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Urology Flashcards

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1
Q

BPH

  • Def
  • Zone affected
  • Effect and end result
A

Benign proliferation of inner transitional zone of prostate gland

Increasing tissue bulk = narrowing urethral lumen
Inc prostatic smooth muscle tone (Alpha adrenergic)
Leads to Bladder obstruction

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2
Q

% 50-60 with BPH

% 70-80 with BPH

A

40%

80%

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3
Q

Pathophys of BPH

A

Age related androgen mediated epithelial and stromal hyperplaesia

  • Inc epithelial tissue in transitional zone
  • Inc number of alpha-1a receptors in prostatic capsule
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4
Q

BPH symptoms:

  • Storage symptoms (FUN)
  • Voiding symptoms (HIPP)
A

Frequency, urgency, nocturia

Hesitancy, incomplete empty, Poor flow, Post-void dribbling

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5
Q

BPH Ix triad

A

1) PSA - inc in Ca or Prostatitis
2) DRE
3) TRUSS ± biopsy

other: USS KUB (rule out hydronephrosis, urolithiasis, mass)

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6
Q

DDx BPH

A

Over active bladder
Prostatitis
Prostate Ca
UTI

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7
Q

Tx BPH

  • Mild
  • Moderate/sev
  • Abnormal PSA/DRE
A

mild:

  • Watch and wait
  • Lifestyle: avoid caffeine, alcohol, bladder training, fluid limiting
  • 1st line: alpha blocker (tamsulosin) OR 5-alpha reductase inhib (finasteride) or NSAID

mod/sev
- Drug therapy + behaviour management

Abnormal:
- Surgical referral

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8
Q

Alph blocker:

  • E.G
  • Effect
  • SE
A

Tamsulosin, Doxazosin

Smooth muscle relaxation in prostate and bladder neck:

SE: postural hypotension, dry mouth

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9
Q

5-alpha reductase inhibitors

  • E.G
  • Effect
A

Finasteride

Reduced conversion of testosterone to dihydrotestosterone

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10
Q

Complications of BPH and Tx complications

A

Progression of symptoms. Urinary retention (2.5% in 5 years)

Sexual dysfunction (due to alpha/5-alpha reductase inhib or surgery

TURP syndrome

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11
Q

What is TURP syndrome

A

Absorption of irrigation fluids by prostate = fluid overload, hyponatraemia (dilution), hypothermia, hypertension (reflex bradycardia)

(Rare but life threatening)

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12
Q

Acute urinary retention

  • Men
  • Women
  • Men & Women
  • Infective
  • Drug-related
  • Neurological
A

BPH, Prostate Ca

Prolapse (cystocele, rectocele, enterocoele) , pelvic mass (fibroids, ovarian cysts, malig)

Calculi, bladder Ca, faecal impaction

Prostatitis, vulvovaginitis, cystitis

Anticholinergic (antipsych, antidepress), Alcohol, opioids

DM (ANS neuropathy), Spinal (cauda equina, cord compression, MS)

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13
Q

Acute urinary retention Pres

A

Uncomfortable
Unable to pass urine
Tender + distended bladder

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14
Q

Urinary retention Ix

A

USS bladder

  • post void residual (over 100ml not acceptable)
  • hydronephrosis
  • structural abnormality

Urinalysis: infection,

  • haematuria,
  • proteinuria,
  • glucosuria

U&E, Cr, GFR

Looking for cause:

  • CT abdo pelvis: compression/mass/stone
  • MRI spine: disc prolapse, cauda equina, MS
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15
Q

Acute urinary retention Tx and complications

A

Immediate catheter decompression

Tx according to cause

Complications: AKI, UTI

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16
Q

Prostate Ca:

  • Def
  • Spread (local, lymph, haem)
  • Epidemiology
  • Genetics
A

Adenocarcinoma from peripheral prostate

Local: capsule to seminal vesicles, bladder, rectum
Pelvic LNs
Haematogenous: 90% of mets sclerotic bone lesion, lung and liver

Most common male cancer (80% incidence over 80)

+ve FH, inc testosterone

BRCA and HPC-1
(hereditary Prostate Ca gene)

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17
Q

Prostate Ca grading score

A 
Gleason
- Each biopsy is Graded 1-5
- Two strongest scored biopsies added together 
Low = 0-6
High = 8-10
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18
Q

Pros and Cons for Prostate Ca screening

A

Pro: commonest male Ca, 3% of all men die of Prostate Ca

Con: uncertain natural history (some low and some high aggressive), PSA non-specific

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19
Q

Prostate Ca Pres

A 
Male over 50
LUTS: Storage and voiding symptoms
Haematuria
Weight loss
Lethargy
Bone pain (mets)
LN palpable (mets)
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20
Q

Prostate Ca Investigations

A

PSA: prostate but not Ca specific (normal 0-4ng/ml)

DRE - hard irregular prostate

TRUSS + Biopsy

  • abnormal cells in 2 diff samples needed
  • Gleason

MRI/CT for staging

Isotope bone scan for mets (esp if PSA over 20)

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21
Q

Prostate Ca Severity

A

Low risk (PSA under 10, Gleason under 6)

Intermediate risk (Gleason 6-8)

High risk (Gleason 8-10, PSA over 20)

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22
Q

Prostat Ca Treatment

A

Low risk/intermediate

  • Active surveillance (PSA, TRUSS) ± brachytherapy (internal radiation) or external beam radiotherapy
  • Androgen deprivation: goserelin

High risk

  • Radical prostatectomy and pelvic LN
  • External beam radiotherapy
  • Androgen deprivation therapy (risk gynaecomastia/erectile dysfunction)
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23
Q

Tx of mets in Prostate Ca

A

Castration (usually chemical) through androgen deprivation therapy
- Goserelin: GnRH so first stimulates and then acts as negative feedback to inhibit release of androgen

80% mets androgen sensitive so Tx = remission

Bisphosphonates/radiotherapy to reduce hypercalcaemia in resistent

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24
Q

What type of epithelium in Bladder.

What type of cells at surface

A

Transitional epithelium

Umbrella cells

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25
Bladder Ca - Types - RF
90% transitional cell (in West) SCC in schistosomiasis Smoking, Occupation (aromatic amines - rubber, dye), Age, Pelvic radiation (Prostate Ca), Scc - Chronic inflammation (schisto, indwelling catheters)
26
T4 bladder cancer
Invasion beyond bladder: prostate, uterus, vagina, pelvic/abdo wall
27
Bladde Ca: - LN - Mets
Pelvic LNs Liver and Lungs
28
Bladde Ca: | - Pres
``` Painless haematuria (frank or microscopic) Dysuria Abdominal mass Weight loss Bone pain (advanced) ```
29
Bladde Ca: | investigations
Urine dip (haematuria) KUB USS Flexible cystoscopy + Biopsy CT Urogram with contrast (shows tumours of bladder and upper urinary tract)
30
Bladde Ca: | Complications
``` Hydronephrosis Upper tract transitional cell cancer Prostatic urethral transitional cell cancer Urinary retention Recurrence ```
31
Bladder Ca tx - No Muscle invasion - Locally invasive - T4/Metastatic disease
Transurethral resection of bladder tumour (TURBT) + immediate Intravesical chemo with mitomycin Delayed Immunotherapy (bacilli Calmette-Guerin) MVAC chemo: - Methotrexate - Vincristine - Doxorubicin (Adriamycin) - Cisplatin
32
When is haematuria relevant?
Frank haematuria SYMPTOMATIC microscopic haematuria
33
Causes of discoloured urine
Myoglobinuria (rhabdomyolysis) Haemoglobinuria (haemolytic anaemia)
34
Causes of microscopic haematuria
``` Menstruation Cystitis Pyelonephritis Acute Prostatitis BPH Trauma ```
35
Haematuria Further investigations
Urine dip: Protein implies renal Culture: Infection DRE: Prostate FBC: Hb (anaemia-renal), WCC (infect), PSA, eGFR/Cr (nephrological) Imaging: USS KUB, Flxible cystoscopy, Non-contract CT (stone), Contrast CT urogram (malignancy)
36
Catheters: - Types - Indications
Urethral (Foley) Suprapubic Acute/Chronic urinary retention, Pre-op emptying, Monitor urine output, manage incontinence (MS)
37
Pros & Cons of SPC Vs Urethral
SPC more omcfortable, more convenient to change, better sexual function SPC inc risk cellulitis/leakage, painful (needs analgesia ± sedation) Both carry infection risk (UTI) with E.coli
38
UTI: - LUTI - UUTI
Cystitis, Prostatitis, Epididymo-orchitis, Urethritis Pyelonephritis
39
What is a complicated UTI
``` In Males, Preg, Children Recurrent UTI Immunocomprimised Dec renal function Abnormal renal tract/obstruction ```
40
UTI RFs
``` Femal Spermicide (dec lactobacilli) Preg (inc risk pyelonephritis) Immunosuppression, DM Obstruction, Stones Catheter Malformation ```
41
UTI organisms
E.coli Staph saprophytic (coagulase -ve) Enterobacteria (Proteus, Klebsiella, Enterococci, GBS)
42
UTI Tx
Trimethoprim 3d (Preg: Nitrofurantoin 7d) UUTI: Cephalosporins Men: Ciprofloxacin 1-2d
43
Age and UTI risk
pH raised following menopause = inc risk
44
Host defence to UTI
Urine flush Tamm-Horsfall Protein Low urine pH Urinary IgA
45
Pathology of UTI
Bacteria from colonic flora Colonise urethral meatus Bacteria Ascend (adhere to urothelium)
46
Definitions of: - Bacteriuria - Pyuria - Sterile Pyuria
Bacteria in urine Presence of leucocytes with assoc infection Presence of white cells but cannot culture bacteria (e.g. chlamydia, recently Tx UTI, In situ bladder cancer)
47
What is uncomplicated UTI
UTI in healthy woman without functional or anatomical tract abnormalities
48
Pyelonephritis Pres
Loin pain Costovertebral angle tenderness Fever
49
UTI investigations
Mid stream culture and sensitivity Urine dip Urine microscopy (RBC, WBC, Bacteria) Urine culture KUB USS: Post void residual, stone, hydronephrosis, tumour
50
UTI Presentation
DUF - dysuria - urgency - frequency
51
UTI in men - Organisms - RFs
E.coli, Klebsiella, Proteus BPH (poor flow), Calculi, urinary surgery, incomplete emptying, reflux, DM Urinalysis (microscopy + culture), KUB USS (stone, abscess) CT (urinary calculi, tumour Ciprofloxacin (IV if severe)
52
Catheter assoc infection
100% at one month Prophylactic Abx: Amoxicillin
53
Prostatitis - Def & mechanism - Organism - Pres
Inflammation/infection of prostate gland due to intraprostatic reflux E.coli in 80% Pain in lower abdominal, ejaculatory, perineum LUTS (DUF: dysuria, urgency, frequency) Fever/chills Malaise
54
Prostatitis investigations
``` Urinalysis (microscopy: leukocytes, bacteria), culture (MSU MC+S) Blood cultures (if febrile) ```
55
Prostatitis treatment
If sepsis: IV taz + Gent + NSAID + releyó obstruction No sepsis: Ciprofloxacin/Flouroquinolone + NSAID + relief of obstruction
56
Urethritis: - Common causes - RF - Classically seen.. - complications
N.Gonorrhoea C.trachomatis New sexual partner, under 25 yrs, multiple partners, unprotected sex Urethral discharge after unprotected sex Gonococcal: reactive arthritis, meningitis, endocarditis Chlamydia: infertility
57
Epidydimo orchitis - Def - Pres - Important Ddx - Causes in under 35yr & over 35yr - Pathology
Inflammation of epididymis and testicle Unilateral pain/swelling. Assoc with LUTS (DUF), discharge, fever Rule out Torsion! STI (Chlaydia, Gonorrhoea), Viral (mumps) UTI (e.coli) assoc with bladder obstruction (BPH) or instrumentation (catheter) ascent of pathogens retrograde via ejaculatory ducts
58
Urethritis/epididymo-orchitis Ix
First catch urine (dip - leukocytes, microscopy, culture) If suspect torsion: surgical exploration
59
Urine Dip - Nitrites - Leukocytes
Nitrites formed from nitrates by G- bacteria e.g. E.coli Neutrophil/Macrophage release leukocyte esterase. If this positive then sign of infection/inflammation
60
Renal Calculi - % lifetime risk - RF - Imaging - 3 most common sites
10% Chronic dehydration, Diet, Obesity, +ve FH, Some drugs (Cipro) Non-contrast CT Pelviureteric junction (renal pelvis) Pelvic brim Vesicoureteric junction
61
Renal calculi - Reasons for formation - Stone types
- Elevated urine solutes (Ca, Uric acid, Oxalate, Sodium) - Low urine volume, high/low pH - infection (striate) Calcium stones (80% - most common. most calcium oxalate, some calcium phosphate -hydroxyapetite) Uric acid stones (10-20% seen with gout) Struvite stones (5%. Common cause stag horn calculi - Both 's') Cystine stones
62
Calcium oxalate stone - RF - Stone features
Low urine vol, Hypercalciuria/oxaliuria Spiky opaque stones
63
Calcium phosphate stone - RF - Stone features
Low urine vol, high pH, Hypercalciuria, High phosphate (Hyper PTH) Smooth opaque stone
64
Urate stone - RF - Stone features
Low pH, Hyperuricaemia (gout) Smooth brown, radiolucent
65
Struvite stone - RF - Composition (MAP) - Stone features
Infection Magnesium, Ammonium, Phosphate Staghorn
66
Renal colic Ddx
``` Appendicits (-ve non-contrast C) Ectopic (preg test) Ovarian cyst (AUSS) Diverticulitis AAA (consider in over 50: CT abdo) ```
67
Renal colic pres
Severe flank pain (loin to groin: depends on site of stone) unilateral Nausea&Vomiting Worse with fluid Microscopic haematuria (Urine microscopy) Costovertebral angle tenderness (pyelonephritis)
68
Renal colic investigation
Non-contrast CT = Gold standard (stones appear white in collecting system) Urinalysis: dip (±leukocytes, nitrites), Microscopy (microhaematuria) and culture FBC: raised WCC if infection Pregnancy test U&E (hyperuricaemia - gout, hypercalcaemia - PTH)
69
Signs of sepsis
Fever tachycardia Hypotension (seen in obstructing stones with infection)
70
Renal stones Tx - Acute - + bacteruria - Under 10mm - Over 10mm
Hydration, Pain control (IV morphine), Antiemetic (Ondansetron - 5HT) Rectal dicolfenca Abx: Trimethoprim/nitrofurantoin Alpha blocker (tamsulosine), CCB (nifedipine). 95% undr 5mm pass with IV fluid in 2w Surgical (extracorporeal shock wave lithotripsy), Percutaneous stereoscopy if over 15mm, Percutaneous nephrostolithotomy if over 20mm/Proximal stones
71
Prevention of kidney stones
Overhydration (2.5-3L a day) Dec: sodium, protein, oxalate, Weight High: - Ca: thiazide + potassium citrate - Uric acid: allopurinol Struvite: Tx infection
72
Scrotal swelling what to determine in examination
Is it separate from the testicle Is it cystic or solid
73
Scrotal swelling - Separate from testicle and cystic in nature - Separate and solid - Testicular and cystic - Testicular and solid - Cant get above it
Epididymal cyst Epididymitis or varicocele Hydrocele Tumour/Orchitis Inguinal hernia
74
Acute, tender enlargement
Torsion until proven otherwise
75
Epididymal cyst - Def - Pres - Ix - Assoc - Tx
Smooth cysts in head of epididymis Small and painless lump, will transluminate, separate from testes. may be bilateral USS, aspiration (milky) CF (absent Vas deferens), infertility Common and benign, no Tx needed
76
Varicocele - Def - Side - Cause - Complication
Abnormal dilatation of internal veins of pampiform plexus draining testes 90% left sided Increased hydrostatic pressure, incompetent valves. Sometimes assoc with Left RCC Infertility
77
Varicocele - Pres - Investigations - Tx
Painless scrotal mass, like bag of worms Dull ache Scrotal USS Reassure & Observe Surgery if abnormal semen parameters
78
Hydrocele: - Def - Type - Cause
Serous fluid (peritoneal) collecting along the spermatic cord Communicating (Patent processes vaginalis: risk of indirect inguinal hernia) Or non-communicating (No longer patent) Infant: congenital Adult: trauma, infection, tumour, varicocele, tumour
79
Hydrocele: - Pres - Tx
Scrotal mass in scrotum or extending to inguinal canal. Transluminates Enlarged post activity (inc abdo pressure) May resolve spontaneously Surgery/aspiration if discomfort/infection
80
Testicular torsion - def - pres - Ix - Tx
Twisting of testicle on spermatic cord. Constricts vascular supply. Time sensitive ischaemia of testicle Tender, Swollen, Hot, High, Transverse lie, Absent cremasteric reflex Doppler USS if under 24 hrs, Surgical exploration Possible orchidectomy is ischaemia
81
Testicular cancer: - Pres - Ix - Age group
Hard, painless nodule on testicle USS testicle 20-35 yr
82
Types of testicular caner:
Germ cell (90%) - Seminoma (55%) - Non-seminoma (teratoma, choriocarcinoma) Non-germ cell - Leydig - Stromal
83
Seminoma Mets (type of germ cell)
25% get mets | Most common lymphatic spread to retroperitoneal nodes (back pain)
84
Testicular cancer: RFs
Cryptorchism (bilateral undescended) ``` FH, personal Hx Taller men Kleinfelter's infertility Chromosome 12 mutation (Testicular germ cell tumour 1) ```
85
Testicular cancer: Pres
Painless nodule, haemospermia, secondary hydrocele Extratesticular: - bone pain (skeletal mets), gynaecomastia (b-HCG), Lower extremity swelling (venous occlusion), back pain (seminoma - para-aortic mets)
86
Testicular cancer: Ix
BAL markers (b-HCG, AFP, Lactate dehydrogenase) USS CT abdo&Pelvis (LNs) B-HCG - Seminoma AFP (alpha-fetoprotein) Teratocarcinoma, embryonal (not seminoma) LDH
87
Tx Testicular cancer:
Radical orchidectomy (don't biopsy just remove) for all Early stage: external beam radiotherapy + Carboplatin ``` Late stage (LN, Mets e.g. lung) - BEP chemo (Bleomycin, Etoposide, CisPlatin ``` Prognosis is good. 90% cure with chemo for metastatic disease
88
What is erectile dysfunction
difficulty in attaining, maintaining an erection or a marked decrease in rigidity
89
Erectile dysfunction causes
Age Pain Vascular: HTN, CHD, DM, Smoking, Obese Neurological: MS, Spinal cord injury Hormonal: dec androgens, inc prolactin, hypothyroid Psychological: Anxiety, depression, substance misuse Drugs: SSRI, Beta-blocker, Alcohol, Anti-psychotics (prolactin)
90
Investigations
Testosterone, Prolactin, FSH/LH, TSH Cholesterol BP Fasting Glucose, HbA1c
91
Modifiable RF in Erectile dysfunction
Drugs | Sedentary, obesity, smoking, alcohol, DM, HTN, Hyperlipidaemia
92
Erectile dysfunction Treat
PDE5 inhibitor (sildenafil): headache, facial flushing, (CI in hypotension) Alprostadil (Intrecavernous injection Vacuum pump + constriction ring Implant Psychosexual therapy
93
Erectile dysfunction psychosexual therapy
CBT - dysfunctional belief, sensate focus (couples), personal sexual growth programme Psychodynamic therapy - relate to early behaviours + current problem Systemic therapy (focus on context) Intergrative therapy
94
Neurogenic bladder - def ANS and nerves in - Detrusor contraction - Urethral contraction & inhib detrusor Voluntary control micturition
Bladder dysfunction either flaccid or spastic due to neurological damage. Overflow incontinence PSNS (cholinergic) S2,3,4 (Pelvic Splanchnic) SNS, T11-L2 (hypogastric) External urethral sphincter
95
Classification of incontinence
Stress: Poor closure of bladder (incontinence in cough, sneeze etc) Urge: Overactive bladder Overflow: Poor bladder contraction Mixed
96
Neurogenic bladder causes
CNS - CVA - Spinal injury - ALS - Meningomyelocele PNS - Diabetes - Alcohol - Vit B12 neuropathy - Herniated disc - Pelvic surgery (damage) Psrkinson, Ms, tumours
97
Flaccid Neurogenic bladder - Cause - Def
Peripheral nervier spinal nerve damage at S2-4 Bladder volume large, pressure low, contractions absent
98
Spastic bladder - Cause - Def - What occurs
Brain, cord damage above T12 Involuntary & uncoordinated detrusor/sphinter contraction Involuntary dedication/urination
99
Investigation incontinence
Urodynamic studies
100
Neurogenic bladder investigation
Serum Cr Renal USS (Hydronephrosis) Post-voidal residual volume Urodynamics
101
Incontinence Tx
Kegel exercises Lifestyle: weight loss, caffeine/alcohol Bladder training Sling procedures
102
Complications of Radiotherapy for Prostate Ca
Colon cancer, Bladder Ca, Rectal Ca
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