Urology and GUM Flashcards
Presentation of prostate cancer
2WW for asymptomatic screening raised PSA
Abnormal DRE
weight loss investigations
bone pain
renal failure
investigations for prostate cancer
MRI
US biopsy
how can the US biopsy for prostate cancer be taken
trans-rectally
trans-perineum
management options for prostate cancer
surgery: robotic prostatectomy
external beam radiotherapy + androgen deprivation therapy
brachytherapy
active surveillance
watchful waiting
ADT drugs used in prostate cancer in risks
LHRH agonist e.g. leuporelin; risk = tumour flare; give anti-androgen tablet a week before and after starting
LHRH antagonist e.g. degarelix
side effects of ADT
weight gain, hot flushes, cognitive impairment, osteoporosis, metabolic syndrome, erectile dysfunction
what is brachytherapy
o Radiation seeds put into prostate under GA
what is the difference between active surveillance and watchful waiting
active surveillance: deferred radical treatment + close monitoring
PSA: every 3 months
DRE: every 6 months
TRUS and biopsy annually to check progression
watchful waiting: deferred palliative treatment
where does prostate cancer usually metastasise to
bones
lymph nodes
management of spinal cord compression
o V Urgent MRI spine o Steroids – 8mg oral steroids BD 8am + 2pm (don’t give at bedtime) o PPI o Bedrest o RT/neurosurgery
investigations for haematuria
flexible cystoscopy
CTIVU
investigations for LUTS
ipss score
frequency volume chart
flow rate
complications of poor bladder emptying
- Kidney obstruction due to backlog; can lead to renal failure
- Bladder stones: e.g. Jackstone; stagnant urine predisposes to stone formation
investigations for someone presenting with possible stones
non contrast CT
bloods: U+E, Ca, uric acid
exclude sepsis
immediate management of someone with stones
pain relief
what is paraphimosis
o Tight foreskin, stuck behind corona –> swells up; can’t be pulled up over glans penis
questions to ask both sexes as part of a sexual health history
o Last sexual intercourse o Regular/casual partner o Male/female o Condom use o Type of Sexual intercourse
questions to ask women as part of a sexual history
Menstrual history
Pregnancy history
Contraception
Cervical cytology history
questions to ask en as part of a sexual history
when last voided urine
asymptomatic screening for women
o Self-taken Vulvo-vaginal swab for Gonorrhoea/Chlamydia NAAT (Nucleic Acid Amplification Test)
o Blood for STS + HIV
asymptomatic screening for heterosexual men
first void urine for chlamydia/gonorrhoea NAAT
bloods test for STS + HIV
asymptomatic screening for MSM
first void urine for chlamydia/gonorrhoea NAAT
rectal and pharyngeal swab for chlamydia/gonorrhoea NAAT
blood tests for STS, HIV, Hep B (+ C indicated)
when is hep b screening indicated
MSM
CSW and partners
IVDU and sex partners
people from high risk areas and their partners (africa, asia, eastern europe)
symptoms of GU disease in women
- Vaginal discharge
- Vulval discomfort/soreness, itching or pain
- Superficial dyspareunia
- Pelvic pain/deep dyspareunia
- Vulval lumps
- Vulval ulcers
- Inter-menstrual or post coital bleeding
symptoms of GU disease in men
- Pain/burning during micturition
- Pain/discomfort in the urethra
- Urethral discharge
- Genital ulcers, sores or blisters
- Genital lumps
- Rash on penis or genital area
- Testicular pain/swelling
symptomatic STI screen for women
vulvo-vaginal swab for gonorrhoea + chlamydia NAAT
high vaginal swab (wet + dry) for BV, TV and candida
cervical swab for slides + gonorrhoea culture
dipstick urinalysis if dysuria present
bloods for STS and HIV
symptomatic STI screen for heterosexual men
urethral swab for slide + gonorrhoea culture
first void urine for gonorrhoea + chlamydia NAAT
dipstick urine if dysuria
bloods for STS + HIV
symptomatic STI screen for MSM
tests as for asymptomatic screen
+ urethral and rectal slides
+ urethral, rectal, pharyngeal culture plates
what is pyuria
presence of leucocytes in the urine
what are the 2 clinical syndrome subtypes of UTIs
- Lower tract: cystitis (infection of bladder)
* Upper tract: pyelonephritis (infection of kidney and upper tracts)
how can bacteriuria be classified
asymptomatic
symptomatic
- uncomplicated
- complicated
what is the difference between complicated and uncomplicated bacteriuria
uncomplicated bacteriuria: non pregnant women with normal urinary tract
complicated: pretty much everyone else - men, pregnant women, children, urosepsis, structural abnormality etc.
what is the difference in treatment between complicated and uncomplicated bacteriuria
uncomplicated: 3 days oral antibiotics
complicated: 7 days; may need IV if systemically unwell
what are the 3 most common pathogens. that cause UTIs
E coli
proteus
klebseilla
which UTI causing pathogens are gram negative rods
proteus
e coli
klebseila
pseudomonas aeruginosa
which UTI causing pathogens are gram positive cocci
staph aureus
staph saprophyticus
enterococci
which UTI causing pathogen is associated with renal stones and through which mechanism
proteus - increases pH
which UTI causing pathogen is associated with hospitals/catheters
klebseilla
what are risk factors for UTIs
- Female
- Previous UTIs
- Post-menopausal
- Age
- Diabetes
- Pregnancy
- Anatomical abnormalities of urinary tract
- Catheters
which features contribute to UTI formation
stasis during pregnancy
pathogen adaptation e.g. ecoli fimbriae, proteus + pH
short urethra in women
catheterisation –> colonisation
poor urinary flow
obstruction: bladder tumor/stones; ureteric stones, prostatic enlargement
signs of UTI
supra-pubic pain
delirium
pyelonephritis
- renal angle tenderness
- haematuria
- sepsis
UTI symptoms
Dysuria Frequency Urgency Malodorous urine Strangury
pyelonephritis: loin pain, pyrexia, rigors, haematuria
investigations for UTI and what they show
dipstick: leucocytes and nitrates
MSU microscopy, culture and sensitivity: WBC > 10^4; Bacteria > 10^5
lifestyle advice for UTI
increase fluid intake
void before and after intercourse
good hygiene
what is the 1st line antibiotic for uncomplicated UTI
nitrofurantoin 50mg QDS
when is nitrofurantoin contraindicated
allergy
final trimester pregnancy
renal function <45ml/min
investigations for UTI in pregnancy
culture instead of dipstick and confirm with second sample
when should you treat asymptomatic bacteriuria and why
pregnant women
20-40% develop acute symptomatic pyelonephritis if untreated
definition of recurrent UTI
more than 2 infections within 6 months or 3 within a year
management of recurrent UTI
stepwise
conservative e.g. control diabetic blood sugar, avoid constipation, vaginal oestrogens etc.
self start antibiotics
post-coital prophylaxis
long term low dose prophylaxis
most common group affected by pyelonephritis
women <35
classic triad of pyelonephritis
fever
loin pain
pyuria
management of pyelonephritis
o Fluid replacement due to hypokalaemia
o IV antibiotics: broad spectrum; e.g. co-amoxiclav
o Drain obstructed kidney if present
o Catheter
o Analgesia
o Complete 7-14 (depending in antibiotic choice)
complications of pyelonephritis
renal abscess
emphysematous pyelonephritis
genes associated with prostate cancer
Genetics: HPC-1 (hereditary prostate cancer gene); BRCA-1+2
what factors are associated with prostate cancer
age - rare before the age of 50
ethnicity - black men
diet - less common in Japan and the far east where there is an increased use of soy
peak incidence of prostate cancer is at which age
men in their 70s
what zone of the prostate does BPH usually occur
transitional zone
what zone of the prostate do most prostate cancers occur
peripheral zone
which bones do prostate cancers usually metastasise to
Axial skeleton most common (spine and pelvis), followed by proximal long bones, clavicles and ribs
signs and symptoms of prostate cancer
- Lower urinary tract symptoms
- Haematospermia (blood in semen)
- Incidental finding with raised PSA
- Abnormal DRE (hard, nodular, craggy)
- Bone or back pain (due to metastases)
- Signs of metastatic spread
investigations for prostate cancer
PSA DRE MRI US biopsy bone scan to look for bone metastases
arguments for screening for prostate cancer
- Common condition
- Acceptable and cheap screening test
- Screening reduces deaths from prostate cancer
arguments against screening for prostate cancer
- Not extremely specific or sensitive
- Morbidity from biopsies
- Over-diagnosis
- Over-treatment
- “prostate specific anxiety”
which scoring system is used to grade prostate cancer
gleason’s pattern scale
staging of prostate cancer
- T1: impalpable, picked up via PSA + biopsy
- T2: palpable but localised
- T3: locally advanced – e.g. into seminal vesicle
- T4: advanced going into other structures e.g. rectum
what groups are suitable for active surveillance
Gleason group 1 + 2
what does radical prostatectomy involve
o Removal of prostate and seminal vesicles
o Bladder anastomosed to urethra
o Lymph node dissection
o Urethral catheter for 10 days post-op
what does external beam radiotherapy involve
o 3/12 neo-adjuvant hormones to shrink prostate beforehand
o Adjuvant hormones for up to 3 years
o Side effects – LUTS, GI symptoms e.g. rectal discomfort or bleeding, erectile dysfunction (30-50%)
o Risk of second malignancy in long term survivors (1 in 70)
what does brachytherapy involve and when is it contraindicated
o US guided trans-perineal implantation of radioactive seeds I125
o Contraindicated in previous TURP, large prostate and moderate to severe LUTS
examples of focal therapies
high intensity focused ultrasound (HIFU), cryotherapy, photodynamic therapy
example of a peripheral androgen receptor antagonist
bicalutamide
when can peripheral androgen receptor antagonist
- in combination with LHRH agonist to prevent tumour flare
- can be used in monotherapy
- can be used with LHRH agonist long-term for maximum androgen blockade in castrate resistant disease
metastatic prostate cancer treatment options
- ADT
- docetaxel chemotherapy
- bone targeted therapies e.g zoledronic acid
- palliative radiotherapy
other: carbizitaxel chemotherapy, Abiraterone and Enzalutamide hormone therapy , immunotherapy
complications of metastatic prostate cancer
bone pain fractures hypercalcaemia SCC retention of urine obstructive uropathy
how to manage obstructive uropathy
Nephrostomy: tube placed into kidneys through skin to relieve pressure and allow renal function to normalise
• For severe symptoms e.g. renal failure, hyperkalaemia. (bring potassium levels down first using medical management)
Can also use renal stenting through bladder if symptoms are not too severe (requires GA)
Always check bladder is empty and symptoms not due to chronic retention
what are differentials for visible haematuria
o Menstruation
o Vigorous exercise e.g. long-distance running
o Nephrological disease (usually have associated symptoms/ renal impairment)
o Beeturia
o Drugs e.g. rifampicin and sulphonamides
questions to ask a patient presenting with haematuria
o When does it occur?
Initial: suggestive of urethral pathology
Throughout
Terminal: suggestive base of bladder or prostatic pathology
o Any clots?
Might be at risk of clot retention
o Any pain (flank - kidney, suprapubic, dysuria)?
o How long has this been a problem; how often does it occur
o Associated features e.g. occupation, smoking history, weight loss
common causes of haematuria
• Kidneys
o Pelvis-calyceal: TCC, stones
o Pre-renal: e.g. clotting disorders, rhabdomyolysis (myoglobinuria)
o Renal: e.g. glomerulonephritis, acute tubular necrosis, Henoch-Schoenlein purpura, cancer, trauma
• Ureters
o TCC, stones
• Bladder
o TCC, other cancers, stone, cystitis, radiation cystitis, UTI
• Prostate
o Malignancy, BPE, Prostatitis
• Urethra
o TCC, trauma
• Vagina
o Rule out vaginal bleeding
• Pseudo-haematuria
o E.g. beetroot, rifampicin
investigations for haematuria
exclude UTI check renal function USS kidneys (non-visible, poor kidney function <40)/CTIVU flexible cystoscopy (consider PSA)
initial management of someone with significant haematuria
ABCDE: oxygen, IV access, fluids
bloods: clotting, group and save, U+E FBC
catheter: 3-way catheter, urine sample, irrigation/washouts
indications for urological 2ww
• 2WW: aged 45 and over with:
o Unexplained visible haematuria without a UTI or
o Visible haematuria that persists after successful UTI treatment
o Aged 60+ with unexplained non-visible haematuria and dysuria or raised WCC on blood test
• Routine referral: 60+ with recurrent or persistent UTIs
risk factors for bladder cancer
- Aged over 40
- History of smoking
- Exposure to dyes or cyclophosphamides
- Previous bladder irradiation
- Irritative bladder symptoms
when is the peak incidence of chlamydia
16 - 25
what gender has a higher incidence of chlamydia
women
what gender has a higher incidence of gonorrhoea
men
peak incidence of gonorrhoea in men
roughly 19 - 30
proper name for chlamydia
chlamydia trachomatis
proper name for gonorrhoea
Neisseria gonorrhoea
areas of the body affected by chlamydia/gonorrhoea in adults
urethra, endocervical canal, rectum, pharynx, conjunctiva,
areas of the body affected by chlamydia/gonorrhoea in neonates
conjunctiva
lungs - atypical pneumonitis (chlamydia)
incubation period for chlamydia
men: 7 - 21 days
women: ill defined
incubation period for gonorrhoea
men: 2 - 5 days
women: up to 10 days
% of gonorrhoea patients who are asymptomatic
men: 10%
women: 50%
% of chlamydia patients who are asymptomatic
men: at least 50%
women: over 70%
presentation of chlamydia/gonorrhoea in men
dysuria
urethral discharge
presentation of chlamydia/gonorrhoea in women
dysuria
vaginal discharge
menstrual irregularity
complications of gonorrhoea/chlamydia in men
epididymo-orchitis
reactive arthritis
(more likely to occur due to chlamydia infection)
complications of gonorrhoea/chlamydia in women
- Pelvic inflammatory disease –> tubal factor infertility, ectopic pregnancy, chronic pelvic pain
- Neonatal transmission: ophthalmia neonatorum, atypical pneumonia (with CT)
- Fitz Hugh Curtis Syndrome: peri-hepatitis
tests to diagnose chlamydia
NAAT
women: self-collected vaginal swab
men: first void urine
first line management of chlamydia
Doxycycline 100mg bd for 7 days
management of chlamydia in pregnant women
Azithromycin 1g followed by 500mg daily for 2 days currently recommended if doxycycline is not suitable
what resistant condition is associated with chlamydia
mycoplasma genitalium
how to prevent resistance when treating chlamydia
give 1 large dose of azithromycin if using followed by smaller doses for following 2 days
antibiotics resistance testing
test of cure 5 weeks later
diagnosing gonorrhoea
microscopy of gram stained smears: urethra, endocervix and rectum
Culture on selective medium to confirm
sensitivity testing
NAAT
pharmacological management of gonorrhoea
1mg ceftriaxone IM
factors in the STI/HIV transmission model
reproductive rate: >1 = chance of infection
behavioural factors: some sexual behaviours increase risk of transmission
chances of infection: e.g. number of partners
Duration of infection/until diagnosis
