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DPD 2019 > Urology (x4) > Flashcards

Urology (x4) Flashcards

1
Q

Outline the areas of the prostate

A

Central zone (wraps around the urethra)

Transition zone (area that increases in size during the life of a man, and causes obstruction of the urethra in a benign way)

Anterior fibromuscular zone

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2
Q

T/F prostate size correlates to cancer risk

A

F

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3
Q

What kind of diagnosis of BPH

A

Histological diagnosis

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4
Q

What are voiding symptoms and what are they due to

A

Poor flow, due to bladder outflow obstruction such as BPH/strictures

VOIDING SYMPTOMS
Incl. Hesitancy
Weak stream
Intermittency
Incomplete emptying
Post-void dribbling
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5
Q

What are storage symptoms and what are they due to

A

Strong flow, detrusor overactivity due to incorrect brain signals causing bladder to contract

STORAGE SYMPTOMS
Frequency,
urgency,
nocutia

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6
Q

What happens to bladder and detrusor in bladder outflow obstruction leading to voiding symptoms

A

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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7
Q

Define lower urinary tract symptoms (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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8
Q

Define Benign Prostatic Enlargement (BPE)

A

the clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia

a histological diagnosis

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9
Q

Define Bladder Outflow Obstruction (BOO)

A

bladder outlet obstruction caused by benign prostatic enlargement (clinical finding)

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10
Q

Define Benign Prostatic Hyperplasia (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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11
Q

Outline the international scoring system

What is it used for

A

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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12
Q

How is QoL assessed for prostate

A

The Bother score

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13
Q

Risk factors for BPH

A 
Age
Androgens
Functional androgen receptors
Obesity
Diabetes (& elevated fasting glucose)
Dyslipidaemia
Genetic
Afro-Caribbean
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14
Q

When taking a prostate history/examination?

A 
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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15
Q

Which investigations for prostate

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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16
Q

Common size compairsons to help assess prostate size

improve

A

Walnut

Ping pong

Golf

Clementine

Tennis

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17
Q

Obstructued flow is considered to be lower than what flow on urine flow measurements

A

<12ml per second

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18
Q

Treatment of voiding symptoms (i.e. BOO)

A

Conservative:
Reassure
Fluid intake advice (reduce evening fluid intake)

Medical management: 
Alpha blockers (Tamsulosin, Alfuzosin)

5 alpha-reductase inhibitors (Finasteride, Dutasteride)

Surgical management:
TURP (transurethral resection of the prostate)

(alternatively, rezum/steam, urolift (=staples), lazer surgery)

Possibly an anticholinergic if storage symptoms too but DON’T start with this (as it may relax the bladder too much on top of the already present voiding issues, causing acute urinary retention)

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19
Q

Why are 5a-reductase inhibitors give for prostate

improve

A

Inhibit testosterone production to shrink prostate

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20
Q

Management of storage problems (i.e. can’t store, i.e. detrusor overactivity)

A

Conservative management:
Reassure (& treat triggering UTI)
Dietary advice
Bladder Retraining Exercises (NICE recommended)

Medical management:
Anticholinergics (Oxybutinin, Detrusitol, Solifenacin)
Betmiga

Surgical management:
Intravesical Botox injection, (improve- but lasts for 6 months so you might need to catheterise for up to this time if surgery isn’t great)

(Bladder augmentation; urinary diversion/conduit)

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21
Q

Management of urinary retention

A

Catheterise

Dipstick/CSU

FBC, U & E (if they’ve been in high pressure retention then the pressure on the kidneys might have put them into renal failure, and they may then have an episode of diuresis)

Measure Residual Urine

Neurological examination if necessary

Prescribe - Antibiotics,

Laxatives, Alpha blocker if necessary

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22
Q

Types of short term and long term catheters

A 
Simplastic (short term )
PTFE coated (short term 
Hydrogel coated (long term)
Silicone (long term)
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23
Q

When would a 3 way catheter be used

A

To wash out any clots (it can be used to irrigate)

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24
Q

Differentiate acute and chronic urinary retention

Why is it important to check U&E in acute retention

A

Acute Retention (AUR) = painful

Chronic Retention (CUR)= postvoid residual >800ml

Chronic occurs over months or years

So both acute and chronic retention can be high or low pressure.

If the U&Es are affected, ti indicates there was high pressure retention which has caused renal failure.

Patients who have acute urinary retention with renal failure can have a large diuresis so need to be admitted, as they may need fluids

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25
Q

What is the management of low pressure retention (and how do you know it’s low pressure)

A

Normal U &Cr , no hydronephrosis

Consider starting alpha blockers and

Trial Without Catheter (TWOC) 1 week later

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26
Q

What is the management of high pressure retention (and how do you know it’s low pressure)

A

Raised U & Cr

Bilateral hydronephrosis.

ADMIT THEM

Measure urinary output, BP, body weight

They may need fluids if they have a large diuresis

Only < 10 % need fluid replacement

NEVER TWOC!

BOO Surgery or Longterm Catheter will be needed

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27
Q

What might you give for urgency in a voiding patient (even though urgency is a storage issue)

A

You might want to give anticholingergic for urgency

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28
Q

What is the most common cancer in males

A

Prostate cancer

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29
Q

Presenting symptoms of prostate cancer

A

Asymptomatic; raised PSA

LUTS

Urinary retention / renal failure

(Pain)

Haematuria

Bone pain/weight loss/ spinal cord compression (Mets)

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30
Q

Prostate caner risk factors

A

Age
Race (afro-caribbean heritage)
Family history
BRCA 2 gene

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31
Q

T/F PSA increases with age

A

T

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32
Q

Does PSA meet screening criteria?

A

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

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33
Q

Causes of raised PSA

A

BPH

Urinary Retention

Urine infection

Catheterisation / instrumentation of urethra

Prostate cancer

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34
Q

T/F DRE can significantly raise PSA

A

Digital rectal examination is not significant.

Don’t worry about doing DRE then sending for PSA blood test

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35
Q

Assessment of prostate cancer

A

Counselling

History – LUTS? Bone pain? Weight loss? Blood in urine?

Family history

Examination

DRE!

Check PSA (if high, then you should check urine to make sure it’s not a urine infection)

MRI scan (to differentiate high and low risk prostate cancer)

TRUS Biopsy

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36
Q

What can MRI scan add to the investigation of prostate cancer?

A

Can differentiate between high risk and low risk prostate cancer

Grade using PIRADS

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37
Q

A prostate cancer is identified as high risk using PIRADS scoring. What is the next step in the investigations

A

Then go onto have a biopsy to have a tissue diagnosis

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38
Q

A prostate cancer is identified as low risk using PIRADS scoring. What is the next step in the investigations

A

They can be reassured, they don’t need to have a biopsy.

They just need to have their PSA monitored

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39
Q

How is a biopsy taken from the prostate what is the risk

A

Transrectal ultrasound guided biopsy (TRUS).

But there is clearly a significant risk of sepsis as you’re going throuhg the rectum (1% end up hospitalised due to infection)

New techniques include transperineal biopsy

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40
Q

What happens to the biopsy

A

It is graded according to the gleason score

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41
Q

Outline the grading of prostate cancers according to gleason score

What about staging

A

Grading: Gleason score
Low riks 3+3
High risk 5+5

Staging: TNM

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42
Q

Where does prostate cancer metastasize to

Asymptomatic older male patient with raised PSA. How to manage.

A

Lymph nodes and bone

  1. Repeat PSA and check MSU (they may have a urine infection, which is a common cause of raised PSA, and the PSA may fall when the infection is resolved)

IF the PSA doesn’t come down,

  1. Send for MRI prostate and TRUS biopsy if necessary
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43
Q

Management of prostate cancer

So the patient has now had a biopsy and there is prostate cancer

A

Staging – MRI / Bone scan.

Managed by the MDT.

Options:
Active surveillance (low risk low volume disease, but monitoring for increased disease)

Surgery – radical prostatectomy (robotic or laparoscopic)

Radical Radiotherapy

Watchful waiting (elderly / co-morbid patients)

Hormones (given LHRH agonist to shrink the prostate before radiotherapy)

Chemotherapy

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44
Q

When are hormone treatments most useful

A

In metastases

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45
Q

More minimally invasive treatments for prostate cancer

A

Surgery: laparoscopic, robotic

Radiotherapy

Brachytherapy

HIFU

Cryotherapy

46
Q

Why has surgery for prostate cancer become unpopular

A

More bleeding
higher incontinence
Likely erectile dysfunction
May not die anyway

47
Q

Hormonal therapy examples

A

Can be used in conjunction with radiotherapy or alone

LHRH agonist (e.g. Zoladex) (there is initially a rise in testosterone before it falls)

Anitandrogen

48
Q

What is the risk with hormonal therapy

A

Beware tumour flare (a metastasis could become unstable)

This is because the testosterone actually increases at the beginning of LHRH agonist injections, so you give antiandrogen therapy in advance

The LHRH could actually cause the tumour to cause spinal cord compression during this time

49
Q

Name of LHRH agonist

A

Zoladex

50
Q

What causes spinal cord compression in prostate cancer

A

Due to vertebral bone metastases

51
Q

Management of spinal cord compression

A

Start steroids (dexamethasone iv)

Urgent MRI

Suppress testosterone

Decompress cord with spinal surgery or radiotherapy (if you don’t decompress within 12 hrs they will end up in a wheelchair)

52
Q

How is RRP followed up

A

PSA as followup 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

53
Q

What do you do if there is a PS failure post RT

A

Nadir +2
Consider HIFU or salvage surgery
Hormones

54
Q

What is the active surveillance

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

55
Q

When should you treat prostate cancer on active surveillance

A 
PSA >10
PSA dt <3 years
Grade progression on rebiopsy
Clinical progression
Patient choice
56
Q

Where can PSA monitoryong be done

A

Post radical treatment- radiotherapy/surgery
On Hormones
Cancer- watchful waiting
Raised PSA after MRI and/or biopsies

Active surveillance – in secondary care as requires regular MRI and re-biopsy

57
Q

What s a hydrocele

A

Fluid within Tunica vaginalis

Can get above it

Transilluminates!

58
Q

Treatment of hydrocele

A

Surgical repair if large

59
Q

What is epididymitis (orchitis) and what are the causes

A

Infection of epididymis or testis or both

Causes
STIs
UTIs
Post-operative

60
Q

Who does testicular affect

A

Younger men

61
Q

Types of testicular cancer

A

Germ Cell

  • Seminomatous
  • Non-seminomatous

Non-Germ Cell

62
Q

Why is sperm banking done before surgery for testicular cancer

A

testicular cancer likely to affect the single testicle, but subsequent chemo/radio can affect fertility

63
Q

What operation is done in testicular cancer

A

Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?)

64
Q

Post op care for radical inguinal orchitectomy

A

Surveillance +- chemotherapy (BEP) +- Radiotherapy +-RPLND

65
Q

Causes of haematuria

A 
Infection
Cancer
Medical
Trauma
(kidney stones)
66
Q

What does a three way catheter help with in haematuria

A

Irrigate the bladder and filter out the clots (stops the catheter being blocked by clots in the bladder)

67
Q

What is the management of haematuria

A 
Resuscitate incl. transfusion
3 way catheter
Hx Ex 
Bloods incl. Clotting and G&amp;S; KUB
MSU
68
Q

Why are you going to be caustious about putting suprapublic catheter in with haematuria

A

Could spread a bladder cancer into the abdminal wall

69
Q

Criteria for admission in haematuria

A

Frank haematuria with clots
Drop in Hb
Social circumstance

70
Q

Role of haematuria clinic

A

2 week rule

One-stop

71
Q

Haematuria- irrigation and theatre?

A 
ivi
Transfuse if necessary
Thorough bladder washout
Continuous irrigation
May need clot evacuation in theatre
Monitor closely and review regularly
72
Q

Investigations for haematuria

A

FBC, clotting, U&E

MSU MC&S

Urine cytology / NMP22 ?

CT Urogram or KUB, U/S

Flexible cystoscopy (will show a bladder tumour)

73
Q

What type of cancers are bladder cancers

A

90% are adenocarcinoma, 10% are transition cell cancer

74
Q

Follow up issues for haematura

A

Blocked catheters
Persistant haematuria
UTI / Antibiotics

75
Q

Who are renal stones most common in

A

More common in caucasian men

76
Q

What should you consider for family history for renal stones

A

CYSTINURIA

77
Q

What predisposes you to renal stones

A

Anatomical and biochemical Factors

78
Q

Why are renal stones important

A

Obstruction can lead to hydronephrosis and renal impairment

Painful

Infection (life threatening gram -ve sepsis)

Can indicate underlying metabolic problem

Underlying anatomical problems

79
Q

What underlying metabolic problems might lead to kidney stones

A

Hyperparathyroidism, gout, cysteinuria

80
Q

Underlying anatomical problems leading to renal stones

A

(eg. PUJ-o, MSK, Horseshoe kidney, ureteric stricture)

81
Q

Classification of stones

A

Size, location, xray characteristics, stone composition

82
Q

Outline classification of stones by size

A

<5mm; 5-20mm; >20mm; staghorn

83
Q

Outline classification of stones by location

A

Renal (calyceal, pelvic, diverticular); Ureteric

84
Q

Outline classification of stones by x-ray characteristics

A

radiolucent; radioopaque

85
Q

Outline classification of stones by stone composition

A

CaOx, CaP, Uric acid, cysteine, indinavir; Infection MAP/Struvite

86
Q

Diagnosis of renal stones

A

Hx

Ex (will be a soft abdomen)

Bloods, Urine dip (RBC, WBC, Nitrites, pH) & MSU

Imaging: KUB (gold standard) / US (won’t pick up uteric stones)/ CT-KUB / IVU

87
Q

When do you need immediate imaging for renal stones

A

Fever
solitary kidney
diagnosis unclear

88
Q

Presentation of uteric colic

A

Loin pain, Soft abdo, Mic haem 85%

89
Q

When is uteric colic an emergency

A

SEPSIS

90
Q

Causes of uteric colic

A

Stones, TCC, blood clot, RPF, ?BPH/CaP

91
Q

Differential diagnosis for uteric colic

A 
AAA
Testicular torsion
Perforated PU
Appendicitis
Ruptured ectopic
MI
Diverticulitis
Prostatitis
92
Q

Uteric colic in a&e

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
93
Q

Drug for helping passing stone

A

A blocker (controversial)

94
Q

General advice for renal stones

A

High fluid intake – urine champagne colour

Normal diet – do not cut out dairy products (milk can bind oxalate in the gut)

95
Q

When to attend a&e with renal stones

A

Pain not controlled by analgesia

PYREXIA

96
Q

Treatment of stones

A

Conservative

Medical / Metabolic

ESWL
Ureteroscopy

PCNL

97
Q

When can a stone be dissolved

A

Uric acid (with potassium citrate)

98
Q

Outline conservative renal stone management

A

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

99
Q

Outline medical renal stone management

A

Alkalinise / acidify urine
Treat / prevent UTIs
Allopurinol?

100
Q

Outline surgical renal stone management

A

Uretero-renoscopy +- laser
ESWL
PCNL
(Lap / Open)

101
Q

What is ESWL lithotripter

A

….

102
Q

When would you do a PCNL: percutaneous nephrolithotomy

A

If the stone is in the kidney and more than 2cm

103
Q

Follow up issues with renal stones

A

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

104
Q

What is obstructive pyelonephrosis

Why is it dangerous

A

= Obstruction + infection

Risk of fatal GRAM –ve sepsis

105
Q

How to manage obstructive pyonephrosis

A 
Immediate resuscitation + iv antibiotics
Culture
Urgent imaging (KUB &amp; U/S)
Discuss with urology SpR
Consider urgent nephrostomy (or JJ stent)
Monitor closely (HDU)
106
Q

Futher treatment of obstructive pyonephrosis

A 
Imaging to determine cause
CT KUB
Nephrostogram
Antegrade stent
Plan ureteroscopy / ESWL / PCNL

May need drainage if perinephric abscess
May need nephrectomy if XGP or EPN

107
Q

DDx testiscular torsion

A

Torted appendix testis, epididymitis, viral orchitis, bleed into testicular tumour

With torted appendix testis… usually cannot distinguish from testicular torsion
Blue dot sign
Manage conservatively only if confident of diagnosis

108
Q

When is testicular torsion rare beyond

A

Rare beyond 35y of age

109
Q

What underlying deformity predisposes testicular torsion

A

Underlying deformity:

extension of tunica vaginalis behind testicle  clapper bell

110
Q

Presentation of testicular torsion

A

Sudden onset
Ex: swollen, tender, high riding (contralat horiz)
Loss of cremateric reflex in children

111
Q

Investigation for testicular torsion

A

: MSU (urgent microscopy if Sy suggest UTI/epididymitis)

DPD 2019 (30 decks)

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