Urology Flashcards
What are the symptoms of Lower UTI?
Frequency and nocturia Dysuria Urgency Haematuria Smelly urine Suprapubic pain / tenderness Stranguary: painful, frequent urination of small volume, expelled only by straining despite a severe sense of urgency
What are the predisposing factors to lower UTI?
Female sex: due to short urethra
pregnancy: dip during and treat due to risk of premature Labour
Menopause
Obstruction / tract malformation
Catheter: always infected, do not investigate unless symptomatic
Diabetes: glycosuria, reduced host defences
What investigations should be done for a patient with a suspected infection?
Urine dipstick: double positive: nitrates and leucocytes
Midstream urine MCS (confirms diagnosis if >10^5 pathogenic organisms/ml
Urine dip is very often double positive in a hospital population
MSU
?ask about discharge
What are the causes of sterile pyuria? (raised WBC but no organisms grown)
Recently treated UTI Appendicitis TB chlamydia Bladder cancer
What circumstances should prompt further investigations for UTI?
Males, children, treatment resistant UTI, recurrent UTI, if pyelonephritis suspected or if an unusual organism is grown:
USS: to assess for renal scarring or obstruction (hydronephrosis)
CT/IV urography: to exclude small stones, tumours or bladder diverticula
What is the most common organism causing UTI?
E.Coli (75%)
Others: Proteus, Staphylococcus, streptococcus, Klebsiella, Pseudomonas
What is the treatment of UTI?
Advice: drink plenty of fluids and urinate often
Empirical: Nitrofurantoin 100mg BD for 3 days (review when MCS comes back)
What is the treatment of pyelonephritis?
IV tazocin 4.5g TDS )review when MCS comes back)
therapy continued for at least 7 days
How is a UTI / asymptomatic bacteriuria in pregnant women treated?
Treat - follow local guideline / speak to microbiology
How is recurrent UTI managed?
Advice on high fluid intake, frequent voiding (after sex)
avoidance of spermicidal jellies and avoidance of constipation
If this fails, prophylaxis with trimethoprim / nitrofurantoin at night may be started
What are the treatment outcomes for UTIs
Eradication: no further infection
Relapse: recurrence of the same infection within 7 days due to inadequate eradication of infection
Reinfection: bacteriuria absent for at least 14 days, but recurs due to susceptible tract
What does acute ureteric obstruction cause?
Enlargement of the urinary tract, superior to the obstruction
Dilation of the renal pelvis is known as hydronephrosis
What are the causes of ureteric obstruction?
Luminal, mural, extramural
What are the luminal causes of ureteric obstruction?
Calculus (stone) sloughed renal papilla (in diabetes / long term NSAID use) Blood clot TCC of the renal pelvis / ureter Bladder tumour
What are the mural causes of ureteric obstruction?
Ureteric stricture (TB, post-calculus, post-surgery) Congenital pelviureteric neuromuscular dysfunction Congenital megaureter
What are the extramural causes of ureteric obstruction?
Pelviureteric compression (due to external tumours, diverticulitis, AAA, retroperitoneal fibrosis)
What are the symptoms / signs of ureteric obstruction?
Varying loin pain to groin pain - greater when urine volume increases (alcohol / diuretics)
Anuria (if complete bilateral obstruction) / polyuria (if partial blockage causes renal impairment) due to post-renal AKI
Loin tenderness and palpable hydrfonephrotic kidney
What investigations should be done for ureteric obstruction?
Urine MCS
USS to confirm upper tract dilation
Abdominal plain film
CT to outline detailed cause of obstruction
Retrograde pyelogram may be used at cystoscopy to further outline ureteric abnormalities (e.g. TCC)
What is the management of ureteric obstruction?
Analgesia - rectal diclofenac
Nephrostomy may be required to decompress the pelvicalyceal system, preserving the kidney function and preventing infection from developing
Surgical management: e.g. stenting may be required depending on the cause
Where do renal calculi form?
In the collecting ducts - may be deposited anywhere from the renal pelvis to the urethra
Where are the classic sites of renal calculi deposition?
Pelviureteric junction, pelvic brim and vesicoureteric junction
What are renal stones most commonly made of?
Calcium oxalate (75%) with other being magnesium ammonium phosphate or urate based
Describe the lifetime risk of kidney stones?
15% lifetime risk, peak age 20-40 years, M:F 3:1
How do patients with kidney stones present?
Renal colic: excruciating loin to groin spasms, with nausea and vomiting, patient often cannot lie still
Occurs if stone is impacted in the ureter
Dull loin pain: if the stone is in a major/minor calyx
UTI: secondary to the partial / complete obstruction
What are the risk factors for kidney stones?
Obesity, Dehydration / low fluid intake
Family history, personal history of stone disease
Anatomical abnormalities
What are the investigations for kidney stones?
Bloods: include calcium, phosphate, glucose, bicarbonate and urate levels
Urine dip: 95% positive for blood, rule out infection
bHCG is vital
Urine MCS
Imaging:
AXR - 80% visible
Non-contrast CT: 99% visible, can exclude abdominal ddx
What is the acute management of renal stones?
A-E + fluids 75mg diclofenac PR (post renal Aki beware) IV metaclopramide IV abx if signs of infection Assess whether admission is required
What are the requirements for admission with a stone?
If there is still severe pain at 1 hour
If there is a risk of AKI
If there are signs of shock / infection
If there is uncertainty over diagnosis
What are the indications for active treatment of renal stones?
Low chance of spontaneous passage (>10mm) Persistent pain Ongoing obstruction Signs of infection Renal insufficiency
What are the active treatments of renal stones?
Extracorporeal shockwave lithotripsy (ESWL) - shock waves to break the stone
Uretoscopy
Percutaneous nephrolithotomy
What is ESWL?
Outpatient procedure that focuses shock waves on the stone to break it up, and it can then be passed spontaneously
If there is a hydronephrosis present, they may need a percutaneous nephrostomy to decompress the pelvicalyceal system prior to outpatient ESWL
What is uretoscopy?
Small telescope passed into the ureter - basket retrieval or laser / shock waves / electrical energy to fragment
What is percutaneous nephrolithotomy used for?
Renal (NOT ureteric calculi) that do not respond to ESWL
Scope inserted through small incision in the back to remove kidney stones
What are the medical treatments for renal stones?
Tamsulosin (first line / alpha blocker) or nifedipine increase the rate of spontaneous expulsion
Advice for home:
80% pass naturally
High fluid intake
Advise to return if there is any increase in pain, or signs of infection
First time stone formers - pass urine through a sieve to try and collect the stone for analysis
Refer the patient to urology within 1 week
What are the causes of bladder calculi?
Bladder outflow obstruction
Presence of a foreign body (prolonged catheterisation_
Upper urinary tract stone passing down
What is the presentation of bladder calculi?
Symptoms of UTI as there is often significant bacteriuria (frequency, pain and haematuria)
Haematuria and pain generally occur at the END of micturition as the bladder contracts
IN males, the pain can be felt at the tip of the penis, rather than a general burning
There also may be perineal pain if there is trigonitis and anuria / bladder distension if the stone is obstructing
What are the investigations / managements for bladder calculi?
Investigation = same as upper urinary tract stone
Bloods: include calcium, phosphate, glucose, bicarbonate and urate levels
Urine dip: 95% positive for blood, rule out infection
bHCG is vital
Urine MCS
Imaging:
AXR - 80% visible
Non-contrast CT: 99% visible, can exclude abdominal ddx - CTKUB
MX: medical expulsive / ESWL if the stone is large
What are the complications of bladder stones?
Can predispose to SCC
What does a renal cell carcinoma arise from?
Proximal tubular epithelium
Accounts for 90% renal tumours
What is the main risk factor for renal cell carcinoma?
Prolonged harm-dialysis (15% develop this)
What is the presentation of renal cell carcinoma?
50% incidental
10% = classic triad of haematuria, loin pain and an abdominal mass plus vague B symptoms
Rarely, invasion of the left renal vein leads to a varicocele
May be signs of polycythaemia / HTN (if renin / EPO secretion)
What investigations can be done for renal cell carcinoma?
Urine cytology
USS can differentiate solid from cystic mass
CT/MRI to assess tumour
CXR: cannon ball metastases
Renal angiography (if considering partial nephrectomy)
What is the management of renal cell carcinoma?
Radical nephrectomy
Partial nephrectomy:
If perineal tumour smaller than 5cm or if bilateral tumours / poor kidney function
Post-operative chemotherapy
What is prognosis like for RCC?
65% 5 year survival if N0, 25% if nodal involvement, 5% if distant mets
What % of childhood malignancies are Wilm’s tumours?
20% childhood malignancies
What Is a Wilm’s tumour?
Undifferentiated mesodermal tumour
Generally presents at 3.5 years with flank pain and an abdominal mass
Should not be biopsied
Treatment is with nephrectomy, with pre-operative chemotherapy
Who gets renal cysts?
Elderly - 50% will have a renal cyst by the age of 50
Often asymptomatic, or can cause haematuria / pain
PKD is a common cause, with other causes being medullary cystic disease (childhood disease leading to ESRF) or medullary sponge kidney
What type of epithelium lines the calyces, renal pelvis, ureter, bladder and urethra?
Transitional cell epithelium
therefore get transitional cell carcinoma
What are the risk factors for transitional cell carcinoma
smoking
aromatic amines: rubber / plastic / dye industry workers
chronic cystitis
pelvic irradiation
What is the presentation of transitional cell carcinoma?
Painless haematuria +/- clots: most common presentation
recurrent UTI
Voiding symptoms
Pain from invasion of local structures
What investigations should be done for TCC?
Urine MCS / cytology (cancers can cause sterile pyuria)
cystoscopy and biopsy (gold standard)
CT/MRI or lymphangiography to assess spread
What is the treatment of TCC?
Carcinoma in situ, or T1 bladder carcinoma:
transurethral resection of bladder tumour (TURBT) at cystoscopy with intravesical chemotherapy
5 year survival = 95%
T2/T3 / high grade:
radical cystectomy is gold standard with pre-operative chemotherapy
ileal conduit is used to leave an urostoma
T4: invasion beyond the bladder: treated palliatively
Long-term follow up with cystoscopy is then required
What other types of bladder cancer are there?
SCC of the bladder (more rare), however presents similarly
Risk factors are anything that irritates the lining of the bladder leading to squamous metaplasia e.g. schistomiasis or bladder calculi
What is the management of trauma to the bladder?
Intraperitoneal bladder rupture - treated with laparotomy and suturing of the bladder
Extraperitoneal bladder rupture: treated conservatively with prolonged urethral or suprapubic catheterisation
What are the causes of bladder outlet obstruction?
Luminal
Mural
extramural
What are the luminal causes of bladder outlet obstruction?
bladder tumour
What are the mural causes of bladder outlet obstruction?
urethral stricture (post calculus / infection)
congenital abnormalities
neuropathic bladder
What are the extramural causes of bladder outlet obstruction?
BPH / Prostatic carcinoma
Phimosis / paraphimosis
What are the clinical features of bladder outlet obstruction?
Suprapubic pain
Hesitancy and diminished force of the stream
Terminal dribbling
Overflow incontinence (retention with overflow, leakage of small amounts)
Signs of infection due to stasis of urine
What are the signs of bladder outlet obstruction?
Palpable full bladder
Loin tenderness / palpable hydronephrotic kidney
Enlarged prostate on PR (poor sensitivity for prostatic obstruction)
What investigations can be done for bladder outlet obstruction?
Bloods: FBC (infection), U+Es
Urine: Dip, MCS
USS: hydronephrosis
CT/MRI
What is the management of bladder outlet obstruction?
Catheterisation (suprapubic, urethral)
Beware of large diuresis following relief of obstruction
Find and treat underlying cause
What is BPH?
Benign nodular / diffuse proliferation of glandular layers of the prostate, leading to enlargement of the inner transitional zone
affects 70% of those over 70
What are the symptoms of BPH?
Filling symptoms: due to bladder overactivity
Frequency, first noticed as nocturia
Urgency / stranguary
Voiding symptoms: due to bladder outlet obstruction: hesitancy, poor/intermittent stream, post-void dribbling, stranguary
symptoms due to complications: occasionally haematuria (rupture of veins into the cyst)
Symptoms of associated UTI
What investigations are done for BPH?
PR: typically sulcus = still palpable Frequency / volume chart Bloods: FBC, U&Es, PSA Urinalysis / MCS Uroflowmetry Bladder USS (pre/post-void) Transrectal USS +/- biopsy to rule out carcinoma
What is PSA?
Prostate cancer marker, concentrations below 4.0ng/mL are deemed normal
Can be adjusted ‘normal’ tased on age and prostate size
What are the positive findings for BPH from uroflowmetry
Requires >150ml to be voided
Flow rate <12ml/sec suggests obstruction or weak bladder contractility
What are the complications of BPH?
UTI overflow incontinence Bladder calculi Bladder diverticulae Bilateral hydronephrosis and renal failure
What is the acute management for BPH?
(acute retention): attempt urethral catheter drainage
Suprapubic drainage if urethral catheterisation not possible
What lifestyle modifications can be told to treat non-acute BPH?
Avoid alcohol / caffeine
Relax when voiding
Void twice in a row to help emptying
Bladder retraining therapy
Watchful waiting, if more troublesome, medical therapy
What medical treatments can be given for BPH urinary relief?
Alpha-blockers e.g. doxasosin / tamsulosin
reduce smooth muscle tone
SE: drowsiness, dizziness, depression, hypotension
5-alpha-reductase inhibitors e.g. finasteride
Stop conversation of testosterone to dihydrotestosterone, thus decreasing enlargement but effects are slow.
SE: impotence and reduced libido and it is excreted in semen so condoms should be used
What are the surgical options for BPH?
transurethral resection of the prostate:
Holmium laser prostatectomy (HoLEP) - endoscopic, used for very large prostates
What are the long term effects of TURP?
10% risk of impotence and 20% will need a repeat within 10 years
retrograde ejaculation almost universal after procedure
other Risks are bleeding / and rarely TURP syndrome
absorption of washout leads to hyponatremia and fits
What are the long term effects of HoLEP?
Urinary incontinence if too much gland is removed
What kind of cancers are prostate carcinomas?
Adenocarcinomas, arising in the peripheral prostate
thus, biopsy must be transrectal
How does prostate cancer spread?
Local (seminal vesicles, bladder, rectum), lymphatic or haematogenous, classically to bone
Risk factors: family history and raised testosterone levels
What is the presentation of prostate cancer?
Often asymptomatic, found on PR / histology of BPH resection
May present with filling, voiding or complication symptoms, as per BPH
Weight loss / bone pain suggest metastatic disease
On examination - hard and craggy prostate
What investigations should be done for prostate cancer?
PR: vital to give clinical T stage
PSA: rises >10ng are highly suggestive of tumour
Affected by many factors, thus not a reliable screening method
Mountain biking, infection, recent intercourse (48h), cystoscopy
Transrectal USS/biopsy
Vital for Gleason grading
Bone XR / scan and contrast enhanced MRI for staging
What is the Gleason grade? how is it done?
2 areas of tissue are graded out of 5 to give a combined score out of 10
Gleason grade is vital for prognosis; scores of 6 or less considered ‘low risk’ and 8 or more ‘high risk’
What is the D’amico risk stratification?
Gleason score + clinical score + PSA to give a more accurate prognostic score than using Gleason alone
What is the management for localised prostate cancer (T1/T2)
Active surveillance: regular PSA / DRE / re-biopsy monitoring
Radiotherapy / brachytherapy
Surgery: radical prostatectomy is tx of choice BUT risks of impotence / incontinence
What is the management for advanced prostate cancer (T3/T4)
Active surveillance not recommended
Choice between radiotherapy and surgery
No difference in outcomes between the two
How is metastatic prostate cancer managed?
Hormonal therapy, GnRH agonists e.g. goserelin / buserelin
Can be palliative or used in high-risk disease as an adjunct to a curative treatment
First stimulate, then inhibit pituitary LH release, thus reducing testosterone production
An anti-androgen such as cytoproterone acetate is co-prescribed initially to prevent the early rise in testosterone
