Week 3 - Urology Cases of the Week - UTI and BPH

Question 1

63 year old presents with haematuria, palpable suprapubic mass dull to percuss and nocturia

What do you think is the cause and what do you carry out?

Answer 1

Think prostate hyperplasia

Need to order PSA test and then carry out a PR examination to see what is the cause of the distension

Question 2

Israel triad – haematuria (50-60%), pain, kidney mass

What did the israel triad used to be for?

Answer 2

For renal cell carcinoma but not really reliable - need a massive tumour for it to be palpable

Question 3

What are the two most associated cause with haematospermia?

Answer 3

This would be benign prostate hyperplasia and prostatic malignancy

Question 4

It is important to understand if the haematuria occurs at the start of the urine production, throughout or at the end

What do each suggest for the location of the cause?

Answer 4

Start - likely to be a urethral problem

Throughout - likely to be a kidney, ureter or bladder problem

At the end - likely to be a prostate problem

Question 5

Clinical Problem
Mr Nash, aged 64 makes an urgent appointment to see you, his GP, on a Monday morning because since the previous Saturday night he has been having fever, pain in his back, very frequent micturition and burning throughout the urinary stream

Learning Issues

What specific questions would you ask him to get further details about his presenting symptoms? What would you ask about his urinary function before this episode?

Answer 5

Ask about the assoicated symtoms? does anything make it worse or better? sexual contact?
Have you taken anything for pain relief? Is it keeping you for sleeping? (gives indicator of severity)

Make sure to rule out sepsis so ask about rigors and carry out sews

Would like to ask how this is different from his urinary function before hand

Question 6

What specific features would you look for on clinical examination? Which simple clinical test would you first do in your surgery? in this patient?

Answer 6

In this patinet look for loin pain when palpating, see if palpatable bladder and dull to percuss and rebound tenderness

Carry out a urinalysis in this patinet

Question 7

What does rebound tenderness suggest?

Answer 7

(initial pressure does not cause pain but when the examining hand is released, pain is felt).

Can suggest kidney stones in renal

Peritoneal infection in GI

Question 8

What abnormalities may be seen on urinalysis?
What do you thinn the patient may have?
Why is it important if there is protein/glucose in urinalysis?

Answer 8

Raised leukocyte count - due to the WBC trying to fight infection
Nitrites - bacteria break down nitrates into nitrites

Blood - haematuria due to presence of infection

Protein/glucose - important as the kidneys should not filter these so can suggest inflammation of the glomerulus

Question 9

Which bacteria that can cause urinalysis will not show the presence of nitrites?

Answer 9

Enterococcus - doesnt break down nitrates

Question 10

 Which simple laboratory test would you request at this stage? - to know if kidneys are functioning

Answer 10

Would request ureas and electrolytes to ensure that the kidneys are working
(electorlytes - includes creatinine)

Question 11

 Which organisms would you expect to have been present? (if patient has a UTI)

Answer 11

E.coli
Klebsiella

Proteus

(enterococcus and pseudomonas are less likely)

Question 12

 Would you start any treatment at this stage? (after the urinalysis and sending away urine for culture)

Answer 12

Probably start patient on trimethoprim

Question 13

Which organism is associated with the formation of renal calculi?

Answer 13

Proteus

Question 14

What is the most common type of renal calculi and which type is caused by proteus?

Answer 14

Calcium stones are the most common

Struvite stones are caused by proteus

Question 15

 48 Hours later Mr Nash is no better. Urine culture shows >105 organisms per ml proteus.

 You decide to refer him to the local urology department.
 What simple initial tests would you expect them to carry out?

Answer 15

Would expect a non contrast CT to detect for renal stones

Also could carry out an ultrasound

Question 16

Investigations show a stone in the left kidney, an enlarged benign prostate gland and a residual urine volume of 300 ml.
 What is the significance of each of these abnormal findings in the causation of Mr Nash’s initial presentation

Answer 16

The enlarged prostate in the patient could have caused urinary retention

This increases the risk of infection

Probably infected by the organsim proteus which lead to the formation of renal stones - the proteus may be resitant to the trimethroprim treatment

Question 17

Since it has been discovered that the patinet is a complicated patient

What is the treatment of his UTI?

Answer 17

Give IV amoxicillin and gentamicin

Question 18

Clinical Problem
Mr White - age 67 presents with a year-long history of slowing of his urinary stream, hesitancy

and nocturia x3.

Learning Issues

List the questions you would like to ask to assess the severity of this man’s

complaint and the likely cause for his symptoms.

Answer 18

How long for hesitancy, is there any dribbling or spit flow, increased frequency, how much are you able to void? Was this a gradual presentation? Why have you decided to see the doctor after a year of these symptoms?

Question 19

Carry out a PR exam and an abdominal exam for overflow incontinence in this patient

If the GP suspects it is malignant, what would be carried out before digital rectal examination?

Answer 19

A PSA test

Question 20

Mr White has read a lot recently about prostate cancer and asks if you can tell him if
he has prostate cancer or not.

Which two “investigations” might help you to decide on this?

Answer 20

Cary out a PSA examination/DRE and a TRUS (transrectal USS guided) biopsy

Question 21

After appropriate assessment a diagnosis of bladder outflow obstruction, secondary
to benign prostatic hyperplasia is made.

Make a list of the treatment options.

(patinet is shown to have bother so dont bother with watchful waiting)

Answer 21

1 - give an alpha blocker (tamulosin)

Can also give NSAID or finasteride (5-alpha reductase inhibitor)

Question 22

what is benign prostatic hyperplasia or hypertrophy? symptoms? diagnosis? treatment?

Answer 22

formation of large nodules in the prostate which cause compress the urethra, causing obstruction.
Symptom: urinary frequency, urgency incontinence, voiding at night

Diagnosis: rectal exam

treatmetn: alpha blocker and 5-alpha reductase inhibitors, surgery.