Urology - presentations Flashcards
Haematuria
Presence of blood in the urine, either visible/non-visible
Never a normal finding – has a range of urological/non-urological causes
Haematuria classification
Visible haematuria – blood is visible in the urine
Non-visible haematuria – blood is present in the urine on urinalysis
- Symptomatic non-visible haematuria: haematuria presents with associated symptoms eg. suprapubic pain/renal colic
- Asymptomatic non-visible haematuria: haematuria with no associated symptoms
Haematuria causes
Most common causes – UTI, renal cancer, bladder cancer, renal calculi, prostate cancer & BPH
Less common causes – trauma, radiation cystitis or parasitic infection
Haematuria clinical features
Presence of clots or not
Timing in the stream – total = bladder/upper tract source, terminal = potential severe bladder irritation
Clarify any associated symptoms, such as LUTS, fevers/rigors, suprapubic pain, flank pain, weight loss, recent trauma
Assess drug history & smoking status, any exposure to industrial carcinogens/recent foreign travel
Haematuria investigations
Initial – urinalysis, baseline bloods, PSA
Specialist investigations – flexible cystoscopy is the gold standard investigation for assessing the lower urinary tract
- Ultrasound imaging & CT urogram
Urological referral criteria for haematuria
Aged > 45 yrs with either:
- Unexplained visible haematuria without UTI
- Visible haematuria that persists/recurs after successful treatment of UTI
Aged 60 yrs with have unexplained non-visible haematuria & either dysuria/raised WCC on a blood test
Haematuria management
Treatment of the underlying pathology
Patients with significant haematuria – inpatient admission under urology: insertion of a three-way catheter for ongoing washout & irrigation +/- evacuation of clots
Scrotal lump
Abnormal mass or swelling within the scrotum
Originate from either testicular/extra-testicular sources
Scrotal lump investigations
Ultrasound scan of the scrotum is the first line investigation
Additional blood tests/further imaging may be warranted
Extra-testicular lumps
Hydrocoele
Varicocoele
Epididymal cysts
Epididymitis
Inguinal hernia
Hydrocoele
Abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis enveloping the testis
Present as a painless fluctuant swelling that will transilluminate, either unilateral/bilateral
Presenting with a hydrocoele aged between 20-40 years should undergo urgent ultrasound scan
Varicocoele
Abnormal dilatation of the pampiniform venous plexus within the spermatic cord
Present as a lump, often described as feeling like a ‘bag of worms’ & may disappear on lying flat
90% of varicocoeles are found on the left side as the spermatic vein drains directly into the left renal vein
Surgical management – embolisation by an interventional radiologist & surgical approaches either open/laparoscopic approach for ligation of the spermatic veins
Epididymal cysts
Benign fluid-filled sacs arising from the epididymis
Present as a smooth fluctuant nodule, found above & separate from the testis that will transilluminate
Common – classically seen in middle-aged men, generally do not need treatment
Epididymitis
Inflammation of the epididymis
Presents with unilateral acute onset scrotal pain
May be associated swelling, tender epididymis & pain may be relieved on elevation of the testis
Most commonly bacterial in origin, most cases treated with oral abx & analgesia
Inguinal hernia
Can pass into the scrotum via the external inguinal ring
Can’t get above a hernia within the scrotum
Cough may exacerbate the swelling & may disappear upon lying flat
Should be assessed for strangulation or obstruction
Testicular lumps
Testicular tumours
Testicular torsion
Benign testicular lesions – Leydig cell tumours, Sertoli cell tumours, lipomas or fibromas
Orchitis
Testicular tumours
Painless lumps arising from the testis
Most common malignancy in men aged 20-40 yrs & need urgent USS for diagnosis, alongside tumour markers
Radical inguinal orchidectomy may be required
Testicular torsion
Twisting of the testis on the spermatic cord, leading to ischaemia
Sudden-onset very severe unilateral scrotal pain, often with associated N&V
Predominately affects pubescent boys & may be associated with a ‘Bell-clapper’ deformity
Affected testis is usually extremely tender, raised & swollen, with a loss of cremasteric reflex
Testicular torsion = surgical emergency & must be acted on immediately, with scrotal exploration & fixation of both testes, to prevent irreversible testicular damage
Orchitis
Inflammation of the testis
Main cause = mumps virus
Treatment = rest & analgesia, if intra-testicular abscess may form requiring drainage & occasionally orchidectomy
Cremasteric reflex and Prehn’s sign
Cremasteric reflex – elicited by stroking the proximal and medial aspect of thigh
- Normal response: contraction of the cremaster muscle causing retraction of tests upwards of the ipsilateral side, absence of the cremasteric reflex is a potential sign for testicular torsion
Prehn’s sign – alleviation of scrotal pain by lifting of the testicle
- Suggestive of the diagnosis of acute epididymitis
Scrotal pain investigations
Urine dipstick performed, with the urine sent for further culture (MCS, microscopy, culture sensitivity)
Urethral swab can be taken if STI suspected
Blood tests – FBC, CRP, U&Es
Ultrasound of scrotum can identify any structural/inflammatory pathology
Scrotal pain differential diagnosis
Testicular torsion
Torsion of testicular and epididymal appendages
Epididymitis
Testicular cancer
Non-urological causes – Henoch-schoenlein purpura, viral orchitis
Acute urinary retention
Defined as a new onset inability to pass urine, subsequently leads to pain and discomfort, with significant residual volumes
Most prevalent in older male patients
Acute-on-chronic retention
Either as an acute deterioration of the underlying pathology cause their chronic retention or a new aetiology superimposed on a background of chronic retention
Patients will present often with minimal discomfort, despite very large residual volumes
Should be treated as per acute retention management, more at risk to post-obstructive diuresis
Acute urinary retention aetiology
BPH
Urethral strictures
Prostate cancer
UTIs
Constipation
Severe pain
Medications – anti-muscarinics or spinal/epidural anaesthesia can affect innervation to the bladder
Neurological causes – peripheral neuropathy, iatrogenic nerve damage during pelvic surgery, upper motor neurone disease or DSD
Acute urinary retention clinical features
Acute suprapubic pain & inability to micturate
May be associated with symptoms suggestive of the predisposing cause, such as a UTI, recent change to medication, worsening voiding LUTS
Examination – palpably distended bladder with suprapubic tenderness, perform DRE to assess for any prostate enlargement/constipation
Acute urinary retention investigations
Post-void bedside bladder scan will show the volume of retained urine
Routine bloods
Post-catheterisation, a CSU should also be sent to assess for the presence of infection
High-pressure retention will require an ultrasound scan to assess for the presence of hydronephrosis
- If confirmed -> follow-up repeat imaging will be required in the subsequent weeks following treatment of the retention, to ensure its resolution
Acute urinary retention immediate management
Immediate urethral catheterisation to resolve the retention
Underlying causes should then be treated accordingly
Ensure to check CSU for any evidence of infection and treat with abx if needed
Review patient’s management for any potential contributing causes
Acute urinary retention definitive management
Patients who have a large retention volume would need to be monitored post-catheterisation for evidence of post-obstruction diuresis
No evidence of renal impairment -> trial without catheter (TWOC) will be attempted, whereby the catheter is removed after treatment of cause, all men with history of chronic LUTS/palpably large prostate should be started on a alpha-1 adrenoreceptor antagonist (eg. tamsulosin) & can have their TWOC > 72 hours after commencement
If patient re-enters retention, the patient will require re-catheterisation -> further TWOCs can be attempted, however multiple failed attempts may warrant a long-term catheter, until definitive management can be arranged to treat the underlying cause
Acute urinary retention complications
AKI which can lead to CKD if multiple episodes
Increased risk of UTIs and renal stones
Chronic urinary retention
Painless inability to pass urine
Patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation
Chronic urinary retention aetiology
BPH, urethral strictures, prostate cancer
Women – pelvic prolapse or pelvic masses can also cause chronic retention
Neurological causes – peripheral neuropathies, upper MND
Chronic urinary retention clinical features
Painless urinary retention
May have associated voiding LUTS
Overflow incontinence may also be present whereby the intra-vesical pressures rise greater than those of the urinary sphincter – typically worse at night
Examination – palpable distended bladder with no/minimal tenderness, perform DRE in men
Chronic urinary retention investigations
Post-void bedside bladder scan
Routine bloods
Patients with features of high-pressure chronic retention will require an ultrasound scan of their urinary tract -> assess for the presence of associated hydronephrosis
High-pressure urinary retention
Refers to the urinary retention causing such high intra-vesicular pressures that the anti-reflux mechanism of the bladder and ureters is overcome and ‘backs up’ into the upper renal tract -> hydroureter and hydronephrosis, impairing the kidney’s clearance levels
USS is first-line investigation
Chronic urinary retention management
Very high post-void volumes or evidence of high pressure retention should be catheterisation with a long-term catheter (should be monitored for post-obstructive diuresis)
Patients should not undergo a TWOC due to concerns of repeat renal injury
- They should have long-term catheter before definitive management is planned
- Definitive management of chronic retention depends on the underlying cause
Intermittent self catheterisation – can be used in patients with chronic urinary retention, for those who wish to avoid a long-term catheter
- Patients are taught how to catheterise themselves at regular intervals
Post-obstructive diuresis
Following resolution of the retention through catheterisation, the kidneys can often over-diurese due to the loss of their medullary concentration gradient, which can take time to re-equilibrate
Over-diuresis can lead to a worsening AKI
Patients at risk should have urine output monitored over the following 24 hours post-catheterisation
Chronic urinary retention complications
Stasis of urine -> UTIs and form bladder calculi
Repeat episodes of unmanaged high-pressure retention can lead to CKD
LUTS aetiology
Older men – BPH
Females – lower UTIs
Bladder cancer
Postate cancer
Detrusor muscle weakness, pelvic floor dysfunction, chronic prostatitis, urethral stricture, external compression, neurological disease
Storage symptoms (LUTS)
Increased urinary frequency
Nocturia
Increased sense of urgency to urinate
Urge incontinence
Voiding symptoms (LUTS)
Hesitancy/straining in micturition
Poor flow (< 10mL/s)
Terminal dribble
Feeling of incomplete emptying
LUTS clinical features
Ensure to clarify the exact nature of LUTS present
Associated symptoms – visible haematuria, suprapubic discomfort, colicky pain, their medication history
DRE and/or examination of the external genitalia
International prostate symptom score – useful tool for assessing & monitoring the impact of LUTS on quality of life in men
LUTS initial investigations
Post-void bladder scan and flow rate
Bladder diary is often useful in highlighting patterns
Urinalysis – assessing for signs of UTI, also haematuria or glycosuria, urine culture
Routine blood tests – PSA may be useful
LUTS specialist investigations
Urodynamics – can be used to assess flow rate, detrusor pressure and storage capacity if indicated
- Essential in women who have failed medical treatment for an overactive bladder or stress UI
Cystoscopy – gold standard investigation for assessing the lower urinary tract & may be offered if clinically indicated
Upper urinary tract imaging
LUTS conservative management
Usually treatment of the underlying pathology
Regulating fluid intake
Voiding symptoms – urethral milking techniques or double voiding
Pelvic floor exercises
Bladder training techniques
LUTS pharmacological management
Anticholinergics (eg. oxybutynin) – for overactive bladder, helping to relax bladder muscle by opposing parasympathetic cholinergic control of contraction
Alpha blockers (eg. tamsulosin) and/or 5alpha-reductase inhibitors (finasteride) for BPH can help in reducing prostate size
Loop diuretics (furosemide, bumetanide)
LUTS complications
Patients who retain urine post-micturition are at increased risk of infection and formation of renal and bladder calculi due to stagnation of urine
Chronic obstruction – bladder wall muscle hypertrophy/distention which can lead to overflow incontinence
Renal failure & bilateral hydronephrosis
Acute urinary retention
