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3b specialties > Urology > Flashcards

Urology Flashcards

1
Q

differentials of scrotal swelling?

A 
inguinal hernia
testicular tumour
acute epididymo-orchitis
epididymal cysts
hydrocele
testicular torsion
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2
Q

features of epididymal cyst?

A

lump found posterior and separate from the body of the testicle

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3
Q

associated condition of epididymal cysts?

A

polycystic kidney disease
CF
Von Hippel-Lindau syndrome

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4
Q

diagnosis of epididymal cysts?

A

USS

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5
Q

Mx of epididymal cysts?

A

supportive therapy

surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts

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6
Q

what is a hydrocele?

A

an abnormal collection of fluid between the 2 layers of the tunica vaginalis

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7
Q

causes of hydrocele?

A
  • non-communicating or simple hydrocele- over production of fluid within the tunica vaginalis
  • communicating hydrocele- the processus vaginalis fails to close allowing peritoneal fluid to communicate freely with the scrotal portion
  • hydrocele of the cord- processus vaginalis closes segmentally, trapping fluid within the spermatic cord
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8
Q

presentation of hydrocele?

A

scrotal enlargement with a soft non-tender swelling
No pain
Will trans illuminate with pen torch
Can get above the mass on examination
Testis may be difficult to palpate if the hydrocele is large

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9
Q

Ix of hydrocele?

A

none required for simple hydrocele
USS if in doubt of diagnosis
suplex sonography
serum AFP and HCG levels to exclude malignant teratomas or other germ cell tumours

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10
Q

tx of hydrocele?

A

If in infancy, many resolve spontaneously
In adults, conservative approach may be taken depending on the severity of the presentation
Scrotal support
Therapeutic aspiration
Surgical removal in some cases

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11
Q

what is varicocele?

A

an abnormal dilatation of the testicular veins in the pampiniform venous plexus, caused by venous reflux

  • usually asymptomatic, need to rule out RCC (due to compression of renal vein- swollen testicles can be a symptom)
  • can be associated with infertility
  • reflux
  • valve incompetence
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12
Q

is a varicocele more common on the left or right?

A

LEFT as left testicle vein drains into the left renal vein which has more chance of compression

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13
Q

epidemiology of varicocele?

A

incidence increases after puberty

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14
Q

features of varicocele?

A

usually asymptomatic
scrotum feels like a ‘bag of worms’
scrotal heaviness
infertility

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15
Q

Ix of varicocele?

A

sperm count
USS colour doppler studies
Venography, thermography, CT
Serum FSH/LH/LHRH

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16
Q

tx of varicocele?

A

surgical repair where there is pain, infertility and testicular atrophy

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17
Q

what is testicular torsion?

A

twisting of the spermatic cord resulting in testicular ischaemia and necrosis

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18
Q

RFs for testicular torsion?

A

10-30 years, L sided more commonly affected

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19
Q

features of testicular torsion?

A 
acute swelling of the scrotum
pain-sudden and severe in one testicle 
testicle retracts upwards
loss of cremasteric reflex
lower abdo pain
can come on during sport or physical activity
reddening of the scrotal skin
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20
Q

Ix of testicular torsion?

A

mainly a clinical diagnosis
urinalysis to exclude infection and epididymitis
doppler ultrasound scan- GOLD STANDARD- shows reduced blood flow

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21
Q

tx of testicular torsion?

A

surgery within 6 hours to save testicle

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22
Q

what does the prostate secrete?

A

seminal fluid. it nourishes the sperm

stimulated by the dihydrotestosterone

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23
Q

features of BPH?

A

LUTS:

  • voiding symptoms (obstructive) - weak or intermittent urinary flow, straining, hesitancy, terminal dribbling, incomplete emptying
  • storage symptoms (irritative) - urgency, frequency, urinary incontinence, nocturia
  • post-micturition- dribbling
  • complications- UTI, retention, obstructive uropathy
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24
Q

Ix of BPH?

A

DRE- enlarged prostate
serum electrolyte and renal USS
serum PSA
referral and biopsy if suspicious of malignancy

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25
Q

tx of BPH?

A

1) Alpha blockers- e.g. Tamsulosin, alfuzosin- a1 receptor antagonists
- relax smooth muscle in the bladder neck and prostate
- increase urinary flow rate and an improvement in obstructive symptoms

2) 5-alpha reductase inhibitors e.g. finasteride
- blocks conversion of testosterone to dihydrotestosterone (responsible for prostate growth)- may take 6 months before results are seen
- can slow progression

3) urethral or suprapubic catheterisation
4) prostatectomy/TURP or permanent catheter

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26
Q

SEs of alpha blockers

A

dizziness
postural hypotension
dry mouth
depression

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27
Q

SE of 5-alpha-reductase inhibitors

A 
ED
reduced libido
ejaculation problems
gynaecomastia
(due to lack of testosterone)
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28
Q

complications of BPH?

A 
Bladder obstruction-retention
infections
stones
haematuria
interactive obstructive uropathy
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29
Q

what are the majority of bladder cancers?

A

> 90% are transitional cell carcinomas
2nd type is SCC
incidence peaks in the 8th decade

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30
Q

RFs for transitional cell bladder cancer?

A 
smoking 
aniline dyes 
rubber manufacture
cyclophosphamide
pelvic irritation
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31
Q

RFs for SCC bladder cancer?

A

schistosomiasis
BCG treatment
smoking

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32
Q

what is the grade of a cancer?

A

biological potential to invade and metastasise

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33
Q

what is the stage of a cancer?

A

how far it has spread

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34
Q

features of bladder cancer?

A 
painless haematuria **red flag**
recurrent UTIs
voiding irritability
LUTS
dysuria **red flag**
abdo pain
weight loss/bone pain
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35
Q

Ix of bladder cancer?

A 
urine dipstick-microscopic haematuria
bloods- FBC, U&E, LEFTs
flexible cystoscopy with biopsy is diagnostic
urine- microscopy and cytology
CT urogram 
MRI
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36
Q

tx of bladder cancer?

A

TURBT (resection) +/- intravesicle chemotherapy
2 main agents- mitomycin and BCG vaccine
If muscle invasive- radical surgery and radiotherapy
Chemotherapy

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37
Q

2 week wait for suspected urological malignancy?

A

> 45 years and unexplained macroscopic haematuria or persists after Tx for UTI

> 60 years and unexplained microscopic haematuria and either dysuria or increased ECC on testing

Consider non-urgent referral if >60 and recurrent or persistent UTI

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38
Q

what is the most common type of prostate cancer?

A

95% are adenocarcinomas

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39
Q

causes/RFs of prostate cancer?

A 
age- disease of the elderly
obesity
afro-Caribbean ethnicity
FH
mutations in androgen receptor genes
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40
Q

features of prostate cancer?

A 
localised disease- often asymptomatic
LUTS
pain- back, perineal or testicular
mets to bone- hypercalcaemia
B-symptoms
Marrow replacement- purpura, anaemia, immune suppression
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41
Q

Ix of prostate cancer?

A 
DRE- asymmetrical, hard, craggy, loss of median sulcus
PSA screening tool
PSMA in serum
Urine test for PCA3
Multiparametric MRI
TRUSS- transrectal USS
Prostate biopsy
CT
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42
Q

when should men be referred for further investigation?

A

men aged 50-69 should be referred if PSA .3 OR there is an abnormal DRE

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43
Q

causes of false positive PSA?

A 
prostatis- wait 1 month
UTI- wait 4 weeks
Vigorous DRE- wait 1 week
Vigorous exercise- wait 48 hours
Ejaculation- wait 48 hours
Urinary retention
Surgery/instrument used
BPH
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44
Q

what is the grading system for prostate cancer?

A

GLEASON GRADING SYSTEM

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45
Q

TX of prostate cancer?

A

radical prostatectomy and radiotherapy
focal therapy- high intensity USS
watchful waiting to see if the cancer progresses
active surveillance- follow up examination and PSA level monitoring
brachytherapy- radiotherapy beads

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46
Q

how to manage metastatic prostate cancer?

A

1) Androgen deprivation-
-surgical castration (removing testicles)
-medical castration-> GnRH analogues- buserelin, goserelin, LH antagonists, peripheral androgen receptor antagonists
(need to co-prescribe anti-androgen tx such as cryproterone acetate or flutamide- presents increase in symptoms)

Second line- hormone therapy (abiraterone), cytotoxic chemo, bisphosphonates, palliation of pain, ureteric obstruction, anaemia

47
Q

what is a complication of TURP?

A

TURP syndrome
venous destruction and absorption of the irrigation fluid
causes restlessness, headache, tachypnoea, burning sensation in the face and hands
causes hyponatraemia, fluid overload, glycine toxicity

48
Q

mx of TURP syndrome?

A

ABCDE and resuscitation and O2

fluid overload managed with furosemide

49
Q

what produces testosterone and what produces sperm?

A

testosterone- Leydig cells

sperm- sertoli cells

50
Q

cause of testicular cancer?

A

FH
genetic factors- abnormality in Chr 12, Klinefelter’s syndrome
Unknown- majority

51
Q

RFs for testicular cancer?

A

25-35 years
cryptorchidism (undescended testis)
infertility
mumps

52
Q

types of testicular cancer?

A

95% arise from germ cells- seminomas and teratomas

non germ-cell tumours- Leydig cells, Sertoli cells, sarcomas

53
Q

features of testicular cancer?

A 
painless lump
testicular and/or abdominal pain
dragging sensation in the testicles
hydrocele
gynaecomastia from B-HCG production
Mets in lungs or para-aortic lymph nodes
54
Q

Ix of testicular cancer?

A

USS
Tumour markers- AFP and Beta-HCG
CXR and CT of chest, abdomen and pelvis

55
Q

tx of testicular cancer?

A

orchidectomy
radiotherapy- for seminomas with mets below the diaphragm
chemotherapy
sperm banking

56
Q

what is epididymo-orchitis?

A

infection of the epididymis and/or testes resulting in pain and swelling

57
Q

causes of epididymo-orchitis?

A

local spread of infections from genital tract or bladder
age <35= STI >UTI
age <35= UTI>STI
following urological intervention
in the elderly -> predominantly catheter related

58
Q

features of epididymo-orchitis?

A

unilateral testicular pain and swelling
urethral discharge
rule out testicular torsion

59
Q

Ix of epididymo-orchitis?

A

void urine and the perform CT +/- urethral swab
MSSU
USS to rule out abscesses
Sexual history

60
Q

tx of epididymo-orchitis?

A

if STI suspected- refer to GUM
Abx- quinolone of >35 and not suspecting UTI
doxycycline +/- stat azithromycin if STI more likely
if organism unknown- IM ceftriaxone 500mg single dose plus doxycycline 100mg by mouth BD for 10-14 days
Supportive underwear
NSAIDS if required

61
Q

what is hydronephrosis?

A

dilatation of the renal pelvis or calyces as a result of obstruction of the outflow of urine distal to the renal pelvis

62
Q

causes of hydronephrosis?

A 
SUPER (bilateral) PACT (unilateral)
S- stenosis of the urethra
U-urethral valve
P-prostatic enlargement
E- extensive bladder tumour
R- retroperitoneal fibrosis

P- pelvic-ureteric obstruction (congenital or acquired)
A- abnormal renal pelvis
C-calculi
T-tumours of the renal pelvis

63
Q

Ix of hydronephrosis?

A

USS
IV urogram
antegrade or retrograde pyelography
CT scan- if suspected renal colic

64
Q

tx of hydronephrosis?

A

treat cause
catheter
nephrostomy tube- acute upper urinary tract obstruction
ureteric stent or pyeloplasty- chronic upper UT obstruction

65
Q

what is obstructive uropathy?

A 
functional or anatomical obstruction of urine flow at any level of the urinary tract
can be supravesivle (above the bladder)
or infravesicle (below the bladder)
66
Q

renal causes of obstructive uropathy?

A

cysts (PKD)
Neoplastic- wilm’s tumour, RCC, TCC
Inflammatory- TB, echinococcosis infection
Metabolic- kidney stones
Miscellaneous- sloughed papillae, trauma, renal artery aneurysm

67
Q

ureter causes of obstructive uropathy?

A

congenital- strictures, ectopic kidney
cancer- TCC of the ureter, mets
inflammatory- TB, schistosomiasis, endometriosis
misc- retroperitoneal fibrosis, AA, pelvic lipomatosis, pregnancy
kidney stones

68
Q

bladder and urethra causes of obstructive uropathy?

A

congential- phimosis (narrow foreskin), abnormal opening of urethra
neoplastic- cancers
misc- BPH

69
Q

what is post obstructive diuresis?

A

urine output increases to >200ml/hr
ends when normal levels have been achieved again
normal physiological resonse

70
Q

features of obstruction of urinary tract?

A

dull ache in flank/loin
complete anuria
LUTS

71
Q

Ix of obstruction of urinary tract?

A

imaging- CT, USS
serum creatinine- shows function of the affected kidney
bloods- FBC, U&E, coagulation, ABG
Urine- dipstick, MC&S to rule out infection as cause

72
Q

tx of obstruction of urinary tract?

A 
ABCDE
fluids
analgesia
antibiotics 
catheter
stents
nephrostomies
73
Q

what is acute urinary retention?

A

sudden (<6 hours) inability to voluntarily pass urine
PAINFUL
palpable distented bladder

74
Q

causes of acute urinary retention?

A

BPH
urethral obstruction
meds- anticholinergics, TCAs, antihistamines, opioids, benzodiazepines
neurological- cauda equina, spinal cord compression
UTI
Postoperative
Postpartum

75
Q

Ix of acute urinary retention?

A

DRE
neurological examination/ pelvic exam in women
urinalysis and culture
U&Es and creatinine
FBC and CRP
bladder USS to confirm diagnosis- volume >300cc

76
Q

mx of acute urinary retention?

A

catheterisation

further Ix for underlying cause

77
Q

features of chronic urinary retention?

A 
PAINLESS 
incomplete bladder emptying
frequency, urgency, hesitancy, dribbling
nocturia
incontinence
78
Q

red flag causes of chronic urinary retention?

A 
spinal cord injury
pelvic/sacral fracture
herniated disc
infections
MS
myogenic failure due to chronic detrusor overdistension
79
Q

Ix of chronic urinary retention?

A 
urinalysis
MSSU
bloods (U&amp;Es and creatinine)
bladder diary
imaging of urinary tract
80
Q

mx of chronic urinary retention?

A 
intermittent self-catheterisation
indwelling catheter
stop precipitating drugs
tx for BPH
lifestyle- reduce alcohol and caffeine, reduce evening alcohol, bladder training
81
Q

complications of chronic urinary retention?

A

acute on chronic retention
hypertrophy of detrusor muscle and formation of bladder diverticula
hydronephrosis- leading to AKI or CKD
urinary incontinence due to overflow

82
Q

indications for surgery in urinary problems?

A 
RUSHES
Retention
UTIs
Stones
Haematuria
Elevated creatinine due to bladder outlet obstruction
Symptom deterioration
83
Q

what causes erectile dysfunction?

A

erections are caused by inflow of blood to the corpora cavernosum (corpus spondiosum contains urethra)
->
trabecular smooth muscle relaxation and arteriolar dilatation (through nitric oxide mediator)
->
phosphodiesterase causes penis to return to flaccid state

84
Q

what are the nerves responsible for an erection?

A

parasympathetic- S2,3,4- responsible for erections

sympathetic nerves T11-L2- responsible for ejaculation

85
Q

RFs for ED?

A 
lack of exercise
obesity
smoking
hypercholesterolaemia
hypertension
metabolic syndrome
DM
86
Q

causes of ED?

A
  1. Vascular
  2. Central neurological
  3. Peripheral neurological
  4. Hormone
  5. low testosterone
  6. anatomical
  7. drug causes
  8. psychosexual- lack of arousability, situational
87
Q

central neurological causes of ED?

A

Central neurological- PD, stroke, MS, tumours, traumatic brain injury, CVD, IV disc disease, spinal cord disease or injury

88
Q

peripheral neurological causes of ED?

A

Peripheral neurological- polyneuropathy, DM, alcoholism, uraemia, surgery, peripheral neuropathy

89
Q

hormonal causes of ED?

A

Hormone- hypogonadism, hyperprolactinaemia, cushings disease

90
Q

low testosterone causes of ED?

A

Primary- pituitary, hypothalamus

Secondary- testes (tumour, injury, drugs), Klinefelter’s syndrome, Noonan’s

91
Q

anatomical causes of ED?

A

Peyroine’s disease- penis bends over when it gets on erection to fibrous growth

92
Q

drug causes of ED?

A 
Beta-blockers
anti-depressants e.g. SSRIs, TCAs
anti-hypertensives
recreational drugs
H2 antagonists- ranitidine
93
Q

Ix of ED?

A 
physical exam and ED
fasting glucose
lipid profile
morning testosterone
if low testosterone-> perform prolactin, FSH and LH
94
Q

tx of ED?

A

1st line- lifestyle modification
phosphodiesterase inhibitors- PDE5 inhibitors e.g. sildenafil (Viagra)- effective for 30 mins
Vacuum erection devices 1st line if can’t take PDE5 inhibitors

95
Q

SEs of Viagra?

A 
headache
flushing
dyspepsia
nasal congestion
dizziness
visual disturbance
96
Q

CI of Viagra?

A 
nitrates (decrease BP)
alpha blockers (decrease BP)
97
Q

what is priapism?

A

prolonged erection
if lasts >4 hours there’s a risk of permanent ischaemic damage to the corpora
treat by aspirating the corpora with a 19 gauge needle or inject phenylephrine

98
Q

what is persistent non-visible haematuria?

A

blood present in 2/3 samples tested 2-3 weeks apart

99
Q

causes of persistent non-visible haematuria?

A 
cancer
stones
BPH
prostatis
urethritis e.g. chlamydia
renal causes e.g. IgA nephropathy
100
Q

causes of transient or spurious non-visible haematuria?

A

UTI
menstruation
vigorous exercise
sexual intercourse

101
Q

causes of red/orange urine without blood on dipstick?

A

beetroot, rhubarb

rifampicin, doxorubicin

102
Q

Ix of haematuria?

A

urine dipstick
renal function, albumin:creatinine (ACR) ratio
BP check
urine microscopy

103
Q

tx of haematuria?

A

urgent referral-
>45 years AND
-unexplained visible haematuria without UTI or
-visible haematuria that persists or recurs after successful treatment of UTI

104
Q

organisms causing UTI?

A

Gram negative- E.coli, klebsiella, proteus, Enterobacter

Gram positive- enterococcus

105
Q

RFs for UTI?

A 
sexual intercourse
female (shorter urethra)
post-menopause (decrease oestrogen causes loss of protective vaginal flora)
foley catheter
DM
infant boys with foreskin
impaired bladder emptying
urinary stasis
106
Q

Ix of UTI?

A

Urinalysis- pyuria (leukocytes), nitrites
Urine culture
Renal USS
VCUG- voiding cystourethrogram- vesicoureteral reflux
Renal scintigraphy

107
Q

what is sterile pyuria a sign of?

A

pyuria and urine culture (negative) suggests urethritis e.g. gonorrhoea or chlamydia

108
Q

tx of UTI?

A

Abx- trimethoprim or nitrofurantoin for 3 days

fluids

109
Q

CI of trimethoprim?

A

methotrexate, 1st trimester pregnancy

110
Q

CI of nitrofurantoin?

A

breastfeeding

111
Q

mx of pyelonephritis?

A

admit and broad-spectrum cephalosporin (cefotaxime, ciprofloxacin) or a quinolone for 10-14 days

112
Q

features of pyelonephritis?

A 
fever
rigors
loin pain
vomiting
white cell casts in urine
113
Q

mx of overactive bladder?

A

moderate fluid intake
bladder training
antimuscarinics e.g. oxybutynin, tolterodine or darifenacin

114
Q

signs of a bladder rupture?

A

pelvic fracture and lower abdo peritonism, free fluid in pelvis

3b specialties (7 decks)

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