Urology Flashcards
what type of muscle is the internal urethral sphincter and what control is it under?
smooth muscle under autonomic control
what type of muscle is the external urethral sphincter and what control is it under?
skeletal muscle under voluntary control
what type of acute kidney injury would an obstructive uropathy cause?
“post-renal” acute kidney injury (AKI)
what are the presenting features of an upper urinary tract obstruction?
Loin to groin or flank pain on the affected side
Reduced or no urine output
Non-specific systemic symptoms e.g. vomiting
Impaired renal function on blood tests (i.e. raised creatinine)
what are the presenting features of a lower urinary tract obstruction?
Difficulty or inability to pass urine (e.g., poor flow, difficulty initiating urination or terminal dribbling)
Urinary retention, with an increasingly full bladder
Impaired renal function on blood tests
Name 4 causes of an upper urinary tract obstruction
Kidney stones
Tumours pressing on the ureters
Ureter strictures
Retroperitoneal fibrosis
Bladder cancer
Ureterocele
Name 3 causes of a lower urinary tract obstruction
Benign prostatic hyperplasia
Prostate cancer
Bladder cancer
Urethral strictures
Neurogenic bladder
State 3 causes of a neurogenic bladder
Multiple sclerosis
Diabetes
Stroke
Parkinson’s disease
Brain or spinal cord injury
Spina bifida
what are some complications of an obstructive uropathy?
Pain
Acute kidney injury (post-renal)
Chronic kidney disease
Infection
Hydronephrosis
Urinary retention and bladder distention
Overflow incontinence of urine
what is hydronephrosis?
swelling of the renal pelvis and calyces in the kidney. This occurs due to obstruction of the urinary tract, leading to back-pressure into the kidneys
state 3 indications for inserting a urinary catheter
Urinary retention
Neurogenic bladder
Surgery
Output monitoring
Bladder irrigations
delivery of medications
Name 3 types of catheters
Intermittent
Foley
Three-way
Suprapubic
Coude tip
how should you manage a UTI in a patient with a catheter?
without symptoms = no abx
with symptoms = 7d abx, change catheter as soon as possible
State 5 lower urinary tract symptoms
Hesitancy
Weak flow
Urgency
Frequency
Intermittency
Straining to pass urine
Terminal dribbling
Incomplete emptying
Nocturia
what scoring system can be used to assess the severity of lower urinary tract symptoms?
international prostate symptom score (IPSS)
what is involved in the initial assessment of men presenting with LUTS?
Digital rectal examination
Abdominal examination
Urinary frequency volume chart
Urine dipstick
PSA
what are some common causes of a raised PSA?
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
what should a benign prostate feel like?
smooth, symmetrical and slightly soft, with a maintained central sulcus
what are the 2 medical options of benign prostatic hyperplasia?
Alpha-blockers (e.g., tamsulosin)
5-alpha reductase inhibitors (e.g., finasteride)
what is the main surgical option for benign prostatic hyperplasia?
Transurethral resection of the prostate (TURP)
what are the features of chronic prostatitis?
at least 3 months of:
pelvic pain
LUTS
Sexual dysfunction
Pain with bowel movements
tender and enlarged prostate
what investigations may be done to investigate prostatitis?
Urine dipstick testing
Urine microscopy, culture and sensitivities
Chlamydia and gonorrhoea NAAT testing
what is the management of acute bacterial prostatitis?
Hospital admission if systemically unwell
Oral antibiotics
Analgesia
Laxatives
what is the management of chronic prostatitis?
Alpha-blockers
analgesia
psychological
antibiotics (if <6m or history of infection)
laxatives
what are some complications of acute bacterial prostatitis?
Sepsis
Prostate abscess
Acute urinary retention
Chronic prostatitis
what type are the majority of prostate cancers?
adenocarcinomas
what are risk factors for prostate cancer?
Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids
what are some symptoms of prostate cancer?
LUTS e.g. hesitancy, frequency
haematuria
erectile dysfunction
what is the 1st line investigations for suspected localised prostate cancer?
Multiparametric MRI
what is used to establish a diagnosis of prostate cancer
Prostate biopsy
what grading system is used to guide treatment of prostate cancer?
Gleason grading system
what are the management options in prostate cancer?
Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery
what is the key complications of external beam radiotherapy in the treatment of prostate cancer?
proctitis (inflammation in the rectum)
what are some side effects of hormone therapy in the treatment of prostate cancer?
Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis
what are some causes of Epididymo-orchitis?
Escherichia coli (E. coli)
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
what are the presenting features of Epididymo-orchitis?
Testicular pain
Dragging or heavy sensation
Swelling of testicle and epididymis
Tenderness on palpation, particularly over epididymis
Urethral discharge (should make you think of chlamydia or gonorrhoea)
Systemic symptoms such as fever and potentially sepsis
what investigations may be done in epididymo-orchitis?
urine MC&S
Chlamydia and gonorrhoea NAAT testing
charcoal swab or purulent urethral discharge
Saliva swab (PCR for mumps)
Serum antibodies (for mumps)
Ultrasound (assess for torsion or tumours)
what are complications of Epididymo-orchitis?
Chronic pain
Chronic epididymitis
Testicular atrophy
Sub-fertility or infertility
Scrotal abscess
how does testicular torsion present?
acute rapid onset of unilateral testicular pain
abdominal pain
vomiting
what are the examination findings in testicular torsion?
Firm swollen testicle
Elevated (retracted) testicle
Absent cremasteric reflex
Abnormal testicular lie (often horizontal)
Rotation, so that epididymis is not in normal posterior position
what is a Bell-Clapper deformity?
the fixation between the testicle and the tunica vaginalis is absent
what is the management of testicular torsion?
Nil by mouth, in preparation for surgery
Analgesia as required
Urgent senior urology assessment
Surgical exploration of the scrotum
Orchiopexy (correcting the position of the testicles and fixing them in place)
Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis
state 3 differentials for scrotal lumps
Hydrocele
Varicocele
Epididymal cyst
Testicular cancer
Epididymo-orchitis
Inguinal hernia
Testicular torsion
what is a hydrocele?
fluid within the tunica vaginalis
what are the examination findings in a hydrocele?
The testicle is palpable within the hydrocele
Soft, fluctuant and may be large
Irreducible and has no bowel sounds (distinguishing it from a hernia)
Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)
what can hydroceles be secondary to?
Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma
what is a varicocele?
veins in the pampiniform plexus become swollen
what symptoms may varicoceles present with ?
Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility
what are examination findings in a varicocele?
A scrotal mass that feels like a “bag of worms”
More prominent on standing
Disappears when lying down
Asymmetry in testicular size if the varicocele has affected the growth of the testicle
what investigations may you consider in a varicocele?
Ultrasound with Doppler imaging can be used to confirm the diagnosis
Semen analysis if there are concerns about fertility
Hormonal tests (e.g., FSH and testosterone) if there are concerns about function
what are the examination findings of an epididymal cyst?
Soft, round lump
Typically at the top of the testicle
Associated with the epididymis
Separate from the testicle
May be able to transilluminate large cysts (appearing separate from the testicle)
state 3 risk factors for testicular cancer
Undescended testes
Male infertility
Family history
Increased height
what are the features of a lump suggesting testicular cancer?
Non-tender (or even reduced sensation)
Arising from testicle
Hard
Irregular
Not fluctuant
No transillumination
what is the usual investigation to confirm a diagnosis of testicular cancer?
Scrotal ultrasound
what are the tumour markers for testicular cancer?
Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)
Beta-hCG – may be raised in both teratomas and seminomas
Lactate dehydrogenase (LDH) is a very non-specific tumour marker
what is the staging system for testicular cancer?
Royal Marsden staging system
what are common places for testicular cancer to metastasise to?
Lymphatics
Lungs
Liver
Brain
what are the symptoms of a lower urinary tract infection?
Dysuria (pain, stinging or burning when passing urine)
Suprapubic pain or discomfort
Frequency
Urgency
Incontinence
Haematuria
Cloudy or foul smelling urine
Confusion is commonly the only symptom in older and frail patients
what is the duration of antibiotics for a lower urinary tract infection?
3 days of antibiotics for simple lower urinary tract infections in women
5-10 days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter-related UTIs
state 3 risk factors for pyelonephritis
Female sex
Structural urological abnormalities
Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
Diabetes
what are the triad of symptoms of pyelonephritis?
Fever
Loin or back pain (bilateral or unilateral)
Nausea / vomiting
what antibiotics are given in pyelonephritis and for how long?
Cefalexin
Co-amoxiclav (if culture results are available)
Trimethoprim (if culture results are available)
Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)
7-10 days
what is the typical presentation of interstitial nephritis?
Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
Frequency of urination
Urgency of urination
Symptoms may be worse during menstruation
what cells of the bladder does bladder cancer arise from?
urothelium
state 3 risk factors for bladder cancer
smoking
increased age
aromatic amines (dye and rubber)
schistosomiasis (SCC)
what are the main 2 types of bladder cancer?
Transitional cell carcinoma (90%)
Squamous cell carcinoma
what is the presentation of bladder cancer?
painless haematuria
what investigation is done to diagnose bladder cancer?
Cystoscopy
what are the management options for bladder cancer?
Transurethral resection of bladder tumour (TURBT)
Intravesical chemotherapy
Intravesical BCG
Radical cystectomy
what are the 2 key complications of kidney stones?
Obstruction leading to acute kidney injury
Infection with obstructive pyelonephritis
what are the most common type of kidney stone?
Calcium oxalate (more common)
Calcium phosphate
what is a Staghorn calculus ?
stone forms in the shape of the renal pelvis
what is the initial investigation of choice for diagnosing kidney stones?
Non-contrast computer tomography (CT) of the kidneys, ureters and bladder (CT KUB)
what is the management of kidney stones?
NSAIDs e.g. IM diclofenac
Antiemetics
antibiotics if infection
watchful waiting (if <5mm)
Tamsulosin
surgical -> Extracorporeal shock wave lithotripsy, Ureteroscopy and laser lithotripsy, Percutaneous nephrolithotomy, open surgery
what 2 medications may be given to reduce the risk of kidney stones?
Potassium citrate
Thiazide diuretics
what is the most common type of kidney tumour?
Renal cell carcinoma (RCC)
what is the classic triad of symptoms in renal cell carcinoma?
haematuria, flank pain and a palpable mass
what are the 3 most common subtypes of renal cell carcinoma?
Clear cell (around 80%)
Papillary (around 15%)
Chromophobe (around 5%)
state 4 risk factors for renal cell carcinoma
Smoking
Obesity
Hypertension
End-stage renal failure
Von Hippel-Lindau Disease
Tuberous sclerosis
what paraneoplastic features are associated with renal cell carcinoma?
Polycythaemia
Hypercalcaemia
Hypertension
Stauffer’s syndrome (abnormal LFT’s without liver mets
how are patient and donor kidneys matched?
Human leukocyte antigen (HLA) type A, B and C on chromosome 6
what are patients given 2 doses of after renal transplant surgery to prevent rejection?
Basiliximab
what complications can arise following a kidney transplant?
Transplant rejection (hyperacute, acute or chronic)
Transplant failure
Electrolyte imbalances
