Urological Diseases Flashcards
List causes of hematuria
- Bladder cancer -> painless
- Renal cancer
- UTI
- Urinary tract stone disease
- Prostate disease
- Nephrological disease
- No known cause
What investigations would be used in urological diseases?
- Cystoscopy, upper tract scan (except in females suspected of UTI) if ≥ 45y
- Check GFR, BP, Urine protein excretion in those ≤ 45y
What is the pathophysiology of bladder cancer?
Smoking, dye industry
5th most common cancer
1/3 are invasive but most need local treatment
Investigations: Cystoscopy, kidney CT scan with X-ray contrast (2-5% risk of infection with Cystoscopy)
Treatment: Cystectomy, radiotherapy
What is the pathophysiology of UTI?
- Simple or complex (2º causes: tumour, stone)
- MSU culture + sensitivities
- Some require prophylactic treatment
What investigations can be used in lower UTI?
Since it commonly affects males, should rule out benign prostatic hyperplasia by looking at serum PSA measurements
- Looking for leukocytes + nitrites in the urine
Tx: Cephalexin
Describe acute urinary retention, causes and treatment
Usually affects old men, painful, and catheterisation is required to relieve discomfort
In history:
- Gradually worsening void symptoms
- Recent infection (burning, swelling, UTI)
- Visible hematuria + clots -> bladder tumour
- Neurological (back pain -> cauda equine syndrome - disc prolapse compression) -> spinal decompression, needed urgently
- MS -> urinary symptoms 2nd most common presentation
- Period irregularities, abdo pain/bloating
- Recent new meds - >anticholinergics, opioids
- Bowel habits (constipation)
Exam:
- Tachycardic
- Pelvic mass (dull to percussion) = bladder retention
- Assess perineal + perianal sensation
- Assess prostate size for prostate cancer
500-1000ml retention = acute retention after measuring residual V after catheterisation.
- Check PSA, urine dipstick, Pelvic ultrasound, MRI for cauda equina
What condition classically presents as painless frank hematuria?
Bladder cancer
UTI and Stone Disease tend to cause dysuria + renal colic respectively so are not painless
How would you investigate a 60y old man with painless visible hematuria?
MSU - rule out infection
U&E - investigate renal disease
Flexible Cystoscopy - rule out bladder tumour
CT urogram - exclude renal + ureteric tumours + stone disease
Serum PSA - rule out prostate cancer
Name upper urinary tract and lower urinary tract causes of hematuria
Upper Urinary Tract:
- Renal cancer
- Upper tract urothelial cancer
- Renal stones
- UTI
- Renal trauma
- Intrinsic renal (nephrological) disease
Lower Urinary Tract:
- UTI
- Bladder cancer
- Bladder stone
- Locally advanced prostate cancer
- Radiation cystitis
- Bladder/urethral trauma
- Schistosomiasis
Name the investigations for hematuria and the reason for their use
- Blood tests -> FBC, U&E, PSA, markers of renal disease, Urine tests (MSU, ACR/PCR)
- Renal tract US -> renal masses and whether they’re solid or cystic
- Flexible Cystoscopy -> Excellent visualisation of lower urinary tract; gold standard for bladder cancer diagnosis
- CT scan -> Further define abnormalities seen on US; for some high risk patients if other tests are normal but have visible hematuria
What should be noted about the following:
Hematuria with proteinuria
Asymptomatic non-visible hematuria
Hematuria with proteinuria -> more likely to represent nephrological disorder
Asymptomatic non-visible hematuria -> especially in young (≤45y) patients who don’t smoke is very unlikely to be due to malignancy and such patients do not require a Cystoscopy unless other risk factors are present
What is the definition of microscopic hematuria?
> 5 RBC/high power field on microscopy
What are the causes of red urine?
- Hemoglobin
- Myuoglobin
- Beetroot
- Drugs (rifampicin)
- Porphyrins -> metabolites of inherited metabolic conditions
Name 6 origins of hematuria
- Renal (glomerulus)
- Collecting system (papillae/calyces)
- Ureter
- Bladder
- Prostate
- Urethra
Consider perineal bleeding/hemospermia
What are the differential diagnoses for bilateral loin pain?
- Renal stone disease -> stones, obstruction, infection
- Renal tumours -> benign tumour (angiomyolipoma); malignant tumour (renal cell carcinoma)
- Infection
- Trauma (i.e. from biopsy)
- Enlarged kidneys (Polycystic kidney diseases, Obstruction - Papillary necrosis, ureteric/bladder tumour)
- Glomerular hematuria (IgA nephropathy)
What should be asked in the history for loin pain?
- Blood in the urine?
- Type of pain (colic - obstruction of urinary tract, hyper-peristalsis of smooth muscle cells, dull ache - pain within kidney or stretching of renal capsule)
- Fever
- Weight loss
- Smoking
- Occupational exposure (i.e. dyes)
- Medication (aspirin, NSAIDs, cyclophosphamide) -> papillary necrosis, malignancy
- PMH (i.e. HTN, TB, DXT, procedures)
- FH (Polycystic kidney disease, VHL, TS)
- Examination (flank mass, PV, PR if malignancy is high on list)
What imaging should be requested for loin pain + hematuria?
- KUB X-ray
- Anatomy of urinary tract
- Shows anything leading to calcification of urinary tract (note phlebolith is normal) - Intravenous Pyelogram (IVP0
- If suspecting a stone perform this to determine if ureters are obstructed
- Assesses drainage of kidneys (can contrast empty out into bladder) and function of kidneys
- Also allows surgeons to assess access - Ultrasound
- Should be echogenic and homogenous within
- Useful for looking at kidney architecture - CT scan urography
- Identifying stones - MRI
- Looking at urinary tract - Angiography
- If suspicious of bleeding
- Used if need to undergo embolisation - Nuclear Imaging
- Renogram (differential function, obstruction)
Discuss urological stones in detail
- Pain (colic), hematuria, infection
- Present in 3rd-5th decade
- Males> females
Causes:
- Metabolic (50%) -> Type 1 RTA, hyperparathyroidism, sarcoidosis, Crohn’s disease, cystinuria -> increase Ca2+ levels
- Urological (20%)
- Infection (15%)
- Immobilization (5%)
What are the urological stones composition?
- 75% calcium oxalate
- 10% struvite “staghorn” -> associated with recurrent bacterial infections
- 10% urate “radiolucent” -> only seen in US/CT NOT Xray b/c radiolucent
What is the medical management of stones?
- Increasing fluid intake to reduce solute load
- Dietary modification (decreased animal protein, Na, sugar, oxalate)
- Treat infection
- Alkalinise urine (to dissolve urate stones)
- Specific medical therapies:
1. Bendroflumethazide (hypercalciuria)
2. Allopurinol (hyperuricosuria)
3. Penicillamine (cystinuria)
When is surgical management needed for stones?
If the stone is > 8mm as more likely to become trapped in urinary tract
- Extracopereal shock wave lithotripsy (ESWL)
- Ureteroscopic
- Percutaneous
- Laparoscopic
- Open operation
(From most simple to most severe operation)
What is the pathophysiology of kidney tumours?
Benign:
- Angiomyolipomas -> embolisation = tx
- Oncocytoma
Malignant:
- Renal cell carcinoma (80%)
- Transition cell carcinoma
What is the pathophysiology of Renal cell carcinoma?
- 3% adult malignancy
- Male:female (2:1)
- 4th to 6th decade (unless genetic cause)
Clinical features/triad: hematuria, pain, mass
Metastatic disease/paraneoplastic syndromes
Management:
- Surgical for respectable disease
- Medical for metastatic disease = immunotherapy
What is the pathophysiology of transitional cell carcinoma?
- common
- presentation (hematuria, pain, lower urinary tract symptoms)
- males > females
- > 45y
Risk factors:
- Smoking
- Cyclophosphamide
- Schistosomiasis
- Radiotherapy
- Occupational exposure (dyes)
Management:
- Surgical resection (radical) -> removing whole bladder, create new bladder with bowel
- Intravesical chemotherapy
What is papillary necrosis?
Necrosis and shedding of medullary papillae
Risk factors:
- Analgesia (acetaminophen, NSAIDs)
- Diabetes
- Sickle cell disease
- Infection
Papillae may cause obstruction and pyonephrosis
Urgent drainage and antibiotic treatment essential!
What are kinds of cystic kidney diseases?
Congenital (multicystic dysplastic kidneys)
Simple cysts
Acquired cystic disease (age/end stage renal disease)
Inherited syndromes - Polycystic kidneys
- ADPKD (autosomal dominant), ARPKD (autosomal recessive - child onset), Medullary cystic kidney diseases (presents in childhood)
- Tuberous sclerosis (present with multiple angiomyelopomas)
- Von Hippel Linda
What is the pathophysiology of ADPKD?
Commonest genetic renal disease (1:800 births)
Autosomal dominant (PKD1, PKD2)
10% endstage renal failure population
Approx 50% reach ESRD by age 60y
Cysts may develop from antenatal -0 adulthood with slowly enlarging kidneys Extrarenal cysts (in liver, pancreas, spleen, Berry aneurysms - ask about SAH in family, miral valve prolapse, ?diverticuli)
Investigations:
- Ultrasound (multiple fluid filled cysts with irregular lining of kidneys)
- CT scan (multiple cysts with enlarged kidneys bilaterally + extrarenal cysts)
Management:
- Monitoring renal function (kidney size)
- Family screening
- High morbidity secondary to cardiovascular disease
- Blood pressure control from childhood is essential
- Possible therapies under trial:
1. Vasopressin antagonists
2. MTOR inhibitors
3. Somatostatin analogues - No role for surgical/radiological decompression
- Nephrectomy occasionally necessary for severe pain + poor function
What is the pathophysiology of Von Hippel-Lindau disease (VHL)?
Autosomal dominant (3p25-26)
1:36000
20% familial
80-100% penetrance/delayed expressively
Usually 2nd-3rd decade onset
Present with array of malignancies in CNS, retina, and kidneys:
- CNS hemangioblastoma
- Retinal angioma
- Renal lesions
Renal manifestations:
cortical renal cysts (75%)
Bilateral, multi centric renal cell carcinoma (20-45%)
Hemangioblastoma, renal cell adenoma, renal hemangioblastoma
Screening:
- Asymptomatic patients (Annual USS, CT abdomen every 3y unless multiple cysts)
- At risk relatives (CT abdomen every 3y age 20-65y)
What is the pathophysiology of glomerular hematuria?
History:
- Known hypertension, proteinuria
- Recent URTI
- Systemic symptoms (i.e. rash, joint pain, weight loss)
Investigations:
- Proteinuria
- Renal impairment
- HTN
- Dysmorphic red cells/red cell casts
- Renal biopsy
- IgA nephropathy (Beurger’s disease - episodes of relapsing hematuria + pain triggered by URTI)
Describe renal colic
Renal colic = due to a stone obstructing the ureter
- Very painful
Symptoms/signs:
- Loin to groin pain, severe and of a colicky nature
- N/V
- Occasionally lower urinary tract symptoms (frequency, urgency) if stone in lower ureter
- Hematuria (but not usually visible)
- Signs of tachycardia, dehydration but should NOT be pyrexial or have localised peritonism
Common differential diagnoses:
- Urological -> pyelonephritis
- Gynae -> ectopic pregnancy, torted ovarian cyst
- Gastro -> appendicitis, diverticulitis
- HPB -> pancreatitis, cholecystitis
- Vascular -> ruptured AAA
- Misc -> MSK pain
Diagnostic tests:
- Bloods: FBC, U&E, Ca2+, CRP
- Urine: 85% +ve hematuria + to exclude UTI + pregnancy (urine bHCG)
- Diagnostic imaging: Non-contrast CT scan of abdo/pelvis; 70% of stones visible on KUB X-ray; ultrasound may reveal hydronephrosis
Management:
- Analgesia
- Hydration
- Stones ≤ 5mm: usually pass spontaneously, patient should be treated expectantly with analgesia + followed up with imaging in 2weeks
- Stones ≥ 5mm: will not usually pass, treatment within 1-2weeks should be planned; shockwave lithotripsy (SWL) or ureteroscopy (URS)
NB:
- If patient is pyrexial -> possible pyonephrosis
- Solitary kidney/bilateral stones/ reduced renal function/intractable pain despite analgesia -> stent or nephrostomy may be required to decompress kidney immediately
What are the 5 different kidney stone compositions?
- Calcium oxalate (65-80%)
- Oxalate is a metabolic byproduct and found in various foodtypes
- Stones are radio-opaque (seen on X-ray)
- Envelope-shaped crystals under microscope
- Predisposition: primary hyperoxaluria, inflammatory bowel disease, bowel resection
- Urine pH usually acidic
- Patients can be advised to reduce dietary oxalate intake (chocolate, rhubarb, spinach, nuts, tea etc) - Calcium Phosphate (10-15%)
- Stones radio-opaque (seen on X-ray)
- May respond poorly to lithotripsy due to density
- Predisposition: primary hyperparathyroidism, renal tubular acidosis
- Urine pH usually alkaline
- Dietary calcium restriction is NOT helpful usually
- Thiazide diuretics in pt with hypercalciuria may be helpful - Struvite (10-15%)
- Triple phosphate (magnesium ammonium phosphate) or infection stones
- Strongly associated with UTIs with organisms that produce urease enzymes (proteus species, Klebsiella, Ureaplasma, Serratia, Enterobacter)
- Associated with neuropathic bladders/presence of catheters in urinary tract
- Urease generates ammonium from urea
- May form huge “staghorn” stones
- “Coffin-lid” shaped crystals on microscopy - Uric Acid (5-10%)
- Uric acid is a product of purine metabolism + is highly insoluble in acidic urine
- Stones are radiolucent (cannot be seen on X-ray)
- Predisposition: obesity, DM, high purinergic intake, gout, tumour lysis after chemotherapy
- May be treated by urinary alkalinisation by oral potassium citrate or sodium bicarbonate - Cystine (1%)
- Rare AR disorder resulting in high concert rations of cystine in urine
- Faintly opacifying stones
- Hexagonal crystals under microscope
- Suspect if multiple stone episodes in young patients
- More soluble in alkaline urine
- May be treated by hydration, urinary alkalinisation, and cheating agents such as penacillamine or captopril
How do UTIs usually present?
Far more common in women than men because the shorter length of the female urethra allows bacteria from the vagina to enter the bladder relatively easily, especially after sexual intercourse. They are more common in post-menopausal than pre-menopausal women because the altered hormonal conditions after the menopause abuse an alteration in the normal vaginal bacterial flora that normally compete with pathological bacteria.
Lower UTIs often described by patients as “cystitis” present with increased urinary frequency and urgency accompanied by dysuria. Patient may experience Frank hematuria + may feel systemically unwell
Sometimes the infection can spread upwards to involve the kidney causing an upper UTI which is commmonly referred to as “pyelonephritis”. This often begins with symptoms of lower UTI followed by gradually increasing loin pain that is usually unilateral. Patient is often pyrexial + feels systemically unwell
What investigations are needed for UTIs?
- Urine dipstick test
- Presence of nitrite (bacterial breakdown product), leukocytes, blood, and protein suggests an infection
- MSU sample should then be sent to the lab for microscopy, culture, and sensitivity analysis (takes 48h)
- For UTI to be diagnosed - MSU sample must contain > 100 000 bacteria + WBC/ml
Pts presenting with loin pain + pyrexia that is likely to be pyelonephritis must have a dipstick test + blood cultures taken + an MSU sent to the lab
- Should have immediate upper tract imaging (either CT or ultrasound) to exclude a pyonephrosis (obstructed, infected kidney usually caused by a ureteric stone) because this condition can cause severe sepsis unless decompressed urgently with a nephrostomy tube
Other differential diagnoses for those who look visibly unwell + loin pain:
- Appendicitis
- Pelvic inflammatory disease
- Ruptured AAA
Which are the commonest causes of UTIs and which antibiotics are used to treat them?
Simple Lower UTIs:
- 3D course of antibiotics
- Trimethoprim, cephalexin, nitrofuratoin
Pyelonephritis + pyrexia:
- 24-48h IV gentamicin or temocillin
- Followed by 10D course of oral antibiotics (local guidelines)
What is the definition of recurrent UTIs?
More than 3 episodes of infection/yr
If UTIs are troublesome then they can be treated with long term low dose prophylactic antibiotics
Alternatively, advised to take 1 antibiotic tablet after sex if this is the causative factor or they can “self-start” a 3D course of antibiotics at onset of infective symptoms
Post menopausal ladies are often helped by topical vaginal application of estrogen creams
How is bladder cancer graded and staged?
Grading:
- Grade 1 = least aggressive/most well differentiated histologically
- Grade 2 = intermediate
- Grade 3 = most aggressive/least well differentiated histologically
Staging:
- Stage pTa = tumour cells confined to the epithelium
- Stage cis (carcinoma in situ) = aggressive cells confined to the epithelium, usually flat tumour
- Stage T1 = tumour cells in sub-epithelial connective tissue
- Stage T2/3 = tumour cells in bladder wall muscle
- Stage T4 = tumour cells in adjacent organs such as the prostate or uterus
What is the normal epithelium of the bladder?
Transitional epithelium
Typical malignant changes:
- Hyperdense nuclei
- Nuclear polymorphism
- Overlap of nuclear membranes
- Absence of cellular differentiation
What questions are asked in the international prostate symptom score?
- Incomplete emptying sensation
- Frequency less than every 2h
- Intermittency of stream
- Urgency (difficult to postpone urination)
- Weak stream
- Straining to start urinating
- Getting up at night to urinate
1-7 = mild 8-19 = moderate 20-35 = severe
What is recommended if the PSA is elevated (> 4ng/ml or > 4.5ng/ml in those over 60y)?
- Prostate US
- Prostate biopsy
- Check PSA in 3 mo time
What is ureteric colic?
When stone drops from kidney into ureter. Ureter goes into spasm to push stone along = pain
Ureter has 3 arrows that are narrowed (pelvi-ureter junction, as it crosses iliac vessels, vesico-ureter junction) = characteristic places where stones are found
- Severe 10/10 pain
- Loin to groin pain
- Colickly pain
- N/V
- visible hematuria (not common)
- storage LUTS (urgency, frequency, stranguleria)
Risk factors: previous renal stone
Frequently misdiagnosed:
- Pyelonephritis (bacterial infection of renal cortex, ascending infection from bladder usually E. coli; very severe flank pain starts with LUTI; systemically unwell - fever + rigours)
- Appendicitis
- Diverticulitis
- Ectopic pregnancy (life-threatening)
- Ruptured AAA
- Acute Cholecystitis
- Acute Biliary colic
- Acute Pancreatitis
Clinical Signs:
- Tachycardia
- Dehydration
- Apyrexic
- Non peritonitic (b/c kidneys are retroperitoneal)
What must be monitored when writing a prescription for piperacillin/tazobactam and gentamicin?
eGFR because both drugs are dosed according to renal function and are renally excreted
What is not a first line investigation for a 65y old male presenting with painless frank hematuria?
Urine cytology
Usually reserved for patients with recurrent hematuria where initially investigations have been negative or especially high risk patients - for example if they have had previous bladder cancer
What is the approximate chance of an asymptomatic man with a serum PSA reading of 7ng.ml and a normal DRE having a prostate cancer diagnosed on one set of trans recital prostate biopsies?
20%
Most patients with a mildly raised PSA have non-cancer causes for the abnormal PSA result such as a significant amount of benign prostatic hyperplasia or a recent urine infection
According to NICE guidelines which management strategy should be discussed first with a fit 58y old man who is found to have Gleason score 6 prostate cancer in 2/12 prostate biopsy cores and has a serum PSA of 5ng/ml and a normal feeling prostate on DRE?
Active surveillance
Which of the following is the best initial management for a 70y old male who presents with a 6mo history of poor urinary flow + increased nocturnal urinary frequency who has an IPSS score of 12 and a quality of life score of 4? He has a small, benign freezing prostate and a PA of 3.5ng/ml normal U+E and a clinically empty bladder
An alpha adrenoreceptor blocker
- THis patient’s symptoms are typical of bladder outflow obstruction and alpha blockade is probably the best management for patients with moderate symptoms (as per the IPSS result) of obstruction
Which management option is not appropriate as a next step for a patient who has just had a transurethral bladder tumour resection? The tumour was fully respected and the pathology report from the operation states “transitional cell carcinoma stage pT2 grade 3”. CT scans have shown no spread of the cancer beyond the bladder.
Intravesical BCG therapy
This treatment is useful for patients with superficially invasive (stage pT1) bladder tumour but is ineffective if there is muscle invasion (stage pT2)
A 35y old lady with a previous history of ureteric stone disease presents with a 2d history of severe loin pain. Her temperature is 39ºC, pulse 130 and BP 80/50. Her urine contains nitrite and leukocytes on dipstick. After fluid resuscitation and intravenous antibiotics what should you do next?
An urgent ultrasound scan to exclude pyonephrosis (infected urine behind an obstructing ureteric stone). If pyonephrosis is diagnosed then the management of choice is nephrostomy tube insertion if available and technically possible
