Urology Surgery

Question 1

What is Obstructive Uropathy

Answer 1

The term obstructive uropathy refers to a blockage preventing urine flow through the ureters, bladder and urethra.

Question 2

The key structures of the urinary tract are the:

Answer 2

• Kidneys
• Ureters
• Bladder (with the detrusor muscle)
• Urethra
• Internal urethral sphincter (smooth muscle under autonomic control)
• Prostate (in males)
• External urethral sphincter (skeletal muscle under voluntary control)

Question 3

It is worth being familiar with the basic anatomy of the kidney. From the outside in, the basic structures are the:

Answer 3

Cortex

Medulla

Pyramids and columns

Major and minor calyx (pleural: calyces)

Renal pelvis

Pelviureteric junction (PUJ)

Ureter

Question 4

What does Obstructive Uropathy leads to

Answer 4

Obstruction leads to back-pressure in the urinary system, causing areas proximal to the site of obstruction to become swollen with urine. For example, obstruction at the opening of the ureters in the bladder, from a bladder tumour, will result in swelling of the ureter and kidney on that side

Question 5

Swelling of the kidney is known as ____________

__________ ____ ___ refers to urine refluxing from the bladder back into the ureters.

Answer 5

Swelling of the kidney is known as hydronephrosis.

Vesicoureteral reflux (VUR) refers to urine refluxing from the bladder back into the ureters.

Question 6

When obstructive uropathy leads to an acute reduction in kidney function, it is referred to as a….

Answer 6

When obstructive uropathy leads to an acute reduction in kidney function, it is referred to as a “post-renal” acute kidney injury (AKI)

Question 7

Whenever someone asks you the cause of renal impairment, always answer:

Answer 7

“the causes are pre-renal, renal or post-renal”. This will impress them and allow you to think through the causes more logically.

Question 8

WHat is pre-renal AKI caused by?

Answer 8

by hypoperfusion of the kidneys (e.g., due to dehydration, sepsis or acute blood loss), and “renal” AKI, which refers to damage within the kidney itself (e.g., due to glomerulonephritis or nephrotoxic medications).

Question 9

An upper urinary tract obstruction (i.e. in the ureters) presents with:

Answer 9

• Loin to groin or flank pain on the affected side (due to stretching and irritation of ureter and kidney)
• Reduced or no urine output
• Non-specific systemic symptoms, such as vomiting
• Impaired renal function on blood tests (i.e. raised creatinine)

Question 10

Lower urinary tract obstruction (i.e. in the bladder or urethra) presents with:

Answer 10

• Difficulty or inability to pass urine (e.g., poor flow, difficulty initiating urination or terminal dribbling)
• Urinary retention, with an increasingly full bladder
• Impaired renal function on blood tests (i.e. raised creatinine)

Question 11

An ________ of the kidneys, ureters and bladder can be helpful in diagnosing obstructive uropathy

Answer 11

An ultrasound of the kidneys, ureters and bladder can be helpful in diagnosing obstructive uropathy

Question 12

The word loin referred to as?

Answer 12

sides of the body between the lower ribs and pelvis

sides of the body between the lower ribs and pelvis

umbar region of the back

Question 13

What does loin to groin pain mean

What pathology suggest

Answer 13

“Loin to groin” pain usually refers to pain that circles from the kidney area at the back, round the sides and down into the groin.

“Loin to groin” pain is a sign of pathology in the ureter and kidney on that side, such as kidney stones or pyelonephritis.

Question 14

. The “renal angle”, also called the “costovertebral angle”, refers to

Answer 14

he angle formed by the twelfth rib and vertebral column at the back. The lower part of the kidneys are at the renal angle. Tenderness in the renal angle suggests kidney pathology.

Question 15

Common Causes

Upper urinary tract obstruction

Answer 15

• Kidney stones
• Tumours pressing on the ureters
• Ureter strictures (due to scar tissue narrowing the tube)
• Retroperitoneal fibrosis (the development of scar tissue in the retroperitoneal space)

Question 16

Common Causes

Lower urinary tract obstruction:

Answer 16

• Benign prostatic hyperplasia (benign enlarged prostate)
• Prostate cancer
• Bladder cancer (blocking the neck of the bladder)
• Urethral strictures (due to scar tissue)
• Neurogenic bladder

Question 17

What does Neurogenic Bladder mean

Answer 17

Neurogenic bladder refers to abnormal function of the nerves innervating the bladder and urethra. It can result in overactivity or underactivity in the detrusor muscle of the bladder and the sphincter muscles of the urethra.

Question 18

Neurogenic Bladder

Key causes are:

Answer 18

• Multiple sclerosis
• Diabetes
• Stroke
• Parkinson’s disease
• Brain or spinal cord injury
• Spina bifida

Question 19

Neurogenic bladder can result in a variety of problems, including:

Answer 19

• Urge incontinence
• Increased bladder pressure
• Obstructive uropathy

Question 20

A n_________ may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone)

Answer 20

A nephrostomy may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone)

Question 21

What is nephrostomy

Answer 21

A nephrostomy involves surgically inserting a thin tube through the skin at the back, through the kidney and into the ureter. This tube allows urine to drain out of the body, into a bag.

Question 22

A _______ __ _______ _____ may be used to bypass an obstruction in the lower urinary tract (e.g., a urethral stricture or prostatic hyperplasia).

Answer 22

A urethral or suprapubic catheter may be used to bypass an obstruction in the lower urinary tract (e.g., a urethral stricture or prostatic hyperplasia).

Question 23

What is a urethral/suprapubic catheter

Answer 23

A urethral catheter is a tube, inserted through the urethra, into the bladder.

A suprapubic catheter is a tube, inserted through the skin just above the pubic bone, directly into the bladder.

Question 24

Complications of Obstructive Uropathy

Answer 24

• Pain
• Acute kidney injury (post-renal)
• Chronic kidney disease
• Infection (from bacteria tracking up urinary tract into areas of stagnated urine)
• Hydronephrosis (swelling of the renal pelvis and calyces in the kidney)
• Urinary retention and bladder distention
• Overflow incontinence of urine

Question 25

WHat is Hydronephrosis

Answer 25

Hydronephrosis is swelling of the renal pelvis and calyces in the kidney. This occurs due to obstruction of the urinary tract, leading to back-pressure into the kidneys.

Question 26

________ ________ is the result of a narrowing at the pelviureteric junction (PUJ) – the site where the renal pelvis becomes the ureter. This narrowing may be congenital or develop later. It can be treated with an operation to correct the narrowing and restructure the renal pelvis (________).

Answer 26

Idiopathic hydronephrosis is the result of a narrowing at the pelviureteric junction (PUJ) – the site where the renal pelvis becomes the ureter. This narrowing may be congenital or develop later. It can be treated with an operation to correct the narrowing and restructure the renal pelvis (pyeloplasty).

Question 27

Typical presenting features of hydronephrosis are vague ______ ____ ____and a ____ in the kidney area. It may be seen on an _______ _____ __________(x-ray with IV contrast collecting in the urinary tract)

Answer 27

Typical presenting features of hydronephrosis are vague renal angle pain and a mass in the kidney area. It may be seen on an ultrasound, CT scan or intravenous urogram (x-ray with IV contrast collecting in the urinary tract)

Question 28

Treatment of hydronephrosis involves treating the underlying cause. If required, pressure can be relieved with either:

Answer 28

• Percutaneous nephrostomy – inserting a tube through the skin and kidney into the ureter, under radiological guidance
• Antegrade ureteric stent – inserting a stent through the kidney into the ureter, under radiological guidance

Question 29

Indications Urinary Catheter

Answer 29

The reasons for inserting a urinary catheter include:

• Urinary retention due to a lower urinary tract obstruction (e.g., enlarged prostate)
• Neurogenic bladder (e.g., intermittent self-catheterisation in multiple sclerosis)
• Surgery (during and after)
• Output monitoring in acutely unwell patients (e.g., sepsis or intensive care)
• Bladder irrigation (e.g., to wash out blood clots in the bladder)
• Delivery of medications (e.g., chemotherapy to treat bladder cancer)

Question 30

A ______ ______ can be used to measure the volume of urine in the bladder. A ____ ____ bladder scan (measured after the patient attempts to empty their bladder) can indicate the need for a catheter (e.g., more than 500mls).

Answer 30

A bladder scanner can be used to measure the volume of urine in the bladder. A post-void bladder scan (measured after the patient attempts to empty their bladder) can indicate the need for a catheter (e.g., more than 500mls).

Question 31

What is A common presentation requiring catheterisation

WHat do you start these patients on

Answer 31

A common presentation requiring catheterisation is an older man presenting acutely with urinary retention due to an enlarged prostate.

Typical management involves inserting a catheter, starting tamsulosin (an alpha-blocker) and discharging the patient to have a trial without a catheter (TWOC) in the community. It is worth remembering tamsulosin for your exams, as they may give you this scenario and ask what medication should be started. The key side effect to remember is postural hypotension, leading to dizziness on standing or falls.

Question 32

Urethral catheters are inserted through the urethra into the bladder. There are various types:

Answer 32

• Intermittent catheters – simple catheters used to drain urine, then immediately removed
• Foley catheter (two-way catheter) – the “standard” catheter with an inflatable balloon to hold it in place
• Coudé tip catheter – has a curved tip to help navigate it past an obstruction during insertion
• Three-way catheter – has three tubes used for inflating the balloon, injecting irrigation and drainage

Question 33

_______ ________ are inserted through the abdomen into the bladder, just above the pubic symphysis, under local anaesthetic

Answer 33

Suprapubic catheters are inserted through the abdomen into the bladder, just above the pubic symphysis, under local anaesthetic

Question 34

The catheter you will see most often on the wards and in OSCEs is the ____ catheter (two-way catheter).

Answer 34

The catheter you will see most often on the wards and in OSCEs is the Foley catheter (two-way catheter).

Question 35

If using a Foley catheter fails, it is worth giving a ______ tip catheter a try, as the slightly rigid curved tip can make bypassing an obstruction much easier.

Answer 35

If using a Foley catheter fails, it is worth giving a Coudé tip catheter a try, as the slightly rigid curved tip can make bypassing an obstruction much easier.

Question 36

What is Trial Without Catheter

Answer 36

A trial without a catheter (TWOC) involves removing a urethral catheter to see if a patient can manage without it. After the catheter is removed, the urine output is monitored, and a bladder scanner is used to make sure there is minimal residual urine left in the bladder. They may “fail” the TWOC, in which case another catheter is inserted.

Question 37

There are NICE guidelines on catheter-associated urinary tract infections from 2018, please see the full guidelines when treating patients.

Explain management

Answer 37

Patients without symptoms do not generally require antibiotics for bacteria in the urine (bacteriuria) if they do not have symptoms.

Patients with symptoms require treatment with 7 days of antibiotics. Depending on the severity of symptoms, this may be with oral antibiotics or require admission to hospital and IV antibiotics. The catheter should be changed as soon as possible (but not delaying antibiotics).

Question 38

What is Benign Prostatic Hyperplasia

Answer 38

Benign prostatic hyperplasia (BPH) is a very common condition affecting men in older age (usually over 50 years). It is caused by hyperplasia of the stromal and epithelial cells of the prostate. It usually presents with lower urinary tract symptoms.

Question 39

Lower Urinary Tract Symptoms

There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:

Answer 39

• Hesitancy – difficult starting and maintaining the flow of urine
• Weak flow
• Urgency – a sudden pressing urge to pass urine
• Frequency – needing to pass urine often, usually with small amounts
• Intermittency – flow that starts, stops and varies in rate
• Straining to pass urine
• Terminal dribbling – dribbling after finishing urination
• Incomplete emptying – not being able to fully empty the bladder, with chronic retention
• Nocturia – having to wake to pass urine multiple times at night

Question 40

The international _____ ____ __________ ___ is a scoring system that can be used to assess the severity of lower urinary tract symptoms

Answer 40

The international prostate symptom score (IPSS) is a scoring system that can be used to assess the severity of lower urinary tract symptoms

Question 41

The initial assessment of men presenting with LUTS involves:

Answer 41

• Digital rectal examination (prostate exam) to assess the size, shape and characteristics of the prostate
• Abdominal examination to assess for a palpable bladder and other abnormalities
• Urinary frequency volume chart, recording 3 days of fluid intake and output
• Urine dipstick to assess for infection, haematuria (e.g., due to bladder cancer) and other pathology
• Prostate-specific antigen (PSA) for prostate cancer, depending on the patient preference

Question 42

______ ____ _______ testing is known to be unreliable, with a high rate of false positives (75%) and false negatives (15%). False positive results may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. False negatives may lead to false reassurance. Therefore, it is essential to counsel patients to make an informed decision about whether to have the test.

Answer 42

Prostate-specific antigen (PSA) testing is known to be unreliable, with a high rate of false positives (75%) and false negatives (15%). False positive results may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. False negatives may lead to false reassurance. Therefore, it is essential to counsel patients to make an informed decision about whether to have the test.

Question 43

Common causes of a raised PSA are:

Answer 43

• Prostate cancer
• Benign prostatic hyperplasia
• Prostatitis
• Urinary tract infections
• Vigorous exercise (notably cycling)
• Recent ejaculation or prostate stimulation

Question 44

Benign Prostatic Hyperplasia

Prostate Examination Findings

Answer 44

• A benign prostate feels smooth, symmetrical and slightly soft, with a maintained central sulcus
• A cancerous prostate may feel firm/hard, asymmetrical, craggy or irregular, with loss of the central sulcus

Question 45

BPH Management

The medical options are:

Answer 45

• Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
• 5-alpha reductase inhibitors (e.g., finasteride) gradually reduce the size of the prostate

Question 46

5-alpha reductase converts________ to _________ (DHT), which is a more potent androgen hormone.

Inhibitors of 5-alpha reductase (i.e. finasteride) reduce ___ in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.

Answer 46

5-alpha reductase converts testosterone to dihydrotestosterone (DHT), which is a more potent androgen hormone.

Inhibitors of 5-alpha reductase (i.e. finasteride) reduce DHT in the tissues, including the prostate, leading to a reduction in prostate size. It takes up to 6 months of treatment for the effects to result in an improvement in symptoms.

Question 47

BPH

The surgical options are:

Answer 47

• Transurethral resection of the prostate (TURP)
• Transurethral electrovaporisation of the prostate (TEVAP/TUVP)
• Holmium laser enucleation of the prostate (HoLEP)
• Open prostatectomy via an abdominal or perineal incision

Question 48

The notable side effect of alpha-blockers like tamsulosin is

Answer 48

postural hypotension.

Question 49

The most common side effect of finasteride

Answer 49

sexual dysfunction (due to reduced testosterone).

Question 50

What is Transurethral Resection of the Prostate

Answer 50

Transurethral resection of the prostate (TURP) is the most common surgical treatment of BPH. It involves removing part of the prostate from inside the urethra.

A resectoscope is inserted into the urethra, and prostate tissue is removed using a diathermy loop. The aim is to create a more expansive space for urine to flow through, thereby improving symptoms

Question 51

Major complications of Transurethral Resection of the Prostate TURP

Answer 51

• Bleeding
• Infection
• Urinary incontinence
• Erectile dysfunction
• Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
• Urethral strictures
• Failure to resolve symptoms

Question 52

Other Surgical Options for BPH

Answer 52

Transurethral electrovaporisation of the prostate (TEVAP / TUVP) involves inserting a resectoscope into the urethra. A rollerball electrode is then rolled across the prostate, vaporising prostate tissue and creating a more expansive space for urine flow.

Holmium laser enucleation of the prostate (HoLEP) also involves inserting a resectoscope into the urethra. A laser is then used to remove prostate tissue, creating a more expansive space for urine flow.

Open prostatectomy involves an open procedure to remove the prostate. An abdominal or perineal incision can be used to access the prostate. Open surgery is less commonly used as it carries an increased risk of complications, a more extended hospital stay and longer recovery than other surgical procedures.

Question 53

Prostatitis refers to inflammation of the prostate. It can be classed as:

Answer 53

• Acute bacterial prostatitis – acute infection in the prostate, presenting with a more rapid onset of symptoms
• Chronic prostatitis – symptoms lasting for at least 3 months

Question 54

Chronic prostatitis may be sub-divided into:

Answer 54

• Chronic prostatitis or chronic pelvic pain syndrome (no infection)
• Chronic bacterial prostatitis (infection)

Question 55

The cause of inflammation and pain in chronic prostatitis is unclear. It may be initially triggered by

Answer 55

an infection, with inflammation persisting after the infection has resolved.

Question 56

Chronic prostatitis presents with at least 3 months of:

Answer 56

• Pelvic pain, which may affect the perineum, testicles, scrotum, penis, rectum, groin, lower back or suprapubic area
• Lower urinary tract symptoms, such as dysuria, hesitancy, frequency and retention
• Sexual dysfunction, such as erectile dysfunction, pain on ejaculation and haematospermia (blood in the semen)
• Pain with bowel movements
• Tender and enlarged prostate on examination (although examination may be normal)

Question 57

Acute bacterial prostatitis presents with a more acute presentation of similar symptoms to chronic prostatitis. There may also be systemic symptoms of infection, such as:

Answer 57

• Fever
• Myalgia
• Nausea
• Fatigue
• Sepsis

Question 58

What is National Institute of Health Chronic Prostatitis Symptom Index

Answer 58

The National Institute of Health has an online scoring tool for chronic prostatitis. It can be used to assess the severity of the symptoms and their impact on quality of life. It can also be used to track symptoms over time

Question 59

Investigations of Prostatitis

Answer 59

• Urine dipstick testing can confirm evidence of infection.
• Urine microscopy, culture and sensitivities (MC&S) can identify the causative organism and the antibiotic sensitivities.
• Chlamydia and gonorrhoea NAAT testing on a first pass urine, if sexually transmitted infection is considered.

Question 60

Management of acute bacterial prostatitis:

Answer 60

• Hospital admission for systemically unwell or septic patients (for bloods, blood cultures and IV antibiotics)
• Oral antibiotics, typically for 2-4 weeks (e.g., ciprofloxacin, ofloxacin or trimethoprim)
• Analgesia (paracetamol or NSAIDs)
• Laxatives for pain during bowel movements

Question 61

Management of chronic prostatitis (adapted from NICE CKS, updated 2019):

Answer 61

• Alpha-blockers (e.g., tamsulosin) relax smooth muscle, with rapid improvement in symptoms
• Analgesia (paracetamol or NSAIDs)
• Psychological treatment, where indicated (e.g., cognitive behavioural therapy and / or antidepressants)
• Antibiotics if less than 6 months of symptoms or a history of infection (e.g., trimethoprim or doxycycline for 4-6 weeks)
• Laxatives for pain during bowel movements

Question 62

The complications of acute bacterial prostatitis are:

Answer 62

• Sepsis
• Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
• Acute urinary retention
• Chronic prostatitis

Question 63

The key risk factors for prostate cancer are:

Answer 63

• Increasing age
• Family history
• Black African or Caribbean origin
• Tall stature
• Anabolic steroids

Question 64

Presentation of Prostate Cancer

Answer 64

Prostate cancer may be asymptomatic. It may also present with lower urinary tract symptoms (LUTS), similar to benign prostate hyperplasia. These symptoms include hesitancy, frequency, weak flow, terminal dribbling and nocturia.

Other symptoms include:

• Haematuria
• Erectile dysfunction
• Symptoms of advanced disease or metastasis (e.g., weight loss, bone pain or cauda equina syndrome)

Question 65

The __________ ___ of the prostate produce prostate-specific antigen (PSA). PSA is a __________ that is secreted in the semen, with a small amount entering the blood. Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation. It is specific to the prostate, meaning it is not produced anywhere else in the body. A raised level can be an indicator of prostate cancer

Answer 65

The epithelial cells of the prostate produce prostate-specific antigen (PSA). PSA is a glycoprotein that is secreted in the semen, with a small amount entering the blood. Its enzymatic activity helps thin the thick semen into a liquid consistency after ejaculation. It is specific to the prostate, meaning it is not produced anywhere else in the body. A raised level can be an indicator of prostate cancer

Question 66

PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).

Common causes of a raised PSA are:

Answer 66

Prostate cancer

Benign prostatic hyperplasia

Prostatitis

Urinary tract infections

Vigorous exercise (notably cycling)

Recent ejaculation or prostate stimulation

Question 67

Explain false postitives and false negatives in prostate cancer?

Answer 67

False positives may lead to further investigations, including invasive prostate biopsies, which have complications and may be unnecessary. Additionally, it may lead to the unnecessary diagnosis and treatment of prostate cancer that would never have caused problems (the patient would have died of other causes before experiencing any adverse effects of the prostate cancer).

False negatives may lead to false reassurance.

Question 68

Examination findings of a benign prostate

Answer 68

feels smooth, symmetrical and slightly soft, with a maintained central sulcus (the dip in the middle between the right and left lobe). There may be generalised enlargement in prostatic hyperplasia.

Question 69

Examination Findings

An infected or inflamed prostate (prostatitis)

Answer 69

may be enlarged, tender and warm.

Question 70

Examinations of a cancerous prostate

Answer 70

A cancerous prostate may feel firm or hard, asymmetrical, craggy or irregular, with loss of the central sulcus. There may be a hard nodule.

Any of these features can indicate prostate cancer and warrant further investigation

. In primary care, these findings require a two week wait urgent cancer referral to urology.

Question 71

What is first line for prostate cancer?

Answer 71

Multiparametric MRI of the prostate is now the usual first-line investigation for suspected localised prostate cancer. The results are reported on a Likert scale, scored as:

1 – very low suspicion

2 – low suspicion

3 – equivocal

4 – probable cancer

5 – definite cancer

Question 72

Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the ____ ________ (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).

Answer 72

Prostate biopsy is the next step in establishing a diagnosis. The decision to perform a biopsy depends on the MRI findings (e.g., Likert 3 or above) and the clinical suspicion (i.e. examination and PSA level).

Question 73

Prostate biopsy carries a risk of ______ ______ results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

Answer 73

Prostate biopsy carries a risk of false-negative results if the biopsy misses the cancerous area. Multiple needles are used to take samples from different areas of the prostate. The MRI scan results can guide the biopsy to decide the best target for the needles.

Question 74

There are two options for prostate biopsy:

Answer 74

Transrectal ultrasound-guided biopsy (TRUS)- involves an ultrasound probe inserted into the rectum, providing a good indicate of the size and shape of the prostate. Guided biopsies are taken through the wall of the rectum, into the prostate.

Transperineal biopsy- involves needles inserted through the perineum. It is usually under local anaesthetic.

Question 75

The main risks of a prostate biopsy are:

Answer 75

Pain (particularly lower abdominal, rectal or perineal pain)

Bleeding (blood in the stools, urine or semen)

Infection

Urinary retention due to short term swelling of the prostate

Erectile dysfunction (rare)

Question 76

An _______ _____ _____ (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.

Answer 76

An isotope bone scan (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.

Question 77

A ________ ______ is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton. Metastatic bone lesions take up more of the isotope, making them stand out on the scan.

Answer 77

A radioactive isotope is given by intravenous injection, followed by a short wait (2-3 hours) to allow the bones to take up the isotope. A gamma camera is used to take pictures of the entire skeleton. Metastatic bone lesions take up more of the isotope, making them stand out on the scan.

Question 78

What is

Gleason Grading System

Answer 78

The Gleason grading system is based on the histology from the prostate biopsies. It is specific to prostate cancer and helps to determine what treatment is most appropriate. The greater the Gleason score, the more poorly differentiated the tumour is (the cells have mutated further from normal prostate tissue) and the worse the prognosis is. The tissue samples are graded 1 (closest to normal) to 5 (most abnormal).

Question 79

The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):

Answer 79

• The first number is the grade of the most prevalent pattern in the biopsy
• The second number is the grade of the second most prevalent pattern in the biopsy

Question 80

A Gleason score of:

explain scoring system

Answer 80

• 6 is considered low risk
• 7 is intermediate risk (3 + 4 is lower risk than 4 + 3)
• 8 or above is deemed to be high risk

Question 81

The TNM staging system can be used for prostate cancer, rating the T (tumour), N (lymph nodes) and M (metastasis)

Answer 81

T for Tumour:

TX – unable to assess size

T1 – too small to be felt on examination or seen on scans

T2 – contained within the prostate

T3 – extends out of the prostate

T4 – spread to nearby organs

N for Nodes:

NX – unable to assess nodes

N0 – no nodal spread

N1 – spread to lymph nodes

M for Metastasis:

M0 – no metastasis

M1 – metastasis

Question 82

Management of any cancer is guided by a multidisciplinary team (MDT) meeting to decide the best course of action for the individual patient.

Depending on the grade and stage of prostate cancer, treatment can involve:

Answer 82

• Surveillance or watchful waiting in early prostate cancer
• External beam radiotherapy directed at the prostate
• Brachytherapy
• Hormone therapy
• Surgery

Question 83

A key complication of external beam radiotherapy is ______ caused by __________ affecting the rectum. ______ can cause pain, altered bowel habit, rectal bleeding and discharge. ________ suppositories can help reduce inflammation.

Answer 83

A key complication of external beam radiotherapy is proctitis caused by radiation affecting the rectum. Prostitis can cause pain, altered bowel habit, rectal bleeding and discharge. Prednisolone suppositories can help reduce inflammation.

Question 84

What is Brachytherapy

Answer 84

Brachytherapy involves implanting radioactive metal “seeds” into the prostate. This delivers continuous, targeted radiotherapy to the prostate. The radiation can cause inflammation in nearby organs, such as the bladder (cystitis) or rectum (proctitis). Other side effects include erectile dysfunction, incontinence and increased risk of bladder or rectal cancer.

Question 85

Aim of Hormone therapy Prostrate Cancer

Answer 85

Hormone therapy aims to reduce the level of androgens (e.g., testosterone) that stimulate the cancer to grow. They are usually either used in combination with radiotherapy, or alone in advanced disease where cure is not possible.

Question 86

Hormone therapy for prostrate cancer

Answer 86

• Androgen-receptor blockers such as bicalutamide
• GnRH agonists such as goserelin (Zoladex) or leuprorelin (Prostap)
• Bilateral orchidectomy to remove the testicles (rarely used)

Question 87

Side effects of hormone therapy include:

Answer 87

• Hot flushes
• Sexual dysfunction
• Gynaecomastia
• Fatigue
• Osteoporosis

Question 88

WHat is Radical prostatectomy

Answer 88

involves a surgical operation to remove the entire prostate. The aim is to cure prostate cancer confined to the prostate. Key complications are erectile dysfunction and urinary incontinence.

Question 89

WHat is Epididymo-orchitis

Answer 89

is usually the result of infection in the epididymis and testicle on one side.

Question 90

Basic physiology of sperm

Answer 90

At the back of each testicle is the epididymis. Sperm are released from the testicle, into the head of the epididymis, connected at the top of the testicle. The sperm travel through the head, then body, then tail of the epididymis. Sperm mature and are stored in the epididymis. The epididymis drains into the vas deferens.

Question 91

Causes Epididymo-orchitis

Answer 91

• Escherichia coli (E. coli)
• Chlamydia trachomatis
• Neisseria gonorrhoea
• Mumps

Think of mumps in patients with parotid gland swelling and orchitis. Mumps tends only to affect the testicle, sparing the epididymis. It can also cause pancreatitis.

Question 92

Epididymo-orchitis typically presents with a gradual onset, over minutes to hours, with unilateral:

Answer 92

• Testicular pain
• Dragging or heavy sensation
• Swelling of testicle and epididymis
• Tenderness on palpation, particularly over epididymis
• Urethral discharge (should make you think of chlamydia or gonorrhoea)
• Systemic symptoms such as fever and potentially sepsis

Question 93

The key differential diagnosis for epididymo-orchitis is

Answer 93

The key differential diagnosis for epididymo-orchitis is testicular torsion

Question 94

Testicular torsion is a _________ ___________ that requires rapid treatment to avoid the testicle dying. Both present similarly, with acute onset of pain in one testicle. If there is any doubt, treat it as testicular torsion until proven otherwise.

Answer 94

Testicular torsion is a urological emergency that requires rapid treatment to avoid the testicle dying. Both present similarly, with acute onset of pain in one testicle. If there is any doubt, treat it as testicular torsion until proven otherwise.

Question 95

The key with epididymo-orchitis is to distinguish whether the cause is likely to be an enteric organism (e.g., E. coli) or a sexually transmitted organism (e.g., chlamydia or gonorrhoea). The features that make a sexually transmitted organism more likely are (as per NICE CKS 2020):

Answer 95

• Age under 35
• Increased number of sexual partners in the last 12 months
• Discharge from the urethra

Question 96

Epididymo-orchitis

Investigations to help establish the diagnosis are:

Answer 96

• Urine microscopy, culture and sensitivity (MC&S)
• Chlamydia and gonorrhoea NAAT testing on a first pass urine
• Charcoal swab of purulent urethral discharge for gonorrhoea culture and sensitivities
• Saliva swap for PCR testing for mumps, if suspected
• Serum antibodies for mumps, if suspected (IgM – acute infection, IgG – previous infection or vaccination)
• Ultrasound may be used to assess for torsion or tumours

Question 97

Management for Epididymo-orchitis

Answer 97

Acutely very unwell or septic patients are admitted to hospital for treatment (IV antibiotics).

Patients with a high risk of sexually transmitted infection should be referred urgently to genitourinary medicine (GUM) for assessment and treatment.

Local guidelines guide the choice of antibiotic.

Question 98

Epididymo-orchitis

For patients that are at a low risk of STIs, a typical choice is:

Answer 98

Ofloxacin (usually first-line) for 14 days

Question 99

Alternatives Treatment for Epididymo-orchitis

Answer 99

• Levofloxacin / ciprofloxacin
• Doxycycline
• Co-amoxiclav

Question 100

Epididymo-orchitis

Additional measures:

Answer 100

• Analgesia
• Supportive underwear
• Reduce physical activity
• Abstain from intercourse

Question 101

__________ ______ such as ofloxacin, levofloxacin and ciprofloxacin are powerful broad-spectrum antibiotics, often used for urinary tract infections, pyelonephritis, epididymo-orchitis and prostatitis.

Answer 101

Quinolone antibiotics such as ofloxacin, levofloxacin and ciprofloxacin are powerful broad-spectrum antibiotics, often used for urinary tract infections, pyelonephritis, epididymo-orchitis and prostatitis.

Question 102

Quinolone antibiotics such as ofloxacin, levofloxacin and ciprofloxacin are excellent gram-negative cover.

It is worth remembering two critical side effects, as these may be tested in exams and are essential to inform patients about:

Answer 102

• Tendon damage and tendon rupture, notably in the Achilles tendon
• Lower seizure threshold (caution in patients with epilepsy)

Question 103

Complications

Epididymo-orchitis can lead to:

Answer 103

• Chronic pain
• Chronic epididymitis
• Testicular atrophy
• Sub-fertility or infertility
• Scrotal abscess

Question 104

What is Testicular Torsion

Answer 104

Testicular torsion refers to twisting of the spermatic cord with rotation of the testicle. It is a urological emergency, and a delay in treatment increases the risk of ischaemia and necrosis of the testicle, leading to sub-fertility or infertility.

The typical patient is a teenage boy, but it can occur at any age.

Question 105

Testicular torsion is often triggered by

Answer 105

activity, such as playing sports. Ask what the patient was doing at the time when the pain started.

Question 106

Testicular torsion presents with

Answer 106

an acute rapid onset of unilateral testicular pain, and may be associated with abdominal pain and vomiting. Sometimes abdominal pain is the only symptom in boys, and testicular examination to exclude torsion is essential.

Question 107

Examination findings testicular torsion

Answer 107

• Firm swollen testicle
• Elevated (retracted) testicle
• Absent cremasteric reflex
• Abnormal testicular lie (often horizontal)
• Rotation, so that epididymis is not in normal posterior position

If in doubt, or if there is any suspicion of torsion, get an immediate senior urology opinion.

Question 108

What is Bell-Clapper Deformity

Answer 108

A bell-clapper deformity is one of the causes of testicular torsion.

Normally, the testicle is fixed posteriorly to the tunica vaginalis. A bell-clapper deformity is where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply.

Question 109

Management

Testicular torsion

Answer 109

Testicular torsion is a urological emergency, and there is an urgent requirement for treatment. Any delay in treatment will prolong the ischaemia and reduce the chances of saving the testicle.

The management of testicular torsion involves:

• Nil by mouth, in preparation for surgery
• Analgesia as required
• Urgent senior urology assessment
• Surgical exploration of the scrotum
• Orchiopexy (correcting the position of the testicles and fixing them in place)
• Orchidectomy (removing the testicle) if the surgery is delayed or there is necrosis

Question 110

Testicular torsion

A ______ ________ can confirm the diagnosis. However, any investigation that will delay the patient going to theatre for treatment is not recommended. Ultrasound can show the ________ _____, a spiral appearance to the spermatic cord and blood vessels.

Answer 110

A scrotal ultrasound can confirm the diagnosis. However, any investigation that will delay the patient going to theatre for treatment is not recommended. Ultrasound can show the whirlpool sign, a spiral appearance to the spermatic cord and blood vessels.

Question 111

The key causes of scrotal or testicular lumps are:

Answer 111

• Hydrocele
• Varicocele
• Epididymal cyst
• Testicular cancer
• Epididymo-orchitis
• Inguinal hernia
• Testicular torsion

Question 112

What is a hydrocele

Answer 112

A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes. They are usually painless and present with a soft scrotal swelling. The tunica vaginalis is a sealed pouch of membrane that surrounds the testes. Originally the tunica vaginalis is part of the peritoneal membrane. During the development of the fetus, it becomes separated from the peritoneal membrane and remains in the scrotum, partially covering each testicle.

Question 113

Examination findings with a hydrocele are:

Answer 113

• The testicle is palpable within the hydrocele
• Soft, fluctuant and may be large
• Irreducible and has no bowel sounds (distinguishing it from a hernia)
• Transilluminated by shining torch through the skin, into the fluid (the testicle floats within the fluid)

Question 114

Hydroceles can be idiopathic, with no apparent cause, or secondary to:

Answer 114

• Testicular cancer
• Testicular torsion
• Epididymo-orchitis
• Trauma

Question 115

Management hydroceles

Answer 115

Management involves excluding serious causes (e.g., cancer). Idiopathic hydroceles may be managed conservatively. Surgery, aspiration or sclerotherapy may be required in large or symptomatic cases.

Question 116

WHat is Varicocele

Answer 116

A varicocele occurs where the veins in the pampiniform plexus become swollen. They are common, affecting around 15% of men. They can cause impaired fertility, probably due to disrupting the temperature in the affected testicle. They may result in testicular atrophy, reducing the size and function of the testicle

Question 117

The pampiniform plexus is a ______ ____, which is found in the _______ ___ and drains the testes. The pampiniform plexus drains into the ________ ____. It plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery. The testicles need to be at an optimum temperature for producing sperm.

Answer 117

The pampiniform plexus is a venous plexus, which is found in the spermatic cord and drains the testes. The pampiniform plexus drains into the testicular vein. It plays a role in regulating the temperature of blood entering the testes by absorbing heat from the nearby testicular artery. The testicles need to be at an optimum temperature for producing sperm.

Question 118

Varicoceles are the result of ________ ________ in the testicular vein. _________ ____ in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus

Answer 118

Varicoceles are the result of increased resistance in the testicular vein. Incompetent valves in the testicular vein allow blood to flow back from the testicular vein into the pampiniform plexus

Question 119

The right testicular vein drains directly into the _______ ____ _____. The left testicular vein drains into the _______ ______ _____. Most varicoceles (90%) occur on the left due to increased resistance in the ___ testicular vein. A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma.

Answer 119

The right testicular vein drains directly into the inferior vena cava. The left testicular vein drains into the left renal vein. Most varicoceles (90%) occur on the left due to increased resistance in the left testicular vein. A left-sided varicocele can indicate an obstruction of the left testicular vein caused by a renal cell carcinoma.

Question 120

Varicoceles may present with:

Examination Findings

Answer 120

• Throbbing/dull pain or discomfort, worse on standing
• A dragging sensation
• Sub-fertility or infertility

Examination findings are:

• A scrotal mass that feels like a “bag of worms”
• More prominent on standing
• Disappears when lying down
• Asymmetry in testicular size if the varicocele has affected the growth of the testicle

Question 121

_________ that do not disappear when lying down raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.

Answer 121

Varicoceles that do not disappear when lying down raise concerns about retroperitoneal tumours obstructing the drainage of the renal vein. These warrant an urgent referral to urology for further investigation.

Question 122

Varicoceles

Investigations to consider are:

Answer 122

• Ultrasound with Doppler imaging can be used to confirm the diagnosis
• Semen analysis if there are concerns about fertility
• Hormonal tests (e.g., FSH and testosterone) if there are concerns about function

Question 123

Management of Variocele

Answer 123

Uncomplicated cases can be managed conservatively.

Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.

Question 124

WHat are Epididymal Cysts

Answer 124

Epididymal cysts occur at the head of the epididymis (at the top of the testicle). A cyst is a fluid-filled sac. An epididymal cyst that contains sperm is called a spermatocele. Management of epididymal cysts and spermatoceles is identical.

Question 125

Epididymal Cysts

Examination findings are:

Answer 125

• Soft, round lump
• Typically at the top of the testicle
• Associated with the epididymis
• Separate from the testicle
• May be able to transilluminate large cysts (appearing separate from the testicle)

Question 126

Testicular cancer arises from the ____ ___ in the testes.___ ____ are cells that produce ______ (sperm in males). There are other, rare tumours in the testes, such as non-germ cell tumours and secondary metastases.

Answer 126

Testicular cancer arises from the germ cells in the testes. Germ cells are cells that produce gametes (sperm in males). There are other, rare tumours in the testes, such as non-germ cell tumours and secondary metastases.

Question 127

Testicular cancer is more common in

Answer 127

younger men, with the highest incidence between 15 and 35 years.

Question 128

Testicular cancer can be divided into two types:

Answer 128

• Seminomas
• Non-seminomas (mostly teratomas)

Question 129

Testicular Cancer

Risk Factors

Answer 129

• Undescended testes
• Male infertility
• Family history
• Increased height

Question 130

Presentation Testicular Cancer

Answer 130

The typical presentation is a painless lump on the testicle. Occasionally it can present with testicular pain.

The lump will be:

• Non-tender (or even reduced sensation)
• Arising from testicle
• Hard
• Irregular
• Not fluctuant
• No transillumination

Question 131

Rarely, ___________ can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour.

Answer 131

Rarely, gynaecomastia can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour. About 2% of patients presenting with gynaecomastia have a testicular tumour.

Question 132

Testicular Cancer

Ix

Answer 132

Scrotal ultrasound is the usual initial investigation to confirm the diagnosis.

Tumour markers for testicular cancer are:

• Alpha-fetoprotein – may be raised in teratomas (not in pure seminomas)
• Beta-hCG – may be raised in both teratomas and seminomas
• Lactate dehydrogenase (LDH) is a very non-specific tumour marker

A staging CT scan can be used to look for areas of spread and to stage the cancer.

Question 133

Royal Marsden Staging System

Testicular cancer is staged with the Royal Marsden staging system:

Answer 133

Stage 1 – isolated to the testicle

Stage 2 – spread to the retroperitoneal lymph nodes

Stage 3 – spread to the lymph nodes above the diaphragm

Stage 4 – metastasised to other organs

Question 134

The common places for testicular cancer to metastasise to are:

Answer 134

• Lymphatics
• Lungs
• Liver
• Brain

Question 135

Management for testicular cancer

Answer 135

Depending on the grade and stage of testicular cancer, treatment can involve:

• Surgery to remove the affected testicle (radical orchidectomy) – a prosthesis can be inserted
• Chemotherapy
• Radiotherapy
• Sperm banking to save sperm for future use, as treatment may cause infertility

Question 136

Testicular Cancer

Long term side effects of treatment are particularly significant, as most patients are young and expected to live many years after treatment of testicular cancer. Side effects include:

Answer 136

• Infertility
• Hypogonadism (testosterone replacement may be required)
• Peripheral neuropathy
• Hearing loss
• Lasting kidney, liver or heart damage
• Increased risk of cancer in the future

Question 137

Prognosis

Testicular cancer

Answer 137

The prognosis for early testicular cancer is good, with a greater than 90% cure rate. Metastatic disease is also often curable. Seminomas have a slightly better prognosis than non-seminomas.

Patients will require follow-up to monitor for reoccurrence. This usually involves monitoring tumour markers, and may include imaging such as CT scans or chest x-rays.

Question 138

Lower urinary tract infections (UTIs) involve infection in the bladder, causing

Answer 138

cystitis (inflammation of the bladder).

Question 139

UTIs can spread to the kidneys and cause

Answer 139

pyelonephritis.

Question 140

Who are UTIs more common in

Answer 140

Urinary tract infections are far more common in women, where the urethra is much shorter, making it easy for bacteria to get into the bladder.

Question 141

Lower urinary tract infections present with:

Answer 141

• Dysuria (pain, stinging or burning when passing urine)
• Suprapubic pain or discomfort
• Frequency
• Urgency
• Incontinence
• Haematuria
• Cloudy or foul smelling urine
• Confusion is commonly the only symptom in older and frail patients

Question 142

It is important to distinguish between patients with a lower urinary tract infection and those with pyelonephritis. Pyelonephritis is generally a more serious condition with significant complications, including sepsis and kidney scarring. Suspect pyelonephritis in patients with:

Answer 142

• Fever
• Loin/back pain
• Nausea/vomiting
• Renal angle tenderness on examination

Question 143

Indications on urine dipstick for UTI

Answer 143

Postives for nitrates, leukocytes and blood

Question 144

________ ______ is tested on a urine dipstick, which is a product of leukocytes and indicates the number of leukocytes in the urine.

Answer 144

Leukocyte esterase is tested on a urine dipstick, which is a product of leukocytes and indicates the number of leukocytes in the urine.

Question 145

A midstream urine (MSU) sample sent for microscopy, culture and sensitivity testing will determine the infective organism and the antibiotics that will be effective in treatment. Not all patients with an uncomplicated UTI require an MSU. This is important in:

Answer 145

• Pregnant patients
• Patients with recurrent UTIs
• Atypical symptoms
• When symptoms do not improve with antibiotics

Question 146

The most common cause of UTI is Escherichia coli. E. coli are gram-negative, anaerobic, rod-shaped bacteria that are part of the normal lower intestinal microbiome. It is found in faeces and can easily spread to the bladder.

Other causes:

Answer 146

• Klebsiella pneumoniae (gram-negative anaerobic rod)
• Enterococcus
• Pseudomonas aeruginosa
• Staphylococcus saprophyticus
• Candida albicans (fungal)

Question 147

UTI -Abx

Follow local guidelines. An appropriate initial antibiotic in the community would be:

Answer 147

• Trimethoprim (often associated with high rates of bacterial resistance)
• Nitrofurantoin (avoided in patients with an eGFR <45)

Question 148

Alternatives for UTIs management of trimethoprim or nitrofurantoin

Answer 148

• Pivmecillinam
• Amoxicillin
• Cefalexin

Question 149

Duration of Antibiotics (UTI)

• __ days of antibiotics for simple lower urinary tract infections in women
• ___ ____ days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
• __ days of antibiotics for men, pregnant women or catheter-related UTIs

Answer 149

Duration of Antibiotics (UTI)

• 3 days of antibiotics for simple lower urinary tract infections in women
• 5-10 days of antibiotics for immunosuppressed women, abnormal anatomy or impaired kidney function
• 7 days of antibiotics for men, pregnant women or catheter-related UTIs

Question 150

Urinary tract infections in pregnancy increase the risk of

Answer 150

pyelonephritis, premature rupture of membranes and pre-term labour.

Question 151

Management in Pregnancy UTI

Answer 151

Urinary tract infection in pregnancy requires 7 days of antibiotics. All women should have an MSU for microscopy, culture and sensitivity testing.

The antibiotic options are:

• Nitrofurantoin (avoid in the third trimester)
• Amoxicillin (only after sensitivities are known)
• Cefalexin

Question 152

_________ needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).

___________ needs to be avoided in the first trimester as it works as a folate antagonist. Folate is essential in early pregnancy for the normal development of the fetus. ___________ in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.

Answer 152

Nitrofurantoin needs to be avoided in the third trimester as there is a risk of neonatal haemolysis (destruction of the neonatal red blood cells).

Trimethoprim needs to be avoided in the first trimester as it works as a folate antagonist. Folate is essential in early pregnancy for the normal development of the fetus. Trimethoprim in early pregnancy can cause congenital malformations, particularly neural tube defects (e.g., spina bifida). It is not known to be harmful later in pregnancy but is generally avoided unless necessary.

Question 153

What is Pyelonephriti

Answer 153

Pyelonephritis refers to inflammation of the kidney resulting from bacterial infection. The inflammation affects the renal pelvis (join between kidney and ureter) and parenchyma (tissue).

Question 154

Risk factors for pyelonephritis are:

Answer 154

• Female sex
• Structural urological abnormalities
• Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
• Diabetes

Question 155

Causes of Pyelonephritis

Answer 155

Escherichia coli is the most common cause, as with lower urinary tract infections. E. coli are gram-negative, anaerobic, rod-shaped bacteria that are part of the normal lower intestinal microbiome. It is found in faeces and can easily spread to the bladder.

Other causes:

• Klebsiella pneumoniae (gram-negative anaerobic rod)
• Enterococcus
• Pseudomonas aeruginosa
• Staphylococcus saprophyticus
• Candida albicans (fungal)

Question 156

Presentation of Pyelonephritis

Answer 156

Patients have a similar presentation to lower urinary tract infections (i.e. dysuria, suprapubic discomfort and increased frequency) plus the additional triad of symptoms:

• Fever
• Loin or back pain (bilateral or unilateral)
• Nausea / vomiting

Patients may also have:

• Systemic illness
• Loss of appetite
• Haematuria
• Renal angle tenderness on examination

Question 157

Pyelonephritis Ix

Answer 157

• Urine dipstick will show signs of infection, including nitrites, leukocytes and blood.
• Midstream urine (MSU) for microscopy, culture and sensitivity testing is essential to establish the causative organism. The sample should ideally be collected before starting antibiotics.
• Blood tests will show raised white blood cells and raised inflammatory markers (i.e. CRP).
• Imaging may be used to exclude other pathologies, such as kidney stones or abscesses. This could be an ultrasound or CT scan.

Question 158

Management of Pyelonephritis

Answer 158

Referral to hospital if there are features of sepsis or if it is not safe to manage them in the community.

NICE guidelines (2018) recommend the following first-line antibiotics for 7-10 days when treating pyelonephritis in the community:

• Cefalexin
• Co-amoxiclav (if culture results are available)
• Trimethoprim (if culture results are available)
• Ciprofloxacin (keep tendon damage and lower seizure threshold in mind)

Question 159

Patients admitted to hospital with sepsis require the sepsis six; with three tests and three treatments

What are these

Answer 159

Three tests:

• Blood lactate level
• Blood cultures
• Urine output

Three treatments:

• Oxygen to maintain oxygen saturations of 94-98% (or 88-92% in COPD)
• Empirical broad-spectrum IV antibiotics (according to local guidelines)
• IV fluids

Question 160

Pyelonephritis

Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are:

Answer 160

• Renal abscess
• Kidney stone obstructing the ureter, causing pyelonephritis

Question 161

What is Chronic Pyelonephritis

Answer 161

Chronic pyelonephritis presents with recurrent episodes of infection in the kidneys. Recurrent infections lead to scarring of the renal parenchyma, leading to chronic kidney disease (CKD). It can progress to end-stage renal failure.

Question 162

___________ ____ scans involve injecting _______ ______, which builds up in healthy kidney tissue. When imaged using gamma cameras, it indicates scarring or damage in areas that do not take up the DMSA. They are used in recurrent pyelonephritis to assess for renal damage.

Answer 162

Dimercaptosuccinic acid (DMSA) scans involve injecting radiolabeled DMSA, which builds up in healthy kidney tissue. When imaged using gamma cameras, it indicates scarring or damage in areas that do not take up the DMSA. They are used in recurrent pyelonephritis to assess for renal damage.

Question 163

Interstitial cystitis is a chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called ….

Answer 163

bladder pain syndrome and hypersensitive bladder syndrome

Question 164

Interstitial cystitis

Presentation

Answer 164

The symptoms are similar to a lower urinary tract infection, but are more persistent.

The typical presentation is more than 6 weeks of:

• Suprapubic pain, worse with a full bladder and often relieved by emptying the bladder
• Frequency of urination
• Urgency of urination
• Symptoms may be worse during menstruation

Question 165

Interstitial Cystitis

Other causes of symptoms need to be excluded, with:

Answer 165

Urinalysis for urinary tract infections

Swabs for sexually transmitted infections

Cystoscopy for bladder cancer

Prostate examination for prostatitis, hypertrophy or cancer

Question 166

_______ _____, seen during cystoscopy, are a finding in 5-20% of patients with interstitial cystitis. These are red, inflamed patches of the bladder mucosa associated with small blood vessels.

__________ are another finding during cystoscopy in patients with interstitial cystitis. These are tiny haemorrhages on the bladder wall.

Answer 166

Hunner lesions, seen during cystoscopy, are a finding in 5-20% of patients with interstitial cystitis. These are red, inflamed patches of the bladder mucosa associated with small blood vessels.

Granulations are another finding during cystoscopy in patients with interstitial cystitis. These are tiny haemorrhages on the bladder wall.

Question 167

Interstitial cystitis can be difficult to manage. Symptoms are often resistant to treatment and persist long-term, having a significant impact on quality of life.

Supportive management is used initially:

Answer 167

• Diet changes such as avoiding alcohol, caffeine and tomatoes
• Stopping smoking
• Pelvic floor exercises
• Bladder retraining
• Cognitive behavioural therapy
• Transcutaneous electrical nerve stimulation (TENS)

Question 168

Interstitial cystitis can be difficult to manage. Symptoms are often resistant to treatment and persist long-term, having a significant impact on quality of life.

Oral medications may be helpful, including;

Answer 168

• Analgesia
• Antihistamines
• Anticholinergic medications (e.g., solifenacin or oxybutynin)
• Mirebegron (beta-3-adrenergic-receptor agonist)
• Cimetidine (histamine-2-receptor antagonist)
• Pentosan polysulfate sodium
• Ciclosporin (an immunosuppressant)
  *

Question 169

Interstitial cystitis can be difficult to manage. Symptoms are often resistant to treatment and persist long-term, having a significant impact on quality of life.

Intravesical medication may be helpful, given directly into the bladder:

Answer 169

• Lidocaine
• Pentosan polysulfate sodium
• Hyaluronic acid
• Chondroitin sulphate

Question 170

______________ involves filling the bladder with water, to high pressure, during a cystoscopy. It requires a general anaesthetic. This can give a temporary (3-6 month) improvement in symptoms.

Answer 170

Hydrodistention involves filling the bladder with water, to high pressure, during a cystoscopy. It requires a general anaesthetic. This can give a temporary (3-6 month) improvement in symptoms.

Question 171

Interstitial cystitis can be difficult to manage. Symptoms are often resistant to treatment and persist long-term, having a significant impact on quality of life.

Surgical procedures may be used, including:

Answer 171

• Cauterisation of Hunner lesions during cystoscopy
• Butulinum toxin injections during cystoscopy
• Neuromodulation with an implanted electrical nerve stimulator
• Augmentation of the bladder, using a section of ileum, to increase the capacity (ileocystoplasty)
• Cystectomy (removal of the bladder)

Question 172

Bladder Cancer

Cancer in the bladder arises from the endothelial lining (__________). The majority are __________ at presentation.

Answer 172

Cancer in the bladder arises from the endothelial lining (urothelium). The majority are superficial (not invading the muscle) at presentation.

Question 173

Bladder Cancer

Risk Factors

Answer 173

Smoking and increased age are the main risk factors for bladder cancer.

Aromatic amines are worth noting as a carcinogen that causes bladder cancer. Aromatic amines were used in dye and rubber industries but have been heavily regulated or banned for many years. They are also found in cigarette smoke and seem to be the reason smoking causes bladder cancer.

Schistosomiasis causes squamous cell carcinoma of the bladder in countries with a high prevalence of the infection.

Question 174

Typical presentation of bladder cancer

Answer 174

The typical presentation to look out for in your exams is a retired dye factory worker with painless haematuria. Whenever an exam question mentions a patient’s occupation, it is almost certainly relevant and will tell you the diagnosis. Dye factory workers get transitional cell carcinoma of the bladder. Patients with asbestos exposure get mesothelioma. Outdoor workers with significant sun exposure get skin cancer.

Question 175

Types of bladder cancer

Answer 175

• Transitional cell carcinoma (90%)
• Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
• Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma

Question 176

Bladder cancer Presentation

________ _____ is the symptom to remember for your exams.

The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for:

Answer 176

Painless haematuria is the symptom to remember for your exams.

• Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI
• Aged over 60 with microscopic haematuria (not visible but positive on a urine dipstick) PLUS:

-Dysuria or;

-Raised white blood cells on a full blood count

Question 177

The NICE guidelines also recommend considering a non-urgent referral in people over 60 with …….

Answer 177

The NICE guidelines also recommend considering a non-urgent referral in people over 60 with recurrent unexplained UTIs.

Question 178

Diagnosis of Bladder Cancer

Answer 178

Cystoscopy (a camera through the urethra into the bladder) can be used to visualise bladder cancers. The cystoscope can be rigid or flexible. Cystoscopy can be performed under local or general anaesthetic.

Question 179

The TNM staging system is used for bladder cancer, rating the T (tumour), N (lymph node) and M (metastasis) stages.

There is a clear distinction between:

• Non-muscle-invasive bladder cancer (not invading the muscle layer of the bladder)
• Muscle-invasive bladder cancer (invading the muscle and beyond)

Explain this further

Answer 179

Non-muscle-invasive bladder cancer includes:

• Tis/carcinoma in situ: cancer cells only affect the urothelium and are flat
• Ta: cancer only affecting the urothelium and projecting into the bladder
• T1: cancer invading the connective tissue layer beyond the urothelium, but not the muscle layer

Invasive bladder cancer includes T2 – 4 and any lymph node or metastatic spread.

Question 180

Treatment Options for bladder cancer

Answer 180

Tansurethral resection of bladder tumour (TURBT) may be used for non-muscle-invasive bladder cancer. The involves removing the bladder tumour during a cystoscopy procedure.

Intravesical chemotherapy (chemotherapy given into the bladder through a catheter) is often used after a TURBT procedure to reduce the risk of recurrence.

Intravesical Bacillus Calmette-Guérin (BCG) may be used as a form of immunotherapy. Giving the BCG vaccine (the same one as for tuberculosis) into the bladder is thought to stimulate the immune system, which in turn attacks the bladder tumours.

Radical cystectomy involves the removal of the entire bladder.

Question 181

Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder, there are several options for draining urine:

Answer 181

• Urostomy with an ileal conduit (most common)
• Continent urinary diversion
• Neobladder reconstruction
• Ureterosigmoidostomy

Chemotherapy and radiotherapy may also be used.

Question 182

What is Urostomy

Answer 182

A urostomy is used to drain urine from the kidney, bypassing the ureters, bladder and urethra. This is the most common and popular solution after cystectomy

Question 183

What is Continent Urinary Diversion

Answer 183

A continent urinary diversion involves creating a pouch inside the abdomen from a section of the ileum, with the ureters connected. This pouch fills with urine. A thin tube is connected between a stoma on the skin and the internal pouch. Urine does not drain from the stoma (unlike a urostomy), and the patient needs to intermittently insert a catheter into the stoma to drain urine from the pouch.

Question 184

What is Neobladder Reconstruction

Answer 184

Bladder reconstruction involves creating a new bladder from a section of the ileum. This is connected to both the ureters and the urethra and functions similarly to a normal bladder. It may require intermittent catheterisation and bladder washouts to clear secretions from the small bowel tissue.

Question 185

WHat is Ureterosigmoidostomy

Answer 185

A ureterosigmoidostomy involves attaching the ureters directly to the sigmoid colon. Urine drains into and collects in the sigmoid colon. Techniques are used to prevent urine refluxing into the ureters or back through the large bowel. The rectum may be expanded to create a recto sigmoid pouch (called a Mainz II procedure) to create a larger space for urine to collect. The patient can then drain the urine by relaxing the anal sphincter in the same way they open their bowels.

This used to be used more often but is very rarely done now. It is associated with infection in the kidneys, electrolyte imbalances and secondary cancer at the anastomosis (join) between the ureters and sigmoid colon.

Question 186

Renal stones as also referred to as

Answer 186

renal calculi, urolithiasis and nephrolithiasis

Question 187

Kidney Stones

Two key complications are:

Answer 187

• Obstruction leading to acute kidney injury
• Infection with obstructive pyelonephritis

Question 188

Different types of Kidney Stones

Answer 188

Calcium-based stones are the most common type of kidney stone (about 80%). Having a raised serum calcium (hypercalcaemia) and a low urine output are key risk factors for calcium collecting into a stone. There are two types of calcium stones:

• Calcium oxalate (more common)
• Calcium phosphate

Other types of kidney stones include:

• Uric acid – these are not visible on x-ray
• Struvite – produced by bacteria, therefore, associated with infection
• Cystine – associated with cystinuria, an autosomal recessive disease

Question 189

What is Staghorn Calculus

Answer 189

A staghorn calculus is where the stone forms in the shape of the renal pelvis, giving it a similar appearance to the antlers of a deer stag. The body sits in the renal pelvis with horns extending into the renal calyces. They may be seen on plain x-ray films.

Most commonly, this occurs with stones made of struvite. In recurrent upper urinary tract infections, the bacteria can hydrolyse the urea in urine to ammonia, creating the solid struvite.

Question 190

Kidney Stones presentation

Answer 190

Renal stones may be asymptomatic and never cause an issue.

Renal colic is the presenting complaint in symptomatic kidney stones. Renal colic is:

• Unilateral loin to groin pain that can be excruciating (“worse than childbirth”)
• Colicky (fluctuating in severity) as the stone moves and settles

Patients often move restlessly due to the pain.

There may also be:

• Haematuria
• Nausea or vomiting
• Reduced urine output
• Symptoms of sepsis, if infection is present

Question 191

Investigations for Kidney Stones

Answer 191

Urine dipstick usually shows haematuria in cases of kidney stones. A normal urine dipstick does not exclude stones. Urine dipsticks are also helpful to exclude infection.

Blood tests help establish signs of infection and also kidney function. Checking the serum calcium helps identify hypercalcaemia that may have caused the kidney stone.

An abdominal x-ray can show calcium-based stones, but uric acid stones will not show up (they are radiolucent).

Non-contrast computer tomography (CT) of the kidneys, ureters and bladder (CT KUB) is the initial investigation of choice for diagnosing kidney stones. The NICE guidelines (2019) recommend a CT within 24 hours of the presentation.

Ultrasound of the kidneys, ureters and bladder (ultrasound KUB) is a less preferred alternative to CT scan. A negative result does not exclude kidney stones. It is less effective at identifying kidney stones but is helpful in pregnant women and children.

Question 192

Remember _________ as a cause of kidney stones

Answer 192

Remember hypercalcaemia as a cause of kidney stones

Question 193

Managment for Kidney Stones

Answer 193

NSAIDs are the most effective type of analgesia, for example, intramuscular diclofenac. IV paracetamol is an alternative, where NSAIDs are not suitable. Opiates are not very helpful for pain management and are not routinely used.

Antiemetics are used for nausea and vomiting (e.g., metoclopramide, prochlorperazine or cyclizine).

Antibiotics are required if infection is present.

Watchful waiting is usually used in stones less than 5mm, as there is a 50-80% chance they will pass without any interventions. It may also be suitable for patients with stones 5-10mm, depending on individual factors. It can take several weeks for the stone to pass.

Tamsulosin (an alpha-blocker) can be used to help aid the spontaneous passage of stones.

Surgical interventions are required in large stones (10mm or larger), stones that do not pass spontaneously or where there is complete obstruction or infection.

Question 194

Name some surgical Surgical Interventions for Kidney Stones

Answer 194

Extracorporeal shock wave lithotripsy (ESWL):

ESWL involves an external machine that generates shock waves and directs them at the stone under x-ray guidance. The shockwaves break the stone into smaller parts to make them easier to pass.

Ureteroscopy and laser lithotripsy:

A camera is inserted via the urethra, bladder and ureter, and the stone is identified. It is then broken up using targeted lasers, making the smaller parts easier to pass.

Percutaneous nephrolithotomy (PCNL):

PCNL is performed in theatres under a general anaesthetic. A nephroscope (small camera on a stick) is inserted via a small incision at the patient’s back. The scope is inserted through the kidney to assess the ureter. Stones can be broken into smaller pieces and removed. A nephrostomy tube may be left in place after the procedure to help drain the kidney.

Open surgery:

Open surgery can be used to access the kidneys and remove the stones. This is rarely needed as other, less invasive, methods are usually effective.

Question 195

Recurrent Stones

One episode of renal stones predisposes patients to further episodes. NICE guidelines (2019) recommend advising patients to:

Answer 195

• Increase oral fluid intake (2.5 – 3 litres per day)
• Add fresh lemon juice to water (citric acid binds to urinary calcium reducing the formation of stones)
• Avoid carbonated drinks (cola drinks contain phosphoric acid, which promotes calcium oxalate formation)
• Reduce dietary salt intake (less than 6g per day)
• Maintain a normal calcium intake (low dietary calcium might increase the risk of kidney stones)

Question 196

Kidney Stones

Other common recommendations include:

Answer 196

• For calcium stones – reduce the intake of oxalate-rich foods (e.g., spinach, beetroot, nuts, rhubarb and black tea)
• For uric acid stones – reduce the intake of purine-rich foods (e.g., kidney, liver, anchovies, sardines and spinach)
• Limit dietary protein

Question 197

Kidney Stones

Two medications that may be used to reduce the risk of recurrence are:

Answer 197

• Potassium citrate in patients with calcium oxalate stones and raised urinary calcium
• Thiazide diuretics (e.g., indapamide) in patients with calcium oxalate stones and raised urinary calcium

Question 198

most common type of kidney tumour?

Answer 198

Renal cell carcinoma (RCC)

Question 199

Renal cell carcinoma (RCC)

It is a type of _________ that arises from the renal tubules.

Answer 199

It is a type of adenocarcinoma that arises from the renal tubules.

Question 200

Renal Cell Carcinoma

Classic Triad?

Answer 200

The classic triad of presentation is haematuria, flank pain and a palpable mass.

Question 201

Types of Renal Cell Carcinoma

Answer 201

There are several subtypes of renal cell adenocarcinoma, the three most common being:

• Clear cell (around 80%)
• Papillary (around 15%)
• Chromophobe (around 5%)

s.

Question 202

______ _____ is a specific type of tumour affecting the kidney in children, typically under 5 year

Answer 202

Wilms’ tumour is a specific type of tumour affecting the kidney in children, typically under 5 year

Question 203

Risk Factors for Renal Cell Carcinoma

Answer 203

Smoking

Obesity

Hypertension

End-stage renal failure

Von Hippel-Lindau Disease

Tuberous sclerosis

Question 204

Renal cell carcinoma may be asymptomatic, but may present with:

Answer 204

Haematuria

Vague loin pain

Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)

Palpable renal mass on examination

Question 205

Explain 2 week wait referral for renal cell carinoma

Answer 205

The NICE guidelines on recognising cancer (last updated January 2021) advises a two week wait referral for those:

• Aged over 45 with unexplained visible haematuria, either without a UTI or persisting after treatment for a UTI

Question 206

Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava.

_________ ______ in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.

Answer 206

Renal cell carcinoma tends to spread to the tissues around the kidney, within Gerota’s fascia. It often spreads to the renal vein, then to the inferior vena cava.

“Cannonball metastases” in the lungs are a classic feature of metastatic renal cell carcinoma. These appear as clearly-defined circular opacities scattered throughout the lung fields on a chest x-ray.

LOOK up Cannonball metastases

Question 207

Remember cannonball metastases as originating from a renal cell carcinoma. It is worth looking at some images of cannonball metastases. They are an exam favourite and an easy question to get right if you know the answer. They can also appear with __________ (cancer in the placenta) and, less commonly, with prostate, bladder and endometrial cancer.

Answer 207

Remember cannonball metastases as originating from a renal cell carcinoma. It is worth looking at some images of cannonball metastases. They are an exam favourite and an easy question to get right if you know the answer. They can also appear with choriocarcinoma (cancer in the placenta) and, less commonly, with prostate, bladder and endometrial cancer.

Question 208

Renal cell carcinoma is associated with several paraneoplastic syndromes:

Answer 208

• Polycythaemia – due to secretion of unregulated erythropoietin
• Hypercalcaemia – due to secretion of a hormone that mimics the action of parathyroid hormone
• Hypertension – due to various factors, including increased renin secretion, polycythaemia and physical compression
• Stauffer’s syndrome – abnormal liver function tests (raised ALT, AST, ALP and bilirubin) without liver metastasis

Hypercalcaemia can also be caused by bony metastases.

Question 209

Staging

A CT thorax, abdomen and pelvis are used to stage the cancer.

The TNM staging system is the most common staging system for renal cell carcinoma, rating the T (tumour), N (lymph node) and M (metastasis) stages.

There is also a number staging system specific to renal cell carcinoma:

Answer 209

Stage 1: Less than 7cm and confined to the kidney

Stage 2: Bigger than 7cm but confined to the kidney

Stage 3: Local spread to nearby tissues or veins, but not beyond Gerota’s fascia

Stage 4: Spread beyond Gerota’s fascia, including metastasis

Question 210

Renal cell carcinoma

Surgery to remove the tumour is the first-line, where possible. This may involve:

Where patients are not suitable for surgery, less invasive procedures can be used to treat the cancer:

Answer 210

Surgery to remove the tumour is the first-line, where possible. This may involve:

• Partial nephrectomy (removing part of the kidney)
• Radical nephrectomy (removing the entire kidney plus the surrounding tissue, lymph nodes and possibly the adrenal gland)

Where patients are not suitable for surgery, less invasive procedures can be used to treat the cancer:

• Arterial embolisation, cutting off the blood supply to the affected kidney
• Percutaneous cryotherapy, injecting liquid nitrogen to freeze and kill the tumour cells
• Radiofrequency ablation, putting a needle in the tumour and using an electrical current to kill the tumour cells

Chemotherapy and radiotherapy may also be used.

Question 211

What is renal Transplant

Answer 211

A renal transplant is where a kidney is transplanted into a patient with end-stage renal failure. It typically adds 10 years to life compared with just using dialysis and also significantly improves quality of lif

Question 212

What is Donor Matching

Answer 212

Patients and donor kidneys are matched based on the human leukocyte antigen (HLA) type A, B and C on chromosome 6. They don’t have to match fully, but the closer the match, the less likely there is to be organ rejection and the better the outcomes. Recipients can receive treatment to desensitise them to the donor HLA when there is a living donor.

Question 213

Explain Renal Transplant Procedure

Answer 213

The patient’s own kidneys are left in place. The donor kidney blood vessels are connected (anastomosed) with the pelvic vessels, usually the external iliac vessels. The ureter of the donor kidney is anastomosed directly with the bladder. The donor kidney is placed anteriorly in the abdomen and can usually be palpated in the iliac fossa area. A “hockey stick” incision is typically used, and there will be a “hockey stick” scar.

Question 214

fter The Renal Transplant

The new kidney will start functioning immediately.

Patients will require life-long immunosuppression to reduce the risk of transplant rejection. The usual regime is:

Answer 214

• Tacrolimus
• Mycophenolate
• Prednisolone

Other possible immunosuppressants:

• Cyclosporine
• Sirolimus
• Azathioprine

Question 215

When examining a patient with a renal transplant, you can look particularly clever by looking for the side effects of particular immunosuppressant medications.

Name some

Answer 215

• Immunosuppressants often cause seborrhoeic warts and skin cancers (look for scars from skin cancer removal)
• Tacrolimus causes a tremor
• Cyclosporine causes gum hypertrophy
• Steroids cause features of Cushing’s syndrome

Question 216

Complications relating to the transplant

Answer 216

• Transplant rejection (hyperacute, acute and chronic)
• Transplant failure
• Electrolyte imbalances

Question 217

Complications related to immunosuppressants:

Answer 217

• Ischaemic heart disease
• Type 2 diabetes (steroids)
• Infections are more likely, more severe and may involve unusual pathogens
• Non-Hodgkin lymphoma
• Skin cancer (particularly squamous cell carcinoma)

Question 218

Unusual infections can occur secondary to immunosuppressant medication, such as

Answer 218

• Pneumocystis jiroveci pneumonia (PCP/PJP)
• Cytomegalovirus (CMV)
• Tuberculosis (TB)