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3B Specialties > Urology > Flashcards

Urology Flashcards

1
Q

prostatitis

acute causes

A

caused by staphylococcus faecalis and E. coli, chlamydia and TB

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2
Q

prostatitis

acute features

A

UTIs
retention
haematospermia
swollen/ boggy prostate on DRE

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3
Q

prostatitis

actue treatment

A

analgesia

levofloxacin 500mg/day PO for 28/7

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4
Q

Prostatitis

Chronic

A

bacterial or non-bacterial
symptoms same as acute >3/12
Doesn’t respond to abx
anti-inflammatory drugs, alpha blockers and prostatic massage

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5
Q

Balantitis

A

acute inflammation of foreskin and glans
associated with strep and staph infections
more common in diabetics
often seen in children with tight foreskins

Rx - abx, circumcision, hygiene advice

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6
Q

Phimosis

A

foreskin occludes meatus
causes recurrent balantitis and ballooning
time and trials of retraction may prevent need for circumcision
in adults - painful intercourse, infection, ulceration and associated with balantitis xerotica obliterans

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7
Q

Paraphimosis

A

tight foreskin retracted and becomes irreplaceable
–> prevents venous return –> oedema and ischaemia of the glans
Rx –> ask pt to squeeze glans, glucose soaked swab, ice pack, lidocaine
–> may need aspiration, dorsal slit/ circumcision

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8
Q

Prostate Ca

A

commonest male cancer
increasing incidence with age
associated with positive family hx
mostly adenocarincoma arising in peripheral prostate

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9
Q

Symptoms of prostate Ca

A 
asymptomatic 
nocturia 
hesitancy
poor stream 
terminal dribbling 
obstruction
weight loss +/- bone pain suggests mets
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10
Q

DRE of prostate in Ca

A

hard irregular prostate

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11
Q

Diagnosis of Prostate Ca

A 
raised PSA 
transrectal USS & biopsy
X-rays 
bone scan 
MRI/CT
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12
Q

Treatment of Prostate Ca

Disease confined to prostate

A
  • radical prostatectomy
  • radical radiotherapy +/- neoadjuvant & adjuvant hormonal therapy
  • hormone therapy alone - delays disease progression
  • active surveillance
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13
Q

Treatment of Prostate Ca

Metastatic Disease

A
  • hormonal drugs - LHRH agonists goserelin stimulate and then inhibit pituitary gonadotrophin
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14
Q

Symptomatic treatment of Prostate Ca

A

analgesia
treat hypercalcaemia - fluids and allopurinol
radiotherapy for bone mets/ spinal cord compression

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15
Q

Penile Ca

A

rare in the UK - more common in Far East and Africa
very rare if circumcised
related to chronic irritation, viruses and smegma

Presentation: chronic, fungating ulcer, bloody/ purulent discharge - 50% spread to lymph at presentation
radiotherapy if early, amputation and lymph node dissection if late .

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16
Q

Benign Prostatic Hyperplasia

Pathology

A

benign nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate

inner (transitional) zone enlarges in contrast to peripheral layer (vice versa in prostate Ca)

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17
Q

Benign Prostatic Hyperplasia

Features

A

lower urinary tract symptoms
- nocturia, frequency, urgency, post-micturition dribbling, poor stream/ flow, hesitancy, overflow incontinence, haematuria, bladder stones, UTI

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18
Q

Benign Prostatic Hyperplasia

Tests

A 
MSU
U&E
USS
Rule out Ca- PSA
Transrectal USS +/- biopsy
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19
Q

Benign Prostatic Hyperplasia

Lifestyle Management

A

Avoid caffine/ alcohol
relax when voiding
void twice in a row to aid emptying
control urgency by practicing distraction methods
train bladder by holding on to increase time between voids.

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20
Q

Benign Prostatic Hyperplasia

Drugs - alpha blockers

A

(tamulosin, alfuzosin, doxasosin, terazosin) decrease smooth muscle tone (prostate and bladder)

SE: drowsiness, depression, dizziness, low BP, dry mouth, ejaculatory failure, extra-pyrimidal signs, nasal congestio, increased weight

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21
Q

Benign Prostatic Hyperplasia

Drugs - 5alpha-reductase inhibitors

A

e.g. finasteride - decrease testosterone’s conversion to dihydrotestosterone
- excreted in semen so advice to use condoms, women should avoid handling
SE - impotence, low libido

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22
Q

Benign Prostatic Hyperplasia

Surgery

A

Transurethral resection of the prostate
Transurethral incision of the prostate- relieves pressure on urethra
Retropubic prostatectomy
Transurethral laser-induced prostatectomy

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23
Q

Acute Retention

Causes

A

Bladder usually tender (+600ml)
causes - prostatic obstruction, urethral strictures, anticholinergics, alcohol, constipation, post-op, infection, carcinoma, neurological

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24
Q

Acute Retention

MAnagement

A
  • analgesia, privacy, running taps, hot bath
  • alpha blocker
    clot–> 3 way catheter and washout
    catheter and then TWOC
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25
Q

Acute Retention

Prevention

A

Finasteride to decrease proste size and retention risk

tamulosin reduces risk of recatheterisation

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26
Q

Chronic Retention

Presentation

A

more insidious and maybe painless

Overflow incontinence
acute on chronic retention
lower abdo mass
UTI or renal failure

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27
Q

Chronic Retention

Causes

A 
Prostatic enlargement
Pelvic Malignancy
Rectal Surgery 
DM
CNS disease- transverse myelitis/MS
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28
Q

Chronic Retention

Management

A

Avoid catheterising unless pain/UTI or renal impairment
Institute definitive treatment promptly
Intermittent self-catheterisation may be needed

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29
Q

Epididymal Cysts

A

develop in adulthood
contain clear/milky fluid - spermatocele fluid
lie above and behind testis
remove if symptomatic

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30
Q

Hydrocele

A

fluid in the tunica vaginalis
primary- patent processus vaginalis–> common, larger, younger
secondary- trauma/ infection/ tumour

Rx - aspiration or surgery

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31
Q

Epididymo-orchitis

Causes

A 
chlamydia
e.coli
mumps (EBV)
n. gonorrhoea
TB
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32
Q

Epididymo-orchitis

features

A

sudden onset tender swelling
dysuria
sweats/ fever

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33
Q

Epididymo-orchitis

investigations

A

1st catch urine sample
look for urethral discharge
consider STI screen
ward of possible infertility, symptoms may worsen before improving

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34
Q

Epididymo-orchitis

Management

A

<35 doxycycline (treat sexual partners) (if suspect gonorrhoea –> add ceftriaxone)

> 35 (non-STI) ciprofloxacin or ofloxacin

ALSO: analgesia, scrotal support, drainage of abscess

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35
Q

Varicocele

A 
dilated veins of pampiniform plexus
more commonly left-sided
often visible as distended scrotal blood vessels that feel like a bag of worms
Dull ache
associated sub-fertility
36
Q

Haematocele

A

blood in tunica vaginalis
follows trauma
may need drainage or excision

37
Q

Testicular torsion

symptoms

A

sudden onset of pain in one testis
makes walking incomfortable
pain in abdomen
nausea and vomiting

38
Q

Testicular torsion

signs

A

inflammation in one testis- tender, hot, swollen
may lie high and transversely
most common 11-30

39
Q

Testicular torsion

Management

A

Analgesia- opioids

  • consent for possible orchidectomy and bilateral fixation
40
Q

Indirect inguinal hernia

A

pass though internal inguinal ring and then out through the external ring

41
Q

direct inguinal hernias

A

pass directly through the posterior wall of the inguinal canal into a defect in the abdominal wall

Hesselback’s triangle - medial to inferior epigastric vessels, lateral to rectus abdominus

42
Q

Predisposing factors for inguinal hernias

A
  • males
  • chronic cough
  • constipation
  • urinary obstruction
  • heavy lifting
  • ascites
  • past abdominal surgery
43
Q

deep (internal) ring

A

mid-point of the inguinal ligament

1.5cm above femoral pulse- crosses mid-inguinal point

44
Q

superficial (external ring)

A

split into external oblique aponeurosis superior and medial to pubic tubercle

45
Q

relation of the inguinal canal

floor

A

inguinal ligament and lacunar ligament medially

46
Q

relation of the inguinal canal

roof

A

fibers of transversalis, internal oblique

47
Q

relation of the inguinal canal

anterior

A

external oblique aponeurosis

+ internal oblique for lateral 1/3

48
Q

relation of the inguinal canal

posterior

A

laterally - transversalis fascia

medially - conjoint tendon

49
Q

Examination of inguinal hernia

A

-look for previous scars
- feel other side
- examine external genitalia
- is lump visible- can pt reproduce it?
ask pt to cough
- repeat standing

50
Q

Male hypogandism

A

failure of testes to produce testosterone, sperm or both
- small testes, low libido, erectile dysfunction, loss of pubic hair, decreased muscle bulk, increase fat, gynaecomastia, osteoporosis, low mood

If prepubertal - low virilization, incomplete puberty, eunuchoid body, reduced secondary sex characteristics

51
Q

Primary male hypogonadism

A 
testicular failure 
- trauma/ torsion/chemo/radiation
Post orchitis
- mumps/HIV/ brucellosis/ leprosy
Leydig cell toxicity
- Renal failure/ liver cirrhosis or alcohol excess
Chromosome abnormality 
- Kleinfelters syndrome (47XXY)
52
Q

Secondary hypogonadism

A

low gonadotrophins- LH/FSH

  • hypopituitarism
  • prolactinoma
  • Kallman’s syndrome- isolated gonadotrophin releasing homone deficiency with associated anosmia and colour blindness
  • systemic illness e.g. COPD/HIV/DM
  • Laurence-Moon-Beidl & Prader-Willi syndrome
53
Q

Management of hypogonadism

A

testosterone dermal gel

CI if high calcium, polycythaemia, nephrosis, prostate/male breast/ or liver Ca
- monitor PSA

54
Q

Clinical features

acute upper urinary tract obstruction

A

loin pain radiating to groin

- maybe superimposed infection +/- loin tenderness or an enlarged kidney

55
Q

Clinical features

chronic upper urinary tract obstruction

A

flank pain, renal failure, superimposed infection

polyuria may occur due to impaired urinary concentration

56
Q

Clinical features

acute lower urinary tract obstruction

A

acute urinary retention- severe suprapubic pain
preceded by symptoms of bladder outflow obstruction
clincically - distended, palpable bladder, dull to percussion

57
Q

Clinical features

Chronic lower urinary tract obstruction

A 
urinary frequency
hesitancy 
poor stream
terminal dribbling
overflow incontinence
Signs: distended, palpable bladder +/- large prostate on PR 
Complications: UTI, urinary retention
58
Q

Luminal causes of urinary tract obstruction

A

stones
blood clots
sloughed papilla
tumour –> renal/ureteric/bladder

59
Q

Mural causes of urinary tract obstruction

A

congenital/acquired stricture
neuromuscular dysfunction
schistosomiasis

60
Q

Extra-mural causes of urinary tract obstruction

A

abdominal or pelvic mass/ tumour
retroperitoneal fibrosis
iatrogenic - post surgery

61
Q

Urinary Obstruction tests

A

U&E, creatinine
MC&S
USS –> CT –> radionuclear MRI

62
Q

Treatment of upper urinary tract obstruction

A

nephrostomy or ureteric stent
alpha-blockers for related pain
pyeloplasty

63
Q

Treatment of lower urinary tract obstruction

A

urethral or supra-pubic catheter

treat underlying cause if possible

64
Q

non-gonococcal urethritis

A

commoner than GC

  • discharge is thinner and signs less acute
  • women typically asymptomatic - cevicitis, urethritis,or salpingitis (pain/fever/infertility)
65
Q

non-infective urethritis

A

trauma
chemicals
cancer
foreign body

66
Q

Urothelial tumours

site

A

transitional cell carcinomas

  • calyces
  • renal pelvis
  • ureter
  • blader
  • urethra
67
Q

Urothelial tumours

demographics

A

men

over the age of 40

68
Q

Urothelial tumours risk factors

A
  • cigarette smoking
  • exposure to industrial chemicals - benzidine
  • exposure to drugs (phenacetin, cyclophosphamide, ketamine)
  • chronic inflammation (schistosomiasis)
69
Q

Urothelial tumours

clinical features

A

painless haematuria
LUTS (frequency, urgency, dysuria) in the absence of bacteriuria
- pain from locally advance or metastatic disease but may come from clot retention
TCC of kidney/ureters –> haematuria and flank pain

70
Q

Urothelial tumours

Investigations

A
  • plasma creatinine

- renal tract imaging and cystoscopy

71
Q

Urothelial tumours

Management

A

Pelvic and ureteric tumours- nephrouretectomy
- treatment of bladder tumour: local diathermy, cystopic resection, bladder resection, radiotherapy and local/ systemic chemo

72
Q

ureteral stones

urolithiasis

causes

A

calcium oxalate and/ or calcium phosphate

could also be uric acid, magnesium ammonium phosphate and cystine stones

Form when urine becomes super saturated and begins the formation of crystal formation + Calcium stones

73
Q

hypercalciuria

causes

A
  • hypercalcaemia (commonly primary hyperparathyroidism)
  • excessive dietary intake of calcium
  • excessive resorption of calcium from bone e.g. prolonged immobilisation
  • idiopathic hypercalciuria (increased absorption from gut –> increased urinary excretion)

Primary renal disease –> alkaline urine –? calcium stones (precipitation of calcium phosphate)

74
Q

Hyperoxaluria

A

increased oxalate excretion –> formation of calcium oxalate, even with normal calcium excretion

  • dietary hyperoxaluria (spinach/rhubarb/tea) + low dietary calcium
  • enteric hyperoxaluria - chronic intestinal malabsorption of any cause –> low intestinal calcium for oxalate binding (2ndary cause - dehydration due to fluid loss from gut)
  • primary hyperoxaluria rare autosomal recessive enzyme deficiency resulting in high levels of endogenous oxalate production - widespread calcium oxalate deposition (CKD in teens/20s)
75
Q

Uric acid stones

A

hyperuricaemia with or without clinical gout

pts with ileostomy at risk (loss of bicarb from GI secretions –> acid urine and reduced solubility of uric acid)

76
Q

Infection induced stones

A

UTIs with urease producing organisms (proteus, klebsiella, pseudomonas) –> stones of ammonia, magnesium and calcium)
urease hydrolyses urea to ammonia increasing urinary pH
- large stones in pelvicalyceal system produce radiopaque staghorn calculus

77
Q

Cystine stones

A

cystinuria (autosomal recessive condition affecting cystine and dibasic amino acid transport of epithelial cells of renal tubules and GI tract) –> excessive urinary excretion of cystine –> formation of crystals and calculi

78
Q

Clinical features of urinary tract caliculi

A
  • asymptomatic
  • pain most commonly
  • loin pain = staghorn renal caliculi
  • ureteric stones = renal colic
    Nausea, vomiting and sweating
    Haematuria
    urethral stones - bladder outflow obstruction = anuria and painful bladder distention
79
Q

Management of stones

A
  • strong analgesia
  • extracorporeal shock wave lithotripsy
  • endoscopy
80
Q

Investigations of stones

A

MSU for culture and serum urea, electrolytes, creatinine and calcium

Plain KUB x-r
unenhanced helical CT

81
Q

Prevention of stones

A
  • normal calcium, avoid oxalate high foods
  • meticulous control of bacteriuria
  • xanthine oxidase inhibitor (allopurinol)
  • high fluid intake
82
Q

Normal urinary physiology

A

intravesical pressure remains low due to stretching of the bladder wall and the stability of bladder muscle (detrusor) which doesn’t contract involuntarily

  • sphincter mechanisms of bladder neck and urethral muscles
  • decreased sympathetic activity = sphincter relaxation and detrusor contraction
  • overall control in cerebral cortex and the pons
83
Q

stress incontinence

A

sphincter weakness

  • iatrogenic (post prostatectomy)
  • post child birth
  • small leak of urine with increase in intra-abdominal pressure
84
Q

urge incontinence

A

strong desire to void and inability to hold urine

  • usual cause detrusor instability
  • mild cases respond to bladder training
  • anticholinergic agents –> oxybutynin –> decrease detrusor excitability
  • may also be caused by bladder hypersensitivity from local pathology (UTI, bladder stones and tumours
85
Q

Overflow incontinence

A
  • prostatic hypertrophy causing outflow obstruction
  • leakage of small amounts of urine
  • distended bladder is palpable rising out the pelvis

3B Specialties (7 decks)

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