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- Y6 Renal and Urology > Urology Lecture > Flashcards

Urology Lecture Flashcards

1
Q

What are the two main types of lower uritary tract symptoms (LUTS)?

A

—Poor flow – BOO (BPH)

—VOIDING SYMPTOMS

  • —Incl. Hesitancy
  • —Weak stream
  • —Intermittency
  • —Incomplete emptying

—

Strong flow – Detrusor Overactivity

—STORAGE SYMPTOMS

  • —Frequency,
  • —urgency,
  • —nocturia
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2
Q

Why does strong flow occur (LUTS)?

A

Storage symptoms FUN = frequency, urgency, nocturia.

Brain to bladder signals cause detrusor overactivity

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3
Q

What are voiding symptoms?

A

Poor flow

hesitancy/weak stream/intermittency/incomplete emptying

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4
Q

What are storage symptoms?

A

Strong flow

FUN

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5
Q

Describe the aetiology of storage symptoms.

A
  • •The prostate is situated below the bladder and surrounds the urethra. As the prostate enlarges, bladder outflow becomes increasingly obstructed
  • •Enlargement initially develops in the peri-urethral transition zone of the prostate
  • •In order to generate the increased pressures required to void, the bladder detrusor muscle initially becomes hypertrophied, which leads to trabeculation. In the longer term replacement of muscle fibres with collagen results in loss of detrusor efficacy
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6
Q

Define LUTS.

A

—Lower Urinary Tract Symptoms (LUTS) is a non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding)

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7
Q

Define BPE.

A

—Benign Prostatic Enlargement (BPE) is the clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia

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8
Q

Define BOO.

A

—Bladder Outflow Obstruction (BOO) is bladder outlet obstruction caused by benign prostatic enlargement (clinical finding)

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9
Q

Define BPH.

A

—Benign Prostatic Hyperplasia (BPH) properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction

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10
Q

What is the questionnaire used for storage and voiding symptoms?

A

International Prostate Scoring Symptoms (IPSS)

  • •The IPSS is a widely used, validated questionnaire covering the range of storage and voiding symptoms
  • •Patients score each item from 0 to 5 according to the frequency with which the particular symptom is experienced
  • •Total score will range from 0 to 35
  • •The patients IPSS score should be re-evaluated over time to monitor disease progression and response to treatment
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11
Q

What is assessed in the IPSS?

A
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12
Q

What are the risk factors for BPH?

A
  • —Age
  • —Androgens
  • —Functional androgen receptors
  • —Obesity
  • —Diabetes (& elevated fasting glucose)
  • —Dyslipidaemia
  • —Genetic
  • —Afro-Caribbean
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13
Q

How do you assess for BPH?

A

—History and examination

  • —LUTS
  • —IPSS questionnaire
  • —Frequency Volume chart
  • —Haematuria; Dysuria
  • —Full medical history (co-morbidities, drug history and family history)
  • —Examine abdomen – is bladder palpable?
  • —DRE!!!!
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14
Q

What investigations would you do for BPH?

A
  • —Urine dipstick (exclude infection)
  • —Flow rate + POSTVOID RESIDUAL BLADDER SCAN in clinic
  • —Blood tests (U&E, PSA – but need to counsel patient)
  • —?Renal tract ultrasound
  • —? Flexible cystoscopy
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15
Q

How do you assess prostate size?

A
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16
Q

Below which rate of urine output do we suspect BPH?

A

<12ml/sec

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17
Q

How do you manage BPH/voiding symptoms?

A

Conservative - Reassure; Fluid intake advice (reduce evening fluid intake)

Medical -

  • —Alpha blockers (Tamsulosin, Alfuzosin)
  • 5 alpha-reductase inhibitors (Finasteride, Dutasteride)

Surgical

  • —TURP (Transurethral Resection of Prostate) - 20% have no change or get worse as a result of the surgery

Alternatives:

    • Laser surgery
    • Rezum / steam
    • Urolift
    • Embolisation
    • Catheter options
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18
Q

How do you manage an overactive bladder?

A

Conservative -

  • —Reassure (& treat triggering UTI);
  • Dietary advice (avoid caffeine and citrus fruit)
  • —Bladder Retraining Exercises (NICE recommended)

Medical management

  • —Anticholinergics (Oxybutinin, Detrusitol, Solifenacin)
  • —Betmiga (beta agonist)

Surgical management

  • —Intravesical Botox injection - if too much then obstruction and catheterisation until Botox wears off (can take 6 months)
  • —(Bladder augmentation; urinary diversion/conduit)
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19
Q
A
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20
Q
  • —70 year old man presents with inability to pass urine for 10 hours
  • —Previous history of BPH (on tamsulosin and finasteride)
  • —Pain
  • —You are the on call F1

—How are you going to assess him and manage him?

  • —A. Give analgesia
  • —B. Catheterise patient
  • —C. Advise patient to drink less, especially in evening
  • —D. Start on alphablocker medication
  • —E. Advise TURP surgery
A

B - catheterise

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21
Q

How do you manage urinary retention? What investigations would you do?

A
  • Catheterise

Investigations:

  • Dipstick/CSU
  • FBC, U & E
  • Measure Residual Urine
  • Neurological examination if necessary (could be a first presentation of MS)

Prescribe - Antibiotics, Laxatives, Alpha blocker if necessary

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22
Q

What types of catheter are available?

A

—Foleys

  • Simplastic(short term )
  • PTFE coated (short term )
  • Hydrogel coated (long term)
  • Silicone (long term)

— Size?

  • Known as ‘French’ or ‘Charriere’
  • 16F is the diameter x 3

—Special catheters

  • 3 Way
  • Suprapubic
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23
Q

How is urinary retention classified?

A

Acute or Chronic

  • Acute Retention (AUR) = painful
  • Chronic Retention (CUR)= postvoid residual >800ml
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24
Q

What is low presure retention (LPR)? How do you manage it?

A
  • Normal U & Cr , no hydronephrosis
  • consider starting alpha blockers and
  • Trial Without Catheter (TWOC)
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25
Q

What is high pressure retention? How do you manage it?

A
  • raised U & Cr
  • bilateral hydronephrosis,
  • Measure UO, BP , body weight
  • Only < 10 % need fluid replacement
    • NEVER TWOC!
    • BOO Surgery or Longterm Catheter
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26
Q

What is TWOC?

A

trial without catheter

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27
Q

Case:

  • —67y male
  • —Urgency, frequency, poor flow
  • —DRE 40g BPE
  • —PSA 1.2
  • —MSU –ve
  • —US: Normal, postvoid residual 40ml
A

Alpha blocker

Anticholinergic - but dont start with this as it could lead to urinary retention as it reduces detrusr activity signals

  • —Tamsulosin +- Finasteride
  • —If no improvement in urgency add in anticholinergic for Urgency
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28
Q

What are the presenting symptoms of prostate cancer?

A
  • —Asymptomatic; raised PSA
  • —LUTS
  • —Urinary retention / renal failure
  • —(Pain)
  • —Haematuria
  • —Bone pain/weight loss/ spinal cord compression (Mets) - could present as an old male not being able to walk
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29
Q

Is PSA good for screening? How does it change with age?

A

PSA does not meet screening criteria – testing is informed decision process with GP or other clinician

PSA range goes up as you get older

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30
Q

Does DRE raise PSA?

A

Not really, only by 0.1%

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31
Q

What are the risk factors for prostate cancer?

A
  • —Age
  • —Race
  • —Family history
  • —BRCA 2 gene
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32
Q

What are the causes of RASIED PSA?

A
  • —BPH
  • —Urinary Retention
  • —Urine infection
  • —Catheterisation / instrumentation of urethra
  • —Prostate cancer
  • —

—Not significant:

  • —Digital rectal examination
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33
Q

Why is MRI useful for prostate cancer? What classification is used?

A
  • —Can differentiate between high risk and low risk prostate cancer
  • —PIRADS classification 1-5
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34
Q

What invasive technique is used to diagnose prostate cancer?

A
  • TRUS biopsy is used for TISSUE DIAGNOSIS (transrectal ultrasound guided biopsy)

Alternatives:

  • •Transperineal Biopsy
  • •Template Biopsy
  • •Saturation Biopsy
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35
Q

What is the grading system used for prostate cancer?

A

Gleason score

  • Low risk 3+3
  • High risk 5+5 and up

(Staging is done by TNM)

36
Q

—70 year old man referred by GP with PSA 18 ug/L (upper limit 7.2)

—Do you…?

  • —A. Repeat PSA and check MSU
  • —B. Organise MRI prostate and TRUS biopsies
  • —C. Explain likely diagnosis of prostate cancer
  • —D. Advise radical prostatectomy or radiotherapy
A

A

37
Q

What is MSU?

A

Mid stream urine

38
Q

How do you manage a patient diagnosed with prostate cancer?

A
  1. —Active surveillance (low risk low volume disease)
  2. —Surgery – radical prostatectomy (robotic or laparoscopic)
  3. —Radical Radiotherapy
  4. —Watchful waiting (elderly / co-morbid patients)
  5. —Hormones e.g. LHRH agonists can be used to shrink the prostate before surgery
  6. —Chemotherapy
39
Q

How do you manage low risk low volume prostate cancer in a young man?

A

Active suirveillance - no risk of erectlie dysfunction/incontinence. Might therefore be a better option than surgery.

But if the disease is aggressive then radical prostatectomy

40
Q

Why is surgery for prostate cancer unpopular?(3)

A
  • —More bleeding
  • —higher incontinence
  • —Likely erectile dysfunction
  • —May not die anyway
41
Q

What hormonal therapies are available for prostate cancer?

A
  • LHRH agonists e.g. Zoladex
  • Anti-androgen e.g. Bicalutaminde, Casodex

(beware tumour flare)

42
Q

Why is spinal cord compression a urological emergency? How do you manage this(4)?

A

—Due to vertebral bone metastases

  1. —Start steroids (dexamethasone iv)
  2. —Urgent MRI
  3. —Suppress testosterone
  4. —Decompress cord with spinal surgery or radiotherapy
43
Q

What must you monitor patients on hormonal/radiotherapy treatment for postate cancer?

A

PSA must be followed up in post RRP

  • — <0.01 in 6/52
  • —Failure initial PSA >0.2
  • —Early rapid rise indicates disease beyond prostate
  • —Later slow rise local recurrance
  • —Biopsy to confirm
  • —Restage- bone scan /MRI
44
Q

If radiotherapy is not successful in prostate Ca, what do you consider?

A
  • —Nadir +2
  • —Consider HIFU or salvage surgery
  • —Hormones
45
Q

Describe active surveillance in post prostate cancer patients.

A
  • —Gleeson 6 (?7)
  • —Less than 2 cores
  • —PSA <10
  • —T1c or T2

—

  • —PSA FU 3 monthly
  • —MRI scan anually
  • —Rebiopsy year 1,3 & 7

Treat it…

  • —PSA >10
  • —PSA dt <3 years
  • —Grade progression on rebiopsy
  • —Clinical progression
  • —Patient choice
46
Q
A
47
Q

Name 3 types of hydroceles that can occur in the testicles.

A

Can be difficult to tell whether it is a mass or tense hydrocele. Use light to distinguish.

48
Q

Should you treat varicoceles?

A

No, only if symptomatic.

49
Q

What is a spermatocele?

A

A spermatocele is an often pain-free benign cyst that occurs close to a testicle. It may also be known as a spermatic or epididymal cyst. The cyst forms in the epididymis. The epididymis is a coiled tube behind each testicle

50
Q

What is a hydrocele?

A

—What is it?

  • —Fluid within Tunica vaginalis
  • —Can get above it
  • —Transilluminates! - light–> red
  • —Surgical repair if large
51
Q

—25 year old man presents with pain in left testicle swelling and fever;

—How will you assess and manage him?

  • —A. Organise ultrasound
  • —B. Start antibiotics
  • —C. Explain testicular cancer possible
  • —D. Manage conservatively
A

Fever, swelling and discharge –> infection, ?STI

Only do US to exclude Ca or if there is an abscess and you’re planning to drain it

52
Q

What is epididymitis/orchtis? List 3 causes.

A

—Infection of epididymis or testis or both

—Causes:

  • —STIs
  • —UTIs - ascending E-coli (gram -ve rods)
  • —Post-operative
53
Q

Who is most affected by testicular cancer?

A

Affects younger men - under 35yrs

54
Q

What are the two types of testicular cancer?

A

—Germ Cell

  • —Seminomatous
  • —Non-seminomatous

—Non-Germ Cell

55
Q

What investigations would you do for testicular cancer?

A
  • —Important to catch early!!
  • —Ultrasound – urgent on same day
  • —Tumour markers – AFP, HCG, LDH
  • CXR on same day
56
Q

What is the management of testicular cancer?

A
  • —Counselling
  • —Sperm banking
  • —Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?)
  • —Postop:
    • Surveillance +- chemotherapy (BEP) +- Radiotherapy +-RPLND(retroperitoneal lymph node dissection)
57
Q

How are the testicles taken out in testicular cancer and why?

A

Inguinal approach to prevent spreading cancer cells to different lymphatic drainage sites

58
Q

List 4 causes of haematuria?

A
  • —Infection
  • —Cancer
  • —Medical
  • —Trauma
  • —(kidney stones)
59
Q

What kind of catheter do you insert in haematuria?

A

—3 way catheter- for irrigation and evacuation of clots

Check for craggy postate, ballotable kidney, full bladder.

60
Q

What are the criteria for admission in haematuria?

A

—Criteria for admission:

  • —Frank haematuria with clots
  • —Drop in Hb
  • —Social circumstance

Clinic - 2 week rule, one-stop

61
Q

What investigations should you do in haematuria?

A
  • —FBC, clotting, U&E
  • —MSU MC&S
  • —Urine cytology / NMP22 ?
  • —CT* Urogram or KUB, U/S
  • —Flexible cystoscopy

—

You might miss bladder tumour on CT scan because it will look like a natural wrinkle in bladder.

62
Q

What might you need to do if haematuria is particularly bad?

A
  • Resuscitation incl transfusion
  • Group and save (G&S) -determines patient’s blood group for transfusion
  • —Thorough bladder washout
  • —Continuous irrigation
  • —May need clot evacuation in theatre

If a clot is present in catheter - wash it out with 50ml syringe and saline but you might also need to replace it with a large bore catheter.

63
Q

What is the epidemiology of kidney stones?

A
  • —More common in caucasian men
  • —1% of hospital admissions
  • —Lifetime prevalence 12%
  • —Family history: consider CYSTINURIA
64
Q

What are the complications of renal stones?

A
  • Pain and infection (incl life-threatening gram -ve sepsis “infective pyonephrosis”)
  • Renal damage (takes 6-12 weeks for kidney to die)
  • Metabolic probelms (e.g. hyperparathyroidism, gout, cysteinuria)
  • Underlying anatomical problems (e.g. PUJ-o, MSK, Horseshoe kidney, ureteric structure
  • —Renal deterioration after 2-6 weeks if complete obstruction: danger in losing kidney
  • —JJ stent encrustation <6 months in stone formers!
  • —50% patients will have recurrent stones: fluid intake advice
  • —40% of conservatively managed renal stones will enlarge – monitor by imaging & RF
65
Q

How are kidney stones classified?

A
  • —Size: <5mm; 5-20mm; >20mm; staghorn
  • —Location: Renal (calyceal, pelvic, diverticular); Ureteric
  • —Xray Characteristics: radiolucent; radioopaque
  • —Stone composition: Calcium oxalate (most common), CaP, Uric acid, cysteine, indinavir; Infection MAP/Struvite
66
Q

What investigations should you do for kidney stones?

A
  • —Hx
  • —Ex
  • —Bloods, Urine dip* (RBC, WBC, Nitrites, pH) & MSU
  • —Imaging: KUB / US / CT-KUB / IVU

—*up to a third of patients can have a normal dipstick

—NB. Immediate imaging if: (EAU Recommendation)

  • —Fever
  • —solitary kidney
  • —diagnosis unclear
67
Q

Which stones can you not see on X-Ray?

A

Uric acid stones

68
Q

What are the differential diagnoses for ureteric colic?

A
  • —AAA
  • —Testicular torsion
  • —Perforated PU
  • —Appendicitis
  • —Ruptured ectopic
  • —MI
  • —Diverticulitis
  • —Prostatitis
69
Q

What are the BG causes of ureteric colic?

A
  • —Stones,
  • TCC,
  • blood clot,
  • RPF,
  • ?BPH/CaP
70
Q
A
71
Q

What general advice can you give to someone with kidney stones?

A
  • —High fluid intake – urine champagne colour
  • —Normal diet – do not cut out dairy products

—Attend / return to A&E if

  • — Pain not controlled by analgesia
  • — PYREXIA

(If urine is darker than champagne colour then patient is probably not drinking enough)

72
Q

What is the A&E protocol for ureteric colic?

A

—1. Analgesia: 5-10mg Morphine iv +/- antiemetic

  • (Diclofenac if creatinine normal)

— 2. Basic Investigations:

  • —FBC/U+E, Ca, Urate, Urine dipstick, ßHCG (♀)

— 3. Radiological Investigations:

  • —plain both KUB and CT KUB
73
Q

If stone <10mm, pain controlled, no sepsis, how do you treat?

A

—2 week trial of Tamsulosin 400mcg od

  • —Arrange follow-up with appropriate imaging (KUB vs limited IVU vs CT KUB)
  • —2 weeks if significant obstruction or stones >5mm otherwise 4 weeks
74
Q

What is voltarol?

A

AKA Diclofenac

NSAID

75
Q

How do you treat kidney stones?

A

—Conservative

  • —Observe asymptomatic non-obstructive renal stones in selected patients
  • —incl. Metabolic screen

—Medical

  • —Alkalinise / acidify urine
  • —Treat / prevent UTIs
  • —Allopurinol?

—Surgical

  • —Uretero-renoscopy +- laser
  • —ESWL(Extracorporeal shock wave lithotripsy )
  • —PCNL (Percutaneous nephrolithotomy - minimally invasive removal of stones)
  • —(Lap / Open)
76
Q

What is a fibroid?

A

Fibroids are abnormal growths that develop in or on a woman’s uterus. Sometimes these tumors become quite large and cause severe abdominal pain and heavy periods

Calcified fibroid; PUJ & left renal stone not visible on KUB

This is a calcified fibroid.

77
Q

What is Tamsulosin?

A

Drug used for BPH, chornic prostatitis and to help with passage of kidney stones.

78
Q

What is obstructive polynephrosis?

A
  • = Obstruction + infection
  • Risk of fatal GRAM –ve sepsis

Management:

  • —Immediate resuscitation + iv antibiotics
  • —Culture
  • —Urgent imaging (KUB & U/S)
  • —Discuss with urology SpR
  • —Consider urgent nephrostomy (or JJ stent)
  • —Monitor closely (HDU)
79
Q

When does testicular tortion usually occur in males?

A
  • Under age of 23, painful, high riding testicle
  • —Rare beyond 35y of age
80
Q

What is the problem with appendix testis? How might you recognise it ?

A

Cannot distinguish from testicular tortion - should only manage conservatively if confident of diagnosis

Blue dot sign - a tender nodule with blue discoloration on the upper pole of the testis

81
Q
A
82
Q

What is the underlying deformity in testicular tortion?

A

extension of tunica vaginalis behind testicle –> clapper bell

83
Q

What are the differentials for testicular tortion?

A
  • —torted appendix testis,
  • epididymitis,
  • viral orchitis,
  • bleed into testicular tumour
84
Q

What investigation would you do for testicular tortion?

A

MSU (urgent microscopy if Sy suggest UTI/epididymitis)

85
Q

Describe a typical presentation of testicular tortion.

A

<35yrs

Sudden onset

Swollen, tender, high riding (contralat horiz), loss of cremateric reflex in children

- Y6 Renal and Urology (22 decks)

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