UROLOGY Flashcards
Diagnosis for TC
Diagnosis is made by ultrasound of the scrotum
CT scan of abdomen and pelvis assess lymph node spread
Serum Tumour Markers: BHCG
Alpha-feta-protein
What are the histology of testicular cancer?
Germ Cell 95%
Non Germ Cell 5%
What is the peak age of presentation for testicular cancer?
20-40 years
Certain histology types of TC are associated with ?
Serum tumour markers BHCG and alpha feta protein and Lactate dehydrogenase (espeically non seminomatous germ cell tumours)
Placental ALP increased in germ cell seminoma
Where do tumour arise and invade from in testicular cancer?
Arise from testis and can invade locally into tunica albuignea and the spermatic cord
testicular cancer: Where is distant spread initially to ?
Where does it spread in later stages
Initally to the lymph nodes (drainage of the testes is to the paraaortic lymph nodes at level of L2 (adjacent to kidneys)
From here to the thoracic duct and supraclavicular nodes
Later stages: Liver, lung and brain
Treatment for testicular cancer
radical orchidectomy (srugical removal of testis and spermatic cord) \+ radio and chemo (very radio and chemo sensitive)
where is incision made for radical orchidectomy?
superficial ring rather than scrotum to allow resection of the cord in patient
Scrotum: two main groups what are they
Malignant masses (germ cell or non germ cell) Acute Scrotum (truama, torsion or epididymitis)
In absence of trauma in acute scrotum, what are thw two differentials?
Torsion
Epididymitis
Torsion of scrotum: ages it can occur and most commonly when it occurs
10-40
Most commonly 10-25 years of age
What occurs with torsion of scrotum?
testis twist on spermatic cord
What clinical features of patient present with torsion of scortum?
Acute instant onset pain
vomiting and nausea
What is seen on examination in testicular torsino?
exmaination :
testis is boggy, high riding and frequently lying more HORIZONTAL than normal
If torsion is suspected: What is management?
Management: Surgical exploration and untwisting before ischaemia becomes irreversible
Epididmyoorchitis : in younger group and older group what are these associated with?
younger patient: STD should be excluded
older group: urinary tract infection and catheter preences
Onset and clinical examination of epididymoorchitis?
onset over few days
tender testis, boggy, and tight and cellulitic scrotal skin
Vital signs
What is treatment of epididmyoorchitis?
Antibiotics:
Oral: Ciproflaxin
IV: Gentamicin
What is used in diagnostic for epidiymoochritis?
Ultrasound to rule out torsion or abcess
Urinary incontinence definition
failure of the lower urinary tract to store urine
Lower urinary tract comprises of:
bladder + outlet
female lower urinary tract comprises
bladder
4cm urethra
external sphincter surrounding middle 2/4 of the urethra
pelvic floor muscles
what is female bladder outlet characterised by?
male?
LOW resistance and resistance decreases with age due to pelvic floor atrophy
HIGH resistance and resistance increases with age due to prostate age related benign hyertrophy
Male lower urinary tract comprises of
bladder neck
prostate
external sphincter
20cm urethra
VOIDING CYCLE:
storage and voiding phase
storage phase when urine is stored = around 300-400mls and 0 pressure without sensation of distension (3-4 hours) until contractile capacity is rached and pressure inc and associated with sesnation of distension
voiding phase: relaxation of external sphincter which relaxes, bladder contracts and empties under voluntary control
4 catergoris of incontinence
4 catergories include:
- stress
- urge
- mixed
- other - if no features of stress or urge consider uncommon such as fistula or overflow incontience
stress incontinence + pathogenesis
urine flow increased due to activity e.g. laughing/coughing
resitance in outlet reduced and overcome with inc intrabdominal pressure
urge incontinence
loss of urine due overwhelming urge to void during storage phase
etiology of stress incontience
middle aged women:
pelvic floor age related atrophy due to childbirth, chronic cough, chronic constipation, smoking
OTHERS:
injury during surgery
males (iatrogenic during prostate surgery)
Neurological: spina bifida /spinal injury - due to paralysis of sphincter and bladder neck
investgations stress incotinence
urodynamic studies (only if surgery contemplated
Treatment stress inctontinece
pelvic floor exercises
pubovaginal sling surgery
artifical urinary sphincter
Grading on stress incontinence
graded on acitivty:
on trampoline: mild
coughing or laughing: mild
rolling in bed/walking downhill:severe
Fistula: is this rare or common cause of incontinence
rare
most common fistula presenting as incotinince?
vestigovaginal fistula
vestigovaginal fistula presentation
dribbling incontinence
urge incontinence pathogenesis
increases in bladder pressure during storage phase, which causes unstable contractions of bladder and loss of compliance (inapporpriate level of pressure for amount of urine)
What is the etiology in neurologically normal patients for urge incontinence
Idiopathic bladder instability (common)
interstitial cystitis
radiation injury
carcinoma in situ (TCC)
What is the etiology in neurologically abnormal patients for urge incontinence
poor compliance of bladder and instability due to:
UMN spinal cord injury
Parkinsons
Multiple Sclerosis
Stroke (CVA)
Investigations for urge incontinence
- MSU to exclude infection
- Post void residual to exclude retention
- cytology if patient over 60 + haematuria
- renal US if upper tract reflux
- urodynmaics if resistance to anticholinergis or in context of nueorlogical disease.
Treatment for urge incontinence
Fluid management (over hydration and iduretics avoid)
Anticholinergics sucha s oxybutin
Botox
Bladder augmentation
If men have urge incontince day and night what needs to be done and why?
Vesicouteric junction - if pressures are high enough to overcome a high resistance male outlet, they may be high enough to overcome vesicoreteric junction)
Mixed incontience what is this ?
who is this more common in
mixed features of urge and stress incontinence:
more common in women
Other incontinence
If patients do not describe either stress or urge incontinence, they usually describe constant dribbling,
or incontinence without sensation ( just find myself wet.) This may be a reflection of severe stress
incontinence when any slight movement results in leakage. Urodynamics is required to sort this out.
Alternative diagnoses to be considered are:
overflow incontinence or fistula
What is overflow incontinence ?
overflow of urine with patients with chronic retention
how does overflow inctonence present?
Involuntary leakage of urine that results as a complication of urinary retention
NEW noctural urinating in elderly w symptoms of chronic retention
risk factors for fistula
complicated pelvic surgery chronic inflammation (Diverticular inflammatory mass or radiation) pelvic cancer (squamous cell)
Investigations for fistual
Cytoscopy MRI
treatment for fistula
catheter + surgery
chronic retention risk factors
eldelry
male
LMN
diabetic
investigations overflow incontence
post void residuals
upper tract US
serum creatinine level, which may be elevated if there is urinary retention (overflow bladder
Overflow inctonience is complicaiton of chornic retnetion: What are other complications ?
Bilateral hydropnephorisis (kidney swelling) and hydroureter (ureter swelling) indicating g obstructive uropathy and renal failure ( urine is unable to drain into the blader because the bladder is always full and the pressure gradient even with peristalsis has been obliterated
overflow incotninence surgery
catheterisation + TURP Males + surgery females(vaginal sling
Paediatric: Phimosis What is this?
inability to retract the foreskin (prepuce) covering the head (glans) of the penis - can be pathological or physiological)
What is phimosis most common reason for ?
circumscicion Although recurrent balanitis is also indication (inflammation of the glans)
at birth: adhesions present between glans penis and foreskin however when does seperationg occur ?
occurs at birth and continues to seperate - finishing around aged 2 . 9some adolescent boys retain adhesions)
Are adhesions of prepuce normal?
Adhesions are normal and should be treated only if they persist into adolescence and cause problems with masturbation and sexual intercourse
uf a non retractile foreskin is free of symptoms and self limiting, is circumscision needed?
NO
what is difference between non retractile forskin and phimosis ?
non retractile - ballons with urination however on examination urethral meatus is visible and with time will open and allow foreskin to retract normally. Phimosis (true) is where physically cannot usually due to scarring or balantitis
true phimosis treatment ?
what is the two indications
circumscision
steroid creams
recurrent balantitis
restrction to urine flow
Hypospadias what is this ?
condition in which the opening of the urethra is on the underside of the penis instead of at the tip.(underdevelopment of the urethra)
Hyposapdias how common?
surgery cure rate
2 in 1000 males
cure rate = 90%
in hypospadias: what is important to remember about circumscion?
circumcision should be deferred as the foreskin may be utilised in the correction)
cryptorchidism; What is this?
failure of one or both testes to fully descend into scrotum
what is normal for testicular descent
descend through inguinal canal in 7th month in urtero
Where can testes be located in cryptotorchidism?
Normal path of descent (inguinal canal (80%) + abdo) abnormal path (ectopoic testis) such as femoral perineal and suprapubic
What features are associated with crytoptorchidism?
low birth weight + prematurity
diagnosis of cryptotorchidism
tetes absent or cannot be manipulateed into scrotum with gentle pressure
KIDNEY STONES: What is most common type ?
calcium oxolate and calcium phosphate (80%)
What are the second most common two types of kindey stones?
What is least common?
uric acid %5 - hyperuricoasemia due to : excessive purine intake, definiciies in xanthine oxidase and myeloproliferative disorders
5% struvite (mg phosphate and amonia
cyestine 2%
Renal stones: Etiology is usually unknown but what is common precipitate
dehydration
Ureteric stones: What is presntation?
if fever present?
ureteric sspasm + obstruction presents as renal colic:
Lateralised loin pain colicky that radiation to the groin (testes/penis and vulva)
Onset random
comes in waves
Severe and nausea, vomiting and pallor
Fever present: must rule out pyelonephritis
Renal colic is most frequent?
urological cause of acute abdominal pain
Where are three narrowest passage points for UPper tract stones?
pelvicoureteric junction
pelvic brim (where ureter crosses common iliac artery bifurcation)
vesicoureteric junction
What is ACUTE treatment for renal stone simple and complicated:
Simple:
Supportive IV fluids
Analgesia (diclofenac 75mg IM)
alpha blocker 2mg doxazosin)
Complicated Stone: Supportive IV fluids Analgesia (diclofenac 75mg IM) IV antibiotics Gentamicin MET (medical expulsion therapy) a- blockers (doxazocin 2mg) and calcium channel blockers to facilitate stone passage (stones <5mm can typically pass through urethra Urgent Nephrostomy tube Admit to Urology Ward
what size stones can typically pass through urethra?
<4mm
What is interventional treatment for stone?
this is immediately when obstruction is dangerous
first line:
second line
when obstruction is dangerous such as sepsis, renal failure or hydronephrosis :
first Line: ureteric stent via cytoscopy
second line: image guided percutaneous neprhostomy
diagnosis of renal stones: Labs
what are some additional labs that would be needed in recurrent calcium stone formers or paediatric cases?
Imaging:
Labs: CBC (WBC to assess infection) , U and E, ca2+ and phosphate , uric acid and urinalysis (routine and miscroscopy + culture and sensitivity)
Additional Labs: PTH and electrolytes (inc oxalate, citrate and cysteine)
Imaging:
KUB non contrast CT urogram (GOLD STANDARD)
follow up: KUB Xray
Paeds/obstetric: abdo US to avoid radiation
what will urine analysis potentially see with stones?
gross or microscopic haematuria (85%) and an altered urine PH.
A ureteric stone may? (3 things)
pass spontaneously (<4mm 90% chance 6 weeks) Lodged in ureter and pain controlled with analgesia Become lodged in ureter and patient develops complications of obstructed stone
What are 3 complications of obstructing ureteric stone?
- unrelenting pain
- urosepsis
- renal failure (single kindey or pre existing impaired function)
Srugical Stone treatment
- Kidney stones
- ureteral stones
- Bladder stones
Kidney ESWL extra-corporeal showack lithotripsy (ESWL) uf stone <2cm ni renal pelvis Percutaenous neprholithotomy (PNL) if stone >2cm LARGE STONES
ureteral stones
ESWL
Uterescopy stone fragmentation/lithotripsy
Bladder:
transurethral cystolitholapaxy)
Stone prevention
Stone prevention
High fluid intake > 3L orally throughout the day
Normal calcium
Lowered sodium (salt and processed foods)
Referral to nephrology for 24 hr urine if recurrent stone formation
what is most common diagnosed male cancer in NZ ?
prostate cancer
what is second common cuase of cancer death in NZ?
second equal - equal to colo-rectal malignancy in men
PSA: what causes increased PSA
non psecific, can increase with BPH, prostatitis (infection), trauma, and instrumentation such as cathertisiation, carcinoma
what is diagnosis of prostate cancer based on?
both DRE and PSA blood test:
PSA greater than 4 on two or more occasions combined with palable nodule during the DRE then tyou should proceed to the next step:
What is the next step if PSA is greater than 4 on two seperate occasions as well as palpable nodule ?
ultrasound guided transrectal biopsy
what is function of PSA?
fertility and to make ejaculate less viscous and able to reach cervic
screening guidelines for prostate cancer?
should begin earlier in african american men
only useful if men have more than 10 years to live as unlikely to be clinically signigcant within 10 years therefore 50-75 is age range
PSA less than 4
prostate cancer uncommon
PSA between 4 and 10
organ confined and will be present in 25% of biopsies
PSA greater than 20
high grade
4 main levels of treatment prostate cancer
watch and wait (many grow slowly
active surveillance interventional biopsies and MRI scans
radical treatment - radical prostatectomy
external beam readiation and brachytherapy (radioactive seeds) 10+ years
Hormonal treatment bilateral orchidectomy + anti-androgens such as flutamide
Supportive care
risk of prostatetcomy
impotentce and inctonitence
tightest point and most common place for stones
VUJ
3 layers of bladder and cell types
mucosa
lamina propria
detrusor muscle
Mucosa: whole urinary tract is transitional cell carcinoma
Pressure in renal pelvis is higher than in ureters. pressure gradient alone not enough to conduct urine: what is needed?
The ureters are peristaltic and this together with
the gradient conducts boluses of urine to the bladder. ( Pathophysiology of congenital PUJ obstruction
nicely illustrates this ).
asymptomatic macroscopic (visible) haematuria: what % chance of malignancy?
vs
MICROSCOPIC
30%
5-10%
which cases of haematuria should be investigated?
all macroscopic
microscopic only those 2/3 shown 20 million RBCS or more per litre of urine
history haematuria 3 key questions
1/ visible or not
- painful or note
- where in the stream did this occur
painful haematuria more likely
painless
infection /stones
painless = malignancy
examiniation haematuria
full uro + abdo + prostate
Haematuria: investigations:
full imaging CT or US of upper tract
cystoscopcy of lower
before cytoscopcy what screening is undertaken for haematuria?
CX triage test (to rule out bladder cancer) if below 4 + radiology normal no cysotosxcopy needed
3 associated diseases with RCC
Hippell Lindauer
polycystic kidney
renal cystic disease of CKD
what is variocele?
What does this indicate?
variocele is enlargement of veins in scrotum
- indicates RCC as does any other abnormal abdo massess
What can RCCS produce?
paraneoplastic syndromes causing anaemia, hypercalcimia, polycythemia, liver dysfunction ( Stauffer’s syndrome)
Management
radical open nephrectomy
laparscopic nephrectomy
partial nephrectomy
- TCC ureter removed to avoide urothelium recurrence
what is haematuria CT
CT taken ebfore and after injection of contrast
Investigations RCC
urinarlysis + cytology
Haematuria CT, Chest Xray , LFTS, Serum creatine and calcium
if ALP is elevated in RCC?
OR bony pain must do Bone scan
Spread of RCC
immediately to adacent organs
tumour thrombus spread to renal vein, IVC and aorta
distant spread: para aortic nodes, lung and bone
does RCC respond to radiation?
NO
survival RCC :
80% if <7cm and only in one kidney
lymph node spread drops to 20%
mets = v few
Ta Bladder
superficial transitional cell caricnoma: confined to mucosa low rate invasion
T1 bladder
high risk TCC invades lamina propria still good outcome
T2 bladder
invasive bladder cancer through detrusor muscle
age of TCC
female to male
rarely under 40
usually over 65
what is MOST significant risk of transitional cell caricnoma ?
What do patients presentw ith ?
SMOKING and male
painless macroscopic haematuria
investigations
bloods
imaging
labs
procedure
CBC
urinalysis + cytology
renal ultrasound? ct abdo
cytoscopy + biopsy gold standard
Superficial (non muscle invasive treatment of TCC
transurethral resection of bladder lesions (TURBT) + intravesical chemo BCG or mitomycin
Invasive TCC treatment and prognosis
50% 5 year mortality
radical cystectomy
OR if not fit enough TURBT + radiotherapy intravesciel
cystecomty: what are outcomes
stoma and urine bag (ileal conduit) orthotopic neobladder (using bowel no external bag)
UTI simple: two commonest pathogens
E coli
Enterococcus faecialis
urosepsis: what indicates bacteraemia?
what are first signs of sepsis?
fever + rigors
hypotension, reactive tachycardia and reduced sats
UTI uncomplicated: Who does this occur in
young sexually active females
complicated UTI: Who does this occur in
rest of cases
uncomplicated UTI investigations?
none
complicated LOWER UTI
urine culture required
complicated UPPER UTI
CBC, U and E urinarlysis RM + Culture and sensitivty +/- blood cultures
U/S (abcess)
clnical presentaiton lower uti
upper uti
lower uti - dysuria, urgency, haematuria, suprapubic pain
upper UTI: same but more severe fever chills, + flank pain
uncomplicated lower uti
empirical nitrofurantoin or trimethoprim (NOT TO BE USED IN FIRST TRIMESTER AS IS FOLATE ANTAGONIST AND CAN CAUSE NEURAL TUBE DEFECTS
uncopmlicted upper UTI
fluids, analgesia + admission
IV gentamicin + co-trimaxole 10 days
complicated UTI
fluids, analgesia + admission
IV gentamicin + co-trimaxole 10 days but TREAT FOR LONFER 2 weeks and guide by empiiric
recurrent uncomplicated UTI indicates?
treatment
colonic colonistaiton get urine culture and use prophylatic antbitiocs for 12 weeks
usually upper urinaty tract infection is due to ascending, what is the one exception to this?
diabetic abcess = haematogenous spread
1) What is the biggest risk factor for developing female urinary incontinence?
Age
Number of complicated vaginal deliveries
BMI
Number of uncomplicated vaginal deliveries
age
The classic ’triad’ of symptoms of renal cell carcinoma does NOT include which of the following? Haematuria Flank pain Proteinuria A palpable mass
proteinuria: classic triad is haematuria, flank pain and mass
what is the genetic disease associated with RCC?
Von HIppel Lindaeur disease
Which of the following is not a cause of elevated PSA? Increased BMI Prostate inflammation Age Prostate cancer
increased BMI
PSA has a high sensitivity and specificity for it to be used as a routine population screening test
Routine PSA testing decreases prostate cancer-related mortality
Men aged between 50-75 are most likely to benefit from PSA cancer screening
A PSA value of >20ng/L is diagnostic for prostate cancer
c
Which of the following microbes is not a common cause of UTIs? Staph saprophyticus Klebsiella Strep pyogenes E coli Enterococcus faecalis
strep pyogenes
) Which of the following would be sound advice for a patient suffering from recurrent UTIs?
Improving personal hygiene
Using contraceptives other than spermicides
Not ‘holding in’ their urine for too long
Keeping well hydrated
All of the above
all of above
How does testicular cancer usually present?
Painless lump which transilluminates
Painless lump which does not transilluminate
Usually painless lump which is hard/craggy
Painless lump which is separable from the testis
painless lump that is seperateable from testis
Choose the statement that is most true
Biopsy is an appropriate investigation for testicular cancer
U/S can definitively diagnose testicular cancer
Testicular cancer which has metastasised to the brain can be cured
Contraception cannot occur immediately following chemotherapy for testicular cancer
Testicular cancer which has metastasised to the brain can be cured
4) Which of the following is not a cause of hypercalcaemia in patients with RCC?
Lytic bone metastases
Over-production of PTHrP (parathyroid hormone related
Stauffer syndrome (hepatitis - assocatied with disturbed LFTS)
Increased prostaglandin production
tauffer syndrome = hepatic T cell mediated hepatitis
Urodynamics in stress incontinence:
reduced resistance and so when intra abdominal increases this causes overflow
Urodynamics in urge inctonteince
increasde detrusor muscle acitvity + increased bladder pressure
A urodynamic stress test showed incontinence with increased vaginal pressure and no increase in true detrusor pressure. This is consistent with: Stress incontinence Urge incontinence Mixed incontinence Neurological abnormality
stress incontinence
PUJ definition:
obstruction fo flow of urine from renal pelvis to proximal ureter
What is PUJ most common cause of ?
most common cause of antenatal hydronephrosis
Who is antenatal hydronephrosis most common in ?
most common in males compared to females
What kidney is PU more likely to affect?
What % is bilateral?
left kidney 70%
10% cases bilateral
Wjat is most common congenital cause of PUJ obstruction?
Aperistaltic segment of the ureter most Common
common acquired causes of PUJ obstruction?
PUJ obstruction - stones, structures , malignancy
diagnosis infant PUJ
ultrasound scan : hydronephrosisi is seen
treatment: PUJ
surveillance: USS + MAG3 (isotope renography scan)
pyeloplasty
indications for pyeloplasty
pain infection and stones
increased hydroneprhorisis and decreased renal function
diagnosis infant PUJ
FLANK MASS Uti haematuria flank mass failure to thrive
diagmosis adult PUJ
ABDO PAIN
Dietl’s crisis: Intermittent abdominal or flank pain that may worsen during brisk diuresis, for example, after consumption of caffeine or alcohol. +/- nausea and vomiting.
what is rountine with PUJ
Routine antenatal ultrasound scans means that the majority of congenital PUJ obstruction are diagnosed antenatally. Asymptomatic cases may be detected incidentally
in PUJ if less than 10% of kidney function left: what should occrur
neprhectomy
neonatal hydronephrosis all patients diagnosed need
US
MCU -cysto-urothgram xray
Vesicoureteric junction reflux
in neonatal preiods what is distribution?
In later life what is distribution?
neonatal = equal in sexes
later life = more common in females
Veiscouteric presentation in childhood
comment UTIS
Treatment of Vesicouteric relfux conservative and why
tends to be conservative in nature as reflux stops spontaneously in large proportino of patients
faily co trimazole
Surgical treatment of vesicourtereic reflux
ureteral re-implanation
what 3 elements should be taken into account with reflux?
REflux leads to infection which leads to bladder instability, dysfunctional voiding and therefore further reflux
what is one recent advance of treatment of vesicoutereic reflux?
Endoscopic injfection of teflon in submucosa (concerns of polyethelene particle migration a concern)
outflow obstruction: presentation in males
generally outflow obstruction result of strictures
outflor obstruction male or female disease
male disease
mostt common cause of outflow obstruction is?
BPH in ageing male
BPH treatment with outflow obstruction medication
alpha blockers
alpha 5 reductase inhibitros (Tamulosin)
BPH surgical treatment:
Name three early complications of TURP
TURP
- acute hyponatraemia from irrigating fluids
- bleeding
- urosepsis infected urine due to urine contact with open spaces
what incidences increases urosepsis following TURP ?
pre op instrumentation
prostate cancer: spread
lymph nodes first then bones principally
indications for flexible cytoscopy with outflow obstruction ?
over 50 impaired bladder empyting
risk factor for structure
rapid onset symptoms
failure to respond to therapies
s bladder neck dyssynergia treatment (cause of obstruction to outflow)
endoscopic bladder neck incision
Late complications of prostate cancer
stricture
retrograde ejaculation
incontinence
recurrence (10%)
