Urology

Question 1

What is the cremasteric reflex?

Answer 1

Stroking the skin on the medial aspect of the superior thigh causes contraction of the cremaster muscle —> elevation of the testes

May be absent in torsion

Question 2

Remember that testicular torsion is a surgical emergency and needs urgent management

Answer 2

Bot testes have to be fixed to prevent it happening on the ipsilateral side

Question 3

What is your differential for the acute scrotum?

Answer 3

1) testicular torsion
2) torsion of hydatid of Morgagni (blue dot)
3) orchiits
4) strangulated inguinal hernia
5) testicular tumour

Question 4

Epididymis orchitis can be caused by an STI such as chlamydia —> full sexual history, 1st pass urine for chlamydia and gonorrhoea testing

In this case, treatment is with doxycycline

Answer 4

In older men, UTI causes such as e.coli are more likely

Treat with ofloxacin

Question 5

What are the medical options for managing BPH?

Answer 5

1) modify fluid intake
2) alpha blocker e.g. tamsulosim which reduces tone in the bladder neck
3) 5 alpha reductive inhibitors e.g. finasteride which reduces conversion of testosterone to the more potent dihydrotestosterone BUT they take months to work

Always remember that watchful waiting is hugely important - if symptoms are mild and cancer has been excluded, it is highly appropriate

Question 6

Which drug is associated with intra-operative floppy iris syndorme?

Answer 6

Tamsulosin

Question 7

Complications of TURP?

Answer 7

• bleeding
• infection
• anaesthetic risk
• retrograde ejaculation
• impotence
• inconvenience

Question 8

How is suspected prostate cancer investigated?

Answer 8

• trans rectal US guided biopsy (for Gleason score)
• MRI
• bone scan e.g. PET to look for mets

Question 9

What is Goserelin (brand name Zoladex)?

Answer 9

1) Injection which suppresses the production of androgens and oestrogens and is used in the management of advanced prostate and breast cancer
2) A synthetic analogue of LHRH - stimulates LH/FSH release and ultimately down-regulates it
3) Initial stimulation can cause a flare of bone disease so patients are given an anti-androgen e.g. cyproterone acetate

Question 10

90% of bladder cancers are TCC. What are the risk factors for an SCC?

Answer 10

• Schistosomiasis
• long term catheterisation
• chronic infection e.g. prostatis

Question 11

Managment of prostatitis?

Answer 11

Ofloxacin/ ciprofloxacin for 28 days

Question 12

For bladder cancer superficial disease is up to T1 e.g. Conley invades lamina propria

Answer 12

All other stages are invasive e.g. T2 = muscle invasion, T3 = outside bladder, T4 = adjacent organs

Question 13

List some causes of renal stones

Answer 13

Infection
Dehydration
Obesity
Hyperparathyroidism
Calcium supplements
Genetics
Congential abnormalities e.g. horseshoe kidney/ duplex kidney 

Remember if the stone is stuck in the mid/ distal ureter then penile/ labial pain is likley

Question 14

What bloods are indicated for ?kidney stones?

Answer 14

FBC
UE
LFT
Ca + Phospahte
Urate

Question 15

80% of small stones (<6mm) will pass spontaenously

Answer 15

For stones not passing:
ESWL for stones >2cm
Large stone >2cm will need a percutaneous nephrolithotomy

Question 16

A patient is found to have cannonball mets on imaging. What is the most likely diagnosis?

Answer 16

Renal cell carcinoma

Question 17

What is the TNM staging for the kidney?

Answer 17

T1 = <7cm and in kidney
T2 = >7cm and in kidney
T3 = extends beyond kidney e.g. IVC or renal vein
T4 = beyond Gerota’s fascia (connective tissue capsule of the kidney)

Question 18

Give a differential for haematuria?

Answer 18

• renal causes e.g. GN, cancer, infection, stone
• ureter causes e.g. cancer, stone, infection, trauma
• bladder causes e.g. infection, tumour, catheter
• urethra causes e.g. trauma, prostate problems, infection,

Question 19

NMP 22 is a marker for…

Answer 19

Bladder cancer

Question 20

Remember all pregnant women with a UTI need a urine sample kept for culture

Answer 20

They also need re-culture 7 days after antibiotics to check infection has cleared - test of cure

Question 21

Which form of imaging is used if there is suspected renal scarring e.g. after UTI?

Answer 21

DMSA - a nuclear medicine scan

Question 22

List some causes of impotence

Answer 22

Psychological 
Alcohol
Drugs e.g. alpha or beta blocker 
Vascular e.g. PAD, DM, HT
Obesity
Neurological e.g. MS or spinal damage
Endocrine e.g. hyperprolactinaemia 

(always ask if they get spontaneous morning erecions - if so then it is likely to be a psychological cause

Question 23

In a patient with acute cholecystitis - when should a laparoscopic cholecystectomy be performed?

Answer 23

In most parties within 1 week of diagnosis

Question 24

Diffuse Axonal injury e.g. due to shear stress caused by acceleration/ deceleration such as RTA is a common brain injury and is the commonest cause…

Answer 24

Of a persistent vegetative state following head injury

Question 25

Which adults need an immediate CT after head injury?

Answer 25

GCS <13
Seizure
Focal neurological deficit
>1 episode of vomiting 
Basal skull #

Question 26

Who needs a head CT within 8 hours?

Answer 26

>65
Bleeding or clotting disorders
Dangerous MOI e.g. hit by car
>30 minutes retrograde amnesia 
Warfarin

Question 27

Which vessel is most likely to be affected in an extra-dural haematoma?

Answer 27

Middle meningeal artery

Question 28

Double vision post facial trauma is suggestive of a depressed fracture of the zygoma

Answer 28

The patient will also have pain opening their mouth

Question 29

Hypospadius is a CI to circumcision as the forsaking is often used in the repair

Answer 29

Peyronie’s disease is where fibrous plaques of tissue form and cause the penis to curve when erect

Question 30

What are the 3 questions to ask about any scrotal swelling?

Answer 30

1) Is it a swelling of the testes itself? Yes = cyst, orhcitis, tumour.
2) does it transluminate? Yes = hydrocoele and cyst. No = tumour etc
3) can you get above it? No = inguinal hernia, yes = can be anything else

Question 31

Who is eligible for colorectal screening programme?

Answer 31

In Scotland, all patients aged 50-74 are offered a FOB every 2 years

Question 32

Which type of imaging is best for assessing a diffuse axonal injury?

Answer 32

MRI brain

Question 33

The use of laproscopic surgery reduces the risk of adhesions

Answer 33

Gloves coated in talc increase adhesions and therefore should not be used

Question 34

What is the likely diagnosis in a patient with painful rectal bleeding after passing stool and a midline sentinel skin tag?

Answer 34

Fissure in ano

The skin tag is highly suggestive of this diagnosis

Question 35

Which is the best blood test for diagnosing acute pancreatitis?

Answer 35

Serum lipase

it is more sensitive and specific than amylase

Question 36

How do you manage post op ileus in a patient who has just had bowel surgery?

Answer 36

1) NBM and NG tube to decompress

2) Introduce fluids and light diet gradually

Question 37

US is the first line imaging for renal stones

Answer 37

Non-contrast CT is then performed to confirm the diagnosis

Question 38

Upper rectal tumours are usually managed with a anterior resection and colo-rectal anastamosis

Answer 38

Lower rectal tunmours requires a domino-perineal excision

Question 39

Always remember that SAH can present with signs of meningeal irritation

Answer 39

If you are considering meningitis you should also be considering SAH

Question 40

Testicular cancer is generally divided into seminoma and non-seminoma

Answer 40

Non-seminoma included yolk sac, teratoma and choriocarcioma

Although seminomas have the best prognosis, all testicular cancers have a pretty good prognosis

Question 41

Young child with rectal bleeding and the appearance of a cherry red lesion on the anal verge after defaecation?

Answer 41

Juvenile polys

not malignant but the marker of an underlying polyposis disorder