Urology Flashcards
1
Q
What are the indications for treatment of BPH?
A
- Symptomatic
- IPSS moderate (8-19) or severe (20 or more) - Complications
- Prostate: bleeding
- Bladder: infection, stones, retention, diverticulum
- Upper tract: hydronephrosis, obstructive uropathy, renal failure
2
Q
What are the choices for treatment of BPH?
A
- Conservative
- Watchful waiting
- Lifestyle modifications - Medications
- Alpha blockers
- 5a-reductase inhibitors - Minimally invasive therapy
- RF (radiofrequency/TUNA)
- HIFU (high-intensity focused ultrasound)
- TUMT (transurethral microwave therapy)
- Long-term catheterization: foley VS. suprapubic
- Prostatic stenting - Surgical therapy
- Tissue ablation
>> PVP (laser photo-vaporization of the prostate)
>> HoLRP (holmium laser resection of the prostate)
- TURP: monopolar VS. bipolar
- Open prostatectomy
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)
4
Q
What are the mechanisms of action of alpha-blockers and 5a-reductase inhibitors in BPH treatment?
A
- Alpha-blockers: relaxes the smooth muscle of the prostate to allow for better passage of urine (BPH is dynamic obstruction!)
- 5a-reductase inhibitors: blocks synthesis of DHT from testosterone –> decreases the size of the prostate
5
Q
When will the clinical effect of 5a-reductase inhibitors kick in?
A
3-12 weeks
6
Q
In what condition will 5a-reductase inhibitors be especially helpful?
A
Glands >40mL
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!
8
Q
What irrigation fluid is usually used in TURP?
A
1.5% glycine + post-operative NS irrigation
9
Q
Which type of catheter is used in TURP?
A
3-way urethral catheter
10
Q
What are the complications of TURP?
A
- General
- 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
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
12
Q
What are the possible causes of recurrent UTIs?
A
- Failure of treatment — wrong drugs, poor compliance etc.
- Re-infection: different causative organisms
- Relapsing infection: same causative organisms
13
Q
What is the cause of a re-infection in UTI?
A
Failure in the defence mechanism
- Hygiene
- Voiding dysfunction:
>> Large residual volume
>> Bladder Outflow Obstruction (BOO) - Diabetes
14
Q
How do we manage re-infections of UTI?
A
- Post-coital prophylactics
- Long-term suppressive antibiotics
>> Septrim
>> Nitrofurantoin
>> Duration: 6-12 months
>> Stop after 6-12 months if there are no breakthrough infections - Self-treatment
>> In women with infrequent re-infections
>> Especially frequent travellers
15
Q
How should we approach a patient with irritative urinary symptoms (e.g. frequency, urgency, nocturia)?
A
- Any daytime symptoms?
- No = pure nocturia
- Yes >>>>>>>>>>> - High urine output?
- No = true frequency
>> Detrusor hypersensitivity: neurological VS. local irritation
>> Capacity problem: mechanical VS. functional
- Yes >>>>>>>>>>> - Increased intake or increased output only?
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
17
Q
What are the possible causes of nocturnal polyuria?
A
- Age-related changes in the secretion and action of ADH
>> Usually ADH plasma levels are higher at night - Solute diuresis changes (urea, Na, K)
- 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 - Autonomic dysfunction
>> Reduced sympathetic activity
>> Parkinson’s disease - Sleep disorders
>> 50% of patients with obstructive sleep apnea
18
Q
What are the causes of nocturia?
A
- Small volume bladder voids
>> BPH or other causes of BOO
>> Urinary tract infection
>> Low bladder capacity (cystometry <150mL) - Increased urine output at night (noctural polyuria)
>> Age-related
>> Heart failure/edematous states
>> Poorly-controlled DM
>> Diuretic substances ingestion
>> Excessive fluid intake before bed - Sleep-related disorders
>> OSA
>> Restless leg syndrome - Hypertension (supine >140/90mmHg)
19
Q
What are the common reversible causes of urinary incontinence?
A
DIAPERS
- Delirium
- Inflammation/Infection
- Atrophic vaginitis/urethritis
- Pharmaceuticals/Psychological
- Excess U/O
- Restricted mobility/Retention
- Stool impaction
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
21
Q
What are the treatment options for urge incontinence?
A
- Conservative treatment
- Lifestyle changes
- Bladder habit training - Medical treatment
- Anticholinergics: oxybutynin, tolterodine
- B3-adrenergic agonists: mirabegron - Botulinum toxin
- Neuromodulation
22
Q
What are the treatment options for stress incontinence?
A
- Weight loss
- Kegel exercises
- Bulking agents
- Surgery
>> Slings
>> Tension-free vaginal tape
>> Transobturator tape
>> Artificial sphincters
23
Q
What are the potential causes of urethral strictures?
A
- Congenital
- Trauma
- Instrumentation/catheterization
- External trauma
- Foreign body - Infection
- Urinary tract infection from long-dwelling catheters
- STI - Inflammation
- Balanitis Xerotica Obliterans (BXO)
24
Q
What are the things to look for in a filling CMG?
A
- Bladder capacity
- Bladder compliance
- Bladder sensation
- Detrusor activity
25
What causes neurologic voiding dysfunction?
1. Neurogenic detrusor overactivity
2. Detrusor atony
3. Detrusor sphincter dyssnergia (DSD)
4. Peripheral autonomic neuropathy
5. Muscular lesions
26
What is autonomic dysreflexia?
Exaggerated sympathetic response to visceral stimulation below the lesion
For those with spinal cord lesions above T6/7
27
How does autonomic dysreflexia present?
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. Anxiety
-------------------------
5 Headache
6. Reflex bradycardia
28
How do we manage autonomic dysreflexia?
1. Remove noxious stimuli
2. Parenteral ganglionic/alpha-blockers
3. Prophylactic nifedipine against cystoscopy
29
What disorders are associated with interstital cystitis/painful bladder syndrome?
1. IBS
2. Severe allergies
3. Fibromyalgia
30
How do we classify interstitial cystitis?
1. Non-ulcerative
2. Ulcerative (hunner's ulcers)
31
How do we treat interstitial cystitis?
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
What is the definition of a complicated UTI?
1. Pyelonephritis
2. Catheter-induced
3. Iatrogenic complications
4. Pregnancy
5. Immunocompromised
6. Structural and/or functional abnormality
33
What are the common risk factors for UTIs?
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
What are the differential diagnoses for interstitial cystitis?
1. Bladder **T**umour
2. **T**oxins/**I**nflammation
- Radiation cystitis
- Chemical cystitis (cyclophosphamide, ketamine)
- Eosinophilic cystitis
3. **I**nfection
- UTI/Cystitis
- TB cystitis
- Vaginitis
4. **S**tones: bladder calculi
35
What are the clinical features of interstital cystitis?
* *_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
What are the common underlying causes/risk factors for pyelonephritis?
1. **T**rauma
- Catheters
- Instrumentation
2. **I**nflammation/**I**nfection/**I**mmunological
- Immunocompromised
- Diabetes mellitus (DM)
- Pregnancy
3. **C**ysts: PCKD
4. **C**alculi
5. **S**urgery: post-renal transplant
6. **S**ickle cell disease
7. Other causes of stasis and obstruction
- Mechanical: strictures, prostatic obstruction
- Functional: reflux, neurogenic bladder
37
What are the three categories of prostatitis?
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
What is the 4-glass test?
To diagnosis chronic bacterial prostatitis
## Footnote
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
How do we treat acute bacterial prostatitis?
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
How do we treat abacterial chronic pelvic pain syndrome (CPPD)?
1. Supportive measures
2. Trial of antibiotics if newly diagnosed
3. Multi-modal strategy
- Alpha-blockers
- Anti-inflammatories
- Phytotherapy: quercetin, cemilton
41
What are the causative organisms for epididymitis/orchitis?
1. Neisseria gonorrhea
2. Chlamydia trachomatis
3. GI Organisms (e.g. E. coli)
4. TB
5. Mumps: orchitis, parotiditis
6. Syphilis
------------------------------------------------------------------
7. Autoimmune granulomatous disease in elderly men
8. Amiodarone: involves only the *_head of epididymis_*
42
How do we treat epididymitis/orchitis?
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
What are some complications of epididymitis/orchitis?
- Testicular atrophy
- Persistent infertility
44
What are the risk factors for stone disease?
* *_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
What medications predispose to urinary tract stone formation?
- Loop diuretics
- Acetazolamide
- Topiramate
- Zonisamide
46
If a patient suspicious of stone disease develops/presents with fever, it is important to rule out **concurrent pyelonephritis and/or obstruction.**
47
Ureteric stones **_\<5mm_** in diameter usually pass spontaneously in 75% of patients.
48
Which stones are radioopaque and which stones are radiolucent on KUB?
* *_Radioopaque_**
- Calcium
- Struvite
- Cystine (vaguely)
* *_Radiolucent_**
- Uric acid
- Indinavir
49
**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.
50
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?
1. Symptoms/Severe pain
2. Fever/Sepsis
3. Renal function: Cr and K
51
How should a patient with stone disease be managed acutely?
- 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
What are the indications for admission in a patient with stone disease?
1. Intractable pain
2. Intractable vomiting
3. Fever
4. Compromised renal function
\>\> High Cr and K
\>\> Solitary kidney
\>\> Bilateral obstructing stones
5. Pregnancy
53
How should patients with stone disease be managed chronically?
**_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
What are the indications of PCNL in stone disease?
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
Cystine stones are the hardest among all types of stones.
They are least responsive to ESWL.
56
What are the four narrowest passage points for upper tract stones?
1. UPJ (ureteropelvic junction)
2. Pelvic brim
3. Under vas deferens/broad ligament
4. UVJ (ureterovesicular junction)
57
Do not mistake phleboliths for stones in KUB!
58
Although hypercalciuria is a risk factor stone formation, **decreasing dietary calcium is NOT recommended to prevent stone formation.**
Why?
Low dietary calcium leads to increased GI oxalate absorption and higher urine levels of calcium oxalate.
