Urology - conditions

Question 1

Epididymitis pathophysiology

Answer 1

Usually caused by local extension of infection from the lower urinary tract either via enteric or non-enteric organisms
In males < 35 years old = sexual transmission therefore most common organisms are N. gonorrhoeae & C. trachomatis
In males > 35 years old = enteric organisms from a UTI is the more likely mechanism of the disease

Question 2

Epididymitis risk factors

Answer 2

Non-enteric causes = MSM, multiple sexual partners/known contact of gonorrhoea
Enteric causes = recent instrumentation/catherisation, bladder outlet obstruction/an immunocompromised state

Question 3

Epididymitis clinical features

Answer 3

Unilateral scrotal pain & associated swelling
Associated symptoms – dysuria, storage LUTS, urethral discharge
Examination – red & swollen, very tender
Cremasteric reflex which is intact in cases of epididymitis & Prehn’s sign (supine & scrotum is elevated by the examiner -> relieved by elevation)

Question 4

Epididymitis investigations

Answer 4

Urine dipstick
First-void urine should be collected and sent for NAAT for suspected non-enteric epididymitis
Routine bloods
Imaging – typically a clinical one, however USS of the testes can be useful to confirm the diagnosis & rule out any complication

Question 5

Epididymitis management

Answer 5

Appropriate abx therapy and provided with sufficient analgesia
- Enteric organisms: ofloxacin 200mg PO BD for 14 days/levofloxacin 500mg BD for 10 days
- STI organisms: ceftriaxone 500mg IM single dose and doxycycline 100mg PO twice daily for 10-14 days
Abstain from sexual activity

Question 6

Epididymitis complications

Answer 6

Reactive hydrocele formation
Abscess formation
Testicular infarction

Question 7

Testicular cancer risk factors

Answer 7

Cryptorchidism
Previous testicular malignancy
A positive family history
Caucasian ethnicity
Kleinfelter’s syndrome

Question 8

Testicular cancer clinical features

Answer 8

Unilateral painless testicular lump
Examination – mass is typically irregular, firm, fixed & does not transilluminate
Evidence of metastasis – weight loss, back pain or dyspnoea

Question 9

Testicular cancer investigations

Answer 9

Tumour markers can be used for both diagnostic and prognostic means – beta-hCG, AFP, LDH
Scrotal ultrasound
Disease staged via CT imaging with contrast
Trans-scrotal percutaneous biopsy should not be performed – might cause seeding of the cancer

Question 10

Testicular cancer management

Answer 10

Discussed in a specialist MDT
Main treatment options for testicular cancer are surgery, radiotherapy & chemotherapy
Most cases – inguinal radical orchidectomy

Question 11

Testicular torsion pathophysiology

Answer 11

Mobile testis rotates on the spermatic cord
Leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema & infarction to the testis
Males with a horizontal lie to their testes are more prone to developing testicular torsion

Question 12

Testicular torsion risk factors

Answer 12

Age
Previous testicular torsion
Family history of testicular torsion
Undescended testes

Question 13

Testicular torsion clinical features

Answer 13

Sudden onset severe unilateral testicular pain, associated N&V
Examination – testis will have a high position with a horizontal lie
Cremasteric reflex is absent & negative Prehn’s sign

Question 14

Testicular torsion management

Answer 14

Surgical emergency – urgent surgical exploration of the testis
Strong analgesia and anti-emetics
Torsion in confirmed intra-operatively = bilateral orchidopexy
Testis is non-viable = an orchidectomy may be warranted

Question 15

Testicular torsion complications

Answer 15

Delay in surgical exploration leading to prolonged ischaemia can result in testicular infarction
Affected testis may later undergo atrophy
Surgical complications – chronic pain, palpable suture, risk to future fertility & theoretical risk of future torsion

Question 16

Bladder cancer risk factors

Answer 16

Smoking
Increasing age
Aromatic hydrocarbons
Schistosomiasis infection
Previous radiation to the pelvis

Question 17

Bladder cancer clinical features

Answer 17

Painless haematuria
May also present with recurrent UTIs/LUTS
Clinical examination is typically unremarkable

Question 18

Bladder cancer investigations

Answer 18

Urgent cystoscopy – initially via a flexible cystoscopy under local anaesthetic
If suspicion is identified -> rigid cystoscopy will be required for more definitive assessment
- Any tumour identified will require biopsy & potential resection via transurethral resection of bladder tumour (TURBT)
Imaging – CT staging
Urine cytology

Question 19

Stress UI pathophysiology

Answer 19

Urine leakage occurring when the intra-abdominal pressure exceeds the urethral pressure
Impaired urethral support is most often due to weakness of the pelvic floor muscle
Most commonly seen post-partum, risk factors include constipation, obesity, post-menopausal/pelvic surgery

Question 20

Urge UI pathophysiology

Answer 20

Overactive bladder (detrusor hyperactivity), which leads to uninhibited bladder contraction, leading to a rise in intravesical pressure -> leakage of urine
May be due to neurogenic causes, infection, malignancy, idiopathic, cholinesterase inhibitors

Question 21

Overflow UI pathophysiology

Answer 21

Normally a complication of chronic urinary retention
Progressive stretching of the bladder wall leads to damage to the efferent fibres of the sacral reflex & loss of bladder sensation
As bladder fills with urine, becomes grossly distended, however intravesicular pressure builds, leading to a constant dribbling of urine
Most common cause is from prostatic hyperplasia

Question 22

UI investigations

Answer 22

Midstream urine dipstick assessing for evidence of infection or haematuria
Post void bladder scans should also be performed routinely
Further investigations
- Unclear aetiology: urodynamic assessment
- Outflow urodynamics can then be performed
- Cystoscopy
- IV urogram
- Vaginal speculum examination
- MRI imaging

Question 23

UI conservative management

Answer 23

Pelvic floor muscle training which should ideally last for at least 3 months, duloxetine can be trialled to cause stronger urethral contractions
Urge UI – anti-muscarinic drugs can be trialled (eg. oxybutynin or tolterodine)
Bladder training

Question 24

UI surgical management

Answer 24

Urge UI – botulinum toxin A injections, percutaneous sacral nerve stimulation, augmentation cystoplasty, urinary diversion via ileal conduit
Stress UI – tension-free vaginal tape, open colposuspension, intramural bulking agents or an artificial urinary sphincter

Question 25

Urethritis

Answer 25

Inflammation of the urethra most often due to infection Either gonococcal or non-gonococcal

Question 26

Urethritis risk factors

Answer 26

Age < 25 years Men who have sex with men Previous STI Recent new sexual partner More than one partner in the last year

Question 27

Urethritis clinical features

Answer 27

Dysuria Penile irritation Discharge from urethral meatus

Question 28

Urethritis investigations

Answer 28

Urethral gram stain under microscopy should be performed on urethral swabs – pus cells suggest urethritis Gold standard investigation – first-void urine being sent for NAAT Should also have mid-stream urine dipstick performed, triple site testing for culture Consider further STI screening Semen culture

Question 29

Urethritis initial management

Answer 29

Abx management is the mainstay of initial management - Gonococcal: ceftriaxone 1g IM single dose + azithromycin 1g PO single dose - Non-gonococcal: doxycycline 100mg PO BD for 7 days/azithromycin 1g PO single dose

Question 30

Urethritis long term management

Answer 30

Abstain from sexual activity for 7 days after abx course has finished, resolved symptoms & sexual partners have been treated Counsel patients on condom use & advise patient to notify their sexual partners to attend GUM clinic for testing and treatment

Question 31

Pyelonephritis

Answer 31

Inflammation of the kidney parenchyma and the renal pelvis, typically due to bacterial infection Uncomplicated or complicated

Question 32

Pyelonephritis pathophysiology

Answer 32

Acute pyelonephritis – results from bacterial infection of the renal pelvis and parenchyma Bacteria can reach the kidney either by ascending from the lower urinary tract, from the blood stream or via lymph Neutrophils cause suppurative inflammation -> often small renal cortical abscesses and streaks of pus in the renal medulla Most common organism isolated is Escherichia coli

Question 33

Pyelonephritis risk factors

Answer 33

1) Factors reducing antegrade flow of urine – obstructed urinary tract, including BPH 2) Factors promoting retrograde ascent of bacteria – female gender, indwelling catheter/ureteric stents, structural renal abnormalities 3) Factors predisposing to infection or immunocompromise 4) Factors promoting bacterial colonisation – renal calculi, sexual intercourse, oestrogen depletion

Question 34

Pyelonephritis clinical features

Answer 34

Classical triad – fever, unilateral loin pain and N&V Co-existing lower urinary tract infection Examination – often look unwell, often pyrexial, unilateral/bilateral costovertebral angle tenderness Assess patient’s fluid status and measure any post-void residual volumes

Question 35

Pyelonephritis investigations

Answer 35

All patients will require urinalysis, urinary beta-hCG for women of child-bearing age, urine culture Routine bloods Renal US scan, if obstruction is suspected -> non-contrast CT imaging (CT KUB)

Question 36

Pyelonephritis management

Answer 36

A to E approach Empirical antibiotics based on local protocols & IV fluids as appropriate

Question 37

Pyelonephritis complications

Answer 37

Severe sepsis Multi-organ failure Renal scarring leading to CKD Pyonephrosis

Question 38

Chronic pyelonephritis

Answer 38

Repeated infections can lead to chronic pyelonephritis -> fibrosis and destruction of kidney Cases are more common in obstructed systems Reverse any underlying causes, optimise renal function and consider prophylactic abx

Question 39

Emphysematous pyelonephritis

Answer 39

Rare and severe form of acute pyelonephritis, caused by gas-forming bacteria Fails to response to empirical IV abx, CT imaging will show evidence of gas within and around the kidney Most common in diabetic patients -> high glucose allows CO2 production from fermentation by enterobacteria Severe cases may warrant either nephrostomy insertion or percutaneous drainage of any collections present

Question 40

RCC pathophysiology

Answer 40

Adenocarcinoma of the renal cortex, arising predominantly from the PCTs, most often appearing in the upper pole of the kidney RCCs can spread through direct invasion in to perinephric tissues, renal vein (tumour thrombosis), IVC Can spread via lymphatics to pre-aortic and hilar nodes or by haematogenous spread to the bones, liver, brain and lung

Question 41

RCC aetiology

Answer 41

Smoking Industrial exposure to carcinogens Dialysis Hypertension Obesity Anatomical abnormalities – polycystic kidneys & horseshoe kidneys

Question 42

RCC clinical features

Answer 42

Haematuria, mass and flank pain = classical triad (15% of patients) Non-specific symptoms Diagnosed incidentally on abdominal imaging Examination – large RCCs may be palpated in the flank, left-sided masses may also present with a left varicocoele Paraneoplastic syndromes – polycythaemia due to EPO, hypercalcaemia due to PTH, hypertension due to renin, pyrexia of unknown origin, clinical features of metastasis

Question 43

RCC investigations

Answer 43

Lab tests – routine blood tests, urinalysis and urine should be sent for cytology Imaging – CT imaging of abdomen-pelvis pre and post contrast is gold standard Biopsy of renal lesions

Question 44

RCC management (localised disease)

Answer 44

Surgical management - Smaller: partial nephrectomy may be suitable - Larger: radical nephrectomy Percutaneous radiofrequency ablation or laparoscopic/percutaneous cryotherapy if not suitable for surgical management Renal artery embolization may be required for haemorrhaging disease Surveillance imaging can be employed in patients unfit/unwilling to undergo surgery

Question 45

RCC management (metastatic disease)

Answer 45

Nephrectomy combined with immunotherapy Biological agents can be used in combination for metastatic disease Metastasectomy is recommended where disease is resectable & patient is otherwise well

Question 46

Renal cysts

Answer 46

Fluid-filled sacs found in the kidney and can be classified as simple or complex Simple cysts – well-defined outline and homogenous features, very common in older patients - Develop from the renal tubule epithelium in response to previous ischaemia Complex cysts – more complicated structures, have a risk of malignancy & risk increases with its increasing complexity

Question 47

Renal cysts risk factors

Answer 47

Increasing age Smoking Hypertension Male gender

Question 48

Polycystic kidney disease

Answer 48

ADPKD is an inherited condition caused by mutations in the PKD1 or PKD2 genes, resulting in multiple renal cysts forming in affected individuals Condition associated with Berry aneurysm formation, mitral valve disease and liver cysts Eventually develop end-stage renal failure & may require either dialysis/renal transplant

Question 49

Renal cysts clinical features

Answer 49

Most likely to be found incidentally, as they are usually asymptomatic Flank pain Haematuria Uncontrolled hypertension Flank mass

Question 50

Renal cysts investigations

Answer 50

CT/MRI imaging with pre and post enhancement scans with IV contrast Ultrasound often picks up incidental findings of renal cysts Patient’s serum U&Es should also be checked & monitored regularly in patients with a known genetic risk factor

Question 51

Renal cysts management

Answer 51

Asymptomatic simple cysts – not normally need any further follow-up or treatment Symptomatic simple renal cysts – initially with simple analgesia, needle aspiration/cyst deroofing may be warranted if significantly impacting the patient Complex cysts managed depending on their Bosniak stage & may involve continued surveillance/surgical intervention

Question 52

Renal cysts complications

Answer 52

Infection Haemorrhage Rupture

Question 53

Renal tract stones compositions

Answer 53

Calcium – calcium oxalate, calcium phosphate or mixed oxalate & phosphate Struvite stones – magnesium ammonium phosphate Urate stones Cystine stones – associated with familial disorders affecting cystine metabolism

Question 54

Renal tract stones pathophysiology

Answer 54

Over-saturation of urine Urate stones – high levels of purine either from diet or through haematological disorders, results in increase of urate formation & subsequent crystallisation in the urine Cystine stones – typically associated with homocystinuria, an inherited defect that affects the absorption and transport of cystine in the bowel and kidneys

Question 55

Location of ureteric stones

Answer 55

1) Pelviureteric junction – renal pelvis becomes the ureter 2) Crossing the pelvic brim, where iliac vessels travel across the ureter in the pelvis 3) Vesicoureteric junction – ureter enters the bladder

Question 56

Ureteric stones clinical features

Answer 56

Loin to groin pain, sudden onset and severe Haematuria – non-visible Examination – only demonstrating some tenderness in the affected flank

Question 57

Ureteric stones investigations

Answer 57

Urine dip Routine bloods – FBC, CRP, U&E, urate and calcium levels Imaging – non-contrast CT scan of the renal tract (gold standard), AXRs, ultrasound to assess for any hydronephrosis

Question 58

Ureteric stones initial management

Answer 58

Adequate fluid resus Sufficient analgesia IV abx therapy & urgent referral to the urology team

Question 59

Ureteric stones criteria for inpatient admission

Answer 59

Post-obstructive AKI Uncontrollable pain from simple analgesics Evidence of an infected stone Large stones

Question 60

Stent insertion vs nephrostomy

Answer 60

Retrograde stent insertion – placement of a stent within the ureter, approaching from distal to proximal via cystoscopy - Allows the ureter to kept patent & temporarily relieve the obstruction Nephrostomy – tube placed directly into the renal pelvis and collecting system, relieving the obstruction proximally

Question 61

Ureteric stones definitive management

Answer 61

Can be achieved by several methods for stones that do not pass spontaneously 1) Extracorporeal shock wave lithotripsy – targeted sonic waves to break up the stone to then be passed spontaneously 2) Percutaneous nephrolithotomy – used for renal stones only, percutaneous access to the kidney is performed with a nephroscope passed into the renal pelvis -> stones can then be fragmented using various forms of lithotripsy 3) Flexible uretero-renoscopy – involves passing a scope retrograde up into the ureter, allowing stones to be fragmented through laser

Question 62

Ureteric stones complications

Answer 62

Infection Post-renal AKI Recurrent renal stones -> renal scarring & loss of kidney function

Question 63

Bladder stones

Answer 63

Typically form from urine stasis within the bladder, commonly seen in cases of chronic urinary retention Most often present with LUTS Definitive management is through cystoscopy, allowing the stones to drain/fragmenting them through lithotripsy if required Can predispose to the development of SCC bladder cancer

Question 64

BPH

Answer 64

Non-cancerous hyperplasia of the glandular-epithelial and stromal tissue of the prostate leading to an increase in its size Most common cause of bladder outlet obstruction

Question 65

BPH pathophysiology

Answer 65

Androgens play a role Prostate converts testosterone to dihydrotestosterone using the enzyme 5a-reductase DHT is more potent & prostate retains the ability to respond to testosterone so levels of DHT remain high through life

Question 66

BPH risk factors

Answer 66

Age Family history Black African/Caribbean ethnicity Obesity

Question 67

BPH clinical features

Answer 67

LUTS – mainly voiding symptoms (hesitancy, weak stream, terminal dribbling or incomplete emptying) Can get haematuria and haematospermia DRE is essential – firm, smooth, symmetrical prostate

Question 68

BPH investigations

Answer 68

Urinary frequency and volume chart Bedside urinalysis and a post-void bladder scan Counselled for a PSA test Ultrasound scan of the renal tract Urodynamic studies

Question 69

BPH medical management

Answer 69

Alpha-adrenoreceptor antagonist (tamsulosin) – act by relaxing prostatic smooth muscle - Provide a symptomatic benefit within a few days For those who remain symptomatic – finasteride (5a-reductase inhibitors) are often trialled - Act to prevent the conversion of testosterone to DHT

Question 70

BPH surgical management

Answer 70

TURP – endoscopic removal of obstructive prostate tissue using a diathermy loop to increase the urethral lumen size Holmium laser enucleation of the prostate – laser used to heat and dissect section of prostate into the bladder Simple prostatectomy Prostate artery embolisation

Question 71

TURP syndrome

Answer 71

Life-threatening complication of TURP Use of hypoosmolar irrigation during procedure -> significant fluid overload & dilutional hyponatraemia as the fluid enters the circulation through the expodes venous beds Present with confusion, nausea, agitation or visual changes Needs urgent management by addressing the fluid overload and carefully reduced the level of hyponatraemia

Question 72

BPH complications

Answer 72

High-pressure retention Recurrent urinary tract infections Significant haematuria episodes

Question 73

Prostate cancer pathophysiology

Answer 73

Adenocarcinomas – most from the peripheral zone Often multi-focal Can be categorised into two types: 1) Acinar adenocarcinomas – originates in the glandular cells that line the prostate gland 2) Ductal adenocarcinomas – originates in the cells that line the ducts of the prostate gland

Question 74

Prostate cancer risk factors

Answer 74

Age Black African/Caribbean ethnicity Family history of prostate cancer Other less significant modifiable risk factors – obesity, diabetes mellitus, smoking, degree of exercise

Question 75

Prostate cancer clinical features

Answer 75

LUTS Haematuria, dysuria, incontinence, haematospermia, suprapubic pain, loin pain & even rectal tenesmus DRE essential for diagnosis – asymmetry, nodularity or fixed irregular mass

Question 76

Prostate cancer investigations

Answer 76

PSA MRI scan of prostate Biopsies of prostate tissue: 1) Transperineal biopsy 2) Transrectal ultrasound-guided biopsy – involves sampling the prostate transrectally, usually ultrasound as guidance & sampling tissue in systematic manner Imaging for staging – CT chest-abdomen-pelvis and PET-CT nuclear medicine scan

Question 77

Prostate cancer management

Answer 77

MDT meeting Watchful waiting Radial treatments – radical prostatectomy Radiotherapy Chemotherapy agents & anti-hormonal agents

Question 78

Prostatitis

Answer 78

Inflammation of the prostate gland Comprised of acute bacterial prostatitis, chronic bacterial prostatitis (+ nonbacterial prostatitis & prostatodynia)

Question 79

Prostatitis pathophysiology

Answer 79

Acute bacterial prostatitis – caused by ascending urethral infection Causative organisms: E. coli, Enterobacter, serratia, pseudomonas and proteus, STIs are a rare cause Chronic bacterial prostatitis – chronic bacterial infection of the prostate with/without prostatitis symptoms & caused by inadequately treated acute prostatitis

Question 80

Prostatitis risk factors

Answer 80

ABP: indwelling catheters, phimosis/urethral stricture, recent surgery, immunocompromised CBP: intraprostatic ductal reflux, neuroendocrine dysfunction, dysfunctional bladder

Question 81

Prostatitis clinical features

Answer 81

ABP – LUTS, features of systemic infection, perineal/suprapubic pain or urethral discharge Rectal examination – very tender and boggy prostate, associated inguinal lymphadenopathy may also be present CBP – pelvic pain/discomfort for 3 months, alongside LUTS, perineum is the most common site for pain

Question 82

Prostatitis investigations

Answer 82

Urine culture, abx therapy can be guided from sensitivities obtained STI screen, routine bloods Transrectal prostatic ultrasound CT imaging

Question 83

Prostatitis management

Answer 83

ABP – prolonged abx treatment (typically quinolone) Suitable analgesia CBP – focused on symptom control, 4-6 week trial of alpha blocker, 6 week course of abx if symptoms < 6 months Consider referral to a chronic pain specialist (MDT approach)