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Phase 4 Question Knowledge > Urology > Flashcards

Urology Flashcards

1
Q

BPH

A

benign increase in size of prostate

inner (transitional) zone enlarges

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2
Q

BPH Px

A

LUTS
Storage
- frequency
- urgency, urgency incontinence
- nocturia
SHIPP
- straining
- hesitancy
- incomplete emptying
- poor / intermittent stream
- post-micturition dribbling
- also overflow incontinence

  • enlarged bladder on abdo exam
  • UTI sx, bladder stone
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3
Q

BPH Ix

A
  • urine dip
  • DRE - smooth, enlarged
  • U/E
  • urinary freq/vol chart
  • transrectal US - not routine
  • PSA
  • International Prostate Symptom Score
  • US / CT / cystoscopy
  • post-void bladder scan
  • urodynamic studies if dx unsure
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4
Q

BPH Mx

A
  • avoid caffeine, alcohol

Medical
- tamsulosin
- finasteride
- consider tolterodine / darifenacin

Surgical
- transurethral resection of prostate (TURP)
- transurethral incision of prostate (TUIP)
- Transurethral electrovaporisation of prostate (TEVAP/TUVP)
- Holmium laser enucleation of prostate (HoLEP)
- Open prostatectomy

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5
Q

BPH indications for surgery - RUSHES

A
  • Retention
  • UTIs
  • Stones
  • Haematuria
  • Elevated creatinine due to bladder outlet obstruction (BOO)
  • Sx deterioration
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6
Q

LUTS Ix

A
  • bladder diary
  • post-void bladder scan
  • urinalysis
  • DRE
  • urinary freq/vol chart
  • IPSS
  • bloods
  • urodynamic studies
  • cystoscopy / US / CT
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7
Q

LUTS Mx

A

Voiding sx
- pelvic flood muscle training, bladder training
- tamsulosin / finasteride

Overactive bladder
- bladder retraining
- oxybutynin, tolterodine, darifenacin
- mirabegron

Nocturia
- furosemide in late afternoon
- desmopressin may help

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8
Q

Prostatitis

A

inflammation of prostate

E coli most commonly

RFs
recent UTI, intermittent catheterisation, recent biopsy…

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9
Q

Prostatitis Px

A
  • pelvic pain, genital pain
  • LUTS
  • fever, rigors, N+V
  • sexual dysfunction
  • pain with bowel movts
  • inguinal lymphadenopathy
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10
Q

Prostatitis Ix

A
  • DRE - tender, boggy
  • STI screen
  • urine dip, MC+S
  • FBC, blood cultures
  • National Institute of Health Chronic Prostatitis Sx index
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11
Q

Prosatitis Mx

A

Acute
- 14d ciprofloxacin
- admit if unwell

Chronic
- tamsulosin, analgesia

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12
Q

Prostate cancer

A

growth of peripheral zone of prostate - adenocarcinoma

RFs
- older, FHx, black ethnicity, tall, anabolic steroids

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13
Q

Prostate cancer Px

A
  • asym
  • LUTS
  • haematuria
  • erectile dysfunction
  • wt loss, bone pain, cauda equina
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14
Q

Prostate cancer Ix

A
  • PSA - 50-69yo refer if PSA >3 OR abnormal DRE
  • DRE - firm, craggy, irregular
  • multiparametric MRI
  • Biopsy - transrectal / transperineal - Gleason Grading for severity
  • isotope bone scan
  • CT / MRI for mets
  • TNM staging
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15
Q

Prostate cancer Mx

A
  • surveillance / W+W
  • external beam radiotherapy
  • brachytherapy

Hormone therapy
- androgen-receptor blockers - bicalutamide
- GnRH agonists - goserelin, leuprorelin (Prostap)

  • chemo
  • radical prostatectomy
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16
Q

Bladder cancer

A

cancer of urothelium of bladder (endothelium) - transitional cell carcinoma

RFs
- smoking
- hydrocarbon exposure - 2-naphthylamine
- Schistosomiasis causing chronic bladder inflammation

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17
Q

Bladder cancer Px

A
  • painless, macroscopic haematuria
  • LUTS
  • wt loss, bone pain etc
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18
Q

Bladder cancer Ix

A

2ww if
- >45yo, unexplained visible haematuria
- >60yo, microscopic haematuria + dysuria / raised WCC
- non urgent referral if >60yo, recurrent unexplained UTIs

  • cystoscopy, biopsy (flexible then rigid)
  • CT / MRI / PET
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19
Q

Bladder cancer Mx

A
  • TURBT - transurethral resection of bladder tumour
  • intravesical chemo
  • BCG vaccine
  • radical cystectomy (+ urostomy + ileal conduit)
  • chemo / radio
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20
Q

Renal cell carcinoma (RCC)

A
  • adenocarcinoma of kidney - from PCT, majority clear cell type
  • Wilms tumour in paeds

Paraneoplastic
- polycythaemia - EPO
- hypercalcaemia - PTH mimic
- HTN - renin
- Stauffers syndrome

RFs
- smoking, obesity, HTN, ESRF, tuberous sclerosis, von Hippel-Lindau, industrial exposure, dialysis

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21
Q

RCC Px

A
  • asym
  • haematuria
  • loin pain
  • wt loss, fatigue, anorexia, night sweats
  • renal mass
  • PUO
  • varicocele
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22
Q

RCC Ix

A
  • FBC, U/E, LFTs, bone profile, PTH
  • urinalysis, cytology
  • US kidney
  • CXR - cannonball mets
  • CT chest, abdo, pelvis
  • ?biopsy
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23
Q

RCC Mx

A
  • nephrectomy - partial / radical
  • arterial embolisation
  • percutaneous cryotherapy
  • radiofrequency ablation
  • chemo / radio
  • biological tx
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24
Q

Testicular cancer

A

commonly germ cells (produce gametes)

Mets to lymphatics, lungs, liver, brain

RFs
- undescended, infertility, FHx, taller

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25
Testicular cancer Px
- lump +/- pain - hard, irregular - non-fluctuant - no transillumination - gynaecomastia - Leydig cell tumour
26
Testicular cancer Ix
- scrotal US - Tumour markers - alpha-fetoprotein, bhCG, LDH - staging CT - Royal Marsden staging
27
Testicular cancer Mx
- radical orchidectomy - chemo / radio - sperm banking
28
Epididymo-orchitis
infection of epididymis +/- testes Causes - genital tract - chlamydia, gonorrhoea - bladder - E coli - mumps
29
Epididymo-orchitis Px
- unilateral testicular pain + swelling - dragging - tender on palpation - urethral discharge - fever, LUTS - Prehn's positive - elevation of scrotum eases pain
30
Epididymo-orchitis Ix
- STI screen - first pass urine, charcoal swab of discharge - MSU - dip + MC+S - saliva swab / serum ABs - mumps - ?US testes
31
Epididymo-orchitis Mx
- GUM referral Organism unknown - ceftriaxone 1g IM + doxycycline 100mg oral BD 10-14d Enteric organism likely - ofloxacin / co-amox
32
Testicular torsion
twisting of spermatic cord --> testicular ischaemia / necrosis in 4-6hrs RFs - FHx, undescended, age - often sports related
33
Torsion px
- severe, sudden onset pain - referred lower abdo pain - N+V - loss of cremasteric reflex - Prehn's sign negative - horizontal testicular lie - rotation - epididymis not in normal position
34
Torsion Ix
- clinical dx - USS - whirlpool sign - urine dip - r/o infection
35
Torsion Mx
- NBM - analgesia - surgical exploration - for dx - orchidopexy - orchidectomy - if necrosis
36
Hydrocele
- collection of fluid within tunica vaginalis that surrounds testes - communicating - patent processus vaginalis - non-communicating - excessive fluid production Causes - idiopathic, cancer, torsion, epididymo-orchitis, trauma
37
Hydrocele Px
- painless - soft scrotal swelling - fluctuant - testicle palpable within hydrocele - irreducible, no bowel sounds - transilluminates
38
Hydrocele Ix
- US
39
Hydrocele Mx
- conservative - surgery / aspiration
40
Varicocele
- swelling of veins in pampiniform plexus Causes - incompetent valves - L>R - drains into L renal vein - higher resistance - RCC - left
41
Varicocele Px
- throbbing, dull pain, worse standing - dragging sensation - sub/infertility - bag of worms scrotal mass, worse standing - red flags - acute onset, R side, remains whilst flat -> urology referral
42
Varicocele Ix
- US - semen analysis - fertility - hormone tests - FSH, test - if concern about function
43
Varicocele Mx
- conservative - surgery / endovascular embolisation if painful / testicular atrophy / infertility
44
Epididymal cyst
- fluid filled cyst at head of epididymis - PKD, CF, von Hippel Lindau associations
45
Epididymal cyst Px
- asym - soft, round lump - at top of testicle - transilluminates - can get above lump
46
Epididymal cyst Ix
US
47
Epididymal cyst Mx
- conservative - surgical removal - if pain / discomfort
48
Scrotal lumps DDx
hydrocele varicocele epididymal cyst testicular cancer epididymo-orchitis inguinal hernia testicular torsion
49
Renal stones
stones form in renal pelvis, get stuck in ureters obstruction -> AKI infection -> obstructive pyelonephritis get stuck at - PUJ, pelvic brim, VUJ Types - calcium oxalate - Uric acid, - Struvite - Cystine
50
Renal stones RFs
- dehydration - hypercalciuria, hyperparathyroidism, hypercalcaemia - cystinuria - high dietary oxalate - renal tubular acidosis - medullary sponge kidney, PKD - gout - drugs - loop diuretics, steroids, acetazolamide, theophylline
51
Renal stones Px
- renal colic - loin/groin pain - haematuria - dysuria - N+V - reduced UO - sepsis sx
52
Renal stones Ix
- urine dip - blood +/- infection - Bloods - FBC, U/E, Ca, CRP, coag - NCCT KUB - AXR - US KUB - pregnancy / children
53
Renal stones Mx
- analgesia, antiemetics - Abx if infection - stones <5mm - W+W - tamsulosin admit if: - AKI, uncontrollable pain, infected, large >5mm stones >10mm - extracorporeal shock wave lithotripsy (ESWL) - ureteroscopy + laser lithotripsy - percutaneous nephrolithotomy (PCNL) - open surgery infection / AKI - stent / nephrostomy - decompress - prevent hydronephrosis
54
Renal stones prevention
- increase fluids - lemon juice, avoid carbonated drinks, reduce salt, normal Ca intake, reduce oxalate/purine rich foods, limit dietary protein - potassium citrate / thiazide diuretics
55
Bladder stones
- from stasis of urine in bladder - chronic urinary retention / schistosomiasis Px - LUTS Ix - as for renal stones Mx - cystoscopy, fragment with lithotripsy
56
Acute urinary retention
- acute inability to pass urine
57
Acute urinary retention causes
- BPH - urethral strictures, calculi, cystocele, constipation, masses - meds - anticholinergics, TCAs, antihistamines, opioids, benzos - neuro cause - post-op, post-partum
58
Acute urinary retention Px
- no UO - lower abdo discomfort, distension - acutely confused - pain, distress
59
Acute urinary retention Ix
- MSU for MC+S - bloods - U/E, FBC, CRP - DRE - bladder scan - >300mls, also check post-void residual volume
60
Acute urinary retention Mx
- catheter - if >1000mls - US kidneys to r/o high-pressure chronic retention / hydronephrosis - Ix / Tx cause - TWOC after tx cause - IV fluids for post-obstructive diuresis
61
Chronic urinary retention
- chronic inability to pass urine - bladder desensitised - high-pressure - impaired renal function, bl hydronephrosis, bladder outflow obstruction - low-pressure - normal renal function, no hydronephrosis
62
Chronic urinary retention causes
- BPH - pelvic prolapse - pelvic masses - fibroids - neuro - peripheral neuropathies, MS, Parkinson's
63
Chronic urinary retention Px
- painless urinary retention - LUTS - weak stream, hesitancy - overflow incontinence - palpable distended bladder
64
Chronic urinary retention Ix
- post-void bladder scan - bloods - FBC, CRP, U/E - USS urinary tract
65
Chronic urinary retention Mx
- catheter - long-term / intermittent self-catheterisation
66
Neurogenic bladder
Abnormal function of nerves innervating bladder / urethra Causes - MS, DM, stroke, Parkinson's, brain / spinal cord injury, spina bifida Results in - urge incontinence - increased bladder pressure - obstructive uropathy
67
Hydronephrosis
Swelling of renal pelvis + calyces in kidney
68
Hydronephrosis causes
Unilateral - PACT - Pelvic-ureteric obstruction (congenital or acquired) - Aberrant renal vessels - Calculi - Tumours of renal pelvis Bilateral - SUPER - Stenosis of the urethra - Urethral valve - Prostatic enlargement - Extensive bladder tumour - Retro-peritoneal fibrosis
69
Hydronephrosis Px
- vague renal angle tenderness - mass
70
Hydronephrosis Ix
- USS - CT - IV urogram - XR with IV contrast in urinary tract
71
Hydronephrosis Mx
- tx cause - nephrostomy - antegrade ureteric stent
72
Lower UTI
infection of urethra / bladder Uncomplicated - normal renal tract structure / function Complicated - GU tract abnormality, eg stones, obstruction, DM - men
73
Lower UTI causes
KEEPS - klebsiella - e coli - most common - enterococcus - pseudomonas - staph (coagulase negative - candida - catheters
74
Lower UTI Px
- dysuria - suprapubic pain / discomfort - frequency, urgency, incontinence - haematuria - cloudy / foul-smelling urine - confusion
75
Lower UTI Ix
Urine dip - Nitrites / leucocytes, blood MSU to MC+S - if pregnant, recurrent, atypical sx, no resolution with abx, men, haematuria
76
Lower UTI Mx
Non-pregnant women >16yo - nitrofurantoin / trimethoprim - nitro / pivmecillinam / fosfomycin Pregnant women >12yo - nitrofurantoin (avoid 3rd trim) - amoxicillin / cefalexin Men 16yo - trimethoprim / nitro Abx duration - 3d - simple, women - 5-10d - immunosuppressed, abnormal anatomy, impaired kidney function - 7d - men, pregnant, catheter Catheter - change catheter - abx if sx
77
Pyelonephritis
infection of kidney - renal pelvis / parenchyma Uncomplicated - normal structure / function, non-immunocompromised, female Complicated - opposite of above, male RFs - female. structural issues, VUR, diabetes Causes - as lower UTI, typically e coli
78
Pyelonephritis Px
- lower UTI sx - fever - rigors - loin / back pain - unilateral - N+V - anorexia - haematuria
79
Pyelonephritis Ix
- Urine dip - MSU to MC+S - bloods - USS / CT
80
Pyelonephritis Mx
Non-pregnant women, men >16yo - oral - cefalexin, co-amox, trimethoprim, cipro - IV - co-amox, cefuroxime, ceftriaxone, cipro, gent Pregnant >12yo - oral cefalexin - IV cefuroxime
81
Chronic pyelonephritis
- recurrent infections - scarring of parenchyma, CKD, ESRF - DMSA scan to assess
82
Interstitial cystitis
chronic inflammation of bladder complex causes, various dysfunction
83
Interstitial cystitis Px
- LUTS - suprapubic pain, worse with full bladder, relieved on emptying - >6wks
84
Interstitial cystitis Ix
- urinalysis - ?UTIs - swabs - ?STIs - cystoscopy - ?bladder Ca - may see Hunner lesions, granulations - DRE - prostate
85
Interstitial cystitis Mx
- supportive - meds - surgery
86
Circumcision
- in Jewish and Islamic faiths - reduces risk of penile cancer, UTI, HIV Medical indications - phimosis - recurrent balanitis - BXO - paraphimosis - exclude hypospadias first
87
Balanitis
- inflammation of glans penis - various causes Ix - clinical dx - swab if needed - biopsy if doubt on cause / extensive skin change Mx - gentle saline washes - 1% hydrocortisone - irritation / dermatitis - topical clotrimazole - candida - oral fluclox / clari - staph / strep infection - metronidazole - anaerobic balanitis - clobetasol / circumcision - lichen sclerosus
88
Erectile dysfunction
- inability to maintain erection sufficient for satisfactory sexual performance Causes Organic - gradual sx onset, normal libido Psychogenic - sudden onset, decreased libido, good quality spontaneous erections, major life events, psych problems Mixed RFs - older age, CVD (obesity, DM, lipids, HTN, smoking), alcohol, SSRIs, BBs
89
Erectile dysfunction Ix
- QRISK - free testosterone level (9-11am) - if low, rpt with FSH, LH, prolactin
90
Erectile dysfunction Mx
- PDE-5 inhibitors - sildenafil - if young and always had problem - refer to urology - if pt cycles >3hrs/wk - stop
91
Urethral injury
- blood in meatus - bulbar rupture - straddle injury, urinary retention, perineal haematoma - membranous rupture - penile/perineal haematoma, prostate displaced upwards Ix - ascending urethrogram Mx - suprapubic catheter
92
Bladder injury
- haematuria, suprapubic pain, inability to void Ix - IVU / cystogram Mx - laparotomy / conservative
93
Penile fracture
- traumatic rupture of corpus cavernosa and tunica albuginea in erect penis Px - snap / popping - immediate pain / swelling - Aubergine sign - firm immobile haematoma Ix - clinical dx - US - retrograde urethrography if ?urethral injury Mx - surgical repair - no sex for 6-8wks
94
Urethral stricture
- narrowing of urethra Causes - iatrogenic (catheter) - STIs - gonorrhoea - penile fracture - hypospadias - lichen sclerosus Px - decreased stream, incomplete bladder emptying, spraying of stream, dysuria Ix - uroflowmetry - US postvoid residual (PVR) measurement Mx - dilatation - endoscopic urethrotomy
95
Vasectomy
- under LA - semen analysis 2x post-op before sex Cx bruising, haematoma, infection, sperm granuloma, chronic testicular pain
96
Priapism
- persistent penile erection >4hrs, not associated with sexual stimulation Patho - ischaemic - due to impaired vasorelaxation, reduced outflow - non-ischaemic - high arterial inflow - eg fistula formation Causes - sickle cell, sildenafil, drugs (anti-HTN, anticoagulants, antidepressants...), trauma
97
Priapism Px
- erection >4hrs - pain in penis - if not painful / fully rigid - more so non-ischaemic
98
Priapism Ix
- cavernosal blood gas - ischaemic pO2 / pH reduced, pCO2 increased - doppler / duplex US - FBC, tox screen
99
Priapism Mx
- ischaemic - emergency - aspirate blood - inject phenylephrine, rpt 5 mins - consider surgery - shunt
100
Haematuria
- blood in urine - non/visible, a/symptomatic Causes - UTI, renal cancer, bladder cancer, renal calculi, prostate cancer, BPH, trauma, schistosomiasis, glomerulonephritis, HSP - pseudo - eg rifampicin, beetroot, methyldopa
101
Haematuria Hx
- ask about urine colour, clots, timing in stream - LUTS, fever, rigors, flank pain etc - recent trauma - smoking, occupational exposures
102
Haematuria Ix
- DRE, examine external genitalia - urinalysis - FBC, U/E, clotting, PSA - flexible cystoscopy - USS / CT urogram
103
Haematuria 2ww
>45yo with - unexplained visible haematuria w/o UTI - visible haematuria after UTI Ix >60yo - unexplained non-visible haematuria + dysuria / raised WCC
104
Haematuria Mx
- Tx cause - if clot retention - 3 way catheter - washout / irrigation - to control bleed - rigid cystoscopy
105
Stress incontinence
- urine leakage with increased intra-abdo pressure - coughing / straining - weakness of pelvic floor muscle - post-partum, constipation, obesity, post-menopausal, pelvic surgery
106
Urge incontinence
- overactive bladder - detrusor hyperactivity - eg stroke, infection, malignancy, cholinesterase inhibitors
107
Overflow incontinence
- from chronic urinary retention - stretching of bladder -> loss of bladder sensation, urine overflows - BPH, spinal cord injury, congenital defects
108
Continuous incontinence
- constant leakage of urine - anatomical abnormality - ectopic ureter, bladder fistulae
109
Urinary incontinence Px
- involuntary leakage of urine - ask about other urinary sx
110
Urinary incontinence Ix
- bladder diaries - QoL questionnaire - examine prostate, prolapse, ?fistula - urine dip - post-void bladder scan - urodynamic studies - cystoscopy, IV urogram, MRI
111
Urinary incontinence Mx
- wt loss, reduce caffeine, stop smoking Stress - pelvic floor muscle training - duloxetine - surgery - tension-free vaginal tape.... Urge - bladder retraining - oxybutynin, tolterodine - mirabegron - botox injections, ....
112
Urethritis
- inflammation / infection of urethra - gonococcal - N gonorrhoeae - Non-gonococcal - chlamydia, mycoplasma genitalium... RFs - MSM - <25yo - previous STIs - new sexual partner - >1 partner in last yr
113
Urethritis Px
- dysuria - penile irritation - discharge - sx of epididymitis / ReA
114
Urethritis Ix
- urethral swab / STI screen / first-void urine / MSU
115
Urethritis Mx
gonococcal - ceftriaxone 1g IM + azithromycin 1g oral Non-gonococcal - oral doxy 7d / single dose oral azithromycin contact tracing etc
116
Fournier's gangrene
- nec fasc that affects perineum - eg GAS, e coli... RFs - DM, alcohol, poor nutrition, steroids, trauma... Px - severe pain, fever, unwel - crepitus, skin necrosis, haemorrhagic bullae Ix - clinical dx - FBC, U/E, CRP, LFT, coag, cultures - CT - tissue / pus to MC+S Mx - broad spec abx - surgical debridement - skin grafts
117
Paraphimosis
- inability to replace retracted foreskin -> glans swells, reduced venous return -> penile ischaemia, infection RFs - phimosis, catheter, poor hygiene, prior occurrence Px - pain, swelling Mx - analgesia - manual pressure - dextrose soaked gauze - needle punctures into glans penis, drain swelling - Dundee technique - dorsal slit / emergency circumcision
118
Penile cancer
- rare urological cancer - mostly SCC - HPV 6,16,18 association RFs - HPV, phimosis, smoking, lichen sclerosis, untreated HIV - circumcision protective Px - ulcerating lesion on glans - +/- pain, - discharge / bleeding - inguinal lymphadenopathy Ix - penile biopsy - CT TAP, PET - TNM staging Mx - surgical removal - radio / chemo
119
Peyronie's disease
- acquired curvature of penis from fibrosis of tunica albuginea - may affect sexual function / erectile dysfunction - from minor trauma -> inflammation -> fibrosis in healing -> normal architecture disrupted Px - curvature / shortening of penis - erectile dysfuncion - psychological impact - painful erection in acute phase Ix - clinical dx - US - fibrotic plaques Mx - sildenafil - vacuum pumps - surgery - ?penile prosthesis

Phase 4 Question Knowledge (35 decks)

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