Genitourinary D+M Flashcards
Causes of enlarged kidney
Bilaterally enlarged, ballotable kidneys can occur in polycystic kidney disease or amyloidosis.
A unilaterally enlarged, ballotable kidney can be caused by a renal tumour.
urolithiasis
Renal calculi are formed when urine is supersaturated with salt and minerals such as calcium oxalate, uric acid and cystine.
Vary in size from gravel like to large staghorn calculi
May stay in position where they formed, or can move down urinary tract causing symptoms
Another factor leading to formation is formation of randall’s plaques. Calcium oxalate precipitates form in the basement membrane of thin loops of henle; these eventually accumulate in subepithelial space of renal papillae, leading to Randall’s plaque and eventually a calculus.
Male:female 3:1
Peak age for stones developing is 30-50 years old
Bladder calculi
Bladder calculi account for 5% urinary tract stones and usually occur because of foreign bodies, obstruction or infection.
Most common cause is urinary stasis from failure to empty, from bladder outflow obstruction
Urolithiasis risk factors
Anatomical anomalies in urinary tract - horseshoe kidney, urethral stricture etc Family history HTN Gout Hyperparathyroidism Immobilisation Dehydration Metabolic disorders - chronic metabolic acidosis, hypercalciuria, hyperuricosuria Deficiency of citrate in urine Cystinuria Drugs: diuretics like triamterene and calcium or vitamin D supplements Hot climates Higher socio-economic status
Urolithiasis presentation
Asymptomatic in many cases
Renal colic: sudden severe pain starting at loin moving to the groin with tenderness of loin or renal angle
Pain is sharp and more constant than intestinal colic, with dull pain as periods of relief
Tends to ‘writhe around in agony’
Sometimes with haematuria
If stone is high, pain can be in flank but as stone moves down pain moves anteriorly towards groin
Stones moving cause greater pain than static ones
Pain can radiate towards testis, scrotum, labia or anterior thigh
Rigors and fever
Dysuria
Urinary retention
Nausea and vomiting
Urolithiasis investigations
Abdominal exam
Stick testing of urine for haematuria, white cells and nitrites (both suggest infection) and pH (>7 suggests urea-splitting organisms, <5 suggests uric acid stones)
Midstream specimen for microscopy
Bloods: FBC, CRP, renal function, electrolytes, calcium, phosphate and urate, creatinine
Prothrombin time and INR if intervention planned
Urgent CT
USS for pregnant women, children and young people
KUB and AXR
Stone analysis: suggests for all first times, all those with recurrent stones and those who’ve had late recurrence after long time stone-free period
Urolithiasis management
Prevention advice: increase fluid intake to maintain UO at 2-3 L/day, reduce salt intake, reduce meat and animal protein, reduce oxalate intake (chocolate, rhubarb, nuts) and urate rich foods (offal, certain fish), drink cranberry juice, maintain Ca intake as normal, depending on stone can be given medications to help prevent such as thiazide diuretics for calcium stones, allopurinol for uric acid stones and calcium citrate for oxalate stones Hospitalisation for systemic features (fever), known non-functioning kidney, solitary kidney, persistent pain, dehydration, anuria, pregnancy, >60 years with concerns on clinical condition Urgent outpatient appointment: pain relieved, able to drink large volumes, no complications evident NSAIDs or paracetamol for analgesia (NSAIDs thought best first line for pain) Antiemetics and rehydration therapy PRN Majority of stones pass spontaneously within 1-3 weeks; those who have not passed stone in that time or have continuing symptoms need monitoring weekly for progression CCB (nifedipine) or alpha-blockers (tamsulosin) given for medical expulsive therapy >3 weeks to facilitate stone passage Shockwave lithotripsy (SWL) is noninvasive procedure to break up stones Surgery for stones that will not pass or there are signs of obstruction. Includes ESWL, PCNL, ureteroscopy and open surgery
Urolithiasis complications and prevention
Complete obstruction can cause irreversible kidney damage if >48 hours
Symptomatic >4 weeks there is 20% risk of complications like deterioration of renal function, sepsis and ureteric stricture
Infection
Pyelonephritis
prevention:
Increase oral fluid intake and reduce calcium intake
Correct metabolic abnormalities
Treat infections UTI promptly
Urinary alkalinisation eg sodium bicarbonate 5-10g/24hour PO in water (for cystine and urate stones)
Male lower UTI and risk factors
Infection of any part of the urinary tract
Usually caused by bacteria (80% E coli)
UTI less common in men than women but higher in elderly men
Risk factors: BPH and other obstruction to urinary flow (strictures, stones etc) Catheterisation Previous UTI Immunocompromised state
Lower UTI presentation
Dysuria Frequency Urgency Change in urine appearance or odor Nocturia Suprapubic discomfort Delirium Reduced functional ability
Lower UTI investigations
male:
Urine culture and sensitivity (DIAGNOSTIC)
Urine dipstick or microscopy
female:
Urine dipstick (nitrites and leukocytes and RBC high or normal)
Urine culture for pregnancy, >65 years, persistent symptoms, recurrent UTI, catheterised, VH or NVH
Male lower UTI management
Hospitalisation for nausea and vomiting, confusion, tachypnea, tachycardia, hypotension
Empirical antibiotic treatments: trimethoprim or nitrofurantoin (CAN COLOUR URINE RED) 7 days (3 days for women) for non-catheterised or pivmecillinam 2nd line or cefalexin
Follow up in 48 hours; if not improving review sensitivity and use narrow spectrum AB where possible
Refer to urology if needed: ongoing symptoms despite treatment, underlying causes suspected or recurrent episodes (>2 in last 6 months)
Consider trial of daily antibiotics prophylaxis - trimethoprim 100mg at night or nitrofurantoin at night first line
Female lower UTI management
Simple lower UTI:
Self care: analgesia and hydration
Antibiotics (delayed script for mild cases non-pregnancy) nitrofurantoin (CAN COLOUR URINE RED) 50mg QDS 3 days (7 days in men)
Persistent haematuria after treatment must be followed up for underlying causes
Refer unknown causes of recurrent UTI, if catheterised or malignancy suspected
Hygiene, topical vaginal oestrogen and antibiotic prophylaxis can be considered
Pregnancy:
Asymptomatic or suspected UTI treated promptly with 7 day course antibiotics and followed up - first line nitrofurantoin (50mg QDS 3 days - CAN COLOUR URINE RED)
Amoxicillin, cephalexin can be 2nd line if symptoms don’t improve within 48 hours of 1st line
Consider ‘back up’ prescription that can only be taken in 48 hours if symptoms do not improve
Urgent specialist advice for recurrent UTI, catheter associated, atypical pathogens or underlying cause suspected
Antenatal services following treatment of UTI must be followed up
During term of pregnancy CANNOT be prescribed nitrofurantoin as causes neonatal haemolysis
Trimethoprim CI in pregnancy (teratogenic risk)
Pyelonephritis
Infection within renal pelvis usually accompanied by infection within renal parenchyma
Source of infection is often ascending infection from the bladder
Causative organisms are same for lower UTI: e coli, klebsiella, proteus, enterococcus etc
Repeated attacks of acute pyelonephritis can lead to chronic pyelonephritis, involving destruction and scarring of renal tissue due to repeated inflammation
Acute:
Occurs at any age
1% boys and 3% girls have had by age 7
Highest incidence in women ages 15-29, followed by infants and elderly
chronic:
Scarring of kidneys occurring after recurrent or persistent infections
Pyelonephritis acute and chronic risk factors
acute: Structural renal abnormalities, including vesicoureteric reflux Calculi and catheterisation Stents or drainage procedures Pregnancy Diabetes Primary biliary cirrhosis Immunocompromised Neuropathic bladder Prostate enlargement
chronic: Structural abnormalities, obstruction or calculi VUR Intrarenal reflux in neonates Diabetes Factors predisposing recurrent UTI
Acute pyelonephritis presentation
Rapid onset over day or two
Uni or bilateral loin pain, suprapubic pain or back pain
Fever variable can produce rigors
Malaise
Nausea and vomiting
Anorexia
Occasionally diarrhoea
Accompanying lower UTI features: frequency, dysuria, gross haematuria or hesitancy
Pain on firm palpation of one/both kidneys
Moderate suprapubic tenderness without guarding
Presentation in children can be less specific
Acute pyelonephritis investigations
Urinalysis: urine often cloudy with odor, +ve for blood, protein, leukocyte esterase and nitrite
MSU sent for microscopy and culture
Catheter specimen
Bloods: FBC, CRP, WCC, SR, plasma viscosity and cultures
Contrast enhanced CT (CECT) and KUB gold standard!
Children first line is urine samples
DMSA scan for detailed renal cortical views
MRI
Renal biopsy to exclude papillary necrosis
acute Pyelonephritis management and complications
Fluid intake and analgesia
Hospitalisation for severe condition or comorbidities
Antibiotics whilst awaiting culture and sensitivity (1st line ciprofloxacin or co-amoxiclav, trimethoprim if sensitivity confirmed)
Surgery rare needed to drain renal or perinephric abscesses or to relieve obstructions like stones
Complications: Sepsis Perinephric abscess Renal abscess Acute papillary necrosis Pregnancy tends to be more complex: can cause preterm labour, consider prophylaxis antibiotics if >3 x infection within a year Impaired renal function
Chronic pyelonephritis presentation and investigations
Often asymptomatic Fever Malaise Loin pain Nausea and vomiting Dysuria HTN Failure to thrive Features of CKD
investigations:
Urine microscopy, culture and sensitivity
Renal USS
Intravenous pyelogram (IVP) small kidneys, ureteric and calyceal dilatation with cortical scarring
Micturating cystourethrogram MCUG
USS and KUB
Technetium scan for renal scars most sensitive
Renal biopsy
Chronic pyelonephritis management and complications
BP controlled to slow progression of CKD ideally with ACEi
Supervening UTI may need long courses antibiotics
Severe underlying VUR in children may need antibiotic prophylaxis until puberty or resolution
Calculi removal
Surgical reimplantation of ureters in severe cases
Dialysis or renal transplant in severe cases
Monitored for development of hyperlipidaemia, HTN, diabetes and deteriorating renal function
Complications:
Progressive renal scarring with reflux nephropathy and CKD
Secondary HTN
Pyonephrosis
Focal glomerulosclerosis
Urea splitting organisms can lead to staghorn calculi
balanitis and cause
Inflammation of glans penis
If foreskin also inflamed it is termed balanoposthitis, although commonly still called balanitis
More common in men than boys
Cause:
Intertrigo
Infection with candida is cause of less than 20% cases, often signifies underlying dermatosis
Bacterial cases may be polymicrobial (candida, staph or strep especially group B, anaerobes etc)
Fixed drug eruption (particularly sulfonamides and tetracycline)
Circinate balanitis (associated with reactive arthritis)
Zoon’s balanitis (plasma cell infiltration); a benign, idiopathic condition presenting as a solitary, smooth, shiny, red-orange plaque of the glans and prepuce of a middle-aged to older man
Queyrat’s erythroplasia (penile Bowen’s disease - carcinoma in situ)
Psoriasis
Lichen planus
Leukoplakia
Seborrhoeic dermatitis
Pemphigus
Pemphigoid
Irritation or contact dermatitis: wet nappies, poor hygiene, smegma, soap, condoms.
Trauma: zippers, accidental or inappropriate foreskin retraction by a child/parent.
Stevens-Johnson syndrome.
Severe oedema due to right heart failure.
Morbid obesity.
balanitis risk factors
Diabetes Oral antibiotics Poor hygiene in uncircumcised males Immunosuppression Chemical or physical irritation of glans
Balanitis presentation
Sore, inflamed and swollen glans/foreskin
Non-retractile foreskin/phimosis
Penile ulceration
Penile plaques
Satellite lesions
May be purulent and/or foul smelling discharge (most common with strep or anaerobic infections)
Dysuria
Interference with urinary flow in severe cases
Obscuration of glans/external urethral meatus
Impotence or pain during coitus
Regional lymphadenopathy
Balanitis investigations and complications
blood/urine testing for glucose if diabetes possible
Swab of discharge for microscopy, gram staining, culture and sensitivity
Refer to GUM clinic is STI suspected
Bacterial infection suspected: swab and await results/consider GUM referral
Complication:
Difficulty retracting foreskin can develop especially if recurring or chronic
Balanitis management
Daily cleansing with warm water and gentle drying. Saline baths (4 tbs salt in bath)
STI screening and treatment of patient and partners PRN
If dermatological cause; treat cause with advice from GUM/dermatology referral. Biopsy may be needed for referral
Contact irritant causes = Avoid triggers (latex condoms etc.) usually resolves over period of days with irritant removal
Topical hydrocortisone 1% therapy recommended (ONCE DAILY UP TO 14 DAYS). Systemic for severe inflammation affecting penile shaft or marked genital oedema
No improvement = stop hydrocortisone and take subpreputial swab to exclude or confirm fungal or bacterial infection - manage according to results
Candidal infection suspected = clotrimazole cream 1% or miconazole 2% apply twice daily until symptoms settle
Nystatin if resistance suspected
Topical imidazole with 1% hydrocortisone if marked inflammation
Bacterial = flucloxacillin or erythromycin. Anaerobic = metronidazole 400mg 2x daily for one week or co-amoxiclav.
Consider hospital for IV antimicrobials for gross inflammation or systemic illness
Surgery considered for circumcision if recurrent or pathological phimosis present
Prognosis:
Depends on underlying cause and presence of risk factors
More likely to recur in diabetes, poor genital hygiene, phimosis, contact irritants if re exposed
Prostatitis
Inflammation of prostate gland and can result in various clinical syndromes
Acute symptoms of bacterial prostatitis more likely to drive patients to consult GP or A+E
Prostate pain syndrome PPS sometimes used to describe men with chronic prostatic pain with no identifiable infective cause
If prostate can’t be identified as source of pain, the term pelvic chronic pain syndrome CPPS sometimes used
2-10% adult men experience symptoms compatible with chronic prostatitis at some point
Chronic is much more common than acute (chronic defined as >3 months symptoms)
Bacterial is most common form in <35 years
HIV predisposes to prostate cancer, also suggested that chronic prostatitis may be associated with benign prostatic hyperplasia and prostate cancer
Causes:
Bacterial: usually gram negative organisms, especially E coli, enterobacter, serratia, pseudomonas and proteus species. STIs can also cause. Rarer causes include mycobacterium tuberculosis
Non-bacterial (more common): elevated prostatic pressures. Pelvic floor myalgia. Emotional disorders
Causes of prostatitis and risk factors
Bacterial: usually gram negative organisms, especially E coli, enterobacter, serratia, pseudomonas and proteus species. STIs can also cause. Rarer causes include mycobacterium tuberculosis
Non-bacterial (more common): elevated prostatic pressures. Pelvic floor myalgia. Emotional disorders
Risk factors:
STI
UTI
Indwelling catheters
Acute bacterial prostatitis can occur after sclerotherapy for rectal prolapse
Follow manipulation of gland eg post-biopsy
Increasing age
Prostatitis presentation
Fever, malaise, arthralgia, myalgia
Urinary frequency, urgency, dysuria, nocturia, hesitancy and incomplete voiding
Low back pain, low abdominal pain, perineal pain and pain in urethra. Chronic pelvic pain common finding of chronic prostatitis
Pain on ejaculation common especially with CPPS. also significant association with premature ejaculation
Urethral discharge
Examination:
Acute bacterial:
Nodular gland, boggy or possibly normal
Tender on palpation
Feels hot to touch
Inguinal lymphadenopathy and urethral discharge
Features of UTI and systemic infection - tachycardia, dehydration
Chronic bacterial and nonbacterial:
Glands feel normal or can be hard from calcification
Prostatitis investigations
Bloods: FBC, U+E, creatinine and cultures if toxic or septic
Acute bacterial diagnosis made on urine culture
Urine microscopy for white blood cells and bacterial count as well as oval fat bodies and lipid laden macrophages
Do NOT use prostatic massage in acute prostatitis (painful and may spread infection)
Suspicion of cancer = check PSA (can be elevated by prostatitis anyway)
chronic nonbacterial prostatitis overview
Impairs quality of life and diagnostic index needed to aid diagnosis research outcome
National institutes of health funded chronic prostatitis collaborative research network has developed index of symptoms and quality of life impact in men with chronic prostatitis
Cause is unknown but thought to be unidentified infection, immune reaction, pelvic SNS dysfunction, interstitial cystitis, prostatic cysts and calculi. Mechanical problems causing retention of prostatic fluid
Contains 13 items scored in three discrete domains:
Pain
Urinary symptoms
Quality of life impact
Diagnostic criteria includes:
Symptoms suggestive of prostatitis (pelvic discomfort/pain) lasting >3 months
Negative cultures of urine and prostatic fluid
Inflammatory type, leukocytes present in prostatic fluid, vice versa non-inflammatory type
Management of acute prostatitis
Hospitalisation for acute symptoms or oral AB intolerance (septic shock, fluid resus)
Analgesia
Urine retention = catheterisation (may need suprapubic)
Avoid repeated PR exam (spread infection)
If sexually transmitted; GUM clinic may be referred to
FIRST LINE fluoroquinolones (CIPROFLOXACIN or OFLOXACIN) for four weeks (review at 14 days) SIDE EFFECTS: convulsion risk, tendon damage, Aortic aneurysm and dissection risk
Severely ill pts may need parenteral aminoglycosides (gentamicin) in addition
Second line = levofloxacin 500BD 14 days then review or co-trimoxazole 960mg BD for 14 days then review
Referral for inadequate AB response, immunocompromised, pre-existing urological conditions, acute urinary retention
Following recovery all need referral for investigation of urinary tract, to exclude structural abnormalities
Management of chronic prostatitis
Chronic infectious prostatitis:
Referral made for all chronic cases
Antibiotics while awaiting referral (quinolone for 4-6 weeks, repeated PRN)
Analgesia and stool softeners
Where calculi serve as focal point for infection, transurethral resection of prostate (TURP) or total prostatectomy may be needed
Chronic nonbacterial prostatitis:
Simple analgesia (paracetamol or NSAIDs)
Antibiotics for infection but avoid repeating
Prazosin or other alpha blocker may be of value. Give for 3-6 months if beneficial ad less highly selective blockers preferred
Stress management for suspected strong psychological component
MDT approach (urologist, pain specialist, nurse, physiotherapist, GP, CBT specialist, sexual health specialist etc)
Emerging therapies: thermotherapy, bioflavonoids, bee pollen etc.
epididymitis and orchitis
Inflammation of the epididymis
Acute epididymo-orchitis is clinical syndrome consisting of pain, swelling, inflammation of the epididymis, with (Epididymo-orchitis) or without (epididymitis) testes inflammation
Orchitis (infection limited to tesis) is much less common
Chronic epididymitis refers to epididymal pain and inflammation (usually without scrotal swelling) lasting for more than 6 months
Acute epididymitis commonly present in aged 15-30 and >60 years
Prepubertal epididymitis thought to be post viral infectious phenomenon
epididymitis cause
Under 35 YO, most likely STI eg chlamydia or gonorrhea
In men over 35 YO, most often due to gram negative enteric organism causing UTI eg E coli, pseudomonas spp. Specific risk factors include recent instrumentation or catheterisation
Mumps
Extrapulmonary TB (40-45% cases in UK)
12-19% men with Behcets disease will develop EO. noninfective and thought to be part of more severe disease process
Also reported as adverse side effect of amiodarone (dose dependent)
cause of acute orchitis
Viral: mumps is most common. Coxsackievirus A, varicella and echoviral infections are rarer
Bacterial and pyogenic: E coli, klebsiella, pseudomonas, staph and strep species (rare causes)
Granulomatous: syphilis, TB, leprosy (rare causes)
Trauma
Epididymitis risk factors
Previous gonorrhoea infections
Instrumentation and indwelling catheters for acute epididymitis
Structural or functional abnormalities of urinary tract common risk factors for gram negative enteric organisms
Anal sex (enteric pathogens)
Strenuous exertion with full bladder
Epididymitis presentation
Unilateral scrotal pain (bilateral sometimes)
Relatively acute onset swelling of scrotum
In sexually transmitted cases of epididymo-orchitis may be urethritis or urethral discharge
History suggestive of UTI or bacteriuria
Mumps: headache, fever, uni or bilateral parotid swelling.
Symptoms of TB infection: subacute/chronic scrotal swelling, systemic symptoms of TB, scrotal sinus or thickened scrotal skin
Tenderness to palpation on affected side
Palpable swelling
Urethral discharge
Secondary hydrocele
Erythema or oedema of scrotum on affected side and pyrexia
Lifting testis over symphysis may ease pain
Epididymitis-orchitis investigations
Exclude STI with screening
Gram stained urethral smear microscopy
Gram stained prep of first passed urine (FPU) for microscopy
Urethral swabs for STI
Microscopy and culture of midstream urine for bacteria including nitrate and leukocyte esterase test
HIV if suspected
Doppler USS for blood flow to differentiate between torsion
management of epididymitis-orchitis
Possible torsion: urgent urology opinion
Possible STI: refer to GU clinic for full screening, treatment and contact tracing. Advise against unprotected sex until treatment and follow up
Rest, analgesia (NSAIDs) and scrotal support. Abstain from intercourse until resolved and followed up especially with STI
Empirical therapy to all patients with epididymo-orchitis before culture/NAAT results. Antibiotic given should be chosen determined by immediate tests as well as history
For sexually transmitted: ceftriaxone 250mg IM single dose + doxycycline 1–mg orally 2x daily 10-14 days
Enteric organisms: ofloxacin 200mg oral 2x daily 14 days
Severe symptoms: IV antibiotics
All cases of cephalosporin/tetracycline allergy given ofloxacin 200 mg oral 2xdaily 14 days
Surgical: scrotal exploration if torsion or tumour cannot be ruled out
Follow up:
No improvement after 3 days reassess patient diagnosis and treatment
Two week follow up to assess compliance, partner notification and symptom improvement
Swelling and tenderness can persist but should be significantly improved, with little improvement, consider USS or surgical assessment
urethritis
Urethral inflammation
Can be result of infectious or noninfectious causes
Primarily a sexually acquired disease
Can affect both sexes
Chlamydia most common in those aged 15-24 (most common STI in UK)
Gonorrhoea also common cause
Classification of male urethritis:
Gonococcal - caused by neisseria gonorrhoeae
Non-gonococcal urethritis (NGU) - caused by number of organisms as well as non infective agents
Persistent or recurrent urethritis - 10-20% cases treated for NGU
urethritis presentation
Asymptomatic (90-95% men with gonorrhoea, 50% patients with chlamydial infections)
Urethral discharge with/without blood, more noticeable in morning after holding urine overnight (more common in gonococcal infection)
Urethral pruritus, dysuria or penile discomfort
Skin lesions in herpes simplex virus
Systemic symptoms if other organs involved: conjunctivitis or arthritis
Haematuria or lymphadenopathy can be present
urethritis risk factors
Sexually active Male Unprotected vaginall sex Male with male sex or bisexual More common in cities Age <35-40 years Recent partner change
urethritis diagnosis
Mucopurulent or purulent discharge from urethral meatus
Gram stain of urethral smear showing >5 PMN cells per high power field (highly sensitive test)
First pass urine FPU positive for >10 PMN per high power field.
Urethritis in women: Urine sample to screen for bacteria High vaginal swab (HVS) Cystoscopy USS for pelvic inflammation caused by STIs Sexual health swabs/screen
urethritis complications
Epididymitis and/or orchitis
Prostatitis
Systemic dissemination of gonorrhoea - eg,
conjunctivitis, skin lesions.
Reactive arthritis
Pelvic inflammatory disease (PID) - infection of
female partners with the organisms that cause
urethritis can cause PID and subsequent
complications
HIV transmission is increased
urethritis management
Explain likely causes, advise partner notification, explain subsequent consequences of inadequate treatment and emphasise complications and importance of abstaining from sex (inclduing oral) for seven days after treatment (if azithromycin used) or on completion (if doxycycline used) and until symptoms resolve and partners also completed treatment
Patients should also be offered HIV, hepatitis B and syphilis testing (associated diseases)
Must be treated as early as possible and presumed chlamydial infection (most common cause)
NGU:
Doxycycline 100mg 2xdaily 7 days
Or azithromycin 1g stat then 500g OD for next 2 days (patients advised to abstain from sex for 14 days after start of treatment or until symptoms resolve to limit trasmission of resistant organisms)
Or if known to be M genitalium positive: azithromycin 500mg stat then 250mg daily for four days
Ofloxacin 200mg BD or 400mg OD for 7 days
Gonococcal urethritis:
Confirmed and uncomplicated = ceftriaxone 500mg IM + azithromycin 1g stat oral
Empirical treatment - specialist service encouraged
Doxycycline 100mg BD 7 days or azithromycin 1g single dose for presumed chlamydial cases
Testicular torsion
Torsion of the spermatic cord, causing occlusion of blood flow to the testes
Unless prompt action taken, ischaemia rapidly occurs resulting in loss of testis
Urological emergency
Typically occurs in neonates or post-pubertal boys but can occur at all ages
Left side more commonly affected than right
Bilateral cases are rare
Testicular torsion presentation
Acute swelling of scrotum and retracted upwards
Assume torsion in young boys until proven otherwise
Severe sudden onset pain in testis
Lower abdominal pain
Often comes on during sport or activity
Nausea and vomiting
Often history of brief pain similar to this that resolves itself (torsion that spontaneously resolves - indicates intermittent torsion/de-torsion)
Can present with mild less acute symptoms
Pain can ease and may indicate necrosis
Erythema of scrotal skin
Lifting testis over symphysis increases pain
Testicular torsion investigations and complications
USS most important with colour doppler
Do not delay surgical intervention with high suspicion
Complications:
Infarction and atrophy, infection and cosmetic deformity
Subfertility and infertility (although provided other functions normally will not impact fertility
Testicular torsion management
Immediate referral to emergency urology or surgical team
Give analgesia and ensure NBM
Extent of torsion has major influence on immediate salvage rate and later atrophy. Duration <6 hours has good salvation rate, >24 hours necrosis is likely
Benign prostatic hyperplasia
Increased size of prostate gland without malignancy present
Can put pressure on urethra causing difficulty passing urine
Does not increase cancer likelihood, can increase UTI likelihood
Common with increasing age
Seems likely to be from failure of apoptosis and some drugs can also induce the process
Unusual before 45
More severe in afro-american men often
BPH presentation and investigations
Urinary frequency Urgency Hesitancy Incomplete emptying Push or strain during micturition
Investigations:
Examination: check for palpable bladder
PR exam assess prostate size: should be below two fingers breadth. Firm but not hard and smooth (normally)
Urine dipstick and MSU microscopy and culture
Bloods: FBC, U+E and creatinine, LFTs
PSA elevated with large benign cases
USS or KUB of urinary tract
Management of BPH
Watch and wait if symptoms are minimal
Trial medications: alpha adrenergic antagonists (tamsulosin, alfuzosin) or alpha blockers (doxazosin) reduce tone in muscle of bladder (relieve mod-severe voiding symptoms)
Tamsulosin important to advise patient of risk of intraoperative floppy iris syndrome (causes billow out of iris during cataract surgery)
For those with enlarged prostate, raised PSA and elderly should use 5 alpha reductase inhibitor eg finasteride or dutasteride (HIGHLY teratogenic - women should not touch), can also use in combination with alpha blocker
If unsuccessful surgery can be used: transurethral resection TURP is standard technique. Risk of bleeding is high
urinary retention
Inability to voluntarily pass urine
May be secondary to urethral blockage, drug treatments (antimuscarinics, tricyclic antidepressants), conditions reducing detrusor contractions or interfering with relaxation of urethra, neurogenic causes or can occur postpartum or postoperatively
Acute retention is a medical emergency with abrupt development of inability to pass urine over period of hours
Chronic retention is gradual over months or years developing an inability to empty the bladder completely, characterised by residual volume greater than 1L or associated with presence of distended or palpable bladder
Urinary retention is more common in men and more common cause is BPH
causes of acute urinary retention
Obstructive
BPH, prostate cancer, glynae mass, bladder stones, faecal impaction, vaginal prolapse
Infectious/inflammation
UTI, prostatic abscess, acute vulvovaginitis
Neurologic
Cauda equina syndrome, cord compression, transverse myelitis, spinal cord trauma, MS
Medications
Tricyclic antidepressants, antipsychotics, opioids, diphenhydramine, ephedrine, NSAIDs, drugs with anticholinergic activity
presentation and investigations of acute urinary retention
Severe abdominal pain
Unable to pass urine for hours
Sensation of needing to void
On examination may have distended bladder with suprapubic dullness to percussion
History of haematuria - think of clot retention
Investigation: Bladder USS Post void 300ml + of urine 150ml + may also be significant Bloods: infection markers and eGFR renal function
acute Urinary retention management
Catheter insertion if patient is safe to go home, give all appropriate info
Trial without catheter usually occurs in 2 weeks time
Assess and investigate any underlying causes and treat PRN
If patient drains 1000ml + needs referral for admission to urology team
chronic urinary retention and presentation
Not immediately life threatening but can lead to hydronephrosis and renal impairment over time
presentation: Symptoms usually develop slowly and may not be noticed Urinary frequency Urgency Hesitancy Poor stream Incomplete voiding sensation Increasing lower abdo discomfort Acute retention Lethargy Pruritus Recurrent infections HTN due to CKD
chronic urinary retention investigations
BP for HTN
Abdominal and GU exam: palpable non-tender bladder
PR exam for evidence of prostatomegaly or carcinoma
Examine external genitalia in children for urethral abnormalities might be causing obstruction
Neurological exam to exclude cord compression and neuro conditions
Urinalysis
MSU
Bloods: U+E, FBC, glucose
PSA
Voiding diary
Secondary care investigations: USS, MRI, CT, cystometry etc.
chronic Urinary retention management
Intermittent bladder catheterisation offered before an indwelling catheter
Catheter may be long term solution where persistent retention causes incontinence, infection, renal dysfunction and surgery is not an option
Consider surgery on bladder with no renal impairment
Monitoring kidney function and urine output throughout life
Ureteric trauma
Relatively uncommon but very severe as can result in serious complications due to diagnosis often being delayed
Often associated with micro or macroscopic haematuria (absent in about 25% cases)
causes:
Iatrogenic from laparoscopic procedures (most commonly gyanae procedures)
Traumatic: uncommon <1% urological trauma, direct trauma from penetrating injury
Ureteric trauma presentation and diagnosis
Classic clinical signs and symptoms may also be absent, but pts may present with abdominal/flank pain, renal failure and/or urine leaking from vagina
Diagnosis:
Often based on high index of clinical suspicion
CT with contrast
Immediate diagnosis and correction will give good prognosis
Ureteric trauma management and complications
Ureteric stents may be needed for obstruction
Percutaneous nephrostomy if surgery not sufficient
Complications:
Haematoma
Abscess and intra-abdominal sepsis
Urinoma (urine collections usually found in retroperitoneal space)
Strictures and obstructive nephropathy or renal failure
Ureterovaginal fistula
Renal injury
Account for 10% abdominal trauma
Risk of injury increases in preexisting congenital or acquired renal pathologies
Majority of isolated renal trauma is minor (95-98%) due to favourable anatomical position of the kidneys protected by ribs and retroperitoneal position
Causes:
Blunt force from motor vehicle collisions, falls and personal collisions are most common cause (85%) from deceleration injuries from collision of kidney with vertebrae or ribs
Iatrogenic from surgery, percutaneous renal biopsy, nephrostomy, extracorporeal shock wave lithotripsy (ESWL)
Serious injuries associated with blunt and penetrating trauma associated with multiorgan injuries in 80% cases
Spectrum of renal injuries and presentation
Contusion/haematoma
Laceration
Haemorrhage
Avulsion of renal pedicle leading to devascularization of kidney
Pseudoaneurysm
AV fistula
Renal artery thrombosis, transection or dissection
Presentation:
Tend to present with VH or NVH
Flank and/or abdominal pain
Hypotension and shock in severe cases
Renal injury investigations, management and complications
Imaging reserved for hemodynamically stable pt usually while unstable pt taken directly to surgery
CT main line of imaging
Management:
Depends on trauma and complications present
Complications: Urinoma most common complication Delayed bleeding within 1-2 weeks injury Urinary fistula Perinephric abscess HTN from renal artery injury Hydronephrosis Pyelonephritis
acute kidney injury
Abrupt loss of kidney function
Can occur in those with or without preexisting renal disease
Causes:
Prerenal:
Majority of AKI due to prerenal state (90% cases)
Volume depletion (haemorrhage, vomiting, diarrhoea)
Oedematous states: cardiac failure, cirrhosis, nephrotic syndrome
Hypotension
Cardiovascular: cardiac failure and arrhythmias
Renal hypoperfusion: NSAID or selective COX-2 inhibitors, ACEi, angiotensin-II receptor antagonists (AIIRAs), AAA, renal artery stenosis, hepatorenal syndrome
Intrinsic: Glomerular disease Tubular injury Acute interstitial nephritis Vascular disease: vasculitis, renal artery stenosis etc Eclampsia
Postrenal: Calculus Blood clot Papillary necrosis Urethral stricture Prostatic hypertrophy or malignancy Bladder tumour Radiation fibrosis Pelvic malignancy Retroperitoneal fibrosis
risk factors for acute kidney injury
Pt having iodinated contrast agent: CKD Diabetes Heart failure >75 YO Increasing volume of contrast agent Intra-arterial administration of contrast agent
Pt having surgery: Emergency surgery particularly with sepsis or hypovolaemia Intraperitoneal surgery CKD (with eGFR <60 in adults) Diabetes HF >65YO Nephrotoxic medication
presentation of AKI
Depends on underlying cause
Decreasing urine volume (oliguria or anuria)
And rise in serum creatinine
Associated with one of the following: creatinine 26umol/L or more within 48 hours, 50% or greater increase in serum creatinine within 7 days or a fall in urine output to less than 0.5ml/kg/hour for more than 6 hours
Nausea and vomiting
Dehydration
Confusion
Hypertension
Dehydration with postural hypotension
Fluid overload with raised JVP, peripheral or pulmonary oedema
AKI NICE criteria and investigations
Creatinine 26umol/L or more within 48 hours
50% or greater increase in serum creatinine within 7 days
Fall urine output to less than 0.5ml/kg/hour for more than 6 hours
In children or young people a fall in eGFR of 25% or more in preceding seven days
Stages of AKI:
Investigations:
Detected and monitored by serum creatinine readings which acutely rise
Urine output
eGFR
Management:
No specific management - largely supportive
Monitor UO and fluid intake
AKI from prerenal cause often responds to fluid replacement and temporary withdrawal of drugs affecting kidney function
Stop nephrotoxic drugs where possible
Monitor creatinine, Na, K, Ca, phosphate, glucose
Identify and treat infection
Urgent relief of urinary tract obstruction
Refer to nephrologist for specific treatment of intrinsic renal disease
AKI management and prevention
No specific management - largely supportive
Monitor UO and fluid intake
AKI from prerenal cause often responds to fluid replacement and temporary withdrawal of drugs affecting kidney function
Stop nephrotoxic drugs where possible
Monitor creatinine, Na, K, Ca, phosphate, glucose
Identify and treat infection
Urgent relief of urinary tract obstruction
Refer to nephrologist for specific treatment of intrinsic renal disease
Prevention:
Best ‘treatment’ for AKI
Close monitoring of UO and creatinine levels for early detection
Avoid nephrotoxic drugs
All acutely ill pts in hospital should be closely monitored for signs of AKI developing
At risk pt who need iodinated contrast agents should be offered IV volume expansion with saline
CKD and risk factors
Abnormal kidney function and/or structure
Definition is based on presence of kidney damage (albuminuria) or decreased function (GFR) <60ml/minute per 1.73m2 for three months of more
Often associated with old age, diabetes, HTN, obesity and CVD
Risk factors: CVD AKI HTN Diabetes Smoking Proteinuria African, african-carribean or asian family origin Chronic NSAID use Untreated urinary outflow tract obstruction
other evidence of CKD
Persistent microalbuminuria
Persistent haematuria without other explanation
Structural abnormalities of kidney seen on USS or other radiological tests eg polycystic kidney disease, reflux nephropathy
Biopsy proven chronic glomerulonephritis
presentation of CKD
Usually asymptomatic Specific symptoms usually only develop in severe CKD Anorexia Nausea and vomiting Fatigue Weakness Pruritus Lethargy Peripheral oedema Dyspnoea Insomnia Muscle cramps Pulmonary oedema Nocturia Polyuria Headache Sexual dysfunction Hiccups Pericarditis Coma and seizures
CKD investigation
eGFR
Albumin:creatinine ratio (ACR) - Increased ACR and decreased GFR associated with risk of adverse outcomes
Urine testing: haematuria and proteinuria suggest glomerulonephritis which may progress rapidly
Renal USS
staging of CKD and management
I: 90+
Normal: eGFR >90ml/minute/1.73m2 with other evidence of CKD
Observation and control of BP
II: 60-89
Mild impairment: eGFR 60-89 with other evidence of CKD
Observation, control BP and CVD risk factors
IIIa: 45-59
moderate impairment: eGFR 45-59
Observation, control BP and CVD risk factors
IIIb: 30-44
moderate impairment: eGFR 30-44
Observation, control BP and CVD risk factors
IV: 15-29
severe impairment: eGFR 15-29
Planning for end-stage kidney disease
V: <15
established renal failure (ERF): eGFR <15 or on dialysis
Transplant or dialysis
renal replacement therapy
Most pts with CKD stage 4-5 or rapid progressing stage 3 need nephrologist referral, ideally a year before they might need renal replacement therapy
Three choice available for end stage kidney disease: conservative care and symptom control, dialysis (peritoneal or haemodialysis) and kidney transplant
Dialysis usually begins when GFR <10 ml/min or 15 if diabetic
Peritoneal considered first choice for children <2 years or people with residual renal function and adults without significant comorbidities
haemodialysis and peritoneal dialysis
Blood filtered outside of the body via machine
To prep will need one time minor surgery to create vascular access to sustain high flow rate (fuse artery to vein creating fistula or grafting a synthetic tube)
In emergency - can use catheter via jugular veins for temporary access
Blood flows through machine (acts as capillaries using dialysate fluid to osmotically remove waste and add bicarbonate for pH, medications, anticoagulants and erythropoietin) based on patients needs
Normally performed as four hour treatments 3x weekly
Complications: blood infection, thrombosis, internal bleeding
Peritoneal dialysis:
Catheter introduces dialysate fluid into the abdomen, and peritoneum acts as natural filtering surface
Can be done automatically at night for longer periods of time
Less effective than haemodialysis but is better tolerated and can be done for longer
kidney transplantation
Provides best long term outcome for end stage kidney disease
Can come from cadaver or live donor
All pts should be considered for transplant but comorbidities affect survival likelihood
Need follow up after discharge 2-3 times weekly initially
To prevent rejection will receive induction with depleting or non-depleting monoclonal/polyclonal antibodies directed against T cells
Immunosuppression maintained in long term for effective transplant
Followed up for life including annual screening for cancers, drug toxicity and CVD
CI for transplant: cancer, active infection, uncontrolled IHD, acquired immunodeficiency, active viral hepatitis, extensive peripheral vascular disease and mental incapacity
Prognosis shows 10 year survival between 71-89%
Haematuria
Blood in the urine Non-visible haematuria (NVH) is microscopic/dipstick positive. Can be symptomatic NVH (s-NVH) symptoms including voiding lower urinary tract symptoms. Or can be asymptomatic NVH (a-NVH) Visible haematuria (VH) Intermittent Persistent: suspect cancers Painful: renal or ureteric stones Painless: renal Ca/bladder cancer Urological and non-urological causes
Significant haematuria defined as:
Single episode of VH
Any single episode of s-NVH in absence of UTI or other transient cause
Persistent a-NVH in absence of UTI or other transient cause. Persistence is defined as 2 out of 3 dipstick positive for NVH
timing:
Early stream: indicates urethral bleeding
End stream: indicates bladder
Continuous indicates ureter or kidneys
causes of Haematuria
Malignancy of kidney, ureter or bladder BPH Bilirubinuria Urinary calculi UTI Anticoagulation therapy Glomerulonephritis: IgA nephropathy Polycystic kidney disease Schistosomiasis False positive: myoglobin eg extreme exercise (MbU) *Red urine can be caused by food or medications such as beetroot, rhubarb, black pudding, rifampicin, senna laxatives, pyridium (urinary analgesic) *Urine contamination during menstruation (NOT haematuria)
Haematuria investigations
Exclude transient causes eg exercise induced, myoglobinuria, menstruation Exclude UTI Plasma creatinine and eGFR Measure proteinuria Urine send for protein:creatinine ratio 24 hour urine sample for protein Measure BP FBC Urine red cell morphology (dysmorphic suggest renal origin) Cytological examination of urine USS renal tract Cystoscopy (GOLD STANDARD) IV urography Renal angiography, CT scan or renal biopsy
Haematuria management
Indications for referral: All children with haematuria All patients with VH: consider nephrology referral is glomerulonephritis suspected All patients with s-NVH All patients with a-NVH >40 years
Management:
VH, sNVH, aNVH >40 years old, refer to urologist for imaging and cystoscopy
NVH with eGFR <60, PU, high BP or family history of renal disease referral to nephrologist
Those with unknown diagnosis need repeated investigations whenever gross haematuria occurs or after 4-6 months. Occult cancer will become evidence within one year usually
Monitoring for those who don’t need referral: voiding LUTS, VH. significant or increasing proteinuria, progressive renal impairment, hypertension and if meet criteria; refer as appropriate
Frank haematuria: Hospitalisation 3 way catheter insertion VBG; check Hb, G+S Resus if unstable
2WW criteria for pelvic related cancers
Bladder or renal cancer: VH and unexplained haematuria with/without UTI or persists or recurs after successful treatment of UTI in patients >45 years
Bladder cancer: NVH and unexplained haematuria with dyuria or raised WCC in patients aged 60+
Endometrial cancer: VH with low haemoglobin levels or thrombocytosis or hyperglycaemia or unexplained vagainal discharge in women >55 years. Consider direct access USS
Prostate cancer: VH in men. Consider prostate specific antigen (PSA) est and PR exam.
Consider non-urgent referral for bladder cancer in ages >60 with recurrent or persistent unexplained UTI
dysuria
Pain on micturition
Lower UTI: urethritis - cystitis (dysuria is common in adult women)
STI: vaginitis - balanitis
Causes:
Abdominal causes can be appendicitis, ectopic pregnancy (irritation of nearby structures)
Urinary tract causes: UTI (urethritis eg chlamydia), kidney stones, malignancy, interstitial cystitis
Genital causes: trauma or foreign body, herpes simplex, vaginitis (vaginal candidiasis, atrophic vaginitis, bacterial vaginosis etc), prostatitis, epididymo-orchitis, epididymitis
Other: spondyloarthropathy or compression from pelvic mass
Irritants: drugs (NSAIDs), chemicals (soaps, contraceptives), mechanical (poorly fitted contraceptives), radiation or chemical exposure
dysuria presentation and history taking
Lower urinary tract symptoms:
Voiding symptoms: poor flow, hesitancy, post-micturition dribbling
Storage symptoms: frequency, nocturia, urgency, urge incontinence
History taking:
Pain: onset, duration, abdominal, radiation of pain (lion or back suggests UTI pathology)
Other symptoms: fever, malaise (pyelonephritis), haematuria (infection, stones, neoplasms, renal disease), urethral or vaginal discharge (genital tract infection), odour (bacterial), pruritus (genital candidiasis), frequency and urgency (bladder irritation), urine volume and flow (obstruction)
Possible pregnancy?
Past history of UTI, GU disease, pelvic surgery, irradiation, medications
Recent sexual history: method of contraception
Occupation: exposure to dyes and solvents risk factors for bladder cancer
investigations for dysuria
Physical examinations Urine dipstick, microscopy and culture Pregnancy test STI screening USS of urinary tract KUB Urodynamic studies Urine cytology Cystoscopy
frequency (urinary symptoms)
Vesical storage symptoms:
Frequency = frequent/more than usual (4-7/day) but usually total volume is normal or less than
Nocturia: most often due to too much drinking before bed or BPH (men >50)
Urgency = has no warning or little control
Causes of increased frequency: UTI Benign Prostatic Hyperplasia, prostatitis Urinary stone Pregnancy Diuretics Anxiety Urinary incontinence
polyuria overview
Excessive urine output >3L/d Common causes: Polydipsia Osmotic diuresis (hyperglycaemia, glycosuria) Diabetes insipidus Diuretics CKD
Polyuria vs frequency:
Important to differentiate between the two
In polyuria = total amount is increased
In frequency = number of episodes increases
Urinary frequency and polyuria can exist singular or co-exist
oliguria
Urine output <0.5 mL/kg/hour in children
<400mL/day adults
<0.1mL/kg/hr infants
Pathological causes:
Pre-renal: perfusion disorder (e.g. dehydration, vascular collapse or low CO) (70% cases)
Renal: renal parenchymal disease
Post-renal: urinary obstruction (most commonly blocked catheter)
oliguria history and investigations
Excessive fluid loss (diarrhoea, vomiting)
Drugs: NSAIDs, gentamicin
Gross haematuria and oedema (children) indicates glomerular disease or postinfectious glomerulonephritis
Symptoms of urinary tract obstruction: complete failure to pass urine (ANURIA) is medical emergency needs USS urgently
Investigations: Midstream specimen of urine (MSU) dipstick CRP Renal function and electrolytes Creatinine FBC ABG Renal USS with doppler Kidney biopsy PRN
oliguria management
Treat underlying cause
Fluid resus and catheterisation
Correct electrolyte imbalances
Surgery if secondary to obstructive cause
Prophylaxis of recurrent UTI
Nitrofurantoin immediate release 50-100mg OD at night or 100mg following exposure to trigger Trimethoprim 100mg OD at night or 200mg one dose following exposure to trigger Methenamine hippurate (HIPREX) broad spectrum cover
bladder carcinoma
90% are transitional cell carcinomas, 10% SCC
¾ cases are male
5 year survival rate is 55%
Majority of cases occur over aged 60
Uses TNM staging
Arise from endothelial lining (urothelium)
Bladder carcinoma risk factors
Increasing age
Smoking (50% cases caused by)
Occupational exposure to aromatic amines, polycyclic aromatic hydrocarbons and chlorinated hydrocarbons and dyes, paints, solvents etc
Radiation of pelvis
Squamous cell tumours causing chronic inflammation from stones or indwelling catheters
Presentation of bladder cancer
Most commonly haematuria (painless, usually visible)
Changes to pattern of urination (frequency, urgency)
If advanced: pelvic pain, general bone pain, weight loss, leg swelling
Metastatic disease: usually to lymph nodes, lung, liver, bone and CNS
Bladder cancer investigations and 2WW criteria
Urinalysis: if a patient presents with haematuria and infection, always follow up again once infection is treated to see if the haematuria is cleared also. Always send to the lab for NVH especially in males. MALES with haematuria is ALWAYS a RED FLAG
Abdominal exam
Bloods: FBC, eGFR, U+Es
Urine cytology
CT/MRI: T staging of tumour, node and metastases
Cystoscopy
White light-guided TURBT (specialist only)
Biopsy of prostatic urethra
2WW criteria:
In patients >45 YO
With unexplained VH without UTI
VH persisting of recurs after successful UTI treatment
>60YO with unexplained NVH and either dysuria or raised WCC on FBC
Management bladder cancer
Not invading the muscle
Transurethral Resection of a Bladder Tumour (TURBT)
Chemo into bladder after surgery (use barrier contraception afterwards)
Weekly treatments for 6 weeks with BCG vaccine squirted into the bladder via catheter, then every six months for 3 years.
Muscle-invasive bladder cancer
Radical cystectomy with ileal conduit
Radiotherapy (as neoadjuvant, primary treatment or palliative)
IV chemotherapy as neoadjuvant or palliative
Monitoring:
Follow up on completion of treatment
Those with low risk non invasive with no recurrence within 12 months discharged to primary care
Those with intermediate risk non invasive offered cystoscopy follow up at 3, 9 and 18 months and annually after
Those with high risk non invasive offered cystoscopy follow up every 3 months for first 2 years, then 6 months for two years then annually
renal cancer
60% cases are male
5 year survival rate is 55%
Types: Clear cell 75-90% Papillary 10% Chromophobe 5% Collecting duct carcinoma 1% Wilms tumour (children <5 years )
renal cancer risk factors
Smoking Obesity HTN Long term dialysis Von hippel-lindau disease
Renal carcinomas presentation and 2WW criteria
Often asymptomatic
Similar presentation to bladder cancer: Most commonly haematuria (painless, usually visible) Changes to pattern of urination (frequency, urgency)
May also present with back/flank pain at earlier stage
May have renal failure
Cannonball metastases in lungs are common
Vague loin pain
Non-specific symptoms of cancer (weight loss, fatigue, anorexia, night sweats)
Paraneoplastic features: polycythaemia (RCC secretes unregulated erythropoietin), hypercalcaemia (RCC secretes hormone mimics PTH) and stauffer syndrome (abnormal liver function tests demonstrate obstructive jaundice without any localised metastases)
2WW criteria:
45+ YO with VH persisting or recurring after UTI treatment
Unexplained haematuria without UTI
always review haematuria AFTER UTI treatment!!
Renal cancer investigations and management
Urine analysis Abdominal exam Bloods: FBC, U+E, eGFR Cystoscopy Urine cytology
Management:
Surgery (partial nephrectomy first line)
Radiotherapy and chemotherapy depending on disease stage
Prostate cancer and risk factors
Most common male cancer
Currently has no screening program
Tends to be more slow growing
Staging used is TNM
Risk factors: Increasing age Family history Black ethnicity Tall Use of anabolic steroids
Prostate cancer presentation and 2WW criteria
Frequency of urination Nocturia (>2 times per night raises suspicion) Hesitancy Straining or long time to wee Weak flow Haematuria in urine or semen Erectile dysfunction General cancer signs (weight loss, night sweats, fatigue, bone pain)
HOW TO DIFFERENTIATE FROM BPH
BPH will have bilateral smooth enlargement
Cancer will be lumpy, unilateral and craggy/one lobe will feel different to another in size and texture
2WW criteria: Any DRE suspicious texture/feel Erectile dysfunction VH Nocturia: urinary frequency: urgency or retention PSA high for age range
Prostate cancer investigations and grading
PSA: non-specific but good for monitoring
DRE: Cancer will be lumpy, unilateral and craggy/one lobe will feel different to another in size and texture
Prostate biopsy for definitive diagnosis
Gleason grading system: specific to prostate cancer, helps determine what treatment most appropriate. Higher grade = worse prognosis Gleason grading system: Well differentiated Moderately differentiated Moderately differentiated Poorly differentiated Anaplastic
Prostate cancer management and complications
Watch and wait in early stages
Radiotherapy directed at prostate
Brachytherapy: radioactive seeds implanted in prostate for continuous targeted delivery
Hormonal treatment: antiandrogen therapy to stop growth
Surgery - total prostatectomy
Complications of radial treatment: Erectile dysfunction Urinary incontinence Radiation induced enteropathy - GI symptoms like PR bleeding, pain, incontinence) Urethral strictures
testicular cancer and presentation
Peak age 30-35 YO
Most common male cancer between ages 16-24
5 year survival almost 100% very good prognosis
Seminome 50% cases, teratoma 50% cases, rarely other types.
Presentation:
Lump or enlargement in either testicle (usually non-tender), hard without fluctuance or transillumination, irregular
Feeling of heaviness in scrotum
Dull ache in abdomen or groin
Sudden collection of fluid in scrotum
Pain or discomfort in testicle or scrotum
Back pain
Metastases: Lymphatics Lungs Liver Brain
Testicular cancer investigations and 2WW criteria
Testicular examination
USS
Tumour markers: alpha-fetoprotein raised in teratomas, beta-hCG raised in both but more commonly teratomas, lactate dehydrogenase
2WW criteria:
Non painful testicular enlargement or change in shape
Consider direct USS in men with unexplained or persistent testicular problems
Testicular cancer management
Orchiectomy with testicular prosthesis
Chemotherapy or radiotherapy based on staging
Monitoring post treatment with tumour markers and imaging
Prognosis is good unless metastatic, slightly better for seminomas
Wilms tumour
Undifferentiated mesodermal tumors of intermediate cell mass (primitive renal tubules and mesenchymal cells)
Most common intra abdominal tumour of children
1 in 10,000 children affected, only 3% adults affected
10% cases associated with overgrowth syndromes: excessive prenatal and postnatal somatic growth and edwards syndrome (trisomy 18)
Hereditary wilms is uncommon, all are autosomal dominant caused by mutations in at least three genes
Staged I-V
Wilms tumour presentation
Usually in first five years of life 95% unilateral Asymptomatic abdominal mass Abdominal pain Haematuria UTI HTN Fever (uncommon) Advanced disease: respiratory symptoms from lung metastases
Wilms disease screening and investigations
Recommended for high risk children (family or associated conditions)
Surveillance by clinical geneticist carried out by renal USS every 3-4 months
Continue until 5 years old aside from beckwith-wiedemann syndrome, simpson-golabi-behmel syndrome and some familial wilms tumour pedigrees when should continue to 7 years old
Investigations: Bloods: FBC, eGFR, U+Es Urinalysis Genetic studies USS Renal angiography CT/MRI Renal biopsy Chest CT for metastases
