Case 14- Bladder Cancer Flashcards
Investigations for haematuria
Urinalysis, urine cytology and urine cultures
FBC UE LFT clotting
Cystoscopy with biopsy
CT KUB- gives more of an overview of the whole renal tract
Renal and bladder ultrasound- if CT contraindicated
NB- if history fits more with an infection- think of urine microscopy. If microscopic haematuria (found on dip stick) and under 45- don’t need urological investigation
Prostate cancer
Usually adenocarcinoma in the peripheral zone
Common organisms causing UTI
E. coli- most common
Klebsiella pneumoniae
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans
BPH
Growth occurs in the transitional zone
Complications post obstructive uropathy
Hyperkalaemia
Metabolic acidosis
Post obstructive diuresis (delirium)
Sodium and bicarbonate loss
Infection
Investigations for renal colic/ suspected nephrolithiasis
Urinalysis, Urine culture
Pregnancy test- exclude ectopic
Palpate abdomen for AAA- expansile mass
FBC UE - WCC if infection and maybe hypercalcaemia/ hyperuricaemia
non contrast CT KUB- gold standard for diagnosing stones
Bladder cancer differentials
BPH (male), haemorrhagic cystitis, prostatitis (male), renal cell carcinoma, nephrotlithiasis, pelvic cancer (vulval for women), radiation cystitis (if recent radiation treatment)
Prostate cancer Sx
FUNWISE
Frequency, Urgency, Nocturia, Weak stream, Intermittency, Straining, Emptying incomplete
Exam and tests- abnormal DRE, elevated PSA
Advanced disease- haematuria, weight loss, bone pain, palpable lymph nodes
NB- normal PSA doesn’t exclude prostate cancer
Investigations for suspected prostate cancer
Urinalysis
Bloods- PSA (refer if above 3, cancer is usually 4+), FBC, UE, bone profile, CRP (inflammation), LFT (whether androgen deprivation possible and ALP levels (bony metastasis)), testosterone (see if androgen deprivation possible)
DRE- after PSA taken
Miltiparametric MRI is now first line
2nd line- Trans rectal USS guided Prostate biopsy with Gleason score calculated
Bone scan- if signs of advanced disease
Increased PSA levels
Cancer, BPH, UTI, prostatitis, trauma, DRE, ejaculation, cycling
BPH investigations
Urinalysis (exclude infection), urine culture, urinary output chart
Bloods- PSA (pre-DRE), UE (bladder outlet obstruction), LFT (ALP)
DRE
IPSS score
Management of UTI
Non pregnant women- 3 days of trimethoprim, nitrofurantoin, cirpofloxacin
Pregnant women- avoid trimethoprim and cirpofloxacin in 1st trimester, and nitrofurantoin in the 3rd trimester. Local guidelines
Men- 7 days of trimethoprim and nitrofurantoin
NB- trimethoprim or cephalosporins (not in penicillin allergy) post-partum when breastfeeding (nitrofurantoin/ciprofloxacin should be avoided when breastfeeding)
Obstructive uropathy causes
Mechanical- BPH, urethral stricture, bladder calculi, phimosis, pelvic tumour
Functional- MS, anticholinergics eg. tricyclic antidepressants, diabetic autonomic neuropathy (NOT NEPHROPATHY), opioids
Obstructive uropathy vs renal colic/ pyelonephritis
Same Sx- will be able to pass urine in the latter 2 conditions
Management of obstructive uropathy
Treat underlying cause
Analgesia
Fluids- post obstructive diuresis
Catheter- not in upper obstruction (if more than 400cc, keep catheter in)
If upper- ureteric stent or nephrostomy
Acute urinary retention vs chronic urinary retention
Sudden onset vs slower progression
Painful inability to void vs painless
Patient is restless and distressed vs nocturnal incontinence or nocturnal enuresis
Nephrolithiasis vs pyelonephritis
Same Sx but fever in pyelonephritis
Nephrostomy vs urinary stoma
Nephrostomy- between skin and kidney
Urinary stoma- between skin and either bowel (kidney diversion) or ureters
Investigations for bladder cancer
Urinalysis with cytology
FBC UE LFT
Cystoscopy with biopsy
CT urogram
Differentials for prostate cancer
BPH, prostatitis, bladder cancer
Treatment of prostate cancer
Watchful waiting
Radio or brachy therapy
Hormonal therapy eg. Bilateral orchidectomy, goserelin (GnRH agonist- works to reduce sex hormone levels over time, be wary of initial tumour flare (initial increase in sex hormones)), bicalutamide (blocks androgen receptor)
Total prostatectomy last resort
NB- GnRH ANTagonists are being investigated
Castration resistant prostate cancer
Requires anti androgen therapy (bicalutamide) and chemotherapy
Features of a lower UTI
Dysuria, frequency, haematuria, flank pain, costovertebral angle tenderness, suprapubic pain, delirium (elderly)
Differentials for a UTI
BPH, urinary tract stones, pyelonephritis, bladder cancer, renal cancer, prostate cancer, STI
Investigations for a UTI
MSU dip and urinalysis for cultures and sensitivities
If concerned- CT urogram
Management of UTI
Fluids, analgesia (not ibuprofen or aspirin), rest etc.
ABX;
-3 days if simple in women
-5-10 days in immunocompromised women, abnormal anatomy, impaired kidney function
-7 days for men, pregnant women or catheter related UTI
Men and non pregnant women- either trimethoprim or nitrofurantoin
Trimethoprim
Men, non pregnant women, 2nd and 3rd trimester
Nitrofurantoin
1st and 2nd semester
Obstructive uropathy symptoms
Flank pain, fever, LUTS, distended abdomen, anuria, reduced renal function
Investigations for obstructive uropathy
Urine dip and urinalysis
FBC UE PSA
Renal USS
Obstructive uropathy complications
Hyperkalaemia
Metabolic acidosis
Post obstructive diuresis (eg. 250ml/hour after catheterisation, causes confusion and AKI)
Infection
Electrolyte disturbance
When to wait for a PSA
2 weeks- urinary retention
4 weeks- infection
Contraindications to urethral catheterisation
Urethral trauma, recent urethral surgery, acute bacterial prostatitis
Management of renal stones
Conservative- Stones less than 5mm should pass naturally
Medical- NSAID antiemetic fluids (if they need admission- give IM diclofenac), thiazide diuretics for calcium stones
Surgical;
Ureteric obstruction with signs of infection eg. Fever, systemic compromise- decompression (nephrostomy, ureteric catheters, ureteric stents)
Less than 2cm- extracorporeal shockwave lithotripsy
Less than 2cm and pregnant- ureteroscopy
Complex renal calculi and staghorn calculi- percutaneous nephrolithotomy
Lifestyle management to prevent renal stones (at increased risk after one episode)
Increase fluids
Reduce dietary salt
Limit protein
Reduce oxalate- spinach nuts rhubarb tea
Reduce urate- kidney liver sardines
NB- normal calcium diet however!!!
Referral to nephrology or urology for haematuria
Below 40- nephrology
Above 40- urology
Features of an upper UTI
Typically pyelonephritis
Fever, rigors, loin pain, vomiting white cell casts in urine, renal angle tenderness
Management of an upper UTI eg. Pyelonephritis
Hospital admission
Broad spectrum cephalosporin (cef-) for 10-14 days
May require drainage
When to send a urine culture in suspected UTI
65+
Haematuria (visible or non visible)
Pregnant women
First line ABX in pregnancy
Nitrofurantoin (avoid in 3rd trimester, near term)
Trimethoprim is teratogenic so avoid in 1st and 2nd trimesters
Asymptomatic bacteriuria in pregnant women
Urine culture at first antenatal visit
Antibiotic prescription
Send urine again to test if treatment has been effective
Catheterised patients
Do not treat asymptomatic bacteriuria
Look for signs and symptoms such as delirium, pyrexia, tachypnoea, tachycardia, painful bladder on palpation, hameaturia etc.
Features of a UTI in children
Infants- poor feeding, vomiting, irritability
Young children- abdominal pain, fever, dysuria
Older children- dysuria, frequency, hameaturia
NB- upper UTI (fever, loin pain, regal angle tenderness)
Management of UTI in children
Less than 3 months- urgent referral to paediatrician
Upper UTI- consider admission to hospital
Over 3 months- trimethoprim or nitrofurantoin for 3 days (bring back if they remain unwell after 24-48 hours)
Prophylaxis given for recurrent UTI’s
NB- if below 6 months may require a follow up USS in a few weeks to assess anatomy
Features of BPH
LUTS
Voiding (obstructive)- weak or intermittent stream, straining, hesitancy, terminal dribbling, incomplete emptying
Storage (irritative)- urgency, frequency, nocturia, urgency incontinence
Dribbling, UTI, retention
Management of BPH
Watchful waiting
Supportive measures- less caffeine, pads, don’t drink too late at night, bladder training, void in a sitting position, double voiding etc.
medication- tamsulosin (troubling symptoms), finasteride (enlarged prostate), combination therapy if voiding symptoms and prostatic enlargement, if these don’t work try anticholinergic (antimuscarinic) such as oxybutinin or tolterodine
Surgery- TURP (destroys transitional zone, but peripheral zone still present so may still get cancer- although BPH is not a risk factor for cancer development)
Tamsulosin
Alpha 1 antagonist
Decreases smooth muscle tone of prostate and bladder
Considers first line
Dizziness, postural hypotension, dry mouth, depression
Finasteride
5 alpha reductase inhibitors
Block conversion of testosterone to dihydrotestosterone
Indicated if patient has enlarged prostate and is considered high risk of progression (but symptoms may not improve for 6 months)
SE’s- erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia
Nephroblastoma
First 4 years of life
Mass associated with haematuria (pyrexia in 50%)
Often mestasise early (usually to lung)
Treated by nephrectomy
Younger children have a better prognosis
Post prostatectomy syndromes (TURP)
Haemorrhage
Urosepsis
Retrograde ejaculation
Electrolyte disturbance
Priapism
Persistent penile erection (4 hours+)
Causes of priapism
Idiopathic
Sickle cell disease/haemaglobinopathies
Erectile dysfunction medication (sildenafil)
Anti HTN, anticoagulants, antidepressants, recreational drugs eg. Cocaine, cannabis, ecstasy
Trauma
Features of priapism
Persistent erection
Pain localised to penis
Investigations and management of priapism
Cavernosal blood gas- differentiate between ischaemic and non ischaemic (ischaemic- pO2 and pH reduced, whilst pCO2 increased)
Doppler USS
FBC toxicology screen
If ischaemic- aspiration of blood from cavernosa, flush with saline, if this fails, phenylephrine injections, then surgery
If non ischaemic- observation
Upper PSA limits
50-59 3
59-69 4
70+ 5
Contraindications to urethral catheterisation
Urethral trauma
Recent urethral surgery
Acute bacterial prostatitis
Bladder cancer referral
A patient >= 60 years of age with unexplained non-visible haematuria and either dysuria or a raised white cell count on a blood test should be referred using the suspected cancer pathway (within 2 weeks) to exclude bladder cancer
Trospium chloride
Antimuscarinic
Urinary incontinence
Pelvic fracture and highly displaced prostate
Membranous urethral rupture
Most common renal stone
Calcium oxalate
Calcium oxalate stones
most common
radio opaque
variable urinary pH
Uric acid stones
children with inborn errors of metabolism
adults with excess tissue breakdown eg. malignancy
radiolucent
acidic urinary pH
Calcium phosphate
renal tubular acidosis
radio opaque
normal-alkaline urinary pH
Styruvite (triple phosphate) stones
composed of magnesium, ammonium, and phosphate
chronic infections
staghorn calculi (Proteus mirabilis)
radio opaque
alkaline urinary pH
Xanthine stones
radiolucent
Xanthine stones
radiolucent
Radiolucent stones
Uric acid
Xanthine
Radio opaque stones
Calcium oxalate
Cystine
Calcium phosphate
Styruvite
Risk factors for renal stones
dehydration
hypercalciuria, hyperparathyroidism, hypercalcaemia
cystinuria
high dietary oxalate
renal tubular acidosis
medullary sponge kidney, polycystic kidney disease
beryllium or cadmium exposure
Risk factors for urate stones
-gout
-ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid
Drug causes
-drugs that promote calcium stones: loop diuretics, steroids, acetazolamide, theophylline
-thiazides can prevent calcium stones (increase distal tubular calcium resorption)
Prevention of renal stones
Calcium stones
-high fluid intake
-low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet)
-thiazides diuretics (increase distal tubular calcium resorption)
Oxalate stones
-cholestyramine reduces urinary oxalate secretion
-pyridoxine reduces urinary oxalate secretion
Uric acid stones
-allopurinol
-urinary alkalinization e.g. oral bicarbonate
