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DPD > Urology > Flashcards

Urology Flashcards

1
Q

What does LUTS stand for and what are the two types?

A

Lower Urinary Tract Symptoms
These are storage symptoms = irritative
Or voiding symptoms = obstructive

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2
Q

What are some common storage / irritative LUTS?

A

FUN
frequency
urgency
nocturia

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3
Q

What are some common voiding / obstructive LUTS?

A 
WISED
Weak urinary stream
Intermittent flow
Straining to urinate
incomplete bladder Emptying
post-micturition Dribble
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4
Q

What is the mechanism of LUTS?

A

The prostate is situated below the bladder and surrounds the urethra. As the prostate enlarges, bladder outflow becomes increasingly obstructed
Enlargement initially develops in the peri-urethral transition zone of the prostate
In order to generate the increased pressures required to void, the bladder detrusor muscle initially becomes hypertrophied, which leads to trabeculation. In the longer term replacement of muscle fibres with collagen results in loss of detrusor efficacy

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5
Q

Give a definition for LUTS

A

LUTS is a non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding)

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6
Q

Define BPE

A

BPE (benign prostatic enlargement) is the clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia

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7
Q

Define BOO

A

BOO is bladder outlet obstruction caused by benign prostatic enlargement (clinical finding)

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8
Q

Define BPH

A

Benign prostatic hyperplasia (BPH) properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction

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9
Q

What is a simplified overview of LUTS?

A

poor flow - BOO (BPH)

strong flow - detrusor overactivity

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10
Q

What are some risk factors for LUTS?

A 
Age
Androgens
Functional androgen receptors
Obesity
Diabetes (& elevated fasting glucose)
Dyslipidaemia
Genetic
Afro-Caribbean
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11
Q

LUTS investigations

A 
History and examination
LUTS
Haematuria
IPSS questionnaire
Full medical history (co-morbidities, drug history and family history)
Examine abdomen
DRE!!!!
Urine dipstick (exclude infection)
Flow rate in clinic
Blood tests (U&E, PSA – but need to counsel patient)
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12
Q

What key differential can a urine dipstick exclude?

A

infection

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13
Q

Why is creatinine checked in LUTS?

A

Chronic retention can lead to renal failure due to high pressure

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14
Q

Why is prostate size relevant?

A

If prostate is over 120cc (tennis ball) surgery becomes unsafe
Some drugs only work on sizes over 30-40 cc (ping pong ball to gold ball)

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15
Q

How are LUTS managed?

A

conservative management:
reassure
fluid restriction & advice (e.g. drink less at night more in day)

medical management:
alpha blockers (tamsulosin, alfuzosin)
5 alpha-reductase inhibitors (finasteride (only works on prostates larger 30-40cc pingpong+), dutasteride)
drugs take a long time to work so manage patient’s expectations

surgical management:
TURP (transurethral resection of prostate)
chip away at prostate under GA to open channel and help with passing water. Done endoscopically
Laser surgery & catheter options also available.

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16
Q

70 year old man presents with inability to pass urine for 10 hours
Previous history of BPH (on tamsulosin and finasteride)
Pain

You are the on call F1
How are you going to assess him and manage him?

A

DRE - smoothly enlarged prostate
Palpate bladder
CATHETER!!
catheterise if they need to pee

dispstick/CSU (exclude UTI)
check U&Es (exclude renal failure - can be fatal)
check FBC
measure residual urine
neurological examination if necessary (exclude spinal nerve compression from metastatic prostate cancer)
prescribe - antibiotics/laxatives/alpha blockers

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17
Q

Why is it essential to check U&Es on a urinary retention patient?

A

If you send them home when they have an undiagnosed renal failure, they could become polyuric and dehydrate and die

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18
Q

Why do we sometimes prescribe laxative for urinary retention patients?

A

Constipation is a common cause of urinary retention in older patients

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19
Q

What is the difference between acute and chronic urinary retention?

A

Acute Urinary Retention AUR is painful

Chronic Urinary Retention CUR is postvoid residual >800ml

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20
Q 
How would you manage this very common case?
67y male 
Urgency, frequency, poor flow
DRE 40g BPE
PSA 1.2
MSU –ve
US: Normal, postvoid residual 40ml
A

Tamsulosin +- Finasteride

If no improvement in urgency add in anticholinergic for Urgency

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21
Q

Why is prostate cancer often asymptomatic?

A

It arises from the peripheral part of the prostate, so often does not affect function

22
Q

What is PSA?

A

prostate specific antigen

23
Q

does a raised PSA = prostate cancer?

A

an abornmal PSA is because of prostate cancer in 25% of patients. 75% have elevated PSA because of other reasons e.g. pH

24
Q

What do you do if DRE & PSA is abnormal?

A

Perform an MRI & prostate biopsy
note normal MRI suggests it is likely a non-aggressive prostate cancer but not definite
prostate biopsy done with a gun and local anaesthetic

25
Q

What is the name of the histology scoring for prostate cancer GRADE?

A

the Gleason score (grading)
low risk 3+3
high risk 5+5
TNM staging

26
Q

70 year old man referred by GP with PSA 18 ug/L (upper limit 6.5)

How are you going to assess?

Do you
A. Repeat PSA and check MSU
B. Organise MRI prostate and TRUS biopsies
C. Explain likely diagnosis of prostate cancer
D. Advise radical prostatectomy or radiotherapy

A

A) Repeat PSA and check MSU

27
Q

Management of prostate cancer i.e. what are the different management plans and what would you do initially?

A

Staging – MRI / Bone scan (check for metastases to spine)
MDT discussion and breaking news to patient
Options

Active surveillance (low risk low volume disease) (prostate cancer often causes no harm)
Surgery – radical prostatectomy
Radical Radiotherapy
Watchful waiting (elderly / co-morbid patients) (not trying to cure the cancer when it’s grown - offer hormonal medication)
Hormones (stops testosterone using anti-androgens)

28
Q

What should you look out for in active surveillance?

A

Incontinence and Impotence (erectile dysfunction)

A bigger, more aggressive tumour (can perform radical prostatectomy)

29
Q

Hormonal Therapy of prostate cancer

A

occur with radiotherapy

LHRH agonist (zoladex) (initially hyperstimulates pituitary, before disabling - so a metastasis could grow a lot which can cause spinal cord depression and be serious - might need an orchidectomy on these patients)
Cord compression is a urological emergency:
START STEROIDS
URGENT MRI

30
Q

At what PSA do you treat on active surveillance?

A

PSA >10

Grade progression

31
Q

Hydrocele

A

the accumulation of serous fluid in a body sac esp. the testicle

32
Q

Varicocele

A

a mass of varicose veins in the spermatic cord
not treated unless painful or affects fertility
often recurrent symptoms after treatment

33
Q

Epididymal Cyst

A

a cyst on the epidiymus
on presentation if the mass feels smooth, soft and is mobile - unlikely to be testicular cancer (reassure patient at this point)

34
Q

What are some feature of Testicular cancer?

A

usually painless
hard mass
non-mobile/attached to testicle
these grow very quickly so important to diagnose ASAP

35
Q

25 year old man presents with pain in left testicle swelling and fever

How will you assess and manage him?
Pick two. What is a likely cause?

After history and examination, do you
A. Organise ultrasound
B. Start antibiotics
C. Explain testicular cancer possible
D. Manage conservatively
A

suspect epididymal cyst infection

so A&B reasonable

36
Q

Epididymitis and Orchitis

A

Infection of epididymis or testis or both

Causes
STIs
UTIs
Post-operative

37
Q

How to distinguish between testicular torsion and testicular cancer?

A

testicular torsion has intense pain, whilst testicular cancer is usually painless

38
Q

Testicular cancer

A 
Affects younger men
Germ Cell
Seminomatous
Non-seminomatous
Non-Germ Cell
Important to catch early!!
Ultrasound – urgent on same day
Tumour markers – AFP, HCG, LDH
CXR on same day
Counselling
Sperm banking
Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?) (treatment of choice)
39
Q

Haematuria is also known as.

A

CANCER UNTIL PROVEN OTHERWISE

40
Q

Define Haematuria

A

blood in the urine

41
Q

What are some causes of haematuria?

A

Infection (commonest)
Cancer
Medical
Trauma

42
Q

How would you examine haematuria?

A

resuscitate including transfusion
3 way catheter
Hx Ex
Bloods including clotting & G&S; KUB
MSU (exlude most common cause (infection))

blood clot in bladder can cause many problems - so need to wash out the blood clot - keep irrigating them to do this

43
Q

How do you manage a blood clot in the bladder?

A

Continuously irrigate the bladder to wash it out

44
Q

Why should you be careful with suprapubic catheters with haematuria?

A

Potential to spread a bladder cancer and make it very serious

45
Q

Haematuria suggests cancer in which location?

A

It can be anywhere in the urinary tract: bladder cancer, ureter cancer etc.
Thus you need to investigate thoroughly to exclude the entire urinary tract. Exclude kidney stones also.

46
Q

In terms of urinary tract cancers what is imaged well on a CT scan?

A

CT scan is great for looking at kidneys and ureters, however terrible for bladders - a wrinkle could be a cancer - so a cystoscopy may be needed

47
Q

What do bladder tumours look like on a cystoscopy?

A

Like algae, like nebulae - star dust floating about

48
Q

2 features of Renal Stones background

A

more common in caucasian men

1% hospital admissions

49
Q

Why are renal stones important? i.e. what do they cause and what can they be a sign of?

A

Pain (spectrum)
Infection (incl. life-threatening gram –ve sepsis)
Renal damage
Underlying metabolic problems (eg. Hyperparathyroidism, gout, cysteinuria)
Underlying anatomical problems (eg. PUJ-o, MSK, Horseshoe kidney, ureteric stricture)
(Litigation)

50
Q

Storage symptoms are?

A

IRRITATIVE

51
Q

Voiding symptoms are?

A

OBSTRUCTIVE

DPD (8 decks)

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