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DPD 2020 > Urology > Flashcards

Urology Flashcards

BPH/ prostate cancer. Hydrocele/ epididymitis/ orchitis/ testicular cancer (tumour markers). Haematuria, renal tract tumours and stones. Testicular torsion.

1
Q

What is benign prostatic hyperplasia?

A
  • A histological diagnosis.
  • Benign enlargement of prostate [transitional zone of prostate]
  • Common- over twenty percent of males over seventy
  • May be associated with urinary symptoms, due to resulting in bladder outflow obstruction
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2
Q

What are the different types of lower urinary tract symptoms?

A

> Poor flow- BOO- bladder outflow obstruction (BPH).

Voiding symptoms (obstructive):

  • hesitancy,
  • intermittency,
  • poor stream,
  • incomplete emptying,
  • straining

Detrusor muscle works harder to compensate- hypertrophy

> Strong flow- detrusor overactivity- overactive bladder

Storage symptoms (irritative):

  • frequency
  • urgency
  • nocturia
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3
Q

Define lower urinary tract symptoms (LUTS).

A

Non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding).

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4
Q

Define benign prostatic enlargement (BPE).

A

CLINICAL finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia.

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5
Q

Define bladder outflow obstruction (BOO).

A

Bladder outlet obstruction caused by benign prostatic enlargement (clinical finding).

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6
Q

Define benign prostatic hyperplasia (BPH).

A

Properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction.

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7
Q

What are the risk factors for BPH?

A
  • Age
  • Obesity
  • Androgens
  • Functional androgen receptors
  • Diabetes (&elevated fasting glucose)
  • Dyslipidaemia
  • Genetic
  • Afro-Caribbean
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8
Q

What are the important aspects of a BPH history and examination?

A
  • LUTS.
  • IPSS questionnaire.
  • FREQUENCY VOLUME CHART- objective
  • Haematuria
  • Dysuria.
  • Full medical history (co-morbidities [eligible for surgical treatment or not?], drug history and family history).
  • Examination of abdomen (is bladder palpable?).
  • DRE.
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9
Q

What are the important investigations to order for BPH?

A

Urine dipstick (exclude infection).

Flow rate [if in hospital- bad if below 12ml/sec] + post void residual bladder scan in clinic.

Blood tests (U&E, PSA, need to counsel patient).

? Renal tract ultrasound.

? Flexible cystoscopy.

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10
Q

What is the management plan for patients with voiding symptoms/ BPH?

A

Conservative management:

Reassure

Fluid intake advice (reduce evening fluid intake).

Medical management:

alpha blockers (tamsulosin, alfuzosin)

5-alpha-reductase inhibitors (finasteride, dutasteride).

[alpha-blockers= relax smooth muscle,

5-alpha-reductase inhibitors= shrink prostate [add if prostate size more than thirty ml, slower acting- weeks/months instead of two days]

Surgical management:

TURP (transurethral resection of prostate)

  • Seventy percent resolve

Alternatives include laser surgery, rezum/steam [atrophy of prostate], urolift [staples prostate], embolization [cause ischaemia of prostate], catheter options.

If unsuitable/unwilling for surgery- can catheterise for urinary retention- indwelling, self catheterise, suprapubic

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11
Q

What is the treatment for overactive bladder/ storage symptoms?

A

Conservative management:

reassure

[treat triggering UTI]

dietary advice- cut out caffeine/citrus fruit

bladder retraining exercises (NICE recommended)- 6 weeks

Medical management:

anticholinergics (oxybutinin, detrusitol, solifenacin)

Beta agonists- betmiga [less side effects]

Surgical management:

intravesical botox injection [if botox too strong- need to self catheterise- lasts 6 months]

bladder augmentation

urinary diversion/conduit.

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12
Q

Case 1: 70y/o man presents with inability to pass urine for 10hrs. Previous history of BPH (on tamsulosin and finasteride). Pain. How do you assess and manage this patient? a) give analgesia b) advise the patient to drink less, especially in evening c) start an alpha blocker d) catheterise patient e) advise TURP surgery

A

d] Catheterise patient

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13
Q

How should you proceed in the case of a patient with urinary retention?

A

Catheterise.

Dipstick/CSU - infection

FBC, U and E - renal failure-back pressure on kidneys

Measure residual urine- bladder scan

Neurological examination if necessary.

DRE- check for constipation

ADMIT IF ABNORMAL U+E

Prescribe: antibiotics, laxatives, alpha blocker if necessary.

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14
Q

What are the different types of urinary retention?

A

Acute retention (AUR) = painful.

Chronic retention (CUR) = postvoid residual >800mL- gradual increase over months and years.

Acute on chronic.

Can all be either high pressure or low pressure

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15
Q

How is low pressure urinary retention (LPR) managed?

A

Normal U and Cr, no hydronephrosis.

Consider starting alpha blockers.

Trial without catheter (TWOC).

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16
Q

How is high pressure urinary retention (HPR) managed?

A

Admit to hospital

Raised U and E; Cr, bilateral hydronephrosis.

Measure UO, BP, body weight.

Only 10% need IV fluid replacement- if more than 200ml/hr urine output Never TWOC.

BOO surgery or longterm catheter.

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17
Q

Case 2: 67y/o male. Urgency, frequency, poor flow. DRE 40g BPE. PSA 1.2 MSU -ve. US normal, postovoid residual 40mL. What do you prescribe? a) alpha blocker b) 5-alpha-reductase inhibitor c) anticholinergic

A

Alpha blocker [+5 alpha reductase inhibitor-large prostate] Anticholinergic can be added later to address urgency- not immediately b/c could cause urinary retention- relax detrusor activity + already obstructed flow

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18
Q

What are the presenting symptoms of prostate cancer?

A

Asymptomatic; raised PSA.

LUTS- sometimes

Urinary retention/ renal failure.

(Pelvic pain).

Haematuria.

Bone pain/ weight loss/ spinal cord compression (metastases).

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19
Q

What are the risk factors for prostate cancer?

A

Age

Race (Afro-Caribbean)

Family history (2 1st degree relatives)

BRCA 2 gene.

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20
Q

What are the causes of raised PSA (prostate specific antigen)?

A

BPH.

Urinary retention.

Urinary infection.

Catheterisation/ instrumentation of urethra.

Prostate cancer.

DRE is not a significant risk factor.

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21
Q

How do you assess a patient with suspected prostate cancer? What are the investigations needed in prostate cancer?

A

Counselling.

History: LUTS? bone pain? weight loss? blood in urine?

Family history.

Examination.

DRE!

Check PSA.

MRI: can differentiate between high risk and low risk prostate cancer-PIRADS classification 1-5.

TRUS {transrectal ultrasound guided] biopsy- Gleason Score [high risk if above four]

Take multiple samples

(risk of infection, bleeding- so can also do transperineal, template, or saturation biopsy).

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22
Q

How is prostate cancer histologically analysed?

A

Grading: Gleason score.

Low risk 3+3, high risk 5+5.

Staging: TNM- MRI/bone scan.

[t2 confined to prostate, common mets=lymph nodes, bone]

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23
Q

Case 3: 70y/o man referred by GP with PSA 18ug/L (upper limit 7.2). How are you going to assess?

Pick 2.

a) repeat PSA and check MSU
b) organise MRI prostate and TRUS biopsies
c) explain likely diagnosis of prostate cancer
d) advise radical prostatectomy or radiotherapy

A

Repeat PSA and check MSU.

Then: Organise MRI prostate and TRUS biopsies.

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24
Q

What is the management plan for a patient with prostate cancer?

A

Active surveillance (low risk low volume disease) - offered treatment if worsens

Surgery: radical prostatectomy - remove prostate completely + join bladder to urethra via anastomosis - (robotic or laparoscopic).

Radical radiotherapy- better for older patients

[Surgery and radiotherapy have similar outcomes]

Watchful waiting (elderly/comorbid patient).

Hormones- only useful if metastases- shrinks cancer by reducing testosterone- works for a few months

Chemotherapy.

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25
Q

What are some minimally invasive treatments for prostate cancer?

A

Surgery: open, laparoscopic, robotic.

Radiotherapy.

Brachytherapy- radioactive seeds put into prostate High intensity focal ultrasound (HIFU).

Cryotherapy.

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26
Q

Why has surgery been unpopular for prostate cancer treatment?

A

More bleeding.

Higher incontinence.

Likely erectile dysfunction.

May not die anyway.

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27
Q

What is the hormonal therapy for prostate cancer?

A

LHRH agonist (e.g. zoladex)- injection AND

Antiandrogen- to prevent tumour flare-

LHRH agonist causes initial rise in testosterone- increases chance of mets and cord compression before lowering testosterone

Can be used in conjunction with radiotherapy or alone.

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28
Q

What is a scrotal hydrocele?

A

Small, can still palpate testicle in fluid.

May be non-communicating [adults], communicating (paediatric- patent processus vaginalis- fluid leaking down), or hydrocele of the cord.

Transluminates with torch placed on scrotum (goes red).

Collection of water.

Cannot separate swelling from testicle In children- tie off patent processus vaginalis In adults - surgery directly on scrotal swelling- drain fluid and close up aganin

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29
Q

What is a scrotal varicocele?

Aetiology

Management?

A

Dilated veins of pampiniform plexus

Feels like a bag of worms. Stand patient up- lying down, blood drains out of veins so can’t feel it anymore.

Soft and separate to testicle.

Can be due to renal tumour- compressing left testicular vein

Management:

Usually doesn’t cause infertility and can be left if asymptomatic- but if causing lots of pain/infertility- treat

Radiological embolization

Surgery [high recurrence]

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30
Q

What is an epididymal cyst/ spermatocele?

Aetiology

Management

A

Lump close to testicle but not attached.

Mobile and soft.

Aetiology

Blocked spermatic duct

Management:

Can leave alone or surgery

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31
Q

What are the symptoms of testicular cancer?

What does testicular cancer feel like on examination?

A

Painless hard lump on testicle

Hard, craggy, immobile, attached to testicle.

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32
Q

Case 4: 25y/o man presents with pain in left testicle, swelling and fever.

How will you assess and manage him? a) organise ultrasound b) start antibiotics c) explain testicular cancer possible d) manage conservatively

A

Start antibiotics.

Organise ultrasound to rule out sinister cause e.g. cancer or abscess- would need drainage

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33
Q

What are the causes of haematuria?

A

Infection- glomerulonephritis, nephritic syndrome

UTI

Cancer

Trauma

Kidney stones- microscopic usually

Assume cancer unless proven otherwise

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34
Q

How should you assess, investigate and manage a patient with haematuria?

A

Resuscitate incl. transfusion.

3 way catheter.

History and examination- masses, DRE-craggy prostate

Bloods- FBC, U+E, clotting and G and S

Urine cytology/ NMP22 ?

CT KUB or CT urogram. MSU- MCS

Flexible cystoscopy- bladder cancer- do after haematuria resolves

Caution: no suprapubic catheter- would spread undiagnosed bladder cancer into abdominal wall

If serious enough to need admission: IVI

Transfuse if necessary.

Thorough bladder washout. Continuous irrigation.

May need clot evacuation in theatre.

Monitor closely and review regularly.

35
Q

Which investigations are ordered for haematuria?

A

FBC, clotting, U&E.

MSU MC&S.

Urine cytology/ NMP22 ?

CT urogram with contrast or KUB, U/S

Flexible cystoscopy.

Treat causes, follow up as appropriate.

36
Q

What are the follow up issues of haematuria?

A

Blocked catheters.

Persistent haematuria.

UTI/ antibiotics.

37
Q

What is the epidemiology of renal stones?

A

More common in caucasian men.

1% of hospital admissions.

Common- Lifetime prevalence 12%.

Family history: consider cystinuria.

38
Q

Why are renal stones important?

A

Pain (spectrum).

Infection (incl. life-threatening gram -ve sepsis- pyonephritis

Renal damage.

Signify underlying metabolic problems (e.g. hyperparathyroidism, gout, cysteinuria

Underlying anatomical problems (e.g. PUJ-o, MSK, horseshoe kidney, ureteric stricture).

39
Q

How are renal stones classified?

A

Size: <5mm [pass spontaneously]; 5-20mm; >20m; staghorn.

Location: renal (calcyeal, pelvic, diverticular).

X-ray characteristics: radiolucent-uric acid, radiopaque- all seen on CT-

KUB Stone composition: CaOx, CaP, uric acid, cysteine, indinavir; infectious magnesium ammonium phosphate/ struvite- most common worldwide.

40
Q

How are renal stones diagnosed?

A

History: may be asymptomatic, dull ache-renal colic - constant, or excruciating pain.

Examination: completely soft abdomen.

Urine dip (RBC, WBC, nitrites, pH- may have haematuria)

MSU

Bloods-

FBC- may have high WCC,

CRP,

U+E-dehydration due to vomiting [high creatinine]

Imaging:

Xray KUB.

US- hydronephrosis, stones in kidney

CT-KUB- gold standard, only scan that shows ureter stones VU. Immediate imaging recommended if: fever; solitary kidney; diagnosis unclear.

41
Q

How does ureteric colic present?

A

Loin [to groin] pain, soft abdomen,

Microscopic haematuria- 85%.

Emergency if sepsis.

42
Q

What are the causes of ureteric colic?

A

Stones.

TCC.

Blood clot.

RPF.

?BPH/CaP.

43
Q

What is the differential diagnosis for ureteric colic?

A

AAA.

Testicular torsion.

Perforated peptic ulcer

Appendicitis.

Ruptured ectopic.

MI.

Diverticulitis.

Prostatitis.

So do CT abdo and erect CXR

44
Q

How are kidney stones treated?

A

Conservative:

observe

asymptomatic - non-obstructive renal stones in selected patients

incl. metabolic screen.

Drink lots of water

Do not cut out dairy product- milk bind to oxalate to remove it

Medical:

alkalinise/acidify urine for uric acid stones- potassium citrate;

treat/prevent UTIs

Alpha blockers- tamsulosin for two weeks if stone <10 mm [controversial]- follow up imaging after this

Surgical:

ureteroscopy ± laser [rigid if in kidney, flexible if in ureter/calyx]

external shock wave litigation ESWL[pain, can’t have if on anticoagulants]

PCNL- percutaneous nephrolithotomy- incision, shock to break stone up, suction pieces out; (lap/open). Put stent after to allow recovery- often can block/move- causing pain

A and E if:

Uncontrollable pain by analgesia

Fever [

Kidney may be obstructed]

45
Q

What is obstructive pyonephrosis and how is it investigated/managed?

A

Obstruction + infection- emergency.

Risk of fatal Gram -ve sepsis.

Difficult to differentiate from pyelonephritis

Immediate resuscitation

IV Antibiotics.

Culture.

Urgent imaging (KUB & U/S).

Discuss with urology SpR

Consider urgent nephrostomy or JJ stent

Monitor closely (HDU)

Then treat underlying obstruction after infection resolved.

46
Q

What is the treatment of obstructive pyonephrosis once the patient is stable/infection is gone?

A

Imaging to determine cause: CT KUB, nephrostogram.

Anterograde stent.

Plan ureteroscopy/ ESWL/ PCNL.

May need drainage if perinephric abscess.

May need nephrectomy if XGP or EPN.

47
Q

How does testicular torsion present?

A

Sudden onset

tender

swollen

high-riding on examination.

No cremasteric reflex

No penile discharge, temperature

Longer cords and mobile testicles- clapper bell pathology

Can get intermmitent torsion- pain on and off leading up to complete torsion

Unlikely if patient above age of 23

48
Q

What is the underlying deformity in testicular torsion?

A

Extension of tunica vaginalis behind testicle- clapper bell.

49
Q

What is the differential diagnosis for testicular torsion?

A

Torted appendix testis.

Epididymitis.

Viral orchitis.

Bleed into testicular tumour.

50
Q

What are the different zones of the prostate?

A

Central [next to urethra]

Transitional zone

Peripheral zone

51
Q

Which zone does prostate cancer most commonly occur in?

A

Peripheral zone

Grows outwards- so asymptomatic- does not compress the urethra so no LUTS [lower urinary tract symptoms]

52
Q

Which zone does BPH happen in?

A

Transitional zone

53
Q

Does prostate size correlate to cancer risk/?

A

No

54
Q

How can the severity of BPH be assessed?

A

Using the IPSS International Prostate Scoring System

And ask patient about how symptoms are affecting quality of life

And looking at prostate size

55
Q

What are the side effects of medication used for overactive bladder

  • anticholinergics?
  • beta agonist?
A

Anticholinergics- dry mouth, dry eyes, closed angle glaucoma

Beta agonist- hypertension

56
Q

Types of catheter

A

Foley Size

Special catheters

  • Three way
  • Suprapubic
57
Q

Types of catheter [more detail]

A

Foley

Can be short term - Simplastic/PTFE coated

Long term- Hydrogel coated/Silicone

Size 16F/14F- can get through obstructed urethra

[Sizes= French/Charriere units]

Special catheters

  • Three way- haematuria- wash out blood clots/debris- so catheter is not blocked- can irrigate bladder to wash clots out
  • Suprapubic
58
Q

Does PSA increase with age?

A

Yes

59
Q

How to manage spinal cord compression from prostate cancer mets?

A

Urological emergency

Steroids- IV dexamethasone

Urgent MRI spine

Urgent spinal surgery referral- spinal surgery or radiotherapy decompression done

Suppress testosterone

60
Q

How is PSA monitored after prostate cancer surgery/radiotherapy?

How is a relapse managed?

A

Failure of treatment if initial PSA >0.2

Early rapid rise indicates disease mets beyond prostate

Later slow rise in PSA- indicates local prostate cancer recurrence

Do a biopsy to confirm + re stage [MRI/bone scan]

After radiotherapy if relapse:

  • HIFU- high intensity focused ultrasound/ salvage surgery
  • Or Hormone therapy
61
Q

In which prostate cancer patients is active surveillance done? How is it done?

A

Gleason 6

Less than two cores

PSA <10

Stage T1c or T2= confined to prostate

PSA- Three monthly

MRI- once a year

Rebiopsy - one, three, seven years

62
Q

What symptoms point towards epididymitis?

A

Swollen scrotum

Painful

Separate to testicle

Fever

Penile discharge

63
Q

Causes of epididymitis and orchitis?

A

STI

UTI- E coli etc.

Post operative- TURP, scrotal surgery

64
Q

Testicular cancer

Epidemiology

Types

Investigations

Management

Other considerations

A

Testicular cancer

Epidemiology

Younger men 35-45

Types

Teratoma

Seminoma

Non germ cells: Leydig/sertoli cells

Investigations

tumour markers- AFP, bHCG, LDH

US -urgent, same day

Management

Radical inguinal orchidectomy through inguinal canal- to avoid spread to separate lymph node route and mets

Prosthesis- cosmetic

Sperm banking before surgery

65
Q

When should you admit someone with haematuria to hospital?

A

Frank haematuria with clots

Drop in Hb

Social circumstance

66
Q

Why are bladder clots washed out?

A

If they remain in bladder they encourage more bleeding

67
Q

What does this CT scan show?

A

Renal cancer- adenocarcinoma

68
Q

Renal cancer types

A

Adenocarcinomas- cortex of kidney -Ninety percent

Transitional cell carcinomas- collecting duct + system- ten percent

69
Q

What does this image show?

A

Cystoscopy showing bladder cancer

Tumour looks like algae

70
Q

What are the stages of bladder cancer

How do the stages affect management

A

Superficial - resect tumour-electrically heated loop- rarely metastasise

Invaded into muscles - radical cystectomy- ileal conduit- bag of new bladder

Radiotherapy- more elderly

71
Q

What can be problems with haematuria treatment

A

Blocked catheters- flush with saline and aspirate clot

Persistent haematuria

UTI- uncommon- treat with antibiotics

72
Q

What causes kidney stones?

A

Anatomical- medullary sponge kidney

Biochemical- high calcium, urate etc

73
Q

What is the acute, symptomatic management of ureteric colic in A and E

What are the investigations done

A

Analgesia- IV Morphine- 5-10mg [diclofenac if creatinine ok]

Anti emetic if needed

Investigations

FBC

U+E

Calcium

Urate

Urine dipstick bHCG if pregnant

Radiology - KUB [plain X-ray] CT KUB

74
Q

What does this scan show

Where is the stone?

What position should you put patient in due to this?

A

Vesicoureteric junction

Image patient again lying down on stomach

Then can tell if stone moves down into bladder or is stuck in vesico ureteric junction

75
Q

What does this show?

A

Complex case with multiple stones

difficult to remove them all

76
Q

What are the follow up issues after kidney stone treatment?

A
  • Recurrent stones in 50%- prevent with good fluid intake
  • 40% of conservatively managed stones- get bigger- monitor with imaging
  • Stents after procedures get calcified
  • Stents can cause obstruction
  • Renal damage can occur after two to six weeks if there was complete obstruction- failure of kidny
77
Q

What are the follow up issues after kidney stone treatment?

A
  • Recurrent stones in 50%- prevent with good fluid intake - 40% of conservatively managed stones- get bigger- monitor with imaging -Stents after procedures get calcified - Stents can cause obstruction - Renal damage can occur after two to six weeks if there was complete obstruction- failure of kidney
78
Q

What does this picture show?

A

Testicular torsion

79
Q

What are the signs of torsion of appendix testes? How should it be treated?

A

Blue dot sign on skin

Hard to distinguish from testicular torsion

Conservative treatment- but only if completely sure about diagnosis

80
Q

How do you investigate testicular torsion? How do you manage testicular torsion?

A

Investigations

  • MSU to exclude UTI/epididymitis
  • No time for anything else

Management

  • Exploratory surgery within six to twelve hours
  • Untwist, wait for colour to come back
  • Fix both testicles in place to avoid future twisting

If after 6-8 hours: Testicle dead- do orchidectomy - this doesn’t affect fertiity

81
Q

What are the follow up issues of testicular torsion?

A

Recurrent testicular pain

Fertility- if only one testicle- paternity rate same but takes longer to conceive

Prosthesis- but issues with chronic inflammation and infection

Medicolegal

82
Q

What does this show?

A

Stone in right kidney

Seen on CT but not on plain X ray KUB

Right kidney hydronephritis

83
Q

What is this?

A

Calcified fibroid

Not in midline- bladder stone would be

84
Q
A

Stent in kidney

DPD 2020 (48 decks)

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