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Phase 3b > Urology > Flashcards

Urology Flashcards

1
Q

Hospital treatment for pyelonephritis

A

ciprofloxacin
(oral is as good as IV for penetration into kidney)
If not working would then consider IV gentamicin

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2
Q

invex for high psa

A

mri prostate
prostate biopsy
bone scan

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3
Q

what is the imaging of choice for prostate

A

MRI

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4
Q

can you use nitrofurantoin for pyelonephritis

A

no - does not penetrate kidney’s well

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5
Q

management of prostate cancer: locally advanced and high grade

A

androgen therapy

chemotherapy

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6
Q

what genes are linked to prostate cancer

A

Hereditary prostate cancer 1 = HPC-1
BRCA 1
BRCA-2

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7
Q

When asking family hx in suspected prostate cancer what other cancers should you consider asking about

A

Breast cancer

BRCA 1 and 2 linked

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8
Q

what part of the prostate are most cancers found in

A

peripheral zone (75%)can feel this on prostate exam

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9
Q

in what part of the prostate is most BPH found

A

transitional zone - cant feel this from rectum but prostate may feel enlarged

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10
Q

what type of cancer is prostate cancer

A

adenocarcinoma

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11
Q

how does prostate cancer spread

A

Through capsule, into lymph nodes and to bones

Occasionally spread to organs but more common to lymph nodes and bones

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12
Q

how is prostate cancer diagnosed

A 
DRE - digital rectal exam 
PSA
If these abnormal - pt goes on to have prostate biopsy 
In 
40s <2.5
50s: <3
60s: <4
70s: <5
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13
Q

list some other causes of raised PSA

A

UTI
BPH (age)
Instrumentation of urinary tract (catheter or cytoscope)
Retention
It is a protease produced by prostatic epithelium - prevents coagulation of seminal fluid
DRE can slightly raise PSA but only v small amount

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14
Q

Arguments for and against screening for prostate cancer

A

PSA not specific enough for screening
Morbidity with biopsies
Over diagnosis - some cancers wont go on to cause any harm
Over treatment
Anxiety that can come from a raised PSA but no cause found

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15
Q

how would a tumour feel on DRE

A

Asymmetry
Nodule
Craggy mass (hard, irregular?)
NB. Most cancers found on DRE will be locally advanced (60%) - 50% of positive DRE are prostate cancer

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16
Q

Investigations for prostate cancer

A

MRI prostate - best practice pre biopsy

Transrectal ultrasound and prostate biopsy

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17
Q

What are the risks of prostate biopsy

A 
Infection (1-2% sepsis)
Bleeding (semen, urine, stool) 
Discomfort
Acute retention
False negative
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18
Q

What are the risks of prostate biopsy

A 
Infection (1-2% sepsis)
Bleeding (semen, urine, stool) 
Discomfort
Acute retention
False negative (still possible to miss some cancers in prostate even on biospy - MRI should help prevent this)
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19
Q

What is the scoring system for prostate cancer

A

Gleason score (1-5)
Two most common scores are added together
Dont really see gleasons 1-2, mainly see 3-5 as these are when patients are symptomatic
Now graded (1-5)

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20
Q

How is a gleasons score calculated

A

A total score is calculated based on how cells look under a microscope, with the first half of the score based on the dominant, or most common cell morphology (scored 1—5), and the second half based on the non-dominant cell pattern with the highest grade (scored 1—5). These two numbers are then combined to produce a total score for the cancer.

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21
Q

Describe the staging of prostate cancer

A

T1 - impalpable but localised (not picked up on DRE, would be picked up by PSA and biopsy)
T2 - palpable but localised (picked up on DRE)
T3 - locally advanced eg into seminal vesicle, lymph nodes
T4 - advanced into other organs

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22
Q

what is active surveillance vs watchful waiting

A

active surveillance - deferred radical treatment for pts with a low grade cancer (waiting for right time to treat)
watchful waiting - deferred androgen deprivation therapy for pts not eligible for radical treatment (waiting to see if need any non-radical treatment)

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23
Q

What is the management of localised prostate cancer

A 
active surveillance 
radical prostatectomy (removal of prostate and seminal vesicle) 
external beam radiotherapy (neo-adjuvancts used to shrink prostate before hand)
brachytherapy (radioactive seeds into prostate - one off procedure - ultrasound guided transperineal implantation of radioactive seeds)
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24
Q

what do seminal vesicles do

A

add sugar (fructose) to semen for sperm

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25
Q

what is a neoadjuvant

A

Neoadjuvant therapy is the administration of therapeutic agents before a main treatment.

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26
Q

side effects of radiotherapy for prostate cancer

A

erectile dysfunction
LUTS
risk of second malignancy - need to consider this in a younger man

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27
Q

what is the management of locally advanced prostate cancer (T3-4)

A

radical prostatectomy
radiotherapy + androgen deprivation therapy
ADT alone

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28
Q

what are the different types of androgen deprivation therapy

A 
Surgical orchiectomy (removal of testes)
LHRH agonists (work slowly - initial surge and then downregulation of LHRH receptor, so stimulate and then inhibit the axis)
LHRH antagonists (work quickly)
Peripheral androgen receptor antagonists
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29
Q

how is metastatic prostate cancer treated

A 
Androgen deprivation therapy
Chemotherapy (if pt fit enough)
Plus:
Bone targetted therapies - bisphosphonates
palliative radiotherapy
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30
Q

complications of metastatic prostate cancer

A 
Bone pain 
Fractures 
Hypercalcaemia 
Spinal cord compression
Retention 
Obstructive uropathy
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31
Q

List some lower urinary tract symptoms

A 
Urgency 
Nocturia 
Poor flow 
Hesitancy 
Post micturation dribbling
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32
Q

Red flags prostate cancer

A 
Back pain 
Weight loss
Lethargy 
Erectile dysfunction 
Haematuria
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33
Q

What is the PSA cut off for urgent urology referal

A

> 3

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34
Q

what examination finding is suspicious of prostate cancer

A

Hard and nodular mass

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35
Q

Which men can request a PSA

A

Over 50

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36
Q

When should you do PSA testing

A

LUTS - unexplained by UTI or alternative diagnosis, or if other red flags
Any red flags for prostate cancer - haematuria, back pain, weight loss, lethargy

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37
Q

What must you do before offering PSA testing

A

Counsel patient about pros and cons of PSA testing - what the result will mean

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38
Q

When should you do a DRE

A

Any lower urinary tract symptoms (LUTS), such as nocturia, urinary frequency, hesitancy, urgency or retention.
Erectile dysfunction.
Visible haematuria.
Unexplained symptoms that could be due to advanced prostate cancer (for example lower back pain, bone pain, weight loss).
Concerns about the possibility of prostate cancer, for example increased prostate-specific antigen (PSA) levels.

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39
Q

When should a man be referred 2 we for prostate

A

Hard, nodular mass on DRE exam (+ve DRE)

PSA >3 (if over 50)

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40
Q

How is a diagnosis of prostate cancer confirmed in secondary care

A

Transrectal ultrasound and biopsy
Additional imaging - MRI
(not all referrals will have imagine, depends on DRE and other RFs evaluated in secondary care)

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41
Q

What examination should you do for a man with LUTS

A

Abdominal exam (distended bladder, suprapubic dullness)
GU - phimosis, meatal stenosis, penile cancer
Perineum - sensory changes
DRE

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42
Q

What are the different types of LUTS in men

A

Storage symptoms, including urgency, daytime urinary frequency, nocturia, urinary incontinence, and feeling the need to urinate again just after passing urine. The man should also be asked about bedwetting, which can be a sign of chronic urinary retention.

Voiding symptoms, including hesitancy, weak or intermittent urinary stream sometimes causing splitting or spraying, straining, incomplete emptying, and terminal dribbling.

Post-micturition symptoms, including post-micturition dribble and the sensation of incomplete emptying.

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43
Q

What investigations should you do and why in a man with LUTS

A

Dipstick (UTI, Haematuria)
U&E - creatinine (retention, renal stones)
FBC - infection, cancer
PSA if indicated and discussed with patient

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44
Q

Prostate cancer/ LUTS differentials and investigations

A 
BPH
UTI
Prostatitis 
Diabetic neuropathy (erectile dysfunction) 
MS
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45
Q

What reasons should you delay PSA testing

A

An active urinary infection (PSA may remain raised for many months).
Ejaculation in the previous 48 hours.
Vigorous exercise in the previous 48 hours.
A prostate biopsy in the previous 6 weeks.

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46
Q

Where do LHRH agonists exert their effects

A

anterior pituitary

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47
Q

management of cord compression

A

Urgent MRI spine
Dexamethasone 8MG BD 8am and 2pm otherwise dont sleep
Plus PPI

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48
Q

How long does it take an lhrh agonist to bring testosterone down

A

1 month

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49
Q

First line management for kidney stones

A

Analgesia
Imaging - CTKUB (non contrast) - first line imaging to look for a stone
KUB x ray as follow up to see if stone has gone?

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50
Q

what safety netting should be given to pt with kidney stone in ureter

A

if get fever, loin pain or feel unwell, must seek medical help - bc of risk of pyelonephritis

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51
Q

Indications for gonorrhea treatment

A

Identification of intracellular Gram-negative diplococci on microscopy
A positive culture for gonorrhoeae
A confirmed positive NAAT for gonorrhoeae
Sexual partner of confirmed case of gonococcal infection

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52
Q

when can you do a HIV test

A

From 3 weeks
But usually takes longer to seroconvert - 6 weeks
Repeat test in 4 weeks if negative and clinical suspicion

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53
Q

complications of gonorrhea and chlamydia for baby

A

opthalmia neonatarum
conjunctivitis from chlamydia or gonorrhea
can lead to blindness (panopthlamitis) or corneal scarring/ ulceration
Gonorrhea needs iv ceftriaxone
Chlamydia needs iv azithromycin

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54
Q

management of chlamydia in pregnancy

A

erythromycin 500 mg BD 10-14 days

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55
Q

management of chlamydia - not pregnant

A

Doxycycline
Azithromycin
7 day course for each

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56
Q

treatment of uncomplicated gonorrhea

A

IM ceftriaxone 1g

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57
Q

which common STIs need to be treated differently in pregnancy/ cause pregnancy/ fetal risk

A

Bacterial Vaginosis
Chlamydia
Gonorrhea
BCG

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58
Q

what other sti often co-exists with trichomonas

A

gonorrhea

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59
Q

how are chlamydia and gonorrhea managed in terms of index and contact patient

A

Index - confirm diagnosis and treat

Contact - investigate and treat empirically

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60
Q

when do HIV symptoms present

A

2-3 months post infection

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61
Q

when does primary syphillis present

A

3 weeks after infection

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62
Q

what is the incubation period for syphilis

A

3 weeks

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63
Q

what is the time course for syphilis

A

primary - days-weeks (usually 3) - painless ulcer
secondary - 1-3 months (systemic -skin, lymph nodes)
tertiary - years - brain, heart, gumma - granuloma - rubber with necrotic tissue

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64
Q

what is the 2 ww criteria for bladder cancer

A

> 45 and unexplained visible haematuria

>60 and unexplained non-visible haematuria AND raised WCC OR dysuria

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65
Q

when should you do a non-urgent referral for bladder cancer

A

> 60 and persistent/ recurrent UTI

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66
Q

What HPV types does vaccine cover

A

HPV 16 and 18, and 6 and 11 (for genital warts)

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67
Q

what STI doesnt need partner notification/ contract tracing

A

genital warts

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68
Q

how many drugs are in prep

how many drugs are in post exposure prophylaxis

A

2 drugs - can be given up to 48 hrs after sex

3 drugs - post exposure

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69
Q

men who have sex w men sexual health screen

A

throat, rectal, urine gc/ chlamydi, HEP C SEROLOGY

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70
Q

commonest STI cause of epididymo-orchitis

A

chlamydia

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71
Q

most common cause of epididymitis

A

UTI, sti, mumps

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72
Q

what should you always think of in rash differential in neonate

A

syphillis

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73
Q

what are the different types of tests for syphilis

what are the functions

A

Ones that test for bacteria (treponema test) - serological test - is IgG and IgM to bacteria (good for diagnosis of secondary and latent syphillis). Not useful for monitoring disease.
Direct tests - look for bacteria in swabs taken from lesions: dark field microscopy, and PCR.

Ones that dont test for bacteria, but test for antibodies produced from antigens released by cells damaged by T pallidum (non-treponema tests) - VDRL
VDRL is good for detecting secondary syphilis and can be used when patient doesnt have any symptoms (i.e. lesions to swab). Good for monitoring disease.

74
Q

what tests should be used to diagnosed syphilis

A

Primary lesion: microscopy or PCR
Secondary syphilis (eg systemic symptoms): Serological test - can be treponema or non treponema
Latent - serological tests (treponema or non treponema)
Tertiary - serological treponema test (or direct from gumma ?)
VDRL only used to monitor disease

75
Q

What imaging should be first line for visible haematuria

A 
CT urogram (CT with contrast) this allows visualisation of renal pelvis, ureters, bladder and urethra (i.e. urinary tract)
USS can be used, but can miss stones and some cancers
76
Q

What neurological condition should you always consider and rule out in any acute urological presentation

A

Cauda equina

77
Q

List red flags to ask in urological hx

A

Pain / pain less (painless - malignancy, pain - acute trauma/ retention/ pathology)
Blood in urine
Perineal sensation / perianal sensation - cauda equina

78
Q

Differential diagnosis for acute scrotal pain

A

Testicular torsion
Epididymo-orchitis
torted hydatid of morgagni

79
Q

How does testicular torsion lay

A

Transverse when compared with other testis

80
Q

What is testicular torsion like on examination

A 
High riding, fixed testicle 
Extremely tender
Horizontal lay
Swelling 
Discolouration of scrotal skin
81
Q

How do you manage testicular torsion

A 
ABCDE 
IV access
Fluid resus if needed
Bloods - FBC, CRP, clotting, U&amp;E
Full hx
Examine
Urine dip (exclude epidiymo-orchitis as differential)
Inform senior
Keep NBM
Inform surgical team and anaesthetics
82
Q

What should you ask in testicular torsion hx

A 
Infection/ Torsion:
When did pain come on 
Has it changed over time
Does it radiate (can radiate to loin/ groin)
Trauma
Recent unprotected sex
Penile discharge
Dysuria
Fever
LUTS 
UTIs?
Recent instrumentation/ catheterisation of urinary tract 
Recent surgery
83
Q

Hx for acute testicular pain

A 
Onset - acute (torsion), sub-acute (infection)
N&amp;V - torsion 
Recent unprotected sex (infection)
UTI symptoms (infection)
Urethral discharge (infection)
Fever (infection)
Trauma (torsion)
After strenuous activity (torsion)
During sleep (torsion)
Low temperatures (torsion)
84
Q

What age group is testicular torsion most common in

A

15-30

85
Q

What catheter should you use for haematuria

A

3 way - large central tube so clots can pass

86
Q

what must you do when managing acute urinary retention

A

two way catheter - measure residual volume
urine sample
monitor for diuresis
fluid monitoring

87
Q

what should you include in differential diagnosis of acute urinary retention

A

Urological obstructions - cancers, strictures, inflammation
GI obstructions - constipation, cancers, IBD
Neuro causes - MS, GBS
Drugs - anticholinergics
Systemic causes - infection

88
Q

What must you always rule out with acute urinary retention

A

Cauda equina syndrome

Ask about weakness, perineal sensory change, bowel changes

89
Q

what is the hydatid of morgagni

A

remnant of the Müllerian duct

90
Q

what is the main differential diagnosis for testicular torsion

A

epididymo-orchitis

91
Q

management of obstructed kidney

A

ABCDE
Access and bloods - infection focused, cultures, CRP, lactate, calcium (stone)
Urine dip, pregnancy test
Fluid monitoring
CTKUB
JJ stent or nephrostomy to drain infected kidney
Then definitive treatment to remove the stone

92
Q

advice to reduce kidney stones

A

Stay hydrated
Ensure adequate calcium (low calcium causes more calcium oxalate)
Lower sodium - more sodium causes more renal calcium
Reduce red meat - lower uric acid in kidney

93
Q

management of acute retention (lower urinary tract obstruction)

A 
ABCDE
IV access 
Bloods - FBC (malignancy), PSA, Cultures, CRP (infection), U&amp;E (hyperkalaemia and for monitoring), Lactate 
Catheter - 3 way (to help clots come out) - urine sample - MCS
Measure residual volume
Pregnancy test (if female) 
Monitor for diuresis (>1L)
Replace losses if diuresis 
Monitor for electrolyte disturbances
94
Q

management of acute obstructed kidney (upper urinary tract)

A 
ABCDE 
IV access 
Fluid resus 
Bloods - cultures, CRP, U&amp;E, FBC, Calcium, urate, lactate
Urine sample - MCS
Pregnancy test 
Start antibiotics if ?infection 
(later - uteric stent, or nephrostomy)
95
Q

presentation of upper urinary tract obstruction

A 
Pain - loin to groin 
Renal angle tenderness 
Mid ureter - appendicitis 
Infection symptoms 
Haematuria 
Normal to oligouria
96
Q

presentation of retention (lower urinary tract obstruction)

A

Suprapubic pain
Restless
Anuria
Perineal pain

97
Q

causes of acute upper urinary tract obstruction (obstructed kidney)

A

Stones - common - calcium, urate, cystein (renal pathology) - magnesium (recurrent UTIs)
Renal malignancy/ rethroperitoneal malignancy
Infection
Trauma
Renal pathology - glomerulonephritis

98
Q

common sites for renal stones

A

pelvic-uteric junction
over iliac vessels
vesico-uteric junction

99
Q

common investigations to upper and lower urinary tract

A

Upper - CT KUB (stones), CT Urogram (contrast - malignancy, more detail than CT with no contrast)
Lower - Bladder scan (USS), cystoscopy, CT pelvis, MRI prostate

100
Q

Ureteric referred pain

A

Nervous supply to the ureters is delivered via the renal, testicular/ovarian and hypogastric plexuses. Sensory fibres from the ureters enter the spinal cord at T11-L2, with ureteric pain referred to those dermatomal areas.

101
Q

Symptoms of ureteric injury

A 
Insidious onset of:
abdominal pain (T11-L2)
peritonitis 
Ileus 
Cause is always iatrogenic (abdominal surgery, or instrumentation of ureters)
102
Q

Investigation for renal trauma

Example of blunt trauma injuries

A 
CT Urogram (contrast)
Sports injuries, car injuries
103
Q

When should bladder injury be suspected

A

Any pelvic trauma

104
Q

How should a patient with bladder trauma be catheterised

A

By someone senior in urology

105
Q

Signs and symptoms of bladder trauma

Imaging of choice

A 
Abdominal distension 
Peritonism 
Any pelvic trauma/ fracture 
Ileus 
Anuria/ oliguria 
Haematuria 
Perineal scrotal bruising 
Cystogram
106
Q

penis fracture - presentation and management

A

‘snap’ ‘pop’ followed by detumesence
Swelling, bruising
Urgent urology review and surgery to preserve erectile function

107
Q

What is paraphimosis, presentation and management

A 
Tight retraction of foreskin behind glans - swelling of glams and cant be pulled back into place
Presentation: 
Retracted foreskin
Glans odema 
Discolouration (ischemia)
Pain 
Management: reduce swelling:
1. Lidocaine and ice 
2. Sugar 
3. Surgical intervention - cut foreskin 
Always need follow up with urology
108
Q

Cause of paraphimosis and risks associated

A

Catheterised patients whose foreskin has not been put back properly
Risks - ischemic necrosis

109
Q

What is Fournier’s gangrene - causes and presentation

A

Necrotising fasciitits of genitals/ perineum
Causes: being immune compromised, DM, steroids, perineal infection
Presentation: red area, blistering, perineum, extremely painful, creptitis, systemically unwell

110
Q

Management of fournier’s gangrene

A 
ABCDE 
Access
Bloods - infection focussed, cultures, CRP, lactate 
Antibiotics 
On call urologist 
Inform anaesthetists
Inform ITU 
Inform general surgeons
111
Q

What is priapism, what are the types

A

Erection >4 hours - absence of sex stimulation
Low flow - venous occlusion, painful and ridid
High flow - arterial shunt - caused by trauma, vessels rupture and too much blood flows into penis - semi rigid and not painful, can be managed conservatively or if needed artery embolisation
Recurrent - cause sickle cell crisis in penis

112
Q

Management of priapism

A

Need to call on-call urologist
Low flow - emergency. Can ask pt to do exercise - walk up and down stairs (increases venous return), ice packs, needs surgical aspiration, or injection of alpha agonist (vasoconstrictors), or shunt - high chance of ED if gets to this level
High flow - conservative, if doesnt work artery embolisation
Recurrent - hyperhydrate, hyperoxygenate (promotes vasodilation to help sickle occlusion to pass), analgesia

113
Q

Causes of recurrent priapism

A

Haem problems: sickle cell

Neuro problems and valcular tone: DM, spinal cord pathology, anything that can cause nephropathy

114
Q

What cancer should you consider in a pt with left sided varicocele

A

Renal cancer

Left gonadal vein drains into left renal vein

115
Q

what is stauffers syndrome

A

Paraneoplastic syndrome of renal cell carcinoma where you get liver damaged from RCC (raised LFTs)

116
Q

List some congenital kidney diseases - what associated kidney pathology is there

A

Horseshoe kidney - kidneys fuse, cant ascend higher than inferior mesenteric artery - risk of stones and reflux/ kidney damage
Polycystic kidney disease - autosomal dominant and recessive - different types - CKD, HTN - loss of renal tubules from cysts - progressively lose kidney function
Ectopic kidney

117
Q

What is most common renal cancer, what is presentation, what are risk factors

A

Renal cell carcinoma - incidental usually, classic triad of haematuria, mass and loin pain is rare presentation. RFs: any progressive kidney damage/ inflammations: HTN, CKD, smoking, Age, men, Family hx cancer - overlap with HNPCC, cowdens, congenital abnormalities
Transitional cell carcinoma

118
Q

Signs and symptoms of renal cancer

A 
Haematuria 
Flank pain 
Abdominal mass
Left varicocele
Lethargy (anaemia symptoms) 
Night sweats 
Weight loss
Haemoptysis 
consitpation (possibly)
Presence of RFs: smoking, any renal hx (dialysis, CKD, congenital disease), other cancer family hx, HTN 
Paraneoplastic symptoms - symptoms of hypercalcaemia (thirst, groans, bones, moans, stones), liver - abnormal LFTs
119
Q

What is the main important differential diagnosis of kidney stones
List some other important ones and how to differentiate

A

AAA

Peritonitis - pt cant sit still with kidney stones

120
Q

Signs and symptoms of renal stones

A

Loin to groin pain
Unable to stay still (differentiate from peritonitis)
Haematuria
Nausea
Clammy
Tachycardia
Dont usually have loin tenderness unless infection, can have renal angle tenderness - L shape between T12 - muscle next to lumbar vertebra

121
Q

red flags for renal stones (requiring hospital admission)

A

Any signs infection - tachycardia, pyrexial, tachypnea, raised inflammatory markers

122
Q

Types of stones

A 
Calcium oxalate - most common
Uric acid - high protein/ purine diet 
Struvite - Kidney infections
Cystine - genetic 
Calcium phosphate - rare
123
Q

Causes / RFs for renal stones

A

Low calcium
Dehydration
Male - testosterone (increases oxalate)
recurrent UTIs
High sodium diet
High meat diet
Any kidney pathology making stasis more likely - eg horseshoe kidney,
Any medical condition causing more calcium in kidney - hyperparathyroid
Any medications causing calciuria - loop diuretics, steroids, antiepileptics

124
Q

Management of renal stones

A

If no red flags:
Conservative - hydration and sometimes Tamsulosin - most will pass in 3 days (especially if in lower ureter)
If doesnt work can do extracorporeal shockwave lithotripsy
Can also do urteroscopy (go in and fragment and pull out)
If high up and in kidney - can do percutaneous nephrolithotomy
(open nephrolithotomy rarely done)

125
Q

Bladder stones signs and symptoms

A 
Suprapubic pain
Haematuria  
LUTS 
UTI symptoms 
Distended bladder (if obstruction)
Perineal pain (if obstruction)
Anuria or oligouria (only if there is obstruction)
126
Q

What are the common causes of bladder stones

A

Urine stasis - obstruction eg prostate englargment

Catheter - form on tip of catheter

127
Q

What imaging should you do for suspected bladder stones

A

USS

Flexible cystoscopy

128
Q

Management of bladder stones

A

Cystolitholapaxy (scope and stone crusher)
Laser fragmentation
Pneumatic lithotripsy

129
Q

Types of bladder cancer

A

Transitional cell carcinoma (most common)
Adenocarcinoma (uncommon)
Squamous cell carcinoma (uncommon)

130
Q

What are the Risk factors for bladder cancer

A 
Smoking *
Long term catheter *
Aromatic amine exposure - paint, rubber*
HNPCC 
Schistosomiasis 
Recurrent UTIs
Drugs - cyclophosphamide
131
Q

Signs and symptoms of bladder cancer

A

Haematuria - visible/ non-visible
Suprapubic mass
LUTS - obstruction/ retention presentation
Recurrent UTI
Bladder/ abdominal/ loin pain
Other malignancy symptoms: weight loss, night sweats, lethargy

132
Q

Investigations / first line management of bladder cancer

A

Bloods: FBC (Raised WCC), U&E, LFT (renal cancer paraneoplastic), Calcium, CRP (infection screen)
Imaging: USS/ CT, Flex cystoscopy

133
Q

Testicular cancer tumour markers

A

HCG
Alpha feto protein
Lactate dehydrogenase

134
Q

Risk factors for testicular cancer

A

Age: 20-45 years
Cryptorchidism - undescended testicles
HIV

135
Q

Testicular cancer red flags

A 
Age 
Hard testicular lump that you can get above (i.e. it is in the testicle) 
Does not transluminate 
Palpable local lymph nodes (spread) 
Subfertility**
Haemoptysis (spread)
Hepatomegaly (spread)
Hx of cryptorcidism 
HIV
136
Q

Types of testicular tumours

A

Germ cell : Seminoma (most common), teratoma, choriocarcinoma, yolk sac
Non-cerm cell: Sertoli, leydig, lymphoma, mesenchymal

137
Q

Spread of testicular cancer and grades

A

Testicle (I)
Lymph nodes and kidneys (II)
Liver, lungs (III)

138
Q

Signs and symptoms

A 
Any young man with urology/ renal symptoms, flank/ loin pain/ tenderness, examine scrotum for lump/ swelling - remember left gondal vein 
Hard testicular lump 
Painless/ or painful 
Enlarged lymph nodes 
Haemoptysis 
Hepatomegaly 
Weight loss 
Fatigue 
Night sweats
139
Q

History (what to ask) and exam (what to check)

A

Check red flags: Haemoptysis, abdominal pain (liver mets), B symptoms, any other urology (kidney mets), hx of undescended testicles, any suggestion of being immune compromised - HIV, Family hx of cancer
**Subfertility
Differential - infection/ hernia, cyst - penile discharge, recent unprotected sex, worse on movement

140
Q

Investigations for ?testicular cancer and first line management

A

Bloods: FBC (anaemia of malignancy), LFT (mets), U&E (mets), tumour markers (alpha feto protein, HCG, Lactate dehydrogenase), calcium
SAME DAY ULTRASOUND
Urology will then do: CXR (mets), CT
Management will be orchidectomy plus minus chemo/ radiotherapy

141
Q

When should testes descend

A

Term babies - at term

Prem - by 3 months

142
Q

What are the different types/ presentation of undescended testes

A

Palpable / unpalpable
Maldescended (along normal path) / ectopic (somewhere else - abdomen/ thigh)

Feel if palpable testes in inguinal canal - if so, can it be brought down (retractable? - this is a normal variant but needs some monitoring in case it ascends and need orchiopexy - fixing in scrotum), if cant be brought down then needs referral
If unpalpable - referral
If two unpalpable testes - needs referral and karyotyping

143
Q

What are risk of undescended testes

A

Infertility
Cancer
Torsion

144
Q

What is the management of undescended testes

A

Orchiopexy - fixing in the scrotum

145
Q

List common testicular lumps and features

A

Hydrocele - can be primary (not a worry), secondary to malignancy or infection. If communicating with peritoneum may change size with laying up down.
Varicocele - bag of worms, aching, dragging.
Epididymal cyst - fluctuates, can be painful/ painless
Sebaceous scrotal cyst - on skin, not attaches to testicles

146
Q

When should you be concerned about a new testicular lump that appears benign

A

If new left sided - consider renal cancer

147
Q

what testicular lumps fluctuate in size

A

hydrocele

epididymal cyst

148
Q

What is epididymo-orchitis

A

Infection of epididymis and testicle

149
Q

Causes of epididymo-orchitis

A

UTI - ecoli
STI - chlamydia, gonorrhea
Mumps

150
Q

Presentation of epididymo-orchitis and main differential diagnosis

A

Hot, swollen, painful testicle (hemi testicle)
Fever
Penile discharge
DD: testicular torsion

151
Q

What gland should you check in suspected epididymo-orchitis

A

Parotid glands - mumps

152
Q

What should you include in history for epididymo-orchitis

A 
Sexually health history 
Urinary tract 
Trauma - torsion 
Penile discharge 
Recent unprotected sex 
LUTS 
Mumps - recent viral symptoms, swollen glands?
153
Q

Management of epididymo orchitis

A

Rule out torsion
STI screen - urine NAAT chlamydia and gonorrhea
UTI screen - urine sample - MCS
Treat with relevant antibiotics for 10-14 days, follow up with GP

154
Q

Causes of erectile dysfunction

A
  1. Psychogenic:
    Stress, anxiety, depression
  2. Organic:
    CVS - HTN, Diabetes, Hyperlipidaemia, Atherosclerosis
    Neurology - Parkinsons, any spinal cord disease via distruption of parasympathetic/ sympathetic pathways, eg MS
    Endocrine - Diabetes, Hyperprolactinaemia, Low testosterone (drugs eg steroids or adrenal insufficiency), Hypopituitarism
    Drugs - SSRIs, SNRIs, antiHTN, antiCholinergics, steroids
    Anatomical - prostate cancer, pelvic surgery/ radiotherapy/ chemo
155
Q

definition of erectile dysfunction

A

inability to achieve and maintain erection for satisfactory sex

156
Q

investigations for erectile dysfunction

A 
Bloods:
CVS: lipids
Hormones: Testosterone, sex binding globulin, LH, FSH, prolactin, TFT
Glucose 
?PSA
157
Q

Management of erectile dysfunction

A

Psychogeneic - psychosexual therapy
Organic - PDE5 inhibitors, prostaglandin injections, intracavernosal injection, vacuum pump, testosterone replacement, prostheses

158
Q

Questions to ask in hx to identify if psychogenic cause of erectile dysfunction

A

Morning erection
Able to masturbate
Able to achieve erection, if so for how long, pain

159
Q

What questions should you ask to elicit psychosexual history in pt with erectile dysfunction

A

Ask about relationship status, difficulties, anxiety and depression

160
Q

What is penile fracture

A

Rupture of tunica albuginea (sheath that encases corpus cavernosum and spongiosum)

161
Q

what is peyronies disease

A

curvature of the penis caused by firbotic tissue in the tunica albugina

162
Q

what is the cause of peyronies disease

A

unknown but thought to be because of minor trauma to tunica albugina

163
Q

what diseases is peyronies disease associated with

A

Diabetes, high cholesterol, dupetrens contracture, plantar fasciitis

164
Q

presentation of peyronies disease

A

Curvature of penis when erect (not when flaccid)
Penile pain
Erectile dysfunction
Penile shortening
Palpable fibrous plaque along shaft of the penis

165
Q

management of peyronies disease

A

Not for surgery unless plaque is known to be stable
Meds - phentoxyfyline, verapamil
Non meds - vacuum

166
Q

what is phimosis

A

tight foreskin that is unable to retract over glans

167
Q

signs and symptoms of phimosis

A

ballooning of foreskin during micturation
painful sex
infection of foreskin and glans (balanoposthitis)

168
Q

management of phimosis

A

circumcision

169
Q

what is physiological phimosis

A

phimosis in <16 years

170
Q

what is balantis xerotica obliterans

A

Male lichens sclerosis
Inflammatory condition
Hardening of foreskin
Fibrous tight foreskin that is grey/ white

171
Q

what is urethral stricture disease

A

fibrosis within the corpus spongiosum restricting the urethra

172
Q

causes of urethral stricture disease

A

catheter, inflammation (urethritis)

173
Q

what should you ask in a hx for urethral stricture disease

A 
sexual health hx (chronic urethritis)
Incontinence 
Hx of urological surgery 
Hx of catheter use 
Hx of recurrent UTIs
174
Q

what are the symptoms of urethral stricture disease

A

retention
LUTS
UTIs

175
Q

what is the treatment of urethral stricture disease

A

Surgical dilation of urethra

176
Q

Outline the management of UTIs

A

Uncomplicated = females <65, not pregnant
If have 3 of classic symptoms (dysuria, frequency, urgency, suprapubic pain, polyuria, haematuria) then dont dip, can treat empirically. 3 day course of abx.
If have <3 symptoms - dipstick and treat.

Complicated = everyone else: men, pregnant, children
Dont use dipstick - MSU. Treat 7 day course empirically - first line usually nitrofurantoin.

177
Q

Management of BPE

A

Mild - conservative
Moderate - alpha blockers, 5 alpha reductase inhibitors (Finasteride), add on anticholinergic if needed
Severe - surgery - TURP

178
Q

Differentials for pyelonephritis

A

PID, LL pneumonia, cystitis, prostatitis, pelvic pain syndrome

179
Q

How do you identify an obstructed kidney

A

1.Urine output :
Anuria
Oliguria
2. Clinic presentation of urinary obstruction:
stone
malignancy
stricture
3. Size of stone on CTKUB, if >5mm needs to be removed
4. Clinical stability (eg signs of distributive shock/ collapse)
5. Bloods - worsening AKI - signs of kidney deterioration

180
Q

What is the difference between a GnRH agonist and antagonist in regards to androgen deprivation therapy

A

Agonist - not immediate effect - takes days (2-3 days - can get flare of prostate cancer symptoms as a result of this for about 1 week). Has agonist phase (cancer may get worse) and then antagonistic phase. Slower transition of side effects.
Antagonist. Immediate effect. Abrupt onset of side effects.

Phase 3b (13 decks)

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