Urology I Flashcards
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.
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
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
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
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
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)
Management of Cord Compression due to prostatic cancer? [3]
(mainly) Radiotherapy
Rest and dexamethasone
Neurosurgery (if urgent decompression required)
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.
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
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 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 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).
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
Urge inconteince
Which patient population is oxybutnin often CI in? [1]
What do you give instead [1]
Old frail people
- Give mirabegron
A patient presents with a non-seminoma. What biomarker would raised to suggest this? [1]
AFP
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
Name some CI for sildenafil use for ED? [5]
Individuals taking nitrates
Hypertension/hypotension
Arrhythmias
Unstable angina
Stroke
Recent myocardial infarction.
Patients receiving which form of treatment increaese their risk of RCC? [1]
15% of haemodialysis patients develop RCC
What is the difference in renal cancer staging between 1-4? [4]
Stage 1: < 7cm; no spread
Stage 2: > 7cm; no spread
Stage 3: > 7cm; spread locally
Stage 4: Spread to abdomen; adrenal glands; lymph nodes
Treatment for localised renal cancer?: T1 [2] & T2 [1]
T1 tumours:
- < 3 cm: ablative therapies
- up to 7 cm: partial nephrectomy
T2:
Radical nephrectomy (open, laporoscopic, open)
Treatment for metastatic RCC? [6]
Debulking surgery
Adjuvent chemotherapy
Immunotherapy tyrosine kinase inhibitors:
* ipilimumab
* nivolumab
* Sunitinib: inhibitor of tyrosine kinase receptors
* Pazopanib: inhibitor of tyrosine kinase receptors
* Temsirolimus: inhibitor of the mammalian target of rapamycin (mTOR)
* Everolimus: inhibitor of the mammalian target of rapamycin (mTOR)
Where patients are not suitable for surgery, which les invasive procedures can be used to treat the RCC? [3]
Arterial embolisation,
- cutting off the blood supply to the affected kidney
Percutaneous cryotherapy,:
- injecting liquid nitrogen to freeze and kill the tumour cells
Radiofrequency ablation,
- putting a needle in the tumour and using an electrical current to kill the tumour cells
Name 4 differential diagnosises of cannonball metastasis
- renal
- choriocarcinoma
less commonly, with prostate, bladder and endometrial cancer.
Explain why RCC causes each of the following cause of paraneoplastic syndrome
Polycythaemia
Hypercalcaemia
Hypertension
Stauffer’s syndrome
Polycythaemia:
- due to secretion of unregulated erythropoietin
Hypercalcaemia:
- due to secretion of a hormone that mimics the action of parathyroid hormone
Hypertension
- due to various factors, including increased renin secretion, polycythaemia and physical compression
Stauffer’s syndrome
- abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis
Describe what is meant by Stauffer syndrome
Stauffer syndrome: RCC paraneoplastic syndrome
Hepatosplenomegaly
+
Cholestatic LFTs (elevated bilirubin; ALP and GGT)
Clinical features of bladder cancer? [4]
Painless haematuria: most common symptom
recurrent UTIs
Dysuria
Frequency
Urgency
Suprapubic pain
Describe NICE guidelines regarding haematuria that determines investigating for bladder cancer [2]
Painless haematuria:
Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI. 2/3 samples positive for blood require investigation
Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:
Dysuria or;
Raised white blood cells on a full blood count
What investigations would you conduct for bladder cancer:
- All patients given? [1]
- NVH v VH? [2]
All patients given cytoscopy (rigid or flexible) - with biospy: diagnostic
NVH: USS renal tract
VH: CT urogram
Describe the treatment for Mild [2], Intermediate [2] & High [3] risk patients of Non-Muscle Invasive Bladder Cancer (NMIBC)
Mild:
- Transurethral resection of bladder tumor (TURBT): provides diagnosis, staging, and initial treatment of diathermy
- Post TURBT - Intravesical chemotherapy (mitomycin or gemcitabine) given using a catheter: reduces risk of relapse
Moderate:
- Transurethral resection of bladder tumor (TURBT): provides diagnosis, staging, and initial treatment
- Post TURBT - Intravesical chemotherapy (mitomycin) given using a catheter; 6 doses - liquid place directly in bladder
High:
- Transurethral resection of bladder tumor (TURBT): X2
- BCG vaccine
- Cystectomy – totally remove the bladder
Describe treatment for Muscle Invasive Bladder Cancer (MIBC) [3]
Radical cystectomy: - gold standatd
- Complete surgical removal of the bladder, prostate or uterus, and regional lymph nodes
- Requires urinary diversion
Radiotherapy:
- organ sparing
(Adjuvant &/OR) Chemotherapy:
- Cisplatin before radical cystectomy
Describe the treatment for metastatic bladder cancer [3]
First-line therapy:
- platinum-based combination chemotherapy, such as gemcitabine-cisplatin or dose-dense methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC).
Immune checkpoint inhibitors:
- For patients ineligible for cisplatin or after progression on first-line chemotherapy, pembrolizumab, atezolizumab, or nivolumab are options.
Targeted therapy:
- For patients with specific molecular alterations (e.g., FGFR3), targeted therapies like erdafitinib may be considered.
Describe the therapy options provided post-radical cystectomy [4]
Ileal conduit:
- A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous.
- The ends of the ureters are anastomosed to the separated section of the ileum.
- The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag
Continent urinary diversion:
- Create a pouch inside the abdomen from a section of the ileum, with the ureters connected and fills with urine
- A thin tube is connected between a stoma on the skin and the internal pouch
- Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.
Neobladder formation:
- Formed from ileum; connected to both ureters and urethra
- Functions as normal bladder
Ureterosigmoidostomy (rare)
- Attaching the ureters directly to the sigmoid colon.
- The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect.
- The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.
What is the name for this operation? [1]
Continent urinary diversion
Name this operation [1]
Ileal conduit
Describe the difference classes of testicular cancer [4]
Germ cell tumours (95% of cancers):
- Seminomas
- Non-seminomas: including embryonal, yolk sac, teratoma and choriocarcinoma
Non-germ cell tumours:
- include Leydig cell tumours and sarcomas.
Describe clinical presentation of testicular cancer [4]
- A painless lump is the most common presenting symptom
- Pain may also be present in a minority of men
- Other possible features include hydrocele, gynaecomastia (drastic level of β-hCG)
- Haematospermia
Describe the treatment for metastatic testicular cancer [3]
Chemotherapy:
- Cisplatin & Etoposide (cornerstone)
- Bleomycin (added)
Describe 4 different stages of testicular cancer [4]
Describe which parameters of varicoceles determine if treatment is given [2]
Grade II or III varicocoele Management:
* Asymptomatic AND normal semen parameters Semen analysis every 1-2yrs
* Symptomatic OR abnormal semen parameters: Surgery
nvestigations for suspected epididymo-orchitis are guided by age:
sexually active younger adults: []
older adults with a low-risk sexual history: []
nvestigations for suspected epididymo-orchitis are guided by age:
sexually active younger adults: NAAT for STIs
older adults with a low-risk sexual history: MSSU
Label the tumour marker for each type of testicular cancer [4]
A: hCG & AFP
B: AFP
C: hCG
D: no rise
[] is the most common cause of primary hyperaldosteronism
Bilateral idiopathic adrenal hyperplasia is the most common cause of primary hyperaldosteronism
A 28-year-old female presents to the gastroenterology clinic with a history of irritable bowel symptoms and weight loss. She undergoes upper endoscopy and colonoscopy. A terminal ileal biopsy shows transmural inflammation, non-caseating granulomas and skip-lesions. As a result, she is started on a short course of steroids to induce remission of her underlying condition.
Which medication would be most appropriate to maintain remission?
Ciclosporin
Low dose prednisone
Mercaptopurine
Mesalazine
Tacrolimus
A 28-year-old female presents to the gastroenterology clinic with a history of irritable bowel symptoms and weight loss. She undergoes upper endoscopy and colonoscopy. A terminal ileal biopsy shows transmural inflammation, non-caseating granulomas and skip-lesions. As a result, she is started on a short course of steroids to induce remission of her underlying condition.
Which medication would be most appropriate to maintain remission?
Ciclosporin
Low dose prednisone
Mercaptopurine
Mesalazine
Tacrolimus
Azathioprine or mercaptopurine is used first-line to maintain remission in patients with Crohn’s
