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REN > Week 9 > Flashcards

Week 9 Flashcards

1
Q

The urinary tract

A

The uro-epithelium:
-3-5 layers thick
-impervious to urine
-from the calyx to external meatus
-urinary carcinogens
Continuous production of urine
Urine is sterile
Unidirectional flow
Stagnation, reflux and UTI

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2
Q

Urology in nutshell

A

LUTS- micturition cycle, pharmacology. OAB, BPH
Urinary incontinence- urodynamics, stress incontinence, neuropathic bladder
PSA- DRE/TRUS/MRI/prostate zones, Ca prostate
Haematuria- imaging, endoscopy, risk factor,renal and urothelial Ca
Pain- imaging, stone aetiology, urinary stones, scrotal pathology
Dysuria- microbiology, UTI
Retention- catheterisation, causes acute/chronic retention
Lumps- inguino scrotal anatomy, scrotal lumps, hernia, torsion, testicular tumours
Erectile dysfunction infertility- physiology of erection, sperm physiology, andrology

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3
Q

LUTS

A

Storage symptoms:
-day frequency
-night frequency
-urgency
-incontinence
— urge
—stress
—overflow
—anatomical
Voiding symptoms
-hesitancy
-poor stream
-terminal dribbling
-post micturition dribbling

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4
Q

Micturition cycle

A

Bladder filling:
-detrusor muscle relaxes, urethral sphincter tone, pelvic floor tone
first sensation to void:
-detrusor muscle relaxed
-urethral sphincter contracts
-pelvic floor contracts
Normal desire to void:
-detrusor muscle contacts
-urethral sphincter relaxes (voluntary control)
-pelvic floor relaxes
-micturition
Bladder filling:
-detrusor muscle relaxes
-urethral sphincter tone
-pelvic floor tone

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5
Q

Assessment of LUTS

A

Essential
-symptom questionnaires
-MSU
-U/E ?PSA
-bladder scan
-frequency/vol chart
Optional:
-flow rate
-plain X-ray KUB
-USS renal tract/CT
-urodynamics
-cystoscopy

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6
Q

Examination

A

Abdominal examination
-suprapubic tenderness
-palpable bladder
-consistency
-shape
-abnormalities
Genitalia examination
Digital rectal examination/vaginal exam

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7
Q

Flow rates

A

Maximum and mean flow rates decrease with age
Flow rates between 10 and 15 mls/sec may be normal over 70 years of age
>15mls/sec normal
10-15 mls/sec-equivocal
<10mls/sec-obstructed

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8
Q

Causes of voiding dysfunction

A

UTI
Overactive bladder
Bladder outlet obstruction
Bladder cancer
Prostate cancer
Gynaecological problems
Bladder stones
Fistulas

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9
Q

Management of LUTS

A

Conservative
Medical therapy: alpha blocker/ 5 alpha reductase inhibitors, anti cholinergic
Surgical treatment:
-urolift
-rezum/steam therapy
-TURP/green light laser prostatectomy
-holmium laser enucleation of prostate
-open/robotic prostatectomy

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10
Q

Urinary incontinence

A

Types of incontinence:
-overflow: urethral blockage, bladder unable to empty properly
-stress: relaxed pelvic floor, increased abdominal pressure
- urge: bladder over sensitivity from infection, neurologic disorders

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11
Q

Causes of urinary incontinence

A

Genuine stress incontinence- congenital weakness of bladder neck, denervation of sphincter mechanism of pelvic floor (during delivery), oestrogen deficiency in menopause etc
Detrusor instability
Retention with overflow incontinence
Urogenital fistula
Temporary- UTI, drugs-a-blockers
-urethral diverticulum

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12
Q

Management of urinary incontinence

A

Conservative
Urethral catheter for overflow incontinence
Anti cholinergic/adrenergic agonists for urge incontinence
Surgical for significant stress incontinence
-plugs, bulking agents, tapes, mesh, artificial urinary sphincters
-correction of anatomical cause

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13
Q

Haematuria

A

Visible Haematuria
Non-visible Haematuria
-symptomatic
-asymptomatic

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14
Q

Haematuria investigations

A

FBC/ U&E, MSU— essential
Urine cytology/ blood PSA in men
CT urogram
Other imaging: USS; retrograde pyelogram; MRI
Endoscopy: essential flexible/rigid cystoscopy; ureteroscopy
Rarely biopsy

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15
Q

Bladder cancer classification

A

G1, G2, G3, CIS
PTa, pT1, pT2, pT3, pT4
Low risk: TURBT mitomycin C X1
Medium risk: mitomycin C X6
High risk: BCG therapy/radical cystectomy
Muscle invasive: radical cystectomy or radiotherapy

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16
Q

Bladder cancer outcomes

A

Superficial:
-70% remain superficial and have an excellent outcome
-30% can become invasive and their outcome depends on the treatment offered
Invasive:
-surgery 60% 5 yr survival
-radiotherapy 40% 5 yr survival

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17
Q

renal cancer

A

May not present with Haematuria
May be incidentally discovered on USS or CT
Tumour types:
-renal parenchyma (Renal cell ca) more common
-collecting system TCC
-other rare types

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18
Q

Renal cancer evaluation

A

Solid/cystic
-if cystic-> characters
-if solid-> is it malignant
Other kidney conditions
Baseline renal function
Any signs of advanced disease
Any metastasis

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19
Q

PSA

A

Prostatic specific antigen
Protease enzyme secreted in the seminal fluid
Small amounts gets to blood stream during cell division
Bound tightly to plasma proteins
Raised in blood stream:
-enlarged prostate
-prostatitis
-ca prostate,
-all these conditions can have normal PSA
Age specific ranges (oesterling)
40-49 years- 2.5
50-59- 3.5
60-69- 4.5
70 > -6.5

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20
Q

Prostate cancer

A

Asymptomatic
Raised PSA/abnormal DRE
LUTS
Backache
Symptoms of metastasis
Symptoms of local progression
Diagnosis:
-PSA
-TRUS biopsy
-TURP
Staging:
-DRE
-bone scan
-CT/MRI

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21
Q

Retention of urine

A

Acute
-painful
-residual Vol 1<1000ml
-relief on catheterisation
Chronic retention;
-usually painless
-usually residual vol >1000ml
2 types:
-low pressure
-high pressure: back-pressure effects on kidney

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22
Q

Management of retention

A

Check bloods before catheterisation
Type and size of catheter
Record residual volume
If chronic renal failure then closely monitor urinary output
Plan TWOC or definitive surgery

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23
Q

Physiology of micturition

A

Bladder wall parasympathetic
Urethral sphincter voluntary- pudendal
Storage: BW relaxed, US contacted/tonic
Voiding: BW contracted, sustained, US relaxed

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24
Q

Red flag signs and symptoms

A

Abnormal PSA/DRE
Haematuria
Renal mass (palpable or on scan)
Testicular mass (palpable or on scan)
Penile lump/discharge

25
Q

Reciprocal induction

A

Day 32- ureteric bud (metanephric duct) sprouts into intermediate mesoderm- metanephric blastema
The ureteric bud bifurcates repeatedly- each bifurcation capped with mesoderm which eventually give foetal kidney its lobulated appearance
The ureteric bud and kidney rely on signals from each other to keep developing (an example of reciprocal induction) ie in the absence of one the other will regress
The metanephric duct gives rise to collecting ducts and the metanephric bastema the rest of the nephron
Urine production begins at about week 10 when all tubules have finally canalised and joined together
Ureteric bud division ceases about week 15 where a nephrons continue to develop to week 36

26
Q

What is the prostate

A

Small walnut sized gland found in men
Produces and secretes fluid which nourishes sperm
-proteolytic enzymes, prostatic acid and phosphatase, fibrinolysin, zinc, PSA (prostate-specific antigen)

27
Q

Lobes of prostate gland

A

Anterior lobe
Median lobe
Lateral lobes
Posterior lobe

28
Q

Prostate zones

A

“McNeal” zone
Peripheral zone: < 70% glandular tissue, origin 70-80% prostate cancers
Central zone: 25% glandular tissue, origin <5% of prostate cancers surrounds ejaculatory ducts
Transition zone: 10% glandular tissue, origin of benign prostatic hyperplasia
Anterior fibromuscular stroma: ~5%, no glandular components

29
Q

Diseases of prostate

A

Surgical sieve
Vascular
Infection/inflammation
Traumatic
Autoimmune
Metabolic
Idiopathic/iatrogenic
Neoplastic
Degenerative
Most common prostate diseases:
-prostatitis
-benign prostatic enlargement
—lower urinary tract symptoms
—urinary retention
-prostate cancer

30
Q

Benign prostatic enlargement

A

By age 65, 50% men will experience BPE
-at age of 90, 90% of men will have BPE
Benign increase in the number of epithelial and stroma cells in the transition zone
BPE is a clinical diagnosis
-LUTS, DRE, uroflowmetry, imaging
Benign prostatic hyperplasia is a histological diagnosis, has to be proven at biopsy
Symptoms not always proportional to degree of BPE
May present with urinary retention

31
Q

Lower urinary tract symptoms LUTS

A

Storage symptoms:
-frequency
-urgency
-urge incontinence
-nocturia
-nocturnal enuresis (bedwetting)
-incomplete emptying

Voiding symptoms:
-haematuria- red flag symptom
-dysuria
-hesitancy
-poor flow
-intermittent stream
-spraying/splitting of stream
-terminal dribbling

32
Q

BPE-investigations

A

Uroflowmetry (“flow studies”)
Post-void residual
PSA and renal function
Urine dipstick testing +/- urine MC&S
Bladder diary
Urodynamics, USS KUB may be necessary

33
Q

BPE-medical management

A

Alpha 1 adrenoceptor antagonist:
-tamsulosin
-inhibits effect of noradrenaline on smooth muscle in the prostate and bladder neck, relaxing smooth muscle and relieving obstructive symptoms
-Hours/days full effect within weeks
-retrograde ejaculation, dizziness, postural hypotension (take medications before bed), floppy iris syndrome during cataract surgery
5alpha reductase inhibitor:
-finasteride, dutasteride
-inhibits conversion of testosterone to dihydrotestosterone- more potent form drive hyperplasia works to shrink gland
-6weeks-6months
-erectile dysfunction, reduced libido, gynaecomastia (1-2%) doesn’t resolve with stopping medication, ejaculation disorders

34
Q

BPE-medical management

A

Watchful waiting- not all men require treatment
Combination therapy (tamsulosin and finasteride) more effective than monotherapy

35
Q

Surgical management

A

Transurethral resection of prostate (TURP)
Holmium laser enucleation of the prostate (HoLEP)
Greenlight laser prostatectomy
Prostatic urethral lift
Open prostatectomy
Aquablation (Rezum )

36
Q

Urinary retention types

A

Acute urinary retention: the acute and painful inability to pass urine which is relived by insertion of catheter
-immediate management: 2 way 14-16Fr urethral catheter
-document residual volume, colour of urine, easy or difficult passage
Chronic urinary retention: adapting to distal obstruction, low pressure, high pressure HPCR
-over time the bladder stretches and capacity increases
-often painless
-large residual volume >800ml
-renal impairment/hydronephrosis
-decompression haematuria
-post obstructive diuresis

37
Q

Causes of urinary retention

A

Inflammatory: UTI, prostatitis
Obstructive: BPE, stricture, bladder neck stenosis, constipation, pelvic mass, clot retention
Drugs: alcohol, diuretics, spinal/epidural anaesthesia, opioids
Neurogenic: cauda equina syndrome CES, spinal cord injury, MS, Parkinson’s disease, pelvic injury/trauma, pelvic surgery

38
Q

Urinary retention

A

Red flag symptoms:
-low back pain, lower limb neurology, saddle anaesthesia-> think cauda equina syndrome- full neuro exam
-weight loss, bony pain, haematuria -> think malignancy
-nocturnal bedwetting indicative of HPCR
Examination:
-abdomen- has pain and abdominal swelling resolved
-DRE- is prostate enlarged, smooth, craggy, hard, nodules, tender, blood, faecal loading, anal tone, saddle anaesthesia
Investigations:
- urine MC&S, FBC, UE (urea and electrolytes), CRP (if infection)
Management: treat the cause
-hourly UO monitoring
—post obstructive diuresis indicates HPCR
—if UO >150ml/hr over 2 consecutive hours
—Normal saline (0.9% NaCl) replacement of half that volume over the following hour
-tamsulosin 400mg trial without catheter
If HPCR do not remove catheter
-options: long term catheter, intermittent self-catheterisation, surgery ie TURP

39
Q

Prostatitis

A

Causative pathogen detected in only 10%
-acute bacterial prostatitis -E.coli
-chronic prostatitis (>3 months symptoms)- wider spectrum
-immunosuppressed states- TB, candida
Risk factors: UTI/epididymitis , transurethral surgery, indwelling catheter, immunosuppression
History: fevers, rigors, general malaise, perineal pain, LUTS
May present as AUR or recurrent UTIs
Examination: suprapubic tenderness, palpable bladder
-DRE: tender, “boggy” prostate, fluctuance suggests abscess
Investigations: urine dip, FBC, UE, CRP, lactate
-post void bladder scan to assess residual urine
-mid stream urine for culture
-blood culture if febrile
Management:
-may be septic-> resuscitation with A to E
-Sepsis 6
Antibiotic choice guided by local protocols and previous sensitivities
-often broad spectrum penicillin +/or quinolone (ciprofloxacin)
-consider extended oral course on discharge

40
Q

Prostate cancer presentation

A

Prostate adenocarcinoma is the most common cancer in men in uk
Signs and symptoms:
-may be asymptomatic opportunistic PSA testing
-LUTS
-haematuria, haematospermia
-abnormal DRE (hard, nodular, craggy prostate, asymmetry)
Advanced disease:
-leg swelling, anorexia, weight loss, bony pain, coagulopathy, neurological defects
Risk factors:
-age, ethnicity, family history, BRCA2 gene mutations

41
Q

Prostate cancer- evaluation

A

PSA- prostate specific antigen
-enzyme produced by the prostate to liquefy semen
- raised serum PSA in UTI, prostatitis, urinary retention, urethral instrumentation incl, catheterisation, ejaculation, BPE and cancer
-age specific “normal” ranges
-must be corroborated with history, examination and DRE
MRI of prostate- diagnosis and local staging
TRUS biopsy (transrectal ultrasound guided prostate biopsy)
Or transperineal prostate biopsy
Gleason grading system:
-cells are graded 1-5 (5 most abnormal)
-the most common and second most common grades are noted and added together
-Gleason 4+3 is more abnormal than 3+4

42
Q

Prostate cancer staging

A

T1: non palpable disease
T2: palpable confined prostate
T3: spreads outside prostate
T4: adjacent organs involved
N: lymph node spread
M: non regional lymph node spread
MRI: T, N
Nuclear medicine bone scan- M
CT TAP (thorax, abdo, pelvis)- N, M

43
Q

Prostate cancer management

A

All patients should be discussed in urology MDT
Active surveillance:
-aim is to avoid treating indolent cancers by only treating if sign of progression
-suitable if medically fit, life expectancy> 10-15 years, localised disease
-regular monitoring PSA +DRE look for evidence progression
Watchful waiting: not fit for curative treatment
-suitable if life expectancy<10-15 years, significant comorbidities therefore not fit for radical treatment
-avoiding treatment unless patient develops symptoms
-disease control rather than cure

44
Q

Prostate cancer- management types

A

Radiotherapy: is suitable for local and locally advanced cancer, symptomatic relief of painful bony metastases
Surgery: radical prostatectomy (open, laparoscopic, robotic) with or without lymphadenopathy
Hormone treatment: can be used for locally advanced or metastatic disease
Chemotherapy: used in metastatic disease, especially those who become resistant to hormone treatment
Role of cancer nurse specialist is vital

45
Q

Shock definition

A

“Failure of the circulation to deliver oxygenated blood to meet tissue requirements”

46
Q

Does shock matter

A

A reduction in blood flow to tissues depriving them of oxygen (ischaemia)
Organs of vital importance, brain, heart, and kidneys can suffer irreversible damage, eventually leading to death
Inadequate cellular oxygen delivery-> anaerobic metabolism—> inadequate energy production and lactic acid production—> metabolic failure and metabolic acidosis—> cell death

47
Q

How to measure degrees of shock

A

Lactate levels
Measure in arterial blood gas
Urinary catheter- 0.5mls/kg. 30-40mls/hr

48
Q

What determines how much oxygen gets to the tissue

A

Amount of oxygen in the blood
-ie (oxygen content of blood both dissolved and carried by Hb)
-the flow of blood around the circulation ie (CO)

49
Q

Oxygen delivery

A

DO2= CO x (Hbx SPO2 x1.34) + (PaO2 x 0.2)

50
Q

Oxygen carrying capacity

A

Increase fraction of inspired oxygen they breathe in will optimise oxygen delivery
Hb- direct measure: reduced with haemorrhage, increased with blood transfusion
O2- oxygen saturation (direct measure), dissolved oxygen. All patients in shock should get high flow oxygen

51
Q

What determines cardiac output

A

Is the volume of blood ejected from left ventricle in a minute
CO= stroke volume x heart rate = 5L/min
SV (is the volume ejected each heart beat):
-preload (EDV)
-myocardial contractility
-afterload- (pressure the heart must work against to eject blood during systole) systemic vascular resistance

52
Q

Shock preload, inotropy, afterload

A

Preload- Hypovolaemic: haemorrhage
Inotropy- cardiogenic: CHF, ACS, dysrhythmia, valve, cardiac tamponade
Afterload- distributive: sepsis, thryotoxicosis, anaphylaxis, neurogenic
MAP= (SV xHR) xSVR

53
Q

What could be causing shock in our trauma patient

A

Reduced venous return
Impaired cardiac function
Reduced vascular tone- unable to vasoconstrict
Body has compensatory mechanisms to maintain oxygen delivery to essential organs

54
Q

Why a high respiratory rate

A

Reduced delivery of oxygen
Increased anaerobic metabolism
Increased lactic acid production
Fall in arterial pH
Stimulation of peripheral chemoreceptors: carotid bodies (Glossopharyngeal nerve), aortic bodies (vagus nerve)
Respiratory centre (medulla)
Respiratory muscles: increased depth and increased rate of

55
Q

Other symptoms of shock

A

High heart rate
Clammy skin
Cold peripheries
Pale skin
Poor capillary refill
Reduced urine output

56
Q

Why do you get a reduced urine output

A

Renin-angiotensin- aldosterone pathway
Juxtaglomerular cells in the kidney respond to a reduction in blood volume
Renin released into blood
Angiotensinogen-> angiotensin I—ACE—> angiotensin II
Vasoconstriction, thirst, adrenal cortex (releasing aldosterone)
Vasoconstriction— increase blood pressure,
Thirst increases blood volume
Aldosterone make kidneys increase Na+ reabsorption from filtrate increase blood volume
Increase in blood volume increases blood pressure

57
Q

ADH and urine output

A

Reduced blood flow to pituitary
Secretes ADH
Capillary ADH secreted into nephron water moves into capillary
ADH increases amount water reabsorbed from filtrate into blood
Urine output is reduced as more water is returned to the blood

58
Q

Treatment

A

Therefore to:
-recognise shock
-treats underlying cause
-support the body in maintaining oxygen delivery to tissues

REN (11 decks)

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