Urology Flashcards
Urology
What questions should you ask a Pt who presents with urinary problems?
FUNDHIPS
Storage/irritative: F-requency U-rgency N-octuria D-ysuria
Voiding/obstructive: H-esitancy I-ncomplete emptying P-oor stream S-training
Other: terminal dribbling, overflow incontinence
What is benign prostatic hyperplasia?
Slowly progressive hyperplasia of the peri-urethral (transitional) zone of the prostate gland
What is the epidemiology of BPH?
Very common- most common cause of LUTS in men
What are the clinical findings of BPH?
FUNDHIPS
Severe pain if acute retention
DRE- smooth bilateral enlargement
What are the investigations for BPH?
Usually clinical diagnosis
U+Es for decreased renal function
Ultrasound
What is the management for BPH?
Acute retention- catheterise
Conservative- watchful waiting
Medical- alpha-blockers (tamsulosin); 5-alpha-reductase (finasteride)
Surgical- TURP; open prostatectomy
What are the clinical findings of prostate cancer?
FUNDHIPS
Malignant symptoms- bone pain, cord compression, FLAWS, paraneoplasm
DRE- asymmetrical hard nodule
What are the investigations for prostate cancer?
PSA- low specificity
Transrectal ultrasound-guided biopsy
CT/MRI- assess local invasion/mets
LFTs/bone profile- check for mets
What is the histology of bladder cancers?
Most are transitional cell carcinomas
Rarely can be squamous cell carcinomas
What are the risk factors for bladder cancers?
Dye stuffs Pelvic irradiation Smoking Chronic UTIs Schistosomiasis
What are the symptoms for bladder cancers?
Painless macroscopic haematuria
FUND (no HIPS)
FLAWS
What are the investigations for bladder cancer?
Cystoscopy with biopsy
CT/MRI for staging
What are some causes of urinary incontinence?
Stress incontinence Urge incontinence Cord compression Normal pressure hydrocephalus Functional incontinence Overflow incontinence
What is stress incontinence?
Physical movement/activity places stress on bladder
Due to poor closure of the bladder
Childbirth is a risk factor
What is urge incontinence?
Urine leaks as you feel a sudden urge to void
Due to detrusor overactivity
What is function incontinence?
Individual is aware of the need to urinate, but are unable to get to the bathroom in time due to physical/mental reasons
What is overflow incontinence?
Involuntary release of urine from an overfull bladder, in the absence of any need to urinate
What are urinary tract calculi?
Crystal deposition within the urinary tract AKA nephrolithiasis
What are the symptoms of urinary tract calculi?
Often asymptomatic
Severe loin to groin pain
Nausea and vomiting
Consider leaking AAA in elderly
What is the epidemiology of urinary tract calculi?
3x more common in men
What are the causes of urinary tract calculi?
Idiopathic
Metabolic (eg. hypercalcaemia/hyperuricaemia)
What are the risk factors of urinary tract calculi?
Low fluid intake
Structural urinary tract abnormalities
What are the types of stones seen in urinary tract calculi?
Calcium oxalate- most common
Magnesium ammonium phosphate aka struvite
Urate
Cysteine
What are the investigations for urinary tract calculi?
Urine dipstick- microscopic haematuria
Non-contrast CT-KUB
Ultrasound
U+E- renal Fx
What is the management for urinary tract calculi?
Analgesia
<5mm- allow natural passage
> 5mm- surgery:
- Ureteroscopic lithotripsy
- Extracorporeal shockwave lithotripsy
- Percutaneous nephrolithotomy
Any sign of obstructed and infected kidney requires urgent surgery
What is testicular torsion?
Twisting/torsion of the spermatic cord resulting in testicular ischaemia.
This is a surgical emergency
What are the clinical features of testicular torsion?
Sudden onset hemiscrotal pain
Nausea and vomiting
Swollen and erythematous scrotum
What are the differential diagnoses for testicular torsion?
Epididymo-orchitis
Strangulated inguinal hernia
What is the management for testicular torsion?
Exploratory surgery within 6 hrs
Both testicles are fixed in place
Necrotic tissue may need removal
Duplex US
What is a hydrocele?
An excessive collection of serous fluid in the tunica vaginalis
What is the epidemiology of hydroceles?
Very young boys <1yr
Older men
What are the causes of hydroceles?
Idiopathic
Infection
Trauma
Tumour
What are the symptoms of hydroceles?
Usually asymptomatic swelling
Can get above the swelling
Transilluminates
Swelling can’t be separated from the testes
What are the investigations for hydroceles?
Ultrasound- exclude tumour
Testicular tumour markers- AFP, HCG, LDH
Urine dipstick/MSU- check for infx
What is a varicocele?
Dilation of the pampiniform plexus forming a scrotal mass
What is the background of a varicocele?
More common on the left (80-90%)
Associated with infertility
What are the clinical features of varicoceles?
Usually asymptomatic
Feels like a bag of worms
Swelling may reduce when lying down
What is epididymo-orchitis?
Inflammation of the epididymis/testis
What is the epidemiology of epididymo-orchitis?
Most common in the 20-30s
What are the causes of epididymo-orchitis?
<35yrs- Chlamydia, Gonococcus
>35yrs- Coliforms (eg. Enterobacter, Klebsiella)
Other- mumps, Candida
What are the clinical features of epididymo-orchitis?
Painful, swollen, tender testis/epididymis (less acute than torsion)
Penile discharge if STI
Fever
Facial swelling if mumps orchitis
What are the investigations of epididymo-orchitis?
Urine dipstick
Urine MC+S
Bloods (FBC, CRP)
What is the background of testicular cancer?
Commonest malignancy in males between 20-40s
Risk factors- maldescended testes
What are the types of testicular cancer?
Seminoma- 50%
Non-seminoma eg. teratoma- 30%
Other eg. Sertoli and Leydig cell tumours
What are the symptoms of testicular cancer?
Painless, hard testicular mass
Testicular swelling/discomfort
Backache (metastases to para-aortic nodes)
What are the investigations for a testicular cancer?
Tumour markers
- aFP
- bHCG
- LDH
Testicular ultrasound guided biopsy
CT- staging
What are the differences between teratomas and seminomas?
Teratoma:
- younger Pts
- raised aFP and bHCG
Seminoma:
- older Pts
- raised bHCG only
A 67-year-old man has been urinating around 12-14 times per day over the past 6 months. His stream is ‘weak’ and often takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him?
A. Oxybutynin B. Solifenacin C. Tamsulosin D. Nitrofurantoin E. Co-trimoxazole
C. Tamsulosin
A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis?
A. Pyelonephritis B. Glomerulonephritis C. Bladder Cancer D. Prostate Cancer E. Ureteric Stone
C. Bladder Cancer
An 80-year-old man has had considerable difficulty urinating. He goes about 10-12 times per day, including at night, and has described his stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which investigation is most likely to provide a definitive diagnosis?
A.PSA B. Acid phosphatase C.CT scan D.Transrectal ultrasound guided biopsy E.Isotope bone scan
D.Transrectal ultrasound guided biopsy
A 43-year-old woman presents to her GP having wet herself several times since the birth of her third child, 4 months ago. Whenever she laughs or coughs, a little bit of urine leaks out without her control. Which type of incontinence does she have?
A.Functional incontinence B.Stress incontinence C.Urge incontinence D.Overflow incontinence E.Double incontinence
B.Stress incontinence
A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become overwhelmed by the feeling of needing to urinate. Before she can even think about finding a toilet, she has wet herself. Which type of incontinence is this?
A.Functional incontinence B.Stress incontinence C.Urge incontinence D.Overflow incontinence E.Double incontinence
C.Urge incontinence
A 42-year-old man presents with severe pain in his right flank. He adds that the pain moves towards his right groin. Although he is writhing around in pain, no abnormalities are detected on abdominal examination.
Urine Dipstick: + blood
Which investigation would you do next?
A. Renal ultrasound B.Cystoscopy C.CT-KUB D.MRI E.Urine MC&S
C.CT-KUB
Which type of urinary tract stone is most common?
A. Magnesium ammonium phosphate B. Calcium oxalate C. Cysteine D. Urate E. Hydroxyapatite
B. Calcium oxalate
A 13-year-old boy is brought to A&E with sudden-onset pain and swelling in his scrotum, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to vomit. On examination, his right hemiscrotum is red and swollen. What is the most appropriate first step in his management?
A.Doppler ultrasound of the testes B.CT Scan C.Exploratory surgery D.Empirical antibiotics E.Abdominal X-ray
C.Exploratory surgery
A 50-year-old man has developed a swollen scrotum that has been bothering him for the past 2 weeks. The swelling is uncomfortable but not painful. On examination, the left hemiscrotum is enlarged, fluctuant and non-tender. It is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis?
A.Varicocele B.Hydrocele C.Testicular tumour D.Epididymal cyst E. Indirect inguinal hernia
B,Hydrocele
A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘bag of worms’, and is uncomfortable but not painful. On examination, the patient’s scrotum looks normal when lying down, however, the left hemiscrotum becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis?
A.Indirect inguinal hernia B.Direct inguinal hernia C.Hydrocele D.Varicocele E.Epididymal cyst
D.Varicocele
A 21-year-old man visits his GP complaining that his scrotum feels ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with orchidopexy. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to?
A. Inguinal B. Femoral C. Para-aortic D. Iliac E. Mesenteric
C. Para-aortic
A 32-year-old man presents with a 2-week history of frequent urination and excessive thirst. He has also noticed that he feels much weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient?
A.Tented T waves B.Absent P waves C. ST elevation D.J waves E.U waves
E.U waves
This patient has Conn’s syndrome – a condition in which an aldosterone-secreting adenoma leads to inappropriately elevated aldosterone levels. The excessive sodium reabsorption and potassium excretion caused by the high aldosterone leads to hypertension and hypokalaemia. Hypokalaemia induces nephrogenic diabetes insipidus, which, consequently, leads to polyuria and polydipsia. Furthermore, muscle weakness is another feature of hypokalaemia. The main ECG features of hypokalaemia are U waves, ST depression, flattened T waves and prolonged PR interval. In any young patient presenting with hypertension, consider secondary causes such as Conn’s syndrome, coarctation of the aorta and renal artery stenosis.
Tented T waves are a feature of hyperkalaemia. Absent P waves can be seen in several different conditions, most notably atrial fibrillation and supraventricular tachycardia. J waves (sometimes referred to as Osborn waves) are see in hypothermia.
