Urology

Question 1

263. How do you assess a middle aged patient who presents with an episode of microscopic haematuria?

Answer 1

Microscopic haematuria >10RBC per high powered field

History

• How was the microscopic haematuria detected and why was the test done?
• LUTS: dysuria, frequency, urgency, hesitancy, dribbling
• Has the patient even had visible blood in the urine?
• Fever or systemic symptoms (weight loss, night sweats)?
• PMHx/PSHx: UTI stones, prostate issues
• Menstrual history for female patients
• Meds/allergies
• Family history: renal or bladder issues?
• SHx: smoking, EtOH, travel, occupation, exercise

Examination

• Vitals (HR, BP, RR, SaO2, temperature)
• General inspection
• Abdominal examination
• External genetalia
• PR examination in males

Investigations

• Urinalysis + urine MCS
• FBC (renal dysfunction)
• Coags
• CRP/ESR
• Urinary tract USS
• Consider PSA for a male patient
• Consider non-contrast CT
• Consider urine cytology

Question 2

264. A 60 year old woman attends ED with a 3 week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for 1 month. There is nothing remarkable in the rest of her history. On exam, she is pale, pulse of 100bpm, BP 105/70mmHg, her Hb is 8.2g/dl with a pattern consistent with iron deficiency, rest of her blood work is normal.

What is the important diagnosis to exclude and what investigations do you want to do?

Answer 2

Important diagnosis to exclude: urological malignancy

• Bladder carcinoma (most likely transitional cell carcinoma)
• Renal cell carcinoma

Investigations:

• History and examination
• FBC, EUC, LFTs, Coags, ESR/CRP, IgA
• Urinalysis and urine MCS
• Urine protein: Creatinine (if dipstick shows more than 1+ protein)
• Urine cytology x3
• USS of the urinary tract
• CT KUB if positive cytology, abnormal USS< or high clinical suspicion

Question 3

265. You are asked to see a 75 year of age man in ED. He has not been able to urinate for 12 hours and is in acute pain. The ED doctor referring him has excluded all other conditions, but has had to attend a resus room case before considering his urinary tract, no imaging modality is available.

What will you do to assess this man and how will you treat him?

Answer 3

Diagnosis: Acute urinary retention

History

• SOCRATES
• Previous episodes?
• Urge to urinate?
• LUTS before inability to pass urine? Dysuria, frequency, urgency, dribbling, nocturia, haematuria
• Fever
• Neurological symptoms
• Known prostate disease? (BPH or carcinoma)
• Previous surgery
• PMHx: stones
• Current medications

Examination

• Vitals (BP, HR, RR, SaO2, temperature)
• Abdominal examination – palpate the bladder
• PR examination
• Neurological examination

Investigations

• FBC, UEC,
• Bladder USS (although this is unavailable)

Management:

• Catheterisation to decompress the bladder
  
  • Urethral – indwelling Foley catheter or in-out catheterisation
    
    • Contraindicated if recent urology surgery
  • Suprapubic – if urethral catheter failure or the patient has had recent urological surgery
    
    • Urological referral will be needed to do this
• Analgesia
  
  • If the pain is not completely relieved by the decompression
• Urology referral for follow up

Aetiology of acute urinary retention:

• Obstructive
  
  • Men: BPH, meatal stenosis, phimosis, paraphimosis, prostate cancer, constricting bands
  • Women: organ prolapse, pelvic mass, retroverted impacted gravid uterus
  • Both: aneurysmal dilations, bladder calculi, bladder neoplasm, faecal impaction, retroperitoneal masses, urethral strictures, foreign bodies, stones, oedema
  • Infectious/inflammatory causes
• Pharmacological
  
  • Anticholinergics, antidepressants, antihistamines, antiarrhythmics, antiparkinsonian agents, antipsychotics, hormonal agents, muscle relaxants, sympathomimetics, antihypertensives
• Neurological
  
  • Autonomic or peripheral nerve lesions
  • Brain or spinal cord disease
    
    • Interruption of innervation to detrusor muscle
    • Incomplete relaxation of urinary sphincter
    • Inefficient detrusor contraction

Question 4

266. An 81 yoa man presents to the ED complaining of difficulty passing urine. This has been a problem for 6 months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else.

What is the diagnosis?Why is he complaining of bedwetting?

Answer 4

Diagnosis: chronic urinary retention due to begnign prostatic hyperplasia (BPH)

Clinical presentation

• Irritative symptoms
  
  • Frequency
  • Urgency
  • Dysuria
• Obstructive symptoms
  
  • Hesitancy
  • Straining
  • Intermittent stream
  • Dribbling
  • Sensation of incomplete voiding
• Haematuria

Pathophysiology: Overflow incontinence

• The bladder outlet obstruction caused by BPH causes incomplete emptying and chronic urinary retention (i.e. increasing levels of residual urine)
• This leads to bladder distension, an atonic bladder and ultimately overflow incontinence
• Nocturnal enuresis is a common presentation due to relaxation of the pelvic floor muscle during sleep, combined with an overfilled bladder

Question 5

267. An 81 yoa man presents to the ED complaining of difficulty passing urine. This has been a problem for 6 months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else.

What is the diagnosis?What is the management?

Answer 5

Diagnosis: chronic urinary retention due to benign prostatic hyperplasia (BPH)

Management:

• Urinary retention
  
  • Consider catheterisation
• Watchful waiting and behavioural modification
  
  • Voiding sitting down
  • Avoiding fluids before bedtime/ going out
  • Double voiding to completely empty the bladder
• Pharmacotherapy
  
  • Alpha blockers – tamsulosin, doxazosin
  • 5-alpha reductase inhibitors – finasteride, dutasteride
  • Antimuscarinics – oxybutynin
• Surgery
  
  • Indications
    
    • Moderate to severe symptoms that are bothersome to the patient
    • Acute urinary retention refractory to medical management
    • Renal insufficiency secondary to BPH
    • Median lobe configuration leading to occlusion of bladder neck when the bladder contracts
• The decision to treat usually guided by bother caused by the symptoms. Measurable by the I-PSS and a score >8 may indicate patients that wound benefit from a trial of medical or surgical therapy

Question 6

268. An 81 yoa man presents to the ED complaining of difficulty passing urine. This has been a problem for 6 months, and is getting worse. He has a poor flow when he passes water, is getting up at night more frequently, and has wet the bed on several occasions in the last month. His bowels open regularly, every second day, and have not changed. On examination, there is a palpable, non-tender, suprapubic mass which is dull to percussion. The rest of the abdominal and systemic exams are normal. DRE reveals a large, smooth, soft prostate gland and nothing else.

What is the diagnosis? What features of the prostate, if found on examination, would make you concerned about prostate cancer?

Answer 6

Diagnosis: chronic urinary retention due to benign prostatic hyperplasia (BPH)

PR examination features of Prostate Cancer:

• Hard nodules
• Asymmetrical surface
• Loss of the median furrow

Systemic signs

• Cachexia
• Lymphadenopathy
• Bony tenderness
• Lower limb oedema
• DVT

PR examination findings for prostate cancer

T1

Feels normal on palpation or smooth enlargement consistent with BPH

T2

Nodular, asymmetrical surface

T3

Large, hard, irregular gland, extension beyond the capsule or into the seminal vesicles, obliteration of the lateral sulcus with induration of lateral lobe

T4

Tumour fixed to bone, or adjacent pelvic organs

Question 7

269. What are the advantages of screening 55 yoa man with a PSA test for prostate cancer?

Answer 7

• Low risk investigation
• Easily conducted and widely available
• PSA elevation can precede clinical disease by 5-10 years
• Results are reproducible and not-operator dependent
• There is a small mortality benefit
  
  • For every 1000 men aged 55-65 screened, 4 will eventually die of prostate cancer and only one man will possibly be saved through testing
• There is an increasd benefit from screening high-risk men (African-american men, FHx)

Question 8

270. What are the disadvantages of screening a 55yoa man with a PSA test for prostate cancer?

Answer 8

• Sensitivity and specificity is poor – 4ng/mL is used then sensitivity is 20%, specificity 90%
  
  • Many false positives and some false negatives
  • PSA is elevated in a number of benign conditions
  • For every 1000 men aged between 55-65 who had an annual PSA screening test, 87 will have learned they had received a false positive after an invasive biopsy – there harm and risk (anxiety, risks of biopsy and anaesthetic etc.)
• Of the 1000 men aged between 55-65 who had an annual PSA screening test, 37 men with an elevated PSA were found to have a slow-growing cacner (i.e. harmless and therefore overdiagnosed)
• 25-40% of the men who have treatment will experience importance and/or urinary incontinence or bowel problems
• There is a small morality benefit – for every 1000 men aged 55-65 screened, 4 will eventually die of prostate cancer and only one man will possibly be saved through testing.

The RACGP does not recommend prostate cancer screening in men using the PSA test and welcomes the NHMRC guidelines which quite clearly do not recommend it either.

Question 9

271. What are the classical symptoms and signs of renal cell carcinoma?

Answer 9

Triad:

• Haematuria
• A palpable mass
• Flank pain

However all three of these features are present only in 15% of cases and 1 in 3 is present in 40% of patients

Thus diagnosis is commonly made as incidental finding on USS or CT

Question 10

272. A 60 year old woman attends ED with a 3 week history of blood in the urine, including some clots. She has had an intermittent urinary stream in the past 24 hours, and is complaining of suprapubic pain when voiding. She has had frequency and urgency of voiding for 1 month. The is nothing remarkable in the rest of her history. On exam, she is pale, pulse of 100bpm, BP 105/70mmHg, her Hb is 8.2g/dl with a pattern consistent with iron deficiency, rest of her blood work is normal.

What is the important diagnosis to exclude, what factors are relevant in taking a history in this case?

Answer 10

Diagnosis to exclude: urological malignancy

• Bladder carcinoma (most likely transitional cell carcinoma)
• Renal cell carcinoma

History:

• pain or painless - pain suggests stone, inflammation, or infection, while painless is more likely to be a malignancy.
• include whether the haematuria is initial (indicates urethral cause), terminal (indicates bladder stones), or throughout the stream (origin anywhere in the urinary tract)
• risk factors including smoking, pelvic irradiation, occupational exposure to bezenes and amines
• enquire about menstruation, trauma, or vigorous exercise or sexual activity within 24hrs
• gross haematuria with clots almost always indicates a lower tract source.
• FHx of renal disease and tendency for renal calculi formation.
• medications, especially aspirin, warfarin, NSAIDs, cytotoxin agents such as cyclophosphamide
• recent sore throat (glomerulonephritis)
• other respiratory treat infection (IgA nephropathy)
• systemic illness and sign of vasculitis
• travel abroad - exclude infectious disease such as malaria/schistosomiasis

Question 11

273. You are an ED intern. A 40 yoa woman presents to the emergency department. She has a fever of 39.4C, Blood pressure of 90/40mmHg, pulse 120 regular, respiratory rate of 24, she is drowsy and confused when answering questions. She initially complained of left sided abdominal pain, and the pain came in waves 3 - 10 minutes apart, with an urge to pass urine. She has a history of left sided renal calculi, and 48 hours before presentation she had lithotripsy (ESWL) to her left sided kidney stone.

What is the likely diagnosis? What will you do?

Answer 11

Most likely diagnosis: urosepsis as a complication of urolithiasis

The uretic colic is likely a complications of the ESWL “ steinsttrassie – failed passage of calculus fragments

Plan

• Complete primary survey – ABCDE
  
  • Give O2
  • Place 2x large bore cannulas
    
    • Take bloods
      
      • VBG, UEC, cultures
    • Give IV crystalloids
  • Give analgesia – opioid analgesia or diclofenac
  • Give anti-emetic if required
• Empirical antibiotics – gentamicin + ampicillin
• Measure urine output- consider IDC
  
  • Perform urinalysis and urine MCS
• CT KUB
• Urgent urology consult
  
  • She is likely to require decompression with ureteric stent or drainage via a percutaneous nephrostomy tube

Question 12

274. A 30 year old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is separate from the rest of the testis and epidisymis, is not tender and does not transilluminate. Abdominal and chest exam are normal.

What is the likely diagnosis, what are the necessary investigations?

Answer 12

• Most likely diagnosis: testicular cancer

Investigations:

• Testicular USS
• CT chest/ abdo/ pelvis
• Alpha-fetoprotein (AFP)
• Beta HCG
• Lactate dehydrogenase (LDH)
• FBC, UEC, ESR/CRP
• Urinalysis and urine MCS

Classification of testicular cancer:

• Germ cell tumours (95%)
  
  • Seminiomas (>50%)
  • Non-seminomatous
    
    • Tertoma
    • Embryonal carcinoma
    • Choriocarcinoma
    • Yolk-sac tumours
    • Mixed germ cell tumours
• Non-germ cell tumours (5%)
  
  • Leydig cell tumours
  • Sertoli cell tumours
  • Lymphoma

Question 13

275. A 30 year old man presents with a lump in the right testicle. It is painless, he noticed it a few weeks ago, due to discomfort running. He is a smoker and has a persistent cough. On examination, there is a 3cm distinct lump within the right testis, it is seperate from the rest of the testis and epidisymis, is not tender and does not transilluminate. Abdominal and chest exam are normal.

What is the likely diagnosis, how do you differentiate between different scrotal lumps on clinical examination?

Answer 13

most likely diagnosis: testicular cancer

Question 14

276. What are the indications for a person to be put on the kidney transplant waiting list?

Answer 14

• Medical indications
  
  • All patients with end stage renal failure should be considered
  • Stage 4/5 eGFR <20 + uraemia
  • Before dialysis – better long term survival benefit
  • Consider as soon as dialysis appears to be inevitable and imminent within the next year
  • Refer when eGFR < 30 as this gives time for evaluation and interventions should not be performed unless GFR <20 + evidence of progressive, irreversible deterioriation over 6-12 months
  • Anticipated low perioperative mortality
  • 80% likelihood of surviving atleast 5 years after transplantation
• Psychosocial indications
  
  • Ability to understand risk and benefits and cooperate with medical regimen
  • Adequate psychosocial support
  • Able to pay for follow up care, post-transplant medications etc.
• Absence of absolute contraindications
  
  • Noncompliance
  • Chronic systemic infection
  • Substance abuse
  • Malignancy

Irreversible 2^nd organ failure

Question 15

277. What tissue matching tests are required when the transplant service is deciding which patient on the waiting list gets a donor organ when one becomes available?

Answer 15

• ABO
  
  • Best match, rheusus doesn’t matter as its only on RBCs
  • Deceased donor – must be compatible
  • Living donor – incompatible possible
    
    • Desentisation rx – plasma exchange or immunoabsorption to remove AB
• HLA antigens
  
  • DNA typing
  • >4/6
  • Even full match – still immune response from other major/minor HLA differences
  • Matching – utility vs equity of access
• HLA antibodies – PRA
  
  • Looks for antibodies to HLA in patient serum
  • If there are HLA antibodies = donor organ which doesn’t have them
  • Can receive antibodies from transfusions, pregnancy, infections
  • Higher percent reactive antibody (PRA) = higher risk of rejction
• Cross match
  
  • If recipient cells attack and kill donor cells = positive cross match = rejection
  • If no reaction = negative cross match = transplant can go ahead.

Question 16

278. This is a CT scan of a patient with a congenital renal abnormality.
279. Can you identify the problem?
280. What does this situation predispose to?
281. How might the patient present?

Answer 16

Possible diagnosis:

• Horseshoe kidney
• Duplex kidney
• Renal ectopic (crossed or uncrossed)

Predisposes to:

• Most patients are asymptomatic
• Hydronephrosis due to pelviuretic obstruction
• Recurrent UTI due to defective anti-reflux mechanism
  
  • Dysuria
  • Pain
• Renal calculi due to urinary stasis
  
  • Haematuria
  • Pain
• Pyelonephritis from UTIs
  
  • Fever
  • Pain