Urology Flashcards
1
Q
What is the surgical treatment for renal stones?
A
Nephoscopy, to remove stones
2
Q
Define Acute Urinary retention?
A
- painful inability to void
- followed by relief of pain on catherization: may be an alternative cause to the pain if it isn’t relieved from this
- <1L of urine in the bladder (acute)
- May be a bladder outflow obstruction (BOO) or contractility problem?
3
Q
What may cause Bladder outflow obstruction?
A
- BPH
- Prostate cancer
- Stricture
- urethral stone
- Clot retention
- pelvic organ prolapse
- UTI/abscess
4
Q
What would cause a contractility problem in the bladder?
A
- Drugs
- antimuscarinics and benzodiazepine opiates
- Pain
- Cord compression
- MS
- cord compression effecting bladder control
- Diabetes
- Post-op
- UTI
5
Q
What Initial assessments would be carried out when presenting with Acute urinary retention?
what would you expect to see?
A
- History
- Clinical examination (abdo, neuro, DRE)
- Temperature
- Urinalysis
- Bladder scan
- IV access?
- FBC / UEs
6
Q
What is the treatment for acute urinary retention?
A
- Insert catheter
- Urethral
- suprapubic
- Record residual volume
- Midstream urine cultures (MSU)/ blood cultures +/- antibiotics
- Admit if pain is severe or if there is renal impairment
7
Q
Define Chronic Urinary Retention
A
- Painless inability to void
- May present with ‘acute on chronic retention’
- May present with nocturnal incontinence alone
- high pressure
- > 1L urine in bladder
- Two types; high pressure or low pressure
8
Q
Explain what Haematuria is and it’s causes
A
- Blood in the urine - microscopic or macroscopic
- non-visible and visible → associated with more sinister pathologies than non-visible
- Usually not an emergency
- only when a significant amount of blood is released enough to cause clots where the patient goes into clot retention
- clots can block the urethra causing patient to go back into urinary retention
- Urine dip detects haem, myoglobin, porphyrins – microscopy is needed
- non-visible
- Causes of bleeding
- Tumour (24% in macro, <5% in microscopic)
- Infection
- cystitis (Lower UTI) , pylo nephritis (Upper UTI)
- Trauma
- Stones
9
Q
What are important features to pick out in a history that involves haematuria
A
- Where in the stream is the blood
- malignant cause/ systemic cause/nephrological cause/ infective cause
- Associated urinary symptoms
- History of Trauma?
- Employment/ Social history
- barber sprays in 80’s (bladder cancer), textiles, rubber manufacturing
- smoking history (cause not risk factor) - cause of bladder cancer
10
Q
What investigations would you carry out to investigate haematuria?
A
- Bloods – FBC / UEs / PSA? / Coag? / G+S
- Urine – dip / m,c&s / cytology
- Imaging – US+KUB / CT Urogram
- Cystoscopy
- camera through the urethra into the bladder
11
Q
What imaging modality is this and what does it show?
A
Bladder cancer - CT
12
Q
What imaging modality is this and what does it show?
A
Bladder cancer - cystoscopy
13
Q
Which haematuria patients would be admitted to the hospital vs investigated as an outpatient?
A
Outpatient investigation
- Microscopic and voiding
- Macroscopic and voiding
Admit
- Macroscopic and anaemia
- Macroscopic and clot retention
- Haemodynamically compromised
14
Q
What is the Etiology of Renal trauma?
A
- Occurs in 8-10% of abdominal trauma
- Blunt 90% - crushes kidney against ribcage
- Penetrating 10%
- 80% associated with other abdominal visceral injury
- 95% of isolated renal injuries are minor
15
Q
What signs would indicate Renal Trauma?
A
- Loin or abdominal bruising
- Cullen’s sign (rare)
- Loin tenderness
- Loss of loin contour
- Loin mass
- Macroscopic haematuria / clots
16
Q
What is the management for Renal Trauma?
A
- ABCDEs
- Resuscitate the patient
- Other associated injuries may prove fatal first
- Imaging - defines the extent of the injury
- triple phase CT (pre-contrast, venous, arterial)
- Graded from (least sever) I-V(most severe)
- Mainly conservative - bed rest, 5/7 antibiotics
- More sever grades require intervention
- Surgical: nephrectomy
- Radiological: arterial embolisation
17
Q
Explain what Torsion is?
A
- Tunica Vaginalis layer moves proximally far into the posterior aspect of the testicle : Bell clapper deformity
- This makes the testicles more likely to spin in the horizontal axis
- causes spermatic cords and vas deferens where vessels are to coil up, causing ischaemia
18
Q
What are differentials for scrotal pain?
A
- Testicular Torsion
- Torsion of the Hydatid of Morgagni/testicular appendix
- Epididymitis
- Orchitis
19
Q
How does Testicular Torsion Present?
A
- Twisting of spermatic cord and thus testicular artery; ischaemic pain
- Acute onset of painful testicle
- Nausea / vomiting
- Lower abdo pain
- Horizontal lie of testicle on examination
- and high lying in scrotum
- may be red and inflamed initially
20
Q
What is the management of testicular torsion?
A
- Testicle may die within 4-6 hours
- Scrotum to be explored as soon as possible surgically
- Assess the severity of the twist and if the testicle is viable
- untwist and see if it perfuses (pale white) - but it back inside scrotum otherwise must be removed
- The other testes must be fixed, Bell clapper deformity likely to be on the opposite side
21
Q
What is the sign/presentation of Hydatid of Morgagni?
What is the management?
A
- Blue dot sign
- Excise lesion as soon as possible
- when presenting would still take to theatres to rule out testicular torsion otherwise can be treated conservatively with
- Anti-inflammatory’s
- Painkillers
- Antibiotics (rarely)
22
Q
What is the presentation of Epididymo-orchitis?
What is the treatment?
A
- Treat with antibiotics
- <35 y/o - more concerned for STI
- > 35 y/o - more concerned for for UTI
- may have a history of repeat infections
- may need to be explored, if diagnosis is unsure (TT?)
- if patient is more than 35 less likely to be testicular torsion as most torsion happens in those will bell Clapper and would have likely caught it before the age of 35.
23
Q
Explain what Phimosis and what is the management for it?
A
-
Phimosis: the inability to retract the foreskin
- by the age of 16 only 1% of population expected to have a tight foreskin
- means foreskin is tight enough that it cannot be retracted behind the glans → the ability to retract allows for ejaculation during intercourse
- can be caused by Balanitis xerotica obliterans: chronic disease can also cause urethral stenosis
- Both managed with circumcision
24
Q
What is Paraphimosis and what’s the mangement?
A
-
Paraphimosis: when a tight foreskin retracts behinds the glands and gets stuck
- this is an emergency
- longer it remains there it tightens around the penile shaft obstructing venous return and eventually arterial flow → necrosis of the gland
- common in catheterised patients; when foreskin not repositioned
- Managed by: reducing it
- Gentle manual retraction, place thumbs on the glans and hold the ring → perform a traction-counter traction maneuver (most common way to relieve a paraphimosis)
- Dundee method -local anesthetic, no adrenaline (no collateral blood supply as they are end digit terminal arteries)
- Surgical release if the above fails
25
What are key epidemiological points in the population presenting with renal stones?
* Prevalence
* Developed western populations 5-20%
* Age
* Peaks 20-40 yrs
* Sex M\>F 3:1
* becoming closer (2 & a bit to 1)
* 35,000 vs 16,000 completed episodes
* HES data 2005/6
* Less urinary oxalate Oestrogen protects vs Test promotes
* Ethnicity
* White\>Hispanic\>Asian\>African American
26
What are the risk factors for developing renal stones?
_Intrinsic_
* Age
* Sex
* Genetics
_Extrinsic_
* Geography
* Diet + Fluid (salt)
* Climate
* Occupation
27
What are the familial and genetic links with renal stones?
* 25% of patients have a FHx
* Hypercalciuric patients have up to a 65% FHx
* Poly/monogenic mutations: SAC, VDR, CaSR, CLCN5
* Cystinuria -Autosomal Recessive disorder
* very dramatic presentation in hospital
* Xanthine & dihydroxyadenine
28
What is the composition of renal stones? (5)
Calcium Oxalate 60%
Calcium Phosphate 20%
Urate 10%
Struvite 8%
Cystine 1 %
29
What is the first line treatment for managing renal colic?
* the BAUS recommend an NSAID as the analgesia of choice for renal colic
* whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing
* the CKS guidelines suggest for patients who require admission: '*Administer a parenteral analgesic (such as **intramuscular diclofenac)** for rapid relief of severe pain*'
30
How does Renal Stones present?
Renal colicky pain
Haematuria (visible, non-visible)
Urinary tract infection
Incidental
31
How do you asses for renal stones?
* Bloods (renal function)
* Creatinine & eGFR (high)
* Ca2+ (raised)
* urate
* K+
* +/- PTH (sequels of primary hyperthyroidism)
* Urine
* Dip → infection & pH
* blood and positive for nitrates and leukocytes
* Spot test cystine- sodium cyanide nitroprusside
* Culture + sensitivity
* Microscopy
* Stone Analysis
* Imaging to confirm
* plain abdominal X-ray (KUB)
* Intravenous Urogram
* Non-contrast Ct scan (occasionally US)
* Isotope renography
32
What imaging modality is this and what is the pathology?
Non-contrast CT showing a Staghorn calculus
33
What are the managements options for renal stones?
In acute presentations you may have to decompress the kidney → nephrostomy tube or a stent to bypass the stone to get to the bladder then you deal with the renal stones
* Conservative
* Medical
* Medical Expulsive Therapy (MET)
* uses Tamsulosin which is an alpha-blocker to relax the ureteric walls
* Chemolysis - Uric acid stones
* alkalise the urine → prevents uric acid stones (dissolves stones better for long term management, not very effective in chronic setting)
* Shock Wave Lithotripsy - ESWL
* Ureteroscopy & Ureterorenoscopy
* Percutaneous Surgery - PCNL
* Laparoscopic Surgery
* Open Surgery
34
What is the medical and pharmacological treatment for renal colic?
In an acute painful episode, give analgesia, radiological imaging, relieve the obstruction (preserve renal function) and treat the infection)
* **NSAIDS**
* Diclofenac via PR or suppository
* Analgesics
* Opiates
* Antiemetics
35
When should intervention be introduced in renal cholic?
* Pain – Uncontrolled & Persisting
* Infection
* Deteriorating renal function
* Solitary Kidney
* Failure to progress
* Degree of obstruction, Time, Stone size, Stone position
* Patient circumstances or preference
36
What are potential complications of ESWL Lithiotripsy
* Steinstrasse 2-10%
* Residual fragment re-growth 21-59%
* Fragment colic 2-4%
* Sepsis 1-2%
* Macro haematuria majority Renal haematoma Symptomaic \<1%
* Renal haematoma Asymptomatic 4%
* Bowel perforation - rare
* Liver & splenic haematoma - rare
37
What is Lithiotripsy (ESWL)?
* These are shockwaves that can be
* Electroconductive
* Electromagnetic
* Piezoelectric waves
* Waves are focused on the stone which is localized using either ultrasound or fluoroscopy
* This breaks the stone up into small fragments that can be more easily passed
* 2 or 3 attempts are used before alternative modality is used
38
What is Ureteroscopy?
* Camera is passed through the ureter up to the kidney
* The stone can be gather using a basket on the end which captures it and pulls the stone out of the body
* A laser can also be used to break the stone up (Lasertripsy)
* a flexible ureterscope can also be used which allows the camera to go into the kidney
39
Compare the use of ESWL and Ureteroscopy for treating renal stones
Ureteroscopy has an increased clearance at as single sitting but an increased risk of complications
40
Explain Percutaneous nephrolithotomy
Entering the kidney through the back to either troll, laser larger stones in the kidney or upper ureter.
This is usually used for larger stones **\>2cm** or for complex stones or in difficult anatomical regions
41
Gallstones vs renal stones
80% of renal stones are radiopaque
20% of gallstones are radiopaque
42
What are ways to prevent getting renal stones?
* Urine dilution
* 2.5l/day throughout the day
* Tap water not sugary water
* Optimise body weight
* Fruit, veg & fiber
* citrate
* Low salt \<6g/day & lower animal protein intake
* Avoid excess sugar
* Some dairy products
* Plant fat instead of animal fat
43
Give the epidemiology of Bladder Cancer
* 7th most commonest cancer in men
* 11th most commonest cancer in both genders
* 75% confined to mucosa/ submucosa (pT1/pTa)
44
What is the aetiology of bladder cancer?
* Tobacco Smoke commonest cause. 50% of cases (for both transitional cell and squamous)
_for Transitional cell carcinoma_
* Occupational Exposure e.g in prining and textile industry
* paints
* Aniline dyes: 2-napthyalmine, benzidine
* petroleum.
* Chlorination/arsenic in drinking water
* Cyclophosphamide
* Egypt and middle east
* Schistosomiasis (for squamous cell carcinoma of the bladder)
45
What is the staging for bladder cancer?
* divided between muscle invasive (T2 onwards) and non-muscle invasive (Ta-T1) bladder cancer
* Tis (carcinoma in situ) → T4a (advanced into the prostate gland)
46
What are the signs/ symptoms of bladder cancer?
* Visible haematuria
* Non-visible haematuria
* Lower Urinary tract symptoms i.e urgency: may suggest Tis (carcinoma in situ)
* urgency is being unable to delay the need for the toilet until later
* incidental
* On examination, rarely find features unless it's metastatic
47
What imaging can be done to investigate for bladder cancer?
* CT Chest – for staging
* CT Urogram
* (contrast) Delayed phase for review of filling defects in upper tract
* Synchronous UTUC 1.8% but 7.5% in trigonal tumours
* Urothelium lining throughout
* Ultrasound – Limitiations. Helpful for Renal Masses/Hydronephrosis ¨ Urinary Cytology – High sensitivity in High Grade/CiS tumours
48
Explain the pathology of the metastatic spread of bladder cancer and how this is related to this image
* Lining of the bladder is urothelium (transitional cell) and is continuous from the distal urethra in the penis to the collecting system in the kidney
* The image shows a dark spot in the collecting system of the kidney's which is a filling defect which is indicative of a tumor invading the kidney and the ureter
* hence if you have a tumor in the bladder you can have a cancer anywhere along that tract
* These are called upper tract transitional cell carcinomas
49
How are non-muscle invading bladder cancers managed?
Follow -up guidance?
* Transurethral resection of bladder tumour
* single shot intravesical chemotherapy immediately post op
* Follow up based on risk assessment
* grade of tumour (G1-G3, how aggressive a tumour is) / age/ smoking cessation/ presence of VH
* multifocal
* recurrences can occur quickly
50
What is the follow up for Non-muscle invading bladder cancer based on risk?
* Low Risk
* Check Cystoscopy surveillance
* Intermediate Risk
* Intravesical Chemotherapy
* Check Cystoscopy closely surveillance
* High Risk
* Relook TURBT
* BCG/Intravesical Chemotherapy
* Tb vaccine - kills tumour cells in the bladder
* Chemo given through catheter
* Annual CT Urogram for 3 years
* Check Cystoscopy very closely surveillance
* Radical Cystectomy
51
What is the management for Muscle Invading Bladder Cancer?
* Following TURBT with confirmation of Muscle Involvement.
* Local Staging CT/MRI useful in detecting T3b Dx and LN Status.
* CT Chest for completion staging
* Charleston Co-morbidity Index used to assess long term prognosis and survival.
* ten year mortality for a patient
* Radical Cystectomy – Open vs Laparoscopic vs Robotic
vs
* Multimodal Therapy
* scrape out as much as they can see
* give chemo therapy to shrink cancer
* then radiotherapy
52
What is a radical Cystectomy?
Removal of the whole bladder and the nearby lymph nodes and creation of a urinary conduit formed of the ileum or a neo bladder. The ureters are attached to the ileum then attached to the skin just like a colostomy. Produces urine instead
* it provides 5 year survival in 50% of patients
* this improves with cisplatin based neo-adjuvant chemotherapy
* No evidence of post op RT
* limited evidence on Pre-op RT role
53
What are the indication for a radical cystectomy?
* T2-T4 N0M0 MIBC
* High grade (HG) NMIBC
* G3/T1
* Cis
* Highest risk groups include
* recurrent HG
* Multiple HG
* G3pT1 with concurrent Bladder/prostatic urethra Cis
* Lymphovascular invasion
* BCG refractory groups
* Palliative Cystectomy
* symptomatic relief
54
What is external beam radiotherapy?
when is it used?
* Target dose for curative intent – 60-66Gy
* Used as part of Multimodality Therapy
* Macroscopic Clearance of Bladder Ca - TURBT
* Systemic Chemotherapy/Radiosensitisers
* EBRT
* 5 Yr Cancer Specific Survival 55-80% with salvage cystectomy 10-30%
* Comparable Outcomes to Early Cystectomy
55
What is the management of Metastatic Bladder Cancer?
* Poor Prognosis Generally
* First Line Treatment – Cisplatin based combination chemo(if fit) or carboplatin based combination chemo (if unfit)
* Second Line Treatment – Checkpoint inhibitors eg: pembrolizumab or platinum based combination chemo
* Zoledronic Acid for Bone Met
56
Give the epidemiology of prostate cancer
* The most common cancer in males in the UK and 2nd most common cause of cancer death
* 26% of all new cancer cases in males in the UK
* 13% of all new cancer cases in both genders
* 14% of all cancer deaths in males in the UK and 7% of all deaths in both genders combined
* 1 in 6 males will be diagnosed with prostate cancer in their lifetime in UK
* Not clearly linked to any preventable risk factors
57
What are the risk factors etiology of prostate cancer?
* **Age** - most common in men 75 - 79 years
* **Ethnicity** – most common in black-African men and least common in Asian men
* **Genetics** & family history - BRCA1, BRCA2, Lynch syndrome hereditary non-polyposis colorectal cancer (HNPCC)
* **High BMI** (25-30) or higher
* **Height** – taller, higher risk
* Insulin like growth factor (IGF-1) – higher, higher
* Previous ca
* Vasectomy
* Prostatitis
* Tobacco smoke (cadmium)
58
What is the staging for prostate cancer?
TNM staging
59
What is the Type/Grading of prostate cancer
Grade 1-5 / Gleason Score up to 10
Types
* Acinar adenocarcinoma
* Ductal adenocarcinoma
* Transitional cell or urothelial cancer
* Squamous cell cancer
* Small cell prostate cancer (less than 2%)
* NET
* Sarcoma
60
What are signs/ symptoms of prostate cancer?
* Lower UTS – Nocturia, Frequency, Urgency
* due to pressure effect of growing cancer
* Haematuria / haematospermia
* Usually asymptomatic
* Bony Pain/Renal Failure/Cord compression
* sign of metastatic cancer
* Usually Incidental – Raised PSA
61
What examinations would you carry out to investigate for prostate cancer?
* DRE
* normal smooth feeling prostate, and a hard graggy prostate
* PSA
* can be raised due to other things to do with cycling i.e by a UTI or prostatitis/ can be lowered by txt for BPH
* PSA is relative to the size of the prostate
* MRI - NICE 2019 (first line investigative modality)
* if biopsy needed, guides biopsy
* monitor (active surveillance)
* stage
62
Where does prostate cancer anatomically present in the prostate?
* Peripheral zone - 70% of cancers
* more aggressive - tends to invade the peri-prostatic tissues
* when examining that's why you feel posteriorly
* far away from the prostatic urethra hence unlikely to cause any compression
* Transitional Zone - 20%
* relatively non-aggressive
* Benign prostatic hyperplasia (BPH) more likely to occur here, hence causing LUTS
63
What further investigation can be done for suspected prostate cancer?
* TRUS biopsy (transrectal ultrasound)
* Fusion Biopsy (combines MRI imaging for more targeting)
* Template/ transperineal biopsy
64
What other imaging can be done for a suspected prostate cancer?
* MRI Multiparametric
* If High Risk Disease/Concerns of Metastatic Spread for for staging using CT CAP(LN Status) and Bone Scan(Metastatic Spread). PSMA PET EMERGING
* Choline PET-CT scan (Post Radical Treatment/Specific)
* USS – assess for hydronephrosis/Renal Failure if no recent CT scan
65
What is treatment for Prostate cancer?
* Active surveillance - intervene when concerned
* Radical Treatment (Localised and Locally Advanced Ca)
* Radical Prostatectomy – Open vs Laparoscopic vs Robotic
* Radical Radiotherapy
* Primary Chemotherapy – Metastatic Disease
* Hormone therapy – Metastatic Disease/Watchful Waiting.
* frail patients, where radical therapy is not suitable
* improves quality of life
* Cryotherapy/HIFU – in Trial capacity
66
Explain the epidemiology of Renal cancer
* 7th most common cancer in the UK
* 2-3% of all cancers worldwide
* More common in elderly people
* 60-80 y/o
* More common in males
67
What are risk factors of renal cancer?
* Smoking
* Obesity
* HTN
* Family history of renal ca
* Medications (phenacetin, diuretics)
* End Stage Renal Failure/Disease
* Gender (2x more common in men)
* Genetics
68
What are the types/grade of renal cancer?
* Renal Cell Cancer - 80% of renal cancer
* _Clear cell (75%)_
* _Papillary (10%)_
* _Chromophobe (5%)_
* _Carcinoma of collecting ducts_
* _Renal medullary carcinoma_
* _all can have Sarcomatoid in their features_
* Transitional Cell Cancer of kidney or ureter (7-8%)
* Wilm's tumour (pediatrics)
69
What is the staging for renal cancer?
TNM
* pT1
* pT2
* pT3
* pT4
Stage I-IV
70
What are Signs/ Symptoms of renal cancer?
* Usually incidental finding on CD
* Haematuria
* Flank pain
* Flank/abdominal mass
71
What Investigations would you do to confirm Renal cancer?
* Ultrasound
* CT - triple phase/ renal/ abdomen & pelvis with contrast
* characterize the size and morphology
* CT chest for staging - Pulmonary Mets/ Cannon Ball lesions
* common in Renal cell cancer
72
What is the management for renal cancer?
In general can be wait and watch, consider age and fitness
* T1a - Nephron Sparing Treatment
* Cryotherapy (cause coagulative necrosis of the tumour cells)
* Radiofrequency Ablation
* Partial Nephrectomy – Open vs Robotic.
* T1b/T2 – Radical Nephrectomy
* T3 Dx – Tertiary Centre - Radical Nephrectomy with LN excision /vena caval thrombus excision/metastatectomy/need for cardiac bypass
* T4 – Radical Nephrectomy with removal of adjacent organs. Usually Palliative/Cytoreductive.
73
What is the management for metastatic renal cell cancer?
* Consideration of
* Cytoreductive Nephrectomy
* Metastectomy
* Systemic Therapy - (Interferon alpha/ Interleukin 2)
* Systemic Therapy - (Tyroskine Kinase Inhibitors) n Treatment Naïve – usually Sumitinib n Treatment Refractory – usually Sorafenib
* Palliative
* Palliative Nephrectomy
* Tumour Embolisation
* Palliative Radiotherapy
74
What are the features of an Epidydimal cyst and how is it diagnosed?
Epididymal cysts are the most common cause of scrotal swellings seen in primary care. Feutres:
* separate from the body of the testicle
* found posterior to the testicle
Diagnosed by ultrasound
75
What conditions are associated with Epidydimal cysts?
* polycystic kidney disease
* cystic fibrosis
* von Hippel-Lindau syndrome
76
What is the Management of Epidydimal cysts
usually supportive management but surgical removal or sclerotherapy may be attempted for larger symptomatic cysts
77
What is a Hydrocele
accumulation of fluid within the tunica vaginalis, can be communicating and non-communicating
* _Communicating_: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum.
* Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life
* _Non-communicating_: caused by excessive fluid production within the tunica vaginalis
78
What conditions may a hydrocele occur secondarily to?
* epididymo-orchitis
* testicular torsion
* testicular tumours
79
What are clinical features of a Hydrocele
* soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle
* the swelling is confined to the scrotum, you can get 'above' the mass on examination
* transilluminates with a pen torch
* the testis may be difficult to palpate if the hydrocele is large
80
How is a Hydrocele diagnosed and managed?
can be diagnosed from clinical findings and an ultrasound is required if there is doubt or if the underlying testis cannot be palpated
Management
* infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years
* in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour
81
What is a Varicocele and what are features of this pathology?
A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.
Varicoceles are much more common on the left side (\> 80%). Features:
* classically described as a 'bag of worms'
* subfertility
82
What is the management of a Varicocele?
* usually conservative
* occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility
83
What is acute urinary retention and what is the epidemiology of this pathology
Acute urinary retention is when a person suddenly (over a period of hours or less) becomes unable to voluntarily pass urine. It is the most common urological emergency and there are several potential causes that must be investigated for.
Epidemiology
* Whilst acute urinary retention is common in men, it rarely occurs in women (incidence ratio of 13:1). It occurs most frequently in men over 60 years of age and incidence increases with age.
* It has been estimated that around a third of men in their 80s will develop acute urinary retention over a five year period.
84
What do patients with urinary retention present with sub acutely
* Inability to pass urine
* Lower abdominal discomfort
* Considerable pain or distress
* an acute confusional state may also be present in elderly patients
patients with chronic urinary retention is typically painless with a background of chronic urinary retention
85
What are causes of Acute urinary retention
* In men, acute urinary retention most commonly occurs secondary to benign prostatic hyperplasia →The enlarged prostate presses on the urethra which can make the bladder wall thicker and less able to empty.
* Other urethral obstructions; including urethral strictures, calculi, cystocele, constipation or masses.
* Medications can cause acute urinary retention by affecting nerve signals to the bladder: these include → anticholinergics, tricyclic antidepressants, antihistamines, opioids and benzodiazepines.
* Less commonly, there may be a neurological cause for the acute urinary retention.
* In patients with predisposing causes, a simple urinary tract infection can be enough to cause acute urinary retention
* Acute urinary retention often occurs postoperatively and in women postpartum: usually secondary to a combination of the above risk factors.
86
What investigations are carried out in acute urinary retention
* Urine sample for urinalysis and culture. This might only be possible after urinary catheterisation.
* Serum U&Es and creatinine should also be checked to assess for any kidney injury.
* A FBC and CRP should also be performed to look for infection
* confirm diagnosis with bladder ultrasound volume \> 300 cc confirms diagnosis
* if history and examination are consistent and this isn't seen on the bladder scan it is still AUR
* _PSA is not appropriate in acute urinary retention as it is typically elevated_
87
What is the management of Acute urinary retention?
* Decompressing the bladder via catherization
* in suspect AUR the volume of urine drained in 15 minutes is measured. if the volume \<200cc patient does not have AUR
* if volume drained is \>400cc catheter should be left in place
* Investigations to find out underlying cause i.e, prostate, neurological and gynaecological causes
88
What are complications of Acute Urinary retention?
* post-obstructive diuresis
* the kidneys may increase diuresis due to the loss of their medullary concentration gradient. This can take time re-equilibrate
* this can lead to volume depletion and worsening of any acute kidney injury
* some patients may therefore require IV fluids to correct this temporary over-diuresis
89
How would you be able to recognise a normal testicular sample?
* It's smooth and soft
* you would be able to pull out a string of tissue that is very long
* the coiled seminiferous tubules
90
Review this image and identify key structures
91
What is the aetiology of Acute Epididiymo-orchitis?
* Most cases of acute epididymo-orchitis occur in men aged 20 – 39 years
* Associated with sexually transmitted diseases such as _Chlamydia trachomatis and Neisseria gonorrhoea_
* In older men over 40 years the most common cause is _E.coli infection_
* The inflammation is initially confined to the epididymis and later spreads to the testis
92
What is Acute Epididymo-orchitis and what are its symptoms/ presentations?
- clinical investigations
* inflammation of the epididymis
* Pain and swollen epididymis due to inflammation with a predominance of neutrophils
* Clinical investigations show
* raised C-Reactive protein
* a culture and sensitivity of urethral secretions to identify the bacterial cause
* ultrasound scan to differentiate epididymo-orchitis from torsion
93
What is the treatment and management for epididymo-orchitis
* Treat with antibiotics, pain relief and supportive care (scrotal elevation)
* If not resolved may require inpatient care
* May heal with scarring leading to sterility
94
Why does Torsion occur and how is it managed?
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* Torsion occurs due to twisting of the spermatic cord which cuts off the venous drainage of the testis
* Presents with sudden onset of testicular pain which may or may not be related to trauma
* If untreated leads to infarction of the testis
* If ‘untwisted’ within 6 hours there is a chance that the testis will remain viable
* The contralateral testis should be fixed to the scrotum _(orchidopexy)_ to risk reduce risk of torsion
95
What is this an image of?
Torsion of the Testis
96
Give an overview of the epidemiology of Testicular Cancer
* Most common solid malignant tumour in men 30-34 years of age
* Incidence of testicular cancer higher in caucasian men than black men
* Testicular cancer accounts for less 1% of all new cancers in the UK with 28% increase since the early 1990s
97
What are the causes of Testicular Cancer?
* Cryptorchidism/undescended testis increases the risk of cancer 4 – 8 times
* History of previous testicular cancer (father and brother)
* Genetic abnormality: Klinefelter’s syndrome (47XXY) & Down’s syndrome (trisomy 21)
* FH of testicular cancer – First degree relatives have a higher risk than the general population
* Men with infertility problems are more likely to develop testicular cancer
* Exposure to oestrogens (diethylstilbestrol) in utero → cryptorchidism→ increases the risk of testicular cancer
* given to women who are threatened risk of miscarriage --\> increases risk of undescended testis --\> increase risk of testicular cancer
98
How are Testicular Tumours classified?
* Germ Cell Tumours
* Seminiomatous tumours
* non-seminomatous tumours
* Sex Cord/Stromal Tumours (Less than 5% of testicular tumours)
* Leydig cell tumour
* Sertoli tumour
99
Give an overview of Germ Cell Tumours
* More than 90% of cancers of the testis arise in germ cells
* Germ cells produce the sperm
* Germ cell tumours are divided into seminomas and non-seminomatous
* Mixed germ cell tumours consists of seminoma and non-seminomatous components
* Germ cell carcinoma in situ or intra-tubular germ cell neoplasia is the precursor lesion (precancerous)
100
Explain what type of Tumours Semnomas are
* Seminomas tend to grow and spread more slowly than non-seminomatous tumours, they are a type of Germ Cell layer tumour
* There are two main sub-types:
* **Classical Seminoma:**
* Constitutes more than 95% of seminomas
* Affect men between 25 and 45 years of age
* Tumours markers can be normal or raised
* **Spermatocytic Seminoma/Tumour:**
* Rare tumour; affects older men; average age of 65yrs
* Grow more slowly than classical seminomas and are less likely to spread to other parts of the body
101
Explain what Non-seminomatous Tumours are
* germ cell tumours that usually occur in men in their late teens and early 30s
* Four main types of non-seminomatous germ cell tumours
* Embryonal carcinoma
* Yolk sac carcinoma/tumour
* Choriocarcinoma
* Teratoma
102
Explain what Embryonal Carcinomas are
* They are a form of Non-seminomatous germ cell tumour
* Present in about 40% of testicular tumours
* Pure embryonal carcinoma occurs in only 3% to 4% of cases
* tend to present as part of the mixed GCT
* Microscopically, looks like tissues of very early embryos
* Tends to grow rapidly and spread outside the testis (very aggressive tumour)
103
Explain what Yolk Sac Carcinoma/Tumour is
* a type of non-seminomatous GCT
* The cells look like the yolk sac of an early embryo
* The most common form of testicular cancer in children
* Pure yolk sac tumours are rare in adults
* Have better prognosis in children than adults
104
Explain what a Choricarcinoma is
* a type of non-seminomatous GCT
* A very rare and fast-growing testicular cancer in adults
* Pure choriocarcinoma _tends to spread_ rapidly to other parts of the body, including the lungs, bones, and brain
* Usually present in mixed germ cell tumours with associated haemorrhage
* can present in women after pregnancy, due to abnormal trophoblastic proliferation
* both will have raised beta-HCG
105
Explain what a Teratoma is
* a non-seminomatous GCT from three layers of the embryo
* Endoderm (innermost layer)
* Mesoderm (middle layer)
* Ectoderm (outer layer)
* Pure teratomas of the testicles are rare
* No increase tumour markers
* Most teratomas are components of mixed germ cell tumours
106
What types of Teratomas are there?
* **Mature teratomas**
* Tumours are formed by cells similar to adult tissues
* They rarely spread, can usually be cured with surgery, but may recur after treatment
* **Immature teratomas**
* Are less well-developed cancers with cells that resemble those of an early embryo
* More likely than a mature teratoma to invade nearby tissues, _metastasise outside the testis and recur years after treatment._
* teratomas are always malignant int the testis but not malignant in the ovaries
107
What are the clinical presentation of testicular cancer?
* Any painless swelling or nodule in the testis is cancer until proved otherwise
* Mass or nodule not separate from the testis
* Dull ache or heavy sensation in the lower abdomen
* Advanced cancer + mets may present with:
* Back pain due to enlarged para-aortic L nodes
* Supraclavicular lymphadenopathy
* Cough, chest pain, haemoptysis and shortness of breath due to metastases to the lungs
* Marked gynecomastia in patients with tumours secreting beta HCG as in choriocarcinoma
108
What imaging is used in Testicular Cancer?
* **Ultrasound scan (USS)** will distinguish between:
* A tumour in the testis and external to the testis
* is it from the epididymis
* A complex cyst: most likely malignant and a simple cyst: most likely benign
* A solid tumour and a cyst
* **CT scan**: chest, abdomen and pelvis to assess for metastases in the lymph nodes, liver and lungs
* **MRI** of brain and bone if metastases suspected
* **PET scan** for recurrent disease after treatment lesions appear ‘hot’ when there is a viable cancer
109
What are the tumour markers in testicular cancer?
- Different tumours secrete specific TMs
* Alpha-fetoprotein (AFP) - yolk sac tumour, embryonal carcinoma
* Human chorionic gonadotropin (HCG) - Choriocarcinoma, embryonal carcinoma, seminoma
* Lactate dehydrogenase (LDH) - seminoma
* All TMs are raised in a mixed germ cell tumour
- TMs used for follow-up of patients after therapy
110
What is the treatment for Testicular cancer?
* Radical orchidectomy with isolated testicular mass followed by adjuvant chemotherapy
* If metastases are present at the time of presentation patients receive neo-adjuvant chemotherapy then orchidectomy
* There maybe no tumour in the removed testis on the pathological examination which is termed complete pathologic response to chemotherapy
* Patients are offered sperm banking prior to orchidectomy
* Patients are offered a prosthesis after orchidectomy
