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CP3 Surgery > Urology > Flashcards

Urology Flashcards

1
Q

What are the symptoms of Lower UTI?

A 
Frequency and nocturia 
Dysuria 
Urgency 
Haematuria 
Smelly urine 
Suprapubic pain / tenderness
Stranguary: painful, frequent urination of small volume, expelled only by straining despite a severe sense of urgency
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2
Q

What are the predisposing factors to lower UTI?

A

Female sex: due to short urethra
pregnancy: dip during and treat due to risk of premature Labour
Menopause
Obstruction / tract malformation
Catheter: always infected, do not investigate unless symptomatic
Diabetes: glycosuria, reduced host defences

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3
Q

What investigations should be done for a patient with a suspected infection?

A

Urine dipstick: double positive: nitrates and leucocytes
Midstream urine MCS (confirms diagnosis if >10^5 pathogenic organisms/ml
Urine dip is very often double positive in a hospital population

MSU
?ask about discharge

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4
Q

What are the causes of sterile pyuria? (raised WBC but no organisms grown)

A 
Recently treated UTI
Appendicitis
TB
chlamydia
Bladder cancer
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5
Q

What circumstances should prompt further investigations for UTI?

A

Males, children, treatment resistant UTI, recurrent UTI, if pyelonephritis suspected or if an unusual organism is grown:

USS: to assess for renal scarring or obstruction (hydronephrosis)
CT/IV urography: to exclude small stones, tumours or bladder diverticula

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6
Q

What is the most common organism causing UTI?

A

E.Coli (75%)

Others: Proteus, Staphylococcus, streptococcus, Klebsiella, Pseudomonas

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7
Q

What is the treatment of UTI?

A

Advice: drink plenty of fluids and urinate often
Empirical: Nitrofurantoin 100mg BD for 3 days (review when MCS comes back)

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8
Q

What is the treatment of pyelonephritis?

A

IV tazocin 4.5g TDS )review when MCS comes back)

therapy continued for at least 7 days

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9
Q

How is a UTI / asymptomatic bacteriuria in pregnant women treated?

A

Treat - follow local guideline / speak to microbiology

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10
Q

How is recurrent UTI managed?

A

Advice on high fluid intake, frequent voiding (after sex)
avoidance of spermicidal jellies and avoidance of constipation

If this fails, prophylaxis with trimethoprim / nitrofurantoin at night may be started

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11
Q

What are the treatment outcomes for UTIs

A

Eradication: no further infection
Relapse: recurrence of the same infection within 7 days due to inadequate eradication of infection
Reinfection: bacteriuria absent for at least 14 days, but recurs due to susceptible tract

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12
Q

What does acute ureteric obstruction cause?

A

Enlargement of the urinary tract, superior to the obstruction
Dilation of the renal pelvis is known as hydronephrosis

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13
Q

What are the causes of ureteric obstruction?

A

Luminal, mural, extramural

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14
Q

What are the luminal causes of ureteric obstruction?

A 
Calculus (stone)
sloughed renal papilla (in diabetes / long term NSAID use)
Blood clot 
TCC of the renal pelvis / ureter 
Bladder tumour
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15
Q

What are the mural causes of ureteric obstruction?

A 
Ureteric stricture (TB, post-calculus, post-surgery) 
Congenital pelviureteric neuromuscular dysfunction 
Congenital megaureter
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16
Q

What are the extramural causes of ureteric obstruction?

A

Pelviureteric compression (due to external tumours, diverticulitis, AAA, retroperitoneal fibrosis)

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17
Q

What are the symptoms / signs of ureteric obstruction?

A

Varying loin pain to groin pain - greater when urine volume increases (alcohol / diuretics)

Anuria (if complete bilateral obstruction) / polyuria (if partial blockage causes renal impairment) due to post-renal AKI

Loin tenderness and palpable hydrfonephrotic kidney

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18
Q

What investigations should be done for ureteric obstruction?

A

Urine MCS
USS to confirm upper tract dilation
Abdominal plain film
CT to outline detailed cause of obstruction

Retrograde pyelogram may be used at cystoscopy to further outline ureteric abnormalities (e.g. TCC)

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19
Q

What is the management of ureteric obstruction?

A

Analgesia - rectal diclofenac
Nephrostomy may be required to decompress the pelvicalyceal system, preserving the kidney function and preventing infection from developing

Surgical management: e.g. stenting may be required depending on the cause

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20
Q

Where do renal calculi form?

A

In the collecting ducts - may be deposited anywhere from the renal pelvis to the urethra

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21
Q

Where are the classic sites of renal calculi deposition?

A

Pelviureteric junction, pelvic brim and vesicoureteric junction

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22
Q

What are renal stones most commonly made of?

A

Calcium oxalate (75%) with other being magnesium ammonium phosphate or urate based

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23
Q

Describe the lifetime risk of kidney stones?

A

15% lifetime risk, peak age 20-40 years, M:F 3:1

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24
Q

How do patients with kidney stones present?

A

Renal colic: excruciating loin to groin spasms, with nausea and vomiting, patient often cannot lie still
Occurs if stone is impacted in the ureter

Dull loin pain: if the stone is in a major/minor calyx

UTI: secondary to the partial / complete obstruction

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25
Q

What are the risk factors for kidney stones?

A

Obesity, Dehydration / low fluid intake
Family history, personal history of stone disease
Anatomical abnormalities

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26
Q

What are the investigations for kidney stones?

A

Bloods: include calcium, phosphate, glucose, bicarbonate and urate levels

Urine dip: 95% positive for blood, rule out infection

bHCG is vital

Urine MCS

Imaging:
AXR - 80% visible
Non-contrast CT: 99% visible, can exclude abdominal ddx

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27
Q

What is the acute management of renal stones?

A 
A-E + fluids 
75mg diclofenac PR (post renal Aki beware) 
IV metaclopramide
IV abx if signs of infection 
Assess whether admission is required
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28
Q

What are the requirements for admission with a stone?

A

If there is still severe pain at 1 hour
If there is a risk of AKI
If there are signs of shock / infection
If there is uncertainty over diagnosis

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29
Q

What are the indications for active treatment of renal stones?

A 
Low chance of spontaneous passage (>10mm) 
Persistent pain
Ongoing obstruction 
Signs of infection 
Renal insufficiency
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30
Q

What are the active treatments of renal stones?

A

Extracorporeal shockwave lithotripsy (ESWL) - shock waves to break the stone

Uretoscopy

Percutaneous nephrolithotomy

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31
Q

What is ESWL?

A

Outpatient procedure that focuses shock waves on the stone to break it up, and it can then be passed spontaneously

If there is a hydronephrosis present, they may need a percutaneous nephrostomy to decompress the pelvicalyceal system prior to outpatient ESWL

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32
Q

What is uretoscopy?

A

Small telescope passed into the ureter - basket retrieval or laser / shock waves / electrical energy to fragment

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33
Q

What is percutaneous nephrolithotomy used for?

A

Renal (NOT ureteric calculi) that do not respond to ESWL

Scope inserted through small incision in the back to remove kidney stones

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34
Q

What are the medical treatments for renal stones?

A

Tamsulosin (first line / alpha blocker) or nifedipine increase the rate of spontaneous expulsion

Advice for home:
80% pass naturally
High fluid intake
Advise to return if there is any increase in pain, or signs of infection

First time stone formers - pass urine through a sieve to try and collect the stone for analysis
Refer the patient to urology within 1 week

35
Q

What are the causes of bladder calculi?

A

Bladder outflow obstruction
Presence of a foreign body (prolonged catheterisation_
Upper urinary tract stone passing down

36
Q

What is the presentation of bladder calculi?

A

Symptoms of UTI as there is often significant bacteriuria (frequency, pain and haematuria)

Haematuria and pain generally occur at the END of micturition as the bladder contracts

IN males, the pain can be felt at the tip of the penis, rather than a general burning

There also may be perineal pain if there is trigonitis and anuria / bladder distension if the stone is obstructing

37
Q

What are the investigations / managements for bladder calculi?

A

Investigation = same as upper urinary tract stone
Bloods: include calcium, phosphate, glucose, bicarbonate and urate levels

Urine dip: 95% positive for blood, rule out infection

bHCG is vital

Urine MCS

Imaging:
AXR - 80% visible
Non-contrast CT: 99% visible, can exclude abdominal ddx - CTKUB

MX: medical expulsive / ESWL if the stone is large

38
Q

What are the complications of bladder stones?

A

Can predispose to SCC

39
Q

What does a renal cell carcinoma arise from?

A

Proximal tubular epithelium

Accounts for 90% renal tumours

40
Q

What is the main risk factor for renal cell carcinoma?

A

Prolonged harm-dialysis (15% develop this)

41
Q

What is the presentation of renal cell carcinoma?

A

50% incidental
10% = classic triad of haematuria, loin pain and an abdominal mass plus vague B symptoms

Rarely, invasion of the left renal vein leads to a varicocele
May be signs of polycythaemia / HTN (if renin / EPO secretion)

42
Q

What investigations can be done for renal cell carcinoma?

A

Urine cytology
USS can differentiate solid from cystic mass
CT/MRI to assess tumour

CXR: cannon ball metastases

Renal angiography (if considering partial nephrectomy)

43
Q

What is the management of renal cell carcinoma?

A

Radical nephrectomy

Partial nephrectomy:
If perineal tumour smaller than 5cm or if bilateral tumours / poor kidney function

Post-operative chemotherapy

44
Q

What is prognosis like for RCC?

A

65% 5 year survival if N0, 25% if nodal involvement, 5% if distant mets

45
Q

What % of childhood malignancies are Wilm’s tumours?

A

20% childhood malignancies

46
Q

What Is a Wilm’s tumour?

A

Undifferentiated mesodermal tumour
Generally presents at 3.5 years with flank pain and an abdominal mass

Should not be biopsied
Treatment is with nephrectomy, with pre-operative chemotherapy

47
Q

Who gets renal cysts?

A

Elderly - 50% will have a renal cyst by the age of 50

Often asymptomatic, or can cause haematuria / pain

PKD is a common cause, with other causes being medullary cystic disease (childhood disease leading to ESRF) or medullary sponge kidney

48
Q

What type of epithelium lines the calyces, renal pelvis, ureter, bladder and urethra?

A

Transitional cell epithelium

therefore get transitional cell carcinoma

49
Q

What are the risk factors for transitional cell carcinoma

A

smoking
aromatic amines: rubber / plastic / dye industry workers
chronic cystitis
pelvic irradiation

50
Q

What is the presentation of transitional cell carcinoma?

A

Painless haematuria +/- clots: most common presentation
recurrent UTI
Voiding symptoms
Pain from invasion of local structures

51
Q

What investigations should be done for TCC?

A

Urine MCS / cytology (cancers can cause sterile pyuria)
cystoscopy and biopsy (gold standard)
CT/MRI or lymphangiography to assess spread

52
Q

What is the treatment of TCC?

A

Carcinoma in situ, or T1 bladder carcinoma:
transurethral resection of bladder tumour (TURBT) at cystoscopy with intravesical chemotherapy
5 year survival = 95%

T2/T3 / high grade:
radical cystectomy is gold standard with pre-operative chemotherapy
ileal conduit is used to leave an urostoma

T4: invasion beyond the bladder: treated palliatively

Long-term follow up with cystoscopy is then required

53
Q

What other types of bladder cancer are there?

A

SCC of the bladder (more rare), however presents similarly
Risk factors are anything that irritates the lining of the bladder leading to squamous metaplasia e.g. schistomiasis or bladder calculi

54
Q

What is the management of trauma to the bladder?

A

Intraperitoneal bladder rupture - treated with laparotomy and suturing of the bladder

Extraperitoneal bladder rupture: treated conservatively with prolonged urethral or suprapubic catheterisation

55
Q

What are the causes of bladder outlet obstruction?

A

Luminal
Mural
extramural

56
Q

What are the luminal causes of bladder outlet obstruction?

A

bladder tumour

57
Q

What are the mural causes of bladder outlet obstruction?

A

urethral stricture (post calculus / infection)
congenital abnormalities
neuropathic bladder

58
Q

What are the extramural causes of bladder outlet obstruction?

A

BPH / Prostatic carcinoma

Phimosis / paraphimosis

59
Q

What are the clinical features of bladder outlet obstruction?

A

Suprapubic pain
Hesitancy and diminished force of the stream
Terminal dribbling
Overflow incontinence (retention with overflow, leakage of small amounts)
Signs of infection due to stasis of urine

60
Q

What are the signs of bladder outlet obstruction?

A

Palpable full bladder
Loin tenderness / palpable hydronephrotic kidney
Enlarged prostate on PR (poor sensitivity for prostatic obstruction)

61
Q

What investigations can be done for bladder outlet obstruction?

A

Bloods: FBC (infection), U+Es
Urine: Dip, MCS
USS: hydronephrosis
CT/MRI

62
Q

What is the management of bladder outlet obstruction?

A

Catheterisation (suprapubic, urethral)
Beware of large diuresis following relief of obstruction

Find and treat underlying cause

63
Q

What is BPH?

A

Benign nodular / diffuse proliferation of glandular layers of the prostate, leading to enlargement of the inner transitional zone

affects 70% of those over 70

64
Q

What are the symptoms of BPH?

A

Filling symptoms: due to bladder overactivity
Frequency, first noticed as nocturia
Urgency / stranguary

Voiding symptoms: due to bladder outlet obstruction: hesitancy, poor/intermittent stream, post-void dribbling, stranguary

symptoms due to complications: occasionally haematuria (rupture of veins into the cyst)

Symptoms of associated UTI

65
Q

What investigations are done for BPH?

A 
PR: typically sulcus = still palpable
Frequency / volume chart 
Bloods: FBC, U&Es, PSA 
Urinalysis / MCS
Uroflowmetry 
Bladder USS (pre/post-void)
Transrectal USS +/- biopsy to rule out carcinoma
66
Q

What is PSA?

A

Prostate cancer marker, concentrations below 4.0ng/mL are deemed normal

Can be adjusted ‘normal’ tased on age and prostate size

67
Q

What are the positive findings for BPH from uroflowmetry

A

Requires >150ml to be voided

Flow rate <12ml/sec suggests obstruction or weak bladder contractility

68
Q

What are the complications of BPH?

A 
UTI
overflow incontinence
Bladder calculi 
Bladder diverticulae 
Bilateral hydronephrosis and renal failure
69
Q

What is the acute management for BPH?

A

(acute retention): attempt urethral catheter drainage

Suprapubic drainage if urethral catheterisation not possible

70
Q

What lifestyle modifications can be told to treat non-acute BPH?

A

Avoid alcohol / caffeine
Relax when voiding
Void twice in a row to help emptying
Bladder retraining therapy

Watchful waiting, if more troublesome, medical therapy

71
Q

What medical treatments can be given for BPH urinary relief?

A

Alpha-blockers e.g. doxasosin / tamsulosin
reduce smooth muscle tone
SE: drowsiness, dizziness, depression, hypotension

5-alpha-reductase inhibitors e.g. finasteride
Stop conversation of testosterone to dihydrotestosterone, thus decreasing enlargement but effects are slow.
SE: impotence and reduced libido and it is excreted in semen so condoms should be used

72
Q

What are the surgical options for BPH?

A

transurethral resection of the prostate:

Holmium laser prostatectomy (HoLEP) - endoscopic, used for very large prostates

73
Q

What are the long term effects of TURP?

A

10% risk of impotence and 20% will need a repeat within 10 years

retrograde ejaculation almost universal after procedure
other Risks are bleeding / and rarely TURP syndrome
absorption of washout leads to hyponatremia and fits

74
Q

What are the long term effects of HoLEP?

A

Urinary incontinence if too much gland is removed

75
Q

What kind of cancers are prostate carcinomas?

A

Adenocarcinomas, arising in the peripheral prostate

thus, biopsy must be transrectal

76
Q

How does prostate cancer spread?

A

Local (seminal vesicles, bladder, rectum), lymphatic or haematogenous, classically to bone

Risk factors: family history and raised testosterone levels

77
Q

What is the presentation of prostate cancer?

A

Often asymptomatic, found on PR / histology of BPH resection

May present with filling, voiding or complication symptoms, as per BPH

Weight loss / bone pain suggest metastatic disease
On examination - hard and craggy prostate

78
Q

What investigations should be done for prostate cancer?

A

PR: vital to give clinical T stage
PSA: rises >10ng are highly suggestive of tumour
Affected by many factors, thus not a reliable screening method

Mountain biking, infection, recent intercourse (48h), cystoscopy

Transrectal USS/biopsy
Vital for Gleason grading

Bone XR / scan and contrast enhanced MRI for staging

79
Q

What is the Gleason grade? how is it done?

A

2 areas of tissue are graded out of 5 to give a combined score out of 10
Gleason grade is vital for prognosis; scores of 6 or less considered ‘low risk’ and 8 or more ‘high risk’

80
Q

What is the D’amico risk stratification?

A

Gleason score + clinical score + PSA to give a more accurate prognostic score than using Gleason alone

81
Q

What is the management for localised prostate cancer (T1/T2)

A

Active surveillance: regular PSA / DRE / re-biopsy monitoring

Radiotherapy / brachytherapy

Surgery: radical prostatectomy is tx of choice BUT risks of impotence / incontinence

82
Q

What is the management for advanced prostate cancer (T3/T4)

A

Active surveillance not recommended
Choice between radiotherapy and surgery

No difference in outcomes between the two

83
Q

How is metastatic prostate cancer managed?

A

Hormonal therapy, GnRH agonists e.g. goserelin / buserelin

Can be palliative or used in high-risk disease as an adjunct to a curative treatment
First stimulate, then inhibit pituitary LH release, thus reducing testosterone production

An anti-androgen such as cytoproterone acetate is co-prescribed initially to prevent the early rise in testosterone

CP3 Surgery (12 decks)

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