Urology - presentations

Question 1

Haematuria

Answer 1

Presence of blood in the urine, either visible/non-visible
Never a normal finding – has a range of urological/non-urological causes

Question 2

Haematuria classification

Answer 2

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

Question 3

Haematuria causes

Answer 3

Most common causes – UTI, renal cancer, bladder cancer, renal calculi, prostate cancer & BPH
Less common causes – trauma, radiation cystitis or parasitic infection

Question 4

Haematuria clinical features

Answer 4

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

Question 5

Haematuria investigations

Answer 5

Initial – urinalysis, baseline bloods, PSA
Specialist investigations – flexible cystoscopy is the gold standard investigation for assessing the lower urinary tract
- Ultrasound imaging & CT urogram

Question 6

Urological referral criteria for haematuria

Answer 6

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

Question 7

Haematuria management

Answer 7

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

Question 8

Scrotal lump

Answer 8

Abnormal mass or swelling within the scrotum
Originate from either testicular/extra-testicular sources

Question 9

Scrotal lump investigations

Answer 9

Ultrasound scan of the scrotum is the first line investigation
Additional blood tests/further imaging may be warranted

Question 10

Extra-testicular lumps

Answer 10

Hydrocoele
Varicocoele
Epididymal cysts
Epididymitis
Inguinal hernia

Question 11

Hydrocoele

Answer 11

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

Question 12

Varicocoele

Answer 12

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

Question 13

Epididymal cysts

Answer 13

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

Question 14

Epididymitis

Answer 14

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

Question 15

Inguinal hernia

Answer 15

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

Question 16

Testicular lumps

Answer 16

Testicular tumours
Testicular torsion
Benign testicular lesions – Leydig cell tumours, Sertoli cell tumours, lipomas or fibromas
Orchitis

Question 17

Testicular tumours

Answer 17

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

Question 18

Testicular torsion

Answer 18

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

Question 19

Orchitis

Answer 19

Inflammation of the testis
Main cause = mumps virus
Treatment = rest & analgesia, if intra-testicular abscess may form requiring drainage & occasionally orchidectomy

Question 20

Cremasteric reflex and Prehn’s sign

Answer 20

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

Question 21

Scrotal pain investigations

Answer 21

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

Question 22

Scrotal pain differential diagnosis

Answer 22

Testicular torsion
Torsion of testicular and epididymal appendages
Epididymitis
Testicular cancer
Non-urological causes – Henoch-schoenlein purpura, viral orchitis

Question 23

Acute urinary retention

Answer 23

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

Question 24

Acute-on-chronic retention

Answer 24

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

Question 25

Acute urinary retention aetiology

Answer 25

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

Question 26

Acute urinary retention clinical features

Answer 26

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

Question 27

Acute urinary retention investigations

Answer 27

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

Question 28

Acute urinary retention immediate management

Answer 28

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

Question 29

Acute urinary retention definitive management

Answer 29

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

Question 30

Acute urinary retention complications

Answer 30

AKI which can lead to CKD if multiple episodes Increased risk of UTIs and renal stones

Question 31

Chronic urinary retention

Answer 31

Painless inability to pass urine Patients have long standing retention, therefore have significant bladder distension which results in bladder desensitisation

Question 32

Chronic urinary retention aetiology

Answer 32

BPH, urethral strictures, prostate cancer Women – pelvic prolapse or pelvic masses can also cause chronic retention Neurological causes – peripheral neuropathies, upper MND

Question 33

Chronic urinary retention clinical features

Answer 33

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

Question 34

Chronic urinary retention investigations

Answer 34

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

Question 35

High-pressure urinary retention

Answer 35

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

Question 36

Chronic urinary retention management

Answer 36

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

Question 37

Post-obstructive diuresis

Answer 37

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

Question 38

Chronic urinary retention complications

Answer 38

Stasis of urine -> UTIs and form bladder calculi Repeat episodes of unmanaged high-pressure retention can lead to CKD

Question 39

LUTS aetiology

Answer 39

Older men – BPH Females – lower UTIs Bladder cancer Postate cancer Detrusor muscle weakness, pelvic floor dysfunction, chronic prostatitis, urethral stricture, external compression, neurological disease

Question 40

Storage symptoms (LUTS)

Answer 40

Increased urinary frequency Nocturia Increased sense of urgency to urinate Urge incontinence

Question 41

Voiding symptoms (LUTS)

Answer 41

Hesitancy/straining in micturition Poor flow (< 10mL/s) Terminal dribble Feeling of incomplete emptying

Question 42

LUTS clinical features

Answer 42

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

Question 43

LUTS initial investigations

Answer 43

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

Question 44

LUTS specialist investigations

Answer 44

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

Question 45

LUTS conservative management

Answer 45

Usually treatment of the underlying pathology Regulating fluid intake Voiding symptoms – urethral milking techniques or double voiding Pelvic floor exercises Bladder training techniques

Question 46

LUTS pharmacological management

Answer 46

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)

Question 47

LUTS complications

Answer 47

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