Urology Flashcards
How might prostate cancer present itself?
2 week wait referral Abnormal DRE Bone pain Renal failure Weight loss
What do you give with an LHRH agonist to prevent tumour flares?
Anti-androgen
Most common site of prostate mets
Bone
Most common site of prostate mets
Bone
Bladder cancer investigation
Flexible cystoscopy
+ dip/MSU, urine cytology
+ pelvic MRI for local spread and CT for distant mets
Haematuria imaging?
U&E (to check if renal function is okay for contrast)
CTIVU (ureteric cancer)
Flexible cystoscopy
2 week wait referral indications for haematuria
> 45 and:
Unexplained visible haematuria in absence of UTI
Persistant visible haematuria following successful UTI treatment
> 60 and non-visible haematuria with dysuria or raised WCC
Consider non-urgent referral if >60 and recurrent UTIs
Prostate cancer DRE findings
Enlarged, hard, nodular, asymmetrical
When would you carry out a DRE on a patient
LUTS Haematuria Raised PSA ED Unexplained symptoms (e.g. weight loss, back pain, bone pain)
What must be avoided before a PSA test
Ejaculation or vigorous exercise in last 48 hours
Urological intervention in last 6 weeks
UTI in last 6 weeks
First line investigation of prostate cancer and what scoring system is used for this imaging of prostate cancer
Multiparametric MRI
Likert scoring (5 point)
When to do a prostate biopsy?
Likert score 3 and over
Low risk prostate cancer criteria
PSA <10NG/ML AND <6 Gleason AND T1-T2A
High risk prostate cancer criteria
PSA >20NG/ML or 8-2 Gleason or >T2c
Management of localised prostate cancer
Active surveillance (only in low or intermediate risk), radical prostatectomy or radical radiotherapy
Management of metastatic prostate cancer
Docetaxel chemotherapy and androgen deprivation therapy
Most common cause of scrotal swelling, diagnosis and management
Epididymal cyst
Ultrasound
Usually supportive, or sclerotherapy or surgical removal if large
Characteristics of acute urinary retention
Painful
600ml-L
normal U&Es
Relieved by catheter
Management of acute urinary retention
Catheter Alpha blocker (tamsulosin) for TWOC)
Chronic urinary retention characteristics
Impaired renal function and hydronephrosis (if high pressure)
Painless
Risk of stones and infection
Management of non-muscle-invasive bladder cancer
TURBT (trans urethra removal of bladder tumour)
Intermediate risk: + intravesical mitomysin C
High risk: + repeat TURBT after 6 weeks + intravesical BCG or radical cystectomy
Radical cystectomy given with cisplatin
Management of muscle-invasive bladder cancer
Radical cystectomy or radiotherapy
Neoadjuvant cisplatin given before cystectomy
Management of epididymo-orchitis
IM ceftriaxone + ora doxycycline
What is Prehn’s sign and what is it suggestive of
Testicular pain that eases on elevation of the teste
Suggests epidiymo-orchitis as relieves the pressure on epididymis
Presentation and management of testicular torsion
Sudden severe pain in testicle often referred to lower abdomen
Nausea and vomiting
Swollen, red and elevated teste
Prehn’s sign absent
Loss of cremasteric reflex
Mx: surgical fixation of both testes
Causes and symptoms of urethral stricture
STIs
Hypospadias
Lichen sclerosis
Traumatic placement of catheter
Sx: painful/difficulty urinating, dribbling, incomplete emptying
Why can chemotherapy increase risk of renal stones?
Increases uric acid
Most common type of renal stones?
Calcium oxalate
What renal stones are associated with chronic infection?
Struvite - staghorn stones
Result of urease producing bacteria (proteus mirabilis)
Characteristics of testicular cancer
Painless lump
Raised LDH, AFP and hCG (in non-seminomas) can be seen
Gynaecomastia
Types of testicular cancer
Seminomas
Non-seminomas (teratoma, embryonal, yolk sac)
Risk factors associated with testicular cancer
Cryptorchidism
Infertility
Kleinfelters
Fhx
Diagnosis and management of testicular cancer
Ultrasound
Orchidectomy
Chemo/radio
Renal cell carcinoma triad and other features
Flank pain
Haematuria
Renal mass
Left varicocele (occlusion of left testicular vein)
Eryhtropoeitin production (polycythaemia)
PTH (hypercalcaemia), renin, ACTH
Paraneoplastic hepatic dysfunction syndrome (Stauffer) with hepatosplenomegaly and cholestasis
Management of renal cell carcinoma
Partial/total nephrectomy
Alpha-interferon and IL-2 (if mets or to reduce tumour size)
Sunitinib (receptor tyrosine kinase inhibitor)
Infection associated with squamous cell carcinoma of the bladder
Schistostomiasis (African)
Management of metastatic prostate cancer
HORMONAL THERAPY GnRH agonists (goserelin)
+ anti-androgen (cyproterone acetate or flutamide) to prevent rise in testosterone
Orchidectomy
Main complication of prostatectomy
Erectile dysfunction
Main risk associated with radiotherapy for prostate cancer
Bladder, colon and rectal cancer
Definition of chronic urinary retention
> 500ml post-voiding
Normal post-void volumes in < and >65s
<50mls in <65s
<100mls in >65s
Inguinal hernia characteristics
Can’t get above the swelling
Cough impulse
Reducible
Hydrocele characteristics
Non-painful Can transilluminate Can get above it Often presenting feature of testicular cancer in young men Filled with clear fluid
Characteristics of varicocele
Often left side (testicular vein drains into renal vein)
Can be presenting feature of renal cell carcinoma
Affected testis may be smaller
Bilateral varicoceles can affect fertility
Causes of acute epididymo-orchitis
Chlamydia
Assoc with dysuria and urethral discharge
Investigation of testicular cancer
USS
Serum AFP and bHCG
Features of epidiymal cysts
Possible to get above the swelling Filled with clear or opalescent fluid Painless 40s Lie above and behind testes
Most common cause of cancer in an ileal neobladder
Adenocarcinoma (most common cancer in bowel)
Most common causative organism of epidymitis in >35s?
<35s?
> 35s/MSM: E.coli
<35s: Chlamydia
Chronic high pressure urinary retention characteristics
Renal function impairment or hydronephrosis
Renal stone first-line investigation
Non-contrast CT KUB
Management of acute upper urinary tract obstruction
Nephrostomy tube (depressurise kidneys) followed by removal of obstruction
E.g. ESWL (extra-corporeal shockwave lithotripsy) or cystoscopy
Diagnosis of hydronephrosis
Ultrasound
IV urogram to detect position
CT if suspect renal colic
Balanitis xerotica obliterans (BXO) associations?
Phimosis
Squamous cell carcinoma
Risk of infection
Most common causes of acute prostatitis
E. coli
Young men: STI (Gonorrhoea and chlamydia)
Management of acute prostatitis
14 days of quinolone
Congenital contraindication for circumcision
Hypospadias (foreskin used in repair)
Initial management of renal stone
IM diclofenac
Definitive management of renal stones
<5mm: pass spontaneously
<2cm: lithotripsy
<2cm in pregnant females: ureteroscopy (stent)
Complex or staghorn: percutaneous nephrolithotomy
Initial erectile dysfunction screen
cardiovascular system (BP)
HbA1c and lipids
Testosterone (for hypogonadism) - 6 month trial of testosterone if consistently less than 12nmol/l
TURP syndrome characteristics
Hyponatraemia
Hyperammonia
CNS disturbances
Respiratory symptoms
Caused by prolonged irrigation by glycine
Management of hydrocele in babies?
Should self-resolve by 18 months to 2 years of age
Common causes of urinary retention
BPH Ureteric strictures Post-operative/post-partum Uterine fibroids Constipation UTI Medications
What medications can cause urinary retention?
Anti-cholinergics TCAs Anti-histamines Benzos Anti-histamines Opioids
Management of overractive bladder
Antimuscarinics (oxybutinin)
Moderate fluid intake
Bladder retraining
Management of nocturia
Moderate fluid intake in evening
Furosemide late afternoon
Desmopressin
Management of voiding symptoms in men
Conservative pelvic floor muscle exercises and bladder training
Moderate-severe: alpha blocker
Enlarged prostate: 5-alpha reductase inhibitor (finasteride)
Alpha blocker examples
Doxazosin
Tamsulosin
5-alpha reductase inhibitor example
Finasteride
Pelvic fracture with perineal oedema and non-palpable prostate
Membranous urethral rupture
Prophylaxis against calcium renal stones
Thiazide diuretic
Irregular non-calcified mass in kidney/adrenal gland in a child with hypertension
Nephroblastoma (Wilms)
If was calcified and normotensive - neuroblastoma
Treatment of balanitis
STI: appropriate treatment
Dermatitis: topical hydrocortisone
Candida: clotrimazole or nystatin cream
Bacterial: fluclox or erythromycin
Recurrent: circumcision
Most common cause of renal cancer and how does it affect the lung?
Renal adenocarcinoma
Cannon ball mets in lung –> haemoptysis
Most effective treatment of renal cell carcinoma
Radical nephrectomy (resistant to chemo and radio)
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.
Varicocele
Management of hydrocele in adults
Refer for urgent testicular ultrasound (associated with cancer)
What needs to be monitored following relief of acute urinary retention?
Diuresis - risk of hypovolaemia and hyponatraemia
Monitor U&Es
Tamsulosin side effects
Dizziness and postural hypotension
Causes of priapism
Sickle cell and other haemoglobinopathies
Drugs for ED (sildenafil)
Medications (antihypertensives, anticoagulants, cocaine, marijuana)
Trauma
Investigations for priapism
Cavernous blood gas (raised CO2 and low O2 if ischaemic)
Doppler as alternative to assess blood flow
FBC
Toxicology
Management of ischaemic priapism
- Aspiration of blood in cavernosa and injection of saline to clear the viscous blood
- Intracavernosal injection of phenylephrine every 5 mins
- surgery
Management of non-ischaemic priapism
Observation
Medication used to aid spontaneous passage of ureteric stone
Alpha blocker (sometimes CCB)
What kinds of testicular cancer would have a raised hcg and afp?
Teratomas or yolk sac tumours
Management of asymptomatic varicocele with normal semen parameters?
Semen analysis every 1-2 years
Complications of TURP?
TURP syndrome
Urethral stricture
Retrograde ejaculation
Perforation of prostate
When can vasectomy be confirmed to be contraceptive
Clear sperm analysis
How long does finasteride take to be effective in BPH?
up to 6 months
Young man with history of urinary incontinence and previous gonorrhoea - likely dx?
Urethral stricture
Woman admitted with loin pain, fever and dysuria. Treatment?
Pyelonephritis - IV gentamicin
Investigations for high PSA
MRI prostate
Prostate biopsy
Bone scan
Androgen deprivation therapy main side effects patients complain of
Hot flushes, fatigue, erectile dysfunction
Older man with history of nocturnal enuresis presents with inability to void. Catheter shows residual of 2.4L. Management?
Admit, U&Es, monitor diuresis
High pressure chronic retention, could lead to renal dysfunction and hydronephrosis and can cause dehydration
