Urology Flashcards
Narrowest 3 points of ureters
Uteropelvic junction
Pelvic brim
Vesicoureteric junction
Types of renal stones
Mainly Calcium oxalate
Uric Acid
magnesium ammonium phosphate
Presentation of renal stones
Loin to groin renal colic pain
N&V
haematuria
fever
Investigation of renal stones
urinarysis (normal)
AXR (uric acid dont show)
CT
Management of renal stones
Conservative <5mm
analgesic: diclofenac, coedine
SM relaxants; alpha receptor blockers (tamsulosin)
CCB - nifedipine
>5mm or conservate doesnt work
- extracorporeal shock wave lithotripsy
- percuteaneous nephrolithomy (>2cm, stag horn: Mg ammonium phos)
Causes of urinary tract obstruction
Luminal - stones, blood clots, tumour Mural - stricture, neuromuscular problem Extramural - abdominal/pelvic mass/tumour, peritoneal fibrosis
Causes of acute urinary retention
Prostatic, urethral strictures, anticholinergics, alcohol, constipation, neurological
What is BPH?
Hyperplasia of connective and glandular tissue
Presentation of BPH
Storage symptoms - frequency, urgency, nocturia
Voiding symptoms - Hesitancy, Intermittent/incomplete emptying, post void dribbling, poor flow
Investigations for BPH
Symptoms score questionnaire
DRE (smooth symmetrical enlargement)
Abdo exam (palpable bladder - urinary retension)
PSA
Urine flow analysis
Treatment of BPH
lifestyle: avoid alcohol, caffeine
1st: alpha blockers - tamsulosin (decrease smooth muscle tone, s/e - drowsy, dizzy, dry)
5a-reductase inhibitors - finasteride
Surgical - TURP (transurethral resection of prostate)
- TUIP (transurethral incision of prostate) removes less than TURP
Symptoms of RCC
1) haematuria
2) loin pain
3) abdo mass
anorexia, malaise, weight loss
Investigations of RCC
BP : HTN bc renin secreted by tumour
FBC: Erythrocytosis from XS EPO production. Anaemia of chronic disease
LDH and corrected Calcium: if high poor prognostic marker
LFT: elevated AST/ALT show mets
urine: haematuria and/or proteinuria
Imaging:US, *CT, MRI, CXR (cannonball metastases)
Management of RCC
1st line: if fit for surgery - partial or radical nephrectomy
1st line: if not fit for surgery - suveillance -> ablation
If RCC stage 4 (metastatic)
- targeted molecular therapy: pazopanib
- consider surgery, chemo and palliative radio
Most common prostate cancer
Adenocarcinoma arising from peripheral prostate
Innervation of ureters
T12-L2 (back and sides of abdo, top inner thigh & genitals
Parasympathetic nervous system function on detrusor
Causes detrusor contraction, from sacral spinal cord
Sympathetic nervous system function on detrusor
Causes detrusor relaxation, from lumbar spinal cord
Pathology of BPH
Inner transitional zone hyperplasia
Static component - increased bulk narrows lumen
Dynamic component - increased smooth muscle tone mediated by alpha adrenergic receptors
4 complications of BPH
Progression, sexual dysfunction, acute urinary retention, TURP syndrome
What is TURP syndrome?
Absorption of irrigation fluids into prostatic venous sinus
Presentation of Prostate Cancer
- haematuria
- haematospermia
- LUTS
- Incontinence
- Impotence
- Rectal Pain
- weight loss, bone pain
factors that increase PSA
BPH, prostate cancer, bicyling, sex, prostatitis
Investigations for ?Prostate cancer
PSA
DRE
Urinalysis
Transurethral ultrasound of prostate (TRUS) ± biopsy
MRI
Possible findings on DRE
- normal- walnut sized, smooth, palpable, central sulcus
- cancer- hard craggy
- BPH - smooth, symmetrical enlargement
- Prostatitis - soft, boggy, tender
Where does prostate cancer commonly met to
- bone
- lymph nodes
- bladder
- rectum
- seminal vesicles
Scoring system for prostate cancer and how does it work
Gleason Score, 2 numbers, first and second most common type of growth X+Y=Z
1= small uniform glands
5= only occasional gland formation
Management of prostate cancer
Watchful waiting- no active management, repaeting PSA/DRE at intervals
Active surveillance - specific regime of tests view to treat radically
Radical prostatectomy - no mets, symptomatic/progressive disease. Remove prostate, seminal vesicels and surrounding connective tissue. SE= incontinence, sexual dysfunction, DVT
Radiotherapy - elderly, radical RT given everyday for several weeks, palliative given once to relieve symtoms
Androgen suppression - non localised disease. Bicalutaminde. LHRH antagonists (gosereline)
Stag horn canniculi
magnesium ammonium phosphate
How does finasteride work?
5 alpha reductase inhibs
block conversion of testosterone -> dihydrotestosterone
high dihydrotestosterone associated with larger prostate
most common bladder cancer?
Transitional cell carcinoma
presentation of bladder cancer
- painless haematuria
- UTI symptoms (dysuria) but -ve MC+S
- flank pain: obstruction
Bladder cancer investigations
Urinalysis: haematuria, RBC casts if glomerular bleeding
Urine cytology: +ve
Imaging: USS, CT, cystoscopy
Management of bladder cancer
Non muscle invasive
TURBT + post op chemo ±BCG
Locally invasive
1st: radical/partial cystectomy + pre/post op chemo
2nd: immunotherapy - atezolizumab
Metastalic
1st: chemo + surgery/radio
2nd: immunotherapy -atezolizumab
What does the spermatic cord contain?
Pampiniform plexus (veins)
tesicular nerves
testicular artery
Cremasteric artery
Nerve to cremasteric artery
Lymphatic vessesl
vas deferens
What happens in testicular torsion and how does it present?
Spermatic cord twists cutting off blood supply to testicle -> testicular death
- painful, swollen, tender testis
- fever, nausea vomiting
investigations for ? test torsion
USS doppler
cremasteric reflex (not super sensitive)
surgical exploration
management of testicular torsion?
surgery
When you would you diagnose AKI?
<48 hour increase in
1) serum creatinine >=26.4 above baseline
2) serum creatinine increase >50%
3) Oligouria <0.5mL/kg/hour for >6 hours
*average pt weight 70kg so <35mls/hour would be AKI
How do you break down the causes of AKI?
Pre renal
Renal
Post renal
What are the pre-renal causes of AKI?
dehydration
sepsis
What are the renal causes of AKI?
Nephrotoxic meds
vasculitis
glomerulonephritis
What are the post renal causes of AKI?
stones
strictures
tumours
prostate: BPH
which drugs are nephrotoxic?
NSAIDs
gentamicin
antifungals
antivirals
How does AKI present?
Altered UP
N&V, dehydration
confusion
What would you find OE in a patient with AKI?
Increased JVP if fluid overloaded
BP low
How do you manage a patient with AKI?
ABC
haemodynamic restoration: fluids and inotropes
Med review
Treat hyperkalaemia, infection
Urinalysis
Immunology: Bence Jones, ANA and anti-dsDNA
which patients are at higher risk of developing AKI
- CKD: decreased function
- Db: metformin causes lactic acidosis, prescribed ACE I
- Atherosclerotic disease: poor inflow, ACEI
- CCF: poor inflow ACE
- Elderly: have above
How to prevent AKI
- avoid nephrotoxins
- monitor at risk pt
- give IV sodium bicarb or 0.9% sodium chloride if at risk
What causes erectile dysfunction
Physical: Age, meds, HTN, endocrine, trauma, MS
Psychological: Depression, relationship issues, unsure of sexual orientation
Which meds are linked to ED?
HTN meds, chemo, anti D
Which investigations would you carry out for ED?
random plasma gluoce: DM
serum testosterone, prolactin, LH, SHBG
TFT
FBC
LFT
Medical management of ED?
- sildenafil 30/60m before sex
- tadalfil daily
- alprostadil, TU injection
Non medical management of ED?
- vacuum device
- penile/scrotal rings
- kegal exercises
- relationship/individual therapy
Describe the anatomy of the penis
2 corpora cavernosa and 1 corpus spongiosum (surrounds urethra) which extends to form glans (tip) of penis
all 3 sponge like and contain large spaces between and loose networks of tissue
Describe the physiology of an erection
- blood flows into spaces causing distension and elevation of penis
- Arteries dilate and veins contain valves which restrict outflow of blood.
- Corpus spongiosum doesnt become erect so semen can leave urethra
innervation of the penis
Erection: parasympathetic reflex S2 and S3
Ejaculation: sympathetic, L1 root
what is nephritic syndrome?
inflammatory response to immune cells causes damage to basement membrane allowing proteins, WBC and RBC into urine
What causes nephritic syndrome?
Bergers, post infectious, SLE
How does nephritic syndrome present?
Haematuria
Oliguria
HTN
Odema/fluid retension
Nephritic syndrome diagnosis and management
Dipstick
Diuretics, IVIG
What is nephrotic syndrome?
Damage to basement membrane increases permeability of serum protein
proteinuria >3.5g/day
serum hypoalbuminaemia <30g/L
What causes nephrotic disease?
minimal change disease
focal segmental glomerulosclerosis
SLE
nephrotic syndrome presentation
Periorbital oedema (scrotal, vulval, ankle)
frothy urine (proteinuria)
Ascites
SOB
fatigue
Investifations of nephrotic syndrome
Dipstick
MC+S
clotting: decreased AF-III
Hyperlipidaemia
types of nephrotic syndrome
Steroid sensitive: minimal change
Steroid sensitive: focal segmental glomerulosclerosis
Features of steroid sensitive nephrotic syndrome
reponds to steroids
doesnt lead to renal failure
diagnosed with microscopy and biopsy
features of steroid resistant nephrotic syndrome
- diagnosed with biopsy showing scarring
- 1/3rd lead to renal failure
- Mangement: ACEi, ARB, BP control
ADPKD presentation
loin pain
nocturia
HTN
Kidney enlargement
gross haematuria post traums
extra-renal presentation of ADPKD
-due to mass effect
dyspnoea
GORD
back pain
-due to cyst complications
haemorrage
infection
torsion
rupture
Investigations for ADPKD
Urinalysis: infection, protein
MC+S: coliforms
FBC: high RBC (XS erythropoietin)
U&E: creatinine, eGFR
Imaging: USS, CT
Genetic testing
Management of ADPKD
Lifestyle: Patient education, Screening, No contact sport (rupture), CVD lifestyle
Monitoring: BP, annual blods and USS
Medical
HTN: ACEI
UTI
Pregnancy: increased risk of severe HTN and pre-eclampsia
What are the pros and cons for screening for ADPKD in utero?
+ family planning
+early detection and treatment of complications
- insurance/employment discrimination
- psychological effects of having incurable disease
