UROLOGY Flashcards
3 types of urinary retention:
Chronic
Acute
Drug induced
Types of chronic urinary retention, and their differentiating factors?
High Pressure: impaired renal function, bilateral hydronephrosis usually due to bladder outflow obstruction
Low Pressure: normal renal function, no hydronephrosis
What can occur post-catheterisation for chronic retention, and what is the treatment?
Decompression haematuria due to rapid decrease in pressure.
No treatment required.
Acute urinary retention is the most common urological emergency, coming on over hours or less. Classical patient script of someone presenting with acute urinary retention:
Man over 60, history of e.g. BPH.
Lower abdominal pain / tenderness / causing distress has come on over a few hours.
Inability to pass urine, ?confusion in elderly.
Clinical examinations indicated in acute urinary retention:
Rectal +/- abdominal
Neurological
Pelvic if female
Most common cause of acute urinary retention in men is BPH. Give some other causes.
Obstructive e.g. calculi, strictures, cystocele, constipation, mass
Medications e.g. anticholinergics, TCA, antihistamines, opioids, benzos
Neurological cause
Can occur postpartum
Investigations in acute urinary retention and management:
Urinalysis with microscopy and culture
U+Es to check renal function, eGFR, creatinine
FBC and CRP for infection
PSA is NOT indicated, as it typically elevated in urinary retention
US bladder >300 cc = Catheterise!
Complication of acute urinary retention and how is this managed?
Post obstructive diuresis
Loss of medullary concentration gradient, can lead to volume depletion and worsening of AKI
?IV fluids to correct the temporary fluid loss
Discuss LUTS, splitting them into 3 groups of voiding, storage and post-micturition, and give 3 examination / investigations to go alongside these symptoms.
Voiding: incomplete bladder emptying, hesitancy, poor stream / dribbling, straining
Storage: urgency, frequency, nocturia, incontinence
Post-micturition: feeling of incompleteness
What can you get from the patient who is presenting with LUTS to assess impact on life and to guide management?
Urine frequency / volume chart - distinguishes between frequency, polyuria, nocturia and nocturnal polyuria.
IPSS (International Prostate Symptom Score) - assesses impact of Sx on life, categorised into mild mod and severe
Management of predominantly voiding symptoms:
Pelvic floor / bladder training, prudent lifestyle advice inc reduced fluid intakes.
If moderate to severe = alpha blocker e.g. tamsulosin
If large prostate / high risk of progression, give 5-alpha reductase inhibitor as well = finasteride
Management of predominantly overactive bladder:
Bladder retraining
Oxybutynin, tolterodine, darifenacin first line options.
Mirabegron 2nd line.
Urine dipsticks should NOT be used for the diagnosis in 3 different groups:
Catheter
Women >65
Men
When should urine culture be sent in confirmed / suspected UTI?
Men
Women >65
Pregnancy
Recurrent UTI (2 episodes in 6 months / 3 in 12)
Haematuria
Management of symptomatic and asx UTI in pregnancy:
Nitrofurantoin 7 days
Also send test of cure urine cultures
Who should get 7 day courses of antibiotics for a UTI?
Men
Pregnant women
Catheterised with symptoms
Signs / symptoms and treatment of acute pyelonephritis:
Fever, rigor
Loin pain
Nausea and vomiting
Dysuria
Urinary frequency
MSU sent before commencing antibiotics. Can be managed in community if stable. Ceftriaxone or cipro
Malignant causes of haematuria:
Renal cell carcinoma
Bladder cancer - TCC, squamous, adenoma
Prostate carcinoma
Penile cancer
Structural abnormalities that can cause haematuria:
BPH due to hypervascularisation of the gland
PKD
Renal vein thrombosis in RCC
Non visible haematuria can be found as a one off cause or it can be more persistent. Give causes that would fit into each of these two groups.
One off findings:
UTI
Vigorous exercise
Menstruation
Sexual intercourse
Persistent:
Malignancy
Stones
BPH
Prostatitis
IgA nephropathy
Chlamydia urethritis
When should an urgent referral be made in the context of haematuria?
45 or over + unexplained visible haematuria without a UTI OR visible haematuria that persists or returns even after treatment
60 or over with unexplained non-visible haematuria + dysuria OR raised white cell count
When should a non-urgent referral be made in the context of haematuria?
Over 60 with recurrent or persistent UTI
Investigations when haematuria is present:
Urine dipstick (persistent non-visible is diagnosed twice 2-3 weeks apart)
U+Es, eGFR
Albumin creatinine or protein creatinine ratio
Urine microscopy
Blood pressure!
Who do you NOT need to refer in the context of haematuria?
<40, normal renal function, no proteinuria and BP normal
Risk factors for testicular cancer:
Cryptorchidism
Infertility
Klinefelter syndrome
Family history
Mumps orchitis
First line investigation in suspected testicular cancer:
Ultrasound
Discuss the different types of testicular cancer. 95% are germ cell tumours.
95% germ cell (Other type is Leydig cell)
Germ cell is split into seminoma and non-seminoma.
Non-seminomas are further split into embryonal, yolk sac, teratoma and choriocarcinoma
Tumour marker in seminomas?
hCG in 20%
Tumour marker for germ cell tumours in general?
Raised lactate dehydrogenase
Tumour markers for all non-seminomas?
AFP + bhCG
Why does gynaecomastia occur in germ-cell tumours and Leydig cell tumours respectively?
Germ cell = hCG is raised, causing leydig cell dysfunction, increases oestradiol and testosterone, but more oest.
Leydig = directly secretes more oestradiol and converts additional androgen precursors to oestrogens.
What is the most common organism that causes acute epididymo-orchitis?
Chlamydia
There are 2 types of bladder cancer, what are they and which is the most common?
1 = Uroepithelial carcinoma / Transitional cell carcinoma
Squamous cell
Risk factors for squamous cell carcinoma of the bladder:
Smoking
Shistosomiasis (endemic in e.g. African origin)
Risk factors for transitional cell carcinoma of the bladder:
Smoking
Rubber factory
Aniline dyes e.g. printing and textiles industry
Cyclophosphamide
*Current or previous smokers of the last 20 years have a 2-5x increased risk of bladder cancer
Most common presenting complaint for bladder cancer:
Painless visible haematuria
Regional lymph nodes around the bladder that a bladder cancer would metastasise to first (single = N1, multiple = N2):
Hypogastric
Obturator
External iliac
Pre-sacral
Describe the structures that are invaded in T4, T4a and T4b bladder cancer:
T4 - prostatic stroma, seminal vesicles, uterus, vagina
T4a - uterus, prostate, bowel
T4b - pelvic sidewall or abdominal wall
A bladder cancer has invaded into the perivesicular fat. What stage is it?
T3
Ta in bladder cancer refers to non-invasive papillary carcinoma. What invasion does T1, T2a and T2b describe?
Ta = non-invasive papillary
T1 = subepithelial connective tissue
T2a = superficial muscularis propria
T2b = deep muscularis propria
Investigations in suspected bladder cancer:
Cystoscopy
Biopsies
Management options for bladder cancer:
TURBT
Recurrence / higher grade or risk = intravesical chemotherapy.
?Intravesical BCG vaccine = thought to stimulate the immune system.
Radical cystectomy with urostomy and ileal conduit
4 surgical options for draining urine post radical cystectomy:
Urostomy - drains urine directly from kidney, bypassing ureter, bladder and urethra. Ileal conduit created.
Continent urinary diversion - pouch created inside abdomen from a section of the ileum with the ureters connected. Intermittent catheterisation done by the patient.
Neobladder reconstruction - new bladder from section of ileum. May require intermittent catheterisation and washout.
Uterosigmoidostomy - ureters drain directly into sigmoid colon. Rarely done.
Which types of TCC’s will have a worse prognosis and why?
70% of TCCs have a papillary growth pattern and are more superficial.
Those with a mixed pattern / solid only pattern are more prone to invasion, may be of a higher grade / worse prognosis.
Investigation of suspected prostate cancer:
PSA
DRE
Multi-parametric MRI is first line
?Bone scan for staging
What type of cancer are 95% of prostate cancers?
Prostatic adenoma
What is the name of the system used to grade prostate cancer, and describe how to use it?
Gleason
Multiple biopsies taken.
Grades of a) most prevalent cell types and b) most prevalent cell type are assessed.
Grades added together e.g. 3+4 = 7
6 = low risk
7 = moderate
8 = high
Which nodes will prostate cancer first spread to via lymphatics?
Obturator
4 causes of false positive PSA result:
Vigorous DRE
Ejaculation
Acute urinary retention
BPH
UTI
Prostatitis
Who should the watch and wait option be for in prostate cancer?
Elderly
Multiple comorbidities
Low Gleason score
External radiotherapy is both potentially curative and palliative. Give 2 complications.
Rectal malignancy
Radiation proctitis
Standard treatment for localised disease of the prostate +1 common side effect:
Radical prostatectomy + obturator node excision
Erectile dysfunction is a common side effect
Testosterone stimulates prostate tissue and prostate cancers usually show some degree of testosterone dependence. As 95% of testosterone is derived from the testis, which operation could reduce the testosterone and therefore cause regression of the prostate cancer?
Bilateral orchidopexy
Multi-parametric MRI of the prostate is now the first line investigation for suspected cancer. What scale are the results reported on and what do they mean?
Likert scale 5 points
1-2 = discuss pros and cons of biopsy
>3 = offer MRI influence biopsy
Anti-androgen therapy is key in treating metastatic prostate cancer. What kind of drug is Goserelin, and how does it work?
GnRH agonist
Causes overstimulation of the pituitary, disrupting normal endogenous feedback systems, resulting in paradoxically low LH eventually.
Testosterone rises initially for 2-3 weeks before falling to castration level.
When is hormone therapy considered in prostate cancer?
Advanced metastatic cancer
What type of drug is bicalutamide and when is it used in prostate cancer?
Non-steroidal anti-androgen / androgen receptor blocker
Metastatic disease
Peak incidence of testicular torsion, and what actually happens?
10-13 years
Twisting of the spermatic cord, can result in ischaemia and necrosis
Symptoms and clinical examination findings of testicular torsion:
Severe, sudden onset pain
Can be referred to the abdomen
Prehn’s sign - pain NOT alleviated by elevation of the testes
Testis will be retracted, may be red
Nausea and vomiting
Loss of cremasteric reflex
Often triggered by playing sport
Management of suspected testicular torsion:
Urgent surgical exploration under anaesthesia, immediate.
<6 hours is time frame where least incidence of testes loss
Fix both - orchidopexy
What is meant by a bell-clapper deformity?
Normally the testis is tethered posteriorly to the tunica vaginalis, but in bell clapper this is not the case / not fixed.
Testis sits more horizontally. Is bilateral.
Able to rotate = this is why there is twisting of the cord.
What is an arbitrary window of time from symptom onset that surgery should be done in in testicular torsion?
? 6 hours
