Urology II Flashcards
Which of the following has been shown to increase the risk of prostate cancer? (Please select 1 option) Caucasian race Exposure to cadmium Family history of colon cancer Low intake of animal fats Occupational exposure to dust
Cadmium
Black ethnicity is associated with a higher risk of prostate cancer than Caucasian.
A family history of breast cancer increases the risk of prostate cancer as does a family history of prostate cancer.
An occupation in farming also seems to increase the risk of prostate cancer.
High intake of animal fats and low selenium intake as well as exposure to radiation and cadmium all increase the risk of prostate cancer.
A 56-year-old male who has presented with chest pain, has a PSA of 45 ng/ml (normal s management?
(Please select 1 option)
An elevated PSA is a definitive test for prostate cancer
High selenium intake is related to prostate cancer
Prostate cancer is more aggressive with increasing age
Prostate cancer is typically squamous call carcinoma
The most commonly used pathological grading system is the Gleason score
The most commonly used pathological grading system is the Gleason score CorrectCorrect
Prostate-specific antigen (PSA) may be elevated in
Prostatitis
Benign prostatic hyperplasia
Prostate cancer.
As a rule, prostate cancer is more aggressive in younger men.
Prostate cancer is an adenocarcinoma.
The Gleason score is recommended by the American College of Pathologists.
The most well differentiated tumours have a Gleason score of 2, and the most poorly differentiated a Gleason score of 10.
High intake of animal fats is related to prostate cancer as well as low intake of selenium.
A 56-year-old male presents with pain in the lower back.
The pain has a girdle-like distribution beginning in the lower back and radiating to the lower abdomen. He has not been on any drugs.
The patient is hypertensive but there are no other physical signs of note. Investigations reveal a normocytic normochromic anaemia, raised erythrocyte sedimentation rate and C reactive protein. Renal function is impaired. Ultrasound scanning reveals bilateral hydronephrosis.
Which of the following investigations is most likely to give you the diagnosis?
(Please select 1 option)
Computerised tomogram of abdomen
Intravenous urogram
Isotope renogram
Renal biopsy
Retrograde urogram
CT abdo
The patient has idiopathic retroperitoneal fibrosis (peri-aortitis).
This is a condition in which the ureters become embedded in dense fibrous tissue usually at the junction of the middle and lower thirds of the ureters. This results in unilateral or bilateral ureteric obstruction.
CT scanning will show a peri-aortic mass.
Histological confirmation is obtained by CT guided biopsy or laparotomy.
A 15-year-old boy presents with acute left testicular pain. He is not sexually active. On examination the scrotum appears normal but he has a tender, swollen left testis. Right testis appears normal. What is the most likely diagnosis? (Please select 1 option) Acute epididymitis Mumps orchitis Ruptured epididymal cyst Testicular neoplasm Testicular torsion
Testicular torsion This is the correct answerThis is the correct answer
The features of acute testicular pain suggest testicular torsion and should prompt surgical referral.
Torsion: acute pain and swelling of testis, with absent cremasteric reflex.
Epididimitis: acute pain and swelling. Rare before puberty, and commoner in sexually active.
A 23-year-old man with a teratoma of the testis attended for review following chemotherapy. Which one of the following serum tumour markers is of most value in monitoring the clinical progression of his disease? (Please select 1 option) Alpha-fetoprotein Carbohydrate antigen CA 15-3 Carbohydrate antigen CA 19-9 Carbohydrate antigen CA 125 Carcinoembryonic antigen
AFP
Alpha-fetoprotein (AFP), beta-hCG and PLAP (placental like isoenzyme of alkaline phosphatase) are the major tumour markers in use for the monitoring of testicular teratoma.
CA 125 is a tumour marker used for ovarian tumours.
CA 15-3 is a tumour marker for breast carcinoma, and CA 19-9 is used in pancreatic tumours.
Carcinoembryonic antigen (CEA) is a marker for colonic tumours.
Which one of the following is true of undescended testes?
(Please select 1 option)
25% of undescended testes descend in the first year of life
Is associated with a reduced risk of testicular malignancy
Is associated with normal fertility
Laparoscopy is indicated for impalpable testes
Surgery should be considered in the neonatal period
Laparoscopy is indicated for impalpable testes
Undescended testes affect 3% of full-term boys. However, the majority of these lie in the inguinal canal and approximately 75% of undescended testes descend into the scrotum during the first year of life.
Undescended testes are associated with an increased risk of testicular malignancy which develops in 5% of intra-abdominal testes.
Overall, 80% of males with bilateral descended testes are fertile but only 30% of men with bilateral undescended testes have normal fertility.
Surgery should be performed at 12-18 months of age.
Boys with an undescended but palpable testis should undergo a routine orchidopexy.
Impalpable testes should be assessed with laparoscopy
A 28-year-old male presents with a small painless lump in his left testis. On examination the lump lies within the testes and does not transilluminate.
Neoplasm of the testes
Testicular tumours are the most common in males between the age of 20-40. In 80% of cases the patient notices a painless lump in one testis, or that one testis is larger than the other.
A 32-year-old male presents with pain in his left testis. On examination his left testicle is red tender and swollen. Prehn’s sign is positive.
Acute epididymitis
Neoplasm of the testes
Testicular tumours are the most common in males between the age of 20-40. In 80% of cases the patient notices a painless lump in one testis, or that one testis is larger than the other.
A 25-year-old army officer presents with a discomfort of his left testicle. On examination his testicle feels like a bag of worms with a cough impulse.
Varicocele of the testes
A varicocele is a dilation of the pampiniform venous plexus and the internal spermatic vein.
A 14-year-old boy presents with severe pain in his right testicle. On examination the testis is tender and high in the scrotum. Prehn’s sign is negative
Torsion of the testes
Torsion of the testes is a surgical emergency and typically presents with severe painful, swollen and tender testes. Prehn’s sign distinguishes between bacterial epididymitis and testicular torsion. Scrotal elevation relieves pain in epididymitis but not torsion.
A 58-year-old gentleman presents with vomiting and anorexia of six days duration. He has had a right nephrectomy for chronic pyelonephritis two years ago and now suffers from recurrent left renal calculi. His urea is 27 mmol/l and creatinine 456 µmol/l.
Normal ranges are:
Urea 3-8 mmol/l
Creatinine 50-110 µmol/l
ESR 1-10 mm/hr
ARF
This patient has developed acute renal failure secondary to obstruction due to renal calculi (since he has got only one kidney). It is essential to exclude obstruction as the cause for acute renal failure particularly in patients with a solitary kidney. The obstruction needs to be relieved either surgically (neprostomy/ extracorporeal shock wave lithotripsy) or radiologically (percutaneous) depending on the level and type of calculi, and the patient’s general health.
Normal ranges are: Urea 3-8 mmol/l Creatinine 50-110 µmol/l ESR 1-10 mm/hr 38-year-old gentleman of Pakistani origin complains of increased urinary frequency, haematuria and evening pyrexia. His ESR is 98 mm/hr but routine urine culture is negative.
Renal tuberculosis
Renal tuberculosis usually occurs between the ages of 20 and 40, and is more common in men. Urinary frequency is often the earliest symptom. The urine shows sterile pyuria and urine culture is negative. Haematuria is present in 5% of cases. Constitutional symptoms such as weight loss and evening pyrexia are common. ESR may be raised. The patient may have other symptoms such as cough, haemoptysis suggestive of lung involvement or symptoms of intestinal tuberculosis.
Normal ranges are: Urea 3-8 mmol/l Creatinine 50-110 µmol/l ESR 1-10 mm/hr A 65-year-old man undergoes nephrostomy to relieve hydronephrosis of his left kidney. Four hours post-operatively he develops rigors, pyrexia and his blood pressure is 100/60 mmHg. Investigations show a urea of 28 mmol/l and a creatinine of 330 µmol/l.
Gram negative sepsis
This patient has developed Gram negative sepsis due to instrumentation of the renal tract. The common organisms include Escherichia coli, coliforms, and Bacteroides. Prophylaxis with an aminoglycoside such as gentamicin is usually recommended before surgery or instrumentation of the renal tract.
A 73-year-old man presents to the surgical outpatient clinic with a three month history of difficulty in passing urine. On further questioning, he states that he wakes up frequently at night to pass urine but has difficulty in voiding or in maintaining the stream.
After baseline investigations, he is referred to the urologists who make a diagnosis of carcinoma of the prostate. He does not have any local or regional metastasis. He undergoes a transurethral resection of prostate and makes an uneventful post-operative recovery.
Assuming he remains symptom-free for the next five years, what is the most appropriate investigation to follow up this patient's condition? From the options below choose the one that you think is the most appropriate answer: (Please select 1 option) Bone scan Computerised topographic scan Magnetic resonance imaging Prostate specific antigen level Transrectal ultrasonography
PSA
The prostate specific antigen (PSA) level will be the most appropriate investigation in this patient since it is an excellent marker in the follow up of patients with established prostate cancer.
PSA is an enzyme produced by the prostate. Its normal function is to liquefy gelatinous semen after ejaculation, thus allowing the spermatozoa more easily to navigate through the cervix. PSA levels less than 4 ng/mL are generally considered normal; however, an age-specific PSA reference range level is widely used.
Transrectal ultrasonography may be used in the diagnosis of carcinoma prostate but has no role in the follow up of the disease.
CT scan may be used for staging of the disease and not for prognostic purposes.
Bone scan is indicated in patients with suspected bone metastasis and again not used as a prognostic marker.
A 13-year-old boy presents with a three hour history of right testicular pain. Urinalysis does not reveal any abnormality. On clinical examination he is tender over the superior pole of the right testis and a black spot is visible through the scrotal skin.
Torted appendix testis
The appendix testis may undergo torsion and mimic the presentation of testicular torsion. It usually presents in boys under the age of 16 but can occur in adults. There is acute testicular pain, confined to the upper pole of the testis. There may be a black spot visible through the scrotal skin which suggests this diagnosis. Where there is any doubt the testicle should be explored, if a firm diagnosis can be made the patient can be treated with rest and analgesia and the pain will subside in five to seven days.
A 22-year-old man presents with a two day history of left testicular pain and swelling. Urinalysis reveals leucocytes, blood and nitrites. On examination he has a swollen erythematous scrotum, the testis is non-tender, the epididymis is swollen and exquisitely tender.
Epididymitis
Epididymitis usually occurs in young and middle aged men. There is often a history of lower urinary tract symptoms preceding the testicular pain, urinalysis may show pyuria / nitrites, the scrotal skin may be oedematous and red, there may be a secondary hydrocele and careful examination of the affected side may reveal tenderness confined to a swollen epididymis.
A 21-year-old man presents with a two hour history of severe right testicular pain and swelling. Urinalysis does not reveal any abnormality. On examination his scrotum is swollen and erythematous, his testis is high in the scrotum and exquisitely tender.
Testicular torsion
Testicular torsion most commonly affects adolescent males presenting with severe testicular pain. The overlying skin may be red and oedematous as in epididymitis. The testis is high in the scrotum and the testis and cord cannot be identified as separate structures. Immediate exploration is indicated in all acute presentations with testicular pain where torsion cannot confidently be excluded.
