Urology Flashcards

Question

What is the conservative management of BPH?

Answer 1

Conservative Management: Initial management is usually treatment of the underlying pathology. However, there are a number of conservative measures that may be useful in the initial management of LUTS in some patients whilst investigation of the underlying cause is ongoing. Regulating fluid intake, such as timing and volume of drinks consumed and reducing caffeinated and alcoholic beverages in evenings, is important for all patients. Individuals suffering from voiding symptoms may benefit from urethral milking techniques* (manually emptying the bulbar urethra of residual urine) or double voiding(passing urine and then remaining for a short time before passing urine again) Pelvic floor exercises to strengthen the pelvic floor are useful in cases of stress incontinence or post-micturition dribble. Bladder training techniques, which aim to increase the duration between the urge to void and micturition, when done properly (under supervision) these may be useful in overactive bladder.

Answer 2

Medical: Tamsulosin (alpha blocker therapy) Finasteride Anticholenergics Surgical: Transurethral resection of prostate Holmium laser enucleation of prostate

Answer 3

Immediate catheterisation Take a concise - Hx- patient in retention do not want to talk Get a catheter - 16fr men 12/14fr female Can’t get a catheter in call urology special catheter, aspiration / spc insertion Quick examination: External genitalia Vaginal prolapse DRE size / malignancy Imaging- US KUB/CTKUB ? Hydronephrosis US as for prostate size Investigations- Bloods- FBC, CRP, U&E Producing urine out put per hour should have 50% of their urine output replaced to avoid further deterioration of renal function

Answer 4

Monitor observations- Blood pressure - LSBP Hourly monitoring of fluid output IV Fluid replacement Normal saline at 50% of the previous hour’s urine output. Daily U&Es- Ensure AKI improving Repeat Imaging – US /CT- Ensure resolution of hydronephrosis

Answer 5

Trial Without Catheter (TWOC) Definition: Trial Without Catheter (TWOC) is a planned attempt to remove a urinary catheter to assess whether a patient can urinate independently without retention. Purpose: To determine if the bladder can empty effectively after relief of Acute Urinary Retention (AUR). To avoid unnecessary prolonged catheterization, which increases infection risk.

Answer 6

1. Patient Preparation Alpha-blocker therapy (e.g., tamsulosin) should be started before catheter removal (especially in men with BPH). Ensure adequate hydration. 2. Catheter Removal Typically performed 24–48 hours after AUR catheterization. Performed in a clinical setting where urine output can be monitored. 3. Monitoring Post-Removal Successful TWOC: Patient voids adequately (typically >200 mL per void) without significant residual urine. Failed TWOC: If the patient is unable to urinate, experiences severe discomfort, or has a post-void residual volume >300–500 mL, catheterization is reinserted, and further management is considered. Failed TWOC then Re-catheterise then OP TWOC clinic

Answer 7

BPH , Stricture, Bladder stone: Refer to urology Tamsulosin ,finasteride Bladder outflow obstruction- TURP/HoLEP Urethral dilatation Cystolitholapaxy LTC Infection: Abx Gynaecological: Referral to gynaecology Neurological: Refer to urology Constipation: Laxatives Drugs: Discontinue if possible

Answer 8

Kidney stones are hard, crystalline deposits that form in the kidneys due to the accumulation of minerals and salts in urine. They can vary in size and may cause severe pain when passing through the urinary tract.

Answer 9

Sharp, sudden loin to groin pain Severe, colicky flank pain (radiates to groin). Hematuria (blood in urine). Nausea & vomiting. Dysuria & urinary urgency (if stone reaches bladder)

Answer 10

Dehydration – Concentrated urine increases crystal formation. Diet – High oxalate, salt, animal protein, or low citrate intake. Metabolic disorders – Hypercalciuria, hyperoxaluria, gout. Chronic UTIs – Promote struvite stones. Medications – Loop diuretics, excessive vitamin D, protease inhibitors.

Answer 11

Non-contrast CT scan (gold standard). Ultrasound (preferred in pregnancy). Urinalysis (checks for blood, crystals, infection). Serum & urine tests (to identify metabolic causes)

Answer 12

First-line Treatment: Administer a non-steroidal anti-inflammatory drug (NSAID) by any route to adults, children, and young people with suspected renal colic. Alternative Treatment: If NSAIDs are contraindicated or ineffective, offer intravenous paracetamol Opioids: Consider opioids if both NSAIDs and intravenous paracetamol are contraindicated or insufficient Do not offer antispasmodics for suspected renal colic.

Answer 13

On a CT scan, kidney stones appear as dense, hyperdense (bright white) areas within the kidney or urinary tract. The appearance can vary depending on the type of stone and its composition

Answer 14

Types of Kidney Stones: Calcium Stones (80%) – Most common; caused by high oxalate or calcium levels. Radio-opaque. Struvite Stones (10-15%) – Form due to UTIs; large, irregular staghorn calculi. Radio-opaque. Uric Acid Stones (5-10%) – Linked to high purine intake (red meat, shellfish, gout). Radiolucent (not seen on X-ray). Cystine Stones (<1%) – Due to genetic disorder (cystinuria); yellowish, hexagonal crystals. Faintly radiopaque.

Answer 15

Guided by stone analysis , Hydration, diets, medications changes, referral to metabolic stone clinic

Answer 16

For patients with uteric stones less than 5mm, no AKI and no infection can be discharged with medical expulsion therapy (MET), repeat Ct KUB in 4 weeks and refer to stone MDT and safety net. MET: Tamsulosin relaxes the ureter

Answer 17

Patients with suspected infection/sepsis, ureteric stones greater than 7mm, AKI, solitary kidney and pain not settling with analgesia. Refer to the Urology Team.

Answer 18

A ureteric stent is a small, flexible tube inserted into the ureter—the duct that carries urine from the kidney to the bladder—to ensure the free flow of urine, especially in cases of obstruction. Retrograde Stenting: Performed under general anaesthesia, a cystoscope (a thin tube with a camera) is inserted through the urethra into the bladder. The stent is then placed into the ureter using a guide wire.

Answer 19

Advantages: Internal (no open surgery) No risk to adjacent organs Disadvantages: Infections Ureteric injury Stent symptoms -Frequency -Haematuria -Flank pain on urination -Dysuria Forgotten stent (6 months)

Answer 20

A nephrostomy is a procedure where a catheter is inserted into the kidney through the skin to drain urine directly from the kidney when normal urinary flow is obstructed. This procedure is typically done in cases where the ureter (the tube that connects the kidney to the bladder) is blocked and urine cannot pass to the bladder.

Answer 21

Ureteric Obstruction (e.g., due to kidney stones, tumors, or strictures). Acute Renal Failure due to obstruction, where decompression of the kidney is necessary. Infection in the urinary tract, especially in cases of hydronephrosis (swelling of the kidney due to urine buildup). Post-surgical or Post-trauma recovery where normal drainage may be disrupted.

Answer 22

Percutaneous insertion of nephrostomy tube. Advantages Better for the unwell patient Disadvantages Deranged INR/anticoag Radiologist availability Damage to other organs Nephrostomy bag. Blockages

Answer 23

Stone size Stone position renal/ureteric Stone burden Patient anatomy, horseshoe kidney, single function kidney Patient choice

Answer 24

Ureteroscopy (URS) with Laser Lithotripsy is a minimally invasive procedure used to treat ureteral stones (stones located in the ureter, the tube that carries urine from the kidney to the bladder). This technique combines the use of a ureteroscope (a flexible or rigid tube with a camera) and laser energy to remove or fragment stones. Ureteroscopy (URS)+ laser stone fragment Procedure Ureteroscope inserted into the ureter, locate the stone & laser. Laser used to fragment the stone making it easier to pass through urinary tract. Indications - Distal ureteric stones CI Relative /absolute - GA/spinal risk

Answer 25

Extracorporeal Shock Wave Lithotripsy (ESWL) is a non-invasive treatment for kidney and ureteric stones. It uses shock waves directed through the skin to fragment stones into smaller pieces, allowing them to pass naturally through the urinary tract. Indications: - Upper pole and mid pole - Proximal ureteric stones > 10mm ESWL is recommended as a treatment option based on stone size and location: Renal Stones: 10 to 20 mm: Consider ESWL or ureteroscopy (URS). Larger than 20 mm (including staghorn stones): Percutaneous nephrolithotomy (PCNL) is preferred; URS or ESWL may be considered if PCNL is unsuitable. Ureteric Stones: Less than 10 mm: Offer ESWL. 10 to 20 mm: Offer URS; consider ESWL if stone clearance within four weeks is feasible. CI Relative /absolute: Larger patients Anticoagulation UTI

Answer 26

Percutaneous Nephrolithotomy (PCNL) is a minimally invasive surgical procedure used to remove large or complex kidney stones by puncturing into the kidney. PCNL is typically recommended for the treatment of renal calculi, especially when stones are larger than 2cm or present as staghorn calculi. Indications: - Lower pole and renal pelvis stones - Staghorn calculus - Larger stones >2cm - Abnormal renal anatomy/patient anatomy CI Relative /absolute: - Larger patients - Anticoagulation - UTI

Answer 27

Testicular torsion is a urological emergency where the spermatic cord twists, cutting off blood supply to the testicle, leading to ischemia and potential testicular loss if not promptly addressed. Urgent Referral: Suspected testicular torsion warrants immediate referral to emergency urology or pediatric surgery. Avoid Delays: Diagnostic imaging should not delay surgical exploration if torsion is suspected based on clinical assessment.

Answer 28

bell clapper deformity , undescended testes, previous testicular torsion.

Answer 29

Sudden, Severe Scrotal Pain: Typically unilateral, often accompanied by nausea and vomiting. Physical Examination Findings: Swollen, tender testis retracted upward. Erythema of the scrotal skin. Absence of the cremasteric reflex (lifting the inner thigh does not elevate the testis) Horizontal lie High riding testis Negative Phren's sign (Prehn's sign is a test that involves lifting the scrotum to determine if pain is relieved. A positive sign indicates that pain is relieved, while a negative sign indicates that pain is not relieved.)

Answer 30

Investigations and imaging should not delay surgical exploration for a suspected testicular torsion. US testes/doppler- lack of blood supply. Immediate Surgical Consultation: Prompt scrotal exploration is crucial, ideally within 6 hours of symptom onset to salvage the testicle. Manual Detorsion: Attempted in some cases by rotating the testis outward; however, surgical intervention remains the definitive treatment. Orchidopexy: Fixing both testes to the scrotal wall during surgery to prevent future torsion.

Answer 31

Enlargement of veins within the scrotum. Many varicoceles are asymptomatic and do not require treatment. Regular monitoring may involve periodic semen analyses and physical examinations to detect any changes. Exam findings: “Bag of worms” Non tender No transillumination Better to examine standing Investigations and management: US Testes +/- US KUB (renal mass) NICE advises against offering varicocele surgery solely as a fertility treatment, as evidence does not conclusively support improved pregnancy rates post-surgery. However, surgery may be considered for: Persistent pain unresponsive to conservative measures. Testicular atrophy or growth concerns in adolescents. Abnormal semen parameters in the context of unexplained infertility.

Answer 32

Accumulation of fluid in the tunica vaginalis which can be congenital or acquired. Examination findings: Non tender, smooth and firm Transillumination Able to get above the swelling. Testis sometimes not felt Investigations and Management: US Testes Hydrocele repair if large and causes discomfort

Answer 33

Epididymo-orchitis is an inflammatory condition involving the epididymis and testicle, presenting with scrotal pain and swelling. Common causes include bacterial infections, such as sexually transmitted infections (STIs) like chlamydia and gonorrhea, as well as viral infections like mumps. Exam findings: Tender epididymis+ testicle Phren's sign positive Positive urine dip Investigations and Management: US Testes- rule out abscess Antibiotics NSAIDS for pain relief Refer to GUM clinic Referral for Urology- incomplete bladder emptying

Answer 34

Testicular cancer is a malignancy originating in the testicles, commonly affecting younger men. Exam findings: Painless, Firm irregular Investigations and Management: 2WW US Testes Tumour markers- LDH, AFP, B-HCG Inguinal orchidectomy: Radical inguinal orchidectomy (removal of the affected testicle) is the primary treatment for localized testicular cancer.

Answer 35

Urinary incontinence (UI) is a prevalent condition affecting many women, characterized by the involuntary leakage of urine.

Answer 36

Hx Taking: Establish type Onset Urinary symptoms - Storage/Voiding & red flags - dysuria, haematuria Fluid intake - water caffeine, alcohol Severity - Pads, Impact PMH - Vaginal delivery, instrumentation - Pelvic surgery - Neurological - Diabetes- Controlled Previous surgical treatment Previous treatment

Answer 37

Urine dip - rule out infection! 3-day bladder diary Vaginal- vaginal atrophy, cystocele DRE- BPH

Answer 38

1. Stress Incontinence Cause: Weakness of the pelvic floor muscles or sphincter muscles, often due to pregnancy, childbirth, or aging. Symptoms: Leakage of urine when coughing, sneezing, laughing, or physical activities that put pressure on the bladder. 2. Urge Incontinence (Overactive Bladder) Cause: Bladder muscle overactivity or involuntary contractions, often linked to bladder irritation or neurological disorders. Symptoms: Sudden, intense urge to urinate followed by involuntary leakage before reaching the toilet. 3. Overflow Incontinence Cause: Bladder overfilling, typically due to obstruction or poor bladder contraction, often caused by an enlarged prostate, nerve damage, or urinary retention. Symptoms: Frequent dribbling of urine or inability to fully empty the bladder, leading to constant leakage. 4. Mixed Incontinence Cause: A combination of stress and urge incontinence. Symptoms: A combination of leakage due to physical activity (stress) and a strong, urgent need to urinate (urge). 5. Constant leakage of urine Anatomical abnormality or bladder fistulae (e.g. vesicovaginal fistula). May also be due to severe overflow incontinence.

Answer 39

Lifestyle changes: - Eliminate caffeine, smoking - Loose weight - Timing of fluid Intake Bladder retraining Medication - Anticholinergic (Solifenacin, Oxybutynin) - B3 adrenergic agonist (Mirabegron)

Answer 40

Lose weight Pelvic floor exercise/ supervised

Answer 41

1. Persistent Symptoms Despite Conservative Treatment If lifestyle modifications, pelvic floor exercises, or medications have not improved symptoms, a referral to a urologist may be needed for further evaluation and management. 2. Unexplained Incontinence 3. Mixed Incontinence 4. Severe Symptoms or Impact on Quality of Life 5. Blood in the Urine (Hematuria) 6. Complicated Medical History or Comorbidities 7. Suspected Structural Abnormalities

Answer 42

1. Botox 2. Percutaneous tibial Nerve stimulation (PTNS) 3. Sacral neuromodulation 4. Calm Cystoplasty 5. Urinary diversion

Answer 43

- Urethral bulking - Autologous sling - Colposuspension

Answer 44

Prostate cancer is a malignant tumor that develops in the prostate, a gland in the male reproductive system responsible for producing seminal fluid. According to the National Institute for Health and Care Excellence (NICE), nearly all prostate cancers (approximately 95%) are adenocarcinomas, originating from glandular cells.

Answer 45

Age: The risk of developing prostate cancer increases with age, particularly affecting men over 50. Family History: Having a first-degree relative with prostate cancer can elevate risk. Ethnicity: Higher incidence rates are observed in Black men compared to other ethnic groups.

Answer 46

- LUTS- don’t forget haematuria - Risk factor- Age, Race , family history, breast CA - Previous urological hx - Drug hx - on finasteride, anticoagulants

Answer 47

Examinations/investigations - DRE- asymmetry, “craggy” feeling, nodules - Urine dip- rule out infection Imaging: MRI Prostate with contrast (2ww) - Bone scan (PSA> 20)- rule out bone metastasis) - Refer to urology for Prostate Biopsy Prostate-Specific Antigen (PSA) Test: Measures PSA levels in the blood; elevated levels may indicate prostate cancer. Multiparametric MRI: Imaging technique used to detect and assess prostate abnormalities. Biopsy: Tissue samples are examined to confirm the presence of cancer cells

Answer 48

Prostate-Specific Antigen (PSA) is a protein produced by both normal and cancerous cells of the prostate gland. It is primarily used as a biomarker to assess the health of the prostate. PSA testing is commonly used for screening for prostate cancer, though it is not perfect and can sometimes lead to false positives (suggesting cancer when none is present) or false negatives (missing cancer that is present).

Answer 49

Infection (6 wks.) Ejaculation (48hrs) Vigorous exercise (48hrs) DRE ( 1 wk.) Urinary retention (6 wks.) Catheter insertion/ instrumentation (6 wks.)

Answer 50

Referral for suspected prostate cancer should be considered based on prostate-specific antigen (PSA) levels and the presence of symptoms. Referral Based on PSA Levels: NICE provides age-specific PSA thresholds to guide referrals: Below 40: Use clinical judgement. Ages 40–49: PSA > 2.5 ng/mL Ages 50–59: PSA > 3.5 ng/mL Ages 60–69: PSA > 4.5 ng/mL Ages 70–79: PSA > 6.5 ng/mL Ages 80 and above: Clinical judgment should be used

Answer 51

Dependent on: Gleason scoring – Risk Patient Choice Patient Co-morbidity Active Surveillance: For low-risk, localized prostate cancer; involves regular monitoring without immediate treatment. Curative Treatments: Radical Prostatectomy: Surgical removal of the prostate, typically for localized cancer. Radiotherapy: External beam radiotherapy (EBRT) or brachytherapy (internal radiation). Cryotherapy: Freezing prostate tissue for small localized tumors. Hormone Therapy: Lowers testosterone to slow cancer growth, used for advanced or metastatic cancer. Methods include LHRH agonists, anti-androgens, or orchiectomy. Chemotherapy: For metastatic or castration-resistant cancer, using drugs like docetaxel. Targeted Therapy and Immunotherapy: Target specific cancer pathways or stimulate the immune system, e.g., enzalutamide or sipuleucel-T. Bone-Targeted Therapy: For bone metastases, using drugs like bisphosphonates or denosumab to reduce bone pain and fractures. Palliative Care: Focuses on symptom management and improving quality of life for advanced disease. Follow-Up: Regular PSA tests and monitoring for recurrence or treatment side effects like erectile dysfunction or incontinence.