Urology Flashcards
(42 cards)
What are the causative organisms of a UTI?
Most occur through the introduction of gut flora into the urethra. Usually caused by E. coli (80%). Other infectious agents include Proteus mirabilis, Klebsiella and Enterococci.
What are the clinical features of a UTI?
Patients may be clinically asymptomatic.
Cystitis: Frequency, urgency, dysuria (pain on micturition), haematuria, suprapubic pain and smelly urine. On examination, patient may have suprapubic/abdominal/flank tenderness, or may have bladder distention.
Pyelonephritis: Fever, malaise, rigors, loin/flank pain. Patient may have fever or loin/flank tenderness. They may also have haematuria.
Prostatitis: Fever, lower back/perianal pain, and irritative and/or obstructive symptoms such as hesitancy, urgency, intermittency, poor stream and dribbling. On examination patient may have a tender, swollen prostate.
Elderly: Confusion, incontinence, nocturia and malaise.
What are the risk factors for a UTI?
- Sexually activity
- Pregnancy
- Incomplete bladder emptying
- Urinary calculi
- Diabetes mellitus
- Structural abnormality of the urinary tract
- Urinary catheterisation - UTI is the most common hospital acquired infection, the majority of which are associated with catheter use.
What are the useful investigations for a UTI?
When investigating a suspected uncomplicated UTI/pyelonephritis, helpful investigations include:
- Urine dipstick: leucocytes + nitrites (product of coliform metabolism). If both negative a UTI is unlikely.
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MSU for urine microscopy, culture and sensitivities.
- If squamous epithelial cells present, this suggests urethral contamination, meaning that sample is from urethra not bladder and is therefore not a true MSU. This means it may not be representative of the bladder and is not very clinically relevant.
- Under microscopy: The presence of white cells means pyuria, which is indicative of infection.
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Culture:
- Patients with infection usually have at least 10^5 cfu/mL (cfu = colony forming units) in urine in the bladder. However, the cut off is lower (10^4) for E. Coli, as that amount of growth would be indicative of UTI.
- Patients without infection have sterile bladder urine and with proper collection, voided urine usually contains less than 10^4 cfu/mL.
- Bloods – FBC, UE, CRP (inflammatory markers and renal function)
In which cases of suspected UTI is MC&S recommended?
Laboratory testing for culture and sensitivity should be performed in:
- All pregnant women with bacteriuria, be it asymptomatic, or symptomatic and investigating a possible UTI.
- Patients older than 65 years of age
- Suspected UTI in children.
- Suspected pyelonephritis (high temperature; rigours; nausea; vomiting; diarrhoea; loin pain or tenderness)
- Suspected UTI in men
- Catheterised patients with features of systemic infection.
- Failed antibiotic treatment.
- Community ESBLs
- People with abnormalities of genitourinary tracts and renal impairment.
In which cases of suspected UTI is imaging recommended?
When investing a complicated UTI, particularly if recurrent pyelonephritis or pyelonephritis in a male, it is important to perform a renal USS and/or intravenous urography to investigate underlying structural abnormalities.
Which cases of a suspected UTI should be referred to secondary care?
If the patient has haematuria: Re-test the patient after the course of antibiotics and refer through 2-week referral pathway if persistent and suspecting bladder or gynaecological malignancy.
For men with a UTI, consider referral to urology if:
- Have ongoing symptoms despite appropriate antibiotic treatment.
- May have an underlying cause or risk factor for the UTI (such as suspected bladder outlet obstruction, or have a history of pyelonephritis, urinary calculi, or previous genitourinary tract surgery).
- Have recurrent episodes of UTI (for example, two or more episodes in a 6-month period).
Describe the antibiotic therapy for a UTI
- Most treatment will be empirical therapy as the treatment usually begins before culture and sensitivity results are received. Empirical therapy will be determined by local guidelines, which will take local resistance patterns into account.
- Trimethoprim or Nitrofurantoin is used in the community to treat UTIs. Trimethoprim is becoming more and more redundant, as 40% of E.Coli is already resistant, so in secondary care, they are started on another antibiotic, usually Cefalexin or Nitrofurantoin.
- For men with suspected prostatitis - prescribe a quinolone antibiotic such as Ciprofloxacin or Levofloxacin for 14 days.
Generally management guidelines state:
- 3 day therapy with standard doses for uncomplicated lower urinary tract infection in women
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7 day therapy for:
- Women with previous UTI caused by antibiotic resistant organisms
- If at risk of upper UTI (pyelonephritis)
- Men
- 14 days for men if suspicion of prostatitis. Review after 14 days and prescribe a further 14 days if necessary. If chronic prostatitis then 4-6 weeks.
For pregnant or breastfeeding women:
- 1st line = cefalexin 500mg BD PO for 7 days
- 2nd line = co-amoxiclav 625mg TDS PO for 7 days (avoid nitrofurantoin as may produce neonatal haemolysis at term, but otherwise safe in pregnancy).
- Anaphylactic penicillin allergy: discuss with ID/Micro
What is the definition and epidemiology of Pyelonephrosis?
Pyelonephritis is an infection of the renal pelvis and parenchyma that is usually associated with an ascending bacterial infection of the bladder. It occurs more commonly in females and risk factors include pregnancy and urinary tract obstruction.
What are the clinical features of Pyelonephritis?
Pyelonephritis typically manifests suddenly with signs and symptoms of both systemic inflammation and bladder infection (however, up to 20% do not have bladder symptoms).
- High fever, chills
- Flank pain, costovertebral angle tenderness (usually unilateral, may be bilateral)
- Dysuria as well as other symptoms of cystitis (e.g., frequency, urgency)
- Weakness, nausea, vomiting (diarrhoea may also be present)
- Possible abdominal or pelvic pain
Describe the diagnosis of pyelonephritis
In all people suspected of having acute pyelonephritis, arrange collection of a mid-steam urine (MSU) or catheter specimen of urine (CSU) for culture before starting empirical drug treatment. Presence of micro-organism is needed to confirm diagnosis of pyelonephritis.
Dipstick testing is not necessary.
What are the investigations for Pyelonephrosis in secondary care?
Usually done in secondary care:
- Urinalysis commonly shows blood, protein and nitrites. Pyuria is often present. Microscopy and culture should also be performed.
- All patients should have U&Es to assess renal dysfunction, dehydration, and acute-on-chronic failure. Other important tests include FBC, glucose and blood cultures.
Abdominal X-Ray may show stones or soft-tissue mass on affected side. An USS should be used to exclude obstruction and delineate renal and perirenal collections.
Describe the primary care management of Pyelonephrosis
Admit people to hospital if symptoms or signs suggesting a more serious illness or condition (for example, sepsis).
Consider referral if:
- Patients are male
- Are significantly dehydrated or unable to take oral fluids and medicines.
- Are pregnant.
- Have a higher risk of developing complications — people with known or suspected structural or functional abnormality of the genitourinary tract or underlying disease (such as diabetes mellitus, or immunosuppression).
- Have recurrent episodes of UTI (for example, two or more episodes in a 6-month period).
For women who are not pregnant, men, and people with indwelling catheters, take account of local antimicrobial resistance data, and prescribe either of the following first line options:
- Cefalexin 500mg twice or three times a day (up to 1– 1.5g three or four times a day for severe infections) for 7-10 days.
- Ciprofloxacin 500 mg twice a day for 7 days.
- Co-amoxiclav (only if appropriate in line with culture and sensitivity results) 500/125 mg three times a day for 7-10 days.
- Trimethoprim (only if appropriate in line with culture and sensitivity results) 200mg twice a day for 14 days.
For pregnant women who do not require admission, prescribe:
- Cefalexin 500mg twice or three times a day (up to 1– 1.5g three or four times a day for severe infections) for 7-10 days.
Describe the secondary care management of Pyelonephrosis
- Take an A-E approach and stabilise the patient with I.V fluids. Maintain with a high level of fluid intake (e.g. 3L/24h). Monitor fluid balance and urine output carefully for the first 48-72h.
- Give IV antibiotics
- Organise drainage of infected and obstructed urinary system.
- Analgesia: try opiates. Avoid NSAIDs in AKI.
What is the definition and epidemiology of nephrolithiasis?
Kidney stones (nephrolithiasis) refers to the presence of crystalline stones (calculi) within the urinary system.
It is quite common, with lifetime incidence up to 12%. Peak age at presentation is 20-50 years. Affects males more than females (2:1).
What are the clinical features of urinary calculi?
A history of nephrolithiasis is a strong risk factor (50% of patients will develop another kidney stone within 10 years). Depending on the size, it may be asymptomatic.
When stones cause pain, we can call this renal colic (though not entirely colicky). The pain tends to be severe and acute onset around the flank just over the kidneys. It then radiates to the groin and scrotum/labia when the stone lodges in the ureter, causing spasms - at this point, the pain is very severe, and gets worse in a colicky nature.
Patients can also have symptoms of dysuria, increased frequency, strangury (painful frequent urination with feeling of incomplete emptying) and penile tip pain. Patients may also complain of nausea and vomiting.
Haematuria is also a common feature. This can be macroscopic or microscopic (present in up to 90% of cases).
Occasionally, patients may also have signs and symptoms of a Urinary Tract Infection.
What are the investigations for urinary calculi?
Blood tests can show increased WCC (due to UTI) or hypercalcaemia (pointing towards hyperparathyroidism). A pregnancy test should be performed in all female patients. U&Es should be performed to measure kidney function.
Urinalysis may be positive for leukocytes, microscopic/macroscopic haematuria and nitrates. Microscopy and culturemay be indicated if infection is suspected.
A CTKUB non-contrast scan is the preferred imaging modality for nephrolithiasis due to its high sensitivity and specificity, and should be ordered as soon as nephrolithiasis is suspected.
A plain KUB (Kidney, Ureter, Bladder X-ray) shows radio-opaque stones. Up to 85% of stones are visible. An IVU (Intravenous Urogram) is a test where IV contrast followed by radiographs may show a filling defect.
A renal ultrasound can show calcification along the urinary tract as well as hydronephrosis. However stone needs to big to visualise.
Chemical analysis of the stone if passed shows what type of stone it is, and can help guide management.
Describe the management of urinary calculi
All patients need to be hydrated well (orally or IV) and given analgesia including NSAIDs and opiates and offered anti-emetics.
Admit the patient if they have:
- Single kidney
- Pyrexia
- Continuing pain
- Renal impairment
If there is bacteriuria treat with antibiotics and surgical decompression (stent placement).
If the stone is small: do all the above and treat with alpha antagonist like tamsulosin to reduce spasms. This may also help stones pass spontaneously. Still recommended in the NICE guidelines, however controversial.
If the stone is big, or associated with infection it needs to be managed urologically: Extracorporeal shock wave lithotripsy (ESWL) is an un-invasive way to break up the stone, and is considered the first-line therapy. Second line is surgical removal through a cystoscope, from which a laser can be passed through. Uteroscopy is associated with better stone-free rates than EWL.
What is the definition and epidemiology of Prostate cancer?
Prostate cancer refers to a malignant tumour of glandular origin (adenocarcinoma in 95% of cases), situated in the prostate. Prostate cancer is the second commonest cause of cancer mortality. It is very common - approximately 15% of men born today will be diagnosed with prostate cancer at some point in their lives. Less likely to affect Asians.
What are the risk factors for Prostate cancer?
- Age >50
- Black ethnicity (increased prevalence as well as mortality risk) or European descent.
- Family history of prostate cancer. 2-fold increased risk of prostate cancer in men with a FHx in a single first-degree relative, a 5-fold risk if there were 2 affected relatives, and a relative risk of 10.9 when there were 3 first-degree relatives with prostate cancer.
- High levels of dietary fat.
What are the clinical features of Prostate cancer?
The most common presenting finding is an elevated PSA level, beyond normal for their age.
Patients are usually asymptomatic as prostate cancer arises from the peripheral zone of the prostate. Symptoms similar to Benign Prostatic Hyperplasia are not very common in low-risk disease. If present, may be a sign of higher T-stage or BPH itself:
- Nocturia
- Urinary hesitancy
- Urinary frequency
- Dysuria (difficulty or painful urinating?)
On examination, a abnormal digital rectal examination is common (asymmetrical or nodular with loss of medial sulcus).
Signs of advanced metastatic disease include weight loss/anorexia, lethargy, bone pain and palpable lymph nodes.
Describe the diagnosis of Prostate cancer
PSA is usually elevated
- the cut-off is now age-adjusted:
- 50-59 years >3.0 mg/l.
- 60-69 years >4.0 mg/l.
- > 70 years >5.0 mg/l.
PSA levels may also be raised by*:
- Benign prostatic hyperplasia (BPH)
- Prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment)
- Ejaculation (ideally not in the previous 48 hours)
- Vigorous exercise (ideally not in the previous 48 hours)
- urinary retention
- instrumentation of the urinary tract
On rectal examination, the prostate may feel enlarged and ‘craggy’ or a hard nodule may be palpable.
Patients with a suspicious PSA test OR rectal examination should be referred using the 2 week pathway.
The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation. The results are reported using a 5-point Likert scale. If the Likert scale is >=3 a MRI-influence prostate biopsy is offered.
If a malignancy is diagnosed, the staging procedures involve a bone scan and pelvic CT/MRI scans (and extra-pelvic if further metastases are suspected).
Describe the staging of Prostate cancer
Using the TNM system.
- T1 = clinically apparent, but not visible (on imaging) nor palpable.
- T2 = visible tumour
- T3 (advanced) = tumour extents beyond the prostate capsule
- T4 (advanced) = Tumour invades beyond seminal vesicles
N1 = metastases in regional lymph nodes
M1 = distant metastases (including non-regional lymph nodes).
Describe the management of Prostate cancer
Localised prostate cancer (T1/T2)
Treatment depends on life expectancy and patient choice. Options include:
- Conservative: active monitoring & watchful waiting
- Radical prostatectomy
- Radiotherapy: external beam and brachytherapy
Localised advanced prostate cancer (T3/T4)
Options include:
- Hormonal therapy: see below
- Radical prostatectomy: erectile dysfunction is a common complication
- Radiotherapy: external beam and brachytherapy. Patients are at increased risk of bladder, colon, and rectal cancer following radiotherapy for prostate cancer.
Metastatic prostate cancer disease - hormonal therapy
- Synthetic GnRH agonist e.g. Goserelin (Zoladex). Cover initially with anti-androgen to prevent rise in testosterone.
- Anti-androgen such as cyproterone acetate prevents DHT binding from intracytoplasmic protein complexes.
- Orchidectomy
