Urology Flashcards
What is the duration of abx course in UTI of a non-pregnant woman?
3 days of nitrofurantoin or trimethoprim
What is the duration of abx course in UTI of a man?
7 days of trimethoprim or nitrofurantoin should be offered first-line unless prostatitis is suspected
Do you need to treat catheterised patients for bacterial growth in urine?
- Do not treat asymptomatic bacteria in catheterised patients
- If the patient is symptomatic they should be treated with a 7 day antibiotics course
- Consider removing or changing the catheter as soon as possible if it has been in place for longer than 7 days
What is the mechanism of action of tamsulosin?
Alpha-1 antagonists - decrease smooth muscle tone of the prostate and bladder
*This is first-line for BPH
What is the mechanism of finasteride?
5 alpha-reductase inhibitors
Block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH
What are side effects of tamsulosin?
- Dizziness
- Postural hypotension
- Dry mouth
- Depression
- Retrograde ejaculation
What are side effects of finasteride?
- Erectile dysfunction
- Reduced libido
- Ejaculation problems
- Gynaecomastia
- Retrograde ejaculation
What are causes of urethral strictures?
- idiopathic
- iatrogenic e.g. traumatic placement of indwelling urinary catheters
- sexually transmitted infections e.g. gonorrhoea
- penile fractures e.g. secondary to sexual trauma
- hypospadias
- lichen sclerosus
What are features and investigations of urethral strictures?
Features:
* decreased urinary stream
* incomplete bladder emptying
* less common symptoms including spraying of urinary stream and dysuria
Investigations:
* uroflowmetry
* ultrasound postvoid residual (PVR) measurement
What is the management of urethral strictures?
- Dilation
- Endoscopic urethrotomy
What are featues of renal cell carcinoma?
Triad: haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Endocrine effects: increased EPO and PTHrp (hypercalcaemia)
Where does a renal cell carcinoma orignate from and what is the most common histological subtype?
It arises from proximal renal tubular epithelium.
The most common histological subtype is clear cell (75 to 85 percent of tumours).
What is the first-line investigation of suspected prostate cancer?
Multiparametric MRI - reported on a likert scale
*This is now preferred over transrectal ultrasound-guided (TRUS)
What non-pain relief medical management can be given in ureteric stones?
Tamsulosin - promote smooth muscle relaxation and dilation of the ureter. potentially easing stone passage.
NICE only recommends for stones <10mm
What is the first-line management of renal stones?
- watchful waiting if < 5mm and asymptomatic
- 5-10mm shockwave lithotripsy
- 10-20 mm shockwave lithotripsy OR ureteroscopy
- > 20 mm percutaneous nephrolithotomy
What is the first-line management of ureteric stones?
- < 10mm shockwave lithotripsy ± alpha blockers
- 10-20 mm ureteroscopy
What should you do for patients with obstructive urinary calculi and signs of infection?
Urgent renal decompression and IV antibiotics due to the risk of sepsis
How do GnRH agonists (e.g. goserelin) help with prostate cancer?
Paradoxically result in lower LH levels longer term by causing overstimulation, resulting in disruption of endogenous hormonal feedback systems. The testosterone level will therefore rise initially for around 2-3 weeks before falling to castration levels
When do you start hormonal therapy in prostate cancer?
Localised advanced prostate cancer (T3/T4)
What are medical indications for circumcision?
- phimosis
- recurrent balanitis
- balanitis xerotica obliterans
- paraphimosis
How does a bladder rupture commonly present?
Pelvic fracture
Lower abdominal peritonism - with free fluid
Inability to pass urine
What are the different types of urethral injury?
Bulbar rupture
and
Membranous rupture
What are features of a bulbar urethral rupture?
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma, blood at the meatus
What are features of a membranous urethral rupture?
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)
What can you give if NSAIDs are contraindicated or not providing sufficient pain relief in renal colic?
IV paracetamol (according to NICE)
What are risk factors of testicular cancer?
- infertility (increases risk by a factor of 3)
- cryptorchidism
- family history
- Klinefelter’s syndrome
- mumps orchitis
What tumour markers can be identified in germ cell tumours?
- seminomas: hCG may be elevated in around 20%
- non-seminomas: AFP and/or beta-hCG are elevated in 80-85%
LDH is elevated in around 40% of germ cell tumours
What is the mechanism of gynaecomastia in germ cell tumours?
Germ-cell tumours → hCG → Leydig cell dysfunction → increases in both oestradiol and testosterone production, but rise in oestradiol is relatively greater than testosterone
What is the main difference between nephroblastoma and neuroblastoma?
Nephroblastoma (Wilm’s tumour):
* Intrarenal origin
* Painless abdominal mass, confined to flank
* Lung metastases common
* Non-calcified
Neuroblastoma:
* Extrarenal origin, usually from adrenal glands or sympathetic ganglia
* Painful abdominal mass, often crosses midline
* Bone metastases common
* Calcified
What is angiomyolipoma?
Benign tumours of the kidneys
Tumour is composed of blood vessels, smooth muscle and fat
Linked to tuberous sclerosis
What type of bladder cancer is associated with schistosomiasis?
Squamous cell carcinoma
What is the most common type of bladder cancer?
Transitional cell carcinoma
What is the gold-standard investigation for diagnosis bladder cancer?
Flexible cystoscopy for direct visualisation
*A CT scan or PET-CT may be needed later to assess metastatic spread if a bladder tumour is confirmed by cystoscopy.
What are features and associations of epididymal cysts?
Features:
* separate from the body of the testicle
* found posterior to the testicle
Associations:
* polycystic kidney disease
* cystic fibrosis
* von Hippel-Lindau syndrome
What is BCG treatment?
Form of immunotherapy that is used alongside TUBRT (transurethral resection of bladder tumour).
It involves injection of Mycobacterium bovis into the bladder through a catheter.
What is the ideal management of a bladder carcinoma in situ?
Trans-urethral removal of bladder tumour (TURBT) with adjunct intravesicle chemotherapy
What is the general concensus for referring a patient to 2WW in urology?
> = 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test - to exclude bladder cancer
What can be done to prevent calcium stones?
- high fluid intake
- add lemon juice to drinking water
- avoid carbonated drinks
- limit salt intake
- potassium citrate
- thiazides diuretics (increase distal tubular calcium resorption)
What can be done to prevent uric acid stones?
- allopurinol
- urinary alkalinization e.g. oral bicarbonate
What can be done to prevent oxalate stones?
- cholestyramine reduces urinary oxalate secretion
- pyridoxine reduces urinary oxalate secretion
What organisms are associated with struvite stones?
Struvite = magnesium ammonium phosphate
Proteus mirabilis
*Also associated with klebsiella and staphylococcus species
What are some benefits of circumcision?
- Reduces the risk of penile cancer
- Reduces the risk of UTI
- Reduces the risk of acquiring sexually transmitted infections including HIV
What are some important facts to know about vasectomies?
- Failure rate 1:2000
- Simple operation, under LA or some GA
- Doesn’t work immediately
- Semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 12 weeks)
- Chronic testicular pain in 5-30% of men
What is the preferrred management of removal of renal stones in pregnant women?
Ureteroscopy
What would you see on examination of a testicular torsion?
- Swollen, tender testis retracted upwards. The skin may be reddened
- Cremasteric reflex is lost
- Elevation of the testis does not ease the pain (Prehn’s sign)
What is the most common organic cause of erectile dysfunction?
Vascular causes
What investigations should be done when a patient presents with erectile dysfunction?
- 10-year cardiovascular risk - with lipids and fasting glucose
- Free testosterone
Which lymph nodes are first affected in testicular cancers?
Retroperitoneal lymph node (from the anatomy where they derive their blood supply from around the kidneys
You can get inguinal lymphadenopathy in T4 disease where there has been adjacent spread - poor prognostic factor
Where do the testicular veins drain into?
Right: inferior vena cava
Left: left renal vein
What are features of obstructive LUTS?
- Weak or intermittent urinary stream
- Straining when urinating
- A hesitation before urine flow starts
- A sense that the bladder has not emptied completely
- Dribbling at the end of urination or leakage afterward
What are features of storage-related LUTS?
- An increased frequency of urination, particularly at night
- An urgent need to urinate
- Urge incontinence
- Bladder pain or irritation when urinating
What are contraindications to shockwave lithotripsy?
- Infection/sepsis
- Aneurysm
- Pregnancy
- Anticoagulation or bleeding disorders
What is the treatment of staghorn calculi?
Percutaneous nephrolithotomy
What does a positive Prehn’s sign suggest?
A positive Prehn’s sign indicates relief of pain upon elevation of the scrotum and is associated with epididymitis
What is the most common kidney stone?
Calcium oxalate (85%)
Which kidney stones are radio-lucent?
Urate stones
Xanthine stones
What is the management of UTI in men?
- Urine culture should be sent in all cases before antibiotics are started
- 7 days course of abx - trimethoprin or nitrofurantoin unless prostatitis is suspected
Which common medications cause erectile dysfunction?
SSRIs
Beta-blockers
How should you investigate suspected epididymo-orchitis?
Sexually active younger adults: NAAT for STIs
Older adults with a low-risk sexual history: MSSU
What should you be worried about if a patient has an unresolving left varicocoele?
You would be worried about a renal tract cancer - due to the embryological anatomy linking the left renal vein and the left testicular vein, where there is a tumour compressing the veins
You need to do a renal tract USS
What organsims cause epididymo-orchitis?
Commonly caused by local spread of infections from the genital tract (such as Chlamydia trachomatis and Neisseria gonorrhoeae, typically seen in sexually active younger adults)
OR
the bladder (E. coli, typically seen in older adults with a low-risk sexual history).
