Urology questions Flashcards
What are the features of renal tract cancer
- classical triad:
- haematuria
- loin pain
- abdominal mass
- pyrexia of unknown origin
- endocrine effects
- may secrete erythropoietin (polycythaemia)
- parathyroid hormone-related protein (hypercalcaemia), renin
- ACTH
- 25% have metastases at presentation
- paraneoplastic hepatic dysfunction syndrome
- varicocele
- majority are left-sided
- caused by the tumour compressing veins
- Stauffer syndrome
- a paraneoplastic disorder associated with renal cell cancer
- typically presents as cholestasis/hepatosplenomegaly
- it is thought to be secondary to increased levels of IL-6
Investigation for bladder cancer?
Cystoscopy
First line management for renal colic?
Oral NSAIDs
GnRH agonists may cause what in prostrate cancer?
tumour flare’ when started, resulting in bone pain, bladder obstruction and other symptoms
What does circimcision reduce the rate of?
HIV, UTI, penile cancer,
What is commonest cause of epidymo orchitis in 50 yo low risk sti man
Enteric organismsms like E. coli
Factors favouring an organic cause of ED?
Gradual onset of symptoms
Lack of tumescence
Normal libid
Prevention of calcium stones?
- High fluid intake
- low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet)
- thiazides diuretics (increase distal tubular calcium resorption)
Prevention of future oxalate stones?
- cholestyramine reduces urinary oxalate secretion
- pyridoxine reduces urinary oxalate secretion
Prevention of Uric acid stones?
Allopurinol and uribar alkalisation eg oral bicarbonate
First line in BPH?
Tamulosin which is an alpha 1 antagonist
Investigations for ED?
all men have their 10-year cardiovascular risk calculated by measuring lipid and fasting glucose serum levels.
Free testosterone should also be measured in the morning between 9 and 11am. If free testosterone is low or borderline, it should be repeated along with follicle-stimulating hormone, luteinizing hormone and prolactin levels. If any of these are abnormal refer to endocrinology for further assessment.
Opinion on testosterone measurement differs between some experts but CKS advises universal measurement of testosterone in men with erectile dysfunction as recommended by the British Society for Sexual Medicine and the European Association of Urology.
Complications of Transurethral Resection: TURP
Tur syndrome
U rethral stricture/UTI
R etrograde ejaculation
P erforation of the prostate
What does a CT KUB often look for?
Stones in the renal tract
A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should be what?
referred using the suspected cancer pathway (within 2 weeks) to exclude bladder cancer
Why are urate stones radiotranslucent?
Coated with calcium and will therefore be radiotranslucent
What are cystine stones associated with?
Inherited metabolic disorders
Chronic infection with urease producing enzymes can produce an alkaline urine with formation of what?
Struvite stones
What are struvite stones formed from?
magnesium, ammonium and phosphate
TURP syndrome
irrigation with large volumes of glycine, which is hypo-osmolar and is systemically absorbed when prostatic venous sinuses are opened up during prostate resection
Investigations in epididymis orchisits?
- younger adults assess for sexually transmitted infections (STI)
- in older adults with a low-risk sexual history send a mid-stream urine (MSU) for microscopy and culture
Features of Wilm’s tumour (nephroblastoma)
- present as a mass associated with haematuria (pyrexia may occur in 50%)
- Often metastasise early (usually to lung)
Use of bicalumatide?
- non-steroidal anti-androgen
- blocks the androgen receptor
Use of cytoterone acetate?
- steroidal anti-androgen
- prevents DHT binding from intracytoplasmic protein complexes
- used less commonly since introduction of non-steroidal anti-androgens
- Prevents paradoxical increase in symptoms with GnRH agonists
- GnRH agonists may cause ‘tumour flare’ when started, resulting in bone pain, bladder obstruction and other symptoms
Features of angiomyolipoma?
- 80% of these hamartoma type lesions occur sporadically, the remainder are seen in those with tuberous sclerosis
- Tumour is composed of blood vessels, smooth muscle and fat
- Massive bleeding may occur in 10% of cases
What is Balanitis Xerotica Obliterans the equivalent of in women?
Lichen sclerosis
What is hypospasia?
defect in boys in which the opening of the urethra is not located at the tip of the penis but along the shaft. It is a contraindication to circumcision in infancy as the foreskin is used in the repair. Some of the repairs done during the surgery include creating the opening of the urethra in the right place, correcting the curve in the penis, and repairing the skin around the opening of the urethra.
Most common stage for renal cell carcinoma?
Stage 4
Non-seminoma germ cell testicular tumours (e.g. teratomas) are associated with what?
raised hCG and AFP
How should testicular torsion be managed?
Bilateral orchiipezy to prevent torsion of the other testis
What has a better prognosis seminomas or tetatomas?
Seminomas
Think terrortomas
What age is BPH most common?
Over 65
Voiding symptoms (weak flow, terminal dribbling, and incomplete emptying) and a history of gonorrhoea in patients that are not the typical age for prostate problems (generally 65 years or older) should raise suspicion of what?
Urethral stricture
What is the treatment of a renal cell carcinomas
Radical nephrectomy as often resistant to chemotherapy and radiotherapy
Most common cause of scrotal swellings in primary care?
Epidymal cyst
Features of a hydrocele?
- soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
- the swelling is confined to the scrotum, you can get ‘above’ the mass on examination
- transilluminates with a pen torch
- the testis may be difficult to palpate if the hydrocele is large
What is a varicocele?
abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Risk factors for testicular cancer?
- infertility (increases risk by a factor of 3)
- cryptorchidism
- family history
- Klinefelter’s syndrome
- mumps orchitis
Common complication of radical prostatectomy?
Erectile dysfunction
Most common type of renal stone?
Calcium oxalate
NICE advice that, as PSA levels may be increased, testing should not be done within at least what criteria?
- 6 weeks of a prostate biopsy
- 4 weeks following a proven urinary infection
- 1 week of digital rectal examination
- 48 hours of vigorous exercise
- 48 hours of ejaculation
Features of testicular torsion?
pain is usually severe and of sudden onset
the pain may be referred to the lower abdomen
nausea and vomiting may be present
on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened
cremasteric reflex is lost
elevation of the testis does not ease the pain (Prehn’s sign)
Most common histological type of renal cell cancer?
clear cell
What is the first line invesigation for renal cell cancer?
CT scan of the abdomen and pelvis
How to remeber goserelin?
GOserelin : GO GO GO testosterone
It’s a GnRH agonist
What is Flutamide?
a synthetic antiandrogen, can be used preemptively to attenuate the tumour flare through its antagonistic effects at androgen receptors.
Symptoms of voiding problems in urinating?
Hesitancy
Poor or intermittent stream
Straining
Incomplete emptying
Terminal dribbling
Obstructive urinary calculi and signs of infection require what?
Urgent renal decompression and IV antibiotics due to the risk of sepsis
Managements of adults with a hydrocele?
in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
Management of predominantly OAB?
conservative measures include moderating fluid intake
bladder retraining should be offered
antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation)
mirabegron may be considered if first-line drugs fail
Management of predominantly voiding symptoms?
conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products
if ‘moderate’ or ‘severe’ symptoms offer an alpha-blocker
if the prostate is enlarged and the patient is ‘considered at high risk of progression’ then a 5-alpha reductase inhibitor should be offered
if the patient has an enlarged prostate and ‘moderate’ or ‘severe’ symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor
if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added
Low pressure chronic urinary retention presents with what?
painless distended bladder, but no associated hydronephrosis or renal impairment.
What does chronic urinary retention look like?
impaired renal function and bilateral hydronephrosis
typically due to bladder outflow obstruction
Causes of unilateral hydronephrosis?
PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
Causes of bilateral hydronephrosis?
SUPER
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
Investigations for hydronephrosis?
ultrasound - first-line: identifies presence of hydronephrosis and can assess the kidneys
IVU- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
if suspect renal colic: CT scan (majority of stones are detected this way)
First line investigation for raised PSA?
multiparametric MRI
Management of acute bacterial prostatitis?
Clinical Knowledge Summaries currently recommend a 14-day course of a quinolone
consider screening for sexually transmitted infections
Management of epidiymo-orchitis if STI most likely cause but organism unknown?
Ceftriaxone 500mg intramuscularly single dose, plus doxycycline 100mg by mouth twice daily for 10-14 days
Most common cause of erectile dysfunction?
Vascular causes
What is the mechanism of actions of tamsulosin?
Alpha 1 antagonist
When do infantile hydroceles normally resolve by?
1-2 years
reteric obstruction due to stones together with infection is what?
surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement.
What is a stag horn calculus made of?
Struvite
A 72-year-old man is diagnosed with prostate cancer and goserelin (Zoladex) is prescribed. Which one of the following is it most important to co-prescribe for the first three weeks of treatment?
Cyproterone acetate to prevent tumour flare
WHat is an indication of renal stone passage?
Fat stranding
What stones are radiolucent?
Urate and xanthine stones
Side effects of alpha 1 antagonisits?
dizziness, postural hypotension, dry mouth, depression
Adverse effects of 5 alpha reductase?
erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
Investigations for acute urinary retention?
Patients should all be investigated with a urine sample which should be sent for urinalysis and culture. This might only be possible after urinary catheterisation.
Serum U&Es and creatinine should also be checked to assess for any kidney injury.
A FBC and CRP should also be performed to look for infection
PSA is not appropriate in acute urinary retention as it is typically elevated
When is cremasteric reflex perserved?
When the torsion affects the appendage only
What is a variocele?
abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Features in bulbar rupture?
most common
straddle type injury e.g. bicycles
triad signs: urinary retention, perineal haematoma, blood at the meatus
Features of membranous rupture?
can be extra or intraperitoneal
commonly due to pelvic fracture
Penile or perineal oedema/ hematoma
PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult)
Perfered method of stone removal in pregnnat women?
Ureteroscopy
Features in bladder injury?
rupture is intra or extraperitoneal
presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void: always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury
Management of renal cell cancers?
for confined disease a partial or total nephrectomy depending on the tumour size
patients with a T1 tumour (i.e. < 7cm in size) are typically offered a partial nephrectomy
alpha-interferon and interleukin-2 have been used to reduce tumour size and also treat patients with metatases
receptor tyrosine kinase inhibitors (e.g. sorafenib, sunitinib) have been shown to have superior efficacy compared to interferon-alpha
Can mild varioceles be mamaged conservatively?
Yes
Investigations for priapism?
Cavernosal blood gas analysis to differentiate between ischaemic and non-ischaemic: in ischaemic priapism pO2 and pH would be reduced whilst pCO2 would be increased.
Doppler or duplex ultrasonography: this can be used as an alternative to blood gas analysis to assess for blood flow within the penis.
A full blood count and toxicology screen can be used to assess for an underlying cause of the priapism.
Diagnosis of priapism is largely clinical, with investigations helping to categorise into ischaemic and non-ischaemic as well as assessing for the underlying cause.
What commonly occurs after catheterisation in chronic urinary retention?
Decompression haematuria occurs commonly after catheterisation for chronic retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment.
Presentation of bladder cancer?
Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection excluded).
What does recureent balantitis require?
Circumcision
What can a variocele be a sign of?
malignancy due to compression of the renal vein between the abdominal aorta and the superior mesenteric artery - known as the nutcracker angle
First line investigation for testicular cancer?
US
PSA wait times?
Prostate biopsy: 2 months
Prostatitis: 1 month
Ejaculation or vigorous exercise: 48 hrs
