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Surgery > Urology > Flashcards

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

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2
Q

What are the main 5 urology malignancies?

A

Renal, Bladder, Testicular, Prostate, and Penile

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3
Q

Which of the 2 urology malignancies are the most common?

A

Prostate (in older men, testicular in younger men) and kidney

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4
Q

How can the urology emergenices be classified?

A 
Haematuria
Retention
Flank pain
Testicular pain
Other
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5
Q

How can the urology benign conditions be classified?

A 
BPH
Stones
Infections
Obstruction
Other
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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

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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
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8
Q

Define urinary retention

A

The inability to empty the bladder completely

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9
Q

How can retention be classified?

A

Acute and painful, or chronic and painless

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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

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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

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12
Q

What is the most common cause of urinary retention?

A

Outflow obstruction of bladder

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13
Q

How should acute retention be managed initially?

A

Treatment with urinary catheter

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14
Q

What can cause obstructive retention in men specifically?

A 
BPH
Meatal stenosis
Paraphimosis/Phimosis
Prostate cancer
Penile constricting bands
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15
Q

What can cause obstructive retention in women specifically?

A

Prolapse
Pelvic mass
Retroverted gravid uterus

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16
Q

What pelvic masses might women have?

A

Gynae malignancy
Uterine fibroid
Ovarian cyst

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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
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18
Q

What infections/inflammation can cause retention in men?

A

Balanitis
Prostatitis
Prostatic abscess

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19
Q

What infections/inflammation can cause retention in women?

A

Acute vulvovaginitis
Vaginal lichen planus and lichen sclerosis
Vaginal pemphigus

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20
Q

What other infections/inflammation can cause retention?

A 
Bilharzia
Cystitis
HSV
VZV
Peri-urethral abscess
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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

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22
Q

What peripheral nerve or autonomic dsfunction causes retention?

A 
Autonomic neuropathy
DM
Guillain-Barre syndrome
Pernicious anaemia
Spinal cord trauma
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23
Q

Which spinal nerves are responsible for innervating the bladder?

A

S2,3,4

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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.

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25
Q

What conditions affecting the brain can cause retention?

A 
Parkinson's disease
MS
Neoplasm
Hydrocephalus
CVD
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26
Q

What conditions affecting the spinal cord can cause retention?

A 
Disc disease
MS
Spina bifida
Haematoma/abscess
Trauma
Spinal stenosis
Tumours
Cauda equina
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27
Q

What signs are there for retention on examination?

A

Full, palpable, tender bladder

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28
Q

Retention M:F? Why?

A

M>F due to BPH

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29
Q

What symptoms other than pain could urinary retention present with?

A 
Frequency
Urgency
Hesitancy
Poor stream
Post-mic dribbling
Nocturia
Incontinence
Sensation of incomplete emptying
Lethargy
Recurrent infections
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30
Q

What are the two types of haematuria?

A

Visible and non-visible

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31
Q

What are the 2 main differentials for haematuria that have to be ruled out?

A

Neoplasia

Glomerulonephritis

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32
Q

Where can the blood originate from in haematuria?

A

Anywhere in the urinary tract!

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33
Q

What transient things can cause haematuria?

A

UTI
Menstruation
Exercise induced
Post-coital

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34
Q

What can non-visible haematuria be divided into?

A

Symptomatic and asymptomatic

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35
Q

What are the differentials for haematuria? Give it a go, it’s a long old list…

A
  • 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
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36
Q

What could red urine be if not visible haematuria?

A
  • Haemoglobinuria (haemolysis)
  • Myoglobinuria (measure CK)
  • Bilirubinuria (obstructive jaundice)
  • Beetroot
  • Drugs - rifampicin, nitrofurantoin, senna
  • Porphyria
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37
Q

What questions should you ask in the history for haematuria? (HxPC)

A
  • How often?
  • How much?
  • Where in the stream?
  • Only associated wiht voiding?
  • Any associated pain? Location?
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38
Q

What questions should you ask in the history for haematuria? (Associated symptoms)

A
  • Any masses
  • Trauma
  • Happened before?
  • Systemic symptoms?
  • Recent medical and travel history
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39
Q

What questions should you ask about PMH in the history for haematuria?

A

Previous stones, cancer, anticoagulation, HTN, diabetes, chemotherapy

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40
Q

What questions should you ask about SH in the history for haematuria?

A 
Smoking
Fumes and chemicals (Leather, rubber, dyes, beta naphthylamines)
Radiotherapy
Immunosuppression
Schistosoma
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41
Q

What questions should you ask about FH in the history for haematuria?

A
  • Alport’s syndrome (Deafness)
  • General renal disease
  • TB contact
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42
Q

What can we see (potentially) with MC&S of urine?

A
  • Schistosoma ova

- Red cell casts

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43
Q

What do red cell casts suggest?

A

Glomerular disease

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44
Q

What else can we do with urine?

A
  • Dip it

- Send it for cytology

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45
Q

What investigations can we do for haematuria?

A
  • U&Es, creatinine for renal function
  • FBC (?chronic disease, infection)
  • Clotting
  • PSA
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46
Q

What other investigations (not bloods) can we do for haematuria?

A
  • USS
  • CT (***contrast and renal function)
  • Cystoscopy
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47
Q

What other features make glomerular pathology more likely in haematuria?

A
  • Proteinuria

- Red cell casts

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48
Q

What are the differentials for flank pain?

A
  • Muscular pain
  • Dermatological problem
  • Neuropathic
  • Pleural pain
  • Infection
  • Pyelonephritis
  • Renal abscess
  • Vascular - renal infarction or venous obstruction
  • Tumour
  • Stricture
  • External compression
  • Outlet obstruction
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49
Q

In a renal examination, how should the pt be positioned?

A

At 45 degrees

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50
Q

In a renal examination, what can we look for from the end of the bed?

A

Catheter - output, colour
Peritoneal dialysis bag
Skin turgor, bruising, uraemic tinge, scratch marks, vasculitic rashes
Alternative vacular access routes

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51
Q

What is the main aim of a renal examination?

A

Assess fluid status - are they fluid depleted, euvolaemic, or in fluid overload

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52
Q

What signs can be seen in the hands in a renal examination?

A
  • Pallor (anaemia secondary to end stage renal disease)
  • Skin turgor
  • Cap refill >2s
  • Temperature
  • Radial pulse
  • Uraemic flapping tremor
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53
Q

What signs can be seen in the arms in a renal examination?

A
  • BP

- Any AV fistulae - recent use, thrills, pulse collapse on elevation

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54
Q

What signs can be seen in the neck and face in a renal examination?

A
  • JVP
  • Eyes - xanthalasma, corneal arcus, pale conjunctivae
  • Tongue for mucous membrane moistness
55
Q

How do we assess the chest and abdomen in a renal examination?

A

Using parts of the CVS, resp, and GI examinations

56
Q

What elements of the CVS examination does a renal examination use?

A
  • Listen for heart murmurs

- Palpate for sacral oedema

57
Q

What elements of the respiratory examination does a renal examination use?

A

-Auscultate for pulmonary oedema

58
Q

What elements of the GI examination does a renal examination use?

A
  • Abdo scars or masses/asymmetry
  • Palpation
  • ***Ballot the kidneys
  • Percussion
  • Auscultate for renal bruits
59
Q

Where do you auscultate for renal bruits?

A

1cm superior and lateral to the umbilicus

60
Q

What signs can there be of renal disease O/E of the legs

A

-Peripheral oedema

61
Q

How can a renal examination be completed?

A
  • Blood pressure readings (lying and sitting/standing) in both arms
  • Digital Rectal Examination
  • Urine dipstick
  • Fundoscopy (for any evidence diabetic or hypertensive retinopathy)
62
Q

What are some risk factors for stone formation?

A
  • Dehydration/low fluid intake
  • Urinary stasis (***bladder stones)
  • Foreign body presence eg sutures
  • Indwelling catheter
  • Gout
63
Q

What can renal stones be formed from (main 2 compounds)?

A
  • Calcium oxalate (75%)

- Magnesium ammonium phosphate (15%)

64
Q

What other compounds can stones be formed from?

A
  • Urate
  • Hydroxyapatite
  • Brushite
  • Cystine
  • Mixed
65
Q

When is the peak age for urinary tract calculi?

A

20-40 years old

66
Q

Where do stones commonly get stuck?

A
  • pelviureteric junction
  • pelvic brim
  • vesicoureteric junction
67
Q

What is the classical presentation of testicular torsion in a young boy?

A 
Severe lower abdo pain
Unilateral testicular swelling and elevation
V v v tender to touch
Apyrexial
Cremasteric reflex absent
68
Q

How should testicular torsion be managed?

A

Emergency surgical exploration within 4-6 hours

69
Q

What is the consequence if testicular torsion is not taken to theatre within 4-6 hours?

A

Irreversible testicular necrosis

70
Q

Tell me some stats about testicular cancer.

A

Most common malignancy in men aged 20-30.

95% are germ cell tumours

71
Q

What is the classic triad for renal cancer?

A

Flank pain
Mass
Haematuria

72
Q

How do we treat renal calculi in acute presentations?

initial management and surgical intervention

A

Analgesia (e.g. diclofenac)
Antiemetic
IV fluids

Surgery - percutaneous nephrostomy &/or ureteric stent insertion

73
Q

If a pt with a stone comes in for elective surgery, what can we do?

A

Extracorporeal shock wave lithotripsy
Percutaneous nephrolithotomy
Endoscopic treatment
Open nephrolithotomy/ureterolithotomy

74
Q

How do we prevent stone formation?

A 
Increase oral fluid intake
Decrease calcium intake
Prompt treatment of infection
Urinary alkalisation
Thiazide diuretics
75
Q

What is the bad thing that happens due to ureteric obstruction?

A

Hydronephrosis

76
Q

What are the clinical features of obstruction?

A

Lion pain
Fever &/or rigors
Signs and symptoms of renal failure/AKI

77
Q

How do we treat obstruction?

A

Identify and treat the cause

78
Q

How do we emergency treat obstruction?

A

Drain the kidney via percutaneous nephrostomy or retrograde ureteric stent

79
Q

What is BPH?

A

A non malignant enlargement of the prostate gland

80
Q

How many men over 60 have BPH?

A

~40%

81
Q

What are the main features of BPH?

A
  • Storage problems (frequency, urgency, nocturia, incontinence)
  • Voiding problems (hesitancy, poor stream, terminal dribble, straining)
  • Dysuria/haematuria due to superimposed infection
  • Retention
82
Q

O/E what signs are there for BPH?

A
  • DRE -> smooth enlargement of gland
  • Palpable bladder if in retention
  • Check for neuro signs with LUTS
83
Q

What tests would you do for BPH?

A
  • Urinalysis
  • Urine flowmetry
  • Serum creatinine
  • Serum PSA to assess for features of malignancy
84
Q

What medical treatment can we offer for BPH?

A
  • Watchful waiting if not complicated
  • alpha-adrenergic antagonists eg doxazosin
  • 5 alpha reductase inhibitors e.g. finasteride

Usually combination therapy

85
Q

What surgical intervention can we offer for BPH?

A

Trans-urethral resection of prostate (TURP)
TU incision in the prostate
Prostatectomy (laser or open retropubic)

86
Q

What surgical investigations can we do for BPH?

A

TRUS biopsy (transrectal US) to rule out malignancy
Cystoscopy
Microwave ablation

87
Q

Where do most prostate cancers form?

A

Peripheral zone of the prostate gland

88
Q

Which zones of the prostate are most prone to BPH?

A

Central and transitional zone

89
Q

What is the arterial supply to the prostate?

A

3 vessels - inferior vesical, inferior rectal, internal pudendal

90
Q

What is the venous drainage of the prostate?

A

Plexus beneath the capsule

91
Q

What is the male to female ratio for RCCs?

A

3:1 M:F

92
Q

What are the clinical features of RCC?

A
  • May be asymptomatic
  • Painless haematuria
  • Groin pain
  • Mass in flank
  • Chest symptoms or bone pain if mets
  • FH
93
Q

How should RCC be investigated?

A
  • 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
Q

What surgical interventions are there for RCC?

A

Open or laparoscopic nephrectomy but only under some conditions

95
Q

What types of nephrectomy are there?

A

Partial (peripheral tumours) or radical (large tumours)

96
Q

What are the conditions that mean nephrectomy is excluded in RCC?

A

Elderly pts
Extensive local invasion
Mets (unless one met that can be removed easily)

97
Q

What medical therpies are there for RCC?

A

Only really things to treat mets.

Biological therapies, chemo, hormonal therapy.

Radiotherapy to palliate bony mets

98
Q

Where do TCCs occur?

A

Any part of the urinary epithelium

99
Q

What are the main risk factors for TCC?

A
  • Smoking

- Exposure to aromatic hydrocarbons (petrochemicals, dye, rubber, chimney sweeps - occupational hx)

100
Q

What % of TCCs are superficial?

A

70%

101
Q

What other bladder cancers can there be?

A

Squamous cell and adenocarcinomas

102
Q

What causes squamous cell carcinoma of the bladder?

A

Chronic irritation caused by schistosomiasis, indweliing catheter, repeated previous surgeries

103
Q

What are the clinical features of TCC?

A

Painless haematuria usually

Sometimes present with painful micturition, renal colic, retention

104
Q

How is TCC diagnosed/investigated?

A

Urine cytology
Cystoscopy
Transurethral resection
KUB imaging

105
Q

Why is prostate cancer sooooooo important?

A

It is the most commonly diagnosed cancer affecting men in the western world

106
Q

When is the peak incidence of prostate cancer?

A

8th decade (i.e. pts 70s)

107
Q

What % of prostate cancer pts present with bony mets?

A

20%

108
Q

How does prostate cancer present?

A

With LUTS, just like BPH

May also present with bone pain if mets

109
Q

Is serum PSA good?

A

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
Q

What investigations can we do for suspected prostate cancer?

A
  • TRUS + biopsy
  • Pelvic MRI
  • Laparoscopic node biopsy
  • Isotope bone scan
111
Q

How is localised prostate cancer treated in pts with life expectancy less than 10 years?

A

Active monitoring of PSA
LUTS controlled with alpha blockers
TURP if symptoms severe

112
Q

How is localised prostate cancer treated in pts with life expectancy more than 10 years?

A

Radical prostatectomy
External beam radiotherapy
Brachytherapy

113
Q

What are the risks and benefits of a radical prostatectomy?

A

Benefits - complete removal of cancer, stage and grade cancer well

Risks - incontinence, surgical risks, ED

114
Q

What are the risks and benefits of a external eam radiotherapy?

A

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
Q

What are the risks and benefits of brachytherapy? Also what is it?

A

Radioactive “seeds” planted in prostate - its new so not much evidence long term for it either way yet

116
Q

What do we do with acute testicular pain?

A

Act immediately to preserve testicular function

117
Q

What is the main diagnosis for acute testicular pain?

A

Testicular torsion

118
Q

What appart from testicular torsion are the differentials for testicular pain?

A

Torsion of the testicular appendages
Acute epididymo-orchitis
Scrotal oedema
Acute inguinal lymphadenopathy

119
Q

When is the peak incidence age range for testicular torsion?

A

12-18 years old

120
Q

Why is testicular torsion bad?

A

Venous obstruction -> increased pressure -> arterial compression -> ischaemia -> necrosis

121
Q

How does testicular torsion classically present?

A

Moderate/severe pain, unilateral scrotal pain, with N&V, and abdo pain.

122
Q

What do we find O/E of testicular torsion?

A

Testis globally tender, high in scrotum, slightly enlarged, absent ipsilateral cremasteric reflex (*****)

123
Q

What causes acute epididymo-orchitis?

A

STIs eg chlamydia and gonorrhoea

124
Q

How do you differentiate acute epididymo-orchitis from testicular torsion?

A

Gradual onset
Cremasteric reflex preserved
LUTS/pyrexia/urethral discharge

125
Q

How should acute testicular pain be managed?

A

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
Q

How is testicular torsion managed surgically?

A

Affected testicle is detorted and fixed if viable, but excised if clearly non-viable.
Normal testicle is fixed to prevent it torting

127
Q

Where is renal cell carcinoma likely to metastasise to? What will it look like?

A

The lung - “canon-ball mets”

128
Q

What is the lowest Gleason score that can indicate malignancy?

A

6

129
Q

What is phimosis?

A

When the foreskin is too tight and can not be pulled back past the glans.

130
Q

What infection can cause phimosis?

A

Balanitis Xerotica Obliterans

131
Q

What residual volume of urine is acceptable in pts under 65?

A

Less than 50ml

132
Q

What residual volume of urine is considered acceptable in pts over 65?

A

Less than 100ml

133
Q

What residual volume is chronic urinary retention characterised by?

A

More than 500mls within the bladder after voiding

134
Q

What residual volume suggests acute-on-chronic retention?

A

More than 800mls

Surgery (11 decks)

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