Bladder Cancer / BPH Flashcards
What types of haematuria are there? What are they likely to be caused by?
- Frank/ visible haematuria
- ONNIT:
- Obstruction (calculi, BPH, PKD)
- Neoplasm (TCC/RCC/prostate)
- Nephritic syndrome (GN)
- Inflammation (UTI, TB)
- Trauma (recent procedure/ cateterisation)
- ONNIT:
- Microscopic/non-visible haematuria
- Renal stones (calculi)
- Menstruation
- UTI / pylonephritis
- Trauma (recent intercourse, procedure)
- Cancer
- Haemoglobinuria
- Haemolysis:
- malaria
- sickle cell
- severe burns
- AIHA
- HUS
- Haemolysis:
- Myoglobinuria
- Rhabdomyelisis
What investigations are important to do in cases of haematuria?
- Assess the urine:
- MSU
- Urine microscopy (type of haematuria)
- Urine culture (infective)
- Assess the blood:
- FBC (anaemic? WCC? platelets)
-
U&Es (renal function)
- albumin:creatinine (ACR) or protein:creatinine ratio (PCR)
- blood pressure
- Coagulation screen (underlying coagulopathy)
- CRP
- PSA (prostate Ca, before referal to be discussed in clinic)
- Refer to haematuria clinic for:
- Flexible cystoscopy
- CT urogram (KUB)
What are the 3 most important investigations for haematuria in general practice?
- MSU (to rule out urinary tract infection - UTI)
- Urea and Electrolytes (to investigate for renal disease)
- Full blood count (anaemia, WCC, platelets)
What do nitrites specifically indicate on urine dip?
What should you do next?
Gram-negative UTI
Urine culture
What do WBCs indicate on urine dip?
UTI
On urine dip, what are the differentials for pH:
- Acidic
- Alkaline
What investigations would you do next?
- Acidic:
- Systemic: metabolic/resp acidosis, diarrhoea, starvation
- Diet: acidic diet e.g. high protein / cranberry
- Alkaline:
- Systemic: alkalosis
- Vegeterain / low carb diet
- local: UTI, renal tubular acidosis
Urine culture
VBG
What questions are important in a urinary history?
Before you pee:
- Incontinence
- Frequency
- Urgency
- Peeing at night
- Hesitancy (long wait before anything comes out)
During peeing:
- Weak / stop and start flow
- Straining to pee
- Pain / dysuria
The pee itself:
- Colour
- Blood?
- if so when in urination? (early - urethral damage, late - prostate / bladder base, total - bladder / kidneys)
- any clots? (ribbon clots - uteric cause e.g. stones, uteric Ca)
- Blood?
- Smell
- Sweet (ketones, DM)
- Bad (UTI)
- Appearance
After peeing:
- Dribbling
- Feeling of incomplete emptying
Red flags:
- Back pain
- Loin to groin
- Weight Loss
- ↓Appetite
- Fever / sweats / rigors
- Tiredness
Other:
- Recent procedures / catheters?
- SH - work with dyes?
- DH - anticoagulants / TB treatment
What medications can alter the colour of your urine?
- Rifampicin → red
- levadopa, metronidazole, antimalarials, nitrofurantoin → brown
- amitriptaline, propofol, methylene blue → green / blue
- anti-psychotics → orange
What are the types of incontinence?
- Stress (incompetent sphincter, trauma, neuro)
- Urge (Detrusor instability, spinal cord pathologi - compression, MS, injury, stroke, PD)
- Overflow (spinal cord path, stricture / stone, prostatic hypertrophy)
- True (fistulas)
What are the causes of different coloured urine:
- Red
- Brown
- Green / blue
- Orange
- Red: haematuria / haemaglobinuria, porphyria, beetroot, Rifampacin
- Brown: bile pigments, myoglobin, mehtamoglobin, drugs (levadopa, metronidazole, antimalarials, nitrofurantoin)
- Green / blue: pseudomonas UTI, biliverdin, drugs (amytriptaline, methylene blue, propofol)
- Orange: bile pigments, phenothiazines - antipsycotics
What 2 imaging tests do those with macro (visible) haematuria need?
Who are the exceptions?
a cystoscopy and upper tract imaging (CT or ultrasound)
+ consider CT urogram (contrast) in 45yrs +
except:
- females with proven UTI which resolves on treatment
- asymptomatic patients aged under 45 with micro haematuria (check GFR, blood pressure, urine protein excretion ?nephrological cause)
What are the 5 causes of raised PSA?
- Prostate cancer
- BPH
- Recent instrumentation or biopsy (not DRE!!)
- UTI
- Physiological (riding a bike)
(It takes 4 weeks for PSA to return to normal after UTI/instrumentation)
What is the criteria for urological 2WW?
- Any patient aged over 45 with unexplained visible haematuria without a UTI (or whose haematuria recurs after treatment of the UTI)
- Any patient aged over 60 with unexplained microscopic haematuria
- Any man with a raised PSA or abnormal feeling prostate
- Any man with a testicular mass or possible penile cancer
- UTI in a man
What are the antibiotics commonly given in a simple UTI?
- nitrofurantoin
- trimethoprim
- Ciprofloxacin
What does loin - groin pain indicate?
pylonephritis
What are the features of an UTI?
Features
- dysuria
- urinary frequency
- urinary urgency
- cloudy/offensive smelling urine
- lower abdominal pain
- fever: typically low-grade in lower UTI
- malaise
- In elderly patients, acute confusion
How do you treat a UTI in men?
Ciprofloxacin
refer for urological investigation if
- they have symptoms of upper urinary tract infection,
- fail to respond to appropriate antibiotics or
- have recurrent UTI
How do you treat a UTI in women?
- Check if pregnant, and if not:
- LUTI with a three day course of trimethoprim or nitrofurantoin
- UUTI a course of ciprofloxacin (7 days) or co-amoxiclav (14 days).
What should you offer at inital assessment of PC of lower urinary tract symptoms (voiding, storage, post-micturation)?
- PMH; associated comorbidities e.g. obesity, DM, obstructive sleep apnoea, DI, HTN
- SH; smoking, caffeine, alcohol, reduced activity
- Review current medication
- Physical examinations
- abdomen
- external genitalia
- a digital rectal examination (DRE)
- ask men with bothersome LUTS to complete
- a urinary frequency volume chart
- International Prostate Symptom Score
-
Refer if they have LUTS complicated by
- recurrent or persistent urinary tract infection
- retention
- renal impairment that is suspected to be caused by lower urinary tract dysfunction
- suspected urological cancer
What examination should be done if BPH is suspected?
DRE
What are the spread locations of prostate cancer?
- Lymph nodes
- Bones → an increased bone density - osteosclerosis
What are the clinical features of prostate cancer?
- Haematuria
- Haematospermia
- Incontinence
- Perineal or suprapubic pain
- Impotence
- Rectal pain and tenesmus (sensation of needing to defecate)
- UTIs
- Symptoms of metastatic spread – particularly to the bones (weight loss and bony pain, spinal cord compression, lymph node enlargement)
What are the 3 NICE criteria for a PSA and DRE?
- Any LUTS
- Urinary frequency (particularly noticeable at night)
- Poor flow of urine
- Urgency
- Urge incontinence
- Sensation of incomplete emptying
- Erectile dysfunction
- Visible haematuria
What are the results of a free and bound PSA in someone without prostate cancer?
They are more likely to have high levels of free PSA (around 25%).
Prostate cancer causes more bound PSA therefore less free PSA.
What management steps can a patient with LUTS do to help your assessment?
- urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.
- International Prostate Symptom Score (IPSS): assess the impact on the patient’s life. This classifies the symptoms as mild, moderate or severe
Does haematuria in males, even if it’s a probably UTI, need to be investigated?
Yes!
UTI / haematuria in a male needs to be investigated.
Haematuria in males = 2WW criteria
Does a normal PSA exclude cancer?
Nope!
There are non-PSA secreting tumours
What is the difference between staging and grading? Which methods are used in prostate cancer?
- Staging
- refers to the spread of the tumour from the local site, to peripheral tissues
- TNM
- Grading
- refers to the histological findings – in particular how well differentiated the cells appear
- Gleason grading
How is prostatic cancer investigated?
- GP tests
- examination
- PSA
- kidney function
- At clinic:
- Transrectal ultrasound of prostate (TRUS), often with biopsy
- USS of upper urinary tract
- CT urogram with contrast
- Bone scan / biomarkers
Why does BPH occur?
The prostate naturally grows throughout life – it grows in response to dihyrotestosterone – a breakdown product of testosterone.
As such, BPH does not occur in castrated men.
Does BPH make prostate cancer more likely?
No
What are the features of obstruction caused by BPH?
- Urinary retention
- Recurrent UTI
- Impaired renal function
- Haematuria
What examinations should be done on a man with suspected BPH? What are the findings?
- PR (DRE – digital rectal examination)
- BPH usually causes a smooth, symmetrical prostate enlargement. The dental sulcus can usually be palpated
- Be on the lookout for any signs of prostate cancer (hard, craggy, irregular and asymmetrical prostate)
- Assessing size – each finger breads of width of a prostate is equivalent to about 20g of prostatic mass
- Abdominal examination – check for a palpable bladder which indicates urinary retention (usually chronic if painless, acute retention is very painful)
Can you do a cystoscopy if the patient still has a UTI?
No - it’s contraindicated
What are the treatment options for bladder cancer?
- TURBT is first line, also gives staging
- intravesical mitomycin C
What are the treatment options for prostate cancer?
Depends on stage:
- conservative: active monitoring & watchful waiting (many do not need treatment)
- hormonal therapy
- radical prostatectomy
- radiotherapy: external beam and brachytherapy
What investigations are needed for bladder cancer?
-
CT urogram BEFORE TURBT
- (FYI a normal CT will miss small bladder tumours - still need cystoscopy)
- checks ureters (5% chance tumour will go here)
- a cystoscopy and biopsies or TURBT
- this provides histological diagnosis and information relating to depth of invasion
- pelvic MRI and distant disease CT scanning
- Locoregional spread is best determined using
- PET CT
- Nodes of uncertain significance
What are the treatment options for BPH?
- Conservative
- Lifestyle factors:
- Reduce natural diuretics (caffeine, alcohol)
- Avoid large volume of fluid intake in the evening
- Avoid constipation
- Bladder training and pelvic floor exercises can improve symptoms
- Lifestyle factors:
- Medical
- α-blockers – alfuzosin, doxazosin, tamsulosin – these reduce smooth muscle contractions of the bladder and urethra, generally reducing muscle tension in these regions. This allows for easier passing of urine.
- 5α- reductase – finasteride – these reduce the conversion of testosterone to dihyrotestosterone and thus help to shrink the size of the prostate. These take 4-6 months to have an effect
- Surgical
- TURP
What are the PSA levels for each age group?
Age <49 – <2.5ng/ml
Age 50-59 – <3.5 ng/ml
Age 60-69 – <4.5 ng/ml
Age 70+ – <6.5 ng/ml
