Urology

Question 1

KAnatomy of the Urinary Tract

Answer 1

The key structures of the urinary tract are the:

Kidneys
Ureters
Bladder (with the detrusor muscle)
Urethra
Internal urethral sphincter (smooth muscle under autonomic control)
Prostate (in males)
External urethral sphincter (skeletal muscle under voluntary control)

It is worth being familiar with the basic anatomy of the kidney. From the outside in, the basic structures are the:

Cortex
Medulla
Pyramids and columns
Major and minor calyx (pleural: calyces)
Renal pelvis
Pelviureteric junction (PUJ)
Ureter

Question 2

Obstructive Uropathy

Answer 2

Obstruction leads to back-pressure in the urinary system, causing areas proximal to the site of obstruction to become swollen with urine. For example, obstruction at the opening of the ureters in the bladder, from a bladder tumour, will result in swelling of the ureter and kidney on that side. Swelling of the kidney is known as hydronephrosis. Vesicoureteral reflux (VUR) refers to urine refluxing from the bladder back into the ureters.

When obstructive uropathy leads to an acute reduction in kidney function, it is referred to as a “post-renal” acute kidney injury (AKI). This is different from “pre-renal” AKI, which is caused by hypoperfusion of the kidneys (e.g., due to dehydration, sepsis or acute blood loss), and “renal” AKI, which refers to damage within the kidney itself (e.g., due to glomerulonephritis or nephrotoxic medications).

TOM TIP: Whenever someone asks you the cause of renal impairment, always answer: “the causes are pre-renal, renal or post-renal”. This will impress them and allow you to think through the causes more logically.

Question 3

Presentation of an upper urinary tract obstruction

Answer 3

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

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 4

Presentation of a lower urinary tract obstruction

Answer 4

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

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)

An ultrasound of the kidneys, ureters and bladder can be helpful in diagnosing obstructive uropathy.

TOM TIP: “Loin” is a vague term that can be confusing and does not describe a specific location. Sometimes “loin” is used to describe the sides of the body between the lower ribs and pelvis, although “flank” is also used for the same area. “Loin” is also used to describe the side of the lower back, where the kidneys are situated; as well as the lumbar region of the back, the groin and the area around the hips. “Loin to groin” pain usually refers to pain that circles from the kidney area at the back, round the sides and down into the groin. “Loin to groin” pain is a sign of pathology in the ureter and kidney on that side, such as kidney stones or pyelonephritis. The “renal angle”, also called the “costovertebral angle”, refers to the angle formed by the twelfth rib and vertebral column at the back. The lower part of the kidneys are at the renal angle. Tenderness in the renal angle suggests kidney pathology.

Question 5

Common causes of upper urinary tract obstruction

Answer 5

Kidney stones
Tumours pressing on the ureters
Ureter strictures (due to scar tissue narrowing the tube)
Retroperitoneal fibrosis (the development of scar tissue in the retroperitoneal space)
Bladder cancer (blocking the ureteral openings to the bladder)
Ureterocele (ballooning of the most distal portion of the ureter – this is usually congenital)

Question 6

Common causes of lower urinary tract obstruction

Answer 6

Benign prostatic hyperplasia (benign enlarged prostate)
Prostate cancer
Bladder cancer (blocking the neck of the bladder)
Urethral strictures (due to scar tissue)
Neurogenic bladder

Question 7

Neurogenic bladder

Answer 7

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.

Key causes are:

Multiple sclerosis
Diabetes
Stroke
Parkinson’s disease
Brain or spinal cord injury
Spina bifida

Neurogenic bladder can result in a variety of problems, including:

Urge incontinence
Increased bladder pressure
Obstructive uropathy

Question 8

Managing obstructive uropathy

Answer 8

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 9

Complications of obstructive uropathy

Answer 9

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 10

Hydronephrosis

Answer 10

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 11

Urinary catheters

Answer 11

Urinary catheters are inserted into the bladder to passively drain urine. The urine drains through a tube into a catheter bag. They may be used short term or long term, depending on the indication.

When urinary catheters are left in, a balloon on the end of the catheter bladder is inflated inside the bladder with sterile water (usually 10mls), preventing it from falling out.

Question 12

Indications for urinary catheters

Answer 12

The reasons for inserting a urinary catheter include:

Urinary retention due to a lower urinary tract obstruction (e.g., enlarged prostate)
Neurogenic bladder (e.g., intermittent self-catheterisation in multiple sclerosis)
Surgery (during and after)
Output monitoring in acutely unwell patients (e.g., sepsis or intensive care)
Bladder irrigation (e.g., to wash out blood clots in the bladder)
Delivery of medications (e.g., chemotherapy to treat bladder cancer)

A bladder scanner can be used to measure the volume of urine in the bladder. A post-void bladder scan (measured after the patient attempts to empty their bladder) can indicate the need for a catheter (e.g., more than 500mls).

TOM TIP: A common presentation requiring catheterisation is an older man presenting acutely with urinary retention due to an enlarged prostate. Typical management involves inserting a catheter, starting tamsulosin (an alpha-blocker) and discharging the patient to have a trial without a catheter (TWOC) in the community. It is worth remembering tamsulosin for your exams, as they may give you this scenario and ask what medication should be started. The key side effect to remember is postural hypotension, leading to dizziness on standing or falls.

Question 13

Types of catheter

Answer 13

Urethral catheters are inserted through the urethra into the bladder. There are various types:

Intermittent catheters – simple catheters used to drain urine, then immediately removed
Foley catheter (two-way catheter) – the “standard” catheter with an inflatable balloon to hold it in place
Coudé tip catheter – has a curved tip to help navigate it past an obstruction during insertion
Three-way catheter – has three tubes used for inflating the balloon, injecting irrigation and drainage

Suprapubic catheters are inserted through the abdomen into the bladder, just above the pubic symphysis, under local anaesthetic. An inflated balloon holds them in place in the same way as a urethral catheter. When used long term, they can be easily replaced at regular intervals by an appropriately trained person.

TOM TIP: The catheter you will see most often on the wards and in OSCEs is the Foley catheter (two-way catheter). It might not be possible to insert a Foley catheter into a man with acute urinary incontinence due to an enlarged prostate. If using a Foley catheter fails, it is worth giving a Coudé tip catheter a try, as the slightly rigid curved tip can make bypassing an obstruction much easier. One of the most rewarding jobs as a junior doctor is inserting a catheter for someone in acute urinary retention, where you can almost immediately relieve a patient’s pain and distress.

Question 14

Trial without catheter

Answer 14

A trial without a catheter (TWOC) involves removing a urethral catheter to see if a patient can manage without it. After the catheter is removed, the urine output is monitored, and a bladder scanner is used to make sure there is minimal residual urine left in the bladder. They may “fail” the TWOC, in which case another catheter is inserted.

Question 15

Catheter-Associated Urinary Tract Infections

Answer 15

Infections are a key complication of urinary catheters. The longer the catheter is in place, the more likely bacteria are to grow in the urine. A sample of urine should be taken directly from the catheter or sample port using an aseptic technique (not from the catheter bag as this may be contaminated).

There are NICE guidelines on catheter-associated urinary tract infections from 2018, please see the full guidelines when treating patients.

Patients without symptoms do not generally require antibiotics for bacteria in the urine (bacteriuria) if they do not have symptoms.

Patients with symptoms require treatment with 7 days of antibiotics. Depending on the severity of symptoms, this may be with oral antibiotics or require admission to hospital and IV antibiotics. The catheter should be changed as soon as possible (but not delaying antibiotics).

Question 16

Benign prostatic hyperplasia

Answer 16

Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.

Question 17

Lower urinary tract symptoms

Answer 17

There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:

Hesitancy – difficult starting and maintaining the flow of urine
Weak flow
Urgency – a sudden pressing urge to pass urine
Frequency – needing to pass urine often, usually with small amounts
Intermittency – flow that starts, stops and varies in rate
Straining to pass urine
Terminal dribbling – dribbling after finishing urination
Incomplete emptying – not being able to fully empty the bladder, with chronic retention
Nocturia – having to wake to pass urine multiple times at night

Question 18

International prostate symptom score

Answer 18

The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms.

Question 19

Assessing benign prostatic hyperplasia

Answer 19

The initial assessment of men presenting with LUTS involves:

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

Prostate-specific antigen (PSA) testing is known to be unreliable, with a high rate of false positives (75%) and false negatives (15%). False positive results may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. False negatives may lead to false reassurance. Therefore, it is essential to counsel patients to make an informed decision about whether to have the test.

Common causes of a raised PSA are:

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

Question 20

Prostate examination

Answer 20

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

TOM TIP: When you first start performing any intimate examination, there is a temptation to rush. It is natural to want to reduce the discomfort of the patient and get it over with quickly. It is important to take your time and adequately assess the prostate, feeling for any abnormal area, asymmetry or tenderness. If you rush, you are more likely to miss something. The same is true of breast, vaginal and testicular examinations.

Question 21

Managing benign prostatic hyperplasia

Answer 21

Patients with mild and manageable symptoms may not require interventions.

The medical options are:

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

The general idea is that alpha-blockers are used to treat immediate symptoms, and 5-alpha reductase inhibitors are used to treat enlargement of the prostate. They may be used together where patients have significant symptoms and enlargement of the prostate.

5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone. Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.

The surgical options are:

Transurethral resection of the prostate (TURP)
Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
Holmium laser enucleation of the prostate (HoLEP)
Open prostatectomy via an abdominal or perineal incision

TOM TIP: 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 22

Transurethral resection of the prostate

Answer 22

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.

Major complications:

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

Major complications:

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

Question 23

Transurethral electrovaporisation of the prostate, Holmium laser enucleation of the prostate, Open prostatectomy

Answer 23

Transurethral electrovaporisation of the prostate (TEVAP / TUVP) involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.

Holmium laser enucleation of the prostate (HoLEP) also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.

Open prostatectomy involves an open procedure to remove the prostate. An abdominal or perineal incision can be used to access the prostate. Open surgery is less commonly used as it carries an increased risk of complications, a more extended hospital stay and longer recovery than other surgical procedures.

Question 24

Prostatitis

Answer 24

Prostatitis refers to inflammation of the prostate. It can be classed as:

Acute bacterial prostatitis – acute infection in the prostate, presenting with a more rapid onset of symptoms
Chronic prostatitis – symptoms lasting for at least 3 months

Chronic prostatitis may be sub-divided into:

Chronic prostatitis or chronic pelvic pain syndrome (no infection)
Chronic bacterial prostatitis (infection)

The cause of inflammation and pain in chronic prostatitis is unclear. It may be initially triggered by an infection, with inflammation persisting after the infection has resolved.

Question 25

Presentation of chronic prostatitis

Answer 25

Chronic prostatitis presents with at least 3 months of:

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 26

Presentation of acute bacterial prostatitis

Answer 26

Acute bacterial prostatitis presents with a more acute presentation of similar symptoms to chronic prostatitis. There may also be systemic symptoms of infection, such as:

Fever
Myalgia
Nausea
Fatigue
Sepsis

Question 27

National Institute of Health Chronic Prostatitis Symptom Index

Answer 27

The National Institute of Health has an online scoring tool for chronic prostatitis. It can be used to assess the severity of the symptoms and their impact on quality of life. It can also be used to track symptoms over time.

Question 28

Investigating prostatitis

Answer 28

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 29

Managing acute bacterial prostatitis

Answer 29

Management of acute bacterial prostatitis:

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 30

Managing chronic prostatitis

Answer 30

Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
Analgesia (paracetamol or NSAIDs)
Psychological treatment, where indicated (e.g., cognitive behavioural therapy and / or antidepressants)
Antibiotics if less than 6 months of symptoms or a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks)
Laxatives for pain during bowel movements

Question 31

Complications of acute bacterial prostatitis

Answer 31

Sepsis
Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
Acute urinary retention
Chronic prostatitis

Question 32

Prostate cancer

Answer 32

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.

There is a challenge with prostate cancer, as the ideal situation is to:

Find and treat clinically significant prostate cancers early
Avoid picking up cancers that would not turn out to be clinically significant (avoiding unnecessary stress, investigations and treatment)

Question 33

Risk factors for prostate cancer

Answer 33

Increasing age
Family history
Black African or Caribbean origin
Tall stature
Anabolic steroids

Question 34

Presentation of prostate cancer

Answer 34

Prostate cancer may be asymptomatic. It may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia. These symptoms include hesitancy, frequency, weak flow, terminal dribbling and nocturia.

Other symptoms include:

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

Question 35

Prostate-specific antigen

Answer 35

The epithelial cells of the prostate produce prostate-specific antigen (PSA). PSA is a glycoprotein that is secreted in the semen, with a small amount entering the blood. Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation. It is specific to the prostate, meaning it is not produced anywhere else in the body. A raised level can be an indicator of prostate cancer.

Prostate-specific antigen testing may lead to the early detection of prostate cancer, potentially leading to effective treatment and preventing significant problems. However, research has failed to show that the benefits of using PSA for screening outweigh the risks. In the UK, men over 50 can request a PSA test if they would like one.

PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

Common causes of a raised PSA are:

Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation

False positives may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. Additionally, it may lead to the unnecessary diagnosis and treatment of prostate cancer that would never have caused problems (the patient would have died of other causes before experiencing any adverse effects of the prostate cancer).

False negatives may lead to false reassurance.

TOM TIP: Counselling a patient about whether to have a PSA test is a common OSCE scenario. They are trying to test whether you understand the concept and implications of false positives and false negatives, and whether you can explain this to a patient to allow them to make an informed decision for themselves.

Question 36

Prostate examination

Answer 36

A prostate examination is performed during a digital rectal examination.

A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe). There may be generalised enlargement in prostatic hyperplasia.

An infected or inflamed prostate (prostatitis) may be enlarged, tender and warm.

A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule. Any of these features can indicate prostate cancer and warrant further investigation. In primary care, these findings require a two week wait urgent cancer referral to urology.

Question 37

Multiparametric MRI and prostate cancer

Answer 37

Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:

1 – very low suspicion
2 – low suspicion
3 – equivocal
4 – probable cancer
5 – definite cancer

Question 38

Prostate biopsy

Answer 38

Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the MRI findings (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).

Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

There are two options for prostate biopsy:

Transrectal ultrasound-guided biopsy (TRUS)
Transperineal biopsy

Transrectal ultrasound-guided biopsy involves an ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.

Transperineal biopsy involves needles inserted through the perineum. It is usually under local anaesthetic.

The main risks of a prostate biopsy are:

Pain (particularly lower abdominal, rectal or perineal pain)
Bleeding (blood in the stools, urine or semen)
Infection
Urinary retention due to short term swelling of the prostate
Erectile dysfunction (rare)

Question 39

Isotope bone scan and prostate cancer

Answer 39

An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.

A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton. Metastatic bone lesions take up more of the isotope, making them stand out on the scan.

Question 40

Gleason grading system

Answer 40

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):

The first number is the grade of the most prevalent pattern in the biopsy
The second number is the grade of the second most prevalent pattern in the biopsy

A Gleason score of:

6 is considered low risk
7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
8 or above is deemed to be high risk

Question 41

TNM Staging for Prostate Cancer

Answer 41

The TNM staging system can be used for prostate cancer, rating the T (tumour), N (lymph nodes) and M (metastasis).

T for Tumour:

TX – unable to assess size
T1 – too small to be felt on examination or seen on scans
T2 – contained within the prostate
T3 – extends out of the prostate
T4 – spread to nearby organs

N for Nodes:

NX – unable to assess nodes
N0 – no nodal spread
N1 – spread to lymph nodes

M for Metastasis:

M0 – no metastasis
M1 – metastasis

Question 42

Managing prostate cancer

Answer 42

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

Depending on the grade and stage of prostate cancer, treatment can involve:

Surveillance or watchful waiting in early prostate cancer
External beam radiotherapy directed at the prostate
Brachytherapy
Hormone therapy
Surgery

A key complication of external beam radiotherapy is proctitis (inflammation in the rectum) caused by radiation affecting the rectum. Proctitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.

Brachytherapy involves implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

Hormone therapy aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible. The options are:

Androgen-receptor blockers such as bicalutamide
GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
Bilateral orchidectomy to remove the testicles (rarely used)

Side effects of hormone therapy include:

Hot flushes
Sexual dysfunction
Gynaecomastia
Fatigue
Osteoporosis

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 43

Epididymo-orchitis

Answer 43

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 44

Basic anatomy of the testicle

Answer 44

At the back of each testicle is the epididymis. Sperm are released from the testicle, into the head of the epididymis, connected at the top of the testicle. The sperm travel through the head, then body, then tail of the epididymis. Sperm mature and are stored in the epididymis. The epididymis drains into the vas deferens.

Question 45

Causes of epididymo-orchitis

Answer 45

Escherichia coli (E. coli)
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps

TOM TIP: 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 46

Presentation of epididymo-orchitis

Answer 46

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

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 47

Diagnosing epididymo-orchitis

Answer 47

The key with epididymo-orchitis is to distinguish whether the cause is likely to be an enteric organism (e.g., E. coli) or a sexually transmitted organism (e.g., chlamydia or gonorrhoea). The features that make a sexually transmitted organism more likely are (as per NICE CKS 2020):

Age under 35
Increased number of sexual partners in the last 12 months
Discharge from the urethra

Investigations to help establish the diagnosis are:

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 swab 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 48

Managing epididymo-orchitis

Answer 48

Acutely very unwell or septic patients are admitted to hospital for treatment (IV antibiotics).

Patients at risk of sexually transmitted infection should be referred urgently to genitourinary medicine (GUM) for assessment and treatment.

Local guidelines guide the choice of antibiotic.

The NICE clinical knowledge summaries (updated January 2022) suggest the following options where it is most likely caused by an enteric organism (e.g., E. coli):

Ofloxacin for 14 days
Levofloxacin for 10 days
Co-amoxiclav for 10 days (where quinolones are contraindicated)

The antibiotic choice in patients with a potential sexually transmitted infection will depend on the suspected or confirmed organism and antibiotic sensitivities. Empirical treatment typically involves some combination of:

Intramuscular ceftriaxone (single dose)
Doxycycline
Ofloxacin

Additional measures:

Analgesia
Supportive underwear
Reduce physical activity
Abstain from intercourse

TOM TIP: Quinolone antibiotics such as ofloxacin, levofloxacin and ciprofloxacin are powerful broad-spectrum antibiotics, often used for urinary tract infections, pyelonephritis, epididymo-orchitis and prostatitis. They give excellent gram-negative cover. It is worth remembering two critical side effects, as these may be tested in exams and are essential to inform patients about:

Tendon damage and tendon rupture, notably in the Achilles tendon
Lower seizure threshold (caution in patients with epilepsy)

Question 49

Complications of epididymo-orchitis

Answer 49

Epididymo-orchitis can lead to:

Chronic pain
Chronic epididymitis
Testicular atrophy
Sub-fertility or infertility
Scrotal abscess

Question 50

Testicular torsion

Answer 50

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.

The typical patient is a teenage boy, but it can occur at any age.

There may be a history of recurrent symptoms in patients where there is intermittent testicular torsion.

Question 51

Examining testicular torsion

Answer 51

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 52

Bell-clapper deformity

Answer 52

A bell-clapper deformity is one of the causes of testicular torsion.

Normally, the testicle is fixed posteriorly to the tunica vaginalis. A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply.

Question 53

Managing testicular torsion

Answer 53

Testicular torsion is a urological emergency, and there is an urgent requirement for treatment. Any delay in treatment will prolong the ischaemia and reduce the chances of saving the testicle.

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

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 54

Key causes of scrotal or testicular lumps

Answer 54

Hydrocele
Varicocele
Epididymal cyst
Testicular cancer
Epididymo-orchitis
Inguinal hernia
Testicular torsion

Question 55

Hydrocele

Answer 55

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 56

Examination findings with a hydrocele

Answer 56

The testicle is palpable within the hydrocele
Soft, fluctuant and may be large
Irreducible and has no bowel sounds (distinguishing it from a hernia)
Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)

Question 57

Causes of a hydrocele

Answer 57

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

Testicular cancer
Testicular torsion
Epididymo-orchitis
Trauma

Question 58

Managing hydrocele

Answer 58

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 59

Varicocele

Answer 59

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.

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.

Varicoceles may present with:

Throbbing/dull pain or discomfort, worse on standing
A dragging sensation
Sub-fertility or infertility

Question 60

Examination findings of a varicocele

Answer 60

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 61

Investigating varicocele

Answer 61

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 62

Managing varicocele

Answer 62

Uncomplicated cases can be managed conservatively.

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

Question 63

Epididymal cysts

Answer 63

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 64

Examination findings of a epididymal cyst

Answer 64

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)

Question 65

Managing epididymal cyst

Answer 65

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 66

Testicular cancers

Answer 66

Testicular cancer arises from the germ cells in the testes. Germ cells are cells that produce gametes (sperm in males). There are other, rare tumours in the testes, such as non-germ cell tumours and secondary metastases.

Testicular cancer is more common in younger men, with the highest incidence between 15 and 35 years.

Testicular cancer can be divided into two types:

Seminomas
Non-seminomas (mostly teratomas)

Question 67

Risk factors for testicular cancers

Answer 67

Undescended testes
Male infertility
Family history
Increased height

Question 68

Presentation of testicular cancers

Answer 68

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 69

Investigating testicular cancers

Answer 69

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 70

Royal Marsden Staging System

Answer 70

Testicular cancer is staged with the Royal Marsden staging system:

Stage 1 – isolated to the testicle
Stage 2 – spread to the retroperitoneal lymph nodes
Stage 3 – spread to the lymph nodes above the diaphragm
Stage 4 – metastasised to other organs

Question 71

Common places for testicular cancer to metastasise

Answer 71

Lymphatics
Lungs
Liver
Brain

Question 72

Managing testicular cancers

Answer 72

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

Depending on the grade and stage of testicular cancer, treatment can involve:

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

Long term side effects of treatment are particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:

Infertility
Hypogonadism (testosterone replacement may be required)
Peripheral neuropathy
Hearing loss
Lasting kidney, liver or heart damage
Increased risk of cancer in the future

Question 73

Prognosis of testicular cancers

Answer 73

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 74

Lower urinary tract infections

Answer 74

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. Urinary tract infections are far more common in women, where the urethra is much shorter, making it easy for bacteria to get into the bladder.

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 75

Presentation of lower urinary tract infections

Answer 75

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

TOM TIP: It is important to distinguish between patients with a lower urinary tract infection and those with pyelonephritis. Pyelonephritis is generally a more serious condition with significant complications, including sepsis and kidney scarring. Suspect pyelonephritis in patients with:

Fever
Loin/back pain
Nausea/vomiting
Renal angle tenderness on examination

Question 76

Urine dipstick

Answer 76

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.

Nitrites are a better indication of infection than leukocytes. The NICE clinical knowledge summaries (2020) suggest that the presence of nitrites or leukocytes plus red blood cells indicate that the patient is likely to have a UTI.

If both are present, the patient requires treatment for a UTI. If only nitrites are present, it is worth treating as a UTI. If only leukocytes are present, the patient should not be treated as a UTI unless there is clinical evidence they have one.

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 77

Causes of lower UTIs

Answer 77

The most common cause of UTI is Escherichia coli. E. coli are gram-negative, anaerobic, rod-shaped bacteria that are part of the normal lower intestinal microbiome. It is found in faeces and can easily spread to the bladder.

Other causes:

Klebsiella pneumoniae (gram-negative anaerobic rod)
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans (fungal)

Question 78

Antibiotics choice for lower UTIs

Answer 78

Follow local guidelines. An appropriate initial antibiotic in the community would be:

Trimethoprim (often associated with high rates of bacterial resistance)
Nitrofurantoin (avoided in patients with an eGFR <45)

Alternatives:

Pivmecillinam
Amoxicillin
Cefalexin

Question 79

Duration of antibiotics in lower UTIs

Answer 79

3 days of antibiotics for simple lower urinary tract infections in women
5-10 days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
7 days of antibiotics for men, pregnant women or catheter-related UTIs

It is worth noting that NICE recommend changing the catheter when someone is diagnosed with a catheter-related urinary tract infection.

Question 80

Urinary tract infections in pregnancy increase the risk of

Answer 80

pyelonephritis, premature rupture of membranes and pre-term labour

Question 81

Management of lower UTIs in pregnancy

Answer 81

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 82

Pyelonephritis

Answer 82

Pyelonephritis refers to inflammation of the kidney resulting from bacterial infection. The inflammation affects the renal pelvis (join between kidney and ureter) and parenchyma (tissue).

Question 83

Risk factors for pyelonephritis

Answer 83

Female sex
Structural urological abnormalities
Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
Diabetes

Question 84

Causes of pyelonephritis

Answer 84

Escherichia coli is the most common cause, as with lower urinary tract infections. E. coli are gram-negative, anaerobic, rod-shaped bacteria that are part of the normal lower intestinal microbiome. It is found in faeces and can easily spread to the bladder.

Other causes:

Klebsiella pneumoniae (gram-negative anaerobic rod)
Enterococcus
Pseudomonas aeruginosa
Staphylococcus saprophyticus
Candida albicans (fungal)

Question 85

Presentation of pyelonephritis

Answer 85

Diagnosis can be made clinically with a history and examination.

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 86

Investigating pyelonephritis

Answer 86

Urine dipstick will show signs of infection, including nitrites, leukocytes and blood.

Midstream urine (MSU) for microscopy, culture and sensitivity testing is essential to establish the causative organism. The sample should ideally be collected before starting antibiotics.

Blood tests will show raised white blood cells and raised inflammatory markers (i.e. CRP).

Imaging may be used to exclude other pathologies, such as kidney stones or abscesses. This could be an ultrasound or CT scan.

Question 87

Management of pyelonephritis

Answer 87

Referral to hospital if there are features of sepsis or if it is not safe to manage them in the community.

NICE guidelines (2018) recommend the following first-line antibiotics for 7-10 days when treating pyelonephritis in the community:

Cefalexin
Co-amoxiclav (if culture results are available)
Trimethoprim (if culture results are available)
Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)

Patients admitted to hospital with sepsis require the sepsis six; with three tests and three treatments.

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

Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are:

Renal abscess
Kidney stone obstructing the ureter, causing pyelonephritis

Question 88

Chronic Pyelonephritis

Answer 88

Chronic pyelonephritis presents with recurrent episodes of infection in the kidneys. Recurrent infections lead to scarring of the renal parenchyma, leading to chronic kidney disease (CKD). It can progress to end-stage renal failure.

Dimercaptosuccinic acid (DMSA) scans involve injecting radiolabeled DMSA, which builds up in healthy kidney tissue. When imaged using gamma cameras, it indicates scarring or damage in areas that do not take up the DMSA. They are used in recurrent pyelonephritis to assess for renal damage.

Question 89

Interstitial cystitis

Answer 89

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 90

Presentation of interstitial cystitis

Answer 90

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
Symptoms may be worse during menstruation

Question 91

Investigating interstitial cystitis

Answer 91

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

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 92

Managing interstitial cystitis

Answer 92

Interstitial cystitis can be difficult to manage. Symptoms are often resistant to treatment and persist long-term, having a significant impact on quality of life.

Supportive management is used initially:

Diet changes such as avoiding alcohol, caffeine and tomatoes
Stopping smoking
Pelvic floor exercises
Bladder retraining
Cognitive behavioural therapy
Transcutaneous electrical nerve stimulation (TENS)

Oral medications may be helpful, including;

Analgesia
Antihistamines
Anticholinergic medications (e.g., solifenacin or oxybutynin)
Mirebegron (beta-3-adrenergic-receptor agonist)
Cimetidine (histamine-2-receptor antagonist)
Pentosan polysulfate sodium
Ciclosporin (an immunosuppressant)

Intravesical medication may be helpful, given directly into the bladder:

Lidocaine
Pentosan polysulfate sodium
Hyaluronic acid
Chondroitin sulphate

Hydrodistention involves filling the bladder with water, to high pressure, during a cystoscopy. It requires a general anaesthetic. This can give a temporary (3-6 month) improvement in symptoms.

Surgical procedures may be used, including:

Cauterisation of Hunner lesions during cystoscopy
Butulinum toxin injections during cystoscopy
Neuromodulation with an implanted electrical nerve stimulator
Augmentation of the bladder, using a section of ileum, to increase the capacity (ileocystoplasty)
Cystectomy (removal of the bladder)

TOM TIP: 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.

Question 93

Bladder cancer

Answer 93

Cancer in the bladder arises from the endothelial lining (urothelium). The majority are superficial (not invading the muscle) at presentation.

Question 94

Risk factors for bladder cancer

Answer 94

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.

TOM TIP: 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 95

Types of bladder cancer

Answer 95

Transitional cell carcinoma (90%)
Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma

Question 96

Presentation of bladder cancer

Answer 96

Painless haematuria is the symptom to remember for your exams.

The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for:

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

The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.

Question 97

Diagnosing bladder cancer

Answer 97

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 98

Staging bladder cancer

Answer 98

The TNM staging system is used for bladder cancer, rating the T (tumour), N (lymph node) and M (metastasis) stages.

There is a clear distinction between:

Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
Muscle-invasive bladder cancer (invading the muscle and beyond)

Non-muscle-invasive bladder cancer includes:

Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
Ta: cancer only affecting the urothelium and projecting into the bladder
T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer

Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.

Question 99

Treating bladder cancer

Answer 99

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

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 100

Urostomy

Answer 100

A urostomy is used to drain urine from the kidney, bypassing the ureters, bladder and urethra. This is the most common and popular solution after cystectomy.

Forming a urostomy involves creating an ileal conduit. A section of the ileum (15 – 20cm) is removed, and end-to-end anastomosis is created so that the bowel is continuous. The ends of the ureters are anastomosed to the separated section of the ileum. The other end of this section of the ileum forms a stoma on the skin, draining urine into a urostomy bag. Urine drains from the kidneys to the ureters, then the separated section of ileum (the conduit), then out of the urostomy.

Urostomy bags need to fit tightly around the urostomy to avoid urine coming in contact with the skin. Urine in contact with the skin will cause irritation and skin damage.

Question 101

Continent Urinary Diversion

Answer 101

A continent urinary diversion involves creating a pouch inside the abdomen from a section of the ileum, with the ureters connected. This pouch fills with urine. A thin tube is connected between a stoma on the skin and the internal pouch. Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.

Question 102

Neobladder Reconstruction

Answer 102

Bladder reconstruction involves creating a new bladder from a section of the ileum. This is connected to both the ureters and the urethra and functions similarly to a normal bladder. It may require intermittent catheterisation and bladder washouts to clear secretions from the small bowel tissue.

Question 103

Ureterosigmoidostomy

Answer 103

A ureterosigmoidostomy involves attaching the ureters directly to the sigmoid colon. Urine drains into and collects in the sigmoid colon. Techniques are used to prevent urine refluxing into the ureters or back through the large bowel. The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect. The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.

This used to be used more often but is very rarely done now. It is associated with infection in the kidneys, electrolyte imbalances and secondary cancer at the anastomosis (join) between the ureters and sigmoid colon.

Question 104

Kidney stones

Answer 104

Renal stones as also referred to as renal calculi, urolithiasis and nephrolithiasis. They are hard stones that form in the renal pelvis, where the urine collects before travelling down the ureters. They may be asymptomatic until they irritate or get stuck in the ureters. They might get stuck at any point along the ureters, but commonly at the vesico-ureteric junction.

Question 105

Complications of kidney stones

Answer 105

Obstruction leading to acute kidney injury
Infection with obstructive pyelonephritis

Question 106

Types of kidney stone

Answer 106

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 107

Staghorn Calculus

Answer 107

A staghorn calculus is where the stone forms in the shape of the renal pelvis, giving it a similar appearance to the antlers of a deer stag. The body sits in the renal pelvis with horns extending into the renal calyces. They may be seen on plain x-ray films.

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 108

Presentation of kidney stones

Answer 108

Renal stones may be asymptomatic and never cause an issue.

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

Patients often move restlessly due to the pain.

There may also be:

Haematuria
Nausea or vomiting
Reduced urine output
Symptoms of sepsis, if infection is present

Question 109

Investigating kidney stones

Answer 109

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.

TOM TIP: 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”. The three causes to remember are calcium supplementation, hyperparathyroidism and cancer (e.g., myeloma, breast or lung cancer).

Question 110

Managing kidney stones

Answer 110

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 111

Surgical interventions for kidney stones

Answer 111

Extracorporeal shock wave lithotripsy (ESWL):

ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.

Ureteroscopy and laser lithotripsy:

A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.

Percutaneous nephrolithotomy (PCNL):

PCNL is performed in theatres under a general 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 be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.

Open surgery:

Open surgery can be used to access the kidneys and remove the stones. This is rarely needed as other, less invasive, methods are usually effective.

Question 112

Recurrent kidney stones

Answer 112

One episode of renal stones predisposes patients to further episodes. NICE guidelines (2019) recommend advising patients to:

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)

Other common recommendations include:

For calcium stones – reduce the intake of oxalate-rich foods (e.g., spinach, beetroot, nuts, rhubarb and black tea)
For uric acid stones – reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)
Limit dietary protein

Two medications that may be used to reduce the risk of recurrence are:

Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium

Question 113

Renal cell carcinoma

Answer 113

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 114

Types of renal cell carcinoma

Answer 114

There are several subtypes of renal cell adenocarcinoma, the three most common being:

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 115

Risk factors for renal cell carcinoma

Answer 115

Smoking
Obesity
Hypertension
End-stage renal failure
Von Hippel-Lindau Disease
Tuberous sclerosis

Question 116

Presentation of renal cell carcinoma

Answer 116

Renal cell carcinoma may be asymptomatic, but may present with:

Haematuria
Vague loin pain
Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
Palpable renal mass on examination

The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for those:

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

Question 117

Spread of renal cell carcinoma

Answer 117

Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava.

“Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.

TOM TIP: Remember cannonball metastases as originating from a renal cell carcinoma. It is worth looking at some images of cannonball metastases. They are an exam favourite and an easy question to get right if you know the answer. They can also appear with choriocarcinoma (cancer in the placenta) and, less commonly, with prostate, bladder and endometrial cancer.

Question 118

Paraneoplastic features of renal cell carcinomas

Answer 118

Renal cell carcinoma is associated with several paraneoplastic syndromes:

Polycythaemia – due to secretion of unregulated erythropoietin
Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
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

Hypercalcaemia can also be caused by bony metastases.

Question 119

Staging renal cell carcinoma

Answer 119

A CT thorax, abdomen and pelvis are used to stage the cancer.

The TNM staging system is the most common staging system for renal cell carcinoma, rating the T (tumour), N (lymph node) and M (metastasis) stages.

There is also a number staging system specific to renal cell carcinoma:

Stage 1: Less than 7cm and confined to the kidney
Stage 2: Bigger than 7cm but confined to the kidney
Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia
Stage 4: Spread beyond Gerota’s fascia, including metastasis

Question 120

Managing renal cell carcinoma

Answer 120

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

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 121

Renal transplant

Answer 121

A renal transplant is where a kidney is transplanted into a patient with end-stage renal failure. It typically adds ten years to life compared to just using dialysis and significantly improves quality of life.

Question 122

Donor matching and renal transplant

Answer 122

Patient and donor kidneys are matched based on the human leukocyte antigen (HLA) type A, B and C on chromosome 6. They do not have to match fully, but the closer the match, the less likely there is organ rejection and the better the outcomes. Recipients can receive treatment to desensitise them to the donor HLA in preparation for a transplant from a living donor.

Question 123

Renal transplant procedure

Answer 123

The patient’s kidneys are left in place. The donor kidney blood vessels are connected (anastomosed) with the pelvic vessels, usually the external iliac vessels. The ureter of the donor kidney is anastomosed directly with the bladder. The donor kidney is placed anteriorly in the abdomen and can usually be palpated in the iliac fossa area. A “hockey stick” incision is typically used, and there will be a “hockey stick” scar.

Question 124

After the renal transplant

Answer 124

The new kidney will function immediately.

Basiliximab is a monoclonal antibody targeting the interleukin-2 receptor on T-cells. Two doses are given after surgery to prevent acute rejection.

Patients require life-long immunosuppression to reduce the risk of transplant rejection. There are various options and combinations of:

Tacrolimus
Mycophenolate
Ciclosporin
Azathioprine
Prednisolone

TOM TIP: When examining a patient with a renal transplant, you can look particularly clever by looking for the side effects of particular immunosuppressant medications.

Immunosuppressants 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 125

Complications relating to kidney transplant

Answer 125

Transplant rejection (hyperacute, acute or chronic)
Transplant failure
Electrolyte imbalances

Question 126

Complications related to immunosuppressants

Answer 126

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)

Question 127

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

Answer 127

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