Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Surgery > urology > Flashcards

urology Flashcards

1
Q

which is more concerning, gross or microhematuria

A

gross

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

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

A

glomerulonephritis
UTI
congenital anomalies

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

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

A

UTI
stones
bladder tumour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

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

A

5%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

ddx of hematuria

A

most common are all pre or post renal

tumour
trauma
infections
stones
coagulopathy (doesn't cause gross hematuria)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

things to ask on hx that suggest uro malignancy

A 
weight loss
night sweats
flank pain
N/V
voiding changes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

numer 1 risk factor for urothelial tumours

A

smoking

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what to ask on hx to evaluate stones

A

flank/abdo pain

dysuria

previous stones

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what to ask on hx to evaluate uro infection

A

fever

chills

suprapubic or flank pain

dysuria

frequency

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

can you use IVP or retrograde pyelogram for kidney tumours

A

no

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

what do you use IVP or retrograde pyelogram for

A

suspected stones or urothelial tumours of bladder and ureter

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
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)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

when do we work up hematuria

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

when should you refer a patient with hematuria to a urologist

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

how you do diagnose urothelial carcinoma

A

cytoscopy and biopsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

what should you make sure to have done before making your uro referral for hematuria

A 
hx
px
U/A
urine cytology
imaging to get dx as much as possible, with initial management and stabilizations of patient.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

what is the imaging choice if the suspected cause of the hematuria is:

  1. post renal
  2. renal
A
  1. CT–> post renal

2. U/S–> renal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

what is the workup for urothelial carcinoma

A

cytoscopy and biopsy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

treatment of urothelial cancers

A

transurethral resection of the lesion and underlying detrusor muscle to stage the tumour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

risk factors for urothelial tumours

A 
SMOKING
occupational exposures
meds
previous radiation
chronic infection or inflammation
irritation (i.e catheters)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

ddx of urothelial tumours

A

urothelial carcinoma (transition cell)

adenocarcinoma (dome/trigone of bladder)

squamous cell carcinoma (associated with chronic inflammation from bladder stones, indwelling catheter etc)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

most common urothelial tumour

A

urothelial carcinoma (transitional cell carcinoma)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

what kind of urothelial tumour is associated with associated with chronic inflammation from bladder stones, indwelling catheter etc

A

squamous cell carcinoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

what kind of urothelial tumour is associated with dome/trigone of bladder

A

adenocarcinoma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

how do you assess severity of a urothelial tumour

A
  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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

treatment of non-muscle invasive bladder cancer

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
39
Q

what agent is commonly used as intravesical chemo if bladder cancer is high grade, or multifocal or etc…

A

cisplatin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
40
Q

what might you use to try and prevent recurrence after bladder cancer resection

A

mitomycin C

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
41
Q

how do you treat muscle invasive bladder cancer

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
42
Q

ddx for benign renal mass on imaging

A

oncocytoma
angiomyolipoma –> fat; observable
abscess
pseudotumour –> dromedary hump, hypertrophied column of Bertin, compensatory hypertrophy

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
43
Q

ddx for malignant renal mass on imaging

A

renal cell carcinoma (most common)

urothelial cell carcinoma
mets–> lymphoma/leukemia, lung, breast
Wilms tumour (kids)–> highly treatable, arises from parenchyma

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
44
Q

what is the likely diagnosis for a central renal mass in the collecting duct

A

transitional cell carcinoma/urothelial cell carcinoma

lines the renal pelvis, ureters, bladder

RESECT ALL IF MALIGNANT

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
45
Q

how are renal masses usually detected

A

incidentally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
46
Q

classic triad of symptoms of renal mass

A

flank pain

hematuria

palpable mass (uncommon)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
47
Q

what type of mass makes up 90% of malignant renal masses

A

renal cell carcinoma

25% present with mets

clear cell RCC is the most common subtype

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
48
Q

where are mets commonly from if met to kidney

A

lymphoma
leukemia
lung
breast

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
49
Q

investigations to work up a renal mass

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
50
Q

what test can be done to help distinguish between real kidney tumours and pseudotumours

A

decreased DMSA uptake indicates real tumours, normal uptake indicates psuedotumour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
51
Q

how do you treat RCC

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
52
Q

what chemo agent do you use to treat metastatic RCC (in addition to nephrectomy)

A

sunitinib

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
53
Q

what is the most common cause of renal colic

A

acute obstruction of the ureter by the stone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
54
Q

when do non-obstructing stones cause pain

A

only when occur with UTI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
55
Q

what size stones usually pass on their own?

A

stones less than 4mm are 90% likely to pass

stones over 8mm are only 20% likely to pass

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
56
Q

what are the 3 most common sites of ureteric stones

A

sites of physiologic narrowing–

  1. uretero-pelvic junction
  2. crossing of the iliac vessels
  3. uretero-vesical junction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
57
Q

ddx for renal colic

A

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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
58
Q

lab investigations for renal colic

A

CBC (WBC indicates inflammation and infection)

creatinine (renal function/obstruction)

urine micro (bacteriuria, pyuria, pH)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
59
Q

imaging for renal colic FIRST TEST

A

plain film KUB

85% of stones are radioopaque except uric acid stones (needs CT)–> there is no info about obstruction tho

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
60
Q

which stones are NOT radio opaque

A

uric acid stones

struvite stones

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
61
Q

imaging beyond plain film KUB for renal colic

A

CT scan without contrast or CT-KUB (fast, easy, inexpensive, gives info on obstruction)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
62
Q

how do you manage small stones that are asymptomatic

A

watchful waiting

ALPHA BLOCKERS can relax the ureter and may help with spontaneous passage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
63
Q

when should you refer a patient with stones to a urologist

A
  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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
64
Q

how do you treat stones causing obstruction

A
  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
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
65
Q

what is the most common type of renal stone

A

calcium oxalate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
66
Q

risk factors for calcium oxalate stones

A

hypercalciuria (hyperparathyroidism or dietary intake)

high sodium or protein diet

chocolate

nuts

tea

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
67
Q

what is the second most common type of renal stone

A

calcium phosphate

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
68
Q

in what type of patients do you find calcium phosphate stones

A

those with metabolic abnormalities–hypercalcemia, primary hyperparathyroidism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
69
Q

what types of stones are associated with infectious causes

A

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
Q

risk factors for uric acid stones

A

persistent acidic urine

low urine volumes

gout

excess purine in diet (meat)

71
Q

how do you investigate microhematuria

A

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
Q

describe a diagnostic approach to a scrotal mass

A
  1. infectious–> PAINFUL
    - -epididymitis or orchitis
  2. anatomic
    - -hydrocele, varicocele, spermatocele
    - -testicular torsion or torsion of appendix testis
  3. malignant
    - -testis tumour
73
Q

what investigations should you do in someone with a scrotal mass

A
  1. U/A–> pyuria with epididymitis/orchitis

2. U/S–> very sensitive and specific for testicular tumours

74
Q

what is epididymitis

A

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
Q

how does acute epididymitis present

A

acute pain, testicular swelling, erythema, hardening with or without dysuria, fever, pyuria

investigate with CBC, U/A for pyuria, consider doppler U/S

76
Q

how do you treat acute epididymitis

A

NSAIDs

abx for 4 weeks

ice prn

77
Q

what virus is associated with orchitis

A

mumps–> can lead to sterility

can also be associated with other viruses

78
Q

how does orchitis present

A

swollen and very tender testicles, often bilaterally

79
Q

what is a hydrocele

A

fluid within the layers of the tunica vaginalis at a certain point

is a communicating hydrocele if the processus vaginalis is patent

80
Q

how does a hydrocele typically present

A

painless

transilluminates

testicle palpation is difficult

81
Q

how do you treat a hydrocele

A

none required, may do for cosmetic reason

82
Q

what is a spermatocele

A

aneurysmal blowout of the epididymis (dilation of the tubule)

83
Q

how does a spermatocele usually present

A

typically painless

transilluminates

can palpate testicle separate from mass

84
Q

how do you treat a spermatocele

A

none required as they generally dont grow or cause problems, may treat for cosmetic reasons

85
Q

what is a varicocele

A

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
Q

how does a varicocele usually present

A

typically asymptomatic

increases with standing or valsalva

palpated as “bag of worms”/spaghetti in the scrotum/cord

87
Q

treatment for varicocele

A

surgical or sclerotherapy

88
Q

what is the most common age group to present with testicular torsion

A

12-18 year olds

89
Q

why do we care about testicular torsion

A

surgical emergency requiring surgical scrotal exploration as there is 6 hours to prevent irreversible testicular ischemia

90
Q

how does testicular torsion present on physical exam

A

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
Q

investigations for testicular torsion

A

U/A to rule out pyuria for epididymitis

doppler to clarify diagnosis

92
Q

treatment for testicular torsion

A

surgical detorsion and orchidoplexy (fix the testicle in the scrotum)

93
Q

how does torsion of appendix testis present

A

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
Q

investigations for torsion of appendix testis

A

U/A to rule out epididymitis

dopple to assess perfusion

95
Q

treatment for torsion of appendix testis

A

conservative, symptom management and urological assessment

96
Q

how does testicular cancer usually present

A

as painless mass in young healthy men aged 15-35 found on self exam

on px–> hard, irregular, doesn’t transilluminate, B symptoms

97
Q

what are the types of testicular cancer

A

primary vs secondary

primary is germ cell vs non germ cell

germ cell is non seminoma versus seminoma

98
Q

investigations for testicular cancer

A
  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
Q

treatment rates for testicular cancer

A

cure rates are very good

germ cell tumours are highly chemosensitive

radical orchiectomy (ALWAYS via the inguinal canal retroperitoneal, not the scrotum)

100
Q

where do seminoma germ cell tumours originate

A

germinal epithelium of the seminiferous tubules

older and middle aged patients, less aggressive

101
Q

what are the types of non-seminoma germ test testicular cancers

A

embryonal carcinoma

teratoma or teratocarcinoma

choriocarcinoma

yolk sac tumour

102
Q

list the two types of non germ cell testicular cancers

A

leydig cell tumour

sertoli cell tumour

103
Q

what are the two most common types of secondary testicular cancer

A

lymphoma

leukemia

104
Q

what innervates the detrusor muscle

A

parasympathetics S234 via the pelvic splanchnic nerve to cause urination

105
Q

what innervates the trigone

A

sympathetics T11-L1, L2 via the hypogastric nerves to cause the detrusor relaxation and bladder neck constriction

106
Q

how many sphincters does the male urethra have? female?

A

male–> 2

female–> 1

107
Q

how are the male urethral sphincters innervated

A

internal INvoluntary sphincter–> sympathetic L1/2

external voluntary sphincter–> pudendal nerve from S234

(prostatic, membranous, bulbar and penile parts to the urethra)

108
Q

how does bladder filling work

A

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
Q

how does bladder emptying work

A

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
Q

define neurogenic bladder

A

dysfunction of the urinary bladder due to neurologic dysfunction or insult

111
Q

define spastic bladder–what causes it?

A

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
Q

define flaccid bladder–what causes it?

A

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
Q

what are the two types of voiding dysfunction

A

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
Q

define urge incontinence

A

involuntary loss with strong desire to void

115
Q

etiology of urge incontinence

A

stone

UTI

tumour

overactive bladder

116
Q

investigations for urge incontinence

A

hx/px

urodynamics

UA

urine cx

maybe U/S

117
Q

treatment for urge incontinence

A

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
Q

etiology of stress urinary incontinence

A

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
Q

risk factors for stress urinary incontinence

A

obesity

female

pregnancy and vaginal deliveries

hysterectomy

prostatectomy

strenuous activity

120
Q

treatment for stress urinary incontinence

A

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
Q

what is overflow incontinence and how do you treat it

A

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
Q

what is a pneumonic to remember the causes of transient urinary incontinence

A

DIAPERS

123
Q

what does the DIAPERS mnemonic stand for

A

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
Q

describe the questions included in a focused voiding issue history

A

urgency, frequency, dysuria

fluid intake

associated with valsalva?

medications

neurological deficits (MS, spinal cord injuries, paresthesias)

diseases like diabetes

125
Q

what investigations should be done to investigate voiding problems

A
  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
Q

indications for uro referral with voiding problem

A

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
Q

what are the symptoms associated with storage issues

A

irritative

frequency, urgency, nocturia

128
Q

what are the symptoms associated with obstructive voiding problems

A

hesitancy

slow stream

stuttering stream

dribbling

129
Q

what are symptoms of uncomplicated BPH

A

microhematuria

NOT usually dysuria and incontinence

130
Q

ddx of lower urinary tract symptoms (LUTS) in older men

A
  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
Q

what are the two main types of tissue in the prostate

A

stroma (smooth muscle and collagen)

epithelium

132
Q

where does BPH occur

A

the transition zone

133
Q

where does prostate cancer most often occur

A

peripheral zones

134
Q

what is BPH

A

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
Q

complications of BPH

A

urinary retention

atonic bladder

renal failure and blockage

recurrent UTIs

bladder stones

hematuria

136
Q

alpha blocker size effects

A

dizziness

fatigue

nasal congestion

retrograde ejaculation

137
Q

5-ARI side effects

A

ED

decreased libido

decreased volume of ejaculation (not common)

138
Q

management of BPH–> lifestyle

A

decrease fluids, caffeine, alcohol, decongestants, lose weight, exercise

139
Q

how do you manage BPH

A
  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
Q

what is TURP

A

trans urethral resection of the prostate

involves electrocautery resection endoscopically

can cause bleeding, perforation, and some electrolyte imbalances

141
Q

what are some MIS options for BPH management

A

injections like botox, photodynamic therapy, needle ablation, high intensity U/S, microwave tx etc…

142
Q

when is surgery for BPH indicated

A

mainly if symptoms are refractory to medical therapies (i.e having recurrent UTI, retention, hematuria, renal impairment etc)

143
Q

if the prostate is small and the PSA is low… how do you treat BPH

A

alpha blocker

144
Q

if the prostate is large and the PSA is high… how do you treat BPH

A

combination

145
Q

what are potential causes of gross hematuria after injury

A

renal
ureteric
bladder
urethral injury

146
Q

what is the most commonly injured organ in GU trauma

A

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
Q

how do you work up a possible GU trauma

A

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
Q

what imaging should be done for a GU trauma

A

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
Q

what are absolute indications for surgical treatment of GU trauma

A
  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
Q

relative indications for surgical treatment of GU trauma

A
  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
Q

what is the AAST organ injury severity scale for the kidney

A
  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
Q

how should you manage a person who had a bike accident and presents stable but with gross hematuria

A

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
Q

what is the etiology of blunt bladder trauma

A

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
Q

physical signs of bladder trauma

A

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
Q

investigations for bladder trauma

A

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
Q

when do posterior urethral injuries commonly happen?

A

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
Q

how do you diagnose posterior urethral injury?

A

blood at meatus in 50%

high riding prostate

inability to urinate and place urethral catheter is classic

investigate with retrograde urethrogram

158
Q

treatment for posterior urethral injury

A

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
Q

how are most kidney injuries treated

A

non operatively

160
Q

indications for kidney operation after trauma

A

grade V renal injury

persistent bleeding

suspected ureter or collecting system injury

incomplete staging and already having a lap

161
Q

what should you do for a patient if they have a pelvic fracture?

A

CT cystogram

162
Q

how do you manage most extraperitoneal bladder ruptures

A

conservatively

but consider treating extraperitoneal bladder ruptures OPEN, especially if undergoing lap and definitely if undergoing pelvic ORIF

163
Q

what should you do for a patient presenting with hematemesis

A

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
Q

what should you do for a patient presenting with melena

A

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
Q

what do you do for a patient presenting with hematochezia

A

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
Q

what are the major pathologies associated with/causing upper GI bleeding

A
  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
Q

how do you manage an upper GI bleed

A
  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
Q

what are the major causes of lower GI bleeding

A
  1. anatomic
    - -diverticulosis
  2. vascular
    - -hemorrhoids, ischemia
  3. inflammatory
    - -infectious or IBD
  4. ulcerous
  5. neoplastic
    - -polyp or carcinoma
169
Q

how do upper GI bleeds present

A

hematemesis and melena

if brisk bleeding it can be hematochezia, hypotension and tachycardia

170
Q

how does a lower GI bleed present

A

BRBPR if transverse colon or beyond

may present with melena quite proximal

Surgery (20 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions