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DPD Stuff > Urology > Flashcards

Urology Flashcards

1
Q

What are the zones of the prostate?

A

Central (around the urethra)
Transition (Which increases in size during life- BPH)
Peripheral (Cancer grows this)

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2
Q

What urinary problems may be caused by BPH?

A
  • Poor flow

- Voiding symptoms (hesitancy, weak stream, intermittency, incomplete emptying, post void dribble)

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3
Q

What is a sign of detrusor overactivity?

A
  • Strong flow (detrusor overactivity)

- Storage symptoms (frequency, urgency, nocturia)

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4
Q

How do we treat BPH?

A

Lifestyle changes
Alpha blockers
Surgery

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5
Q

What is the difference between BPE, BOO and BPH?

A 
BPE = benign prostatic enlargement (clinical finding due to BPH)
BOO = bladder outflow obstruction (clinical finding) 
BPH = benign prostatic hyperplasia (Histological finding)
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6
Q

What is the international prostate scoring system?

A

IPSS includes:

  • frequency
  • intermittency
  • urgency
  • weak stream
  • straining
  • nocturia
  • Quality of life
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7
Q

What are the risk factors for BPH?

A
  • Age
  • Androgens
  • Functional androgen receptors
  • Obesity
  • Diabetes
  • Dyslipidaemia
  • Genetic
  • Afro Caribbean
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8
Q

What investigations might you do for BPH?

A
  • LUTS
  • IPSS questionnaire
  • Frequency Volume chart
  • Haematuria; Dysuria
  • Full medical history (co-morbidities, drug history and family history)
  • Examine abdomen – is bladder palpable?
  • DRE
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9
Q

What investigations might you do for BPH?

A

Urine dipstick (exclude infection)
Flow rate + POSTVOID RESIDUAL BLADDER SCAN in clinic
Blood tests (U&E, PSA – but need to counsel patient)
?Renal tract ultrasound
? Flexible cystoscopy

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10
Q

How is urine flow different in BPH?

A

Normal = up to a peak flow then down

BPH = Low flow that tails of sporadically

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11
Q

How do you treat BPH (voiding symptoms)?

A

Conservative management

  • Reassure
  • Fluid intake device

Medical management

  • Alpha blockers (tamsulozin)
  • 5 alpha reductase inhibitors (Finasteride

Surgical management

  • TURP
  • (Laser, steam, urolift, embolisation, catheter option)
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12
Q

What is the treatment of an overactive bladder?

A

Conservative

  • Reassure
  • Dietary advice
  • Bladder Retraining Exercises

Medical

  • Anticholinergics (oxybutinin)
  • Betmiga

Surgical

  • Intravesicle botox injection
  • (Bladder augmentation, urinary diversion)
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13
Q

What do you do if a patient has 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 types of catheter?

A

Foleys
- Simplastic (short term )

  • PTFE coated (short term )
  • Hydrogel coated (long term)
  • Silicone (long term)
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15
Q

What are the sizes of catherter?

A
  • Known as ‘French’ or ‘Charriere’

- 16F is the diameter x 3

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16
Q

What are the special catheters?

A
  • 3 Way

- Suprapubic

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17
Q

How do you tell the difference between acute and chronic retention?

A

Acute Retention (AUR) = painful

Chronic Retention (CUR)= postvoid residual >800ml

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18
Q

How do you treat low pressure urinary retention?

A

Normal U & Cr , no hydronephrosis

  • consider starting alpha blockers and
  • Trial Without Catheter (TWOC)
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19
Q

How do you manage high pressure urinary retention?

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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20
Q

What are the top 3 most common male cancers?

A

Prostate, Lung and bowel

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21
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 (Mets)
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22
Q

What are the RFs for prostate cancer?

A

Age
Race
Family history
BRCA 2 gene

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23
Q

PSA is not good for screening, what are the max PSA levels?

A

40-49: 2.7
50-59: 3.9
60-69: 5.0
70-75: 7.2

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24
Q

What are the causese of raised PSA?

A 
BPH
Urinary Retention
Urine infection
Catheterisation / instrumentation of urethra
Prostate cancer

Not significant:
Digital rectal examination

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25
Q

How do you assess for BPH?

A 
Counselling
History – LUTS? Bone pain? Weight loss? Blood in urine?
Family history
Examination
DRE!
Check PSA
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26
Q

How may an MRI scan be helpful?

A

Can differentiate between high risk and low risk prostate cancer
PIRADS classification 1-5

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27
Q

What are the alternatives to a TRUS biopsy?

A

Transperineal Biopsy

Template Biopsy

Saturation Biopsy

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28
Q

How do you grade and stage a prostate cancer?

A 
Grading: Gleason score 
Low riks 3+3
High risk 5+5
Staging:
       TNM
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29
Q

What is the management of prostate cancer?

A

Staging – MRI / Bone scan
MDT discussion and breaking news to patient
Options

Active surveillance (low risk low volume disease)
Surgery – radical prostatectomy (robotic or laparoscopic)
Radical Radiotherapy
Watchful waiting (elderly / co-morbid patients)
Hormones
Chemotherapy

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30
Q

What are the less invasive treatments?

A 
Surgery: open, laparoscopic, robotic
Radiotherapy
Brachytherapy
HIFU
Cryotherapy
31
Q

Why is surgery unpopular?

A

More bleeding
higher incontinence
Likely erectile dysfunction
May not die anyway

32
Q

What are the hormonal therapies?

A

LHRH agonist (e.g. Zoladex)
Anitandrogen
Beware tumour flare

33
Q

When do you suspect spinal cord compression and how do you manage it?

A

Urological emergency
Due to vertebral bone metastases

Start steroids (dexamethasone iv)
Urgent MRI
Suppress testosterone

Decompress cord with spinal surgery or radiotherapy

34
Q

How does macmillan help?

A

Information
Psychological
Communication with primary care, urology & oncology

35
Q

What do you do if there is a high PSA post RRP?

A 
<0.01 in 6/52
Failure initial PSA >0.2
Early rapid rise indicates disease beyond prostate
Later slow rise local recurrance
Biopsy to confirm
Restage- bone scan /MRI
36
Q

What do you do if there is a PSA failure post RT?

A

Nadir +2
Consider HIFU or salvage surgery
Hormones

37
Q

What do you do for active surveillance?

A

Gleeson 6 (?7)
Less than 2 cores
PSA <10
T1c or T2

PSA FU 3 monthly
MRI scan anually
Rebiopsy year 1,3 & 7

38
Q

When do you choose to treat while doing active surveillance?

A 
PSA >10
PSA dt <3 years
Grade progression on rebiopsy
Clinical progression
Patient choice
39
Q

When can PSA monitoring be done in primary care?

A

Post radical treatment- radiotherapy/surgery
On Hormones
Cancer- watchful waiting
Raised PSA after MRI and/or biopsies

Active surveillance – in secondary care as requires regular MRI and re-biopsy

40
Q

What is a hydrocele?

A

Fluid within Tunica vaginalis

Can get above it

Transilluminates!

Surgical repair if large

41
Q

What are epididymitis/ orchitis?

A

Infection of epididymis or testis or both

Causes
STIs
UTIs
Post-operative

42
Q

What is the background of testicular cancer?

A 
Affects younger men
Germ Cell
Seminomatous 
Non-seminomatous
Non-Germ Cell
Important to catch early
43
Q

What is the management of testicular cancer?

A

Ultrasound – urgent on same day
Tumour markers – AFP, HCG, LDH
CXR on same day
Counselling
Sperm banking
Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?)
Postop: Surveillance +- chemotherapy (BEP) +- Radiotherapy +-RPLND

44
Q

What are the causes of haematuria?

A 
Infection
Cancer
Medical
Trauma
(kidney stones)
45
Q

What is the management of haematuria?

A 
Resuscitate incl. transfusion
(ivi
Transfuse if necessary
Thorough bladder washout
Continuous irrigation
May need clot evacuation in theatre
Monitor closely and review regularly)

3 way catheter
Hx Ex
Bloods incl. Clotting and G&S; KUB
MSU

46
Q

What is the criteria for haematuria admission?

A

Criteria for admission:
Frank haematuria with clots
Drop in Hb
Social circumstance

47
Q

What is the role of the haematuria clinic?

A

2 week rule

One-stop

48
Q

What investigations would you do for haematuria?

A 
FBC, clotting, U&amp;E
MSU MC&amp;S
Urine cytology / NMP22 ?
CT Urogram or KUB, U/S 
Flexible cystoscopy

Treat cause
Follow-up as appropriate

49
Q

What issues may you find on follow up of a patient with haematuria?

A

Blocked catheters
Persistant haematuria
UTI / Antibiotics

50
Q

What is the background of renal stones?

A

More common in caucasian men
1% of hospital admissions
Lifetime prevalence 12%

Family History: consider CYSTINURIA

Anatomical and biochemical Factors

51
Q

Why should we give importance to renal stones?

A

Pain (spectrum)
Infection (incl. life-threatening gram –ve sepsis)
Renal damage
Underlying metabolic problems (eg. Hyperparathyroidism, gout, cysteinuria)
Underlying anatomical problems (eg. PUJ-o, MSK, Horseshoe kidney, ureteric stricture)
(Litigation)

52
Q

What is the classification or renal stones?

A

Size: <5mm; 5-20mm; >20mm; staghorn
Location: Renal (calyceal, pelvic, diverticular); Ureteric
Xray Characteristics: radiolucent; radioopaque
Stone composition: CaOx, CaP, Uric acid, cysteine, indinavir; Infection MAP/Struvite

53
Q

How do you diagnose renal stones?

A

Hx
Ex
Bloods, Urine dip (RBC, WBC, Nitrites, pH) & MSU
Imaging: KUB / US / CT-KUB / IVU

NB. Immediate imaging if: (EAU Recommendation)
Fever
solitary kidney
diagnosis unclear

54
Q

What is ureteric colic?

A

Presentation: Loin pain, Soft abdo, Mic haem 85%
EMERGENCY IF SEPSIS!
Causes: Stones, TCC, blood clot, RPF, ?BPH/CaP

55
Q

What is the differential diagnosis for ureteric colic/ loin pain?

A 
AAA
Testicular torsion
Perforated PU
Appendicitis
Ruptured ectopic
MI
Diverticulitis
Prostatitis
56
Q

What is the A/E protocol for ureteric colic?

A
  1. Analgesia: 5-10mg Morphine iv +/- antiemetic
    (Diclofenac if creatinine normal)
  2. Basic Investigations:
    FBC/U+E, Ca, Urate, Urine dipstick, ßHCG (♀)
  3. Radiological Investigations:
    plain both KUB and CT KUB
57
Q

What do you do if there is a small stone?

A

If stone <10mm, pain controlled, no sepsis: 2 week trial of Tamsulosin 400mcg od

Arrange follow-up with appropriate imaging (KUB vs limited IVU vs CT KUB)
2 weeks if significant obstruction or stones >5mm otherwise 4 weeks

58
Q

What advice do you give people with stones?

A

High fluid intake – urine champagne colour
Normal diet – do not cut out dairy products

Attend / return to A&E if
Pain not controlled by analgesia
PYREXIA

59
Q

Why would someone be admitted with stones?

A

Infected and obstructed
Confirmed stone (any size) and insufficient pain-relief with pethidine
Vomiting, dehydration
Solitary kidney or renal failure
Return to A&E with pain unresponsive to voltarol TTAs
Social circumstance
(for immediate treatment)

60
Q

What management do you always do for stones?

A 
U&amp;E, FBC, CALCIUM, URIC ACID
URINE DIP
PLAIN KUB XRAY
Start Tamsulosin
2 week follow-up (with KUB or CT KUB)
61
Q

What are the 4 treatments for stones?

A

Conservative

Medical / Metabolic

ESWL
Ureteroscopy

PCNL

62
Q

What is the conservative, medical and surgical management of stones?

A 
Conservative 
Observe asymptomatic non-obstructive renal stones in selected patients
incl. Metabolic screen
Medical 
Alkalinise / acidify urine
Treat / prevent UTIs
Allopurinol?
Surgical
Uretero-renoscopy +- laser
ESWL
PCNL
(Lap / Open)
63
Q

What is ESWL?

A

Extracorporeal shockwave lithotripsy

it is a treatment for kidney stones

64
Q

How do you follow up after a ureteric scope procedure?

A

Renal deterioration after 2-6 weeks if complete obstruction: danger in losing kidney
JJ stent encrustation <6 months in stone formers!
50% patients will have recurrent stones: fluid intake advice
40% of conservatively managed renal stones will enlarge – monitor by imaging & RF

65
Q

What is obstructive pyonephrosis?

A

= Obstruction + infection

Risk of fatal GRAM –ve sepsis

66
Q

How do you manage obstructive pyonephrosis acutely?

A 
Immediate resuscitation + iv antibiotics
Culture
Urgent imaging (KUB &amp; U/S)
Discuss with urology SpR
Consider urgent nephrostomy (or JJ stent)
Monitor closely (HDU)
67
Q

How do you manage obstructive pyonephrosis after acute?

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

68
Q

When and why does testicular torsion hapen?

A

Rare beyond 35y of age
Underlying deformity:
extension of tunica vaginalis behind testicle  clapper bell
Presentation: sudden onset

69
Q

What would you find on examination of a testicular torsion?

A

swollen, tender, high riding (contralat horiz)

Loss of cremateric reflex in children

70
Q

What would be the differentials associated with torsion?

A

torted appendix testis, epididymitis, viral orchitis, bleed into testicular tumour

71
Q

What investigations would you do for a testicular torsion?

A

MSU (urgent microscopy if Sy suggest UTI/epididymitis)

72
Q

How do you treat torsion?

A

Rx: Urgent scrotal exploration + fixation
Consent for ± orchidectomy
Irreversible histological ischaemic damage >6h
BUT: longer Hx does not preclude viability

73
Q

What might be follow up issues of torsion?

A

Recurrent testicular pain
Fertility
Prosthesis
Medico-legal

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