Urology Flashcards
1
Q
According to the WHOLE of Kettering, how can urological conditions be classified?
A
Into 5 malignancies, 5 emergencies, and 5 benign/other
2
Q
What are the main 5 urology malignancies?
A
Renal, Bladder, Testicular, Prostate, and Penile
3
Q
Which of the 2 urology malignancies are the most common?
A
Prostate (in older men, testicular in younger men) and kidney
4
Q
How can the urology emergenices be classified?
A
Haematuria Retention Flank pain Testicular pain Other
5
Q
How can the urology benign conditions be classified?
A
BPH Stones Infections Obstruction Other
6
Q
What 4 common operations are big offenders for causing retention in patients up to 3 months after the event?
A
Cataract
Hip
Gallbladder
Hernia repair
7
Q
Name some drugs that cause urinary retention
A
Antihistamines Anti-cholinergics Opiates (via constipation and reduced innervation) TCAs Anti-epileptics Alcohol Ca Channel blockers NSAIDs
8
Q
Define urinary retention
A
The inability to empty the bladder completely
9
Q
How can retention be classified?
A
Acute and painful, or chronic and painless
10
Q
How do these 2 types differ wrt micturition?
A
The pt cannot urinate at all in acute, where as in chronic they can but not fully
11
Q
Given that they may not notice a problem, how does a pt with chronic retention usually present?
A
Urinary incontinence
UTI
Acute-on-chronic retention
12
Q
What is the most common cause of urinary retention?
A
Outflow obstruction of bladder
13
Q
How should acute retention be managed initially?
A
Treatment with urinary catheter
14
Q
What can cause obstructive retention in men specifically?
A
BPH Meatal stenosis Paraphimosis/Phimosis Prostate cancer Penile constricting bands
15
Q
What can cause obstructive retention in women specifically?
A
Prolapse
Pelvic mass
Retroverted gravid uterus
16
Q
What pelvic masses might women have?
A
Gynae malignancy
Uterine fibroid
Ovarian cyst
17
Q
What obstructive causes of retention do both women and men get?
A
Bladder calculi Bladder cancer Faecal impaction GI/Retroperitoneal malignancy Urethral strictures Foreign bodies Stones
18
Q
What infections/inflammation can cause retention in men?
A
Balanitis
Prostatitis
Prostatic abscess
19
Q
What infections/inflammation can cause retention in women?
A
Acute vulvovaginitis
Vaginal lichen planus and lichen sclerosis
Vaginal pemphigus
20
Q
What other infections/inflammation can cause retention?
A
Bilharzia Cystitis HSV VZV Peri-urethral abscess
21
Q
Apart from obstruction, infection/inflammation, and drugs, what other major cause is there for retention?
A
Neurological - spinal cord, brain, ANS, or peripheral nerve
22
Q
What peripheral nerve or autonomic dsfunction causes retention?
A
Autonomic neuropathy DM Guillain-Barre syndrome Pernicious anaemia Spinal cord trauma
23
Q
Which spinal nerves are responsible for innervating the bladder?
A
S2,3,4
24
Q
How do we urinate (briefly)?
A
Pressure sensors in bladder wall signal increased pressure to micturition centre -> cortex decides when it is ok to void -> contraction of detrusor muscle so pressure rises to greater than sphincter pressure -> void.
25
What conditions affecting the brain can cause retention?
```
Parkinson's disease
MS
Neoplasm
Hydrocephalus
CVD
```
26
What conditions affecting the spinal cord can cause retention?
```
Disc disease
MS
Spina bifida
Haematoma/abscess
Trauma
Spinal stenosis
Tumours
Cauda equina
```
27
What signs are there for retention on examination?
Full, palpable, tender bladder
28
Retention M:F? Why?
M>F due to BPH
29
What symptoms other than pain could urinary retention present with?
```
Frequency
Urgency
Hesitancy
Poor stream
Post-mic dribbling
Nocturia
Incontinence
Sensation of incomplete emptying
Lethargy
Recurrent infections
```
30
What are the two types of haematuria?
Visible and non-visible
31
What are the 2 main differentials for haematuria that have to be ruled out?
Neoplasia
| Glomerulonephritis
32
Where can the blood originate from in haematuria?
Anywhere in the urinary tract!
33
What transient things can cause haematuria?
UTI
Menstruation
Exercise induced
Post-coital
34
What can non-visible haematuria be divided into?
Symptomatic and asymptomatic
35
What are the differentials for haematuria? Give it a go, it's a long old list...
- Glomerular pathology
- Tumours - RCC, Wilm's, Ureteric, TCC and SCC of bladder
- Infection
- Polycycstic kidneys
- Trauma
- Strictrue
- Renal infarction/vein thrombosis
- Sickle cell
- NSAIDs, anticoags
- Stones
- Polyps
- Schistosoma haematobium
- Prostatitis
- Urethritis
36
What could red urine be if not visible haematuria?
- Haemoglobinuria (haemolysis)
- Myoglobinuria (measure CK)
- Bilirubinuria (obstructive jaundice)
- Beetroot
- Drugs - rifampicin, nitrofurantoin, senna
- Porphyria
37
What questions should you ask in the history for haematuria? (HxPC)
- How often?
- How much?
- Where in the stream?
- Only associated wiht voiding?
- Any associated pain? Location?
38
What questions should you ask in the history for haematuria? (Associated symptoms)
- Any masses
- Trauma
- Happened before?
- Systemic symptoms?
- Recent medical and travel history
39
What questions should you ask about PMH in the history for haematuria?
Previous stones, cancer, anticoagulation, HTN, diabetes, chemotherapy
40
What questions should you ask about SH in the history for haematuria?
```
Smoking
Fumes and chemicals (Leather, rubber, dyes, beta naphthylamines)
Radiotherapy
Immunosuppression
Schistosoma
```
41
What questions should you ask about FH in the history for haematuria?
- Alport's syndrome (Deafness)
- General renal disease
- TB contact
42
What can we see (potentially) with MC&S of urine?
- Schistosoma ova
| - Red cell casts
43
What do red cell casts suggest?
Glomerular disease
44
What else can we do with urine?
- Dip it
| - Send it for cytology
45
What investigations can we do for haematuria?
- U&Es, creatinine for renal function
- FBC (?chronic disease, infection)
- Clotting
- PSA
46
What other investigations (not bloods) can we do for haematuria?
- USS
- CT (***contrast and renal function)
- Cystoscopy
47
What other features make glomerular pathology more likely in haematuria?
- Proteinuria
| - Red cell casts
48
What are the differentials for flank pain?
- Muscular pain
- Dermatological problem
- Neuropathic
- Pleural pain
- Infection
- Pyelonephritis
- Renal abscess
- Vascular - renal infarction or venous obstruction
- Tumour
- Stricture
- External compression
- Outlet obstruction
49
In a renal examination, how should the pt be positioned?
At 45 degrees
50
In a renal examination, what can we look for from the end of the bed?
Catheter - output, colour
Peritoneal dialysis bag
Skin turgor, bruising, uraemic tinge, scratch marks, vasculitic rashes
Alternative vacular access routes
51
What is the main aim of a renal examination?
Assess fluid status - are they fluid depleted, euvolaemic, or in fluid overload
52
What signs can be seen in the hands in a renal examination?
- Pallor (anaemia secondary to end stage renal disease)
- Skin turgor
- Cap refill >2s
- Temperature
- Radial pulse
- Uraemic flapping tremor
53
What signs can be seen in the arms in a renal examination?
- BP
| - Any AV fistulae - recent use, thrills, pulse collapse on elevation
54
What signs can be seen in the neck and face in a renal examination?
- JVP
- Eyes - xanthalasma, corneal arcus, pale conjunctivae
- Tongue for mucous membrane moistness
55
How do we assess the chest and abdomen in a renal examination?
Using parts of the CVS, resp, and GI examinations
56
What elements of the CVS examination does a renal examination use?
- Listen for heart murmurs
| - Palpate for sacral oedema
57
What elements of the respiratory examination does a renal examination use?
-Auscultate for pulmonary oedema
58
What elements of the GI examination does a renal examination use?
- Abdo scars or masses/asymmetry
- Palpation
- ***Ballot the kidneys
- Percussion
- Auscultate for renal bruits
59
Where do you auscultate for renal bruits?
1cm superior and lateral to the umbilicus
60
What signs can there be of renal disease O/E of the legs
-Peripheral oedema
61
How can a renal examination be completed?
- Blood pressure readings (lying and sitting/standing) in both arms
- Digital Rectal Examination
- Urine dipstick
- Fundoscopy (for any evidence diabetic or hypertensive retinopathy)
62
What are some risk factors for stone formation?
- Dehydration/low fluid intake
- Urinary stasis (***bladder stones)
- Foreign body presence eg sutures
- Indwelling catheter
- Gout
63
What can renal stones be formed from (main 2 compounds)?
- Calcium oxalate (75%)
| - Magnesium ammonium phosphate (15%)
64
What other compounds can stones be formed from?
- Urate
- Hydroxyapatite
- Brushite
- Cystine
- Mixed
65
When is the peak age for urinary tract calculi?
20-40 years old
66
Where do stones commonly get stuck?
- pelviureteric junction
- pelvic brim
- vesicoureteric junction
67
What is the classical presentation of testicular torsion in a young boy?
```
Severe lower abdo pain
Unilateral testicular swelling and elevation
V v v tender to touch
Apyrexial
Cremasteric reflex absent
```
68
How should testicular torsion be managed?
Emergency surgical exploration within 4-6 hours
69
What is the consequence if testicular torsion is not taken to theatre within 4-6 hours?
Irreversible testicular necrosis
70
Tell me some stats about testicular cancer.
Most common malignancy in men aged 20-30.
95% are germ cell tumours
71
What is the classic triad for renal cancer?
Flank pain
Mass
Haematuria
72
How do we treat renal calculi in acute presentations?
| initial management and surgical intervention
Analgesia (e.g. diclofenac)
Antiemetic
IV fluids
Surgery - percutaneous nephrostomy &/or ureteric stent insertion
73
If a pt with a stone comes in for elective surgery, what can we do?
Extracorporeal shock wave lithotripsy
Percutaneous nephrolithotomy
Endoscopic treatment
Open nephrolithotomy/ureterolithotomy
74
How do we prevent stone formation?
```
Increase oral fluid intake
Decrease calcium intake
Prompt treatment of infection
Urinary alkalisation
Thiazide diuretics
```
75
What is the bad thing that happens due to ureteric obstruction?
Hydronephrosis
76
What are the clinical features of obstruction?
Lion pain
Fever &/or rigors
Signs and symptoms of renal failure/AKI
77
How do we treat obstruction?
Identify and treat the cause
78
How do we emergency treat obstruction?
Drain the kidney via percutaneous nephrostomy or retrograde ureteric stent
79
What is BPH?
A non malignant enlargement of the prostate gland
80
How many men over 60 have BPH?
~40%
81
What are the main features of BPH?
- Storage problems (frequency, urgency, nocturia, incontinence)
- Voiding problems (hesitancy, poor stream, terminal dribble, straining)
- Dysuria/haematuria due to superimposed infection
- Retention
82
O/E what signs are there for BPH?
- DRE -> smooth enlargement of gland
- Palpable bladder if in retention
- Check for neuro signs with LUTS
83
What tests would you do for BPH?
- Urinalysis
- Urine flowmetry
- Serum creatinine
- Serum PSA to assess for features of malignancy
84
What medical treatment can we offer for BPH?
- Watchful waiting if not complicated
- alpha-adrenergic antagonists eg doxazosin
- 5 alpha reductase inhibitors e.g. finasteride
Usually combination therapy
85
What surgical intervention can we offer for BPH?
Trans-urethral resection of prostate (TURP)
TU incision in the prostate
Prostatectomy (laser or open retropubic)
86
What surgical investigations can we do for BPH?
TRUS biopsy (transrectal US) to rule out malignancy
Cystoscopy
Microwave ablation
87
Where do most prostate cancers form?
Peripheral zone of the prostate gland
88
Which zones of the prostate are most prone to BPH?
Central and transitional zone
89
What is the arterial supply to the prostate?
3 vessels - inferior vesical, inferior rectal, internal pudendal
90
What is the venous drainage of the prostate?
Plexus beneath the capsule
91
What is the male to female ratio for RCCs?
3:1 M:F
92
What are the clinical features of RCC?
- May be asymptomatic
- Painless haematuria
- Groin pain
- Mass in flank
- Chest symptoms or bone pain if mets
- FH
93
How should RCC be investigated?
- Blood tests - Hb and ferritin (anaemia), U&Es (renal function), Ca and Alk phos (bony mets)
- CT bdo-chest with contrast
- Isotope bone scan (mets)
94
What surgical interventions are there for RCC?
Open or laparoscopic nephrectomy but only under some conditions
95
What types of nephrectomy are there?
Partial (peripheral tumours) or radical (large tumours)
96
What are the conditions that mean nephrectomy is excluded in RCC?
Elderly pts
Extensive local invasion
Mets (unless one met that can be removed easily)
97
What medical therpies are there for RCC?
Only really things to treat mets.
Biological therapies, chemo, hormonal therapy.
Radiotherapy to palliate bony mets
98
Where do TCCs occur?
Any part of the urinary epithelium
99
What are the main risk factors for TCC?
- Smoking
| - Exposure to aromatic hydrocarbons (petrochemicals, dye, rubber, chimney sweeps - occupational hx)
100
What % of TCCs are superficial?
70%
101
What other bladder cancers can there be?
Squamous cell and adenocarcinomas
102
What causes squamous cell carcinoma of the bladder?
Chronic irritation caused by schistosomiasis, indweliing catheter, repeated previous surgeries
103
What are the clinical features of TCC?
Painless haematuria usually
Sometimes present with painful micturition, renal colic, retention
104
How is TCC diagnosed/investigated?
Urine cytology
Cystoscopy
Transurethral resection
KUB imaging
105
Why is prostate cancer sooooooo important?
It is the most commonly diagnosed cancer affecting men in the western world
106
When is the peak incidence of prostate cancer?
8th decade (i.e. pts 70s)
107
What % of prostate cancer pts present with bony mets?
20%
108
How does prostate cancer present?
With LUTS, just like BPH
| May also present with bone pain if mets
109
Is serum PSA good?
Its highly sensitive but not very specific, so it can be used in diagnosis, but is more useful as a tool for monitoring disease progression
110
What investigations can we do for suspected prostate cancer?
- TRUS + biopsy
- Pelvic MRI
- Laparoscopic node biopsy
- Isotope bone scan
111
How is localised prostate cancer treated in pts with life expectancy less than 10 years?
Active monitoring of PSA
LUTS controlled with alpha blockers
TURP if symptoms severe
112
How is localised prostate cancer treated in pts with life expectancy more than 10 years?
Radical prostatectomy
External beam radiotherapy
Brachytherapy
113
What are the risks and benefits of a radical prostatectomy?
Benefits - complete removal of cancer, stage and grade cancer well
Risks - incontinence, surgical risks, ED
114
What are the risks and benefits of a external eam radiotherapy?
Benefits - Option if not fit for surgery, can carry on normal daily activities, painless, no hospital stay
Risks - cystitis, proctitis, ED, lots of travel and hospital visits, long term follow-up
115
What are the risks and benefits of brachytherapy? Also what is it?
Radioactive "seeds" planted in prostate - its new so not much evidence long term for it either way yet
116
What do we do with acute testicular pain?
Act immediately to preserve testicular function
117
What is the main diagnosis for acute testicular pain?
Testicular torsion
118
What appart from testicular torsion are the differentials for testicular pain?
Torsion of the testicular appendages
Acute epididymo-orchitis
Scrotal oedema
Acute inguinal lymphadenopathy
119
When is the peak incidence age range for testicular torsion?
12-18 years old
120
Why is testicular torsion bad?
Venous obstruction -> increased pressure -> arterial compression -> ischaemia -> necrosis
121
How does testicular torsion classically present?
Moderate/severe pain, unilateral scrotal pain, with N&V, and abdo pain.
122
What do we find O/E of testicular torsion?
Testis globally tender, high in scrotum, slightly enlarged, absent ipsilateral cremasteric reflex (*****)
123
What causes acute epididymo-orchitis?
STIs eg chlamydia and gonorrhoea
124
How do you differentiate acute epididymo-orchitis from testicular torsion?
Gradual onset
Cremasteric reflex preserved
LUTS/pyrexia/urethral discharge
125
How should acute testicular pain be managed?
Acutely, give analgesia and establish diagnosis to treat
If testicular torsion is a differential, every case should be sent for immediate surgical exploration
MSU and swab if suspect infection
126
How is testicular torsion managed surgically?
Affected testicle is detorted and fixed if viable, but excised if clearly non-viable.
Normal testicle is fixed to prevent it torting
127
Where is renal cell carcinoma likely to metastasise to? What will it look like?
The lung - "canon-ball mets"
128
What is the lowest Gleason score that can indicate malignancy?
6
129
What is phimosis?
When the foreskin is too tight and can not be pulled back past the glans.
130
What infection can cause phimosis?
Balanitis Xerotica Obliterans
131
What residual volume of urine is acceptable in pts under 65?
Less than 50ml
132
What residual volume of urine is considered acceptable in pts over 65?
Less than 100ml
133
What residual volume is chronic urinary retention characterised by?
More than 500mls within the bladder after voiding
134
What residual volume suggests acute-on-chronic retention?
More than 800mls
