Urology Key Flashcards
1
Q
◙ Sudden colicky Pain in loin/flank radiates to groin/ abdomen +
nausea, vomiting,
hematuria (blood in urine), ± rigours
Ioc?
A
Think → Ureteric “renal” Stones.
◙ The Investigation of Choice for Ureteric Stones:
→ Non-contrast “Spiral” CT scan of KUB “Kidney, ureters, bladder”.
(CT KUB, not U/S KUB)!
2
Q
Mng of ureteric stones
A
If pregnant woman → Ultrasound of KUB.
Management → Generally depends on the Stone Size Rule:
◙ If stone size < 0.5 cm (< 5 mm) → ↑ fluid intake to get rid of it in urine.
◙ If stone size 0.5 cm – 2 cm (5-20 mm) → two options:
√ ESWL (Extracorporeal Shock wave Lithotripsy) “preferred”,
or:
√ [Ureteroscopy] with dormia basket.
“Ureteroscopy is preferred over ESWL if the patient has hydronephrosis. This is
because in ureteroscopy, we can insert JJ stent to relieve ureteric obstruction”.
◙ If stone size > 2 cm (> 20 mm) → Percutaneous Nephrolithotomy.
3
Q
HOWEVER!
◙ If the patient has only one functioning kidney (e.g.,
Hx of the removal of one
kidney) and has a stone (OF ANY SIZE) with dilatation of the pelvicalyceal
system (PCS)
± Anuria,
Fever [Obstructive Uropathy
A
] →
The thing to do is to decompress the PCS to save the remaining
kidney.
This is done by → Percutaneous Nephrostomy
INITIAL If Percutaneous nephrostomy is not among the options,
pick “ureteric stent”. √
4
Q
◙ Similarly, even if the patient has 2 kidneys,
if he develops AKI (impaired urea
and creatinine),
fever and
Hydronephrosis (these together with the presence
of stones are indicators of Obstructive Uropathy),
we shall go for
A
(Percutaneous Nephrostomy) in order to temporarily and instantly
decompress the renal collecting system regardless of the stone size!
We need to drain the urine first to relieve the obstruction and save the AKI.
5
Q
◙ Important: in obstructive uropathy.
What if both Nephrostomy AND Ureteric stenting (JJ stent) are in the options?
√ If BMI is normal or not given in the stem → Nephrostomy
√ If BMI is high eg, 40 kg/m2 (
the patient is Obese) →.
Ureteric stenting.
A
6
Q
Note, Percutaneous nephrostomy is different form Percutaneous
nephrolithotomy
A
Percutaneous Nephrostomy → stoma “catheter” to the Pelvicalyceal system
of the kidney for decompression (Draining the obstructed fluid in kidney).
→ removal of urinary stone percutaneously
• Percutaneous Nephrolithotomy via a scope (if size > 2 cm).
7
Q
If BMI is high eg, 40 kg/m2 (the patient is Obese) →
Ureteric stenting.
Why??
Not per cutaneous nephrostomy?
A
This is because percutaneous nephrostomy in Obese patient would be difficult.
It is done under interventional radiology (U/S). Due to fat, the clarity of U/S
would be reduced.
Also, inserting a catheter through big fatty layers is difficult.
Inserting JJ stent (ureteric stenting) would allow the collecting urine to pass
down
and the peristalsis of ureters to run again and would relieve the
obstruction.
This may lead to the stone to be extracted in urine or
in many cases it would
be followed by ureteroscopy or ESWL “definitive management
8
Q
Example (1):
46 YO ♂ with Hx of left nephrectomy 10 days ago presents with fever, inability
to pass urine for the last 20 hours.
Ultrasound reveals an 8 mm stone in the left lower ureter with dilatation of the pelvicalyceal system.
What is the best
INITIAL step in management?
A
• The best initial step →
Percutaneous Nephrostomy.
The (Stone Size Rule) does not apply here. This patient has obstructive
uropathy with impending renal failure.
We need to, initially, save his
remaining kidney by decompressing the fluid retention in the PCS.
This can
be done by → Percutaneous Nephrostomy.
Afterwards, we can manage the
stone based on the stone size role; (ESWL) in this case.
9
Q
In summary:
◙ Loin pain + Stone ± Hydronephrosis → Manage according to the stone size.
◙ Loin pain + Stone + Hydronephrosis [+] AKI [+] Fever
A
→ Percutaneous Nephrostomy, initially.
10
Q
Example (2):
36 YO ♂ presents with severe loin pain, nausea and vomiting. Ultrasound
shows right hydronephrosis.
Non-enhancing CT reveals a 3.1 cm stone at the
level of the minor calyx.
What is the most appropriate management?
A
• The most appropriate management → Percutaneous Nephrolithotomy.
He has 2 working kidneys with no obstructive uropathy. According to the
“Stone Size Rule”, stone > 2 cm → Percutaneous Nephrolithotomy.
He has 2 working kidneys with no obstructive uropathy. According to the
“Stone Size Rule”, stone > 2 cm → Percutaneous Nephrolithotomy.
11
Q
A
12
Q
A
13
Q
Example (3):
A 33 YO man with Hx of urinary stones has suddenly developed severe left loin
pain that radiates to the groin, nausea and vomiting.
US reveals a 3-mm stone
in the renal pelvis
A
.
The most appropriate management → Advise him to increase fluid intake.
14
Q
Example (4):
A 35 YO man suddenly developed severe left loin pain that radiates to the
groin, nausea and vomiting.
Renal stone is suspected.
The best modality →
A
Non-contrast “Spiral” CT scan of KUB “Kidney, ureters, bladder”
= (Non-enhancing CT)
After Non-enhancing CT, a 3-cm stone was found at the minor calyx.
The most appropriate Rx
→ Percutaneous nephrolithotomy (stone is > 2 cm).
15
Q
Example (5):
A 44 YO man is brought to the A&E with a few days of severe left flank pain
and reduced urine output. He has fever (37.9) and tachycardia (105 bpm). He
was put on IV analgesics, fluids and antibiotics. CTKUB shows a 12 mm stone at
his left distal ureter and hydronephrosis. His kidney function tests are
deteriorating. His WBC and CRP are high. What is the appropriate
management?
D) Observation for 2 months.
E) Suprapubic catheter.
A) ESWL (Extracorporeal shock wave lithotripsy).
B) PCNL “Percutaneous nephrolithotomy”.
C) Ureteric stenting “JJ stent”.
A
√ Infection + Stone + Hydronephrosis → Decompression is a priority.
√ Here, Percutaneous nephrostomy is not among the options,
thus;
decompressing the collecting systems using ureteric stenting is the
appropriate answer.
→ The valid answer here is → C (Ureteric Stenting).
√ Ureteric stenting is a thin tube inserted into the ureter to allow urine
drainage from kidneys → decompression.
After that, ESWL or cystoscopy can
be done as a definitive Rx for the stone.
16
Q
Example (6):
A 46-year-old man is brought to the A&E with a 5-day of severe right groin pain
and reduced urine output. He has fever (37.9) and tachycardia (105 bpm). He
was put on IV analgesics, fluids and antibiotics.
CTKUB shows a 11 mm stone at
his left distal ureter and mild hydronephrosis. His kidney function tests are
deteriorating.
His WBC and CRP are high. What is the appropriate
management?
A) ESWL (Extracorporeal shock wave lithotripsy).
B) PCNL “Percutaneous nephrolithotomy”.
C) Encourage fluid intake.
D) Ureteroscopy.
E) Suprapubic catheterisation.
A
• Since he has hydronephrosis, in addition to the stone removal, a JJ stent to
relieve the obstruction is needed. (A ureteric stent is not among the options).
• Since the stone’s size is between 0.5-2 cm (ie, 5-20 mm), we have 2 options:
√ ESWL (option A), and √ Ureteroscopy (option D).
• Between the 2 options, “Ureteroscopy is preferred over ESWL as the patient
has hydronephrosis.
This is because in ureteroscopy, we can insert JJ stent to
keep ureter temporarily open and thus relieve the ureteric obstruction”.
So, the answer is → D (Ureteroscopy).
17
Q
Loin or flank pain
Unilateral
A
Unilateral Loin/ Flank Pain
• +ve HCG in urine → suspect ectopic pregnancy
• The pain started centrally then went to the right iliac region,
+ Nausea and
vomiting, ± Tenderness and rebound tenderness
→ Appendicitis.
→ Ureteric Colic • -ve HCG, the pain radiates from loin to groin
± ↑ WBCs and CRP ± vomiting
(a stone at the lower part of a ureter
18
Q
A
19
Q
Varicocele
Unilateral bilateral
A
Varicocele • Varicosities of the pampiniform plexus
• Typically occur on left (because left testicular vein drains into renal
vein directly at right angle -high pressure-)
• Often Dull-aching or Dragging pain that is worse after exercise or at
the end of the day.
• described as a “Bag of worms”, bluish, disappear on lying down.
• May show impulse on cough.
• May be a presenting feature of renal cell carcinoma (left kidney
tumour → occlude the left testicular vein → varicocele).
◙ So, sometimes a stem may describe a varicocele along with renal
pain and hematuria → choose renal cell carcinoma.
• Affected testis may be smaller and bilateral varicoceles may affect
fertility
• Ix → Scrotal doppler ▐ US is diagnostic. “not urgent”
• Reassurance. Unless infertility or severe pain → surgery.
20
Q
Testicular torsion
A
• Severe, sudden onset testicular pain
• Risk factors include abnormal testicular lie
• Typically affects adolescents and young males
• On examination testis is tender and pain
The pain in testicular torsion is NOT eased by elevation, while in
epididymo-orchitis, the pain is relieved by elevating testis.
Also, the pain in testicular torsion is felt at the testicle itself while
the pain in epididymo-orchitis is usually confined to the epididymis.
• Hx of similar episodes.
• Examination is intolerable (due to severe pain).
• Urgent Exploratory surgery is indicated, the contra lateral testis
should also be fixed
21
Q
Hydrocele
A
• Non painful, soft fluctuant swelling
• Often possible to ‘get above it’ on examination
• Usually contain clear fluid
• Will often transilluminate
• May be a presenting feature of testicular cancer in young men
• Do → U/S scrotum.
22
Q
Acute epidydimoorchitis
A
• Often history of dysuria -painful micturition-
, pain, and urethral
epididymo-
discharge
orchitis
• Scrotal skin is often red and tender.
• Fever may or may not present
• Swelling may be tender and relieved by elevating the testis (+ve
prehn’s signs).
• Most cases due to Chlamydia, Gonorrhea (sexually active male).
• The symptoms are gradual if compared to the sudden acute onset
of testicular torsion.
• Often, the affected testis is placed HIGHER than the other testis.
• Important part of the investigations → PCR urethral swab for
chlamydia.
• Rx → antibiotics
23
Q
Epididymal cyst
A
• Single or multiple cysts that develop slowly
• May contain clear or opalescent fluid (spermatoceles)
• Usually occur over 40 years of age
• Painless, non-tender
• Lies above and behind testis (upper pole, posterior part of testes).
• It is usually possible to ‘get above the lump’ on examination
• Do → Ultrasound “Diagnostic
24
Q
Testicular tumours
A
Often discrete testicular nodule (may have associated hydrocele)
• Symptoms of metastatic disease may be present
• Ultrasound scrotum and then serum AFP and β HCG required
25
Inguinal hernia
Inguinoscrotal swelling; cannot ‘get above it’ on examination
• Cough impulse may be present
hernia
• May be reducible
26
Management of testicular swellings
Management
• Testicular malignancy is always treated with orchidectomy via an
inguinal approach. Dx “initial” → Ultrasound scrotum.
• Testicular Torsion is commonest in young teenagers. The treatment is
urgent surgical exploration and testicular fixation.
This can be achieved
using sutures or by placement of the testis in a Dartos pouch.
• Varicoceles are usually managed conservatively. If painless → Reassure.
If there are concerns about infertility or persistent severe pain → surgery.
• Epididymal cysts can be excised using a scrotal approach
• Hydroceles are managed differently in children where the underlying
pathology
is a patent processus vaginalis and
therefore an inguinal
approach is used in children so that the processus can be ligated.
In adults, a scrotal approach is preferred and the hydrocele sac excised or
plicated.
• Epididymo-orchitis → Administer Antibiotics.
27
28
√ Remember
The major complication of untreated chlamydia “and N. Gonorrhea” in males
is: →
(Epididymo-Orchitis) or (Epididymitis).
→ Unilateral Testicular Pain.
29
The major complication of untreated chlamydia “and N. Gonorrhea” in
Females is:
→ (Salpingitis).
30
√ Also, Remember:
One of the features that may be associated Mumps is Orchitis (Not always
seen)
)
• Orchitis (4 or 5 days post-parotitis) (NOT ALWAYS) → local severe te sticular
pain and tenderness, Swollen edematous scrotum,
impalpable testes.
31
For anyone whit history of renal stones, remember to advise to
(dehydration is a major risk factor for stones).
→ increase fluid intake
32
Urinary Urgency + Frequency (urinating a lot) for long-time
Suprapubic pain that is worse on bladder filling and relieved after voiding
→ We suspect UTI and send midstream urine for culture.
33
◙ What if the culture returns Negative?
→ Suspect Interstitial Cystitis (Bladder pain syndrome) “Dx of Exclusion”
◙ The next step would be → Cystoscopy (Mainly to R/O Bladder Cancer)
(in 10%, cystoscopy of interstitial cystitis cases shows → Hunner’s ulcers
34
Intestitial nephritis
).
◙ First-line Rx → Bladder training.
Avoid pelvic floor exercise (we need pelvic
floor relaxation).
Avoid triggers like coffee, NSAIDs for pain
◙ Second-line Rx → Amitriptyline, Gabapentin.
35
Vesicovaginal Fistula
◙ Tract between Vagina and Urinary Bladder.
◙ → Urine discharge from bladder to vagina
“leakage of small amount of clear fluid usually with no distinct odour”
Commonly result after Gynaecological and Urinary surgeries (Particularly,
Hysterectomy).
Also, it can occur after pelvic radiotherapy.
36
37
3 swab test
Vesicovaginal
Ureterivaginal
Urethrovaginal
Methylene blue
38
A 63 YO woman presents complaining of a 4 months history of continuous
leakage of small amounts of urine vaginally. It occurs throughout the day and
does not correlate to coughing. She had pelvic radiotherapy 6 months ago for
cervical cancer
.
• The likely Dx →
• to diagnose →
Vesicovaginal fistula.
2 swab test.
39
Urinary Incontinence Management (Important √)
Incontinence → Involuntary leakage of urine.
◙ Stress incontinence √
♦ Leakage of urine during activity (sneezing, coughing, laughing).
♦ The cause → The bladder outlet is weak (weak tone) and cannot counteract
the raised intra-abdominal pressure during activity.
Also, with multiple vaginal deliveries → Pelvic floor muscles become weak.
The initial Rx of choice → 3 times a day, for at least 3 months).
Pelvic floor exercise (at least 8 pelvic contraction
√ If failed → Surgical retropubic mid-urethral tape = (Free-tension vaginal tape)
√ If surgery is not possible → Duloxetine.
40
◙ Urge incontinence (Detrusor Overactivity = Overactive Bladder) √
♦ Leakage of urine when there is a sensation of need to void.
When I feel the desire to pee, I have to go and pee!
Or:
When I feel a desire to pee, sometimes I slightly wet myself “Leakage” before
making it to the bathroom!
♦ The cause → the bladder muscle (Detrusor) is overactive hence loss of urine.
◙ Treatment:
√ Bladder drill (Retraining) → gradually increase the periods between voiding.
(for 6 weeks)
√ If drugs are needed:
→ Antimuscarinic = Anti-cholinergics
(e.g., immediate release oxybutynin
Another important antimuscarinic drug to remember → tolterodine
If there is arrhythmia → Mirabegron (a beta-3 agonist).
41
Transurethral resection of prostate (TURP) Syndrome:
♦ During this operation, excessive irrigation is used to allow good
visualisation.
♦ This fluid can leak inside causing dilutional hyponatremia Agitation.
Confusion
42
Benign Pprostatic Hyperplasia (BPH)
◙ Benign prostatic hyperplasia (BPH) is a common condition seen in old men.
◙ BPH typically presents with lower urinary tract symptoms (LUTS), which may
be categorised into:
♣ Voiding symptoms (obstructive): weak or intermittent urinary flow,
straining, hesitancy, terminal dribbling, and incomplete emptying.
♣ Storage symptoms (irritative): urgency, frequency, incontinence and
nocturia.
♣ Post-micturition: dribbling
♣ Complications:
urinary tract infection,
retention,
obstructive uropathy
◙ DRE “Digital Rectal Examination”, the Prostate is:
→ Firm,
Enlarged, Smooth, Not nodular.
◙ Management of BBH (Benign Prostatic Hyperplasia):
√ Watchful waiting.
√ Medication:
♦ First line → Alpha-1 Blockers (e.g., tamsulosin, doxazocin, alfuzosin).
Side-effects →
postural hypotension,
drowsiness,
dyspnoea,
dry mouth.
43
2nd lime treatment in bph
♦ Second line → 5 alpha-reductase inhibitors (e.g., finasteride).
Side-effects → erectile dysfunction, ejaculation problems, gynecomastia.
Important notes on the management of BPH:
• Tamsulosin (Alpha-1 blocker) is tried first before finasteride (in general).
• However, finasteride (5-alpha-reductase inhibitor) is of choice (used first) if
there are lower urinary tract symptoms + WITH prostate enlargement (> 30
grams) ± or ↑ PSA > 1.4”.
Also, since finasteride can cause erectile dysfunction, they shoud be avoided if
the patient has erectile issues.
√ Surgery→ Transurethral resection of prostate (TURP)
44
(Important) If there is urinary flow obstruction that has been relieved after
inserting catheter
, before jumping to surgery
y
→ prescribe tamsulosin and refer for Trial WithOut Catheter (TWOC).
“TWOC needs to be tried for 1-2 days after giving alpha 1 blockers that would
relax the smooth muscles of prostate and bladder to see of voiding will happen
or further management would be needed
45
Prostate Cancer
Prostate cancer is now the most common cancer in adult males in the UK and is
the second most common cause of death due to cancer in men after lung cancer.
Risk factors
increasing age
▐ obesity
▐ Afro-Caribbean ethnicity (usual hint √)
family history: around 5-10% of cases
have a strong family history.
Features
Early Localised prostate cancer is often asymptomatic.
This is partly because cancers tend to develop in the periphery of the prostate
and hence don’t cause obstructive symptoms early on.
Possible features include:
√ Bladder outlet obstruction: hesitancy, urinary retention.
Or frequency, urgency “sensation of incomplete urination”
√ Haematuria, haematospermia (locally invasive tumour).
√ Pain: back pain, suprapubic pain, perineal or testicular.
√ Weight loss.
√ Digital rectal examination:
asymmetrical,
irregular,
hard,
nodular
enlargement with loss of median sulcus.
46
The most appropriate [Next], initial Investigation → serum psa
Multi parametric mri
is now the first-line investigation for people with
suspected clinically localised prostate cancer.
47
The most appropriate follow up investigation in prostate cancer
→ PSA “Prostate Specific Antigen”.
◙ Based on PSA, when to suspect Prostate Cancer?
Age PSA level (ng/ml)
40-49 years If PSA ≥ 2.0
50-69 years If PSA ≥ 3.0
> 70 years If PSA ≥ 5.0
48
Bone metastases in Cancers
Most common tumour causing bone metastases (in descending order):
Prostate → breast → lung
Most common sites of bone metastasis (in descending order):
Spine → pelvis → ribs → skull → long bones
Other than bone pain, features of bone metastasis may include:
pathological fractures
▐ hypercalcaemia “imp √”
▐ raised ALP▐ ↑ Thirst
49
Secondary mets prostate cancer
Important Notes:
Local spreading of prostate cancer can invade ureter → occluded ureter →
Loin pain and Anuria → Obstructive Uropathy (impaired RFTs).
→ Do Ultrasound of Kidneys, Ureters and Bladder.
Prostate cancer can metastasise to spine causing → Cauda Equina Syndrome
→ Perianal/ groin numbness (Saddle Paraesthesia) ▐
Inability to initiate
voiding “urination”
▐ Back pain.
→ Urgent MRI of Spine
50
A 75 YO ♂ complains of poor, weak, intermittent urine flow. He also has
fatigue and increased thirsty.
On DRE “digital rectal examination”, his
prostate is firm, smooth, without nodules, and enlarged about 2 finger
breadths.
His Labs are as follows:
Hb: 12.8 ▐ PSA: 4.4 ng/ml ▐ serum calcium: 2.1 (normal).
The likely Dx is (Benign Prostatic Hyperplasia BPH or Prostate Cancer
◘ DRE → smooth, no nodularity → goes more with “BPH”.
◘ PSA in age > 70 YO that is suspicious of prostate cancer is ≥ 5
(Here it is 4.4) → Goes more with BPH.
◘ Although there is ↑ thirst, his Calcium level is Normal.
Therefore, the likely diagnosis is → Benign Prostatic Hyperplasia [BPH
51
Example (2),
A 70 YO presents with: intermittent, painless hematuria, hesitancy, frequency,
difficulty in emptying bladder, lower back and pelvic pain. His PSA is 9.
The likely Dx → Prostate Cancer.
√ Obstructive symptoms due to enlarged prostate.
√ High PSA for age (>5 for people >70 YO is suspicious)
√ Low back pain (may be 2ry to bone metastasis) “spine is the commonest
site”
52
Example (3),
A 53 YO man presents to the GP complaining of hesitancy, frequency, drippling
over the past year with a recent hematuria.
He is a known hypertensive and
hyperlipidaemic on medications.
His BP is 160/90. His kidney functions tests
are slightly disturbed and his (PSA is 4.5). What should be done?
→ Refer to urology for consideration of Prostate Cancer.
√ Obstructive symptoms due to enlarged prostate.
√ High PSA for age (>3 for people 50-69 YO is suspicious)
√ + Hematuria
50-69 years If PSA ≥ 3.0
53
Example (4),
A 72 YO African American male presents with Thirst, Fatigue, Frequency,
Terminal Drippling, Weight loss, Hypercalcemia.
The likely Dx → Prostate Cancer.
54
BPH
Elderly + Frequency,
urgency, hesitancy,
incomplete bladder
emptying, drippling.
Normal PSA for age.
DRE → Firm, smooth,
enlarged prostate (no
nodules or irregularity)
55
Elderly + Frequency,
urgency, hesitancy,
incomplete bladder
emptying, drippling
DRE → Hard, nodular,
irregular prostate
Abnormal psa
Other Possible Features:
Hematuria
Low back pain
Weight loss
56
Bladder cancer
Middle aged to elderly ♂
or ♀ +
Gross Painless Hematuria
±
RFs:
√ Smoking
√ ↑ age
√ Exposure to paints, dyes.
57
Sudden severe pain in the loin and radiates to the groin.
± Rigours, Fever, Hematuria.
± Nausea and Vomiting.
A relatively Young Adult
Renal Colic (Stone)
.
Dx → Non-contrast CT scan of KUB “Kidney, ureters, bladder” √
58
(presents with unilateral flank pain, anuria post-op)
After abdominal surgery, one of the complications that we should aware of is
(presents with unilateral flank pain, anuria post-op)
Ureteric injury
To investigate it, perform → Renal Ultrasound
“A ligation/ injury of ureter during an operation will cause backflow of urine to
the kidney
and thus Renal hydronephrosis that can be detected by a non-
invasive US”.
Other features that may be seen are
fever and ↑ WBCs due to infected urine
in the obstructed system.
59
Sarcoidosis
Remember, features of sarcoidosis
Erythema nodosum, (Tender, red nodules over shins).
Bilateral hilar lymphadenopathy, (the most common finding on Chest X ray)
Polyarthralgia
Hypercalcaemia √
Fever.
60
Testicular cancer
◙ Testicular cancer is the most common malignancy in men aged 20-35 years.
◙ Around 95% of cases of testicular cancer are germ-cell tumours.
◙ Germ cell tumours may essentially be divided into:
• Seminomas
• Non-seminomas: including embryonal, yolk sac, teratoma and
choriocarcinoma.
◙ Features
♣ A painless, non-tender lump within the testis itself that is slowly
growing in size in a young man. “important”
.
♣ Sometimes, there is a dragging sensation. Unlike varicocele, dragging
sensation in testicular cancer would not be relieved on lying flat.
61
Testicular cancer investigation
◙ Diagnosis → Ultrasound of scrotum is first-line ▐
Request LDH
◙ Suspect testicular cancer in the GP surgery?
(NOT a routine referral)!
→ Refer to urology within 2 weeks
Important Note:
Hx of Undescended Testis (Cryptorchidism) increases the risk of testicular
cancer by 10 times (
Particularly: Seminoma “a germ cell tumor”) for
which, we request Lactate Dehydrogenase (LDH).
62
Example (1),
A 33 YO man presents with left testicular enlargement that has been growing
slowly over the past 6 months.
O.E, A 4 mm firm, non-tender lump is felt
within the body of the left testicle
The likely Dx → Testicular cancer
Next step → Testicular u/s
If the patient is in the GP surgery
→ 2 week wait referral to urology.
63
Example (2),
A 26 YO man collapsed while playing basketball and was brought to the ED. His
history includes shortness of breath for 2 weeks
and a surgery (Orchiopexy) for
maldescended testes at the age of 4 years
. Chest X-ray shows multiple round
pulmonary masses.
The likely Dx → Testicular Cancer.
“Particularly Seminoma -GCT-
“
LDH
The tumour marker that is likely elevated
→ Hints: Young ages – Hx of maldescended testes – Lung metastasis.
64
Example (3),
A 34-year-old man presents to the GP complaining of a painless lump in his
scrotum.
He describes a dragging sensation in his scrotum which does not
improve on lying down flat.
On examination, there is a palpable mass in the
body of the left testis that is slightly larger than a pea in size. What is the most
appropriate action?
A) Reassurance.
B) Urine culture and microscopy.
C) Advice to wear support underwear.
D) 2 week wait referral to urology.
E) Routine referral to urology.
Answer → D.
• This is most likely a case of testicular cancer that needs to be referred to
urology within 2 weeks (not a routine referral).
• Suspect testicular cancer if the mass is felt within the body of the testis itself.
• Testicular cancers are mostly painless. However, some may feel a dragging
sensation.
• If this was a varicocele case, in addition to a dragging sensation, it would be
described as a bag of worms. Also, the dragging sensation would be relieved
when patient lies down, which is not the case here.
65
Tumour markers
A Quick Reminder
Common Tumour Markers
Breast Cancer CA 15-3
Ovarian Cancer CA 125
Pancreatic Cancer CA 19-9
Colorectal Cancer CEA “Carcinoembryonic Antigen”
Prostatic Cancer PSA “Prostate Specific Antigen”
Liver (HCC)
AFP “Alpha-fetoprotein”
Teratoma (e.g. of testicles, ovaries)
AFP “Alpha-fetoprotein”
Testicular Seminoma LDH (Lactate Dehydrogenase)
66
Remember the differences between Epididymo-orchitis and Testicular
Torsion:
Epididymo-orchitis
• Often history of dysuria -
painful micturition-
, pain, and urethral discharge.
• Scrotal skin is often red (erythema) and tender.
• Fever may or may not be present.
• Swelling may be tender and relieved by elevating the testis (+ve prehn’s sign).
• Most cases due to Chlamydia, Gonorrhea (sexually active male).
• The symptoms are gradual if compared to the sudden acute onset of
testicular torsion.
• The affected testis is often retracted (higher than the other).
• Rx → √ imp.
67
Testicular torsion
NOT • Severe, sudden onset testicular pain.
• Risk factors include abnormal testicular lie.
• Typically affects adolescents and young males.
• On examination testis is tender and pain not eased by elevation
While in epididymo-orchitis, pain is relieved by elevating testis.
Also, the pain in testicular torsion is felt at the testicle itself while
the pain in epididymo-orchitis is usually confined to the epididymis.
• Hx of similar episodes.
• Examination is intolerable (due to severe pain).
• Urgent Exploratory surgery, the contra lateral testis should also be fixed
68
Elderly + Hematuria + No other symptoms
→ Consider Bladder Cancer “transitional cell cancer is the commonest type”
→ Flexible Cystoscopy = cystourethroscopy
Others → CT Urogram to look for renal and ureteric cancers.
Among other Risk Factors, the greatest risk factor for bladder cancer is
→ Smoking
69
Above 40 YO + Frank hematuria →
______
Below 40 YO + Hematuria (malignancy less likely) →
______
Above 40 YO + Frank hematuria → Cystoscopy + CT Urogram.
Below 40 YO + Hematuria (malignancy less likely) → CT-KUB “for stones”
70
Important:
After successful treatment of UTI, the persistence of Hematuria is suspicious
especially in those > 45 YO
even if no risk factors for bladder cancer. Thus,
→ Refer the patient for a 2 week wait appointment with urology or
nephrology.
Cystoscopy might then be done by a urologist.
2 weeks wait (urgent not routine). This is the usual in the UK.
71
Autosomal Dominant Polycystic Kidney Disease (ADPKD)
.
→ think of Adult Polycystic Kidney Disease (ADPKD. “Important √”
• Remember that ADPKD is associated with Intracranial Aneurysm! (Important
• If a patient presents with Hematuria (either microscopic or gross)
[+] HTN [+]
Loin/Flank Pain
72
Example,
A 44 YO ♀ Known cases of Chronic Kidney Disease presents with Hypertension
and loin pain.
Her father died at the age of 54 due to cerebral aneurysm. What
is the likely Investigation that would lead to diagnosis in this lady?
→ Ultrasound of the Kidneys, Ureters and Bladder.
√ You supposed to be able to know that this is a case of ADPKD as this disease
is an Autosomal dominant which means that 50% of children will be affected
(Hx of father) and it is often associated with intracranial aneurysm.
√ Furthermore, ADPKD can lead to progressive CKD.
√ The diagnosis is made by ultrasound as it can detect the cysts.
73
74
Important Table
Hematuria + HTN
Polycystic Kidney Disease (ADPKD) Ultrasound
Hematuria + Hemoptysis
Goodpasture Syndrome
Anti-GBM Abs
Hematuria + Hemoptysis
+ Nasal/Sinus problems
Wegener’s (Granulomatosis with polyangitis)- c-ANCA
Hematuria/ Renal
function impairment +
Bloody diarrhea
Hemolytic Uremic Syndrome (HUS)
75
Painless, gross (frank) hematuria in an elderly man
Bladder cancer until proven otherwise → do Cystoscopy = Cystourethroscopy
76
Reflux Nephropathy
• Urine goes back from bladder to ureters and kidneys (Vesico-Ureteric Reflux) →
Dilated Pelvicalyceal system →
Repeated UTIs → Progressive Renal Failure.
• Occurs mainly in the young (children).
♦ An important cause → Congenital abnormality of the insertion of ureters
into the urinary bladder (can be seen on US).
77
Reflux nephropathy
♦ Dx
√Initial
√Gold standard
√For parenchymal damage
1.→ Renal Ultrasound (+) Urinalysis, urine culture and sensitivity.
2.→ Micturating Cystourethrogram.
(cortical scars)
3. → Technetium Scan (DMSA).
♦ Rx
√ Initially
→ Low-dose antibiotics prophylaxis (trimethoprim) daily.
Failed Or Parenchymal damage? → Surgery (Ureters Re-implantation).
78
Important,
If recurrent UTIs with Normal Ultrasounds and Normal X-rays
→ Cystoscopy “flexible” “to look for anatomical defects that cannot be seen on
US”
79
Recurrent uti
Recurrent UTIs is defined as having 2 UTIs in 6 months or 3 UTIs in
12 months.
80
81
Sudden colicky Pain in loin radiates to groin, nausea, vomiting,
hematuria, ± rigours
• The likely Dx →
• Ix → • Imp: If pregnant (+ve beta Hcg)
Sudden colicky Pain in loin radiates to groin, nausea, vomiting,
hematuria, ± rigours
• The likely Dx →
• Ix → • Imp: If pregnant (+ve HCG)
Ureteric “renal” Stones
Non-contrast “Spiral” CT scan of KUB “Kidney, ureters, bladder” √ imp.
→ U/S of kidney, ureters, bladder (safer in pregnancy).
82
◙ Asymptomatic bacteria in urine should not be treated in:
√ Patients with indwelling catheter.
√ Non-pregnant female.
√ Adult male.
83
Renal Colic
+
Acute Severe episodes of Painful joints (e.g. Knee, Big toe)
Think of a link??
↑ Uric Acid (Hyperuricemia) → Renal stones + Gout
84
Varicocele “Important Points”
]
• Typically affects the left testis.
• Often Dull-aching or Dragging pain that is worse after exercise or at the end
of the day.
• described as a “Bag of worms”, bluish, disappear on lying down.
• May show impulse on cough.
• A soft scrotal swelling that reduces on lying down, particularly more
prominent on one side.
• May be a presenting feature of renal cell carcinoma (left kidney tumour →
occlude the left testicular vein → varicocele).
♣ So, sometimes a stem may describe a varicocele along with renal pain and
hematuria → choose renal cell carcinoma.
• Ix → Scrotal doppler ▐ US is diagnostic. “Not urgent”
.
• Varicoceles are usually managed conservatively.
√ If painless → Reassure.
√ If there are concerns about testicular function of infertility or persistent
severe pain → surgery.
85
Remember,
Spiral CT scan some indications →
Remember,
Spiral CT scan some indications → Ureteric Calculi ▐ Pancreatitis ▐ Aneurysm
86
◙ Asymptomatic bacteria in urine should not be treated in:
√ Patients with indwelling catheter.
√ Non-pregnant female.
√ Adult male.
87
US → obstruction (e.g. obstructive uropathy – hydronephrosis)
CT KUB → Stones
X-ray → Not preferred.
IVU → obsolete nowadays “not used”
88
Renal Colic
+
Acute Severe episodes of Painful joints (e.g. Knee, Big toe)
Think of a link?
?
↑ Uric Acid (Hyperuricemia) → Renal stones + Gout
89
Varicocele “Important Points”]
• Typically affects the left testis.
• Often Dull-aching or Dragging pain that is worse after exercise or at the end
of the day.
• described as a “Bag of worms”, bluish, disappear on lying down.
• May show impulse on cough.
• A soft scrotal swelling that reduces on lying down, particularly more
prominent on one side.
• May be a presenting feature of renal cell carcinoma (left kidney tumour →
occlude the left testicular vein → varicocele).
♣ So, sometimes a stem may describe a varicocele along with renal pain and
hematuria → choose renal cell carcinoma.
• Ix → Scrotal doppler ▐ US is diagnostic. “Not urgent”
.
• Varicoceles are usually managed conservatively.
√ If painless → Reassure.
√ If there are concerns about testicular function of infertility or persistent
severe pain → surgery.
90
PSA “Prostate Specific Antigen)
Not specific for Prostate cancer as it may raise in other conditions such as BPH,
Prostatitis, UTI and after ejaculation, exercise and DRE
.
Advice to avoid ejaculation and exercise 48 hours before serum PSA test.
91
Frequency, Urgency,
Dysuria, Hematuria,
Suprapubic pain,
Fever, Nitrates and
Leucocytes on Dipstick
→ Cystitis (Urinary bladder inflammation, mainly due to infection with E. Coli)
92
Painless hematuria in an elderly man with no other symptoms
Initial investigation = Cystoscopy
93
Painless, non-tender swelling lies above and behind testis
→ epididymal cyst.
94
Urethritis complication in men
→ epididymitis.
95
The major complication of untreated chlamydia “and N. Gonorrhea” in males
is:
→ Unilateral Testicular Pain.
The major complication of untreated chlamydia “and N. Gonorrhea” in
Females
The major complication of untreated chlamydia “and N. Gonorrhea” in males
is: → (Epididymo-Orchitis) or (Epididymitis)
→ Unilateral Testicular Pain.
The major complication of untreated chlamydia “and N. Gonorrhea” in
Females is: → (Salpingitis = PID).
96
A young footballer male presents with severe testicular pain that is not
relieved by elevating the testis
→ Urgent surgical exploration (likely testicular torsion).
97
Testis cancer
→ order LDH (lactate dehydrogenase)
98
Seminoma testis
◙ Hx of Undescended Testis (Cryptorchidism) increases the risk of testicular
cancer by 10 times (Particularly:
Seminoma “a germ cell tumor”) for which, we
order Lactate Dehydrogenase (LDH
99
◙ A 45 YO female heads to the bathroom whenever she has a desire to pee.
She also has frequency
→ Detrusor overactivity (Urge incontinence).
100
Stress incontinence
Incontinence → Involuntary leakage of urine.
◙ Stress incontinence √
♦ Leakage of urine during activity (sneezing, coughing, laughing).
♦ The cause → The bladder outlet is weak (weak tone) and cannot counteract
the raised intra-abdominal pressure during activity.
Also, with multiple vaginal deliveries → Pelvic floor muscles become weak.
101
Treatment of stress incontinence
The initial Rx of choice → (at least 8 pelvic contractions, 3 times a day, for at least 3 months).
√ If failed → Surgical retropubic mid-urethral tape = (Free-tension vaginal tape)
√ If surgery is not possible → Duloxetin
102
Urge incontinence
◙ Urge incontinence (Detrusor Overactivity) √
♦ Leakage of urine when there is a sensation of need to void.
When I feel the desire to pee, I have to go and pee!
Or:
When I feel a desire to pee, sometimes I slightly wet myself “Leakage” before
making it to the bathroom!
♦ The cause → the bladder muscle (Detrusor) is overactive hence loss of urine.
103
Urge incontinence treatment
◙ Treatment:
√ Bladder drill (Retraining) → gradually increase the periods between voiding.
Antimuscarinic.
(for 6 weeks)
√ If drugs are needed → (eg, immediate release
√ If the patient is old and has arrhythmias/ heart conditions → Oxybutynin, Tolterodine).
Mirabegron.
104
105
106
Prolonged “indwelling” urinary catheter
+
UTI “Bacterial colonization of the urinary tract”
→ Bluish (Purple) urine bag syndrome “bacterial colonisation”
→ Do Urine Culture
Patient with indwelling urinary catheters should NOT receive antibiotic if
there are no symptoms such as fever, urgency, frequency even if culture was
positive for bacteria (e.g. E. coli).
We only should → Replace the urinary catheter.
107
→ Urine culture and sensitivity
“to detect the exact causative organism and then commence an appropriate
antibiotic this time”.
A female patient with UTI was treated with amoxicillin but the condition has
not improved
108
◙ A scrotal swelling investigation
→ Ultrasound
109
man who just had surgery a few hours ago. Urine bag is not draining. Vitals
are stable. What to do next?
a) check catheter for blockage
b) Exploratory laparotomy.
c) Give furosemide.
D) Fluid challenge.
A
110
62yr old man presented with increased urinary frequency, urge incontinence
and dribbling. PSA is 4.5ng/ml. Digital examination reveals large,
symmetrical and soft prostate.
What is the mechanism of action of the initial
drug of choice for treatment?
a) Alpha-adrenoceptor blockade
b) 5 alpha reductase inhibitor
c) GNRH agonist
♦ 5 alpha-reductase inhibitors (e.g. finasteride). “of choice if there are lower
urinary tract symptoms + WITH prostate enlargement + WITH ↑ PSA”.
All these are found in this patient, thus, the correct answer is B.
◙ Benign prostatic hyperplasia (BPH) is a common condition seen in old men.
◙ BPH typically presents with lower urinary tract symptoms (LUTS), which may
be categorised into:
♣ Voiding symptoms (obstructive): weak or intermittent urinary flow,
straining, hesitancy, terminal dribbling and incomplete emptying
♣ Storage symptoms (irritative): urgency, frequency, incontinence and
nocturia
♣ Post-micturition: dribbling
DRE “Digital Rectal Examination” → Symmetrically enlarged, Smooth,
Not nodular prostate.
111
112
◙ Management options
√ Watchful waiting.
√ Medication:
♦ 5 alpha-reductase inhibitors (e.g. finasteride). “of choice if there are lower
urinary tract symptoms + WITH prostate enlargement + WITH ↑ PSA”.
♦ Alpha-1 Blockers (e.g. tamsulosin, doxazocin, alfuzosin), “of choice if there
are lower urinary tract symptoms only WITHOUT significant prostate
enlargement”.
◙ Side-effects of alpha blockers:
postural hypotension, drowsiness, dyspnoea, cough
√ Surgery→ transurethral resection of prostate (TURP)
(imp. TURP is associated with hypOnatremia)
113
A young aged Rugby player presented with severe, sudden onset of testicular
pain, testis is tender and the pain is not relieved on raising the testes.
Management
?
A. IV antibiotics
B. Urgent referral to Surgeon
This is a case of testicular torsion that needs urgent surgical exploration
B
114
69 yr old man presents with dysuria, flank pain and fever. He has had
prostate cancer for 10 years. What is the investigation of choice?
A) urine culture and sensitivity
B) Serum acid phosphatase
C) serum PSA
D) Serum Calcium
E) Blood culture
Urine Culture and sensitivity
♦ The most common causative organism of UTI → E. coli (Gram -ve)
• Acute pyelonephritis → Urine Culture → Then Start Antibiotics.
• Upper UTI → Ciprofloxacin (or) Co-amoxiclav.
• Lower UTI → Trimethoprim (or) Nitrofurantoin.
115
After successful treatment of UTI, the persistence of Hematuria is suspicious
especially in those > 45 YO even if no risk factors for bladder cancer. Thus,
→ Refer the patient for a 2 week wait appointment with urology or
nephrology.
Cystoscopy might then be done by a urologist.
2 weeks wait (urgent not
routine). This is the usual in the UK.
√ Above 40 YO + Frank hematuria → Cystoscopy
√ Below 40 YO + Hematuria (malignancy less likely) → CT-KUB “for stones”
116
• Hematuria < 40 YO → do ___followed by CT scan (likely stone).
• Hematuria > 40 YO → do _____ (likely bladder cancer).
• Hematuria < 40 YO → do US followed by CT scan (likely stone).
• Hematuria > 40 YO → do Cystoscopy (likely bladder cancer).
117
The initial investigation for UTI → Dipstick urine analysis.
50
The initial investigation for UTI → Dipstick urine analysis.
118
After successful treatment of UTI, the persistence of Hematuria is suspicious
especially in those > 45 YO even if no risk factors for bladder cancer. Thus,
→ Refer the patient for a 2 week wait appointment with urology
or
nephrology.
Cystoscopy might then be done by a urologist.
2 weeks wait (urgent not routine). This is the usual in the UK.
√ Above 40 YO + Frank hematuria → Cystoscopy
√ Below 40 YO + Hematuria (malignancy less likely) → CT-KUB “for stone
119
120
Acute bacterial prostatitis
◙ Acute bacterial prostatitis is typically caused by gram-negative bacteria
entering the prostate gland via the urethra.
◙ Escherichia coli is the most commonly isolated pathogen.
◙ Risk factors fIr acute bacterial prostatitis include
recent urinary tract
infection,
urogenital instrumentation, intermittent bladder catheterisation and
recent prostate biopsy.
121
Example:
A 55 YO man presents complaining of low backpain on urination over the
past week.
There is also Increased urinary frequency. O/E: there is IupIaIubic
tenderness.
Per-rectal examination detects tender prostate. Midstream urine
is sent for culture and sensitivity. What should be done next?
Prostatitis. “see the features above”.
The likely Dx → prostatis
The next step in management →
Start quinolones such as ofloxacin
No need to wait for the culture and sensitivity results.
122
Cystoscope vs ct kub
◙ Above 40 YO + Frank (macroscopic) hematuria
to look for bladder cancer.
Imp. √
to look for ureteric and renal cancers.
Imp. √
“If cancer is suspected and no cystoscopy in the options,
pick CT KUB”
KUB = Kidney, ureters, bladders.
◙ Below 40 YO + Hematuria (malignancy less likely) → CT-KUB “for stones”
123
124
Important Notes:
In the case of enlarged prostate:
If there is urinary flow obstruction that has been relieved after inserting
catheter, before jumping to surgery
→ prescribe tamsulosin and refer for Trial WithOut Catheter (TWOC).
“TWOC needs to be tried for 1-2 days after giving alpha 1 blockers that would
relax the smooth muscles of prostate and
bladder to see of voiding will happen
or further management would be needed”.
125
Recurrent UTIs in “postmenopausal” women with no other abnormalities
Rx → vaginal oestrogen
Tried first √ in postmenopausal women because of risk of antibiotic resistance.
the risk of antibiotic resistance”.
If failed → Long-term antibiotic prophylaxis.
“It is proposed that oestrogen can restore the normal premenopausal vaginal
flora and acidic pH,
and can improve urogenital atrophy, prolapse and
cystocele.
Thus, it can help reduce urinary tract infection episodes in
postmenopausal women”.
126
Recurrent UTIs in “premenopausal = still menstruating” women with no
other abnormalities
Rx → Long-term antibiotic prophylaxis.
127
A 63 YO man has difficulty passing urine, drippling, suprapubic pain for the
past few weeks.
On insertion a urine catheter, his pain got improved
immediately.
→ Prescribe tamsulosin and refer for trial without catheter (TWOC).
128
Painless firm testicular enlargement (slowly growing) in young age is
suggestive of testicular cancer and the first step i
s (The mass is within the testis not in the scrotum.
It is firm. Slowly growing)
→ Ultrasound of testes.
129
Painful micturition, polyuria, Hx of pyelonephritis, nitrates in urine analysis,
no other symptoms.
Suspect → Lower UTI
→ Mid-stream urine microscopy, culture and sensitivity.
Antibiotics can be started before the results of the cultures.
If the results show
resistance to the antibiotics prescribed, the GP would call the patient to
modify the antibiotics accordingly.
130
A 65-year-old woman presents to her GP with a three-month history of urinary
leakage and a feeling of incomplete bladder emptying.
She reports having to use
incontinence pads, which are often soaked within two hours. Additionally, she
has recently noticed discomfort and redness around her groin area. On
examination, there is significant erythema and some raw areas of skin in the
perineal region. Her bladder is palpable and distended, and she describes the
sensation of not fully emptying her bladder after urination. What is the most
appropriate initial management for this patient?
A) Prescribe a topical cream to manage skin irritation.
B) Refer for pelvic floor exercises.
C) Start an anticholinergic to manage symptoms.
D) Arrange for catheterisation.
E) Request an urgent bladder ultrasound.
Answer:
The correct answer is → D) Arrange for catheterisation.
This patient is experiencing chronic urinary retention with overflow
incontinence, as indicated by the distended bladder and the sensation of
incomplete bladder emptying.
These symptoms suggest that there is a significant
amount of retained urine, which is likely the cause of the overflow incontinence.
Immediate relief of the urinary retention is essential to prevent further
complications such as infections or bladder damage. Catheterisation will relieve
the bladder and reduce the skin irritation caused by leakage, as it will decrease
the persistent moisture around the perineal area.
◙ Explanation of other Important options:
A) Prescribe a topical cream to manage skin irritation.
While topical creams may provide temporary relief for the skin irritation caused
by urine leakage, they do not address the underlying cause, which is urinary
retention. This option does not offer a long-term solution to the problem.
B) Refer for pelvic floor exercises.
Pelvic floor exercises are helpful for stress incontinence, not for overflow
incontinence due to urinary retention.
This patient needs immediate intervention
for her full bladder rather than exercises that would not provide instant relief.
C) Start an anticholinergic to manage symptoms.
Anticholinergic medications are used to treat an overactive bladder and urge
incontinence, not for overflow incontinence due to retention. They could worsen
urinary retention in this scenario, making them an inappropriate choice.
E) Request an urgent bladder ultrasound.
While an ultrasound might help to determine the underlying cause of the
retention (e.g., obstruction, mass), it is not the most immediate step in managing
this patient's symptoms. The priority is to relieve the retention through
catheterisation, after which further investigations can be performed if needed.
131
132
133
Overflow Incontinence
Definition: Overflow incontinence occurs when the bladder cannot empty
fully, causing frequent dribbling of urine due to the build-up of retained urine.
Causes:
o Bladder outlet obstruction (e.g., enlarged prostate, urethral stricture, bladder
stones).
Weakened bladder muscles, often seen in conditions like diabetes or spinal
cord injuries.
o Nerve damage: Conditions such as multiple sclerosis or injuries that affect
bladder control.
134
Overflow incontinence
• Symptoms:
o Constant dribbling of urine.
o Sensation of incomplete bladder emptying.
o Frequent urination with small amounts of urine.
o Possible distended palpable bladder on examination.
• Complications: Risk of urinary tract infections (UTIs), kidney damage, or
bladder damage due to prolonged retention.
• Management of Overflow Incontinence:
✓ Catheterisation: First-line and immediate management. This is because
Immediate bladder emptying to prevent damage and infections and to relieve
symptoms.
✓ Treat underlying cause:
o For prostatic enlargement: Alpha-blockers or 5-alpha-reductase inhibitors.
135
Urge incontinence RX
o For nerve-related issues: Address the neurological condition, if possible, with
possible use of intermittent self-catheterisation.
✓ Medication:
o Alpha-blockers: For reducing bladder outlet resistance in cases like enlarged
prostate.
o Bethanechol: Sometimes used to stimulate bladder muscle contractions
(rare).
✓ Bladder retraining: In mild cases, this can help regain bladder control.
✓ Surgery: May be needed for severe cases, such as prostate surgery for
enlarged prostate or removal of bladder stones.
✓ Regular follow-up: Monitoring for infections, kidney function, and bladder
health.
136
Quick Notes (Mirabegron).
• Mirabegron is a beta 3-agonist. It relaxes detrusor muscle.
• When is Mirabegron used in urge incontinence?
√ After trying the first-line Rx for urge incontinence (which is bladder training)
and antimuscarinic (eg, oxybutynin, tolterodine) with no improvement.
√ Also, it is recommended if the patient with urge incontinence has associated
arrhythmia or cardiovascular conditions.
(Mirabegron is preferred over oxybutynin in cases with arrhythmia).
Note: Pelvic-floor exercises is the first-line Rx for stress incontinence,
whereas
bladder training is the first-line Rx for urge incontinence.
137
A 59-year-old man presents to his GP with a one-month history of painless
haematuria.
He also reports a dull, persistent ache in his left flank but denies any
dysuria or changes in urinary frequency.
There is no history of trauma. He
mentions a recent loss of appetite and unexplained weight loss over the last few
months. His past medical history is unremarkable.
What is the most likely diagnosis?
A) Renal stone.
B) Bladder cancer.
C) Ureteric stricture.
D) Pyelonephritis.
E) Renal cancer.
Answer → E) Renal cancer.
Explanation:
The combination of painless haematuria, a flank ache, and unintentional weight
loss strongly suggests renal cancer.
Although bladder cancer can also present
with painless haematuria,
the presence of a dull flank ache and systemic
symptoms such as weight loss points more towards a renal origin.
• Renal stones typically present with more acute, severe, and colicky pain rather
than a dull ache, often accompanied by haematuria but usually with a history
of stone formation.
• Pyelonephritis would generally present with fever, chills, and signs of
infection, which are absent in this case.
• Ureteric strictures are usually associated with obstructive symptoms like
difficulty in passing urine or renal colic, neither of which are present here.
Thus, the constellation of painless haematuria, dull flank pain, and weight loss
makes renal cancer the most likely diagnosis.
138
Urgent Referral for Unexplained Haematuria in ≥ 45 Years
◙ Patient Profile:
o 55-year-old woman.
o Reddish/pinkish urine for three days.
o Postmenopausal, no associated pain or changes in urinary habits.
o Urinalysis: blood ≥ 3.
◙ Recommended Action: → Urgent referral to urology (2-week wait referral).
◙ Reasoning:
o NICE guidelines: Patients aged ≥ 45 years with unexplained visible
haematuria and without UTI need a suspected cancer pathway referral.
o Ensures timely assessment and diagnosis of potential serious conditions like
renal or bladder cancer
.
◙ Other Options Less Appropriate:
o Ultrasound of kidney, ureter, and bladder: Good for initial investigation but
less comprehensive than specialist referral, particularly in patients ≥ 45 with
unexplained haematuria and no infection
Pelvic ultrasound: Evaluates reproductive organs but not the entire urinary
tract.
o Antibiotics: Inappropriate without evidence of infection.
o Full blood count and coagulation profile: Useful but secondary to ruling out
malignancies.
139
Important Neuroanatomical Pathways
Main Points:
• Patient Profile: 62-year-old man with erectile dysfunction for eight months;
history of hypertension and diabetes.
• Relevant Neuroanatomical Pathway → • Function of Hypothalamospinal Tract: Autonomic regulation of erectile
function, integration, and transmission of signals from the hypothalamus to
the spinal cord.
• Impact of Dysfunction: Disruption in this pathway can lead to erectile
dysfunction eg, patients with conditions like hypertension or diabetes.
140
◙ Other Pathways:
o • Mesolimbic Pathway:
Nigrofrontal
Nigrostriatal
Cerebellothalamic
The mesolimbic pathway is mainly involved
in reward
and pleasure circuits, influencing motivation and addictive behaviors. It plays a
role in sexual behavior,
particularly in the context of reward and pleasure.
However, it does not directly regulate the physiological processes of erection,
which are controlled by the hypothalamospinal tract.
o • Nigrofrontal Pathway: Associated with cognitive processes, no direct role in
erection regulation.
o • Nigrostriatal Pathway: Related to motor control, particularly in Parkinson's
disease, not directly involved in erectile function.
Cerebellothalamic Tract: Involved in coordination and motor planning, not in
autonomic regulation of erections.
141
142
143
What is the diagnosis?
A soft scrotal swelling that reduces on lying down, particularly more prominent
on one side.
→ Varicocele.
144
Quick Urology Notes to Remember:
Mirabegron √ Rx of urge incontinence in old patients who have arrhythmia/ heart
conditions → (safer than Oxybutynin and Tolterodine).
Mirabegron is in a class of medications called beta-3 adrenergic agonists. It
works by relaxing the bladder muscles.
√ Investigation for ureteric stones in “pregnant” females
(instead of CT KUB).
→ Ultrasound of KUB √ If non-pregnant → Non-contrast CT abdomen (or CT KUB).
√ The Initial investigation for suspected testicular cancer
(before considering tumour markers).
→ Ultrasound of the scrotum √
Persistent, foul-smelling, brown vaginal discharge that has developed after
pelvic surgery (eg, hysterectomy)
→ Think: a fi between bladder and vagina (vesicovaginal fistula).
√ If renal calculi < 5 mm → No intervention needed. (↑ fluid, manage pain).
145
Urgent Referral for Unexplained Haematuria in ≥ 45 Years
◙ Patient Profile:
o 55-year-old woman.
o Reddish/pinkish urine for three days.
o Postmenopausal, no associated pain or changes in urinary habits.
o Urinalysis: blood ≥ 3.
◙ Recommended Action:
→ Urgent referral to urology (2-week wait referral).
◙ Reasoning:
o NICE guidelines: Patients aged ≥ 45 years with unexplained visible
haematuria and without UTI need a suspected cancer pathway referral.
o Ensures timely assessment and diagnosis of potential serious conditions like
renal or bladder cancer.
◙ Other Options Less Appropriate:
o Ultrasound of kidney, ureter, and bladder: Good for initial investigation but
less comprehensive than specialist referral, particularly in patients ≥ 45 with
unexplained haematuria and no infection.
o Pelvic ultrasound: Evaluates reproductive organs but not the entire urinary
tract.
o Antibiotics: Inappropriate without evidence of infection.
o Full blood count and coagulation profile: Useful but secondary to ruling out
malignancies
146
147
Renal cyst
Notes on Renal Cysts
• Renal cysts are either simple or complex.
• Most simple cysts are small and asymptomatic.
• They can be found incidentally (for example, during investigations by
imaging as in ultrasound for liver or gallbladder for right upper quadrant pain).
• Small simple cyst that does not cause flank or loin pain can be left alone:
→ Reassure (no further follow up required).
• In rare cases when the cyst is thought to be the cause of loin or flank pain, it
can be managed by percutaneous aspiration or laparoscopic surgical excision
of the cyst wall.
148
Differentiating Testicular Torsion from Epididymo-orchitis
Clinically, it is very difficult to differentiate. However, here are some important
points to remember:
• The pain in testicular torsion is NOT eased by elevation, while in epididymo-
orchitis, the pain is relieved by elevating the testis
• The pain in testicular torsion is felt at the testicle itself while the pain in
epididymo-orchitis is usually confined to the epididymis.
• The symptoms in epididymo-orchitis are gradual if compared to the sudden
acute onset of testicular torsion.
• In epididymo orchitis, there may be a history of multiple sexual partners
(sexually active male), dysuria (painful urination), urethral discharge.
• In epididymo orchitis, the affected testis is often retracted (higher location).
Note: Both conditions can present with or without fever.
◘ If suspected testicular torsion → Urgent exploratory surgery (to save testis).
◘ If epididymo-orchitis → Antibiotics
149
◙◙ Example (1):
A 53-year-old man presents to the GP surgery complaining of an inability to
achieve a firm erection.
He has hypertension and type 2 diabetes.
He is on
enalapril, metformin and gliclazide. He has no history of trauma. He has no
relationship issues with his wife.
His blood pressure is 133/89 mmHg. His
testosterone level is normal. His HbA1c is 51 mmol/mol
. His digital rectal
examination is unremarkable. What is the most appropriate management?
= sildenafil (viagra)
Oral phosphodiesterase inhibitors.
He has DM and hypertension which can cause vascular erectile dysfunction.
Other reasons are denied, particularly the psychosexual cause as he has no
relationship issue, stress, depression or anxiet
150
Erectile dysfunction causes
Erectile Dysfunction (Impotence)
◙ Inability to obtain or maintain an erection sufficient for satisfactory sexual
performance
. Generally seen in men 40-70 years old.
◙ Causes:
◘ Vascular insufficiency:
Examples → Diabetes mellitus, hypertension, hyperlipidemia, smoking.
◘ Psychosexual:
Examples → Depression, anxiety, stress, relationship issues.
Other supportive history points → sudden onset, early collapse of erection,
erection when alone or with one partner but no erection with another partner.
◘ Hormonal: Hypogonadism (low testosterone level).
◘ Drugs: Examples → Antidepressants, Finasteride.
◘ Trauma:
Examples → Pelvic fractures, spinal cord injuries, penile fractures.
◘ Neurogenic
151
Erectile dysfunction
A rare cause. Examples → Multiple sclerosis (MS), Parkinson’s disease.
◙◙ Investigations:
◘ Check for diabetes → Fasting glucose.
◘ Check for testosterone deficiency → Early morning sample of testosterone.
◘ Check for hyperlipidemia → Lipid profile.
◙◙ The Main Lines of Management:
◘ Sildenafil (Viagra).
Sildenafil is an oral phosphodiesterase inhibitor.
It works by releasing nitric
oxide (NO) leading to vasodilation of the penile arterioles and increasing
arterial inflow.
◘ Psychosexual therapy (if there are relationship issues, stress, anxiety
152
A 52-year-old man presents to the GP surgery complaining of an inability to
achieve a firm erection.
His medical history is unremarkable. He has no history
of trauma. He tells you that he has erectile dysfunction when he is with one
partner but he is all fine with another partner.
He also has no issues with
erections and masturbation without the partner.
His blood pressure is 125/80
mmHg. His testosterone level is normal. His HbA1c is 35 mmol/mol.
His digital
rectal examination is unremarkable. What is the most appropriate
management?
→ Psychosexual therapy.
It is clear that the problem is psychosexual as he can achieve erection with one
partner and when alone but fails when with the other partner.
No other reasons are there (no vascular eg, DM, HTN), no trauma, normal
testosterone level.
So, psychosexual therapy is tried first in this case.
153
Quick Comparison
There are shared symptoms between overactive bladder (urge) and benign
prostatic hyperplasia (BPH)
such as (Nocturia,
and urinary frequency).
However,
the symptoms of (terminal drippling,
feeling of incomplete voiding,
having to strain in order to start urination)
are of BPH even is PSA is normal,
◙ The management of Overactive Bladder (Urge Incontinence):
√ Bladder drill (Retraining) → gradually increase the periods between voiding.
√ If medications are needed:
→ Antimuscarinic = Anti-cholinergic.
(eg, immediate release Oxybutynin, Tolterodine).
If associated arrhythmia or cardiovascular conditions → Mirabegron.
(Note, Duloxetine is one line in Rx of stress incontinence, not urge
incontinence.
It can be used if the pelvic floor exercise and surgery failed).
◙ The management of Benign Prostatic Hyperplasia (BPH):
• Tamsulosin (Alpha-1 blocker) is tried first before finasteride (in general).
• However, Finasteride (5-alpha-reductase inhibitor)
is of choice if there are
lower urinary tract symptoms + WITH prostate enlargement (> 30 grams) ± or
↑ PSA > 1.4”.
154
Finasteride side effect
Also, since finasteride can cause erectile dysfunction, they shoud be avoided if
the patient has erectile issues.
155
Suprapubic Catheterization.
• It can be used for long-term bladder drainage or
in emergency conditions
where the obstruction is below the level of bladder (eg, urethra).
• Urethral catheterisation is attempted first, but of fails, suprapubic
catheterisation is attempted.
Example:
A man with urine retention (unable to pass urine) due to enlarged prostate.
Urethral catheterisation has failed.
Next step → Suprapubic catheterisation.
156
The Management of the Ureteric Colic
(Pain caused by ureteric stones)
• Description of Pain:
Sudden unilateral, spasmodic colicky pain, at flank/ loin, can radiate to groin
and testicle
. The patient cannot lie still (move around; severe pain).
• Management of Ureteric Colic: (Imp √)
√ FIRST LINE (particularly √ If NSAIDs is contraindicated or ineffective → Add Paracetamol (Preferred IV).
√ If both NSAIDs + Paracetamol are ineffective or contraindicated → Opioids
→ NSAIDs (eg, tramadol).
Diclofenac: Parenteral, oral or rectal).
(NOTE: Antispasmodics are not recommended for ureteric colic).
157
A 58-year-old man presents to the GP surgery because he has to void more
often and each time, he finds it difficult to initiate voiding and he needs to
strain a lot.
Each time he passes small amounts. He wakes up in the middle of
the night.
On digital rectal examination, he has an enlarged, smooth, not
nodular prostate.
• The most likely Dx → smooth enlarged not nodular prostate…etc).
Benign prostatic hyperplasia (Frequency, Straining,
• The most appropriate n management → Alpha-blocker (eg, tamsulosin).
158
Side effect if alpha blockers?
◙ Management of BBH (Benign Prostatic Hyperplasia):
√ Watchful waiting.
√ Medication:
♦ FIRST LINE → Alpha-1 Blockers (e.g., tamsulosin, doxazocin, alfuzosin).
♦ 5 alpha-reductase inhibitors (e.g., finasteride).
Side-effects of alpha blockers:
postural hypotension,
drowsiness,
dyspnoea,
cough
Important:
Tamsulosin (Alpha-blocker) is tried first before finasteride (in general).
However, finasteride is of choice if there are lower urinary tract symptoms +
WITH prostate enlargement (> 30 grams) ± WITH ↑ PSA > 1.4”.
159
A 73-year-old woman is using oxybutynin for her urge incontinence.
She
developed urinary urgency and frequency in the last 3 days. She micturates
small amounts of urine.
Her abdominal examination is unremarkable. What is
the most appropriate next step in management?
A) Nitrofurantoin.
B) Refer to urinary consultant.
C) Supervised bladder training.
D) Ultrasound of bladder.
E) Pelvic floor exercise.
• She has recent urinary frequency and urgency.
• These are common symptoms of urinary tract infection (UTI).
• Thus, give → nitrofurantoin.
She also has urge incontinence that is being controlled by Antimuscarinic =
Anti-cholinergic (oxybutynin).
So, bladder training should have been tried first
before oxybutynin. Thus, it is not the valid answer.
160
161
162
Scenario (3):
Prostate Cancer.
A 70 YO presents with: intermittent, painless hematuria, hesitancy, frequency,
difficulty in emptying bladder, lower back and pelvic pain.
His PSA is 9.
The likely Dx → prostate cancer
√ He is Old +
√ Obstructive symptoms (eg, hesitancy, urgency) due to enlarged prostate.
√ High PSA for age (>5 for people >70 YO is suspicious).
√ Low back pain (may be 2ry to bone metastasis)
“Spine is the commonest site”
163
Scenario (2):
62 YO man presents with gross (frank) hematuria, no pain or other
symptoms, he is a smoker.
Painless, gross (frank) hematuria in an elderly man
Bladder cancer
until proven otherwise →
do cystoscopy or cystourethroscopy
The major risk factor for bladder cancer is smoking.
164
165
47 YO, presents with frank hematuria of one day. He has been having a
worsening right-sided back pain for 3 months.
His urinalysis shows 3+ blood.
He is non-smoker, no weight loss, no palpable abdominal masses, no fever.
The most likely Dx →
Scenario (1):
Renal stone.
Not old age + unilateral flank or back pain + hematuria
Think → renal stones. (Painful hematuria, unilateral → likely stones).
166
Important 3 Scenarios to compare 3 Different Diagnoses
Renal stone
Bladder cancer
Prostate cancer
167
A 34-year-old man presents to the ER complaining of severe colicky pain on
his right flank.
He is rolling in bed because of the pain. His urinalysis shows
2+ blood. He is also vomiting
.
Kidney stones.
• The likely Dx → • The most appropriate investigation → CT scan WITHOUT contrast (CT KUB).
• The likely diagnosis here is kidney stones which requires CT KUB (CT of
kidney, ureter and bladder). CT KUB is CT without contrast.
• CT with contrast can also detect the stones but it takes a longer time and
exposes the patient to more unnecessary radiation.
168
A 20 YO presents complaining of 3 hours of left scrotal pain and swelling. He
has been having intermittent testicular pain over the past 3 months.
He has
been having sexual intercourse with his partner over the past 4 months.
No Hx of trauma, fever, or urethral discharge. He is fully vaccinated. O/E, the
posterior scrotal skin is tender, with mild erythema and swelling.
The most likely Dx →
The best management →
Epididymo-orchitis.
Prescribe antibiotics.
169
Ureteric stone (severe flank pain, ↓ urine output)
+ Fever
+ CT-KUB showing Hydronephrosis
+ Acute kidney injury (↑ urea, ↑ creatinine)
• This patient has obstructive uropathy (manifested by a ureteric stone that
had led to hydronephrosis -as mentioned →
that has led to acute kidney injury
-high serum urea and creatinine).
→ Next step would be to decompress this obstructive uropathy, relieve pain
and resolve the AKI.
• This is done urgently by either percutaneous nephrostomy or JJ ureteric
stent.
“Be careful, percutaneous nephrostomy is different from percutaneous
nephrolithotomy
170
BMI and nephrostomy and uterus stenting
◙ Important:
What if both Nephrostomy AND Ureteric stenting (JJ stent) are in the options?
√ If BMI is normal or not given in the stem → Nephrostomy.
√ If BMI is high eg, 40 kg/m2 (the patient is Obese) → Ureteric stenting
171
Ureteric stone
.
After relieving the obstruction, the definitive management is done by:
.
After relieving the obstruction, the definitive management is done by:
• ESWL or ureteroscopy
with YAG laser/ or with dormia (if stone is 0.5-2 cm).
• Percutaneous Nephrolithotomy (if stone is > 2 cm).
172
A young man presents with 4 days Hx of gradually worsening scrotal pain.
There is mild erythema on the affected side. There is tenderness on palpating
the scrotum. He is sexually active with a new partner.
He is fully immunized.
He denies fever or urethral discharge
.
Think → epidydimoorchitis
Important part of the investigation → PCR urethral swab for clamydia
“Fever and urethral discharge may or may not present in epididymo-orchitis
173
Non-tender cystic large swelling of scrotum that transilluminates
Think → Do → Hydrocele.
Ultrasound scrotum
174
Sudden colicky Pain in loin radiates to groin, nausea, vomiting,
hematuria, ± rigours
• The likely Dx → Ureteric “renal” Stones
• Ix → Non-contrast “Spiral” CT scan of KUB “Kidney, ureters, bladder” √ imp.
• Imp: If pregnant (+ve HCG)
→ U/S of kidney, ureters, bladder (safer in pregnancy).
175
Painful micturition, polyuria,
Hx of pyelonephritis, nitrates in urine analysis,
no other symptoms
.
Suspect → Lower UTI
→ Mid-stream urine microscopy, culture and sensitivity.
Antibiotics can be started before the results of the cultures. If the results show
resistance to the antibiotics prescribed, the GP would call the patient to
modify the antibiotics accordingly.
176
Painless firm testicular enlargement (slowly growing) in young age is
suggestive of testicular cancer
and the first step is (The mass is within the testis not in the scrotum.
It is firm. Slowly growing
→ Ultrasound of testes.
177
