Urology Flashcards
Define Urolithiasis
Formation of crystalline solutes anywhere along the urinary tracts Renal Stones (in Kidney) or Ureteric
Name 2 stone inhibitors
Magnesium
Citric Acid
State four different types of Renal Stones
Calcium (80%)
Uric Acid (High levels of Purines)
Struvite/Infective
Cystine
Name two causes of high purine levels
High red meat intake
Myeloproliferative Disorders
What is the one type of radiolucent stone
transparent to x ray
Urate
Name the infective organism that most commonly causes Struvite Stones
Proteus
Name the three most common locations for stones to form
PUJ
VUJ
As ureter passes pelvic brim
Give 5 risk factors for stone formation
Age Family History Anatomical Abnormalities (Horseshoe Kidney, Medullary Sponge) Dehydration Crohns
Describe three clinical features of Renal Tract Calculi
Ureteric Colic (Loin to Groin)
Nausea and Vomiting
Haematuria
What is the main differential for flank pain?
AAA
What is the Gold Standard Investigation for Renal Tract Calculi (except in pregnant or young)?
CTKUB WITHOUT contrast
Contrast has a similar density to stone & contrast nephrotxic
What might be present on a CT of an RTC that would indicate infection?
Fat Stranding (ie haziness)
What are Matrix Stones?
Rare stones related to HIV/Hepatitis treatment
Invisible on CT
How is the patient positioned for a CT KUB?
Prone Position
- prone position, because it allows for better assessment of urinary stones at the vesicoureteral junction
Describe the conservative management of RTC
Fluids
Analgesia (Rectal Diclofenac/Paracetamol)
Anti-Emetic
Medical Expulsion Therapy (eg Tamsulosin)
If under 5mm, 68% of stones will pass spontaneously
Name four indications for surgical management of RTCs
Severe Pain > 48hrs
Renal Dysfunction
Previous Renal Disease
Bilateral Stones
Describe three surgical options for RTC
Extracorporeal Shock Wave Lithotripsy
Uteroscopy and Stone Removal (with laser)
Percutaneous Nephrolithotomy (if in kidney)
Name two contraindications to ESWL in RTCs
AAA
Blood Thinners
How would an RTC present if it was close to/in the bladder?
Frequency
Urgency
What happens if an RTC becomes infected?
an infected obstructed system is a urological emergency and patients can die
Describe a 3 step management plan for an Infected Obstructed System
Sepsis 6
Stent under GA or Percutaneous Nephorstomy under LA
HDU/ITU
Define Pyelonephritis
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)
Give 3 risk factors of Pyelonephritis
Halted flow of urine (BPH/Spinal Cord) Retrograde Ascent (Female, Indwelling Catheter) Factors Predisposing (DM, Steroids)
Describe the clinical features of Pyelonephritis
Fever
Loin Pain
Nausea and Vomiting
May have corresponding LUTS
Describe three investigations for Pyelonephritis
Urinalysis
Urine Culture
Renal Ultrasound Scan
How would you manage Pyelonephritis?
Antibiotics
Fluids
Give two complications of Pyelonephritis
Chronic Pyelonephritis and Scarring Emphysematous Pyeonephritis (from gas forming bacteria, gas around kidney, usually in diabetic patients)
Give 3 features of a ‘complex’ Renal Cyst
Thick walls
Calcifications
Risk of Malignancy
Give 4 risk factors for Renal Cysts
Age
Hypertension
Smoking
Gender (PCKD, Von Hippel Lindau)
Give 3 clinical features of Renal Cysts
May be asymptomatic
Flank Pain
Haematuria
What is Bosniak Scoring?
Classifies Renal Cysts from I-V with increasing risk of malignancy
How would you manage Renal Cysts?
Asymptomatic Cysts don’t need further follow up or treatment
Symptomatic - Analgesia and deroofing
Bladder Cancer can be invasive or non-invasive, state three histological subtypes
Transitional Cell Carcinoma
Squamous Cell Carcinoma
Adenocarcinoma
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
Give 3 risk factors for Bladder Cancer
Smoking
2 - Napthylamine
Schistosomiasis
Give 3 clinical presentations of Bladder Cancer
Painless Haematuria
Recurrent UTIs
LUTS
Name 3 investigations for Bladder Cancer
Urgent Cytoscopy
Biopsy via TURBT (Transurethral Resection Bladder Tumour)
CT Staging
Describe the management of non muscle invasive Bladder Cancer
TURBT (Diathermy using cytoscope)
Intravesicle Chemo (Mitomycin C)
Radical Cystectomy
Describe the management of muscle invasive Bladder Cancer
Radical Cystectomy
Neoadjuvant Chemotherapy
How is a Urinary Diversion created surgically?
Ileal Conduit and Urostomy
IE Bladder reconstruction using small bowel
What is the scoring system for BPH called?
International Prostate System Score
What volume of Prostate is considered enlarged?
Over 30ml
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
Describe two types of surgical management for BPH
TURP (using diathermy loop)
Holmum Laser Enucleation of the Prostate (uses heat to dissect)
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
Name the two histological subtypes of Prostate Cancer
Acinar
Ductal
(Adenocarcinomas)
Give 3 risk factors for Prostate Cancer
Age
Ethnicity (Black African and Caribbean)
BRCA1/2
Describe the normal PSA levels
40-49 <2.5
50-59 <3.5
60-69 <4.5
>70 <6.5
Describe the two methods of biopsy for suspected Prostate Cancer
Transperineal
Transrectal
How is Prostate Cancer Graded?
Gleason Grading
How is Prostate Cancer managed?
Asymptomatic and Low Risk- Active Surveillance
High Risk - Radical Treatment (Prostatectomy, Surrounding Tissue and Lymph Nodes) or Radiotherapy
Metastatic - Chemo and Anti Hormonal treatment
Name two Anti-Androgens
LHRH agonists - Goserelin
GnRH Antagonists - Degarelix
Define Prostatitis
Inflammation of the prostate (most common urological disease in men under 50)
Can be acute, chronic or non bacterial
Describe the pathophysiology of Acute Bacterial Prostatitis
Ascending urethral infection
Direct/Lymphatic spread from rectum
Haematogenous spread from sepsis
Describe the pathophysiology of Chronic Bacterial Prostatitis
Inadequately treated Acute Prostatitis
Give 3 risk factors for Prostatitis
Phimosis
Indwelling Catheter
Dysfunctional Bladder
How would a patient with Prostatitis present?
LUTS
Perineal/Suprapubic pain
Urethral Discharge
How would an inflammed postate feel on DRE?
Tender and Boggy
Give 3 investigations for suspected Prostatitis
Urine Culture
STI Check
Transrectal Prostatic Ultrasound
Describe the management of Prostatitis
Prolonged Antibiotics (Quinolones generally have good prostatic penetrance)
Analgesia
Chronic - Tamsulosin/Finasteride
Define Epididymitis
Inflammation of the Epididymis
Generally thought to occur concurrently with Orchitis (inflammation of testes)
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
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)
What is Mumps Orchitis?
Can be uni or bilateral around 4-8d after Parotiditis
Can causes testicular atrophy/infertility
State 3 investigations for Epididymitis
First Void NAAT
Routine Bloods
US Doppler
Describe the management of Epididymitis
Antibiotics (Ciprofloxacin for enteric organisms, Ceftriaxone/Doxycylcine for STI)
Abstinence until antibiotics are completed/symptoms resolved
Define Testicular Torsion
Spermatic cord and its contents twist inside the Tunica Vaginalis, compromising blood supply
Describe the bimodal age distribution of Testicular Torsion
Neonates
Adolescents aged 12-25
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
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
How would you investigate a suspected Testicular Torsion?
Urgent Surgical exploration
Ultrasound doppler
How would you manage Testicular Torsion?
Within 4-6 hours
Cord and Testes are untwisted, both testes are fixed to scrotum (Bilateral Orchidopexy)
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
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
Give 3 risk factors for Testicular Cancer
Cryptorchidism
Klinefelters
Family History
Give 3 Clinical Features for Testicular Cancer
Unilateral Painful Testicular Lump
Weight Loss
If metastasises - Back Pain, Dyspnoea
Give 3 investigations for Testicular Cancer
Tumour Markers (B-HCG, AFP)
Scrotal USS
CT for Staging
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
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)
Define Urethritis
Inflammation of the urethra
Can be Gonococcal or Non Gonococcal
Give 3 clinical features of Urethritis
Dysuria
Penile Irritation
Discharge
Name three investigations for Urethritis
Urethral Swab & Gram Stain
First catch urine and NAAT
STI Screening
Describe the management for Urethritis
1) Gonococcal - IM Ceftriaxone and Azithromycin
Non Gonococcal - Doxycycline
Abstain from sexual activity and contact trace
What is Fournier’s Gangrene?
Necrotising Fasciitis affecting the perineurium
Can be monomicrobial or polymicrobial
Give 3 risk factors for Fourneir’s Gangrene
Alcohol
Diabetes Mellitus
Steroid Use
Give 3 clinical features of Fournier’s Gangrene
Severe Pain (out of proportion to clinical signs)
Crepitus/Necrosis
Sepsis
How would you investigate Fournier’s Gangrene?
Surgical Exploration
How would you manage Fournier’s Gangrene?
Extensive Surgical Debridement (Potentially requiring skin grafts)
Antibiotics
HDU/ITU
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
Give 3 risk factors for Paraphimosis
Phimosis
Indwelling Catheter (and non diplaced foreskin)
Poor Hygiene
Give 3 features of management for Paraphimosis
Analgesia
Consider Circumcision
Reduction
Describe four reduction techniques for Paraphimosis
- Manual pressure and lubricant jelly
- Dextrose soaked gauze
- Dundee Technqiue (puncturing glans)
- Dorsal Slit
Define Priapism
Unwanted painful erection (not associated with sexual desire) lasting longer than four hours
Describe the pathophysiology of Priapism
Blood stays within Corpus Cavernosa
Venous Stasis occurs, which if prolonged can cause fibrosis and impotence
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
Describe the clinical features of Priapism
Ischaemic - Painful and rigid erection
Non Ischaemic - Painless and not fully rigid erection
Describe two investigations for Priapism
Corporeal Blood Gas - to differentiate between ischaemic and non ischaemic
Bloods - to look for underlying cause
How would you manage Priapism
Coproreal Aspiration OR injection of sympathomimetic agent
Shunt insertion
What is a Penile Fracture
Traumatic rupture of Corpus Cavernosa and Tunica Albuginea in an erect penis via blunt trauma
Deviated from axis
How would Penile Fractures present?
Popping sensation with immediate pain/swelling/loss of erection
Aubergine Sign
How would you investigate a Penile Fracture?
Generally a clinial diagnosis
Cavernosonography - locate the rupture site
Retrograde Urethrography if any urethral injury is suspected
Describe the surgical management of Penile Fractures
The penis is degloved, haematoma evacuated and the tear repaired using absorbable sutures
Name two types of Radiotherapy for
Prostate Cancer
External Beam
Brachytherapy (radioactive source directly into the prostate)
Other than bleeding and infection, give two complications of Prostate Cancer Surgery
Impotence (50%) Urinary Incontinence (10%)
Name three types of Renal Cancer
Renal Cell Carcinoma (most common)
Wilm’s Tumour/ Nephroblastoma (paediatric)
Squamous Cell Carcinoma (associated with chronic inflammation - eg Schistosomiasis)
Give 4 Risk Factors for Renal Cell Carcinoma
Smoking Industrial Exposure (eg Lead) Structural Abnormalities (Horseshoe Kidney, ADPCKD) Genetic (Von Hippel Lindau) Obesity
Give three possible presenting features of Renal Cell Carcinoma
Haematuria
Varicocoele (if on left side)
Paraneoplastic (Polycythaemia, Hypertension, Hypercalcaemia)
How would you investigate a suspected Renal Cell Carcinoma?
Urinalysis
Bloods
CT with AND without contrast
May require biopsy
How would you manage localised RCC?
Partial or Radical Nephrectomy (aim to avoid removing adrenal gland - Addisons)
If unfit for surgery - cryotherapy, percutaneous radiofrequency ablation
Surveillance
How would you manage Metastatic RCC
Chemotherapy is NOT effective
Aim for Nephrectomy and Immunotherapy (biologics such as Sunitinib)
