Urology Flashcards
How do you assess a middle aged patient who presents with an episode of microscopic haematuria?
History, examination, investigation.
Hx -> duration, progression, pain, trauma, urinating history, weight loss, FHx, Lx
Ex -> abdo exam, genital exam, PR, general inspection
Ix -> urinalysis, UEC, LFT/coags, USS, CT
A 60 year-old woman attends ED with a three week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for one month. There is nothing remarkable in the rest of her history. On examination, she is pale, pulse of 100 bpm, BP 105/70 mmHg, her Hb is 8.2 g/dl with a pattern consistent with iron deficiency, rest of her blood work is normal. What is the important diagnosis to exclude and what investigations do you want to do?
Concerning diagnosis is a bladder cancer or RCC
B -> FBC, UEC, LFT, Iron studies, O -> MCS X -> USS, CT abdo E -> ECG S -> urinalysis, cystoscopy
Refer to a urological team
You are asked to see a 75 year-old man in ED. He has not been able to urinate for 12 hours and is in acute pain. The ED doctor referring him has excluded all other conditions, but has had to attend a resus room case before considering his urinary tract, no imaging modality is available. What will you do to assess this man and how will you treat him?
This man requires urgent catheterisation, either through Foley or through suprapubic.
Assess amount that leaves catheter, perform abdo exam, PR
Hx -> SOCRATES, nerve damage, urinary symptoms progression
Refer to urologist
An 81 year-old man presents to the ED complaining of difficulty passing urine. This has been a problem for six months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else. What is the diagnosis?
Why is he complaining of bedwetting?
Most likely diagnosis is BPH resulting in urinary retention
Mechanical pressure applied by the prostate results in urinary retention and incomplete voiding with an atonic bladder and urinary incontinence. Bedwetting is a common presentation and is due to relaxation of the pelvic floor muscles at night. He has overflow incontinence.
An 81 year-old man presents to the ED complaining of difficulty passing urine. This has been a problem for six months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else. What is the diagnosis?
What is the management?
Diagnosis of this man is BPH resulting in overflow incontinence.
Management -> insert catheter.
after drainage monitor fluid status and electrolyte levels
medical -> alpha blockers (tamsulosin), 5-alpha reductase inhibitors
surgical -> TURP or green laser prostatectomy
An 81 year-old man presents to the ED complaining of difficulty passing urine. This has been a problem for six months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else. What is the diagnosis?
What features of the prostate, if found on examination, would make you concerned about prostate cancer?
Features on DRE:
asymmetrical, hard, nodular, loss of median furrow
Examination:
weight loss, cachexia, wasting, lymphadenopathy, bony tenderness
What are the advantages of screening a 55 year-old man with a PSA test for prostate cancer?
More agreeable screening method, objective monitoring, cheap, good comparison ability, low risk, results easily reproducible, PSA elevations can precede development by 5 years
What are the disadvantages of screening a 55 year-old man with a PSA test for prostate cancer?
Low specificity and sensitivity, increased risk of over treating and its complications, psychological stress for patients, prone to false negatives,
What are the classical symptoms and signs of renal cell carcinoma?
The classic triad of RCC are:
haematuria, flank tenderness and palpable mass
Other symptoms include polycythaemia, anaemia and bone pain
A 60 year-old woman attends ED with a three week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for one month. There is nothing remarkable in the rest of her history. On examination, she is pale, pulse of 100 bpm, BP 105/70 mmHg, her Hb is 8.2 g/dl with a pattern consistent with iron deficiency, the rest of her blood work is normal. What is the important diagnosis to exclude, what factors are relevant in taking a history in this case?
Important diagnosis to exclude are RCC, bladder cancer, endometrial cancer
Hx -> duration, pain (SOCRATES), progression, FHx, Lx, trauma, sexual history, recent sore throat
Examination -> abdo exam, genital/urethral lesions
Ix -> urinalysis, UEC, LFT, Iron studies, FBC, USS, CT-KUB
You are an ED intern. A 40 year-old woman presents to the ED. She has a fever of 39.4°C, Blood pressure of 90/40 mmHg, pulse 120 regular, respiratory rate of 24, she is drowsy and confused when answering questions. She initially complained of left sided abdominal pain, and the pain came in waves 3 - 10 minutes apart, with an urge to pass urine. She has a history of left sided renal calculi, and 48 hours before presentation she had lithotripsy (ESWL) to her left sided kidney stone. What is the likely diagnosis?
What will you do?
Likely diagnosis is pyelonephritis secondary to lithotripsy causing sepsis.
Patient must be commenced on the sepsis pathway. Red zone criteria of temperature, BP. Yellow zone of pulse.
Give 3 -> O2, fluid (monitor output with catheter) and empirical Abx (vancomycin and penicillin if source is unknown)
Take 3 -> Bloods for culture (2 different spots at 2 different times), VBG (lactate) and baseline bloods (FBC, UEC, LFTs, coags, glucose)
A 30 year-old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is clearly different from the rest of the testis and epididymis, it is not tender and does not transilluminate. Abdominal and chest exam are normal. What is the likely diagnosis, what are the necessary investigations?
Likely diagnosis for this man is testicular cancer. Lymphatic spread, firstly to para-aortic nodes
Exclude symptoms such as fever, night sweats, weight loss
Ix -> Bloods (FBC, UEC, LFT), USS, CT
Tumour markers (B-HCG, alpha foetal protein. Lactate dehydrogenase)
Either a simple or radical orchidectomy can be performed. Prognosis is good for this man.
DO NOT biopsy through the scrotum
A 30 year-old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is clearly different from the rest of the testis and epididymis, it is not tender and does not transilluminate. Abdominal and chest exam are normal. What is the likely diagnosis, how do you differentiate between different scrotal lumps on clinical examination?
Likely diagnosis is testicular cancer
Differentiate between lumps with:
transillumination, cough impulse, tenderness, mobility, consistency, palpate above the mass, separate the mass from the testes.
What are the indications for a person to be put on the kidney transplant waiting list?
Patients requiring transplant > organs available. Indications include:
>80% 5 year survival, ESKD requiring dialysis, low chance of peri-operative mortality. Contraindications of uncontrolled infection, malignancy, vascular disease (DM), severe uncorrectable CVD
What tissue matching tests are required when the transplant service is deciding which patient on the waiting list gets a donor organ when one becomes available?
Tissue matching test include:
ABO -> ensure blood type is appropriate
HLA typing -> HLA has extreme nucleotide polymorphisms
Panel reactive antibody -> HLA antibody detection
Serum leukocyte antigens
