Urology Flashcards
Discuss the management of patient with signs of infection and a stone causing obstruction
Ureteric obstruction due to a stone with infection is a surgical emergency
- sepsis 6
- decompression via nephrostomy tube placement in IR/ ureteric stent placement
Then definitive treatment e.g. stone removal if needed at later date
Management of renal colic with stone of 3.5mm on US
A&A Analgesia and advice on stone prevention
Stones <5mm usually pass spontaneously within 4 wks
When would you consider open surgery for renal stones?
If other treatment failed, if there is complex stone burden or an endoscopic surgery is not an option.
What advice would you give on stone prevention?
High fluid intake
Diet low in animal proteins and low in salt
What are the options without doing open surgery?
Shockwave lithotripsy
Ureteroscopy ± stent placement - good option in pregnant women with stone burden <2cm
Percutaneous nephrolithotomy - complex renal calculi and stag horn calculi
How could you classify renal stones?
By composition - Calcium oxalate 80% - uric acid 5-10% Calcium phosphate + oxalate 10% Struvite 2% Cystine 1%
Someone with Crohn’s disease has a higher risk of forming what type of stone?
Calcium oxalate
What type of stone is classically associated with infection?
Struvite
- proteus? infection
What are the risk factors for renal calculi?
Intrinsic - age 20-50 , male 1.3x, History ( 10% annual recurrence rate), genetic ( 25% have fam hx, caucausion and asian more common, genetic disorders e.g. familial renal tubular acidosis
Extrinsic - low fluid intake, hot climates, diet.
What is the imaging of choice for renal colic?
CT KUB
Pelvic X ray
What is the association between a diet high in Ca and the formation of renal stones?
None
Causes of urethral stricture
Trauma - instrumentation or pelvic #
Infection
Chemo, radiation
Balantitis xerotica obliterans
What are the symptoms of a urethral stricture?
Hesitancy Strangury Poor stream Terminal dribbling Incomplete voiding
Causes of urinary retention
Obstructive
Neurological
Myogenic
Obstructive causes of urinary retention
- mechanical ( BPH, urethral stricture, stones, constipation)
- dynamic ( post op pain, drugs, = increased smooth muscle tone)
Neurological causes of urinary retention
Due to either sensory or motor disruption
- pelvic surgery
- MS
- DM
- Spinal injury / compression
Myogenic causes of urinary retention
Over distension of bladder due to
high alcohol intake or post anaesthesia
Clinical presentation of acute urinary retention
Suprapubic tenderness
Palpable bladder dull to percussion
Large prostate on PR
less then 1L drained on catheterisation
What would be seen on imaginary of patient with urinary retention?
US bladder volume, hydronephrosis, dilate ureters
What are the management options for a patient with urinary retention?
- Conservative ( analgesia, walking, running water or hot bath)
- Catheterise ( + monitor urine output with fluid replacement to manage post-obstructive diuresis. Then try to void without catheter after 24-72hrs.
- TURP indicated if TWOC fails or there is impaired renal fan.
When is a suprapubic catheter contraindicated?
Known or suspected bladder cancer
undiagnosed haematuria
Prep lower abdomen surgery.
Most common type of bladder cancer?
Transitional 90%
SCC 10%
What is a risk factor for SCC?
Schistosomiasis
Large soft mass in the scrotum that can be separated from the testicle. Most prominent with the patient standing
Inguinal Hernia
Non tender, soft, fluctuant lump at the superior pole of the testicle that is separate from the testicle itself. Transilluminated with light
Epididymal cyst
Non tender soft fluctuant lump around the testicle that transilluminates with light
Hydrocele
Mildly tender, soft, irregular lump separate from the testicle
Varicocele
Scrotal exam finds hard, irregular lump, non tender
Testicular cancer
Very tender, hot swollen testicular swelling most prominent at the superior pole and back of the testicle
Epididymo-orchitis
How does LHRH agonist work?
LHRH stimulates release of LH from pituitary. LH then stimulates release of testosterone.
The LHRH agonists bind to the pituitary and initially stimulate LH release but the constantly high levels of LH eventually result in a down regulation and absence of testosterone.
Most common type of testicular cancer
Germ cell tumors 90% ( seminoma most common 50%)
Examples of non germ cell testicular cancers
Epidermoid, adneomatoid, carcinoid
Leydig cell and Sertoli cell tumors are examples of
Mixed germ cell tumors
Most common type of non-seminomatous tumor
Teratoma
Most common type of renal stone
Calcium oxalate
Anabolic steroid use is linked to what type of cancer
Prostate cancer
Exposure to aromatic amines is linked to what
Bladder cancer
Long term dialysis increases risk of what type of cancer
Renal cancer
Best image to use in renal colic
CT KUB
Bell clapper deformity predisposes to what?
Testicular torsion
Why does bell clapper deformity predispose to testicular torsion?
Absence of the normal posterior attachment of the testicle to the tunica vaginalis
21 y/o man with painless, hard, irregular left testicular lump where AFP v elevated, beta hCG elevated, lactate dehydrogenase v elevated? Dgx?
Teratoma
Management of epididymis-orchitis
Ciprofloxacin or doxycycline if STI
Initial management of BPH
Tamsulosin [alpha blocker - relax smooth muscle]
Finasteride [5-a reductase inhibitors = Block testosterone +reduce prostate size]
Time window for testicular torsion
6hrs
Management of stone less than 2cm in aggregate
Lithotripsy
Mgmt stone burden less than 2cm in pregnant female
Ureteroscopy
Complex renal calculi ans staghorn calculi management
Percutaneous nephrolithotomy
Ureteric calculi less then 5mm mgmt
expectantly?
Complications of shockwave lithotripsy
Solid organ injury
Stone fragmentation causing ureteric obstruction
Risk factors for TCC
Smoking
exposure to aniline dyes in printing and textiles
Rubber manufacture
Cyclophosphamide
T/F smoking is a risk factor for SCC of bladder?
true
indications for circumcision
Phimosis
Recurrent balantitis
Balantitis xerotica obliterans
Paraphimosis
Lump not separated from testes that transilluminates
Hydrocoele
Most cases of acute epididymis-orchitis are due to?
Chlamydia
Why doe varicoceles typically occur on the left?
What are possible associations with varicoceles?
Left because testicular vein drains into the renal vein
May be the presenting feature of a renal cell carcinoma
Bilateral varicoceles may affect fertility
What type of drug is tamsulosin and how does it work?
Alpha 1 antagonist
Decreases smooth muscle tone of bladder and prostate
S/Es of tamsulosin
Dixxiness, dry mouth, depression
Risk of orthostatic hypotension
How long for 5 alpha reductase inhibitors to work? Give Eg
MOA
Finasteride
6 moths to reduce prostate volume and slow dx progression
block conversion of testosterone to dihydrotestosterone which induces BPH
Erectile dysfunction, reduced libido, ejaculation problems and gynaecomastia are possible side effects of what drug used for BPH?
5 alpha reductase inhibitor finasteride
Hyponatremia+ Fluid overload + glycine toxicity are part of what?
TURP syndrome
Elevated AFP is associated with what type of cancer?
Testicular non seminoma ENDODERMAL
Difference between a renal cell carcinoma and a renal cyst on CT scan?
RCC is a separated mass containing solid and liquid components
Cysts are not separated.
Cause of epididymitis by age group
less than 35 - STI chlamydia or gonorrhea
over 60 E coli
Tx of erectile dysfunction
Phosphodiesterase inhibitors e.g. sildenafil
Do not give nitrates at same time
tx of kidney stones
If < 0.5cm → Pain control
If > 0.5cm → medical expulsion therapy [e.g. CCB]
If 1.5cm → Stenting or Lithotripsy
If >3cm → Surgery
If septic / acute upper UT obstruction → Nephrostomy tube and figure out after
Causes of haematuria
start from top -> down Medications Drug induced → ketamine + cyclophosphamide Chemical Radiation cystitis Renal Glomerulonephritis PKD Renal cell carcinoma Renal calculi Ureter Urothelial cancer Outside malignancy Cervical ca Calculi Strictures Bladder UTI Most common Cystitis Bladder stones Bladder ca and pelvic ca Prostate Prostate ca BPH Urethra Structures Urethritis
Undescended testes after 3 months
Refer to surgery
Radiouscent gallstones
Urate
Past paper q on bladder cancer
Intrathecal Chemo may be used
what is the link between gynaecomastia and testicular cancer
Gynaecomastia in testicular cancer occurs due to an increased oestrogen:androgen ratio
Typical age for testicular cancer
20-30yrs
small fluid-filled lump. smooth regular character, and that it feels separate from the body of the testicle.
An epididymal cyst
what type of drug is goserelin
GnRH agonist
What is the first-line in patients with benign prostatic hyperplasia
Alpha 1 antagonist
classic age for testicular teratomas and seminomas
Teratomas for the troops (20-30), Seminomas for the Sergeants (30s/40s onwards)
HCG and AFP may be raised in what type of cancers
teratoma and yolk sac
not seminomas
