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Urology Flashcards

1
Q

What is a common complication of radiotherapy for testicular cancer?

A

Proctitis

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2
Q

What are patients at increased risk of following radiotherapy for prostate cancer?

A

Bladder, colon and rectal cancer

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3
Q

What is the management of hard, irregular prostate felt on DRE?

A

2 week wait referral to urology alongside measuring PSA

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4
Q

What is important to exclude before circumcision can take place?

A

Hypospadias

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5
Q

What are the side effects of tamsulosin?

A
  • dizziness
  • postural hypotension
  • dry mouth
  • depression
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6
Q

Ongoing loin pain, haematuria, pyrexia of unknown origin suggests what?

A

Renal cancer

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7
Q

What does circumcision help to reduce?

A

Rates of HIV transmission

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8
Q

What is the first line investigation for prostate cancer?

A

Multiparametric MRI: results reported using a 5-point Likert scale and if >=3 then biopsy.

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9
Q

What is the investigation of choice for renal stones?

A

Non contrast CT KUB

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10
Q

What is the most common form of prostate cancer?

A

Adenocarcinoma

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11
Q

What is the referral criteria for bladder cancer?

A

A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test

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12
Q

What is the analgesia of choice in renal colic?

A

IM Diclofenac

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13
Q

What is the mode of action of tamsulosin?

A

Alpha-1 antagonists which promote relaxation of the smooth muscle of the prostate and the bladder

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14
Q

schistosomiasis is a major risk factor for what?

A

Squamous cell carcinoma of the bladder

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15
Q

What is the treatment of choice for renal stones in pregnant women?

A

Ureteroscopy

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16
Q

Adult patients with hydroceles should have what?

A

Ultrasound scan

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17
Q

How are infantile hydroceles managed?

A

Surgical repair if not resolved spontaneously by ages 1-2

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18
Q

What is the management of epipidimo-orchitis with no known organism?

A

ceftriaxone 500mg intramuscularly single dose, plus oral doxycycline 100mg twice daily for 10-14 days

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19
Q

What are the investigations of choice for epipdidimo-orchitis?

A

Younger adults with sexual history - NAAT
Older adults - MSSU

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20
Q

What should be sent for all women with suspected UTI and haematuria?

A

MSU

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21
Q

Acute vs chronic urinary retention

A

Chronic will have much larger volumes (1.5L) and be painless

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22
Q

What is a complication of losing too much fluid following catheterisation?

A

Post-obstructive diuresis: monitor urine output + replace fluids

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23
Q

How do Tamsulosin and finasteride work?

A

Tamsulosin - alpha blocker - relaxes smooth muscle
Finasteride - 5-alpha reductase inhibitor - inhibits conversion of testosterone to dihydrotestosterone

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24
Q

What are risk factors for bladder cancer?

A
  • Smoking
  • Aromatic amines (paint and dye workers)
  • Schistosomiasis
  • Men 50-8-yrs
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25
Q

Types of bladder cancer?

A
  • Urothelial (transitional cell) cancinoma (>90%)
  • SCC
  • Adenocarcinoma
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26
Q

Characteristics of transitional cell carcinomas of the bladder?

A

papillary growth pattern; superficial and better prognosis than others (SSC and A more prone to local invasion).

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27
Q

CP of bladder cancer?

A

painless macroscopic haematuria

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28
Q

Bladder cancer Ix?

A

TURBT or cystoscopy and biopsy: histological diagnosis.
Spread: pelvic MRI and distant disease CT

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29
Q

What is treatment for TCC of bladder?

A

TURBT

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30
Q

Bladder ca Mx if recurrences or higher grade/risk?

A

intravesical chemotherapy

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31
Q

Bladder ca Mx if T2 (invades supperfical or deep muscularis propria- 60% prog)?

A

Surgery- radical cystectomy and ileal conduit or radical radiotherapy

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32
Q

Where can bladder tumours metastasize to?

A
  • Uterus, rectum, iliac lymph nods, liver, lungs, bone
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33
Q

Management of ureteric stone + signs of infection?

A

Surgical decompression + IV Abx

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34
Q

What do you call a hernia which cannot be reduced and is painless?

A

Incarcerated

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35
Q

What can a left sided varicocele be a complication of?

A

Renal cell carcinoma due to venous congestion of the left testicle

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36
Q

What is the scoring system used to assess prostate cancer severity?

A

Gleason

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37
Q

What is the management options for prostate cancer?

A

Low grade - active surveillance
Radical prostatectomy - robotic in younger/fitter patients
Open prostatectomy

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38
Q

What are causes of urinary retention?

A
  • Stones
  • BPH, Prostate cancer
  • UTIs
  • Post surgery
  • Constipation in elderly
  • Medications such as anticholinergics, benzos
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39
Q

Management of urinary retention

A
  • Bladder scan/renal US
  • Post void residual volume
  • Catheterisation
  • Treat cause
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40
Q

What scoring system can be used to assess prostate symptoms?

A

International Prostate Symptom Score

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41
Q

How should bladder cancer be investigated?

A

Flexible cystoscopy with biopsy
CT urogram for staging

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42
Q

Bladder cancer Mx?

A

superficial lesions= TURBT

higher grade/risk= intravesical chemo

T2 disease= radical radiotherapy or surgery (radical cystectomy and ileal conduit)

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43
Q

TNM staging: T?

A

T0= No evidence of tumour
Ta= Non invasive papillary carcinoma
T1= Tumour invades sub epithelial connective tissue
T2a= Tumor invades superficial muscularis propria (inner half)
T2b= Tumor invades deep muscularis propria (outer half)
T3= Tumour extends to perivesical fat
T4= Tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina
T4a= Invasion of uterus, prostate or bowel
T4b= Invasion of pelvic sidewall or abdominal wall

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44
Q

TNM staging: N?

A

N0= No nodal disease
N1= Single regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node)
N2= Multiple regional lymph node metastasis in the true pelvis (hypogastric, obturator, external iliac, or presacral lymph node metastasis)
N3= Lymph node metastasis to the common iliac lymph nodes

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45
Q

TNM staging: M?

A

M0= No distant metastasis
M1= Distant disease

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46
Q

What are causes of epididymo-orchitis

A

STI - Chlamydia/Gonorrhoea
UTI - E coli in older adults

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47
Q

What are signs of epididymo-orchitis?

A
  • Acute scrotal pain/swelling
  • Fever
  • Dysuria
  • Prehn’s positive: lifting up testicle relieves pain
  • Present cremasteric reflex
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48
Q

Management of epidiymo-orchitis

A
  • Analgesia
  • Scrotal elevation
  • Abx to treat underlying cause (Ceftriaxone + Doxy if any STI, Doxy if chlamydia)
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49
Q

Erectile dysfunction?

A

Persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

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50
Q

What are some causes of erectile dysfunction?

A
  • vascular (HTN, PAD, smoking, obesity)
  • neuronal (MS, Parkinsons, stroke)
  • neurogenic (DM, CKD, liver disease)
  • anatomical (prostate ca)
  • psychogenic (relationship issues, stress, depression, disorders of arousal)
  • drugs
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51
Q

Drugs that may cause erectile dysfunction?

A

antihypertensives, diuretics, antidepressants, hormonal treatments, recreational drugs

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52
Q

Cx of erectile dysfunction?

A

performance anxiety, reduced confidence, depression, increased risk of CVD and stroke, relationship difficulties

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53
Q

Ix for erectile dysfunction

A
  • lifestyle? relationships, mental health, sexual desire, arousal, onset, duration and quality of erections
  • HbA1c, lipid profile and fasting morning total testosterone levels in all men
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54
Q

What is the management of erectile dysfunction?

A
  • Lifestyle: weight loss, smoking cessation
  • Psychosexual therapy
  • PDE-5 inhibitor: Sildenafil 50mg /Tadalafil which increase blood flow to penis (can cause blue vision)
  • Injections
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55
Q

What drugs class is sildenafil 50mg or tadalafil?

A

Phosphodieasterase-5 inhibitor (PDE-5)

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56
Q

When should pts with erectile dysfunction be followed up?

A

after 6-8w

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57
Q

When should pt with erectile dysfunction be admitted to hospital urgently?

A

if priapism (painful prolonged erection for >4hrs)

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58
Q

When should pt be referred with erectile dysfunction?

A

lifeling symptoms, young, not responding to max dose of at least 2 PDE-5 inhibitors; suspected test def or hypogonadism; cardiac risk; psychogenic cause

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59
Q

What is the referral criteria for haematuria?

A

Bladder/Renal
- >45 with unexplained haematuria/haematuria which persists after UTI treatment
- >60 with haematuria + dysuria/raised WCC

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60
Q

What causes a hydrocele?

A

Processes vaginalis does not obliterate complete during foetal development causing abdominal fluid to accumulate in scrotum

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61
Q

Phimosis vs paraphimosis

A

Phimosis - foreskin too tight to be retracted over the glans of the penis
Paraphimosis - inability to replace foreskin to its original position

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62
Q

What is the management of phimosis vs paraphimosis?

A

Phimosis - steroid creams/surgery
Paraphimosis - manual pressure/dorsal slits

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63
Q

What is priapism?

A

Painful erection which continues over 2 hours after sexual activity

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64
Q

What causes priapism?

A

Ischaemic - lack of venous drainage
Non-ischaemic - often due to trauma

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65
Q

What is management of priapism?

A

Aspiration of blood within corpus cavernosa and fluid irrigation
Adrenaline injections

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66
Q

What causes prostatitis?

A

Acute - often due to bacterial infection
Chronic - recurrent/persistent prostatitis usually caused by E coli

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67
Q

How will prostatitis present on DRE?

A

Tender, warm, swollen prostate

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68
Q

How is prostatitis managed?

A

2 weeks of ciprofloxacin

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69
Q

What are the 2 types of renal cancer?

A
  • Clear cell carcinoma
  • TCC
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70
Q

What the 2 most common types of testicular cancer?

A

Germ-cell tumours:
- Seminomas
- Teratoma (non-seminomas)

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71
Q

Example of non-germ cell tumours?

A

Leydig cell tumours and sarcomas

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72
Q

What are risk factors for testicular cancer?

A
  • Younger age (25-35yrs)
  • HIV
  • Undescended testes (cryptochidism)
  • infertility
  • FHx
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73
Q

Testicular cancer CP?

A
  • painless lump mostly (pain may be present)
  • hydrocele
  • gynaecomastia
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74
Q

Why do pts get gynaecomastia in testicular cancer?

A

due to increased oestrogen:androgen ratio

germ cell tumoure -> hCG -> Leydig cell dysfunction -? increases in both oestradiol and testosterone production but more oestradiol

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75
Q

Germ cell tumour markers: what may be elevated in around 20% of seminomas?

A

hCG

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76
Q

Germ cell tumour markers: what may be elevated in around 80% of non-seminomas?

A

AFP and/or beta-hCG

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77
Q

Germ cell tumour markers: what may be elevated in around 40% of of germ cell tumours?

A

LDH

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78
Q

Ix for testicular cancer

A

1st line & diagnostic= scrotal USS
- Tumour markers: hCG, AFP, LDH

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79
Q

What is the management of testicular cancer?

A
  • Radical orchidectomy (+ radio/chemo)
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80
Q

What is testicular torsion?

A

Twisting of the testicle around the spermatic cord -> obstruction of blood flow to testicle

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81
Q

How does testicular torsion present?

A
  • Sudden onset severe pain
  • Absent cremasteric
  • Negative Prehns
  • Following trauma
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82
Q

What is the management of torsion?

A
  • Surgical exploration
  • Bilateral orchidopexy: fix both testicles
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83
Q

What is the management of undescended testes?

A

Bilateral: refer to paeds to rule out genetic causes then surgery at 6 months
Unilateral: review at 6-8 weeks with referal at 3 months

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84
Q

What are causes of raised PSA?

A
  • UTI
  • BPH
  • Prostate cancer
  • Retention
  • Catheterisation
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85
Q

Why are Abx given following prostate biopsy?

A

Minimise risk of infection where bowel flora can move into the prostate

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86
Q

Indications that a mass is renal

A

Moves up and down with respiration, mass palpable on bimanual
palpation, able to get above mass

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87
Q

Why does ureteric obstruction cause pain?

A

Ureteric spasm arises from peristalsis attempting to push the stone and relieve obstruction. This causes local ischaemia and hence pain

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88
Q

What are common sites for ureteric stones?

A
  • Renal pelvis
  • Pelvic-ureteric junction
  • Vesico-ureteric junction
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89
Q

What immediate test should be done with painless scrotal swellings?

A

Trans-illumination: illumination suggests hydrocele

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90
Q

Where are prostate cancers likely to originate?

A

Peripheral zone

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91
Q

Which drugs can cause priapism?

A

Trazadone

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92
Q

What are the most common causes of pyelonephritis?

A
  • E coli: gram negative pink rod shaped bacteria
  • Klebsiella
  • Proteus
  • Enterococcus
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93
Q

What are the common components of renal stones?

A
  • Calcium oxalate (most common)
  • Calcium phosphate
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94
Q

Patients with signs of chronic retention should not have what?

A

TWOC - this can exacerbate renal impairment so they need a long term catheter

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95
Q

Lifestyle interventions for stress incontinence

A
  • Stop smoking
  • Lose weight
  • Avoid alcohol/caffeine
  • Avoid drinking at nightime
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96
Q

Causes of recurrent UTI in men

A
  • Bladder outflow obstruction
  • Urinary tract surgery
  • Immunosuppression
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97
Q

Common organisms which cause UTI

A
  • Escherichia coli
  • Klebsiella
  • Enterococcus
  • Proteus sp
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98
Q

What are causes of urethral strictures?

A
  • Pelvic trauma
  • Perineal trauma
  • Urethral instrumentation
  • Long term catheter
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99
Q

Investigations for urethral strictures

A
  • Cystoscopy
  • U+E
  • Urinalysis
  • Urodynamic testing
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100
Q

What are complications of urethral strictures?

A
  • Calculus formation in the urinary tract
  • Chronic infection
  • Bladder diverticula
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101
Q

What causes bladder diverticula?

A
  • Chronic increase in intravesical pressure causing mucousa to push through the muscle layer -> risk of chronic infection
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102
Q

What is the management of urethral strictures?

A
  • Internal urethrotomy
  • Urethroplasty
  • Graft reconstruction
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103
Q

Men with erectile dysfunction should have what tests

A

Glucose, lipid profile, testosterone

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104
Q

What is the most common testicular tumour in younger men?

A

Non-seminomatous germ cell tumours

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105
Q

What is a Wilms tumour?

A

Nephroblastoma

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106
Q

What is the most common organic cause of erectile dysfunction?

A

DM

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107
Q

Where are staghorn calculi found?

A

Renal pelvis

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108
Q

What are the 2 broad classes of testicular cancers?

A

Seminomas and non-seminomatous germ cell tumours

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109
Q

How do testicular cancers metastasize?

A

Para aortic lymph nodes

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110
Q

How to classify LUTS?

A

Storage: frequency, urgency, nocturia, dysuria
Voiding: hesitancy, poor stream, dribbling

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111
Q

What is a common complication of radical prostatectomy?

A

Erectile dysfunction

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112
Q

How long can finasteride treatment take?

A

6 months

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113
Q

Risk factors for testicular cancer?

A
  • Infertility
  • FH
  • Cryptorchidism
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114
Q

What usually precedes development of a urethral stricture?

A

Urethral inflammation often due to infection

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115
Q

Tumour containing different types of tissue e.g. cartilage?

A

Teratoma

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116
Q

What is the management of neuropathic bladder?

A

Intermittent self catheterisation

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117
Q

Management of mixed colonisation of urinary catheters?

A

No changes needed - mixed growth bacteria is very common and does not cause symptoms usually

118
Q

Cystocele vs Rectocele

A

Cystocele - prolapse of anterior vaginal wall containing bladder
Rectocele - Prolapse of posterior vaginal wall containing rectum

119
Q

What are lifestyle modifications for urge incontinence?

A

Avoid caffeine
Pelvic floor excercises
Bladder retraining
Avoid alcohol/smoking
Weight loss

120
Q

Abx of choice for prostatitis?

A

Ciprofloxacin

121
Q

What is sometimes on present on standing?

A

Varicocele

122
Q

What is an epidydimal cyst?

A

Painless nodule at the head of the epididymis adjacent to inferior pole of testis

123
Q

Gynaecomastia can be a presenting feature of what?

A

Testicular cancer

124
Q

terminal, painful haematuria

A

Think bladder calculi

125
Q

What can present with recurrent balanitis and ballooning around the penis?

126
Q

Bell clapper deformity (testis is not fixed) increases the risk of what?

A

Testicular torsion

127
Q

What is an electrolyte complication of TURP?

A

Hyponatraemia

128
Q

What marker is associated with testicular seminomas?

129
Q

Benign prostatic hyperplasia RFs?

A
  • older age
  • only in men
  • black > white > Asian
130
Q

What do pts with BPH typically present with?

A

LUTS (lower urinary tract symptoms):

1) voiding symptoms (obstructive)
2) storage symptoms (irritative)
3) post-micturition

131
Q

Voiding symptoms in BPH?

A

weak/intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying

132
Q

Storage symptoms of BPH?

A

urgency, frequency, urgency incontinence, nocturia

133
Q

Post-micturition symptoms of BPH?

134
Q

Cx of BPH?

A

UTI, retention, obstructive uropathy

135
Q

Ix for BPH?

A
  • urine dip
  • PSA
  • U&Es
  • urinary frequency volume chart >3days
  • International Prostate Symptom Score (IPSS)
136
Q

What is the International Prostate Symptom Score (IPSS)?

A

tool for classifying the severity of lower urinary tract symptoms (LUTS) and assessing the impact of LUTS on quality of life

Score 20-35: severely symptomatic
Score 8-19: moderately symptomatic
Score 0-7: mildly symptomatic

137
Q

Mx for BPH?

A
  • watch and wait, advice on fluid intake
  • alpha-1 antagonists eg. tamsulosin= if mod-severe LUTS eg. voiding symptoms

-5 alpha-reductase inhibitor eg. finasteride= if prostate >30g or PSA >1.4 and high risk for progression eg. older men

  • combination therapy: if both
  • 4th= antimuscarinic (anticholinergic) eg. tolterodine + alpha blocker= if still have storage symptoms after alpha Mx
  • Surgery: transurethral resection of prostate (TURP)
138
Q

Example of alpha-1 antagonist?

A

Tamsulosin

139
Q

When is alpha-1antagonist eg. tamsulosin indicated?

A

BPH if f mod-severe LUTS, esp. voiding symptoms

140
Q

alpha-1antagonist eg. tamsulosin adverse effects?

A

dizziness, postural hypotension, dry mouth, depression

141
Q

Alpha-1antagonist eg. tamsulosin mechanism of action?

A

decrease smooth muscle tone of the prostate and bladder

142
Q

Example of a 5 alpha-reductase inhibitor?

A

Finasteride

143
Q

When is a 5 alpha-reductase inhibitor eg. finasteride indicated?

A

BPH if if prostate >30g or PSA >1.4 and high risk for progression eg. older men

144
Q

Mechanism of action for 5 alpha-reductase inhibitor eg. finasteride?

A

Block the conversion of testosterone to dihydrotestosterone (DHT), which is known to induce BPH. May decrease PSA. May cause reduction in prostate vol (unlike alpha-1 antagonist) so may slow progression but takes up to 6m.

145
Q

5 alpha-reductase inhibitor eg. finasteride adverse effects?

A

erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia

146
Q

What is TURP syndrome?

A

rare and life-threatening Cx of transurethral resection of prostate surgery

147
Q

What is TURP syndrome caused by?

A

Irrigation with large vols of glycine (hypo-osmolar) and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection. Results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.

148
Q

What does TURP syndrome present with?

A

CNS, resp and systemic symptoms

149
Q

RFs for developing TURP syndrome?

A

surgical time > 1 hr
height of bag > 70cm
resected > 60g
large blood loss
perforation
large amount of fluid used
poorly controlled CHF

150
Q

Epididymo-orchitis?

A

Infection of epididymis +/- testes resulting in pain and swelling

151
Q

Causes of epididymo-orchitis?

A

local spread of infections from genital tract eg. Chlamydia trachomatis and Neisseria gonorrhoeae or the bladder eg. E.coli

152
Q

CP of epididymo-orchitis?

A
  • unilateral testicular pain and swelling
  • urethritis often asymptomatic but urethral discharge may be present
  • factors suggesting testicular torsion eg. <20yrs, severe acute pain
153
Q

What is the most important differential diagnosis of epididymo-orchitis?

A

Testicular torsion- exclude urgently

154
Q

Ix for epididymo-orchitis?

A
  • young pt= STI assessment
  • older= mid-stream urine (MSU) for microscopy and culture
155
Q

Mx for epididymo-orchitis?

A
  • STI most likely= urgent referral to specialist sexual health clinic
  • enteric organism most likley= MSU then empirical Mx with oral quinolone for 2w eg. ofloxacin
156
Q

Mx of epididymo-orchitis if STI cause and referred to sexual health clinic?

A

if organism unknown= ceftriaxone 500mg IM single dose + doxycycline 100mg oral twice daily for 10-14 days

157
Q

95% of prostate cancers are…

A

adenocarcinomas

158
Q

Prostate cancer is multifocal, what does this mean?

A

the different foci may be caused by different genetic mutations, which can differ greatly in growth rate and ability to metastasise

159
Q

Characteristics of most prostate cancers?

A

indolent and grow slowly, minority are aggressive and invade local structures or metastasise to remote tissuesi

160
Q

Localised prostate cancer develops where?

A

Outer zone of prostate where it seldom causes symptoms

161
Q

Locally advanced prostate cancer is where?

A

extends beyond the capsule of the prostate and is often asymptomatic

162
Q

Metastatic prostate cancer most frequently affects what?

A

Bones- causes pain and fragility fractures.

163
Q

RFs for prostate cancer

A

Age, black ethnicity, FHx

164
Q

Prostate cancer should be suspected in people with any of what symptoms that are unexplained?

A

lower back or bone pain
lethargy
erectile dysfunction
haematuria
anorexia/weight loss
LUTS eg. frequency, urgency, hesitancy, terminal dribbling and/or overactive bladder

165
Q

Ix for prostate cancer

A
  • digital rectal exam (DRE)
  • prostate-specific antigen (PSA) test
166
Q

When should urgent referral to urological cancer specialist be arranged?

A
  • prostate is hard and nodular on DRE or benign enlargement (smooth, firm, enlarged gland)
    or
  • PSA level high for their age eg. >4.5 for 60-69yrs
167
Q

Prostate cancer Mx

A
  • watch and wait
  • active surveillance
  • radical treatments eg. prostatectomy or radiotherapy (external beam and brachytherapy)
  • adjunctive and palliative treatments eg. hormonal or chemotherapy with docetaxel
168
Q

Example of hormonal therapy for prostate cancer?

A

GnRH agonists eg. Goserelin (anti-androgen therapy)

169
Q

Prostate-specific antigen (PSA)?

A

Protein produced by prostate gland. Secreted by prostate epithelium into prostatic fluid, it liquefies semen. Small amounts present in blood.

170
Q

Why is blood PSA inaccurate marker for prostate cancer?

A

PSA can be increased by: prostate cancer, BPH, prostatitis, UTI, age.

Cancer can be present without increased PSA.

171
Q

Most men will have a PSA level less than 3. 3 in 4 men with raised PSA level will…

A

not have cancer. 15% men with normal PSA do have cancer

172
Q

What should people not do before PSA test?

A

have active UTI/previous 6w; ejaculated in past 48hrs; vigorous exercise in past 48hrs; had urological intervention eg. prostate biopsy in previous 6w.

173
Q

What should you do before PSA testing?

A

Give info to pt to make informed choice

174
Q

Benefits of PSA testing?

A
  • early detection
  • early treatment
175
Q

Limitations of PSA testing

A
  • false -ves = 15% with normal PSA have ca
  • false +ves = 75% with raised PSA 3+ will have -ve prostate biopsy
  • unnecessary Ix eg. biopsy- adverse effects (bleeding, infection)
  • unnecessary Mx: slow growing tumours common, may not cause symptoms or shorten life.
176
Q

Is there screening for prostate cancer in UK?

177
Q

Mx for erectile dysfunction?

A

Phosphodiesterase-5 inhibitor eg. sildenafil

178
Q

What is the Gleason score?

A

Estimates the grade of prostate cancer according to its architectural differentiation.

179
Q

RFs for urinary incontinence?

A
  • age
  • female
  • previous pregnancy and childbirth
  • high BMI
  • FHx
  • hysterectomy
180
Q

Types/classification of urinary incontinence

A
  • urge incontinence (overactive bladder)
  • stress
  • mixed (urge and stress)
  • overflow
  • functional
181
Q

Urge incontinence (overactive bladder) CP?

A

urge to urinate quickly followed by uncontrollable leakage (few drops-complete emptying) due to detrusor overactivity

182
Q

what type of incontinence is due to detrusor overactivity?

183
Q

Stress incontinence?

A

leaking small amounts when coughing or laughing

184
Q

Mixed incontinence?

A

Both stress and urge

185
Q

Overflow incontinence?

A

due to bladder outlet obstruction eg. due to prostate enlargement

186
Q

What type of incontinence may be due to prostate enlargement?

187
Q

Functional incontinence?

A

Comorbid physical conditions impair the pts ability to get to bathroom in time

188
Q

Causes of functional incontinence?

A

dementia, sedating meds, injury/illness resulting in decreased ambulation

189
Q

Ix for urinary incontinence?

A
  • urine dip
  • vaginal exam= weak pelvic muscles, pelvic organ prolapse or pelvic mass
190
Q

When to do urgent 2ww referral for suspected bladder cancer if pt presents with urinary incontinence?

A

> =45yrs with unexplained visible haematuria without UTI or recurrent
- >=60yrs with unexplained non-visible haematuria and dysuria or raised WCC

191
Q

Mx for stress incontinence?

A
  • 1st: 3m supervised pelvic floor muscle training
  • 2nd: + duloxetine= STRESS
  • 3rd: surgery eg. retropubic mid-urethral tape
192
Q

Mx for urge incontinence?

A
  • 1st: bladder retraining
  • 2nd: + antimuscarinic
  • 3rd: injection or botulinum toxin type A into bladder wall, percutaneous sacral nerve stim, augmentation cystoplasty and urinary diversion
193
Q

Examples of antimuscarinics eg. for urge incontinence?

A

oxybutynin, tolterodine (both immediate release)

194
Q

Who should oxybutynin be avoided in?

A

frail old women (anticholinergic S/Es) so could use mirabegron (beta-3agonist)

195
Q

Mechanism of action for duloxetine?

A

noradrenaline and serotonin reuptake inhibitor

increase synaptic conc of N and S within pudendal nerve -> increase stimulation of urethral striated muscles within the sphincter -> enhanced

196
Q

Causes of transient or spurious non-visible haematuria?

A

urinary tract infection
menstruation
vigorous exercise (this normally settles after around 3 days)
sexual intercourse

197
Q

Causes of persistent non-visible haematuria

A

cancer (bladder, renal, prostate)
stones
benign prostatic hyperplasia
prostatitis
urethritis e.g. Chlamydia
renal causes: IgA nephropathy, thin basement membrane disease
Causes of persistent non-visible haematuria

198
Q

Haematuria spurious causes - red/orange urine, where blood is not present on dipstick?

A

foods: beetroot, rhubarb
drugs: rifampicin, doxorubicin

199
Q

Haematuria Ix

A
  • urine dip
  • renal dunction: albumin:creatinine ratio and BP
  • urine microscopy (time to analyse affects no of RBCs detected
200
Q

Blood being present in 2 out of 3 urine dip samples tested 2-3w apart is the definition for what?

A

Peristent non-visible haematuria

201
Q

Haematuria non-urgent referral criteria?

A

> =60yrs with recurrent or persistent unexplained UTI

202
Q

What pts with haematuria can be managed in primary care and don’t need referral?

A

<40yrs, normal renal function, no proteinuria and normotensive

203
Q

UTI (lower) in adults clinical features?

A

dysuria, urinary frequency, urgency, lower abdo pain, cloudy/offensive smelling urine, fever (low-grade), malaise, acute confusion in elderly

204
Q

What is a common feature in elderly pts with lower UTI?

A

acute confusion

205
Q

Urine dip can be used to aid diagnosis in who?

A

Women <65yrs.

NOT in >65yrs, men or catheterised pts

206
Q

Urine dipsticks results +ve and -ve for UTI

A
  • +ve nitrite or leukocyte and RBC= likely
  • -ve nitrite, +ve leukocyte= likely or other diagnosis
  • -ve for all three= unlikely
207
Q

Urine culture for ?UTI for what pts?

A

women >65yrs, recurrent UTI, pregnant, men, visible or non-visible haematuria

208
Q

Definition of recurrent UTI?

A

2 episodes in 6m or 3 in 12m

209
Q

Lower UTI definition?

A

infection of bladder (cystitis) caused by bacteria from GI tract entering urethra

210
Q

‘uncomplicated UTI’?

A

WOMEN, caused by typical uropathogens, non-pregnant, no anatomical or functional abnorm of urinary tract and no predisposing cormorbidies

211
Q

How long to recover from uncomplicated UTI?

A

usually self-limiting and resolves within few days

212
Q

‘catheter-associated’ UTI?

A

UTI in women who is catheterised or has had a catheter within 48hrs

213
Q

Most common causative uropathogen of lower UTI?

214
Q

Cx of lower UTI?

A

pyelonephritis (upper UTI), renal abscess, acute kideny injury, urosepsis

215
Q

Lower UTI in women Ix?

A
  • pregnancy test
  • urine dip and/or urine culture (MSU for C&S)
216
Q

When to refer to specialist if female pt with lower UTI?

A

recurrent or persistent unexaplained UTI, serious underlying cause eg. urogynaecological malignancy

217
Q

Mx of lower UTI in women?

A
  • self-care measures in mild-moderate eg. paracetamol, hydration
  • Empirical: Nitrofurantoin (100mg tds 3 days) or Trimethoprime (200mg tds 3d)
218
Q

Advise women with lower UTI to seek urgent medical review when?

A

if symptoms rapidly worsen or don’t improve within 48hrs of starting Abx

219
Q

Mx for lower UTI in pregnant women?

A

urine sample for culture and sensitivities BEFORE starting Abx:

cefalexin (3 times a day for 7d)
or amoxicillin (same)
or nitrofurantoin (avoid in 3rd T)
or trimethoprim (avoid 1st T)

220
Q

What if group B strep identified on urine culture on pregnant women with lower UTI?

A

IV intrapartum Abx prophylaxis in labour

221
Q

What should you consider prescribing in postmenopausal women with recurrent UTI?

A

topical vaginal oestrogen

222
Q

When should you consider prescribing single dose or low dose daily Abx prophylaxis for women?

A

recurrent UTI, follow up within 6m

223
Q

When to avoid nitrofuranoin in pregnant women?

A

3rd trimester

224
Q

When to avoid trimethoprim in pregnant women?

A

1st trimester

225
Q

Cx of lower UTI in men?

A

renal function impairment, prostatitis, pylenephritis, sepsis, urinary stones

226
Q

Ix for lower UTI in men?

A

MSU for culture and sensitivites BEFORE starting empirical treatment
- don’t use dip or microscopy to diagnose UTI in men

227
Q

Mx for lower UTI in men

A

Trimethoprim
or
nitrofurantoin (not if prostate invl)

228
Q

Pyelonephritis should be suspected in all children with what?

A

unexplained fever >=38 or loin pain/tenderness

229
Q

UTI CP in children 3m and over?

A

fever, frequency, dysuria, abdo pain, V, poor feeding, dysfunctional voiding, changes to continence

230
Q

All children aged what with suspected UTI should be urgently referred to paeds for Mx with parenteral ABx and urine sample sent for MCS?

A

3m and over

231
Q

What Ix if UTI suspected in child 3m or over?

232
Q

When should Abx be started in children with suspected UTI?

A
  • L & N +ve start Abx
  • If L +ve and N -ve then send urine for culture. If <3yrs then start Abx, if >3yrs start Abx only if good clinical judgement.
  • If L -ve and N +ve then start Abx
233
Q

Abx treatment for children aged 3m or over with cystitis/lower UTI?

A

Oral trimethoprim or nitrofurantoin (if GFR >=45).
2nd: N or amoxicillin/cefalexin

234
Q

What should be considered for children >3m with recurrent UTI?

A

daily Abx prophylaxis

235
Q

Mx for upper UTI/pyleonephritis in children 3m or older?

A

oral cefalexin

236
Q

Phosphodiesterase-5 inhibitors (eg. sildenafil) mechanism of action?

A

cause vasodilation through increase in cGMP leading to smooth muscle relaxation in blood vessels supplying corpus cavernosum

237
Q

Contraindications to PDE-5 inhibitors?

A

hypotension; recent stroke/MI (wait 6m) or taking nitrates and related drugs eg. nicorandil

238
Q

Sidenafil (blue pill- viagra) causes what…

A

blue discolouration of vision

239
Q

Side effects of PDE-5 inhibitors?

A

visual disturbances (blue discolouration); nasal congestion; flushing; GI s/es; headache; priapism

240
Q

Visible haematuria?

A

Macroscopic haematuria

241
Q

Non-visible haematuria?

A

microscopic or dipstick +ve haematuria

242
Q

Causes of transient non-visible haematuria?

A

UTI, menstruation, vigorous exercise, sex

243
Q

Causes of persistent non-visible haematura?

A

cancer (bladder, renal, prostate), stones, BPH, prostatitis, urethritis (chlamydia); renal (IgA neph, thin BM disease)

244
Q

Spurious causes (red/orange urine) where blood is not present on dip?

A

foods eg. beetroot, rhubarb or drugs (rifampicin, doxorubicin)

245
Q

Trauma causes of haematuria?

A

injury to renal tract; renal trauma (blunt injury); ureter trauma (iatrogenic) or bladder trauma (RTA or pelvic fractures)

246
Q

Infective causes of haematuria?

247
Q

Malignant causes of haematuria?

A

renal; urothelial; SCC and adenocarcinoma (rare bladder tumours); prostate; penile (SCC)

248
Q

Renal disease that can cause haematuria?

A

glomerulonephritis or stones

249
Q

Structural causes of haematuria?

A

BPH, PKD, vasucular malformations, renal vein thrombosis due to renal cell carcinoma

250
Q

Iatrogenic causes of haematuria?

A

catheter, radiotherapy, cystitis, severe haemorrhage, bladder necrosis

251
Q

Benign causes of haematuria?

A

Vigorous exercise (normally settles after around 3d)

252
Q

Haematuria that may be drug related?

A
  • cause tubular necrosis or intersitial nephritis= aminoglycosides, chemo
  • intersitial nephritis= penicillin, NSAIDs, sulphonamides
  • anticoag
253
Q

Differential diagnoses in child with acute scrotal problem?

A
  • testicular torsion (around puberty)
  • irreducible inguinal hernia (<2yrs)
  • epididymitis (rare in prepubescent)
254
Q

Most common cause of scrotal swelling seen in primary care?

A

epididymal cyst

255
Q

Scrotal swelling that is separate to the body of the testicle and found posterior to the testicle?

A

Epididymal cyst

256
Q

Epidiymal cysts associated conditions

A

PKD, CF, von Hippel-Lindau syndrome

257
Q

Diagnosis of epididymal cyst confirmed by?

258
Q

Mx of epididymal cyst?

A

supportive but if larger or symptomatic: surgical removal or sclerotherapy

259
Q

Hydrocele?

A

accumulation of fluid within the tunica vaginalis

260
Q

Types of hydrocele?

A
  • communicating: common in newborns, usually resolve in 1st few months; caused buy ppatency of processus vaginalis allowing peritoneal fluid to drain down into scrotum
  • non-communicating: caused by XS fluid production within tunica vaginalis
261
Q

Hydroceles may develop secondary to what?

A
  • epididymo-orchitis
  • testicular torsion
  • testicular tumours
262
Q

CP of hydrocele

A
  • transilluminates with pen torch
  • soft, non-tender swelling of hemi-scrotum
  • usually anterior and below testicle
  • swelling confined to scrotum- you can get above the mass on exam
  • testis may difficult to palpate if hydrocele large
263
Q

Diagnosis of hydrocele?

A

clinical but USS if any doubt or underlying testis can’t be palpated

264
Q

Mx of hydrocele?

A
  • infantile hydroceles repaired (paeds surgeon referral) if don’t spontaneously resolve by 1-2yrs
  • adults: conservative depending on severity; USS warranted to exclude underlying cause eg. tumour
265
Q

Varicocele?

A

abnormal enlargement of testicular veins- usually asymptomatic but important as associated with infertility

266
Q

Typical left sided (80%) scrotal swelling, classically described as ‘bag of worms’ and associated with subfertility?

A

Varicocele

267
Q

Diagnosis of varicocele?

A

USS with Doppler studies

268
Q

Mx of varicocele?

A
  • usually conservative
  • surgery if pain
269
Q

Scrotal swelling: Can’t get above swelling on examination, cough impulse may be present, may be reducible?

A

Inguinal hernia (inguinoscrotal swelling)

270
Q

Scrotal swelling: Often discrete testicular nodule (may have associated hydrocele); symptoms of metastatic disease may be present; USS scrotum and serum AFP and β HCG required?

A

Testicular tumours

271
Q

Scrotal swelling: Often history of dysuria and urethral discharge; swelling may be tender and eased by elevating testis; most cases due to Chlamydia; Infections with other gram negative organisms may be associated with underlying structural abnormality?

A

Acute epididymo-orchitis

272
Q

Scrotal swellings: Single or multiple cysts; may contain clear or opalescent fluid (spermatoceles); usually occur over 40 years of age; painless; lie above and behind testis; it is usually possible to ‘get above the lump’ on examination?

A

Epidiymal cysts

273
Q

Scrotal swellings: Non painful, soft fluctuant swelling; often possible to ‘get above it’ on examination; usually contain clear fluid; will often transilluminate; may be presenting feature of testicular cancer in young men?

274
Q

Scrotal swelling: Severe, sudden onset testicular pain; RFs include abnormal testicular lie; typically affects adolescents and young males; on examination testis is tender and pain not eased by elevation; urgent surgery is indicated, the contra lateral testis should also be fixed?

A

Testicular torsion

275
Q

Scrotal swelling: Varicosities of the pampiniform plexus; g
typically occur on left (because testicular vein drains into renal vein); may be presenting feature of renal cell carcinoma; affected testis may be smaller and bilateral varicoceles may affect fertility?

A

Varicocele

276
Q

What scrotal swelling can the pain be eased by elevating the testis and which is not eased by elevating?

A
  • eased by elevating= acute epididymo-orchitis
  • non-eased by elevating= testicular torsion
277
Q

What scrotal swelling is easy to ‘get above it’ on examination and which is not?

A
  • can get above= hydrocele, epididiymal cyst
  • can’t get above= inguinal hernia
278
Q

What scrotal swelling might the cough impulse be present on?

A

Ingunial hernia

279
Q

Testicular malignany Mx

A

Always Mx with orchidectomy via inguinal approach (allows high ligation of testicular vessels and avoids exposure of another lymphatic field to the tumour)

280
Q

What condition is the cremasteric reflex lost in?

A

Testicular torsion

281
Q

Testicular torsion?

A

Twist of spermatic cord resulting in testicular ischaemia and necrosis

282
Q

CP of testicular torsion

A
  • common 13-15yrs
  • pain severe and acute
  • cremasteric reflex lost and elevation of testis doesn’t ease pain
283
Q

Mx of testicular torsion?

A

Prompt surgical exploration and testicular fiaxtion- both testis should be fixed (condition of bell clapper testis often bilateral). Using sutures or by placement of testis in a Dartos pouch.

284
Q

USS would show what in testicular torsion? (confirms diagnosis but if delays pt going to theatre then not recommended)

A

Whirlpool sign

285
Q

How quick should pt with testicular torsion have surgery?

A
  • within 4hrs of onset of symptoms (90% chance)
  • after 12hrs only 50% chance saving testis
  • > 24hrs then 10%
286
Q

Torsion of appendix testis or appendix epididymis?

A

related but distinct from testicular torsion; occurs in boys 8-11yrs

287
Q

What is the appendix testis?

A

small structure on anterosuperior aspect of testis (embryologic remnant of Mullerian duct)

288
Q

What is the appendix epididymis?

A

small remnant of Wolffian duct located at head of epididymis

289
Q

Features of torsion of appendix testis or appendix epidiymis?

A
  • similar but less severe to testicular torsion eg. acute testicular pain
  • testicular body non-tender but there is a tender mass palpable
  • blue dot sign may be seen through scrotum
290
Q

Diagnosis of torsion of appendix testis or appendix epididymis?

A

Clinical, Doppler USS helpful

291
Q

Mx of torsion of appendix testis or appendix epididymis?

A

conservative Mx possible but many will have exploratory operation to exclude torsion

FINALS (37 decks)

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