Urology Flashcards

Question

Presentation of chronic prostatitis

Answer 1

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)

Answer 2

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

Answer 3

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.

Answer 4

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.

Answer 5

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

Answer 6

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

Answer 7

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

Answer 8

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)

Answer 9

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

Answer 10

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)

Answer 11

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.

Answer 12

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.

Answer 13

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

Answer 14

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)

Answer 15

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.

Answer 16

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

Answer 17

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

Answer 18

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.

Answer 19

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.

Answer 20

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.

Answer 21

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.

Answer 22

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.

Answer 23

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

Answer 24

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)

Answer 25

Epididymo-orchitis can lead to: Chronic pain Chronic epididymitis Testicular atrophy Sub-fertility or infertility Scrotal abscess

Answer 26

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.

Answer 27

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.

Answer 28

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.

Answer 29

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.

Answer 30

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

Answer 31

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.

Answer 32

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)

Answer 33

Hydroceles can be idiopathic, with no apparent cause, or secondary to: Testicular cancer Testicular torsion Epididymo-orchitis Trauma

Answer 34

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.

Answer 35

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

Answer 36

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

Answer 37

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

Answer 38

Uncomplicated cases can be managed conservatively. Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.

Answer 39

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.

Answer 40

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)

Answer 41

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.

Answer 42

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)

Answer 43

Undescended testes Male infertility Family history Increased height

Answer 44

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.

Answer 45

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.

Answer 46

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

Answer 47

Lymphatics Lungs Liver Brain

Answer 48

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

Answer 49

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.

Answer 50

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.

Answer 51

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

Answer 52

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

Answer 53

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)

Answer 54

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

Answer 55

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.

Answer 56

pyelonephritis, premature rupture of membranes and pre-term labour

Answer 57

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.

Answer 58

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).

Answer 59

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

Answer 60

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)

Answer 61

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

Answer 62

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.

Answer 63

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

Answer 64

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.

Answer 65

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.

Answer 66

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

Answer 67

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.

Answer 68

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.

Answer 69

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

Answer 70

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.

Answer 71

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

Answer 72

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.

Answer 73

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.

Answer 74

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.

Answer 75

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.

Answer 76

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.

Answer 77

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.

Answer 78

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.

Answer 79

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.

Answer 80

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.

Answer 81

Obstruction leading to acute kidney injury Infection with obstructive pyelonephritis

Answer 82

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

Answer 83

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.

Answer 84

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

Answer 85

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).

Answer 86

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.

Answer 87

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.

Answer 88

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

Answer 89

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.

Answer 90

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.

Answer 91

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

Answer 92

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

Answer 93

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.

Answer 94

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.

Answer 95

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

Answer 96

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.

Answer 97

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.

Answer 98

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.

Answer 99

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.

Answer 100

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

Answer 101

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

Answer 102

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)

Answer 103

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