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WFH > Urology and GU 17/8 > Flashcards

Urology and GU 17/8 Flashcards

1
Q

metastatic prostate cancer typically spreads to:

A
  • lymph nodes (first to the obturator nodes)
  • bone
  • local spread to seminal vesicles
    can less commonly spread to bladder, lung, liver, brain
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2
Q

risk factors for prostate cancer

A
  • increasing age
  • obesity
  • Afro-Caribbean ethnicity
  • 5-10% of cases have a strong family history (BRCA1+2)
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3
Q

features of prostate cancer

A
  • bladder outlet obstruction: hesitancy, urinary retention
  • haematuria, haematospermia
  • pain: back, perineal or testicular, on urination, on ejaculation
  • digital rectal examination:
    > asymmetrical
    > hard, craggy, nodular enlargement
    > loss of median sulcus
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4
Q

investigating prostate cancer

A
  • PSA
  • DRE
  • multiparametric MRI
  • transrectal ultrasound-guided biopsy
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5
Q

management of localised prostate cancer (T1/T2)

A

depends on age/life expectancy/patient choice

  • active monitoring & watchful waiting
  • radical prostatectomy
  • radiotherapy: external beam and brachytherapy
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6
Q

management of localised advanced prostate cancer (T3/T4)

A

depends on age/life expectancy/patient choice

  • radical prostatectomy
  • radiotherapy: external beam and brachytherapy
  • may be use for androgen therapy eg. goserelin
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7
Q

management of metastatic prostate cancer

A
  • hormonal therapy (can include orchidectomy)
  • chemotherapy (docetaxel)
  • supportive, eg. bone protection/pain relief
  • psychosocial support eg. Macmillan
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8
Q

LUTS

A

Storage:

  • frequency
  • urgency
  • urge incontinence
  • nocturia

Voiding:

  • haematuria/dysuria
  • hesitancy
  • poor flow
  • terminal dribbling
  • incomplete voiding
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9
Q

causes of raised PSA

A
  • benign prostatic hyperplasia (BPH)
  • prostatitis
  • urinary tract infection (postpone the PSA test until 1 month after treatment)
  • ejaculation (ideally not in the previous 48 hours)
  • vigorous exercise (ideally not in the previous 48 hours)
  • urinary retention
  • instrumentation of the urinary tract
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10
Q

management of BPH

A
  • watchful waiting
  • medication:
    > first: alpha-1 antagonists eg. tamsulosin
    > then: 5 alpha-reductase inhibitors eg. finasteride
    surgery: transurethral resection of prostate (TURP)
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11
Q

mechanism of action of tamsulosin (alpha 1 antagonist)

A
  • decrease smooth muscle tone (prostate and bladder)
  • improve symptoms in around 70% of men, considered first-line
  • adverse effects:
    > dizziness and postural hypotension
    > dry mouth
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12
Q

mechanism of action of finasteride (5 alpha-reductase inhibitors)

A
  • blocks conversion of testosterone to dihydrotestosterone, which is known to induce BPH
  • causes a reduction in prostate volume and may slow disease (unlike alpha-1 antagonists)
  • takes time so symptoms may not improve for 6 months
  • may decrease PSA concentrations by up to 50%
  • adverse effects:
    > erectile dysfunction
    > reduced libido
    > ejaculation problems
    > gynaecomastia
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13
Q

causes of acute urinary retention

A
  • BPH
  • medications:
    > anticholinergics
    > tricyclic antidepressants
    > NSAIDs
    > opioids
    > benzodiazepines
  • other urethral blockage, eg. stricture, calculi, cystocoele, constipation, mass
  • postoperative/postpartum
  • neurological
  • UTI in those prone to retention
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14
Q

diagnosis of acute urinary retention

A
  • catheter, send for urinalysis and culture
  • bladder ultrasound (>300cm3 = diagnostic regardless of history/exam)
  • measure vol from catheter, <200cm3 rules out AUR, >400cm3 means catheter should be left in
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15
Q

features of chronic urinary retention

A
  • painless
  • insidious
  • decompression haematuria common on catheterisation

high pressure CUR:
- impaired renal function and bilateral hydronephrosis
- typically due to bladder outflow obstruction
low pressure CUR:
- normal renal function and no hydronephrosis

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16
Q

types of incontinence

A
  • urge incontinence, due to detrusor hyperactivity
  • stress incontinence, due to increased pressure on bladder
  • mixed
  • overflow incontinence, due to bladder outlet obstruction, eg. BPH
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17
Q

investigations for incontinence

A
  • bladder diary (should be kept for at least 3 days)
  • vaginal examination to exclude pelvic organ prolapse
  • urodynamic studies
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18
Q

food/drug causes of haematuria appearance

A 
foods: 
     > beetroot
     > rhubarb
drugs: 
     > rifampicin
     > doxorubicin
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19
Q

criteria for an urgent 2WW referral for haematuria

A

Aged 45+ years AND:
- unexplained visible haematuria without urinary tract infection
OR
- visible haematuria that persists or recurs after successful treatment of urinary tract infection

Aged 60+ years AND:
- have unexplained nonvisible haematuria and either:
> dysuria
OR
> a raised white cell count on blood test

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20
Q

risk factors for transitional cell carcinoma

A
  • age
  • smoking
  • alcohol
  • exposure to aniline dyes in the printing and textile industry
  • rubber manufacture
  • cyclophosphamide
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21
Q

risk factors for squamous cell carcinoma of the bladder

A
  • smoking
  • schistosomiasis
  • chronic irritation (eg. recurrent UTI/calculi)
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22
Q

features of bladder cancer

A
  • painless, macroscopic haematuria
  • may have LUTS
  • weight loss, anaemia, etc
    (mucous in urine may be a sign of adenocarcinoma)
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23
Q

management of bladder cancer

A
  • superficial lesions may be managed using TURBT in isolation
  • with recurrences or higher grade/risk may be offered intravesical chemotherapy
    T2 staging+ offered:
  • surgery (radical cystectomy with ileal conduit)
  • radiotherapy
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24
Q

types of renal calculus

A
  • calcium oxalate (85%)
  • calcium phosphate
  • uric acid
  • struvite
  • cystine
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25
Q

risk factors for renal calculi

A
  • dehydration
  • hypercalciuria, hyperparathyroidism, hypercalcaemia
  • high dietary oxalate (beer, beans, coffee, beetroot)
  • renal tubular acidosis
  • medullary sponge kidney, polycystic kidney disease

for urate, also:

  • gout
  • ileostomy: loss of bicarbonate and fluid results in acidic urine, precipitating uric acid
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26
Q

features of renal calculus

A
  • loin pain: typically severe, colic pain
  • nausea and vomiting
  • haematuria
  • dysuria
  • secondary infection may cause fever
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27
Q

imaging for renal calculi

A
  • non-contrast CT KUB should be performed on all patients, within 14 hours of admission
  • if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed to exclude diagnoses such as ruptured abdominal aortic aneurysm
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28
Q

non-emergency management of renal calculus

A
  • <5mm stones should pass without intervention
  • PR diclofenac for pain relief
  • shockwave lithotripsy (not in pregnancy)
  • percutaneous nephrolithotomy (big stones)
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29
Q

emergency management of renal calculus

A

ureteric obstruction with infection = emergency surgery

  • nephrostomy tube placement
  • insertion of ureteric catheters
  • ureteric stent placement
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30
Q

prevention of oxalate stones

A
  • dietary (reduce coffee, beer, beans, beetroot)

- cholestyramine reduces urinary oxalate secretion

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31
Q

prevention of uric acid stones

A
  • dietary (reduce alcohol, seafood, bacon, turkey, liver)
  • allopurinol
  • urinary alkalinisation e.g. oral bicarbonate
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32
Q

UTI management in pregnancy

A

7 day course of:

  • nitrofurantoin (should be avoided near term)
  • amoxicillin or cefalexin (if near term)

NOT TRIMETHOPRIM

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33
Q

risk factors for testicular cancer

A
  • peak incidence at 25 (teratoma) and 35 (seminoma)
  • infertility (increases risk by a factor of 3)
  • undescended testes
  • family history
  • Klinefelter’s syndrome
  • mumps orchitis
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34
Q

features of testicular cancer

A
  • painless lump (rarely men may have pain)
  • can also have:
    > hydrocele
    > gynaecomastia
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35
Q

diagnosis of testicular cancer

A
  • ultrasound scan = important first line

- tumour markers (aFP, LDH, hCG)

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36
Q

categorisation of testicular cancer

A
  • seminoma
    > occur in all age groups
    > in general, aren’t as aggressive as nonseminomas
  • nonseminoma
    > tend to develop earlier in life and grow and spread rapidly
    > includes choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumor
37
Q

management of testicular cancer

A
  • orchidectomy (+ prosthesis if desired)
  • sperm banking (treatment may cause infertility, but should be fertile with 1 testicle)
  • chemotherapy (more cycles in higher grade cancer)
  • radiotherapy in seminoma/advanced cancer
38
Q

tumour markers for each type of testicular cancer

A
  • seminoma (germ cell), choriocarcinoma (NGC), teratoma (NGC) = may release hCG
  • embryonal (NGC) = aFP or hCG
  • yolk sac (NGC) = aFP commonly secreted
  • leydig (stromal) = testosterone
39
Q

features of hydrocele

A

accumulation of fluid within the tunica vaginalis

  • soft, non-tender swelling of the hemi-scrotum (usually anterior to and below the testicle)
  • the swelling is confined to the scrotum, you can get above the mass on examination
  • transilluminates with a pen torch
40
Q

management of hydrocele

A
  • infantile hydroceles are repaired if they do not resolve spontaneously by 1-2 years
  • in adults a conservative approach may be taken depending on the severity
    > ultrasound usually warranted to exclude any underlying cause eg. tumour
41
Q

causes of hydrocele

A
  • idiopathic
  • testicular abnormality
    > epidiymo-orchitis
    > torsion
    > tumour
42
Q

features of epididymal cyst

A
  • most common cause of scrotal swellings seen in primary care
  • separate from the body of the testicle
  • found posterior to the testicle
43
Q

management of epididymal cyst

A
  • reassurance

- may be removed surgically if too uncomfortable

44
Q

features of varicocele

A
  • abnormal enlargement of the testicular veins
  • usually left sided
  • may have aching/dragging feeling
  • less discomfort on lying down
  • “bag of worms”
45
Q

causes of varicocele

A
  • idiopathic
  • ineffective vein valves in spermatic cord
  • can be a sign of renal cell carcinoma, due to testicular vein draining to renal vein (tumour obstruction causes backlog)
46
Q

complications of varicocele

A
  • infertility (typically only if bilateral)

- testicular atrophy

47
Q

diagnosis/management of varicocele

A
  • ultrasound with doppler

- surgery if troublesome

48
Q

features of testicular torsion

A
  • twist of the spermatic cord resulting in testicular ischaemia and necrosis
  • peak incidence 13-15 years
  • sudden onset, severe pain
  • O/E swollen, tender testis retracted upwards, skin may be reddened
  • cremasteric reflex lost
  • elevation does not relieve pain (unlike epididymo-orchitis)
49
Q

management of testicular torsion

A

urgent paeds/urology surgical referral

- fixation of BOTH testes

50
Q

features of epididymo-orchitis

A

EXCLUDE TESTICULAR TORSION

  • infection of the epididymis +/- testes
  • commonly caused by local spread of infection from the genital tract or bladder
  • unilateral testicular pain and swelling
  • urethral discharge may be present
  • UTI/STI history
51
Q

management of epididymo-orchitis

A

if organism is unknown:
- ceftriaxone 500mg IM single dose AND
- doxycycline 100mg PO twice daily for 10-14 days
if known, use sensitive Abx
also:
- pain relief if required
- urethral smear/urinalysis/urine culture for sensitivities

52
Q

direct vs indirect inguinal hernia

A

direct:

  • hernia comes through inguinal canal posterior wall defect, rather than deep ring
  • protrudes outwards, rather than down towards scrotum

indirect:

  • hernia comes through deep ring of inguinal canal
  • protrudes obliquely (does not protrude towards scrotum)

direct and indirect both have same management

53
Q

management of inguinal hernia

A
  • surgical repair

- hernia truss for those not appropriate for surgery

54
Q

features of testicular appendage torsion

A
  • superior pole of the testis is tender
  • blue dot sign may be visible
  • cremasteric reflex is preserved
55
Q

features of TURP syndrome

A
  • rare and life-threatening complication of transurethral resection of the prostate surgery
  • due to irrigation with glycine (hyperosmolar) causing hyponatraemia
56
Q

vasectomy

A
  • simple operation, can be done under LA
  • go home after a couple of hours
  • not immediately effective
  • semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (16 and 20 weeks)
  • the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
57
Q

complications of vasectomy

A
  • chronic testicular pain (affects between 5-30% men)
  • bruising
  • haematoma
  • infection
  • sperm granuloma
58
Q

most common cause of prostatitis

A

E. coli

59
Q

features of prostatitis

A
  • pain: may be referred to the perineum, penis, rectum or back
  • obstructive LUTS
  • fever/rigors
  • tender, boggy prostate on DRE
60
Q

features of Wilms’ tumour

A
  • usually present in first 4 years of life
  • often presents as a mass associated with haematuria (pyrexia may occur in 50%)
  • often metastasise early (usually to lung)
  • treated by nephrectomy
  • younger children have better prognosis (<1 year of age =80% overall 5 year survival)
61
Q

features of chlamydia

A
  • caused by chlamydia trachomatis
  • asymptomatic in around 70% of women and 50% of men
  • women:
    > discharge
    > bleeding
    > dysuria
  • men:
    > urethral discharge (white, cloudy or watery)
    > dysuria
  • can cause conjunctivitis
62
Q

investigations for chlamydia

A

NAAT testing with:
- for women: vulvovaginal swab
- for men: first void urine test
testing should be done 2 weeks after exposure due to incubation period

63
Q

management of chlamydia

A

referral to GUM

  • doxycycline 100 mg twice daily for 7 days
  • if cannot tolerate doxycycline, eg pregnancy/allergy, azithromycin 1 g orally for one day, then 500mg orally once daily for two days
  • advise that sexual intercourse (including oral sex) is avoided until treatment completed (or waited 7 days after treatment with azithromycin)
  • advise safe sex practices
  • recommend screening for other STIs
64
Q

partner notification in chlamydia

A
  • for men with urethral symptoms:
    > all contacts since, and in the four weeks prior to, the onset of symptoms
  • for women and asymptomatic men:
    > all partners from the last six months or the most recent sexual partner should be contacted
  • contacts of confirmed chlamydia cases should be treated regardless of test result
65
Q

complications of chlamydia

A 
- pelvic inflammatory disease
     > increased incidence of ectopic pregnancies
     > infertility
- epididymo-orchitis
- endometritis
- reactive arthritis
66
Q

features of gonorrhoea

A
  • males: urethral discharge (white, green or yellow), dysuria
  • females: vaginal discharge (thin/watery, green or yellow), dysuria
  • rectal and pharyngeal infection is usually asymptomatic
  • can cause conjunctivitis
67
Q

complications of gonorrhoea

A
  • urethral stricture
  • epididymo-orchitis
  • pelvic inflammatory disease (may lead to infertility)
  • disseminated infection
    > tenosynovitis/polyarthritis/septic arthritis
    > dermatitis (lesions can be maculopapular or vesicular)
68
Q

management of gonorrhoea

A

referral to GUM

  • swabs for NAAT and sensitivities
  • if known gonorrhoea, give ciprofloxacin 500mg single PO dose
  • empirical treatment is IM ceftriaxone 1g
  • advise safe sex practices
  • recommend screening for other STIs
  • advise to abstain from sex until they, and any partners, have completed treatment
69
Q

features of lymphogranuloma venereum (LGV)

A
  • caused by chlamydia trachomatis
  • typically infection comprises of three stages:
    > 1: small painless pustule which later forms an ulcer
    > 2: painful inguinal lymphadenopathy
    > 3: proctocolitis (diarrhoea, inflamm, bleeding)
70
Q

management of lymphogranuloma venereum (LGV)

A

referral to GUM

  • doxycycline 100 mg twice daily for 3 weeks (longer than usual chlamydia)
  • advise safe sex practices
  • recommend screening for other STIs
71
Q

features of mycoplasma genitalium

A 
usually asymptomatic but when symptomatic:
- men
     > urethritis
     > dysuria
     > pain on ejaculation
     > watery or cloudy discharge
- women
     > urethritis
     > increased or altered vaginal discharge.
     > IMB
     > dyspareunia
     > discharge or bleeding after intercourse
72
Q

management of mycoplasma genitalium

A

referral to GUM

  • doxycycline 100 mg twice daily for 7 days
  • if cannot tolerate doxycycline, eg pregnancy/allergy, azithromycin 1 g orally for one day, then 500mg orally once daily for two days
  • advise that sexual intercourse (including oral sex) is avoided until treatment completed (or waited 7 days after treatment with azithromycin)
  • advise safe sex practices
  • recommend screening for other STIs
73
Q

causative organism of syphilis

A

treponema pallidum

- spirochaete

74
Q

features of syphilis

A

PRIMARY
- chancre - painless ulcer at the site of sexual contact
- local lymphadenopathy
SECONDARY (6-10wks after infection)
- systemic: fever, lymphadenopathy, malaise
- rash on trunk, palms and soles
- ‘snail track’ mouth ulcers (30%)
- painless, warty lesions on the genitalia
TERTIARY
- gummas (granulomatous lesions spread to other organs)
- ascending aortic aneurysms
- neurosyphilis
- Argyll-Robertson pupil

75
Q

management of syphilis

A
  • intramuscular benzylpenicillin first-line (doxycycline if allergy)
  • Jarisch-Herxheimer reaction sometimes seen following treatment
    > fever, rash, tachycardia after the first dose of antibiotic
    > unlike anaphylaxis, there is no wheeze or hypotension
76
Q

features of trichomonas vaginalis/trichomoniasis

A 
- vaginal discharge
     > smelly
     > yellow/green
     > frothy
- vulvovaginitis
- strawberry cervix
- pH > 4.5
- in men is usually asymptomatic but may cause urethritis
77
Q

management of trichomonas vaginalis/trichomoniasis

A

GUM referral

- oral metronidazole (400–500 mg twice a day for 5–7 day OR can give metronidazole 2g as a single oral dose)

78
Q

features of genital herpes

A
  • primary infection: may present with a severe ulceration and pain
  • urinary retention may occur
  • painful genital ulceration
79
Q

management of genital herpes

A

oral aciclovir

  • with recurrent episodes prophylactic aciclovir may be prescribed
  • elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
80
Q

HPV strains

A

HPV 6 & 11: causes genital warts

HPV 16 & 18: linked to a variety of cancers, most notably cervical cancer

81
Q

pubic lice features

A
  • itching, especially at night
  • black powder in underwear
  • small spots of blood on your skin caused by lice bites
82
Q

management of pubic lice

A

GUM referral

  • insecticide cream
  • STI screening
83
Q

features of thrush/candida albicans

A
  • non-offensive ‘cottage cheese’ discharge
  • vulvitis: dyspareunia, dysuria
  • itching
84
Q

management of thrush/candida albicans

A

local or oral treatment

  • local = clotrimazole pessary stat
  • oral = itraconazole bd for 1 day (CI in pregnancy, use local)
85
Q

features of bacterial vaginosis

A
  • asymptomatic in 50%
  • vaginal discharge:
    > ‘fishy’ (positive whiff test with KOH)
    > thin, white
  • clue cells on microscopy
  • pH > 4.5
86
Q

management of bacterial vaginosis

A
  • oral metronidazole for 5-7 days (topical if preferred)
87
Q

investigations for erectile dysfunction

A
  • CV health Q risk

- free testosterone (can add FSH/LH/prolactin)

88
Q

management of erectile dysfunction

A
  • PDE-5 inhibitor, eg. sildenafil = first line

- vacuum pumps if sildenafil not appropriate

WFH (18 decks)

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