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Year 5 - Surgery > Urology > Flashcards

Urology Flashcards

1
Q

What are the indications for treatment of BPH?

A
  1. Symptomatic
    - IPSS moderate (8-19) or severe (20 or more)
  2. Complications
    - Prostate: bleeding
    - Bladder: infection, stones, retention, diverticulum
    - Upper tract: hydronephrosis, obstructive uropathy, renal failure
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2
Q

What are the choices for treatment of BPH?

A
  1. Conservative
    - Watchful waiting
    - Lifestyle modifications
  2. Medications
    - Alpha blockers
    - 5a-reductase inhibitors
  3. Minimally invasive therapy
    - RF (radiofrequency/TUNA)
    - HIFU (high-intensity focused ultrasound)
    - TUMT (transurethral microwave therapy)
    - Long-term catheterization: foley VS. suprapubic
    - Prostatic stenting
  4. Surgical therapy
    - Tissue ablation
    >> PVP (laser photo-vaporization of the prostate)
    >> HoLRP (holmium laser resection of the prostate)
    - TURP: monopolar VS. bipolar
    - Open prostatectomy
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3
Q

What are the side effect of a1-adrenergic antagonists (e.g. tamsulosin)?

A
  • Orthostatic hypotension
  • Dizziness
  • Asthenia (tiredness)
  • Nasal congestion
  • Sexual dysfunction: ejaculatory problems (retrograde)
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4
Q

What are the mechanisms of action of alpha-blockers and 5a-reductase inhibitors in BPH treatment?

A
  1. Alpha-blockers: relaxes the smooth muscle of the prostate to allow for better passage of urine (BPH is dynamic obstruction!)
  2. 5a-reductase inhibitors: blocks synthesis of DHT from testosterone –> decreases the size of the prostate
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5
Q

When will the clinical effect of 5a-reductase inhibitors kick in?

A

3-12 weeks

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6
Q

In what condition will 5a-reductase inhibitors be especially helpful?

A

Glands >40mL

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7
Q

What are the side effects of 5a-reductase inhibitors?

A
  • Erectile dysfunction (~5%)
  • In itself, decreases PSA level by 50% –> DON’T BE FOOLED!
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8
Q

What irrigation fluid is usually used in TURP?

A

1.5% glycine + post-operative NS irrigation

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9
Q

Which type of catheter is used in TURP?

A

3-way urethral catheter

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10
Q

What are the complications of TURP?

A
  1. General
  2. Specific
    - Intraoperative
    >> Bleeding
    >> Perforation/injury to adjacent structures
    >> TURP syndrome
    - Early postoperative
    >> Bleeding/Clot retention
    >> Infection
    >> Clip retention
    >> Urge incontinence
    >> TURP syndrome
    - Late postoperative
    >> Strictures
    >> Stress incontinence
    >> Retrograde ejaculation
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11
Q

How is UTI diagnosed?

A
  • History: irritative symptoms
  • Physical examination: fever etc.
  • Multistix: elevated nitrate, leukocyte esterase
  • Urine Microscopy
  • MSU culture
    >> CFU/mL >10^5 for upper tract UTI
    >> Symptomatic female: >=10^2 E. Coli FRU + >= 8 pus cells/mm3 OR >= 10^5 of other organisms
    >> Symptomatic male: >=10^3 pathogenic organism
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12
Q

What are the possible causes of recurrent UTIs?

A
  1. Failure of treatment — wrong drugs, poor compliance etc.
  2. Re-infection: different causative organisms
  3. Relapsing infection: same causative organisms
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13
Q

What is the cause of a re-infection in UTI?

A

Failure in the defence mechanism

  1. Hygiene
  2. Voiding dysfunction:
    >> Large residual volume
    >> Bladder Outflow Obstruction (BOO)
  3. Diabetes
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14
Q

How do we manage re-infections of UTI?

A
  1. Post-coital prophylactics
  2. Long-term suppressive antibiotics
    >> Septrim
    >> Nitrofurantoin
    >> Duration: 6-12 months
    >> Stop after 6-12 months if there are no breakthrough infections
  3. Self-treatment
    >> In women with infrequent re-infections
    >> Especially frequent travellers
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15
Q

How should we approach a patient with irritative urinary symptoms (e.g. frequency, urgency, nocturia)?

A
  1. Any daytime symptoms?
    - No = pure nocturia
    - Yes >>>>>>>>>>>
  2. High urine output?
    - No = true frequency
    >> Detrusor hypersensitivity: neurological VS. local irritation
    >> Capacity problem: mechanical VS. functional
    - Yes >>>>>>>>>>>
  3. Increased intake or increased output only?
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16
Q

What is the definition of nocturnal polyuria?

A

Overproduction of urine at night with a normal 24-hour urine output

For older adults >65 years = nocturnal urine volume greater than 33% of the 24-hour urine volume

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17
Q

What are the possible causes of nocturnal polyuria?

A
  1. Age-related changes in the secretion and action of ADH
    >> Usually ADH plasma levels are higher at night
  2. Solute diuresis changes (urea, Na, K)
  3. Heart failure and other edematous states
    >> Causes third-spacing of fluids
    >> Supine position at night permists mobilization of fluid into the vascular space –> solute diuresis
  4. Autonomic dysfunction
    >> Reduced sympathetic activity
    >> Parkinson’s disease
  5. Sleep disorders
    >> 50% of patients with obstructive sleep apnea
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18
Q

What are the causes of nocturia?

A
  1. Small volume bladder voids
    >> BPH or other causes of BOO
    >> Urinary tract infection
    >> Low bladder capacity (cystometry <150mL)
  2. Increased urine output at night (noctural polyuria)
    >> Age-related
    >> Heart failure/edematous states
    >> Poorly-controlled DM
    >> Diuretic substances ingestion
    >> Excessive fluid intake before bed
  3. Sleep-related disorders
    >> OSA
    >> Restless leg syndrome
  4. Hypertension (supine >140/90mmHg)
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19
Q

What are the common reversible causes of urinary incontinence?

A

DIAPERS

  1. Delirium
  2. Inflammation/Infection
  3. Atrophic vaginitis/urethritis
  4. Pharmaceuticals/Psychological
  5. Excess U/O
  6. Restricted mobility/Retention
  7. Stool impaction
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20
Q

What are the causes of urinary continence?

A

1. Urge Incontinence
>> Detrusor overactivity
- CNS lesion
- Urinary tract inflammation/irritation
~ Infection
~ Tumour
~ Stone
- Bladder neck obstruction
~ Tumour
~ Stone
>> Decreased bladder compliance
- CNS lesion
- Fibrosis
- Sphincteric problem
- Urethral problem

2. Stress Incontinence
>> Urethral hypermobility
- Childbirth
- Pelvic OT
- CaP treatment/radiation
- Aging
>> Intrinsic sphincter deficiency
- Pelvic OT
- Neurological problems
- Aging
- Hypoestrogen

3. Mixed Incontinence

4. Overflow Incontinence

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21
Q

What are the treatment options for urge incontinence?

A
  1. Conservative treatment
    - Lifestyle changes
    - Bladder habit training
  2. Medical treatment
    - Anticholinergics: oxybutynin, tolterodine
    - B3-adrenergic agonists: mirabegron
  3. Botulinum toxin
  4. Neuromodulation
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22
Q

What are the treatment options for stress incontinence?

A
  1. Weight loss
  2. Kegel exercises
  3. Bulking agents
  4. Surgery
    >> Slings
    >> Tension-free vaginal tape
    >> Transobturator tape
    >> Artificial sphincters
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23
Q

What are the potential causes of urethral strictures?

A
  1. Congenital
  2. Trauma
    - Instrumentation/catheterization
    - External trauma
    - Foreign body
  3. Infection
    - Urinary tract infection from long-dwelling catheters
    - STI
  4. Inflammation
    - Balanitis Xerotica Obliterans (BXO)
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24
Q

What are the things to look for in a filling CMG?

A
  1. Bladder capacity
  2. Bladder compliance
  3. Bladder sensation
  4. Detrusor activity
25
Q

What causes neurologic voiding dysfunction?

A
  1. Neurogenic detrusor overactivity
  2. Detrusor atony
  3. Detrusor sphincter dyssnergia (DSD)
  4. Peripheral autonomic neuropathy
  5. Muscular lesions
26
Q

What is autonomic dysreflexia?

A

Exaggerated sympathetic response to visceral stimulation below the lesion

For those with spinal cord lesions above T6/7

27
Q

How does autonomic dysreflexia present?

A

Vasocontriction below the lesion and vasodilation above the lesion

Usually after instrumentation or distension of bladder, urethra, or rectum

  1. Hypertension
  2. Sweating
  3. Piloerection
  4. ## Anxiety5 Headache
  5. Reflex bradycardia
28
Q

How do we manage autonomic dysreflexia?

A
  1. Remove noxious stimuli
  2. Parenteral ganglionic/alpha-blockers
  3. Prophylactic nifedipine against cystoscopy
29
Q

What disorders are associated with interstital cystitis/painful bladder syndrome?

A
  1. IBS
  2. Severe allergies
  3. Fibromyalgia
30
Q

How do we classify interstitial cystitis?

A
  1. Non-ulcerative
  2. Ulcerative (hunner’s ulcers)
31
Q

How do we treat interstitial cystitis?

A
  1. Conservative treatment
    - Patient empowerment
    - Pain management
  2. Medical therapy
    - Oral: pentosan polysulfate sodium, amitriptyline, cimetidine, hydroxyzine
    - Intravesical: DMSO, heparin, lidocaine
    - Others: cyclosporine A, intradetrusor botox
  3. Surgery
    - Augmentation cystoplasty
    - Urinary diversion +/- cystectomy
32
Q

What is the definition of a complicated UTI?

A
  1. Pyelonephritis
  2. Catheter-induced
  3. Iatrogenic complications
  4. Pregnancy
  5. Immunocompromised
  6. Structural and/or functional abnormality
33
Q

What are the common risk factors for UTIs?

A
  1. Stasis and obstruction
    >> Redisual urine due to impaired urine flow
    >> Mechanical obstruction: PUV, BPH, urethral stricture, cystocele
    >> Functional obstruction: reflux, medications, neurogenic bladder
  2. Foreign body
    >> Catheters
    >> Instrumentation: cystoscopy
  3. Decreased resistance to organisms
    >> DM
    >> Malignancy
    >> Spermicide use
    >> Estrogen depletion
    >> Antimicrobials
  4. Trauma
  5. Anatomical abnormalities
  6. Female gender
  7. Sexual activity
  8. Fecal incontinence
34
Q

What are the differential diagnoses for interstitial cystitis?

A
  1. Bladder Tumour
  2. Toxins/Inflammation
    - Radiation cystitis
    - Chemical cystitis (cyclophosphamide, ketamine)
    - Eosinophilic cystitis
  3. Infection
    - UTI/Cystitis
    - TB cystitis
    - Vaginitis
  4. Stones: bladder calculi
35
Q

What are the clinical features of interstital cystitis?

A
  • *History**
    1. Pain associated with the bladder
    2. Urinary urgency
  • *Investigations**
    1. Negative urinalysis, C/S and cytology
    2. Cystoscopy
  • Submucosal petechiae/granulations
  • Hunner’s ulcers (see forepage)
36
Q

What are the common underlying causes/risk factors for pyelonephritis?

A
  1. Trauma
    - Catheters
    - Instrumentation
  2. Inflammation/Infection/Immunological
    - Immunocompromised
    - Diabetes mellitus (DM)
    - Pregnancy
  3. Cysts: PCKD
  4. Calculi
  5. Surgery: post-renal transplant
  6. Sickle cell disease
  7. Other causes of stasis and obstruction
    - Mechanical: strictures, prostatic obstruction
    - Functional: reflux, neurogenic bladder
37
Q

What are the three categories of prostatitis?

A
  1. Category I: Acute Bacterial Prostatitis
    - Ascending urethral infection with KEEPS
    - Acute onset fever, chills, malaise, pain and LUTS
  2. Category II: Chronic Bacterial Prostatitis
    - Recurrent exacerbations of acute prostatitis-like signs and symptoms
    - Recurrent UTI with the same organism
    - Pelvic pain, storage LUTS, ejaculatory pain, post-ejaculatory pain
  3. Category III: Abaceterial Chronic Pelvic Pain Syndrome (CPPD)
    - IIIA: inflammatory
    - IIIB: non-inflammatory
    - Multifactorial: interprostatic urine reflex +/- urethral hypotonia
    - Pelvic pain, storage LUTS, ejaculatory pain, post-ejaculatory pain
38
Q

What is the 4-glass test?

A

To diagnosis chronic bacterial prostatitis

VB1: voided bladder – initial at urethra
VB2: midstream – bladder
EPS: expressed prostatic secretions
VB3: post-massage/DRE

Prostatic source is suggested when colony counts in EPS and VB3 exceed those of VB1 and VB2 by 10 times

39
Q

How do we treat acute bacterial prostatitis?

A
  1. Supportive measures
  2. IV/PO antibiotics depending on how sick the patient is:
    - TMP-SMX 2-4 weeks
    - Ciprofloxacin 4 weeks
  3. Consider catheterization in patients with severe obstructive LUTS or retention
40
Q

How do we treat abacterial chronic pelvic pain syndrome (CPPD)?

A
  1. Supportive measures
  2. Trial of antibiotics if newly diagnosed
  3. Multi-modal strategy
    - Alpha-blockers
    - Anti-inflammatories
    - Phytotherapy: quercetin, cemilton
41
Q

What are the causative organisms for epididymitis/orchitis?

A
  1. Neisseria gonorrhea
  2. Chlamydia trachomatis
  3. GI Organisms (e.g. E. coli)
  4. TB
  5. Mumps: orchitis, parotiditis
  6. Syphilis
  1. Autoimmune granulomatous disease in elderly men
  2. Amiodarone: involves only the head of epididymis
42
Q

How do we treat epididymitis/orchitis?

A
  1. RULE OUT TORSION –> Colour flow Doppler/OT if in doubt
  2. Antibiotics
    - <35 years: IM ceftriaxone and PO doxycyline
    - >35 years: PO ofloxacin
  3. Scrotal support
  4. Ice and analgesia
  5. Bed rest
43
Q

What are some complications of epididymitis/orchitis?

A
  • Testicular atrophy
  • Persistent infertility
44
Q

What are the risk factors for stone disease?

A
  • *Hereditary**
  • Renal tubular acidosis
  • G6PD deficiency
  • Cystinuria
  • Xanthinuria
  • Oxaluria
  • *Lifestyle**
  • Minimal fluid intake
  • Excessive vitamin C
  • Purines
  • Calcium/oxalate
  • *Medications**
  • Loop diuretics
  • Acetazolamide
  • Topiramate
  • Zonisamide
  • *Medical conditions**
  • UTI
  • Gout
  • Obesity
  • IBD
  • Myeloproliferative disorders
  • Hypercalcemia disorders – tumour lysis syndrome, hyperPTH
45
Q

What medications predispose to urinary tract stone formation?

A
  • Loop diuretics
  • Acetazolamide
  • Topiramate
  • Zonisamide
46
Q

If a patient suspicious of stone disease develops/presents with fever, it is important to rule out concurrent pyelonephritis and/or obstruction.

A
47
Q

Ureteric stones <5mm in diameter usually pass spontaneously in 75% of patients.

A
48
Q

Which stones are radioopaque and which stones are radiolucent on KUB?

A
  • *Radioopaque**
  • Calcium
  • Struvite
  • Cystine (vaguely)
  • *Radiolucent**
  • Uric acid
  • Indinavir
49
Q

If a patient with stone disease is septic, URGENT DECOMPRESSION via ureteric stent or percutaneous nephrostomy is indicated.

Definitive treatment of th esotne should be delayed until the sepsis has cleared.

A
50
Q

What are the three things to watch out for in a patient with stone that indicate invasive treatment in the acute setting/the need for hospitalization?

A
  1. Symptoms/Severe pain
  2. Fever/Sepsis
  3. Renal function: Cr and K
51
Q

How should a patient with stone disease be managed acutely?

A
  • Analgesics
  • Antiemetics
  • NSAIDs: lower intra-ureteral pressure
  • IVF if vomiting
  • +/- Antibiotics for bacteriuria
  • Medical expulsion therapy
    >> Alpha-blockers
    >> Calcium channel blockers
  • Interventional: if obstruction endangers patient: sepsis/renal failure
    >> Ureteric stent via cystoscopy
    >> Percutaneous nephrostomy (image-guided)
52
Q

What are the indications for admission in a patient with stone disease?

A
  1. Intractable pain
  2. Intractable vomiting
  3. Fever
  4. Compromised renal function
    >> High Cr and K
    >> Solitary kidney
    >> Bilateral obstructing stones
  5. Pregnancy
53
Q

How should patients with stone disease be managed chronically?

A

Conservative
- Prerequisites
>> Ureteric stone <10mm
>> Renal stone <5mm
>> No complications or symptoms well-controlled
- Increase urine volume to >2L/day (3-4L/day if cystine stones)
- Alkalinization of urine for cystine and uric acid stones
- Periodic imaging to monitor stone position and assess for hydronephrosis
- Progress to intervention if symptoms worsen

Interventional
- Kidney stones
>> ESWL if <2cm
>> PCNL if >2cm
- Ureteric stones
>> Either ESWL or URS
>> URS has better stone-free rates but also higher complication rates
>> Second-line: PCNL
>> Third-line: laparascopic/open stone removal
- Bladder
>> Transurethral stone removal
>> Cystolitholapaxy (lithotripsy by cystoscopy)
>> Remove outflow obstruction with TURP/stricture dilation

Preventional
- Dietary modification
>> Increase K and fluid intake
>> Reduce purines, Na, oxalate, sucrose and fructose intake
>> Avoid high-dose vitamin C supplements
- Medications
>> Thiazides: hypercalciuria
>> Allopurinol: hyperuricosuria
>> Potassium citrate: hyperuricosuria, hypocitraturia

54
Q

What are the indications of PCNL in stone disease?

A
  1. Size >2cm
  2. Cystine stones
  3. Staghorn calculi
  4. UPJ obstruction
  5. Calyceal diverticulum
  6. Anatomical abnormalities
  7. Failure of less invasive modalities
55
Q

Cystine stones are the hardest among all types of stones.

They are least responsive to ESWL.

A
56
Q

What are the four narrowest passage points for upper tract stones?

A
  1. UPJ (ureteropelvic junction)
  2. Pelvic brim
  3. Under vas deferens/broad ligament
  4. UVJ (ureterovesicular junction)
57
Q

Do not mistake phleboliths for stones in KUB!

A
58
Q

Although hypercalciuria is a risk factor stone formation, decreasing dietary calcium is NOT recommended to prevent stone formation.

Why?

A

Low dietary calcium leads to increased GI oxalate absorption and higher urine levels of calcium oxalate.

Year 5 - Surgery (5 decks)

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