Urology and GU 17/8 Flashcards
metastatic prostate cancer typically spreads to:
- lymph nodes (first to the obturator nodes)
- bone
- local spread to seminal vesicles
can less commonly spread to bladder, lung, liver, brain
risk factors for prostate cancer
- increasing age
- obesity
- Afro-Caribbean ethnicity
- 5-10% of cases have a strong family history (BRCA1+2)
features of prostate cancer
- bladder outlet obstruction: hesitancy, urinary retention
- haematuria, haematospermia
- pain: back, perineal or testicular, on urination, on ejaculation
- digital rectal examination:
> asymmetrical
> hard, craggy, nodular enlargement
> loss of median sulcus
investigating prostate cancer
- PSA
- DRE
- multiparametric MRI
- transrectal ultrasound-guided biopsy
management of localised prostate cancer (T1/T2)
depends on age/life expectancy/patient choice
- active monitoring & watchful waiting
- radical prostatectomy
- radiotherapy: external beam and brachytherapy
management of localised advanced prostate cancer (T3/T4)
depends on age/life expectancy/patient choice
- radical prostatectomy
- radiotherapy: external beam and brachytherapy
- may be use for androgen therapy eg. goserelin
management of metastatic prostate cancer
- hormonal therapy (can include orchidectomy)
- chemotherapy (docetaxel)
- supportive, eg. bone protection/pain relief
- psychosocial support eg. Macmillan
LUTS
Storage:
- frequency
- urgency
- urge incontinence
- nocturia
Voiding:
- haematuria/dysuria
- hesitancy
- poor flow
- terminal dribbling
- incomplete voiding
causes of raised PSA
- benign prostatic hyperplasia (BPH)
- prostatitis
- urinary tract infection (postpone the PSA test until 1 month after treatment)
- ejaculation (ideally not in the previous 48 hours)
- vigorous exercise (ideally not in the previous 48 hours)
- urinary retention
- instrumentation of the urinary tract
management of BPH
- watchful waiting
- medication:
> first: alpha-1 antagonists eg. tamsulosin
> then: 5 alpha-reductase inhibitors eg. finasteride
surgery: transurethral resection of prostate (TURP)
mechanism of action of tamsulosin (alpha 1 antagonist)
- decrease smooth muscle tone (prostate and bladder)
- improve symptoms in around 70% of men, considered first-line
- adverse effects:
> dizziness and postural hypotension
> dry mouth
mechanism of action of finasteride (5 alpha-reductase inhibitors)
- blocks conversion of testosterone to dihydrotestosterone, which is known to induce BPH
- causes a reduction in prostate volume and may slow disease (unlike alpha-1 antagonists)
- takes time so symptoms may not improve for 6 months
- may decrease PSA concentrations by up to 50%
- adverse effects:
> erectile dysfunction
> reduced libido
> ejaculation problems
> gynaecomastia
causes of acute urinary retention
- BPH
- medications:
> anticholinergics
> tricyclic antidepressants
> NSAIDs
> opioids
> benzodiazepines - other urethral blockage, eg. stricture, calculi, cystocoele, constipation, mass
- postoperative/postpartum
- neurological
- UTI in those prone to retention
diagnosis of acute urinary retention
- catheter, send for urinalysis and culture
- bladder ultrasound (>300cm3 = diagnostic regardless of history/exam)
- measure vol from catheter, <200cm3 rules out AUR, >400cm3 means catheter should be left in
features of chronic urinary retention
- painless
- insidious
- decompression haematuria common on catheterisation
high pressure CUR:
- impaired renal function and bilateral hydronephrosis
- typically due to bladder outflow obstruction
low pressure CUR:
- normal renal function and no hydronephrosis
types of incontinence
- urge incontinence, due to detrusor hyperactivity
- stress incontinence, due to increased pressure on bladder
- mixed
- overflow incontinence, due to bladder outlet obstruction, eg. BPH
investigations for incontinence
- bladder diary (should be kept for at least 3 days)
- vaginal examination to exclude pelvic organ prolapse
- urodynamic studies
food/drug causes of haematuria appearance
foods:
> beetroot
> rhubarb
drugs:
> rifampicin
> doxorubicincriteria for an urgent 2WW referral for haematuria
Aged 45+ years AND:
- unexplained visible haematuria without urinary tract infection
OR
- visible haematuria that persists or recurs after successful treatment of urinary tract infection
Aged 60+ years AND:
- have unexplained nonvisible haematuria and either:
> dysuria
OR
> a raised white cell count on blood test
risk factors for transitional cell carcinoma
- age
- smoking
- alcohol
- exposure to aniline dyes in the printing and textile industry
- rubber manufacture
- cyclophosphamide
risk factors for squamous cell carcinoma of the bladder
- smoking
- schistosomiasis
- chronic irritation (eg. recurrent UTI/calculi)
features of bladder cancer
- painless, macroscopic haematuria
- may have LUTS
- weight loss, anaemia, etc
(mucous in urine may be a sign of adenocarcinoma)
management of bladder cancer
- superficial lesions may be managed using TURBT in isolation
- with recurrences or higher grade/risk may be offered intravesical chemotherapy
T2 staging+ offered: - surgery (radical cystectomy with ileal conduit)
- radiotherapy
types of renal calculus
- calcium oxalate (85%)
- calcium phosphate
- uric acid
- struvite
- cystine
risk factors for renal calculi
- dehydration
- hypercalciuria, hyperparathyroidism, hypercalcaemia
- high dietary oxalate (beer, beans, coffee, beetroot)
- renal tubular acidosis
- medullary sponge kidney, polycystic kidney disease
for urate, also:
- gout
- ileostomy: loss of bicarbonate and fluid results in acidic urine, precipitating uric acid
features of renal calculus
- loin pain: typically severe, colic pain
- nausea and vomiting
- haematuria
- dysuria
- secondary infection may cause fever
imaging for renal calculi
- non-contrast CT KUB should be performed on all patients, within 14 hours of admission
- if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed to exclude diagnoses such as ruptured abdominal aortic aneurysm
non-emergency management of renal calculus
- <5mm stones should pass without intervention
- PR diclofenac for pain relief
- shockwave lithotripsy (not in pregnancy)
- percutaneous nephrolithotomy (big stones)
emergency management of renal calculus
ureteric obstruction with infection = emergency surgery
- nephrostomy tube placement
- insertion of ureteric catheters
- ureteric stent placement
prevention of oxalate stones
- dietary (reduce coffee, beer, beans, beetroot)
- cholestyramine reduces urinary oxalate secretion
prevention of uric acid stones
- dietary (reduce alcohol, seafood, bacon, turkey, liver)
- allopurinol
- urinary alkalinisation e.g. oral bicarbonate
UTI management in pregnancy
7 day course of:
- nitrofurantoin (should be avoided near term)
- amoxicillin or cefalexin (if near term)
NOT TRIMETHOPRIM
risk factors for testicular cancer
- peak incidence at 25 (teratoma) and 35 (seminoma)
- infertility (increases risk by a factor of 3)
- undescended testes
- family history
- Klinefelter’s syndrome
- mumps orchitis
features of testicular cancer
- painless lump (rarely men may have pain)
- can also have:
> hydrocele
> gynaecomastia
diagnosis of testicular cancer
- ultrasound scan = important first line
- tumour markers (aFP, LDH, hCG)
categorisation of testicular cancer
- seminoma
> occur in all age groups
> in general, aren’t as aggressive as nonseminomas - nonseminoma
> tend to develop earlier in life and grow and spread rapidly
> includes choriocarcinoma, embryonal carcinoma, teratoma and yolk sac tumor
management of testicular cancer
- orchidectomy (+ prosthesis if desired)
- sperm banking (treatment may cause infertility, but should be fertile with 1 testicle)
- chemotherapy (more cycles in higher grade cancer)
- radiotherapy in seminoma/advanced cancer
tumour markers for each type of testicular cancer
- seminoma (germ cell), choriocarcinoma (NGC), teratoma (NGC) = may release hCG
- embryonal (NGC) = aFP or hCG
- yolk sac (NGC) = aFP commonly secreted
- leydig (stromal) = testosterone
features of hydrocele
accumulation of fluid within the tunica vaginalis
- soft, non-tender swelling of the hemi-scrotum (usually anterior to and below the testicle)
- the swelling is confined to the scrotum, you can get above the mass on examination
- transilluminates with a pen torch
management of hydrocele
- infantile hydroceles are repaired if they do not resolve spontaneously by 1-2 years
- in adults a conservative approach may be taken depending on the severity
> ultrasound usually warranted to exclude any underlying cause eg. tumour
causes of hydrocele
- idiopathic
- testicular abnormality
> epidiymo-orchitis
> torsion
> tumour
features of epididymal cyst
- most common cause of scrotal swellings seen in primary care
- separate from the body of the testicle
- found posterior to the testicle
management of epididymal cyst
- reassurance
- may be removed surgically if too uncomfortable
features of varicocele
- abnormal enlargement of the testicular veins
- usually left sided
- may have aching/dragging feeling
- less discomfort on lying down
- “bag of worms”
causes of varicocele
- idiopathic
- ineffective vein valves in spermatic cord
- can be a sign of renal cell carcinoma, due to testicular vein draining to renal vein (tumour obstruction causes backlog)
complications of varicocele
- infertility (typically only if bilateral)
- testicular atrophy
diagnosis/management of varicocele
- ultrasound with doppler
- surgery if troublesome
features of testicular torsion
- twist of the spermatic cord resulting in testicular ischaemia and necrosis
- peak incidence 13-15 years
- sudden onset, severe pain
- O/E swollen, tender testis retracted upwards, skin may be reddened
- cremasteric reflex lost
- elevation does not relieve pain (unlike epididymo-orchitis)
management of testicular torsion
urgent paeds/urology surgical referral
- fixation of BOTH testes
features of epididymo-orchitis
EXCLUDE TESTICULAR TORSION
- infection of the epididymis +/- testes
- commonly caused by local spread of infection from the genital tract or bladder
- unilateral testicular pain and swelling
- urethral discharge may be present
- UTI/STI history
management of epididymo-orchitis
if organism is unknown:
- ceftriaxone 500mg IM single dose AND
- doxycycline 100mg PO twice daily for 10-14 days
if known, use sensitive Abx
also:
- pain relief if required
- urethral smear/urinalysis/urine culture for sensitivities
direct vs indirect inguinal hernia
direct:
- hernia comes through inguinal canal posterior wall defect, rather than deep ring
- protrudes outwards, rather than down towards scrotum
indirect:
- hernia comes through deep ring of inguinal canal
- protrudes obliquely (does not protrude towards scrotum)
direct and indirect both have same management
management of inguinal hernia
- surgical repair
- hernia truss for those not appropriate for surgery
features of testicular appendage torsion
- superior pole of the testis is tender
- blue dot sign may be visible
- cremasteric reflex is preserved
features of TURP syndrome
- rare and life-threatening complication of transurethral resection of the prostate surgery
- due to irrigation with glycine (hyperosmolar) causing hyponatraemia
vasectomy
- simple operation, can be done under LA
- go home after a couple of hours
- not immediately effective
- semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (16 and 20 weeks)
- the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years
complications of vasectomy
- chronic testicular pain (affects between 5-30% men)
- bruising
- haematoma
- infection
- sperm granuloma
most common cause of prostatitis
E. coli
features of prostatitis
- pain: may be referred to the perineum, penis, rectum or back
- obstructive LUTS
- fever/rigors
- tender, boggy prostate on DRE
features of Wilms’ tumour
- usually present in first 4 years of life
- often presents as a mass associated with haematuria (pyrexia may occur in 50%)
- often metastasise early (usually to lung)
- treated by nephrectomy
- younger children have better prognosis (<1 year of age =80% overall 5 year survival)
features of chlamydia
- caused by chlamydia trachomatis
- asymptomatic in around 70% of women and 50% of men
- women:
> discharge
> bleeding
> dysuria - men:
> urethral discharge (white, cloudy or watery)
> dysuria - can cause conjunctivitis
investigations for chlamydia
NAAT testing with:
- for women: vulvovaginal swab
- for men: first void urine test
testing should be done 2 weeks after exposure due to incubation period
management of chlamydia
referral to GUM
- doxycycline 100 mg twice daily for 7 days
- if cannot tolerate doxycycline, eg pregnancy/allergy, azithromycin 1 g orally for one day, then 500mg orally once daily for two days
- advise that sexual intercourse (including oral sex) is avoided until treatment completed (or waited 7 days after treatment with azithromycin)
- advise safe sex practices
- recommend screening for other STIs
partner notification in chlamydia
- for men with urethral symptoms:
> all contacts since, and in the four weeks prior to, the onset of symptoms - for women and asymptomatic men:
> all partners from the last six months or the most recent sexual partner should be contacted - contacts of confirmed chlamydia cases should be treated regardless of test result
complications of chlamydia
- pelvic inflammatory disease
> increased incidence of ectopic pregnancies
> infertility
- epididymo-orchitis
- endometritis
- reactive arthritisfeatures of gonorrhoea
- males: urethral discharge (white, green or yellow), dysuria
- females: vaginal discharge (thin/watery, green or yellow), dysuria
- rectal and pharyngeal infection is usually asymptomatic
- can cause conjunctivitis
complications of gonorrhoea
- urethral stricture
- epididymo-orchitis
- pelvic inflammatory disease (may lead to infertility)
- disseminated infection
> tenosynovitis/polyarthritis/septic arthritis
> dermatitis (lesions can be maculopapular or vesicular)
management of gonorrhoea
referral to GUM
- swabs for NAAT and sensitivities
- if known gonorrhoea, give ciprofloxacin 500mg single PO dose
- empirical treatment is IM ceftriaxone 1g
- advise safe sex practices
- recommend screening for other STIs
- advise to abstain from sex until they, and any partners, have completed treatment
features of lymphogranuloma venereum (LGV)
- caused by chlamydia trachomatis
- typically infection comprises of three stages:
> 1: small painless pustule which later forms an ulcer
> 2: painful inguinal lymphadenopathy
> 3: proctocolitis (diarrhoea, inflamm, bleeding)
management of lymphogranuloma venereum (LGV)
referral to GUM
- doxycycline 100 mg twice daily for 3 weeks (longer than usual chlamydia)
- advise safe sex practices
- recommend screening for other STIs
features of mycoplasma genitalium
usually asymptomatic but when symptomatic:
- men
> urethritis
> dysuria
> pain on ejaculation
> watery or cloudy discharge
- women
> urethritis
> increased or altered vaginal discharge.
> IMB
> dyspareunia
> discharge or bleeding after intercoursemanagement of mycoplasma genitalium
referral to GUM
- doxycycline 100 mg twice daily for 7 days
- if cannot tolerate doxycycline, eg pregnancy/allergy, azithromycin 1 g orally for one day, then 500mg orally once daily for two days
- advise that sexual intercourse (including oral sex) is avoided until treatment completed (or waited 7 days after treatment with azithromycin)
- advise safe sex practices
- recommend screening for other STIs
causative organism of syphilis
treponema pallidum
- spirochaete
features of syphilis
PRIMARY
- chancre - painless ulcer at the site of sexual contact
- local lymphadenopathy
SECONDARY (6-10wks after infection)
- systemic: fever, lymphadenopathy, malaise
- rash on trunk, palms and soles
- ‘snail track’ mouth ulcers (30%)
- painless, warty lesions on the genitalia
TERTIARY
- gummas (granulomatous lesions spread to other organs)
- ascending aortic aneurysms
- neurosyphilis
- Argyll-Robertson pupil
management of syphilis
- intramuscular benzylpenicillin first-line (doxycycline if allergy)
- Jarisch-Herxheimer reaction sometimes seen following treatment
> fever, rash, tachycardia after the first dose of antibiotic
> unlike anaphylaxis, there is no wheeze or hypotension
features of trichomonas vaginalis/trichomoniasis
- vaginal discharge
> smelly
> yellow/green
> frothy
- vulvovaginitis
- strawberry cervix
- pH > 4.5
- in men is usually asymptomatic but may cause urethritismanagement of trichomonas vaginalis/trichomoniasis
GUM referral
- oral metronidazole (400–500 mg twice a day for 5–7 day OR can give metronidazole 2g as a single oral dose)
features of genital herpes
- primary infection: may present with a severe ulceration and pain
- urinary retention may occur
- painful genital ulceration
management of genital herpes
oral aciclovir
- with recurrent episodes prophylactic aciclovir may be prescribed
- elective caesarean section at term is advised if a primary attack of herpes occurs during pregnancy at greater than 28 weeks gestation
HPV strains
HPV 6 & 11: causes genital warts
HPV 16 & 18: linked to a variety of cancers, most notably cervical cancer
pubic lice features
- itching, especially at night
- black powder in underwear
- small spots of blood on your skin caused by lice bites
management of pubic lice
GUM referral
- insecticide cream
- STI screening
features of thrush/candida albicans
- non-offensive ‘cottage cheese’ discharge
- vulvitis: dyspareunia, dysuria
- itching
management of thrush/candida albicans
local or oral treatment
- local = clotrimazole pessary stat
- oral = itraconazole bd for 1 day (CI in pregnancy, use local)
features of bacterial vaginosis
- asymptomatic in 50%
- vaginal discharge:
> ‘fishy’ (positive whiff test with KOH)
> thin, white - clue cells on microscopy
- pH > 4.5
management of bacterial vaginosis
- oral metronidazole for 5-7 days (topical if preferred)
investigations for erectile dysfunction
- CV health Q risk
- free testosterone (can add FSH/LH/prolactin)
management of erectile dysfunction
- PDE-5 inhibitor, eg. sildenafil = first line
- vacuum pumps if sildenafil not appropriate
