Urology Flashcards
What are LUTS?
Nocturnal Frequency Urgency Post-micturition dribbling Poor stream Hesitancy Overflow incontinence Haematuria Bladder stones UTI
What is the normal size of the prostate?
Size of a walnut
3.2cm diameter
What are the differential diagnoses for LUTS?
Cancer - bladder or prostate UTI Stones Detrusor weakness/instability Urethral stricture Neurological pathology
How do you manage BPH?
Conservative: fluid intake, urethral milking, bladder training, collecting devices/sheath
Medical
Surgical
What are the medical options for BPH?
Voiding LUTS: alpha blockers, 5-ARIs
Storage LUTS: anticholinergics +/- alpha blockers
Nocturnal polyuria: latter diuretics, oral desmopressin
How do alpha blockers work?
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
Give 2 examples of alpha blockers used to treat BPH
Tamsulosin
Doxazosin
How do 5-ARIs work?
Shrink the prostate by means of androgen deprivation
Improve symptoms and reduce prostate volume
Max effect may take a few months to achieve
Give an example of a 5-ARI
Finasteride
What are the surgical options for BPH?
TURP
Urolift
Prostatic embolisation
What are the causes of raised BPH?
BPH Prostate cancer UTI Retention Prostatitis Recent instrumentation/catheterisation
When should PSA testing be offered?
If symptomatic or positive family history
And the patient has been counselled
What is the normal range for PSA?
40-49: less than 2.5
50-59: less than 3
60-69: less than 4
Older than 70: less than 5
What is the main cause of urinary incontinence in men?
Prostatic enlargement
What are the different types of urinary incontinence in women?
Functional incontinence
Stress incontinence
Urge incontinence/overactive bladder syndrome
What is functional incontinence?
Caught short or too slow in finding the toilet eg immobility or unfamiliar surroundings
What is stress incontinence?
Leakage from an incompetent sphincter when intra-abdominal pressure rises eg coughing/laughing
What are the risk factors for stress incontinence?
Increasing age Obesity Pregnancy Following childbirth Post-menopause
What is urge incontinence?
Urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts
How is stress incontinence managed?
Pelvic floor exercises: 8 contractions 3 times a day for 3 months
Ring pessary for uterine prolapse
How do you manage urge incontinence?
Bladder training and weight loss
Aids eg absorbent pads
What are the urological causes of loin pain?
Ureteric or renal colic
Pyelonephritis or UTI
What are the non-urological causes of loin pain?
MSK
Gynae
General surgical
Vascular - dissecting iliac aneurysm
What are the key points in a history of loin pain?
Speed of onset Nature of pain: colicky/sharp/severity Radiation Unilateral or bilateral Associated symptoms: systemic/LUTS
What are the causes of ureteric colic?
Ureteric calculi
Clot colic
PUJ obstruction
What is the classic history of ureteric colic?
Sudden onset Severe colicky pain Unilateral Loin to groin Radiation to iliac fossa/genitalia
When would you particularly worried about a patient with ureteric colic?
Temperature / rigors
Hypotensive
Worried about sepsis
How do you investigate suspected ureteric colic?
Urinalysis
FBC, U&E, calcium, urate
CT KUB
USS
What would you see on urinalysis in ureteric colic?
Non-visible haematuria
How do you initially manage ureteric colic?
Analgesia
Anti-emetic
Fluids if dehydrated
When is intervention indicated for ureteric colic?
Larger more proximal stones Renal impairment Intractable pain Solitary kidney Infection Failed conservative management
What are the options for removal of a stone?
Ureteroscopy + lasertripsy
ESWL - extra-corporeal shockwave lithotripsy
JJ stent
Why is infection associated with a stone an emergency?
They may have pyonephrosis
Call for senior help if they are septic
What is pyonephrosis?
Abscess in renal pelvis
How do you manage pyonephrosis?
Resus: O2, IV fluids
ABx: gentamicin + co-amox/Tazocin
Culture blood/urine
ABG
When should a UTI be followed by urological investigation?
Any male with proven UTI
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
What are stones made from?
Crystal aggregates
Mostly calcium oxalate
Where are stones most commonly deposited?
Pelviureteric junction (PUJ)
Pelvic brim
Vesicoureteric junction
How can you prevent stones forming?
Drink plenty
Normal dietary calcium
Calcium stones - thiazides
Urate stones - allopurinol
How does acute pyelonephritis present?
Chills, fever>38
Loin pain
May be more gradual onset, not typically colicky pain
Often systemically unwell
What is the most common organism in acute pyelonephritis?
E.coli
Proteus
Klebsiella
Enterobacter
What investigations should you do for suspected acute pyelonephritis?
Urine dip
FBC, U&E
MSU - MC&S +/- blood cultures
Renal USS to exclude pyonephrosis
How do you manage acute pyelonephritis?
Antibiotics
Analgesia
Antiemetic
DVT prophylaxis
Define urinary retention
Inability to pass urine, rather than inability to make urine
Not emptying the bladder, due to obstruction or reduced detrusor power
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
How does acute urinary retention present?
Pain relieved by drainage
What are the symptoms that indicate problems with urine storage?
Frequency
Urgency
Nocturia
Urinary incontinence
What are the symptoms that indicate a problem with voiding?
Hesitancy Intermittency Straining Poor flow Spraying Post-micturition dribbling
How do you manage urinary retention?
Catheterise urethrally if possible
Record residual volume and document
What medical therapy may be given for acute retention?
Alpha blocker - tamsulosin
5ARI - Finasteride
How do you manage chronic urinary retention?
Long-term I dwelling catheter
TURP if fit
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
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
What are the causes of testicular pain?
Testicular torsion
Epididymitis/orchitis
Testicular tumour
Trauma
How does testicular torsion present?
Often younger patient
Sudden onset unilateral testicular pain
What do you find on examination in testicular torsion?
Apyrexial, may be tachycardic
Scrotum erythematous
Exquisitely tender testis
How do you manage testicular torsion?
Scrotal exploration in theatre as an emergency
+/- orchidectomy
What are the common causes of epididymoorchitis?
STI esp chlamydia
UTI (E.coli)
How does epididymoorchitis present?
Gradual onset, usually unilateral
Recent history of UTI, unprotected intercourse
What do you find on examination in epididymoorchitis ?
Scrotum erythematous
Testis/epididymis enlarged and tender
Fluctuations areas - abscess
How do you treat epididymoorchitis?
Antibiotics
Ciprofloxacin for UTI
Doxycycline if chlamydia suspected
What is Fournier’s gangrene?
Necrotic area of scrotal skin associated with epididymoorchitis
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?
What is the likely diagnosis for a lump that is separate from the testis and cystic?
Epididymal cyst
How do you manage epididymal cysts?
Ultrasound
Reassurance
Conservative management
Remove surgically if symptomatic
What is a hydrocoele?
Fluid in the tunica vaginalis
What is the difference between primary and secondary hydrocoeles?
Primary due to patent processus vaginalis - younger men
Secondary to testis tumour, infection or trauma
How do you manage hydrocoeles?
Aspiration or surgical repair
What is a varicocele?
Dilated veins of pampiniform plexus
How do varicoceles present?
Dull ache at end of day
Left side more commonly affected
What is a haematocele?
Blood in tunica vaginalis
Follows trauma and may need drainage
What are the common types of testicular tumour?
55% Seminoma
33% non-seminomatous germ cell tumour (teratoma)
12% mixed germ cell tumour
How does testicular cancer present?
Painless lump Haematospermia Pain Secondary hydrocele Dyspnoea - lung mets Abdo mass - enlarged nodes
What are the risk factors for testicular cancer?
Undescended testis
Infant hernia
Infertility
What are the tumour markers for testicular cancer?
Alpha fetoprotein
Beta hCG
How are testicular cancers treated?
Seminoma - early stage sensitive to radiotherapy
NSGCT - chemotherapy
What is the incidence of undescended testis?
3% of boys
30% of premature boys
What are the different types of undescended testis?
Cryptorchidism
Retractile testis
Maldescended testis
Ectopic testis
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
What is the treatment for maldescended and ectopic testis?
Orchidopexy
Hormonal with hCG
When is 2ww referral appropriate for haematuria?
Visible haematuria older than 45y
Persistent NVH, no obvious cause older than 60y
What are the urological causes of haematuria?
Cancer - RCC, upper tract TCC, bladder cancer, advanced prostate cancer Stones Infection Inflammation BPH (large)
When should haematuria be referred to nephrology?
Persistent asymptomatic NVH younger than 40, with associated proteinuria, hypertension, low eGFR
What are the important aspects of a history of haematuria?
Pain(less)?
UTI
Anticoagulants
Smoking
What investigations are done at a haematuria 2ww clinic?
DRE Bloods: FBC, U&E, PSA MSU USS renal tract Flexible cystoscope
What are the majority of bladder cancers?
Transitional cell carcinoma
What are the 2 main classifications of bladder cancer?
Muscle invasive
Non-muscle invasive
What is TURBT?
Transurethral resection of bladder tumour
To gain histology
How is muscle invasive bladder cancer further classified?
Organ confined
Metastatic
How is organ confined bladder cancer treated?
Radical cystectomy
+ urinary diversion
How does radical cystectomy differ in males and females?
Males - cystoprostatectomy
Females - cystectomy + anterior exenteration
What are the options for urinary diversion following radical cystectomy?
Ileal conduit
Continent urinary diversion
Neobladder
What treatment is offered for organ confined bladder cancer, if the patient is unfit for cystectomy?
Radical radiotherapy
What is the treatment for metastatic bladder cancer?
Symptom control
Chemotherapy
How does renal cell carcinoma present?
Haematuria Loin pain Abdo mass Anorexia Malaise Weight loss
What are the treatment options for renal cell carcinoma?
Surveillance
Partial nephrectomy
Nephrectomy
Metastatic - oncology
How does transitional cell carcinoma of the urinary tract present?
Painless haematuria Frequency Urgency Dysuria Urinary tract obstruction
Where can transitional cell carcinomas be?
Bladder - 50%
Ureter
Renal pelvis
Describe the epidemiology of prostate cancer
Most commonly diagnosed cancer in UK males
2nd most common cause of cancer-related death
What are the risk factors for prostate cancer?
Increasing age
Family history
BRCA2 mutation
Ethnicity: black>white>Asian
How does prostate cancer present?
Asymptomatic
Urinary symptoms
Bone pain
How is prostate cancer diagnosed?
DRE + PSA + Biopsy (TRUS)
What is TRUS?
Transrectal ultrasound - takes 10-12 core biopsies from different parts of the prostate gland
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)
What factors indicate high risk of progression of prostate cancer?
Any of…
PSA>20
Gleason 8-10
T3-4
What factors indicate low risk of progression of prostate cancer?
All of…
PSA
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
What is the threshold for PSA below which prostate cancer can be excluded?
There is no lower threshold!
What factors influence treatment decisions for prostate cancer?
Age DRE PSA Biopsies - Gleason grade MRI pelvis and bone scan
What do prostate metastases look like?
Sclerotic (osteoblastic) hot spots on bone scan
When are hormones used to treat prostate cancer?
Metastatic disease
Used alongside chemotherapy if PS 0-2
What hormones are used to treat prostate cancer?
LHRH agonist
First stimulate then inhibit pituitary gonadotrophin
What is the main risk of using LHRH agonists?
Risk of tumour flare when first used
How do you treat tumour flare?
Start anti-androgen in susceptible patients
What are the main aspects of palliation in metastatic prostate cancer?
Single dose radiotherapy
Bisphosphonates
What are the options for radical treatment for prostate cancer?
Radical prostatectomy
Radiotherapy - external beam or brachytherapy
What is brachytherapy?
Implantation of radioactive seeds into prostate gland
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
What is lead-time bias?
Living longer knowing you have the disease rather than actually improving survival
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
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
