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Final > Urology > Flashcards

Urology Flashcards

1
Q

BPH

  • Def
  • Zone affected
  • Effect and end result
A

Benign proliferation of inner transitional zone of prostate gland

Increasing tissue bulk = narrowing urethral lumen
Inc prostatic smooth muscle tone (Alpha adrenergic)
Leads to Bladder obstruction

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2
Q

% 50-60 with BPH

% 70-80 with BPH

A

40%

80%

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3
Q

Pathophys of BPH

A

Age related androgen mediated epithelial and stromal hyperplaesia

  • Inc epithelial tissue in transitional zone
  • Inc number of alpha-1a receptors in prostatic capsule
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4
Q

BPH symptoms:

  • Storage symptoms (FUN)
  • Voiding symptoms (HIPP)
A

Frequency, urgency, nocturia

Hesitancy, incomplete empty, Poor flow, Post-void dribbling

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5
Q

BPH Ix triad

A

1) PSA - inc in Ca or Prostatitis
2) DRE
3) TRUSS ± biopsy

other: USS KUB (rule out hydronephrosis, urolithiasis, mass)

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6
Q

DDx BPH

A

Over active bladder
Prostatitis
Prostate Ca
UTI

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7
Q

Tx BPH

  • Mild
  • Moderate/sev
  • Abnormal PSA/DRE
A

mild:

  • Watch and wait
  • Lifestyle: avoid caffeine, alcohol, bladder training, fluid limiting
  • 1st line: alpha blocker (tamsulosin) OR 5-alpha reductase inhib (finasteride) or NSAID

mod/sev
- Drug therapy + behaviour management

Abnormal:
- Surgical referral

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8
Q

Alph blocker:

  • E.G
  • Effect
  • SE
A

Tamsulosin, Doxazosin

Smooth muscle relaxation in prostate and bladder neck:

SE: postural hypotension, dry mouth

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9
Q

5-alpha reductase inhibitors

  • E.G
  • Effect
A

Finasteride

Reduced conversion of testosterone to dihydrotestosterone

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10
Q

Complications of BPH and Tx complications

A

Progression of symptoms. Urinary retention (2.5% in 5 years)

Sexual dysfunction (due to alpha/5-alpha reductase inhib or surgery

TURP syndrome

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11
Q

What is TURP syndrome

A

Absorption of irrigation fluids by prostate = fluid overload, hyponatraemia (dilution), hypothermia, hypertension (reflex bradycardia)

(Rare but life threatening)

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12
Q

Acute urinary retention

  • Men
  • Women
  • Men & Women
  • Infective
  • Drug-related
  • Neurological
A

BPH, Prostate Ca

Prolapse (cystocele, rectocele, enterocoele) , pelvic mass (fibroids, ovarian cysts, malig)

Calculi, bladder Ca, faecal impaction

Prostatitis, vulvovaginitis, cystitis

Anticholinergic (antipsych, antidepress), Alcohol, opioids

DM (ANS neuropathy), Spinal (cauda equina, cord compression, MS)

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13
Q

Acute urinary retention Pres

A

Uncomfortable
Unable to pass urine
Tender + distended bladder

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14
Q

Urinary retention Ix

A

USS bladder

  • post void residual (over 100ml not acceptable)
  • hydronephrosis
  • structural abnormality

Urinalysis: infection,

  • haematuria,
  • proteinuria,
  • glucosuria

U&E, Cr, GFR

Looking for cause:

  • CT abdo pelvis: compression/mass/stone
  • MRI spine: disc prolapse, cauda equina, MS
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15
Q

Acute urinary retention Tx and complications

A

Immediate catheter decompression

Tx according to cause

Complications: AKI, UTI

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16
Q

Prostate Ca:

  • Def
  • Spread (local, lymph, haem)
  • Epidemiology
  • Genetics
A

Adenocarcinoma from peripheral prostate

Local: capsule to seminal vesicles, bladder, rectum
Pelvic LNs
Haematogenous: 90% of mets sclerotic bone lesion, lung and liver

Most common male cancer (80% incidence over 80)

+ve FH, inc testosterone

BRCA and HPC-1
(hereditary Prostate Ca gene)

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17
Q

Prostate Ca grading score

A 
Gleason
- Each biopsy is Graded 1-5
- Two strongest scored biopsies added together 
Low = 0-6
High = 8-10
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18
Q

Pros and Cons for Prostate Ca screening

A

Pro: commonest male Ca, 3% of all men die of Prostate Ca

Con: uncertain natural history (some low and some high aggressive), PSA non-specific

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19
Q

Prostate Ca Pres

A 
Male over 50
LUTS: Storage and voiding symptoms
Haematuria
Weight loss
Lethargy
Bone pain (mets)
LN palpable (mets)
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20
Q

Prostate Ca Investigations

A

PSA: prostate but not Ca specific (normal 0-4ng/ml)

DRE - hard irregular prostate

TRUSS + Biopsy

  • abnormal cells in 2 diff samples needed
  • Gleason

MRI/CT for staging

Isotope bone scan for mets (esp if PSA over 20)

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21
Q

Prostate Ca Severity

A

Low risk (PSA under 10, Gleason under 6)

Intermediate risk (Gleason 6-8)

High risk (Gleason 8-10, PSA over 20)

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22
Q

Prostat Ca Treatment

A

Low risk/intermediate

  • Active surveillance (PSA, TRUSS) ± brachytherapy (internal radiation) or external beam radiotherapy
  • Androgen deprivation: goserelin

High risk

  • Radical prostatectomy and pelvic LN
  • External beam radiotherapy
  • Androgen deprivation therapy (risk gynaecomastia/erectile dysfunction)
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23
Q

Tx of mets in Prostate Ca

A

Castration (usually chemical) through androgen deprivation therapy
- Goserelin: GnRH so first stimulates and then acts as negative feedback to inhibit release of androgen

80% mets androgen sensitive so Tx = remission

Bisphosphonates/radiotherapy to reduce hypercalcaemia in resistent

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24
Q

What type of epithelium in Bladder.

What type of cells at surface

A

Transitional epithelium

Umbrella cells

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25
Q

Bladder Ca

  • Types
  • RF
A

90% transitional cell (in West)
SCC in schistosomiasis

Smoking, Occupation (aromatic amines - rubber, dye), Age, Pelvic radiation (Prostate Ca),

Scc - Chronic inflammation (schisto, indwelling catheters)

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26
Q

T4 bladder cancer

A

Invasion beyond bladder: prostate, uterus, vagina, pelvic/abdo wall

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27
Q

Bladde Ca:

  • LN
  • Mets
A

Pelvic LNs

Liver and Lungs

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28
Q

Bladde Ca:

- Pres

A 
Painless haematuria (frank or microscopic)
Dysuria
Abdominal mass Weight loss
Bone pain (advanced)
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29
Q

Bladde Ca:

investigations

A

Urine dip (haematuria)
KUB USS
Flexible cystoscopy + Biopsy
CT Urogram with contrast (shows tumours of bladder and upper urinary tract)

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30
Q

Bladde Ca:

Complications

A 
Hydronephrosis
Upper tract transitional cell cancer
Prostatic urethral transitional cell cancer
Urinary retention
Recurrence
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31
Q

Bladder Ca tx

  • No Muscle invasion
  • Locally invasive
  • T4/Metastatic disease
A

Transurethral resection of bladder tumour (TURBT) + immediate Intravesical chemo with mitomycin

Delayed Immunotherapy (bacilli Calmette-Guerin)

MVAC chemo:

  • Methotrexate
  • Vincristine
  • Doxorubicin (Adriamycin)
  • Cisplatin
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32
Q

When is haematuria relevant?

A

Frank haematuria

SYMPTOMATIC microscopic haematuria

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33
Q

Causes of discoloured urine

A

Myoglobinuria (rhabdomyolysis)

Haemoglobinuria (haemolytic anaemia)

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34
Q

Causes of microscopic haematuria

A 
Menstruation
Cystitis
Pyelonephritis
Acute Prostatitis
BPH
Trauma
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35
Q

Haematuria Further investigations

A

Urine dip: Protein implies renal

Culture: Infection

DRE: Prostate

FBC: Hb (anaemia-renal), WCC (infect), PSA, eGFR/Cr (nephrological)

Imaging: USS KUB, Flxible cystoscopy, Non-contract CT (stone), Contrast CT urogram (malignancy)

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36
Q

Catheters:

  • Types
  • Indications
A

Urethral (Foley)
Suprapubic

Acute/Chronic urinary retention, Pre-op emptying, Monitor urine output, manage incontinence (MS)

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37
Q

Pros & Cons of SPC Vs Urethral

A

SPC more omcfortable, more convenient to change, better sexual function

SPC inc risk cellulitis/leakage, painful (needs analgesia ± sedation)

Both carry infection risk (UTI) with E.coli

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38
Q

UTI:

  • LUTI
  • UUTI
A

Cystitis, Prostatitis, Epididymo-orchitis, Urethritis

Pyelonephritis

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39
Q

What is a complicated UTI

A 
In Males, Preg, Children
Recurrent UTI
Immunocomprimised
Dec renal function
Abnormal renal tract/obstruction
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40
Q

UTI RFs

A 
Femal
Spermicide (dec lactobacilli)
Preg (inc risk pyelonephritis)
Immunosuppression, DM
Obstruction, Stones
Catheter
Malformation
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41
Q

UTI organisms

A

E.coli
Staph saprophytic (coagulase -ve)
Enterobacteria (Proteus, Klebsiella, Enterococci, GBS)

42
Q

UTI Tx

A

Trimethoprim 3d
(Preg: Nitrofurantoin 7d)
UUTI: Cephalosporins
Men: Ciprofloxacin 1-2d

43
Q

Age and UTI risk

A

pH raised following menopause = inc risk

44
Q

Host defence to UTI

A

Urine flush
Tamm-Horsfall Protein
Low urine pH
Urinary IgA

45
Q

Pathology of UTI

A

Bacteria from colonic flora
Colonise urethral meatus
Bacteria Ascend (adhere to urothelium)

46
Q

Definitions of:

  • Bacteriuria
  • Pyuria
  • Sterile Pyuria
A

Bacteria in urine

Presence of leucocytes with assoc infection

Presence of white cells but cannot culture bacteria (e.g. chlamydia, recently Tx UTI, In situ bladder cancer)

47
Q

What is uncomplicated UTI

A

UTI in healthy woman without functional or anatomical tract abnormalities

48
Q

Pyelonephritis Pres

A

Loin pain
Costovertebral angle tenderness
Fever

49
Q

UTI investigations

A

Mid stream culture and sensitivity

Urine dip
Urine microscopy (RBC, WBC, Bacteria)
Urine culture

KUB USS: Post void residual, stone, hydronephrosis, tumour

50
Q

UTI Presentation

A

DUF

  • dysuria
  • urgency
  • frequency
51
Q

UTI in men

  • Organisms
  • RFs
A

E.coli, Klebsiella, Proteus

BPH (poor flow), Calculi, urinary surgery, incomplete emptying, reflux, DM

Urinalysis (microscopy + culture), KUB USS (stone, abscess)
CT (urinary calculi, tumour

Ciprofloxacin (IV if severe)

52
Q

Catheter assoc infection

A

100% at one month

Prophylactic Abx: Amoxicillin

53
Q

Prostatitis

  • Def & mechanism
  • Organism
  • Pres
A

Inflammation/infection of prostate gland due to intraprostatic reflux

E.coli in 80%

Pain in lower abdominal, ejaculatory, perineum
LUTS (DUF: dysuria, urgency, frequency)
Fever/chills
Malaise

54
Q

Prostatitis investigations

A 
Urinalysis (microscopy: leukocytes, bacteria), culture (MSU MC+S)
Blood cultures (if febrile)
55
Q

Prostatitis treatment

A

If sepsis: IV taz + Gent + NSAID + releyó obstruction

No sepsis: Ciprofloxacin/Flouroquinolone + NSAID + relief of obstruction

56
Q

Urethritis:

  • Common causes
  • RF
  • Classically seen..
  • complications
A

N.Gonorrhoea
C.trachomatis

New sexual partner, under 25 yrs, multiple partners, unprotected sex

Urethral discharge after unprotected sex

Gonococcal: reactive arthritis, meningitis, endocarditis

Chlamydia: infertility

57
Q

Epidydimo orchitis

  • Def
  • Pres
  • Important Ddx
  • Causes in under 35yr & over 35yr
  • Pathology
A

Inflammation of epididymis and testicle

Unilateral pain/swelling. Assoc with LUTS (DUF), discharge, fever

Rule out Torsion!

STI (Chlaydia, Gonorrhoea),
Viral (mumps)

UTI (e.coli) assoc with bladder obstruction (BPH) or instrumentation (catheter)

ascent of pathogens retrograde via ejaculatory ducts

58
Q

Urethritis/epididymo-orchitis Ix

A

First catch urine (dip - leukocytes, microscopy, culture)

If suspect torsion: surgical exploration

59
Q

Urine Dip

  • Nitrites
  • Leukocytes
A

Nitrites formed from nitrates by G- bacteria e.g. E.coli

Neutrophil/Macrophage release leukocyte esterase. If this positive then sign of infection/inflammation

60
Q

Renal Calculi

  • % lifetime risk
  • RF
  • Imaging
  • 3 most common sites
A

10%

Chronic dehydration, Diet, Obesity, +ve FH, Some drugs (Cipro)

Non-contrast CT

Pelviureteric junction (renal pelvis)
Pelvic brim
Vesicoureteric junction

61
Q

Renal calculi

  • Reasons for formation
  • Stone types
A
  • Elevated urine solutes (Ca, Uric acid, Oxalate, Sodium)
  • Low urine volume, high/low pH
  • infection (striate)

Calcium stones (80% - most common. most calcium oxalate, some calcium phosphate -hydroxyapetite)

Uric acid stones (10-20% seen with gout)

Struvite stones (5%. Common cause stag horn calculi - Both ‘s’)

Cystine stones

62
Q

Calcium oxalate stone

  • RF
  • Stone features
A

Low urine vol,

Hypercalciuria/oxaliuria

Spiky opaque stones

63
Q

Calcium phosphate stone

  • RF
  • Stone features
A

Low urine vol, high pH, Hypercalciuria, High phosphate (Hyper PTH)

Smooth opaque stone

64
Q

Urate stone

  • RF
  • Stone features
A

Low pH, Hyperuricaemia (gout)

Smooth brown, radiolucent

65
Q

Struvite stone

  • RF
  • Composition (MAP)
  • Stone features
A

Infection

Magnesium, Ammonium, Phosphate

Staghorn

66
Q

Renal colic Ddx

A 
Appendicits (-ve non-contrast C)
Ectopic (preg test)
Ovarian cyst (AUSS)
Diverticulitis
AAA (consider in over 50: CT abdo)
67
Q

Renal colic pres

A

Severe flank pain (loin to groin: depends on site of stone) unilateral

Nausea&Vomiting

Worse with fluid

Microscopic haematuria (Urine microscopy)

Costovertebral angle tenderness (pyelonephritis)

68
Q

Renal colic investigation

A

Non-contrast CT = Gold standard (stones appear white in collecting system)

Urinalysis: dip (±leukocytes, nitrites), Microscopy (microhaematuria) and culture

FBC: raised WCC if infection

Pregnancy test

U&E (hyperuricaemia - gout, hypercalcaemia - PTH)

69
Q

Signs of sepsis

A

Fever
tachycardia
Hypotension
(seen in obstructing stones with infection)

70
Q

Renal stones Tx

  • Acute
    • bacteruria
  • Under 10mm
  • Over 10mm
A

Hydration, Pain control (IV morphine), Antiemetic (Ondansetron - 5HT)
Rectal dicolfenca

Abx: Trimethoprim/nitrofurantoin

Alpha blocker (tamsulosine), CCB (nifedipine). 95% undr 5mm pass with IV fluid in 2w

Surgical (extracorporeal shock wave lithotripsy), Percutaneous stereoscopy if over 15mm, Percutaneous nephrostolithotomy if over 20mm/Proximal stones

71
Q

Prevention of kidney stones

A

Overhydration (2.5-3L a day)
Dec: sodium, protein, oxalate, Weight

High:
- Ca: thiazide + potassium citrate
- Uric acid: allopurinol
Struvite: Tx infection

72
Q

Scrotal swelling what to determine in examination

A

Is it separate from the testicle

Is it cystic or solid

73
Q

Scrotal swelling

  • Separate from testicle and cystic in nature
  • Separate and solid
  • Testicular and cystic
  • Testicular and solid
  • Cant get above it
A

Epididymal cyst

Epididymitis or varicocele

Hydrocele

Tumour/Orchitis

Inguinal hernia

74
Q

Acute, tender enlargement

A

Torsion until proven otherwise

75
Q

Epididymal cyst

  • Def
  • Pres
  • Ix
  • Assoc
  • Tx
A

Smooth cysts in head of epididymis

Small and painless lump, will transluminate, separate from testes. may be bilateral

USS, aspiration (milky)

CF (absent Vas deferens), infertility

Common and benign, no Tx needed

76
Q

Varicocele

  • Def
  • Side
  • Cause
  • Complication
A

Abnormal dilatation of internal veins of pampiform plexus draining testes

90% left sided

Increased hydrostatic pressure, incompetent valves.
Sometimes assoc with Left RCC

Infertility

77
Q

Varicocele

  • Pres
  • Investigations
  • Tx
A

Painless scrotal mass, like bag of worms
Dull ache

Scrotal USS

Reassure & Observe
Surgery if abnormal semen parameters

78
Q

Hydrocele:

  • Def
  • Type
  • Cause
A

Serous fluid (peritoneal) collecting along the spermatic cord

Communicating (Patent processes vaginalis: risk of indirect inguinal hernia)
Or non-communicating (No longer patent)

Infant: congenital
Adult: trauma, infection, tumour, varicocele, tumour

79
Q

Hydrocele:

  • Pres
  • Tx
A

Scrotal mass in scrotum or extending to inguinal canal.
Transluminates
Enlarged post activity (inc abdo pressure)

May resolve spontaneously
Surgery/aspiration if discomfort/infection

80
Q

Testicular torsion

  • def
  • pres
  • Ix
  • Tx
A

Twisting of testicle on spermatic cord. Constricts vascular supply.
Time sensitive ischaemia of testicle

Tender, Swollen, Hot, High, Transverse lie, Absent cremasteric reflex

Doppler USS if under 24 hrs, Surgical exploration

Possible orchidectomy is ischaemia

81
Q

Testicular cancer:

  • Pres
  • Ix
  • Age group
A

Hard, painless nodule on testicle

USS testicle

20-35 yr

82
Q

Types of testicular caner:

A

Germ cell (90%)

  • Seminoma (55%)
  • Non-seminoma (teratoma, choriocarcinoma)

Non-germ cell

  • Leydig
  • Stromal
83
Q

Seminoma Mets (type of germ cell)

A

25% get mets

Most common lymphatic spread to retroperitoneal nodes (back pain)

84
Q

Testicular cancer: RFs

A

Cryptorchism (bilateral undescended)

FH, personal Hx
Taller men
Kleinfelter's
infertility
Chromosome 12 mutation (Testicular germ cell tumour 1)
85
Q

Testicular cancer: Pres

A

Painless nodule, haemospermia, secondary hydrocele

Extratesticular:
- bone pain (skeletal mets), gynaecomastia (b-HCG), Lower extremity swelling (venous occlusion), back pain (seminoma - para-aortic mets)

86
Q

Testicular cancer: Ix

A

BAL markers (b-HCG, AFP, Lactate dehydrogenase)

USS

CT abdo&Pelvis (LNs)

B-HCG - Seminoma
AFP (alpha-fetoprotein) Teratocarcinoma, embryonal (not seminoma)
LDH

87
Q

Tx Testicular cancer:

A

Radical orchidectomy (don’t biopsy just remove) for all

Early stage: external beam radiotherapy + Carboplatin

Late stage (LN, Mets e.g. lung)
- BEP chemo (Bleomycin, Etoposide, CisPlatin

Prognosis is good. 90% cure with chemo for metastatic disease

88
Q

What is erectile dysfunction

A

difficulty in attaining, maintaining an erection or a marked decrease in rigidity

89
Q

Erectile dysfunction causes

A

Age
Pain
Vascular: HTN, CHD, DM, Smoking, Obese

Neurological: MS, Spinal cord injury

Hormonal: dec androgens, inc prolactin, hypothyroid

Psychological: Anxiety, depression, substance misuse

Drugs: SSRI, Beta-blocker, Alcohol, Anti-psychotics (prolactin)

90
Q

Investigations

A

Testosterone, Prolactin, FSH/LH, TSH

Cholesterol

BP

Fasting Glucose, HbA1c

91
Q

Modifiable RF in Erectile dysfunction

A

Drugs

Sedentary, obesity, smoking, alcohol, DM, HTN, Hyperlipidaemia

92
Q

Erectile dysfunction Treat

A

PDE5 inhibitor (sildenafil): headache, facial flushing, (CI in hypotension)

Alprostadil (Intrecavernous injection

Vacuum pump + constriction ring

Implant

Psychosexual therapy

93
Q

Erectile dysfunction psychosexual therapy

A

CBT - dysfunctional belief, sensate focus (couples), personal sexual growth programme

Psychodynamic therapy - relate to early behaviours + current problem

Systemic therapy (focus on context)

Intergrative therapy

94
Q

Neurogenic bladder
- def

ANS and nerves in

  • Detrusor contraction
  • Urethral contraction & inhib detrusor

Voluntary control micturition

A

Bladder dysfunction either flaccid or spastic due to neurological damage.
Overflow incontinence

PSNS (cholinergic)
S2,3,4 (Pelvic Splanchnic)

SNS, T11-L2 (hypogastric)

External urethral sphincter

95
Q

Classification of incontinence

A

Stress: Poor closure of bladder (incontinence in cough, sneeze etc)

Urge: Overactive bladder

Overflow: Poor bladder contraction

Mixed

96
Q

Neurogenic bladder causes

A

CNS

  • CVA
  • Spinal injury
  • ALS
  • Meningomyelocele

PNS

  • Diabetes
  • Alcohol
  • Vit B12 neuropathy
  • Herniated disc
  • Pelvic surgery (damage)

Psrkinson, Ms, tumours

97
Q

Flaccid Neurogenic bladder

  • Cause
  • Def
A

Peripheral nervier spinal nerve damage at S2-4

Bladder volume large, pressure low, contractions absent

98
Q

Spastic bladder

  • Cause
  • Def
  • What occurs
A

Brain, cord damage above T12

Involuntary & uncoordinated detrusor/sphinter contraction

Involuntary dedication/urination

99
Q

Investigation incontinence

A

Urodynamic studies

100
Q

Neurogenic bladder investigation

A

Serum Cr
Renal USS (Hydronephrosis)
Post-voidal residual volume
Urodynamics

101
Q

Incontinence Tx

A

Kegel exercises
Lifestyle: weight loss, caffeine/alcohol
Bladder training

Sling procedures

102
Q

Complications of Radiotherapy for Prostate Ca

A

Colon cancer, Bladder Ca, Rectal Ca

Final (26 decks)

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