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Urology Flashcards

1
Q

Causes of transient non-visible haematuria

A

UTI
Menstruation
Vigorous exercise (settles after 3 days)
Sexual intercourse

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2
Q

Causes of persistent non-visible haematuria

A 
Cancer (bladder, renal, prostate)
Stones
BPH
Prostatitis
Urethritis eg Chlamydia
Renal causes - IgA nephropathy, thin BM disease
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3
Q

Spurious causes of haematuria

A

Foods - beetroot, rhubarb

Drugs - rifampicin, doxorubicin

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4
Q

Urgent referral criteria for haematuria

A

Age >=45 years AND - unexplained visible haematuria without UTI OR visible haematuria that persists or recurs after successful treatment of UTI

Age >=60 years AND have unexplained non-visible haematuria and either dysuria or raised WCC on blood test

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5
Q

What are the different types of renal stones? Features of each type of stone, including effect on urinary pH?

A

Calcium oxalate (85%)-
Major risk factor is hypercalciuria. Hypocitraturia increases risk because citrate forms complexes with calcium making it more soluble.
Stones are radio-opaque.
pH 6

Calcium phosphate (10%)-
May occur in renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate.
Radio-opaque stones.
pH >5.5

Struvite stones (2-20%) -
Formed from magnesium, ammonium and phosphate.
Occurs as result of urease producing bacteria (associated with chronic infections).
Slightly radio-opaque.
pH >7.2

Uric Acid stones (5-10%) -
May precipitate when urinary pH low. May be caused by disease with extensive tissue breakdown eg malignancy.
Radiolucent.
pH 5.5

Cystine stones (1%) -
Inherited recessive disorder of transmembrane cystine transport leading to decreased absorption of cystine from intestine and renal tubule.
Multiple stones may form
Relatively radiodense because they contain sulphur.
pH 6.5

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6
Q

3 common location of renal stones

A

Pelviureteric junction
Pelvic brim
Vesicoureteric junction

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7
Q

Risk factors for renal stones

A 
Dehydration
Hypercalciuria
Hyperparathyroidism
Hypercalcaemia
Cystinuria
High dietary oxalate
Renal tubular acidosis
Medullary sponge kidney, polycystic kidney disease
Beryllium or cadmium exposure

Urate stones -
Gout
Ileostomy - loss of bicarbonate and fluid results in acidic urine, causing precipitation of uric acid.

Drug causes - loop diuretics, steroids, acetazolamide, theophylline

Thiazides can prevent calcium stones

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8
Q

What are staghorn calculi?

A

Forms shape of staghorn
Body sits in renal pelvis with horns extending into renal calyxes.
Usually composed of struvite.
In recent upper urinary tract infections, bacteria can hydrolyse the urea in urine to ammonia, creating solid struvite.

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9
Q

Symptoms and signs of renal stones?

A 
Asymptomatic
Renal colic - loin to groin pain
Nausea and vomiting
Restless/moving around
Haematuria
Dysuria
Secondary infection may cause fever
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10
Q

Investigations for renal stones

A

Bloods - FBC, U&E, Calcium, phosphate, glucose, bicarbonate, urate
Urine dipstick - usually positive for blood.
MSU - MC&S
Urine pH
24 hour urine

Imaging -
Non-contrast CT scan KUB is gold standard.
AXR still used but not all stones are radio-opaque
USS - used in cases of known stone disease to assess for hydronephrosis.

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11
Q

Initial management of renal stones?

A

Adequate fluid resuscitation if required.
Diclofenac 75mg IV/IM or 100mg PR for analgesia.
Abx (tazocin or gent) if infection.

Stones in lower ureter <5mm will pass spontaneously in 95% of cases. Lithotripsy and nephrolithotomy may be used in severe cases.

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12
Q

Management of renal stones

A

Presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant - more intensive and urgent treatment is indicated.

Ureteric obstruction due to stones together with infection is surgical emergency and system must be decompressed - nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.

Non-emergency setting - extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, open surgery.

Stone burden <2cm - lithotripsy
Stone burden <2cm pregnant - ureteroscopy
Complex renal calculi and staghorn calculi - percutaneous nephrolithotripsy
Ureteric calculi less than 5mm - manage expectantly

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13
Q

How to prevent renal stones?

A

Calcium stones - high fluid intake, low animal protein, low salt diet, thiazide diuretics

Oxalate stones - cholestyramine reduces urinary oxalate secretion
Pyridoxine reduces urinary oxalate secretion

Uric acid stones -
Allopurinol
Oral bicarbonate

Struvite stones - treat infection.

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14
Q

Criteria for urgent intervention of renal stones

A

Post-obstructive acute kidney injury
Uncontrollable pain from simple analgesics
Evidence of infected stones
Large stones >5mm

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15
Q

Cause of bladder stones?

Complications of bladder stones if not treated?

A

Form from urine stasis within bladder - seen in chronic urinary retention.
Secondary to infections or passed ureteric stones.

Chronic irritation of bladder epithelium can predispose to development of TCC bladder cancer.

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16
Q

Presentation of upper and lower urinary tract obstruction

A 
Upper -
Loin to groin pain
Reduced/no urine output
Non-specific symptoms (eg vomiting)
Reduced renal function on bloods

Lower -
Acute urinary retention
Lower urinary tract symptoms - poor flow, terminal dribbling, difficulty initiating urination
Reduced renal function on bloods.

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17
Q

Causes of obstructive uropathy

A 
Upper -
Kidney stones
Local cancer masses pressing on ureters
Ureteric strictures - scar tissue
Anti-cholinergics

Lower -
BPH
Prostate cancer
Ureter or urethral strictures
Neurogenic bladder
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18
Q

Investigations of obstructive uropathy

A

Bloods - U&Es, creatinine, FBC and PSA
Urine - dipstick and MC&S
USS - modality of choice
If evidence of hydronephrosis or hydrometer - CT scan

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19
Q

Treatment of obstructive uropathy

A

Upper -
Nephrostomy or ureteric stent - also give alpha-blocker (tamsulosin) to reduce ureteric spasms.
Pyeloplasty to widen PUJ

Lower -
Insert urethral or suprapubic catheter to relieve acute retention.
Treat underlying cause.

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20
Q

Risk factors for BPH

A

Age - 50% of 50 year old men will have evidence of BPH and 30% will have symptoms.
Black > White > Asian

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21
Q

Clinical Features of BPH

A

Voiding symptoms - weak or intermittent urinary flow, straining, hesitancy, terminal dribbling and incomplete emptying
Storage symptoms - urgency, urgency incontinence, nocturia
Post-micturition - dribbling
Complications - UTI, retention, obstructive uropathy.

DRE - firm, smooth symmetrical prostate is reassuring sign - more rounded prostate of greater than 2 finger widths may indicate enlargement.

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22
Q

Investigations of BPH

A 
Urinary frequency and volume chart
Urinalysis
Post-void bladder scan
PSA
Ultrasound scan of renal tract - calculates volume of prostate and looks for urinary retention or hydronephrosis. Any prostate >30ml is enlarged.
Urodynamic studies
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23
Q

Management of BPH - lifestyle, medication, surgery

A

Lifestyle - avoid caffeine, alcohol, relax when voiding, void twice in a row to aid emptying, bladder training for urgency.

Medical -
If symptomatic, trial alpha adrenoreceptor antagonist such as tamsulosin. They relax prostatic smooth muscle. SE - drowsiness, postural hypotension, dry mouth, depression.
5alpha-reductase inhibitors (finasteride) if still symptomatic. Prevents conversion of testosterone to DHT, reducing prostatic volume. SE - erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia.

Surgery -
TURP - aims to create wider space for urine to flow through, thereby improving symptoms. Complications - bleeding, infection, incontinence, retrograde ejaculation, urethral strictures, failure to resolve symptoms, erectile dysfunction.

Transurethral incision of prostate (TUIP) - less destruction than TURP, less risk to sexual function. Better for patients with a small gland <30g.

Retropubic prostatectomy - open surgery

Transurethral laser-induced prostatectomy (TULIP)

Robotic prostatectomy - less traumatic and minimally invasive treatment option.

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24
Q

What is TURP syndrome?

A

Life-threatening complication of TURP.
Caused by irrigation with large volumes of glycine, which is hypo-osmolar, and is systemically absorbed when prostatic venous sinuses are opened during prostate resection.
Results in hyponatraemia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.

CNS, respiratory and systemic symptoms.

Risk factors for developing TURP syndrome:
Surgical time >1hr
Height of bag >70cm
Resected >60g
Large blood loss
Perforation
Large amount of fluid used
Poorly controlled CHF
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25
What is the most common renal cancer? What are other types of renal cancers?
Renal cell carcinoma (85%) Transitional cell carcinoma (urothelial tumours) Nephroblastoma in children (Wilm's tumour) Squamous cell carcinomas (secondary to renal calculi, infection, schistosomiasis)
26
Risk factors for renal cell carcinoma
``` Smoking Industrial exposure to carcinogens - cadmium, lead, aromatic hydrocarbons Dialysis Hypertension Obesity Anatomical abnormalities such as PCKD von Hippel-Lindau disease BAP1 mutant disease Birthings-Hogg-Dube syndrome ```
27
Features of RCC
Classical triad - haematuria, loin pain, abdominal mass Pyrexia Left varicocele - due to occlusion of left testicular vein Endocrine effects - may secrete erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH 25% have mets Paraneoplastic hepatic dysfunction syndrome - Stauffer syndrome - cholestasis/hepatosplenomegaly
28
Investigations of RCC
``` Bloods - FBC, ESR, U&E, ALP Urine - RBC, cytology Imaging - USS CT/MRI CXR - cannonball mets ```
29
Management of RCC - Localised disease Metastatic disease
Smaller tumours - partial nephrectomy Larger tumours - radical nephrectomy (remove kidney, perinephric fat, local lymph nodes en bloc) Unfit for surgery - Percutaneous radiofrequency ablation or lap cryotherapy Renal artery embolisation for haemorrhaging disease prior to radio frequency ablation, or for unresectable palliative cases. Surveillance - slow growing small renal masses in patients unfit or unwilling to undergo surgery with limited life expectancy. Met disease - Chemo ineffective Fit patients - nephrectomy combined with immunotherapy (IFN-alpha or IL-2 agents) Biological agents - sunitinib (TK inhibitor), pazopanib Metastasectomy
30
Features of bladder cancer
``` Transitional cell carcinoma (90%) Squamous cell carcinoma (1-7%) Adenocarcinoma (2%) Painless, macroscopic haematuria Recurrent UTIs Voiding irritability ```
31
Risk factors of bladder cancer
``` Smoking Aromatic amines Chronic cystitis Schistosomiasis Pelvic irradiation 2-napthylamine ```
32
Investigations for bladder cancer
Cystoscopy with biopsy is diagnostic. Urine - miscoscopy/cytology CT urogram - diagnostic and staging MRI or lymphangiography to show involved pelvic nodes.
33
Management of bladder cancer: Non-muscle invasive Muscle-invasive Locally advanced or Mets
Non-muscle invasive: Tis/T1 - TURBT, BCG injection or mitomycin C (in higher risk disease) Muscle invasive (T2-3): Radical cystectomy Neoadjuvant chemotherapy (cisplatin) Ileal conduit formation with urine draining via a urostomy Bladder reconstruction - from segment of small bowel (neobladder) and urine draining urethrally or via catheter. Locally advanced or mets (T4): palliative Chemotherapy Chronic catheterisation and urinary diversions may help relieve pain
34
Follow up cystoscopy following bladder cancer treatment
High-risk tumours - every 3 months for 2 years then every 6 months Low-risk tumours - first followup after 9 months, then yearly.
35
What is the main type of prostate cancer and which zone in the prostate does it affect commonly? What are the subtypes of the type of prostate cancer?
Adenocarcinomas (95%) Peripheral zone mainly Acinar adenocarcinoma Ductal adenocarcinoma
36
Risk factors for prostate cancer
``` Age Ethnicity - african or caribbean ethnicity Family history of prostate cancer BRCA1 or 2 gene Obesity, DM, smoking ``` Exercise is protective
37
Symptoms of prostate cancer
Asymptomatic Nocturia, hesitancy, poor stream, terminal dribbling, obstruction Advanced disease - haematuria, dysuria, incontience, haematospermia, suprapubic pain, loin pain, rectal tenesmus. DRE - asymmetry, nodularity, fixed irregular mass Mets - weight loss, bone pain.
38
Prostate cancer investigations
``` PSA levels Transrectal US (TRUS) and biopsy Multiparametric MRI is now first-line investigation Bone scan CT/MRI ```
39
When can PSA levels be artificially high?
``` Prostatitis UTI BPH Vigorous DRE Ejaculation ```
40
Management of prostate cancer: Localised disease Localised advanced disease Mets
Localised cancer - Options are conservative (active monitoring and watchful waiting), radical prostatectomy, radiotherapy - brachytherapy. Localised advanced - Hormonal therapy - GnRH agonist (gosereline) or anti-androgen (cyproterone acetate) Radical prostatectomy Radiotherapy - brachytherapy Mets - Hormonal therapy Orchidectomy Treat hypercalcaemia
41
Symptoms of prostatitis
Lower urinary tract symptoms, pyrexia, perineal or suprapubic pain, urethral discharge. DRE - tender boggy prostate. Associated inguinal lymphadenopathy
42
Investigations of prostatitis
Urine culture first line STI screen Routine bloods - FBC, CRP, U&Es
43
Management of prostatitis
Prolonged abx - typically quinolone due to good penetration of prostate. Analgesia Second line - 5alpha reductase inhibitors
44
What is phimosis
Non-retractile foreskin and/or ballooning during micturition in a child under two. Resolves over time. If >2 years of age and recurrent or UTIs then treatment considered.
45
Most common type of testicular cancer
Germ-cell tumours - seminomas and non-seminoas (embryonal, yolk sac, teratoma, choriocarcinoma) Non-germ cell - Leydig cell and sarcomas
46
Risk factors for testicular cancer
``` Peak age - 25 for teratoma, 35 for seminoma Infertility Cryptochidism Family history Klinefelter's syndrome Mumps orchitis ```
47
Features of testicular cancer
``` Painless lump Pain Hydrocele, gynaecomastia AFP elevated in germ cell tumours LDH elevated in 40% of germ cell tumours Seminomas - hCG elevated in 20% ```
48
Diagnosis of testicular cancer
Ultrasound
49
Management of testicular cancer
Orchidectomy | Chemotherapy and radiotherapy may be given depending on staging and tumour type
50
Most common causes of epididymo-orchitis
Chlamydia trachomatis and neisseria gonorrhoeae
51
Features of epididymo-orchitis
Unilateral testicular pain and swelling Urethral discharge may be present Need to rule out testicular torsion.
52
Management of epididymis-orchitis
Ceftriaxone 500mg IM STAT plus doxycycline 100mg PO BD for 10-14 days
53
What is a hydrocele
Accumulation of fluid within tunica vaginalis. Can be communicating (patent processes vaginalis) or non-communicating
54
Causes of hydrocele
epididymis-orchitis Testicular torsion Testicular tumours
55
Features of hydrocele
Soft, non-tender swelling of semi-scrotum. Anterior to and below testicle Confined to scrotum, you can get above the mass on examination Transilluminates with pen torch Testis may be difficult to palpate if hydrocele is large.
56
Diagnosis of hydrocele
Ultrasound but usually clinical
57
Management of hydrocele
Infantile (1-2 years) - resolve spontaneously. | Adults - further investigation warranted, to exclude underlying cause such as tumour.
58
Features of testicular torsion
Pain usually severe and sudden onset Pain can be referred to lower abdomen Nausea and vomiting may be present O/E - usually swollen, tender testis retracted upwards. Skin may be reddened. Cremasteric reflex lost Elevation of testis does not ease the pain (Prehn's sign)
59
Management of testicular torsion
Urgent surgical exploration Orchidopexy If torted testis identified, both testis should be fixed as condition of bell clapper testis is often bilateral.
60
Features of varicocele
Varicosities of pampiniform plexus Typically occur on left because testicular vein drains into renal vein Affected testis may be smaller and bilateral varicoceles may affect fertility.
61
Organic causes of erectile dysfunction
Cardiovascular disease risk factors - obesity, DM, dyslipidaemia, metabolic syndrome, hypertension, smoking Alcohol use Drugs - SSRIs, beta-blockers
62
Psychogenic causes of erectile dysfunction
Depression Problems or changes in relationship History of premature ejaculation
63
Management of erectile dysfunction
PDE-5 inhibitors - viagra
64
Risk factors for urinary incontience
``` Advancing age Previous pregnancy and childbirth High BMI Hysterectomy Family history ```
65
Different classifications of urinary incontinence
Overactive bladder /urge incontinence Stress incontinence Mixed incontinence Overflow incontinence - due to bladder outlet obstruction eg due to prostate enlargement.
66
Initial investigations of urinary incontinence
Bladder diaries should be completed for a minimum of 3 days. Vaginal exam to exclude pelvic prolapse and ability to initiate voluntary contraction of pelvic floor muscles. Urine dipstick and culture Urodynamic studies
67
Management of urge incontinence
Bladder retraining for minimum of 6 weeks Bladder stabilising drugs - antimuscarinics - oxybutinin, tolterodine or darifenacin. Avoid oxybutynin in frail older women. Mirabegron (beta-3 agonist) useful if concern about anticholinergic side-effects in frail elderly patients
68
Management of stress incontience
Pelvic floor muscle training - 8 contractions 3 times a day for minimum of 3 months Surgical procedures - eg retropubic mid-urethral tape procedures.

Surgery (9 decks)

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