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DPD > Urology > Flashcards

Urology Flashcards

BPH/ prostate cancer. Hydrocele/ epididymitis/ orchitis/ testicular cancer (tumour markers). Haematuria, renal tract tumours and stones. Testicular torsion.

1
Q

What is benign prostatic hyperplasia?

A

A histological diagnosis.
Benign enlargement of prostate.
Common.
May be associated with urinary symptoms.

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2
Q

What are the different types of lower urinary tract symptoms?

A 
Poor flow- BOO (BPH).
Voiding symptoms (obstructive): hesitancy, weak stream, intermittency, incomplete emptying.
Strong flow- detrusor overactivity.
Storage symptoms (irritative): frequency, urgency, nocutia.
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3
Q

Define lower urinary tract symptoms (LUTS).

A

Non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding).

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4
Q

Define benign prostatic enlargement (BPE).

A

The clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia.

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5
Q

Define bladder outflow obstruction (BOO).

A

Bladder outlet obstruction caused by benign prostatic enlargement (clinical finding).

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6
Q

Define benign prostatic hyperplasia (BPH).

A

Properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction.

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7
Q

What are the risk factors for BPH?

A 
Age
Androgens
Functional androgen receptors
Obesity
Diabetes (& elevated fasting glucose)
Dyslipidaemia
Genetic
Afro-Caribbean
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8
Q

What are the important aspects of a BPH history and examination?

A

LUTS.
IPSS questionnaire.
Frequency volume chart.
Haematuria, dysuria.
Full medical history (co-morbidities, drug history and family history).
Examination of abdomen (is bladder palpable?).
DRE.

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9
Q

What are the important investigations to order for BPH?

A

Urine dipstick (exclude infection).
Flow rate + post void residual bladder scan in clinic.
Blood tests (U&E, PSA, need to counsel patient).
? Renal tract ultrasound.
? Flexible cystoscopy.

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10
Q

What is the management plan for patients with voiding symptoms/ BPH?

A

Conservative management: reassure; fluid intake advice (reduce evening fluid intake).
Medical management: alpha blockers (tamsulosin, alfuzosin); 5-alpha-reductase inhibitors (finasteride, dutasteride).
Surgical management: TURP (transurethral resection of prostate); alternatives include laser surgery, rezum/steam, urolift, embolisation, catheter options.

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11
Q

What is the treatment for overactive bladder/ storage symptoms?

A

Conservative management: reassure (& treat triggering UTI); dietary advice; bladder retraining exercises (NICE recommended).
Medical management: anticholinergics (oxybutinin, detrusitol, solifenacin).
Surgical management: intravesical botox injection; bladder augmentation; urinary diversion/conduit.

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12
Q

Case 1:
70y/o man presents with inability to pass urine for 10hrs.
Previous history of BPH (on tamsulosin and finasteride).
Pain.
How do you assess and manage this patient?
a) give analgesia
b) advise the patient to drink less, especially in evening
c) start an alpha blocker
d) catheterise patient
e) advise TURP surgery

A

Catheterise patient.

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13
Q

How should you proceed in the case of a patient with urinary retention?

A 
Catheterise.
Dipstick/CSU.
FBC, U&E.
Measure residual urine.
Neurological examination if necessary.
Prescribe: antibiotics, laxatives, alpha blocker if necessary.
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14
Q

What are the different types of urinary retention?

A 
Acute retention (AUR) = painful.
Chronic retention (CUR) = postvoid residual >800mL.
Acute on chronic.
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15
Q

How is low pressure urinary retention (LPR) managed?

A

Normal U and Cr, no hydronephrosis.
Consider starting alpha blockers.
Trial without catheter (TWOC).

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16
Q

How is high pressure urinary retention (HPR) managed?

A 
Raised U & Cr, bilateral hydronephrosis.
Measure UO, BP, body weight.
Only 10% need fluid replacement.
Never TWOC.
BOO surgery or longterm catheter.
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17
Q 
Case 2:
67y/o male.
Urgency, frequency, poor flow.
DRE 40g BPE.
PSA 1.2
MSU -ve.
US normal, postovoid residual 40mL.
What do you prescribe?
a) alpha blocker
b) 5-alpha-reductase inhibitor
c) anticholinergic
A

Alpha blocker.

Anticholinergic can be added later to address urgency.

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18
Q

What are the presenting symptoms of prostate cancer?

A 
Asymptomatic; raised PSA.
LUTS.
Urinary retention/ renal failure.
(Pain).
Haematuria.
Bone pain/ weight loss/ spinal cord compression (metastases).
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19
Q

What are the risk factors for prostate cancer?

A

Age
Race (Afro-Caribbean)
Family history (2 1st degree relatives).
BRCA 2 gene.

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20
Q

What are the causes of raised PSA (prostate specific antigen)?

A 
BPH.
Urinary retention.
Urinary infection.
Catheterisation/ instrumentation of urethra.
Prostate cancer.
DRE is not a significant risk factor.
21
Q

How do you assess a patient with suspected prostate cancer?

A

Counselling.
History: LUTS? bone pain? weight loss? blood in urine?
Family history.
Examination.
DRE!
Check PSA.
MRI: can differentiate between high risk and low risk prostate cancer; PIRADS classification 1-5.
TRUS biopsy (can also do transperineal, template, or saturation biopsy).

22
Q

How is prostate cancer histologically analysed?

A

Grading: Gleason score. Low risk 3+3, high risk 5+5.
Staging: TNM.

23
Q

Case 3:
70y/o man referred by GP with PSA 18ug/L (upper limit 7.2).
How are you going to assess? Pick 2.
a) repeat PSA and check MSU
b) organise MRI prostate and TRUS biopsies
c) explain likely diagnosis of prostate cancer
d) advise radical prostatectomy or radiotherapy

A

Repeat PSA and check MSU.

Organise MRI prostate and TRUS biopsies.

24
Q

What is the management plan for a patient with prostate cancer?

A

Staging- MRI/ bone scan.
MDT discussion and breaking news to patient.
Active surveillance (low risk low volume disease).
Surgery: radical prostatectomy (robotic or laparoscopic).
Radical radiotherapy.
Watchful waiting (elderly/comorbid patient).
Hormones.
Chemotherapy.

25
Q

What are some minimally invasive treatments for prostate cancer?

A 
Surgery: open, laparoscopic, robotic.
Radiotherapy.
Brachytherapy.
High intensity focal ultrasound (HIFU).
Cryotherapy.
26
Q

Why has surgery been unpopular for prostate cancer treatment?

A

More bleeding.
Higher incontinence.
Likely erectile dysfunction.
May not die anyway.

27
Q

What is the hormonal therapy for prostate cancer?

A

Can be used in conjunction with radiotherapy or alone.
LHRH agonist (e.g. zoladex).
Antiandrogen.
Beware tumour flare.

28
Q

What is a scrotal hydrocele?

A

Small, can still palpate testicle in fluid.
May be non-communicating, communicating (paediatric), or hydrocele of the cord.
Transluminates with torch placed on scrotum (goes red).
Collection of water.

29
Q

What is a scrotal varicocele?

A

Feels like a bag of worms.
Stand patient up- lying down, blood drains out of veins so can’t feel it anymore.
Soft and separate to testicle.

30
Q

What is an epididymal cyst/ spermatocele?

A

Lump close to testicle but not attached. Mobile and soft.

31
Q

What does testicular cancer feel like on examination?

A

Hard, craggy, immobile, attached to testicle.

32
Q 
Case 4:
25y/o man presents with pain in left testicle, swelling and fever.
How will you assess and manage him?
a) organise ultrasound
b) start antibiotics
c) explain testicular cancer possible
d) manage conservatively
A

Organise ultrasound to rule out sinister cause e.g. cancer or abscess.
Start antibiotics.

33
Q

What are the causes of haematuria?

A 
Infection
Cancer
Medical
Trauma
Kidney stones
34
Q

How should you assess and manage a patient with haematuria?

A 
Resuscitate incl. transfusion.
3 way catheter.
Hx, Fx.
Bloods incl. clotting and G&S; KUB.
MSU.
Caution: suprapubic catheter.
ivi
Transfuse if necessary.
Thorough bladder washout.
Continuous irrigation.
May need clot evacuation in theatre.
Monitor closely and review regularly.
35
Q

Which investigations are ordered for haematuria?

A 
FBC, clotting, U&E.
MSU MC&S.
Urine cytology/ NMP22 ?
CT urogram with contrast or KUB, U/S.
Flexible cystoscopy.
Treat causes, follow up as appropriate.
36
Q

What are the follow up issues of haematuria?

A

Blocked catheters.
Persistent haematuria.
UTI/ antibiotics.

37
Q

What is the epidemiology of renal stones?

A

More common in caucasian men.
1% of hospital admissions.
Lifetime prevalence 12%.
Family history: consider cystinuria.

38
Q

Why are renal stones important?

A

Pain (spectrum).
Infection (incl. life-threatening gram -ve sepsis).
Renal damage.
Underlying metabolic problems (e.g. hyperparathyroidism, gout, cysteinuria).
Underlying anatomical problems (e.g. PUJ-o, MSK, horseshoe kidney, ureteric stricture).
(Litigation).

39
Q

How are renal stones classified?

A

Size: <5mm; 5-20mm; >20m; staghorn.
Location: renal (calcyeal, pelvic, diverticular).
X-ray characteristics: radiolucent, radiopaque.
Stone composition: CaOx, CaP, uric acid, cysteine, indinavir; infection MAP/struvite.

40
Q

How are renal stones diagnosed?

A

History: may be asymptomatic, dull ache, or excruciating pain.
Examination: completely soft abdomen.
Bloods, urine dip (RBC, WBC, nitrites, pH) & MSU.
Imaging: KUB/ US/ CT-KUB/ IVU.
Immediate imaging recommended if: fever; solitary kidney; diagnosis unclear.

41
Q

How does ureteric colic present?

A

Loin pain, soft abdomen, Mic haem 85%.

Emergency if sepsis.

42
Q

What are the causes of ureteric colic?

A 
Stones.
TCC.
Blood clot.
RPF.
?BPH/CaP.
43
Q

What is the differential diagnosis for ureteric colic?

A 
AAA.
Testicular torsion.
Perforated PU.
Appendicitis.
Ruptured ectopic.
MI.
Diverticulitis.
Prostatitis.
44
Q

How are kidney stones treated?

A

Conservative: observe asymptomatic non-obstructive renal stones in selected patients; incl. metabolic screen.
Medical: alkalinise/acidify urine; treat/prevent UTIs; allopurinol?
Surgical: ureterorenoscopy ± laser; external shock wave litigation ESWL; PCNL; (lap/open).

45
Q

What is obstructive pyonephrosis and how is it investigated/managed?

A 
Obstruction + infection.
Risk of fatal Gram -ve sepsis.
Immediate resuscitation &amp; IVABx.
Culture.
Urgent imaging (KUB &amp; U/S).
Discuss with urology SpR.
Consider urgent nephrostomy (or JJ stent).
Monitor closely (HDU).
46
Q

What is the treatment of obstructive pyonephrosis once the patient is stable?

A

Imaging to determine cause: CT KUB, nephrostogram.
Antegrade stent.
Plan ureteroscopy/ ESWL/ PCNL.
May need drainage if perinephric abscess.
May need nephrectomy if XGP or EPN.

47
Q

How does testicular torsion present?

A

Sudden onset, tender, swollen and high-rising on examination.

48
Q

What is the underlying deformity in testicular torsion?

A

Extension of tunica vaginalis behind testicle- clapper bell.

49
Q

What is the differential diagnosis for testicular torsion?

A

Torted appendix testis.
Epididymitis.
Viral orchitis.
Bleed into testicular tumour.

DPD (32 decks)

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