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clin med > urology > Flashcards

urology Flashcards

1
Q

what is varicocele?

A

dilation of testicular vein and pampiniform plexus

  • predominantly occurs on Left side
  • typically asymptomatic (sometimes dull ache)
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2
Q

PE findings for varicocele?

A

“bag of worms” - often found on ultrasound

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3
Q

is varicocele associated with male-factor infertility?

A

yes but not all men with varicoceles are infertile (impaired spermatogenesis from elevated temperatures)

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4
Q

varicocele grades

A

subliclinical (only detected by US, veins > 3 mm)

grade I - small, palpable with valsalva only

grade II- easily palpable at rest without valsalva

grade III- grosly palpable

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5
Q

how is varicocele treated?

A

subclinical is not treated

treated with syptoms or with infertility or impaired testicular growth. surgical-inbuinal, subinguinal microscopic, laparoscopic varicocelectomy

*abnormal semen analysis/infertility can be reversed with varicocelectomy

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6
Q

collections of fluid in the epididymis (epididymal cysts). PE is smooth, painless, transilluminate

A

spermatocele - tx rarely needed

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7
Q

twisting of the testis around the cord causing ischemia

A

testicular torsion

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8
Q

what is a risk of testicular torsion?

A

bell-clapper deformity - congenital malformation where tunical vaginalis attaches high/improperly on cord **surgical emergency

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9
Q

what is the presentation of testicular torsion?

A

sudden/acute testicular/scrotal pain, swelling

PE: **absent cremasteric reflex, anormal testicular lie

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10
Q

treatment of testicular torsion

A

surgery - manual detorsion “open the book” - physician stands at patient’s feet and manually rotates affected testicle away from midline

ischemia/pain 24 hours - 10% salvage

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11
Q

inflammation of the epididymis/testicle, very common in age 20-35

A

epididymitis/orchitis - can be bacterial (mostly), viral, fungal, idiopathic

Sexually active males 35 yrs think E. Coli

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12
Q

presentation of epididymitis/orchitis

A

pain and swelling over several days, also fever, scrotal erythema, testicular pain, dysuria. can mimic testicular torsion

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13
Q

risk factors for epididymitis/orchitis

A

sexual activity, bladder outlet obstruction, urologic surgery

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14
Q

tx for epididymitis/orchitis

A

males 35 yrs old:
Levofloxacin 500 mg PO daily for 10 days OR Ofloxacin 300 mg PO BID for 10 days

Also, analgesics, scrotal elevation, ice PRN

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15
Q

fluid collection between layers of tunic vaginalis

A

hydrocele

Communicating: Patent processus vaginalis allows fluid to pass from peritoneum to scrotum

Non-Communicating: No connection

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16
Q

difference between communicating and non-communicating hydrocele

A

Non-communicating:
Lymphatic or venous obstruction from trauma or infection
Develop slowly
Most common hydrocele in adults

Communicating:
Present at birth or first year of life
Most will resolve by age 2

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17
Q

how do you diagnose hydrocele?

A

scrotal mass that transilluminates. treat with surgical excision and observation

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18
Q

risk factors for ED

A 
shared with CV disease: 
Smoking
Obesity
Hypercholesterolemia
Metabolic Syndrome
Physical inactivity

ED is a risk factor for CV disease**

prostate cancer treatments

hypogonadism (low testosterone)

Peyronie’s Disease

neurologic conditions (MS, strokes)

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19
Q

prescription drugs that are a risk factor for ED

A

antihypertensives (diuretics, HCTZ, metoprolol)

antidepressants/antianxiety (sertraline, fluoxetine, lorazepam) - SSRIs are prescribed for premature ejaculation

antiandrogens, etc, (lueprolide, bicalutimide)

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20
Q

first line treatment for ED

A

PDE5I

Inhibit PDE5 –> smooth muscle relaxation –> incr blood flow –>veno-occlusive mechanism

-Tadalafil (cialis) has longest half life and also helps BPH

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21
Q

lower urinary tract symptomes (LUTS) of BPH

A 
frequency
nocturia
hesitancy, weak/slow stream
post-void dribbling
incomplete bladder emptying

Static component- direct bladder outlet obstruction from enlarged tissue
Dynamic phase- increased smooth muscle tone and resistance within the enlarged gland

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22
Q

digital rectal exam (DRE) for BPH

A

typically smooth enlargement, rubbery (Pca can be firm, hard, irregular)

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23
Q

Treatment of BPH

A

Surveillance (if mild symptoms, if symptoms are moderate/severe but patient has little or no bother, no complications) - monitor annually

Medical therapy- alpha blockers, alpha reductase inhibitors (decrease PSA by 50%)**have been shown to decrease risk of prostate cancer, combo therapies, phosphodiesterase inhibitors(cialis, MOA not well known)

Minimally invasive therapies

  1. transurethral needle ablation of prostate- TUNA and transurethral microwave thermotherapy-TUMT
    - done outpatient without general anesthesia
  2. Urolift system - trans-prostatic urethral implant that lifts and compresses prostate tissue

Surgical therapies

  • transurethral resection of prostate
  • laser vaporization of prostate ( *gold standard)/photoselective vaporization of prostate –>shorter hospital stay, no risk of TUR syndrome, decreased bleeding
  • simple prostatectomy - more “invasive”, typically done in patients with larger prostates (>100-120 cc) or with large bladder stones
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24
Q

most common urologic diagnosis in males

A

prostatitis - inflammation or infection of prostate that presents as several syndromes with varying clinical features

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25
Q

acute bacterial prostatitis and chronic bacterial prostatitis pathogens

A

80% E coli
10-15% psuedomonas, klebsiella, proteus
5-10% enterococcus

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26
Q

category I - acute bacterial prostatitis presentation and treatment

A

presents with dysuria, frequency, perineal pain, back pain, fever/chills

DRE- enlarged, boggy, tender prostate

labs: elevated WBC, UA - pyuria, bacteria
tx: antibiotics (IV cipro for in patient,, PO levofloxacin for outpatient), antipyretics, IVF, suprapubic catheter drainage

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27
Q

category II - chronic bacterial prostatitis presentation and treatment

A

Presentation-acute episodes of dysuria, perineal pain, frequency with culture-documented UTI (same organism each time)

asymptomatic in between

  • can be ruled out if no culture-documented UTI present
    tx: TMP-SMX and fluoroquinolones (penetrate prostate) x 4-6 weks
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28
Q

Category III: Chronic prostatitis and chronic pelvic pain syndrome (CPPS) presentation and tx

A

Chronic/recurring episodes perineal, pelvic, testicular, penile pain, sometimes assoc with voiding dysfunction in absence of infection

Causes-a primary event leading to immunologic stimulation followed by inflammatory response with persistent stimulation and neuropathic damage
No infectious pathogens

Treatments-??
Empiric ABX, sitz baths, NSAIDs, alpha blockers, etc
Poorly understood and challenging synrome=Many frustrated patients

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29
Q

Category IV

Asymptomatic Inflammatory Prostatitis presentation and tx

A

Can be found incidentally on prostate biopsy

No treatment indicated

30
Q

risk factors for prostate cancer

A

increasing age (more than 80% are diagnosed in men older than 65 years of age)

family history (first degree relatives - two to three X greater risk)

race (AA 1.6 more likely to get and also higher mortality)

dietary factors (high animal fat)

exposures (agent orange)

31
Q

T or F: prior vasectomy and benign prostatic hypertrophy (BPH) increase risk of prostate cancer

A

false

32
Q

prostate cancer development

A

develops in epithelium (possibly from basal cell later)

requires androgens (testosterone)

increased cell proliferation and decreased apoptosis

33
Q

more than 95% or primary prostate cancers are what?

A

adenocarcinomas

34
Q

who should be screened for prostate cancer?

A
  • *do not screen younger than 40
  • individualized screening fro men between 40-54 years
  • men 55-69 shared decision making
35
Q

clinical manifestations of prostate cancer

A

can be asymptomatic and picked up by PSA >4

obstructive voiding symptoms (hesitancy, intermittent urinary stream, decreased force of stream) - typically indistinguishable from BPH

***hematuria and hematospermia

edema of lower extremities or discomfort in pelvic and perineal areas

36
Q

most common mets for prostate cancer

A

bone - can result in pathologic fractures of the long bones or spinal cord compression

37
Q

what should prompt a biopsy for Prostate cancer?

A

a palpable nodule on digital rectal exam

38
Q

what is the PSA threshold for prostate cancer?

A

4 ng/mL- 70-80% or tumors are detected

**age adjusted values 
40-49: 0-2.5
50-59: 0-3.5
60-69: 0-4.5
70-79: 0-6.5
39
Q

what is a genomic prostate score (GPS)?

A

assesses prostate biopsy tissue, assigns a score based on 17 genes to predict the likelihood of high grade or advanced stage disease (T3)

40
Q

prostate biopsy

A

only a snap shot. advanced imaging with 3T MIR dedicated to the prostate can help determine extent of disease. can also help to guide treatment choice

41
Q

where does prostate cancer develop?

A

in the peripheral zone of the prostate (so biopsies directed towards here)

42
Q

what is a gleason score?

A

sum of the two most common histologic patterns seen on each tissue specimen - very predictive of metastases and outcome

43
Q

prostate cancer treatments

A
  • watchful waiting
  • active surveillance
  • hormone therapy - androgen deprivation with lutenizing hormone releasing hormone
  • surgery (robotic is most preferred)
  • radiation
  • cryotherapy
44
Q

what is PCA 3?

A

simple urine test. for men with life expectancy of greater than or equal to 10 years and 1 or more negative biopsies, and PSA of 3 or more

45
Q

most common subtypes of renal cell carcinoma

A

clear cell (75-85%)-proximal tubule origin, abnormalities in chromosome 3p

paillary (15%) - 85% of these are dx as stage I tumors, also proximal tubule in origin

46
Q

epidemiology of renal cell carcinoma

A

male predominance, highest incidence between age 60-80

47
Q

classic triad and presentation of renal cell carcinoma presentaiton

A

flank pain, hematuria, palpable abdominal mass

hematuria present in 40% of patients- often with clots (non-glomerular)

48
Q

how do you diagnose renal cell carcinoma?

A

ultrasound : solid vs. cystic lesions

contrast CT: test of choice to evaluate tumor size, location, lymph node involvement

49
Q

75-86% of RCC is what type?

A

clear cell

50
Q

differences in RCC staging

A

TNM staging system

Stage I-III: localized disease
I: tumor 7 cm- 5 yr survival 88%
III: tumor in major veins or adrenal gland, tumor within gerota’s fascia, or 1 regional lymph node involvement yr survival 59%

Stage IV: advanced, metastatic disease

51
Q

poor prognostic indications for RCC

A

poor performance status, anemia, hypercalcemia, and elevated LDH

52
Q

localized RCC treatment

A

radical nephrectomy is gold standard (open or laparoscopic depending on size and experience) - no role for adjuvant therapy except under investigational protocol

cytoreductive nephrectomy in patients with good performance status

53
Q

advanced RCC treatment

A

primary treatments are systemic therapy with molecularly targeted therapy or immunotherapy

54
Q

what are immunotherapy treatments for advanced RC?

A

IL-2, sorafenib, sunitinib, and temsirolimus

55
Q

does chemo work with RCC?

A

only minimally responsive (overall response 6%)

56
Q

epidemiology of bladder CA

A

older persons (median age is 65)

3 times more common in men (women have worse prognosis)

more prevelant in white persons

57
Q

best known behavioral risk factor for bladder cancer

A

cigarette smoking

58
Q

parasitic infection that is a risk factor for bladder cancer

A

schistosoma haematobium (schistosomiasis) - not common in US but is endemic in africa and middle east

59
Q

most common and classic presentation of bladder cancer

A

Frank hematuria. **painless gross hematuria (consider all patients with gross hematuria to have bladder cancer until proven otherwise)

60
Q

noninvasive test for the diagnosis of bladder cancer

A

voided urine cytology - used to identify high-grade tumors and monitor patients for persistent or recurrent disease following treatment

61
Q

mainstay for diagnosis and surveillance of bladder cancer

A

cystoscopy - provides info about tumor size, location, appearance, and size (direct visualization of the bladder)

62
Q

if a lesion is detected on cystoscopy, what is the next step for bladder cancer?

A

transurethral resection of bladder tumor - under general anesthesia

*if a patient has a positive voided cytology, move straight to the TUR

63
Q

all patients with bladder cancer need what?

A

to evaluate the upper urinary tract -renal ultrasonography, CT with and without IV contrast (urography), MRI

64
Q

treatment for bladder cancer

A

non-muscle invasive tumors: transurethral resection, followed by close observation or intravesical chemotherapy or immunotherapy
*high rate of disease recurrence and progression in non-muscle invasive bladder cancer

muscle invasive disease: radical cystectomy with pelvic lymphadenectomy

65
Q

indications for urine culture

A

pyelonephritis
children, pregnant women
patients with structural abnormalities of the urinary tract
recurrent UTI

66
Q

diagnostic criteria for UTI

A

historically 100,000 colonies/mL of single organism.. lower colony count of 1,000 colonies is accepted now

67
Q

Urine for GC/chlamydia

A

should be first voided urine, needs to be processed as quickly as possible

68
Q

what is the diagnostic procedure to visualize into the bladder?

A

cystoscopy- assess for stone, tumor, cystitis, diverticula

69
Q

indications for diagnostic imaging/evaluation

A

fever after 3 days of antibiotics

proteus in urine if ph > 8 (think struvite stones)

hematuria, suspected obstruction, diabetes, stone disease

70
Q

TMP/SMX treatment

A

Inhibits bacterial synthesis, therefore growth; useful except with P aeruginosa
Dosing: 160 mg TMP/800mg SMX po q 12 hours
UTI 3- 7 days
Uncomplicated pyelonephritis 10-14 days
May use with/without SMX

clin med (12 decks)

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