Urology Flashcards
What is the mean age of diagnosis for prostate cancer?
70-79, increasing with age
Which lower urinary tract symptoms are considered irritative and which obstructive?
Irritative- due to storage of urine
Urgency, incontinence, frequency, nocturia
Obstructive- voiding issues
Hesitancy, poor flow, intermittent stream, terminal dribbling, incomplete emptying
How would prostate cancer be investigated?
Digital rectal exam
Age-related prostate-specific antigen levels
Free: total PSA levels
(the amount of free floating PSA compared to protein-bound PSA reduces in prostate cancer)
Transrectal ultrasonography with guided biopsy.
CT/MRI + isotope bone scan if PSA >10ng/ml
How is prostate cancer graded and staged?
Which system is most useful for prognosis?
GRADING- Gleason score- x+y
Looks at architectural pattern rather than cytology.
Looks at the organisation of the glands to determine how differentiated cells are- are glands recognisable
x = the most frequent pattern seen (more than 50% of the tumour)
y = the next most frequent pattern seen in sample
STAGING TNM score will be given
T= tumour size, related to it’s infiltration of the lobes or the prostate capsule etc
N= nodes, M= metastases
Gleason grade is more useful for estimation of prognosis, but PSA TNM and Gleason will be considered when classifying risk as low, medium or high.
When would active surveillance be suitable in prostate cancer?
For patients with low risk:
low PSA (below 10ng/ml)
stage T1/T2- tumour extends throughout prostate lobes but not the capsule
Low gleason score (6)
NB: PSA is a serine protease used to liquify seminal fluid
What are the potential side effects of radical prostatectomy + external beam radiotherapy used in prostate cancer?
impotence and incontinence
aka
erectile + bowel dysfunction
When would active surveillance, prostatectomy, external beam radiotherapy, hormones or brachytherapy be used in prostate cancer?
Active surveillance- low risk disease or reduced life expectancy due to comorbidity
Prostatectomy- localised disease
Radiotherapy- localised or localised advanced disease.
Brachytherapy (radioactive seeds)- less incontinence than other Rx, but if significant obstructive/irritative symptoms they may worsen.
Makes resection more difficult afterwards.
Hormone treatment- when life expectancy is below 10 years or metastatic disease.
70 year old man with prostate cancer taking LHRH agonist (Goserelin) has had numbness in his legs and has fallen twice.
What question to ask and what management?
Spinal cord compression from bony metastases.
LHRH used to inhibit LH release, may cause initial peak in testosterone, which is converted to oestrogen and increases bone growth.
‘Has there been any urinary incontinance?’
Rx: High dose prednisolone, MRI spine, radiotherapy, start hormone therapy.
What type of cancer is prostate cancer and where does it arise in the prostate?
95% adenocarcinoma- as tissue is glandular
5% sarcoma- from stroma of prostate
70% arise in the peripheral zone, many multifocal
In hormonal treatment of prostate cancer, LHRH agonists are given. How can an initial surge in testosterone be prevented?
Anti-androgen cover for the first 2 weeks may be offered using:
Biclutamide (androgen receptor antagonist)
Flutamide
Cyproterone acetate
What are the risk factors for bladder cancer?
Find 5.
- Commoner in men than women (2:1)
- SMOKING!!!!! -aromatic amines (2-6x increased risk)
3. Jobs: Textiles Rubber industries- analine dye Gas works Sewage treatment
- Chronic irritation:
Long term catheter
Stones
Schistosomiasis (haematobium) via squamous cell cancer. - Previous radiation exposure
Pathology of bladder cancer- types
90% transitional cell carcinoma
squamous cell carcinoma- if chronic irritation from catheters, stones or schistosomiasis
adenocarcinomas- from urachal remnants of the bladder.
(urachus is the fibrous remnant of the allantois- which drains the fetal baldder)
phaeochromatomas rarely.
Patient with frank haematuria or persistent haematuria after UTI is treated.
25% of macroscopic haematuria = cancer
Tends to be painless
Irritative symptoms of: frequency, nocturia, urgency and incontience may also present in bladder cancer.
How should suspected bladder cancer be investigated?
Cystoscopy
Transurethral resection of bladder tumour
include detrusor muscle to determine muscle invasion.
Urine cytology-prior to cystoscopy
Pelvic exam/bimanual under anaesthesia to see if pelvic mass is present- indicates T3 level of disease at least.
Intravenous Urogram
In superficial non-invasive bladder cancers (pTa and pT1) how can reoccurrence be prevented following resection?
pTa and pT1 mean no invasion into bladder muscle yet.
Mitomycin C made be given into the bladder within 6-24 hours, post-resection.
Mitomycin C= potent DNA crosslinker
In high grade non-invasive/superficial bladder cancer- pT1 G3:
intravesical BCG floods the bladder to stimulate the immune system.
Given weekly for 6 weeks.
Regular follow-up cystoscopies needed to monitor disease.
How should ‘carcinoma in situ’ of the bladder be treated?
Carcinoma in situ is where malignant cells that are highly dysplastic have not yet invaded the epithelium to enter muscle.
BCG may be given weekly for 6 months or radical cystectomy may be better (removal of the bladder).
How should muscle-invasive bladder cancer be treated?
Surgery
Men- cystoprostatectomy and pelvic node dissection
Women- pelvic exenteration
anterior pelvic clearance, hysterectomy, salpingo-oopherectomy and upper third vaginectomy
May reconstruct bladder- orthotopic neobladder may use small bowel as the reservoir then reconnect this to the urethra, like a normal bladder.
Ileal conduit takes a piece of small bowel (joining the bowel back up after piece removed) and connects ureters to it, this then connects to urostomy bag on skin.
Neoadjuvant or adjuvant chemotherapy afterwards.
What percentage of cancer in men is due to prostate?
What proportion of cancer mortality is due to prostate cancer?
Commonest cancer in men
1 in 10 men aged 70 get it.
13% of deaths from cancer in men are due to prostate cancer.
What type of bone lesions are seen if prostate cancer metastases to bone?
Osteoblastic thickening of the bone (sclerotic), resembling Paget’s disease.
Other cancer mets- breast/renal cancers form lytic thinning lesions.
How does the risk of prostate cancer increase with the number of first degree relatives who’ve had it?
One 1st degree relative = 2x
Two relatives = 5x
Three relatives =11x
How should locally advanced prostate cancer be treated?
How should metastatic prostate cancer be treated?
With hormone therapy and external beam radiotherapy.
Metastatic- LHRH analogues + anti-androgen cover (to obstruct adrenally produced androgens).
What is intermediate risk prostate cancer?
Gleason 7
PSA 10-20
T stage- 2b
means tumour is in more than half of one of the lobes.
(T3 is both lobes but within capsule)
What is Peyronie’s disease?
Localised connective tissue disorder
Fibrous inelastic scar following inflammation of tunica albuginea
inability to extend corpus cavernosum causes penile angulation
PC: pain, penile nodes, penile angulation, erectile dysfunction
What is phimosis?
At birth the foreskin is fused to the glans penis and is therefore not retractable.
How is Peyronie’s investigated?
Photos to measure deformity
Colour Doppler USS- to assess vascular or plaque abnormalities
Contrast MRI- if complex or extensive fibrosis
How is Peyronie’s disease managed In the acute phase?
Curvature:
Pentoxifylline
A PDE and TGF-1 inhibitor
Verapamil
(Ca2+ channel blocker with smooth muscle)
Pain- Colchine + Vit E
Colchine prevents neutrophil mobility (reduce inflammation)
What proportion of men have congenital curvature, what is it caused by?
4-10%
Asymmetric growth of the corpus cavernosum
Rx: Nesbit procedure (excise on opposite site to deformity)
16 dot plication (shortens the convex side using sutures)
During sex, there was a ‘popping’ noise and sudden loss of erection.
Now my penis is very bruised.
PENILE FRACTURE
rupture of corpus carvernosum ± spongiosum/urethra
IHx: surgical exploration- check for urethral injury
US to isolate defect
Rx: excavate haematoma, close tunica alburginea
How is male infertility investigated?
2 semen analyses (fresh)
look at sperm number, morphology, motility
Seminal vesicle function
FSH level
Genetic tests
DNA karyotype
CF gene
Y microdeletionsWhat investigations suggest ejaculatory duct obstruction?
Semen analysis: low volume, low pH, no fructose
Transrectal ultrasound scan after ejaculation- low sensitivity
Rx: surgery
What needs to be assessed in erectile dysfunction?
Vascular risk factors for atherosclerosis- diabetes, smoking, cholesterol, hypertension
Testosterone
IIEF-5 score is a questionnaire to find out severity of ED
Penile doppler USS- inject PGE1 to induce tumescence
Rigiscan- two rings measuring tumescence, number + duration of nocturnal erections. Demonstrates psychogenic ED.
How is organic erectile dysfunction managed?
PDE-5 inhibitors (prevent cGMP breakdown, more SM relaxation)
CI: nitrates
recent MI, stroke, hypotension, unstable angina
Intracavernosal injection
Given when oral treatments have failed, inject at right angles to corpus cavernosum on the lateral aspect of the penile shaft
Vacuum erection device
Penis is vacuum chamber to increase blood flow, constriction band maintains blood flow there.
Surgery- penile prosthesis (inflatable corpus cavernosum) or penile revascularisation- if clearly a vascular disorder
Has had an erection for last 4hours + without sexual stimulus
PRIAPRISM
What factors make a urethritis more likely to be sexually acquired and which suggest underlying UTI?
Sexually acquired:
New partner/risky sex in last 4 weeks
PC: dysuria, urinary frequency, urethral discharge
UTI:
Unchanging sexual relationships
Aged above 50
PC: frequency, loin pain, malaise, pyrexia
Testicular cancer risk factors
Undescended testes
Infertile men
Contralateral testicular tumour
Kleinfelters (XXY)
Tumour markers for testicular cancer?
AFP (yolk sac, embryonal, teratocarcinoma)
HCG (seminoma, choriocarcinoma, embryonal, teratocarcinoma)
lactate dehydrogenase
When should you refer haematuria?
If visible/frank haematuria
Symptomatic non-visible haematuria
40+ year old with non-visible haematuria
Persistent non-visible haematuria = 2/3 tests +ve
What causes transient (non-significant) haematuria?
UTI- check dipstick for leukocytes and nitrates
Exercise induced
Menstruation
What initial investigations would you do for
symptomatic non-visible haematuria
or persistent asymptomatic haematuria?
Exclude UTI or other causes- dipstick
Plasma creatinine/eGFR - glomerulonephritis
Measure proteinuria on random sample
Blood pressure- nephrotic syndrome
PLAIN KUB XRAY
ULTRASOUND RENAL TRACT
If haematuria is significant how do you decide between a urology or nephrology referral?
Nephrology if
eGFR below 60
proteinuria of PCR >50mg/mmol or ACR >30mg/mmol
everything else urology
for cystoscopy and imaging
What urological investigations used for significant haematuria?
(Visible, symptomatic non-visible or persistent non-visible)
Urine culture and cytology
Cystoscopy
Renal ultrasound
CT UROGRAM
Causes of haemospermia in under 40s
Inflammation of prostate, urethra, epididymus
Infection:
STDs- gonococcus
Entercoccal faecalis, chlamydia trachomatis, viral HSV
Tumour- rare
Causes of haemospermia in 40+ year olds?
Iatrogenic:
post-transrectal ultrasound
prostate biopsy
post prostate cancer radiotherapy etc
3.5 % Cancer: bladder prostate testicular benign prostatic hyperplasia seminal vesicle carcinoma- rare
Vascular:
dilated veins in prostatic urethra
hypertension
Haemospermia investigations?
If persistent or reoccurring:
FBC, PSA, LFTs, clotting
Transrectal USS
Flexible cystoscopy- look for polyps, urethritis, cysts, foreign bodies, stones, vascular abnormalities
Renal ultrasound
Pelvic MRI
Older man has some suprapubic pain, frequency + urgency.
Doctor does a dipstick and notices microscopic haematuria.
Likely diagnosis?
LUTS + peeing blood = bladder cancer
Carcinoma in situ of bladder presents this way and can be very aggressive.
Elderly man presents with a 4/12 history of wetting the bed.
On examination his abdomen looks distended.
Likely diagnosis?
High pressure chronic retention.
Distension due to grossly enlarged bladder, will be tense on palpation if high pressure.
May drain 2L off with catheterisation.
Patient presents with recent onset hesitancy, terminal dribbling, frequency and some loss of sensation to backs of his thighs.
What question needs to be asked?
What investigation is important?
Could be due to spinal cord compression, cauda equina syndrome or a sacral/pelvic tumour
Ask if can feel it when they wipe their bum (S3-5 dermatomes)
Ask about weight loss
MRI scan to determine neurological cause.
Causes of nocturia
Urological:
benign prostatic obstruction
overactive bladder
incomplete bladder emptying
Diabetes:
mellitus
insipidus (central)- lack of ADH
insipidus (nephrogenic)- ADH resistance
Renal failure Hypercalcaemic Obstructive sleep apnoea Autonomic failure Drugs- lithium causing ADH resistance Idiopathic
How should nocturia be investigated?
Record frequency and volume of each void over 24 hours for 7 days.
Definition of polyuria and causes
More than 3L of urine output per 24 hours
Solute diuresis- diabetes
Water diuresis- ADH resistance, or lithium therapy causing resistance
Definition of nocturnal polyuria
Production of more than 1/3rd of total urine output in 24 hours between midnight and 8pm.
Physiologically urine production normally reduces at night.
What is stress incontinence and what is it caused by?
Leakage of urine on coughing or sneezing or exertion.
Increase in abdominal pressure without detrusor contraction.
Caused by intrinsic sphincter deficiency, from bladder neck hypermobility ± neuro deficits
What is urge incontinence and what is it caused by?
Leakage of urine when urge to pee.
May be due to bladder overactivity or if bladder is irritated (infection, tumour, stone).
Patient has a hysterectomy and now complains of a constant leak of urine. What might be causing this?
Fistula communication between the bladder and vagina, post surgery.
If lifelong and low volume, can be due rarely to an ectopic ureter draining into the vagina instead of the bladder.
What is the nervous supply to the bladder?
Pelvic nerve = parasympathetic to detrusor muscle.
ACh- M3 receptors causes contraction and urination.
Hypogastric nerve = sympathetic to detrusor muscle.
NA-B3 receptors causes relaxation of detrusor muscle, no weeing.
What nervous supply controls the internal sphincter and external sphincters of the bladder?
Hypogastric nerve = sympathetic to internal sphincter
NA- a1 receptors cause contraction allowing wee storage.
Women don’t have an anatomical internal sphincter
Pudendal nerve = somatic to external sphincter
ACh- nAChR cause contraction ensuring closure for wee storage.
What comprises the internal sphincter of the bladder in men and women?
In women, it is functional not anatomic
= bladder neck and proximal urethra
In men it is anatomical
= bladder neck and prostate
What is the danger of chronic urinary retention in men?
How is it managed?
If the retention leads to a tense bladder, there may be back pressure onto the kidneys leading to renal failure in 30%.
Rx: intermittent self-catheterisation or indwelling catheter (if bed bound)
How can detrusor overactivity be investigated?
Urodynamic studies illustrate detrusor contractions during the filling phase of the bladder.
When spontaneous or provoked these contractions may cause urinary incontinence.
What can cause low bladder compliance and how might this provoke urinary incontinence?
Without a compliant bladder, filling may lead to a high level of pressure due to increased muscle tone or reduced bladder elasticity.
Myelodysplasia- associated with abnormal development of sacral structures
Spinal cord injury
Radical hysterectomy- scarring
Radiation/interstitial cystitis (scarring)
Proposed mechanisms of stress and urge incontience?
Urge
Detrusor overactivity
Low bladder compliance
Stress
Urethral hypermobility- weak pelvic floor allows descent of bladder neck with increased intra-abdominal pressure
Intrinsic sphincter deficiency
surgery, aging, menopause, childbirth, radiotherapy to prostate
Investigations for urinary incontinence?
Bladder diary- fluid intake, frequency, volume, incontience episodes, urgency, pad usage
Urinalysis + culture- UTI
Flow rate and post-void residual volume (uses USS)
Blood tests, ultrasound scans, cystoscopy
Urodynamic studies
What do urodynamic studies examine?
Pressure of stress incontinence.
Contractions during filling phase (detrusor overactivity)
Compliance (pressure change with volume)
Risk factors for stress incontinence?
Women:
Childbirth, obesity
Ageing, oestrogen withdrawal (menopause)
Previous pelvic surgery
Men:
Sphincter damage
Pelvic fracture or surgery
Prostatectomy or radiotherapy
1st line Rx for stress incontinence?
1st line: Pelvic floor muscle training- for 3 months
8 contractions 3 times a day
Lifestyle- weight loss, smoking, Rx constipation, modify fluid intake
What is the difference between the surgical approaches for stress incontinence?
Urethral bulking- increases outflow resistance
shouldn’t be given if urge incontinence coexists
Retropubic suspension- more invasive than suburethral sling. Elevates and fixes the bladder neck via the pelvic bones above pelvic floor
Suburethral slings or tapes- more superficial, can be inserted under local anaesthetic as day cases. Hooks around urethra lower down outflow tract.
Artificial urethral sphincter- uses a pump to release pressure. Used if other measures have failed or in severe incontinence
1st line Rx of urge incontinence?
Behaviour:
Bladder training- delay micturition, pelvic floor exercises for 6 months
Lifestyle:
Weight, fluid intake, avoid caffeine, alcohol, smoking
What drugs are used in 2nd line treatment of urge incontinence?
Antimuscarinics preventing parasympathetic M3 contraction of detrusor muscle:
Tertiary amines (bladder selective): Tolterodine, Darifenacin
Mixed action antimuscarinic:
Oxybutynin, Popiverine
3rd line:
B3 agonists- activate sympathetics to relax detrusor
Mirabegron
Common side effects of anticholinergics:
Relaxing= let it all hang out
Dry mouth Constipation Blurred vision Urinary retention Cognitive impairment Skin rash with transdermal patches
What are the principles for managing mixed incontinence?
Manage the predominant symptom
If unclear- what occurred first?
What is the difference between low flow and high flow priapism?
What causes it?
Low flow is ischaemic/veno-occlusive priapism where inability of blood to leave penis means a erectile state persists. Pain due to ischaemia.
High flow is due to nonischaemic/arterial inflow into the cavernus spongiosum, more uncommon and painless.
Low flow- haem abnormalities, malignant infiltration.
High flow- arteriovenous malformations.
How does a completely patent urachus present?
May get urine leaking through the belly button in adulthood as it provides a conduit from the bladder towards the umbilicus.
In the fetus, the umbilicus contains the umbilical vein, two arteries and the allantois (transports fetal urine out, forms the fibrous urachal remnant)
How can a patent urachus be shown?
Contrast injection with CT
or ultrasound
Differential of lumps in the groin:
Hernia- inguinal or femoral Enlarged lymph nodes Saphena varix- (dilatation of saphena vein) or femoral aneurysm Cord hydrocele or lipoma Undescended testes Psoas abscess
What signs in groin lumps are indicative of hernias?
Cough impulse presence
Reduce on lying down or with applied pressure
(unless contents of bowel etc are ‘stuck’ in hernia)
In regard to scrotal lumps, what does being able to ‘get above them’ mean and what does it tell us?
Superior edge can be palpated.
Indicates that lumps arise within the scrotum rather than descending from above.
How can an inguinal and femoral hernia be differentiated?
The point when the hernia is reduced indicates origin site.
Femoral hernias- below pubic tubercle
Inguinal hernias- above pubic tubercle
(direct- through abdo wall
indirect- through inguinal ring)
Patient has fever and soft fluctuant, compressible mass in femoral triangle that is painful
What is the diagnosis?
Psoas abscess
contains NAV (lateral to medial)
What is the differential or lumps in the scrotum?
Inguinal hernia Hydrocele, varicocele Epididymal or sebaceous cyst Scrotal skin or testicular tumour TB epididymo-orchitis
What is a hydrocele?
A hydrocele is an abnormal quantity of peritoneal fluid between parietal and visceral layers of the tunica vaginalis (a double layer of peritoneum that descends with the testes).
Tunica vaginalis originates from the processus vaginalis and normally obliterates along it’s length except around the testes.
Features of a scrotal lump suggesting a hydrocele:
Smooth surface, with palpable superior margin
Cannot feel the testes- due to tense fluid collection
Transillumination possible (light shone on one side is visible from other side)
What infection can be a secondary causes of hydrocele
Wuchereria bancrofti cause lymphatic obstruction
When would someone get orchitis without epididymitis?
What sign might be present if so?
Can be due to a viral infection, like mumps where enlargement of salivary/parotid glands may also occur.
Patient has a dull ache in scrotum. On inspection there is a ‘bag of worms’ appearance of the testes.
Varicocele- dilatation of the pampiniform plexus that extend up the spermatic cord.
65 year old man has red scaly plaque on penis that is getting gradually bigger.
What could it be and how is it treated?
Bowen’s disease- squamous skin carcinoma in situ
(could be psoriasis, condylomata- syphilitic warts, balanitis)
IHx: biopsy
Photodynamic therapy, cryotherapy, 5-FU
preferred over excision.
What counts as significant haematuria?
1+ on dipstick
> 3 RBCs on high power field in microscopy
How sensitive is urine cytology for picking up bladder cancers?
30% of low risk bladder cancers
90% of high risk bladder cancers
NMP22 biomarker is expensive but similar sensitivity.
What might the urine dipstick show that indicates haematuria is more likely to be due to a kidney cause rather than a urological/bladder cause?
The presence of protein, which arises from casts suggests kidney cause is more likely.
What can cause proteinuria?
Physiological/strenuous exercise Renal disease- glomerular, tubular-interstitial, renal vascular Multiple myeloma (Ig light chains)
What can cause a false negative in urine dipsticks for white blood cells?
Concentrated urine
Glycosuria
Presence of urobiligen
Consumption of much ascorbic acid (vit C)
What type of bacteria convert nitrates to nitrites, which may be detected with urine dipstick?
Gram negative
Red blood cells will appear dysmorphic on urine microscopy if they have arisen from bleeding in which part of the kidney/bladder?
The glomerulus of the kidney
during their passage they become distorted, may form casts.
Hyaline casts containing just mucoproteins (not WBCs or RBCs) could be due to what?
From tubular epithelial cells: Exercise Heat exposure Pyelonephritis Chronic kidney disease
In urine microscopy, casts with RBCs in them suggest what?
Glomerular bleeding
In urine microscopy what difference might you see in the casts in acute glomerulonephritis or tubulointerstitial nephritis compared to chronic renal disease?
CKD- hyaline casts (mucoproteins of tubular epithelial cells, no RBCs)
Glomerulonephritis- white blood cells in casts too.
What is cystinuria and what is it’s inheritance?
A genetic cause of kidney stones
Autosomal recessive
What’s the difference between cystinuria and cystinosis?
Cystinuria = failure to renally reabsorb cystine Cystinosis = intracellular cystine accumulation leading to Fanconi syndrome due to failure to transport it out of cellular lysosomes
(Cystine is a homodimer of amino acid cysteine)
Staghorn calculi may be composed of which minerals, when do they tend to arise?
Struvite- magnesium ammonium phosphate
Calcium carbonate
Cystine stones
Tend to arise with infections from organisms capable of splitting urea (proteus, pseudomonas, klebsiella).
How can suspected cystinuria be investigated?
Stone analysis
Urine analysis- cystine crystals
Cyanide-nitroprusside test of urine (if positive 24hour urine collection and cystine level)
Which type of renal stones precipitate in acidic urine?
3 C’s
Calcium oxalate (CaC2O4)
UriC acid
Cystine
Which renal stones precipitate in alkaline urine?
2 P’s
Calcium phosphate Triple phosphate (struvite)
What can be the cause of a positive urine cytology result?
Urothelial malignancy
Radiotherapy/chemotherapy in the last 12 months
Urinary tract stones
What is the commonest type of kidney stone?
Calcium oxalate (precipitates in acidic urine)
What are the top five causes of kidney stones, which are radiolucent?
75% Calcium oxalate (opaque- acidic) 15% Struvite (often opaque- alkaline) 5% Calcium phosphate (opaque- alkaline) 5% Uric acid (Lucent- acidic) 1% Cystine (Lucent- acidic)
Which kidney stones are radio-lucent?
Those without calcium in them: Uric acid Cystine Struvite Xanthine
Anti-retro viral drug stones (can’t see on CT)
Pure matrix stones
Which kidney stones are radio-opaque
Those with calcium in them:
Calcium oxalate
Calcium phosphate
Sometimes:
Struvite (triple phosphate)
Patient taking HIV treatment experiences intense colicky loin pain.
CT and Xray are unremarkable.
What could be the cause?
Indinavir-induced renal stone
Which opacities can be confused with stones on Xrays?
Calcified lymph nodes
Or pelvic phleboliths (calcified vein)
For a pregnant woman with suspected renal stones, what imagine modality may be best?
MRI
CT and Xray expose woman to radiation
However rarely are stones confidently excluded or diagnosed with MRI
What can cause post-void residual urine?
Detrusor underactivity- lack of sustained contraction with ageing or neurological disease
Bladder outlet obstruction
What is the key thing residual urinary volume post-void can tell urologists?
Likelihood of back pressure on the kidneys, thus whether it is safe to watch and wait rather than transurethral resection of prostate
How does citrate prevent kidney stone formation?
It forms a soluble complex with calcium, preventing it from crystallising with oxalate or phosphate.
Citrate and magnesium also prevent aggregation of crystals
Patient is found to have hypercalcaemia and a kidney stone. Which other abnormality are they likely to have?
Primary hyperparathyroidism.
PTH = increased Ca2+, decreased PO4-
Which three things cause low levels of urine citrate and predispose to stone formation?
Things that cause proximal tubule to be acidotic increase citrate reabsorption in proximal segment by sodium-citrate cotransporter.
(Cotransporter needs citrate in a 2- ion form.
Citrate 3- ion + proton = citrate 2- ion for uptake)
- Distal renal tubular acidosis (inability to secrete H+ into tubule causes acidosis)
- Hypokalaemia (low K+ may means more H+ swapped for Na+ in proximal tubule)
- Carbonic anhydrase inhibitors
Why does uric acid form in acidic urine?
Uric acid > Sodium urate + H+
The more H+, the more the reaction goes backwards.
Uric acid is insoluble, sodium urate is soluble.
Which type of renal stone is associated with gout?
Uric acid
What is the pathophysiology of type 1 renal tubular acidosis?
What metabolic features do patients get?
Distal RTA:
Insufficient secretion of H+ in the distal portion
Urine becomes alkaline.
Metabolic acidosis
Hypokalaemia (swapping more K+ for Na+)
Low urinary citrate (acidosis in proximal tubule due to more H+ in blood = more citrate 3- converted to citrate 2- for transporter uptake)
Hypercalcaemia (as bone releases CaPO4 to buffer acid)
What causes Type 1 Renal Tubular Acidosis?
Autoimmune diseases- Sjogrens
Inherited
What is the pathophysiology of type 2 renal tubular acidosis?
Proximal RTA:
Failure to resorb bicarbonate in the proximal tubule
More bicarbonate in tubule uses up H+ ions that are needed to turn citrate 3- to citrate 2- so it can be reabsorbed.
Therefore tubular alkalosis leads to increased citrate excretion
Which type of renal tubular acidosis puts the patient at greater risk of stone formation?
Type 1 distal RTA, acidic proximal tubule leads to more citrate uptake and lower levels in urine.
In Type 2, more bicarbonate in tubular (lack of reabsorption) leads to less protons to convert citrate 3- to citrate 2-, so less citrate reabsorption means high citrate urine levels, preventing calcium oxalate crystallisation.
Why do struvite kidney stones form?
Urease-producing bacteria (proteus, klebsiella, pseudomonas) break down urea into ammonia and alkinates urine. In alkaline conditions, magnesium, phosphate and ammonium precipitate.
A patient is found to have a stone, what factors make a renal tubular acidosis more likely?
Bilateral stones
Calcium phosphate stones
Nephrocalcinosis- calcium deposited in kidney (in acidosis more calcium phosphate released from bone to buffer)
Hypocitrataemia (high excretion, type 2 RTA)
Investigations for suspected renal calculi?
Xray
Renal USS
CT-KUB
Which type of stone should not be left to watch and wait?
Staghorn calculi- often related to an infection so to leave can destroy the kidney.
What does ESWL stand for?
Extra corporeal lithotripsy
Externally generated shock transmitted through to target a stone
When is extra corporeal lithotripsy likely to be successful?
When should it be avoided?
If the patient is not obese (needs to transmit through tissue to target stone)
If stone is under 1cm (large fragments may obstruct the ureter)
If stone is not composed of hard minerals (cysteine/calcium oxalate)
May cause renal injury so if susceptible.
What the intracorporeal techniques of stone fragmentation?
Electrohydraulic lithotripsy- voltage across water generates a spark. Used in the bladder and narrow safety margin.
Pneumatic lithotripsy- compressed air propels metal projectile. Used for ureteric stones, can push fragment into renal pelvis, where it can’t access.
Ultrasound lithotripsy- doesn’t damage soft tissues so can be used in kidney region
Laser lithotripsy- photo thermal mechanism vaporises stone, so unlikely to cause it to migrate, but takes time to paint stone
Which intracorporeal stone fragmentation technique doesn’t work if stone is in proximal ureter or near kidney?
Pneumatic lithotripsy is a straight probe, can’t round corners so may push fragments into renal pelvis where it can’t access them.
Electro hydraulic lithotripsy may damage ureters in the process (better for bladder)
Options: laser or ultrasonic lithotripsy
What is the advantage and disadvantage of percutaneous nephrolithotomy (PCNL) for kidney stones?
Advantage:
Higher success rates for stones >3cm
Best for staghorn calculi
Good for stones in lower pole of pelvis
Disadvantage:
More invasive- access through skin
More anaesthesia
When would open stone surgery be used to remove stones instead of percutaneous nephrolithotomy?
If there were multiple stones requiring too many PCNL tracks to gain access. (PCNL tracks have to be straight)
Which stones may dissolve with medical therapy?
Uric acid and cystine stones, (impaired success if calcium is in the stone as well).
Medical therapy for uric acid stones?
Uric acid Rx: sodium bicarbonate to alkalinize urine
Medical therapy for cystine stones?
Alkalinize urine with sodium bicarbonate
2nd line: Penicillamine converts cystine to more soluble forms
Patient has severe colicky flank pain, what is the most important investigation?
Temperature- indicates if infection present proximal to stone
Colicky flank pain and temperature.
Xray shows a stone in the right ureter.
Management?
Ix: urine and blood culture
IV fluids
Antibiotics
Nephrostomy drainage or J stent if fever hasn’t resolved in hours.
Pain relief for ureteric stones?
1st line: NSAIDs
(Anti-inflammatory, reduce ureteric peristalsis)
2nd line: opiates- pethidine/morphine
Uric acid stone suspected.
What would be found on xray and urine pH?
Low urine pH
No stone on Xray
What medication can be offering to increase speed of stone passage for those with small stones?
1a Tamulosin (alpha1 adrenoreceptor blockers) relaxes ureter to allow passage 1b or Nifedipine
- Prednisolone- reduce inflammation
What factors are considered when determining invasive or conservative management of renal calculi?
Size of stone
Severity of symptoms
Age of patient
Occupation (pilots can’t fly until stone free)
What management options are available for buying time in obstructive renal stones where operation is unfeasible?
JJ stent (goes from bladder to kidney) Percutaneous nephrostomy
What factors mean stone removal would be indicated URGENTLY?
One functioning kidney Bilateral ureteric stones CKD or AKI Urosepsis Intractable pain
How to prevent calcium oxalate stones
Increase fluid intake
Higher calcium intake (supplements at meals)
Vegetarian diet
What pain relief should be offered to pregnant women with kidney stones?
Opiates Not NSAIDs (may lead to premature closure of ductus arteriosus by blocking prostaglandin synthesis)
Finasteride inhibits which type of 5-alpha reductase enzyme?
Type 2, found on prostatic stromal cells
Doesn’t effect type 1 5a-reductase found on liver and skin cells
What does 5a-reductase enzyme do?
Converts testosterone to the more potent dihydrotestosterone (DHT)
Causes of bladder outflow obstruction in women
Pelvic prolapse Urethral stricture Urethral diverticulitis Post-surgery for stress incontinence Fowler's syndrome (impaired external sphincter relaxation) Pelvic masses
70 year old man complains of bed wetting, urgency and frequency with poor flow.
What would you be thinking of?
What examination findings would confirm this?
High pressure chronic retention
EHx: grossly distended bladder
Bladder tense on palpation, dull to percussion
What investigations should be performed for patients coming in with Lower Urinary Tract Symptoms?
Urine analysis- UTI
Voiding diary- look for polyuria or nocturia
Serum creatinine- detect renal failure secondary to urinary retention
DRE + PSA
Patient comes in with lower urinary tract symptoms
Serum creatinine is found to be 145, what test should be done?
Renal USS to check for hydronephrosis
High creatinine >115 suggests renal failure secondary to high-pressure urinary retention
What is the conservative management for those with storage symptoms of lower urinary tract (frequency, nocturia, urgency, urge incontinence)?
How long should it be tried?
Overactive bladder:
Bladder training- timed voiding
Reduce alcoholic and caffeinated drinks, normalise fluid consumption
For 3 months
What is the conservative management of those with voiding symptoms of the lower urinary tract (hesitancy, poor flow, terminal dribbling)?
Intermittent self-catheterisation
Terminal dribbling = urethral milking
Surgery is more effective than bladder training for men with proven bladder outflow obstruction
More moderate lower urinary tract symptoms what drugs can be offered?
Alpha blocker- smooth muscle relaxants (-sins)
Alfuzosin, doxazosin, tamulosin
For overactive bladder what drug treatments are available?
Anti-cholinergics
For lower urinary tract symptoms with benign prostatic hyperplasia (PSA above 1.4ng/mL or prostate >30g) what medication can be offered?
5 alpha-reductase inhibitor
Fi astride, dataset ride
What medication could be offered for nocturnal polyuria?
A late afternoon loop diuretic
What are the indications for a transurethral resection of the prostate?
Failure of medical therapy
Recurrent acute urinary retention
Renal impairment from high-pressure
Recurrent haematuria
If a patient is suspected of having acute urinary retention, what volume of urine would be expected to be drained?
> 500mL
Drainage of how much urine would suggest acute-on-chronic retention rather than acute retention?
> 800mL
Causes of acute urinary retention specific to men:
Benign prostatic enlargement
Malignant prostate enlargement
Urethral stricture
What is Fowler’s syndrome?
A primary disorder of bladder sphincter relaxation
Leading to bladder outflow obstruction
(Unlike spinal cord injury which is secondary)
Occurs in women aged 15-30
Associated with polycystic ovaries
What surgical treatments are available for stress incontinence?
Urethral bulking
Suburethral slings- less invasive
Retropubic suspension- open incision
Artificial urinary sphincter- when all else fails or neurological weakness
Medical therapy for urge incontinence?
Anti-cholinergic medications (ACh antimuscarinic- M3 subtypes)
Oxybutynin
Solifenacin
Darifenacin
Tolterodine (bladder specific)
Oxybutinin and Solifenacin medication for overactive bladder (urge incontinence) acts on which receptors?
M3 muscarinic ACh receptors
Which bacterium produces the neurotoxin Botulinum toxin?
Clostridium botulinum =
gram-positive, rod-shaped, anaerobic bacterium
How does Botox work?
Inhibits the release of ACh and other neurotransmitters from pre-synaptic cholinergic nerve terminals, preventing muscle contraction.
How is Peyronie’s disease treated in stable disease that has been present for 12 months?
NESBIT procedure- deglove penis, excise on side of deformity.
SEs: penile shortening, bleeding, unsuccessful
LUE PROCEDURE- venous graft on penis acts as an anatomical tunical substitute to lengthen side of shortening.
What would prompt sooner treatment in post-prostatectomy incontinence, urge or stress incontinence?
Stress incontinence- on coughing etc as it indicates sphincter dysfunction
Constant urine leakage following obstructed labour may be due to…?
How can it be investigated?
Vesicovaginal fistula
A cystogram will show contrast in bladder and vagina
Transient causes of urine incontinence? (DIAPPERS)
Delerium Infection Atrophic vaginitis/urethritis Pharmaceuticals- a-blockers (for HTN, anxiety) Psych problems Excess fluid Restricted mobility Stool compaction
What medical therapy can be offered for stress incontinence?
Type of mechanism?
Duloxetine- a SNRI
Works centrally to increase pudendal nerve activity and enhance sphincter activity
Female presents with stress incontinence, what other symptoms prompt specialist referral?
Pain
Haematuria
Recurrent infection
Voiding symptoms
Herniation of the bladder and urethra through the anterior wall is called?
Which ligament is weakened?
Cystocele- bladder
Urethrocele- urethra
Pubocervical ligament
On examination there is a protrusion through the posterior vaginal wall, what is this likely to be?
Rectocele- rectum
Enterocele- peritoneum
After standing for a long time patient feels pressure in her vagina. She has also noticed urinary frequency and urgency. Diagnosis?
Pelvic organ prolapse
What may cause sterile pyuria?
STIs
TB infection
Carcinoma in situ
Bladder stones
How many UTIs in how many months are required for a diagnosis of recurrent UTI?
2 in 6 months
Or
3 in 12 months
Causes of uncomplicated UTI?
SPECK
E Coli (80% in community-acquired)
Staphylococcus saprophyticus
Proteus mirabilis
Klebsiella
Proteus mirabilis bacteria may contribute to which kind of stone formation?
Struvite stones- produce urease so that cause urea breakdown into ammonia in urine.
Which bacteria can inactivate b-lactam bonds in antibiotics?
Staph aureus
Neisseria gonorrhoea
Enterobacteria
Which antibiotics have b-lactam bonds in, susceptible to b-lactamase enzymes of bacteria?
Penicillins
Cephalosporins
Carbapenems (used last resort for multi-drug resistant bacteria- meropenem)
Proteus is resistant to which common antibiotic given for UTIs?
Nitrofurantoin- forms a highly reactive metabolite that damages bacterial DNA and ribosomes
First line antibiotic for pyelonephritis?
Mechanism of action?
Fluoroquinolone (inhibits topoisomerase needed for super oils)
Cephalosporin (cross links peptidoglycan for cell walls)
Complicated UTI drug treatment?
Same as pyelonephritis:
Fluoroquinolone (inhibit topoisomerase- supercoils DNA)
Cephalosporin (stops cell wall cross linkage)
If a complicated UTI is suspected, what investigation should be done first?
KUB Xray to look for anatomical abnormalities
What form of contraception predisposes women to UTIs?
Spermicide containing nonoxynol-9
Which antibiotics can be given prophylactically in low doses for those with recurrent UTIs?
Trimethoprim (interferes folate synthesis)
Nitrofurantoin (reactive species attack DNA)
Which recreational drug causes a condition that mimics carcinoma in situ of the bladder?
Ketamine
Rx for TB of the bladder?
2 months: Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
Then 4 months: Rifampicin and isoniazid
Which schistosoma species affects the bladder?
Investigations?
Schistosoma haematobium (Middle East)
Serology ELISA
Cystoscopy- eggs in bladder ‘sandy patches’
Treatment for schistosomiasis?
Praziquantel PO
What is associated with squamous cell carcinoma of the bladder?
Schistosomiasis- normally transition cell carcinoma
60 year old patient complains of phimosis (foreskin too tight to be pulled back) and itching of penis.
EHx: White papules and white patches
Diagnosis?
Lichen sclerosis-
On the penis this is known as balanitis xerotica obliterans
Lymphocyte and plasma cell infiltration to the dermis
What is Wilms tumour?
Familial inheritance?
A type of childhood tumour of the kidney arising from embryonic mesenchyme (nephroblastoma)
Autosomal dominance inheritence
First line investigation of loin pain?
Abdominal Ultrasound Scan to determine if mass is present on kidney.
What type of cell carcinoma is a renal cell carcinoma?
Adenocarcinoma
What type of tumours do those with Von Hippel-Lindau get?
Phaeochromocytoma
Renal + pancreatic cysts
Cerebellar haemangioblastoma
Renal cell carcinoma- bilateral + multi focal
Occupations associated with transitional cell carcinoma of the bladder:
Rubber manufacture Paint and dyes Iron processing Hairdressers Plumbers Gas and tar manufacture
(Rub, paint, iron, plumb, gas about it- key things in the household)
On urodynamic studies, what does it mean if stress incontinence occurs at:
90cm H20
60cm H20
above 90cmH20 suggest hypermobility
below 60cmH20 suggest intrinsic sphincter deficiency
What free:total PSA level pattern occurs in prostate cancer?
The amount of free floating PSA compared to protein-bound PSA reduces in prostate cancer
95% of prostate cancers give a ratio below 25%
Surgical options for urge incontinence Rx?
Botox
Neuromodulation
Surgery to thin out the detrusor muscle
Which type of inguinal hernia is more likely to descend into the scrotum
Indirect inguinal hernias
through inguinal ring, direct = through abdo wall
What makes up the borders of the femoral triangle?
superior- inguinal ligament
lateral- sartorius
medial- adductor longus
What are the different types of hydrocele?
Communicating = fluid channel connecting peritoneal cavity and testes
Cord hydrocele= a bubble of fluid that opened up in the obliterated remnant of tunica vaginalis
Tunica vaginalis hydrocele= lots of fluid around testes
What does the ‘blue dot’ sign occur with?
Appendix of testes (a remnant of the Mullerian duct) can undergo torsion
A patient comes in for TURP and afterwards notices ankle swelling, he says that he quite often gets breathless on mild exertion. What has happened? What would you expect has happened to sodium levels?
Excessive irrigation fluid of the endoscope has caused hypervolaemic hyponatraemia in someone already on the verge of heart failure (TUR syndrome)
A 45 year old man has a PSA of 2.8ng/mL, how should you counsel him?
In age specific ranges of PSA, above 2.5 is elevated for a man under 45 so further investigation is warranted.
Someone comes in with LUTS, what three immediate tests should you do?
DRE- hard + lumpy or smooth + firm
PSA- age specific cut offs, higher cut off for afro-carribbeans
Urinanalysis- microscopic haematuria suggests cancer (bladder or prostate)
What’s the difference between active surveillance and watching and waiting? What do they entail?
Waiting and waiting is chosen if a patient is palliative or very old. Active surveillance is for low grade prostate cancer and involves:
Close monitoring of PSA
Repeat biopsies
If someone is on an SSRI and experiencing sexual dysfunction, what can be done?
Reduce SSRI dose
Switch to a non-SSRI (like buproprion)
Between femoral and inguinal hernias which type is elective surgical management always indicated?
Femoral, higher risk of strangulation
What are the indications for treating inguinal hernia’s surgically if they are not strangulating and are reducable?
Females- all Males- if moderate/severe symptoms, or scrotal or recurrent, or 70+
Others can have elective surgery or watchful waiting, avoiding heavy lifting
Woman develops a hernia during pregnancy how should be managed?
Watchful waiting during pregnancy, 4 weeks after pregnancy can consider surgery
How might a hernia be symptomatic?
Pain on heavy lifting
Discomfort
Irreducible
Where is the fluid found in a hydrocele?
Between parietal and visceral layers of tunica vaginalis
Failure of which structure to close during development will lead to a communicating hydrocele?
Processus vaginalis
What manoeuvre can be performed to identify a communicating or non-communicating hydrocele?
Straining will increase the size of a communicating hydrocele but not a non-communicating hydrocele
What is the 1st line investigation used to distinguish a hydrocele or a epididymus or testicular torsion etc?
Doppler USS
Which hydroceles would you think about operating on?
Communicating hydroceles
If newborns born with one that is still there after age 1
Which side do people get varicoceles on and why?
Left side
The L spermatic vein enters the renal vein at a sharp angle compared to the R spermatic vein (obtuse angle) leading to greater prevalence of venous back up on L side
When would you consider treating a varicocele of the testicle?
Varicocele (bag of worms, venous back up)
If the affected testicle is considerably smaller than the other side (suggests it is leading to testicular failure)
Or symptomatic- pain, swelling, heaviness
What is a spermatocele?
A painless fluid filled cyst at head of epididymus (top of the testicle)
Feels separate from testes
Which type of testicular cancer can present with gynaecomastia?
Occasionally in germ cell tumours (95% of cancers) Leydig cells (2% of testicular cancers)
What is the definitive investigation to diagnose testicular cancer?
Pathology result is definitive- but tend to avoid biopsying in case of seeding cancer cells, do radical orchidectomy if sufficient reason to believe it’s cancerous.
If USS is unequivocal often use CT to clarify, and check tumour markers
How do seminomas (testicular germ cell tumours) act compared to non-seminoma germ cell tumours?
Seminomas are normally localised at diagnosis whereas NSGCT’s are normally metastasised.
Seminomas are quite indolent, slow progressing Vs NSGCT that are aggressive
Which types of germ cell tumour in men may have a raised bHCG?
Seminoma
Non seminoma: embryonal or teratocarcinoma
Which germ cell tumours in men may give a raised AFP tumour marker?
Non seminoma: Yolk sac, embryonic, teratocarcinoma
What complication can arise in testicular tumours producing high levels of bHCG?
(Seminoma’S
NSGCT: choriocarcinoma, embryonal, teratocarcinoma)
Paraneoplastic hyperthyroidism with hCG mimicking TSH
Gold standard imaging for radiological diagnosis of kidney stone disease?
Non-contrast CT KUB
What is the test of choice for urinary tract obstruction?
Ultrasound scan to avoid radiation exposure
but may use CT if stone is suspected from Hx and FHx or they have polycystic kidney disease making the USS harder to interpret/visualise
Which imaging can test the function of the kidney?
DSMA- technetium Tc-99m succimer
Identifies scars + fibrosis
In kids who have had nephrotic disease need to wait 4 months before doing one to avoid false result
In those with kidney failure, who should receive an ultrasound scan?
All with renal failure of an unknown cause
What findings on ultrasound suggest irreversible kidney damage?
Cortical thinning
Reduced kidney size
Gross haematuria with passage of clots almost always indicates a problem in which part of the urinary tract?
Lower urinary tract (bladder + urethra)
What type of casts are virtually diagnostic of glomerulonephritis and vasculitis?
Red cell casts
In gross haematuria what can the colour of urine suggest about it’s cause?
Glomerular: coca-cola brown urine (due to methemoglobin formed in alkaline urine) ie nephritides etc
Red to pink: more typical of non-glomerular haematuria
What does proteinuria indicate about the source of bleeding between being glomerular or non-glomerular?
It’s unusual to get increased protein if the source is non-glomerular. Haematuria alone does not raise protein, so high protein suggests glomerular cause.
In someone with haematuria, what would make you think about a renal biopsy rather than cystoscopy?
Signs of kidney damage- raised creatinine
Proteinuria (suggests glomerular cause rather than non-glomerular)
Imaging modality for gross haematuria without evidence of glomerular disease (high creatinine or proteinuria)?
Cystoscopy
If known glomerular disease but clots present, patients need a cystoscopy as clots don’t occur in glomerular causes
Which patient’s with microscopic haematuria should have a cystoscopy?
If they do not have glomerular disease, infection or known cause
And have increased risk of malignancy:
Over 35, smoker, painter/printer, irritative voiding symptoms, analgesic abuse
What is the following imaging used for in urology/nephrology: USS CT- KUB CT-urography + cystoscopy Renal biosy
USS: unexplained renal failure
CT-KUB: suspected stone disease (nephrolithiasis)
CT-U + cystoscopy: unexplained haematuria
Renal biopsy: suspected glomerular disease
Benign causes of a raised PSA
Ejaculation
PMH: BPH, prostatitis, urinary retention, prostatic infact
IHx: DRE, TURP, prostate biopsy, cystoscopy
Causes of orchitis?
Mumps
Syphilis
Granulomatous
How does granulomatous orchitis differ in it’s presentation from infective causes of orchitis? (syphilis or mumps)
In all of them the testes may be unilaterally enlarged but in granulomatous, it is tender whereas in infectious causes it is painless typically
Biopsy shows granuloma, whereas syphilis shows plasma cells and lymphocytes
If a testicular tumour is not a germ cell tumour (95%) what other kind of tumour can it be?
Sex-cord stromal tumour
Lymphoma
There are two types of seminoma (germ cell tumour of the testes), classical and spermatocytic.
What are the differences?
Classical (95%) is from undifferentiated germs cells
Spermatocytic (5%) is from spermatogonia (which is more differentiated, less likely to metastasise) and age of presentation is older = 50s
What types of tumour might arise in a mixed teratoma and germ cell tumour?
50% of malignancies: Teratoma (NSGCT) ± Embryonal carcinoma (undifferentiated NSGCT) ± Yolk sac tumour (HSGCT) ± Seminoma
NSGCT means non-seminoma germ cell tumour
If someone had a testicular mass that was both solid and cystic, what kind of tumour would you be thinking of?
Teratoma or Mixed teratoma and germ cell tumour
Germ cell tumour could be yolk sac, embryonic or seminomatous tumour
You remove a mass from someone testicle that looks pale, well circumscribed and homogenous. What type of tumour is it?
Seminoma (germ cell tumour)
Formed from undifferentiated germ cells (=classical 95%) or spermatogonia (spermatocytic 5%)
Looking at the histology of a testicular tumour you have removed you notice large areas of necrosis and haemorrhage on it.
Microscopically there are irregular sheets of primitive epithelial cells. What type of tumour do you have?
Embryonal carcinoma
A non-seminomatous germ cell tumour
Also known as an undifferentiated malignant teratoma
It’s aggressive, and may produce AFP or b-HCG
Commonest malignant testicular tumour in children?
Yolk sac tumour
On histology what are Schiller-Duval bodies and what type of testicular cancer are they characteristic of?
Lacy bodies of cells around blood vessels
Yolk sac tumour
A boy of 8 has started puberty and noticed a testicular mass. What is the likely malignant cause?
Sex cord tumour (make up 3% of all testicular tumours):
Sertoli cell tumour
Produces androgens + oestrogens
Commonest testicular neoplasm of over 60s?
Lymphoma- often diffuse B-cell lymphoma
How are prostate cancers staged, briefly what is the T staging?
T1- no palpable and observable tumour with imaging
T2- within prostate
T3- outside prostate
T4- invading outside structures that are not the seminal vesicles
If a prostate tumour is staged T2, what is the difference between a, b and c?
T2a- less than half a lobe
T2b- more than half a lobe
T2c- both lobes
T3 = outside capsule
Which TNM and Gleason scores would make active surveillance a viable treatment option?
T2N0M0 (within prostate)
Gleason 3+3 (all very differentiated)
Avoids side effects, most die from something else
What does active surveillance in prostate cancer involve?
Serial:
PSA
MRI
Biopsies
What Gleason score is associated with low, intermediate and high risk prostate cancer?
Low: 3 + 3 = 6
Intermediate: 3 + 4 = 7
High: 4/5 + 4/5 = 8-10
What T scores are associated with low, intermediate and high risk prostate cancer?
Low: T1- T2a
Intermediate: T2b-2c (more than half of one lobe)
High: T3- T4
Mets: M1
How does the Rx differ for low, intermediate, high risk and metastatic prostate cancer?
Metastatic use docletaxel
Intermediate, start adding in androgen deprivation (LnRH)
All others may use brachytherapy, surgery, radiotherapy
How is N staging for bladder cancer split?
N1- one lymph node in true pelvic lymph nodes
N2- 2+ lymph nodes in true pelvis
N3- common iliac lymph nodes
(Different to prostate staging where N1 is any number of lymph nodes anywhere)
What is the similarity between bladder and prostate T staging?
T1- p = not palpable, b = subepithelial invasion
T2- within organ
T3- outside organ (capsule or muscular wall)
T4- invading other organs
For non-invasive bladder tumours what is low, intermediate and high risk?
Low- Grade 1, Ta (papillary- peduncle)
Intermediate- Grade 1-2, recurrent Ta-T1 (subepithelial invasion)
High- Grade 3, Tis or Ta-T1 (Ca in situ)
Which type of bladder cancers do you use intravesical therapy for?
Non-muscle invasive
After transurethral resection of cancer
The following gene mutations are associated with which syndromes that predispose to renal cell carcinoma?
A. VHL tumour supressor
B. C-MET proto-oncogene
VHL = von hippel lindau (phaeochromocytoma, renal + pancreatic cysts, cerebellar haemangioblastoma)
c-met = familial papillary RCC
Rx for advanced kidney cancer?
Beyond the gerota’s fascia- encapsulating adrenals and kidney
Immunotherapy:
1st: high dose IL-2
2nd: VEGF tyrosine kinase inhibitor as very vascular
Which cancer therapy does non-seminoma germ cell tumour not respond to compared to seminoma’s?
Radiotherapy
What surgical procedure do you need to do for non-seminoma germ cell tumour of the testes if cancer has spread to lymph that you don’t need for seminomas?
Retroperitoneal lymph node dissection
May be able to get away with chemo instead
What is the T staging for TNM in testicular cancer?
Tis- in situ within the tubules of the testes
T1- in testes + epididymus, not blood vessels of lymph
T2- in testes + epididymus, blood vessels or lymph
T3- in spermatic cord
T4- in scrotum
What size stone in the lower ureter would be expected to pass on it’s own?
5mm
Prevention of calcium stones in someone with hypercalcaemia?
Thiazides reduce calcium excretion and increase it’s uptake
Thiazides block Na/Cl transporter increasing activity in the Na/Ca transporter
What can be used to reduce the incidence of calcium oxalate stones?
Pyridoxine
Match the description with the stone: Spiky Yellow crystalline Smooth brown + radiolucent Smooth + radio-opaque
Spiky = calcium oxalate (75%)
Yellow crystalline = cystine (1%)
Smooth brown radiolucent = urate (5%)
Smooth radio-opaque = calcium phosphate (5%)
A 45 year old man with back pain has gradually been getting worsening renal function. A CT shows a periaortic mass and ureters are dilated. What could be a non-malignant cause + Rx?
Periaortitis
Autoimmune reaction to atherosclerosis leading to fibrosis of the blood supply to the aorta and surrounds. Ureters become entrapped in fibrosis and progressively obstructed.
Rx: stent for a year, steroids, + surgical dissection out of the ureters
CT shows periaortic mass on a man with worsening renal function. You want to differentiate a malignancy from periaortitis (retroperitoneal fibrosis), how can you?
USS guided biopsy
When someone is in urinary retention, what volume of fluid drainage on catheterisation would suggest you need to watch out for post-obstructive diuresis?
1L
Pain relief ladder in renal colic from stones?
- diclofenac IV/IM
- opioids
IV fluids if extreme vomiting
How does upper urinary tract obstruction present differently in acute and chronic causes?
Both present with loin or flank pain, may have infection also.
In acute- loin may be tender, kidney may be enlarged
In chronic- may have renal failure or polyuria as kidney fails to concentrate urine
How does acute lower urinary tract obstruction present differently to chronic?
(Aka urinary retention)
Both present with outflow obstructive LUTS: urinary frequency, hesitancy, poor stream, terminal dribbling
Acute- suprapubic pain
Chronic- overflow incontinence (wet themselves)
Main organisms responsible for prostatitis?
SEC
Strep faecalis
E Coli
Chlamydia
Rarely TB
Which zone of the prostate enlarges in benign prostatic hyperplasia?
Inner transitional zone
Whereas prostate cancer occurs in peripheral zone
Organisms responsible for epididymo-orchitis?
chlamydia, gonorrhoea
E Coli, mumps, TB
Tender, swollen, dysuria, sweats
EHx: separate to testes and solid
On testicular exam, mass that is separate to testes and cystic?
Epididymal cyst (often contains sperm) Found above and behind the testes
On testicular exam, mass that is separate to testes and solid?
Epididymitis
Varicocele
On testicular exam, mass that is not-separate to the testes and cystic?
Hydrocele (fluid within the tunica vaginalis)
On testicular exam, mass that is not separate to testes and solid?
Tumour
Haematocele
Orchitis: granuloma, gumma
How does Rx differ for epididymo-orchitis by age?
35 not STI:
Ciprofloxacin for E Coli
How many organisms per mL of fresh mid-stream urine defines bacteriuria?
> 10 ^ 5
What things if present make a UTI complicated rather than uncomplicated?
Abnormal anatomy Voiding difficulty/obstruction Reduced kidney function Impaired immunity Virulent organism (staph aureus)
Common organisms in UTIs?
SPEK
Gunna inSPEK the urine
E Coli (95% in community)
Enterobacteriae: Proteus mirabilis, Klebsiella pneumonia
Staphylococcus saprophyticus
How can prostatitis and cystitis be told apart?
Cystitis has more urinary symptoms (frequency, dysuria, urgency etc) and pain is suprapubic
Prostatitis has less urinary symptoms, more flu symptoms and back is lower back
PR- prostate is tender
Causes of sterile pyuria?
Recently treated UTI or UTI with fastidious culture needs
Appendicitis, prostatitis, tubulointerstitial nephritis
TB
Polycystic kidney
Bladder tumour
How does UTI Rx differ for females and males?
Females: trimethoprim/ nitrofurantoin
Males: may need quinolone like levofloxacin for 2 weeks
How does Rx length differ in UTI compared to prostatitis?
UTI- 2 weeks
Prostatitis- 4 weeks
Surgical complications of renal transplant?
Bleed, thrombosis Infection Urinary leaks Lymphocele (collection with fluid) Hernia
What is the pathophysiology of delayed graft function following a kidney transplant?
Ischaemia-reperfusion injury: leads to acute tubular necrosis
What is the difference between acute and chronic rejection following kidney transplant?
Acute- commonly cellular or occasionally antibody mediated
Rx: IV methylpred or exchange transfusion (ab-mediated)
Chronic- Low grade antibody response with fibrosis, gradual creatinine increase after initially stabilised
Rx: Slow progression with sirolimus
After kidney transplant, patient develops tremor and confusion, which drug in their regimen in likely to be responsible?
Calcineurin inhibitors: tacrolimus, ciclosporin
Patient with recent kidney transplant starts getting gum hypertrophy and hair on her face, what si the likely drug cause?
Ciclosporin (Calcineurin inhibitor)
Patient has had a recent kidney transplant, gets hepatitis and agranulocytosis. Which drug is the likely culprit?
Antimetabolites: azathioprine or mycophenolate
What stabilising positioning is important to do with ‘open book’ pelvic fractures?
Pelvis stabilisation: pelvic binder or tight bed sheet
IHx in suspected urethral injury after a road traffic accident?
Urinanalysis- haematuria
Xray- fractures
Retrograde urethrogram- leaks in urethra
CT + contrast- renal trauma
Doppler US- suspected testicular torsion, blood supply
In someone with a road traffic accident, when would a contrast CT be indicated for suspected kidney injury?
Gross haematuria
Microscopic haematuria + shock
Rapid deceleration injuries
What is the difference between seminoma vs teratoma?
Seminomas tend to be in older patients, found earlier, palpable, less aggressive
(Serum placental alkaline phosphatase + hCG)
Teratomas tend to occur in 20-30s, often metastases before it is palpable, may metastasise to mediastinum
(May have raised alpha fetoprotein-like liver cancer)
