Urology Flashcards
What might cause a urinary tract obstruction?
Luminal, mural, extramural
Luminal
Stones,
Clots
Sloughed papillae
Mural
Stricture
Tumour
Neuromuscular dysfunction
Extramural
Prostate
Tumour
Retroperitoneal fibrosis
How might a urinary tract obstruction present?
Acute vs chronic, upper vs lower
Acute upper - loin to groin pain
Acute lower - distension followed by pain
Chronic upper - flank pain and renal failure
Chronic lower - prostate features
How would you investigate a urinary obstruction?
Bloods Urine USS - hydronephrosis Radionucleotide imaging - renal function CT/MRI Ureterograms - allows drainage
how would you manage a urinary obstruction?
Upper
Nephrostomy (stoma)
Ureteric stent
Lower
Urethral or suprapubic catheter
What are some complications of ureteric stenting?
Common: Infection Haematuria Trigonal irritation (part of internal bladder wall) Encrustation
Rare
Obstruction
Rupture
Stent migration
What might cause a urethral stricture?
Trauma inc fractures
Infections e.g. gonorrhoea
Chemotherapy
Balanitis xerotica obliterans (lichen sclerosus)
How would a urethral stricture present?
Voiding difficulty Hesitancy Strangury Poor stream Dribbling Pis en deux
How would you investigate a urethral stricture
PR exam for prostate Palpate urethra and examine meatus Urodynamics Urethr/cystoscopy Retrograde urethrgram
what is the pathogenesis of obstructive uropathy?
Acute retention on a chronic background may go unnoticed for days due to lack of pain
Renal function usually returns after a few days
What are the complications of an obstructive uropathy?
Hyperkalaemia Metabolic acidosis Post obstructive diuresis Na, HCO3 losing nephropathy Infection
What are the causes of acute urinary retention?
Obstructve, neurological, myogenic
Obstructive
BPH, strictures, clots, stones,
Neurological
Surgery, MS, DM, spinal injury
Myogenic
Post anaesthesia, EtOH
What is the management of acute urinary retention?
Conservative
Analgesia, privacy, walking
Catheter (3 way if clots)
Hourly UO recording
Tamsulosin
TWOC
If TWOC fails then TURP
What are the types of chronic urinary retention, and how are they managed?
High and low pressure (detrussor pressure at end micturation)
High pressure-> early catheter
Low pressure -> avoid catheter if poss, early TURP
What are the pros and cons of suprapubic catheterisation?
Pros: Fewer UTIs Reduces stricture formation TWOC without catheter removal More comfortable
Cons:
Comre complex and more complications
What are the causes of haematuria?
Infarction Infecton Trauma inc stones Malignancy GN PKD Prostate problems Bleeding diatheses
How might the timing of haematuria help point to a source?
Beginning of stream -> urethral
Throughout -> renal/bladder/systemic
End -> Bladder stone
What vascular complication is retroperitoneal fibrosis likely to cause?
Periaortitis
What are the common anatomical sites for renal stones to lodge?
Pelviureteric junction
Pelvic brim
Under vas or uterine artery
Vesicoureteric junction
What are the different types of urolithiasis?
Ca Oxalate (75%) esp in Crohns
Struvite (15%)-> staghorn calculus
Urate (5%) radiolucent
What factors are associated with renal stones?
Dehydration Hypercalcaemia UTIs Gout Structural abnormalities Diuretics
What is the gold standard investigation for ?urolithiasis?
CT KUB - 99% of stones visible
Xray KUB for urate and cysteine stones
WHat is the conservative management of a renal stone, and what critera must be met for this to be used?
Must be <5mm in lower 1/3 of ureter
Analgesia
Fluids
Abx if infection
95% pass spontaneously so discharge with a sieve…
What should be done for stones 5-10mm and expected to pass?
Medical expulsive therapy with nifedipine or tamsulosin +- prednisolone
When should a stone be considered for active removal, and what are the options for doing so?
Indications >10mm Persistent Renal insufficiency Infection
Options Lithotripsy (shockwave therapy) Ureterorenoscopy Percutaneous nephrolithotomy Laparotomy - rare
What are the risk factors for renal cell carcinoma?
Obesity Smoking HTN Dialysis (15%) Von Hippel Lindau
What is the histological typing of RCC?
Adenocarcinoma - commonly clear cell
How does RCC present?
50% incidental
Classic triad of haematuria, loin pain, loin mass
Systemic Fx
SOB
What are the paraneoplastic features of RCC?
EPO -> polycythaemia PTHrP -> Hypercalcaemia Renin -> HTN ACTH -> Cushings Amyloid
What is the pathology of transitional cell carcinoma?
V malignant
50% in bladder
Which cell layer is affected in BPH?
Inner transitional layer
What is the medical management of BPH?
1st. alpha blockers e.g. tamsulosin
SFx inc drowsiness and hypotension
2nd 5alpha reductas inhibitors e.g. Finasteride
What is the surgical management of BPH and what are its complications?
TURP
Immediate, early, late
Immediate
TUR syndrome - large fluid absorption leading to hyponatraemia
Haemorrhage
Early
Haemorrhage
Infection
Clot retention
Late Retrograde ejaculation ED Incontinence Strictures Recurrence
Which ethnic group are predisposed to prostate cancer?
Black people
What are the PR findings in prostate cancer?
Hard irregular prostate with loss of the midline sulcus
What is a Gleason score?
Score the two worst affected areas and sum them
What is the management of prostate cancer?
Radical
Radical prostatectomy
Brachytherapy (palladium seeds)
Medical
LHRH analogues e.g. goserelin
ANtiandrogens
What are the common infective agents of prostatitis?
E. Faecalis
E. Coli
Chlamydia
How does prostatitis typically present?
UTI/dysuria
Pain (back/ejaculation)
Fevers and rigors
Retention
How do stress and urge incontinences present in women, and how are they managed??
Stress - leakage on coughing (pelvic floor training)
Urge - sudden unprovoked (bladder training)
What differentials might you give for testicular torsion?
Epididymo orchitis - older pts with UTI symptoms
Torted Hydatid of Morgagni - less painful
Tumour
Trauma
Hernia strangulation
Appendicitis
Varicocele presentation and management?
CFx
Bag of worms which reduces on lying down
Common in cyclists
More common on left hand side
Rx
Scrotal support
Clipping testicular vein
Hydrocele presentation and management?
CFx
May be secondary to tumour/trauma/infection
Transluminates on USS
Rx
Often self limiting
Aspiration
Surgery
Presentation and management of epididimo orchitis?
Fever, dysuria, UTI fx in older man with hot red swollen balls
Rest, analgesia, scrotal support, abx, drainage if necesary
What is the typical presentation of testicular cancewr?
Often incidental lump Haematospermia 2ary hydrocele SOB from mets Abdo mass (lymphadenopathy) Gynaecomastia
What is the commonest type of testicular tumour?
Germ cell (95%) Pure seminomas (40%) Non seminomas inc teratomas (60%)
5% are sex cord stromal (Leydig and Sertoli cells)
What staging system is used for testicular cancer?
Royal Marsden Classification
What are the tumour marker(s) for testicular cancer?
AFP
hCG
What is balanitis?
Acute inflammation of the foreskin and glans
What are the common causes of balanitis?
Strep
Staph
Candida in DM
What is the management of balanitis?
Hygiene
Abx
Circumcision
What is phimosis?
When the foreskin occludes the meatus and cannot be retracted
How does phimosis present and how is it treated?
Dyspareunia, infection, ballooning
Rx with circumcision
What is paraphimosis and its main complication?
Irreplaceable retracted foreskin which may cause glans ischaemia
What are the risk factors for penile cancer?
HPV 16, 18, 31
Smegma
Lichen sclerosis
