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Medicine year 3 ANNA > Bladder Cancer / BPH > Flashcards

Bladder Cancer / BPH Flashcards

1
Q

What types of haematuria are there? What are they likely to be caused by?

A
  1. Frank/ visible haematuria
    • ONNIT:
      • Obstruction (calculi, BPH, PKD)
      • Neoplasm (TCC/RCC/prostate)
      • Nephritic syndrome (GN)
      • Inflammation (UTI, TB)
      • Trauma (recent procedure/ cateterisation)
  2. Microscopic/non-visible haematuria
    • Renal stones (calculi)
    • Menstruation
    • UTI / pylonephritis
    • Trauma (recent intercourse, procedure)
    • Cancer
  3. Haemoglobinuria
    • Haemolysis:
      • malaria
      • sickle cell
      • severe burns
      • AIHA
      • HUS
  4. Myoglobinuria
    • Rhabdomyelisis
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2
Q

What investigations are important to do in cases of haematuria?

A
  • 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)
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3
Q

What are the 3 most important investigations for haematuria in general practice?

A
  1. MSU (to rule out urinary tract infection - UTI)
  2. Urea and Electrolytes (to investigate for renal disease)
  3. Full blood count (anaemia, WCC, platelets)
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4
Q

What do nitrites specifically indicate on urine dip?

What should you do next?

A

Gram-negative UTI

Urine culture

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5
Q

What do WBCs indicate on urine dip?

A

UTI

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6
Q

On urine dip, what are the differentials for pH:

  1. Acidic
  2. Alkaline

What investigations would you do next?

A
  1. Acidic:
    1. Systemic: metabolic/resp acidosis, diarrhoea, starvation
    2. Diet: acidic diet e.g. high protein / cranberry
  2. Alkaline:
    1. Systemic: alkalosis
    2. Vegeterain / low carb diet
    3. local: UTI, renal tubular acidosis

Urine culture

VBG

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7
Q

What questions are important in a urinary history?

A

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)
  • 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
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8
Q

What medications can alter the colour of your urine?

A
  • Rifampicin → red
  • levadopa, metronidazole, antimalarials, nitrofurantoin → brown
  • amitriptaline, propofol, methylene blue → green / blue
  • anti-psychotics → orange
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9
Q

What are the types of incontinence?

A
  • 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)
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10
Q

What are the causes of different coloured urine:

  • Red
  • Brown
  • Green / blue
  • Orange
A
  • 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
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11
Q

What 2 imaging tests do those with macro (visible) haematuria need?

Who are the exceptions?

A

a cystoscopy and upper tract imaging (CT or ultrasound)

+ consider CT urogram (contrast) in 45yrs +

except:

  1. females with proven UTI which resolves on treatment
  2. asymptomatic patients aged under 45 with micro haematuria (check GFR, blood pressure, urine protein excretion ?nephrological cause)
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12
Q

What are the 5 causes of raised PSA?

A
  • 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)

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13
Q

What is the criteria for urological 2WW?

A
  1. Any patient aged over 45 with unexplained visible haematuria without a UTI (or whose haematuria recurs after treatment of the UTI)
  2. Any patient aged over 60 with unexplained microscopic haematuria
  3. Any man with a raised PSA or abnormal feeling prostate
  4. Any man with a testicular mass or possible penile cancer
  5. UTI in a man
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14
Q

What are the antibiotics commonly given in a simple UTI?

A
  • nitrofurantoin
  • trimethoprim
  • Ciprofloxacin
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15
Q

What does loin - groin pain indicate?

A

pylonephritis

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16
Q

What are the features of an UTI?

A

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
17
Q

How do you treat a UTI in men?

A

Ciprofloxacin

refer for urological investigation if

  • they have symptoms of upper urinary tract infection,
  • fail to respond to appropriate antibiotics or
  • have recurrent UTI
18
Q

How do you treat a UTI in women?

A
  • 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).
19
Q

What should you offer at inital assessment of PC of lower urinary tract symptoms (voiding, storage, post-micturation)?

A
  • 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
20
Q

What examination should be done if BPH is suspected?

A

DRE

21
Q

What are the spread locations of prostate cancer?

A
  • Lymph nodes
  • Bones → an increased bone density - osteosclerosis
22
Q

What are the clinical features of prostate cancer?

A
  • 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)
23
Q

What are the 3 NICE criteria for a PSA and DRE?

A
  1. Any LUTS
    • Urinary frequency (particularly noticeable at night)
    • Poor flow of urine
    • Urgency
    • Urge incontinence
    • Sensation of incomplete emptying
  2. Erectile dysfunction
  3. Visible haematuria
24
Q

What are the results of a free and bound PSA in someone without prostate cancer?

A

They are more likely to have high levels of free PSA (around 25%).

Prostate cancer causes more bound PSA therefore less free PSA.

25
Q

What management steps can a patient with LUTS do to help your assessment?

A
  1. urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria.
  2. International Prostate Symptom Score (IPSS): assess the impact on the patient’s life. This classifies the symptoms as mild, moderate or severe​
26
Q

Does haematuria in males, even if it’s a probably UTI, need to be investigated?

A

Yes!

UTI / haematuria in a male needs to be investigated.

Haematuria in males = 2WW criteria

27
Q

Does a normal PSA exclude cancer?

A

Nope!

There are non-PSA secreting tumours

28
Q

What is the difference between staging and grading? Which methods are used in prostate cancer?

A
  • 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
29
Q

How is prostatic cancer investigated?

A
  1. GP tests
    1. examination
    2. PSA
    3. kidney function
  2. At clinic:
    1. Transrectal ultrasound of prostate (TRUS), often with biopsy
    2. USS of upper urinary tract
    3. CT urogram with contrast
    4. Bone scan / biomarkers
30
Q

Why does BPH occur?

A

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.

31
Q

Does BPH make prostate cancer more likely?

A

No

32
Q

What are the features of obstruction caused by BPH?

A
  1. Urinary retention
  2. Recurrent UTI
  3. Impaired renal function
  4. Haematuria
33
Q

What examinations should be done on a man with suspected BPH? What are the findings?

A
  • 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)
34
Q

Can you do a cystoscopy if the patient still has a UTI?

A

No - it’s contraindicated

35
Q

What are the treatment options for bladder cancer?

A
  1. TURBT is first line, also gives staging
  2. intravesical mitomycin C
36
Q

What are the treatment options for prostate cancer?

A

Depends on stage:

  • conservative: active monitoring & watchful waiting (many do not need treatment)
  • hormonal therapy
  • radical prostatectomy
  • radiotherapy: external beam and brachytherapy
37
Q

What investigations are needed for bladder cancer?

A
  1. CT urogram BEFORE TURBT
    • (FYI a normal CT will miss small bladder tumours - still need cystoscopy)
    • checks ureters (5% chance tumour will go here)
  2. a cystoscopy and biopsies or TURBT
    • this provides histological diagnosis and information relating to depth of invasion
  3. pelvic MRI and distant disease CT scanning
    • Locoregional spread is best determined using
  4. PET CT
    • Nodes of uncertain significance
38
Q

What are the treatment options for BPH?

A
  • 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
  • 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
39
Q

What are the PSA levels for each age group?

A

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

Medicine year 3 ANNA (30 decks)

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