Urology I Flashcards
Scrotal swelling you can’t get above: []
Scrotal swelling you can’t get above: inguinal hernia
Describe the GI side effects of bisphosphonates like alendronic acid [3]
How do you instruct patients to take this medication to reduced the risks? [1]
Alendronic acid, a bisphosphonate used in the treatment of osteoporosis, can cause gastrointestinal side effects, including dyspepsia, oesophagitis and gastric ulcers.
It is important for patients to take alendronic acid correctly (with a full glass of water, without lying down for 30 minutes afterwards) to reduce these risks.
What is the differnce between Balanoposthitis and Balanitis [1]?
Balanitis is an inflammation of the glans penis, often caused by infection. It presents with redness, swelling, and pain at the glans but does not involve the foreskin.
Balanoposthitis is the inflammation of both the glans penis (balanitis) and the foreskin (posthitis).
What’s the difference between posthitis and phimosis?
Posthitis: is an inflammation of the foreskin, often caused by infection or irritation.
Phimosis is the inability to retract the foreskin over the glans penis
A patient presents with a non-seminoma. What biomarker would raised to suggest this? [1]
AFP
A 67 year old man is being consented for a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia. He is concerned about the possible complications of the operation. Which is the most common complication?
Priapism
1
Hypernatraemia
2
Increased risk of prostate cancer
3
Loss of sensation over the skin of the scrotum
4
Retrograde ejaculation
A 67 year old man is being consented for a transurethral resection of the prostate (TURP) for benign prostatic hyperplasia. He is concerned about the possible complications of the operation. Which is the most common complication?
Retrograde ejaculation
What are the treatment algorithms for stress and urge incontinence?
Stress:
- Pelvic floor muscle retraining
- Surgery
- Duloxetine
Urge:
- 6 weeks retraining
- Oxybutnin
Urge inconteince
Which patient population is oxybutnin often CI in? [1]
What do you give instead [1]
Old frail people
- Give mirabegron
A patient has BPH and concurrent DMT2 peripheral neuropathy. Which treatment for the peripheral neuropathy is CI because of his BPH? [1]
Amitriptyline due to the risk of urinary retention.
amyDRIPtyline - don’t prescribe to BPH patients with terminal dribbling
Patients with obstructive urinary calculi and signs of infection require what treatment? [2]
Patients with obstructive urinary calculi and signs of infection require urgent renal decompression and IV antibiotics due to the risk of sepsis
How do you treat unilateral and bilateral undescended testes in newborns? [2]
unilateral undescended testis:
- Arrange a review at 6-8 weeks
bilateral undescended testes:
- Refer to a senior paediatrician for endocrine or genetic investigation
- the presence of bilateral undescended testes should prompt the clinician to consider the possibility of an underlying pathology (commonly congenital adrenal hyperplasia (CAH).
How do you decide when to use mirabegron or oxybutynin? [2]
Oxybutynin
- is an immediate-release antimuscarinic drug, often used for urge incontinence.
- However it can lead worsening of dementia and postural hypotension in older patients
Mirabegron
- beta-3 receptor agonist
- it is used in frail elderly patients as it has fewer anticholinergic side-effects so will not worsen dementia.
how do you treat variocele [2]
- Mild varcicoeles do not need intervention and can be managed conservatively
- occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
What is the treatment choice for a women with a UTI who is breast feeding their newborn child? [1]
Trimethoprim 200mg twice daily for 3 days
- While nitrofurantoin can be used to treat UTI, it should be avoided in breastfeeding women, as its presence in milk can cause haemolysis in G6PD-deficient infants.
How do you determine if you give nitrofurantoin or trimethoprim in UTI tx? [2]
Nitrofurantoin (100mg BD for three days):
- eGFR must be greater than or equal to 45ml/minute.
Trimethoprim (200mg BD for three days) is the drug of choice if eGFR < 45ml/minute
State the male LUTS from BPH that can be split into voiding [5], storage [4] and post micturition symptoms [1].
Voiding:
SHITE
- Straining
- Hesitancy
- Intermittant stream
- Terminal dribbling
- (incomplete) emptying
Storage:
- Urgency
- Frequency
- Incontinence
- Nocturia
Post mic:
- Dribbling (more delayed than terminal dribbling)
What is the max flow rate score that is suggestive of bladder outflow obstruction due to BPH? [1]
Max flow rate < 10ml per second is suggestive of bladder outflow obstruction due to BPH
LUTS + what size prostate [1] or PSA score [1] would you move to second line treatment for BPH? [1]
- Prostate larger than 30g
- PSA > 1.4
BPH Treatment:
The general idea is that [] are used to treat immediate symptoms, and [] are used to treat enlargement of the prostate.
They may be used together where patients have significant symptoms and enlargement of the prostate.
The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate.
They may be used together where patients have significant symptoms and enlargement of the prostate.
Describe the MoA of finasteride [4]
5-alpha-reductase inhibitor:
* Blocks conversion of testosterone to DHT;
* DHT is considered to be the primary androgen playing a role in the development and enlargement of the prostate gland. It serves as the hormonal mediator for the hyperplasia upon accumulation within the prostate gland
What is the most common congenital male reproductive disorder?
Testicular torsion
Cryptorchidism
Hydrocoele
Peyronie disease
What is the most common congenital male reproductive disorder?
Testicular torsion
Cryptorchidism
Hydrocoele
Peyronie disease
TOM TIP:
The notable side effect of tamsulosin is [].
The most common side effect of finasteride is [] (due to reduced []).
TOM TIP: The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure.
The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).
1.
Describe surgical treatment for BPH [5]
Transurethral resection of prostate (TURP):
* GOLD STANDARD
* Less than 14% impotent, 1% incontinent & 10% erectile
dysfunction
Transurethral incision of prostate (TUIP):
* Less destruction than TURP and less risk to sexual function, best for smaller prostate
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
- involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.
Holmium laser enucleation of the prostate (HoLEP)
- also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.
Open prostatectomy via an abdominal or perineal incision
Name two anti-cholinergics used for storage symptoms? [2]
- Oxybutynin
- Tolterodine
Describe the MoA of Oxybutynin, Tolterodine [3]
Competitively inhibits acetylcholine, blocking the muscarinic receptors and
promoting bladder relaxation to increase capacity
This reduces urgency and frequency of urination
These muscarinics are selective for M3 receptor which is the main receptor in the bladder
How do you manage acute urinary retention? [4]
- Immediately catheterise;
- Provide alpha blocker (e.g. tamulosin);
- Wait 24hr and remove catheter;
- (If still can’t urinate - schedule for TURP)
Describe the pathophysiology of TURP syndrome? [3]
How serious is it? [1]
It is caused by irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection
This results in hyponatremia, and when glycine is broken down by the liver into ammonia, hyper-ammonia and visual disturbances.
TURP syndrome is a rare and life-threatening complication
Desribe the early presentation [2] and late presentation [5]of TURP syndrome [2
TURP syndrome typically presents with CNS, respiratory and systemic symptoms:
Early features
* mild cases may go unrecognised
* restlessness, headache, and tachypnoea, or a burning sensation in the face and hands
Features of greater severity
* respiratory distress, hypoxia, pulmonary oedema
* nausea, vomiting
* visual disturbance (e.g. blindness, fixed pupils)
* confusion, convulsions, and coma
* haemolysis
* acute renal failure
* reflex bradycardia from fluid absorption
Pneumonic for TURP complications? [4]
Complications of Transurethral Resection: TURP
T urp syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
TURP presents classically as a triad of? [3]
The triad of features are:
1. Hyponatraemia: dilutional
2. Fluid overload
3. Glycine toxicity
How long does finasteride need to be given for results to be seen? [1]
Finasteride treatment of BPH may take 6 months before results are seen
Name two side effects of tamulosin for treating BPH [2]
Dizziness
Postural hypotension
[] is the most effective management option in renal cell carcinoma? [1]
Radical nephrectomy is the most effective management option in renal cell carcinoma - RCC is usually resistant to radiotherapy or chemotherapy
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works as an non-steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an steroidal anti-androgen?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an androgen synthesis inhibitor?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH antagonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works is an GnRH agonist?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Signs and symptoms of:
Early stage prostate cancer? [6]
Late stage prostate cancer? [3]
Early stage:
* Often asymptomatic
* Urinary frequency
* Poor flow
* Nocturia
* Dribbling
* Renal obstruction
* Haematuria / Haematospermia
* Nodular hard craggy prostate on DRE
If metastised:
* Weight loss
* Bone pain
* Anaemia
What levels normal PSA? [1]
What is the upper limit of normal PSA:
- under age of 50 [1]
- over the age of 70 [1]
Normal range varies w/ age, but generally < 4 ng/ml
Upper limit of normal PSA:
< 2.7 ng/ml if under 50;
< 7.2 over 70
Name this form of taking prostate biopsies [1]
Why is it better than trans rectal biopsy? [1]
Template / transperineal biopsy (BP)
Less infections; more biopsies can be taken
A guided biopsy is offered to patients with a Likert score of [] or greater
A guided biopsy is offered to patients with a Likert score of 3 or greater
3 = Chance of clinically significant cancer is equivocal
4 = Clinically significant cancer is likely to be present
5 = Clinically significant cancer is highly likely to be present
What are well, moderately and poorly differentiated Gleason scores? [3]
Well differentiated: Score 2-4
Moderately differentiated: Score 5-7
Poorly differentiated: Score 8-10
Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a [] scale.
Describe the differences in results given from this scale. [5]
The results are reported on a Likert / PIRADS scale
1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer
Describe the treatment types for localised prostate cancer [4]
Radical prostatectomy (if < 75 and fit): can be open, laparoscopic or robotic surgery
Focal therapy:
- Brachytherapy (radioactive seeds)
- Cryotherapy
- HIFU (High frequency focused ultrasound)
Radiotherapy
Radiotherapy & androgen deprivation (stops stimulating the cancer to grow):
- Androgen-receptor blockers such as bicalutamide
- GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Explain how a GnRH agonist works to treat prostate cancer [3]
Gonadotropin-releasing hormone (GnRH) agonist: cause a ‘chemical castration’.
GnRH (also called luteinising hormone-releasing hormone or LHRH) is the hormone that stimulates LH/FSH release from the anterior pituitary.
Initially it causes an increase in LH/FSH release.
However, the persistent presence of an agonist causes downregulation of receptors on the pituitary gland leading to reduced LH/FSH release.
Goserelin is a commonly used GnRH agonist (brand name Zoladex).
Management of Cord Compression due to prostatic cancer? [3]
(mainly) Radiotherapy
Rest and dexamethasone
Neurosurgery (if urgent decompression required)
What does a cancerous prostate feel like? [2]
A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule
Describe the two forms of prostate biospy [2]
There are two options for prostate biopsy:
Transrectal ultrasound-guided biopsy (TRUS):
- ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.
Transperineal biopsy
- involves needles inserted through the perineum. It is usually under local anaesthetic.
A 70-year-old patient with prostate cancer is commenced on goserelin therapy. A week after starting treatment, he attends a local emergency department complaining of worsened lower urinary tract symptoms and new onset back pain.
Which treatment may have helped avoid this deterioration? [1]
Flutamide, a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.
How long after ejaculation and vigorous exercise should you wait before measuring PSA? [1]
How long after protastitis and UTI exercise should you wait before measuring PSA? [1]
ejaculation and vigorous exercise: wait 48hrs
protastitis and UTI: wait 1 month
What is an aide for memorising upper age limit of PSA levels? [1]
(Age-20) / 10
Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer works by preventing DHT binding from intracytoplasmic protein complexes?
Cytoproterone acetate - steroidal anti-androgen
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
Which of the following treatments for prostate cancer is normally the option for the treatment of hormone-relapsed metastatic prostate cancer in patients who have no or mild symptoms after androgen deprivation therapy has failed, and before chemotherapy is indicated?
Cytoproterone acetate
Degarelix
Goserelin
Bicalutamide
Abiraterone
What is Fanconi syndrome and why does it occur? [1]
Fanconi syndrome arises from an underlying dysfunction in the proximal convoluted tubule (PCT), resulting in a broad impairment of reabsorption.
What electrolyte disturbance does Fanconi syndrome present with? [2]
Which other disease state is Fanconi syndrome associated with? [1]
Hypophosphatemia, and hypokalemia
Associated with Wilson’s disease
When would you initiate hormonal / androgen therapy for prostate cancer? [1]
Gleason grade group 2 and above
Name some CI for sildenafil use for ED? [5]
Individuals taking nitrates
Hypertension/hypotension
Arrhythmias
Unstable angina
Stroke
Recent myocardial infarction.
