Urology Flashcards
What are the risk factors for bladder cancer?
Smoking, increased age, aromatic amines (dye + rubber carcinogens), schistosomiasis (squamous cell cancer of bladder)
What are the histological types of bladder cancer?
- Transitional cell (90%)
- Squamous cell cancer (5%)
- Others-> adenocarcinoma, sarcoma, small-cell
How does bladder cancer typically present?
- Painless haematuria
- Dysuria
What is the 2-week wait criteria for bladder cancer?
- Age 45 or over-> unexplained visible haematuria without UTI or after treatment for UTI
- Age 60 or over-> microscopic haematuria + dysuria or raised WCC on FBC
What is the non-urgent referral criteria for bladder cancer?
Aged 60 or over with recurrent UTI
How is bladder cancer diagnosed?
Cystoscopy (rigid or flexible)-> visualise
How is bladder cancer staged?
TMN staging for non-muscle invading + muscle invading
- Tis/carcinoma in situ-> only urothelium + flat
- Ta-> only urothelium + projects into bladder
- T1-> invades connective tissue beyound urothelium
- T2-T4-> muscle invasive + lymph nodes/mets involvement
How is bladder cancer treated?
- Transurethral resection of bladder tumour (TURBT)-> when non-invasive
- Intravesical chemo-> after TURBT to recude recurrence
- Intravesical BCG vaccine-> stimulate immune system to attack tumours
- Radical cystectomy with urostomy + ileal conduit-> continent urinary diversion (intermittent catheter needed), neobladder reconstruction, ureterosigmoidoscopy
What is the most common type of kidney tumour?
Adenocarcinoma of renal tubules
What are the different types of renal cell carcinoma?
- Adenocarcinoma of renal tubules
- Clear cell (80%)
- Papillary
- Chromophobe
- Wilm’s tumour-> in kids under 5
How does renal cell carcinoma present?
- Triad of haematuria + flank pain + palpable mass
- Non-specific cancer signs
- Paraneoplastic features-> polycythaemia, hypertension, hypercalcaemia, Stauffer’s syndrome
What is the 2-week wait criteria for renal cell carcinoma?
Aged 45+ with unexplained visible haematuria without UTI or after UTI treatment
What are the risk factors for renal cell carcinoma?
Smoking, obesity, hypertension, renal failure, tuberous sclerosis, Von Hippel-Lindau disease
Where do renal cell carcinomas metastasise to?
- Gerota’s fascia + tissues around kidney-> via renal vein + IVC
- Lungs-> cannonball mets ie circulat opacities
What might cannonball mets on a CXR be a sign of?
Renal cell carcinoma
What are the paraneoplastic features of renal cell carcinoma?
- Polycythaemia-> unregulated erythropoietin production
- Hypercalcaemia-> secretes hormones mimicing PTH
- HTN-> increased renin
- Stauffer’s syndrome-> abnormal LFTs without liver mets
How is renal cell carcinoma staged?
TMN system with CT-TAP
- Stage 1-> <7cm + kidney only
- Stage 2-> >7cm + kidney only
- Stage 3-> local spread to tissues/veins not beyond Gerota’s fascia
- Stage 4-> beyond Gerota’s fascia including mets
How is renal cell carcinoma managed?
- Surgery-> partial or radical nephrectomy +/- tissues
- Arterial embolisation-> cut off supply to kidney
- Percutaneous cryotherapy-> liquid nitrogen to kill cells
- Radiofrequency ablation
- Chemo or radiotherapy
What are the different indications for a urinary catheter?
- Urinary retention-> obstruction
- Neurogenic bladder
- Surgery
- Output monitoring when acutely unwell
- Bladder irrigation-> wash out blood clots
- Delivery of chemo for bladder cancer
- Post-void bladder scan-> may need if >500mls after emptying attempt
What should be used to monitor a patient during TWOC (trial without catheter)?
- Urine output
- Bladder scanner
How should a sample be collected when a catheter-associated UTI is suspected?
- Directly from catheter or via sample port with aseptic technique
- Catheter bag may be contaminated as not sterile
How are catheter-associated UTIs managed?
- No symptoms-> no antibiotics needed
- Symptoms-> 7 days oral or IV antibiotics eg amoxicillin/nitro/trimethoprim (depending on severity)
What is obstructive uropathy?
- Blockage preventing urine flow through ureters, bladder and urethra
- Can lead to back pressure + hydronephrosis, vesicoureteral reflux, post-renal AKI
Where would you expect to find renal angle tenderness?
Costovertebral angle-> between 12th rib + vertebral column-> where lower kidneys are
How does upper obstructive uropathy present?
- Loin-to-groin or flank pain on affected side
- Reduced/no urine output
- Impaired renal function-> raised creatinine
- Systemic-> vomiting etc
How does lower obstructive uropathy present?
- Difficulty passing urine-> poor flow, difficulty initiating
- Urinary retention
- Impaired renal function-> raised creatinine
What are the causes of upper obstructive uropathy?
Kidney stones, tumours, ureter strictures, retroperitoneal fibrosis, bladder cancer, ureterocele (ballooning- often congenital)
What are the causes of lower obstructive uropathy?
BPH, prostate cancer, bladder cancer, urethral strictures, neurogenic bladder
What is neurogenic bladder?
Abnormal nerve function leads to detrusor under/overactivity + urethral sphincters-> can lead to urge incontinence, increased bladder pressure + obstructive uropathy
What causes neurogenic bladder?
MS, stroke, brain or spinal cord injury
How is obstructive uropathy managed?
- Remove or bypass obstruction
- Urethral or suprapubic catheter-> lower obstruction bypassed
- Nephrostomy-> drain urine
What are the potential complications of obstructive uropathy?
Pain, AKI, CKD, infection, hydronephrosis, retention, overflow incontinence
What is hydronephrosis?
Swelling of renal pelvis + calyces in kidney
What causes hydronephrosis?
- Obstructive uropathy-> BPH, prostate cancer, bladder cancer, urethral strictures, neurogenic bladder
- Idiopathic-> narrow PUJ, congenital etc
What are the features of hydronephrosis?
Renal angle tenderness + palpable mass
How is hydronephrosis investigated?
- US
- CT
- IV urogram-> Xray with contrast
How is hydronephrosis managed?
- Percutaneous nephrostomy
- Antegrade ureteric stent
- Pyeloplasty-> if narrow PUJ
What is benign prostatic hyperplasia (BPH)?
Hyperplasia of the stromal + epithelial cells of the prostate
What are the lower urinary tract symptoms (LUTS)?
FUNWISED-> frequency, urgency, nocturia, weak flow, intermittency, straining, emptying incomplete, dribbling
What are the symptoms of benign prostatic hyperplasia (BPH)?
LUTS ie FUNWISED-> frequency, urgency, nocturia, weak flow, intermittency, straining, emptying incomplete, dribbling
How is benign prostatic hyperplasia (BPH) assessed/investigated?
- Symptoms + international prostate symptom score (IPSS)-> for severity
- DRE-> shape, size, character
- Abdominal exam-> bladder
- PSA blood test
- Urinary dipstick-> infection + haematuria etc
- Urinary frequency volume chart-> 3 days of input/output
What are the potential reasons for a raised PSA (prostate specific antigen) test?
Prostate cancer, BPH, prostatitis, UTI, vigorous exercise, recent stimulation
What are some of the problems surrounding getting a PSA (prostate specific antigen) test?
- Can prompt invasive investigations + complications-> 75% false positives
- Can lead to false reassurance-> 15% false negatives
What might a prostate cancer feel like on DRE?
Firm/hard, arymmetrical, craggy, irregular, loss of sulcus
How is benign prostatic hyperplasia (BPH) managed?
- None if mild + manageable symptoms
- Tamsulosin-> alpha-blocker to relax smooth muscle
- Finasteride-> 5-alpha reductase inhibitor
- Transurethral resection of prostate (TURP)-> remove some via diathermy loop + make room for urine flow
- Other surgery-> transurethral electrovaporisation of prostate (TEVAP/TUVP), open prostatectomy
What are the potential complications of transurethral resection of prostate (TURP)?
Incontinence, erectile dysfunction, retrograde ejaculation, urethral strictures
How does tamsulosin work?
Alpha blocker-> relaxes smooth muscle in prostate
How does finasteride work?
5-alpha reductase inhibitor-> enzyme converts testosterone to dihydrotestosterone so when inhibit this leads to reduction in size of prostate
What type of prostate cancer is the most common?
Adenocarcinoma of the peripheral zone
What are the risk factors for prostate cancer?
Older age, family history, Black African or Caribbean, anabolic steroids
How does prostate cancer present?
- Asymptomatic
- LUTS-> frequency, urgency, nocturia, weak flow, intermittency, straining, emptying incomplete, dribbling
- Haematuria
- Erectile dysfunction
- Mets symptoms-> weight loss, bone pain etc
What is prostate specific antigen?
- Produced by epithelial cells of the prostate
- To thin semen
- Glycoprotein secreted in semen + small amount enters blood
What is considered a normal PSA level?
<4ng/mL
How does the Gleason scoring system for prostate cancer work?
- Based on histology
- Greater score-> poorly differentiated + worse prognosis
- 2 numbers-> grade of most prevalent pattern + 2nd most prevalent
- Scores-> <6 (low risk), 7 (intermediate), 8+ high
What are renal stones usually made out of?
- Calcium oxalate
- Calcium phosphate
- Uric acid
- Struvite-> eg staghorn calculus
- Cystine
What is a staghorn calculus?
Renal stone that forms in the shape of the renal pelvis-> usually struvite made from bacteria in infection
How do renal stones present?
- Asymptomatic
- Renal colic-> unilateral severe loin-to-groin pain, fluctuate in severity
- Restless, N+V, haematuria, reduced urine output, sepsis signs
How are renal stones investigated?
- Non-contrast CT-KUB within 24 hours-> gold standard
- Urine dip-> haematuria
- Bloods-> infection, U+Es, serum calcium
- AXR-> may show calcium-based stones
- US-KUB-> good for kids + pregnancy
- Analyse type-> cause + risk of recurrence
What are the risk factors for renal stones?
- Dehydration
- Low urine output
- Hypercalcaemia-> calcium stones
Where do renal stones usually get stuck + cause symptoms?
- Vesico-ureteric junction
- Ureters
How are renal stones managed?
- Supportive-> diclofenac (IM/rectal), IV paracetamol, antiemetics, antibiotics if needed
- If <5mm-> likely pass on own so watchful waiting
- If >10mm or obstruction/infection-> surgical eg lithotripsy or nephrolithotomy
What are the surgical management options for renal stones?
- Extracorporeal shock wave lithotripsy-> break up stone under X-ray so easy to pass
- Ureteroscopy + laser lithotripsy
- Percutaneous nephrolithotomy-> break up + remove stones under GA via nephroscopy, my keep nephrostomy in
- Open surgery-> uncommon
How are recurrent renal stones prevented?
- 2.5-3L fluid a day
- Lemon juice to water-> binds to urinary calcium
- Reduce salt
- Depends on type-> less oxalate rich foods eg spinach (calcium), less purine rich eg sardines (uric acid)
- Meds for calcium stones-> potassium citrate, indapamide
What is prostatitis?
Inflammation of the prostate
- Acute-> bacterial
- Chronic-> >3 months
What are the different types of chronic prostatitis?
- Chronic prostatitis or chronic pelvic pain syndrome-> no infection but inflammation persists
- Chronic bacterial prostatitis-> infection persists
How does chronic prostatitis present?
3+ months of…
- Pelvic pain-> perineum, testicles, rectum, suprapubic
- LUTS-> frequency, dysuria, hesistancy, retention
- Sexual dysfunction-> erectile, pain, haematospermia
- Pain on bowel movement
- Tender + enlarged prostate on exam
How does acute bacterial prostatitis present?
Acute history of…
- Pelvic pain-> perineum, testicles, rectum, suprapubic
- LUTS-> frequency, dysuria, hesistancy, retention
- Sexual dysfunction-> erectile, pain, haematospermia
- Pain on bowel movement
- Systemic-> fever, myalgia, nausea
- Tender + enlarged prostate on exam
How are the investigations for prostatitis?
- Scoring tool for chronic-> severity + QoL
- Urine dip-> infection
- Urine MC&S-> organism + sensitivities
- 1st pass urine for STI NAAT testing
How is acute prostatitis managed?
- Admit if unwell
- Oral antibiotics-> 2-4 weeks of ciprofloxacin or ofloxacin or trimethoprim
- Analgesia + laxatives
How is chronic prostatitis managed?
- Alpha blockers (tamsulosin)-> relax smooth muscle
- Analgesia, laxatives, CBT
- Antibiotics-> if <6 months of infection give trimethoprim/doxycycline for 4-6 weeks
What are the complications of prostatitis?
Sepsis, abscess (eg fluctuant mass), acute retention, chronic prostatitis
What warrants a 2 week wait referral for prostate cancer?
- Examination shows firm, asymmetrical, craggy, irregular prostate, may lose central sulcus or feel nodules
- PSA levels above age-specific reference range
What is the Linkert scale for prostate cancer and what are its different stages?
- Based on result from multiparametric MRI
- Likelihood of suspected localised prostate cancer
- Very low suspicion (1), low (2), equivocal (3), probable (4), definite (5)
When is a suspected prostate cancer biopsied?
Linkert scale result of 3 or more after multiparametric MRI
How is prostate biopsy performed?
- Use multiple needles to reduce risk of false negative
- Transrectal US-guided-> through rectum wall into prostate
- Transperineal-> use local anaesthetic
- Risks-> pain, bleeding, infection, urinary retention (short term swelling), erectile dysfunction
What are the different TMN stages for prostate cancer?
- Tx-> unable to assess
- T1-> too small to be felt on exam or see on scan
- T2-> contained in prostate
- T3-> extends out of prostate
- T4-> spread to nearby organs
- Nodes-> unable to asess (Nx), none (N0), spread (N1)
- Mets-> M0 (none) or M1 (some)
What investigations may be performed when prostate cancer is suspected?
- Examination
- Serum PSA
- Multiparametric MRI-> for Linkert scale score
- Prostate biopsy-> when Linkert score 3+
- Gleason grading-> based on histology + help with treatment decisions
- TNM staging
- Isotope bone scan-> for mets
What are the treatment options for prostate cancer?
- Surveillance or watchful waiting
- External beam radiotherapy + prednisolone (reduce inflammation
- Brachytherapy-> continuous radiotherapy via implanted metal seeds
- Hormones-> androgen receptor blockers (bicalutamide) or GnRH agonists (eg gosrelin ie Zoladex)
- Bilateral orchidectomy-> hormone therapy
- Radical prostatectomy-> may be curative
What are some of the complications/side effects of external beam radiotherapy treatment for prostate cancer?
Proctitis ie pain, altered bowel habit, bleeding
What are some of the complications/side effects of brachytherapy treatment for prostate cancer?
- Inflammation in nearby organs
- Erectile dysfunction
- Bladder + rectal cancers
What are some of the complications/side effects of hormone therapy treatment for prostate cancer?
Hot flushes, sexyal dysfunction, gynaecomastia, osteoporosis
What are some of the complications/side effects of radical prostatectomy treatment for prostate cancer?
Erectile dysfunction, urinary incontinence
What is epididymo-orchitis?
Infection of epididymis + testicle-> usually unilateral
What can cause epididymo-orchitis?
E.coli, Chlamydia trachomatis, N.gonorrhoea, mumps
What is the anatomy of the testicle and epididymis?
- Epididymis at back of testicle
- Sperm from testicle-> head of epididymis (at top)-> head-> body-> tail-> drain to vas deferens
- Sperm matures + stored in epididymis
How does epididymo-orchitis present?
- Gradual onset-> unilateral pain, dragging/heavy, swelling, tender
- Urethral discharge-> think STI
- Systemic-> fever, sepsis
- Torsion is important differential-> treat as this until proven otherwise
How is epididymo-orchitis diagnosed?
- Torsion is important differential-> treat as this until proven otherwise
- Ultrasound-> if suspect torsion or tumour
- STI more likely-> <35, multiple sexual partners, urethral discharge
- Urine MC&S
- 1st pass urine STI test (NAAT)
- Charcoal swab or discharge
- Saliva swab-> PCR for mumps
- Serum antibodies-> IgG/IgM for mumps
How is epididymo-orchitis managed?
- If low risk of STI-> ofloxacin 14 days 1st line
- Analgesia, supportive underwear, abstain from sex
What are the potential complications of epididymo-orchitis?
Chronic pain + infection, testicular atrophy, sub/infertility, scrotal abscess
What are quinolone antibiotics (eg ciprofloxacin) used for and why?
- UTIs, pyelonephritis, epididymo-orchitis, prostatitis
- Broad spec + give good gram negative cover
What are the side effects of quinolone antibiotics (eg ciprofloxacin)?
- Lowers seizure threshold
- Tendon damage + rupture-> especially Achilles
What is testicular torsion?
Surgical emergency-> twisting of spermatic cord + rotation of testicle
Who typically gets testicular torsion?
Teenagers but can be any age
How does testicular torsion present?
- Often after activity/sport
- Acute + rapid unilateral pain
- Abdominal pain + vomiting
- Examination-> firm + swollen, elevated/retracted, absent cremasteric reflex, horizontal lie, rotation
What is Bell-Clapper deformity?
- Normal fixation between tunica vaginalis and posterior testicle absent
- Testicle horizontal + able to rotate at cord-> twist vessels and cut off supply
- Can cause testicular torsion
How is testicular torsion managed?
- NBM, analgesia + urgent senior urology review
- Scrotal US-> whirlpool sign (spiral appearance to cord + BVs)
- Surgery within 6 hours-> exploration, orchiopexy (correct + fix), orchidectomy (if necrosis/delay)
What is the typical sign for testicular torsion on ultrasound?
Whirlpool sign-> spiral appearance to cord + BVs
What is a hydrocele?
Collection of fluid in tunica vaginalis (sealed membrane pouch surrounding the testes)
What is the tunica vaginalis?
- Sealed membrane pouch surrounding the testes
- Originally from peritoneal membrane-> separates + covers testes in foetal development
How does hydrocele present?
- Painless, fluctuant + soft scrotal swelling
- Can feel testicle within
- Irreducible + no bowel sounds
- Transilluminates
What are the causes of hydrocele?
Idiopathic, testicular cancer, epididymo-orchitis, trauma
How is hydrocele managed?
- Rule out serious causes (eg TC)
- Conservative
- Surgery
- Aspiration
- Scleopathy
What is a varicocele?
Veins of the pampiniform plexus (in spermatic cord) swell due to increased resistance in testicular vein
What is the role of the pampiniform plexus?
- Venous drainage of testes into testicular vein
- Regulates temperature of blood entering the testes by absorbing head from the testicular artery
What is the pathophysiology of a varicocele?
- Increased resistance in testicular vein-> blood flow back into pampiniform plexus
- Can be due to incompetent valve
- Left sided may be renal cell carcinoma-> left testicular vein drains into left renal artery (obstruction-> backlog)
What might a left-sided varicocele indicate and why?
- Renal cell carcinoma
- Left testicular vein drains into left renal artery (obstruction-> backlog)
How does varicocele present?
- Throbbing/dull pain, dragging, worse on standing
- Sub/infertility
- Exam-> asymmetrical, ‘bag of worms’ scrotal mass, more prominent on standing, disappear when lie down
If a varicocele doesn’t disappear when the patient lies down, what might that indicate?
Retroperitoneal tumour-> obstruction to renal vein drainage
How is varicocele investigated?
- Examination
- US doppler
- Semen analysis + hormone tests if concerns
How is varicocele managed?
- Conservative if uncomplicated
- If complications-> surgery, endovascular embolisation
What are the potential complications of varicocele?
Impaired fertility, atrophy (affect size + function)
What is an epididymal cyst?
- Fluid-filled sac at head of epididymis
- If contains sperm-> spermatocele
- Very common
How do epididymal cysts present?
- Asymptomatic or incidental finding on US
- May have felt lump
- Exam-> soft round lump, top of testicle, separate from testicle, may transilluminate if large
How are epididymal cysts managed?
- Usually leave alone
- Surgical removal if painful
- Can sometimes cause torsion
What age group is testicular cancer most common in?
15-35 years
What are the two types of testicular cancer?
- Seminomas
- Non-seminomas (eg teratomas)
What cell type do the majority of testicular cancers arise from?
Germ cells in testes (produce gametes)
How does testicular cancer present?
- Lump-> painless, from testicle, hard, irregular, non-fluctuant, no transillumination
- Common mets-> lymphatics, lungs, liver, brain
- Gynaecomastia-> with Leydig cell tumours
How is testicular cancer investigated?
- Examination
- Scrotal US
- Staging CT
- Tumour markers-> b-hCG, AFP (teratomas only), LDH (non-specific)
What is the Royal Marsden staging system and what are its different stages?
Staging system for testicular cancer
- 1-> isolated to testicle
- 2-> spread to retroperitoneal lymph nodes
- 3-> spread to lymph nodes above diaphragm
- 4-> mets to other organs
How is testicular cancer treated?
- Chemotherapy
- Radiotherapy
- Radical orchidectomy +/- prosthesis
- Sperm banking
- Follow up-> tumour markers, CTs, CXRs
What are the side effects of treatment for testicular cancer?
Infertility, hypogonadism (may need testosterone replacement), peripheral neuropathy, hearing loss, kidney/liver/heart damage, increased risk of other cancers
What is the prognosis of testicular cancer?
- 90% cure when treated early
- Can cure mets
- Seminomas have better prognosis
What is interstitial cystitis?
AKA bladder pain syndrome of hypersensitive bladder syndrome-> chronic inflammation due to dysfunction of nerves, BVs, immune system and epithelium
Who is interstitial cystitis more common in?
Women
How does interstitial cystitis present?
- Persistent lower UTI for 6+ weeks
- Suprapubic pain-> worse with full bladder + better when empty
- Frequency + urgency
- Symptoms worse during menstruation
How is interstitial cystitis investigated?
- Urinalysis
- STI swabs
- Cystoscopy-> Hunner lesions (red and inflamed lesions) + granulations (haemorrhages)
- Prostate exam if indicated
What might be seen on cystoscopy when a patient has interstitial cystitis?
- Hunner lesions (red and inflamed lesions)
- Granulations (haemorrhages)
How is interstitial cystitis managed?
- Pelvic floor exercises
- Bladder retraining
- Transcutaneous electrical nerve stimulation-> TENS
- Analgesia
- Anticholinergics-> oxybutynin or solifenacin
- Mirabegron-> beta-3 adrenergic receptor antagonist
- Ciclosporin-> immunosuppression
- Intravesical meds-> lidocaine, hyaluronic acid, botox
- Hydrodistention-> fill bladder with water during cystoscopy (under GA)
- Cauterise Hunner lesions
