Urology Flashcards
What does LUTS stand for and what are the two types?
Lower Urinary Tract Symptoms
These are storage symptoms = irritative
Or voiding symptoms = obstructive
What are some common storage / irritative LUTS?
FUN
frequency
urgency
nocturia
What are some common voiding / obstructive LUTS?
WISED Weak urinary stream Intermittent flow Straining to urinate incomplete bladder Emptying post-micturition Dribble
What is the mechanism of LUTS?
The prostate is situated below the bladder and surrounds the urethra. As the prostate enlarges, bladder outflow becomes increasingly obstructed
Enlargement initially develops in the peri-urethral transition zone of the prostate
In order to generate the increased pressures required to void, the bladder detrusor muscle initially becomes hypertrophied, which leads to trabeculation. In the longer term replacement of muscle fibres with collagen results in loss of detrusor efficacy
Give a definition for LUTS
LUTS is a non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding)
Define BPE
BPE (benign prostatic enlargement) is the clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia
Define BOO
BOO is bladder outlet obstruction caused by benign prostatic enlargement (clinical finding)
Define BPH
Benign prostatic hyperplasia (BPH) properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction
What is a simplified overview of LUTS?
poor flow - BOO (BPH)
strong flow - detrusor overactivity
What are some risk factors for LUTS?
Age Androgens Functional androgen receptors Obesity Diabetes (& elevated fasting glucose) Dyslipidaemia Genetic Afro-Caribbean
LUTS investigations
History and examination LUTS Haematuria IPSS questionnaire Full medical history (co-morbidities, drug history and family history) Examine abdomen DRE!!!! Urine dipstick (exclude infection) Flow rate in clinic Blood tests (U&E, PSA – but need to counsel patient)
What key differential can a urine dipstick exclude?
infection
Why is creatinine checked in LUTS?
Chronic retention can lead to renal failure due to high pressure
Why is prostate size relevant?
If prostate is over 120cc (tennis ball) surgery becomes unsafe
Some drugs only work on sizes over 30-40 cc (ping pong ball to gold ball)
How are LUTS managed?
conservative management:
reassure
fluid restriction & advice (e.g. drink less at night more in day)
medical management:
alpha blockers (tamsulosin, alfuzosin)
5 alpha-reductase inhibitors (finasteride (only works on prostates larger 30-40cc pingpong+), dutasteride)
drugs take a long time to work so manage patient’s expectations
surgical management:
TURP (transurethral resection of prostate)
chip away at prostate under GA to open channel and help with passing water. Done endoscopically
Laser surgery & catheter options also available.
70 year old man presents with inability to pass urine for 10 hours
Previous history of BPH (on tamsulosin and finasteride)
Pain
You are the on call F1
How are you going to assess him and manage him?
DRE - smoothly enlarged prostate
Palpate bladder
CATHETER!!
catheterise if they need to pee
dispstick/CSU (exclude UTI)
check U&Es (exclude renal failure - can be fatal)
check FBC
measure residual urine
neurological examination if necessary (exclude spinal nerve compression from metastatic prostate cancer)
prescribe - antibiotics/laxatives/alpha blockers
Why is it essential to check U&Es on a urinary retention patient?
If you send them home when they have an undiagnosed renal failure, they could become polyuric and dehydrate and die
Why do we sometimes prescribe laxative for urinary retention patients?
Constipation is a common cause of urinary retention in older patients
What is the difference between acute and chronic urinary retention?
Acute Urinary Retention AUR is painful
Chronic Urinary Retention CUR is postvoid residual >800ml
How would you manage this very common case? 67y male Urgency, frequency, poor flow DRE 40g BPE PSA 1.2 MSU –ve US: Normal, postvoid residual 40ml
Tamsulosin +- Finasteride
If no improvement in urgency add in anticholinergic for Urgency
Why is prostate cancer often asymptomatic?
It arises from the peripheral part of the prostate, so often does not affect function
What is PSA?
prostate specific antigen
does a raised PSA = prostate cancer?
an abornmal PSA is because of prostate cancer in 25% of patients. 75% have elevated PSA because of other reasons e.g. pH
What do you do if DRE & PSA is abnormal?
Perform an MRI & prostate biopsy
note normal MRI suggests it is likely a non-aggressive prostate cancer but not definite
prostate biopsy done with a gun and local anaesthetic
What is the name of the histology scoring for prostate cancer GRADE?
the Gleason score (grading)
low risk 3+3
high risk 5+5
TNM staging
70 year old man referred by GP with PSA 18 ug/L (upper limit 6.5)
How are you going to assess?
Do you
A. Repeat PSA and check MSU
B. Organise MRI prostate and TRUS biopsies
C. Explain likely diagnosis of prostate cancer
D. Advise radical prostatectomy or radiotherapy
A) Repeat PSA and check MSU
Management of prostate cancer i.e. what are the different management plans and what would you do initially?
Staging – MRI / Bone scan (check for metastases to spine)
MDT discussion and breaking news to patient
Options
Active surveillance (low risk low volume disease) (prostate cancer often causes no harm)
Surgery – radical prostatectomy
Radical Radiotherapy
Watchful waiting (elderly / co-morbid patients) (not trying to cure the cancer when it’s grown - offer hormonal medication)
Hormones (stops testosterone using anti-androgens)
What should you look out for in active surveillance?
Incontinence and Impotence (erectile dysfunction)
A bigger, more aggressive tumour (can perform radical prostatectomy)
Hormonal Therapy of prostate cancer
occur with radiotherapy
LHRH agonist (zoladex) (initially hyperstimulates pituitary, before disabling - so a metastasis could grow a lot which can cause spinal cord depression and be serious - might need an orchidectomy on these patients)
Cord compression is a urological emergency:
START STEROIDS
URGENT MRI
At what PSA do you treat on active surveillance?
PSA >10
Grade progression
Hydrocele
the accumulation of serous fluid in a body sac esp. the testicle
Varicocele
a mass of varicose veins in the spermatic cord
not treated unless painful or affects fertility
often recurrent symptoms after treatment
Epididymal Cyst
a cyst on the epidiymus
on presentation if the mass feels smooth, soft and is mobile - unlikely to be testicular cancer (reassure patient at this point)
What are some feature of Testicular cancer?
usually painless
hard mass
non-mobile/attached to testicle
these grow very quickly so important to diagnose ASAP
25 year old man presents with pain in left testicle swelling and fever
How will you assess and manage him?
Pick two. What is a likely cause?
After history and examination, do you A. Organise ultrasound B. Start antibiotics C. Explain testicular cancer possible D. Manage conservatively
suspect epididymal cyst infection
so A&B reasonable
Epididymitis and Orchitis
Infection of epididymis or testis or both
Causes
STIs
UTIs
Post-operative
How to distinguish between testicular torsion and testicular cancer?
testicular torsion has intense pain, whilst testicular cancer is usually painless
Testicular cancer
Affects younger men Germ Cell Seminomatous Non-seminomatous Non-Germ Cell Important to catch early!! Ultrasound – urgent on same day Tumour markers – AFP, HCG, LDH CXR on same day Counselling Sperm banking Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?) (treatment of choice)
Haematuria is also known as.
CANCER UNTIL PROVEN OTHERWISE
Define Haematuria
blood in the urine
What are some causes of haematuria?
Infection (commonest)
Cancer
Medical
Trauma
How would you examine haematuria?
resuscitate including transfusion
3 way catheter
Hx Ex
Bloods including clotting & G&S; KUB
MSU (exlude most common cause (infection))
blood clot in bladder can cause many problems - so need to wash out the blood clot - keep irrigating them to do this
How do you manage a blood clot in the bladder?
Continuously irrigate the bladder to wash it out
Why should you be careful with suprapubic catheters with haematuria?
Potential to spread a bladder cancer and make it very serious
Haematuria suggests cancer in which location?
It can be anywhere in the urinary tract: bladder cancer, ureter cancer etc.
Thus you need to investigate thoroughly to exclude the entire urinary tract. Exclude kidney stones also.
In terms of urinary tract cancers what is imaged well on a CT scan?
CT scan is great for looking at kidneys and ureters, however terrible for bladders - a wrinkle could be a cancer - so a cystoscopy may be needed
What do bladder tumours look like on a cystoscopy?
Like algae, like nebulae - star dust floating about
2 features of Renal Stones background
more common in caucasian men
1% hospital admissions
Why are renal stones important? i.e. what do they cause and what can they be a sign of?
Pain (spectrum)
Infection (incl. life-threatening gram –ve sepsis)
Renal damage
Underlying metabolic problems (eg. Hyperparathyroidism, gout, cysteinuria)
Underlying anatomical problems (eg. PUJ-o, MSK, Horseshoe kidney, ureteric stricture)
(Litigation)
Storage symptoms are?
IRRITATIVE
Voiding symptoms are?
OBSTRUCTIVE
