urology Flashcards

1
Q

which is more concerning, gross or microhematuria

A

gross

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2
Q

describe an approach to hematuria

A

divide into:

  1. pre-renal
    - -coagulation disorders
    - -pseudohematuria (beets, dyes, laxatives)
  2. renal
    - -stones
    - -trauma
    - -tumours
    - -infection
    - -glomerulonephritis
    - -vascular malformations
  3. post renal
    - -stones
    - -trauma
    - -tumours
    - -infection
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3
Q

most likely cause of hematuria in age:
0-20 years
(in order of frequency)

A

glomerulonephritis
UTI
congenital anomalies

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4
Q

most likely cause of hematuria in age:
20-40 years
(in order of frequency)

A

UTI
stones
bladder tumour

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5
Q

most likely cause of hematuria in age:
40-60 years
(in order of frequency)

A

male–> bladder tumours, stones, UTI

female–> UTI, stones, bladder tumours

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6
Q

most likely cause of hematuria in age:
over 60 years
(in order of frequency)

A

male–> BPH, bladder tumour, UTI

female–> bladder tumour, UTI

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7
Q

what % chance is there that gross hematuria is a urological malignancy

A

25%

*gross, painless hematuria is malignancy until proven otherwise (trauma, infection, stones etc are generally symptomatic and picked upon hx)

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8
Q

what % chance is there that micro hematuria is a urological malignancy

A

5%

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9
Q

ddx of hematuria

A

most common are all pre or post renal

tumour
trauma
infections
stones
coagulopathy (doesn't cause gross hematuria)
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10
Q

things to ask on hx that suggest uro malignancy

A
weight loss
night sweats
flank pain
N/V
voiding changes
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11
Q

numer 1 risk factor for urothelial tumours

A

smoking

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12
Q

risk factors for urothelial tumours

A

smoking

occupational exposure (aniline dyes, hairdressers, painters, leather tanners)

meds (cyclophosphamide etc)

previous radiation exposure

chronic cystitis (catheters, infections)

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13
Q

what to ask on hx to evaluate stones

A

flank/abdo pain

dysuria

previous stones

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14
Q

what to ask on hx to evaluate uro infection

A

fever

chills

suprapubic or flank pain

dysuria

frequency

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15
Q

what investigations should you order to evaluate hematuria

A
  1. U/A and culture
    - -leukocytes and nitrites suggest infection
    - -dysmorphic RBCs with or without protein suggest glomerular cause or stones (maybe crystals)
    - -C and S for infection
  2. urinary cytology
    - -collect specimen, more sensitive and specific depending on the grade of malignancy
  3. CBC
    - -hemoglobin and platelets (bleeding diathesis or coagulopathy?)
    - -WBC for infection
  4. PTT/INR
    - -bleeding diathesis?
  5. kidney function
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16
Q

what are the options for imaging the urinary tract

A
  1. ultrasound
  2. CT IVP/triphasic CT
  3. MRI
  4. IVP or retrograde pyelogram
  5. plain film KUB or CT KUB without contrast
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17
Q

for imaging the urinary tract:

pros of ultrasound

A

good for RENAL TUMOURS, STONES within kidney and hydronephrosis in the kidney

first investigation for microscopic hematuria (depends on risk category–> 40 yo or risk factors)

first step for signs of infection–> can do CT with contrast if there are findings

inexpensive and safe

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18
Q

for imaging the urinary tract:

cons of ultrasound

A

will miss ureteral stones, ureteral tumours and most small or flat bladder and renal tumours

may not differentiate blood clot from tumour in bladder or renal pelvis

no functional info

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19
Q

what is the first choice imaging test for patient with gross hematuria

A

CT IVP/triphasic CT

arterial/venous (later after injection)/excretory phase

image the ureters, kidney and bladder

contrast in the collection system can obscure views of stones tho

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20
Q

for imaging the urinary tract:

pros of CT IVP

A

most sensitive test for any GU pathology

accurate staging of renal/ureteric tumours and renal trauma

non contrast CT for patiens with renal colic

may demonstrate other disorders like abdominal aneurysm, ascesses, fluid collections, filling defects in the ureteric phase

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21
Q

for imaging the urinary tract:

cons of CT IVP

A

there can be adverse reactions to the IV contrast (allergy, nephrotoxicity)

expensive and has radiation exposure

contraindications for renal dysfunction, multiple myeloma, contrast allergy, pregnancy

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22
Q

can you use IVP or retrograde pyelogram for kidney tumours

A

no

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23
Q

what do you use IVP or retrograde pyelogram for

A

suspected stones or urothelial tumours of bladder and ureter

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24
Q

when do you use KUB or CT KUB without contrast in uro imaging

A

flank pain/renal colic–> good for ID stones (plain film will miss uric acid stones)

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25
when do we work up hematuria
if its gross hematuria if malignancy is suspected if they're symptomatic and have risk factors concerning for etiologies (i.e cancer) hematuria in the acutely bleeding patient--> stabilize with fluids or blood and ABCs, irrigate the bladder and manage surgically
26
when should you refer a patient with hematuria to a urologist
any patient with gross hematuria needs both upper (radiology) and lower tract (cytoscopy) imaging cytoscopy can be done fairly easily in the uro clinic all patient with gross hematuria should see a urologist unless there is an obvious alternative
27
how you do diagnose urothelial carcinoma
cytoscopy and biopsy
28
what should you make sure to have done before making your uro referral for hematuria
``` hx px U/A urine cytology imaging to get dx as much as possible, with initial management and stabilizations of patient. ```
29
what is the imaging choice if the suspected cause of the hematuria is: 1. post renal 2. renal
1. CT--> post renal | 2. U/S--> renal
30
what is the workup for urothelial carcinoma
cytoscopy and biopsy
31
treatment of urothelial cancers
transurethral resection of the lesion and underlying detrusor muscle to stage the tumour
32
risk factors for urothelial tumours
``` SMOKING occupational exposures meds previous radiation chronic infection or inflammation irritation (i.e catheters) ```
33
ddx of urothelial tumours
urothelial carcinoma (transition cell) adenocarcinoma (dome/trigone of bladder) squamous cell carcinoma (associated with chronic inflammation from bladder stones, indwelling catheter etc)
34
most common urothelial tumour
urothelial carcinoma (transitional cell carcinoma)
35
what kind of urothelial tumour is associated with associated with chronic inflammation from bladder stones, indwelling catheter etc
squamous cell carcinoma
36
what kind of urothelial tumour is associated with dome/trigone of bladder
adenocarcinoma
37
how do you assess severity of a urothelial tumour
1. grade--> histologic appearance is high vs low grade 2. stage--> - -non-muscle invasive bladder cancer (T1 disease) vs. muscle invasive (above T1 disease) - -T1 involves invasion into lamina propria, T2 begins shallow muscle invasion
38
treatment of non-muscle invasive bladder cancer
transurethral resection of lesion if high grade or multifocal, use more invasive measures like chemo or BCG (which we think stimulates the immune system) consider mitomycin C to prevent recurrence consider intravesical chemo if high grade, lamina propria invasion (T1), multifocal, carcinoma in situ, unable to completely reset or rapid recurrence after resection - -> commonly cisplatin - -more effective as neoadjuvant treatment reassess response to theraoy (persistent CIS after chemo?) may need radical treatment
39
what agent is commonly used as intravesical chemo if bladder cancer is high grade, or multifocal or etc...
cisplatin
40
what might you use to try and prevent recurrence after bladder cancer resection
mitomycin C
41
how do you treat muscle invasive bladder cancer
radical cystectomy with or without systemic chemo--> may even be done palliatively to stop bleeding or pain radical cystectomy is indicated if muscle invasive disease, high grade NMIBC refractory to intravesical therapy, unresectable NMIBC or palliation to control hemorrhage requires a urinary diversion--.> ileal conduit is simple but has stoma and incontinence//neobladder has no bag, but has higher risks of complications and recurrence
42
ddx for benign renal mass on imaging
oncocytoma angiomyolipoma --> fat; observable abscess pseudotumour --> dromedary hump, hypertrophied column of Bertin, compensatory hypertrophy
43
ddx for malignant renal mass on imaging
renal cell carcinoma (most common) urothelial cell carcinoma mets--> lymphoma/leukemia, lung, breast Wilms tumour (kids)--> highly treatable, arises from parenchyma
44
what is the likely diagnosis for a central renal mass in the collecting duct
transitional cell carcinoma/urothelial cell carcinoma lines the renal pelvis, ureters, bladder RESECT ALL IF MALIGNANT
45
how are renal masses usually detected
incidentally
46
classic triad of symptoms of renal mass
flank pain hematuria palpable mass (uncommon)
47
what type of mass makes up 90% of malignant renal masses
renal cell carcinoma 25% present with mets clear cell RCC is the most common subtype
48
where are mets commonly from if met to kidney
lymphoma leukemia lung breast
49
investigations to work up a renal mass
CT abdo/pelvis--> characterize mass (malignany, tumour size, nodes, mets) CXR--> assess for mets Labs--> - -ALP (for bone mets) - -liver function tests (for hepatic mets or portal vein involvement) - -calcium (good for bone mets or paraneoplastic syndrome) - -paraneoplastic syndrome can cause other things (HTN, polycythemia, increased ESR etc)--> decreased DMSA uptake indicates real tumours, normal uptake indicates psuedotumour biopsy--> kind of useless because we resect anyways but can help with dx
50
what test can be done to help distinguish between real kidney tumours and pseudotumours
decreased DMSA uptake indicates real tumours, normal uptake indicates psuedotumour
51
how do you treat RCC
if locally confined, can use nephrectomy or partial nephrectomy (if less than 7 cm, bilateral tumours, only one kidney, hereditary syndrome etc) if metastatic, combine nephrectomy with targeted chemo (sunitinib) if not surgical candidate, can try ablation but hard to tell if there is tumour left over after
52
what chemo agent do you use to treat metastatic RCC (in addition to nephrectomy)
sunitinib
53
what is the most common cause of renal colic
acute obstruction of the ureter by the stone
54
when do non-obstructing stones cause pain
only when occur with UTI
55
what size stones usually pass on their own?
stones less than 4mm are 90% likely to pass stones over 8mm are only 20% likely to pass
56
what are the 3 most common sites of ureteric stones
sites of physiologic narrowing-- 1. uretero-pelvic junction 2. crossing of the iliac vessels 3. uretero-vesical junction
57
ddx for renal colic
very broad therefore must have diagnosis with imaging and microhematuria workup before referring to a urologist 1. urgent--> AAA (rupture?), appendicitis, ectopic pregnancy, septic stone 2. GI--> cholecystitis, biliary colic, diverticulitis, IBD 3. gyne--> PID, ovarian torsion 4. GU--> renal/ureteric calculi, pyelonephritis 5. other--> lumbar disc herniation, herpes zoster
58
lab investigations for renal colic
CBC (WBC indicates inflammation and infection) creatinine (renal function/obstruction) urine micro (bacteriuria, pyuria, pH)
59
imaging for renal colic FIRST TEST
plain film KUB 85% of stones are radioopaque except uric acid stones (needs CT)--> there is no info about obstruction tho
60
which stones are NOT radio opaque
uric acid stones struvite stones
61
imaging beyond plain film KUB for renal colic
CT scan without contrast or CT-KUB (fast, easy, inexpensive, gives info on obstruction)
62
how do you manage small stones that are asymptomatic
watchful waiting ALPHA BLOCKERS can relax the ureter and may help with spontaneous passage
63
when should you refer a patient with stones to a urologist
1. fever/chills, bacteriuria, high WBC or other risks of urosepsis 2. obstructed ureter with diabetes 3. solitary kidney 4. renal failure 5. significant comorbidities
64
how do you treat stones causing obstruction
1. retrograde ureteric stents--> double J stents can be placed antegrade or retrograde under GA, and stay in place with low risk of bleeding 2. percutaneous nephrostomy tubes--> placed under local anesthetis by IR after pus drained, but these have higher bleeding risks 3. remove stone--> conservative passed if uncomplicated with alpha blocker, hydration, NSAIDs - -ESWL if less than 2 cm or ureteric stone (shocks localized by xray fragment the stones) - -ureteroscopy with basket (if stone small enough) or laser (if stone too large for basket) - -percutaneous nephrolithotomy (for stones about 1-2 cm and/or up near the kidney or staghorn stones)--> risks include bleeding and renal perforation
65
what is the most common type of renal stone
calcium oxalate
66
risk factors for calcium oxalate stones
hypercalciuria (hyperparathyroidism or dietary intake) high sodium or protein diet chocolate nuts tea
67
what is the second most common type of renal stone
calcium phosphate
68
in what type of patients do you find calcium phosphate stones
those with metabolic abnormalities--hypercalcemia, primary hyperparathyroidism
69
what types of stones are associated with infectious causes
struvite stones--> forms staghorn stones can only form if urine pH is above 8, thus usually only present with urease positive bacteria made of Mg, ammonium phosphate, calcium
70
risk factors for uric acid stones
persistent acidic urine low urine volumes gout excess purine in diet (meat)
71
how do you investigate microhematuria
repeat measurement (more than 5 red cells for HPF?) assess for proteinuria (if normal, likely not renal cause) send for micro for closer assessment renal U/S refer to urologist for cystoscopy
72
describe a diagnostic approach to a scrotal mass
1. infectious--> PAINFUL - -epididymitis or orchitis 2. anatomic - -hydrocele, varicocele, spermatocele - -testicular torsion or torsion of appendix testis 3. malignant - -testis tumour
73
what investigations should you do in someone with a scrotal mass
1. U/A--> pyuria with epididymitis/orchitis | 2. U/S--> very sensitive and specific for testicular tumours
74
what is epididymitis
infectious scrotal mass common in young adults (under 35) and is often associated with STI or babies with UTI or older men with BPH UTIs older than 35 years, usually e coli presents with tender, indurated (hardened) epididymis
75
how does acute epididymitis present
acute pain, testicular swelling, erythema, hardening with or without dysuria, fever, pyuria investigate with CBC, U/A for pyuria, consider doppler U/S
76
how do you treat acute epididymitis
NSAIDs abx for 4 weeks ice prn
77
what virus is associated with orchitis
mumps--> can lead to sterility can also be associated with other viruses
78
how does orchitis present
swollen and very tender testicles, often bilaterally
79
what is a hydrocele
fluid within the layers of the tunica vaginalis at a certain point is a communicating hydrocele if the processus vaginalis is patent
80
how does a hydrocele typically present
painless transilluminates testicle palpation is difficult
81
how do you treat a hydrocele
none required, may do for cosmetic reason
82
what is a spermatocele
aneurysmal blowout of the epididymis (dilation of the tubule)
83
how does a spermatocele usually present
typically painless transilluminates can palpate testicle separate from mass
84
how do you treat a spermatocele
none required as they generally dont grow or cause problems, may treat for cosmetic reasons
85
what is a varicocele
most are left sided in the pampiniform plexus, which drains the testicle can lead to male factor infertility, but most men have normal fertility
86
how does a varicocele usually present
typically asymptomatic increases with standing or valsalva palpated as "bag of worms"/spaghetti in the scrotum/cord
87
treatment for varicocele
surgical or sclerotherapy
88
what is the most common age group to present with testicular torsion
12-18 year olds
89
why do we care about testicular torsion
surgical emergency requiring surgical scrotal exploration as there is 6 hours to prevent irreversible testicular ischemia
90
how does testicular torsion present on physical exam
associated with bell clappers deformity and high riding horizontal testicle often has absent cremasteric reflex Prehn sign--> relief of pain when supporting scrotum (suggests epididymitis)
91
investigations for testicular torsion
U/A to rule out pyuria for epididymitis doppler to clarify diagnosis
92
treatment for testicular torsion
surgical detorsion and orchidoplexy (fix the testicle in the scrotum)
93
how does torsion of appendix testis present
may mimic testicular torsion but commonly has a blue dot sign uncommon in older men testes may be inflamed and tender at appendix but not likely elevated or horizontal
94
investigations for torsion of appendix testis
U/A to rule out epididymitis dopple to assess perfusion
95
treatment for torsion of appendix testis
conservative, symptom management and urological assessment
96
how does testicular cancer usually present
as painless mass in young healthy men aged 15-35 found on self exam on px--> hard, irregular, doesn't transilluminate, B symptoms
97
what are the types of testicular cancer
primary vs secondary primary is germ cell vs non germ cell germ cell is non seminoma versus seminoma
98
investigations for testicular cancer
1. bHCG--> produced by choriocarcinoma and some seminomas 2. alpha fetoprotein--> produced by yolk sac, embryonal carcinoma, teratocarcinoma 3. LDH--> correlated with tumor volume 4. scrotal U/S and CT abdo pelvis 5. CXR and CT head for mets 6. CT for staging
99
treatment rates for testicular cancer
cure rates are very good germ cell tumours are highly chemosensitive radical orchiectomy (ALWAYS via the inguinal canal retroperitoneal, not the scrotum)
100
where do seminoma germ cell tumours originate
germinal epithelium of the seminiferous tubules older and middle aged patients, less aggressive
101
what are the types of non-seminoma germ test testicular cancers
embryonal carcinoma teratoma or teratocarcinoma choriocarcinoma yolk sac tumour
102
list the two types of non germ cell testicular cancers
leydig cell tumour sertoli cell tumour
103
what are the two most common types of secondary testicular cancer
lymphoma leukemia
104
what innervates the detrusor muscle
parasympathetics S234 via the pelvic splanchnic nerve to cause urination
105
what innervates the trigone
sympathetics T11-L1, L2 via the hypogastric nerves to cause the detrusor relaxation and bladder neck constriction
106
how many sphincters does the male urethra have? female?
male--> 2 female--> 1
107
how are the male urethral sphincters innervated
internal INvoluntary sphincter--> sympathetic L1/2 external voluntary sphincter--> pudendal nerve from S234 (prostatic, membranous, bulbar and penile parts to the urethra)
108
how does bladder filling work
as bladder fills--> sympathetic reflex is initiated to keep you dry via stimulation of alpha adrenergic receptors at the bladder neck/internal sphincter and beta-3 receptors in the detrusor muscle to inhibit contraction also direct inhibition of the detrusor motor neurons in the sacral spinal cord with gradual increase in urethral pressure, the pudendal nerve activates the external sphincter formation of a mucosal seal
109
how does bladder emptying work
increased bladder pressure gives the sense of distension and needing to void coordination of the detrusor contraction and external sphincter relaxation is managed by the pontine micturition center which inhibits the steady state of continence also needs relaxation of the internal sphincter in men and absence of any obstruction
110
define neurogenic bladder
dysfunction of the urinary bladder due to neurologic dysfunction or insult
111
define spastic bladder--what causes it?
UMN lesion no normal signal from the brain inhibiting emptying so the bladder will reflexively empty on its own with filling loss of voluntary control of micturition may be due to cerebral injury (stroke, tumour) causing detrusor overactivity may be due to basal ganglia disease (i.e parkinsons) leading to detrusor overactivity and short contractions and urge incontinence may be due to suprasacral spinal cord damage above T6--> reflex micturition with detrusor-sphincter dyssyngergy leading to overactivity may be due to suprasacral spinal cord damage below T6--> reflex micturition with detrusor-sphincter synergy leading to overflow incontinence
112
define flaccid bladder--what causes it?
LMN lesion atonic with overflow incontinence or need for catheterization sacral spinal cord damage--> i.e pelvic fracture--> causes acontractile bladder and poor bladder sensation peripheral nerve damage--> i.e diabetes or pelvic surgery
113
what are the two types of voiding dysfunction
failure to store (incontinence)--detrusor overactivity or outlet incompetence failure to void (retention)--ie LNM lesion --detrusor underactivity or outlet obstruction (i.e BPH, uretheral stricture)
114
define urge incontinence
involuntary loss with strong desire to void
115
etiology of urge incontinence
stone UTI tumour overactive bladder
116
investigations for urge incontinence
hx/px urodynamics UA urine cx maybe U/S
117
treatment for urge incontinence
treat underlying cause timed voiding (every 2 hours to prevent overfilling) bladder training via biofeedback exercises meds--> anticholinergics for the bladder, TCAs surgical--> bladder pacemaker or augmentation (to increase storage capacity) or even urinary diversion
118
etiology of stress urinary incontinence
urinary retention or detrusor overactivity with increased abdo pressure may involve intrinsic sphincter deficiency may involve uretheral hypermobility (often related to weak pelvic floor muscles)
119
risk factors for stress urinary incontinence
obesity female pregnancy and vaginal deliveries hysterectomy prostatectomy strenuous activity
120
treatment for stress urinary incontinence
kegel exercises or bladder training with biofeedback exercises meds--> alpha agonist (TCA or SSRIs) to increase sphincter tone, estrogen periurethral collagen injections for urethral stability pessaries (for prolapse) surgery (bladder neck suspension or urethral slings, artificial sphincter that can be pump controlled in the scrotum)
121
what is overflow incontinence and how do you treat it
obstruction--> treat underlying cause acontractile bladder/atonic bladder--> can result from overstretching can treat with timed voiding, clean intermittent catheterization, indwelling or suprapubic cathether
122
what is a pneumonic to remember the causes of transient urinary incontinence
DIAPERS
123
what does the DIAPERS mnemonic stand for
causes of transient urinary incontinence Delirium (cognitive dysfunction can lead to functional incontinence) Infection Atrophic vaginitis (may be post menopausal) Pharmaceuticals (diuretics, anticholinergics--impair contraction, narcotics--impair contraction, alpha agonists--increased sphincter tone, alpha blockers--lead to stress incontinence Excessive urine production (i.e diuretics, diabetes) Restricted mobility Stool impaction (constipation impairs bladder function and is especially relevant in elderly patients)
124
describe the questions included in a focused voiding issue history
urgency, frequency, dysuria fluid intake associated with valsalva? medications neurological deficits (MS, spinal cord injuries, paresthesias) diseases like diabetes
125
what investigations should be done to investigate voiding problems
1. UA or serum creatinine 2. voiding diary and post void residual 3. urine cytology (if there are irritative voiding symptoms) 4. urodynamics if refractory to treatment (i.e flow) 5. cytoscopy 6. renal US
126
indications for uro referral with voiding problem
hx or px suggests neuro disease hematuria, recurrent UTIs, bladder stones, renal insufficiency persistent incontinence, especially post op or once underlying causes are corrected.
127
what are the symptoms associated with storage issues
irritative frequency, urgency, nocturia
128
what are the symptoms associated with obstructive voiding problems
hesitancy slow stream stuttering stream dribbling
129
what are symptoms of uncomplicated BPH
microhematuria NOT usually dysuria and incontinence
130
ddx of lower urinary tract symptoms (LUTS) in older men
1. prostate--> BPH, cancer, prostatitis 2. bladder--> cystitis, bladder tumour, bladder stone 3. urethra--> urethral stricture, meatal stenosis, phimosis 4. neurologic--> parkinson's, stroke, spinal cord disease 5. Other--> diabetes, sleep apnea, meds, pelvic mass
131
what are the two main types of tissue in the prostate
stroma (smooth muscle and collagen) epithelium
132
where does BPH occur
the transition zone
133
where does prostate cancer most often occur
peripheral zones
134
what is BPH
involves growth of the stromal component of the prostate , via increased alpha 1 receptors increasing smooth muscle tone size and degree of outlet obstruction doesnt fully correlate with degree of symptoms
135
complications of BPH
urinary retention atonic bladder renal failure and blockage recurrent UTIs bladder stones hematuria
136
alpha blocker size effects
dizziness fatigue nasal congestion retrograde ejaculation
137
5-ARI side effects
ED decreased libido decreased volume of ejaculation (not common)
138
management of BPH--> lifestyle
decrease fluids, caffeine, alcohol, decongestants, lose weight, exercise
139
how do you manage BPH
1. lifestyle mods 2. phytotherapy (i.e saw palmetto) 3. alpha blockers 4. 5 ARIs (prevent formation of 5-DHT)--> can decrease size and PSA and rate of surgery 5. anticholinergics if there is lots of overactivity 6. surgery--> TURP, MIS, green light to vaporize prostate, open prostatectomy
140
what is TURP
trans urethral resection of the prostate involves electrocautery resection endoscopically can cause bleeding, perforation, and some electrolyte imbalances
141
what are some MIS options for BPH management
injections like botox, photodynamic therapy, needle ablation, high intensity U/S, microwave tx etc...
142
when is surgery for BPH indicated
mainly if symptoms are refractory to medical therapies (i.e having recurrent UTI, retention, hematuria, renal impairment etc)
143
if the prostate is small and the PSA is low... how do you treat BPH
alpha blocker
144
if the prostate is large and the PSA is high... how do you treat BPH
combination
145
what are potential causes of gross hematuria after injury
renal ureteric bladder urethral injury
146
what is the most commonly injured organ in GU trauma
kidney 10% of all serious injuries in the abdomen have associated renal injury variable etiology depending on the area--> rural is 90% blunt trauma, whereas urban is less blunt trauma and more penetrating trauma
147
how do you work up a possible GU trauma
if penetrating trauma--everyone should get a CT if blunt trauma--imaging with if.... - -gross hematuria - -microhematuria plus shock - -microhematuria with acceleteration/deceleration...but honestly everyone gets a CT
148
what imaging should be done for a GU trauma
CT IVP with contrast... "delayed" films if preferred single shot film at 10 minutes post injection with 2cc/kg IV contrast...allows safe avoidance of renal exploitation and is highly specific for urinary extravasation
149
what are absolute indications for surgical treatment of GU trauma
1. high grade renal injury--> nephrectomy or repair; kidney repair with sutures is actually quite effective 2. vascular injury in one kidney--> vascular repair 3. penetrating renal injuries
150
relative indications for surgical treatment of GU trauma
1. persistent bleeding more than 2 units a day 2. devitalized segment with urinary extravasation 3. renal pelvis or ureter injury 4. significant vein or artery thrombosis
151
what is the AAST organ injury severity scale for the kidney
1. grade 1--> bruise in the subcapsule 2. grade II--> perinephric hematoma with laceration less than 1 cm 3. grade III---> hematoma with deeper laceration as far as the pyramids 4. grade IV--> stretch injury with some thrombosis and deep laceration, likely extravasation 5. grade V--> complete fractionation of kidney and separation of the hilum
152
how should you manage a person who had a bike accident and presents stable but with gross hematuria
bed rest and monitoring of blood and hgb abx to manage urine extravasation radiographic embolization urinary diversion--> ureteral stenting and nephrostomy drainage surgery (reconstruction or nephrectomy) usually only if unstable
153
what is the etiology of blunt bladder trauma
rare often associated with severe or high energy injuries often associated with urethral rupture and pelvic fracture posterior urethral injuries occur most often in pelvic fractures between the prostatic and pelvic urethra (indicated by high riding prostate)
154
physical signs of bladder trauma
95% have gross hematuria (may have micro) usually gross painless hematuria after trauma with normal kidneys is a bladder injury adbo pain and tenderness abdo bruising urethral catheter does not return urine--> double check all suspected ureter/urethra injuries with a CT with contrast just in case--if the foley isnt draining, its probably not in the right place other wise its likely a urethral injury signs also include no urine output, fever, peritonitis, increased BUN or creatinine
155
investigations for bladder trauma
plain cystography with contrast to check for extravastion is very accurat when done properly---> look for extra peritoneal and intraperitoneal contrast drainage films to check for adequate filling CT cystography is preferred with dilute contrast
156
when do posterior urethral injuries commonly happen?
in pelvic fractures with tearing between the prostatic and pelvic urethra (especially saddle fractures/pubic rami fractures) happens more often in males associated with bladder rupture sometimes, and rectal injury with urethral-rectal fistula rarely
157
how do you diagnose posterior urethral injury?
blood at meatus in 50% high riding prostate inability to urinate and place urethral catheter is classic investigate with retrograde urethrogram
158
treatment for posterior urethral injury
if unable to place a foley, can place suprapubic catheter for drainage, wait and inspect for injury, and then surgically re-establish the connection later
159
how are most kidney injuries treated
non operatively
160
indications for kidney operation after trauma
grade V renal injury persistent bleeding suspected ureter or collecting system injury incomplete staging and already having a lap
161
what should you do for a patient if they have a pelvic fracture?
CT cystogram
162
how do you manage most extraperitoneal bladder ruptures
conservatively but consider treating extraperitoneal bladder ruptures OPEN, especially if undergoing lap and definitely if undergoing pelvic ORIF
163
what should you do for a patient presenting with hematemesis
check for hemodynamic stability before doing upper endoscopy (if unstable, resuscitate and consult surgery/IR until they are stable) if a source is not IDed but bleeding continues, attempt enteroscopy or angiography, then eventually laparoscopy if source not IDed but bleeding is minimal, evaluate for obscure bleeding
164
what should you do for a patient presenting with melena
check for hemodynamic stability before doing colonoscopy if source not IDed but bleeding continues, attempt enteroscopy or angiography before colonoscopy if source not IDed but bleeding is minimal, perform colonoscopy then evaluate for obscure bleeding if bleeding continues without an IDed source, try deep small bowel enteroscopy, Meckel's scan or laparoscopy
165
what do you do for a patient presenting with hematochezia
check for hemodynamic stability before doing upper colonoscopy if source not IDed and bleeding continues, attempt deep small bowel enteroscopy, Meckel's scan or laparoscopy
166
what are the major pathologies associated with/causing upper GI bleeding
1. ulcerative - -PUD - -esophagitis 2. portal HTN - -esophageal varices 3. arterial, venous, other vascular malformations 4. trauma or post-surgical - -mallory weiss tear - -post gastric/duodenal polypectomy 5. tumours
167
how do you manage an upper GI bleed
1. CBC, lytes, coag studies, liver enzymes, albumin/BUN/creatinine 2. obtain type and screen or type and crossmatch while attempting hemodynamic stabilization 3. NG lavage if the source of the bleeding is unclear (helps clean the stomach too before endoscopy) 4. monitor ABCDEs and vitals and urine output and NG output 5. NPO and establish IV access and supplemental O2 6. transfuse if necessary 7. consult GI and surgery and IR
168
what are the major causes of lower GI bleeding
1. anatomic - -diverticulosis 2. vascular - -hemorrhoids, ischemia 3. inflammatory - -infectious or IBD 4. ulcerous 5. neoplastic - -polyp or carcinoma
169
how do upper GI bleeds present
hematemesis and melena if brisk bleeding it can be hematochezia, hypotension and tachycardia
170
how does a lower GI bleed present
BRBPR if transverse colon or beyond may present with melena quite proximal