Urology Flashcards
What are the zones of the prostate?
Central (around the urethra)
Transition (Which increases in size during life- BPH)
Peripheral (Cancer grows this)
What urinary problems may be caused by BPH?
- Poor flow
- Voiding symptoms (hesitancy, weak stream, intermittency, incomplete emptying, post void dribble)
What is a sign of detrusor overactivity?
- Strong flow (detrusor overactivity)
- Storage symptoms (frequency, urgency, nocturia)
How do we treat BPH?
Lifestyle changes
Alpha blockers
Surgery
What is the difference between BPE, BOO and BPH?
BPE = benign prostatic enlargement (clinical finding due to BPH) BOO = bladder outflow obstruction (clinical finding) BPH = benign prostatic hyperplasia (Histological finding)
What is the international prostate scoring system?
IPSS includes:
- frequency
- intermittency
- urgency
- weak stream
- straining
- nocturia
- Quality of life
What are the risk factors for BPH?
- Age
- Androgens
- Functional androgen receptors
- Obesity
- Diabetes
- Dyslipidaemia
- Genetic
- Afro Caribbean
What investigations might you do for BPH?
- LUTS
- IPSS questionnaire
- Frequency Volume chart
- Haematuria; Dysuria
- Full medical history (co-morbidities, drug history and family history)
- Examine abdomen – is bladder palpable?
- DRE
What investigations might you do for BPH?
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
How is urine flow different in BPH?
Normal = up to a peak flow then down
BPH = Low flow that tails of sporadically
How do you treat BPH (voiding symptoms)?
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)
What is the treatment of an overactive bladder?
Conservative
- Reassure
- Dietary advice
- Bladder Retraining Exercises
Medical
- Anticholinergics (oxybutinin)
- Betmiga
Surgical
- Intravesicle botox injection
- (Bladder augmentation, urinary diversion)
What do you do if a patient has urinary retention?
Catheterise Dipstick/CSU FBC, U & E Measure Residual Urine Neurological examination if necessary Prescribe - Antibiotics, Laxatives, Alpha blocker if necessary
What are the types of catheter?
Foleys
- Simplastic (short term )
- PTFE coated (short term )
- Hydrogel coated (long term)
- Silicone (long term)
What are the sizes of catherter?
- Known as ‘French’ or ‘Charriere’
- 16F is the diameter x 3
What are the special catheters?
- 3 Way
- Suprapubic
How do you tell the difference between acute and chronic retention?
Acute Retention (AUR) = painful
Chronic Retention (CUR)= postvoid residual >800ml
How do you treat low pressure urinary retention?
Normal U & Cr , no hydronephrosis
- consider starting alpha blockers and
- Trial Without Catheter (TWOC)
How do you manage high pressure urinary retention?
raised U & Cr bilateral hydronephrosis, Measure UO, BP , body weight Only < 10 % need fluid replacement - NEVER TWOC! - BOO Surgery or Longterm Catheter
What are the top 3 most common male cancers?
Prostate, Lung and bowel
What are the presenting symptoms of prostate cancer?
Asymptomatic; raised PSA LUTS Urinary retention / renal failure (Pain) Haematuria Bone pain/weight loss/ spinal cord compression (Mets)
What are the RFs for prostate cancer?
Age
Race
Family history
BRCA 2 gene
PSA is not good for screening, what are the max PSA levels?
40-49: 2.7
50-59: 3.9
60-69: 5.0
70-75: 7.2
What are the causese of raised PSA?
BPH Urinary Retention Urine infection Catheterisation / instrumentation of urethra Prostate cancer
Not significant:
Digital rectal examination
How do you assess for BPH?
Counselling History – LUTS? Bone pain? Weight loss? Blood in urine? Family history Examination DRE! Check PSA
How may an MRI scan be helpful?
Can differentiate between high risk and low risk prostate cancer
PIRADS classification 1-5
What are the alternatives to a TRUS biopsy?
Transperineal Biopsy
Template Biopsy
Saturation Biopsy
How do you grade and stage a prostate cancer?
Grading: Gleason score
Low riks 3+3
High risk 5+5
Staging:
TNMWhat 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
What are the less invasive treatments?
Surgery: open, laparoscopic, robotic Radiotherapy Brachytherapy HIFU Cryotherapy
Why is surgery unpopular?
More bleeding
higher incontinence
Likely erectile dysfunction
May not die anyway
What are the hormonal therapies?
LHRH agonist (e.g. Zoladex)
Anitandrogen
Beware tumour flare
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
How does macmillan help?
Information
Psychological
Communication with primary care, urology & oncology
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
What do you do if there is a PSA failure post RT?
Nadir +2
Consider HIFU or salvage surgery
Hormones
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
When do you choose to treat while doing active surveillance?
PSA >10 PSA dt <3 years Grade progression on rebiopsy Clinical progression Patient choice
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
What is a hydrocele?
Fluid within Tunica vaginalis
Can get above it
Transilluminates!
Surgical repair if large
What are epididymitis/ orchitis?
Infection of epididymis or testis or both
Causes
STIs
UTIs
Post-operative
What is the background of testicular cancer?
Affects younger men Germ Cell Seminomatous Non-seminomatous Non-Germ Cell Important to catch early
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
What are the causes of haematuria?
Infection Cancer Medical Trauma (kidney stones)
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
What is the criteria for haematuria admission?
Criteria for admission:
Frank haematuria with clots
Drop in Hb
Social circumstance
What is the role of the haematuria clinic?
2 week rule
One-stop
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
What issues may you find on follow up of a patient with haematuria?
Blocked catheters
Persistant haematuria
UTI / Antibiotics
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
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)
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
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
What is ureteric colic?
Presentation: Loin pain, Soft abdo, Mic haem 85%
EMERGENCY IF SEPSIS!
Causes: Stones, TCC, blood clot, RPF, ?BPH/CaP
What is the differential diagnosis for ureteric colic/ loin pain?
AAA Testicular torsion Perforated PU Appendicitis Ruptured ectopic MI Diverticulitis Prostatitis
What is the A/E protocol for ureteric colic?
- Analgesia: 5-10mg Morphine iv +/- antiemetic
(Diclofenac if creatinine normal) - Basic Investigations:
FBC/U+E, Ca, Urate, Urine dipstick, ßHCG (♀) - Radiological Investigations:
plain both KUB and CT KUB
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
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
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)
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)
What are the 4 treatments for stones?
Conservative
Medical / Metabolic
ESWL
Ureteroscopy
PCNL
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)
What is ESWL?
Extracorporeal shockwave lithotripsy
it is a treatment for kidney stones
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
What is obstructive pyonephrosis?
= Obstruction + infection
Risk of fatal GRAM –ve sepsis
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)
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
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
What would you find on examination of a testicular torsion?
swollen, tender, high riding (contralat horiz)
Loss of cremateric reflex in children
What would be the differentials associated with torsion?
torted appendix testis, epididymitis, viral orchitis, bleed into testicular tumour
What investigations would you do for a testicular torsion?
MSU (urgent microscopy if Sy suggest UTI/epididymitis)
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
What might be follow up issues of torsion?
Recurrent testicular pain
Fertility
Prosthesis
Medico-legal
