Urology Flashcards
1
Q
Define Urolithiasis
A
Formation of crystalline solutes anywhere along the urinary tracts Renal Stones (in Kidney) or Ureteric
2
Q
Name 2 stone inhibitors
A
Magnesium
Citric Acid
3
Q
State four different types of Renal Stones
A
Calcium (80%)
Uric Acid (High levels of Purines)
Struvite/Infective
Cystine
4
Q
Name two causes of high purine levels
A
High red meat intake
Myeloproliferative Disorders
5
Q
What is the one type of radiolucent stone
A
Urate
6
Q
Name the infective organism that most commonly causes Struvite Stones
A
Proteus
7
Q
Name the three most common locations for stones to form
A
PUJ
VUJ
As ureter passes pelvic brim
8
Q
Give 5 risk factors for stone formation
A
Age Family History Anatomical Abnormalities (Horseshoe Kidney, Medullary Sponge) Dehydration Crohns
9
Q
Describe three clinical features of RTC
A
Ureteric Colic (Loin to Groin)
Nausea and Vomiting
Haematuria
10
Q
What is the main differential for flank pain
A
AAA
11
Q
What is the Gold Standard Investigation for RTCs (except in pregnant or young)?
A
CTKUB WITHOUT contrast
Contrast has a similar density to stone
12
Q
What might be present on a CT of an RTC that would indicate infection?
A
Fat Stranding (ie haziness)
13
Q
What are Matrix Stones?
A
Rare stones related to HIV/Hepatitis treatment
Invisible on CT
14
Q
How is the patient positioned for a CT KUB?
A
Prone Position
Otherwise hard to differentiate position of stone
15
Q
Describe the conservative management of RTC
A
Fluids
Analgesia (Rectal Diclofenac/Paracetamol)
Anti-Emetic
Medical Expulsion Therapy (eg Tamsulosin)
If under 5mm, 68% of stones will pass spontaneously
16
Q
Name four indications for surgical management of RTCs
A
Severe Pain > 48hrs
Renal Dysfunction
Previous Renal Disease Bilateral Stones
17
Q
Describe three surgical options for RTC
A
Extracorporeal Shock Wave Lithotripsy
Uteroscopy and Stone Removal (with laser)
Percutaneous Nephrolithotomy (if in kidney)
18
Q
Name two contraindications to ESWL in RTCs
A
AAA
Blood Thinners
19
Q
How would an RTC present if it was close to/in the bladder?
A
Frequency
Urgency
20
Q
What happens if an RTC becomes infected?
A
an infected obstructed system is a urological emergency and patients can die
21
Q
Describe a 3 step management plan for an Infected Obstructed System
A
Sepsis 6
Stent under GA or Percutaneous Nephorstomy under LA
HDU/ITU
22
Q
Define Pyelonephritis
A
Inflammation of Kidney Parenchyma and Renal Pelvis, typically due to bacterial infection
Bacteria can reach by ascending urinary tract, haematogenous spread, or lymphatic spread (from retroperitoneal abscess)
23
Q
Give 3 risk factors of Pyelonephritis
A
Halted flow of urine (BPH/Spinal Cord) Retrograde Ascent (Female, Indwelling Catheter) Factors Predisposing (DM, Steroids)
24
Q
Describe the clinical features of Pyelonephritis
A
Fever
Loin Pain
Nausea and Vomiting
May have corresponding LUTS
25
Describe three investigations for Pyelonephritis
Urinalysis
Urine Culture
Renal Ultrasound Scan
26
How would you manage Pyelonephritis?
Antibiotics
| Fluids
27
Give two complications of Pyelonephritis
```
Chronic Pyelonephritis and Scarring
Emphysematous Pyeonephritis (from gas forming bacteria, gas around kidney, usually in diabetic patients)
```
28
Give 3 features of a 'complex' Renal Cyst
Thick walls
Calcifications
Risk of Malignancy
29
Give 4 risk factors for Renal Cysts
Age
Hypertension
Smoking
Gender (PCKD, Von Hippel Lindau)
30
Give 3 clinical features of Renal Cysts
May be asymptomatic
Flank Pain
Haematuria
31
What is Bosniak Scoring?
Classifies Renal Cysts from I-V with increasing risk of malignancy
32
How would you manage Renal Cysts?
Asymptomatic Cysts don't need further follow up or treatment
| Symptomatic - Analgesia and deroofing
33
Bladder Cancer can be invasive or non-invasive, state three histological subtypes
Transitional Cell Carcinoma
Squamous Ce;; Carcinoma
Adenocarcinoma
34
Describe the four layers of the bladder wall
Inner Lining - Urothelium (Transitional Epithelium)
Second Layer - Lamina Propria
Third Layer - Muscular Layer
Fourth Layer - Outer CT
35
Give 3 risk factors for Bladder Cancer
Smoking
2 - Napthylamine
Schistosomiasis
36
Give 3 clinical presentations of Bladder Cancer
Painless Haematuria
Recurrent UTIs
LUTS
37
Name 3 investigations for Bladder Cancer
Urgent Cytoscopy
Biopsy via TURBT (Transurethral Resection Bladder Tumour)
CT Staging
38
Describe the management of non muscle invasive Bladder Cancer
TURBT (Diathermy using cytoscope)
Intravesicle Chemo (Mitomycin C)
Radical Cystectomy
39
Describe the management of muscle invasive Bladder Cancer
Radical Cystectomy
| Neoadjuvant Chemotherapy
40
How is a Urinary Diversion created surgically?
Ileal Conduit and Urostomy
| IE Bladder reconstruction using small bowel
41
What is the scoring system for BPH called?
International Prostate System Score
42
What volume of Prostate is considered enlarged?
Over 30ml
43
Describe two types of medical management for BPH
Alpha Blockers (eg Tamsulosin) - relax prostatic smooth muscle
5a Reductase Inhibitors (eg Finasteride) - prevents conversion of testosterone to DHT
44
Describe two types of surgical management for BPH
TURP (using diathermy loop)
Holmum Laser Enucleation of the Prostate (uses heat to dissect)
45
What is TURP Syndrome?
The use of hypo-osmolar irrigation during the procedure can result in hypervolaemia and hyponatraemia
Presenting with confusion, nausea and agitation
46
Name the two histological subtypes of Prostate Cancer
Acinar
| Ductal
47
Give 3 risk factors for Prostate Cancer
Age
Ethnicity (Black African and Caribbean)
BRCA1/2
48
Describe the normal PSA levels
40-49 <2.5
50-59 <3.5
60-69 <4.5
>70 <6.5
49
Describe the two methods of biopsy for suspected Prostate Cancer
Transperineal
| Transrectal
50
How is Prostate Cancer Graded?
Gleason Grading
51
How is Prostate Cancer managed?
Asymptomatic - Surveillance
High Risk - Radical Treatment (Prostatectomy, Surrounding Tissue and Lymph Nodes)
Metastatic - Chemo and Anti Hormonal treatment
52
Name two Anti-Androgens
LHRH Antagonists - Goserelin
| GnRH Antagonists - Degarelix
53
Define Prostatitis
Inflammation of the prostate (most common urological disease in men under 50)
Can be acute, chronic or non bacterial
54
Describe the pathophysiology of Acute Bacterial Prostatitis
Ascending urethral infection
Direct/Lymphatic spread from rectum
Haematogenous spread from sepsis
55
Describe the pathophysiology of Chronic Bacterial Prostatitis
Inadequately treated Acute Prostatitis
56
Give 3 risk factors for Prostatitis
Phimosis
Indwelling Catheter
Dysfunctional Bladder
57
How would a patient with Prostatitis present?
LUTS
Perineal/Suprapubic pain
Urethral Discharge
58
How would an inflammed postate feel on DRE?
Tender and Boggy
59
Give 3 investigations for suspected Prostatitis
Urine Culture
STI Check
Transrectal Prostatic Ultrasound
60
Describe the management of Prostatitis
Prolonged Antibiotics (Quinolones generally have good prostatic penetrance)
Analgesia
Chronic - Tamsulosin/Finasteride
61
Define Epididymitis
Inflammation of the Epididymis
| Generally thought to occur concurrently with Orchitis (inflammation of testes)
62
There is a bimodal age distribution of Epididymitis, explain the respective pathophysiology of both
Under 35 - STI (Gonorrhoea, Chlamydia
| Over 35 - Infection secondary to UTI
63
Give 5 clinical features of Epididymitis
```
Unilateral Scrotal Pain and Swelling
Fevers/Rigors
Dysuria
Urethral Discharge
Positive Prehn's Sign (elevating the testes relieves pain)
```
64
What is Mumps Orchitis?
Can be uni or bilateral around 4-8d after Parotiditis
Can causes testicular atrophy/infertility
65
State 3 investigations for Epididymitis
First Void NAAT
Routine Bloods
US Doppler
66
Describe the management of Epididymitis
Antibiotics (Ciprofloxacin for enteric organisms, Ceftriaxone/Doxycylcine for STI)
Abstinence until antibiotics are completed/symptoms resolved
67
Define Testicular Torsion
Spermatic cord and its contents twist inside the Tunica Vaginalis, compromising blood supply
68
Describe the bimodal age distribution of Testicular Torsion
Neonates
| Adolescents aged 12-25
69
Describe the pathophysiology of Testicular Torsion
Mobile Testes rotate, reducing arterial blood flow, impairing venous return, causing venous congestion and oedema
More prone if bell clapper deformity
In neonates the attachment between the scrotum and tunica vaginalis is not fully formed therefore it can all twist - extra vaginal torsion
70
Describe the clinical presentation of Testicular Torsion
```
Sudden onset severe, unilateral testicular pain
Referred Abdominal Pain
Nausea and Vomiting
Absent Cremasteric Reflex
Negative Prehns Sign
```
71
How would you investigate a suspected Testicular Torsion?
Urgent Surgical exploration
| Ultrasound doppler
72
How would you manage Testicular Torsion?
Within 4-6 hours
| Cord and Testes are untwisted, both testes are fixed to scrotum (Bilateral Orchidopexy)
73
One of the main differentials for Testicular Torsion is Hyatid of Morgagni Torsion, describe it
Remnant of Mullerian ducts that become torted
| Blue dot on upper half of hemiscrotum
74
Describe the two types of Primary Testicular Tumour
Germ Cell - Seminomas (slow growing and good prognosis) or Non Seminomas (Yolk Sac, Choriocarcinomas, Teratoma)
Non Germ Cell - Leydig or Sertoli
75
Give 3 risk factors for Testicular Cancer
Cryptorchidism
Klinefelters
Family History
76
Give 3 Clinical Features for Testicular Cancer
Unilateral Painful Testicular Lump
Weight Loss
If metastasises - Back Pain, Dyspnoea
77
Give 3 investigations for Testicular Cancer
Tumour Markers (B-HCG, AFP)
Scrotal USS
CT for Staging
78
Describe the staging of Testicular Cancer
I - Confined to testes
II - Infradiaphragmatic Lymph Node Involvement
III - Supra and Infradiaphragmatic Lymph Node Involvement
IV - Extralymphatic Metastatic Spread
79
Describe the management of Testicular Cancer
Mainstay of treatment is Inguinal Radical Orchidectomy (testes and spermatic cord)
If metastatic then chemoradiotherapy (this may render them infertile so consider cryopreservation)
80
Define Urethritis
Inflammation of the urethra
| Can be Gonococcal or Non Gonococcal
81
Give 3 clinical features of Urethritis
Dysuria
Penile Irritation
Discharge
82
Name three investigations for Urethritis
Urethral Swab & Gram Stain
First catch urine and NAAT
STI Screening
83
Describe the management for Urethritis
1) Gonococcal - IM Ceftriaxone and Azithromycin
Non Gonococcal - Doxycycline
Abstain from sexual activity and contact trace
84
What is Fournier's Gangrene?
Necrotising Fasciitis affecting the perineurium
| Can be monomicrobial or polymicrobial
85
Give 3 risk factors for Fourneir's Gangrene
Alcohol
Diabetes Mellitus
Steroid Use
86
Give 3 clinical features of Fournier's Gangrene
Severe Pain (out of proportion to clinical signs)
Crepitus/Necrosis
Sepsis
87
How would you investigate Fournier's Gangrene?
Surgical Exploration
88
How would you manage Fournier's Gangrene?
Extensive Surgical Debridement (Potentially requiring skin grafts)
Antibiotics
HDU/ITU
89
What is Paraphimosis?
Inability to pull a retracted foreskin over the glans
Causes the glans to become increasingly oedematous due to reduced venous return leading to vascular engorgement
Can cause penile ischaemia if left untreated
90
Give 3 risk factors for Paraphimosis
Phimosis
Indwelling Catheter (and non diplaced foreskin)
Poor Hygiene
91
Give 3 features of management for Paraphimosis
Analgesia
Consider Circumcision
Reduction
92
Describe four reduction techniques for Paraphimosis
- Manual pressure and lubricant jelly
- Dextrose soaked gauze
- Dundee Technqiue (puncturing glans)
- Dorsal Slit
93
Define Priapism
Unwanted painful erection (not associated with sexual desire) lasting longer than four hours
94
Describe the pathophysiology of Priapism
Blood stays within Corpus Cavernosa
| Venous Stasis occurs, which if prolonged can cause fibrosis and impotence
95
Describe the three subtypes of Priapism
High Flow - Non Ischaemic, blood flows faster than it can be drained, associated with initial sexual stimulation
Low Flow - Blockage to venous drainage
Stuttering/Intermittent - Repetitive and painful episodes, associated with Sickle Cell
96
Describe the clinical features of Priapism
Ischaemic - Painful and rigid erection
| Non Ischaemic - Painless and not fully rigid erection
97
Describe two investigations for Priapism
Corporeal Blood Gas - to differentiate between ischaemic and non ischaemic
Bloods - to look for underlying cause
98
How would you manage Priapism
Coproreal Aspiration OR injection of sympathomimetic agent
| Shunt insertion
99
What is a Penile Fracture
Traumatic rupture of Corpus Cavernosa and Tunica Albuginea in an erect penis via blunt trauma
Deviated from axis
100
How would Penile Fractures present?
Popping sensation with immediate pain/swelling/loss of erection
Aubergine Sign
101
How would you investigate a Penile Fracture?
Generally a clinial diagnosis
Cavernosonography - locate the rupture site
Retrograde Urethrography if any urethral injury is suspected
102
Describe the surgical management of Penile Fractures
The penis is degloved, haematoma evacuated and the tear repaired using absorbable sutures
103
What may cause pseudohaematuria?
- drugs like rifampicin or methylodopa
- hyperbilirubinurea
- myoglobinurea
- beetroot and rubarb
104
What may cause haematuria? (give at least 5)
- infection: bladder, prostate, kidney
- malignancy: bladder, kidney, ureter, prostate
- renal calculi
- trauma, recent surgery
- radiation cystitis
- schistomiasis
- BPH
- antiplatelet or anti coag drugs (investigate as normal)
- glomerular nephritis
- recent transrectal biopsy of prostate
105
Where do RCCs tend to arise from and where do they spread to?
- arise from PCT and appear most often in upper poles of kidneys
- spread directly to perinephris tissues, adrenal gland or into renal vein (may cause tumour thrombosis), IVC, lymphatic system (pre aeortic or hilar nodes) and to bone, liver, brain and lung via the blood.
106
Give 5 risk factors for RCC
- SMOKING (biggest)
- industrial exposure to cadmium or aromatic hydrocarbons
- dialysis (30x increase)
- hypertension
- obesity
- APCKD
- horseshoe kidneys
- some other rarer genetic disorders
107
Describe the clinical features of RCC
- haematuria (usually visible, may be invisible, is most common PC)
- flank pain
- flank mass
- lethargy, weight loss, pyrexia of unknown origin
- left varicocele if impinging left testicular vein
- paraneoplastic syndrome
- hypertension
- features of mets such as haemoptysis or
108
What paraneoplastic syndromes may RCC cause
- EPO secretion-> polycythaemia
- PTH-> hypercalcaemia
- Renin-> hypertension
109
How is suspected RCC investigated?
USS usually already one
- CT abdo pelvis with contrast
- CXR for mets
- Biopsy to stage
110
How can RCC be managed? (if small, large, unfit for surg and metastatic)
- SMALL-> partial nephrectomy
- LARGE-> radial nephrectomy
- not fit for surg-> percutaneous radiofrequency ablation, laparoscopic cyrotherappy, renal artery embolisation
- If old person + slow growing tumour+ unfit for surg-> surveillance
- METASTATIC-> immunotherapy (sunitinib) + nephrectomy +/- metastatectomy
- CHEMO CONSIDERED INEFFECTIVE
111
How does an upper tract TCC usually present?
- haematuria (visible or invisible)
- post renal AKI +/- hydronephrosis
- loin pain
- palpable mass
112
What suggests a TCC is higher risk?
- hydronephrosis
- infiltrative features
- high grade
113
How is TCC managed? (if high and low risk)
- radical nephroureterectomy with bladder cuff excision
| - lower risk TCCs can be managed more conservatively
