Urology

Question 1

An upper urinary tract obstruction (i.e. in the ureters) presents with:

Answer 1

Loin to groin or flank pain on the affected side (due to stretching and irritation of ureter and kidney).

Reduced or no urine output

Non-specific systemic symptoms, such as vomiting

Impaired renal function on blood tests (i.e. raised creatinine)

Question 2

Lower urinary tract obstruction (i.e. in the bladder or urethra) presents with:

Answer 2

Difficulty or inability to pass urine (e.g., poor flow, difficulty initiating urination or terminal dribbling)

Urinary retention, with an increasingly full bladder

Impaired renal function on blood tests (i.e. raised creatinine)

Question 3

Neurogenic bladder

Answer 3

Neurogenic bladder refers to abnormal function of the nerves innervating the bladder and urethra. It can result in overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra.

Multiple sclerosis

Diabetes

Stroke

Parkinson’s disease

Brain or spinal cord injury

Spina bifida

Question 4

How is urinary obstruction managed?

Answer 4

Management involves removing or bypassing the obstruction.

A nephrostomy may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone). A nephrostomy involves surgically inserting a thin tube through the skin at the back, through the kidney and into the ureter. This tube allows urine to drain out of the body, into a bag.

A urethral or suprapubic catheter may be used to bypass an obstruction in the lower urinary tract (e.g., a urethral stricture or prostatic hyperplasia). A urethral catheter is a tube, inserted through the urethra, into the bladder. A suprapubic catheter is a tube, inserted through the skin just above the pubic bone, directly into the bladder.

Question 5

Complications of obsturctive neuropathy to think about:

Answer 5

Pain

Acute kidney injury (post-renal)

Chronic kidney disease

Infection (from bacteria tracking up urinary tract into areas of stagnated urine)

Hydronephrosis (swelling of the renal pelvis and calyces in the kidney)

Urinary retention and bladder distention

Overflow incontinence of urine

Question 6

Read summary of hydronephrosis:

Answer 6

Hydronephrosis is swelling of the renal pelvis and calyces in the kidney. This occurs due to obstruction of the urinary tract, leading to back-pressure into the kidneys.

Idiopathic hydronephrosis is the result of a narrowing at the pelviureteric junction (PUJ) – the site where the renal pelvis becomes the ureter. This narrowing may be congenital or develop later. It can be treated with an operation to correct the narrowing and restructure the renal pelvis (pyeloplasty).

Typical presenting features of hydronephrosis are vague renal angle pain and a mass in the kidney area. It may be seen on an ultrasound, CT scan or intravenous urogram (x-ray with IV contrast collecting in the urinary tract).

Treatment of hydronephrosis involves treating the underlying cause. If required, pressure can be relieved with either:

Percutaneous nephrostomy – inserting a tube through the skin and kidney into the ureter, under radiological guidance

Antegrade ureteric stent – inserting a stent through the kidney into the ureter, under radiological guidance

Question 7

What medication should be started for an enlarged prostate and what are the side effects?

Answer 7

Tamsulosin - alpha blocker

The key side effect to remember is postural hypotension, leading to dizziness on standing or falls.

Question 8

In men with LUTS such as hesitancy and dribbling what initial investigations should be done?

Answer 8

Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate

Abdominal examination to assess for a palpable bladder and other abnormalities

Urinary frequency volume chart, recording 3 days of fluid intake and output

Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology

Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference

Question 9

OSCE style description of a benign prostate:

Answer 9

A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus.

Question 10

OSCE description of a cancerous prostate:

Answer 10

A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus

Question 11

Management of BPH

Answer 11

Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms.

5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate.

Question 12

What are the common side effects of medications used to treat BPH?

Answer 12

The notable side effect of alpha-blockers like tamsulosin is postural hypotension. If an older man presents with lightheadedness on standing or falls, check whether they are on tamsulosin and check their lying and standing blood pressure. The most common side effect of finasteride is sexual dysfunction (due to reduced testosterone).

Question 13

Read the surgical procedure used to manage BPH.

Answer 13

Transurethral resection of the prostate (TURP) is the most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra. A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms.

Question 14

Presentation of chronic prostatitis:

I’d just read the following flash cards on prostatitis.

Answer 14

Pelvic pain, which may affect the perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area

Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention

Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen)

Pain with bowel movements

Tender and enlarged prostate on examination (although examination may be normal)

Question 15

Presentation of acute bacterial prostatitis:

Answer 15

• Fever, myalgia, fatigue, sepsis.
• Pelvic pain, which may affect the perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area
• Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention
• Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen)
• Pain with bowel movements
• Tender and enlarged prostate on examination (although examination may be normal)

Question 16

Investigations of prostatitis:

Answer 16

• Urine dipstick testing can confirm evidence of infection.
• Urine microscopy, culture and sensitivities (MC&S) can identify the causative organism and the antibiotic sensitivities.
• Chlamydia and gonorrhoea NAAT testing on a first pass urine, if sexually transmitted infection is considered.

Question 17

Management of acute bacterial prostatitis:

Answer 17

• Hospital admission for systemically unwell or septic patients (for bloods, blood cultures and IV antibiotics)
• Oral antibiotics, typically for 2-4 weeks (e.g., ciprofloxacin, ofloxacin or trimethoprim)
• Analgesia (paracetamol or NSAIDs)
• Laxatives for pain during bowel movements

Question 18

Read summary of prostate cancer:

Answer 18

Prostate cancer is the most common cancer in men. It varies in how aggressive it is, and many prostate cancers are very slow-growing and do not cause death. Advanced prostate cancer most commonly spreads to the lymph nodes and bones. Prostate cancer is almost always androgen-dependent, meaning they rely on androgen hormones (e.g., testosterone) to grow. The majority are adenocarcinomas and grow in the peripheral zone of the prostate.

Question 19

How does prostate cancer present?

Answer 19

LUTS e.g hesitancy, frequency, weak flow, terminal dribbling and nocturia.

Haematuria

Erectile dysfunction

Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome).

Question 20

How is prostate cancer investigated?

Answer 20

DRE

PSA

MRI - can go on to guide a prostate biopsy.

Isoptope bone scan in cases of metastasis.

Question 21

Treatment of prostate cancer:

Answer 21

Surveillance or watchful waiting in early prostate cancer

External beam radiotherapy directed at the prostate

Brachytherapy

Hormone therapy

Surgery

Radical prostatectomy involves a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate. Key complications are erectile dysfunction and urinary incontinence.

Question 22

Define epididymo-orchitis:

Answer 22

Epididymitis is inflammation of the epididymis. Orchitis is inflammation of the testicle. Epididymo-orchitis is usually the result of infection in the epididymis and testicle on one side.

Question 23

What are the most common causes of epididymo-orchitis?

Answer 23

Escherichia coli (E. coli)

Chlamydia trachomatis

Neisseria gonorrhoea

Mumps

Question 24

In a patient with parotid gland swelling, and orchitis think what cause?

Answer 24

Think of mumps in patients with parotid gland swelling and orchitis. Mumps tends only to affect the testicle, sparing the epididymis. It can also cause pancreatitis.

Question 25

Presentation of epididymo-orchitis?

Answer 25

Epididymo-orchitis typically presents with a gradual onset, over minutes to hours, with unilateral:

• Testicular pain
• Dragging or heavy sensation
• Swelling of testicle and epididymis
• Tenderness on palpation, particularly over epididymis
• Urethral discharge (should make you think of chlamydia or gonorrhoea)
• Systemic symptoms such as fever and potentially sepsis

Question 26

What is an important differential not to miss with epididymo-orchitis?

Answer 26

The key differential diagnosis for epididymo-orchitis is testicular torsion. Testicular torsion is a urological emergency that requires rapid treatment to avoid the testicle dying. Both present similarly, with acute onset of pain in one testicle. If there is any doubt, treat it as testicular torsion until proven otherwise.

Question 27

Investigations for epididymo-orchitis:

Answer 27

Urine microscopy, culture and sensitivity (MC&S)

Chlamydia and gonorrhoea NAAT testing on a first pass urine

Charcoal swab of purulent urethral discharge for gonorrhoea culture and sensitivities

Saliva swap for PCR testing for mumps, if suspected

Serum antibodies for mumps, if suspected (IgM – acute infection, IgG – previous infection or vaccination)

Ultrasound may be used to assess for torsion or tumours

Question 28

Management of epididymo-orchitis:

Answer 28

Antibiotics and referral to GUM in cases of suspected STI.

Question 29

Testicular torsion

Answer 29

Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle. It is a urological emergency, and a delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility.

Question 30

How does testicular torsion present on examination?

Answer 30

Testicular torsion is often triggered by activity, such as playing sports. Ask what the patient was doing at the time when the pain started.

It presents with an acute rapid onset of unilateral testicular pain, and may be associated with abdominal pain and vomiting. Sometimes abdominal pain is the only symptom in boys, and testicular examination to exclude torsion is essential.

Examination findings are:

Firm swollen testicle

Elevated (retracted) testicle

Absent cremasteric reflex

Abnormal testicular lie (often horizontal)

Rotation, so that epididymis is not in normal posterior position

If in doubt, or if there is any suspicion of torsion, get an immediate senior urology opinion.

Question 31

Management of testicular torsion:

Answer 31

The management of testicular torsion involves:

• Nil by mouth, in preparation for surgery
• Analgesia as required
• Urgent senior urology assessment
• Surgical exploration of the scrotum
• Orchiopexy (correcting the position of the testicles and fixing them in place)
• Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis

Question 32

What investigation is diagnostic of testicular torsion and what will be seen in this investigation?

Answer 32

A scrotal ultrasound can confirm the diagnosis. However, any investigation that will delay the patient going to theatre for treatment is not recommended. Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.

Question 33

Summary of the causes of testicular lumps:

Answer 33

The key causes of scrotal or testicular lumps are:

Hydrocele

Varicocele

Epididymal cyst

Testicular cancer

Epididymo-orchitis

Inguinal hernia

Testicular torsion

Question 34

Description of a Hydrocele

Answer 34

A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes. They are usually painless and present with a soft scrotal swelling. The tunica vaginalis is a sealed pouch of membrane that surrounds the testes. Originally the tunica vaginalis is part of the peritoneal membrane. During the development of the fetus, it becomes separated from the peritoneal membrane and remains in the scrotum, partially covering each testicle.

Question 35

Causes of a hydrocele:

Answer 35

Hydroceles can be idiopathic, with no apparent cause, or secondary to:

• Testicular cancer
• Testicular torsion
• Epididymo-orchitis
• Trauma

Question 36

Management of hydroceles:

Answer 36

Management involves excluding serious causes (e.g., cancer). Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.

Question 37

Varicocele description:

Answer 37

A varicocele occurs where the veins in the pampiniform plexus become swollen. They are common, affecting around 15% of men. They can cause impaired fertility, probably due to disrupting the temperature in the affected testicle. They may result in testicular atrophy, reducing the size and function of the testicle.

Question 38

Pathophysiology of a varicocele (just read).

Answer 38

The pampiniform plexus is a venous plexus, which is found in the spermatic cord and drains the testes. The pampiniform plexus drains into the testicular vein. It plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery. The testicles need to be at an optimum temperature for producing sperm.

Varicoceles are the result of increased resistance in the testicular vein. Incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus.

The right testicular vein drains directly into the inferior vena cava. The left testicular vein drains into the left renal vein. Most varicoceles (90%) occur on the left due to increased resistance in the left testicular vein. A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma.

Question 39

Presentation of varicocele and findings on examination:

Answer 39

Varicoceles may present with:

Throbbing/dull pain or discomfort, worse on standing

A dragging sensation

Sub-fertility or infertility

Examination findings are:

A scrotal mass that feels like a “bag of worms”

More prominent on standing

Disappears when lying down

Asymmetry in testicular size if the varicocele has affected the growth of the testicle

Question 40

What finding on examination would warrant further investigation and why?

Answer 40

Varicoceles that do not disappear when lying down raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.

Question 41

Investigation carried out in varicoeles:

Answer 41

Varicoceles that do not disappear when lying down raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.

Investigations to consider are:

Ultrasound with Doppler imaging can be used to confirm the diagnosis

Semen analysis if there are concerns about fertility

Hormonal tests (e.g., FSH and testosterone) if there are concerns about function

Question 42

Varicocele - read the management:

Answer 42

Uncomplicated cases can be managed conservatively.

Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.

Question 43

Epididymal cyst

Answer 43

Epididymal cysts occur at the head of the epididymis (at the top of the testicle). A cyst is a fluid-filled sac. An epididymal cyst that contains sperm is called a spermatocele. Management of epididymal cysts and spermatoceles is identical.

Epididymal cysts are very common in adults, occurring in around 30% of men. Most cases are asymptomatic. Patients may present having felt a lump, or they may be found incidentally on ultrasound for another indication.

Question 44

Examination finding of an epididymal cyst:

Answer 44

• Soft, round lump
• Typically at the top of the testicle
• Associated with the epididymis
• Separate from the testicle
• May be able to transilluminate large cysts (appearing separate from the testicle)

Usually, they are entirely harmless and are not associated with infertility or cancer. Occasionally, they may cause pain or discomfort, and removal may be considered. Exceptionally rarely, there may be torsion of the cyst, causing acute pain and swelling.

Question 45

Types of testicular cancer:

Answer 45

Testicular cancer can be divided into two types:

Seminomas

Non-seminomas (mostly teratomas)

Question 46

Risk factors or testicular cancer:

Answer 46

• Undescended testes
• Male infertility
• Family history
• Increased height

Question 47

How do testicular cancers present?

Answer 47

The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain.

• The lump will be:
• Non-tender (or even reduced sensation)
• Arising from testicle
• Hard
• Irregular
• Not fluctuant
• No transillumination

Rarely, gynaecomastia (breast enlargement) can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour. About 2% of patients presenting with gynaecomastia have a testicular tumour.

Question 48

What investigations are done to investigate testicular cancer?

Answer 48

Scrotal ultrasound is the usual initial investigation to confirm the diagnosis.

Tumour markers for testicular cancer are:

Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)

Beta-hCG – may be raised in both teratomas and seminomas

Lactate dehydrogenase (LDH) is a very non-specific tumour marker

A staging CT scan can be used to look for areas of spread and to stage the cancer.

Question 49

Read managment of testicular cancers:

Answer 49

Depending on the grade and stage of testicular cancer, treatment can involve: (MDT guided)

Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted

Chemotherapy

Radiotherapy

Sperm banking to save sperm for future use, as treatment may cause infertility

Question 50

What is the prognosis of testicular cancers?

Answer 50

The prognosis for early testicular cancer is good, with a greater than 90% cure rate. Metastatic disease is also often curable. Seminomas have a slightly better prognosis than non-seminomas.

Patients will require follow-up to monitor for reoccurrence. This usually involves monitoring tumour markers, and may include imaging such as CT scans or chest x-rays.

Question 51

LUTI

Answer 51

Lower urinary tract infections (UTIs) involve infection in the bladder, causing cystitis (inflammation of the bladder). They can spread up to the kidneys and cause pyelonephritis.

♦

The primary source of bacteria for urinary tract infections is from the faeces. Normal intestinal bacteria, such as E. coli, can easily make the short journey to the urethral opening from the anus. Sexual activity is a crucial method for spreading bacteria around the perineum. Incontinence or poor hygiene can also contribute to the development of UTIs.

Urinary catheters are a key source of infection, and catheter-associated urinary tract infections tend to be more significant and challenging to treat.

Question 52

Lower UTI symptoms

Answer 52

Lower urinary tract infections present with:

• Dysuria (pain, stinging or burning when passing urine)
• Suprapubic pain or discomfort
• Frequency
• Urgency
• Incontinence
• Haematuria
• Cloudy or foul smelling urine
• Confusion is commonly the only symptom in older and frail patients

Question 53

Suspect pyelonephritis in patients that have what symptoms?

Answer 53

Fever

Loin/back pain

Nausea/vomiting

Renal angle tenderness on examination

Question 54

Urine dipstick analysis

Answer 54

Nitrites – gram-negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites. The presence of nitrites suggest bacteria in the urine.

Leukocytes are white blood cells. It is normal to have a small number of leukocytes in the urine, but a significant rise can result from an infection or other cause of inflammation. Leukocyte esterase is tested on a urine dipstick, which is a product of leukocytes and indicates the number of leukocytes in the urine.

Red blood cells in the urine indicate blood. Microscopic haematuria is where blood is identified on a urine dipstick but not seen when looking at the sample. Macroscopic haematuria is where blood is visible in the urine. Haematuria is a common sign of infection but can also be present with other causes, such as bladder cancer or nephritis.

Question 55

When to ask for a MSU:

Answer 55

A midstream urine (MSU) sample sent for microscopy, culture and sensitivity testing will determine the infective organism and the antibiotics that will be effective in treatment. Not all patients with an uncomplicated UTI require an MSU. This is important in:

Pregnant patients

Patients with recurrent UTIs

Atypical symptoms

When symptoms do not improve with antibiotics

Question 56

When is nitrofurantoin containdicated?

Answer 56

In patients with a GFR less than 45

Question 57

Pregnant women with UTI’s are at increased risk of what?

Answer 57

Urinary tract infections in pregnancy increase the risk of pyelonephritis, premature rupture of membranes and pre-term labour.

Question 58

Read summary on antibiotics in pregnancy:

Answer 58

Urinary tract infection in pregnancy requires 7 days of antibiotics. All women should have an MSU for microscopy, culture and sensitivity testing.

The antibiotic options are:

Nitrofurantoin (avoid in the third trimester)

Amoxicillin (only after sensitivities are known)

Cefalexin

Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).

Trimethoprim needs to be avoided in the first trimester as it works as a folate antagonist. Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.

Question 59

Presentation of pyelonephritis:

Answer 59

Patients have a similar presentation to lower urinary tract infections (i.e. dysuria, suprapubic discomfort and increased frequency) plus the additional triad of symptoms:

• Fever
• Loin or back pain (bilateral or unilateral)
• Nausea / vomiting

Patients may also have:

• Systemic illness
• Loss of appetite
• Haematuria
• Renal angle tenderness on examination

Question 60

Pyelonephritis can lead to sepsis, recount the sepsis 6.

Answer 60

Three tests:

• Blood lactate level
• Blood cultures
• Urine output

Three treatments:

• Oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD)
• Empirical broad-spectrum IV antibiotics (according to local guidelines)
• IV fluids

Question 61

Interstitial cystitis

Answer 61

Interstitial cystitis is a chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called bladder pain syndrome and hypersensitive bladder syndrome.

There is no simple explanation for the symptoms, and the pathophysiology is likely a complex combination of various factors, including dysfunction of the blood vessels, nerves, immune system and epithelium.

It is much more common in women than men. It can have a significant impact on quality of life and mental health.

Question 62

How does interstitial cystitis present?

Answer 62

The symptoms are similar to a lower urinary tract infection, but are more persistent.

The typical presentation is more than 6 weeks of:

• Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
• Frequency of urination
• Urgency of urination

Question 63

Investigations for interstitial cystitis:

Answer 63

Other causes of symptoms need to be excluded, with:

• Urinalysis for urinary tract infections
• Swabs for sexually transmitted infections
• Cystoscopy for bladder cancer
• Prostate examination for prostatitis, hypertrophy or cancer

Question 64

Note:

Hunner lesions, seen during cystoscopy, are a finding in 5-20% of patients with interstitial cystitis. These are red, inflamed patches of the bladder mucosa associated with small blood vessels.

Granulations are another finding during cystoscopy in patients with interstitial cystitis. These are tiny haemorrhages on the bladder wall.

Answer 64

Hunner lesions, seen during cystoscopy, are a finding in 5-20% of patients with interstitial cystitis. These are red, inflamed patches of the bladder mucosa associated with small blood vessels.

Granulations are another finding during cystoscopy in patients with interstitial cystitis. These are tiny haemorrhages on the bladder wall.

Question 65

Management of interstitial cystitis:

Answer 65

Interstitial cystitis is a complex condition with complex treatments. You certainly don’t need to remember all the treatments, and they are unlikely to be tested in medical school exams. Just keep it in mind as a differential diagnosis and be generally aware of the investigations (including cystoscopy) and treatment options.

Supportive management, oral meds, vesical meds, hydrodistension, surgical intervention.

Question 66

Risk factors for bladder cancer:

Answer 66

Smoking and increased age are the main risk factors for bladder cancer.

Aromatic amines are worth noting as a carcinogen that causes bladder cancer. Aromatic amines were used in dye and rubber industries but have been heavily regulated or banned for many years. They are also found in cigarette smoke and seem to be the reason smoking causes bladder cancer.

Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.

Question 67

Top tip:

Answer 67

The typical presentation to look out for in your exams is a retired dye factory worker with painless haematuria. Whenever an exam question mentions a patient’s occupation, it is almost certainly relevant and will tell you the diagnosis. Dye factory workers get transitional cell carcinoma of the bladder. Patients with asbestos exposure get mesothelioma. Outdoor workers with significant sun exposure get skin cancer.

Question 68

2 week wait guidelines for bladder cancer:

Answer 68

Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:

Dysuria or;

Raised white blood cells on a full blood count

Question 69

How is bladder cancer diagnosed?

Answer 69

Cystoscopy (a camera through the urethra into the bladder) can be used to visualise bladder cancers. The cystoscope can be rigid or flexible. Cystoscopy can be performed under local or general anaesthetic.

Question 70

Read treatments of bladder cancer:

Answer 70

MDT

Transurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.

Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.

Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.

Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder, there are several options for draining urine:

Urostomy with an ileal conduit (most common)

Continent urinary diversion

Neobladder reconstruction

Ureterosigmoidostomy

Chemotherapy and radiotherapy may also be used.

Question 71

Different types of kidney stone:

Answer 71

Calcium-based stones are the most common type of kidney stone (about 80%). Having a raised serum calcium (hypercalcaemia) and a low urine output are key risk factors for calcium collecting into a stone. There are two types of calcium stones:

Calcium oxalate (more common)

Calcium phosphate

Other types of kidney stones include:

Uric acid – these are not visible on x-ray

Struvite – produced by bacteria, therefore, associated with infection

Cystine – associated with cystinuria, an autosomal recessive disease

Question 72

Staghorn calculus

Answer 72

Most commonly, this occurs with stones made of struvite. In recurrent upper urinary tract infections, the bacteria can hydrolyse the urea in urine to ammonia, creating the solid struvite.

Question 73

Kidney stones symptoms:

Answer 73

Renal colic is the presenting complaint in symptomatic kidney stones. Renal colic is:

• Unilateral loin to groin pain that can be excruciating (“worse than childbirth”).
• Colicky (fluctuating in severity) as the stone moves and settles.
• Haematuria
• Nausea or vomiting
• Reduced urine output
• Symptoms of sepsis, if infection is present

Question 74

Gold standard initial investigation for diagnosing kidney stones:

Answer 74

CT of KUB

Question 75

Investigations for kidney stones:

Answer 75

• Urine dipstick usually shows haematuria in cases of kidney stones. A normal urine dipstick does not exclude stones. Urine dipsticks are also helpful to exclude infection.
• Blood tests help establish signs of infection and also kidney function. Checking the serum calcium helps identify hypercalcaemia that may have caused the kidney stone.
• An abdominal x-ray can show calcium-based stones, but uric acid stones will not show up (they are radiolucent).
• Non-contrast computer tomography (CT) of the kidneys, ureters and bladder (CT KUB) is the initial investigation of choice for diagnosing kidney stones. The NICE guidelines (2019) recommend a CT within 24 hours of the presentation.
• Ultrasound of the kidneys, ureters and bladder (ultrasound KUB) is a less preferred alternative to CT scan. A negative result does not exclude kidney stones. It is less effective at identifying kidney stones but is helpful in pregnant women and children.
• Stones can be analysed to determine the type, which can help establish the cause and reduce the risk of recurrence.

Question 76

Kidney stones may present with what our features (linking to the most common cause of kidney stones)?

Answer 76

Remember hypercalcaemia as a cause of kidney stones. You can remember the presentation of hypercalcaemia with the mnemonic “renal stones, painful bones, abdominal groans and psychiatric moans”.

Question 77

What are the three main causes of hypercalcemia?

Answer 77

The three causes to remember are:

• Calcium supplementation
• Hyperparathyroidism
• Cancer (e.g., myeloma, breast or lung cancer).

Question 78

What are the main treatments for kidney stones?

Answer 78

• NSAIDs are the most effective type of analgesia, for example, intramuscular diclofenac. IV paracetamol is an alternative, where NSAIDs are not suitable. Opiates are not very helpful for pain management and are not routinely used.
• Antiemetics are used for nausea and vomiting (e.g., metoclopramide, prochlorperazine or cyclizine).
• Antibiotics are required if infection is present.
• Watchful waiting is usually used in stones less than 5mm, as there is a 50-80% chance they will pass without any interventions. It may also be suitable for patients with stones 5-10mm, depending on individual factors. It can take several weeks for the stone to pass.
• Tamsulosin (an alpha-blocker) can be used to help aid the spontaneous passage of stones.
• Surgical interventions are required in large stones (10mm or larger), stones that do not pass spontaneously or where there is complete obstruction or infection.

Question 79

One episode of renal stones predisposes patients to further episodes.

What advice do NICE give to reduce risk of kidney stones?

Answer 79

Increase oral fluid intake (2.5 – 3 litres per day)

Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)

Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)

Reduce dietary salt intake (less than 6g per day)

Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)

Question 80

What is the classic triad of symptoms for renal cell carcinoma?

Answer 80

Renal cell carcinoma (RCC) is the most common type of kidney tumour. It is a type of adenocarcinoma that arises from the renal tubules.

The classic triad of presentation is haematuria, flank pain and a palpable mass.

Question 81

Types of renal cell carcinoma:

Answer 81

Clear cell (around 80%)

Papillary (around 15%)

Chromophobe (around 5%)

Wilms’ tumour is a specific type of tumour affecting the kidney in children, typically under 5 years.

Question 82

What are the causes of cannon ball metastasis?

Answer 82

Renal cell carcinoma, they can also appear with choriocarcinoma (cancer in the placenta) and, less commonly, with prostate, bladder and endometrial cancer.

Question 83

What paraneoplastic syndromes are renal cell cancers associated with?

Answer 83

Polycythaemia – due to secretion of unregulated erythropoietin.

Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone / also caused by bone mets.

Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression.

Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis.

Question 84

Management of renal cell carcinoma:

Answer 84

Surgery to remove the tumour is the first-line, where possible. This may involve:

• Partial nephrectomy (removing part of the kidney)
• Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland

Where patients are not suitable for surgery, less invasive procedures can be used to treat the cancer:

• Arterial embolisation, cutting off the blood supply to the affected kidney
• Percutaneous cryotherapy, injecting liquid nitrogen to freeze and kill the tumour cells
• Radiofrequency ablation, putting a needle in the tumour and using an electrical current to kill the tumour cells
• Chemotherapy and radiotherapy may also be used.

Question 85

Common side effects of immunosuppressant medications e.g those used following renal transplant.

Answer 85

Immunosuppressants often cause seborrhoeic warts and skin cancers (look for scars from skin cancer removal)

Tacrolimus causes a tremor

Cyclosporine causes gum hypertrophy

Steroids cause features of Cushing’s syndrome

Question 86

Skim the complications following renal transplant:

Answer 86

Complications

Complications relating to the transplant:

• Transplant rejection (hyperacute, acute and chronic)
• Transplant failure
• Electrolyte imbalances

Complications related to immunosuppressants:

• Ischaemic heart disease
• Type 2 diabetes (steroids)
• Infections are more likely, more severe and may involve unusual pathogens
• Non-Hodgkin lymphoma
• Skin cancer (particularly squamous cell carcinoma)

Unusual infections can occur secondary to immunosuppressant medication, such as:

• Pneumocystis jiroveci pneumonia (PCP/PJP)
• Cytomegalovirus (CMV)
• Tuberculosis (TB)