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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
How do you assess for BPH?
``` Counselling History – LUTS? Bone pain? Weight loss? Blood in urine? Family history Examination DRE! Check PSA ```
26
How may an MRI scan be helpful?
Can differentiate between high risk and low risk prostate cancer PIRADS classification 1-5
27
What are the alternatives to a TRUS biopsy?
Transperineal Biopsy Template Biopsy Saturation Biopsy
28
How do you grade and stage a prostate cancer?
``` Grading: Gleason score Low riks 3+3 High risk 5+5 Staging: TNM ```
29
What is the management of prostate cancer?
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
30
What are the less invasive treatments?
``` Surgery: open, laparoscopic, robotic Radiotherapy Brachytherapy HIFU Cryotherapy ```
31
Why is surgery unpopular?
More bleeding higher incontinence Likely erectile dysfunction May not die anyway
32
What are the hormonal therapies?
LHRH agonist (e.g. Zoladex) Anitandrogen Beware tumour flare
33
When do you suspect spinal cord compression and how do you manage it?
Urological emergency Due to vertebral bone metastases Start steroids (dexamethasone iv) Urgent MRI Suppress testosterone Decompress cord with spinal surgery or radiotherapy
34
How does macmillan help?
Information Psychological Communication with primary care, urology & oncology
35
What do you do if there is a high PSA post RRP?
``` <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
What do you do if there is a PSA failure post RT?
Nadir +2 Consider HIFU or salvage surgery Hormones
37
What do you do for active surveillance?
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
When do you choose to treat while doing active surveillance?
``` PSA >10 PSA dt <3 years Grade progression on rebiopsy Clinical progression Patient choice ```
39
When can PSA monitoring be done in primary care?
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
What is a hydrocele?
Fluid within Tunica vaginalis Can get above it Transilluminates! Surgical repair if large
41
What are epididymitis/ orchitis?
Infection of epididymis or testis or both Causes STIs UTIs Post-operative
42
What is the background of testicular cancer?
``` Affects younger men Germ Cell Seminomatous Non-seminomatous Non-Germ Cell Important to catch early ```
43
What is the management of testicular cancer?
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
What are the causes of haematuria?
``` Infection Cancer Medical Trauma (kidney stones) ```
45
What is the management of haematuria?
``` 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
What is the criteria for haematuria admission?
Criteria for admission: Frank haematuria with clots Drop in Hb Social circumstance
47
What is the role of the haematuria clinic?
2 week rule | One-stop
48
What investigations would you do for haematuria?
``` FBC, clotting, U&E MSU MC&S Urine cytology / NMP22 ? CT Urogram or KUB, U/S Flexible cystoscopy ``` Treat cause Follow-up as appropriate
49
What issues may you find on follow up of a patient with haematuria?
Blocked catheters Persistant haematuria UTI / Antibiotics
50
What is the background of renal stones?
More common in caucasian men 1% of hospital admissions Lifetime prevalence 12% Family History: consider CYSTINURIA Anatomical and biochemical Factors
51
Why should we give importance to renal stones?
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
What is the classification or renal stones?
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
How do you diagnose renal stones?
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
What is ureteric colic?
Presentation: Loin pain, Soft abdo, Mic haem 85% EMERGENCY IF SEPSIS! Causes: Stones, TCC, blood clot, RPF, ?BPH/CaP
55
What is the differential diagnosis for ureteric colic/ loin pain?
``` AAA Testicular torsion Perforated PU Appendicitis Ruptured ectopic MI Diverticulitis Prostatitis ```
56
What is the A/E protocol for ureteric colic?
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
What do you do if there is a small stone?
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
What advice do you give people with stones?
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
Why would someone be admitted with stones?
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
What management do you always do for stones?
``` U&E, FBC, CALCIUM, URIC ACID URINE DIP PLAIN KUB XRAY Start Tamsulosin 2 week follow-up (with KUB or CT KUB) ```
61
What are the 4 treatments for stones?
Conservative Medical / Metabolic ESWL Ureteroscopy PCNL
62
What is the conservative, medical and surgical management of stones?
``` 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
What is ESWL?
Extracorporeal shockwave lithotripsy it is a treatment for kidney stones
64
How do you follow up after a ureteric scope procedure?
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
What is obstructive pyonephrosis?
= Obstruction + infection | Risk of fatal GRAM –ve sepsis
66
How do you manage obstructive pyonephrosis acutely?
``` Immediate resuscitation + iv antibiotics Culture Urgent imaging (KUB & U/S) Discuss with urology SpR Consider urgent nephrostomy (or JJ stent) Monitor closely (HDU) ```
67
How do you manage obstructive pyonephrosis after acute?
``` 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
When and why does testicular torsion hapen?
Rare beyond 35y of age Underlying deformity: extension of tunica vaginalis behind testicle  clapper bell Presentation: sudden onset
69
What would you find on examination of a testicular torsion?
swollen, tender, high riding (contralat horiz) | Loss of cremateric reflex in children
70
What would be the differentials associated with torsion?
torted appendix testis, epididymitis, viral orchitis, bleed into testicular tumour
71
What investigations would you do for a testicular torsion?
MSU (urgent microscopy if Sy suggest UTI/epididymitis)
72
How do you treat torsion?
Rx: Urgent scrotal exploration + fixation Consent for ± orchidectomy Irreversible histological ischaemic damage >6h BUT: longer Hx does not preclude viability
73
What might be follow up issues of torsion?
Recurrent testicular pain Fertility Prosthesis Medico-legal

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