Urology Flashcards
What is a staghorn calculus?
A stone in the renal pelvis and at least 2 of the calices
Usually a struvite stone
What is the risk of a second stone after the initial one?
50% chance
Risk factors for renal stones
High protein + salt diet, dehydration, age 20-50, gout, hyperparathyroidism, sarcoidosis, myeloproliferative disease, steroids, FH
Anatomy: horseshoe kidney, PUJO
What are the types of renal stones?
75% Calcium 10-15% Struvite 5-10% Uric acid 1% Cystine (Endevamir stones)
What type of stones do chemo patients mostly get?
Uric acid- tumour lysis syndrome
What is the most important differential of a renal stone presentation?
Ruptured AAA
What investigation is used to diagnose renal stones?
CTKUB
Management of renal stones
Conservative- analgesia, if <6mm 60% will pass spontaneously
Medical: urinary alkalination prevents formation of stones
Surgical: Stenting, lithotripsy, PCNL, ureteroscopy, radical nephrectomy
Indications for surgery in renal stones
AKI, unmanageable pain, UTI or other infection in tract, unlikely to pass
What is the best analgesia for ureteric colic?
PR Diclofenac
What are lower urinary tract syptoms?
- Storage Sx- frequency, urgency, nocturia
2. Voiding Sx- hesitancy, poor stream, intermittent stream, straining
Which of sympathetic and parasympathetic stimulation causes weeing and not weeing?
Parasympathetic = Peeing (detrusor contraction) Sympathetic = Stop peeing (detrusor relaxation)
What is Benign Prostatic Hyperplasia?
Hyperplasia of cells in transitional zone of prostate
Which nerve root does the parasympathetic supply to the bladder come from?
Pelvic nerve
S2-S4
Which receptors and neurotransmitters are involved in parasympathetic response of the bladder?
Acetylcholine release - works on M3 muscarinic Ach receptors
What is normal urine output?
> 0.5ml/kg/hr
Causes of urinary retention
BPH, Nerve dysfunction, Infection, Constipation, Drugs (anticholergics, antidepressants, opioids), Prolapse, Prostate/Bladder Ca, Meatal stenosis
Management of Urge incontinence
Lifestyle- reduce caffeine, weight loss Bladder training- 1st line Anticholinergics- Oxybutinin, Tolterodine Botulinum Toxin A Surgery- augmentation cystoplasty
Which nerves does the Cauda Equina include?
L2-L5 + coccylgeal nerve
Red Flags for Cauda Equina syndrome?
Saddle/perineal anaesthesia
Incontinence/retention of urine/faeces
Reduced anal tone
Paralysis/loss of sensation lower limbs
Investigation of Cauda Equina syndrome
Urgent MRI
Name the 4 sections of the male urethra
- Prostatic
- Membranous
- Bulbar
- Penile
What are Lower Urinary Tract Symptoms?
Storage: urgency, daytime urinary frequency, nocturia, urinary incontinence, sensation of incomplete emptying
Voiding: hesitancy, weak or intermittent urinary stream, straining, incomplete emptying, terminal dribbling
What is found on PR examination in BPH?
Smooth enlarged prostate
Which parts of a urine dip are raised in a UTI?
Leukocytes, Nitrites, high pH, Blood
Management of BPH
Conservative: limit caffeine, pads for incontinence
Medical: Alpha blockers eg Tamsulosin/Doxazocin (relax prostate smooth muscle), 5-alpha reductase inhibitors- Finasteride (stop conversion of testosterone to stop hyperplasia of prostate)
Surgical: TURP- Transurethral resection of prostate
Risks of Transurethral resection of prostate (TURP)?
Bleeding, UTI, urinary incontinence, ED, injury to rectum, urethral strictures, lymphocele (cysts)
TURP syndrome
What is TURP syndrome?
Fluid overload and hyponatraemia from irrigation fluid absorbed through venous sinuses
Presentation of TURP syndrome
Respiratory distress, N&V, confusion, haemolysis, acute renal failure, reflex bradycardia
Management of TURP syndrome
Furosemide + Hypertonic saline
Where is ADH produced and stored?
Produced in hypothalamus
Stored in pituitary gland
Action of ADH
Increases water permeability in some places, allowing water reabsorption and concentration of urine
Increases urea permeability in inner medullary collecting duct
Increase of sodium absorption in ascending loop
Functions of the kidney
- Producing + concentrating urine
- Electrolyte regulation
- Renin production/BP regulation
- Erythropoeitin production
- Conversion of vitamin D to active hydroxylated form
- Acid-base regulation
What is normal plasma osmolality?
285-295
Equation for serum osmality
2 x (Na + K) + BUN/2.8 + Glucose/18
Functions of Angiotensin II
Arterioles- vasoconstriction
Kidney- stimulates Na+ reabsorption
Sympathetic nervous system: increased release of noradrenaline
Adrenal cortex: release of aldosterone
Hypothalamus: increased thirst + stimulates ADH release
Examples of ACE inhibitors
Ramipril
Lisinopril
Enalapril
Mechanism of action of ACE inhibitors
Inhibit ACE –> reduce Angiotensin II
- Reduced alveolar resistance
- Reduced arteriolar vasoconstriction
- Reduced cardiac output
- Increased sodium excretion in kidneys
Side effects of ACE inhibitors
Dry cough, hyperkalaemia, headache, dizziness, fatigue, renal impairment, angioedema
Causes of Urinary tract obstruction
Pregnancy, stones, BPH, prostate cancer, other tumours, polyps in ureter, anticholinergic drugs, spinal cord injury, strictures due to surgery, radiotherapy or drugs, ureterocele, abscesses, rectal impaction
What is a ‘Page Kidney’?
Systemic hypertension secondary to extrinsic compression of the kidney by a subcapsular collection eg haematoma, seroma, urinoma
- -> reduced blood flow to renal parenchymal tissue and induction of renin secretion
- -> RAAS activated
- -> Hypertension
Main sign of Page Kidney
Hypertension
What is the nervous supply to the ureters?
Sympathetic- T10-L1
Parasympathetic- S2-S4
What is the most likely location of a ureteric stone?
Narrowest locations:
- Ureteropelvic junction
- Where ureter passes over pelvic brim
- Vesicoureteric junction
Complications of ureteric obstruction
Hydronephrosis- obstructed kidney
Pyonephrosis- infected obstructed kidney
Stones due to urinary stasis
Presentation of ureteric colic
Pain in loin/flank, radiates to testicles/labia due to T12-L1 innervation
N&V, haematuria, fever, sweats, dysuria, urinary frequency, straining
What is the most common type and location of prostate cancer?
Adenocarcinoma in peripheral zone (transitional)
Findings on DRE in prostate cancer
Prostate feels hard and craggy
Investigations of prostate cancer
Raised PSA
Needle biopsy
CT/MRI
What score is used for classifying prostate cancer?
Gleason score: histology of prostate cancer 1-5
What are urinary stones made from?
- Calcium
- Uric acid
- Struvite
- Cysteine
Management of Prostate cancer
T1-2: Active surveillance, radical prostatectomy, radical radiotherapy
T3-4: Androgen deprivation therapy, external beam radiotherapy
What is Brachytherapy?
Places radioactive sources inside the patient to damage cancer cells DNA and their ability to grow and divide
What is Androgen deprivation therapy?
Reduces testosterone
Surgical: bilateral orchidectomy
Medical: LHRH analogue eg Goserelin- down-regulation of LH receptors on testes –> stop producing testosterone
How do you manage the initial surge in testosterone upon starting androgen deprivation therapy?
Give anti-androgen- Cyproterone citrate
What is Pyelonephritis?
Infection of the renal cortex and medulla
Aetiology of pyelonephritis
Ascending (from UTI) or Haematogenous (IVDU, endocarditis)
What are the most common causative organisms of pyelonephritis?
E coli, Klebsiella, Proteus miribalis
Presentation of Pyelonephritis
Loin pain, fever, rigors, N&V
Tenderness in renal angle
What is found on urinalysis in Pyelonephritis?
Blood, protein, leukocytes
Investigation of Pyelonephritis
Ultrasound KUB
Management of Pylonephritis
Gentamicin IV (but nephrotoxic)
Risk factors for Pyelonephritis
Vesicoureteric reflux, calculi, catheter, pregnancy, diabetes, primary biliary cirrhosis, immunocompromise, BPH
Complications of Pyelonephritis
Sepsis, parenchyma renal scarring, recurrent UTIs, preterm labour in pregnancy
What is pyonephrosis?
Pus in upper collection system of kidney
Presentation of Pyonephrosis
Fever, flank pain
Findings on USS of Pyonephrosis
Urinary tract obstruction
Dilatation of pelvicalyceal system
Echogenic debris in collecting system
Management of Pyonephrosis
Emergency insertion of percutaneous nephrostomy
Causes of raised PSA
Prostate cancer BPH Prostatitis UTI Old age TURP Urinary catheterisation Acute urinary retention
Investigation in suspected Pyonephrosis
Ultrasound KUB
Which 4 substances can urolithiasis be caused by?
- Calcium oxalate
- Calcium phosphate
- Urate
- Struvite
Where do urinary stones tend to lodge?
Narrowings:
- PUJ
- Pelvic brim
- VUJ
Presentation of Urolithiasis
Intense loin to groin pain, loin tenderness
Microscopic haematuria
Investigations in Urolithiasis
Urine dipstick: microscopic haematuria
Blood calcium + urate levels
Abdo x-ray- 50% radio-opaque
CTKUB
What % of stones can be seen on x-ray?
50% of stones radio-opaque
Management of Urolithiasis
Stones < 7mm left to pass naturally
Surgery: Lithotripsy, Lithaloplaxy, Percutaneous nephrolithotomy
Management of recurrent urate stones
Allopurinol
Most common type of bladder cancer in UK
Transitional cell carcinoma
Types of bladder cancer
- Transitional cell carcinoma
- Squamous cell carcinoma
- Adenocarcinoma
Risk factors for bladder cancer
Age, smoking, male
TCC: exposure to aromatic amines
SCC: Schistosomiasis, long-term indwelling catheter, hx recurrent bladder stones
Presentation of bladder cancer
Painless haematuria, acute urinary retention (clots stuck), urinary frequency, dysuria, suprapubic pain
Anaemia, palpable pelvic mass
Investigations of bladder cancer
FBC for anaemia
Cystoscopy, CT/MRI
Management of bladder cancer
Low-grade non-invasive: TURBT, intravesical mitomycin C chemo
High-grade invasive: radical cystectomy, lymphadenectomy, radical radiotherapy, chemotherapy
Presentation of testicular torsion
Typically teenage boys
Acute, sudden onset testicular pain, hot swollen testicle, high-lying transverse testis
Absent cremasteric reflex
Which reflex can be tested in suspected testicular torsion?
Cremasteric reflex- absent
Testicle retracted on stroking of the inner thigh
Risk factors for testicular torsion
Often triggered by activity
‘Bell-Clapper’ deformity- testicle normally fixed by tunica vaginalis- fixation is absent
Management of testicular torsion
Medical emergency- 6hr window after onset before ischaemia is irreversible
Urgent urological assessment
Immediate scrotal exploration, bilateral orchidopexy, orchidectomy
Complications of testicular torsion
Subfertility
Psychological
Presentation of testicular cancer
Non-tender irregular lump arising from testicle, hard without fluctuance/transillumination
Typically age group for testicular cancer
Age 15-40
How is testicular cancer diagnosed?
USS
Tumour markers for testicular cancer
AFP- seminoma
BhCG- more in teratomas
Lactate dehydrogenase
Management of testicular cancer
Orchidectomy/chemo/radiotherapy
Types of testicular cancer
50% Teratoma
50% Seminoma
What is an Epididymal cyst?
Smooth extratesticular spherical cysts in the head of the epididymus
Benign
Average age for presentation with Epididymal cyst?
Age 40
Presentation of Epididymal cyst
Well-defined, fluctuant lump which will transilluminate
Testis is palpable separate from cyst
Investigation of Epididymal cyst
Scrotal USS
Management of Epididymal cyst
Surgery if painful/big
What is a Hydrocele?
Abnormal collection of fluid within the remnants of the processus vaginalis
Types of Hydrocele
Simple
Communicating
Non-communicating
Causes of a simple Hydrocele in older people
Trauma, testicular torsion, varicocele, testicular tumour
Prognosis of simple Hydrocele
Usually disappears within 1-2yrs if neonatal
What is a communicating Hydrocele?
Persistence of the processus vaginalis –> free flow of peritoneal fluid
What is a non-communicating Hydrocele?
Excessive production of fluid within processus vaginalis
Presentation of Hydrocele
Scrotal enlargement with non-tender smooth cystic swelling
Lies anterior + below testis, will transilluminate
Investigation of Hydrocele
USS if unsure
Management of Hydrocele
Observation if < 2yrs old
Therapeutic aspiration if large
Surgical removal
What is a Varicocele?
Abnormal dilatation of testicular veins in panpiniform plexus
On which side is Varicocele more common?
Left
Presentation of Varicocele
Usually asymptomatic
Testis feels like a ‘bag of worms’
Poor sperm production + reduced semen quality –> infertility
Investigation of Varicocele
Colour doppler studies
Sperm count
Management of Varicocele
Surgery if pain/infertility
