Urology

Question 1

Presentation of an obstructive uropathy (split into upper and lower urinary tract) ?

Answer 1

Upper Urinary Tract Obstruction (i.e. ureters):

-Loin to groin / flank pain on affected side (result of stretching / irritation of ureter and kidney
-Reduced / no urine output
-Non-specific symptoms (e.g. vomiting)
-Reduced renal function on bloods

Lower Urinary Tract Obstruction (i.e. bladder / urethra):

-Acute urinary retention (unable to pass urine and increasingly full bladder)
-Lower urinary tract symptoms (e.g. poor flow, difficulty initiating urination, terminal dribbling)
-Reduced renal function on bloods

Question 2

Common causes of an obstructive uropathy (split into upper and lower urinary tract) ?

Answer 2

Upper Urinary Tract:

-Kidney stones
-Local cancer masses pressing on the ureters
-Ureter strictures (scar tissue narrowing tube)

Lower Urinary Tract:

-Benign prostatic hyperplasia (enlarged prostate)
-Prostate cancer
-Ureter or urethra strictures (from scar tissue)
-Neurogenic bladder (no neurological signal telling bladder to contract)

Question 3

Name 5 complications of an obstructive uropathy

Answer 3

-Acute Kidney Injury (postrenal AKI)
-Eventually chronic kidney disease
-Infection (from pooling of urine and retrograde infection: bacteria tracking back up urinary tract)
-Dilated kidney / ureters / bladder
-Pain

Question 4

Presentation of acute urinary retention ?

Answer 4

Pt is uncomfortable, unable to pass urine, tender + distended bladder.

Question 5

Investigations for acute urinary retention + what could they potentially show ?

Answer 5

-USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities
-Urinalysis - infection, haematuria, proteinuria, glucosuria
-MSU - infection
-Blood tests: FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)
-Hunting for cause/depending on history
-CT abdo pelvis - looking for mass causing bladder neck compression
-MRI spine - disc prolapse, cauda equina, spinal cord compression MS

Question 6

Management of acute urinary retention ?

Answer 6

Immediate and complete bladder decompression with catheter.

Men should be offered an alpha blocker prior to removal

Question 7

What is the most common type of kidney cancer + how is it staged ?

Answer 7

Renal cell carcinoma.

The TNM system.

Question 8

What are “Cannon ball metastases” and how are they relevant to the kidneys ?

Answer 8

Cannonball metastases is a description given to a select type of lung metastases in which multiple large masses are evident.

Renal cell carcinoma is by far the commonest cause - This is a common exam question.

Question 9

Presentation of kidney cancer ?

Answer 9

-Often asymptomatic
-Haematuria
-Vague loin pain
-Non-specific symptoms of cancer (e.g. weight loss, fatigue, anorexia, night sweats)

Question 10

Types of renal cell carcinoma ?

Answer 10

-Clear cell (75-90%)
-Papillary (10%)
-Chromophobe (5%)
-Collecting duct carcinoma (1%)
-Children: Wilms Tumour (in children < 5 years old)

Question 11

RF’s for kidney cancer ?

Answer 11

-Smoking
-Obesity
-Hypertension
-Long-term dialysis
-Von Hippel-Lindau Disease

Question 12

Management of kidney cancer ?

Answer 12

-Surgery (partial nephrectomy first line) / - radiotherapy and chemotherapy depending on disease stage.

Question 13

Paraneoplastic features of RCCs ?

Answer 13

-Polycythaemia (RCC secretes unregulated erythropoietin)
-Hypercalcaemia (RCC secretes a hormone that mimics the action of PTH)
-Stauffer Syndrome (abnormal liver function tests demonstrating an obstructive jaundice – without any localised liver or biliary me

Question 14

Types of bladder cancer ?

Answer 14

-90% transitional cell carcinoma
-10 % squamous cell carcinomas
-Rarer causes are adenocarcinoma, sarcoma, small cell.

Question 15

RF’s for bladder cancer ?

Answer 15

-Smoking (50%)
-Key workplace carcinogens - Carcinogens include aromatic amines, polycyclic aromatic hydrocarbons, arsenic and tetrachloroethylene. These are found in hair dyes, industrial paint, rubber, motor, leather, and rubber workers, blacksmiths etc.
-Age, 70% > 65
-Pelvic radiation (prostate Ca)
-Men > Women
-HNPCC for upper tract urothelial cancers
-Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma

Question 16

Presentation of bladder cancer ?

Answer 16

-PAINLESS HAEMATUIRA(frank or microscopic)
-Dysuria
-Abdominal mass
-RFs
-Systemic weight loss + bone pain

Question 17

How is bladder cancer staged ?

Answer 17

TNM system

Question 18

Bladder cancer note:

Answer 18

The majority are superficial (not invading the muscle) at presentation

Question 19

Bladder cancer note

Answer 19

STAGE:

Tis - in situ ‘flat tumour’ worst prognosis

Ta - non-invasive papillary carcinoma

T1 - tumour invades subepithelial connective tissue (lamina propria):
-Not felt

T2 - tumour invades superficial muscle (detrusor or muscularis propria):
-Rubbery thickening

T3 - tumour invades perivesical tissue:
-Mobile mass

T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall:
-Fixed mass

SPREAD:

Lymphatic: Pelvic

Haematogenous: Liver and lungs

Question 20

Bladder cancer gold standard investigation + other investigations ?

Answer 20

Flexible cystoscopy with biopsy TURBT.

Other investigations:

-Urine dip - Haematuria (80% of patients) ± pyuria
-Urine MC + S - cancers may cause sterile pyuria
-KUB USS
-Bimanual EUA for staging
-CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour
or obstruction
-Urinary cytology - abnormal cells
-FBC - mild anaemia
-CXR, isotope bone scan, alkaline phosphatase etc…..

Question 21

Treatment of bladder cancer ?

Answer 21

Not invading the muscle:
-Transurethral Resection of a Bladder Tumour (TURBT)
-Chemo into bladder after surgery (use barrier contraception afterwards)
-Weekly treatments for 6 weeks with BCG vaccine squirted into the bladder via catheter, then every six months for 3 years.

Muscle-invasive bladder cancer:
-Radical cystectomy with ileal conduit
-Radiotherapy (as neoadjuvant, primary treatment or palliative)
-IV chemotherapy as neoadjuvant or palliative

Question 22

Presentation of BPH ?

Answer 22

Storage symptoms:
-FUN - frequency, urgency, nocturia

Voiding symptoms:
-HIIPP - hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling

Question 23

Investigations for BPH ?

Answer 23

TRIAD:
-DRE
-TRUSS ± biopsy
-PSA - increased may indicate prostate cancer or prostatitis

Other investigations:

Urinalysis - MSU/urine dip to rule out pyuria and complicated UTI

Scoring system -IPSS - International Prostate Symptom Score (0-35) also includes quality of life
Mild = 0-7, Mod = 8-19, Severe = 20+

-Volume chart

-USS KUB - To rule out hydronephrosis, urolithiasis, mass

Question 24

Management of BPH ?

Answer 24

Treatment depends on severity and impact on life:

For all = behavioural management:
-Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids

Mild (no bother):
-Watch and wait

Mild (bother):
-FIRST LINE: Alpha blocker (tamsulosin or doxazosin) or 5-alpha reductase (finasteride) or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)

Mod/severe - as above, first line drug + behavioural management

Abnormal DRE or elevated PSA:
-Surgical referral
-Prostate < 80g - TURP, TUVP (transurethral resection/vaporisation) or HoLEP (Holmium laser enucleation of the prostate )
-Prostate > 80g - Open prostatectomy

Question 25

Complications of TURP ?

Answer 25

Bleeding Infection Incontinence Retrograde ejaculation (semen goes backwards and is not produced from the urethra during ejaculation) Urethral strictures Failure to resolve symptoms Erectile dysfunction

Question 26

How do alpha blockers work in relation to BPH ?

Answer 26

Smooth muscle relaxation in prostate and bladder neck.

Question 27

How do 5-alpha reductase inhibitors work ?

Answer 27

They reduce the conversion of testosterone into dihydrotestosterone

Question 28

Presentation of prostate cancer ?

Answer 28

->50M -LUTS -Haematuria -Weight loss/anorexia/lethargy (advanced metastatic) -Bone pain (advanced metastatic) -Palpable LNs (advanced metastatic)

Question 29

How does a benign vs a cancerous prostate feel during a DRE ?

Answer 29

-A benign prostate feels smooth, symmetrical and slightly soft with a maintained central sulcus -A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular with loss of the central sulcus

Question 30

PSA note in relation to prostate cancer:

Answer 30

-Traditionally done prior to DRE to avoid stimulating release of PSA -Not very sensitive or specific (positive and negative results are unreliable) -Most useful in monitoring the progression of the disease and success of treatment

Question 31

Main diagnostic test to confirm prostate cancer ?

Answer 31

Prostate biopsy -The definitive method for diagnosing prostate cancer -Still not particularly sensitive because cancers may be located in areas not biopsied -Multiple needle biopsies are taken to minimize risk of missing the cancer Options: Transrectal Ultrasound-Guided Biopsy (TRUS): -Ultrasound inserted into rectum and a needle biopsy taken through rectal wall into prostate under US guidance -Usually around 10 biopsys are taken to try and pick up the cancer Transperineal: -This method allow more biopsys to be taken (around 35) -This has a higher sensitivity than TRUS It takes longer than TRUS and requires general anaesthetic Note: -MRI + CT can be used for staging the cancer if the diagnosis is confirmed. (TNM system is used for staging)

Question 32

What is the Gleason grading system ?

Answer 32

-A grading system specific to prostate cancer -Helps to determine what treatment is most appropriate -The Gleason Score ranges from 1-5 and describes how much the cancer from a biopsy looks like healthy tissue (lower score) or abnormal tissue (higher score). -Since prostate tumours are often made up of cancerous cells that have different grades, two grades are assigned for each patient. A primary grade is given to describe the cells that make up the largest area of the tumour and a secondary grade is given to describe the cells of the next largest area. For instance, if the Gleason Score is written as 3+4=7, it means most of the tumour is grade 3 and the next largest section of the tumour is grade 4

Question 33

Management of prostate cancer ?

Answer 33

Watchful waiting in early prostate cancer Radiotherapy directed at the prostate Brachytherapy: -Radioactive seeds implanted into the prostate -Deliver continuous, targeted radiotherapy to the prostate Hormonal treatment (antiandrogen therapy): -Prostate tissue grows in response to androgens like testosterone -Hormonal therapy aims to block androgens and slow or stop prostate cancer growth -Side effects include hot flushes, sexual dysfunction, gynaecomastia, fatigue and osteoporosis -Options: 1 = Bilateral orchidectomy is the gold standard hormonal treatment 2 = LHRH agonists cause chemical castration (e.g. goserelin) 3 = Androgen receptor blockers (e.g. bicalutamide) Surgery in the form of total prostatectomy

Question 34

Complications of Radical Treatment with Prostatectomy and Radiotherapy ?

Answer 34

-Erectile dysfunction -Urinary incontinence -Radiation induced enteropathy (giving gastrointestinal symptoms like PR bleeding, pain, incontinence etc) -Urethral strictures

Question 35

What is epididymo-orchitis ?

Answer 35

Epididymitis – inflammation / infection of the epididymis Orchitis – inflammation /infection of the teste

Question 36

Causes of epididymo-orchitis ?

Answer 36

E. coli Chlamydia trachomatis Neisseria gonorrhea Mumps

Question 37

Presentation of epididymo-orchitis ?

Answer 37

Don’t miss testicular torsion as a differential, if any doubt at all – treat as torsion -Gradual onset over minutes / hours (as opposed to rapid onset with torsion) -Usually unilateral -Testicular pain and tenderness -Dragging / heavy sensation -Urethral discharge (think chlamydia / gonorrhea) -Tender on palpation, particularly over epididymis -Swelling of testicle and epididymis -Erythema to scrotum

Question 38

Management of epididymo-orchitis ?

Answer 38

-Admit and treat sepsis if septic, otherwise as outpatient -Antibiotics as per local guidelines (e.g. ciprofloxacin for 2 weeks) -Tight underwear for scrotal support during illness -Abstain from intercourse during illness -Confirm diagnosis with ultrasound of the scrotum (exclude torsion and tumours)

Question 39

What is testicular torsion ?

Answer 39

A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of vascular supply and time-sensitive ischaemia of testicle Note: -Typically in teenage boys, but can occur at any age -“6 hour window” after onset before damage from ischaemia is irreversible

Question 40

Presentation of testicular torsion ?

Answer 40

-Sudden onset, unilateral testicular pain -High transverse lie -Nausea and vomiting -Abdominal pain -Red, hot swollen testicle -Absent cremasteric reflex

Question 41

What is a "Bell-clapper deformity" + why is this one of the main causes of testicular torsion ?

Answer 41

-Normally the testicle is fixed posteriorly to the tunica vaginalis -Bell-clapper deformity is where this fixation is absent -Allows testicle to rotate within tunica -As it rotates it twists the vessels and cuts of its blood supply

Question 42

Management of a testicular torsion ?

Answer 42

-Urgent urology assessment Immediate surgical scrotal exploration: -Untwist the testicle -Both testicles are fixed in correct position to prevent further episodes (orchiplexy) -Possible orchiectomy if delayed surgery / necrotic testicle present

Question 43

Main complication of testicular torsion ?

Answer 43

Subfertility / infertility

Question 44

Differential diagnoses for a testicular/ scrotal lump + how would each present + which test would you use to differentiate between the differentials ?

Answer 44

Confirm diagnosis with scrotal ultrasound scan TESTICULAR CANCER: -Non tender (or even reduced sensation) -Arising from testicle -Hard without fluctuance or transillumination -Irregular -Age 15-40 HYDROCELE -Tunica vaginalis is a membrane around each testicle -Hydrocele is fluid built up inside this membrane -Transilluminated by shining torch into the fluid -It is soft, fluctuant and may be large -It is irreducible and has no bowel sounds -May indicated underlying testicular cancer -May require surgical intervention VARICOCELE -Soft “bag of worms” -Swollen pampiniform venous plexus (testicular veins) -Can cause dragging or soreness -Usually harmless EPIDIDYMAL CYST -A cyst (sac of fluid) -At the epididymis (at the top of the testicle) -Soft, fluctuant lump at the top of the testicle -Usually harmless EPIDIDYMO-ORCHITIS -Tender -Generally swollen INGUINAL HERNIA -Separate from testicle -Soft -Bowel sounds -Reducible TESTICULAR TORSION -Extremely tender -Abnormal lie -Suggestive history

Question 45

Note:

Answer 45

The right testicular vein arises from the inferior vena cava. The left testicular vein arises from the left renal vein. Therefore a unilateral left sided varicocele can indicate an obstruction of the left testicular vein, for example caused by a renal cell carcinoma. However, it is worth noting that NICE CKS recommend NOT routinely referring men with a left sided varicoceles for an ultrasound to investigate for renal tumours.

Question 46

Types of testicular cancers ?

Answer 46

-Seminoma (50%) (germ cell) -Teratoma (50%) (germ cell) -Rarely other types

Question 47

Investigations for testicular cancer ?

Answer 47

Tumour markers (BAL): -Beta-hCG - may be raised in teratomas and seminomas, but more often in teratomas -Alpha-fetoprotein - may be raised in teratomas (not seminomas) -Lactate dehydrogenase -USS (95% sensitive) -CT abdomen and pelvis (LNs)

Question 48

Name 4 common sites for testicular cancer to metastasise to ?

Answer 48

-Lymphatics -Lungs -Liver -Brain

Question 49

Prognosis of testicular cancer ?

Answer 49

Prognosis Good prognosis unless metastatic (>90% cure rate) Even metastatic disease is often curable Slightly better prognosis for seminomas

Question 50

Management of testicular cancer ?

Answer 50

-Orchidectomy (offer testicular prosthesis) -Chemotherapy / radiotherapy based on staging -Monitoring post treatment with tumour markers and imaging

Question 51

What is pyelonephritis ?

Answer 51

Infection of the renal pelvis and parenchyma

Question 52

Name 3 RF's for pyelonephritis ?

Answer 52

-Female -Structural urological abnormalities -Diabetes

Question 53

Name four common organisms that cause pyelonephritis (include most common cause) ?

Answer 53

-Escherichia coli is the most common cause -Klebsiella -Enterococcus -Pseudomonas

Question 54

Presentation of pyelonephritis ?

Answer 54

-High fever and rigors -Loin to groin pain -Dysuria and urinary frequency -Haematuria -Other non-specific symptoms (e.g. vomiting) -Renal angle tenderness

Question 55

Investigations for pyelonephritis ?

Answer 55

-Urine dipstick -Blood and urinary cultures Imaging -Renal USS -CT contrast -Dimercaptosuccinic acid (DMSA) scan - involves injecting radiolabelled DMSA, which builds up in the kidneys and when imaged using gamma cameras gives an indication of renal scarring. This is used in recurrent pyelonephritis to assess the damage.

Question 56

What would a urine dipstick show in someone with pyelonephritis ?

Answer 56

-Blood -Protein -Leukocyte esterase (produced by neutrophils) -Nitrite (gram negative organisms metabolise nitrates in the urine )

Question 57

Management of pyelonephritis ?

Answer 57

-Broad spectrum antibiotics (e.g. co-amoxiclav) until culture and sensitivities are available -Admission if systemically unwell or complicated -IV rehydration -Analgesia -Antipyretics

Question 58

Note:

Answer 58

Chronic pyelonephritis: -Recurrent kidney infections -Leads to scarring of the renal parenchyma -Can result in chronic kidney disease -Can result in abscess and/or pus in or around the kidney -May be a role for prophylactic antibiotics

Question 59

What are the different types of renal stone ?

Answer 59

-Calcium oxalate forms 80% of stones -Calcium phosphate -Uric acid (not visible on xray) -Struvite (magnesium ammonium phosphate)

Question 60

What is a staghorn calculus, what is it usually composed of, how does it form and how can they be seen ??

Answer 60

-Renal calculus that forms the shape of a staghorn -The body sits in the renal pelvis with horns extending into renal calyxes -Usually composed of struvite -In recurrent upper urinary tract infections, the bacteria can hydrolyse the urea in urine to ammonia, creating the solid struvite -Can be seen on plan xray films

Question 61

How do renal stones present ?

Answer 61

-May be asymptomatic and never cause an issue -Renal colic -Excruciating loin to groin pain -May have haematuria, nausea, vomiting and oliguria -May have symptoms of sepsis if infection present (i.e. fever)

Question 62

Investigations for kidney stones (highlight gold standard diagnostic test)?

Answer 62

-CT KUB (non-contrast scan of kidney, ureters and bladder) is gold standard for identifying stones -Urine dipstick (haematuria in stones but also exclude infection) -Bloods for infection, kidney function, Ca and uric acid levels. -Renal stones may not be visible on abdominal xray

Question 63

Management of kidney stones ?

Answer 63

-NSAIDs are usually the most effective type of analgesia (e.g. PR diclofenac) -Antiemetic if nausea and vomiting -Fluids -Antibiotics if infection is present -Stones less than 6mm have greater than 50% chance of passing without intervention -Spontaneous passage can take several weeks -Tamsulosin (an alpha-blocker) can be used to help aid spontaneous passage of stones -Surgical Interventions in large stones or stones that do not pass

Question 64

Surgical interventions for nephrolithiasis ?

Answer 64

Extracorporeal Shock Wave Lithotripsy: -An external machine generates shock waves and directs them at the stone under xray guidance. -Breaks the stone to smaller parts to make them easier to pass. Ureteroscopy and Laser Lithotripsy: -Camera inserted via urethra, bladder and ureter -Stone identified -The stone is broken up by targeted lasers -The smaller parts are easier to pass Percutaneous Nephrolithotomy: -Performed in theatres under anaesthetic -A nephroscope (small camera on a stick) is inserted via a small incision at the patient’s back -The scope is inserted through the kidney to assess the ureter -Stones can either be removed or broken up to small stones Open Surgery

Question 65

One episode of renal stones predisposes patients to further episodes. What advice would you give to pts to reduce the change of a reoccurrence ?

Answer 65

-Increase oral fluids -Reduce dietary salt intake -Reduce intake of oxalate-rich foods for calcium stones (e.g. spinach, nuts, rhubarb, tea) -Reduce intake of urate- rich foods for uric acid stones (e.g. kidney, liver, sardines) -Limit dietary protein