Urology Flashcards
What is acute urinary retention?
Acute urinary retention is a medical emergency marked by the onset of the inability to pass urine over a certain period of time, usually hours to days
Aetiology of acute urinary retention?
BPH
Urethral stricture
Luminal causes; stone, blood clot, tumour, UTI
Mural causes; stricture, neuromuscular dysfunction
Extra-mural; abdominal/ pelvic masses/ tumours, retroperitoneal fibrosis
Neurological pathologies; cauda equina, MS
Obstructive pathologies
Infection
Medication; anticholinergics
Post operative complications
Constipation
Signs and symptoms of acute urinary retention?
Inability to pass urine
Lower abdominal discomfort
Pain or distress
Suprapubic tenderness
Suprapubic mass (due to an enlarged bladder)
Delirium (hypoactive or hyperactive)
Investigations to diagnose acute urinary retention?
Bladder scan/USS renal tract
Digital Rectal Exam
Urinalysis and urine MCS
Evaluation of post-void residual
Bloods tests: FBC, renal profile (renal function is often preserved due to the acuity, unlike in chronic urinary retention), CRP
Consider non-contrast CT KUB if stones suspected
Management of acute urinary retention?
Relieve retention with catheter
Post catheterisation treat the cause
What is balanoposthitis?
Inflammation of the glans of the penis and the prepuce due to infection, dermatological conditions , pre-malignant or malignant conditions
Aetiology of balanoposthitis?
Bacterial infections (e.g., Streptococcus, Staphylococcus)
Fungal infections, predominantly Candida species
Viral infections, such as human papillomavirus (HPV) or herpes simplex virus (HSV)
Dermatological conditions such as psoriasis, lichen planus, or lichen sclerosus
Chemical irritants
Poor hygiene
Phimosis (tight foreskin)
Presentation of balanoposthitis?
Redness and swelling of the glans penis and prepuce
Pain or discomfort
Itching
Presence of a foul-smelling discharge
Difficulty retracting the foreskin (phimosis)
Differentials for balanoposthitis?
Penile carcinoma
Contact dermatitis
Psoriasis
Genital herpes
Genital warts
Lichen sclerosus
Investigations to diagnose balanoposthitis?
Swabs for culture
Skin biopsy
Management of balanoposthitis?
Treat cause; if infectious targetted antibiotics
Avoid irritants like soap or laundry detergent
Keep area dry
What is BPH?
Non cancerous enlargement of the prostate gland (particularly in the transition zone) leading to compression of the urethra and subsequent LUTIS
Epidemiology of BPH?
Highly prevalent among ageing men
By 60 significant proportion exhibit histological evidence of BPH and by 80 nearly 90%
Aetiology of BPH?
Hormonal changes influenced by dihydrotestosterone (DHT) plays role in development
Genetic predisposition and lifestyle factors
Pathophysiology of BPH?
Nodular overgrowth of prostatic tissue predominantly in the transition zone
Growth impinges on the prostatic urethra causing dynamic and static obstruction leading to urinary symptoms
Signs and symptoms of BPH?
Hesitancy
Weak stream
Frequency
Urgency
Nocturia
Sensation of incomplete emptying
Differentials for BPH?
Prostatic cancer
UTI
Neurogenic bladder dysfunction
Urethral stricture
Investigations to diagnose BPH?
International prostate symptom score; used to assess severity of LUTS
Score 20–35: severely symptomatic.
Score 8–19: moderately symptomatic.
Score 0–7: mildly symptomatic.
DRE; assess prostate size, consistency and presence of nodules
PSA test to rule out prostate cancer
NICE guidelines for men presenting with BPH?
Refer men using a suspected cancer pathway referral for prostate cancer if their prostate feels malignant on DRE.
Consider a PSA and DRE to assess for prostate cancer in men with:
Any lower urinary tract symptoms, such as nocturia, urinary frequency, hesitancy, urgency or retention, or
Erectile dysfunction, or
Visible haematuria.
Refer men using a suspected cancer pathway referral (for an appointment within 2 weeks) for prostate cancer if their PSA levels are above the age-specific reference range.
Management of BPH?
Watchful waiting
Lifestyle modification; Fluid restriction, avoid caffeine and alcohol, timed voiding
Medical therapy;
Alpha blockers; tamsulosin
5 alpha reductase inhibitors; finasteride
TURP
Proctectomy
What is bladder cancer?
Malignant growth within urinary bladder
Epidemiology of bladder cancer?
11th most common cancer in UK
In developed countries 90% of bladder cancer is transitional cell carcinoma with majority of remaining cases being squamous cell carcinomas
Risk factors for bladder cancer?
Transitional cell carcinoma;
Smoking
Exposure to aromatic amines (employed in rubber, dyes, and chemical industry)
Use of Cyclophosphamide
Squamous cell carcinoma;
Schistosomiasis infection
Long-term catheterisation (10+ years)
Adenocarcinoma
Presence of other types of bladder cancer
Local bowel cancer
Types of bladder cancer?
Transitional cell carcinoma
Squamous cell carcinoma
Adenocarcinoma
Small cell bladder cancer
Signs and symptoms of bladder cancer?
Painless visible haematuria
Recurrent UTIs
Hydronephrosis
Neuropathic pain in medial thigh due to obturator nerve invasion
Unintended weight loss
Night sweats
Differentials for bladder cancer?
UTIs
Kidney stones
BPH
Interstitial cystitis
Investigations to diagnose bladder cancer?
Urine dipstick
MCS urine
CT urogram
Flexible cystoscopy
2WW referral criteria;
45 and over with visible haematuria without UTI or visible haematuria after successful treatment of UTI
60 and over with unexplained non visible haematuria and either dysuria or raised WCC
Classification of bladder cancer?
TNM system
Management of bladder cancer?
Non muscle invasive bladder cancer’
Surgery: Transurethral resection of the bladder tumour (TURBT) is the gold standard.
Chemotherapy: The bladder can be instilled with chemotherapeutic agents such as Mitomycin C (single dose if low risk, 6 week course if intermediate risk).
Immunotherapy: BCG immunotherapy can be instilled into the bladders of patients with high-risk non-muscle invasive cancers or carcinoma in situ (CIS).
If there is high-risk muscle non-muscle invasive cancer/CIS a radical cystectomy may still be considered
Muscle invasive bladder cancer;
Radical cystectomy with urinary diversion (ileal conduit, neo-bladder, or Mitrofanoff procedure)
Radiotherapy, chemotherapy
What is chronic urinary retention?
Consistent long term inability for the bladder to completely evacuate its contents leading to progressive bladder enlargement and may culminate in bladder contraction failure
Classification of chronic urinary retention?
Detrusor activity causes high pressure chronic retention which increases the risk of renal damage, high blood pressure and upper renal tract damage.
Low pressure chronic urinary retention and detrusor inactivity, you have distension of the bladder which does not back up pressure to the kidneys to cause hydronephrosis or reduce renal function.
Epidemiology of chronic urinary retention?
More common in older men with BPH
Increases with age
Aetiology of chronic urinary retention?
Benign prostatic hyperplasia (BPH) (most common)
Prostate cancer
Certain medications such as antihistamines, anticholinergics, or antispasmodics
Congenital conditions such as posterior urethral valves
Signs and symptoms of chronic urinary retention?
Storage:
Frequency
Hesitancy
Lower abdominal swelling (if the bladder becomes significantly enlarged)
Voiding;
Urgency
Dribbling
Poor urinary stream
Nocturia
Nocturnal enuresis
Incontinence
Differentials for chronic urinary retention?
Overactive bladder
Bladder stones
Urethral stricture
Neurogenic bladder
Investigations to diagnose chronic urinary retention?
Physical examination, potentially revealing a distended bladder or other physical signs correlating with the underlying cause
Urinalysis to detect infection or other abnormalities
Blood tests, including renal function tests
Bladder ultrasound to estimate post-void residual urine volume
Uroflowmetry to measure urine flow rate
Cystoscopy for direct visualization of the urethra and bladder
Urodynamic studies to assess bladder and sphincter functionality
Complications of chronic urinary retention?
Post obstructive diuresis
CKD
Hydronephrosis
Bladder diverticula
Management of chronic urinary retention?
Alleviating the obstruction, typically achieved via catheterization, surgery, or the use of specific medications.
Addressing the underlying cause, which may involve changing medications contributing to urinary retention, managing prostate conditions, or correcting congenital abnormalities.
Patients may also require intravenous fluids to manage post-obstructive diuresis.
What is post obstructive diuresis?
> 200ml/hr for 2 consecutive hours, or or production of >3L of urine in 24 hours.
What is epididymo- orchitis?
Epididymo-orchitis is a clinical condition characterized by inflammation of the epididymis and the testicle
Epidemiology of epididymo-orchitis?
More common in sexually active males, especially those aged 19-35 years
Aetiology of epididymo-orchitis?
STI infection; chlamydia, gonorrhoea
UTI; E.coli
Mumps
Tuberculosis
Signs and symptoms of epididymo-orchitis?
Testicular swelling and tenderness
Fever
Dysuria (painful urination)
Urethral discharge
Prehn’s positive (lifting up testicle relieves pain due to inflammation)
Cremasteric reflex is intact (this helps differentiate clinically from torsion)
Differentials for epididymo-orchitis?
Testicular torsion
Inguinal hernia
Testicular cancer
Investigations to diagnose epididymo- orchitis?
Clinical history and physical examination
Urinalysis and urine culture to identify urinary tract infections
Sexually transmitted infection screening via nucleic acid amplification tests (NAATs)
Urethral swab and gram stain can also be performed. If this reveals an intracellular organism Chlamydia is the likely cause, and if it shows grame negative diplococci this suggests Gonorrhoea.
Scrotal ultrasound may be needed to rule out testicular torsion`
Management of epididymo-orchitis?
Symptomatic management with analgesics for pain relief
Scrotal elevation and rest
Antibiotics;
If it’s due to any STI - treat empirically with ceftriaxone 1 g intramuscular (IM) injection as a single dose, plus oral doxycycline 100 mg twice daily for 10–14 days. Referral to sexual health clinic and contact tracing are likely necessary.
If most likely due to chlamydia or other non-gonococcal organisms (if no risk factors for gonorrhoea) - treat empirically with oral doxycycline 100 mg twice daily for 10–14 days
If an enteric organism (e.g. E.coli), or UTI is the most likely cause - treat with levofloxacin (10 days) or ofloxacin (14 days).
What is erectile dysfunction?
consistent or recurrent inability to attain and/or maintain penile erection sufficient for satisfactory sexual performance.
Epidemiology of erectile dysfunction?
More common in older men
ED is not considered a normal part of aging and can affect men at any age
Affects over half the men over 60 years
Risk factors for erectile dysfunction?
Vascular disease: Atherosclerosis can lead to impaired blood flow to the penis, leading to ED.
Autonomic neuropathy: This can cause penile denervation, most commonly seen in conditions like diabetes or with excessive alcohol intake.
Medications: Certain drugs, such as antihypertensive agents, can cause ED.
Psychogenic: Anxiety, depression, and other psychological factors can contribute to ED.
Endocrine causes: Conditions like prolactinoma and hypogonadism can cause hormonal imbalances leading to ED.
Pelvic surgery: Procedures involving the bladder, prostate, or other pelvic structures can damage nerves and blood vessels, leading to ED.
Anatomical abnormalities: Conditions like Peyronie’s disease, characterized by fibrous scar tissue inside the penis, can cause ED.
Signs and symptoms of erectile dysfunction?
Reduced sexual desire
Difficulty in ejaculation
Anxiety or depression related to sexual performance
Signs which suggest an organic cause is more likely - lack tumescence, slow-onset, normal libido.
Signs which suggest a psychogenic cause - if situational, high levels of stress, still having early morning erections.
Differentials for erectile dysfunction?
Premature ejaculation
Hypogonadism
Peyronie’s disease
Investigations to diagnose erectile dysfunction?
Sexual and psychological history
Bloods; FBC, U+E, TFT, lipid profile, testosterone, prolactin
Management of erectile dysfunction?
Psychosexual therapy to address any underlying psychological factors.
Oral phosphodiesterase inhibitors, such as Sildenafil, to enhance the effect of nitric oxide, increasing blood flow to the penis.
Vacuum erection devices to draw blood into the penis by applying negative pressure.
Intra-cavernosal injections to directly increase blood flow.
Penile prostheses for cases resistant to other treatments.
Contraindications to sildenafil?
Individuals taking nitrates
Hypertension/hypotension
Arrhythmias
Unstable angina
Stroke
Recent myocardial infarction.
Cautions for use of sildenafil?
Patients with angina
Peptic ulcer
Liver or kidney impairment
Peyronie’s disease
Those on complex antihypertensive regimes
Types of haematuria?
Macroscopic haematuria: Blood in the urine, visible to the naked eye.
Microscopic haematuria: Blood in the urine, detectable only on urinalysis.
Aetiology of haemturia?
Kidney related causes;
Glomerular: IgA nephropathy, Alport’s syndrome, Glomerulonephritis.
Non-glomerular: Tumours (Renal cell carcinoma, Wilm’s tumour), Nephrolithiasis, Infection, Polycystic kidneys, Trauma, Urethral stricture, Vascular conditions (infarction, renal vein thrombosis), Sickle cell disease, Certain drug
Ureter/ bladder related causes;
Stones
Tumours
Strictures
Infection
Urethral causes
Benign prostatic hypertrophy
Prostate cancer
Prostatitis
Trauma
Other causes
Menstruation
Post-coital
Certain medications
Viral illness
Investigations to diagnose haematuria?
Bedside - urinalysis.
Urine culture.
Urine microscopy - the type of blood cells seen may indicate the cause; dysmorphic red blood cells suggest glomerular origin, if red cell casts visible this suggests renal origin (precipitate with protein made in renal tubules)
Blood tests: Full Blood Count (FBC), Urea and Electrolytes (U+E), Prostate-Specific Antigen (PSA) for men, and coagulation studies.
Imaging: Renal tract ultrasound, Computed Tomography of kidneys, ureters, bladder (CT KUB).
Cystoscopy.
Renal biopsy.
What is hydrocele?
pathological accumulation of serous fluid in a sac-like cavity specifically around the testicle. It typically presents as an enlarged scrotum with swelling localised to one testis but can occur around both testicles
Epidemiology of hydrocele?
Most common in newborns affecting 5-10% of newborns
Aetiology of hydrocele?
Congenital due to patency of the processus vaginalis
Secondary; malignancy, trauma, infection
Signs and symptoms of hydrocele?
Scrotal swelling
Discomfort
Pain
Redness
Differentials for hydrocele?
Inguinal hernia
Varicocele
Testicular torsion
Epididymitis
Epididymal cyst
Haematocele
Testicular cancer
Investigations to diagnose hydrocele?
Clinical diagnosis
USS
Screen for infection and tumour markers; CRP, ESR, FBC, AFP, LDH, HCG
Management of hydrocele?
Watch and wait; most resolve by 12 months of age
Surgical correction; cord’s repair
Complications of hydrocele?
Recurrence of hydrocele
Infection or injury to local structures during surgery
What are LUTS?
group of symptoms that occur as a result of abnormal storage, voiding, or post-micturition function of the bladder, prostate (in men), or urethra.
Aetiology of LUTS?
UTI
Bladder underactivity
BPH
Prostate cancer
Ovarian/ fibroid mass
Urethral stricture
What are LUTS?
Voiding Symptoms;
Weak or intermittent urinary stream
Straining
Hesitancy
Terminal dribbling
Incomplete emptying
Storage Symptoms;
Urgency
Frequency
Urgency incontinence
Nocturia
Differentials for LUTS?
Bladder outlet obstruction
Overactive bladder syndrome
Prostatitis
Bladder cancer
Urethral stricture
Investigations to diagnose LUTS?
Urinalysis
Digital Rectal Examination (DRE)
Bladder diary
Urodynamics
What is phimosis?
Foreskin is too tight to be retracted over the glans of the penis
What is paraphimosis?
Inability to replace foreskin to its original position after it has been retracted leading to venous congestion leading to oedema and ischaemia to the glans of the penis
Aetiology of phimosis?
Sexually Transmitted Infections (STIs)
Eczema
Psoriasis
Lichen planus
Lichen sclerosis
Balanitis
Aetiology of paraphimosis?
Not replacing retracted foreskin
Presentation of phimosis?
Inability to retract foreskin
Interference with urination or sexual function
Presentation of paraphimosis?
Swollen painful glans
Tight band of foreskin behind glans
Differentials for phimosis?
Balanitis Xerotica Obliterans
Balanitis
Presentation of Balanitis Xerotica Obliterans?
White skin changes
Pruritus
Painful erections
Difficulty micturition
This is lichen sclerosus and is a pre-malignant condition
What is paraphimosis?
Penile fracture
Penile carcinoma
Investigations to diagnose phimosis?
Clinical history
USS
Uroflowmetry
Management of phimosis?
Topical steroids
Circumcision
Management of paraphimosis?
Reduce oedema; manual pressure
Dorsal sit in foreskin to relieve constriction
What is priapism?
Prolonged painful erection lasting more than 2 hours after sexual activity
Not related to sexual desire or stimulation
Epidemiology of priapism?
Priapism is a relatively rare condition, though exact prevalence rates vary.
It can occur in males of all ages, including newborns, but two age peaks are most common: 5-10 years and 20-50 years.
Conditions such as sickle cell disease, leukemia, and use of certain medications (like those for erectile dysfunction) can increase the risk.
Aetiology of priapism?
Ischaemic (low flow) priapism; lack of venous drainage from corpora cavernosa caused by sickle cell disease, malignancy and use of medications
Non ischaemic (high flow) priapism; trauma resulting in unregulated cavernous arterial inflow
Presentation of priapism?
A persistent erection lasting over two hours beyond sexual activity
Erection without sexual stimulation or arousal
Erection that may or may not be painful
Differentials for priapism?
Penile fracture
Peyronie disease
Balanitis
Investigations to diagnose priapism?
Laboratory testing: Includes full blood count, reticulocyte count, and blood gas analysis of the aspirated cavernous blood.
Imaging: An arteriogram may be performed to identify arterial-lacunar fistula in cases of suspected high-flow priapism.
Further investigations might be guided by suspected underlying conditions (e.g., tests for sickle cell disease)
Management of priapism?
Aspiration of blood in corpus cavernosa
Irrigation with saline
Intracavernosal injection of alpha agonist (adrenaline, phenylephrine)
Surgical shunt
What is prostate cancer?
Prostate cancer is a malignant tumour that arises from the cells of the prostate, most common type being adenocarcinoma
Epidemiology of prostate cancer?
Prostate cancer is responsible for approximately 48,000 new diagnoses each year in the UK, accounting for 13% of all cancer cases. It is the second most prevalent cancer among men globally, preceded only by lung cancer
Risk factors for prostate cancer?
Non modifiable;
African ethnicity
BRCA gene mutations
Family history of prostate cancer
Age
Modifiable;
Obesity
Smoking
Diet rich in animal fats and dairy products
Signs and symptoms of prostate cancer?
Urinary symptoms, including difficulty initiating or stopping urination
Poor urine stream
Haematospermia (blood in semen)
Pelvic discomfort
Bone pain, potentially indicating metastatic disease
Erectile dysfunction
Differentials for prostate cancer?
BPH
Prostatitis
UTI
Bladder cancer
Investigations to diagnose prostate cancer?
DRE
Urine dip
PSA blood test
Multi parametric MRI
Biopsy and gleason grading
2WW referral;
Refer if their prostate feels malignant on DRE.
Consider referring a person with possible symptoms of prostate cancer using a suspected cancer pathway referral (for an appointment within 2 weeks) if their PSA level is above the threshold for their age (see above)
Classification of prostate cancer?
T (Tumour):
T1: The tumour is not palpable or visible by imaging.
T1a: Tumour found incidentally in less than 5% of tissue removed.
T1b: Tumour found incidentally in more than 5% of tissue removed.
T1c: Identified by needle biopsy due to elevated PSA (prostate-specific antigen) levels.
T2: The tumour is confined to the prostate.
T2a: Tumour involves half or less of one side of the prostate.
T2b: Tumour involves more than half of one side but not both sides.
T2c: Tumour involves both sides.
T3: The tumour extends beyond the prostate.
T3a: Tumour extends through the prostate capsule.
T3b: Tumor invades seminal vesicle(s).
T4: The tumour invades adjacent structures other than seminal vesicles (e.g., bladder, rectum).
N (Lymph Nodes):
N0: No regional lymph node involvement.
N1: Regional lymph node involvement.
M (Metastasis):
M0: No distant metastasis.
M1: Distant metastasis present.
M1a: Non-regional lymph nodes.
M1b: Bones.
M1c: Other sites or multiple sites.
Management of prostate cancer?
T1 (T1a, T1b, T1c)
Active surveillance (for low-risk cases)
Watchful waiting
Radical prostatectomy (for selected cases)
T2 (T2a, T2b, T2c)
Radical prostatectomy (standard treatment)
External beam radiation therapy
Brachytherapy (seed implantation)
Active surveillance (for low-risk cases)
T3 (T3a, T3b)
Hormonal therapy (to delay progression)
Radical prostatectomy (selected cases)
External beam radiation therapy
T4
Hormonal therapy (palliative, delays progression)
Radiation therapy (palliative)
Symptomatic management
Not Fit for Radical Prostatectomy Hormonal therapy (palliative)
Metastatic (M1)
Hormonal therapy (androgen deprivation)
Chemotherapy (docetaxel, cabazitaxel)
Targeted therapy (abiraterone, enzalutamide)
Immunotherapy (sipuleucel-T)
What is prostatitis?
Inflammation/ infection of the prostate gland
Epidemiology of prostatitis?
Commonly affects men aged 30-50 years
Risk factors for prostatitis?
Preexisting urinary tract infection
Epididymitis
Catheter use
Previous urethral surgery
Presence of prostate stones
Aetiology of prostatitis?
Acute; bacterial infection, STI
Chronic; recurrent episodes of prostatitis with symptoms lasting >3 weeks
E.coli
Signs and symptoms of prostatitis?
Perineal or prostatic pain
Lower urinary tract symptoms including dysuria, frequency, urgency
Systemic symptoms like fever and myalgia
Boggy prostate on PR examination
Differentials for prostatitis?
UTI
Epididymitis
BPH
Investigations to diagnose prostatitis?
Focused history taking
Digital rectal examination, which typically reveals a tender, warm, and swollen prostate
Midstream sample of urine for culture and sensitivity
Screening for sexually transmitted infections, as gonorrhoea can cause prostatitis
Management of prostatitis?
Antibiotic therapy, tailored according to the identified or suspected pathogen, usually fluoroquinolones for 2/52.
Symptom relief using analgesics
Management of urinary retention if present, which could involve temporary catheterisation
What is urolithiasis?
Urolithiasis refers to urinary calculi (stones) anywhere in the urinary tract. They form due to supersaturation of urine causing crystal formation, which then aggregate into larger stones
Epidemiology of renal stones?
Common with men more commonly affected
More common in 35-45 year olds
Risk factors for renal stones?
Obesity
Chronic dehydration
High ambient temperature
Diet high in oxalate, urate, sodium and animal protein
White ethnicity
Family history
Structurally abnormal renal tract (e.g. vesicoureteric reflux, horseshoe kidney)
Comorbidities including diabetes, gout, hyperparathyroidism, Crohn’s disease, cystinuria
Aetiology of renal stones?
Calcium oxalate stones
Majority (approximately 70%) of stones
Radiopaque
Can form in any urine pH
Associated with low urine volume and hypercalciuria
Calcium phosphate stones
Approximately 10% of stones
Radiopaque
Tend to form in alkaline urine
Associated with renal tubular acidosis types 1 and 3
Associated with primary hyperparathyroidism
Uric acid stones
Approximately 10% of stones
Radiolucent
Only form in acidic urine (pH < 5.5)
Associated with diabetes, obesity and gout
May occur due to malignancy (due to high cell turnover, especially due to chemotherapy)
Struvite stones
Approximately 5% of stones
Radiopaque
Composed of magnesium, ammonium and phosphate
Often occur due to urease-producing bacterial infection (e.g. Proteus, Enterobacter, Klebsiella)
Associated with alkaline urine
May form staghorn calculi (which involve the renal pelvis and extend into mulitple calyces)
Cystine stones
1% of stones
Faintly radiopaque
Occur due to cystinuria (an autosomal recessive condition affecting renal reabsorption of amino acids)
More likely to form in alkaline urine
Often occur in young patients
Medication-induced stones
1% of stones
Occur due to crystallisation of medications or their compounds
e.g. indinavid, ceftriaxone, allopurinol, zonisamide
Signs and symptoms of renal stones?
Can be asymptomatic
Ureteric colic; severe spasmodic pain that radiates loin to groin and scrotum, usually sudden onset
Renal angle tenderness
Visible haematuria
Dysuria
Urinary frequency
Nausea
Vomiting
Fever
Diaphoresis
Rigors
Urinary hesitance
Intermittent stream
Differentials for renal colic?
Pyelonephritis
Appendicitis
Diverticulitis
Ovarian torsion
Ectopic pregnancy
Rupture/ dissection of abdominal aortic aneurysm
Investigations to diagnose renal colic?
Bedside:
Urinalysis for haematuria; nitrites and leukocytes may be present in infection (leucocytes may also be present in urine due to ureteral irritation) - urine pH may also guide the likely cause of stones
Urine MC&S looking for any bacteria that may be causing a complicating infection or struvite stones
24 hour urine collection in recurrent stone formers to assess urine volume, calcium, oxalate, uric acid, citrate, sodium and creatinine
Bloods:
Full blood count may show raised white cell count due to infection
U&Es may show deranged renal function e.g. if there is obstruction
CRP which may be significantly raised in infection
Bone profile looking for hypercalcaemia
Serum urate if raised may increase suspicion of uric acid stones
Venous blood gas may show acidosis and low bicarbonate if there is underlying renal tubular acidosis; lactate may be raised in patients systemically unwell with infection
Coagulation screen to check for a bleeding diathesis prior to intervention
Blood cultures in patients with suspected infection
Imaging:
Non-contrast CT KUB should be done urgently in patients with suspected renal colic
Ultrasound KUB is an alternative that should be offered to pregnant women and under 16 year olds
Abdominal X-ray also has a role e.g. to follow up radio-opaque stones that are being managed conservatively
Special tests:
Stone analysis to identify their composition and guide prophylactic management - sieving urine may be advised to retrieve fragments especially if there is recurrent stone formation
Management of renal colic?
Conservative;
If under 5mm wait to pass naturally
Drink 2.5-3 litres of water per day
Avoid carbonated drinks (may acidify urine)
Add fresh lemon juice to water (contains citrate which reduces stone formation)
Eat a balanced diet and maintain a healthy weight
Reduce salt intake
Do not restrict dietary calcium intake
Medical management; analgesia (NSAIDs) are first line, PR diclofenac
If over 10mm consider tamsulosin
Antibiotics; gentamicin, co-amoxiclav
IV fluids
Medical prophylaxis;
Potassium citrate is used for recurrent calcium oxalate stones
Thiazide diuretics may also be used for recurrent calcium oxalate stones
Surgical management;
Decompression and nephrostomy insertion
Extracorporeal shockwave lithotripsy
Ureteroscopy
Percutaneous nephrolithotomy
Open stone surgery
Complications of renal stones?
Obstruction
Infection
Ureteric strictures
Increased risk of renal cancer
Renal calyx rupture
Prognosis of renal stones?
95% of stones < 5mm will pass spontaneously within 40 days
70% of distal ureteric stones (of all sizes) will pass spontaneously
Rates of spontaneous passage are lower for more proximal stones (25% of proximal ureteric stones pass spontaneously)
Recurrence rates are high - 80% at 10 years - although 50% of these people will only have one recurrence
Frequent recurrence is seen in approximately 10% of patients
What is renal cell carcinoma?
Adenocarcinoma of the renal cortex that originates from the PCT
Well circumscribed with yellowish appearance denoting high fat and glycogen content
Microscopic appearance shows clear cytoplasm
What is transitional cell carcinoma?
Affects renal cell carcinoma that shares properties with TCC of the bladder, ureter
Macroscopically can be papillary or flat
Microscopically show areas of squamous differentiation, extensive keritinisation and intracellular bridges
Epidemiology of renal cancer?
Peak age is 85-89
Risk factors for renal cancer?
Non-modifiable risk factors for RCC:
North American and European ethnicity
Modifiable risk factors:
Obesity
Smoking
Diet (low in vitamins and minerals)
Hypertension
Signs and symptoms of RCC?
Haematuria (50%)
Loin pain (40%)
Flank mass (30%)
Metastatic disease (10%)
Evidence of paraneoplastic syndrome
Erythropoietin (EPO) Production:
Ruddy Complexion: Some patients may exhibit a ruddy or reddish complexion due to the increased production of erythropoietin, leading to polycythemia.
Parathyroid Hormone-Related Peptide (PTHrP):
Hypercalcemia: PTHrP secretion can result in hypercalcemia, leading to symptoms such as fatigue, weakness, and constipation.
Adrenocorticotropic Hormone (ACTH):
Cushing’s Syndrome: ACTH secretion may lead to Cushing’s syndrome, characterized by features such as central obesity, moon face, and muscle wasting.
Differentials for RCC?
Polycystic kidney disease
Renal angiomyolipoma
Oncoytoma
Investigations to diagnose RCC?
Ultrasound
CT of kidneys
MRI Imaging
Intravenous Urogram
Flex cystoscopy (to rule out bladder cancer)
Chest X-Ray (CXR) - to look for cannonball secondaries in the lung
Criteria for 2WW for renal cancer?
If they are aged 45 years and over and have:
Unexplained visible haematuria without urinary tract infection, or
Visible haematuria that persists or recurs after successful treatment of urinary tract infection.
Management of RCC?
RCC is relatively insensitive to chemotherapy and radiotherapy, making surgery the primary treatment. The extent of the surgery depends on the stage of cancer as well as the function of the contralateral kidney.
T1 lesions: Usually managed by partial nephrectomy, providing equivalent oncological outcomes to radical nephrectomies.
T2 and above: Typically managed by radical nephrectomy. A partial nephrectomy would be considered if the contralateral kidney offers insufficient function on its own.
Management of TCC?
TCC can be treated with both surgery and chemotherapy.
Surgery: Offers the best chance of cure with a procedure called a radical nephroureterectomy, involving removal of the kidney and ureter. It is typically only offered if there is no distant disease. Lesions can also be treated with a laser, which is usually offered to individuals who only have one kidney, poor combined renal function or are not fit enough for general anaesthesia and a major operation.
Chemotherapy: May be offered to patients who have an incomplete resection to reduce the chances of recurrence, or to palliative patients.
Radiotherapy: Not commonly used, but can be of use in a palliative setting.
What is testicular cancer?
Testicular cancer refers to any malignant neoplasm that originates from the tissues of the testicle.
Classification of testicular cancer?
Germ cell account for 95%; seminomas, non seminoma subtypes
Non germ cell account for 5%; leydig tumour
Seminoma (55% of cases)
Teratoma (33% of cases)
Mixed seminoma teratoma (12% of cases)
Epidemiology of testicular cancer?
Most common as a solid tumour in men aged between 20 and 45 years
Risk factors for testicular cancer?
Age under 45 years
Caucasian ethnicity
Previous history of testicular cancer
Cryptorchidism (undescended testicles)
Human Immunodeficiency Virus (HIV) infection
Previous mumps orchitis infection
Klinefelter’s syndrome
Presentation of testicular cancer?
The primary clinical manifestation of testicular cancer is a painless lump in the scrotum.
Germ cell tumours may be hormone-producing and can increase the oestrogen:androgen ratio, resulting in gynaecomastia.
Differentials for testicular cancer?
Epididymal cyst
Tentacular torsion
Epididymitis
Hydrocele
Varicocele
Inguinal hernia
Investigations to diagnose testicular cancer?
Scrotal USS
Serum tumour markers; AFP, hCG, LDH
CT TAP
2WW if non painful enlargement, change in shape/ texture of the testes
Management of testicular cancer?
Radical orchidectomy: This surgical procedure involves the removal of the affected testicle, usually the initial step in management.
Radiotherapy: Particularly beneficial for seminomas, which are highly sensitive to radiation.
Chemotherapy: Used as adjuvant therapy or for advanced disease, with cisplatin-based regimens being the most effective.
What is testicular cancer?
Urological emergency due to twisting of the testicle around the spermatic cord due to inadequet attachment to tissues within scrotum
Epidemiology of testicular torsion?
Most common between 13 and 16 years
Aeitology of testicular torsion?
Bell-Clapper deformity: An anomaly where the testis is inadequately fixed, allowing it to rotate freely.
Undescended testicle: Testicles that have not descended fully into the scrotum may be more prone to torsion.
Trauma: Physical injury may precipitate torsion, although it often occurs spontaneously.
Prior intermittent torsion: Those who have previously experienced episodes of intermittent torsion may be at higher risk.
Testicular tumour: Patients with a testicular tumour may first present with testicular torsion.
Presentation of testicular torsion?
Sudden onset, severe pain in one testicle
The event often follows minor trauma
The affected testicle may be upwards and horizontally in the scrotum, associated with erythema and swelling
Unilateral loss of cremaster reflex
Persistent pain despite the elevation of the testicle (negative Prehn’s sign)
Nausea and vomiting due to pain
In neonates, torsion may present as painless scrotal swelling which does not transilluminate.
Differentials for testicular torsion?
Epiddymo- orchitis
Trauma
Inguinal hernia
Torsion of epididymal appendage
Investigations to diagnose testicular torsion?
Doppler USS; whirlpool sign of spiral pattern in the spermatic cord
Urinalysis
Management of testicular torsion?
Urgent surgical exploration and de-torsion
Bilateral ochidopexy
Complications of testicular torsion?
Necrosis
Impaired fertility
Contralateral testicular torsion occurs in up to 40% of cases without bilateral fixation.
Prognosis of testicular torsion?
Testicular torsion in neonates bears a worse prognosis, as the testis is rarely viable.
In older children and teenagers, testicular salvage depends on the extent and duration of the testicular torsion.
Types of incontinence?
Stress incontinence
Urge incontinence
Overflow incontinence
Functional incontinence
Mixed incontinence
Aetiology of incontinence?
D - Delirium
I - Infection
A - Atrophic vaginitis or urethritis
P - Pharmaceutical (medications)
P - Psychiatric disorders
E - Endocrine disorders (e.g. diabetes)
R - Restricted mobility
S - Stool impaction
Investigations to diagnose urinary incontinence?
Physical examination
An examination will identify features of pelvic organ prolapse as well as the ability to contract pelvic floor muscles
Questionnaires
These are recommended in order to quantify the symptoms and assess the severity on patients quality of life which may help when deciding if a patient would benefit from more invasive treatment
Bladder diary
These are also useful for quantifying symptoms and documenting the number and type of episodes of incontinence. They may potentially show a relationship between causes and symptoms.
Urinalysis
This will help to rule out infection as an acute cause
Cystometry
This is an investigation which measures bladder pressure whilst voiding. It is not recommended in patients with clear histories where the diagnosis is clear.
Cystogram
If a fistula is suspected, contrast is instilled into the bladder and a radiological image is obtained in order to see if the contrast travels anywhere else.
Risk factors for urge incontinence?
Recurrent urinary tract infections
High BMI
Advancing age
Smoking
Caffeine
Causes of functional incontinence?
Sedating medications
Alcohol
Dementia
What is functional incontinence?
This involves an individual having the urge to pass urine, but for whatever reason they’re unable to access the necessary facilities and as a result are incontinent.
What is cryptorchidism?
Cryptorchidism, or undescended testes, is a congenital condition in which one or both of the testes fail to descend into the scrotum before birth.
Epidemiology of cryptorchidism?
Cryptorchidism is present in approximately 1-4.5% of term newborns and about 30-45% of premature newborns. By the first year of life, around two-thirds of these cases will have spontaneously descended.
Aetiology of undescended testes?
Genetic
Environmental
Maternal factors; alcohol, smoking and exposure to medication
Low birth weight
Differentials for cryptorchidism?
Retractile testes
Inguinal hernia
Ectopic testes
Management of cryptorchidism?
For undescended testes that are bilateral at birth, an urgent referral to a senior paediatrician within 24 hours is needed for potential endocrine or genetic investigation (e.g. congenital adrenal hyperplasia, or CAH). If these conditions are ruled out and the testes remain undescended by 3 months, the child should be referred to surgeons by 6 months of age.
For undescended testes that are unilateral at birth, arrange a review at 6-8 weeks of age. If the testis remains undescended at the 3-month review, re-examine at 4-5 months
At 4–5 months (corrected for gestational age), if the testis remains undescended, arrange referral to paediatric surgery or urology for specialist management depending on local referral pathways, to be seen by 6 months of age
The British Association of Paediatric Surgeons (BAPS) recommends that if orchidopexy is indicated, it should be performed around 12 months of age
Aetiology of UTI?
E.coli- most common
Klebsiella pneumoniae
Proteus mirabilis
Enterococcus faecalis
Staphylococcus
Signs and symptoms of UTI?
Urinary frequency
Dysuria
Urgency
Foul-smelling urine
Suprapubic pain
Clinical examination may be normal or reveal suprapubic tenderness.
Red flag symptoms such as haematuria, loin pain, rigors, nausea, vomiting, and altered mental state may indicate more serious infection, and these patients may have/are at risk of developing pyelonephritis (see below) and likely need referral to A&E.
Investigations for UTI?
Urine dipstick; leucocytes and nitrates
Mid stream urine
FBC, U+E, CRP
USS KUB
Management of UTI?
For LUTIs:
First line management is with oral nitrofurantoin or trimethoprim. Antibiotic duration can vary (see below) however in women the standard course length is 3 days.
The patient should be advised on conservative measures to reduce the risk of further infection e.g. regular fluid intake, post-coital voiding.
Specific situations
UTI in Men:
Empirical antibiotic drug treatment (if no cultures with sensitivities) with trimethoprim or nitrofurantoin for 7 days.
Refer to urology if there are ongoing symptoms despite treatment, if there is an underlying risk factor for UTIs (e.g. urinary calculi, suspected obstruction, previous GU surgery), or if there are recurrent episodes of UTI.
UTI during Pregnancy (with no haematuria):
First-line antibiotics are nitrofurantoin (but avoid at term), for 7 days.
If nitrofurantoin is not suitable due to e.g. renal function, or there is no improvement in symptoms, consider second-choice antibiotics such as amoxicillin/cefalexin for 7 days.
What is varicocele?
Varicocele is a condition characterized by an enlargement of the veins within the scrotum, similar in nature to varicose veins that can occur elsewhere in the body.
Epidemiology of varicocele?
15-20% of men
Slightly more common in infertile men
Aetiology of varicocele?
Faulty valves in spermatic vein causing blood to pool and enlarge veins
Presentation to varicocele?
Aching or heavy feeling in the scrotum
Visibly enlarged or twisted veins in the scrotum, often described as a “bag of worms”
Testicular atrophy
Impaired fertility
Differentials for varicocele?
Epididymitis
Testicular torsion
Inguinal hernia
Hydrocoele
Investigations for varicocele?
Physical examination: Varicoceles can often be identified by palpation of the scrotum, especially while standing or during a Valsalva maneuver.
Doppler ultrasound: This imaging modality can identify the enlarged veins and assess for retrograde blood flow, confirming the diagnosis.
Hormonal assays: In cases where infertility is suspected, evaluation of testosterone, FSH, LH, and semen analysis can be useful.
Management of varicoele?
Watchful waiting: For asymptomatic varicoceles or those not causing fertility problems.
Embolization: This minimally invasive procedure involves blocking the blood flow to the enlarged veins.
Surgery: Varicocele repair surgery can be performed through open surgery, laparoscopically, or with robotic assistance.
