Urology Flashcards
weight of a healthy prostate?
20grams
where is the prostate located anatomically?
Inferior to the bladder neck
anterior to the rectum
what is the arterial supply of the prostate?
internal iliac artery -> inferior vesical artery -> prostatic arteries -> urethral and capsular arteries
venous drainage of the prostate?
prostatic plexus near dorsal vein -> internal iliac vein-> IVC
lymphatic drainage of the prostate?
obturator and internal iliac channels
which part of the prostate is the origin for most prostate cancers?
peripheral zone of prostate
which part of the prostate is responsible for BPH?
transitional zone of prostate
where increased number of cells in BPH
what is the physiological function of the prostate?
to make seminal fluid to aid sperm passage
prevents retrograde ejaculation by acting like a sphincter
what are the properties of seminal fluid that aid it in assisting passage of sperm?
alkaline
contains fructose
prostaglandins
clotting factors
LUTS symptoms refer to symptoms caused by pathology from which part of the urethral tract?
from the bladder down
what are the 2 categories of LUTS symptoms?
storage
voiding
what are the storage symptoms of LUTS?
Frequency
Urgency
Nocturia
What are the voiding symptoms of LUTS?
Weak stream
Intermittency
Straining
Emptying incompleteness
BPH red flags/other sx:
bone pain weight loss haematuria infection incontinence pain sexual dysfunction
why is family history important when suspected BPH?
BRCA gene linked
3 times when you wouldn’t do a DRE:
no consent
,<16yo
neutropenic sepsis
what is the difference between hyperplasia and hypertrophic?
hyperplasia - increased number of cells - increased size of tissue
hypertrophic - increased size of cells
definition of BPH:
histological diagnosis reflecting:
- hyperplasia/hypertrophia
- bladder outlet obstruction
- LUTS
aetiology of BPH:
age-related hormone changes
hyperplasia of transitional zone cells
vascular/inflammatory event
metabolic syndrome
pathophysiology of BPH:
mechanical fault or smooth muscle pathology -> detrusor overactivity (bladder smooth muscle)
which category of LUTS is commoner?
voiding
what are the complications of BPH?
persistent UTIs
incontinence
urinary retention
what investigations would you do for BPH:
bloods - glucose, HbA1c, PSA
urinalysis
?USS
special tests
what special tests would you do to ix BPH?
flow studies frequency-volume chart IPSS score - sx, QOL score -> mild/mod/sev cystoscopy Urodynamics
management options for BPH:
conservative
medical
surgical
what are the conservative mx for BPH:
fluid intake manipulation caffeine reduction and other trigger reduction bladder training tx constipation meds rec (diuretics)
what are the 3 main medication classes for BPH?
- alpha 1 blockers (Tamsulosin)
- 5a-reductase inhibitors (Finasteride)
- Anticholinergics
what are some sfx of tamsulosin (2):
orthostatic hypotension
retrograde ejaculation
what is the benefit of using tamsulosin to tx BPH?
works fast
what are some sfx of Finasteride?
mood
sex dysfunction
gynaecomastia
tx for hairloss!
mechanism of action of finasteride?
prevents the conversion of testosterone to dihydrotestosterone (DHT) so less serum DHT
less proliferation of prostate
less mechanical pinching
what are the benefits of using finasteride to treat BPH?
halves PSA
30% reduction if prostate size
how long does finasteride take to work fully
6/12
name some surgical options for BPH?
TURP Urolift Steam treatment Holep laser / green light laser open prostatectomy prostatic artery embolisation
What is TUR syndrome and what causes it?
absorption of glycine in too high a concentration triad: -hyponatraemia -fluid overload -glycine toxicity
what are the symptoms of TUR syndrome?
CNS - blindness, confusion, coning
Heart - arrhythmias, SOB, pain
Abdo - n/v
what type of cancer are most prostate cancers?
adenocarcinoma
which races are at higher risk for prostate cancer?
black>white>asian
what are the risk factors for prostate cancer?
congen- fhx, age, race
acquired - metabolic syndrome
signs and sx of prostate cancer?
asx non-spec ca sx bone/back pain LUTS haematuria incidental finding from TURP for BPH abnormal DRE
how does prostate feel on DRE in BPH?
smooth
how does prostate feel on DRE in prostate cancer?
hard, craggy
what is PSA?
prostate specific antigen
protein made by prostate epithelial cells
what are normal PSA levels for different ages?
50-60 - <3ng/ml blood
60-70 - <4ng/ml blood
70-80 - <5ng/ml blood
80+ - no limit
if PSA > 50, what does this usually indicate?
usually prostate cancer
is PSA > 100, what does this usually indicate?
metastatic prostate cancer
is PSA used to screen for prostate cancer?
no
how many PSA’s are needed to confirm suspicion and prompt further tests?
2 separate high PSA scores
what imaging is done to ix prostate cancer?
- MP-MRI - look for high grade prostate cancer, measure size of prostate
- CT abdo/pelvis
NM bone scan
special tests done to ix prostate cancer? (and methods of doing this)
prostate biopsy - transrectal v transperineal**
what are the benefits of doing a transperineal prostate biopsy?
fewer risks and increased accuracy
what does staging of prostate cancer tell us?
how far ca spread from origin
what staging system is used for prostate cancer?
TNM
what does grading tell us about prostate cancer?
how well differentiated cells are
what score indicates the grading?
Gleason score
what 3 features make up the risk stratification of prostate cancer?
Gleason score
initial PSA
T score
general management of prostate cancer?
mdt
specialist nurse
lower RFs
ca support groups
what are the 4 treatment options for prostate cancer?
watchful wait
active surveillance
surgery
medicine
what is the difference between watchful wait and active surveillance?
watchful wait - defer further tx til metastasis or PSA increase - palliative
active surveillance - chance to cure active disease - watched more regularly like a hawk
what are the surgical options for prostate cancer and what are the indication for doing ?
- RALP (robot assisted Laproscopic Prostatectomy) - da vinci machine
radical (T3+) - RT +/- brachytherapy. oncologists
during a RALP, what anastamosis is formed?
bladder neck - urethra
side effects of RALP?
infertility erectile dysfunction incontinence bleeding infection catheter conversion to open leaking anastamosis
what is the name of the type of drug used to treat prostate cancer - who gets this?
Androgen Deprivation Therapy (ADT)
If metastatic, with oncology input
how does ADT work?
fast acting anti-androgen given on day 1 (acts on testes to decrease testosterone)
slower acting LHRH analogue/antagonist (acts on hypothalamus)
what types of anti-androgen drugs are there (give commonest eg)
steroidal
non-steroidal (bicalutamide)
ADT side effects?
manopause
gynaecomastia, loss libido, OP, fatigue, erectile dysfunction. flushes, metabolic syndrome
what other prostate cancer treatments are there?
RT to bone lesions
chemo
trials - atlanta
67yom ED with PSA 150, incontinence, leg weakness - dx
SC compression from metastasis
leading to corda equina syndrome (plus saddle anaethesia) URGENT
what is investigation for ?corda equina syndrome in prostate cancer?
MRI whole spine
what is the treatment of corda equina syndrome?
high dose steroids
ADT to decrease prostate cancer size - degarelix - fast acting
onc/surg input
Prostate cancer emergencies:
SC compression
ureteric compression
#
retention
66-M go to the toilet more often than usual and that he can not control the desire to urinate. Bathroom 4 times in the night to urinate. Otherwise fit and well. Normal sized prostate. Which ix would be most appropriate to demonstrate the aetiology of this gentlemen’s problem?
urodynamic studies
for voiding problems
38-M 3 month history of scrotal swelling and discomfort. Unilateral swelling in the left scrotum which transilluminates. The swelling is soft and non-tender. Due to the presence of fluid, the testis is not fully palpable. Most appropriate next course of action?
urgent uss testes
in hydrocele could be tumour
60-M BPH lower abdominal pain and inability to urinate. After inserting a catheter, >2L of clear urine drained, with immediate relief of the pain.
Three hours later you are asked to review the patient as his urine is now a pale pink colour. The patient feels well in himself, and his observations are stable.
What is the most appropriate management?
no mx - obs are stable
decompression haematuria caused this
20M severe pain and swelling of the scrotum after a cystoscopy. He had mumps as a child. The testis is tender. The urine dipstick is positive for leucocytes. dx?
epididymo-orchitis
20-M severe pain in the right scrotal area after jumping onto his moped. He has also noticed discomfort in this area over the past few months. Swollen, painful testis that is drawn up into the groin. dx?
torsion
ass with retracted testes
8M scrotal swelling. He has just recovered from an acute viral illness with swelling of the parotid glands. On examination both testes are tender and slightly swollen. dx?
orchitis
44-F 32/40, nephrology consultant ?renal stones. PMH HTN. IHD. CT-KUB report shows a renal stone, 1.5cm in size. mx?
ureteroscopy
stone burden of less than 2cm, the preferred definitive option of management would be:
lithotripsy
Complex renal calculi and staghorn calculi mx:
percutaneous nephrolithotomy
ureteric calculi <5mm mx?
expectant mx
69M haematuria. He worked in the textile industry. He has a left flank mass. CT IVU shows a lesion of the left renal pelvis.
dx?
renal transitional cell ca
2M right renal mass. Irregular mass arising from the right flank and is hypertensive. A CT scan shows a non calcified irregular lesion affecting the apex of the right kidney and the right adrenal gland. dx?
nephroblastoma
35M haematuria. He is found to have bilateral masses in the flanks. He has a history of epilepsy and learning disability. dx?
angiomyelipoma
tuberous sclerosis
What is the most common organic cause of erectile dysfunction in otherwqise fit male?
vascular causes
drugs that cause Erectile dysfunction?
alcohol,
BBs
SSRIs
35M ED->12 hour history of abdominal pain. The pain is on his right side and he feels it shooting from the side of his abdomen down into his groin. Urine dipstick is positive for blood and leucocytes. He asks for pain relief. What would be the most appropriate analgesic given the likely diagnosis?
IM diclofenac
nsaids
67-M-> GP urine does not flow as well as it used to. He does not report any strong urges to urinate and no nocturia. Some post-terminal dribbling and feels he does not empty his bladder fully. He is troubled by these symptoms as this has never happened before.
PMH heart failure and smokes 10 cigarettes a day.
On digital rectal examination, his prostate feels hard and irregular. serum prostate-specific antigen 2.0 ng/ml. Managed?
urgent 2ww referral
regardless of PSA score - DRE findings like that need further ix in secondary care
Gynaecomastia may be a presenting feature of?
testicular ca
33M -> ED suspected renal colic. He has a ultrasound that shows a probable stone in the left ureter. What is the most appropriate next step with respect to imaging?
Non-contrast CT KUB
Epididymo-orchitis in individuals with a low STI risk (e.g. married male in 50s, wife only partner) is likely due to?
e coli
A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment?
cyproterone acetate
decreases risk of tumour flare
A 67-year-old man presents with painless frank haematuria. He recently began complaining of a mild testicular ache and describes his scrotum as a ‘bag of worms’. He is a heavy smoker smoking 60 cigarettes a day for 47 years. On examination he is cachectic. His left testicle appears to have a tortuous texture. His blood reveals anaemia and polycythemia. dx?
rcc left kidney
commnenest rcc subtype?
clear cell
A 56-year-old man presents with lethargy, haematuria and haemoptysis. On examination he is hypertensive and has a right loin mass. A CT scan shows a lesion affecting the upper pole of the right kidney, it has a small cystic centre. dx?
renal adenocarcinoma
commonest type. cannonball mets -> haemoptysis
cx of radical prostatectomy?
incontinence
ED
62-M 4/12 hx worsening LUTS and nocturnal enuresis. Painless distended bladder. DRE: smoothly enlarged prostate. Bladder scan shows 1.2L residual. US KUB shows bilateral hydronephrosis.
UE normal except: Creatinine 290 µmol/L(55 - 120)
diagnosis?
chronic high pressure urinary retention
If renal function impaired or hydronephrosis present
What is the mechanism of action of tamsulosin?
alpha-1 antagonist
what is a contraindication to circumcision in infancy?
hypospadias
as the foreskin used in the repair
two most common reasons why children in the UK have medical circumcisions?
phimosis
balantis xerotica obliterans (can also cause phimosis, SCC)
recurrent balantitis also
first-line investigation in suspected prostate cancer?
multiparametric MRI
mx torsion?
surgical fixation of both testes emergent
other one at risk too following first one
A 23-year-old male is admitted with left sided loin pain and fever. His investigations demonstrate a left sided ureteric calculi that measures 0.7cm in diameter and associated hydronephrosis. mx?
percutaneous nephrostomy
broad spectrum abx
A 23-year-old man is admitted with left sided loin pain that radiates to his groin. His investigations demonstrate a 1cm left sided ureteric calculus with no associated hydronephrosis. mx?
extra corporeal shock wave lithotripsy
Stag-horn calculi are composed of?
struviate and form in alkaline urine (ammonia producing bacteria predispose) - proteus mirabilis
66 M undergone TURP. The operation notes describe using 1.5% glycine as the irrigation fluid. A prolonged operative time (1 hour 30 minutes) occurred due to the size of the resection required to optimise flow from the gland. The patient has now become agitated, confused and developed worsening of his breathlessness. You conduct a venous blood gas which demonstrates the patient to be hyponatraemic (118mmol/l). dx?
turp syndrome
Complications of Transurethral Resection: TURP
T ur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
acute upper urinary tract stone mx?
nephrostomy
better prognosis for testicular ca - teratoma or seminoma?
seminoma
A 6-year-old boy presents to the emergency department with his father with a persistent painful penile erection lasting 5 hours. According to his father, the boy has a history of sickle cell disease.
Which initial action is most appropriate?
Cavernosal blood gas analysis is a useful investigation for priapism
55M oil rig worker ->ED with new frank haematuria. Passing blood and clots when urinating for 2/7. He has no dysuria or abdominal pain. He is apyrexial, hr 83, bp 132/84. Abdomen is soft and he has no abdominal tenderness and no palpable masses in the abdomen or renal angles. 25 pack-year history. appropriate in the first instance to investigate the cause of his haematuria?
felxible cystoscopy
bladder ca r/o
how long before vasectomy is an effective contraception?
until clear semen analysis
male more effective than female sterilisation
chr pain seen in >5%
26-M->ED with general malaise and pain in his perineum and scrotum. 2/7. Increased urinary frequency and some burning pain on passing urine. HR75, RR16, BP118/80, t37.6ºC. On DRE prostate is tender and there is boggy enlargement.
What is an appropriate investigation?
STI screening
in young male with acute prostatitis
ecoli commonest overall cause just not in young male
Patients with chronic urinary retention should be managed?
intermittent self catheterisation first
then long term catheter
Scrotal swelling you can’t get above:
inguinoscrotal hernia
low grade prostate ca mx:
watchful wait
What is the most common type of renal stone?
calcium oxalate
haematuria and ballotable mass and renal angle tenderness are more in keeping with ?
a renal cell carcinoma than a bladder tumour.
what might give false high PSA?
ejaculation (ideally not in the previous 48 hours)
vigorous exercise (ideally not in the previous 48 hours
prostatitis (wait a month)
DRE (wait 1 week)
UTI (4 weeks)
6 weeks - prostate biopsy
A 43-year-old man is admitted with severe, episodic pain in his right loin region. Urine dipstick is positive for blood and a KUB x-ray shows a probable stone in the ureter. He is given intramuscular diclofenac for pain relief. Which one of the following types of medication may also be beneficial in this scenario?
alpha adrenergic blocker
also ccb
Periureteric fat stranding may indicate?
recent ureteric stone passage
78M unable to pass urine for the last 5 hours. He is extremely uncomfortable. You insert a catheter, which drains 1 litre of urine. Feels much better. PR exam: enlarged, hard nodular prostate. Urology Registrar recommends to admit + observe for 24 hours; he warns that following an episode of acute urinary retention a complication may occur. Which test is most important to (re)check in the next 12 hours to help identify such a complication?
serum creatinine
AKI
always do U+Es after catheter for retention
Rhabdomyolysis can cause AKI due to???
acute tubular necrosis
tumour maker for testicular cancer?
HCG
An 28-year-old man presents with pain in the testis and scrotum. It began 10 hours previously and has worsened during that time. On examination he is pyrexial, the testis is swollen and tender and there is an associated hydrocele. dx?
acute infective epididymo-orchitis
A 15-year-old boy develops sudden onset of pain in the left hemiscrotum. He has no other urinary symptoms. On examination the superior pole of the testis is tender and the cremasteric reflex is particularly marked. dx?
torsion of testicular appendage
A 14-year-old boy develops sudden onset severe pain in the left testicle radiating to the left groin. He is distressed and vomits. On examination the testis is very tender and the cremasteric reflex is absent.
dx?
torsion of spermatic cord
most effective management option in renal cell carcinoma - >?
radical nephrectomy
rcc usually resistant to chemo and radio
risk factors for testicular ca?
infertility cryptorchidism family history Klinefelter's syndrome mumps orchitis
any man presenting with erectile dysfunction - ix?
testosterone level
if abnormal -> FSH, LH, prolactin along with repeat testosterone ix
22M RTA. Pelvic fracture. While on the ward the nursing staff report that he is complaining of lower abdominal pain. On examination you find a distended tender bladder. What is the best management?
suprapubic catheter
which testicular pathology associated with infertility?
variciocele
radiotherapy for prostate cancer increases risk of?
bladder, colorectal ca
Acute epididymo-orchitis is most commonly caused by ?
chlamydia <35
ecoli >35
bladder ca (TCC) associated with which occupational hazard?
aniline dye - textile, rubber
granular, muddy-brown urinary casts??
acute tubular necrosis
hydrocele in infants - mx?
likely resolve by 1yr old - reassure
communicating ones >3% newborns
prostatitis mx?
14-day course of ciprofloxacin 500mg BD
Having a normal libido is suggestive of ?
organic cause of ED
A 32-year-old male presents to the GP with a painless lump in his testicle. On examination, it is possible to get above the lump, the testicle does not transilluminate and is found on the posterior side of the testicle and is separate from the body of the testicle. dx?
epididymal cyst
cyst is separate from the body of the testicle and typically found posterior to the testicle.
A 50-year-old woman presents with a dragging sensation that she feels comes from the lump in her groin. On examination, there is a palpable lump in the groin that is below and lateral to the pubic tubercle. It is not possible to get above it and it has a cough impulse.
dx?
femoral hernia
commonly in females. On examination, it is not possible to get above a palpable lump
A 40-year-old male presents to the GP complaining of a painless lump in his groin. On examination, the lump is medial and superior to the pubic tubercle. The size of the lump is approximately 3cm and it is smooth and mobile. There is no cough impulse. dx?
lipoma
A 22-year-old man attends an appointment with his general practitioner. He has noticed a non-tender lump in his scrotum. He is concerned that he is developing bilateral breast enlargement. ix?
USS testicle - ca?
mild varicocele mx?
reassure and observe
80% left sided
A 56-year-old man is involved in a road traffic accident. He is found to have a pelvic fracture. He reports that he has some lower abdominal pain. He has peritonism in the lower abdomen. The nursing staff report that he has not passed any urine. A CT scan shows evidence of free fluid. dx?
bladder rupture
pelvic fracture and lower abdominal peritonism should raise suspicion
A 52-year-old man falls off his bike. He is found to have a pelvic fracture. On examination he is found to have perineal oedema and on PR the prostate is not palpable. A urine dipstick shows blood. dx?
membranous urethral rupture
A 46-year-old African gentleman presents with painless haematuria. Whilst taking a urological history he mentions that he has had Schisotosoma haematobium infection in the past. What malignancy is he at increased risk of developing as a result?
squamous cell ca bladder
Patients with obstructive urinary calculi and signs of infection require?
urgent iv abx and renal decompression (nephrostomy)
A 56-year-old man is admitted with acute retention of urine. He has had a recent urinary tract infection. An USS shows bilateral hydronephrosis. What is the best course of action?
urethral catheter
retention often caused by UTI
von hippel-lindau =
cysts
which testicular ca can have normal markers?
seminomas
A 22-year-old man is involved in a road traffic accident. He is found to have a pelvic fracture. While on the ward the nursing staff report that he is complaining of lower abdominal pain. On examination you find a distended tender bladder. What is the most likely diagnosis?
urethral injury
A 31-year-old man presents as he and his partner have been having problems conceiving. On examination there is a diffuse lumpy swelling on the left side of his scrotum. This is not painful and the testicle, which can be felt separately, is normal. dx?
varicocele
best ix for hydronephrosis
USS
A 65-year-old man presents with lower urinary tract symptoms. For the past few months, he has had problems with urinary urgency and has had several episodes of incontinence when he could not reach the toilet in time. He describes good urinary flow with no hesitancy or straining. Urinalysis and prostate examination are unremarkable. mx?
antimuscarinics
overactive bladder
Renal stones on x-ray:
cystine - semi-opaque
urate and xanthine stones - radio-lucent
Following neobladder reconstruction, patients are at increased risk of?
adenocarcinoma
