Flashcards in Urology Deck (65)
Presentation of an obstructive uropathy (split into upper and lower urinary tract) ?
Upper Urinary Tract Obstruction (i.e. ureters):
-Loin to groin / flank pain on affected side (result of stretching / irritation of ureter and kidney
-Reduced / no urine output
-Non-specific symptoms (e.g. vomiting)
-Reduced renal function on bloods
Lower Urinary Tract Obstruction (i.e. bladder / urethra):
-Acute urinary retention (unable to pass urine and increasingly full bladder)
-Lower urinary tract symptoms (e.g. poor flow, difficulty initiating urination, terminal dribbling)
-Reduced renal function on bloods
Common causes of an obstructive uropathy (split into upper and lower urinary tract) ?
Upper Urinary Tract:
-Local cancer masses pressing on the ureters
-Ureter strictures (scar tissue narrowing tube)
Lower Urinary Tract:
-Benign prostatic hyperplasia (enlarged prostate)
-Ureter or urethra strictures (from scar tissue)
-Neurogenic bladder (no neurological signal telling bladder to contract)
Name 5 complications of an obstructive uropathy
-Acute Kidney Injury (postrenal AKI)
-Eventually chronic kidney disease
-Infection (from pooling of urine and retrograde infection: bacteria tracking back up urinary tract)
-Dilated kidney / ureters / bladder
Presentation of acute urinary retention ?
Pt is uncomfortable, unable to pass urine, tender + distended bladder.
Investigations for acute urinary retention + what could they potentially show ?
-USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities
-Urinalysis - infection, haematuria, proteinuria, glucosuria
-MSU - infection
-Blood tests: FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)
-Hunting for cause/depending on history
-CT abdo pelvis - looking for mass causing bladder neck compression
-MRI spine - disc prolapse, cauda equina, spinal cord compression MS
Management of acute urinary retention ?
Immediate and complete bladder decompression with catheter.
Men should be offered an alpha blocker prior to removal
What is the most common type of kidney cancer + how is it staged ?
Renal cell carcinoma.
The TNM system.
What are “Cannon ball metastases” and how are they relevant to the kidneys ?
Cannonball metastases is a description given to a select type of lung metastases in which multiple large masses are evident.
Renal cell carcinoma is by far the commonest cause - This is a common exam question.
Presentation of kidney cancer ?
-Vague loin pain
-Non-specific symptoms of cancer (e.g. weight loss, fatigue, anorexia, night sweats)
Types of renal cell carcinoma ?
-Clear cell (75-90%)
-Collecting duct carcinoma (1%)
-Children: Wilms Tumour (in children < 5 years old)
RF's for kidney cancer ?
-Von Hippel-Lindau Disease
Management of kidney cancer ?
-Surgery (partial nephrectomy first line) / - radiotherapy and chemotherapy depending on disease stage.
Paraneoplastic features of RCCs ?
-Polycythaemia (RCC secretes unregulated erythropoietin)
-Hypercalcaemia (RCC secretes a hormone that mimics the action of PTH)
-Stauffer Syndrome (abnormal liver function tests demonstrating an obstructive jaundice – without any localised liver or biliary me
Types of bladder cancer ?
-90% transitional cell carcinoma
-10 % squamous cell carcinomas
-Rarer causes are adenocarcinoma, sarcoma, small cell.
RF's for bladder cancer ?
-Key workplace carcinogens - Carcinogens include aromatic amines, polycyclic aromatic hydrocarbons, arsenic and tetrachloroethylene. These are found in hair dyes, industrial paint, rubber, motor, leather, and rubber workers, blacksmiths etc.
-Age, 70% > 65
-Pelvic radiation (prostate Ca)
-Men > Women
-HNPCC for upper tract urothelial cancers
-Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma
Presentation of bladder cancer ?
-PAINLESS HAEMATUIRA(frank or microscopic)
-Systemic weight loss + bone pain
How is bladder cancer staged ?
Bladder cancer note:
The majority are superficial (not invading the muscle) at presentation
Bladder cancer note
Tis - in situ ‘flat tumour’ worst prognosis
Ta - non-invasive papillary carcinoma
T1 - tumour invades subepithelial connective tissue (lamina propria):
T2 - tumour invades superficial muscle (detrusor or muscularis propria):
T3 - tumour invades perivesical tissue:
T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall:
Haematogenous: Liver and lungs
Bladder cancer gold standard investigation + other investigations ?
Flexible cystoscopy with biopsy TURBT.
-Urine dip - Haematuria (80% of patients) ± pyuria
-Urine MC + S - cancers may cause sterile pyuria
-Bimanual EUA for staging
-CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour
-Urinary cytology - abnormal cells
-FBC - mild anaemia
-CXR, isotope bone scan, alkaline phosphatase etc…..
Treatment of bladder cancer ?
Not invading the muscle:
-Transurethral Resection of a Bladder Tumour (TURBT)
-Chemo into bladder after surgery (use barrier contraception afterwards)
-Weekly treatments for 6 weeks with BCG vaccine squirted into the bladder via catheter, then every six months for 3 years.
Muscle-invasive bladder cancer:
-Radical cystectomy with ileal conduit
-Radiotherapy (as neoadjuvant, primary treatment or palliative)
-IV chemotherapy as neoadjuvant or palliative
Presentation of BPH ?
-FUN - frequency, urgency, nocturia
-HIIPP - hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling
Investigations for BPH ?
-TRUSS ± biopsy
-PSA - increased may indicate prostate cancer or prostatitis
Urinalysis - MSU/urine dip to rule out pyuria and complicated UTI
Scoring system -IPSS - International Prostate Symptom Score (0-35) also includes quality of life
Mild = 0-7, Mod = 8-19, Severe = 20+
-USS KUB - To rule out hydronephrosis, urolithiasis, mass
Management of BPH ?
Treatment depends on severity and impact on life:
For all = behavioural management:
-Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids
Mild (no bother):
-Watch and wait
-FIRST LINE: Alpha blocker (tamsulosin or doxazosin) or 5-alpha reductase (finasteride) or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)
Mod/severe - as above, first line drug + behavioural management
Abnormal DRE or elevated PSA:
-Prostate < 80g - TURP, TUVP (transurethral resection/vaporisation) or HoLEP (Holmium laser enucleation of the prostate )
-Prostate > 80g - Open prostatectomy
Complications of TURP ?
Retrograde ejaculation (semen goes backwards and is not produced from the urethra during ejaculation)
Failure to resolve symptoms
How do alpha blockers work in relation to BPH ?
Smooth muscle relaxation in prostate and bladder neck.
How do 5-alpha reductase inhibitors work ?
They reduce the conversion of testosterone into dihydrotestosterone
Presentation of prostate cancer ?
-Weight loss/anorexia/lethargy (advanced metastatic)
-Bone pain (advanced metastatic)
-Palpable LNs (advanced metastatic)
How does a benign vs a cancerous prostate feel during a DRE ?
-A benign prostate feels smooth, symmetrical and slightly soft with a maintained central sulcus
-A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus