Urology Flashcards
Risk factors for bladder cancer
smoking aromatic amine exposure
Most common type of bladder cancer
TCC
Most common presenting symptom in bladder cancer
haematuria
Gold standard investigation in bladder cancer
cystoscopy
Management of bladder cancer Superficial disease Invasive disease
Endoscopic resection and intravesical chemo Radical cystectomy / radical radiotherapy §
Most kidney cancers are?
adenocarcinomas
Hippel-Lindau disease =
familial variant of RCC
Clinical features of kidney cancer
haematuria loin pain weight loss abdo mass hypertension hypercalcaemia
where does kidney cancer usually spread to?
lungs / bone / lymph
Imaging in kidney cancer?
USS CT - gold standard
Treatment of choice in kidney cancer
nephrectomy
Symptoms of urinary obstruction
Hesitancy Poor stream Dribbling Incomplete voiding Retention
Key examination to be done in suspected BPH
PR - nodular prostate
Blood tests in BPH
FBC UandE PSA
Treatment of BPH Conservative Medical Surgical
Watch and wait Catheterise for retention Alpha blocker - tamsulosin 5 alpha 2 reductase inhibitors - finasteride TURP
Symptoms of bladder irritation
Frequency Nocturia Urgency
In which part of the prostate does BPH usually develop ->
Urethral prostate (centre)
In which part of the prostate does prostate cancer usually develop ->
Peripheral so presents late often
How is response to therapy measure in prostate cancer?
PSA
scans in prostate cancer
transurethral US CT/MR abdo for staging bone scan
Brachytherapy =
radioactive seeds implanted in the prostate
Treatment of prostate cancer Medical Surgical
Chemo / radio Hormone therapy Radical prostatectomy for T1 and T2
SE of radical prostatectomy
Impotence and incontinence
Where does prostate cancer often metastasie to?
bone
Causes of urine w/ puss
TB partially treated UTI Malignancy Kidney stones
Causes of a UTI (bacteria)
E.coli Staphlyococci Enterobacteria
Which bacteria are associated with stone formation?
proteus
Risk factors for a UTI
DM Pregnancy Abnormal urinary tract Stones Poor bladder emptying
Cystitis presentation
Dysuria Haematuria Suprapubic tenderness Nocturia
Prostatitis presentation
Back pain Tender prostate on examination
Pyelonephritis presentation
Loin to groin pain Fever Rigors Vomiting Renal angle tenderness Smelly urine increased frequency of micturition
Two main things on dip for a UTI
Nitrites Leukocytes
Further tests / imaging suggested for which groups with a UTI?
US/ KUB - frequent UTIs and a women - single UTI in man / child
Treatment for prostatitis
ciprofloxacin
Acute pyelonephritis treatment
admit for fluids Cefuroxime
Definition of polyuria
>3.5L/ 24hrs
Causes of polyuria
Polydipsia Hyperglycaemia Hypercalcaemia Hyperureamia Diabetes Diuretics
Associated symptoms with polyuria
Polydypsia Thirst Weight loss
Bed side investigations in polyuria
Fluid balance Weigh the patients Bloods - FBC, UandE, calcium, glucose, LFTs, osmolality Urine dip Urine culture Urine osmolality
Definition of oliguria
<300ml/ 24hrs
Causes of oliguria Pre renal Renal Postrenal
Hypotension - sepsis, cardiogenic, renal artery obstruction Glomerulonephritis AKI / failure Acute tubular nephrosis
Bedside tests in oliguria
BP Hydration status Bloods - FBC, UandEs, osmolality, glucose, calcium, bicarb, urate Urine dip Urine osmolality
Imaging in oliguria
US DMSA scan
What two conditions does haematuria differentiate?
Nephritic from nephrotic syndrome
BURPS - causes of haematuria
Bladder Urethra Renal Prostate Systemic causes
Bladder causes of haematuria
Trauma Cystitis Infection Stones Malignancy
Urethra / ureter causes of haematuria
Trauma Stones Tumour
Renal causes of haematuria
Trauma Infection Nephritic syndrome Trauma
Prostate causes of haematuria
Trauma Prostatitis TB Tumour
Systemic causes of haematuria
Bleeding disorder Drugs - anticoag / NSAIDs
Associated questions with haematuria
How much blood Which part of the stream What colour Pain B symptoms
Causes of painful haematuria
Stones UTI
Causes of painless haematuria
Nephritic syndrome Cancer Renal infection
Bedside tests in haematuria
Urine dip, culture Early morning sample for TB
Blood tests in haematuria
FBC U&Es CRP Clotting screen
Imaging in haematuria
x-ray KUB CT urogram US
Further tests in haematuria
Cystoscopy Renal biopsy
Cancer usually causing canon ball chest mets
RCC
Imaging to stage renal cancers
CT
Commonest male cancer between 20-40 Subtypes of this cancer in this age group?
Testicular (seminoma / teratoma)
Testicular cancer in those <10
Yolk sac
How quickly does a torsion need to be fixed?
6hrs
Most common cause of painful testicle
Orchitis
Main imaging for testicular swelling
US
Tumour marker for testicular cancer
Beta HCG Alpha fetoprotein
Penile rash / lump on the penis ddx
Viral wart STD Fungal infection Penile cancer in situ
Ddx of haematuria
UTI Bladder Ca Stone Trauma - exercise Rhabdomyolysis Sexual intercourse Nephrological - think nephrotic syndrome
Painless frank haematuria is what till proven otherwise?
Bladder Ca
What imaging should be chosen according to the type of haematuria?

What grading system is used in prostate cancer
Gleason score
Typical Gleason Scores range from 6-10. The higher the Gleason Score, the more likely that the cancer will grow and spread quickly.
6 - PSA testing regularly
>8 - IMMEDIATE TREATMENT
Complicatins of prostatectomy
Impotence (50%)
Urinary incontinence (10%)
Renal pelvis parallel with which level of the spine
L1
Where is the narrowing of the ureter
Pelvic brim
PUJ
VUJ
Renal obstruction immediate treatment
Nephrostomy insertion
important non urological ddx that can present like renal stone / pyelonephritis
AAA
Haematuria + palpable bladder
think clot retention
Management of clot retention in the bladder
ABCDE
3 way catheter with a wash out
SE of clot retention
further bleeding - needing surgery
perforation
Torsion of the testicle presenation
Loss of cremestaric reflex
Extreme pain (sudden onset)
sometimes changes to the skin colour
bell clapper deformity - horizontal lie and high riding
treatment of testicular torsion
Three point fixation (if viable)
and secure the other side
Size of urological stone indicating medical management
”” surgical management
<10mm
>10mm
Medical management of urological stones
Pain relief
Hydration
Anti emetic
alpha blocker to promote passage of stones
Surgical management of uriteric stones
Surgical decompression - stent / percut nephrostomy
Extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy are considered first-line treatments. However, ureteroscopy in general is associated with better stone-free rates than ESWL.
Medication in stress incontinence
alpha agonist
horomone replacement therapy
Red flags in urology
Haematuria
Blood in stool
Change in bowel habts
Dysuria
Fever
Weight loss
Bone paom
Voiding symptoms in urology hx (prostate problems)
Flow symptoms
- hesitancy
- intermitnent
- weak
- dribbling
- straining
- feeling of retention
- erectile dysfunction
Storage symptoms in urology hx (overactive bladder)
urgency
frequency
nocturia
incontinence
pads?
Fluid questions in urology
alcohol
caffeine
late night drinking
limiting fluids
Urology pmh q.
SH
FH
STI
UTIs
Kidney stones
Surgery
HTN
IHD
Diabetes
SH - alcohol / smoking / occupation
FH - prostate cancer etc
What are you looking for in the prostate on PR exam?
Enlarged?
Smooth
Can you feel the sulcus
Hard / gritting / irregular / nodule
Urology investigations
Urine dip - +ve send for culture
Bloods - PSA (look for a trend/ >10 / big jump
CRP
FBC
U&Es
LFTs
?bladder scan
Investigations for prostate cancer
TRVS + biopsy
or if on warfarin do an MRI
Gleason score
Life style management of LUTS in males
Cut out alcohol / caffeine / limit late night fluids
Physiotherapy
Medications for BPH which relaxes smooth muscle
Tamsulosin (alpha blocker)
SE - hypotension, incontinence, retrograde ejaculation
Medications for BPH which reduces the size of the prostate
5 AR inhibitors
SE - gynaecomastia
Erectile dysfunction
RE
Can take up to 6m to work
Storage symptoms medication
Oxybutinin
SE
can’t shit / spit / see (dizzy and dry eyes) / pee
Definition of poluria
Increased urine output
>3.5 L /24hrs
4 groups of causes of polyuria
Too much fluid intake
Diuresis
Diabetes
Renal failure (acute/ chronic)
Causes of diuresis
Hyperglycaemia
Hypercalcaemia
Hyperurea
Diuretics
Tests in polyuria
Water balance - weight
Urine dipstick
Urine microscopy and culture
24hr urine collection
Bloods - FBC, U&E, Calcium, glucose, LFTs, osmolarity
Water deprevation test?
Who are most likely to go into acute urinary retention?
Males > 60 y/o
Most common cause of acute urinary retention
Secondary to BPH - enlarged prostate presses on the urethra, making the bladder wall thicker and less able to empty
Cause of acute urethral obstruction
Stricture
Calculi
Cystocele
Constipation
Masses
Medications - anticholinergics, TAD, anti histamines, opioids, benzos
Neurological cause e.g. CES
Symptoms of acute urinary retention
Inability to pass urine
Low abdo pain
Examination for acute urinary retention
Abdo exam
PR
Neurological exam
Pelvic exam in women
Investigations in urinary retention
Urine sample - urinalysis and culture
UandEs
FBC and CRP
Bladder USS - volume >300 cc
Management of acute urinary retention
Catheterisation
measure volume of water drained in 15 mins
< 200 - not acute
> 400 - catheter should be left in place
Most common cause of testicular cancer
Germ cell tumour
Risk factors for testicular cancer
Infertility
Cryptorchidism
FH
Klinefelter’s syndrome
Mumps orchitis
Most common presenting feature in testicular cancer
Painless lump
First line diagnosis for testicular cancer
US
Usual cause of epidiymo-ortchitis in men < 35 years
Chlamydia and Gonorrhoea
Drug causing non infective epididymo-orchitis
Amiodarone
Torison vs epididymo-orchitis presentation
Torsion - whole testes is painful
E-O - only epidiymis is painful
Testicular torsion =
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
What reflex is lost in testicular torsion
Cremestaric
Risk factors for urinary incontinence
Advanced age
Previous pregnancy / childbirth
High BMI
Hysterectomy
FH
3 types of incontinence
Urge
Stress
Overflow - bladder outflow obstruction causing e.g. prostate englargement
Initial investigations in urinary incontinence
Bladder diary for 3 days
Urine dip and culture
Vaginal examination to exclude prolapse
Management of urge incontinence
bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding)
bladder stabilising drugs: antimuscarinic is first-line. NICE recommend oxybutynin (immediate release), tolterodine (immediate release) or darifenacin (once daily preparation). Immediate release oxybutynin should, however, be avoided in ‘frail older women’
Management of stress incontinence
pelvic floor muscle training: NICE recommend at least 8 contractions performed 3 times per day for a minimum of 3 months
surgical procedures: e.g. retropubic mid-urethral tape procedures
urolithiasis =
Ureteric calculi
1st line treatment of urinary obstruction
pain relief - ketrolac or morphine
rehydration
Definitive treatment for obstructive uropathy and sepsis
Nephrostomy or Uriteric stent
+ Abx e.g. gent or ceftriaxone
Treatment for obstructive uropathy without sepsis signs
Pain relief - ketorolac / morphine
Rehydration
Alpha blocker if stone <10mm e.g. tamsulosin / alfuzosin
or active stone removal (>10mm)
extracorporeal shock wave lithotripsy, ureteroscopy with laser lithotripsy, and percutaneous nephrolithotomy
Complications of TURP
T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
Transurethral resection of the prostate (TURP) syndrome occurs when irrigation fluid enters the systemic circulation. The triad of features are:
- Hyponatraemia: dilutional
- Fluid overload
- Glycine toxicity