Urology

Question 1

Urinary incontinence

Answer 1

Males: BPH, detrussor overactivity, urethral strictures
Females:
Functional: no physiological issue. Immobility, unfamiliar surroundings

Stress: Leakage from incompetent sphincter (when intra-abdominal pressure increases e.g. coughing)
Causes: pelvic floor weakness, pregnancy
Tx:
Pelvic floor exercises
Surgery: Colposuspension, rectal fascial sling, retropubic mid-urethral mesh sling
Complications: pelvic organ prolapse
Duloxetine (serotonin-NA reuptake inhibitor)

Urge incontinence/overactive bladder: urge to urinate quickly followed by contraction of detrussor muscle (detrussor overactivity)
Triggers: obesity, caffeine
Cause: brain damage - stroke, dementia, UTI, diuretics
Tx: incontinence chart, check SC/CNS
bladder training exercises, weight loss, antimuscarinics eg. Tolterodine

Question 2

Testicular/bladder/prostate/renal Ca

Answer 2

Renal Ca
Renal cell carcinoma (90%): Arises from epithelium of proximal tubule
Transitional carcinoma
Wilm’s tumour - Nephroblastoma. Children - abdo mass, haematuria

Risk fx: smoking, aromatic hydrocarbons, haemodialysis, polycystic kidneys, Von-Hippel Lindau
Sx: loin pain, painless haematruria, abdo mass
Signs: varicocele (due to left renal vein compressing left testicular vein)

Spread:
Local: renal vein
Blood: bone, liver

Ix: BP (high), FBC (high due to increased EPO), UEs, LFTs (high Alk phos - bone mets)
Urinalysis, cytology (non-visible haematuria)
Renal US
CT-KUB
Tx: partial/radical nephrectomy
radiofrequency ablation, cryotherapy - for those unfit
Chemo and radiotherapy not effective
Biologics: tyrosine kinase inhibitor (Pazopanib)

Prostate Ca
Commonest male Ca.
Risk fx: family hx, age, Afro-Caribbean, BRCA1/2
Adenocarcinomas (most arise from peripheral zone)

Acinar adenocarcinoma - from glandular cells line prostate gland (most common)
Ductal adenocarcinoma - from cells that line ducts in prostate gland - more aggressive

Sx: lower urinary tract symptoms e.g. dribbling, hesitancy, weak flow
weight loss, bone pain - mets
Signs: irregular, nodular prostate on PR

DDx: BPH, prostatitis (infection of prostate, usually E. coli), bladder Ca

PSA (enzyme produced by prostate gland to liquify semen) - raised in BPH, prostate Ca, exercise, ejaculation, recent PR

Ix:
PSA (30% in those with prostate Ca)
PR exam
Transperineal biopsy - Under general anaesthetic. Better access to prostate, lower risk infection
Transrectal US guided biopsy - Under local anaesthetic. Higher risk of infection.

CT abdo pelvis - staging

Risk stratification
Gleason grading - based on histological appearence
PSA
TNM

Low risk - active surveillance
Medium/High risk - radical prostatectomy (laprascopic/robotic) SE: erectile dysfunction, stress incontinence
External beam radiotherapy

Mets - LHRH agonists e.g. Goserelin (stimulates then inhibits gonadotropin release)

Bladder Ca
Transitional cell carcinoma (90%)
Adenocarcinoma
Squamous cell (schistosomiasis)

Risk fx: male, smoking, aromatic hydrocarbons, schistosomiasis

Sx: painless haematuria, recurrent UTIs, lower urinary tract symptoms
Signs: ureteric obstruction

Ix:
cystoscopy + biopsy (TURBT - transurethral resection of bladder tumour)
CT urogram : staging
urine microscopy,cytology: sterile pyuria

TNM staging
T1:  contained in basement membrane
T2: muscularis propria
T3: perivesical layers
T4: into adjacent structures 

Tx:
T1: TURBT
T2: radical cystectomy + chemo (M-VAC: methotrexate, vinblastine, doxorubicin, cisplatin)
T4: palliative chemo/radio

Follow up
Superficial tumours have high risk recurrence
High risk: exam, cystoscopy every 3 mnths for 2 yrs
Low risk: cystoscopy yrly

Spread
Local: pelvic structures
Lymphatic: iliac, para-aortic nodes
Blood: liver, lungs

Testicular
Risk fx: young, Caucasian
Germ cell tumours (95%) - semimomas, non-semimomas
Non-Germ cell tumours - usually benign - Leydig, Sertoli cell tumours, teratomas

Risk fx: undescended testes (Cryptorchidism), Kleinfelter’s, family hx

Sx: unilateral painless lump (irregular, firm, no transillumation)
Signs: SOB (mets to lungs), back pain

DDx: hydrocoele (fluid around testes (tunica vaginalis) epididymal cyst

Ix: B-HCG, LDH, AFP
Scotral US
CT abdo-pelvis
NO biospy - as may cause seeding

Tx: radical orchidectomy
Chemo and radio can impair fertility - offer semen cryopreservation if reproductive age

Prognosis: high rate remission