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Phase 2 > Urology > Flashcards

Urology Flashcards

1
Q

What are LUTS?

A 
Nocturnal
Frequency
Urgency
Post-micturition dribbling
Poor stream
Hesitancy
Overflow incontinence
Haematuria
Bladder stones
UTI
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2
Q

What is the normal size of the prostate?

A

Size of a walnut

3.2cm diameter

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3
Q

What are the differential diagnoses for LUTS?

A 
Cancer - bladder or prostate
UTI
Stones
Detrusor weakness/instability
Urethral stricture
Neurological pathology
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4
Q

How do you manage BPH?

A

Conservative: fluid intake, urethral milking, bladder training, collecting devices/sheath
Medical
Surgical

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5
Q

What are the medical options for BPH?

A

Voiding LUTS: alpha blockers, 5-ARIs
Storage LUTS: anticholinergics +/- alpha blockers
Nocturnal polyuria: latter diuretics, oral desmopressin

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6
Q

How do alpha blockers work?

A

Relax smooth muscle within prostate and bladder neck
Rapid symptom relief
No effect on prostate volume and don’t reduce overall long-term risk or need for surgery

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7
Q

Give 2 examples of alpha blockers used to treat BPH

A

Tamsulosin

Doxazosin

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8
Q

How do 5-ARIs work?

A

Shrink the prostate by means of androgen deprivation
Improve symptoms and reduce prostate volume
Max effect may take a few months to achieve

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9
Q

Give an example of a 5-ARI

A

Finasteride

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10
Q

What are the surgical options for BPH?

A

TURP
Urolift
Prostatic embolisation

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11
Q

What are the causes of raised BPH?

A 
BPH
Prostate cancer
UTI
Retention
Prostatitis
Recent instrumentation/catheterisation
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12
Q

When should PSA testing be offered?

A

If symptomatic or positive family history

And the patient has been counselled

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13
Q

What is the normal range for PSA?

A

40-49: less than 2.5
50-59: less than 3
60-69: less than 4
Older than 70: less than 5

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14
Q

What is the main cause of urinary incontinence in men?

A

Prostatic enlargement

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15
Q

What are the different types of urinary incontinence in women?

A

Functional incontinence
Stress incontinence
Urge incontinence/overactive bladder syndrome

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16
Q

What is functional incontinence?

A

Caught short or too slow in finding the toilet eg immobility or unfamiliar surroundings

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17
Q

What is stress incontinence?

A

Leakage from an incompetent sphincter when intra-abdominal pressure rises eg coughing/laughing

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18
Q

What are the risk factors for stress incontinence?

A 
Increasing age
Obesity
Pregnancy
Following childbirth
Post-menopause
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19
Q

What is urge incontinence?

A

Urge to urinate quickly followed by uncontrollable and sometimes complete emptying of the bladder as the detrusor muscle contracts

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20
Q

How is stress incontinence managed?

A

Pelvic floor exercises: 8 contractions 3 times a day for 3 months
Ring pessary for uterine prolapse

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21
Q

How do you manage urge incontinence?

A

Bladder training and weight loss

Aids eg absorbent pads

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22
Q

What are the urological causes of loin pain?

A

Ureteric or renal colic

Pyelonephritis or UTI

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23
Q

What are the non-urological causes of loin pain?

A

MSK
Gynae
General surgical
Vascular - dissecting iliac aneurysm

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24
Q

What are the key points in a history of loin pain?

A 
Speed of onset
Nature of pain: colicky/sharp/severity
Radiation
Unilateral or bilateral
Associated symptoms: systemic/LUTS
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25
Q

What are the causes of ureteric colic?

A

Ureteric calculi
Clot colic
PUJ obstruction

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26
Q

What is the classic history of ureteric colic?

A 
Sudden onset
Severe colicky pain
Unilateral
Loin to groin
Radiation to iliac fossa/genitalia
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27
Q

When would you particularly worried about a patient with ureteric colic?

A

Temperature / rigors
Hypotensive
Worried about sepsis

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28
Q

How do you investigate suspected ureteric colic?

A

Urinalysis
FBC, U&E, calcium, urate
CT KUB
USS

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29
Q

What would you see on urinalysis in ureteric colic?

A

Non-visible haematuria

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30
Q

How do you initially manage ureteric colic?

A

Analgesia
Anti-emetic
Fluids if dehydrated

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31
Q

When is intervention indicated for ureteric colic?

A 
Larger more proximal stones
Renal impairment
Intractable pain
Solitary kidney
Infection
Failed conservative management
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32
Q

What are the options for removal of a stone?

A

Ureteroscopy + lasertripsy
ESWL - extra-corporeal shockwave lithotripsy
JJ stent

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33
Q

Why is infection associated with a stone an emergency?

A

They may have pyonephrosis

Call for senior help if they are septic

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34
Q

What is pyonephrosis?

A

Abscess in renal pelvis

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35
Q

How do you manage pyonephrosis?

A

Resus: O2, IV fluids
ABx: gentamicin + co-amox/Tazocin
Culture blood/urine
ABG

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36
Q

When should a UTI be followed by urological investigation?

A

Any male with proven UTI

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37
Q

How is pyonephrosis managed surgically?

A

Drainage:
External percutaneous nephrostomy
Internal - ureteric stent (GA)
Discharge home with drain in situ and readmit electively to have the stone treated

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38
Q

What are stones made from?

A

Crystal aggregates

Mostly calcium oxalate

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39
Q

Where are stones most commonly deposited?

A

Pelviureteric junction (PUJ)
Pelvic brim
Vesicoureteric junction

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40
Q

How can you prevent stones forming?

A

Drink plenty
Normal dietary calcium
Calcium stones - thiazides
Urate stones - allopurinol

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41
Q

How does acute pyelonephritis present?

A

Chills, fever>38
Loin pain
May be more gradual onset, not typically colicky pain
Often systemically unwell

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42
Q

What is the most common organism in acute pyelonephritis?

A

E.coli

Proteus
Klebsiella
Enterobacter

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43
Q

What investigations should you do for suspected acute pyelonephritis?

A

Urine dip
FBC, U&E
MSU - MC&S +/- blood cultures
Renal USS to exclude pyonephrosis

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44
Q

How do you manage acute pyelonephritis?

A

Antibiotics
Analgesia
Antiemetic
DVT prophylaxis

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45
Q

Define urinary retention

A

Inability to pass urine, rather than inability to make urine

Not emptying the bladder, due to obstruction or reduced detrusor power

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46
Q

Give some causes of urinary retention

A 
Prostatic enlargement
Constipation
UTI
Excess fluid/delayed voiding
Neurological eg cauda equina
Urethral stricture/phimosis
Surgery
Drugs inc alcohol
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47
Q

How does acute urinary retention present?

A

Pain relieved by drainage

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48
Q

What are the symptoms that indicate problems with urine storage?

A

Frequency
Urgency
Nocturia
Urinary incontinence

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49
Q

What are the symptoms that indicate a problem with voiding?

A 
Hesitancy
Intermittency
Straining
Poor flow
Spraying
Post-micturition dribbling
50
Q

How do you manage urinary retention?

A

Catheterise urethrally if possible

Record residual volume and document

51
Q

What medical therapy may be given for acute retention?

A

Alpha blocker - tamsulosin

5ARI - Finasteride

52
Q

How do you manage chronic urinary retention?

A

Long-term I dwelling catheter

TURP if fit

53
Q

What is post-obstructive diuresis?

A

High pressure chronic retention leads to hydronephrosis and AKI
They often produce a large amount of urine in the acute phase of relief of obstruction

54
Q

How do you manage patients with post-obstructive diuresis?

A

Don’t give back the residual volume
Unless they are dehydrated, they don’t need IV fluids unless diuresis is prolonged and they can’t have oral fluids
Keep reassessing fluid status clinically

55
Q

What are the causes of testicular pain?

A

Testicular torsion
Epididymitis/orchitis
Testicular tumour
Trauma

56
Q

How does testicular torsion present?

A

Often younger patient

Sudden onset unilateral testicular pain

57
Q

What do you find on examination in testicular torsion?

A

Apyrexial, may be tachycardic
Scrotum erythematous
Exquisitely tender testis

58
Q

How do you manage testicular torsion?

A

Scrotal exploration in theatre as an emergency

+/- orchidectomy

59
Q

What are the common causes of epididymoorchitis?

A

STI esp chlamydia

UTI (E.coli)

60
Q

How does epididymoorchitis present?

A

Gradual onset, usually unilateral

Recent history of UTI, unprotected intercourse

61
Q

What do you find on examination in epididymoorchitis ?

A

Scrotum erythematous
Testis/epididymis enlarged and tender
Fluctuations areas - abscess

62
Q

How do you treat epididymoorchitis?

A

Antibiotics
Ciprofloxacin for UTI
Doxycycline if chlamydia suspected

63
Q

What is Fournier’s gangrene?

A

Necrotic area of scrotal skin associated with epididymoorchitis

64
Q

What 3 questions do you need to answer on examination of a testicular lump?

A

Can you get above it?
Is it separate from the testis?
Is it cystic or solid?

65
Q

What is the likely diagnosis for a lump that is separate from the testis and cystic?

A

Epididymal cyst

66
Q

How do you manage epididymal cysts?

A

Ultrasound
Reassurance
Conservative management
Remove surgically if symptomatic

67
Q

What is a hydrocoele?

A

Fluid in the tunica vaginalis

68
Q

What is the difference between primary and secondary hydrocoeles?

A

Primary due to patent processus vaginalis - younger men

Secondary to testis tumour, infection or trauma

69
Q

How do you manage hydrocoeles?

A

Aspiration or surgical repair

70
Q

What is a varicocele?

A

Dilated veins of pampiniform plexus

71
Q

How do varicoceles present?

A

Dull ache at end of day

Left side more commonly affected

72
Q

What is a haematocele?

A

Blood in tunica vaginalis

Follows trauma and may need drainage

73
Q

What are the common types of testicular tumour?

A

55% Seminoma
33% non-seminomatous germ cell tumour (teratoma)
12% mixed germ cell tumour

74
Q

How does testicular cancer present?

A 
Painless lump
Haematospermia
Pain
Secondary hydrocele
Dyspnoea - lung mets
Abdo mass - enlarged nodes
75
Q

What are the risk factors for testicular cancer?

A

Undescended testis
Infant hernia
Infertility

76
Q

What are the tumour markers for testicular cancer?

A

Alpha fetoprotein

Beta hCG

77
Q

How are testicular cancers treated?

A

Seminoma - early stage sensitive to radiotherapy

NSGCT - chemotherapy

78
Q

What is the incidence of undescended testis?

A

3% of boys

30% of premature boys

79
Q

What are the different types of undescended testis?

A

Cryptorchidism
Retractile testis
Maldescended testis
Ectopic testis

80
Q

What are the complications of maldescended and ectopic testis?

A

Infertility
40x increased risk of testicular cancer
Increased risk of testicular trauma and torsion
Association with hernias

81
Q

What is the treatment for maldescended and ectopic testis?

A

Orchidopexy

Hormonal with hCG

82
Q

When is 2ww referral appropriate for haematuria?

A

Visible haematuria older than 45y

Persistent NVH, no obvious cause older than 60y

83
Q

What are the urological causes of haematuria?

A 
Cancer - RCC, upper tract TCC, bladder cancer, advanced prostate cancer
Stones
Infection
Inflammation
BPH (large)
84
Q

When should haematuria be referred to nephrology?

A

Persistent asymptomatic NVH younger than 40, with associated proteinuria, hypertension, low eGFR

85
Q

What are the important aspects of a history of haematuria?

A

Pain(less)?
UTI
Anticoagulants
Smoking

86
Q

What investigations are done at a haematuria 2ww clinic?

A 
DRE
Bloods: FBC, U&E, PSA
MSU
USS renal tract
Flexible cystoscope
87
Q

What are the majority of bladder cancers?

A

Transitional cell carcinoma

88
Q

What are the 2 main classifications of bladder cancer?

A

Muscle invasive

Non-muscle invasive

89
Q

What is TURBT?

A

Transurethral resection of bladder tumour

To gain histology

90
Q

How is muscle invasive bladder cancer further classified?

A

Organ confined

Metastatic

91
Q

How is organ confined bladder cancer treated?

A

Radical cystectomy

+ urinary diversion

92
Q

How does radical cystectomy differ in males and females?

A

Males - cystoprostatectomy

Females - cystectomy + anterior exenteration

93
Q

What are the options for urinary diversion following radical cystectomy?

A

Ileal conduit
Continent urinary diversion
Neobladder

94
Q

What treatment is offered for organ confined bladder cancer, if the patient is unfit for cystectomy?

A

Radical radiotherapy

95
Q

What is the treatment for metastatic bladder cancer?

A

Symptom control

Chemotherapy

96
Q

How does renal cell carcinoma present?

A 
Haematuria
Loin pain
Abdo mass
Anorexia
Malaise
Weight loss
97
Q

What are the treatment options for renal cell carcinoma?

A

Surveillance
Partial nephrectomy
Nephrectomy
Metastatic - oncology

98
Q

How does transitional cell carcinoma of the urinary tract present?

A 
Painless haematuria
Frequency
Urgency
Dysuria
Urinary tract obstruction
99
Q

Where can transitional cell carcinomas be?

A

Bladder - 50%
Ureter
Renal pelvis

100
Q

Describe the epidemiology of prostate cancer

A

Most commonly diagnosed cancer in UK males

2nd most common cause of cancer-related death

101
Q

What are the risk factors for prostate cancer?

A

Increasing age
Family history
BRCA2 mutation
Ethnicity: black>white>Asian

102
Q

How does prostate cancer present?

A

Asymptomatic
Urinary symptoms
Bone pain

103
Q

How is prostate cancer diagnosed?

A

DRE + PSA + Biopsy (TRUS)

104
Q

What is TRUS?

A

Transrectal ultrasound - takes 10-12 core biopsies from different parts of the prostate gland

105
Q

What is the Gleason score?

A

Prostate cancer graded from 3 (least aggressive) to 5 (most aggressive)
Gleason score is the sum of the 2 most common patterns of tumour growth
So score ranges from 6(3+3) to 10(5+5)

106
Q

What factors indicate high risk of progression of prostate cancer?

A

Any of…
PSA>20
Gleason 8-10
T3-4

107
Q

What factors indicate low risk of progression of prostate cancer?

A

All of…

PSA

108
Q

What percentage of men aged 50-70 have a raised PSA? How many of these will have prostate cancer?

A

10% have raised PSA

25% of these will have prostate cancer

109
Q

What is the threshold for PSA below which prostate cancer can be excluded?

A

There is no lower threshold!

110
Q

What factors influence treatment decisions for prostate cancer?

A 
Age
DRE
PSA
Biopsies - Gleason grade
MRI pelvis and bone scan
111
Q

What do prostate metastases look like?

A

Sclerotic (osteoblastic) hot spots on bone scan

112
Q

When are hormones used to treat prostate cancer?

A

Metastatic disease

Used alongside chemotherapy if PS 0-2

113
Q

What hormones are used to treat prostate cancer?

A

LHRH agonist

First stimulate then inhibit pituitary gonadotrophin

114
Q

What is the main risk of using LHRH agonists?

A

Risk of tumour flare when first used

115
Q

How do you treat tumour flare?

A

Start anti-androgen in susceptible patients

116
Q

What are the main aspects of palliation in metastatic prostate cancer?

A

Single dose radiotherapy

Bisphosphonates

117
Q

What are the options for radical treatment for prostate cancer?

A

Radical prostatectomy

Radiotherapy - external beam or brachytherapy

118
Q

What is brachytherapy?

A

Implantation of radioactive seeds into prostate gland

119
Q

What is the difference between active surveillance and watchful waiting in prostate cancer?

A

Active - regular investigations to monitor disease progression. In younger males when progression is more likely and who would be fit for treatment
Watchful waiting - no investigations

120
Q

What is lead-time bias?

A

Living longer knowing you have the disease rather than actually improving survival

121
Q

What is length-time bias?

A

Picking up slower-growing (hence more easily treatable) cancers, rather than fast-growing tumours
So more likely to be treatable

122
Q

What are the issues with PSA testing?

A

Not accurate
False positive means many more investigations
Only 1 in 3 with raised PSA have prostate cancer
No way to tell if cancer would actually impinge on health
May have bad effect from treatment that wasn’t needed

Phase 2 (21 decks)

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