Urology/Nephrology Flashcards
What can cause a raised PSA?
Prostate cancer
Prostatitis
Benign prostatic hyperplasia
Which is the most common cancer in men in the U.K.?
Prostate
What is the classic triad of clinical features of hypernephroma/clear cell adenocarcinoma of renal tubular epithelium?
Haematuria
Loin pain
Abdominal mass
What are features of hypernephroma?
Haematuria Loin pain Abdominal mass Anaemia Polycythemia Hypercalcaemia Left varicocoele
What is the treatment of choice for hypernephroma?
Nephrectomy
What are treatment options for benign prostatic hypertrophy?
TURP/prostatectomy
Alpha blockers
5 alpha reductase inhibitors
What are clinical features of benign prostatic hypertrophy?
Hesitancy
Poor urine flow (less than 18ml/sec)
Frequency
Urgency
What investigations should be done in a patient presenting with symptoms of benign prostatic hypertrophy?
Urine microscopy and culture
Rectal examination
Biopsy
PSA
What are risk factors for renal calculi?
Low urine output Hypercalciuria Hyperoxaluria Hyperuricuria Hypercitraturia
What percent of renal calculi are radio opaque?
90%
What does exposure to schistosoma haematobium increase the risk of?
Squamous cell carcinoma of the bladder
What are symptoms of gonococcal urethritis?
Purulent discharge
Dysuria
Proctitis
Pharyngitis
What are some complications of gonococcal urethritis?
Prostatitis Bartholinitis Epididymitis Arthritis Septicaemia
What is the treatment of gonococcal urethritis?
Ceftriaxone 500mg IM stat
Azithromycin 1g orally stat
What are causes of uric acid stone renal calculi?
Gout Myeloproliferative disorders Chronic diarrhoea Ileostomy Excessive meat eating
What is cystinuria? What is the treatment?
Defect in tubular reabsorption of cystine, orthinine, arginine and lysine
Autosomal recessive
Urinary alkalinisation and penicillamine
A 22 year old man presents with a hard lump in his right testicle. What is the likely diagnosis? What are useful tumour markers for this?
Teratoma of the testis
LDH and bHCG
How do you make a diagnosis of ureteric colic caused by a renal stone?
Plain abdominal X-ray KUB
Renal tract USS
IV urogram / unenhanced CT
What are obstructive and irritative symptoms of prostatism?
Obstructive: poor stream, hesitancy, terminal dribbling
Irritative: dysuria, urgency
How does acute epididymitis present?
Sub acute onset (1-3 days) of testicular pain accompanied by febrile illness
Affected testis is swollen, painful and tender
What is the likely cause of epididymitits in differing age groups?
Children: viral
Teenagers/young men: STI
Middle aged/elderly: complicates UTI
How do you treat epididymitits?
Antibiotics
Analgesics
Scrotal support
What are risk factors for renal stone formation?
Dehydration Hypercalciuria Hyperparathyroidism Hypercalcaemia Cystinuria High dietary oxalate Renal tubular acidosis Medullary sponge kidney Polycystic kidney disease Beryllium or cadmium exposure
What are risk factors for urate stone formation?
Gout
Ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
What drugs can promote calcium stone formation?
Loop diuretics, steroids, acetazolamide, theophylline
What is the acute management of renal colic?
Diclofenac: intramuscular/oral
Alpha-adrenergic blockers to aid stone passing
Ultrasound initial imaging modality of choice. Complications such as hydronephrosis can also be quickly identified
Non-contrast CT (NCCT) to confirm the diagnosis. 99% of stones are identifiable
What size of renal stone will likely pass spontaneously?
Less than 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases
What are options to treat ureteric colic when there is an infection present?
Nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement
What different therapeutic options are available treat renal stones and which would you select for different indications?
Lithotripsy: Stone burden of less than 2cm in aggregate
Ureteroscopy: Stone burden of less than 2cm in pregnant females
Percutaneous nephrolithotomy: Complex renal calculi and staghorn calculi
Expectant management: ureteric calculi less than 5mm
A 63 year old man attends GP stating he has had 2 episodes of visible blood in his urine. There was not any pain. He denies lower urinary tract symptoms. A urinalysis shows +++ blood but is negative for all other markers. What investigation should be ordered?
Cystoscopy due to frank haematuria and his age
What are the symptoms of benign prostatic hyperplasia?
LUTS
Voiding: weak or intermittent flow, straining, hesitancy, terminal dribbling, incomplete emptying
Storage: urgency, frequency, urge incontinence, nocturia
What are complications of benign prostatic hyperplasia?
Urinary tract infection
Retention
Obstructive uropathy
What are management options for benign prostatic hyperplasia?
Watchful waiting
Medication: alpha 1 antagonist, 5 alpha reductase inhibitor
Surgery: transurethral resection of prostate (TURP)
What are possible side effects of tamulosin and alfuzosin?
Dizziness
Postural hypotension
Dry mouth
Depression
What are possible side effects of finasteride?
Erectile dysfunction
Reduced libido
Ejaculation problems
Gynaecomastia
What is the mechanism of action of finasteride?
5 alpha reductase inhibitor
Block conversion of testosterone to DHT which is known to induce BPH
Causes a reduction in prostate volume so slows disease progression but this takes time and might not improve symptoms for 6 months
What is the most common cause of scrotal swelling seen in primary care?
Epididymal cysts
What are features of epididymal cysts?
Separate from the body of the testicle
Found posterior to the testicle
What conditions are associated with epididymal cysts?
Polycystic kidney disease
Cystic fibrosis
Von Hippel Lindau syndrome
How is a diagnosis of epididymal cyst confirmed?
USS
What is the management for epididymal cysts?
Supportive
Surgical removal or sclerotherapy if large or symptomatic
What is the difference between communicating and non communicating hydrocoele?
Communicating: patency of processus vaginalis allowing peritoneal fluid to drain down into scrotum. Seen in newborn males and usually revolve in first few months of life
Non communicating: excessive fluid production in tunica vaginalis
What may be some causes of a hydrocoele?
Epididymo-orchitis
Testicular torsion
Testicular tumour
What are features of a hydrocoele?
Soft non tender swelling of the hemi scrotum usually anterior and below the testicle
Swelling confined to the scrotum, can get above it
Transilluminates
Testis difficult to palpate
What is the management for hydrocoele?
Infantile hydrocoele repaired if they do not resolve spontaneously by age of 1-2 years
Adults: depends on severity of presentation
USS usually warranted to exclude underlying causes
Why are varicocoeles important to recognise even if they are asymptomatic?
Associated with infertility
On which side are varicocoeles more common?
Much more common on the left (>80%)
What are features of a varicocoele?
Bag of worms
Subfertility
How is a diagnosis of a varicocoele made?
USS with Doppler
What should be done before commencing a patient on goserelin for prostate cancer? Why?
Pretreatment with flutamide (synthetic antiandrogen)
Goserelin may cause transient increase in symptoms - flare effect due to increase in leutenising hormone production prior to down regulation
What are treatment options for localised prostate cancer (T1/2)?
Conservative: active monitoring and watchful waiting
Radical prostatectomy
Radiotherapy: external beam and brachytherapy
What are treatment options for localised advanced prostate cancer (T3/4)?
Hormonal therapy
Radical prostatectomy
Radiotherapy: external beam and brachytherapy
What are treatment options for metastatic prostate cancer?
Synthetic GnRH agonist: goserelin. Cover initially with anti androgen: flutamide
Anti androgen: cyproterone acetate prevents DHT binding
Orchidectomy
A 23 year old male is admitted with loin pain and fever. He has a ureteric calculi that measures 0.7cm in diameter and is associated with hydronephrosis. What do you do?
Urgent decompression
Either ureteroscopy or nephrostomy
Broad spectrum IV antibiotics
What size renal stones can be considered for extracorporeal shock wave lithotripsy?
Less than 2cm
What should be done to treat large proximal renal stones?
Percutaneous nephrolithotomy
What is the most sensitive and specific diagnostic test for renal stones?
Non contrast CT
When is intensive and urgent treatment required for renal stones?
Ureteric obstruction
Renal developmental abnormality - horseshoe kidney
Previous renal transplant
What cancer is histologically graded using a Gleason score?
Prostate
How is a diagnosis of prostate cancer made?
PSA measurement
Digital rectal examination
Trans rectal USS +/- biopsy
MRI/CT and bone scan for staging
What is the normal upper limit of PSA?
4 ng/ml
What may cause false positive raised PSA results?
Prostatitis
UTI
BPH
Vigorous DRE
What type of cancer mainly causes prostate cancer?
Adenocarcinoma
Where do the majority of prostate cancers lie?
Peripheral zone
How does the Gleason score work?
Two grades awarded 1-5
1 for most dominant grade 1-5
2 for second most dominant grade 1-5
2 has best prognosis, 10 the worst
Where does prostate cancer spread first?
Obturator nodes
What is the management for prostate cancer?
Watchful waiting - elderly, multiple comorbidities, low Gleason score
External radiotherapy/brachytherapy
Surgery - radical prostatectomy including obturator nodes
Hormonal therapy - LHRH analogues and anti androgens
In which patient group is active surveillance the preferred management for prostate cancer?
Low risk men Clinical stage T1c Gleason score 3+3 PSA density <0.15 Cancer in less than 50% cores <10 mm of any core involved
What is a common side effect of radical prostatectomy?
Erectile dysfunction
What are some late problems of using radiotherapy to treat prostate cancer?
Radiation proctitis
Rectal malignancy
A 34 year old man presents to emergency surgery with abdominal pain located in his left flank and radiating to his groin. What is the most suitable initial management?
IM Diclofenac 75mg
What can be done to prevent renal stones?
High fluid intake Low animal protein, low salt diet Thiazide diuretics (increase distal tubular calcium resorption)
A 22 year old woman presents with macroscopic haematuria. She is sexually active. She is known to have renal calculi and had a berry aneurysm clipped. What is the likely diagnosis?
Adult Polycystic kidney disease - liver cysts, berry aneurysms, pancreatic cysts, renal calculi, HTN
A 45 year old woman presents with haematuria and loin pain. She has a temp of 37 and is found to have a Hb of 180 and a creatinine of 156. Her urine shows 3+ blood. Blood and urine cultures are negative. What is the diagnosis?
Renal vein thrombosis - renal cell carcinoma
What are feature of renal cell carcinoma?
Renal vein thrombosis
Pyrexia of unknown origin
Left varicocoele
Paraneoplastic endocrine effects - EPO, renin, ACTH, PTHrP
A 62 year old man presents with nocturia, hesitancy and terminal dribbling. Prostate exam reveals moderately enlarged prostate with no irregular features and a well defined median sulcus. Blood tests show PSA of 1.3. What is the most appropriate management?
Alpha 1 antagonist
What are features of hypospadias?
Ventral urethral meatus
Hooded prepuce
Chordee (ventral curvature of the penis) in more severe forms urethral meatus may open more proximally in the more severe variants However, 75% of the openings are distally located
When and how is hypospadias corrected?
Corrective surgery is performed before 2 years of age. It is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure. In boys with very distal disease no treatment may be needed
What is a retractile testis?
A testis that appears in warm conditions or which can be brought down on clinical examination and does not immediately retract
What is a congenital undescended testis?
Failed to reach the bottom of the scrotum by 3 months of age
What defects are associated with undescended testis?
Patent processus vaginalis Abnormal epididymis Cerebral palsy Mental retardation Wilms tumour Abdominal wall defects: gastroschisis, prune belly syndrome
What are reasons for correction of cryptorchidism?
Reduce risk of infertility
Allows the testes to be examined for testicular cancer
Avoid testicular torsion
Cosmetic appearance
What is the treatment for cryptorchidism?
Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into dartos pouch
Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy
What are features of renal cell carcinoma?
Triad: haematuria, loin pain, abdominal mass
Pyrexia of unknown origin
Left varicocele (due to occlusion of left testicular vein)
Endocrine effects: erythropoietin (polycythaemia), parathyroid hormone (hypercalcaemia), renin, ACTH
25% have metastases at presentation
What are some causes of transient non visible haematuria?
Urinary tract infection
Menstruation
Vigorous exercise (normally settles after around 3 days)
Sexual intercourse
What are some causes of persistent non visible haematuria?
Cancer (bladder, renal, prostate) Stones Benign prostatic hyperplasia Prostatitis Urethritis e.g. Chlamydia Renal causes: IgA nephropathy, thin basement membrane disease
What are some causes of red urine where blood is not present?
Foods: beetroot, rhubarb
Drugs: rifampicin, doxorubicin
What is the definition of persistent non visible haematuria?
Blood being present in 2 out of 3 samples tested 2-3 weeks apart
What features of haematuria presentation require a 2 week wait referral?
Aged 45 or more and: Unexplained visible haematuria without urinary tract infection, visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged 60 or more and: unexplained nonvisible haematuria and either dysuria or a raised white cell count on a blood test
What is the most common malignancy in men aged 20-30?
Testicular cancer
What is the average age of onset of seminomas?
40
What tumour marker results would you expect with a seminoma?
Normal AFP, HCG and LDH in most
What are risk factors for testicular cancer?
Cryptorchidism Infertility Family history Klinefelters syndrome Mumps orchitis
How might a testicular cancer present?
Painless lump
Pain
Hydrocoele
Gynaecomastia
How do you diagnose testicular cancer?
USS
CT chest abdo pelvis for staging
Tumour markers - AFP, HCG, LDH
What is the management of testicular cancer?
Orchidectomy - inguinal approach
Chemo and radiotherapy depending on staging
Abdo lesions >1cm following chemo need retroperitoneal lymph node dissection
What are the infections which usually cause epididymo-orchitis in men <35?
Gonorrhoea or chlamydia
What drug is a recognised non infective cause of epididymitis?
Amiodarone
Who gets seminomas and teratomas?
Seminoma - usually over 30
Teratoma - 18-25
What is Peyronie’s disease?
Fibrotic process in tunica albuginea related to penile trauma and scarring during intercourse
Associated with penile curvature and pain
May be associated with dupuytrens contracture
What is the most common presenting feature in transitional cell carcinoma?
Haematuria
What type of surveillance is performed for patients following a diagnosis of transitional cell carcinoma?
Cystoscopic
How long after treating a UTI should you wait before taking a PSA measurement?
2 weeks
What can happen if urinary retention is not treated promptly?
Hydronephrosis and acute renal failure
What can be a complication of prostate surgery which can lead to urinary retention?
Bladder neck stenosis
Where are suprapubic catheters inserted? And how?
Approximately 2 finger breadths above symphysis pubis under USS guidance