococcygeus (anterior) part, the coccygeus and the fascia.
110
What is the levator ani?
This is a broad sheet of muscle composed by 3 separate muscles:
The puborectalis, the pubococcygeus and the iliococcygeus.
111
What are the attachments and origins of the levator ani?
Puborectalis: originates from the posterior pubis and forms a "v" shape sling around the anal canal, creating the anorectal angle.
The Pubococcygeus: originates from the posterior pubis each side and acts to support the pelvic organs.
The iliococcygeus: originates from the ischial spines and the internal obturator fascia. It inserts onto the coccyx, perineal body and the anococcygeal ligament.
Acts to elevate the anorectal canal and the pelvic floor.
112
What is the innervation of the levator ani?
The pudendal nerve
113
What are the origin and insertions of the coccygeus muscle?
Small triangular muscle posterior to the levator ani. Originates from the ischial spines and inserts onto the coccyx supporting the viscera. Innervated by the S4-S5.
114
What is the anal canal and what are its boundaries?
This is a midline structure within the ischioanal fossa which contains fat to allow for expansion of the anal canal.
Borders:
Roof= levator ani
Medial = anus
Floor = skin
Lateral = obturator internus
115
What are the boundaries of the urogenital triangle?
Bounded by the pubic symphysis, ischiopubic rami and the theoretical line between the ischial tuberosities.
It has a layer of strong deep fascia called the perineal membrane which has two pouches: the superficial and deep.
116
What are the contents of the deep perineal pouch?
Males:
- membranous urethra
- external sphincter
- pudendal nerve
- bulbourethral gland
- dorsal nerve
Females:
- urethra
- vagina
- pudendal nerve
- nerve to clitoris
117
What are the contents of the superficial perineal pouch?
-erectile tissue
- ischiocavernosus and bulbospongiousus
- bartholins glands
118
What are the layers of the urogenital triangle (deep to superficial)?
1. Deep perineal pouch
2. Perineal membrane
3. Superficial perineal pouch.
4. Perineal fascia (colles and superficial layer)
5. Skin
119
What is the perineal body?
This is an irregular fibromuscular mass located at the junction between the urogenital and anal triangles. It lies deep to the skin and acts an an attachment for the muscles of the pelvic floor and perineum: levator ani, bublospongiosus, perineal transverse muscles, external anal sphincter and external urethral sphincter
120
Describe the basic anatomy of the penis.
Anatomically divided into 3 parts:
1. Root (located in the superficial perineal pouch of the pelvic floor). Contains the erectile tissues (2x crura and the bulb of the penis) and the two muscles (ischiocavernosus and bulbospongiosus).
2. The body (suspended from the pubic symphysis) and composed of three cylinders of erectile tissue ( 2x corpus cavernosa and the corpus spongiousum).
3. Glands (formed by the distal expansion of the corpus spongiosum).
121
What are the functions of the two penile muscles?
The 2x bulbospongiosus muscle contract to empty the spongy urethra. Its anterior fibres also aid in maintaining an erection.
The 2x ischiocavernosus muscles surround the L and R crura to contract and force blood from the cavernous spaces to the corpea cavernosum.
122
What are the fascial layers of the penis?
Superficial: Colles fascia (continuous with scarpa's fascia).
Deeper: Bucks Fascia (continuous with the deep perineal fascia - a strong thick membrane).
Beneath this is the tunica albuginea (forms the individual capsule around each cavernous body with an incomplete septum.
123
What are the ligaments of the penis?
Suspensory ligament: condensation of the deep fascia connecting the erectile tissues to the pubic symphysis.
The fundiform: condensation of the subcut tissue running from the linea alba around the penis, acting like a sling.
124
What is the arterial supply of the penis?
Dorsal arteries, deep arteries and bulbourethral artery. All derived from the internal pudendal, which is a branch of the IIA.
125
What is the venous drainage of the penis?
Dorsal vein and superficial dorsal veins - prostatic plexus
126
What is the lymphatic drainage of the penis?
Inguinal and iliac nodes
127
What are the bulbourethral glands?
These sit posterolateral to the membranous urethra (superior to the bulb of the penis) and secrete lubricating glycoprotein fluid into the spongy urethra. Acts to lubricate, expel dead cells and urine, and neutralise acid.
128
What are the seminal glands?
These are 5cm long tubular glands located between the bladder fundus and the rectum.
They combine with the vas deferens to form the ejaculatory duct which enters the prostatic urethra. They are lines with pseudostratefied epithelium which is controlled by testosterone and produced seminal secretions (alkaline, fructose, prostoglandins and clotting factors).
129
What are the indications for TURP?
- High pressure chronic retention
- Bladder stones
- Infections
130
What is the genetic mutation associated with prostate cancer?
Deletions or mutations in the PI3K-AKAT
131
How can you judge the test of a radical prostactomy?
PSA measurements.
A high PSA suggests recurrence
132
Why is PSA not always reliable?
Organ specific but not cancer specific (high sensitivity and low specificity)
Can be falsely elevated in; BPH, exercise, infection, recent trauma/surgery, ejaculation.
133
How is Gleason score calculated and why is it important?
Can be focal so need to take samples from different sites, need multiple needle samples.
Malignant glands may be mixed with benign.
The cells can be differentiated from rectal cells via immunohistochemistry (rectal has CEA).
Gleason score is 6-12 samples. They have a number of 1-5 for the most prevalent grade (1-5) and the second most prevalent grade is given a number (1-5).
134
What blood test could you use to assess for bony mets of prostate?
ALP
135
What type of bony metastases do you get in prostate cancer and why?
Sclerotic
Because it stimulates the osteoblasts.
136
What is the most common organism that causes UTI?
E.Coli
137
Why may you consider a bilateral orchidectomy in prostate cancer.
Removal of the Leydig cells as they are a source of testosterone (as androgens produce pro-growth and pro-survival genes).
138
What are the lobes of the prostate?
Anterior, 2x lateral, posterior and medial
139
What is Peyronie's Disease?
This is fibromatosis affecting the tunica albuginea around the corpus cavernosum.
140
What are the features of Peyronies disease?
Pain, deviation of erection
Often associated with duputryens and plantar fascial contractures.
141
How do you manage Peyronie's disease?
ESWL
Nesbut operation
Plaque excision
142
What is the most common histological subtype of penile cancer?
SCC
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What are the features of penile cancer?
Erythematous, indurated area which mimics an ulcer or wart +/- lymphadenopathyW
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Where does penile cancer metastasise to?
Shaft - superficial inguinal nodes
Glans - deep inguinal nodes.
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What is penile SCC associated with?
HPV 16,18,31
HIV
Phimosis
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What are the management options for penile Ca?
Circumcision
Glansectomy + skin reconstruction
Topical Chemo
Penis amputation +/- radical lymph node clearance
147
What are the causes of erectile dysfunction?
Vascular disease
Neurogenic (MS or spinal)
Trauma
Alcohol/Drugs (antidepressants)
Hypogonadism
Peyriones
Diabetes/renal failure
148
How do you manage erectile dysfunction?
Phosphodiesterase inhibitors (maintain cGMP in smooth muscle)
149
What is priapism?
Prolonged, painful erection not associated with sexual disease.
Occurs due to low flow (venous congestion) or high flow (due to an AV malformation).
150
What are some causes of priapism?
Haematological: sickle cell, clots, malignancy, EPO)
Neurological (CVA, disc prolapse)
Drugs (SSRI, trazadone)
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How do you manage priapism?
Aspiration of the corpus and irrigation.
10mg Terbutamine
Intracavernosal phenylephrine
Surgical shunting
152
What is the difference between phimosis and paraphimosis?
Phimosis = non-retractable foreskin
Paraphimosis = foreskin is retracted but cannot be replaced causing constriction of the glans
153
What is balanitis xerotica obliterans?
This is phimosis due to scarring of the foreskin. It required circumcision.
154
How would you manage paraphimosis acutely?
Try to reduce swelling and attempt reduction.
LA ring block and aspirate
Circumcision
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What are the complications of circumcision?
Bleeding, retention, infection, change in sensation, urethral damage.
MUST use bipolar diathermy.
156
What investigations would you undertake for haematuria?
Bedside: A-E, observations, Urinalysis, Urine MC&S and cytology
Bloods: Hb, UE, coag and PSA
Imaging: Plain XR, USS KUB or CT KUB
Invasive: Flexible cystoscopy
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What are the most common subtypes of RCC and from where do they arise?
Clear cell = epithelium of the DCT
Papillary = PCT
Chromophobe = collecting duct
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What is Von-Hippel Lindau?
This is a rare genetic condition characterised by cysts and tumours in
multiple organ systems
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Where does RCC metastasise to?
Lungs (most common), bones, liver, adrenals and lymph
160
What are the paraneoplastic syndromes associated with renal cell carcinoma?
* hypercalcaemia
* polycythaemia from erythropoietin production
* Stauffer syndrome: comprising abnormal liver function tests and
coagulation defects
* Cushing syndrome
* anaemia
* neuromyopathy.
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How would you manage a seminoma with staging demonstrating T1 N0 M0
Radial inguinal orchidectomy with post-op surveillance (recurrence is 15-20%)
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How would you manage a testicular teratoma with lung mets?
Radial orchidectomy (inguinal)
Combination chemo (bleomycin, etoposide and cisplatin)
163
What is the name given to the deformity that predisposes patients to
testicular torsion?
* The ‘bell clapper deformity’.
* The tunica vaginalis joins the spermatic cord higher than normal,
leaving the testicle to be more mobile, and thus more likely to
tort.
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What would you include when consenting for surgical exploration for testicular torsion?
Additional procedures:
* orchidectomy and contralateral testicular fixation (if the torted
testicle is non-viable)
* bilateral testicular fixation (if unilateral torsion is present, but the
testicle is viable following detorsion)
* excision of hydatid of Morgagni or appendix epididymis (these
can cause testicular pain).
Benefits:
* diagnostic (to assess for cause of pain)
* therapeutic (to treat possible torsion, and to prevent further
torsion).
Alternative procedures:
* do nothing
* perform ultrasound ± Doppler – with a discussion around the risks
of delaying surgery, ie potential loss of testicle.
Risks:
* early: pain, scar, bleeding, risks of general anaesthetic
* middle: pain, scar, infection, haematoma
* late: unsatisfactory cosmesis, scar, recurrence of torsion.
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What is the blood supply of the adrenal glands?
There are three arteries for each adrenal gland:
* the superior adrenal is a branch of the inferior phrenic arteries
* the middle adrenal artery is a direct branch from the aorta
* the inferior adrenal branches off the renal artery. There is a single
adrenal vein that drains into the respective renal vein on the left and
directly into the inferior vena cava on the right
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When does the urinary bladder become palpable?
Normally can be felt when it holds >500ml of urine
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How is urine prevented from refluxing and damaging the kidneys?
* At the vesicoureteric junction, the ureters enter the bladder wall at an
oblique angle, discouraging reflux. This is one of the narrowest parts
of the ureter and, as a consequence, stones may get impacted in this
region.
* In addition, intrinsic detrusor muscle tonicity prevents vesicoureteric
reflux.
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What is the nerve supply to the testes and to where is pain from the testes referred?
Innervation is from the sympathetic fibres. They refer pain to the T10
dermatome (umbilicus).
169
What measures can be taken to try and prevent TURP syndrome?
* Pre-operative correction of electrolytes.
* Optimisation of pre-existing cardiac disease pre-operatively.
* Limiting operative time.
* Careful dissection to minimise open vessels through which
absorption of irrigation fluid can occur.
* Low positioning of the irrigation bag, to limit hydrostatic pressure of
fluid.
* Frequent drainage of the bladder.
* Regular monitoring of the observations: close communication with
the anaesthetist to pick up early signs and terminate the operation if
necessary.
* If there is a breach of the prostatic capsule, aim to finish the
operation quickly.
* Maintain adequate blood pressure to prevent increased absorption of
irrigation fluid.
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What are some causes of hyponatraemia.
* Patients with hyponatraemia are either hypovolaemic or
hypervolaemic.
* Hypovolaemic causes include burns, diarrhoea and vomiting, excess
diuretic therapy and Addison's disease.
* Hypervolaemic causes include congestive cardiac failure, polydipsia,
excess intravenous fluids, renin–angiotensin–aldosterone system
stimulation, and syndrome of inappropriate antidiuretic hormone
(SIADH), TURP syndrome
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What are the causes of SIADH?
Head trauma, intracerebral tumours, opiates, PE, chest infections, lung tumours.
172
Where is squamous cell carcinoma more common and why?
In African countries due to the presence of the parasite schistosoma haematobium transmitted
by freshwater snails. It causes chronic inflammation of the bladder and ureters leading to
bladder cancer and obstructive kidney disease.
173
What are the causes of squamous cell carcinoma in the western world and why?
Indwelling catheters and bladder calculi
Trauma or prolonged irritation.
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What are the types of bladder cancer?
TCC, SCC
Less common: adenocarcinoma, small cell carcinoma and metastases
175
What is PSA?
It is a glycoprotein 'peptidase' enzyme that is secreted by the epithelial cells of the prostate gland. It liquefies semen allowing sperm to move freely and dissolves cervical mucus. It is elevated in certain prostatic disorders.
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What is the half life of PSA and why is this clinically important?
serum half life of PSA following removal of the prostate gland is 2-3 days. Therefore PSA levels should be expected to fall below detectable levels within 4-6
weeks. If it is high then you may be concerned about recurrence
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What is an example of the hormone therapies that can be used to manage prostate Ca?
LHRH agonists (goserelin)
Bicalutamide/ Flutamide is an anti-androgen medication which competitively antagonises androgen receptors preventing testosterone from binding to the prostate cancer cells and thus inhibiting their growth.
178
What are the management options for BPH?
Conservative
Lifestyle: no drinks before bed, exercise, patient support
Bladder training
Medication
Alpha blockers e.g. tamsulosin & alfuzosin to relax the smooth muscle
Finasteride & dutasteride- block dihydrotestosterone
Surgery
105
Trans-urethral resection of the bladder
Open prostatectomy
Newer techniques e.g. laser enucleation
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Where do the urethral sphincter muscles lie in relation to the prostate gland?
The internal urethral sphincter (smooth muscle) lies above the prostate gland at the bladder neck
The external urethral sphincter (skeletal muscle) lies below the prostate gland in the deep perineal pouch
180
What are the complications of crypto-orchidism?
Cryptorchidism is a risk factor for testicular cancer, with a 40 fold increase compared to the normal population. Patients are also at risk of infertility
181
What is the most common location of an undescended testis?
70% are found within the inguinal canal.
182
What are the risk factors for undescended testicle?
Low birth weight, family Hx, hormonal abnormalities, gastroschisis
183
How would you manage crypto-orchidism?
Management is normally withheld until 6 months of age to allow the testicle to descend spontaneously. After 6 months, spontaneous descent is rare. The child should have an orchidoplexy, where the testis is mobilized and then fixed in a dependent position in the scrotum
184
Does orchidoplexy for crypto-orchidism reduce the risk of infertility and testicular cancer?
Orchidoplexy is thought to reduce the risk of both infertility and testicular cancer; however, it does not reduce either to normal levels. A major benefit of the testes new location in the scrotum is the facilitation of self-examination, allowing earlier detection of a suspicious lump.
185
Is radiotherapy effective for testicular tumours?
Yes in seminoma
No in non-seminoma
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