Urology Flashcards
Causes of acute urinary retention
BPH Prostate cancer Urethral strictures Prolapse - cystocele, rectocele, uterine Fibroids Ovarian cyst Bladder cancer Infection - prostatitis, cystitis Anticholinergics Alcohol Constipation Cauda equina syndrome Multiple sclerosis Spinal cord compression
Investigations for acute urinary retention
USS bladder Urinalysis MSU FBC PSA MRI spine - cauda equina/cord compression
Management for acute urinary retention
Catheterise
alpha blocker - tamsulosin
TWOC - trial without catheter
What zone of the prostate enlarges in benign prostatic hyperplasia?
Inner (transitional) zone
Symptoms for benign prostatic hyperplasia
Frequency Urgency Nocturia Hesitancy Poor stream/flow Terminal dribbling Bladder stones Haematuria Overflow incontinence UTI
Investigations for benign prostatic hyperplasia
PSA - rule out prostate cancer
Rectal examination - smooth, symmetrical and soft, maintained central sulcus
Urine dipstick
What conditions is PSA raised in?
BPH Prostate cancer Urinary retention UTI Vigorous exercise
Management for benign prostatic hyperplasia
Lifestyle - avoid caffeine and alcohol, train bladder
Alpha blockers - Tamsulosin
5alpha-reductase inhibitors - Finasteride
Surgery - TURP
How do alpha blockers (tamsulosin) work?
Relaxes smooth muscles
Side effects of tamsulosin
Postural hypotension
Dizziness
Dry mouth
How does 5alpha-reductase inhibitors (finasteride) work?
Block conversion of testosterone to dihydroxysterone
Side effects of finasteride
Impotence
Low libido
Side effects of TURP surgery
Incontinence
Retrograde ejaculation
Erectile dysfunction
Strictures
Risk factors for prostate cancer
Old age Family history - BRCA, HPC-1 Tall Use of steroids Increased testosterone
Symptoms of prostate cancer
Nocturia Hesistency Poor stream Terminal dribble Obstruction Haematuria Erectile dysfunction Weight loss Fatigue Bone pain Anorexia Palpable lymph nodes
Where does prostate cancer metastase to?
Bone
Lung
Liver
Lymph nodes
Investigations for prostate cancer
PSA - elevated
DRE - firm/hard, asymmetrical, irregular
Transrectal USS and biopsy
What grading system is used to grade prostate cancer
Gleason grading system
Name the grades in the grading system used for prostate cancer
Grade 1 = Well differentiated cancer
Grade 2&3 = Moderately differentiated
Grade 4 = Poorly differentiated
Grade 5 = Anaplastic
Management for prostate cancer
Disease confined to prostate - radical prostatectomy, radical radiotherapy, brachytherapy, hormone treatment
Metastatic disease - Hormonal drugs e.g. Goserelin, bilateral orchidectomy
Where does renal cell carcinoma arise from?
Proximal renal tubular epithelium
Symptoms of renal cell carcinoma
Classic TRIAD:
Haematuria
Loin pain
Abdominal mass
Anorexia
Weight loss
Fatigue
Night sweats
Risk factors for renal cell carcinoma
Smoking Obesity Hypertension Long term dialysis Von Hippel-Lindau disease
Investigations for renal cell carcinoma
Increased BP
FBC - polycythaemia from EPO secretion
Chest x-ray “cannon ball” metastases
Treatment for renal cell carcinoma
Partial nephrectomy - 1st line
Radiotherapy + chemotherapy -> Sunitumab, bevacizumab, sorafenib
What is the main type of bladder cancer?
Transition cell carcinoma (90%)
What are other types of bladder cancer?
Squamous cell carcinoma (10%)
Adenocarcinoma
Sarcoma
Small cell
What organism causes squamous cell carcinomas?
Schistosomiasis
Causes of bladder cancer
Smoking
Rubber industry/dyes
Schistosomiasis -> squamous cell carcinomas
Symptoms of bladder cancer
Painless haematuria Recurrent UTI's Voiding irritability Weight loss Bone pain
“Dye factory worker with painless haematuria”
Investigations for bladder cancer
Cystoscopy with biopsy - diagnostic
Urine - microscopy/cytology
CT urogram
Urine dipstick - haematuria
Treatment for bladder cancer
Transurethral resection of a bladder tumour (TURBT)
Chemotherapy - mitomycin + doxorubicin + cisplatin
Radical cystectomy - gold standard
Palliative chemo-radiotherapy
Complications of cystectomy
Sexual and urinary malformation
Urinary retention
Hydronephrosis
Which locations are renal stones commonly located?
Pelvic brim
Pelviuteric junction
Vesicouteric junction
What is the most common type of renal stone?
Calcium oxalate
What are other types of renal stone?
Calcium phosphate
Magnesium ammonium phosphate (struvite)
Urate
Cysteine
Where is urate renal stones seen?
In hyperuricaemia seen in leukaemia
Causes of renal stones
Recurrent UTIs Hypercalcaemia Hyperparathyroidism Sarcoidosis Hyperthyroidism Addison's Cushing's Renal tubular acidosis Medications - Diuretics, antacids, corticosteroids, aspirin Foreign body - stents, catheters
Symptoms of renal stones
Renal colic Loin to groin pain Colicky Nausea and vomiting Cannot lie still Haematuria Fever Rigors
Investigations for renal stones
Urine dipstick - haematuria
FBC, U&E’s
Non-contrast KUB - gold standard
Treatment for renal stones
Diclofenac - risk of CV disease
Antiemetic if nausea and vomiting
Fluids
Stones <5mm = pass spontaneously
Stones >5mm = Medical explusive therapy - tamsulosin, nifedipine
Extracorporeal shockwave lithotripsy - contraindicated in pregnancy
Ureteroscopy in pregnancy
Define pyelonephritis
Infection in the renal pelvis (between the kidney and ureter and parenchyma)
Risk factors for pyelonephritis
Female
Structural urological deformities
Diabetes
Common organisms causing pyelonephritis?
E.coli
Klebsiella
Enterococcus
Pseudomonas
Symptoms of pyelonephritis
High fever Loin to groin pain Haematuria Rigors Dysuria and urinary frequency Pain on bimanual palpation of the renal angle (over kidney)
Investigations for pyelonephritis
Urine dipstick - haematuria, proteinuria, leukocyte esterase, nitrite
CT scan
Ultrasound scan
DMSA scans - shows renal scarring
Management for pyelonephritis
Broad spectrum antibiotics e.g. co-amoxiclav
IV rehydration
Analgesia
Antipyretics
Name the two types of testicular tumours
Seminoma
Teratoma
Which type of testicular tumour is most common in the young (20-30 year olds)?
Teratoma
What age group are seminomas common in?
30-65 years old
Risk factors for testicular tumours
Infant hernia
Infertility
Undescended testes
Signs in testicular tumours
Painless testis lump
Haemospermia
Secondary hydrocele
Dyspnoea - lung mets
What are the tumour markers found in testicular tumours
Alpha fetoprotein
Beta-hCG
Lactate dehydrogenase
What tumour markers are raised in teratomas?
Alpha fetoprotein
Beta-hCG
What tumour markers are raised in seminomas?
Beta-hCG
How does testicular tumours spread to the lymph nodes
Via para-aortic node
Where do testicular tumours metastasise?
Lymphatics
Lung
Liver
Brain
Treatment for testicular tumours
Radical orchiectomy
Chemo/radiotherapy
Define hydrocele
Fluid within the tunica vaginalis
Treatment: Aspiration, surgery
Define varicocele
Dilated veins of pampiniform plexus (testicular veins)
Feels like ‘a bag of worms’
Left side more commonly affected
Dullache, dragging or soreness
What can cause a varicocele
Renal cell carcinoma (RCC) - compression of the renal vein
Define epididymal cyst
Small painless cysts, bilateral
USS for confirmation - milky fluid = spermatocele
Define epididymo-orchitis
Epididymitis = inflammation of epididymis Orchitis = inflammation of teste
Causes of epididymo-orchitis
Chlamydia (in under 35 year olds) E.coli Mumps N. gonorrhoea (in under 35 year olds) TB
Features of epididymo-orchitis
sudden-onset swelling Dysuria Sweats/fever Unilateral Urethral discharge Dragging/heavy sensation
Investigations for epididymo-orchitis
First catch urine sample - chlamydia/gonorrhoea
USS
Urine culture
Treatment for epididymo-orchitis
Doxycycline - Chlamydia
Ceftriaxone - Gonorrhoea
Antibiotics
Analgesia
Define testicular torsion
Acute/sudden onset of unilateral testicular pain
Often triggered by activity (e.g. playing sports)
6 hour window after onset before damage is irreversible
Symptoms of testicular torsion
Sudden onset of pain in one testis Abdominal pain Nausea and vomiting Tender, hot and swollen Abnormal lie - horizontal, rotated and elevated Absent cremasteric reflex
Differential diagnoses for testicular torsion
Epididymo-orchitis - has symptoms of UTI and more gradual onset
Management for testicular torsion
Untwist the testicle
Possible orchiectomy
Define urinary incontinence
Involuntary leakage of urine
Define urge/overactive bladder
Overactivity of the detrusor muscle of the bladder
Suddenly feeling the urge to pass urine
Symptoms of urge/overactive bladder
Urgency
Frequency
Nocturia
Key in door - latchkey incontinence
Causes of urge/overactive bladder
Stroke Parkinson's Dementia Urinary infection Diabetes Diuretics Atrophic vaginitis Urethritis
Define stress incontinence
Weakness of the sphincter muscles
Occurs when coughing, laughing, lifting and exercise
Causes of stress incontinence
Pregnancy
Following birth
Post-menopausal women - low oestrogen - weakening pelvic support
Define mixed incontinence
Combination of urge and stress incontinence
Define overflow incontinence
Due to obstruction to the outflow of urine
Causes of overflow incontinence
Prostate enlargement Anticholinergics Fibroids Pelvic tumours Multiple sclerosis Diabetic neuropathy Spinal cord injuries
Risk factors for incontinence
Increased age Postmenopausal status Increased BMI Previous pregnancies Pelvic organ prolapse Pelvic floor surgery Multiple sclerosis Cognitive impairment and dementia
Investigations for incontinence
Urinalysis - UTI check
Frequency volume chart
Post-void residual bladder volume
Urodynamic testing
Medical management for stress incontinence
Duloxetine - SNRI
Surgical management for stress incontinence
Tension free vaginal tape
Sling
Colposuspension
Non-pharmalogical management for stress incontinence
Pelvic floor exercises
Medical management for urge incontinence
Anticholinergics - Oxybutynin, tolteridone, solifenacin
Mirabegron - Beta3 adrenergic agonist
Botox
Non-pharmacological management for urge incontinence
Bladder training
Side effects of oxybutynin
Blurred vision
Constipation
Retention
Dry mouth
