Urology (x4) Flashcards
Outline the areas of the prostate
Central zone (wraps around the urethra)
Transition zone (area that increases in size during the life of a man, and causes obstruction of the urethra in a benign way)
Anterior fibromuscular zone
T/F prostate size correlates to cancer risk
F
What kind of diagnosis of BPH
Histological diagnosis
What are voiding symptoms and what are they due to
Poor flow, due to bladder outflow obstruction such as BPH/strictures
VOIDING SYMPTOMS Incl. Hesitancy Weak stream Intermittency Incomplete emptying Post-void dribbling
What are storage symptoms and what are they due to
Strong flow, detrusor overactivity due to incorrect brain signals causing bladder to contract
STORAGE SYMPTOMS
Frequency,
urgency,
nocutia
What happens to bladder and detrusor in bladder outflow obstruction leading to voiding symptoms
In order to generate the increased pressures required to void, the bladder detrusor muscle initially becomes hypertrophied, which leads to trabeculation. In the longer term replacement of muscle fibres with collagen results in loss of detrusor efficacy
Define lower urinary tract symptoms (LUTS)
Lower Urinary Tract Symptoms (LUTS) is a non-specific term for symptoms which may be attributable to lower urinary tract dysfunction (storage and voiding)
Define Benign Prostatic Enlargement (BPE)
the clinical finding of an enlarged prostate due to the histological process of benign prostatic hyperplasia
a histological diagnosis
Define Bladder Outflow Obstruction (BOO)
bladder outlet obstruction caused by benign prostatic enlargement (clinical finding)
Define Benign Prostatic Hyperplasia (BPH)
Benign Prostatic Hyperplasia (BPH) properly describes the histological basis of a diagnosis of benign prostatic enlargement (BPE) resulting in bladder outflow obstruction
Outline the international scoring system
What is it used for
The IPSS is a widely used, validated questionnaire covering the range of storage and voiding symptoms
Patients score each item from 0 to 5 according to the frequency with which the particular symptom is experienced
Total score will range from 0 to 35
The patients IPSS score should be re-evaluated over time to monitor disease progression and response to treatment
How is QoL assessed for prostate
The Bother score
Risk factors for BPH
Age Androgens Functional androgen receptors Obesity Diabetes (& elevated fasting glucose) Dyslipidaemia Genetic Afro-Caribbean
When taking a prostate history/examination?
LUTS IPSS questionnaire Frequency Volume chart Haematuria; Dysuria Full medical history (co-morbidities, drug history and family history) Examine abdomen – is bladder palpable? DRE!!!!
Which investigations for prostate
Urine dipstick (exclude infection)
Flow rate + POSTVOID RESIDUAL BLADDER SCAN in clinic
Blood tests (U&E, PSA – but need to counsel patient)
?Renal tract ultrasound
? Flexible cystoscopy
Common size compairsons to help assess prostate size
improve
Walnut
Ping pong
Golf
Clementine
Tennis
Obstructued flow is considered to be lower than what flow on urine flow measurements
<12ml per second
Treatment of voiding symptoms (i.e. BOO)
Conservative:
Reassure
Fluid intake advice (reduce evening fluid intake)
Medical management: Alpha blockers (Tamsulosin, Alfuzosin)
5 alpha-reductase inhibitors (Finasteride, Dutasteride)
Surgical management:
TURP (transurethral resection of the prostate)
(alternatively, rezum/steam, urolift (=staples), lazer surgery)
Possibly an anticholinergic if storage symptoms too but DON’T start with this (as it may relax the bladder too much on top of the already present voiding issues, causing acute urinary retention)
Why are 5a-reductase inhibitors give for prostate
improve
Inhibit testosterone production to shrink prostate
Management of storage problems (i.e. can’t store, i.e. detrusor overactivity)
Conservative management:
Reassure (& treat triggering UTI)
Dietary advice
Bladder Retraining Exercises (NICE recommended)
Medical management:
Anticholinergics (Oxybutinin, Detrusitol, Solifenacin)
Betmiga
Surgical management:
Intravesical Botox injection, (improve- but lasts for 6 months so you might need to catheterise for up to this time if surgery isn’t great)
(Bladder augmentation; urinary diversion/conduit)
Management of urinary retention
Catheterise
Dipstick/CSU
FBC, U & E (if they’ve been in high pressure retention then the pressure on the kidneys might have put them into renal failure, and they may then have an episode of diuresis)
Measure Residual Urine
Neurological examination if necessary
Prescribe - Antibiotics,
Laxatives, Alpha blocker if necessary
Types of short term and long term catheters
Simplastic (short term ) PTFE coated (short term Hydrogel coated (long term) Silicone (long term)
When would a 3 way catheter be used
To wash out any clots (it can be used to irrigate)
Differentiate acute and chronic urinary retention
Why is it important to check U&E in acute retention
Acute Retention (AUR) = painful
Chronic Retention (CUR)= postvoid residual >800ml
Chronic occurs over months or years
So both acute and chronic retention can be high or low pressure.
If the U&Es are affected, ti indicates there was high pressure retention which has caused renal failure.
Patients who have acute urinary retention with renal failure can have a large diuresis so need to be admitted, as they may need fluids
What is the management of low pressure retention (and how do you know it’s low pressure)
Normal U &Cr , no hydronephrosis
Consider starting alpha blockers and
Trial Without Catheter (TWOC) 1 week later
What is the management of high pressure retention (and how do you know it’s low pressure)
Raised U & Cr
Bilateral hydronephrosis.
ADMIT THEM
Measure urinary output, BP, body weight
They may need fluids if they have a large diuresis
Only < 10 % need fluid replacement
NEVER TWOC!
BOO Surgery or Longterm Catheter will be needed
What might you give for urgency in a voiding patient (even though urgency is a storage issue)
You might want to give anticholingergic for urgency
What is the most common cancer in males
Prostate cancer
Presenting symptoms of prostate cancer
Asymptomatic; raised PSA
LUTS
Urinary retention / renal failure
(Pain)
Haematuria
Bone pain/weight loss/ spinal cord compression (Mets)
Prostate caner risk factors
Age
Race (afro-caribbean heritage)
Family history
BRCA 2 gene
T/F PSA increases with age
T
Does PSA meet screening criteria?
PSA does not meet screening criteria – testing is informed decision process with GP or other clinician
Causes of raised PSA
BPH
Urinary Retention
Urine infection
Catheterisation / instrumentation of urethra
Prostate cancer
T/F DRE can significantly raise PSA
Digital rectal examination is not significant.
Don’t worry about doing DRE then sending for PSA blood test
Assessment of prostate cancer
Counselling
History – LUTS? Bone pain? Weight loss? Blood in urine?
Family history
Examination
DRE!
Check PSA (if high, then you should check urine to make sure it’s not a urine infection)
MRI scan (to differentiate high and low risk prostate cancer)
TRUS Biopsy
What can MRI scan add to the investigation of prostate cancer?
Can differentiate between high risk and low risk prostate cancer
Grade using PIRADS
A prostate cancer is identified as high risk using PIRADS scoring. What is the next step in the investigations
Then go onto have a biopsy to have a tissue diagnosis
A prostate cancer is identified as low risk using PIRADS scoring. What is the next step in the investigations
They can be reassured, they don’t need to have a biopsy.
They just need to have their PSA monitored
How is a biopsy taken from the prostate what is the risk
Transrectal ultrasound guided biopsy (TRUS).
But there is clearly a significant risk of sepsis as you’re going throuhg the rectum (1% end up hospitalised due to infection)
New techniques include transperineal biopsy
What happens to the biopsy
It is graded according to the gleason score
Outline the grading of prostate cancers according to gleason score
What about staging
Grading: Gleason score
Low riks 3+3
High risk 5+5
Staging: TNM
Where does prostate cancer metastasize to
Asymptomatic older male patient with raised PSA. How to manage.
Lymph nodes and bone
- Repeat PSA and check MSU (they may have a urine infection, which is a common cause of raised PSA, and the PSA may fall when the infection is resolved)
IF the PSA doesn’t come down,
- Send for MRI prostate and TRUS biopsy if necessary
Management of prostate cancer
So the patient has now had a biopsy and there is prostate cancer
Staging – MRI / Bone scan.
Managed by the MDT.
Options: Active surveillance (low risk low volume disease, but monitoring for increased disease)
Surgery – radical prostatectomy (robotic or laparoscopic)
Radical Radiotherapy
Watchful waiting (elderly / co-morbid patients)
Hormones (given LHRH agonist to shrink the prostate before radiotherapy)
Chemotherapy
When are hormone treatments most useful
In metastases
More minimally invasive treatments for prostate cancer
Surgery: laparoscopic, robotic
Radiotherapy
Brachytherapy
HIFU
Cryotherapy
Why has surgery for prostate cancer become unpopular
More bleeding
higher incontinence
Likely erectile dysfunction
May not die anyway
Hormonal therapy examples
Can be used in conjunction with radiotherapy or alone
LHRH agonist (e.g. Zoladex) (there is initially a rise in testosterone before it falls)
Anitandrogen
What is the risk with hormonal therapy
Beware tumour flare (a metastasis could become unstable)
This is because the testosterone actually increases at the beginning of LHRH agonist injections, so you give antiandrogen therapy in advance
The LHRH could actually cause the tumour to cause spinal cord compression during this time
Name of LHRH agonist
Zoladex
What causes spinal cord compression in prostate cancer
Due to vertebral bone metastases
Management of spinal cord compression
Start steroids (dexamethasone iv)
Urgent MRI
Suppress testosterone
Decompress cord with spinal surgery or radiotherapy (if you don’t decompress within 12 hrs they will end up in a wheelchair)
How is RRP followed up
PSA as followup post RRP
<0.01 in 6/52
Failure initial PSA >0.2
Early rapid rise indicates disease beyond prostate
Later slow rise local recurrance
Biopsy to confirm
Restage- bone scan /MRI
What do you do if there is a PS failure post RT
Nadir +2
Consider HIFU or salvage surgery
Hormones
What is the active surveillance
Gleeson 6 (?7)
Less than 2 cores
PSA <10
T1c or T2
PSA FU 3 monthly
MRI scan anually
Rebiopsy year 1,3 & 7
When should you treat prostate cancer on active surveillance
PSA >10 PSA dt <3 years Grade progression on rebiopsy Clinical progression Patient choice
Where can PSA monitoryong be done
Post radical treatment- radiotherapy/surgery
On Hormones
Cancer- watchful waiting
Raised PSA after MRI and/or biopsies
Active surveillance – in secondary care as requires regular MRI and re-biopsy
What s a hydrocele
Fluid within Tunica vaginalis
Can get above it
Transilluminates!
Treatment of hydrocele
Surgical repair if large
What is epididymitis (orchitis) and what are the causes
Infection of epididymis or testis or both
Causes
STIs
UTIs
Post-operative
Who does testicular affect
Younger men
Types of testicular cancer
Germ Cell
- Seminomatous
- Non-seminomatous
Non-Germ Cell
Why is sperm banking done before surgery for testicular cancer
testicular cancer likely to affect the single testicle, but subsequent chemo/radio can affect fertility
What operation is done in testicular cancer
Radical Inguinal Orchidectomy +/- Prosthesis (does the patient want one?)
Post op care for radical inguinal orchitectomy
Surveillance +- chemotherapy (BEP) +- Radiotherapy +-RPLND
Causes of haematuria
Infection Cancer Medical Trauma (kidney stones)
What does a three way catheter help with in haematuria
Irrigate the bladder and filter out the clots (stops the catheter being blocked by clots in the bladder)
What is the management of haematuria
Resuscitate incl. transfusion 3 way catheter Hx Ex Bloods incl. Clotting and G&S; KUB MSU
Why are you going to be caustious about putting suprapublic catheter in with haematuria
Could spread a bladder cancer into the abdminal wall
Criteria for admission in haematuria
Frank haematuria with clots
Drop in Hb
Social circumstance
Role of haematuria clinic
2 week rule
One-stop
Haematuria- irrigation and theatre?
ivi Transfuse if necessary Thorough bladder washout Continuous irrigation May need clot evacuation in theatre Monitor closely and review regularly
Investigations for haematuria
FBC, clotting, U&E
MSU MC&S
Urine cytology / NMP22 ?
CT Urogram or KUB, U/S
Flexible cystoscopy (will show a bladder tumour)
What type of cancers are bladder cancers
90% are adenocarcinoma, 10% are transition cell cancer
Follow up issues for haematura
Blocked catheters
Persistant haematuria
UTI / Antibiotics
Who are renal stones most common in
More common in caucasian men
What should you consider for family history for renal stones
CYSTINURIA
What predisposes you to renal stones
Anatomical and biochemical Factors
Why are renal stones important
Obstruction can lead to hydronephrosis and renal impairment
Painful
Infection (life threatening gram -ve sepsis)
Can indicate underlying metabolic problem
Underlying anatomical problems
What underlying metabolic problems might lead to kidney stones
Hyperparathyroidism, gout, cysteinuria
Underlying anatomical problems leading to renal stones
(eg. PUJ-o, MSK, Horseshoe kidney, ureteric stricture)
Classification of stones
Size, location, xray characteristics, stone composition
Outline classification of stones by size
<5mm; 5-20mm; >20mm; staghorn
Outline classification of stones by location
Renal (calyceal, pelvic, diverticular); Ureteric
Outline classification of stones by x-ray characteristics
radiolucent; radioopaque
Outline classification of stones by stone composition
CaOx, CaP, Uric acid, cysteine, indinavir; Infection MAP/Struvite
Diagnosis of renal stones
Hx
Ex (will be a soft abdomen)
Bloods, Urine dip (RBC, WBC, Nitrites, pH) & MSU
Imaging: KUB (gold standard) / US (won’t pick up uteric stones)/ CT-KUB / IVU
When do you need immediate imaging for renal stones
Fever
solitary kidney
diagnosis unclear
Presentation of uteric colic
Loin pain, Soft abdo, Mic haem 85%
When is uteric colic an emergency
SEPSIS
Causes of uteric colic
Stones, TCC, blood clot, RPF, ?BPH/CaP
Differential diagnosis for uteric colic
AAA Testicular torsion Perforated PU Appendicitis Ruptured ectopic MI Diverticulitis Prostatitis
Uteric colic in a&e
- Analgesia: 5-10mg Morphine iv +/- antiemetic
(Diclofenac if creatinine normal) - Basic Investigations:
FBC/U+E, Ca, Urate, Urine dipstick, ßHCG (♀) - Radiological Investigations:
plain both KUB and CT KUB
Drug for helping passing stone
A blocker (controversial)
General advice for renal stones
High fluid intake – urine champagne colour
Normal diet – do not cut out dairy products (milk can bind oxalate in the gut)
When to attend a&e with renal stones
Pain not controlled by analgesia
PYREXIA
Treatment of stones
Conservative
Medical / Metabolic
ESWL
Ureteroscopy
PCNL
When can a stone be dissolved
Uric acid (with potassium citrate)
Outline conservative renal stone management
Observe asymptomatic non-obstructive renal stones in selected patients
incl. Metabolic screen
Outline medical renal stone management
Alkalinise / acidify urine
Treat / prevent UTIs
Allopurinol?
Outline surgical renal stone management
Uretero-renoscopy +- laser
ESWL
PCNL
(Lap / Open)
What is ESWL lithotripter
….
When would you do a PCNL: percutaneous nephrolithotomy
If the stone is in the kidney and more than 2cm
Follow up issues with renal stones
Renal deterioration after 2-6 weeks if complete obstruction: danger in losing kidney
JJ stent encrustation <6 months in stone formers!
50% patients will have recurrent stones: fluid intake advice
40% of conservatively managed renal stones will enlarge – monitor by imaging & RF
What is obstructive pyelonephrosis
Why is it dangerous
= Obstruction + infection
Risk of fatal GRAM –ve sepsis
How to manage obstructive pyonephrosis
Immediate resuscitation + iv antibiotics Culture Urgent imaging (KUB & U/S) Discuss with urology SpR Consider urgent nephrostomy (or JJ stent) Monitor closely (HDU)
Futher treatment of obstructive pyonephrosis
Imaging to determine cause CT KUB Nephrostogram Antegrade stent Plan ureteroscopy / ESWL / PCNL
May need drainage if perinephric abscess
May need nephrectomy if XGP or EPN
DDx testiscular torsion
Torted appendix testis, epididymitis, viral orchitis, bleed into testicular tumour
With torted appendix testis… usually cannot distinguish from testicular torsion
Blue dot sign
Manage conservatively only if confident of diagnosis
When is testicular torsion rare beyond
Rare beyond 35y of age
What underlying deformity predisposes testicular torsion
Underlying deformity:
extension of tunica vaginalis behind testicle clapper bell
Presentation of testicular torsion
Sudden onset
Ex: swollen, tender, high riding (contralat horiz)
Loss of cremateric reflex in children
Investigation for testicular torsion
: MSU (urgent microscopy if Sy suggest UTI/epididymitis)
