Urology Flashcards
1
Q
What are LUTS?
A
Nocturnal Frequency Urgency Post-micturition dribbling Poor stream Hesitancy Overflow incontinence Haematuria Bladder stones UTI
2
Q
What is the normal size of the prostate?
A
Size of a walnut
3.2cm diameter
3
Q
What are the differential diagnoses for LUTS?
A
Cancer - bladder or prostate UTI Stones Detrusor weakness/instability Urethral stricture Neurological pathology
4
Q
How do you manage BPH?
A
Conservative: fluid intake, urethral milking, bladder training, collecting devices/sheath
Medical
Surgical
5
Q
What are the medical options for BPH?
A
Voiding LUTS: alpha blockers, 5-ARIs
Storage LUTS: anticholinergics +/- alpha blockers
Nocturnal polyuria: latter diuretics, oral desmopressin
6
Q
How do alpha blockers work?
A
Relax smooth muscle within prostate and bladder neck
Rapid symptom relief
No effect on prostate volume and don’t reduce overall long-term risk or need for surgery
7
Q
Give 2 examples of alpha blockers used to treat BPH
A
Tamsulosin
Doxazosin
8
Q
How do 5-ARIs work?
A
Shrink the prostate by means of androgen deprivation
Improve symptoms and reduce prostate volume
Max effect may take a few months to achieve
9
Q
Give an example of a 5-ARI
A
Finasteride
10
Q
What are the surgical options for BPH?
A
TURP
Urolift
Prostatic embolisation
11
Q
What are the causes of raised BPH?
A
BPH Prostate cancer UTI Retention Prostatitis Recent instrumentation/catheterisation
12
Q
When should PSA testing be offered?
A
If symptomatic or positive family history
And the patient has been counselled
13
Q
What is the normal range for PSA?
A
40-49: less than 2.5
50-59: less than 3
60-69: less than 4
Older than 70: less than 5
14
Q
What is the main cause of urinary incontinence in men?
A
Prostatic enlargement
15
Q
What are the different types of urinary incontinence in women?
A
Functional incontinence
Stress incontinence
Urge incontinence/overactive bladder syndrome
16
Q
What is functional incontinence?
A
Caught short or too slow in finding the toilet eg immobility or unfamiliar surroundings
17
Q
What is stress incontinence?
A
Leakage from an incompetent sphincter when intra-abdominal pressure rises eg coughing/laughing
18
Q
What are the risk factors for stress incontinence?
A
Increasing age Obesity Pregnancy Following childbirth Post-menopause
19
Q
What is urge incontinence?
A
Urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts
20
Q
How is stress incontinence managed?
A
Pelvic floor exercises: 8 contractions 3 times a day for 3 months
Ring pessary for uterine prolapse
21
Q
How do you manage urge incontinence?
A
Bladder training and weight loss
Aids eg absorbent pads
22
Q
What are the urological causes of loin pain?
A
Ureteric or renal colic
Pyelonephritis or UTI
23
Q
What are the non-urological causes of loin pain?
A
MSK
Gynae
General surgical
Vascular - dissecting iliac aneurysm
24
Q
What are the key points in a history of loin pain?
A
Speed of onset Nature of pain: colicky/sharp/severity Radiation Unilateral or bilateral Associated symptoms: systemic/LUTS
25
What are the causes of ureteric colic?
Ureteric calculi
Clot colic
PUJ obstruction
26
What is the classic history of ureteric colic?
```
Sudden onset
Severe colicky pain
Unilateral
Loin to groin
Radiation to iliac fossa/genitalia
```
27
When would you particularly worried about a patient with ureteric colic?
Temperature / rigors
Hypotensive
Worried about sepsis
28
How do you investigate suspected ureteric colic?
Urinalysis
FBC, U&E, calcium, urate
CT KUB
USS
29
What would you see on urinalysis in ureteric colic?
Non-visible haematuria
30
How do you initially manage ureteric colic?
Analgesia
Anti-emetic
Fluids if dehydrated
31
When is intervention indicated for ureteric colic?
```
Larger more proximal stones
Renal impairment
Intractable pain
Solitary kidney
Infection
Failed conservative management
```
32
What are the options for removal of a stone?
Ureteroscopy + lasertripsy
ESWL - extra-corporeal shockwave lithotripsy
JJ stent
33
Why is infection associated with a stone an emergency?
They may have pyonephrosis
| Call for senior help if they are septic
34
What is pyonephrosis?
Abscess in renal pelvis
35
How do you manage pyonephrosis?
Resus: O2, IV fluids
ABx: gentamicin + co-amox/Tazocin
Culture blood/urine
ABG
36
When should a UTI be followed by urological investigation?
Any male with proven UTI
37
How is pyonephrosis managed surgically?
Drainage:
External percutaneous nephrostomy
Internal - ureteric stent (GA)
Discharge home with drain in situ and readmit electively to have the stone treated
38
What are stones made from?
Crystal aggregates
| Mostly calcium oxalate
39
Where are stones most commonly deposited?
Pelviureteric junction (PUJ)
Pelvic brim
Vesicoureteric junction
40
How can you prevent stones forming?
Drink plenty
Normal dietary calcium
Calcium stones - thiazides
Urate stones - allopurinol
41
How does acute pyelonephritis present?
Chills, fever>38
Loin pain
May be more gradual onset, not typically colicky pain
Often systemically unwell
42
What is the most common organism in acute pyelonephritis?
E.coli
Proteus
Klebsiella
Enterobacter
43
What investigations should you do for suspected acute pyelonephritis?
Urine dip
FBC, U&E
MSU - MC&S +/- blood cultures
Renal USS to exclude pyonephrosis
44
How do you manage acute pyelonephritis?
Antibiotics
Analgesia
Antiemetic
DVT prophylaxis
45
Define urinary retention
Inability to pass urine, rather than inability to make urine
| Not emptying the bladder, due to obstruction or reduced detrusor power
46
Give some causes of urinary retention
```
Prostatic enlargement
Constipation
UTI
Excess fluid/delayed voiding
Neurological eg cauda equina
Urethral stricture/phimosis
Surgery
Drugs inc alcohol
```
47
How does acute urinary retention present?
Pain relieved by drainage
48
What are the symptoms that indicate problems with urine storage?
Frequency
Urgency
Nocturia
Urinary incontinence
49
What are the symptoms that indicate a problem with voiding?
```
Hesitancy
Intermittency
Straining
Poor flow
Spraying
Post-micturition dribbling
```
50
How do you manage urinary retention?
Catheterise urethrally if possible
| Record residual volume and document
51
What medical therapy may be given for acute retention?
Alpha blocker - tamsulosin
| 5ARI - Finasteride
52
How do you manage chronic urinary retention?
Long-term I dwelling catheter
| TURP if fit
53
What is post-obstructive diuresis?
High pressure chronic retention leads to hydronephrosis and AKI
They often produce a large amount of urine in the acute phase of relief of obstruction
54
How do you manage patients with post-obstructive diuresis?
Don't give back the residual volume
Unless they are dehydrated, they don't need IV fluids unless diuresis is prolonged and they can't have oral fluids
Keep reassessing fluid status clinically
55
What are the causes of testicular pain?
Testicular torsion
Epididymitis/orchitis
Testicular tumour
Trauma
56
How does testicular torsion present?
Often younger patient
| Sudden onset unilateral testicular pain
57
What do you find on examination in testicular torsion?
Apyrexial, may be tachycardic
Scrotum erythematous
Exquisitely tender testis
58
How do you manage testicular torsion?
Scrotal exploration in theatre as an emergency
| +/- orchidectomy
59
What are the common causes of epididymoorchitis?
STI esp chlamydia
| UTI (E.coli)
60
How does epididymoorchitis present?
Gradual onset, usually unilateral
| Recent history of UTI, unprotected intercourse
61
What do you find on examination in epididymoorchitis ?
Scrotum erythematous
Testis/epididymis enlarged and tender
Fluctuations areas - abscess
62
How do you treat epididymoorchitis?
Antibiotics
Ciprofloxacin for UTI
Doxycycline if chlamydia suspected
63
What is Fournier's gangrene?
Necrotic area of scrotal skin associated with epididymoorchitis
64
What 3 questions do you need to answer on examination of a testicular lump?
Can you get above it?
Is it separate from the testis?
Is it cystic or solid?
65
What is the likely diagnosis for a lump that is separate from the testis and cystic?
Epididymal cyst
66
How do you manage epididymal cysts?
Ultrasound
Reassurance
Conservative management
Remove surgically if symptomatic
67
What is a hydrocoele?
Fluid in the tunica vaginalis
68
What is the difference between primary and secondary hydrocoeles?
Primary due to patent processus vaginalis - younger men
| Secondary to testis tumour, infection or trauma
69
How do you manage hydrocoeles?
Aspiration or surgical repair
70
What is a varicocele?
Dilated veins of pampiniform plexus
71
How do varicoceles present?
Dull ache at end of day
| Left side more commonly affected
72
What is a haematocele?
Blood in tunica vaginalis
| Follows trauma and may need drainage
73
What are the common types of testicular tumour?
55% Seminoma
33% non-seminomatous germ cell tumour (teratoma)
12% mixed germ cell tumour
74
How does testicular cancer present?
```
Painless lump
Haematospermia
Pain
Secondary hydrocele
Dyspnoea - lung mets
Abdo mass - enlarged nodes
```
75
What are the risk factors for testicular cancer?
Undescended testis
Infant hernia
Infertility
76
What are the tumour markers for testicular cancer?
Alpha fetoprotein
| Beta hCG
77
How are testicular cancers treated?
Seminoma - early stage sensitive to radiotherapy
| NSGCT - chemotherapy
78
What is the incidence of undescended testis?
3% of boys
| 30% of premature boys
79
What are the different types of undescended testis?
Cryptorchidism
Retractile testis
Maldescended testis
Ectopic testis
80
What are the complications of maldescended and ectopic testis?
Infertility
40x increased risk of testicular cancer
Increased risk of testicular trauma and torsion
Association with hernias
81
What is the treatment for maldescended and ectopic testis?
Orchidopexy
| Hormonal with hCG
82
When is 2ww referral appropriate for haematuria?
Visible haematuria older than 45y
| Persistent NVH, no obvious cause older than 60y
83
What are the urological causes of haematuria?
```
Cancer - RCC, upper tract TCC, bladder cancer, advanced prostate cancer
Stones
Infection
Inflammation
BPH (large)
```
84
When should haematuria be referred to nephrology?
Persistent asymptomatic NVH younger than 40, with associated proteinuria, hypertension, low eGFR
85
What are the important aspects of a history of haematuria?
Pain(less)?
UTI
Anticoagulants
Smoking
86
What investigations are done at a haematuria 2ww clinic?
```
DRE
Bloods: FBC, U&E, PSA
MSU
USS renal tract
Flexible cystoscope
```
87
What are the majority of bladder cancers?
Transitional cell carcinoma
88
What are the 2 main classifications of bladder cancer?
Muscle invasive
| Non-muscle invasive
89
What is TURBT?
Transurethral resection of bladder tumour
| To gain histology
90
How is muscle invasive bladder cancer further classified?
Organ confined
| Metastatic
91
How is organ confined bladder cancer treated?
Radical cystectomy
| + urinary diversion
92
How does radical cystectomy differ in males and females?
Males - cystoprostatectomy
| Females - cystectomy + anterior exenteration
93
What are the options for urinary diversion following radical cystectomy?
Ileal conduit
Continent urinary diversion
Neobladder
94
What treatment is offered for organ confined bladder cancer, if the patient is unfit for cystectomy?
Radical radiotherapy
95
What is the treatment for metastatic bladder cancer?
Symptom control
| Chemotherapy
96
How does renal cell carcinoma present?
```
Haematuria
Loin pain
Abdo mass
Anorexia
Malaise
Weight loss
```
97
What are the treatment options for renal cell carcinoma?
Surveillance
Partial nephrectomy
Nephrectomy
Metastatic - oncology
98
How does transitional cell carcinoma of the urinary tract present?
```
Painless haematuria
Frequency
Urgency
Dysuria
Urinary tract obstruction
```
99
Where can transitional cell carcinomas be?
Bladder - 50%
Ureter
Renal pelvis
100
Describe the epidemiology of prostate cancer
Most commonly diagnosed cancer in UK males
| 2nd most common cause of cancer-related death
101
What are the risk factors for prostate cancer?
Increasing age
Family history
BRCA2 mutation
Ethnicity: black>white>Asian
102
How does prostate cancer present?
Asymptomatic
Urinary symptoms
Bone pain
103
How is prostate cancer diagnosed?
DRE + PSA + Biopsy (TRUS)
104
What is TRUS?
Transrectal ultrasound - takes 10-12 core biopsies from different parts of the prostate gland
105
What is the Gleason score?
Prostate cancer graded from 3 (least aggressive) to 5 (most aggressive)
Gleason score is the sum of the 2 most common patterns of tumour growth
So score ranges from 6(3+3) to 10(5+5)
106
What factors indicate high risk of progression of prostate cancer?
Any of...
PSA>20
Gleason 8-10
T3-4
107
What factors indicate low risk of progression of prostate cancer?
All of...
| PSA
108
What percentage of men aged 50-70 have a raised PSA? How many of these will have prostate cancer?
10% have raised PSA
| 25% of these will have prostate cancer
109
What is the threshold for PSA below which prostate cancer can be excluded?
There is no lower threshold!
110
What factors influence treatment decisions for prostate cancer?
```
Age
DRE
PSA
Biopsies - Gleason grade
MRI pelvis and bone scan
```
111
What do prostate metastases look like?
Sclerotic (osteoblastic) hot spots on bone scan
112
When are hormones used to treat prostate cancer?
Metastatic disease
| Used alongside chemotherapy if PS 0-2
113
What hormones are used to treat prostate cancer?
LHRH agonist
| First stimulate then inhibit pituitary gonadotrophin
114
What is the main risk of using LHRH agonists?
Risk of tumour flare when first used
115
How do you treat tumour flare?
Start anti-androgen in susceptible patients
116
What are the main aspects of palliation in metastatic prostate cancer?
Single dose radiotherapy
| Bisphosphonates
117
What are the options for radical treatment for prostate cancer?
Radical prostatectomy
| Radiotherapy - external beam or brachytherapy
118
What is brachytherapy?
Implantation of radioactive seeds into prostate gland
119
What is the difference between active surveillance and watchful waiting in prostate cancer?
Active - regular investigations to monitor disease progression. In younger males when progression is more likely and who would be fit for treatment
Watchful waiting - no investigations
120
What is lead-time bias?
Living longer knowing you have the disease rather than actually improving survival
121
What is length-time bias?
Picking up slower-growing (hence more easily treatable) cancers, rather than fast-growing tumours
So more likely to be treatable
122
What are the issues with PSA testing?
Not accurate
False positive means many more investigations
Only 1 in 3 with raised PSA have prostate cancer
No way to tell if cancer would actually impinge on health
May have bad effect from treatment that wasn't needed
