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APhase 3b flashcards > Urology > Flashcards

Urology Flashcards

1
Q

Benign prostate hyperplasia pathophysiology

A

Benign proliferation of the musculofibrous and glandular layers of the prostate to give an increase in stromal:epithhelial ratio of tissue.
Static - increase tissue bulk.
Dynamic- increase prostates smooth muscle tone (alpha receptor mediated).

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2
Q

Stereotypical patient with BPH

A

👨🏻‍🦳

Over 50, male, Hx of smoking.

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3
Q

S+S of benign prostate hyperplasia

A 
Lower urinary tract symptoms (LUTS):
Frequency (passing small or large amounts each time)
Urgency + incontinence
Hesitancy, poor stream and dribbling.
Feeling of non-complete void

O/E:
Palpate bladder - retention, outflow obstruction?
DRE - assess prostate size, texture, couture. (red flag = firm, nodular and no clear median sulcus)

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4
Q

Investigating benign prostate hyperplasia

A 
In primary care : 
Urine dipstick
MSU for mc+s
PSA
Urinary frequency and volume chart

In secondary care:
USS of bladder

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5
Q

Assessment tool for BPH

A

International Prostate Symptom Score

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6
Q

Management for benign prostate hyperplasia

A

Lifestyle advice - avoid caffeine, take diuretics early evening to avoid nocturia.
Alpha blocker - tamsulosin, doxazosin.
5-alpha reductase inhibitor - finasteride.
Surgery - prostatectomy (over 80g) or TURP (under 80g).

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7
Q

Which BPH patients get surgery?

A

Refractive to medical treatment
Recurrent gross haematuria
Recurrent UTI
Retention

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8
Q

1) TURP

2) TUIP

A

1) Transurethral resection of the prostate.

2) Transurethral incision of the prostate.

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9
Q

When to refer a man with LUTS to specialist?

A

LUTS +

  • recurrent or persistent UTIs.
  • urine retention.
  • renal impairment with suspected cause due to urine tract.
  • suspected urological caner.
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10
Q

Complications to council a patient with BPH on…

A
  • Sexual dysfunction from 5-alpha reductase inhibitors.
  • Acute urinary retention
  • Recurrent UTIs
  • Look out for blood in urine
  • TURP syndrome from surgery
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11
Q

TURP syndrome

A

Large volumes of fluid absorbed though venous sinus.
Fluid overload + electrolyte imbalance esp hyponatraemia!
Hypothermia
Hypertension
Bradycardia
Headache, confusion, nausea and vomiting, restless.

Can present within minutes or 24hrs post-op.
Mx = A-E, arterial line monitoring, hypertonic saline IV.

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12
Q

Histology of prostate cancer

A

Adenocarcinomas, multi-focal.

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13
Q

RFx for prostate cancer

A 
Older age (80% of over 80yrs have evidence of prostate Ca).
High testosterone.
Black ethnicity
FHx - HOXB13, BRCA1/2
Obesity
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14
Q

Prognosis of prostate cancer

A

85% survive 5yrs or more 😁

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15
Q

Common sites for prostate cancer to metastasis

A

Bones

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16
Q

Complications of prostate cancer

A

Metastasis - pathological fractures, spinal cord compression.
LUTS

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17
Q

Presentation of prostate cancer

A 
Lower back pain
Erectile dysfunction
haematuria
Anorexia and weight loss
Lethargy
LUTS - hesitancy, incomplete void, frequency, urgency, nocturia.

O/E:
HARD AND NODULAR PROSTATE with ill defined sulcus, seems immobile/adhesion to surrounding tissue.

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18
Q

PSA

A

Prostate-specific antigen,
Protein found in normal and cancerous cells. Liquefy semen.
Increased in prostate cancer, BPH, UTI, prostatitis.

No screening programme but can be given to a man on request.

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19
Q

Level of PSA which is concerning?

A

Over 3nanogram/mL or high in man 50-69 refer for 2 week wait.

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20
Q

Investigating suspected prostate cancer

A

Main 3:
DRE
PSA
Transrectal US + biopsy

Others:
Prostate cancer antigen 3 in urine.
Testosterone, FBC and LFT
mpMRI
Isotope bone scan
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21
Q

Management of prostate cancer

A

Depends on stage.
Localised = active surveillance or radical prostatectomy.
Locally advanced = Radical prostatectomy, radio or brachy - therapy.
Advanced = androgen deprivation therapy, pallative

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22
Q

Risk stratification in prostate cancer

A

Gleason score (from biopsy) + PSA + clinical stage (TNM).

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23
Q

Components of active surveillance

A

PSA 6monthly
DRE 12monthly
Biopsy 12monthly

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24
Q

Androgen deprivation therapy

A

Castration can aid metastatic disease.
Surgical castration
or
Medical (androgen deprivation therapy): luteinising hormone releasing hormone against // GnRH analogue + tamoxifen + flutamide.

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25
Q

3 sites for renal calculi to obstruct

A

Vesico-ureteric junction.
Mid-ureter where is crosses iliac vessels.
Pelvi-ureteric junction

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26
Q

Composition of renal calculi

A

80% calcium stones -either calcium oxalate, calcium phosphate.

Others:
Struvite (magnesium, ammonium, phosphate from bacterial infection)
Uric acid (low urine pH)
Cystine (genetic cause).

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27
Q

Risk factos for renal calculi

A

FHx
Obesity

Dehydration
Dudes (males)
Dietary = excess animal protein
Drugs = vitamin D supplements
Diseases = hyperparathyroidism, gout, HTN
Deformities = anatomical abnormalities in urine tract (horseshoe kidney, ureteric stricture)

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28
Q

S+S of renal calculi

A

Renal colic = sudden onset severe unilateral pain in the loin area and radiated to groin/labia area.
Pain can occur in spasms/intervals but usually constant.
Nausea, vomiting, haematuria.
Hx of dysuria, frequency or straining.

O/E - restless (peritonitis pts are still), pyrexial.

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29
Q

Investigating renal calculi

A

Urine dipstick = ++RBC
MSU for ms+c
FBC, CRP, U+Es, serum calcium, phosphate, urate
Pregnancy test in females

Imaging:
Non-contrast CT, KUD Xray

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30
Q

Management of renal calculi

A

1) Stabilise patient. Analgesia = diclofenac +/- anti-emetic e.g. metoclopramide. Good fluid intake.
2) May pass spontaneously if <5mm
3) Medical expulsion therapy = alpha blocker (tamsulosin) or CCB.
4) Extracorporeal shock wave lithotripsy.
5) Ureteroscopy with laser to break up stone if >1cm
6) Surgical nephrolithotomy or nephrostomy.

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31
Q

Differentials for severe, sudden loin to groin area pain

A

Ruptured AAA
UTI
Ovarian cyst rupture
Appendicitis

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32
Q

If renal colic pain is acute and super really bad what can you give?

A

IM or rectal diclofenac.

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33
Q

What is nephrolithiasus

A

Presence of renal calculi in urinary system.

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34
Q

Male and female causes of acute urinary retention

A

Male:
BPH, prostate cancer, prostatitis.

Female:
Vaginal prolapse, uterine fibroids, gynae malignancy,

Both:
Bilharzia, Herpes simplex, bladder cancer, CRC, anticholingeric drugs, neurological disease (MS, Guillain-Barre syndrome, caudal equina).

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35
Q

Investigating and managing acute urinary retention

A

MSU ms+c
Urine dipstick
Bladder USS

Mx = immediate bladder decompression with catheter.

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36
Q

Types of haematuria and which are clinically relevant?

A 
Frank = visible.
Microscopic = picked up on urine dipstick or urine MC+S has >2red cells/mm2.

All frank haematurias need further investigation and all symptomatic microscopic haematurais

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37
Q

Causes of haematuria

A

Most common = BPH, urinary calculi, transitional cell carcinoma of bladder, UTI, urethritis, prostate cancer.

Vascular - sickle cell disease, coagulopathy.
Infective - glomerulonephritis, schistosomiasis, cystitis, prostatitis, urethritis.
Trauma - catheter, post retention catheterisation.
Autoimmune - Goodpasture’s syndrome, Henoch-Schonlein purpura, IgA nephropathy.
Iatrogenic - anticoagulation therapy e.g. warfarin, NSAIDs.
Neoplastic - Wilm’s tumour, renal cell carcinoma, transitional cell carcinoma of bladder.
Congenital - sickle cell disease.

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38
Q

Investigating haematuria

A 
Urine dipstick
Urine MC+S
DRE - ?BPH
FBC, clotting profile, PT/INR, PSA, creatinine, eGFR, U+E.
KUB USS
Flexible cystoscopy.
Non-contrast CT.
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39
Q

Pathophysiology behind a varicocele

A

Scrotal swelling formed from dilated veins and venous reflux in the pampiniform plexus in the spermatic cord.

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40
Q

S+S of varicocele

A 
Asymptomatic.
ON LEFT SIDE!!! (esp with renal cell carcinoma)
BAG OF WORMS SCROTUM 🐛 
Heavyness and mass in scrotum
Infertility

O/E:
Lower hanging scrotum on side of varicocele.
Small testis.
Valsalva manoeuvre and standing up increased dilation and vessels so that they can be palpated and visualised.

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41
Q

Who gets varicoceles?

A

Tall, thin men.

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42
Q

Ix and Mx for varicocele

A

Ix = clinical diagnosis, can use US and colour Doppler US.

Mx = Reassurance, observation, surgical repair (not routine!).

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43
Q

A man comes and requests a PSA test, what are you going to discuss?

A
  • Can be high for reasons other than prostate cancer.
  • If it is high, you will go on to have further investigations which may be unnecessary and have complications e.g. infection.
  • Having prostate cancer will not necessarily kill you or interrupt your life. May be no need to act on the result.
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44
Q

Hydrocele

A

Collection of fluid in the laters of the tunica vaginalis surrounding testis and spermatic cord. PAINLESS, can get ‘above’ O/E. More common in infants/babies and resolve on their own. Surgery rare.
Ix = transilluminate.

45
Q

Testicular torsion

A

Twisting of testicle, constricting spermatic cord and its content (vasculature, nerves). Leads to ischaemia and necrosis if left untreated.

46
Q

S+S of testicular torsion

A 
LEFT
Sudden onset.
Swelling
Pain in scrotum - can ease during necrosis so not a good sign!
Abdo pain
Nausea and vomiting

O/E:
Red, hot, swollen testis, retracted upwards.
Lifting of testis increases pain.
‘bell-clapper’ position of testis.
Absent Cremasteric reflex. (L1/L2 spinal nerve).

Occurs commonly during sport

47
Q

Ix and Mx for testicular torsion

A

US with Colour Doppler.

if suspicion is high, treat first and investigate later.

Mx = emergency scrotal exploration, orchidectomy + bilateral fixation (orchidoplexy)

48
Q

If testicular pain eases on lifting testis what is the differential? and if the pain doesn’t ease….?

A

Eases on lifting = epididymitis.

No ease = testicular torsion.

49
Q

Acute epididymo-orchitis

A

Pain, swelling and inflammation of epididymitis +/- testicular inflammation. Symptoms develop over days usually but within 6weeks.

50
Q

Common organisms for epididymo-orchitis

A

Under 35yrs/sexually active = Chlamydia trachomatis, Neisseria gonorrhoeae.
Over 35yrs = E.coli.

51
Q

S+S of epididymo-orchitis

A 
Unilateral scrotal pain
Unilateral scrotal swelling
LUTS  - frequency.
Urethral discharge
Hx of STI
52
Q

Ix and Mx for epididymo-orchitis

A

RULE OUT TESTICULAR TORSION!
Ix = colour Doppler US, Gram stained smear of urethral discharge. First catch urine for STI NAAT + PCR, MSU for mc+s, urine dipstick.

Rx = Analgesia e.g. paracetamol, supportive underwear. ABx for infection (ceftriaxone + doxycycline)

53
Q

Common bacteria in prostatits

A

E.coli, Pseudomonas aeruginosa.

54
Q

Risk factors for prostatitis

A

UTI, catheters, STI

55
Q

S+S of prostatits

A

Pain on ejaculation.
Pain between testis and rectum (perineum).
LUTS (frequency, urgency, hesitancy).
Fever, malaias, myalgia, artralgia.

O/E:
Check for distended bladder and DRE.
In acute prostatitis: DRE IS VERY PAINFUL! boggy, tender, enlarged prostate on DRE, hot to touch, urethral discharge, inguinal lymphadenopathy.

56
Q

Prostate pain syndrome

A

Chronic prostatitis and no identifiable causative organism.

57
Q

Ix and Mx for acute prostatitis

A 
If septic = SEPSIS 6!! 🐃🐂🐄 (Buffalo)
Ix = 
FBC, U+E, creatinine.
Urine dipstick
Mid-stream urine sample mc+s.
PSA - will be raised and with Rx will go down.

Mx = ABx e.g. Ciprofloxacin. Can give alpha-blocker e.g. tamsulosin to aid symptoms.
Adequate hydration, paracetamol analgesia.

58
Q

Histology of bladder cancers

A

Transitional cell carcinomas // urothelial carcinoma.
Squamous cell carcinoma
RARE adenocarcinoma

59
Q

Risk factors for bladder cancer

A

Smoking
Exposure to aromatic amines, dye, rubber.
Radiation
Male

60
Q

S+S of bladder cancer

A

PAINLESS HAEMATURIA
Weight loss
Dysuria
Supra-pubic mass
Urinary retention (clots/cancer block urethra) use 3 way catheter and bladder scan.
Anaemic - subconjunctival pallor, angular stomatitis.

61
Q

Risk factor for squamous cell carcinoma of bladder

A

Schistosomiasis
Cyclophosphamide
BCG treatment for a transitional carcinoma

62
Q

When to refer someone to specialist investigations for ?bladder cancer

A

2 week wait if:

  • 45yrs or over and unexplainable haematuria or haematuria which persists despite successful UTI treatment.
  • 60yrs or over and unexplainable non-visible haematuria with dysuria or raised WCC.
63
Q

When to refer for 2 week wait in ?renal cancer

A

If over 45yrs and have:

  • unexplainable visible haematuria with no UTI.
  • visible haematuria which persists/reoccurs after successful UTI treatment.
64
Q

When to refer for ?prostate cancer 2 week wait?

A

DRE results = feels malignant.

PSA level is above normal for age range.

65
Q

Investigations for ?bladder cancer

A

Exclude infection with urine dipstick.
Exclude stones with CT KUb non-contrast.

Ix:
Cystoscopy.
CT/MRI esp for staging.

Diagnostic:
Flexible cystoscopy + transurethral resection of bladder tumour.

66
Q

Management of bladder cancer

A

Dependent on stage.

Not late stages: Transurethral resection of bladder tumours. Mitocmyin C drug course.
If advance: radical cystectomy or radical chemotherapy

67
Q

Common organism in UTI

A

E.coli

Enterobacteria e.g. Klebsiella.

68
Q

Types of UTI

A 
Uncomplicated = typical pathogen, normal urinary tract and kidney function, no predisposing co-morbidities.
Complicated = anatomical, functional or pharmacological predisposition to a persistent, recurrent or refractive to treatment UTI.

Upper UTI = pyelonephritis.
Lower UTI = cystitis, prostatitis, urethritis.

Recurrent = 2 or more episodes in 6 months or 3 or more episodes in a year.

69
Q

RFx for UTIs

A 
Being female
Spermicide use
DM
Pregnancy
Immunosuppressed e.g. chemotherapy.
Malformation in urinary tract
Obstruction e.g. BPH
Renal calculi.
70
Q

Bacteriuria

A

Presence of bacteria in urine with or without symptoms.

71
Q

S+S of a UTI

A 
Urinary frequency, urgency, incontinence, nocturia.
Dysuria
Haematuria
Cloudy and foul-smelling urine.
Supra-pubic pain
Pyrexia
In elderly = confusion.
72
Q

Investigating a UTi

A

Urine dipstick = +nitrite, +leukocytes, +RBC
Mid-stream urine sample for MC+S
Pregnancy test

73
Q

Pyelonephritis features (rather than lower UTI)

A

Loin pain
Fever
Rigors

74
Q

Red flag symptoms in ?UTI patient

A

Haematuria, loin pain, riggers, nausea and vomiting, altered mental state –> SEPSIS?

75
Q

Management of UTI

A

Females:
Nitrofurantoin or trimethoprim (both oral and for 3 days).
Nitrofurantoin can be taken during pregnancy.
2nd line = pivmecillinam if not pregnant or amoxicillin if pregnant.

Males:
Trimethoprim or nitrofurantoin (both oral and for 7 days).

76
Q

ABx in prostatitis

A

Ciprofloxacin.

77
Q

Extra investigations for male under 45yrs UTI

A

KUB USS

KUB CT scan

78
Q

Types of testicular cancers

A

Most are germ cell cancers:

  • Seminoma
  • Teratoma
  • Embryonal carcinoma
  • Yolk sac tumour etc etc

Other types include
Non-germ cell e.g. Leydig cell tumour, gonadoblastoma.

79
Q

Age of testicular cancer patient

A

15-40

80
Q

Risk factors for testicular cancer

A

Male infertility
Klinefelter’s syndrome
Maldescent of the testis
FHx

81
Q

S+S of testicular cancer

A

Mass on one testis - usually painless

‘Dragging sensation’

82
Q

Ix and Mx for testicular cancer

A

Ix = ultrasound scab, biopsy histology is done after inguinal orchidectomy.
Tumour markers = beta-hCG, alpha-fetoprotein, lactate dehydrogenase, non are very specific.
Mx = orchidectomy.

83
Q

Definition of erectile dysfunction

A

Persistent inability to attain or maintain an erection sufficient to permit satisfactory sexual intercourse.

84
Q

Causes of erectile dysfunction (organic)

A 
MS, Parkinsons, spinal cord trauma.
CVD, HTN
DM
Penile cancer
Hypospadias
Major surgery to pelvis or ureter.
Drugs = tricyclic antidepressants, spironolactone, beta-blockers, finasteride, corticosteroids and many more 🚮
85
Q

Management of erectile dysfunction

A

In primary care: phosphhodiesterase-5 inhibitor e.g. Sildenafil, tadalafil.
Lifestyle advice - stop smoking, reduce alcohol, increase exercise, medicine review, reduce cycling, information and education.

86
Q

What is cryptorchidism

A

Maldescent of the testis.

87
Q

Volume of urine drained in acute urine retention

A

600ml-1L.

88
Q

Zone of prostate cancer and zone of BPH

A

BPH = transitional zone.

Prostate Ca = peripheral zone.

89
Q

Lymph nodes where prostate cancer initially spreads to

A

Obturator nodes

90
Q

Innervation for urinary storage and voiding.

A 
Storage = sympathetic
Voiding = parasympathetic
91
Q

4 types of incontinence and pathology

A
  • Stress - sphincter weakness e.g. traumatic labour. Leak on cough, laugh, sneeze. Rx with pelvic floor exercises.
  • Urge - detrusor overactivity. ‘Irritable bladder syndrome’. Urgency of needing to void. Rx with bladder retraining, acetylcholinergic/anti-muscarinic agents.
  • Overflow - blockage to urine flow e.g. BPH. Bladder distension, dysuria.
  • Mixed
  • Neurological - MS, dementia, brainstem stroke.
92
Q

Causes of bilateral and unilateral hydronephrosis

A 
Bilateral:
S – stenosis of the urethra
U – urethral valve
P – prostatic enlargement
E – Extensive bladder tumour
R – retroperitoneal fibrosis 
Unilateral:
P – Pelvic-ureteric obstruction (congenital or acquired)
A – Abnormal renal vessels 
C – Calculi
T – Tumours of the renal pelvis
93
Q

Causes of chronic urinary retention

A

BPH
Prostate cancer
Drugs – antispasmodics, antihistamines, anticholinergics, BoTox (used to treat overactive bladder)
Iatrogenic – following local surgery
Urethral strictures – infective or traumatic
Neurological – MS, diabetic neuropathy, stroke

94
Q

Side effects of

  1. alpha blocker
  2. 5 alpha reductase inhibitor
A
  1. Postural hypotension, dizziness.

2. Erectile dysfunction, low libido, gynaecomastia.

95
Q

Medical treatment for erectile dysfunction. Who can not take them and what are some side effects

A

5 phosphodiesterase inhibitors e.g. Sildenafil.
Can’t be given to people on nitrogen drugs e.g angina.
Those taking alpha blockers for BPH.
SEs = headache, flushing, dizziness.

96
Q

4 reasons for circumsion on NHS

A
  • Phimosis - foreskin cannot be retracted from the glans
  • Recurrent balanitis
  • Balanitis xerotica obliterans
  • Paraphimosis – where the foreskin can NOT be pulled over the glans.
97
Q

Benefits of circumsion

A

Reduce risk of penile cancer
Reduce risk of UTI
Reduce STI risk

98
Q

who cant have anticholinergics for urgency incontinence?

A

acute glaucoma

99
Q

SE of anticholinergics

A 
tachycardia
dizzy
dry mouth
retention
constipation
100
Q

where is pain felt in ureteric obstruction and why

A

innervated by T12 - L2, pain in scrotum, front thigh, lower back.

101
Q

How to make someone pee after cystectomy

A

Ileal conduit + urostomy/urinary diversion.
Bladder reconstruction
Continent urinary diversion.

102
Q

Complications of urostomy

A

Immediate - bleeding, ischaemic
Early - necrosis, infection, obstructed, retraction.
Late - parasternal hernia, prolapse, retraction, varicies.

103
Q

Why does renal cell carcinoma cause left varicocele

A

Testicular vein in left comes off renal vein, closer to kidney, easier to compress.
Testicular vein comes off IVC in right so harder to compress.

104
Q

Why CXR for ?renal cell carcinoma

A

Cannon-ball mets

105
Q

What electrolyte imbalance is seen in renal cell carcinoma?

A

Secrete parathyroid hormone related protein, causes calcium release from bone –> hypercalcaemia.

106
Q

Sign O/E for pyelonephritis

A

Renal angle tenderness.

On the back, full fist percussion/punch where kidney is.

107
Q

3 zones of prostate and which are affected by BPH and cancer?

A

Central, transition, peripheral zones.
Cancer = peripheral
BPH = transition.

108
Q

Venous drainage of prostate

A

Batson’s plexus

APhase 3b flashcards (16 decks)

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