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159 Cards in this Set

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  • Back

Briefly describe motor nerve supply of the bladder. Also name the neurotransmitters which are involved and their effect on normal bladder function.

Parasympathetic:


S2-4 supplies detrusor via pelvic nerves, acetylcholine is the neurotransmitter and it causes contraction of the detrusor



Sympathetic:


T10-L2 supplies detrusor via hypogastric and pelvic plexuses, noradrenaline acts on the beta receptors causing relaxation of detrusor


T10-L2 supplies smooth muscle in bladder neck and proximal sphincter, noradrenaline acts on alpha adrenergic receptors causing contraction of the sphincter



Somatic:


S2-3 supplies distal sphincter via nervi ergentes, it also supplies peri-urethral striated loop via pedundal nerve

Name the types of medication that has an effect on the bladder

1. Anti-cholinergics - Inhibits Detrusor contraction


2. Alpha receptor agonists - Causes bladder neck and proximal sphincter contraction

Briefly describe the sensory nerve supply to the bladder

Run in spinal column through sympathetic and parasympathetic fibres to the cerebral cortex and micturition centre in pons

Name the commonest underlying causes of urinary retention

1. BPH


2. Prostatic carcinoma


3. Urethral stricture


4. Severe haematuria


5. Bladder stone

Name the possible causes which precipitate acute urinary retention in a patient who already ahs some benign prostatic hyperplasia. Also describe briefly the mechanism by which these conditions can precipitate retention

Prostatitis - Swelling of prostate


Drugs - Alpha receptor agonists/anticholinergics


Alcohol - Diuresis = overextended bladder


Constipation - Share same nerve supply as bladder


Cardiac failure - Congestion of pelvic veins


Post-operatively - Anaesthetics, IV fluid

Describe the differences in the clinical picture of a cute and chronic urinary retention.

Acute:


Painful, tender bladder accompanied by urgent need to urinate



Chronic:


No urgency, pain or tenderness felt.

What is overflow incontinence ?

constant dribbling incontinence in the presence of a full bladder



OR



Bladder is full due to retention, therefore any small amount of urine entering the bladder causes overflow leading to excretion of that small amount of urine

Name the obstructive and irritative LUTS.

Obstructive:


W - Waiting to micturate


H - Hesitancy


I - Intermittency


T - Terminal incontinence


E - Emptying incompletely


S - Straining and weak Stream



Irritative:


F - Frequency


U - Urgency


N - Nocturia


D - Dysuria


S - Straining

What are the specific or unique complications of catheterisation in a patient with chronic urinary retention ?

Post-obstructive diuresis, which results in severe dehydration causing hypovolaemic shock and ultimately death

What are the indications for a patient with chronic retention to be catheterized ?

UTI's


Incontinence


Renal failure

What is a suprapubic cystostomy ?

An opening or outlet is made in the bladder using a suprapubic stab catheter or with open surgical insertion

What are the contraindications to insert a suprapubic catheter ?

Small bladder


Empty bladder


Previous lower abdominal surgery


Macroscopic haematuria

What is the most important, absolute requirement which must be met before a suprapubic stab catheter is inserted ?

A palpable percussable full bladder

What are the complications of a suprapubic stab catheter ?

Bowel injury


Bleeding from skin


Haematuria


Recurrence of retention

How often does a transurethral silicone catheter have to be replaced ?

every 3 months

Name three important practical points about the technique for the insertion of a transurethral catheter in a man.

Sterile technique


Adequate lubricant


Make sure catheter is in bladder before inflating the balloon

Name 4 complications of BPH

Chronic retention


Overflow incontinence


Infection


Kidney failure


Hydronephrosis


Haematuria

Name the possible options in the treatment of a patient with BPH and give an example of each.

Medical treatment -


Alpha-adrenergic blockers


5-Alpha-reductase inhibitors



Surgical treatment-


Transurethral resection of the prostate (TURP)


Prostatectomy

Name the indications of surgical treatment for BPH

Chronic or recurrent urinary retention


UTI


Epididymo-orchitis


Overflow incontinence


Bladder calculi


Bladder wall changes


Recurrent haematuria


Failed medical treatment

Name the possible complications of trans-urehtral resection of the prostate (TURS)

TUR-syndrome


Blood loss


Septicaemia


Epididymo-orchitis


Retention


Incontinence


Urethral stricture


Retrograde ejaculation


Impotence

Name 2 factors that are important in the development of BPH

Age


Androgens

Name the enzyme which is therapeutically blocked during treatment of BPH

5-alpha-reductase

Briefly describe what TURP is

Tranurethral resection of the prostate - With a resectoscope and electrodiatherapy, the peri-urethiral part of the prostate is cut away in small pieces, chips are washed into the bladder by irrigation fluid, then out of the bladder with an Elik evacuator

From which part of the prostate does BPH rise

The transitional zone

Name the different causes of urethral strictures in men

Infection


Iatrogenic


Trauma


Congenital


Malignancies

Name the complications of urethral strictures in males

bladder wall changes


Fistula formation


Peri-urethral abscess formation


Bladder stones


Urinary retention


Infection


Hydro-ureteronephrosis


Infertility


Haematuria


Squamous cell carcinoma of the bladder

Name the infective complications that can arise in men with a urethral stricture

Cystitis


Prostatitis


Epididymitis


Epididymorchitis


Necrotizing Fascitis

How can the diagnosis of a urehtral stricture be confirmed ?

Catheterisation


Antegrade urethrogram


retrograde urethrogram


Urethroscopy

What are the options of urethral stricture treatment ?

They are surgical:


Urethroplasty


Internal urethrotomy (Sachse's Procedure)


Dilatation

Name the possible complications of dilatation or optical internal urethrotomy (Sachse's procedure)

Urethral bleeding


False passage


Septicaemia


recurrence of stricture


Rectal perforation

Name 5 types of incontinence

1. Stress urinary incontinence


2. Urge incontinence


3. Overflow incontinence


4. Paradoxical incontinence


5. Total urinary incontinence

Define primary nocturnal enuresis

No daytime symptoms of bed-wetting and has never had a dry period for longer than 6 months

Which child with enuresis does not need any special investigations ?

A child with primary nocturnal enuresis with normal special investigations and a normal examination

How can a child with monosymptomatic, primary enuresis be treated ?

General measures (such as education)


Enuresis alarm (most effective)


Pharmacotherapy-


Imipramine


Desmopressing


Anti-cholinergics

Name the possible causes of enuresis in children or adults

Developmental delay


Inadequate ADH release


Reduced bladder capacity


Psychological problems


Sleep disorders

What is the so called overactive bladder ?

This is where normal nocturnal surge of ADH secretion does not occur leading to increased urine production at night

Name common conditions that may cause a neurogenic bladder

Cardiovascular Acident


Brain tumour


Concussion


Dementia


Spinal cord injury


Diabetes Mellitus


Hepres infection

Which imaging investigations should be performed after an acute UTI in children ?

Ultrasond


IVP

Name the clinical signs and symtpoms of acute pyelonephritis

Fever


Rigors


Pain


Vomiting


Tachycardia

Name the 2 route of infection which can lead to pyelonephritis and name the most common causative organism

Haematogenous - Staphylococcus aureus


Ascending - E. coli

Which organism causing UTI's may be associated with alkaline urine and formation of bladder or renal calculi ?

Proteus

Which urinary tract factors will predispose a patient to urinary tract infections ?

Obstrucion of upper tracts


Dilated blood vessels


Bladder outflow obstruction


Foreign bodies


Instrumentation


Trauma to urinary tract

Name 4 clinical observations that can help you to differentiate between a upper and lower UTI

A lower UTI would present in the following manner:


Not systemically unwell


Low grade fever


Haematuira


Irritative LUTS

What is the typical finding on examination of the urine in a patient with tuberculosis of the urinary tract ?

Acid and sterile pyuria

Name the possible causes of a sterile pyuria

TB


UTI which has already been treated with AB


Stones in urinary tract


Papillary necrosis


Bladder cancer

Name the features of urinary tract TB on an IVP.

Papillary necrosis


Cavities in renal medulla


Moth eaten calyces


Infundibular stenosis


Blunting of calyces


Distended calyces


Ureter strictures

Briefly describe the life cycle of the bilharzia parasite which involves the urinary tract in the humans

Worm -


Ova -


Meracidia -


Sporocysts -


Cercariae

What is the treatment for active Bilharzia of the urinary tract ?

Praziquantel

Name the complications of bilharzia with regards to the urogenital system

Squamous cell carcinoma of the bladder


Ureteric strictures


Vesico-ureteric reflux


Fibrosis and calcification of bladder and genital tract

List 2 hormones that are secreted by the foetal testes

Testosterone


MIF

When does the testis normally descend into the scrotum

28-32 weeks gestation

What does the term cryptorchidism mean ?

Undescended testes

What is the difference between undescended, absent, ectopic and retractile testes ?

Undescended - Stuck somewhere in path of normal decent


Absent - There are no testes


Ectopic - Testes are in a place that is not in the normal path of decent


Retractile - Testes are pulled up out of the scrotum do to overactive cremasteric muscle

What are the complications of undescended testes ?

Infertility


Malignancy


Inguinal hernia


Psychological problems

What are the treatment options in undescended testes ?

Orchidopexy


Hormonal treatment

What is the difference between hypospadias and epispadia ?

Hypo - Opening of meatus of urethra is on the ventral side of penis


Epi - Opening of meatus of urethra is on the dorsal side of the penis

List the characteristics of hypospadias

Chordee of the penis


Dorsal hood of skin


Ventral opening of urehtral meatus

What is chordee

Ventral curvature of penile shaft

Why should circumcision not be performed on a patient with hypospadias ?

The dorsal hood is necessary for surgical repair thereof

What is the defining characteristic of true hermaphroditism ?

Baby has both testicular and ovarian tissue

What is the underlying abnormality or cause of female pseudohermaphroditism ? Why may babies with this condition die shortly after birth ?

Due to Congenital Adrenal Hyperplasia, death due to deficiency of cortisol

What are the possible causes of male pseudohermaphroditism ?

Decrease in testosterone synthesis


Deceased androgen receptor sensitivity


Deficiency of 5-alpha-reductase enzyme

Define phimosis

Inability of the foreskin to retract over the glans of the penis

List the causes of phimosis

Recurrent balantitis


Recurrent dermatitis


Repeated forcible retraction of baby's foreskin


Foreskin is too tight to be pulled back over the glans

List the indications of circumcision

True phimosis


Paraphimosis


Recurrent balantitis


Genital warts affecting the foreskin


Carcinoma of the foreskin


Religous reasons


Cultural reasons

Define paraphimosis

Tight foreskin is retracted behind the glans and then cannot be reduced


Define balanitis

Infection or inflammation of the glans of the penis

Define Balano-posthitis

Infection of the glans and the foreskin of the penis


Define circumcision

Surgical removal of the foreskin

What are the advantages of circumcision ?

Lower incidence of UTI's


Lower incidence of malignancy


Lower incidence of STD transmission


Easier hygiene

What are the complications of circumcision ?

Injury to the glans


Removal of too much skin


Injury to the urethra


Bleeding


Decreased sensation of the glans


Infection

Name the most common causes of painless scrotal swelling

Hudrovoele


Spermatocoele


Varicocoele


Inguinal hernia


Testicular tumour


Chronic epididymitis

What is the underlying abnormality in a congenital hydrocoele ?

A patent processus vaginalis

Tabulate the differences in a hydrocoele and an inguinal hernia

Hydrocoele:


Cannot be reduced


No cough impulse


Dull to percussion


No bowel sounds over it


Swelling stops at superficial inguinal ring



Hernia:


Can be reduced


Cough impulse


Resonant on percussion


Bowel sounds heard


Swelling extends through inguinal canal

Name the possible reasons why a hydrocoele is sometimes not transilluminable

1. Turbid fluid


2. Thickened wall


3. Scrotal skin too pigmented


4. Loculated


5. Light source not bright enough


6. Room not dark enough

Name the options in the management of an idiopathic hydrocele

Reassurance


Sclerotherapy and aspiration


Hydrocoelectomy

What are the possible complications of hydrocoele treatment ?

Pain


Bleeding


Infection


Recurrence

Which organism causes a chronic epididymitis with a draining scrotal sinus ?

Mycobacterium tuberculosis

What is a varicocele ?

Varices of the pampiniform plexus

What are the causes of a varicocele ?

Absence of valves in the testicular veins


The angle with which the left vein joins the renal vein predisposes formation thereof


The nutcracker effect caused by the aorta and the superior mesenteric artery predisposes formation thereof

Name the commonest cause of acute pain and swelling of the scrotum

Epididymitis/epididymo-orchitis


Torsion


Inguinal hernia


Trauma


Necrotizing fascitis

Describe the typical clinical picture of torsion of the testis

Acute onset


Severe pain from time of onset


Onset with activity/trauma


Swelling begins hour or more after pain


Abdominal pain


Nausea and vomiting


Testis situated high in scrotum


Elevation of testis worsens pain


Thick short spermatic cord


Anteriorly situated epididymis


Testis lies horizontally

Describe the typical clinical picture of epididymo orchitis

Gradual onset


Pain gradually worsens


No relationship with activity/trauma


Swelling begins before or together with pain


No abdominal pain


No nausea and vomiting


Testis in normal position


Elevation of scrotum relieves pain


Normal spermatic cord


Posteriorly situated epididymis


Testis lies longitudinally

What is the optimal option for the management of testicular torsion ?

Manual detorsion, followed by orchidopexy of both testes

What are the most common cause of epididymo-orchitis in men (i) under 35 and (ii) over 35

(i) - Neisseria gonorrhoeae; Chlamydia trachomatis



(ii) - Gram negative coliforms

Which organism is most commonly the cause of acute orchitis ?

Mumps virus

Which organisms usually cause necrotizing fascitis ?

Gram negative aerobes and anaerobes and streptococci

Describe the typical clinical picture of necrotizing fascitis

Pain and swelling of scrotum


Oedema


Crepitus


Gangrene


Fever and systemic toxicity


What is the best screening investigation for imaging of the urinary tract in a trauma patient with macroscopic haematuria ?

IVP

What are the contra-indications of performing a IVP ?

Haemorrhagic shock


Pregnancy


Allergy


Renal failure

List the complications of renal injuries

haemorrhagic shock


Ileus


Secondary bleeding


Necrosis


Perinephric urinoma


Hypertension

What are the common causes of secondary haemorrhage in renal injuries ?

A-V fistula formation


Pseudoaneurysm

What is the possible mechanism by which renal injury can cause hypertension ?

Secretion of renin due to ischaemic part of kidney

Name 3 common causes of macroscopic haematuria with blunt trauma over the lower abdomen

Interstitial rupture


Intraperitoneal rupture


Extraperitoneal rupture

Name 4 possible complications of injury of the posterior urethra after a pelvic fracture

Urethral stricture


Impotence


Incontinence


Para-urethral abscesses


Necrotizing fascitis


Fistula formation

What is the best imaging investigation to demonstrate bladder rupture ?

Abdominal x-ray with high pressure cystogram

How is a high pressure cystogram done ?

Infusion of approximately 300 ml water soluble x-ray contrast agent at a pressure of about 50-100cm water, until inflow of contrast stops spontaneously

Which investigation is used to demonstrate a urethral injury, and how is this done ?

A retrograde urethrogram, contrast is infused through the meatus, and an x-ray is performed in order to detect and limit extravasation of contrast

Name the clinical signs of a urethral injury in a male with a pelvic fracture

Passing of blood at the external meatus


Acute urinary retention


Genital swelling


High-riding prostate

What is the difference between a retrograde and a prograde urethrogram ?

Retrograde - Contrast injected through the external meatus of urethra


Prograde - Contrast injected into bladder

What are the complications of a urethral injury in males ?

Urethral stricture formation


Impotence


Peri-urethral abscess formation


Fistula formation


Necrotizing fasciitis


Cystitis


Epididymo-orchitis

Name 4 organisms that commonly cause urethritis in males

Neisseria gonorhoea


Chlamydia trachomatis


Ureaplasma urealyticum

What antibiotics would you use in the treatment of a 20 year old male with a urethral discharge

Ofloxacin


Doxycycline

What organism is the commonest cause of acute epididymitis in a heterosexual man younger than 35 years ?

Chlamydia trachomatis

Name the infective conditions which cause ulcerative lesions of the penis, and name the organism involved in each

Syphilis - Treponema pallidum


Chancroid - Haemophilus ducreyi


Lymphogranuloma venereum - Chlamydia trachomatis


Granuloma inguinale - Calymmatobacterium granulomatis


Hepres simplex - HSV T 2


Condylomata acuminata - HPV

List the differences in the primary lesions and lymph nodes in (i) syphilis and (ii) chancroid

(i) Chancre is painless, deeply puncehd out, clear base, not purulent with bilaterally enlarged rubbery non-tender lymph nodes



(ii) Chancroid is painful, with purulent and bleeding ulcer with a unilaterally enlarged lymph node that is soft and very tender

Name the different types of prostitis

Bacterial


Non-bacterial


Prostatodynia

List 5 conidtions which can be confused with the clinical pciture of prostitits

BPH


Urethral stricture


Cystitis


Bladder stone


Prostate cancer


Bladder cancer

Name 5 serious conditions that should be excluded in a woman with a long history of urinary symptoms and sever pelvic pain before interstitial cystitis is amde

Bacterial cystitis


Endometriosis


Bladder cancer


Bladder stone


Pelvic infection

Name the classical presenting symptoms and signs in a patient with renal cell carcinoma

Haematuria


Palpable kidney mass


Loin pain

What is the curative treatment for localized RCC ?

radical nephrectomy

Name 3 contraindications for doing an IVP

Renal failure


Allergy


Pregnancy

Name the 2 most common types of genetic cysric renal conditions and the way of inheritance of each`

Adults: Autosomal dominant polycystic kidney disease



Infantile: Autosomal recessive polycystic kidney disease

What are the causes of a filling defect on IVP ?

Renal TB


Carcinoma


Renal stones


Ureteric stones


Pelvi-ureteric junction obstruction

Name 5 paraneoplastic syndromes which can be associated with renal cell carcinoma

Hypertension


Aneamia


Polycythaemia


Weight loss


Fever

List 3 associated abnormalities of adult polycystic kidney disease

Diverticuli of the colon


Mitral valve prolapse


Berry aneurysm

What are the sonographic differences between a simple renal cyst and a solid renal mass ?

Simple Renal Cyst-


Uniform round border


No internal echoes


Clear signal enhancement of distal wall



Solid Renal mass-


Irregular, poorly circumscribed border


Internal echoes


No signal enhancement of distal wall

What is the differential diagnosis of a palpable kidney mass in children?

Autosomal recessive polycystic kidney disease


Multicystic dysplastic kidney disease


Hydronephrosis


Lymphoma


Neuroblastoma


Nephroblastoma

How can renal cell carcinoma present clinically ?

Haematuria


Palpable kidney mass


Loin pain



Metastatic symptoms:


Dyspnea


Bone pain


Fractures


Neurological symtpoms


Varicocele


Oedema



Paraneoplastic symptoms:


Anaemia


Fever


Weight loss


Polycythaemia


Hypertension

In which age group does Nephroblastoma (Wilm's tumour) usually occur ?

ages 2-3

How is Wilms tumour treated ?

Surgical nephrectomy, radiotherapy and chemotherapy

What is an angiomyolipoma of the kidney ?

A benign hamartoma that consist of muscle, fat and blood vessels

Name the ways in which autosomal recessive polycystic kidney disease can present clinically

Oligohydramnios


Palpable kidney mass


Renal failure


Respiratory distress (due to oligohydramnios)

Name the types of cysts or cystic kidney diseases which may occur in the kidneys

Simple renal cyst


Hydatid disease


Autosomal dominant polycystic kidney disease


Autosomal recessive polycystic kidney disease


Multicystic dysplastic kidney

What drug can be used to treat an echinococcus cyst of the kidney ?

Albendazole

In what part of the prostate does prostate cancer usually start

The peripheral zone

Which conditions can elevate serum PSA ?

BPH


Prostate cancer


Prostatic biopsy


Prostatic infarction

What are the possible complications of a transrectal prostatic biopsy ?

Bacteraemia


Speticaemia


Prostatitis


Haematuria


Rectal bleeding


Cystitis

Discuss the methods of (hormonal) treatment of metastatic prostate cancer

Bilateral orchidectomy


Estrogen therapy


Anri-androgens


LHRH Agonists

Name the most common symtpom of metastatic prostate carcinoma

LUTS (Both obstructive and irritative)

How is a prostate biopsy usually performed

transrectally

What are the complications of a transrectal biopsy of the prostate ?

Bleeding


Bacteraemia


Prostatitis


Septicaemia


Cystitis


Haematuria

In what age group does prostate cancer usually apear

>45-50 years

What is the most common histological type of bladder cancer ?

Transitional cell carcinoma

What is the classic presenting sign of bladder cancer ?

Painless macroscopic haematuria

Name 3 histologically different types of bladder cancer

Transitional cell carcinoma


Squamous cell carcinoma


Adenocarcinoma

What is usually the treatment for superficial transitional cell carcinoma of the bladder ?

Trans Urethral Resection of Bladder Tumour (TURBT)

List 5 causes of a filling defect in the bladder on an IVP

Bladder cancer


Bladder stone


Catheter


Fungal ball


Bowel gas


BPH

What type of urinary diversion is usually done on a patient with a radical cystectomy ?

Bricker's diversion

Name the aetiological factors of squamous cell carcinoma of the bladder

Bilharzia


Bladder stones


Recurrent cystitis


Longterm indwelling catheter

What operation is done to cure TCC of the upper urinary tract ?

Nephro-ureterectomy

What are the possible causes of a filling defect in the renal pelvis on a IVP ?

TCC


Uriac acid stone


Blood clot


Air bubble


Fungus ball


Necrotising papilla


Cystic ureteritis

What type of kidney stone will usually be visible on an X-ray ?

Calcium containing stones

What is the usual finding on examination of the urine in a patient with a stone in the ureter ?

Microscopic haematuria

Which kidney stone is not visible on X-ray film, and what is the medical treatment thereof ?

Uric acid stone, it is treated medically with Citro Soda

Which organisms play a common role in the formation of infection stones ?

Klebsielle and proteus

How does Klebsiella and proteus organisms cause the formation of infection stones ?

They produce the enzyme urease, which breaks up urea in the urine causing the urine to become more alkaline. Therefore calcium and phosphate precipitates more easily, leading to stone formation

What is the typical appearance of an infection stone ?

Staghorn appearance

What are the treatment options for a ureteric stone than will not pass spontaneously ?

ESWL (lithotripsy)


Urethroscopic urethrolithotripsy


Dormia extraction


Urethrolitotomy

What is the treatment option for a large infection stone in a well functioning kidney ?

Percutaneous nephrolithotomy

Name the 4 chemical elements usually found in struvite stones

Phosphate


Calcium


Magnesium


Ammonium

Name the 4 common types of urinary tract stones

1. Caclium oxalate


2. Struvite


3. Uric acid


4. Cystine

Which enzyme can be inhibited to decrease the formation of uric acid stones ?

Xanthine oxidase inhibitors

List the biochemical risk factors for the formation of urinary tract calculi

Stasis


Concentration


Ph


Nidus


List the indications for referral with regards to urinary tract stones

Renal failure


Worsening pain


Not resolving


Bilateral stones


Multiple stones


Very large stone

Name the causes of bladder stone formation

Anything that will cause bladder outflow obstruction:



BPH


Urehtral stricute


Posterior urethral valve


Porostate cancer


Hameaturia


Foreign object in the bladder

Name the factors that promote calcium stone formation in the urinary tract

Hypercalciuria


Hyperoxaluria


Hyperuricosuria


Hypomagnesuria


Hypocytraturia

Name the 2 inhibitors of calcium stone formation

Citrate


Magnesium

Which drug is an inhibitor of xanthine oxidase

Allopurinol