Urology - mx

Question 1

Urethral stricture management options

Answer 1

Cystoscopy to visualise the urethral stricture and then

• Dilation
• Urethral stent
• Cystoscopic urethrotomy
• Surgery to remove the affected portion

Question 2

Indications for urgent dialysis

Answer 2

• eGFR <10ml/min + benefits outweigh risks
• eGFR <6ml/min + no reversible features
• Life-threatening complications
• Hyperkalaemia (>6.5mM)
• High creatinine (>1000μM)
• Hyperuricaemia (>300mM)
• Symptoms or complications of uraemia (e.g. pericarditis)
• Uraemic encephalopathy
• Fluid overload (severe pulmonary oedema)
• Severe acidosis (pH <7.2) refractory to medical management
• Drug overdose by BLAST drugs – Barbiturates, Lithium, Alcohol, Salicylates, Theophyline

Question 3

Complications of bladder catheterisation

Answer 3

• UTI (proteus mirabilis) - dysuria, confusion, pyleonephrtis
• Urethral trauma - pain, bleeding
• Urethral scarring + Stricture - slow-flowing micturition, dysuria, urinary retention
• Creation of false passage in the urethra - pain, infection
• Bladder perforation - pain, bleeding, peritonitis

Question 4

Incontinence management

Answer 4

• Anti-muscarinics (tolterodine, oxybutynin)

PNS - pelvic nerve + Ach receptors –> stimulate contraction of detrusor muscle

SNS - hypogastric nerve + NA receptors –> inhibit contraction of detrusor muscle

Question 5

To alleviate outflow obstruction

Answer 5

• A adrenergic blockers (doxazosin, prazosin, tamsulosin, afluzosin)
  Act on a receptors + block contraction of internal urethral sphincter + SM of prostate capsule

Question 6

AKI Mx

Answer 6

• Asses volume status + aim for euvolaemia
  If pt is dehydrated, stop diuretics
  Match daily input to loss + 500ml for insensible loss but more if pyrexic
• Withhold drugs that reduce eGFR
• Withhold nephrotoxic drugs (ACEi, ARBs, gentamicin)
• Withhold/reduce drugs that are renally excreted (e.g. metformn if eGFR <30, sulphonylureas, insulin, co-amoxiclav)
• Adequate nutrition
• If using contrast, hydrate patient pre- + post-contrast
• BP control
• Treat the underlying cause
  Pre-renal: Correct volume depletion with appropriate fluids, antibiotics (IF sepsis), inotropes (norepinephrine, dobutamine, IF signs of shock)
  Post-renal: Catheterise + imaging of renal tract (CTKUB) + urology + reversal
  Intrinsic renal: Refer early to nephrology

- Manage complications 
   Hyperkalaemia 
   Pulmonary oedema 
   Uraemia 
   Acidemia 

Renal replacement therapy – haemodialysis and haemofiltration if any complications are refractory to medical Mx

Question 7

Pre-renal azotaemia (high levels of nitrogen compounds in the blood) mx

Answer 7

• IVF +/- blood transfusionIn intrinsic renal failure, if there is pre-existing pre-renal azotaemia, treat with volume expansion

Question 8

Indications for renal replacement therapy (haemodialysis, haemofiltration)

Answer 8

If renal function does not improve

• Uraemia
• Severe metabolic acidosis
• Hyperkalaemia refractory to medical management (>6.5 mM)
• Volume overload unresponsive to diuretics

Question 9

Supportive management in patients with AKI

Answer 9

• Intensive control of their a) fluid balance, b) electrolytes
• Oxygenation
• Nutrition
• Glycaemic control

Question 10

Management of the 6 complications of AKI

Answer 10

Hyperkalaemia** (K+ >6.5mM)
- 10ml 10% IV calcium gluconate/IV calcium
- Calcium resonium
- 10 U actrapid (insulin) + 50ml 50% glucose
or
5U actrapid + 100ml 20% dextrose
- Nebulsied salbutamol

• • In an emergency
• Salbutamol nebulisers
• Insulin and dextrose –> They activate the co-transporters on cells which move potassium back into cells and lowers serum potassium for 30-45 minutes

Other answers are used in the treatment of hyperkalaemia but not during emergencies

Hyperphosphatemia (ectopic calcification, secondary hyperparathyroidism, renal osteodystrophy)

• Dietary restriction
• Adminisration of phosphate binders (calcium acetate, calcium carbonate, sevelamer, lanthanum carbonate)
• DialysisPulmonary oedema (hypoxia, hypercapnia, acidosis, SOB)
• Sit up + High-flow O2
• Diuretics - IV furosemide
• Nitrates
• Opiates - diamoprhine 2.5mg IV + cyclizine 50mg
• Non-invasive positive pressure ventilation
• Renal replacement therapy if a) unresponsive to diuretics, b) absence of a reasonable urinary output

Fluid-overload

• Diuretics (careful not to dehydrate patient + give them a pre-renal AKI)
• Renal replacement therapy if unresponsive to diuretics

Acidosis

• Often improves with management of hyperkalaemia
• Sodium bicarbonate 50-100ml of 8.4% IV sodium bicarbonate

Uraemia (pericarditis, encephalopathy, uraemic frost, twitching, hiccups, lethargy, confusion)
- Dialysis

Question 11

Proteinuria mx

Answer 11

• Control oedema - diuretics, low salt diet
• AT II blockade
• ACEi, ARB
  ACEi contraindicated in renal artery stenosis
• Treat cause - immunosuppresion/steroids may be needed

Question 12

Rhabdomyolysis mx

Answer 12

Fluid resuscitation

Question 13

Immediate urolithiasis management (immediate + general advice)

Answer 13

Immediate

• ABC
• IVF (vomiting - dehydration)
• Multimodal analgesia (paracetamol + PR diclofenac, may need opioids)

General advice

• Increase fluid intake
• avoid red/brown foods - contain oxalic acid that increases stone formation
• Do not cut out dairy products - milk binds to oxalate

Question 14

Definitive urolithiasis management

kidney stones

Answer 14

Stone <5 mm - allow to pass spontaneously
*Infection - abx, nephrostomy to help drain the kidney
*Obstruction - stent
*No infection/obstruction - conservative management, analgesia + medication to relax the ureters and help them pass the stones
Tamsulosin - a-blocker (superior to nifedipine)
Nifedipine - CCB
* Potassium citrate for uric acid stones
Alkalises urine + dissolves stones + inhibits formation of crystals

Stone >5mm - surgery
*Infection - abx, nephrostomy to help drain the kidney
*Obstruction - stent, precutaneous nephrolithotomy
*No infection/obstruction
ESWL (extracorporeal shock wave lithotripsy) - if small (renal stone <2cm, ureteric stone <1cm)
Flexible URS (ureteronoscopy) removal/Uteroscopic lithotripsy - if too large/contraindcations for ESWL, if patient obese or pregnant
Precutanous nephrolithotomy (PCNL) - third line after ESWL, URS used for large stones (>2cm) staghorn calculi, cysteine stones
Stenting (JJ stent)/precutaneous nephrostomy - if obstruction can’t be resolved surgically, to prevent hydronephrosis
Laparoscopic/open surgery - if ESWL, URS, PCNL fail

EMERGENCY - any signs or an obstructed + infected kidney –> urgent nephrostomy to relieve the obstruction

Abx cover given if any invasive procedure is employed

Question 15

Causes + Management of

Calcium oxalate + Calcium phosphate stones

Answer 15

• Hypercalciuria - exclude hyperparathyroidism, low-calcium diet
• Hyperuricosuria - allopurinol (inhibits production of uric acid during breakdown of nucleic acids)
• Hypocitraturia - potassium citrate (alkalises urine and inhibits crystal formation)

Question 16

Causes + Management of Uric acid stones

radiolucent
the only type of kidney stones that dissolves

Answer 16

• Hyperuricaemia
• Gout
• Potassium citrate (alkalizes urine + prevents crystal formation, dissolves stone)
• Allopurinol

Question 17

Causes + Management of Struvite/ MAP (magnsium ammonium phosphate stones)

Answer 17

2y to infections w urease producing bacterium/ammonia producing organism (break down urea into ammonium)

Most common bacteria: Proteus, pseudomonas, Klebsiella
Treatment of underlying infection

Question 18

Causes + management of cysteine stones

Answer 18

-Cystinuria (AR w increased cysteine excretion)

• Increase fluid intake
• Potassium citrate
• Cysteine binding drugs given if all else fails (e.g. tiopronin)

Question 19

5 situations in which patients with urolithiasis will need to be admitted

Answer 19

• Evidence of UTI
  Infection proximal to obstruction is a medical emergency and needs surgical drainage
• Evidence of renal impairment/failure - raised U, Cr, K
• Refractory pain despite analgesia
• Bilateral obstructing stones/single obstructing stone when 1 kidney present
• Elderly/young/unwell

Question 20

Surviving sepsis guidelines

Answer 20

• IVF
• O2
• Analgesia
• Abx
• Blood cultures
• VBG
• Assess renal function
• Watch out for intrarenal/perinephric abscess

Question 21

TURP complications (7)

Answer 21

• TURP syndrome
• Urethral stricture
• UTI
• Incontinence
• Haemorrhage
• Retrograde ejaculation
• Erectile dysfunction

Question 22

UTI during pregnancy

Which abx to use?

Answer 22

Ok to use

• Penicillins + Cephalosporins (e.g. cephalexin)
• Nitrofurantoins

Not ok to use

• Trimethoprim - folic acid antagonist
• Fluoroquinolones + tetracyclines - teratogenic
• Ampicillin - no longer used because of increased resistance

Vancomycin can also be used but it has to be given IV and is suitable for gram +ve cover, whereas most of the UTIs are caused by gram -ve bacteria (E.coli)

Question 23

UTI management

a) Females, uncomplicated
b) Females, complicated
c) Males

Answer 23

a) Nitrofurantoin/Trimethroprim
b) Ciprofloxacin (outpatient)
IV gentamicin
(inpatient - Considered for women with fever, increased WCC, emesis, volume depletion in addition to UTI symptoms )

c) TrimethorpimNitrofurantoin (2y option)
b) complicated means not just urological symptoms –> patient is confused, complaints of generalised loin pain, has a temperature

Question 24

BPH mx

Answer 24

• Emergency – Acute urinary retention – catheterisation
• Conservative – watchful waiting + reduce evening fluid intake

• Medical
o Selective α-blockers (e.g. tamsulosin, alfuzosin) – relax the smooth muscle of the internal urinary sphincter + prostate capsule
o 5α- reductase inhibitors (e.g. finasteride, dutasteride) – inhibit conversion of testosterone to dihydrotestosterone  can reduce prostate size by about 20% (work in larger prostates, >30g/ml/cc (cubic centimeters) or PSA >1.4ng/ml)
o PDE-5 inhibitor (phosphodiesterase-5) (e.g. sildenafil/Viagra) – considered for pt with BPH + erectile dysfunction
o Anti-cholinergic agent (e.g. tolterodine) – helps storage/irritative symptoms

• Surgery
o TURP

o Open prostatectomy

o Alternatives
 Laser surgery – mutilating (cut the whole lobe out) or ablative (vaporise a bit of the prostate to create a channel)
 Rezum/steam – causes prostate tissue to boil + atrophy
 Urolift – staples in prostate to staple it to one side + create a channel
 Embolization – cuts off the blood supply
 Catheter options

Question 25

Management of overactive bladder/incontinence

Answer 25

• Management of overactive bladder (management of storage symptoms caused by overactive detrusor muscle) o Conservative management – reassure, dietary advice (caffeine, citrus fruit can really irritate the bladder), bladder retraining exercises o Medical management – anticholinergics (e.g. tolterodine, oxybutinin, detrusitol, solifenacin), β-agonists (betmiga) o Surgical management – intravesical Botox injection

Question 26

Testicular cancer mx

Answer 26

• Radical R/L orchidectomy • Radical orchidectomy performed via an inguinal incision rather than a scrotal incision o Removing malignant testes through scrotal incision - risk of seeding malignant cells into scrotum during the procedure o Lymph node supply of scrotal skin (inguinal nodes) is different to that of the inguinal cord + the testicle (para-aortic nodes) you don’t want to spread cancer cells from one compartment (where the testicle drains) to the other (where the scrotal skin drains) • Collect sperm prior to procedure – safeguard against reduction in fertility after surgery/radiotherapy * Seminomas highly radiosensitive * Teratomas are not radiosensitive • Post-op – surveillance +/- chemo +/- radio +/- RPLND (retroperitoneal lymph node dissection) • Seminoma o Chemotherapy (carboplatin) post orchiectomy o External beam radiation post-orchidectomy • Teratoma o RPLND post-orchidectomy o Chemotherapy post-orchidectomy • Advanced cancer/metastasis o Combination chemotherapy post-orchidectomy following orchidectomy seminomas with metastases are treated using chemo

Question 27

Testicular torsion mx

Answer 27

• Do not delay surgery (90% of rescuing tests at 6h, 5% at 24h, testicular necrosis >24h) o Emergency scrotal exploration + operative repair within 6h of the onset of symptoms o If there is delay in reaching theatre - attempt manual de-rotation of the testis (outwards rotation) o Bilateral orchidopexy - suturing the testicle to the scrotal tissue to prevent recurrence o If testicle is necrotic - orchidectomy • Supportive care o Analgesia (morphine sulfate) o Anti-emetics (ondansetron)

Question 28

Urinary incontinence mx

Answer 28

o Conservative management – reassure, dietary advice (caffeine, citrus fruit can really irritate the bladder), bladder retraining exercises o Medical management Anticholinergics (e.g. tolterodine, oxybutinin, detrusitol, solifenacin) β-agonists (betmiga) o Surgical management – intravesical Botox injection

Question 29

Epidydimo-orchitis mx

Answer 29

• Bacterial infection o Gonorrhoea/Chlamydia – ceftriaxone + doxycycline o Gonorrhoea/Chlamydia/enteric organisms – ceftriaxone + ofloxacin/levofloxacin o Enteric organisms – ofloxacin/levofloxacin o Mycoplasma genitalium – moxifloxacin o NSAIDs/paracetamol • Idiopathic/viral o NSAIDs/Paracetamol • TB o Treat with systemic abx to local guidelines (highly variable TB strains + abx resistance patterns) • Severe epididymo-orchitis w features of bacteraemia – IVF – Electrolyte imbalance correction – IV broad-spectrum abx (cefuroxime)

Question 30

CKD management

Answer 30

1) Limit progression/complications BP: target <130/80 ( <125/75 is diabetic) Tight glucose control in DM Decrease CVS risk ( stop smoking, lose weight etc) Diet: moderate protein, restrict K+, avoid high phosphate foods Renal osteodystrophy: - Calcichew - Ca supplement - Calcium acetate - phosphate binders - Cinacalcet (calcimimetic) – reduce PTH levels Symptom control - Anaemia: Human EPO might be required - Acidosis: Consider sodium bicarbonate supplements for patients with low serum bicarbonate. - Oedema: loop diuretics, restriction of fluids

Question 31

CKD mx

Answer 31

Education + lifestyle BP control Aim for <140/80 DM w ACR >70 - <130/80 ACEi/ARB if ACR>70, ACR >30 + HTN, ACR >3 + DM Statins Offer to all w CKD Atorvastatin 20mg Immunisations

Question 32

Name 2 potassium sparring diuretics

Answer 32

Spironolactone | Amiloride

Question 33

First line mx for nephrotic syndrome

Answer 33

Fluid restriction Diuretics Consider Prophylactic anticoagulation + discourage bed rest (hypercoaguable state)