Urology Flashcards
What is obstructive uropathy
blockage preventing urine flow through the ureters, bladder and urethra
swelling of the kidney
hydronephrosis
presentation of upper urinary tract obstruction
- loin to groin/ flank pain on the affected side
- Reduced or no urine output
- vomiting
- Impaired renal function
presentation of lower urinary tract obstruction
- Difficulty or inability to pass urine (e.g., poor flow, difficulty initiating urination or terminal dribbling)
- Urinary retention
- Impaired renal function
how to diagnose obstructive uropathy
USS KUB
causes of upper urinary obstruction
- Kidney stones
- Tumours pressing on the ureters
- Ureter strictures (due to scar tissue narrowing the tube)
- Retroperitoneal fibrosis (the development of scar tissue in the retroperitoneal space)
- Bladder cancer
- Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)
Causes of lower urinary tract obstruction
- BPH
- Prostate cancer
- Bladder cancer
- Urethral strictures (due to scar tissue)
- Neurogenic bladder
what is neurogenic bladder
abnormal function of the nerves innervating the bladder and urethra = overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra
causes of neurogenic bladder
- MS
- diabetes
- stroke
- parkinson’s
- brain/spinal chord injury
- spina bifida
issues related to beurogenic bladder
- urge incontinence
- increased pressure
- obstructive uropathy
Mx of obstructive uropathy
remove or bypass obstruction
- nephrostomy: drain urine out of body (UUTO)
- urethral/suprapubic catheter (LUTO)
complications of obstructive uropathy
- Pain
- AKI
- CKD
- Infection (from bacteria tracking up urinary tract into areas of stagnated urine)
- Hydronephrosis
- Urinary retention and bladder distention
- Overflow incontinence of urine
Mx of hydronephrosis
treat cause
- percutaneous nephrostomy
- antegrade ureteric stent
reasons for a catheter
- Urinary retention
- Neurogenic bladder
- Surgery
- Output monitoring in acutely unwell patients (e.g., sepsis or intensive care)
- Bladder irrigation (e.g., to wash out blood clots in the bladder)
- Delivery of medications (chemotherapy to treat bladder cancer)
types of catheter and use
- Intermittent catheters: simple catheters used to drain urine, then immediately removed
- Foley catheter (two-way catheter): “standard” catheter with an inflatable balloon to hold it in place
- Coudé tip catheter: has a curved tip to help navigate it past an obstruction during insertion
- Three-way catheter: has three tubes used for inflating the balloon, injecting irrigation and drainage
- suprapubic catheter: through abdomen into bladder
define BPH
- enlarged prostate due to hyperplasia of stromal and epithelial cells of the prostate
- very common in older men
presentation of BPH
- hesitancy
- weak flow
- urgency
- nocturia
- intermittency
- straining
- terminal dribbling
- incomplete emptying
how to assess BPH
- DRE
- abdo exam
- urinary frequency volume chart
- urine dipstick
- PSA
Use international prostate symptom scoring system
Causes of a raised PSA
- Prostate cancer
- BPH
- Prostatitis
- UTI
- Vigorous exercise (notably cycling)
- Recent ejaculation or prostate stimulation
Mx of BPH
MEDICAL
- alpha blocker (tamsulosin) relax smooth muscle
- 5-alpha reductase inhibitors (finasteride): reduce prostate size
can take up to 6 months to reduce prostate size.
SURGICAL
- TURP
- transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- holium laser enucleation of the prostate (HoLEP)
- open prostatectomy
side effect of tamsulosin
postural hypotension
side effect of finasteride
sexual dysfunction due to reduced testosterone
complication of TURP
- bleeding
- infection
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation
- Urethral strictures
- Failure to resolve symptoms
define prostatitis
inflammation of the prostate
- acute bacterial: rapid
- chronic: >3months sx
chronic can be subdivided into chronic or chronic bacterial
presentation of chronic prostatitis
> 3months:
- pelvic pain
- Lower urinary tract sx
- sexual dysfunction
- pain with bowel movements
- tender/enlarged prostate
presentation of acute prostatitis
chronic sx +
- fever
- myalgia
- nausea
- fatigue
- sepsis
Ix for prostatitis
- urine dipstick
- Urine MC&S
- chlamydia and gonorrhoea NAAT test
- DRE
Mx of prostatitis
acute
- admission if unwell
- oral abx (cipro or trimethoprim for 2-4 weeks)
- analgesia
- laxatives
chronic
- Alpha-blockers relax smooth muscle
- Analgesia
- Psychological treatment, where indicated
- Abx if < 6 months of sx or hx of infection (e.g., trimethoprim or doxycycline for 4-6 weeks)
- Laxatives
complications of acute prostatitis
- sepsis
- prostate abscess
- acute urinary retention
- chronic prostatitis
most common cancer in men
prostate
where does advanced prostate cancer spread to
lymph nodes and bones
what is prostate cancer dependent on
androgens (testosterone)
most common type of prostate cancer
adenocarcinoma in the peripheral zone
RFs for prostate cancer
- Increasing age
- Family history
- Black African or Caribbean origin
- Tall stature
- Anabolic steroids
presentation of prostate cancer
asymptomatic or lower urinary tract sx
- hesitancy
- frequency
- weak flow
- terminal dribbling
- nocturia
- haematuria
- erectile dysfunction
- FLAWS for advanced
what is the function of PSA
secreted in semen to stop ejaculate from clotting
Ix for prostate cancer
- PSA
- DRE
- multiparametric MRI (1st line)
- prostate biopsy (if MRI says could be cancer) TRUS or trasnperineal
- isotope bone scan for mets
- Gleason Grading based on histology from biopsy
what is gleason grading
grade tissues 1-5
add 2 scores:
- most prevalent histology pattern and second most
6= low risk
7= intermediate
8= high risk
staging for Prostate cancer
TNM
Mx of prostate cancer
MDT
- Surveillance or watchful waiting in early prostate cancer
- External beam radiotherapy directed at the prostate
- Brachytherapy
- Hormone therapy
- Surgery
side effect of external beam radiotherapy
proctitis (inflammation of the rectum)
bladder, colon, rectal cancer
what is epididymo-orchitis
inflammation of the epididymis and testicle usually on one side
function of the epididymis
store sperm whilst they mature
causes of epididymo-orchitis
- E coli
- chlamydia trachomatis
- neisseria gonorrhoea
- mumps
presentation of epididymo-orchitis
gradual onset, over minutes to hours, with unilateral:
- 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
key differential for epididymo-orchitis
testicular torsion
Ix for epididymo-orchitis
- urine MC&S
- Chlamydia and gonorrhoea NAAT testing
- Charcoal swab of purulent urethral discharge for gonorrhoea culture and sensitivities
- Saliva swab for mumps
- Serum antibodies for mumps (IgM – acute infection, IgG – previous infection or vaccination)
- Ultrasound may be used to assess for torsion or tumours
need to distinguish whether E coli or STI cause
Mx of epididymo-orchitis
very unwell = IV abx
E-coli:
- ofloxacin 14 days
- Levofloxacin 10 days
- Co-amoxiclav 10 days
STI
- IM ceftriaxone
- doxycycline
- ofloxacin
complications of epidiymo-orchitis
chronic pain
chronic epididmitis
testicular atrophy
sub-fertility/infertility
scrotal abscess
define testicular torsion
twisting of the spermatic cord with rotation of the testicle
EMERGENCY
Presentation of testicular torsion
- acute rapid onset of unilateral testicular pain
- abdo pain
- vomiting
- firm swollen testicle
- elevated testicle
- absent cremasteric reflex
- horizontal testicle
- rotation of testicle
A cause of testicular torsion
Bell Clapper deformity
Mx of testicular torsion
NBM
analgesia
surgical exploration
orchioplexy or orchidectomy
USS sign in testicular torsion
whirlpool sign
causes of scrotal or testicular lumps
- testicular cancer
- hydrocele
- varicocele
- epididymal cyst
- Epididymo-orchitis
- Inguinal hernia
- Testicular torsion
what is a hydrocele
collection of fluid within the tunica vaginalis that surrounds the testes
presentation of hydrocele
- painless
- soft scrotal swelling
- TRANSILLUMINATES
- testicle palpable
- irreducible and no bowel sounds
causes of hydrocele
- idiopathic
- Testicular cancer
- Testicular torsion
- Epididymo-orchitis
- Trauma
Mx of hydrocele
conservative
surgery/aspiration in large cases
define varicocele
Veins in the pampiniform plexus become swollen.
most commonly left side
Side effect of varicocele
- infertility
- testicular atrophy
presentation of varicocele
- Throbbing/dull pain or discomfort, worse on standing
- A dragging sensation
- Sub-fertility or infertility
- “bag of worms” scrotum
- prominent on standing, disappears lying down
- asymmetry in testicular size
concerning signs of varicocele
do not disappear on lying down
suggests retroperitoneal tumours
urgent referral
Mx of varicocele
conservative
surgery if painful, testicular atrophy or infertile
what is an epididymal cyst
fluid filled sac at the head of the epididymis
if it contains sperm = spermatocele
presentation of 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
Mx of epididymal cyst
harmless- conservative
removed if painful
what is testicular cancer
arises from the germ cells in the testes (produce sperm)
incidence 15-35yrs
types of testicular cancer
seminomas
non-seminomas (mostly teratomas)
what is a teratoma
germ cell tumour that often contains different types of tissue, including cartilage and epithelium
can have teeth and hair
RFs for testicular cancer
- undescended testes
- male infertility
- FH
- tall
presentation of testicular cancer
- painless lump on testicle
- hard
- irregular
- non fluctuant
- no transillumination
- rarely gynaecomastia (leydig cell tumour)
Ix for testicular cancer
Scrotal USS
AFP
B-hCG
LDH
Staging CT
What staging criteria is used for testicular cancer
Royal Marsden staging system
common sites of testicular cancer metastasis
- lungs
- lymphatics
- liver
- brain
Mx of testicular cancer
MDT
- surgery
- chemo
- radiotherapy
- sperm banking
long term side effects of treatment for testicular cancer
- Infertility
- Hypogonadism (testosterone replacement may be required)
- Peripheral neuropathy
- Hearing loss
- Lasting kidney, liver or heart damage
- Increased risk of cancer in the future
prognosis of testicular cancer
- early- 90% cure rate
- metastatic often curable
- seminomas better prognosis than non-seminomas
what is a LUTI
infection in the bladder
causes of UTI
E coli
klebsiella pneumoniae
enterococcus
pseudomons aeruginosa
staph saprophyticus
candida albicans
presentation of LUTI
- Dysuria
- Suprapubic pain/discomfort
- Frequency
- Urgency
- Incontinence
- Haematuria
- Cloudy or foul smelling urine
- Confusion is common in older and frail patients
Mx of LUTI
trimethoprim
nitrofurantoin (not in GFR <45)
3 days simple
5-10 days immunosuppressed
7 days- men, pregnant, catheter
Mx of LUTI in pregnancy
- nitrofurantoin (avoid in third trimester neonatal haemolysis)
- cefalexin
- trimethoprim avoidede generally due to risk of neural tube defects in first trimester
what is pyelonephritis
inflammation of the kidney resulting from bacterial infection
RFs for pyelonephritis
- female
- structural urological abnormalities
- Vesico-ureteric reflux
- Diabetes
causes of pyelonephritis
- e coli
- Klebsiella pneumoniae
- Enterococcus
- Pseudomonas aeruginosa
- Staphy saprophyticus
- Candida albicans
presentation of pyelonephritis
LUTI sx +
- fever
- loin/back pain
- N&V
- renal angle tenderness
Ix for pyelonephritis
- urine dipstick
- MSU
- Bloods (WCC, CRP)
- USS or CT
Mx of pyelonephritis
7-10 days of cefalexin
what is chronic pyelonephritis
recurrent episodes of infection in the kidneys
lead to CKD and ESRF
Can do DMSA scan
what is interstitial cystitis
chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain
Presentation of interstitial cystitis
similar to LUTI. At least 6 weeks of:
- Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
- Frequency
- Urgency
- Symptoms may be worse during menstruation
Ix of cystitis
Need to exclude other causes:
- urinalysis
- swabs
- cystoscopy: see Hunner lesions and granulations
- prostate exam
Mx of interstitial cystitis
supportive
oral:
- analgesia, antihistamine, contraceptive
intravesical medication:
- lidocaine,hyaluronic acid
surgery: cauterise hunner lesions, botox
what is bladder cancer
cancer in the bladder arises from the endothelial lining
majority are superficial at presentation
RFs for bladder cancer
- smoking
- increased age
aromatic amines (dye/rubber industries) (transitional cell)
schistosomiasis (SCC)
types of bladder cancer
- transitional cell carcinoma (90%)
- squamous cell carcinoma (5%)
- adenocarcinoma (2%)
- sarcoma
- small cell carcinoma
presentation of bladder cancer
painless haematuria
Ix bladder cancer
flexible cystoscopy
staging for bladder cancer
TNM
- non-muscle invading BC (Tis-T1)
- muscle invasive BC (T2-T4)
Mx of bladder cancer
- transurethral resection of bladder tumour (early stage)
- intravesical chemo
- intravesical BCG
- radical cystectomy (need a urostomy after)
- chemo and radiotherapy
what are renal stones
renal calculi, urolithiasis and nephrolithiasis
hard stones that form in the renal pelvis, where the urine collects before travelling down the ureters
where to stones commonly get stuck
vesico-ureteric junction
complications of kidney stones
- obstruction –>AKI
- infection with obstructive pyelonephritis
types of kidney stones
Calcium
- calcium oxalate (MC)
- calcium phosphate
Other
- uric acid
- struvite (staghorn)
- cystine (inherited)
what is a staghorn calculus
stone forms in the shape of the renal pelvis
presentation of renal stones
- renal colic: unilateral loin to groin pain, colicky
- haematuria
- N&V
- reduced urine output
- sx of sepsis if infection
Ix of kidney stones
- urine dipstick
- blood tests
- Xray
- Non contrast CT KUB
- USS KUB
Mx of kidney stones
- Analgesia (NSAID IM diclofenac)
- antiemetic
- Abx if infection
- watchful waiting <5mm
- tamsulosin (muscle relax to help passage)
- 5-10mm shockwave lithotripsy
- surgery >10mm, or if infection
surgical mx for kidney stones
- Extracorporeal shock wave lithotripsy (ESWL): shock externally
- Ureteroscopy and laser lithotripsy: camera inserted and then use laser
- percutaneous nephrolithotomy (PCNL): camera through pt back and break stones up
- open surgery
How to prevent future stones
- increase fluids
- add lemon juice to water
- avoid fizzy drinks
- reduce salt
- normal calcium intake
medications to prevent recurrence of kidney stones
- potassium citrate: calcium oxalate stones
- thiazide diuretics: calcium oxalate stones
what is renal cell carcinoma
most common type of kidney tumour
adenocarcinoma from renal tubules
triad presentation of RCC
- haematuria
- flank pain
- palpable mass
(FLAWS)
types of RCC
- clear cell (80%)
- papillary (15%)
- chromophobe (5%)
- Wilm’s tumour in children <5yrs
RFs for RCC
- smoking
- obesity
- hypertension
- ESRF
- Von Hippel-Lindau Disease
- Tuberous sclerosis
where does RCC spread to?
- tissues around the kidney within the Gerota’s fascia
- cannonball metastasis
which paraneoplastic syndromes is RCC associated with?
- polycythaemia
- hypercalcaemia
- hypertension
- Stauffer’s syndrome
Staging of RCC
CT thorax, abdo, pelvis
- Stage 1: < 7cm + confined to the kidney
- Stage 2: > 7cm + confined to the kidney
- Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia
- Stage 4: Spread beyond Gerota’s fascia, including metastasis
Mx of RCC
Surgery
- partial nephrectomy
- radical nephrectomy
Non-surgical
- arterial embolisation
- percutaneous cryotherapy
- radiofrequency. ablation
what is a renal transplant
a kidney is transplanted into a patient with end-stage renal failure
adds 10 yrs to life compared to dialysis
how is the donor kidney transplanted
- donor kidney blood vessels are connected (anastomosed) with the pelvic vessels, usually the external iliac vessels
- ureter of the donor kidney is anastomosed directly with the bladder.
- placed anteriorly in the abdomen, “hockey stick” incision
immunosuppressants needed after renal transplant
Tacrolimus
Mycophenolate
Ciclosporin
Azathioprine
Prednisolone
side effects of immunosuppressants
- Immunosuppressants cause seborrhoeic warts and skin cancers (look for scars from skin cancer removal)
- Tacrolimus causes a tremor
- Cyclosporine causes gum hypertrophy
- Steroids cause features of Cushing’s syndrome
Complications of renal transplant
- Transplant rejection (hyperacute, acute or chronic)
- Transplant failure
- Electrolyte imbalances
complications related to immunosuppressants
- Ischaemic heart disease
- Type 2 diabetes (steroids)
- Infections are more likely, more severe and may involve unusual pathogens
- Non-Hodgkin lymphoma
- Skin cancer (particularly squamous cell carcinoma)
Infections secondary to immunosuppressant meds
- Pneumocystis jiroveci pneumonia (PCP/PJP)
- Cytomegalovirus (CMV)
- Tuberculosis (TB)
Cause of phimosis
- Balanitis Xerotica Obliterans (lichen sclerosis
