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Phase 3b > Urology and GUM > Flashcards

Urology and GUM Flashcards

1
Q

Presentation of prostate cancer

A

2WW for asymptomatic screening raised PSA

Abnormal DRE

weight loss investigations

bone pain

renal failure

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2
Q

investigations for prostate cancer

A

MRI

US biopsy

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3
Q

how can the US biopsy for prostate cancer be taken

A

trans-rectally

trans-perineum

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4
Q

management options for prostate cancer

A

surgery: robotic prostatectomy

external beam radiotherapy + androgen deprivation therapy

brachytherapy

active surveillance

watchful waiting

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5
Q

ADT drugs used in prostate cancer in risks

A

LHRH agonist e.g. leuporelin; risk = tumour flare; give anti-androgen tablet a week before and after starting

LHRH antagonist e.g. degarelix

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6
Q

side effects of ADT

A

weight gain, hot flushes, cognitive impairment, osteoporosis, metabolic syndrome, erectile dysfunction

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7
Q

what is brachytherapy

A

o Radiation seeds put into prostate under GA

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8
Q

what is the difference between active surveillance and watchful waiting

A

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

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9
Q

where does prostate cancer usually metastasise to

A

bones

lymph nodes

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10
Q

management of spinal cord compression

A 
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
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11
Q

investigations for haematuria

A

flexible cystoscopy

CTIVU

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12
Q

investigations for LUTS

A

ipss score
frequency volume chart
flow rate

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13
Q

complications of poor bladder emptying

A
  • Kidney obstruction due to backlog; can lead to renal failure
  • Bladder stones: e.g. Jackstone; stagnant urine predisposes to stone formation
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14
Q

investigations for someone presenting with possible stones

A

non contrast CT
bloods: U+E, Ca, uric acid
exclude sepsis

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15
Q

immediate management of someone with stones

A

pain relief

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16
Q

what is paraphimosis

A

o Tight foreskin, stuck behind corona –> swells up; can’t be pulled up over glans penis

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17
Q

questions to ask both sexes as part of a sexual health history

A 
o	Last sexual intercourse
o	Regular/casual partner
o	Male/female
o	Condom use
o	Type of Sexual intercourse
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18
Q

questions to ask women as part of a sexual history

A

 Menstrual history
 Pregnancy history
 Contraception
 Cervical cytology history

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19
Q

questions to ask en as part of a sexual history

A

when last voided urine

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20
Q

asymptomatic screening for women

A

o Self-taken Vulvo-vaginal swab for Gonorrhoea/Chlamydia NAAT (Nucleic Acid Amplification Test)

o Blood for STS + HIV

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21
Q

asymptomatic screening for heterosexual men

A

first void urine for chlamydia/gonorrhoea NAAT

bloods test for STS + HIV

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22
Q

asymptomatic screening for MSM

A

first void urine for chlamydia/gonorrhoea NAAT

rectal and pharyngeal swab for chlamydia/gonorrhoea NAAT

blood tests for STS, HIV, Hep B (+ C indicated)

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23
Q

when is hep b screening indicated

A

MSM
CSW and partners
IVDU and sex partners
people from high risk areas and their partners (africa, asia, eastern europe)

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24
Q

symptoms of GU disease in women

A
  • Vaginal discharge
  • Vulval discomfort/soreness, itching or pain
  • Superficial dyspareunia
  • Pelvic pain/deep dyspareunia
  • Vulval lumps
  • Vulval ulcers
  • Inter-menstrual or post coital bleeding
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25
Q

symptoms of GU disease in men

A
  • 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
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26
Q

symptomatic STI screen for women

A

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

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27
Q

symptomatic STI screen for heterosexual men

A

urethral swab for slide + gonorrhoea culture

first void urine for gonorrhoea + chlamydia NAAT

dipstick urine if dysuria

bloods for STS + HIV

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28
Q

symptomatic STI screen for MSM

A

tests as for asymptomatic screen
+ urethral and rectal slides
+ urethral, rectal, pharyngeal culture plates

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29
Q

what is pyuria

A

presence of leucocytes in the urine

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30
Q

what are the 2 clinical syndrome subtypes of UTIs

A
  • Lower tract: cystitis (infection of bladder)

* Upper tract: pyelonephritis (infection of kidney and upper tracts)

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31
Q

how can bacteriuria be classified

A

asymptomatic
symptomatic
- uncomplicated
- complicated

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32
Q

what is the difference between complicated and uncomplicated bacteriuria

A

uncomplicated bacteriuria: non pregnant women with normal urinary tract

complicated: pretty much everyone else - men, pregnant women, children, urosepsis, structural abnormality etc.

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33
Q

what is the difference in treatment between complicated and uncomplicated bacteriuria

A

uncomplicated: 3 days oral antibiotics
complicated: 7 days; may need IV if systemically unwell

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34
Q

what are the 3 most common pathogens. that cause UTIs

A

E coli
proteus
klebseilla

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35
Q

which UTI causing pathogens are gram negative rods

A

proteus
e coli
klebseila
pseudomonas aeruginosa

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36
Q

which UTI causing pathogens are gram positive cocci

A

staph aureus
staph saprophyticus
enterococci

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37
Q

which UTI causing pathogen is associated with renal stones and through which mechanism

A

proteus - increases pH

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38
Q

which UTI causing pathogen is associated with hospitals/catheters

A

klebseilla

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39
Q

what are risk factors for UTIs

A
  • Female
  • Previous UTIs
  • Post-menopausal
  • Age
  • Diabetes
  • Pregnancy
  • Anatomical abnormalities of urinary tract
  • Catheters
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40
Q

which features contribute to UTI formation

A

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

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41
Q

signs of UTI

A

supra-pubic pain
delirium

pyelonephritis

  • renal angle tenderness
  • haematuria
  • sepsis
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42
Q

UTI symptoms

A 
Dysuria 
Frequency 
Urgency 
Malodorous urine 
Strangury

pyelonephritis: loin pain, pyrexia, rigors, haematuria

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43
Q

investigations for UTI and what they show

A

dipstick: leucocytes and nitrates

MSU microscopy, culture and sensitivity: WBC > 10^4; Bacteria > 10^5

44
Q

lifestyle advice for UTI

A

increase fluid intake
void before and after intercourse
good hygiene

45
Q

what is the 1st line antibiotic for uncomplicated UTI

A

nitrofurantoin 50mg QDS

46
Q

when is nitrofurantoin contraindicated

A

allergy
final trimester pregnancy
renal function <45ml/min

47
Q

investigations for UTI in pregnancy

A

culture instead of dipstick and confirm with second sample

48
Q

when should you treat asymptomatic bacteriuria and why

A

pregnant women

20-40% develop acute symptomatic pyelonephritis if untreated

49
Q

definition of recurrent UTI

A

more than 2 infections within 6 months or 3 within a year

50
Q

management of recurrent UTI

A

stepwise

conservative e.g. control diabetic blood sugar, avoid constipation, vaginal oestrogens etc.

self start antibiotics

post-coital prophylaxis

long term low dose prophylaxis

51
Q

most common group affected by pyelonephritis

A

women <35

52
Q

classic triad of pyelonephritis

A

fever
loin pain
pyuria

53
Q

management of pyelonephritis

A

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)

54
Q

complications of pyelonephritis

A

renal abscess

emphysematous pyelonephritis

55
Q

genes associated with prostate cancer

A

Genetics: HPC-1 (hereditary prostate cancer gene); BRCA-1+2

56
Q

what factors are associated with prostate cancer

A

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

57
Q

peak incidence of prostate cancer is at which age

A

men in their 70s

58
Q

what zone of the prostate does BPH usually occur

A

transitional zone

59
Q

what zone of the prostate do most prostate cancers occur

A

peripheral zone

60
Q

which bones do prostate cancers usually metastasise to

A

Axial skeleton most common (spine and pelvis), followed by proximal long bones, clavicles and ribs

61
Q

signs and symptoms of prostate cancer

A
  • 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
62
Q

investigations for prostate cancer

A 
PSA
DRE
MRI
US biopsy 
bone scan to look for bone metastases
63
Q

arguments for screening for prostate cancer

A
  • Common condition
  • Acceptable and cheap screening test
  • Screening reduces deaths from prostate cancer
64
Q

arguments against screening for prostate cancer

A
  • Not extremely specific or sensitive
  • Morbidity from biopsies
  • Over-diagnosis
  • Over-treatment
  • “prostate specific anxiety”
65
Q

which scoring system is used to grade prostate cancer

A

gleason’s pattern scale

66
Q

staging of prostate cancer

A
  • 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
67
Q

what groups are suitable for active surveillance

A

Gleason group 1 + 2

68
Q

what does radical prostatectomy involve

A

o Removal of prostate and seminal vesicles
o Bladder anastomosed to urethra
o Lymph node dissection
o Urethral catheter for 10 days post-op

69
Q

what does external beam radiotherapy involve

A

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)

70
Q

what does brachytherapy involve and when is it contraindicated

A

o US guided trans-perineal implantation of radioactive seeds I125
o Contraindicated in previous TURP, large prostate and moderate to severe LUTS

71
Q

examples of focal therapies

A

high intensity focused ultrasound (HIFU), cryotherapy, photodynamic therapy

72
Q

example of a peripheral androgen receptor antagonist

A

bicalutamide

73
Q

when can peripheral androgen receptor antagonist

A
  • 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
74
Q

metastatic prostate cancer treatment options

A
  • ADT
  • docetaxel chemotherapy
  • bone targeted therapies e.g zoledronic acid
  • palliative radiotherapy

other: carbizitaxel chemotherapy, Abiraterone and Enzalutamide hormone therapy , immunotherapy

75
Q

complications of metastatic prostate cancer

A 
bone pain 
fractures 
hypercalcaemia 
SCC
retention of urine 
obstructive uropathy
76
Q

how to manage obstructive uropathy

A

 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

77
Q

what are differentials for visible haematuria

A

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

78
Q

questions to ask a patient presenting with haematuria

A

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

79
Q

common causes of haematuria

A

• 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

80
Q

investigations for haematuria

A 
exclude UTI
check renal function 
USS kidneys (non-visible, poor kidney function <40)/CTIVU
flexible cystoscopy 
(consider PSA)
81
Q

initial management of someone with significant haematuria

A

ABCDE: oxygen, IV access, fluids

bloods: clotting, group and save, U+E FBC
catheter: 3-way catheter, urine sample, irrigation/washouts

82
Q

indications for urological 2ww

A

• 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

83
Q

risk factors for bladder cancer

A
  • Aged over 40
  • History of smoking
  • Exposure to dyes or cyclophosphamides
  • Previous bladder irradiation
  • Irritative bladder symptoms
84
Q

when is the peak incidence of chlamydia

A

16 - 25

85
Q

what gender has a higher incidence of chlamydia

A

women

86
Q

what gender has a higher incidence of gonorrhoea

A

men

87
Q

peak incidence of gonorrhoea in men

A

roughly 19 - 30

88
Q

proper name for chlamydia

A

chlamydia trachomatis

89
Q

proper name for gonorrhoea

A

Neisseria gonorrhoea

90
Q

areas of the body affected by chlamydia/gonorrhoea in adults

A

urethra, endocervical canal, rectum, pharynx, conjunctiva,

91
Q

areas of the body affected by chlamydia/gonorrhoea in neonates

A

conjunctiva

lungs - atypical pneumonitis (chlamydia)

92
Q

incubation period for chlamydia

A

men: 7 - 21 days
women: ill defined

93
Q

incubation period for gonorrhoea

A

men: 2 - 5 days
women: up to 10 days

94
Q

% of gonorrhoea patients who are asymptomatic

A

men: 10%
women: 50%

95
Q

% of chlamydia patients who are asymptomatic

A

men: at least 50%
women: over 70%

96
Q

presentation of chlamydia/gonorrhoea in men

A

dysuria

urethral discharge

97
Q

presentation of chlamydia/gonorrhoea in women

A

dysuria
vaginal discharge
menstrual irregularity

98
Q

complications of gonorrhoea/chlamydia in men

A

epididymo-orchitis
reactive arthritis

(more likely to occur due to chlamydia infection)

99
Q

complications of gonorrhoea/chlamydia in women

A
  • 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
100
Q

tests to diagnose chlamydia

A

NAAT

women: self-collected vaginal swab
men: first void urine

101
Q

first line management of chlamydia

A

Doxycycline 100mg bd for 7 days

102
Q

management of chlamydia in pregnant women

A

Azithromycin 1g followed by 500mg daily for 2 days currently recommended if doxycycline is not suitable

103
Q

what resistant condition is associated with chlamydia

A

mycoplasma genitalium

104
Q

how to prevent resistance when treating chlamydia

A

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

105
Q

diagnosing gonorrhoea

A

microscopy of gram stained smears: urethra, endocervix and rectum

Culture on selective medium to confirm

sensitivity testing

NAAT

106
Q

pharmacological management of gonorrhoea

A

1mg ceftriaxone IM

107
Q

factors in the STI/HIV transmission model

A

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

Phase 3b (9 decks)

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