Urology Surgery Flashcards
1
Q
What is Obstructive Uropathy
A
The term obstructive uropathy refers to a blockage preventing urine flow through the ureters, bladder and urethra.
2
Q
The key structures of the urinary tract are the:
A
- 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)
3
Q
It is worth being familiar with the basic anatomy of the kidney. From the outside in, the basic structures are the:
A
Cortex
Medulla
Pyramids and columns
Major and minor calyx (pleural: calyces)
Renal pelvis
Pelviureteric junction (PUJ)
Ureter
4
Q
What does Obstructive Uropathy leads to
A
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
5
Q
Swelling of the kidney is known as ____________
__________ ____ ___ refers to urine refluxing from the bladder back into the ureters.
A
Swelling of the kidney is known as hydronephrosis.
Vesicoureteral reflux (VUR) refers to urine refluxing from the bladder back into the ureters.
6
Q
When obstructive uropathy leads to an acute reduction in kidney function, it is referred to as a….
A
When obstructive uropathy leads to an acute reduction in kidney function, it is referred to as a “post-renal” acute kidney injury (AKI)
7
Q
Whenever someone asks you the cause of renal impairment, always answer:
A
“the causes are pre-renal, renal or post-renal”. This will impress them and allow you to think through the causes more logically.
8
Q
WHat is pre-renal AKI caused by?
A
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).
9
Q
An upper urinary tract obstruction (i.e. in the ureters) presents with:
A
- 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)
10
Q
Lower urinary tract obstruction (i.e. in the bladder or urethra) presents with:
A
- 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)
11
Q
An ________ of the kidneys, ureters and bladder can be helpful in diagnosing obstructive uropathy
A
An ultrasound of the kidneys, ureters and bladder can be helpful in diagnosing obstructive uropathy
12
Q
The word loin referred to as?
A
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
13
Q
What does loin to groin pain mean
What pathology suggest
A
“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.
14
Q
. The “renal angle”, also called the “costovertebral angle”, refers to
A
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.
15
Q
Common Causes
Upper urinary tract obstruction
A
- 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)
16
Q
Common Causes
Lower urinary tract obstruction:
A
- Benign prostatic hyperplasia (benign enlarged prostate)
- Prostate cancer
- Bladder cancer (blocking the neck of the bladder)
- Urethral strictures (due to scar tissue)
- Neurogenic bladder
17
Q
What does Neurogenic Bladder mean
A
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.
18
Q
Neurogenic Bladder
Key causes are:
A
- Multiple sclerosis
- Diabetes
- Stroke
- Parkinson’s disease
- Brain or spinal cord injury
- Spina bifida
19
Q
Neurogenic bladder can result in a variety of problems, including:
A
- Urge incontinence
- Increased bladder pressure
- Obstructive uropathy
20
Q
A n_________ may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone)
A
A nephrostomy may be used to bypass an obstruction in the upper urinary tract (e.g., a ureteral stone)
21
Q
What is nephrostomy
A
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.
22
Q
A _______ __ _______ _____ may be used to bypass an obstruction in the lower urinary tract (e.g., a urethral stricture or prostatic hyperplasia).
A
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).
23
Q
What is a urethral/suprapubic catheter
A
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.
24
Q
Complications of Obstructive Uropathy
A
- 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
25
WHat is Hydronephrosis
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.
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 (\_\_\_\_\_\_\_\_).
**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**).
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)
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)
28
Treatment of hydronephrosis involves treating the underlying cause. If required, pressure can be relieved with either:
* **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
29
Indications Urinary Catheter
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)
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).
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).
31
What is A common presentation requiring catheterisation
WHat do you start these patients on
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.
32
Urethral catheters are inserted through the urethra into the bladder. There are various types:
* **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
33
\_\_\_\_\_\_\_ ________ are inserted through the abdomen into the bladder, just above the pubic symphysis, under local anaesthetic
**Suprapubic catheters** are inserted through the abdomen into the bladder, just above the pubic symphysis, under local anaesthetic
34
The catheter you will see most often on the wards and in OSCEs is the ____ catheter (two-way catheter).
The catheter you will see most often on the wards and in OSCEs is the **Foley** catheter (two-way catheter).
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.
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.
36
What is Trial Without Catheter
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.
37
There are NICE guidelines on catheter-associated urinary tract infections from 2018, please see the full guidelines when treating patients.
Explain management
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).
38
What is Benign Prostatic Hyperplasia
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.
39
Lower Urinary Tract Symptoms
There are typical lower urinary tract symptoms (LUTS) that occur with prostate pathology:
* **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
40
The international _____ \_\_\_\_ __________ \_\_\_ is a scoring system that can be used to assess the severity of lower urinary tract symptoms
The international **prostate symptom score (IPSS)** is a scoring system that can be used to assess the severity of lower urinary tract symptoms
41
The initial assessment of men presenting with LUTS involves:
* **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
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.
**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.
43
Common causes of a raised PSA are:
* Prostate cancer
* Benign prostatic hyperplasia
* Prostatitis
* Urinary tract infections
* Vigorous exercise (notably cycling)
* Recent ejaculation or prostate stimulation
44
Benign Prostatic Hyperplasia
Prostate Examination Findings
* 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
45
BPH Management
The medical options are:
* **Alpha-blockers** (e.g., **tamsulosin**) relax smooth muscle, wit**h rapid improvement in symptoms**
* **5-alpha reductase inhibitors** (e.g., **finasteride**) gradually reduce the size of the prostate
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.
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.
47
BPH
The surgical options are:
* 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
48
The notable side effect of alpha-blockers like tamsulosin is
postural hypotension.
49
The most common side effect of finasteride
sexual dysfunction (due to reduced testosterone).
50
What is Transurethral Resection of the Prostate
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
51
Major complications of Transurethral Resection of the Prostate TURP
* Bleeding
* Infection
* Urinary incontinence
* Erectile dysfunction
* Retrograde ejaculation (semen goes backwards and is not produced from the urethra)
* Urethral strictures
* Failure to resolve symptoms
52
Other Surgical Options for BPH
**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.
53
Prostatitis refers to inflammation of the prostate. It can be classed as:
* **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
54
Chronic prostatitis may be sub-divided into:
* Chronic prostatitis or chronic pelvic pain syndrome (no infection)
* Chronic bacterial prostatitis (infection)
55
The cause of inflammation and pain in chronic prostatitis is unclear. It may be initially triggered by
an infection, with inflammation persisting after the infection has resolved.
56
Chronic prostatitis presents with at least 3 months of:
* **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)
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:
* Fever
* Myalgia
* Nausea
* Fatigue
* Sepsis
58
What is National Institute of Health Chronic Prostatitis Symptom Index
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
59
Investigations of Prostatitis
* **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.
60
Management of acute bacterial prostatitis:
* **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
61
Management of chronic prostatitis (adapted from NICE CKS, updated 2019):
* **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
62
The complications of acute bacterial prostatitis are:
* Sepsis
* Prostate abscess (may be felt as a fluctuant mass and requires surgical drainage)
* Acute urinary retention
* Chronic prostatitis
63
The key risk factors for prostate cancer are:
* Increasing age
* Family history
* Black African or Caribbean origin
* Tall stature
* Anabolic steroids
64
Presentation of Prostate Cancer
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)
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
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
66
PSA testing is unreliable, with a high rate of false positives (75%) and false negatives (15%).
Common causes of a raised PSA are:
Prostate cancer
Benign prostatic hyperplasia
Prostatitis
Urinary tract infections
Vigorous exercise (notably cycling)
Recent ejaculation or prostate stimulation
67
Explain false postitives and false negatives in prostate cancer?
**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.
68
Examination findings of a benign prostate
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.**
69
Examination Findings
An infected or inflamed prostate (prostatitis)
may be enlarged, tender and warm.
70
Examinations of a cancerous prostate
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.
71
What is first line for prostate cancer?
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
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).
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).
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.
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.
74
There are two options for prostate biopsy:
**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.
75
The main risks of a prostate biopsy are:
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)
76
An _______ \_\_\_\_\_ _____ (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.
An **isotope bone scan** (also called a radionuclide scan or bone scintigraphy) can be used to look for bony metastasis.
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.
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.
78
What is
Gleason Grading System
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).
79
The Gleason score will be made up of two numbers added together for the total score (for example, 3 + 4 = 7):
* 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
80
A Gleason score of:
explain scoring system
* 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
81
The TNM staging system can be used for prostate cancer, rating the T (tumour), N (lymph nodes) and M (metastasis)
**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
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:
* Surveillance or watchful waiting in early prostate cancer
* External beam radiotherapy directed at the prostate
* Brachytherapy
* Hormone therapy
* Surgery
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.
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.
84
What is Brachytherapy
**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.
85
Aim of Hormone therapy Prostrate Cancer
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.
86
Hormone therapy for prostrate cancer
* **Androgen-receptor blockers** such as bicalutamide
* **GnRH agonists** such as goserelin (Zoladex) or leuprorelin (Prostap)
* **Bilateral orchidectomy** to remove the testicles (rarely used)
87
Side effects of hormone therapy include:
* Hot flushes
* Sexual dysfunction
* Gynaecomastia
* Fatigue
* Osteoporosis
88
WHat is Radical prostatectomy
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.
89
WHat is Epididymo-orchitis
is usually the result of infection in the epididymis and testicle on one side.
90
Basic physiology of sperm
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.
91
Causes Epididymo-orchitis
* 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.
92
Epididymo-orchitis typically presents with a gradual onset, over minutes to hours, with unilateral:
* 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
93
The key differential diagnosis for epididymo-orchitis is
The key differential diagnosis for epididymo-orchitis is **testicular torsion**
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.
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.
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):
* Age under 35
* Increased number of sexual partners in the last 12 months
* Discharge from the urethra
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Epididymo-orchitis
Investigations to help establish the diagnosis are:
* **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
97
Management for Epididymo-orchitis
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**.
98
Epididymo-orchitis
For patients that are at a low risk of STIs, a typical choice is:
Ofloxacin (usually first-line) for 14 days
99
Alternatives Treatment for Epididymo-orchitis
* Levofloxacin / ciprofloxacin
* Doxycycline
* Co-amoxiclav
100
Epididymo-orchitis
Additional measures:
* Analgesia
* Supportive underwear
* Reduce physical activity
* Abstain from intercourse
101
\_\_\_\_\_\_\_\_\_\_ ______ such as ofloxacin, levofloxacin and ciprofloxacin are powerful broad-spectrum antibiotics, often used for urinary tract infections, pyelonephritis, epididymo-orchitis and prostatitis.
**Quinolone antibiotics** such as ofloxacin, levofloxacin and ciprofloxacin are powerful broad-spectrum antibiotics, often used for urinary tract infections, pyelonephritis, epididymo-orchitis and prostatitis.
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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:
* Tendon damage and tendon rupture, notably in the Achilles tendon
* Lower seizure threshold (caution in patients with epilepsy)
103
Complications
Epididymo-orchitis can lead to:
* Chronic pain
* Chronic epididymitis
* Testicular atrophy
* Sub-fertility or infertility
* Scrotal abscess
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What is Testicular Torsion
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.
105
Testicular torsion is often triggered by
activity, such as playing sports. Ask what the patient was doing at the time when the pain started.
106
Testicular torsion presents with
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.
107
Examination findings testicular torsion
* 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.
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What is Bell-Clapper Deformity
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.
109
Management
Testicular torsion
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
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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.
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.
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The key causes of scrotal or testicular lumps are:
* Hydrocele
* Varicocele
* Epididymal cyst
* Testicular cancer
* Epididymo-orchitis
* Inguinal hernia
* Testicular torsion
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What is a hydrocele
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.
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Examination findings with a hydrocele are:
* 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)
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Hydroceles can be idiopathic, with no apparent cause, or secondary to:
* Testicular cancer
* Testicular torsion
* Epididymo-orchitis
* Trauma
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Management hydroceles
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.
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WHat is Varicocele
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
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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.**
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.**
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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
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
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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.
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.
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Varicoceles may present with:
Examination Findings
* 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
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\_\_\_\_\_\_\_\_\_ 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.
**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.
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Varicoceles
Investigations to consider are:
* 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
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Management of Variocele
Uncomplicated cases can be managed conservatively.
Surgery or endovascular embolisation may be indicated for pain, testicular atrophy or infertility.
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WHat are Epididymal Cysts
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.
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Epididymal Cysts
Examination findings are:
* 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)
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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.
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.
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Testicular cancer is more common in
younger men, with the highest incidence between 15 and 35 years.
128
Testicular cancer can be divided into two types:
* Seminomas
* Non-seminomas (mostly teratomas)
129
Testicular Cancer
Risk Factors
* Undescended testes
* Male infertility
* Family history
* Increased height
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Presentation Testicular Cancer
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
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Rarely, ___________ can be a presentation of testicular cancer, particularly a rare type of tumour called a Leydig cell tumour.
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.
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Testicular Cancer
Ix
**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.
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Royal Marsden Staging System
Testicular cancer is staged with the Royal Marsden staging system:
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
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The common places for testicular cancer to metastasise to are:
* Lymphatics
* Lungs
* Liver
* Brain
135
Management for testicular cancer
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
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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:
* Infertility
* Hypogonadism (testosterone replacement may be required)
* Peripheral neuropathy
* Hearing loss
* Lasting kidney, liver or heart damage
* Increased risk of cancer in the future
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Prognosis
Testicular cancer
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.**
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Lower urinary tract infections (UTIs) involve infection in the bladder, causing
cystitis (inflammation of the bladder).
139
UTIs can spread to the kidneys and cause
pyelonephritis.
140
Who are UTIs more common in
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.
141
Lower urinary tract infections present with:
* 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
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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:
* Fever
* Loin/back pain
* Nausea/vomiting
* Renal angle tenderness on examination
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Indications on urine dipstick for UTI
Postives for nitrates, leukocytes and blood
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\_\_\_\_\_\_\_\_ ______ is tested on a urine dipstick, which is a product of leukocytes and indicates the number of leukocytes in the urine.
**Leukocyte esterase** is tested on a urine dipstick, which is a product of leukocytes and indicates the number of leukocytes in the urine.
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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:
* Pregnant patients
* Patients with recurrent UTIs
* Atypical symptoms
* When symptoms do not improve with antibiotics
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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:
* Klebsiella pneumoniae (gram-negative anaerobic rod)
* Enterococcus
* Pseudomonas aeruginosa
* Staphylococcus saprophyticus
* Candida albicans (fungal)
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UTI -Abx
Follow local guidelines. An appropriate initial antibiotic in the community would be:
* Trimethoprim (often associated with high rates of bacterial resistance)
* Nitrofurantoin (avoided in patients with an eGFR \<45)
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Alternatives for UTIs management of trimethoprim or nitrofurantoin
* Pivmecillinam
* Amoxicillin
* Cefalexin
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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
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
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Urinary tract infections in pregnancy increase the risk of
pyelonephritis, premature rupture of membranes and pre-term labour.
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Management in Pregnancy UTI
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
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\_\_\_\_\_\_\_\_\_ 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.
**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.
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What is Pyelonephriti
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).
154
Risk factors for pyelonephritis are:
* Female sex
* Structural urological abnormalities
* Vesico-ureteric reflux (urine refluxing from the bladder to the ureters – usually in children)
* Diabetes
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Causes of Pyelonephritis
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)
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Presentation of Pyelonephritis
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
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Pyelonephritis Ix
* **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.
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Management of Pyelonephritis
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)
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Patients admitted to hospital with sepsis require the sepsis six; with three tests and three treatments
What are these
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
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Pyelonephritis
Two things to keep in mind with patients that have significant symptoms or do not respond well to treatment are:
* Renal abscess
* Kidney stone obstructing the ureter, causing pyelonephritis
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What is Chronic Pyelonephritis
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.
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\_\_\_\_\_\_\_\_\_\_\_ ____ 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.
**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.
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Interstitial cystitis is a chronic condition causing inflammation in the bladder, resulting in lower urinary tract symptoms and suprapubic pain. It is also called ....
bladder pain syndrome and hypersensitive bladder syndrome
164
Interstitial cystitis
Presentation
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
165
Interstitial Cystitis
Other causes of symptoms need to be excluded, with:
Urinalysis for urinary tract infections
Swabs for sexually transmitted infections
Cystoscopy for bladder cancer
Prostate examination for prostatitis, hypertrophy or cancer
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.
**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.
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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.
## Footnote
Supportive management is used initially:
* Diet changes such as avoiding alcohol, caffeine and tomatoes
* Stopping smoking
* Pelvic floor exercises
* Bladder retraining
* Cognitive behavioural therapy
* Transcutaneous electrical nerve stimulation (TENS)
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;
* 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)
*
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:
* Lidocaine
* Pentosan polysulfate sodium
* Hyaluronic acid
* Chondroitin sulphate
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.
**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.
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:
* 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)
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Bladder Cancer
Cancer in the bladder arises from the endothelial lining (\_\_\_\_\_\_\_\_\_\_). The majority are __________ at presentation.
Cancer in the bladder arises from the endothelial lining (**urothelium**). The majority are **superficial** (not invading the muscle) at presentation.
173
Bladder Cancer
Risk Factors
## Footnote
**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.
174
Typical presentation of bladder cancer
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.
175
Types of bladder cancer
* Transitional cell carcinoma (90%)
* Squamous cell carcinoma (5% – higher in areas of schistosomiasis)
* Rarer causes are adenocarcinoma (2%), sarcoma and small-cell carcinoma
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:
**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
177
The NICE guidelines also recommend considering a non-urgent referral in people over 60 with .......
The NICE guidelines also recommend considering a non-urgent referral in people over 60 with **recurrent unexplained UTIs.**
178
Diagnosis of Bladder Cancer
**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.
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
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.
180
Treatment Options for bladder cancer
**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.
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Radical cystectomy involves the removal of the entire bladder. Following removal of the bladder, there are several options for draining urine:
* Urostomy with an ileal conduit (most common)
* Continent urinary diversion
* Neobladder reconstruction
* Ureterosigmoidostomy
Chemotherapy and radiotherapy may also be used.
182
What is Urostomy
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
183
What is Continent Urinary Diversion
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.
184
What is Neobladder Reconstruction
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.
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WHat is Ureterosigmoidostomy
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.
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Renal stones as also referred to as
renal calculi, urolithiasis and nephrolithiasis
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Kidney Stones
Two key complications are:
* Obstruction leading to acute kidney injury
* Infection with obstructive pyelonephritis
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Different types of Kidney Stones
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
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What is Staghorn Calculus
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.
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Kidney Stones presentation
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
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Investigations for Kidney Stones
**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.
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Remember _________ as a cause of kidney stones
Remember **hypercalcaemia** as a cause of kidney stones
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Managment for Kidney Stones
**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 i**s 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.
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Name some surgical Surgical Interventions for Kidney Stones
**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.
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Recurrent Stones
One episode of renal stones predisposes patients to further episodes. NICE guidelines (2019) recommend advising patients to:
* 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)
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Kidney Stones
Other common recommendations include:
* 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
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Kidney Stones
Two medications that may be used to reduce the risk of recurrence are:
* 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
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most common type of kidney tumour?
Renal cell carcinoma (RCC)
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Renal cell carcinoma (RCC)
It is a type of _________ that arises from the renal tubules.
It is a type of **adenocarcinoma** that arises from the renal tubules.
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Renal Cell Carcinoma
Classic Triad?
The classic triad of presentation is haematuria, flank pain and a palpable mass.
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Types of Renal Cell Carcinoma
There are several subtypes of renal cell adenocarcinoma, the three most common being:
* Clear cell (around 80%)
* Papillary (around 15%)
* Chromophobe (around 5%)
s.
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\_\_\_\_\_\_ _____ is a specific type of tumour affecting the kidney in children, typically under 5 year
**Wilms’ tumour** is a specific type of tumour affecting the kidney in children, typically under 5 year
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Risk Factors for Renal Cell Carcinoma
Smoking
Obesity
Hypertension
End-stage renal failure
Von Hippel-Lindau Disease
Tuberous sclerosis
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Renal cell carcinoma may be asymptomatic, but may present with:
Haematuria
Vague loin pain
Non-specific symptoms of cancer (e.g., weight loss, fatigue, anorexia, night sweats)
Palpable renal mass on examination
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Explain 2 week wait referral for renal cell carinoma
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
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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.
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
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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.
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.
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Renal cell carcinoma is associated with several paraneoplastic syndromes:
* **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.
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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:
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
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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:
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.
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What is renal Transplant
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
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What is Donor Matching
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.
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Explain Renal Transplant Procedure
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.**
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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:
* Tacrolimus
* Mycophenolate
* Prednisolone
Other possible immunosuppressants:
* Cyclosporine
* Sirolimus
* Azathioprine
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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
* 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
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Complications relating to the transplant
* Transplant rejection (hyperacute, acute and chronic)
* Transplant failure
* Electrolyte imbalances
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Complications related to immunosuppressants:
* 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)
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Unusual infections can occur secondary to immunosuppressant medication, such as
* Pneumocystis jiroveci pneumonia (PCP/PJP)
* Cytomegalovirus (CMV)
* Tuberculosis (TB)
