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Urology MCQ Revision ‘A game of 20 questions’Overview of the session 20 MCQ Questions Polls Learning Points • Taken from PassMedicine • Will show the question on • Once the correct answer is • Covers the major themes screen, along with a poll to shown, we’ll walk through put your answer why this is the case • As per normal exam conditions, you will have 80 seconds to answer the question • I won’t pick anyone out to answer any questions!1)1)1) Psoas Abscess - Psoas is a flexor muscle of the hip - Would expect to see a fever - Would expect severe pain on hyperextension of the hip - Not the ‘typical’ patient - IVDU Crohn’s Hernias - Has a job heaving lifting Ureteric Calculus - No mention of a palpable lump however - Intermittent ‘loin to groin’ pain - Wouldn’t explain haematuria - Presence of haematuria - Systemically well - History of ?dehydration2)2)2) CT with contrast - Renal stones appear the same density as contrast, so it would make stones ‘invisible’ on the CT scan - Generally avoid giving contrast in those with renal impairment IV Urogram - Same logic as above - It is also only a 2D image Abdominal X-Ray - May see stones, but gives no Ultrasound - 1st line investigation for hydronephrosis information about the kidney/hydronephrosis - Best way to see an obstruction and kidneys - First line treatment is nephrostomy, which is Urine Dip US guided - Same as above (could point to certain pathology, but cannot diagnose by itself)3)3)3) IV Paracetamol - 2nd line and given if NSAIDS are ineffective or contraindicated IV tramadol / oral morphine - This is given if NSAIDS and paracetamol are ineffective IM Diclofenac - For MCQ’s, this is the 1st line option - Contraindicated if there is cardiac history IV Ibuprofen - NICE guidance says this can now be given 1st line as well, but IV is rarely given due to cost4)4)4) Clinical Features Management choice Stone less than 5mm (0.5cm) Conservative management Stone between 0.5cm and 2cm Lithotripsy Stone between 0.5cm and 2cm (pt is pregnant) Ureteroscopy Stones larger than 2cm / Complex stones Percutaneous neprolithotomy5)5)5) Terazosin - This is the same class of drug as tamsulosin (alpha-1-antagonist), so wouldn’t be given 2nd line Desmopressin - It is synthetic ADH - Can be given as third-line treatment for those stills symptomatic with nocturnal polyuria Finasteride Tolterodine - It’s an antimuscarinic - This is the 2nd line management for BPH - Can be used 2nd line for mixed Tamsulosin voiding/storage symptoms - This is the classic 1st line management for BPH6)6)6) Urethral catheters - Traumatic urethral injury is a contraindication for urethral catheter. Others are; - Urethral stricture - Resistance - High riding prostate - Blood at meatus - Unlikely they’d get you to pick a specific urethral catheter! Suprapubic catheter Pain relief and review - Procedure to place the catheter through the skin above the pubis into the bladder - Pain relief could be sensible for the - Avoids the likely damaged urethra, fracture alone, however given the preventing further injury distended bladder, there is a need to catheterise7)7)8)8)8) Staging CT scan - Need to confirm primary cancer first Cystoscopy with prostate biopsy - Too invasive a procedure considering unreliability with PSA Prostatectomy - Need to confirm prostate cancer first! Multiparametric MRI - 1st line investigation for investigating possible prostate cancer TRUS-guided biopsy - Used to be 1st line - 2/3rds of patients with elevated PSA don’t have prostate cancer9)9)9) Renal cell carcinoma Urinary stone disease - Painless haematuria - Could explain haematuria and ballotable - Red flag symptoms mass (?hydronephrosis) - Smoking history - However would expect pain to be present! - Renal angle tenderness with ballotable mass Prostatitis Transitional cell carcinoma of the bladder - Would expect pain, dysuria and a fever - Same as above, however would not explain - Prostate would be tender and boggy examination findings Cystitis - Similar features to prostatitis - Negative urine dip for nitrates10)10)10) Chronic interstitial nephritis - Would be a slow progressive decline in renal function Renal artery stenosis Acute tubular necrosis - Would expect hypertension - History + bloods - No atherosclerotic conditions suggestive of - Not on any antihypertensives rhabdomyolysis - Brown muddy casts in the Glomerulonephritis urine - Some causes of this such as Acute interstitial nephritis goodpasture's can cause rapid AKI - Develops over weeks, typically after starting new - However, would then expect drug haemoptysis - Rash and fever - Eosinophils in blood11)11)11) Stress urinary incontinence - Not related to cough or sneeze Urge urinary incontinence - Does not mention any signs of urge Functional urinary incontinence - No mobility issues Prostatic hyperplasia - From the history, sounds exactly like this Urethral stricture - However, patient is very young to have - Classic voiding symptoms of obstruction within urethra prostate issues - Previous history of gonorrhoea12)12)Testicular Torsion Epididymitis Testicular Torsion Epididymitis Loss of cremasteric Cremasteric reflex reflex remains Elevation of the Elevation of the testes does not testes relieves pain relieve the pain12) Immediate referral for surgery - Elevation relieves pain means testicular torsion is less likely - Plus, he is older than 35 Ultrasound scan - This could be appropriate for testicular torsion Nucleic acid amplification test - This is good for looking for STI’s - Patient is over 35, and has 1 regular partner, Mid-stream urine sample so STI is less likely - Age and single partner make STI unlikely Urethral swab - In his age group, most likely cause is - Aren’t as good as NAAT’s for looking for STI’s then E.Coli - Used mainly for urethritis13)13)13) 7 day course of doxycycline - Not an infective cause Discharge the patient - Manual de-twisting is not definitive - Likely to reoccur again and can impact fertility Keep the patient in for 4 hours - Same as above - If they did have another episode, wouldn’t change management Bilateral prophylactic fixation - High risk of torsion in other testicle Surgical fixation of left testis - Also helps to protect fertility - High risk of torsion in other testicle14)14)14) Pseudomonas aeruginosa - Does not cause epididymitis Staphylococcus aureus - Does not cause epididymitis E. Coli - This is the most likely option if they are over 35 and have reduced risk of STI Chlamydia trachomatis Enterococcus faecalis - Patient is under 35 - This causes epididymitis - Sexually active - Seen in men that have anal sex15)15)15) Malingering - Does not explain haematuria or CT findings Urothelial carcinoma of the ureter - Would expect chronic obstruction with hydronephrosis - Would have been seen on the CT Pyelonephritis - Would expect systemic upset with a fever Spontaneously passed ureteric calculus and non-radiating renal angle pain - Clear history of renal stones - Would have perinephric fat stranding - Most stones pass by themself - This causes inflammation around the Ureteric rupture structures they pass through - Would expect to see a urinoma in the retroperitoneal space16)16)16) Prostate cancer - DRE showed smoothly enlarged prostate Detrusor instability - Would have urge incontinence as seen here - However, is not a cause for a distended bladder or hydronephrotic kidney High-pressure chronic urinary retention Acute urinary retention - It is high-pressure when there is renal - Would be in severe pain impairment and bilateral hydronephrosis - Unlikely to have renal involvement Low-pressure chronic urinary retention - Typically has less than 1L of urine in the - Low pressure is when there is still some bladder patency within the urethra, so does not affect kidneys17)17)18)18)19)19)19) Sperm granuloma - These are small lumps caused by a collection of sperm, typically see after a vasectomy Testicular tumour - Would be a hard mass - Wouldn’t transilluminate Epididymal cyst - Would transilluminate - Would be separate from the testis Hydrocele Varicocele - Soft - Soft - Non-tender - Non-tender - Transilluminates - Typically described as a bag of worms - Cannot ‘get above’ the mass on palpation - Can be associated with testicular cancer - Can be associated with renal cell cancer19) Sperm granuloma - These are small lumps caused by a collection of sperm, typically see after a vasectomy Testicular tumour - Would be a hard mass - Wouldn’t transilluminate Epididymal cyst - Would transilluminate - Would be separate from the testis Hydrocele - Undistinguishable from testis Varicocele - Transilluminates - Would be described as a bag of worms - No pain - Would be distinguishable from testis20)20)Thank you! Any questions → joshua.williams@student.manchester.ac.uk luqman.aizan@student.manchester.ac.uk Please fill out the feedback form! Next session is this thursday on paediatric pyloric stenosis, gastroschisis & exomphalos, appendicitis, undescended testis and more!
