Case 14 - Urological Disease Flashcards
What is included in lower UTI?
- Cystitis
- Prostatitis
What is included in upper UTI?
Pyelonephritis
What are the risk factors of UTI?
- Sexual activity
- Menopause
- Pregnancy
- Dehydration
- Birth control
- Personal hygiene
- Chronic health conditions - DM, immunosuppression, obstruction, stones, catheter,
What are the symptoms of lower UTI?
- Dysuria (pain, stinging or burning when passing urine)
- Suprapubic pain or discomfort
- Frequency
- Urgency
- Incontinence
- Gross haematuria
- Polyuria
- Confusion is commonly the only symptom in older more frail patients
What are the symptoms of upper UTI?
- Fever is a more prominent
- Loin, suprapubic or back pain.
- Looking and feeling generally unwell
- Vomiting
- Rigor
- Loss of appetite
- Haematuria
- Costovertebral angle pain
- Septic like symptoms
What are the differential diagnosis for UTI?
Look unwell with loin pain:
- Appendicitis
- Pelvic inflammatory disease
- Ruptured AAA
What invetigations are done in UTI?
- MSU dipstick: nitrates confirm infection diagnosis
- MSU dipstick: positive leukocyte esterase (enzyme produced by WBC)
- MSU microscopy: More accurate
Which bacteria is more likely to cause UTI?
E.coli
What is complicated UTI?
UTI in the presence of a structural/functional abnormality of genitourinary tract, e.g. obstruction, catheter, stones, neurogenic bladder, renal transplant.
What is an uncomplicated UTI?
Normal renal tract structure and function
What are the symptoms of prostatitis?
- Perineal/rectal/scrotal/penis/bladder/lower back pain
- Fever
- Malaise
- Nausea
- Swollen/tender on PR exam
- What is the treatment for lower UTI?
- How long should it be taken?
Trimethoprim or Nitrofurantoin
- 3 days for non-pregnant women
- 5-10 days for non-pregnant women with complicated infection
- 7 days for men
What is classified as recurrent UTI?
> 3/year
- What is the treatment for lower UTI in pregnant women?
- How long should it be taken?
- What should be avoided?
- First line: nitrofurantoin
- Second line: cefalexin or amoxicillin
- 7 days in pregnant women
- Avoid ciprofloxacin and trimethoprim in 1st trimester, and nitrofurantoin in 3rd trimester.
What is the treatment for pyelonephritis?
- Ciprofloxacin for 7 days for Non-pregnant women, men and people with in-dwelling catheters
- Cefalexin for 10-14 days for pregnant women who do not require admission
What is the pathogenesis of BPH?
It is caused by hyperplasia of the stromal and epithelial cells of the transitional zone of the prostate.
What are the symptoms of BPH?
- LUTS
- Gross haematuria: due to increase in vascularity `
What are the storage symptoms of LUTS?
- Urinary frequency
- Urinary urgency and urge incontinence
- Nocturia
- Dysuria
What are the voiding symptoms of LUTS?
- Hesitancy: difficulty to initiate micturition. Delayed onset of urination.
- Straining to urinate
- Poor and/or intermittent stream (not continuous)
- Prolonged terminal dribbling
- Sensation of incomplete voiding
What investigations are conducted in BPH?
- Urine dipstick (exclude infection)
- PSA: raised in prostatitis or prostate cancer
- Rectal exam to assess prostate size, shape and characteristics
- IPS score
What is the IPS score?
- Max 35 points, 7 questions
- Combination of obstructive and irritative symptoms
- > 1-7: mild symptoms
- > 8-19: moderate symptoms
- > ≥20: severe symptoms
- Important QoL due to symptoms question at the end – Ranked out of 6.
How to treat BPH for IPS score 0-7?
Watchful waiting: monitor fluid intake, reduce alchol intake and ensure bladder emptying.
What is the medical therapy for BPH?
1st - Alpha blockers (relax smooth muscle, inhibits a1 receptors, reduced symptoms)
2nd - 5-alpha reductase inhibitors (block testosterone to DNT conversion and actually help reduce the size of the prostate)
- Phosphodiesterase type 5 inhibitors
What are the side effects of Tamsulosin (alpha blockers)?
- Postural hypotension
- Retrograde ejaculation
- Headaches
- Drowsiness
- Sexual dysfunction
What are the side effects of Finasteride (5-alpha reductase inhibitors)?
- Sexual dysfunction: erectile dysfunction, decreased libido, ejaculatory dysfunction
- Gynecomastia
What is tadalafil?
When is it given?
- Phosphodiesterase type 5 inhibitors
- Mild/moderate BPH symptoms and erectile dysfunction
What are the surgical interventions for BPH if prostate <80g?
- Transurethral resection of the prostate (TURP) – resection of the hyperplastic prostatic tissue. If prostate
- Transurethral incision of the prostate (TUIP) – less invasive, no resection of prostate, only neck widened.
What are the surgical interventions for BPH if prostate >80g?
Open prostatectomy - (HoLEP)
What is the most common type of prostate cancer?
Where in the prostate is it more likely to occur in?
- Adenocarcinoma
- Peripheral zone (posterior zone)
What are the risk factors for prostate cancer?
- Older males
- African Americans
- Tall males
- Males who use anabolic steroids
- Obese
- High fat diet
- Genetic: BRCA 2, Lynch
What are the symptoms of bladder cancer?
- Fatigue
- Loss of appetite, weight loss
- Urinary symptoms: Nocturia, urinary frequency, urinary hesitancy, dysuria, haematuria
- Bone pain
- Palpable lymph nodes
What investigations are done in prostate cancer?
- DRE: Irregular and nodular prostate (suspect malignancy)
- PSA: >4 mcg, done prior to DRE
- Biopsy: confirm diagnosis
- MRI: metastasis
What are the 2 different types of biopsies that can be taken for prostate cancer?
- Trans-rectal ultrasound (TURS) guided needle biopsy: 12 prostate samples, quicker
- Transperineal biopsy – takes 35 samples, more sensitive
What is Gleasons score?
Grading system used to define aggressiveness of the cancer
What is the result of the Gleasons?
- Score of 3-5 are considered cancerous but score 1 -2 are not cancer.
- Addition of 2 most common scores
- The lowest is 6 and highest is 10.
What is the ISUP grading for prostate cancer?
- Grade 1: Gleason 6
- Grade 2: Gleason 3+4
- Grade 3: Gleason 4+3
- Grade 4: Gleason 8
- Grade 5: Gleason 9/10
What is the treatment for localised prostate cancer?
- Radiation therapy: external beam therapy or brachytherapy (implantation of radioactive seeds, iodine 125)
- Prostatectomy
What is the treatment for high grade/metastatic prostate cancer?
- GnRH/LHRH agonists (Leuprolide and Goserelin) -
bicalutamide/flutamide (Anti-androgen therapy) given 3 days before LHRH agonists and continued for a week after.
-GnRH/LHRH antagonist (Degarelix) - reduction in circulating LH and ↓ synthesis of testosterone.
- What is the most common type of bladder cancer?
- Transitional cell carcinoma
- Non muscle invasive
What are the risk factors for bladder cancer?
- Age >55y
- Male gender
- Family history
- Smoking
- Occupational exposure e.g. Dye industry, rubber manufacturing
- Exposure to 2-Naphthylamine
- Pelvic radiation
- Systemic chemotherapy
- Chronic bladder inflammation: schistosomiasis
What are the symptoms of bladder cancer?
- Painless gross haematuria throughout micturition
- Irritative voiding symptoms: dysuria, urinary frequency, urgency
- Dysuria is typical of carcinoma in situ,
- UTIs that do not resolve despite antibiotic treatment.
Where does bladder cancer arise from?
Endothelial lining (urothelium)
What investigations are done in bladder cancer?
- MSU dipstick and culture: rule out infection
- Cystoscopy and biopsy: confirms diagnosis
What is the treatment for non invasive bladder cancer?
- Low risk (below Stage T1): transurethral resection of bladder tumour (TURBT) + immediate post-operative intravesical chemotherapy (mitomycin)
- High risk (Stage T1 or Grade 3): TURBT and BCG vaccine into the bladder.
What is the treatment for invasive bladder cancer?
- Stage T2 and above: cystectomy with pelvic lymph node dissection.
- Neo-adjuvant chemotherapy: CMV (cisplatin, methotrexate and vinblastine)
- Adjuvant chemotherapy: M-VAC (methotrexate, vinblastine, Adriamycin and cisplatin)
What is macroscopic/Gross/Frank haematuria?
Blood in urine visible to the eye
What is microscopic haematuria?
Blood in urine not visible to the eye.
What investigations can be done in haematuria?
1st - Urine dipstick: +ve for blood, then do
2nd - Microscopy: confirms presence of RBC
3rd - Imaging: required to identify bleeding source
What are the different causes of haematuria?
- Trauma
- No known cause
- Nephrolithiasis
- Polycystic kidney disease
- Kidney tumours
- Glomerular haematuria
What is nephrolithiasis?
Stones usually form in the collecting ducts of kidneys but may be deposited along the entire urogenital tract from renal pelvis to the urethra.
What are the symptoms of nephrolithiasis?
- Severe unilateral and colicky flank pain (renal colic) – loin to groin pain
- Radiates anteriorly to the lower abdomen, groin, labia, testes or perineum
- Haematuria
- Dysuraia, frequency and urgency
Who is likely to present with nephrolithiasis?
- Often present 30-50y
- Male > female
What are the causes of nephrolithiasis?
- Metabolic disturbances (hyperparathyroidism)
- Outflow obstruction/stasis
- Infection
- Immobilisation: reabsorption of bone occurs during immobilisation
What are the different types of stones?
- 75% calcium oxalate
- 10% struvite - staghorn calculi associated with recurrent bacterial infections.
- 10% urate – appear radiolucent on X-ray, requires other imaging such as USS or CT.
- Calcium phosphaste
- Cystine
What is the treatment for renal colic?
- ↑fluid intake
- Treat any bacterial infections with trimethoprim
- Alkalinise urine for urate stones
- Analgesics
- Specific for stone size
What are benign kidney tumours?
What is the risk if they grow in size?
- Angiomyolipomas
- oncocytoma
- Risk of bleeding
What are 2 types of malignant kidney tumours?
- Renal cell carcinoma (80%)
- Transitional cell carcinoma
- What is the clinical triad of renal cell carcinoma?
- How to treat?
- Haematuria, pain, palpable mass
- Surgical or medical immunotherapy
- How does transitional cell carcinoma present?
- What are the risk factors?
- How to treat?
- Haematuria, pain and LUTS
- smoking, infections due to schistosomiases, radiotherapy, occupational exposure
- Surgical resection
What are the cause of raised PSA?
How long to wait before doing PSA again?
- BPH
- UTI
- Prostitis
- Trauma
- 4 weeks
What are the different types of bladder cancer types?
- Transitional cell carcinoma
- Squamous cell carcinoma
- Adenoma
What is the most common cause of squamous cell carcinoma?
Schistosomiasis
What is the treatment for renal stones <5mm?
Lower ureter, no obstruction:
- Analgesia’s
- Fluid intake
- Anti-emetics
- Medical expulsion therapy: alpha adrenergic blockers (tamsulosin) and CCB
What is the treatment for renal stones >8mm?
- Extracorporeal shock wave lithotripsy
- Uteroscopy (if present in ureters or bladder)
- Percutaneous nephrolithotomy - laparoscopic surgical stone removal for >20mm and complicated stones)
What is used to treat bacterial infections in renal colic?
Trimethoprim
- What are the different diagnostic tests done for renal colic?
- What is the gold standard test?
- Urine dipstick (haematuria in stones but also exclude infection)
- Bloods for infection and kidney function
- Non contrast CT KUB is gold standard
