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60 Cards in this Set

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Prostate cancer RF
urban blacks
FHx 1° → 2x risk
1° & 2° → 9x risk
high dietary fat → 2x risk
cigarettes
Prostate ca pathology
>95% adeno ca
often multifocal
transitional cell ca 4.5%
- assoc/w TCC of bladder
- not hormone responsive
endometrial ca - rare
- ca of utricle
Prostate ca location
peripheral zone - 60-70%
transition zone - 10-20%
central zone - 5-10%
Prostate ca clinical features
usually asymp
most commonly detected by DRE, ↑PSA, or incidental with TURP
locally advanced dz - obst/irritative symp (uncommon w/o spread)
suspect with prostatism +/- back pain
Prostate ca Mets
bony to axial skeleton (osteoblastic)
visceral less common - liver, lung, adrenal
local invasion
LN obturator>iliac>presacral/para-aortic
hematogenous early
Prostate ca investigations
DRE
PSA
TRUS → local staging, size
TRUS guided bx
can omit bone scan if PSA <10
lymphanigiogram + CT for mets
DDx of prostate nodule
prostate ca (30%)
BPH
prostatitis
prostatic infarct
prostatic calculus
TB prostatitis
Prostate ca grading
Gleason score = aggregate score of 2 most prominent histo patterns
1-4 well diff
5-6 mod diff
8-10 poorly diff
Rx of prostate ca - T1
T1 = small well diff associated w slow growth rate
Young - consider radical prostatectomy, brachytherapy/ XRT
Elderly - f/u (cancer death rate ≤10%
Rx of prostate ca - T2
radical prostatectomy or XRT (70-85% 10yr S) or brachytherapy
Rx of prostate ca - T3, 4
staging lymphadenectomy and XRT or hormonal Rx
Rx of prostate ca - N>0 or M>0
hormone therapy or palliative XRT to mets
Options:
b/l orchiectomy - removes 90% testosterone
LHRH agonists - leuprolide, goserelin
DES
antiandrogens
- steroidal and non-steroidal
- inhibitors of steroidogenesis
chemo
- docetaxel (may ↑survival in advanced prostate ca no longer responsive to H therapy)
LHRH agonists
leuprolide, goserelin
- initially stim LH → ctestosterone & cause "flare"
→→ ↓testosterone
S/E "hot flashes"
Estrogens in prostate ca
DES
- inhibits LH
- cytotoxic effects on tumor cells
↑risk CVS S/E
antiandrogens in prostate ca
Steroidal - cyproterone acetate
Non-steroidal - flutamide
- both compete w DHT for cytosolic receptors
- testosterone ↔/↑
Inhibitors of steroidogenesis
Ketoconazole, spironolactone
- block multiple enzymes in pathway including adrenal androgens
- ↑androgen blockade by combining antiandrogen w LHRH agonist or orchiectomy
PSA may be ↑ with
prostate ca
BPH
prostatitis
prostate ischemia/infarct
acute urinary retention
prostate bx/Sx
prostatic massage
urethral catheterization
TRUS
strenuous exercise
ejaculation
ARF
CABG
XRT
after DRE
free-to-total PSA
complexed PSA ↑s in prostate ca → ↓%age free PSA
<10% free suggestive of ca
>20% free suggest benign cause
Testicular tumors
most common solid malignancy in males 15-34y/o
95% germ cell (all malignant)
Seminoma 35%
NSGCT
embryonal cell ca 20%
teratoma 5%
mixed cell type 40%
choriocarcinoma <1%
yolk sace <<1%
Nongerm cell tumors (~benign)
5%
Leydig
Sertoli
Seminomas
classic
anaplastic
spermatocytic
NonSeminomatous germ cell tumors
embryonal cell ca (20%)
teratoma 5%
choriocarcinoma <1%
yolk sac <<1%
mixed cell 40%
Non-germ cell tumors (testicular ca)
usually benign
Leydig
- testosterone
- precocious puberty
Sertoli
- gynecomastia
- ↓libido
Clinical features of testicular tumors
painless testicular enlargement (painful if hemorrhage/infarction)
firm, nontender mass
dull heavy ache in ↓er abd, anal area, scrotum
associated hydrocele 10%
supraclavicular & inguinal LN
Investigations of testicular ca
Dx established by radical orchiectomy
tumor markers
βhCG & AFP +ve in 85% NSGCT
βhCG +ve in 7% seminomas
AFP NEVER ↑ in seminomas
testicular U/S
testicular U/S findings suggestive of Ca
hypoechoic area within tunica albuginea
Causes of acute and reversible urinary incontinence
"DRRIIPP"
Delerium
Restricted mobility/Retention
Inflammation/Infection
Pharmaceuticals/Polyuria
Urinary Incontinence ♂ Etiologies
Bladder
- detrusor overactivity
- ↓compliance of bladder wall
Spincter/urethra
- urethral hypermobility
- intrinsic sphincter dysfunction (most common - 2° to Sx disruption of outlet)
Classification of urinary incontinence
Stress
- urine loss with sudden ↑ intra-abd pressure (uretral hypermobility/intrinsic sphincter dysfunction/both)
Urge
- urine loss precede by strong, sudden urge to void
- assoc/w inflam/neuro disorder
Overflow
- urine loss when intravesical pressure > urethral pressure
- obstructive
- hypotonic bladder
Total
- constant loss of urine s warning
Functional
- urine loss caused by inability to reach toilet in time
Rx of stress incontinence
Kegel's
topical estrogen cream
injectable agents to prox urethra
- Sx - reinforce bladder neck/urethra with cystourethropexy or slings to prevent urethral descent or kink hypermobile urethra
Rx of urge incontinence
antispasmodics
- oxybutynin
anticholinergics
- propanthaline
- tolterodine
TCAs
- imipramine
Botox injection
Rx of retention associated urinary incontinence
catheterization to prevent bladder/kidney damage
Rx underlying cause
Urinary retetion causes:
Outflow obstruction
Loss of bladder innervation
pharmacologic
Urinary retention d/t outflow obstruction
Prostate
- BPH
- prostate ca
- prostatitis
Urethra
- stricture
- traumatic disruption
Bladder neck/urethra
- calculus
- FB
- clot
Urinary retention d/t meds
anticholinergics
narcotics
anti-HTN
- ganglionic blockers
- methyldopa
OTC cold meds with ephedrine/pseudoephedrine
Antihistamines
Clinical features of urinary retention
palpable/percussable bladder
+/- purulent/bloody meatal d/c
DRE - prostate size, anal tone
Neuro - DTRs, "anal wink", normal sensation
BPH definition
hyperpasia of stroma & epithelium in periurethral area of prostate (transition zone)
also ↑tone of smooth muscle
25% require Rx
Clinical features of BPH
result from outlet obstruction & compensatory changes in detrusor function
obstructive - d/t outflow obstruction & impaire detrusor contractility
Irritative - d/t detrusor instability, ↓compliance
prostate - smooth, rubbery, symmetrically enlarged on DRE
Complications of BPH
retention
incontinence
hydronephrosis
renal compromise
infection
gross hematuria
Investigations for BPH
hx
DRE
U/A to r/o UTI
PSA to r/o malignancy (if life expectancy >10yrs)
+/- uroflowmetry
+/- bladder U/S for residual volume
cystoscopy for potential Sx mngt
Rx for BPH
Mild
watchful waiting - 50% improve spontaneously
lifestyle changes - pm fluid restriction, activity planning
Meds
α-blockers ↓sm.m tone (terazosin, doxazosin, tamsulosin, alfuzosin)
5α-reductase inhbitors - blocks testosterone → DHT conversion (acts on epithelial component of prostate) - finesteride
TURP
Renal Colic DDx
acute urethral obstruction by other causes
- UPJ obstruction
- sloughed papillae
- clot colic from gross hematuria
Acute abd crisis
- biliary, bowel, pancreas, AAA
Gyne
- ectopic
- torsion/rupture of ovarian cyst
pyelo
L1 radiculitis
Location of renal calculi
calyx
+/- flank discomfort, recurrent infection, persistent hematuria
pelvis
- tend to obstruct at UPJ
- staghorn calculi = renal pelvis + ≥1 calyx
- often assoc/w infection that doesn't resolve until stone clears
Ureter
<5mm pass spontaneously in 75%
Renal calculi pathogenesis
supersaturation of stone constituents
stasis, ↓flow/V urine
crystal formation & stone nidus
Loss of Inhibitory factors
citrate - forms soluble complex w Ca
Mg - forms soluble complex w oxalate
Pyrophosphate
Tamm-Horsfall glycoprotein
4 narrowest passage points for upper GUT stone
1. UPJ
2. pelvic brim
3. under vas deferens/broad lig
4. UVJ
Renal caliculi - Ca stones etiology
75-85% all stones
Ca oxalate > Ca phosphate/mixed
Hypercalciuria
Hyperuricosuria (25%)
Hyperoxaluria (<5%)
Hypocitraturia (12%)
Other
hypomagnesemia (assoc/w hyperoxaluria, hypocitraturia)
high diet Na - ↑Ca excretion, ↓urinary citrate
↓urinary proteins - Tamm-Horsfall glycoprotein, uropontin
Hypercalciuria etiology
↑intestinal absorption
- ↑ingestion (Ca, VitD)
- renal PO₄leak → ↓PO₄→ ↑1,25(OH)₂VitD
- idiopathic
Resorption Ca from bone
- HyperPTH
- immobilization
- malignancy
- steroids
Other
- sarcoidosis
- distal RTA
Hyperuricosuria and renal caliculi
25% of pts with Ca stones
- uric acid crystals can act as nidus for Ca stone formation, independent of uric acid stone formation
- acid urine (pH<5.8)
- dehydration
Hyperoxaluria
<5% pts with Ca stones
↑intestinal absorption (most common)
Has large effect on stone formation with small ∆ urinary []
- pts with SI resection, IBD, malabsorption
- ↑intestinal fat binds dietary Ca → unavailable to bind oxalate → ↑oxalate absorption in LI + ↑urinary excretion
Endogenous overproduction
- end production of AbN metabolism of glycine, ascorbic acid, hydroxyproline & serine
↑ingested oxalate (tea, coffee, beer, leafy veggies, chocolate, ethylene glycol)
Hypocitraturia
citrate usuall complexs w Ca → inhibits stone formation
↓ d/t
systemic acidosis (includes distal RTA)
hypokalemia - thiazides, chronic diarrhea
high animal protein diet
Struvite stones
5-10% renal stones
Mg ammonium phosphate (MAP)
alkaline urine pH d/t infection w urea-splitting organisms precipitates MAP
- proteus, psudomonas, klebsiella, mycoplasma, serratia, S. aureus (NOT E. coli)
perpetuate UTI b/c stone itself harbours organism - must remove stone to cure infection
- assoc/w staghorn calculi
Uric acid stones
5-10%
Not seen on plain Xray
precipitate in ↓V, acidic urine with ↑uric acid []
Hyperuricosuria alone
- ↓urine pH, ↓V (eg GI H2O loss)
- ASA, thiazides
- purine rich diet (red meats)
Hyperuricosuria w hyperuricemia
Gout
high cell turnover/death
Cystine stones
AR defect in SI mucosal absorption and renal tubular absorption of dibasic a.a.'s
→ "COLA" in urine (cystine, ornithine, lysine, arginine)
Aggressive stone dz in children/young adults (recurrent stones, FHx)
aggregation in acidic urine
Dx
- +ve urine Na nitroprusside test
- urine chromatography for cystine
Indinavir stones
only stones radiolucent on spiral CT AND plain film
Investigations of renal calculi
CBC, SMA7, U/A, urine C&S
Imaging
KUB - DDx opaque vs non (90% opaque)
Spiral CT - no contrast
DDx - radiolucent stone from soft tissue defect
uric acid stones visible
Abd U/S
+/- shows stones (difficult in ureter)
+/- shows hydronephrosis
cystoscopy
- for suspected bladder stone
Metabolic studies for recurrences
Ca, PO4, urate,
PTH if hypercalcemic
24h urine x2 for Cr, Ca, PO4, uric acid, Mg, oxalate, citrate
Indications for admission for renal caliculi
intractable pain
fever
single kidney w ureteral obstruction
b/l obstructing stones
compromised renal fxn
Rx of renal caliculi
analgesics +/- antiemetics
NSAIDs - ↓intra-ureteral P
+/- Abx for UTI
IV fluids if vomiting
Conservative if <5mm
Specific Rx of Calcium oxalate stones
thiazides
+/- K+ citrate
+/- allopurinol, Ca
Specific Rx of uric acid stones
alkalinize urine - HCO3, K+citrate
+/- allopurinol
Specific Rx of struvite stones
Abx
remove stone
Specific Rx of cystine stones
alkalinize urine
penicillamine/α-MPG
captopril
Indications for ESWL and percutaneous nephrolithotomy
ESWL
stone <2.5cm (unless cystine)
nephrolithotomy
stone >2.5cm
staghorn
UPJ obstruction
calyceal diverticulum
cystine stones