Urology Flashcards
What is the most common bladder cancer (89-90%) & renal cancer (85%)?
Transitional cell carcinoma - bladder
Renal cell carcinoma (adenocarcinoma) - kidneys
4 layers of the bladder wall
Inner lining - transitional epithelium/ urothelium
2nd - CT lamina propria
3rd - muscularis propria
4th - fatty CT
(Trigone with internal urethral orifice & ureter orifices)
How does bladder cancer present?
Painless haematuria
(Visible/ non)
Recurrent UTIs/ LUTS
May ureteric obstruction
Locally advanced - pelvic pain
Metastatic - systemic
How do we stage bladder can ear?
TNM
Tis - in situ T1 - lamina propria T2 - muscularis propria T3 - perivesical tissues T4 - adjacent local structures
N0 - no nodal involvement
N1 - single node <2cm
N2 - single node 2-5cm/ multiple
N3 - 1+ nodes >5cm
M0 - no metastases
M1
Investigations for bladder cancer
Urgent flexible cystoscope
Suspicious lesion -> rigid cystoscope (GA)
Tumours identified - biopsy, transurethral resection of bladder tumour (TURBT)
Muscle invasive - CT staging
May initially have US/ CT
Management of bladder cancer
T1 - TURBT
Higher risk - intravesical therapy (BCG/ Mitomycin C), radical cystectomy
70% recurrence 3yrs - regular cytology & cystoscopy
Muscle invasive: radical cystectomy, neoadjuvant chemoT (cisplatin) -> urinary diversion (ileal conduit formation, bladder reconstruction segment SB) - regular CT, bloods, B12, folate
Locally advanced/ metastatic - otherwise well ChemoT (cisplatin/ carboplatin)
Investigations BPH
Urinary frequency & volume chart Urinalysis Post void bladder scan DRE PSA USS renal tract Urodynamic studies
Medical & main surgical management BPH
Alpha-adrenoreceptor antagonist e.g. tamsulosin (relax SM)
❌postural hypotension, asthenia, rhinitis, retrograde ejaculation
5alpha- Reductase inhibitors e.g. Finasteride
Prevent conversion testosterone-> DHT (decrease prostatic volume)
Surgery:
TURP
❌TURP syndrome - fluid overload & hyponatremia (confusion, N, agitation, visual changes)
What are prostate cancers >95% & which zone do they occur? How can it be categorised?
Adenocarcinomas
75% peripheral zone
Acinar adenocarcinoma - most common
Ductal adenocarcinoma - metastases faster
Gleason grading of prostate cancer
1 - small, uniform glands
->
5 - only occasional gland formation
Most common growth pattern + 2nd most common
Lowest with cancer = 3+3
Watchful waiting vs active surveillance
WW - symptom guided, definitive therapy deferred & hormonal therapy initiated if symptoms
Generally older with lower life expectancy
AS - low risk disease, monitoring 3 monthly PSA, 6 month-annual DRE, re biopsy 1-3 yearly intervals
Intervening when appropriate
Treatment prostate cancer
Radical prostatectomy
External beam radioT
BrachyT - radioactive seeds
ChemoT - metastatic
Chemo drugs: docetaxel, cabazitaxel
Androgen deprative therapies: LHRH agonists (goserelin), GnRH R agonists (degarelix)
Types of prostatitis
Acute bacterial
Chronic bacterial
Non bacterial
Prostatodynia
Pathophysiology of prostatitis
Ascending urethral infection/ lymphatic spread from rectum/ haematogenous bacterial sepsis
E.coli most common
Enterobacter
Serratia
STIs rare causes
Chronic - inadequately treated acute
Investigations prostatitis
DRE - tender & boggy
Inguinal lymphadenopathy
Urine culture
STI screen
Routine bloods
PSA
Initial therapy failed (quinolone prolonged) - TRUS
Transrectal prostatic USS / CT
A sign for epididymitis
Prehn’s sign - supine, scrotum elevated by examiner
Pain relieved by elevation +ve
What is bell-clapper deformity & what does it put you at risk of?
Horizontal lie, lack normal attachment to tunica vaginalis
Testicular torsion (twisting of spermatic cord within tunica vaginalis)
Clinical features testicular torsion
Sudden onset severe unilateral testicular pain
N&V secondary to pain
Referred abdo pain
Testis high position with horizontal lie
Swollen
Tender
Cremasteric reflex absent
Pain despite elevation of testis (-ve prehn’s sign)
What’s a bilateral orchidopexy & when is it done?
Cord & testis untwisted & both testicals fixed to the scrotum
Prevent testicular torsion (within 4-6hrs)
How are primary testicular tumours categorised?
Germ cell tumours 95%
- seminoma (localised until late)
- non-seminomatous (yolk sac tumours, choriocarcinoma, embryonal carcinoma, teratoma - metastasise early)
Usually malignant
Non-germ cell tumours 5%
- leydig cell tumours -> androgens
- Sertoli cell tumours -> oestrogen
Usually benign
Investigations testicular cancer
Tumour markers:
BetaHcG elevated 60% NSGCTs & 15% seminoma
AFP raised some NSGCTs
LDH tumour volume
Scrotal USS
CT with contrast Chest-abdo-pelvis
No biopsy as could cause seeding of cancer
How can urethritis be classified?
Gonococcal - caused by N.gonorrhoeae
✅ceftriaxone + azithromycin
Non-gonococcal - most often C.trachomatis, M.genitalium, T.vaginalis
✅doxycycline or azithromycin
Urethritis symptoms & investigations
Dysuria
Penile irritation
Discharge
Epididymitis
Reactive arthritis
Gram stain - urethral swabs
First void urine - NA
Mid stream urine dipstick
Sti screening
What is paraphimosis? What causes it & what can it lead to?
Inability to pull forward a retracted foreskin over glans penis -
often due tight constricting band as part of foreskin -> glans oedematous
- > vascular engorgement
- > ischaemia/ infection (Fournier’s gangrene)
✅urgent reduction
What is priapism? Pathophysiology? What can it lead to?
Unwanted painful erection not associated with sexual desire
>4 hrs
Low flow/ Ischaemic priapism - blood stays within corpus cavernosa, prolonged venous stasis, veno-occlusive - associated intracavernosal drug therapy, SCD, haematological disorders, pelvic malignancy - painful & rigid
High flow/ non-ischaemic - unregulated cavernous arterial inflow (more quickly than can be drained) - associated trauma, can triggered stimulation - painless & not fully rigid
Can lead to fibrosis & impotence
Management of priapism
Corporeal aspiration - alleviates 30%
Also obtains corporeal blood gas sample
If no response - intracavernosal injection of sympathomimetic agent e.g. phenylephrine trialled
Surgical: shunt between corpus cavernosa & glans - 70% (can lead to erectile dysfunction)
What is a penile fracture?
Traumatic rupture of corpus cavernosa & tunica albuginea in erect penis
Caused blunt trauma (penis violently deviated away from axis)
Popping sensation
Penile swelling & discolouration - aubergine sign - deviation
May firm immobile haematoma shaft - rolling sign
Investigations & management penile fracture
Clinical diagnosis Bloods Cavernosography- identify rupture site Ultrasonography Urethral injury - retrograde urethography
✅surgical exploration & repair - sutures, haematoma evacuated
Abstinence 6-8weeks
What is Fournier’s gangrene? Signs & management?
Necrotising fasciitis (rapidly spreading necrosis)affects perineum, mortality 20-40%
Monomicrobial/ polymicrobial - Group A streptococcus, C. Perfringes & E.coli
Severe pain out of proportion to signs or pyrexia -> crepitus, skin necrosis, haemorrhagic bullae-> sepsis
✅ Immediate surgical exploration, bloods, CT -> surgical debridement +/- partial/ total orchiectomy, broad ABs, fluid
Define pyelonephritis, what causes it?
Inflammation of the kidney parenchyma & renal pelvis typically due bacterial infection (ascending UTI, blood stream, lymphatics)
Uncomplicated - structurally/ functionally normal urinary tract, non-immunocompromised
80% Escherichia coli
Klebsiella, proteus
Enterococcus faecalis - catheters
Symptoms of pyelonephritis
Classic triad: fever, unilateral loin pain, N&V
Typically over24-48hrs
UTI Symptoms
Haematuria
Costovertebral angle tenderness
- renal USS
- CT non contrast if obstruction suspected
What are urinary tract stones made from?
80% calcium Calcium oxalate 35% Ca phosphate 10% Mixed 35% Struvite Urate (radiolucent) - ⬆️purine red meats/ haematological disorder Cystine - hypocystinuria
Over saturation urine
Where do ureteric stones typically impact?
3 narrowed points
- pelviureteric junction
- crossing pelvic brim where iliac vessels travel across ureter
- vesicoureteric junction
Clinical features of renal tract calculi & investigations
Ureteric colic
Loin to groin
N&V
Haematuria 90%, typically non visible
Urine dip
Bloods (urate, Ca)
Retrieval stone - analysis
⭐️non contrast CT KUB
USS - hydronephrosis
Management renal tract calculi
Majority pass spontaneously
Infection - IV ABs
Obstructive nephropathy/ significant infection - stent insertion/ nephrostomy
Stones do not pass:
Extracorporeal shock wave lithotripsy
Percutaneous nephrolithotomy
Flexible uretero-renoscopy
Recurrent: Stay hydrated Oxalate - avoid high purine foods Ca - PTH levels Urate - avoid high purine Cystine - genetic testing
Types of renal malignancies
Renal cell carcinoma - 85% (adenocarcinoma)
TCC
Nephroblastoma children (Wilm’s tumour)
Squamous CC
Risk factors for renal cancer
Smoking doubles Industrial exposure carinogens Dialysis 30X Hypertension Obesity Anatomical abnormalities (polycystic kidneys, horseshoe kidneys) Genetic disorders
Clinical features of renal cancer
Haematuria - most common presenting complaint
Flank pain
Flank mass
Weight loss
Lethargy
50% incidental on abdo imaging (compression left testicular vein as joins renal vein)
Left masses - left varicocele
Paraneoplastic syndromes - secretions of hormones -> polycthaemia, hypercalcaemia, hypertension, pyrexia
Triad 15% haematuria, flank pain, mass
25% metastases at presentation
Simple vs complex renal cysts
Simple - well defined outline, homogenous, older pts, from renal tubule epithelium
Complex - thick walls/ septations/ calcification/ heterogenous enhancement on imaging, all risk malignancy
Risk factors for renal cysts & clinical features
Older Smoking Hypertension Male Genetic conditions - PKD, tuberous sclerosis
Often found incidentally abdo imagin Usually asymptomatic Flank pain Haematuria Uncontrolled hypertension - PKD Flank mass - PKD
Ct/ mri IV contrast
Storage vs voiding symptoms LUTs
Storage - when bladder should otherwise be storing urine
Urgency, frequency, nocturia, urgency incontinence
Voiding - bladder outlet obstruction
Hesitancy, intermittency, straining, terminal dribbling, incomplete emptying
Pharmacological management of LUTs
Conservative insufficient
Anticholinergics e.g. oxybutynin, tolterodine
OAB
Alpha blockers e.g. alfuzosin. Tamsulosin
5 alpha reductase inhibitors e.g. finasteride
BPH
Loop diuretics, desmopressin
Prevent nocturia
6 Ss for describing a scrotal lump & acronym for palpating
Site Size Shape Symmetry Skin changes Scars
CAMPFIRE Consistency Attachments Mobility Pulsation Fluctuation Irreducibility Regional LNs Edge (Temp, transillumination, tenderness)
Differentials for scrotal lumps
Extra-testicular:
Hydrocoele - collection peritoneal fluid between parietal & visceral layers of tunica vaginalis
Painless, transilluminate, fluctuant
Varicocele - abnormal dilation pampiniform plexus
May disappear lie flat, 90% left (renal vein)
Epididymal cysts - smooth, fluctuant nodule, transilluminate
Epididymitis- pain, swelling, erythematous, fever
Inguinal hernia
Testicular:
Tumours - cancer firm, irregular, painless
Orchitis - inflammation testis, mumps
Torsion - severe pain, N&V
Benign lesions - leydig cell tumours, Sertoli cell tumours, lipomas, fibromas, lysts
Causes of acute & chronic urinary retention
BPH Urethral strictures Prostate cancer UTIs -> urethral sphincter close Constipation Severe pain Meds (anti-muscarinics, spinal/ epidural anaesthesia) Neurological (peripheral neuropathy, iatrogenic nerve damage pelvic surgery, UMNd, bladder sphincter dysinergy)
Chronic: BPH Urethra strictures Prostate cancer Pelvic prolapse (cystocele, rectocele, uterine prolapse) Pelvic masses (large fibroids) Neurological
What is high pressure urinary retention? As well as a post void bedside bladder scan, routine bloods & CSU (catheterised specimen of urine) what other investigation is required for high pressure cases? Treatment?
Urinary retention causing high intra-vesicular pressures that anti reflux mechanism of bladder & ureters is overcome & backs up into upper renal tract
-> hydroureter & hydronephrosis
(Impairing kidneys clearance levels)
Confirmed USS - assess hydronephrosis
Follow up subsequent weeks
✅keep catheters in situ until definitive management can be arranged due risk further episodes leading AKI -> renal scaring & CKD
- no evidence renal impairment TWOC
What do patients with large retention volume (>1000mls - only seen acute on chronic) need to be monitored post catheterisation for?
Post obstructive diuresis
Kidneys can often over diurese due to loss of medullary conc grad -> worsening AKI
Monitor Urine output over following 24hrs
> 200mls/ hr - should have 50% of urine output replaced IV fluids
Which major vessel provides the arterial supply to the bladder?
Internal iliac artery
Causes of haematuria
Urological UTI Urothelial carcinoma Stone disease Adenocarcinoma prostate BPH Trauma/ recent surgery Radiation cystitis Parasitic - schistosomiasis
Non-urological:
Medical (cyclophosphamide, naproxen, nitrofurantoin)
Pseudohaematuria
Urological referral criteria for haematuria
For specialist haematuria investigation:
Aged >45yrs with any
- unexplained visible H without UTI
- visible H persists or recurs after successful treatment UTI
Aged >60yrs with any
- unexplained non visible H & dysuria or raised WCC
Asymptomatic Non visible H 2/3 tests
Causes of urinary incontinence & treatment options
Stress ✅PFMT -> duloxetine (serotonin- NA reuptake inhibitor), tension free vaginal tape, open colposuspension, intramural bulking agents, artificial urinary sphincter
Urge (OAB/ detrusor hyperactivity - neurogenic/ infection/ malignancy/ idiopathic/ cholinesterase inhibitors)
✅anti muscarinics e.g. oxybutynin/ tolterodine, bladder training, botulinum toxin A injections, percutaneous sacral N stimulation, augmentation cystoplasty, urinary diversion via ileal conduit
Mixed (stress & urge)
Overflow (complication chronic urinary retention)
Continuous (constant leaking - anatomical abnormality e.g. ectopic ureter/ bladder fistulae severe overflow IC)
