urology

Question 1

Bladder cancer: risk factors

Answer 1

Risk factors for transitional cell carcinoma of the bladder include:
Smoking
Exposure to aniline dyes in the printing and textile industry: examples are 2-naphthylamine and benzidine
Rubber manufacture
Cyclophosphamide

Risk factors for squamous cell carcinoma of the bladder include:
Schistosomiasis
Smoking

Question 2

Stag-horn calculi composition

Answer 2

composed of Struvite (ammonium magnesium phosphate, triple phosphate)
form in alkaline urine (ammonia producing bacteria such as Ureaplasma urealyticum and Proteus therefore predispose)

Question 3

Hydrocele

Answer 3

Non painful, soft fluctuant swelling
Often possible to ‘get above it’ on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young men

Question 4

overactive bladder mx

Answer 4

conservative measures include moderating fluid intake
bladder retraining should be offered
antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron may be considered if first-line drugs fail

Question 5

Periureteric fat stranding

Answer 5

recent stone passage, if a ureteric calculus is not present.

Question 6

peyronies

hypospadias

Answer 6

fibrotic bending of penis

urethra on underside of penis

Question 7

risk facotrs for testicular cancer

Answer 7

infertility (increases risk by a factor of 3)
cryptorchidism
family history
Klinefelter's syndrome
mumps orchitis

Question 8

hydronephrosis Unilateral: PACT Bilateral: SUPER

Answer 8

Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis

Question 9

priaprism ix

Answer 9

Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.

Question 10

PSA levels may also be raised by

Answer 10

benign prostatic hyperplasia (BPH)
prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours)
urinary retention
instrumentation of the urinary tract

Question 11

bph mx

Answer 11

watchful waiting

medication: alpha-1 antagonists, 5 alpha-reductase inhibitors. The use of combination therapy was supported by the Medical Therapy Of Prostatic Symptoms (MTOPS) trial
surgery: transurethral resection of prostate (TURP)

Question 12

radiolucent stones

Answer 12

urate and xanthine

Question 13

types of hydrocele

Answer 13

communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
non-communicating: caused by excessive fluid production within the tunica vaginalis

Question 14

Epididymo-orchitis

Answer 14

Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis.

Question 15

Angiomyolipoma

Answer 15

80% of these hamartoma type lesions occur sporadically, the remainder are seen in those with tuberous sclerosis
Tumour is composed of blood vessels, smooth muscle and fat
Massive bleeding may occur in 10% of cases

Question 16

turp syndrome

Answer 16

TURP syndrome is a rare and life threatening complication of transurethral resection of the prostate surgery. The pathophysiology is venous destruction and absorption of the irrigation fluid.

There are risk factors for developing TURP syndrome are : 
surgical time > 1 hr
height of bag > 70cm
resected > 60g
large blood loss
perforation
large amount of fluid used
poorly controlled CHF

Question 17

bladder volumes

Answer 17

Post-void volumes of <50 ml are considered physiological in patients aged < 65 years old.

Post-void volumes of < 100ml are considered physiological in patients aged > 65 years old.

Chronic urinary retention is defined by the presence of >500ml within the bladder after voiding.

Post-catheterisation urine volume of >800 ml suggests acute-on-chronic urinary retention.

Question 18

vasectomy fx

Answer 18

Male sterilisation - vasectomy
failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation
simple operation, can be done under LA (some GA), go home after a couple of hours
doesn’t work immediately
semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks)
complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men)
the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years

Question 19

a1 blocker side effects tamsulosin

Answer 19

adverse effects: dizziness, postural hypotension, dry mouth, depression

Question 20

stone mx without hydronephrosis
smaller than 2cm
large

Answer 20

lithotripsy

percutaneous nephrolithotomy

Question 21

LUTS

Answer 21

Voiding	
Hesitancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling

Storage	
Urgency
Frequency
Nocturia
Urinary incontinence	

Post-micturition
Post-micturition dribbling
Sensation of incomplete emptying

Question 22

bladder injury

Answer 22

Basics
rupture is intra or extraperitoneal
presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void: always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
Investigation
IVU or cystogram

Management
laparotomy if intraperitoneal, conservative if extraperitoneal

Question 23

urethral injury

Answer 23

Bulbar rupture
most common
straddle type injury e.g. bicycles
triad signs: urinary retention, perineal haematoma, blood at the meatus

Membranous rupture
can be extra or intraperitoneal
commonly due to pelvic fracture
Penile or perineal oedema/ hematoma
PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)

Investigation
ascending urethrogram

Management
suprapubic catheter (surgical placement, not percutaneously)

Question 24

ix in unresolving varicocele after cystoscopy

Answer 24

In an unresolving left varicocoele we are concerned patients are suffering from a renal tract cancer. This is due to the embryological anatomy linking the left renal vein and the left testicular vein.

Question 25

drugs that can help passage of stone

Answer 25

alpha blocker, calcium channel blocker

Question 26

co prescribe with goserelin (gnrh agonist)

Answer 26

Anti-androgen treatment such as cyproterone acetate should be co-prescribed when starting gonadorelin analogues due to the risk of tumour flare. This phenomenon is secondary to initial stimulation of luteinising hormone release by the pituitary gland resulting in increased testosterone levels.

The BNF advises starting cyproterone acetate 3 days before the gonadorelin analogue.

Question 27

psychogenic cause of ED

Answer 27

Symptoms which suggest a psychogenic cause include:
Sudden onset.
Early collapse of erection.
Self-stimulated or waking erections.
Premature ejaculation or inability to ejaculate.
Problems or changes in a relationship.
Major life events.
Psychological problems.

Question 28

rf for ED

Answer 28

Other than increasing age, risk factors include:
cardiovascular disease risk factors: obesity, diabetes mellitus, dyslipidaemia, metabolic syndrome, hypertension, smoking
alcohol use
drugs: SSRIs, beta-blockers