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Urology - AS Flashcards

1
Q

Causes of urinary tract obstruction

A

Luminal: stones, clots, sloughed papilla (from renal papillary necrosis - most commonly caused by infection)

Mural: congenital/acquired stricture, tumor (renal, ureteric, bladder), intramuscular dysfunction

Extramural: prostatic enlargement, abdo/pelvis mass/tumour, retroperitoneal fibrosis

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2
Q

How does an acute upper urinary tract obstruction present?

A

loin-groin pain

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3
Q

How does an acute lower urinary tract obstruction present?

A

bladder outflow obstruction precedes severe supra pubic pain with distended palpable bladder

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4
Q

How does a chronic upper urinary tract obstruction present?

A 
flank pain
renal failure (may be polyuric)
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5
Q

How does a chronic lower urinary tract obstruction present?

A

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

distended, palpable bladder +/- large prostate

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6
Q

What investigations should be done in urinary tract obstruction?

A

Bloods: FBC, U+E
Urine: dip, MCS
Imaging: US (for hydronephrosis, hydroureter), ante-grade/retrograde uretograms (allow theraputic drainage), radionucleotide imaging (renal function), CT/MRI

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7
Q

What is the management for upper urinary tract obstruction?

A

nephrostomy

ureteric stent

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8
Q

What is the management for lower urinary tracts obstruction?

A

urethral or suprapubic catheter

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9
Q

What are the complications of ureteric stents?

A

Common: infection, haematuria, trigonal irratation, encrustation

Rare: obstruction, ureteric rupture, stent migration

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10
Q

What is the aetiology of urethral strictures?

A

Trauma: instrumentation, penis #
Infection: gonorrhoea
Chemotherapy
Balanitis xerotica obliterans

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11
Q

How do urethral strictures present?

A

hesitancy, stangury, poor stream, terminal dribbling, urgency after voiding

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12
Q

What should be examined in ? urethral strictures?

A

PR: to exclude prostatic cause
Palpate urethra through penis
Examine meatus

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13
Q

What investigations should be done in ? urethral stricture?

A

urodynamics: decreased peak flow rate, increased micturition time
urethroscopy and cystoscopy
retrograde urethrogram

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14
Q

What are the management options for urethral strictures?

A

internal urethrotomy
dilatation
stent

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15
Q

What are the complications of obstructive uropathy?

A

hyperkalaemia,

metabolic acidosis

post obstructive diuresis: kidneys produce lots of urine in acute phase after relief of obstruction, must keep up with losses to avoid dehydration

Na and HCO3 losing nephropathy: dieuresis may lead to loss of Na and HCO3. May need replacement

Infection

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16
Q

What are the causes of urinary retention?

A

Obstructive:

mechanical: BPH, urethral stricture, clots, stones, constipation
dynamic: increase in smooth muscle tone (a-adrenergic), post op 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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17
Q

Clinical features of acute urinary retention

A

suprapubic tenderness
palpable bladder - dull to percuss, cant get beneath it
large prostate on PR: check anaol tone and sacral sensation
>1 litre drained on cauterization

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18
Q

What investigations should be carried out in acute urinary retention?

A

blood: FBC, U and E, PSA
urine: dip, MCS
Imaging: US (bladder volume, hydronephrosis), Pelvic XR

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19
Q

Management of acute urinary retention

A

conservative: analgesia, privacy, walking, running water/hot bath

catheterise: use 3 way if clots, hourly urine output and replace - post-obstruction diuresis
TWOC after 24-72 hours

TURP: if failed TWOC, impaired renal function, elective

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20
Q

What is the classification of chronic urinary retention?

A

High pressure: high detrusor pressure at end of micturition, typically bladder outflow obstruction, leads to bilateral hydronephrosis and decreased renal function

Low pressure: low detrusor pressure at end of micturition, large volume retention with very compliant bladder, kidney able to excrete urine, no hydronephrosis therefore normal renal function

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21
Q

How does chronic urinary retention present?

A 
insidious as bladder capacity increased
typically painless
overflow incontinence/nocturnal enuresis
acute on chronic retention
lower abdo mass
UTI
renal failure
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22
Q

What is the management of high pressure chronic urinary retention?

A

catheterise if: renal impairment, pain, infection
Hourly UO + replace: post-obstruction diueresis
consider TURP before TWOC

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23
Q

What is the management of low-pressure chronic urinary retention?

A

avoid catheterisation if possible - risk of introducing infection
Early TURP: often do poorly due to poor detrusor function, may need permenant catheter

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24
Q

What are the advantages of suprapubic catheterisation?

A

decrease risk UTIS
decrease risk of stricture formation
patient preference - increase comfort
maintain sexual function

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25
What are the disadvantages of suprapubic catheterisation?
more complex - need skilled persons | serious complications can occur
26
What are the contraindications to suprapubic catheterisation?
known or suspected bladder CA Undiagnosed haematuria Previous lower abdo surgery - risk of adhesion of small bowel to abdo wall
27
What are the false causes of haematuria?
beetroot, rifampicin, porphiria, PV bleed
28
What are the causes of haematuria?
Renal: infarct, trauma (stones), infection, neoplasm, GN, polycystic kidneys Ureter: stone, tumour Bladder: infection, stones, tumour, exercise Prostate: BPH, prosatitis, tumour Urethra: Infection, stones, trauma, tumour General: HSP, bleeding diathesis
29
What is the significance of the timing of haematuria?
beginning of stream: urethral throughout stream: renal/systemic, bladder end of stream: bladder stone, schisto
30
What investigations should be done for haematuria?
Bloods: FBC, U and E, Clotting Urine: dip, MCS, cytology Imaging: renal US, Flexi cystoscopy, CT KUB, renal angio
31
What is peri-aortitits?
inflammatory condition which typically involves the infrarenal portion of the abdominal aorta An exaggerated inflammatory response to advanced atherosclerosis has been thought to be the main pathogenetic process.
32
What is idiopathic retroperitoneal fibrosis?
This inflammatory pathology is thought to arise as an autoimmune response to ceroid which leaks out of the atherosclerotic plaques and causes vasculitis. AI vasculitis Fibrinoid necrosis of vasa vasorum affects aorta and small/medical sized retroperitineal vessels ureters are embedded in dense, fibrous tissue causing bilateral obstruction
33
How does peri-aortitits present?
middle aged man vague loin, back or abdo pain increased BP chroinc urninary tract obstruction
34
What investigations should be done in > peri-aortitis and what would you expect to find?
Blood: increased urea and creatinine, increased ESR/CRP US: bilateral hydronephrosis + medial ureteric deviation CT: peri-aortic mass Biopsy: to exclude CA
35
What is the management for peri-aortitis?
relieve obstruction: retrograde stent placement ureterolysis: dissection of ureters from retroperitoneal tissues +/- immunosuppression
36
What is the epidemiology of urolithiasis (stones)?
lifetime incidence: 15% | young men - peak age 20-40, m>F=3:1
37
What is the pathophysiology of urolithiasis (stones)?
increased concentration of urinary solute decreased urine volume urinary stasis
38
What are the common sites for urolithiasis?
pelviureteric junction crossing the illiac vessels at the pelvic brim under the vas or uretine artery vesicoureteric junction
39
What are the types of urinary tract stones?
Calcium Oxalate: 75%, increased risk in Crohn's triple phosphate (struvite): 15%, may form staghorn calculi, associated with proteus infection Urate: 5%, radiolucant, double risk if confirmed gout
40
What are the associated factors for developing urinary stones?
dehydration hypercalcaemia increase oxalte excretion: strawberries, tea UTIs hyperuricaemia eg. gout urinary tract abnormalities eg. bladder diverticulae drugs: furosemide, thiazides
41
What is the presentation of urinary tract stones?
Ureteric colic: loin to groin pain, assoc. n+v, pt cannot lie still bladder or urethral obstruction: bladder irritability (freq, dysuria, haematuria), strangury (painful urinary tenesmus), suprapubic pain radiating to tip of penis or labia, pain and haematuria worse at end of micturition
42
What investigations should be done in ? urinary tract stones?
urine: dip, MCS Bloods: fbc, U&E, Ca, PO4, urate Imaging: XRay KUB: 90% radio opaque USS: hydronephrosis non-contrast CTKUB: 99% of stones visuales
43
How can urinary stones be prevented?
drink plentry treat UTIs rapidly decrease oxalate intake - chocolate, tea, strawberries
44
What is the inital management of urinary stones?
analgesia: diclofenac 75mg PO/IM or 100mg PR Fluids if unable tolerate PO Abx if infection
45
What is conservative management of urinary stones and when can it be used?
used if <5mm in lower 1/3 of ureter 90-95% pass spontaneously can discharge on analgesia
46
What are the risk factors for renal cell carcinoma?
``` obesity smoking HTN dialysis (15% of pts develop RCC) 4% heritable eg. VHL syndrome:Von Hippel-Lindau syndrome, hemangioblastomas) ```
47
What is the pathology of renal cell carcinoma?
adenocarcinoma from proximal renal tubular epithelium
48
What are the subtypes of renal cell carcinoma?
clear cell: 70-80% papillary: 15% chromophobe: 5% collecting duct: 1%
49
How does renal cell carcinoma present?
50% incidental finding Triad: haematuria, loin pain, loin mass systemic: weight loss, anorexia, malais, pyrexia of unknown origin Clot retention invasion of left renal vein can cause varicocele (1%) Cannonball mets can cause SOB
50
What are the paraneoplastic features of renal cell carcinoma?
``` EPO - polycythemia PTHrP - increased calcium Renin - HTN ACTH - Cushings syndrome Amyloidosis ```
51
What is the pattern of spread of renal cell carcinoma?
direct - renal vein lymph haematogenous: bone, liver, lung
52
What investigations should be done in ?renal cell carcinoma?
blood: polycythemia, ESR, U and E, ALP, Ca urine: dip, cytology Imaging: CXR: cannonball mets, US: mass IVU: filling defect CT/MRI
53
What is the robson stagin for renal cell carcinoma?
1. confined to kidney 2. involves perinephric fat but not Garota's fascia 3. spread to renal vein 4. spread to adjacent/distant organs
54
What is the management of renal cell carcinoma?
Medical: reserved for pts with poor prognosis. Temsirolimus: mTOR inhibitor Surgical: radical nephrectomy - consider partial if small tumor or 1 kidney
55
What is the epidemiology of Renal cell carcinoma?
90% of renal cancers Age: 55yrs Sex: M>F=2:1
56
What is the epidemiology of transitional cell carcinoma?
2nd most common renal cancer age: 50-80 yrs sex: M>F=4:1
57
What are the risk factors for developing transitional cell carcinoma?
smoking amine exposure (rubber industry) cyclophospamide
58
What urinary tract locations can be affected by transitional cell carcinoma?
bladder - 50% ureter renal pelvis
59
How does transitional cell carcinoma present?
painless haematuria frequency, urgency, dysuria urinary tract obstruction
60
What investigations should be done in transitional cell carcinoma?
urine cytology CT/MRI IVU: pelviceal filling defect
61
How is transitional cell carcinoma managed - not in bladder?
nephroueretectomy | regular follow up - 50% develop bladder tumours

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