1
Q
What is the most common cause of LUTS in
- men
- women
A
- BPH
2. UTI
2
Q
name 3 lifestyle factors that may exacerbate LUTS
A
- late night fluid intake
- excess alcohol intake
- excess caffeine intake
3
Q
- What are storage symptoms caused by?
2. Name 4 examples of storage symptoms
A
- when the bladder has problems storing urine
- increased urinary frequency
nocturia
urgency
urge incontinence
4
Q
- what are voiding symptoms caused by?
2. name 4 examples of voiding symptoms
A
- occur due to bladder outlet obstruction
- hesitancy
poor flow
terminal dribble
feeling of incomplete emptying
5
Q
Name 3 symptoms associated to LUTS that are associated to ask about
A
- haematuria
- suprapubic discomfort
- colicky pain
6
Q
name 3 classes of medication that can exacerbate LUTS
A
- anticholinergics
- antihistamines
- bronchodilators
7
Q
What scoring system can be used to assess LUTS (and impact on QOL)
A
IPSS
8
Q
Define the following:
- Stress incontinence
- Urge incontinence
- Mixed incontinence
- Overflow incontinence
- continuous incontinence
A
- intra-abdominal pressure > urethral pressure. Most commonly caused by pelvic floor weakness
- Overactive bladder/detrusor hyperactivity leads to uninhibited bladder contraction
- combination of stress and urge incontinence
- normally a complication of chronic urinary retention. progressive stretching of the bladder leads to damage to the efferent fibres of the micturition reflex and loss of bladder sensation. Gross distension causes intravesicular pressure to build, leading to a constant dribbling of urine
- constant leakage of urine, typically due to anatomical abnormality or bladder fistulae.
9
Q
Which type of urinary retention is:
- painful
- painless
A
- acute
2. chronic
10
Q
Name 5 causes of acute urinary retention
A
- BPH
- UTIs (can cause urethral sphincter to close)
- constipation (compression of urethra)
- antimuscarinics and spinal/epidural anaesthesia
- neuropathy
11
Q
Name investigations for acute urinary retention
A
- bedside bladder scan
- routine bloods
- urine culture
- ultrasound of urinary tract
12
Q
how does chronic urinary retention occur?
A
chronic urinary retention can cause progressive distension of the bladder
This can lead to detrusor muscle hypertrophy and bladder desensitisation
13
Q
What is a complication of catheterisation following urinary retention?
A
post-obstructive diuresis
14
Q
How may a patient with acute on chronic retention present?
A
minimal discomfort despite large residual volumes due to bladder desensitisation
15
Q
Define the following:
- uncomplicated UTI
- Complicated UTI
- Recurrent UTI
- UTI relapse
A
- infection in a healthy, non-pregnant, pre-menopausal female patient with an anatomically and functionally normal urinary tract
- infection associated with factors increasing colonisation and decreasing effect of therapy:
- hx of childhood utis
- immunocompromised
- preadolescent or post-menopausal
- pregnant
- underlying metabolic disorder
- urological abnormalities - bacteriuria is absent after treatment for at least 14 days followed by recurrence of infection with the same or different organisms Defined as 2 or more infections in 6 months, or>3 infections in 12 months
- recurrence of bacteruria with the same organism within 7 days of completion of antibacterial treatment. Treatment failure may suggest associated stones, scarred kidneys, polycystic disease or bacterial prostatitis
16
Q
Name 2 common causative organisms of UTIs
A
- Urogenic E.coli
2. Staph saprophyticus
17
Q
Name 8 risk factors for UTI
A
- female
- new sexual activity (particularly in females)
- indwelling urinary catheter
- urinary tract stones
- urinary tract stasis
- diabetes
- immunosuppression
- dementia
18
Q
Name 5 clinical features of cystitis
A
- frequency of micturition
- painful voiding
- suprapubic pain and tenderness
- haematuria
- foul smelling urine
19
Q
name 4 clinical features of pyelonephritis
A
- loin pain and tenderness
- fever
- rigors
- night sweats
20
Q
How may an elderly person with a UTI present
A
may be asymptomatic with new confusion the only symptom
21
Q
- How can uncomplicated UTIs be diagnosed in women under 65?
- How can UTIs be diagnosed in other patient groups?
A
- presence of dysuria, urgency, and frequency. Urine dip can be done but does not enhance diagnostic sensitivity
- culture of clean-catch mid stream urine specimen
22
Q
Name 3 causes of UTI symptoms with negative culture
A
- urethral syndrome
- interstitial cystitis
- irritable bladder
23
Q
- Which antibiotics are indicated for uncomplicated lower UTI?
- Which antibiotics are indicated for complicated UTI?
- Which antibioitics are indicated for pyelonephritis
A
- trimethoprim and nitrofurantoin
- ciprofloxacin
- ciprofloxacin
- gentamycin
24
Q
- How can urinary tract obstruction lead to AKI?
2. What is an obstruction that causes dilatation of the renal pelvis and/or ureter known as?
A
- delayed transit of urine > raised urinary tract and intrarenal pressure > renal impairment (only if obstruction is bilateral)
- hydronephrosis
25
Causes of Urinary Tract Obstruction:
1. Within the lumen (4)
2. Within the wall (4)
3. external pressure (6)
1. calculus
blood clot
sloughed papillae
tumour
2. ureteric stricture
congenital bladder neck obstruction
neuropathic bladder
congenital urethral valve
```
3. tumours
diverticulitis
aortic aneurism
constipation
prostatic obstruction
phimosis
```
26
Describe major clinical features for urinary tract obstruction
- loin pain
- oliguria/anuria (complete anuria is strongly suggestive of complete bilateral obstruction)
- features of infection
- LUTS
- acute urinary retention
27
What investigations would you perform for ?urinary tract obstruction?
1. urinalysis (for haematuria)
2. mid stream urinary sample for microscipy, culture and sensitivity
3. bloods
4. US
5. plain abdominal film (may detect stones)
6. CT KUB - high sensitivity
7. Antegrade pyelography and ureterography or retrograde uretography
8. Cystopscopy
28
How is urinary tract obstruction managed?
1. catheterisation
2. percutaneous nephrostomy
3. cystoscopy retrograde stenting
29
What is post obstructive diuresis?
diuresis occurring after relief of any obstruction, due to the osmotic effect of retained solutes and the correction of defective renal tubular reabsorbative capacity
Usually self limiting but can lead to severe severe water, sodium and potassium depletion, requiring IV replacement
30
What is the most common age group in which testicular cancer is diagnosed?
20-40
31
Name 4 risk factors for testicular cancer
1. previous testicular malignancy
2. positive family hx
3. undescended testes (cyroptorchidism)
4. Kleinfelter's syndrome
32
1. Which are more common: germ cell or non-germ cell testicular tumours?
2. How are germ cell tumours categorised?
1. germ cell (95% of all testicular tumours)
| 2. seminomas or non-seminomatous
33
1. What are the most aggressive testicular tumours? (2)
2. Which testicular tumours are associated with better prognosis
3. which testicular tumours secrete hCG?
4. Which testicular tumours secrete alpha fetoprotein?
1. embryonal and choriocarcinoma (non-seminomatous)
2. seminomas
3. embryonal and choriocarcinoma
4. yolk sac tumours
34
What are the clinical features of testicular cancer?
unilateral painless testicular lump
- o/e, irregular, firm, fixed and does not transilluminate
painless/dull ache and heavy sensation in suprapubic region
may have extratesticular symptoms due to metastases
35
1. which investigative tests are important for ?testicular cancer
2. why is it important to perform TFTs?
```
1. transillumination test
testicular ultrasound
bloods
- serum hCG
- serum alpha fetoprotein
- TFTs
CT abdomen and pelvis (staging)
```
2. mHCG is structurally similar to TSH, LFH and LH. Can cause hyperthyroid features in choriocarcinomas (and gynaecomastia)
36
1. Which tissue of the prostate undergoes hyperplasia in BPH?
2. Describe how BPH is driven by androgens
1. glandular epithelial and stromal tissue
2. prostate converts testosterone to DTH via 5 alpha reductase
DHT is more potent than testosterone; the prostate retains the ability to respond to testosterone throughout life, converting it to DHT. DHT drives prostatic hyperplasia
37
What are the main presenting features of BPH?
```
Voiding LUTS
- hesitancy
- weak stream
- terminal dribbling
- feeling of incomplete emptying
-
```
38
How can BPH cause storage LUTS?
chronic retention due to obstruction leads to detrusor hypertrophy and thus weakness
39
Which sign on digital rectal examination is reassuring in distinguishing BPH from prostate cancer
smooth prostate
40
What is the name of the scoring system used as part of the initial assessment of LUTS
- IPSS
41
Name 5 tests that are useful in the investigation of ?BPH
1. urine frequency and volume chart
2. urinalysis (to exclude UTI)
3. post void bladder scan (assess for chronic retention)
4. ultrasound
5. urodynamic studies (bladder contractility, flow rate, storage capacity)
42
1. Describe conservative management of BPH
2. What is the first line treatment of BPH? What is its MOA?
3. What is the second line treatment of BPH?
What is its MOA?
1. moderate caffeine and alcohol intake
limit late night fluid intake
2. tamsulosin (alpha blocker; acts to relax prostatic smooth muscle)
3. Finasteride (5 alpha reductase inhibitor; reduces prostate size; can take up to 6 months for patients to perceive symptomatic benefit)
43
When examining scrotal lumps, what is important to note (6s's and TTTCAMPFIRE)
6 S's
- site
- size
- shape
- symmetry
- skin changes
- scars
TTTCAMPFIRE
- tenderness
- temperature
- transillumination
- consistency
- attachments
- mobility
- pulsation
- fluctuation
- irriducibility
- regional lymph nodes
- edge
44
1. What is the first line investigation for scrotal lumps?
| 1. What other tests may be warranted if the lump is suspected cancer
1. scrotal USS
2. LDH
alpha fetoprotein
hCG
CT TAP
45
1. What is a hydrocoele?
| 2. Describe its clinical features
1. abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis that envelopes the testis
2. painless, fluctuant swelling that transilluminates
may cause bilateral leg swelling of occluding the lymphatic vessels of the leg
46
1. What is a varicocoele?
2. What is its clinical features?
3. Describe 2 complications of varicocoeles
4. how are varicocoeles managed?
1. abnormal dilation of the venous plexus within the spermatic cord
2. lump often described as "bag of worms"; most found on left side; associated dragging sensation
3. infertility and testicular atrophy
4. embolisation or ligation of spermatic veins (symptomatic varicocoeles only)
47
1. What is an epididymal cyst?
| 2. how do they present?
1. benign fluid filled sacs arising from the epididymis
| 2. smooth, fluctuant nodule, above and separate from the testes that will transilluminate
48
1. What is epididymitis?
2. How does it present?
3. What is its main aetiology?
1. inflammation of the epididymis
2. unilateral, acute onset scrotal pain; may be associated with swelling, overlying erythema and systemic symptoms of infection
3. Bacteria (thus managed with antibiotics and analgesia)
49
1. What is orchitis?
| 2. How is it managed?
1. inflammation of the testis
| 2. treated with rest and analgesia
50
How does a testicular tortion occur?
mobile testis rotates in the spermatic cord, within the tunica vaginalis, reducing arterial blood flow and venous return
51
1. What is the peak incidence of testicular tortion?
| 2. What is a risk factor for testicular tortion?
1. neonates and adolescents
| 2. undescended testes
52
What is the main complication of testicular tortion?
testicular infarction
53
What are the clinical features of testicular tortion
sudden onset, severe unilateral testicular pain
- often associated with nausea and vomiting
- pain continues despite elevation of the testis
Testis will have a high position compared to the contralateral side
54
1. What is the main investigation of ?testicular tortion?
2. How are patients with testicular tortion acutely managed?
3. How is a testicular tortion surgically managed:
a) if the testis is viable?
b) if the testis is unviable?
1. surgical exploration
2. analgesia; anti-emetics; nil by mouth
3a) bilateral orchidoplexy - untwist the cord and testis and fix both testicles to the scrotum to prevent further tortion)
3b) orchidectomy
Phase 2 Metabolic
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