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4th year everything > Urology AS > Flashcards

Urology AS Flashcards

1
Q

What are the causes of urinary tract obstruction?

A

Luminal
Mural
Extramural

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2
Q

What are the luminal causes of urinary tract obstruction?

A

Stones
Blood Clots
Sloughed papilla

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3
Q

What are mural causes of urinary tract obstruction?

A

Congenital/acquired stricture
Tumour: renal, ureteric, bladder
Neuromuscular dysfunction

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4
Q

What are the extramural causes of urinary tract obstruction?

A

Prostatic enlargement
Abdo/pelvic mass/tumour
Retroperitoneal fibrosis.

Medications - anticholingerics, tricyclic, antihistamine,benzos.

Acute retention often postpartum.

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5
Q

What is the acute presentation of an acute upper urinary tract obstruction?

A

Loin pain –> groin

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6
Q

What is the acute presentation of an acute lower urinary tract obstruction?

A

Bladder outflow obstruction precedes severe suprapubic pain with distended palpable bladder.

Triad

  • Inability to pass urine
  • Lower abdo discomfort
  • COnsiderable pain or distress.

May be due to previous UTI. Due to urethritis, subsequent urethral oedema.

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7
Q

What is the chronic presentation of upper urinary tract obstruction?

A 
Flank pain/Typically painless. 
Renal failure (may be polyuric)
  • May have palpable distended urinary bladder
  • Lower abdo tenderness.
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8
Q

What is the chronic presentation of lower urinary tract obstruction?

A

Frequency, hesitancy, poor stream, terminal dribbling, overflow incontinence

Distended, palpable bladder ± PR.

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9
Q

Investigation for Urinary Tract Obstruction?

A

Bloods: FBC, U+E
Urine: Dip, MC+S

Following relief of urinary retention patients undero physiological diuresis. POlyuric state large volumes of salt and water lost.

Imaging:

  • US: Hydronephrosis or hydroureter
  • Anterograde/retrograde ureterograms (Allow therapeutic drainage)
  • Radionucleotide imaging: renal function
  • CT/MRI
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10
Q

Management of upper urinary tract obstruction?

A

Leading to hydronephrosis. Therefore need to relieve obstruction ASAP. The pressure on the system needs to be relieved first.

Nephrostomy
Ureteric stent

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11
Q

Management of lower urinary tract obstruction?

A

Urethral or suprapubic catheter

  • May be large post-obstructive diuresis.
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12
Q

Complications of ureteric stents?

A

Infection
Haematuria
Trigonal irritation
Encrustation

Rare

  • Obstruction
  • Ureteric rupture
  • Stent migration
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13
Q

What is the aetiology of a urethral stricture ?

A

Trauma

  • Instrumentation
  • Pelvic fractures

Infection: e.g gonorrhoea

Chemotherapy
Balanitis xerotica obliterans

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14
Q

Presentation of a urethral stricture?

A 
Hesitancy
Strangury
Poor stream 
Terminal dribbling 
Pis en deux
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15
Q

Examination of urethral stricture?

A
  • PR: Exclude prostatic cause
  • Palpate urethra through penis
  • Examine meatus
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16
Q

Investigations of urethral stricture?

A

Decreased flow rate
Increased micturition time

  • Ureteroscopy and cystoscopy
  • Retrograde Urethrogram
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17
Q

Management of urethral stricture?

A

Internal urethrotomy
Dilatation
Stent

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18
Q

What is an obstructive uropathy?

A

Acute retention on a chronic background may go unnoticed for days due to lack of pain.

Se Cr may be up to 1500uM

Renal function should return to normal over days
Some background impairment may remain.

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19
Q

Obstructive uropathy complications?

A

Hyperkalaemia
Metabolic acidosis

Post-obstructive diuresis

  • Kidney produce a lot of urine in the acute phase after relief of obstruction.
  • Must keep up with losses to avoid dehydration.

Na and HC3 losing nephropathy

  • Diuresis may –> loss of Na and HCO3
  • May require replacement with 1.26% NaHCO3

Infection

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20
Q

What are the causes of urinary retention?

A 
Obstruction 
- Mechanical 
BPH
Urethral stricture 
Clots, stones 
Constipation
  • Dynamic: increased smooth muscle tone (alpha-adrenergic)
    Post-operative pain
    Drugs

Neurological
- Interruption of sensory or motor innervation
Pelvic surgery, MS, DM, Spinal Injury/compression

Myogenic
- Over-distension of the bladder (Post-anaesthesia, high ETOH intake)

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21
Q

What are the clinical features of acute urinary retention (AUR)?

A

Suprapubic tenderness
Palpable bladder
- Dull to percussion
- Can’t get beneath it

Large prostate on PR
- Check anal tone and sacral sensation

<1L drained on catheterisation

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22
Q

What investigations are needed for acute urinary retention?

A
  • Blood: FBC, U+E, PSA (prior to PR)
  • Urine: Dip, MC+S
  • Imaging:
    US: Bladder volume, hydronephrosis
    Pelvic XR.

BLadder volume >300 confirms diagnosis.

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23
Q

Management of acute urinary retention?

A

Conservative

  • Analgesia
  • Privacy
  • Walking
  • Running water or hot bath

Catheterise
- Use correct catheter: eg 3-way if clots
- ± STAT gent cover
- Hrly UO + replace: post-obstruction diuresis
- Tamsulosin: decreased risk of recatheterisation after retention
- TWOC after 24-72hrs
May d/c and f/up in OPD
More likely to be successful if predisposing factor and lower residual volume (<1L)

Volume of less than 200 confirms patient dint have AUR. >400 suggest should be in place.

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24
Q

When to use a TURP?

A

Failed TWOC
Impaired renal function
Elective

Transurethral resection of the prostate.

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25
Q

What is chronic urinary retention (CUR)

A

Classified into high pressure or low pressure.

High pressure: high detrusor pressure @ end of micturition
Typically bladder outflow obstruction
–> Bilateral hydronephrosis and decreased renal function.

Low pressure (stroke, poor detrusor)

  • Low detrusor pressure @ end of micturition
  • Large volume retention with very compliant bladder
  • Kidney able to excrete urine
  • No hydronephrosis so normal renal function.
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26
Q

Presentation of chronic urinary retention?

A
  • Insidious as bladder capacity increased (>1.5L)
  • Typically painless
  • Overflow incontinence/nocturnal enuresis
  • Acute on chronic retention
  • Lower abdo mass
  • UTI
  • Renal failure
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27
Q

Management of urinary retention?

A

Trial patient with intermittent self-catheterisation first.

High pressure 
- Catheterise if: 
renal impairment 
Pain 
infection
  • Hrly UO + replace: post-obstruction diuresis
  • Consider TURP before TWOC.

Low pressure
- Avoid catheterisation if possible
RIsk of introducing infection

Early TURP

  • Often do poorly due to poor destrusor function
  • Need CISC or permanent catheter.
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28
Q

What are the advantages of suprapubic catheters?

A 
Decreased UTIs
Decreased stricture formation 
TWOC without catheter removal 
Pt preference: increased comfort. 
Maintain sexual function.
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29
Q

Disadvantage of suprapubic catheter?

A

More complex: need skill
Serious complications can occur.

Contra-indication

  • Known or suspected bladder carcinoma
  • Undiagnosed haematuria
  • Previous lower abdo surgery
  • -> Adhesion of small bowel to abdo wall.
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30
Q

What are the causes of false haematuria?

A

Beetroot
Rifampicin
Porphyria
PV Bleed

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31
Q

What are the causes of true haematuria?

A 
General
Renal 
Ureter
Bladder 
Prostate
Urethra
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32
Q

What are the causes of general haematuria?

A

HSP

Bleeding Diathesis

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33
Q

What are the causes of renal haematuria?

A 
Infarct
Trauma: inc stones
Infection 
Neoplasm
GN 
Polycystic kidneys
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34
Q

What are the causes of ureter haematuria?

A

Stone

Tumour

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35
Q

What are the causes of bladder haematuria?

A

Infection
Stones
Tumour
Exercise

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36
Q

What are the causes of prostate haematuria?

A

BPH
Prostatitis
Tumour

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37
Q

What are the causes of urethra haematuria?

A

Infection
Stones
Trauma
Tumour

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38
Q

What are the clinical features of haematuria?

A

Timing

  • Beginning of stream: urethral
  • Throughout stream: renal/systemic, bladder
  • End of stream: bladder stone, schisto

Painful or painless
Obstructive symptoms
Systemic symptoms: weight loss, appetite

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39
Q

What are the investigations for haematuria?

A 
Bloods: FBC, U+E, Clotting 
Urine: Dip, MC+S, Cytology
Imaging 
- Renal US
- IVU
- Flexible cystoscopy + biopsy 
- CT/MRI 
- Renal angio
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40
Q

What is peri-aortitis?

A

Aetiology

  • Idiopathic retroperitoneal fibrosis
  • Inflamatory AAAs
  • Perianeurysmal RPF
  • RPF 2ndry to malignancy: e.g lymphoma
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41
Q

What is idiopathic retroperitoneal fibrosis?

A

Autoimmune vasculitis
Fibrinoid necrosis of vasa vasorum
Affects aorta and other small/medium sized retroperitoneal vessels.
Ureter are embedded in dense, fibrous tissue ==> bilateral obstruction

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42
Q

What is peri-aortitis associated with?

A
  • Drugs: b-B, bromocriptine, meythsergide, methyldopa
  • AI disease: thyroiditis, SLE, ANCA+ vasculitis
  • Smoking
  • Asbestos
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43
Q

What is the presentation of peri-aortitis?

A
  • Middle-aged male
  • Vague loin, back or abdo pain
  • Increased BP
  • Chronic urinary tract obstruction
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44
Q

Investigations of peri-aortitis?

A

Blood: Increase U and Cr, Increased ESR/CRP, decreased Hb.

US: Bilateral hydronephrosis + medial ureteric deviation

CT/MRI: Peri-aortic mass
Biopsy: Exclude Ca

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45
Q

Management of peri-aortitis?

A

Relieve obstruction: retrograde stent placement

Ureterolysis: Dissection of ureters from retroperitoneal tissue.

± immunosuppression.

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46
Q

What is the epidemiology of urolithiasis?

A 
Epidemiology 
- Lifetime incidence: 15% 
- Young men 
Peak age: 20-40yrs 
Sex: M>F = 3:1
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47
Q

What is the pathophysiology of urolithiasis?

A

Increased concentration of urinary solute
Decreased urine volume

Urinary stasis

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48
Q

Common anatomical sites of urolithiasis?

A
  • Pelviureteric junction
  • Crossing the iliac vessels at the pelvic brim
  • Under the vas or uterine artery
  • Vesicoureteric junction
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49
Q

What are the types of stones in renal colic?

A

Mostly Calcium oxalate: 75%
Increased risk in Crohns. Opaque.

Triple phosphate: 15% - Struvite - opaque

  • PO4, Mg, NH4 - phosphate
  • May form staghorn calculi
  • Associated with proteus infection

Urate - radiolucent

  • Double if confirmed gout
  • Can also be in chemo/cell death high uric acid levels.

Cysteine (radiolucent)
- Associated with Fanconi’s syndrome.

Xanthine
- Radio-lucent

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50
Q

Associated factors for renal colic?

A
  • Dehydration
  • Hypercalcaemia: primary HPT, immobilisation
  • Increased oxalate excretion: tea, strawberries
  • UTIs
  • Hyperuricaemia: e.g gout
  • Urinary tract abnormalities: e.g bladder diverticulae
  • Drugs: Frusemide
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51
Q

Presentation of ureteric colic?

A

Severe loin pain radiating to the groin

Associated with n/v

Pt cannot lie still

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52
Q

Presentation of bladder or urethral obstruction?

A

Bladder irritability: frequency, dysuria, haematuria

Strangury: Painful urinary tenesmus

Suprapubic pain radiating –> tip of penis or in labia

Pain and haematuria worse at the end of micturition

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53
Q

Other possible features of urolithiasis?

A

UTI
Haematuria
Sterile Pyuria
Anuria

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54
Q

Examination of urolithiasis?

A

Usually no loin tenderness

Haematuria

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55
Q

What to do on urine dip?

A

Dip + haematuria

MC + S

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56
Q

Bloods on urolithiasis?

A

FBC, U+E, Ca, PO4, Urate

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57
Q

Imaging of Urolithiasis?

A

Spiral non-contrast CT-KUB - FIRST LINE.

KUB XR
USS -
IVU

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58
Q

What will you see on XR KUB?

A

90% of stones radio-opaque

Urate stones are radiolucent, cysteine stones are faint

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59
Q

What will USS show? on urolithiasis

A

Hydronephrosis

Best means of investigation - US ie from a complicated ureteric stone.

Then IVU - assess the position of obstruction

Antegrade or retrograde pyelography - allows treatment

If suspect renal colic: CT scan.

If you don’t see a stone, you’ll see fat stranding beside the urter.

  • unilateral =

Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

  • Bilateral
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
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60
Q

Spiral non-contrast CT-KUB?

A

99% of stones visible
Gold standard

Kidney, ureters and bladder.

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61
Q

IVU? - when is it used and what does it show?

A

600x radiation dose of KUB
IV contrast injected and control, immediate and serial films taken until contrast @ level of obstruction.

Abnormal findings

  • Failure of flow to the bladder
  • Standing column of constrast
  • Clubbing of the calyces: back pressure
  • Delayed, dense nephrogram: no flow from kidney

CI

  • contrast allergy
  • Severe asthma
  • Metformin
  • Pregnancy
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62
Q

Functional scans in investigating urolithiasis?

A

DMSA: Dimercaptosuccine acid
DTPA: diethylenetriamene penta-acetic acid
MAG-3

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63
Q

Prevention of urolithiasis?

A

Drink plenty
Treat UTI
decreased oxalate intake: chocolate, tea, strawberries

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64
Q

What is the management of urolithiasis?

A

Analgesia

  • Diclofenac 75mg PO/IM or 100mg PR. Offer IM as first lin.e
  • Opiods if NSAIDs CI: e.g pethidine

Fluids: IV if unable to tolerate PO
Abx if infection: e.g cefuroxime 1.5mg IV TDS.

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65
Q

Conservatives: <5mm in lower 1/3 of ureter?

A
  • 90-95% pass spontaneously
    Can discharge pt with analgesia
  • Sieve urine to collect stone for OPD analysis.

If patients present with obstructive. The stone is obstructing the ureter and causing hydronephrosis and she is pyrexial suggesting super-added infection.

Therefore renal decompression via a ureteric stent or percutaneous nephrostomy should be performed.

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66
Q

Medical expulsive therapy (MET)

A

Indications

  • Stone 5-10 mm
  • Stone expected to pass
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67
Q

Drugs used for medical expulsive therapy?

A

RARELY USED: Nifedipine or tamsulosin. Used for small, uncomplicated stones.
± prednisolone
Most pass within 48hr, 80% within 30day.

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68
Q

Active stone removal is indicated when?

A
  • Low likelihood of spontaneous passage e.g >10mm
  • persistent obstruction
  • Renal insufficiency
  • Infection
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69
Q

Extracorporeal shockwave lithotripsy (SWL)

A
  • Stones <20mm in kidney or proximal ureter
  • SE: renal injury may –> Increased BP
  • CI: pregnancy, AAA, bleeding diathesis
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70
Q

What is ureterorenoscopy (URS) used for?

A
  • Stone >10mm in distal ureter or if SWL failed
  • Stone >20mm in renal pelvis

More likely used for pregnant females.Use for patients where SWL is contraindicated.

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71
Q

What is percutaneous nephrolithotomy (PNL)

A

Stone >20mm in renal pelvis

E.g staghorn calculi: Do DMSA first.

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72
Q

If patient is febrile with renal obstruction?

A

Surgical emergency
Percutaneous nephrostomy or ureteric stent
IV Abx: e.g cefuroxime 1.5g IV TDS.

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73
Q

Management summary for urolithiasis?

A

Conservative: stone <5mm in distal ureter
MET: Stone 5-10 mm and expect to pass

Active: Stones >10mm, persistent pain, renal insufficiency

Prevention

  • Calcium with fluid and thiazide diuretics - absorb calcium from urine
  • Cholestyramine to reduce oxalate secretion

Uric acid stones
- Allopurinol or urinary alkalinisation.

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74
Q

What is the epidemiology of renal cell carcinoma?

A

90% of renal cancers
Age: 55yrs
Sex: M>F = 2:1

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75
Q

Risk factors of renal cell carcinoma?

A 
Obesity 
Smoking 
HTN 
Dialysis 
4% heritable: e.g VHL syndrome
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76
Q

Pathology of renal cell carcinoma?

A

Adenocarcinoma from proximal renal tubular epithelium

Adenocarcinoma presents with polycythaemia.

  • Subtypes
    Clear Cell: 70-80% (histology is a complex, septated appearance)
    Papillary: 15%
    Chromophobe: 5%
    Collecting Duct: 1%
    Renal transitional cell carcinoma = 7% of all renal tumours.
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77
Q

What is the presentation of renal tumours?

A

50% incidental finding
Triad: haematuria, loin pain, loin mass.

Systemic: anorexia, malaise, weight loss, PUO

Clot retention

Invasion of L renal vein –> varicocele

Cannonbol mets –> SOB

Stauffer Syndrome = Cholestasis/hepatomegaly

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78
Q

Renal Cell Tumours may have paraneoplastic features?

A 
EPO --> polycythaemia 
PTHrP --> increased Ca 
Renin --> HTN 
ACTH --> Cushing's syndrome 
Amyloidosis
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79
Q

Spread of renal tumours?

A

Direct: renal vein
Lymph
Haematogenous: bone, liver, lung.

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80
Q

Investigations for renal tumours?

A

Blood: polycythaemia, ESR, U+E, ALP, Ca

urine dip: cytology
Imaging 
- CXR: cannonball bets 
- US: mass 
- IVU: filling defect
- CT/MRI
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81
Q

Robson staging of renal cell carcinoma?

A
  1. Confined to kidney
  2. Involves perinephric fat, but not Garota’s fascia
  3. Spread into renal vein
  4. Spread to adjacent/distant organs
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82
Q

Management of renal tumours?

A

1st line: Surgical

  • Radical nephrectomy
  • Consider partial if small tumour or 1 kidney

Radio + chemo is resistant to surgery is often first line.

Medical

  • reserved for patient with poor prognosis
  • Temsirolimus (mTOR inhibitor)
  • Alpha-interferon and interleukin-2 have been used to reduce tumour size and treat patients.
  • Sorafenib, sunitinib can also be used.
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83
Q

Transitional Cell Carcinoma epidemiology?

A

2nd commonest renal cancer
Age: 50-80yrs
Sex: M>F = 4:1

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84
Q

Risk factors for TCC?

A

Smoking
Amine Exposure (rubber industry)
Aniline dye
Cyclophosphamide

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85
Q

Pathology of TCC?

A

Highly malignant

  • In bladder: 50%
  • Ureter
  • renal pelvis

Can affect renal pelvis in 10%.

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86
Q

Presentation of TCC?

A

Painless haematuria
Frequency, urgency, dysuria
Urinary Tract Obstruction

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87
Q

Investigations of TCC?

A

Urine Cytology
Cystoscopy - diagnose bladder cancer.

CT/MRI (assess mets)
IVU: pelviceal filling defect

88
Q

Management of TCC?

A

Nephrouretectomy

Regular f/up: 50% develop bladder tumours.

89
Q

Nephroblastoma?

A

Childhood tumour of primitive renal tubules and mesenchymal cells
May be assoc with WAGR syndrome

90
Q

Other neoplasms of renal tumours?

A

Cysts: Very common

Renal papillary adenomas

Oncocytoma: eosinophilic cells with numerous mitochondria

Angiomyolipoma: seen in tuberous sclerosis.

91
Q

Malignant neoplasms in renal tumours?

A

SCC: assoc with chronic infected staghorn calculi

92
Q

What is the pathology of bladder tumours?

A

Transitional cell carcinomas accounting for 90%

SCCs: associated with schistosomiasis

Adenocarcinoma

93
Q

Natural history of bladder tumours?

A

Low grade tumours

  • 80%
  • Non-invasive generally not life-threatening
  • HIgh rate of recurrence

High-grade tumours

  • 20%
  • Invasive and life-threatening
  • High recurrence rates
94
Q

Risk factors for bladder tumours?

A 
Smoking 
Amine exposure 
Previous renal TCC
Chronic cystitis 
Schistosomiasis 
Urechal remnants 
- embryological remnant of communication between umbilicus and bladder.

Pelvic irradiation

95
Q

Presentation of bladder tumours?

A
  • Painless haematuria
  • Voiding irritability: dysuria, frequency, urgency
  • Recurrent UTIs
  • Retention and obstructive renal failure
96
Q

Examination of bladder tumours?

A

Anaemia
Palpable bladder mass
Palpable liver

97
Q

TNM Staging for bladder tumours?

A

80% confined to mucosa
20% penetrate muscle

Tis = Carcinoma in situ 
Ta = confined to epithelium
T1 = tumour in lamina propria
T2 = Superficial muscle involved (rubbery thickness) 
T3 = Deep muscle involved (mobile mass) 
T4 = invasion of prostate, uterus, vagina = Fixed mass.
98
Q

Investigations of bladder tumour?

A

Urine: Dip (sterile pyuria), cytology

IVU: filling defect

Cystoscopy with biopsy: diagnostic

Bimanual EUA: helps to assess spread

CT/MRI: helps stage

99
Q

Management of bladder tumour? Tis, Ta, T1

A

Depends on Tis, Ta, T1 (superficial)

  • 80% of all patients
  • Diathermy via transurethral cystoscopy/Transurethral resection of bladder tumour (TURBT)
  • Intravesicular chemo: mitomycin C
  • Intravesicular immunotherapy: BCG.
100
Q

Management of bladder tumour T2,T3?

A
  • Radical cystectomy with ileal conduit is gold standard
  • Radiotherapy: worse 5 yrs but preserves bladder.
  • Salvage cystectomy can be performed.
  • Adjuvant chemo: e.g M-VAC.
    Neoadjuvant chemo may have a role.
101
Q

management of T4 bladder cancer?

A

Palliative chemo/radiotherapy
Long-term catherisation
Urinary Diversions

102
Q

Complications of surgery for bladder tumours?

A

Massive bladder haemorrhage

Cystectomy -> sexual and urinary malfunction

103
Q

Follow-up for bladder cancer?

A

Up to 70% of bladder tumour recur therefore intensive follow up is required.

History, examination and regularly cystoscopy
High risk tumours: every 3 months of 2 yrs, then every 6 months.

Low-risk tumours: @ 9 months, then yrly.

104
Q

Prognosis of bladder tumours?

A

Depends on age and stage
Tis, Ta, T1: 95% 5yrs

T2: 40-50% 5 yrs
T3: 25% 5yrs
T4: <1 yrs medial survival

105
Q

Benign Prostatic hypertrophy pathophysiology?

A

Benign nodular or diffuse hyperplasia of stromal and epithelial cells

Affects inner (transitional) layer of prostate . –> Urethral compression.

DHT produced from testosterone in stromal cells by 5a-reductase enzyme.

DHT induced GTs –> increased stromal cells and decreased epithelial cell death.

106
Q

Presentation of BPH?

A

Storage symptoms

  • Nocturia
  • Frequency
  • Urgency
  • Overflow incontinence

Voiding symptoms

  • Hesistancy
  • Straining
  • Poor stream/flow + terminal dribbling
  • Strangury (urinary tenesmus)
  • Incomplete emptying: pis en deux.
Bladder stones (due to stasis) 
UTI (Due to stasis)
107
Q

Examination for BPH?

A

PR

  • Smoothly enlarged prostate
  • Definable median sulcus

Bladder not usually palpable unless acute-on-chronic obstruction

108
Q

Investigations for BPH?

A

Blood: U+E, PSA (after PR)

Urine: Dip, MC+S

Imaging: transrectal US ± Biopsy

Urodynamics: pressure/Flow cystometry

Voiding diary

109
Q

Management of BPH?

A

Decreased caffeine, ETOH
Double voiding
Bladder training: hold on –> Increased time between voiding

110
Q

Medical management of BPH?

A

Useful in mild disease and while awaiting TURP

1st: a-blockers. Relax smooth muscle of prostate.
Tamsulosin, doxazosin
Relaxed prostate smooth muscle
SE: Drowsiness, decreased BP, depression, EF, weight increased, extra-pyramidal signs, postural hypotension.

2nd line: 5a-reductase inhibitor

  • Finasteride
  • Inhibit conversion of testosterone –> DHT. Reduce prostate volume so slow disease but takes time.
  • Preferred if significantly enlarged prostate
  • SE: excrete in semen (use condoms), ED. gynaecomastia.
111
Q

Surgical management and indications of BPH?

A

Symptoms affect QoL
Complications of BPH

TURP

  • Cystoscopic resection of lateral and middle lobes
  • <14% become impotent

Transurethral incision of prostate (TUIP)

  • < destruction –> Decreased risk of sexual function
  • Similar benefits to TURP if small prostate (<30g)

transurethral electrovaporisation of prostate
- Electric current –> tissue vaporisation

Laser prostatectomy

  • decreased ED and retrograde ejactulation
  • Similar efficacy as TURP.

Open retropubic prostatectomy for very large prostates (>100g)

112
Q

What are the complications of TURP?

A

Immediate
- TURP syndrome
Absorption of large quantity of fluids –> Decreased Na
- Haemorrhage

113
Q

Early complications of TURP?

A

Haemorrhage
Infection Clot retention: requires bladder irrigation

Late

  • Retrograde ejaculation: common
  • ED: ~10%
  • Incontinence: <10%
  • Urethral stricture
  • Recurrence
114
Q

What is the epidemiology of prostate cancer?

A

Commonest male Ca
3rd most common cause of male cancer death
80% men >80.
Race: increased in blacks/Afro-Caribbean

115
Q

Pathology of prostate cancer?

A

Adenocarcinoma

Peripheral zone of prostate

116
Q

Presentation of prostate cancer?

A

usually asymptomatic
Urinary: nocturia, frequency, hesitancy, poor stream, terminal dribbling, obstruction
Systemic: weight loss, fatigue
Mets: bone pain.

117
Q

Examination of prostate cancer?

A

Hard irregular prostate on PR

Loss of midline sulcus

118
Q

Spread of prostate cancer?

A

Local: seminal vesicles, bladder, rectum

Lymph: para-aortic nodes

Haem: Sclerotic bony lesions

119
Q

Bloods in prostate cancer?

A

PSA, U+E, Acid and alk phos, Ca

Imaging

  • XR chest and spine
  • Transrectal US + biopsy
  • bone scan - look for mets.
  • Staging MRI

Contrast enhancing magnetic nanoparticles increased detection of affected nodes.

120
Q

What is the PSA used for?

A

Proteolytic enzymes used in liquefaction of ejaculate

Not specific for prostate Ca
- Increased with age, PR, TURP, prostatitis

> 4ng/ml: 40-90% sensitivity, 60-90% specificity
- Only 1 in 3 will have Ca

Normal in 30% of small cancers.

NICE advise PSA levels may be increases therefore testing should not be done within

  • 6 weeks of a prostate biopsy
  • 4 weeks following a proven urinary infection
  • 1 week of digital rectal examination
  • 48 hours of vigorous exercise
  • 48 hours of ejaculation

Limits
= 50-59 = 3
= 60-69 -= 4
= >70 = 5

121
Q

Gleason Grade for prostate cancer?

A

Once raised PSA + LUTS and examination are suspicious for cancer.

First line? 2019 = Multiparametric MRI
Do a TRUS biopsy of prostate.

Score two worst affected areas
Sum is inversely proportional to prognosis

TNM

  • Tis = Carcinoma in situ
  • T1 = Incidental finding on TURP or increased PSA
  • T2 = Intracapsular tumour with deformation of prostate
  • T3 = Extra-prostatic extension
  • T4 = Fixed to pelvis + invading neighbouring structures

N1-4 = 1 or more lymph nodes involved

M1 = Distant mets, e.g spine.

122
Q

Prognostic factors for prostate cancer?

A
  • Help determine whether to pursue radical management
  • Age
  • Pre-Rx PSA
  • Tumour stage
  • Tumour grade
123
Q

Management of prostate cancer?

A

Difficult to know which tumours are indolent and will not –> mortality before something else.

Radical therapy associated with significant morbidity.

124
Q

Conservative management: active monitoring (T1/T2)

A

Close monitoring with DRE and PSA. Watchful waiting.

Active surveillance = routine follow-up, PSA.

Later on consider radical prostatectomy +

Radiotherapy: External beam + brachytherapy. Increased risk of bladder, colon and rectal cancer.

125
Q

Radical therapy?

A

T3/T4 mainly.

Hormonal +

Radical prostatectomy (+ goserelin if node +ve)

  • Performed laparoscopically with robot
  • Only improves survival vs active monitoring if <75yrs.

Leads to SE

Brachytherapy: implantation of palladium seeds
SE: ED, urinary incontinence, death.

Radiotherapy: External beam + brachytherapy. Increased risk of bladder, colon and rectal cancer.

126
Q

Medical management for prostate cancer - Used in Metastatic cancer.

A

T4s

Used for metastatic or node +ve disease

LHRH analogues / GnRH agonist. Blocks pituitary therefore stops testosterone.

  • Goserlin
  • INhibits pituitary gonadotrophins –> decreased testosterone
  • May cause a transient increase in symptoms of prostatic cancer. - Flare effect.

Anti-androgens
- Cyproterone acetate, flutamide. Used preempitvely to attentuate the tumour flare through antagonistic effects.

Symptomatic

  • TURP for obstruction
  • Analgesia
  • Radiotherapy for bone mets/cord compression.
127
Q

Screening with the PSA

A
  • Population based screening not recommended in UK
  • PSA not an accurate tumour marker
  • ERSPC trial showed small mortality benefit
128
Q

What is prostatitis?

A

Aetiology

  • S.faecalis
  • E.coli
  • Chlamydia
Presents with 
- >35yrs old 
- UTI/dysuria 
- Pain 
Low backache
Pain on ejaculation 
- Haematospermia 
- Fever and rigor 
- Retention 
- Malaise
129
Q

Examination of prostatitis?

A

Pyrexia
Swollen/boggy/tender prostate on PR
Examine testes to exclude epididyo-orchitis.

130
Q

Investigation of prostatitis?

A

Blood: FBC, U+E, CRP
Urine: dip, MC+S
Swab for STIs

131
Q

Management of prostatitis?

A

Analgesia

Levofloxacin 500mg/d for 28 days

132
Q

Urinary incontinence? Male

A

Ususally caused by prostatic enlargement

  • Urge incontinence or dribbling may result from partial retention
  • Retention may –> overflow (palpable bladder after voiding)

TURP and pelvic surgery may weaken external urethral sphincter

133
Q

Management of urinary incontinence?

A

Check

  • PR: faecal impaction
  • Palpable bladder after voiding: retention with overflow
  • UTI
  • DM
  • CNS: MS, Parkinson’s, Stroke, spinal trauma
  • Diuretics
134
Q

What is the epidemiology of undescended testes?

A

3% at birth
1% at 1yrs
Unilateral 4x commoner compared with bilateral.
Should have genetic testing if bilateral for Noonan’s or Prader-Willi.

Commoner in prems: incidence up to 30%.

135
Q

What is normal descent of testes?

A

Testes remain in abdomen until 7 months.
Gubernaculum connects inferior pole of testis to scrotum.

Testis descend through inguinal canal to scrotum with an out-pouching of peritoneum: processus vaginalis.

136
Q

What is the classification of undescended testes?

A

Cryptorchidism

  • Complete absence of testis from scrotum
  • Anorchism = absence of both testes
137
Q

Retractile testis?

A

Normal development but excessive cremasteric reflex
TEsticle often found at external inguinal ring
Will descend: no management required/

138
Q

Maldescended testis?

A

Found anywhere along normal path of descent.
Testis and scrotum are usually under-developed.

Often associated with patient processus vaginalis.

139
Q

Ectopic testis?

A
  • Found outside line of descent
    Usually in superior inguinal pouch - anterior to external oblique aponeurosis
  • Abdominal, perineal, penile, femoral triangle.
140
Q

Complications of undescended testes?

A

Infertility
10x increased risk of malignancy (remains after surgery)
Increased risk of trauma
Increased risk of torsion

141
Q

Management of undescended testes?

A

Restores potential for spermatogenesis

Makes Ca easier to Dx

142
Q

What is the surgical management of undescended testes?

A

Orchidopexy by Dartos Pouch Procedure

  • Perform before 2yrs
  • Mobilisation of testis and cord
  • Removal of patent processus
  • Testicle brought through a hole made in the dartos
143
Q

Lump in the groin, can’t get above it?

A

Inguinoscrotal hernia

144
Q

Lump in groin - separate cystic

A

Epididymal cyst.

145
Q

Lump in groin: separate, solid?

A

Varicocele, sperm granuloma, epididymitis

146
Q

Lump in groin: testicular, cystic

A

Hydrocele

147
Q

Lump in groin - testicular, solid

A

Tumour, orchitis, haematocele

148
Q

What is an epididymal cyst?

A 
Develop in adulthood
Contain clear or milky fluid 
Lie above and behind testis
Remove if symptomatic
Possible to get above lump.
149
Q

What is a varicocele?

A 
Dilated veins of pampiniform plexus 
- Presentation 
= feel like bag of worms in the scrotum 
- 80% on the left hand side. 
May be visible dilated veins 
Decreased size on lying down 
Patient may complain of dull ache 
May --> oligospermia (decreased fertility)
150
Q

What is the pathology of a varicocele?

A

primary: left side commoner: - drain into left renal vein
secondary: left renal tumour has tracked down renal vein –> testicular vein obstruction

Malignancy –> compression of the renal vein between abdominal aorta and superior mesenteric vein –> nutcracker angle for RCC. Compressing renal vein and backpressure.

151
Q

Management of varicocele?

A

Subclinical or Grade I varicoeles - offer reassurance and observation.

If asymptomatic and normal semen parameters = semen analysis every 1-2yrs

If symptomatic or abnormal semen = Surgery.

Surgical: clipping the testicular vein

152
Q

What is a sperm granuloma?

A

Painful lump of extravasated sperm after vasectomy

153
Q

What is a hydrocele?

A

Collection of serous fluid within the tunica vaginalis

Primary

  • Associated with patent processus vaginalis
  • Commoner, larger, tense, younger men.
  • Communicating found in 5-10% of newborn males. Usually resolves within first few months. Therefore reassure that it is not sinister and will likely resolve in 1yr.

Secondary

  • Tumor, trauma, infection
  • Smaller, less tense.

Investigation
- US testicle to exclude tumour

Management 
- May resolve spontaneously 
- Surgery
Lord's Repair: plication of the sac
- Jaboulay's repair: Eversion of the sac

Aspiration

  • Usually recur so not 1st line
  • Send fluid for cytology and MC+S
154
Q

What is a haematocele?

A

Blood in the tunica vaginalis
Hx for trauma
May need drainage or excision

155
Q

What is epididymo-orchitis?

A

From STI: Chlamydia, gonorrhoea

Ascending UTI: e.coli

Mumps

In men over >35 = E.coli

156
Q

Features of epididymo-orchitis?

A

Sudden onset tender swelling
Dysuria
Sweats, fever

157
Q

Examination of epididymo-orchitis?

A

Tender, red, warm swollen testis and epididymis
- Elevating testicles may relieve pain

Secondary hydrocele

Urethral discharge

158
Q

Imaging for epididymo-orchitis?

A

Bloods: FBC, CRP
Urine: dip, MC+S, (First catch may be best)
Urethral swab and STI screen
US: May be needed to exclude abscess

159
Q

Complications and management of epididymo-orchitis?

A

May –> Infertility

Management 
- Bed rest 
- Analgesia
- Scrotal support 
- Abx: doxycycline or cipro 
If unknown give ceftriaxone + doxycycline 
- Drain abscess if present
160
Q

What is the epidemiology of testicular tumours?

A

Commonest male malignancies from 15-44yrs

White > Blacks = 5:1

161
Q

Presentation of testicular tumours?

A

Painless testicular lump
- Often noticed after trauma

  • Haematospermia
  • 2ndry hydrocele
  • Mets: SOB from lungs mets
  • Abdo mass: para-arotic
  • lymphadenopathy
  • Hormones: gynaecomastia, virilisation
  • Contralateral tumour in 5%
162
Q

What are the risk factors for testicular tumours?

A

Undescended testis
- 10% occur in undescended testes

Infant hernia
Infertility
Klinefelters
Mumps orchitis

163
Q

What is the pathology of testicular tumours?

A

Germ cells

Sex-cord stromal

Lymphoma/leukaemia

164
Q

What are the types of germ cell?

A

Pure seminomas - normal AFP/hCG.

Non-seminoma: Mixed NSGCT, Teratoma, Yolk Sac, Choriocarcinoma

165
Q

What is a pure seminoma:40%?

A 
Commonest single subtype of germ cell. 
30-40yrs old 
Increased bhCG in 15% 
Increased placental ALP in some 
Very radiosensitive

Better prognosis.

166
Q

What is a teratoma?

A

Teratoma affects 25

Arise from all 3 germ layers 
Common and benign in children 
Rare and malignant in adults 
Secrete bhCG and or AFP. 
Chemosensitive

need for orchidopexy associated with increased risk in developing testicular cancer.

167
Q

What is a yolk sac tumour

A

Commonest testicular tumour in children

168
Q

Diagnosis of choriocarcinoma?

A

Increased bHCG.

169
Q

Most common non-seminomas?

A

Mixed - Non-seminoma germ cell tumour.

170
Q

What are the sex-cord tumours ?

A

Leydig cell

  • Mostly benign
  • May secrete androgens or oestrogen

Sertoli cell

  • Mostly benign
  • May secrete oestrogen
171
Q

Lymphoma types/leukaemia types presentation?

A

NHL: commonest malignant testicular mass >60yrs

ALL: commonest malignant testicular mass <5yrs

172
Q

What is the staging for testicular tumours?

A

Royal Marsden Classification

    1. Disease only in testis
    1. Para-aortic nodes involves (below diaphragm)
    1. Supra and infra-diaphragmatic LNs involved
    1. Extra-lymphatic spread: Lungs, liver.
173
Q

Investigation for testicular tumours?

A

If lump found - first line = US.

Tumour markers (not raised in all cancer so not first line)

  • Useful for monitoring
  • Increased AFP and increased hCG in 90% of teratomas
  • Increased hCG in 15% of seminomas
  • Normal AFP in pure seminomas.

Scrotum US

Staging

  • CXR
  • CT

NB. Percutaneous biopsy should not be performed as it may lead to seeding along needle tract.

174
Q

Management of testicular tumours?

A

If both testes are abnormal, semen can be cryopreserved.

175
Q

What is the management of a seminoma?

A

Stage 1-2: inguinal orchidectomy + radiotherapy
- Groin incision allows cord clamping to prevent seeding.

Stage 3-4: as above + chemo (BEP). Bleomycin, etoposide, cisplatin.

176
Q

What is the management of non-seminoma?

A

Normally worse prognosis.

Stage 1: inguinal orchidectom + surveillance
Stage 2: orchidectomy + chemo + para-aortic LN dissection

Stage 3: orchidectomy + chemo

Close follow-up to detect relapse

  • Typically within 18-24mon
  • Repeat CT scanning and tumour markers
177
Q

What is balanitis?

A

Acute inflammation of the foreskin and glans
Causes:

  • candida = very common, itching + white non-urethral discharge.
  • Contact/dermatitis = itchy, sometimes painful + associated with a clear non-urethral discharge.
  • Dermatitis - Itchy but no discharge. May have skin condition elsewhere.
  • Bacterial - Painful and can be itchy –> non urethral discharge and due to Staph A.
  • Lichen planus - May be itchy, presence of Wickhams striae + violaceous papules.
  • Lichen sclerosus (balanitis xerotica obliterans) - itchy + scarring.

Investigations
- Can swab.

RFs: DM, young children with tight foreskin

Rx: hygiene advice, Abx, circumcision. Consider steroids.

Candidiasis = Topical clotrimazole 2 weeks.
Bacerial balanitis - Staph A or Strep. oral fluclox or clari.

178
Q

What is phimosis?

A

Foreskin occludes the meatus
Children
- Presentation: recurrent balanitis and ballooning
- Management: gentle retraction, steroid cream, circumcision

Adult

  • Presentation: dyspareunia, infection
  • Management: circumcision
  • Associated with balanitis xerotica obliterans: thickening of foreskin and glans –> phimosis + meatal narrowing. The equivalent of lichen sclerosis in women. Increases risk of SCC, predisposed to infectio. Does not cause protaste hyperplasia.
179
Q

What is paraphimosis

A

Tight foreskin is retracted and becomes irreplaceable
Decreased venous return –> oedema and swelling of the glans
–> can rarely lead to glans ischaemia

Causes: Catheterisation, masturbation, intercourse

Management

  • Manual reduction: use ice and lignocaine jelly
  • May require glans aspiration or dorsal slit
180
Q

What is hypo/epi-spadias?

A

Developmental abnormality of the position of the urethral opening

Hypospadias: opens on the ventral surface of penis - do not circumsize as it is a contraindication as foreskin used as repair.
Epispadias: opens on the dorsal surface

181
Q

Penile cancer?

A

Epidemiology

  • Incidence: 1:100,000
  • Geo: commoner in Far East Africa
Aetiology 
- V.rare if circumcised 
- Risk factors 
HPV infection 
Chronic irritation 2ndry to smegma
182
Q

What is the pathology of penile cancer?

A

Erythroplasia of Querat: penile CIS

SCC

183
Q

Presentation of penile cancer?

A

Chronic fungating ulcer
Bloody/purulent discharge
50% have inguinal nodes at presentation

184
Q

Medical management of penile cancer?

A

Medical

  • Early growths with no urethral involvement
  • DXT and iridium wires

Surgical

  • Amputation required if urethral involvement
  • Lymph node dissection
185
Q

Rhabdomyolysis

A

Patient who has fallen or prolonged epileptic seizure and is found to have AKI.

Elevated CK
myoglobinuria
hypocalcaemia (myoglobin binds calcium)
elevated phosphate (released from myocytes)
hyperkalaemia (may develop before renal failure)
metabolic acidosis

Statins can cause Rhabdo.
Management = IV Fluids
- Urinary alkalinisation is sometimes used.

186
Q

Dialysis disequilibirum syndrome?

A

Rare but serious complication of haemodialysis.

Usually affects those who have recently started renal replacement therapy. Caused by cerebral oedema.

187
Q

Circumcision

A

Not available on the NHS

  • Reduced penile cancer
  • reduced risk of UTi
  • Reduced risk of STI including HIV

Medical infications

  • Phimosis
  • Recurrent balanitis
  • Balanatis xerotica obliterans
  • Paraphimosis

Done under local or general anaesthetic.

188
Q

Erectile dysfunction

A

Common causes are CVD, obesity, diabetes, metabolic syndrome.

Also SSRIs, Beta-blockers.

Symptoms which suggest a psychogenic cause include:

  • Sudden onset.
  • Early collapse of erection.
  • Self-stimulated or waking erections.
  • Premature ejaculation or inability to ejaculate.
  • Problems or changes in a relationship.
  • Major life events.
  • Psychological problems.

Organic cause
- Gradual onset.
- Normal ejaculation.
- Normal libido (except hypogonadal men).
Risk factor in medical history (cardiovascular, endocrine or neurological).
- Operations, radiotherapy, or trauma to the pelvis or scrotum.
- A current drug recognised as associated with ED.

Smoking, high alcohol consumption, use of recreational or bodybuilding drugs.

Investigations

  • 10yr CVS risk calculated by measuring lipid + glucose
  • Free testosterone measured in the morning between 9 and 11am.
  • If low repeat with FSH, LH, prolactin.

Management
- PDE-5 inhibitors. Sildenafil.

189
Q

Urethral injury?

A

Mainly in males
- Blood at the meatus
There are 2 types:

Bulbar rupture:

  • Most common
  • Straddle type injury (bicycles)
  • Triad signs = Urinary retention, perineal haematoma, blood at the meatus.
Membranous rupture
can be extra or intraperitoneal
commonly due to pelvic fracture
Penile or perineal oedema/ hematoma
PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)

Investigation
ascending urethrogram

Management
suprapubic catheter (surgical placement, not percutaneously)
190
Q

Bladder injury

A

Basics
rupture is intra or extraperitoneal
presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void: always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
Investigation
IVU or cystogram

Management
laparotomy if intraperitoneal, conservative if extraperitoneal

191
Q

Testicular Torsion?

A

The pain is severe, sudden-onset and may be referred to the lower abdomen. Nausea and vomiting are often present. On examination the testis is red, swollen and retracted upwards.

The cremasteric reflex is lost (as the nerve to cremaster travels with the cord). Elevation of the testis does not ease the pain (Prehn’s sign) and may worsen it. Both testes should be fixed as both sides are at risk of future episodes.

Cremasteric = stroke inner thigh and ipsilateral testicle pulled towards inguinal canal.

Compared to epididymo-orchitis
= It similarly produces testicular pain, redness and swelling, but comes on over a few days. Patients are often systemically unwell (e.g. fever, chills) and may have urethral discharge. The cremasteric reflex is in tact and elevation relieves pain (by removing pressure from the epididymis holding the testis).

Treatment is with urgent surgical exploration
if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

192
Q

Post void volumes in patients?

A

<50ml

<100ml is normal in >65.

Chronic urinary retention = >500ml after voiding.

Post-catheterisation urine volume of >800ml suggests acute on chronic urinary retention.

193
Q

Tuberous Sclerosis renal involvement?

A

Angiomyolipoma

194
Q

Neuroblastoma?

A

Most common tumour of childhood.
Neural rest origin.
Calcified.

195
Q

Nephroblastoma?

A

Rare in children.
90% have a mass
50% will be HTN.
Diagnostic work up included US and CT scanning.

196
Q

Management of overactive bladder?

A

Conservative = bladder training offered.

Antimuscarinic drugs include oxybutynin, tolterodine and darifenacin.

Mirabegron if first line fail.

197
Q

LUTS voiding symptoms?

A 
Hesitancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling
198
Q

LUTS storage symptoms?

A

Urgency
Frequency
Nocturia
Urinary incontinence

199
Q

Post-micturition symptoms

A

Post-micturition dribbling

Sensation of incomplete empytying

200
Q

Management of voiding symptoms?

A

Pelvic muscle training, bladder training.

Moderate or severe offer alpha blocker.

Then add a 5-alpha reductase.

201
Q

Management of nocturia?

A

Advise about moderate fluid at night
Furosemide 40mg in late afternoon
Desmopressin may be helpful

202
Q

Can you get above it?

A

No = Inguinoscrotal hernia

203
Q

If yes, can you palpate it sepateately? YEs

A

Yes = does it transilluminate? yes = epididymal cyst

If it does not = Varicocele
Spermatocele
Sperm granuloma
Epididymitis

204
Q

If no to separe palpable? No it does not transiluminate?

A

Tumour
Orchitis
Haematocele

Yes it does transilluminate = Hydrocele.

205
Q

Plasma cell balanitis of Zoon

A

Not itchy and clearly circumscribed areas of inflammation

206
Q

Circinate balanitis?

A

Not itchy and not associated with any discharge.

The key features is painless erosions and it can be associated with Reiter’s syndrome.

207
Q

Vasectomy?

A

Failure rate: 1 per 2000. Male sterilisation is more effective method of contraception than female sterilisation.

Simple operative, can be under LA (Some GA), go home after a couple of hours.

Doesn’t work immediately.

Semen analysis needs to be performed twice following vasectomy.

Complications - Bruising, haematoma, infection, sperm granuloma, chronic testicular pain.

208
Q

Patient has had a previous ileal neobladder reconstruction following cystprostectomy for bladder cancer? What cancer are they at risk for

A

Adenocarcinoma

  • Most common type of cancer affecting the bowel.
  • Neobladder reconstruction utilised components of bowel.
209
Q

What does muddy brown granular casts reveal?

A

Acute Tubular Necrosis.

210
Q

Smoking and Schistosomiasis?

A

Causes Squamous Cell Carcinoma of the bladder - SSS.

211
Q

Stress incontinence

A

Symptoms of incontinence precipitated by sneezing/coughing.

Common in women with vaginal delivery.

212
Q

Urge incontinence?

A

Sudden need to urinate and not by a small dribble every so often.

213
Q

Priapism investigation and management?

A

Persistent penile erection - defined as lasting longer than 4 hrs and not associated with sexual stimulation.

Ischaemic or non-ischaemia (due to high arterial inflow)

5-10 yr old r 20-50yr old.

Cavernosal blood gas analysis is essential to differentiate between ischaemic and non-ischaemic priapism.

  • In ischaemic priapism pO2 and pH would be reduced whilst CO2 increased.

Management
- Aspirate blood from cavernosa with injection of saline to clear viscous blood.

214
Q

Peyronie’s Disease?

A

Scar tissue in the penis making it bent.

215
Q

Patient is 3 days post-operative, has catheter removed this morning. Complaining of abdo pain now. Tender in the suprapubic region and right upper quadrant

A

Urinary retention

RF: urinary catherer, constipation, immobility, opiate analgesia, infection haematuria, BPH.

4th year everything (43 decks)

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