Urology Flashcards
What is BPH? Which areas enlarge?
Benign, nodular or diffuse proliferation of musculofibrous and glandular layers of the prostate.
Enlargement of the inner transitional zone
The lower urinary tract Sx from BPH come from outlet obstruction. What are the 2 components of this?
Static component - increasing tissue bulk leads to narrowing urethral lumen
Dynamic component - increase in prostatic smooth muscle tone mediated by alpha adrenergic receptors
Name 3 Sx of BPH
Storage symptoms:
FUN -
frequency, urgency, nocturia
Voiding symptoms:
HIIPP -
hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling
Name 3 Ix in BPH + 1 to rule out other cause of Sx
DRE
TRUSS ± biopsy
PSA - increased may indicate prostate cancer or prostatitis
Urinalysis
MSU/urine dip to rule out pyuria and complicated UTI
Volume chart
USS KUB
To rule out hydronephrosis, urolithiasis, mass
What is the scoring system for BPH ?
IPSS - International Prostate Symptom Score (0-35)
also includes quality of life
[Mild = 0-7, Mod = 8-19, Severe = 20+]
3 parts of behavioural Mx for BPH
Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids
Most common Mx for BPH
watch and wait
Pharma Mx for BPH
Mild (bother)
FIRST LINE: Alpha blocker (tamsulosin or doxazosin)
or 5-alpha reductase inhibitor (finasteride)
[or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)]
How do alpha blockers work for BPH ? SEs?
Smooth muscle relaxation in prostate and bladder neck:
SE: postural hypotension, dry mouth
How do 5-a reductase inhibitors work for BPH
Reduced conversion of testosterone to dihydrotestosterone
Mx of abnormal DRE / PSA ?
Surgical referral
Prostate < 80g - TURP or TUVP (transurethral resection/vaporisation)
Prostate > 80g - Open prostatectomy
Name 2 comps of BPH
Progression - reduced by alpha blockers
Sexual dysfunction - due to alpha blockers, 5-alpha reductase inhibitors or surgical management
Acute urinary retention (roughly 2.5% over 5 years)
TURP syndrome
What is TUPR syndrome? Sx?
Consequence of absorption of irrigating fluids into prostatic venous sinuses - basically goes into blood stream and fucks your system
Fluid overload, disturbed electrolyte balance, hyponatraemia and hypothermia (bladder source of heat loss)
i.e. hypertension + reflex bradycardia, restless, headache, N + V, confusion
Mx of TUPR syndrome
ABCDE
Supportive
100% O2 non-rebreather,
monitor BP with arterial line,
correct hyponatraemia
Name 3 causes of acute urinary retention ? 2 for women only?
1 drug?
BPH / Ca
Bladder/urethral calculi, bladder cancer, faecal impaction
Infective
Women - Prolapse, pelvic mass
Drugs
ANTICHOLINERGICS + ALCOHOL
Neuro Autonomic neuropathy (DM), spinal cord damage (disc disease, MS, spinal stenosis, cauda equina, cord compression), pelvic surgery
3 Ix in acute urinary retention?
USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities
Urinalysis - infection, haematuria, proteinuria, glucosuria
MSU - infection
[Blood tests
FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)
CT abdo pelvis - looking for mass causing bladder neck compression
MRI spine - disc prolapse, cauda equina, spinal cord compression MS]
Mx of acute urinary retention
Immediate bladder decompression with catheter
What should men be offered prior to removal of catheter in acute retention
alpha blocker
Type of Ca are prostate?
adenocarcinoma
Spread of prostate Ca? 1 is muy important
Haematogenous - *bone sclerotic (90%), lung (50%) and liver
[Local - through capsule to seminal vesicles, bladder, rectum
Lymphatic - pelvic LNs]
What is used to grade prostate cA
Gleason - level of differentiation
Who is screened for prostate Ca and how?
?PSA + DRE
40s 2.5, 50s 3, 60s 4, 70s 5
1 argument for and 1 against prostate screening
For: commonest cancer in men, 3% men die of PC
Against: uncertain natural history, PSA not specific
Name 2 Sx of pres for prostate Ca and 2 features that would indicate advanced metastatic
LUTS: fill and void
Haematuria
Advanced metastatic:
Weight loss/anorexia/lethargy
Bone pain
Palpable LNs
3 Ix in prostate Ca
PSA (protease responsible for liquefaction of semen - prostate specific not prostate cancer specific)
Normal = 0-4 ng/ml
DRE - hard and irregular prostate
TRUSS + biopsy (infection 1pc serious, bleed, retention, fp)
Abnormal cells in 2 different samples
MRI + CT for staging
Isotope bone scan for metastasis (If
PSA > *20)
Testosterone (baseline if considering androgen deprivation)
FBC/LFT - normal
Active surveillance is an option for very low risk prostate Ca.
What other Mx could you do for low risk?
brachytherapy (radioactive source to prostate)
external beam radiotherapy
Mx of high risk prostate Ca ? ( T3/4, PSA > 20, Gleason 8-10)
Radical prostatectomy plus pelvic LN dissection
External beam radiotherapy (every day M:F 7-8W) + brachytherapy/androgen deprivation (shrinks tumour)
Mx of mets in prostate Ca
They are usually androgen sensitive:
Androgen deprivation therapy
chemical castration
Surgical castration
Drug used for chemical castration
Goserelin (GnRH analogue -
[stimulates then inhibits pituitary gonadotrophin so symptoms may get worse, offer an anti-androgen e.g. flutamide]
Main comp in surgical castration
risk of impotence if cut cavernous nerve of penis
Mx if prostate mets are castration resistant?
Bisphosphonates - reduce pain
palliative radiotherapy
Name 3 comps of prostate Ca mx
Erectile dysfunction - radiation, surgery, androgen deprivation
Hormone induced gynaecomastia
Hormone induced hot flush
Radiation induced LUTS for a few weeks + haematuria + bowel bleeding
How to prevent hormone induced gynaecomastia
tamoxifen
Usual Ca in bladder? what if schisto?
Transitional cell carcinoma (90%)
Squamous
Name 3 RFs for bladder Ca ? genetic cause?
Smoking (50%)
Occupational: aromatic amines (rubber + dye), polycyclic aromatic hydrocarbons (aluminum and coal)
Age, 70% > 65
Pelvic radiation (prostate Ca)
Men > Women
HNPCC for upper tract urothelial cancers
Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma
Bladder Ca stage
Ta - non-invasive papillary carcinoma
T1 - tumour invades subepithelial connective tissue (lamina propria)
Not felt
T2 - tumour invades superficial muscle (detrusor or muscularis propria)
Rubbery thickening
T3 - tumour invades perivesical tissue
Mobile mass
T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall
Fixed mass
Where does bladder Ca spread?
Lymphatic: Pelvic
Haematogenous: liver and lungs
How does bladder Ca present?
Painless haematuria (frank or microscopic), dysuria, abdominal mass, RFs,
systemic weight loss + bone pain
Name 4 Ix in bladder Ca
Urine dip
Haematuria (80% of patients) ± pyuria
Urine MC + S - cancers may cause sterile pyuria
KUB USS
Bimanual EUA for staging
*Flexible cystoscopy with biopsy TURBT
CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour or obstruction
Urinary cytology - abnormal cells
FBC - mild anaemia
CXR, isotope bone scan, alkaline phosphatase etc…..
3 Comps of bladder Ca
Hydronephrosis Upper tract TCC Prostatic urethral TCC Urinary retention Recurrence
Most bladder Ca presents with low-grade non muscle invasiion.
Mx?
Transurethral Resection of Bladder Tumour
+intravesical chemo (direct into bladder through catheter)
+intravesical BCG (bacille Calmette-Guerin) immunotherapy)
Mx of invasive bladder Ca?
mets?
cystectomy with pelvic LN dissection + chemo
mets = chemo
Other than haematuria give 2 causes of discoloured red(ish) urine
myoglobinuria (rhabdomyolysis or muscle destruction),
haemoglobinuria (haemolytic anaemias)
beeturia (beetroot),
rifampicin = pseudohematuria
Total haematuria -> bladder or upper tract (kidney/ureter)
What if the haematuria is at the start/end of voiding?
urethra, prostate, seminal vesicles or bladder neck.
3 causes of haematuria
Medical UTI Warfarin/clopidogrel etc Coagulopathies Menstruation contamination (pseudohaematuria) Acute pyelonephritis Trauma/instrumentation
Surgical
Stones
Urological malignancy - renal, bladder, ureter, prostate
BPH
4 Ix for haematuria
Urine dip - protein implies renal
Culture - infection
DRE - prostate
Bloods FBC: Hb/pt Clotting/coagulation studies/INR WCC (infx) PSA Nephrological - eGFR, Cr
Imaging USS KUB Flexible cystoscopy Non-contrast CT - stone Contrast CT urogram - excreting for malignancy
3 times you might use a catheter
Acute urinary retention
Pre-op prophylactic emptying
Monitoring urine output in critically ill patients
Chronic urinary retention (bladder outlet obs)
Management of incontinence (MS, terminal)
2 pros and 2 cons of a suprapubic catheter vs normal foley
SPC more comfortable, more convenient change, better self-image, better sexual function
SPC increased risk cellulitis, leakage, prolapse through urethra, surgical procedure
3 complications of catheters
Failure e.g. phimosis, BPH (try a larger catheter)
Create false passages
Urethral strictures/perforation/bleeding
Infection (E.coli) bacteriuria is inevitable 5% per day, 50% in one week 100% in one month
3 Rfs for UTI
Female, sex, spermicide (decrease lactobacilli), pregnancy, decreased host defense (immunosuppression, DM), obstruction, stones, catheter, malformation
2 Most common cause of uncomplicated UTI / how to differentiate?
E.coli - 70-95%
Staph saprophyticus 5-20% (coagulase -ve)
Which bacteria are cause of some hospital (12%) UTIs? What added complication do you get?
Proteus mirabilis
Klebsiella
-> increased risk of stones
[secrete urease -> raise pH -> Stones (Struvite)]
Abx in UTIs? If pregnant? men?
Trimethoprim 3 days (in uncomplicated)
Nitrofurantoin 7 days (in pregnancy as trimethoprim is teratogenic)
Men -> ciprofloxacin
2 forms of host defence against UTIs
Antegrade urine flush (lost in stasis, reflux, preg),
low urine pH,
Tamm-Horsfall protein (mucopolysaccharide), urinary IgA
Usually no mx for aSx bacteruria. Why do you treat if pregnant?
high risk pyelonephritis
What is pyuria
leucocytes in urine associated with infection
Name 2 things that would classify UTI as complicated
Functional impairment Structural impairment Kidney involvement UTI in pregnancy Indwelling catheter Immunosuppressed
What might you suspect in UTI if Costovertebral angle tenderness + fever
pyelonephritis
3 Ix of urine in UTI
Urine dipstick, microscopic urinalysis (bacteria, WBC, RBC),
*urine culture +s of MSU
give 2 DDx of UTI
Overactive bladder (-ve dipstick)
Urothelial Ca (positive urine cytology)
Non-infectious urethritis (dysuria in absence of UTI)
STI (discharge) - -ve urine dipstick, analysis and MC+S
Interstitial cystitis - painful bladder syndrome, pain associated with bladder filling + urgency and frequency in absence of UTI
Atypical infx (fungal, adenovirus, TB) may present with recurrent voiding - symptom of sterile pyuria
Mx if known/suspected ABx resistant UTI
ciprofloxacin
Mx of complicated and hospital admission UTI
IV gent
UTIs in men are uncommon = complicated
Usually either due to klebsiella + proteus
Or Abnormal function or structure of urinary tract
Therefore what Ix do you do?
Dipstick
Urine microscopy
Urine culture (>10^2)
IMAGING
CT renal tract (perirenal abscess, urinary calculi, tumour)
KUB USS (stone, abscess)
Usual cause of prostatitis?
e.coli (80%)
[+ enterococcus/pseudomonas]
O/E prostatitis
warm or soft, exquisitely boggy prostate
How does E coli get to the prostate
intraprostatic reflux (urine into prostatic duct)
4 ix in prostatitis
Urinalysis (microscopy - leukocytes, bacteria), urine culture (MSU, MC+S)
Culture of prostatic secretions (by massage)
Blood cultures (important in acute + febrile)
Serum PSA (may be elevated)
STI screen
TRUSS (?prostatic abscess)
Prostatitis Mx (no sepsis - as then just BUFALO)
ciprofloxacin
+ NSAID + relief of obstruction + drainage of abscess
What Sx if gonococcal urethritis is untreated and disseminates?
reactive arthritis, meningitis, endocarditis
key DDx in epididymo-orchitis
torsion
3 Ix in epididymo-orchitis
Colour duplex USS - enlarged hyperaemic epididymis
First catch urine or NAAT for chlam/gon
Gram stain urethral secretions - intracellular gram neg diplocococci
Urine dip - +ve leucocyte esterase
Urine microscopy (first void) - > 10 WBC per high power field
Urine culture
If suspect torsion -> surgical exploration
epididymo-orchitis Mx if liekly STI? UTI?
sti - single dose ceftriaxone IM + doxycycline PO
UTI - levofloxacin
Where are the most common locations of Nephrolithiasis/renal calculi
Nephrolithiasis = stones
Pelviureteric junction
Pelvic brim/cross internal iliac artery
Vesicoureteric junction
3RFs for stones
Chronic dehydration, diet, obesity, positive family history, specific medicines
Most common type of renal stone
calcium (oxalate)
2 comps of stones
Pressure necrosis
Obstruction -> hydronephrosis
Infection -> pyelonephritis, SEPSIS
Give 3 DDx of renal stones a
Acute appendicitis - -ve urine and NCCT
Ectopic pregnancy: preg test +ve and raised HCG
Ovarian cyst: AUSS - cystic adnexal lesions
Diverticular disease - NCCT shows absence of renal stones
*AAA or UTI - USS/CT abdomen shows presence of AAAConsider this for 50+ until proven otherwise
4 Ix for Nephrolithiasis
*NCCT (Gold-standard) - 99% sensitive - stones (white) in collecting system, ureter ± hydropehrosis
Urinalysis - urine dip and MC+S
Microhaematuria, ± leukocytes, nitrates
FBC - raised WCC -> infection
U+E+Cr- hypercalcaemia (PTH), hyperuricaemia (gout)
Pregnancy test
KUB USS
Symtomatic Mx acute Nephrolithiasis
Pain control - Diclofenac (or morphone + ondansetron)
Hydration
Mx of stone without obstruction
Medical expulsive therapy - alpha blocker (tamsulosin) or CCB (nifedipine)
If large:
ESWL (extracorporeal shock wave lithotripsy)
Mx of big ass stones >15mm / with obstruction
Percutaneous ureteroscopy / nephrostolithotomy
+surgical decompression
General prevention of stones
Overhydration (2.5-3 l)
Decreased sodium, protein, oxalate, weight
Increased citrate
Normal calcium (restriction may lead to decreased oxalate binding in GI -> increased excretion)
Prevention of specific causes of stones
Hypercalciuria -
Hyperuricosuria -
Hyeroxaluria-
Cystinuria -
Struvite stones -
Hypercalciuria - thiazide diuretics + potassium citrate (to counter low potassium + cit)
Hyperuricosuria - allopurinol or potassium citrate (urinary alkalisation)
Hyeroxaluria- calcium carbonate (binds oxalate)
Cystinuria - potassium citrate (alkalisation), penicillamine (cysteine binder)
Struvite stones - treat infection, urease inhibitor
Epididymal cyst:
Pres?
Ix?
Condition associated?
Mx?
Small painless cysts, bilateral
USS for confirmation - will transluminate, aspiration (milky fluid = spermatocele)
CF
Benign and need no mx
What is a varicocele ?
Where?
Abnormal dilatation of internal spermatic veins and pampiniform plexus that drains the testes
90% on left side
varicocele presentation?
Ix?
Mx?
Comp of mx?
Painless scrotal mass
Dull ache
Feels like bad of worms
Examination of testicles
Scrotal USS with doppler
Reassure
large -> surgery -> likely hydrocele
Can be secondary to compression of the renal vein!!!!! At the nutcracker angle - so always keep in mind the RCC
What is a hydrocele
Collection of serous fluid between layers of the tunica vaginalis or along the spermatic cord
Mx hydrocele
Observation if no discomfort or infection (once underlying pathology ruled out)
Surgery or aspiration if discomfort (recurrence and pain is complication)
Testie ca presents as hard, painless nodule on one testicle. Dx?
USS of testicle is 90-95% accurate in diagnosis
2 main types of testie ca and ages
seminoma - 30-65 year olds, 25% metastasise
teratoma - 20-30 year olds, 50% metastasise
Ix in testie tumour (first 3 are essential)
BALUC - [like bollock]
(b-hcg, afp, ldh)
USS (95% sensitive)
CT abdomen and pelvis (LNs)
CXR: mediastinal and lung mets (haematogenous spread)
[Raised alpha-fetoprotein (AFP) - teratocarcinoma, yolk sac, embryonal (not seminoma)
Raised B-HCG (choriocarcinoma and 5-10% of seminoma)
Serum LDH (50% raised, only elevated marker in 10% of non-seminomas)]
Main comps of mx of testie tumour
Infertility
Treatment related neutropenia, nausea, pulmonary toxicity requires CXR for monitoring (bleomycin), renal failure (cisplatin)
tesie Ca mx
Radical orchiectomy + chemo / radio
What is erectile dysfunction
difficulty in attaining, maintaining an erection or a marked decrease in rigidity
What 3 qs might you ask about erectile dysfunction
Early morning erections?
Foreplay?
Masturbation?
name 3 causes of ED
Age
Pain
Vascular
HTN, CHD, diabetes, smoking, obesity
Neurological
MS, spinal cord injury
Hormonal
Decreased androgens, increased prolactin, hypothyroidism
Psychological
Anxiety, depression, substance misuse
Surgical
Prostate
Drugs
SSRI, beta-blockers, alcohol, all psych drugs
Bar treating underlying condition give 2 pharma and 2 non pharma Mx of ED
PDE5 inhibitor (sildenafil) - headache, facial flushing, CI: hypotension
Alprostadil (PGE1)
Vacuum pump
Constriction ring
Penile implant
Psychosexual therapy
Mx of stress incontinence
pelvic floor, physio, surgery, sling (TVT, TOT)
M: artificial sphincter, male sling
Mx of urge incontinence
Behavioural: F/V chart, caffeine, alcohol
Drugs: anticholinergics (oxybutinin), B3 agonists (mirabegron), botulinum toxin
Bladder augmentation: detrusor myectomy/*cystoplasty (small bowel)
What causes a Flaccid (hypotonic) neurogenic bladder?
What does this lead to?
Conus or below destroyed or non-functioning -> AREFLEXIC BLADDER/BOWEL
Peripheral nerve or spinal nerve damage at S2-4
High residual volume predisposes to infection and overflow
What causes a spastic bladder? sx?
Brain damage or spinal cord damage above T12
Involuntary urination/defecation
2 Comps of neurogenic bladder
Reduced quality of life and embarrassment
Increased UTI and calculi
Hydronephrosis with VUR
High thoracic or cervical spinal cord lesions are at risk of autonomic disreflexia
Sx of autonomic dysreflexia
Life threatening Malignant hypertension Brady/tachycardia Headache Piloerection Sweating
Aims of mx for neurogenic bladder
Bladder safety (an unsafe bladder may damage the kidneys) -> *protect the kidneys
Continence/symptom control
Prevent AUTONOMIC DYSREFLEXIA
Preserve body image and sexuality
Usual type of incontince in neurogenic
Overflow incontinence (both flaccid and spastic) due to retained urine and dribbling
3 ix in neurogenic bladder
Serum creatinine (kidney function)
+ renal ultrasound (hydronephrosis)
Post-void residual volume (normal < 100 ml)
Urodynamics if considdering surgery
Bubbly urine 2 DDx
Gas producing UTI
Fistula - Eg in malignancy
