Urology Flashcards
What are the signs of upper urinary tract obstruction?
- Loin to groin or flank pain
- Reduced or no urine output
- Non-specific symptoms (e.g., vomiting)
- Impaired renal function (raised creatinine)
What imaging is useful for diagnosing obstructive uropathy?
Ultrasound of the kidneys, ureters, and bladder
What are common causes of upper urinary tract obstruction?
- Kidney stones
- Tumors pressing on the ureters
- Ureter strictures
- Retroperitoneal fibrosis
- Bladder cancer blocking ureteral openings
- Ureterocele
What are common causes of lower urinary tract obstruction?
- BPH
- Prostate cancer
- Bladder cancer blocking the bladder neck
- Urethral strictures
- Neurogenic bladder
What is neurogenic bladder, and what are its causes?
Abnormal nerve function of the bladder/urethra leading to overactivity or underactivity. Causes include:
- MS
- Diabetes
- Stroke
- Parkinson’s disease
- Brain/spinal cord injury
- Spina bifida
How is an upper urinary tract obstruction treated?
Nephrostomy: A tube inserted through the skin, kidney, and into the ureter to drain urine externally.
Antegrade ureteric stent: A stent placed under radiological guidance through the kidney into the ureter.
How is a lower urinary tract obstruction treated?
Urethral catheter: Inserted through the urethra into the bladder.
Suprapubic catheter: Inserted through the skin above the pubic bone directly into the bladder.
What are common complications of obstructive uropathy?
- Pain
- post-renal AKI
- CKD
- Infection (from stagnated urine)
- Hydronephrosis
- Urinary retention and bladder distention
- Overflow incontinence
What are the typical presenting features of hydronephrosis?
- Vague renal angle pain
- Mass in the kidney area
- Seen on ultrasound, CT, or intravenous urogram
How is hydronephrosis treated?
By treating the underlying cause. If pressure needs relief:
- Percutaneous nephrostomy: Inserting a tube through the skin into the kidney and ureter.
- Antegrade ureteric stent: Placing a stent from the kidney into the ureter.
What tool is used to assess LUTS severity in BPH?
International Prostate Symptom Score (IPSS).
What are the components of the initial assessment for BPH?
- Digital rectal examination (DRE): To assess prostate size, shape, and characteristics.
- Abdominal examination: To check for a palpable bladder or abnormalities.
- Frequency volume chart: Record of 3 days of fluid intake and urine output.
- Urine dipstick: To detect infection or haematuria.
- PSA test: For prostate cancer screening based on patient preference.
What are common causes of a raised PSA?
Prostate cancer
BPH
Prostatitis
Urinary tract infections
Vigorous exercise (e.g., cycling)
Recent ejaculation or prostate stimulation
What distinguishes a benign prostate on DRE?
Smooth, symmetrical, slightly soft, with a central sulcus.
What distinguishes a cancerous prostate on DRE?
Firm or hard, asymmetrical, craggy, irregular, with a loss of the central sulcus.
What medical treatments are used for BPH?
Alpha-blockers (e.g., tamsulosin): Relax smooth muscle, providing rapid symptom relief.
5-alpha reductase inhibitors (e.g., finasteride): Gradually reduce prostate size by inhibiting DHT formation.
How long does it take for 5-alpha reductase inhibitors to improve symptoms?
6 months
What are common side effects of tamsulosin and finasteride?
Tamsulosin: Postural hypotension.
Finasteride: Sexual dysfunction due to reduced testosterone.
What are the surgical options for BPH?
- Transurethral resection of the prostate (TURP): Removing prostate tissue via a diathermy loop.
- Transurethral electrovaporisation of the prostate (TEVAP/TUVP): Vaporising prostate tissue with a rollerball electrode.
- Holmium laser enucleation of the prostate (HoLEP): Using a laser to remove prostate tissue.
- Open prostatectomy: Open surgery to remove the prostate via abdominal or perineal incision.
What are the major complications of TURP?
- Bleeding
- Infection
- Urinary incontinence
- Erectile dysfunction
- Retrograde ejaculation
- Urethral strictures
- Failure to resolve symptoms
What are the symptoms of chronic prostatitis?
- Pelvic pain (e.g., in the perineum, testicles, scrotum, penis, rectum, groin, lower back, or suprapubic area).
- Lower urinary tract symptoms (e.g., dysuria, hesitancy, frequency, retention).
- Sexual dysfunction (e.g., erectile dysfunction, pain on ejaculation, haematospermia).
- Pain during bowel movements.
- Tender and enlarged prostate on examination (though it may be normal).
How does acute bacterial prostatitis differ in presentation from chronic prostatitis?
Acute onset of symptoms similar to chronic prostatitis.
Systemic symptoms of infection, such as:
- Fever
- Myalgia
- Nausea
- Fatigue
- Sepsis
What tool is used to assess and track chronic prostatitis symptoms?
National Institute of Health Chronic Prostatitis Symptom Index.
What investigations are performed for prostatitis?
- Urine dipstick: To confirm infection.
- Urine microscopy, culture, and sensitivities (MC&S): To identify causative organisms and antibiotic sensitivities.
- Chlamydia and gonorrhoea NAAT testing: For suspected STIs
How is acute bacterial prostatitis managed?
- Hospital admission: For systemically unwell or septic patients (to conduct blood tests, cultures, and administer IV antibiotics).
- Oral antibiotics: 2-4 weeks (e.g., ciprofloxacin, ofloxacin, or trimethoprim).
- Analgesia: Paracetamol or NSAIDs.
- Laxatives: For pain during bowel movements.
How is chronic prostatitis managed?
- Alpha-blockers (e.g., tamsulosin): Relax smooth muscle for symptom relief.
- Analgesia: Paracetamol or NSAIDs.
- Psychological treatment: Cognitive behavioural therapy or antidepressants if indicated.
- Antibiotics: For <6 months of symptoms or a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks).
- Laxatives: For bowel movement-related pain.
What are the complications of acute bacterial prostatitis?
- Sepsis.
- Prostate abscess: May present as a fluctuant mass and require surgical drainage.
- Acute urinary retention.
- Chronic prostatitis.
Where does advanced prostate cancer commonly spread?
Lymph nodes and bones
What type of cancer is most prostate cancer?
Adenocarcinoma, typically growing in the peripheral zone of the prostate.
What are the key risk factors for prostate cancer?
- Increasing age.
- Family history.
- Black African or Caribbean origin.
- Tall stature.
- Anabolic steroid use.
Why is PSA testing controversial?
- High false-positive rate (75%) and false-negative rate (15%).
- Risks of unnecessary biopsies and overdiagnosis.
- May lead to false reassurance.
What is the first-line investigation for suspected localised prostate cancer?
Multiparametric MRI.
What is the Likert scale for MRI results?
1 – Very low suspicion.
2 – Low suspicion.
3 – Equivocal.
4 – Probable cancer.
5 – Definite cancer.
When is a prostate biopsy performed?
Based on MRI findings (Likert 3 or above) and clinical suspicion (PSA and DRE findings).
What are the two types of prostate biopsy?
Transrectal ultrasound-guided biopsy (TRUS): Biopsies taken through the rectum.
Transperineal biopsy: Biopsies taken through the perineum under local anaesthetic.
What is the Gleason grading system?
Grades (prostate biopsy) tissue samples from 1 (normal) to 5 (abnormal).
Score = most prevalent pattern + second most prevalent pattern.
Scores:
6: Low risk.
7: Intermediate risk (3+4 is lower risk than 4+3).
8+: High risk.
What are the treatment options for prostate cancer?
- Surveillance or watchful waiting (early cancer).
- External beam radiotherapy.
- Brachytherapy.
- Hormone therapy.
- Surgery (radical prostatectomy).
What are the complications of external beam radiotherapy?
Proctitis (pain, altered bowel habits, bleeding, discharge).
What are the complications of brachytherapy?
- Cystitis or proctitis.
- Erectile dysfunction.
- Incontinence.
- Increased bladder or rectal cancer risk.
What are the side effects of hormone therapy?
Hot flushes, sexual dysfunction, gynaecomastia, fatigue, osteoporosis.
What are the complications of radical prostatectomy?
Erectile dysfunction and urinary incontinence.
What is the function of the epididymis?
It stores and matures sperm, which travel from the testicle through the head, body, and tail of the epididymis before draining into the vas deferens.
What are common infectious causes of epididymo-orchitis?
Bacterial:
- Escherichia coli (E. coli)
- Chlamydia trachomatis
- Neisseria gonorrhoea
Viral: Mumps
What are the typical symptoms of epididymo-orchitis?
- Gradual onset of unilateral testicular pain.
- Dragging or heavy sensation.
- Swelling of the testicle and epididymis.
- Tenderness over the epididymis.
- Urethral discharge (suggests STI).
- Systemic symptoms: fever and possibly sepsis.
What is the key differential diagnosis for epididymo-orchitis?
Testicular torsion
What investigations help establish the cause of epididymo-orchitis?
- Urine MC&S.
- Chlamydia and gonorrhoea NAAT testing on first-pass urine.
- Charcoal swab of urethral discharge for gonorrhoea culture and sensitivities.
- PCR testing for mumps (saliva swab).
- Serum antibodies for mumps (IgM for acute, IgG for past infection or vaccination).
- Ultrasound for torsion or tumours.
What antibiotics are recommended for enteric causes of epididymo-orchitis?
- Ofloxacin for 14 days.
- Levofloxacin for 10 days.
- Co-amoxiclav for 10 days (if quinolones are contraindicated)
What empirical antibiotics are used for suspected STIs?
- Intramuscular ceftriaxone (single dose).
- Doxycycline.
- Ofloxacin (based on sensitivities).
What are the potential complications of epididymo-orchitis?
- Chronic pain.
- Chronic epididymitis.
- Testicular atrophy.
- Sub-fertility or infertility.
- Scrotal abscess.
What are two critical side effects of quinolones?
- Tendon damage or rupture, especially the Achilles tendon.
- Lower seizure threshold (caution in epilepsy).
What are the examination findings in testicular torsion?
- Firm, swollen testicle.
- Elevated (retracted) testicle.
- Absent cremasteric reflex.
- Abnormal testicular lie (often horizontal).
- Rotation of the testicle (epididymis not in the normal posterior position).
What is the bell-clapper deformity?
A congenital absence of fixation between the testicle and the tunica vaginalis, allowing the testicle to hang horizontally and rotate freely.
What is the initial management for testicular torsion?
- Nil by mouth (in preparation for surgery).
- Analgesia.
- Urgent senior urology assessment.
What surgical procedures are performed in testicular torsion?
Orchiopexy: Corrects the testicle’s position and fixes it in place.
Orchidectomy: Removes the testicle if necrosis has occurred.