Case 14 - Bladder Cancer/Prostate Disease Flashcards by Rosemarie Stringfellow

What are the common causes of haematuria?

UTI
Nephrological causes
Urinary tract stone disease
Cancer - bladder cancer, upper tract urothelial cancer, renal cancer and prostate cancer

How well did you know this?

Not at all

Perfectly

How does bladder cancer commonly present?

Painless haematuria
Recurrent UTIs
Voiding irritability

How well did you know this?

Not at all

Perfectly

How would you investigate someone presenting with painless visible haematuria?

Urine dipstick - to rule out infection
U&E - investigate renal disease
Flexible cystoscopy - to rule our bladder tumour
CT urogram - to exclude renal and ureteric tumours and stone disease
PSA (in men) - to rule out prostate cancer

How well did you know this?

Not at all

Perfectly

What are the risk factors for bladder cancer?

Male sex (3-4x more common in men)
Smoking 
Occupational exposure to (rubber industry) (anlinine dye industry)
Chronic cystitis 
Schistosomiasis

How well did you know this?

Not at all

Perfectly

What is the difference between macroscopic and microscopic haematuria?

Macroscopic - is gross/frank/clots

Microscopic - you cannot see (<5RBC per high power field)

How well did you know this?

Not at all

Perfectly

What are the main different types of kidney stones?

Calcium oxalate (75%)
Struvite/triple phosphate (10%)
Urate (10%)

How well did you know this?

Not at all

Perfectly

What is the typical presentation of Urinary tract calculi (renal stones)?

Renal colic pain - loin to groin spasm pain with nausea/vomiting
Obstructive pain - pain depends on place in obstruction
UTI (may co exist)
Haematuria
Proteinuria

How well did you know this?

Not at all

Perfectly

What are the medial drugs used to prevent kidney stones?

Bendroflumethiazide - used to treat calcium stones as decreases the amount of calcium excreted in urine
Allopurinol - used to reduce urate stones
Penicillamine - used to reduce cysteine stones

How well did you know this?

Not at all

Perfectly

What is the management of kidney stones dependant on size?

Conservative management: <5mm, lower ureter, no obstruction
Medical expulsive therapy - nifedipine or tamsulosin to promote expulsion
If they still do not pass then try extracorporeal shockwave lithotripsy (ESWL) - ultrasound waves shatter stones
Can also do keyhole surgery to remove stones when large, multiple or complex

How well did you know this?

Not at all

Perfectly

How is autosomal dominant polycystic kidney disease managed (ADPKD)?

Monitor renal function (kidney size)
Family screening
Blood pressure control
Pain relief

How well did you know this?

Not at all

Perfectly

What is Von hippal lindau syndrome?

Inherited disorder characterised by abnormal growth of both benign and cancerous tumour and cysts in the kidneys, pancreas and genital tract

How well did you know this?

Not at all

Perfectly

How do patients with a lower UTI usually present?

Increased frequency 
Increased urgency 
Dysuria 
Frank haematuria 
Feeling systemically unwell

How well did you know this?

Not at all

Perfectly

How do patients with an upper UTI present?

Symptoms of lower UTI first (frequency, urgency, dysuria)
Followed by gradually increasing loin pain that is usually unilateral
Patient is often pyrexial
Patient feels systemically unwell

How well did you know this?

Not at all

Perfectly

Why are UTIs more common in women post menopause?

Altered hormone conditions cause alteration in normal vagical bacterial flora

How well did you know this?

Not at all

Perfectly

How would you investigate a UTI?

Urine dipstick - look for nitrate, leucocytes, blood and protein
Send MSU sample to lab for microscopy, culture and sensitivity analysis (this takes 48 hours)

If suspected upper UTI take blood cultures and have CT/ultrasound to exclude pyonephrosis (as this can cause sepsis)

How well did you know this?

Not at all

Perfectly

What is the treatment for lower UTIs?

3 day course of antibiotic

Usually trimethoprim, cephalexin or nitrofurantoin

What is the treatment for pyelonephritis?

24-48 hours IV gentamicin or temocillin

Followed by 10 day course of oral antibiotics

Define recurrent UTIs?

How would you treat them?

More than 3 episodes of infection per year

Long term low dose prophylactic antibiotic
Take one antibiotic after sexual intercourse if this is the causing factor

How are Tis/Ta/T1 bladder cancers treated?

Transurethral resection of the bladder tumour (TURBT)

If tumour is histologically aggressive (grade 3) then they also require BCG therapy

What are the different TMN staging of bladder cancer?

Tis - carcinoma in situ
Ta - tumour confined to epithelium
T1 - tumour in Lamina propria
T2 - tumour cells in superficial bladder wall muscle
T3 - tumour cells in deep bladder wall muscle
T4 - invasion beyond bladder e.g, prostate or uterus

How are T2/T3 bladder cancers treated?

Radical cystectomy

Also can offer radiotherapy but gives 5year worse survival rates

What type of cancer is bladder cancer?

Transitional cell carcinoma (TCC)

What are the symptoms of BPH/Prostate Cancer?

Nocturia 
Hesitancy
Poor stream 
Terminal dribbling 
Obstruction 
Weight loss or bone pain suggest mets

How is prostate cancer diagnosed?

PSA raised
Transrectal USS & biopsy
X rays
Bone scan for mets

What type of cancer are the majority of prostate cancers?

Adenocarcinoma

Where abouts are the majority of prostate cancers?

70% in the peripheral zone

How are prostate cancers graded?

Using the Gleason grading system (2-10) 2 is best prognosis, 10 is the worst

When is active surveillance the preferred option in prostate cancer?

Low risk men e.g, T1c, Gleason score of 6, PSA <0.15ng/ml/ml Cancer in less than 50% of biopsy cores In elderly patients In patients with multiple co morbities

What is the treatment for localised prostate cancer (T1/T2)?

Conservative monitoring Radical prostatectomy Radiotherapy: external beam and brachytherapy

What is the treatment for metastatic prostate cancer?

Hormonal therapy with synthetic GnRH agonist (Goserelin) This provides negative feedback to the anterior pituitary

What are the age adjusted upper limits for PSA?

50-60 : PSA - 3.0ng/ml 60-70 : PSA - 4.0ng/ml 70-80 : PSA - 5.0ng/ml However, must refer any man over 50 yrs if PSA >3.0 or if there is abnormal DRE

Why might PSA levels be raised?

``` Prostate cancer BPH UTI Ejaculation (in previous 48 hours) Vigorous Exercise (in previous 48 hours) ```

What should be co prescribed alongside goserelin (Zoladex) for prostate cancer in the first few weeks of treatment and why?

Cyproterone acetate It is an anti-androgen treatment so prevents the risk of tumour flare BNF advices starting cyproterone acetate 3 days prior to GnRH analogue

What are the post operative complications of radical prostatectomy?

Infection Incontinence Erectile dysfunction Urethral stenosis

What lifestyle factors are suggested to people with BPH?

Avoid caffeine and alcohol to reduce urgency and nocturia Relax when voiding Control urgency by practicing distraction methods (e.g, breathing exercises)

What medication is used to treat BPH?

Alpha blockers - tamsulosin | 5alpha reductase inhibitors - finasteride

If a patient presents with UTI like symptoms as well as being septic and having loin pain, what investigation would you do?

Urgent upper tract ultrasound To look for pyonephrosis

What is the criteria for a 2ww urology referral?

Any patient over 45 with unexplained visible haematuria without UTI Any patient over 60 with unexplained microscopic haematuria Any main with raised PSA or abnormal feeling prostate Any man with a testicular mass or possible penile cancer