Urology Flashcards
Benign prostate hyperplasia pathophysiology
Benign proliferation of the musculofibrous and glandular layers of the prostate to give an increase in stromal:epithhelial ratio of tissue.
Static - increase tissue bulk.
Dynamic- increase prostates smooth muscle tone (alpha receptor mediated).
Stereotypical patient with BPH
👨🏻🦳
Over 50, male, Hx of smoking.
S+S of benign prostate hyperplasia
Lower urinary tract symptoms (LUTS): Frequency (passing small or large amounts each time) Urgency + incontinence Hesitancy, poor stream and dribbling. Feeling of non-complete void
O/E:
Palpate bladder - retention, outflow obstruction?
DRE - assess prostate size, texture, couture. (red flag = firm, nodular and no clear median sulcus)
Investigating benign prostate hyperplasia
In primary care : Urine dipstick MSU for mc+s PSA Urinary frequency and volume chart
In secondary care:
USS of bladder
Assessment tool for BPH
International Prostate Symptom Score
Management for benign prostate hyperplasia
Lifestyle advice - avoid caffeine, take diuretics early evening to avoid nocturia.
Alpha blocker - tamsulosin, doxazosin.
5-alpha reductase inhibitor - finasteride.
Surgery - prostatectomy (over 80g) or TURP (under 80g).
Which BPH patients get surgery?
Refractive to medical treatment
Recurrent gross haematuria
Recurrent UTI
Retention
1) TURP
2) TUIP
1) Transurethral resection of the prostate.
2) Transurethral incision of the prostate.
When to refer a man with LUTS to specialist?
LUTS +
- recurrent or persistent UTIs.
- urine retention.
- renal impairment with suspected cause due to urine tract.
- suspected urological caner.
Complications to council a patient with BPH on…
- Sexual dysfunction from 5-alpha reductase inhibitors.
- Acute urinary retention
- Recurrent UTIs
- Look out for blood in urine
- TURP syndrome from surgery
TURP syndrome
Large volumes of fluid absorbed though venous sinus.
Fluid overload + electrolyte imbalance esp hyponatraemia!
Hypothermia
Hypertension
Bradycardia
Headache, confusion, nausea and vomiting, restless.
Can present within minutes or 24hrs post-op.
Mx = A-E, arterial line monitoring, hypertonic saline IV.
Histology of prostate cancer
Adenocarcinomas, multi-focal.
RFx for prostate cancer
Older age (80% of over 80yrs have evidence of prostate Ca). High testosterone. Black ethnicity FHx - HOXB13, BRCA1/2 Obesity
Prognosis of prostate cancer
85% survive 5yrs or more 😁
Common sites for prostate cancer to metastasis
Bones
Complications of prostate cancer
Metastasis - pathological fractures, spinal cord compression.
LUTS
Presentation of prostate cancer
Lower back pain Erectile dysfunction haematuria Anorexia and weight loss Lethargy LUTS - hesitancy, incomplete void, frequency, urgency, nocturia.
O/E:
HARD AND NODULAR PROSTATE with ill defined sulcus, seems immobile/adhesion to surrounding tissue.
PSA
Prostate-specific antigen,
Protein found in normal and cancerous cells. Liquefy semen.
Increased in prostate cancer, BPH, UTI, prostatitis.
No screening programme but can be given to a man on request.
Level of PSA which is concerning?
Over 3nanogram/mL or high in man 50-69 refer for 2 week wait.
Investigating suspected prostate cancer
Main 3:
DRE
PSA
Transrectal US + biopsy
Others: Prostate cancer antigen 3 in urine. Testosterone, FBC and LFT mpMRI Isotope bone scan
Management of prostate cancer
Depends on stage.
Localised = active surveillance or radical prostatectomy.
Locally advanced = Radical prostatectomy, radio or brachy - therapy.
Advanced = androgen deprivation therapy, pallative
Risk stratification in prostate cancer
Gleason score (from biopsy) + PSA + clinical stage (TNM).
Components of active surveillance
PSA 6monthly
DRE 12monthly
Biopsy 12monthly
Androgen deprivation therapy
Castration can aid metastatic disease.
Surgical castration
or
Medical (androgen deprivation therapy): luteinising hormone releasing hormone against // GnRH analogue + tamoxifen + flutamide.
3 sites for renal calculi to obstruct
Vesico-ureteric junction.
Mid-ureter where is crosses iliac vessels.
Pelvi-ureteric junction
Composition of renal calculi
80% calcium stones -either calcium oxalate, calcium phosphate.
Others:
Struvite (magnesium, ammonium, phosphate from bacterial infection)
Uric acid (low urine pH)
Cystine (genetic cause).
Risk factos for renal calculi
FHx
Obesity
Dehydration
Dudes (males)
Dietary = excess animal protein
Drugs = vitamin D supplements
Diseases = hyperparathyroidism, gout, HTN
Deformities = anatomical abnormalities in urine tract (horseshoe kidney, ureteric stricture)
S+S of renal calculi
Renal colic = sudden onset severe unilateral pain in the loin area and radiated to groin/labia area.
Pain can occur in spasms/intervals but usually constant.
Nausea, vomiting, haematuria.
Hx of dysuria, frequency or straining.
O/E - restless (peritonitis pts are still), pyrexial.
Investigating renal calculi
Urine dipstick = ++RBC
MSU for ms+c
FBC, CRP, U+Es, serum calcium, phosphate, urate
Pregnancy test in females
Imaging:
Non-contrast CT, KUD Xray
Management of renal calculi
1) Stabilise patient. Analgesia = diclofenac +/- anti-emetic e.g. metoclopramide. Good fluid intake.
2) May pass spontaneously if <5mm
3) Medical expulsion therapy = alpha blocker (tamsulosin) or CCB.
4) Extracorporeal shock wave lithotripsy.
5) Ureteroscopy with laser to break up stone if >1cm
6) Surgical nephrolithotomy or nephrostomy.
Differentials for severe, sudden loin to groin area pain
Ruptured AAA
UTI
Ovarian cyst rupture
Appendicitis
If renal colic pain is acute and super really bad what can you give?
IM or rectal diclofenac.
What is nephrolithiasus
Presence of renal calculi in urinary system.
Male and female causes of acute urinary retention
Male:
BPH, prostate cancer, prostatitis.
Female:
Vaginal prolapse, uterine fibroids, gynae malignancy,
Both:
Bilharzia, Herpes simplex, bladder cancer, CRC, anticholingeric drugs, neurological disease (MS, Guillain-Barre syndrome, caudal equina).
Investigating and managing acute urinary retention
MSU ms+c
Urine dipstick
Bladder USS
Mx = immediate bladder decompression with catheter.
Types of haematuria and which are clinically relevant?
Frank = visible. Microscopic = picked up on urine dipstick or urine MC+S has >2red cells/mm2.
All frank haematurias need further investigation and all symptomatic microscopic haematurais
Causes of haematuria
Most common = BPH, urinary calculi, transitional cell carcinoma of bladder, UTI, urethritis, prostate cancer.
Vascular - sickle cell disease, coagulopathy.
Infective - glomerulonephritis, schistosomiasis, cystitis, prostatitis, urethritis.
Trauma - catheter, post retention catheterisation.
Autoimmune - Goodpasture’s syndrome, Henoch-Schonlein purpura, IgA nephropathy.
Iatrogenic - anticoagulation therapy e.g. warfarin, NSAIDs.
Neoplastic - Wilm’s tumour, renal cell carcinoma, transitional cell carcinoma of bladder.
Congenital - sickle cell disease.
Investigating haematuria
Urine dipstick Urine MC+S DRE - ?BPH FBC, clotting profile, PT/INR, PSA, creatinine, eGFR, U+E. KUB USS Flexible cystoscopy. Non-contrast CT.
Pathophysiology behind a varicocele
Scrotal swelling formed from dilated veins and venous reflux in the pampiniform plexus in the spermatic cord.
S+S of varicocele
Asymptomatic. ON LEFT SIDE!!! (esp with renal cell carcinoma) BAG OF WORMS SCROTUM 🐛 Heavyness and mass in scrotum Infertility
O/E:
Lower hanging scrotum on side of varicocele.
Small testis.
Valsalva manoeuvre and standing up increased dilation and vessels so that they can be palpated and visualised.
Who gets varicoceles?
Tall, thin men.
Ix and Mx for varicocele
Ix = clinical diagnosis, can use US and colour Doppler US.
Mx = Reassurance, observation, surgical repair (not routine!).
A man comes and requests a PSA test, what are you going to discuss?
- Can be high for reasons other than prostate cancer.
- If it is high, you will go on to have further investigations which may be unnecessary and have complications e.g. infection.
- Having prostate cancer will not necessarily kill you or interrupt your life. May be no need to act on the result.
Hydrocele
Collection of fluid in the laters of the tunica vaginalis surrounding testis and spermatic cord. PAINLESS, can get ‘above’ O/E. More common in infants/babies and resolve on their own. Surgery rare.
Ix = transilluminate.
Testicular torsion
Twisting of testicle, constricting spermatic cord and its content (vasculature, nerves). Leads to ischaemia and necrosis if left untreated.
S+S of testicular torsion
LEFT Sudden onset. Swelling Pain in scrotum - can ease during necrosis so not a good sign! Abdo pain Nausea and vomiting
O/E:
Red, hot, swollen testis, retracted upwards.
Lifting of testis increases pain.
‘bell-clapper’ position of testis.
Absent Cremasteric reflex. (L1/L2 spinal nerve).
Occurs commonly during sport
Ix and Mx for testicular torsion
US with Colour Doppler.
if suspicion is high, treat first and investigate later.
Mx = emergency scrotal exploration, orchidectomy + bilateral fixation (orchidoplexy)
If testicular pain eases on lifting testis what is the differential? and if the pain doesn’t ease….?
Eases on lifting = epididymitis.
No ease = testicular torsion.
Acute epididymo-orchitis
Pain, swelling and inflammation of epididymitis +/- testicular inflammation. Symptoms develop over days usually but within 6weeks.
Common organisms for epididymo-orchitis
Under 35yrs/sexually active = Chlamydia trachomatis, Neisseria gonorrhoeae.
Over 35yrs = E.coli.
S+S of epididymo-orchitis
Unilateral scrotal pain Unilateral scrotal swelling LUTS - frequency. Urethral discharge Hx of STI
Ix and Mx for epididymo-orchitis
RULE OUT TESTICULAR TORSION!
Ix = colour Doppler US, Gram stained smear of urethral discharge. First catch urine for STI NAAT + PCR, MSU for mc+s, urine dipstick.
Rx = Analgesia e.g. paracetamol, supportive underwear. ABx for infection (ceftriaxone + doxycycline)
Common bacteria in prostatits
E.coli, Pseudomonas aeruginosa.
Risk factors for prostatitis
UTI, catheters, STI
S+S of prostatits
Pain on ejaculation.
Pain between testis and rectum (perineum).
LUTS (frequency, urgency, hesitancy).
Fever, malaias, myalgia, artralgia.
O/E:
Check for distended bladder and DRE.
In acute prostatitis: DRE IS VERY PAINFUL! boggy, tender, enlarged prostate on DRE, hot to touch, urethral discharge, inguinal lymphadenopathy.
Prostate pain syndrome
Chronic prostatitis and no identifiable causative organism.
Ix and Mx for acute prostatitis
If septic = SEPSIS 6!! 🐃🐂🐄 (Buffalo) Ix = FBC, U+E, creatinine. Urine dipstick Mid-stream urine sample mc+s. PSA - will be raised and with Rx will go down.
Mx = ABx e.g. Ciprofloxacin. Can give alpha-blocker e.g. tamsulosin to aid symptoms.
Adequate hydration, paracetamol analgesia.
Histology of bladder cancers
Transitional cell carcinomas // urothelial carcinoma.
Squamous cell carcinoma
RARE adenocarcinoma
Risk factors for bladder cancer
Smoking
Exposure to aromatic amines, dye, rubber.
Radiation
Male
S+S of bladder cancer
PAINLESS HAEMATURIA
Weight loss
Dysuria
Supra-pubic mass
Urinary retention (clots/cancer block urethra) use 3 way catheter and bladder scan.
Anaemic - subconjunctival pallor, angular stomatitis.
Risk factor for squamous cell carcinoma of bladder
Schistosomiasis
Cyclophosphamide
BCG treatment for a transitional carcinoma
When to refer someone to specialist investigations for ?bladder cancer
2 week wait if:
- 45yrs or over and unexplainable haematuria or haematuria which persists despite successful UTI treatment.
- 60yrs or over and unexplainable non-visible haematuria with dysuria or raised WCC.
When to refer for 2 week wait in ?renal cancer
If over 45yrs and have:
- unexplainable visible haematuria with no UTI.
- visible haematuria which persists/reoccurs after successful UTI treatment.
When to refer for ?prostate cancer 2 week wait?
DRE results = feels malignant.
PSA level is above normal for age range.
Investigations for ?bladder cancer
Exclude infection with urine dipstick.
Exclude stones with CT KUb non-contrast.
Ix:
Cystoscopy.
CT/MRI esp for staging.
Diagnostic:
Flexible cystoscopy + transurethral resection of bladder tumour.
Management of bladder cancer
Dependent on stage.
Not late stages: Transurethral resection of bladder tumours. Mitocmyin C drug course.
If advance: radical cystectomy or radical chemotherapy
Common organism in UTI
E.coli
Enterobacteria e.g. Klebsiella.
Types of UTI
Uncomplicated = typical pathogen, normal urinary tract and kidney function, no predisposing co-morbidities. Complicated = anatomical, functional or pharmacological predisposition to a persistent, recurrent or refractive to treatment UTI.
Upper UTI = pyelonephritis.
Lower UTI = cystitis, prostatitis, urethritis.
Recurrent = 2 or more episodes in 6 months or 3 or more episodes in a year.
RFx for UTIs
Being female Spermicide use DM Pregnancy Immunosuppressed e.g. chemotherapy. Malformation in urinary tract Obstruction e.g. BPH Renal calculi.
Bacteriuria
Presence of bacteria in urine with or without symptoms.
S+S of a UTI
Urinary frequency, urgency, incontinence, nocturia. Dysuria Haematuria Cloudy and foul-smelling urine. Supra-pubic pain Pyrexia In elderly = confusion.
Investigating a UTi
Urine dipstick = +nitrite, +leukocytes, +RBC
Mid-stream urine sample for MC+S
Pregnancy test
Pyelonephritis features (rather than lower UTI)
Loin pain
Fever
Rigors
Red flag symptoms in ?UTI patient
Haematuria, loin pain, riggers, nausea and vomiting, altered mental state –> SEPSIS?
Management of UTI
Females:
Nitrofurantoin or trimethoprim (both oral and for 3 days).
Nitrofurantoin can be taken during pregnancy.
2nd line = pivmecillinam if not pregnant or amoxicillin if pregnant.
Males:
Trimethoprim or nitrofurantoin (both oral and for 7 days).
ABx in prostatitis
Ciprofloxacin.
Extra investigations for male under 45yrs UTI
KUB USS
KUB CT scan
Types of testicular cancers
Most are germ cell cancers:
- Seminoma
- Teratoma
- Embryonal carcinoma
- Yolk sac tumour etc etc
Other types include
Non-germ cell e.g. Leydig cell tumour, gonadoblastoma.
Age of testicular cancer patient
15-40
Risk factors for testicular cancer
Male infertility
Klinefelter’s syndrome
Maldescent of the testis
FHx
S+S of testicular cancer
Mass on one testis - usually painless
‘Dragging sensation’
Ix and Mx for testicular cancer
Ix = ultrasound scab, biopsy histology is done after inguinal orchidectomy.
Tumour markers = beta-hCG, alpha-fetoprotein, lactate dehydrogenase, non are very specific.
Mx = orchidectomy.
Definition of erectile dysfunction
Persistent inability to attain or maintain an erection sufficient to permit satisfactory sexual intercourse.
Causes of erectile dysfunction (organic)
MS, Parkinsons, spinal cord trauma. CVD, HTN DM Penile cancer Hypospadias Major surgery to pelvis or ureter. Drugs = tricyclic antidepressants, spironolactone, beta-blockers, finasteride, corticosteroids and many more 🚮
Management of erectile dysfunction
In primary care: phosphhodiesterase-5 inhibitor e.g. Sildenafil, tadalafil.
Lifestyle advice - stop smoking, reduce alcohol, increase exercise, medicine review, reduce cycling, information and education.
What is cryptorchidism
Maldescent of the testis.
Volume of urine drained in acute urine retention
600ml-1L.
Zone of prostate cancer and zone of BPH
BPH = transitional zone.
Prostate Ca = peripheral zone.
Lymph nodes where prostate cancer initially spreads to
Obturator nodes
Innervation for urinary storage and voiding.
Storage = sympathetic Voiding = parasympathetic
4 types of incontinence and pathology
- Stress - sphincter weakness e.g. traumatic labour. Leak on cough, laugh, sneeze. Rx with pelvic floor exercises.
- Urge - detrusor overactivity. ‘Irritable bladder syndrome’. Urgency of needing to void. Rx with bladder retraining, acetylcholinergic/anti-muscarinic agents.
- Overflow - blockage to urine flow e.g. BPH. Bladder distension, dysuria.
- Mixed
- Neurological - MS, dementia, brainstem stroke.
Causes of bilateral and unilateral hydronephrosis
Bilateral: S – stenosis of the urethra U – urethral valve P – prostatic enlargement E – Extensive bladder tumour R – retroperitoneal fibrosis
Unilateral: P – Pelvic-ureteric obstruction (congenital or acquired) A – Abnormal renal vessels C – Calculi T – Tumours of the renal pelvis
Causes of chronic urinary retention
BPH
Prostate cancer
Drugs – antispasmodics, antihistamines, anticholinergics, BoTox (used to treat overactive bladder)
Iatrogenic – following local surgery
Urethral strictures – infective or traumatic
Neurological – MS, diabetic neuropathy, stroke
Side effects of
- alpha blocker
- 5 alpha reductase inhibitor
- Postural hypotension, dizziness.
2. Erectile dysfunction, low libido, gynaecomastia.
Medical treatment for erectile dysfunction. Who can not take them and what are some side effects
5 phosphodiesterase inhibitors e.g. Sildenafil.
Can’t be given to people on nitrogen drugs e.g angina.
Those taking alpha blockers for BPH.
SEs = headache, flushing, dizziness.
4 reasons for circumsion on NHS
- Phimosis - foreskin cannot be retracted from the glans
- Recurrent balanitis
- Balanitis xerotica obliterans
- Paraphimosis – where the foreskin can NOT be pulled over the glans.
Benefits of circumsion
Reduce risk of penile cancer
Reduce risk of UTI
Reduce STI risk
who cant have anticholinergics for urgency incontinence?
acute glaucoma
SE of anticholinergics
tachycardia dizzy dry mouth retention constipation
where is pain felt in ureteric obstruction and why
innervated by T12 - L2, pain in scrotum, front thigh, lower back.
How to make someone pee after cystectomy
Ileal conduit + urostomy/urinary diversion.
Bladder reconstruction
Continent urinary diversion.
Complications of urostomy
Immediate - bleeding, ischaemic
Early - necrosis, infection, obstructed, retraction.
Late - parasternal hernia, prolapse, retraction, varicies.
Why does renal cell carcinoma cause left varicocele
Testicular vein in left comes off renal vein, closer to kidney, easier to compress.
Testicular vein comes off IVC in right so harder to compress.
Why CXR for ?renal cell carcinoma
Cannon-ball mets
What electrolyte imbalance is seen in renal cell carcinoma?
Secrete parathyroid hormone related protein, causes calcium release from bone –> hypercalcaemia.
Sign O/E for pyelonephritis
Renal angle tenderness.
On the back, full fist percussion/punch where kidney is.
3 zones of prostate and which are affected by BPH and cancer?
Central, transition, peripheral zones.
Cancer = peripheral
BPH = transition.
Venous drainage of prostate
Batson’s plexus
