Presentation of an obstructive uropathy (split into upper and lower urinary tract) ?
Upper Urinary Tract Obstruction (i.e. ureters):
- Loin to groin / flank pain on affected side (result of stretching / irritation of ureter and kidney
- Reduced / no urine output
- Non-specific symptoms (e.g. vomiting)
- Reduced renal function on bloods
Lower Urinary Tract Obstruction (i.e. bladder / urethra):
- Acute urinary retention (unable to pass urine and increasingly full bladder)
- Lower urinary tract symptoms (e.g. poor flow, difficulty initiating urination, terminal dribbling)
- Reduced renal function on bloods
Common causes of an obstructive uropathy (split into upper and lower urinary tract) ?
Upper Urinary Tract:
- Kidney stones
- Local cancer masses pressing on the ureters
- Ureter strictures (scar tissue narrowing tube)
Lower Urinary Tract:
- Benign prostatic hyperplasia (enlarged prostate)
- Prostate cancer
- Ureter or urethra strictures (from scar tissue)
- Neurogenic bladder (no neurological signal telling bladder to contract)
Name 5 complications of an obstructive uropathy
- Acute Kidney Injury (postrenal AKI)
- Eventually chronic kidney disease
- Infection (from pooling of urine and retrograde infection: bacteria tracking back up urinary tract)
- Dilated kidney / ureters / bladder
Presentation of acute urinary retention ?
Pt is uncomfortable, unable to pass urine, tender + distended bladder.
Investigations for acute urinary retention + what could they potentially show ?
- USS bladder - post void residual urine (<50ml is normal, <100ml is acceptable), hydronephrosis, structural abnormalities
- Urinalysis - infection, haematuria, proteinuria, glucosuria
- MSU - infection
- Blood tests: FBC, U+E, Cr, eGFR, PSA (n.b. this is elevated in the context of AUR so not great)
- Hunting for cause/depending on history
- CT abdo pelvis - looking for mass causing bladder neck compression
- MRI spine - disc prolapse, cauda equina, spinal cord compression MS
Management of acute urinary retention ?
Immediate and complete bladder decompression with catheter.
Men should be offered an alpha blocker prior to removal
What is the most common type of kidney cancer + how is it staged ?
Renal cell carcinoma.
The TNM system.
What are “Cannon ball metastases” and how are they relevant to the kidneys ?
Cannonball metastases is a description given to a select type of lung metastases in which multiple large masses are evident.
Renal cell carcinoma is by far the commonest cause - This is a common exam question.
Presentation of kidney cancer ?
- Often asymptomatic
- Vague loin pain
- Non-specific symptoms of cancer (e.g. weight loss, fatigue, anorexia, night sweats)
Types of renal cell carcinoma ?
- Clear cell (75-90%)
- Papillary (10%)
- Chromophobe (5%)
- Collecting duct carcinoma (1%)
- Children: Wilms Tumour (in children < 5 years old)
RF’s for kidney cancer ?
- Long-term dialysis
- Von Hippel-Lindau Disease
Management of kidney cancer ?
-Surgery (partial nephrectomy first line) / - radiotherapy and chemotherapy depending on disease stage.
Paraneoplastic features of RCCs ?
- Polycythaemia (RCC secretes unregulated erythropoietin)
- Hypercalcaemia (RCC secretes a hormone that mimics the action of PTH)
- Stauffer Syndrome (abnormal liver function tests demonstrating an obstructive jaundice – without any localised liver or biliary me
Types of bladder cancer ?
- 90% transitional cell carcinoma
- 10 % squamous cell carcinomas
- Rarer causes are adenocarcinoma, sarcoma, small cell.
RF’s for bladder cancer ?
- Smoking (50%)
- Key workplace carcinogens - Carcinogens include aromatic amines, polycyclic aromatic hydrocarbons, arsenic and tetrachloroethylene. These are found in hair dyes, industrial paint, rubber, motor, leather, and rubber workers, blacksmiths etc.
- Age, 70% > 65
- Pelvic radiation (prostate Ca)
- Men > Women
- HNPCC for upper tract urothelial cancers
- Chronic inflammation, schistosoma infection and indwelling cancers - squamous cell carcinoma
Presentation of bladder cancer ?
- PAINLESS HAEMATUIRA(frank or microscopic)
- Abdominal mass
- Systemic weight loss + bone pain
How is bladder cancer staged ?
Bladder cancer note:
The majority are superficial (not invading the muscle) at presentation
Bladder cancer note
Tis - in situ ‘flat tumour’ worst prognosis
Ta - non-invasive papillary carcinoma
T1 - tumour invades subepithelial connective tissue (lamina propria):
T2 - tumour invades superficial muscle (detrusor or muscularis propria):
T3 - tumour invades perivesical tissue:
T4 - tumour beyond bladder: prostate, uterus, vagina, pelvic/abdo wall:
Haematogenous: Liver and lungs
Bladder cancer gold standard investigation + other investigations ?
Flexible cystoscopy with biopsy TURBT.
-Urine dip - Haematuria (80% of patients) ± pyuria
-Urine MC + S - cancers may cause sterile pyuria
-Bimanual EUA for staging
-CT urogram with contrast - in excretory phase shows bladder tumour, upper urinary tract tumour
-Urinary cytology - abnormal cells
-FBC - mild anaemia
-CXR, isotope bone scan, alkaline phosphatase etc…..
Treatment of bladder cancer ?
Not invading the muscle:
- Transurethral Resection of a Bladder Tumour (TURBT)
- Chemo into bladder after surgery (use barrier contraception afterwards)
- Weekly treatments for 6 weeks with BCG vaccine squirted into the bladder via catheter, then every six months for 3 years.
Muscle-invasive bladder cancer:
- Radical cystectomy with ileal conduit
- Radiotherapy (as neoadjuvant, primary treatment or palliative)
- IV chemotherapy as neoadjuvant or palliative
Presentation of BPH ?
-FUN - frequency, urgency, nocturia
-HIIPP - hesitancy, intermittent/incomplete emptying, poor flow/post-void dribbling
Investigations for BPH ?
- TRUSS ± biopsy
- PSA - increased may indicate prostate cancer or prostatitis
Urinalysis - MSU/urine dip to rule out pyuria and complicated UTI
Scoring system -IPSS - International Prostate Symptom Score (0-35) also includes quality of life
Mild = 0-7, Mod = 8-19, Severe = 20+
- Volume chart
- USS KUB - To rule out hydronephrosis, urolithiasis, mass
Management of BPH ?
Treatment depends on severity and impact on life:
For all = behavioural management:
-Avoid caffeine, alcohol (decrease storage problems), void twice in row, bladder training, limit fluids
Mild (no bother):
-Watch and wait
-FIRST LINE: Alpha blocker (tamsulosin or doxazosin) or 5-alpha reductase (finasteride) or NSAID (preferably a COX-2 inhibitor e.g. celecoxib)
Mod/severe - as above, first line drug + behavioural management
Abnormal DRE or elevated PSA:
- Surgical referral
- Prostate < 80g - TURP, TUVP (transurethral resection/vaporisation) or HoLEP (Holmium laser enucleation of the prostate )
- Prostate > 80g - Open prostatectomy
Complications of TURP ?
Bleeding Infection Incontinence Retrograde ejaculation (semen goes backwards and is not produced from the urethra during ejaculation) Urethral strictures Failure to resolve symptoms Erectile dysfunction
How do alpha blockers work in relation to BPH ?
Smooth muscle relaxation in prostate and bladder neck.
How do 5-alpha reductase inhibitors work ?
They reduce the conversion of testosterone into dihydrotestosterone
Presentation of prostate cancer ?
- > 50M
- Weight loss/anorexia/lethargy (advanced metastatic)
- Bone pain (advanced metastatic)
- Palpable LNs (advanced metastatic)
How does a benign vs a cancerous prostate feel during a DRE ?
- 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
PSA note in relation to prostate cancer:
- Traditionally done prior to DRE to avoid stimulating release of PSA
- Not very sensitive or specific (positive and negative results are unreliable)
- Most useful in monitoring the progression of the disease and success of treatment
Main diagnostic test to confirm prostate cancer ?
- The definitive method for diagnosing prostate cancer
- Still not particularly sensitive because cancers may be located in areas not biopsied
- Multiple needle biopsies are taken to minimize risk of missing the cancer
Transrectal Ultrasound-Guided Biopsy (TRUS):
- Ultrasound inserted into rectum and a needle biopsy taken through rectal wall into prostate under US guidance
- Usually around 10 biopsys are taken to try and pick up the cancer
-This method allow more biopsys to be taken (around 35)
-This has a higher sensitivity than TRUS
It takes longer than TRUS and requires general anaesthetic
-MRI + CT can be used for staging the cancer if the diagnosis is confirmed. (TNM system is used for staging)
What is the Gleason grading system ?
- A grading system specific to prostate cancer
- Helps to determine what treatment is most appropriate
- The Gleason Score ranges from 1-5 and describes how much the cancer from a biopsy looks like healthy tissue (lower score) or abnormal tissue (higher score).
- Since prostate tumours are often made up of cancerous cells that have different grades, two grades are assigned for each patient. A primary grade is given to describe the cells that make up the largest area of the tumour and a secondary grade is given to describe the cells of the next largest area. For instance, if the Gleason Score is written as 3+4=7, it means most of the tumour is grade 3 and the next largest section of the tumour is grade 4
Management of prostate cancer ?
Watchful waiting in early prostate cancer
Radiotherapy directed at the prostate
- Radioactive seeds implanted into the prostate
- Deliver continuous, targeted radiotherapy to the prostate
Hormonal treatment (antiandrogen therapy):
-Prostate tissue grows in response to androgens like testosterone
-Hormonal therapy aims to block androgens and slow or stop prostate cancer growth
-Side effects include hot flushes, sexual dysfunction, gynaecomastia, fatigue and osteoporosis
1 = Bilateral orchidectomy is the gold standard hormonal treatment
2 = LHRH agonists cause chemical castration (e.g. goserelin)
3 = Androgen receptor blockers (e.g. bicalutamide)
Surgery in the form of total prostatectomy
Complications of Radical Treatment with Prostatectomy and Radiotherapy ?
- Erectile dysfunction
- Urinary incontinence
- Radiation induced enteropathy (giving gastrointestinal symptoms like PR bleeding, pain, incontinence etc)
- Urethral strictures
What is epididymo-orchitis ?
Epididymitis – inflammation / infection of the epididymis
Orchitis – inflammation /infection of the teste
Causes of epididymo-orchitis ?
Presentation of epididymo-orchitis ?
Don’t miss testicular torsion as a differential, if any doubt at all – treat as torsion
- Gradual onset over minutes / hours (as opposed to rapid onset with torsion)
- Usually unilateral
- Testicular pain and tenderness
- Dragging / heavy sensation
- Urethral discharge (think chlamydia / gonorrhea)
- Tender on palpation, particularly over epididymis
- Swelling of testicle and epididymis
- Erythema to scrotum
Management of epididymo-orchitis ?
- Admit and treat sepsis if septic, otherwise as outpatient
- Antibiotics as per local guidelines (e.g. ciprofloxacin for 2 weeks)
- Tight underwear for scrotal support during illness
- Abstain from intercourse during illness
- Confirm diagnosis with ultrasound of the scrotum (exclude torsion and tumours)
What is testicular torsion ?
A urological emergency caused by the twisting of the testicle on the spermatic cord leading to constriction of vascular supply and time-sensitive ischaemia of testicle
- Typically in teenage boys, but can occur at any age
- “6 hour window” after onset before damage from ischaemia is irreversible
Presentation of testicular torsion ?
- Sudden onset, unilateral testicular pain
- High transverse lie
- Nausea and vomiting
- Abdominal pain
- Red, hot swollen testicle
- Absent cremasteric reflex
What is a “Bell-clapper deformity” + why is this one of the main causes of testicular torsion ?
- Normally the testicle is fixed posteriorly to the tunica vaginalis
- Bell-clapper deformity is where this fixation is absent
- Allows testicle to rotate within tunica
- As it rotates it twists the vessels and cuts of its blood supply
Management of a testicular torsion ?
-Urgent urology assessment
Immediate surgical scrotal exploration:
- Untwist the testicle
- Both testicles are fixed in correct position to prevent further episodes (orchiplexy)
- Possible orchiectomy if delayed surgery / necrotic testicle present
Main complication of testicular torsion ?
Subfertility / infertility
Differential diagnoses for a testicular/ scrotal lump + how would each present + which test would you use to differentiate between the differentials ?
Confirm diagnosis with scrotal ultrasound scan
- Non tender (or even reduced sensation)
- Arising from testicle
- Hard without fluctuance or transillumination
- Age 15-40
- Tunica vaginalis is a membrane around each testicle
- Hydrocele is fluid built up inside this membrane
- Transilluminated by shining torch into the fluid
- It is soft, fluctuant and may be large
- It is irreducible and has no bowel sounds
- May indicated underlying testicular cancer
- May require surgical intervention
- Soft “bag of worms”
- Swollen pampiniform venous plexus (testicular veins)
- Can cause dragging or soreness
- Usually harmless
- A cyst (sac of fluid)
- At the epididymis (at the top of the testicle)
- Soft, fluctuant lump at the top of the testicle
- Usually harmless
- Generally swollen
- Separate from testicle
- Bowel sounds
- Extremely tender
- Abnormal lie
- Suggestive history
The right testicular vein arises from the inferior vena cava. The left testicular vein arises from the left renal vein. Therefore a unilateral left sided varicocele can indicate an obstruction of the left testicular vein, for example caused by a renal cell carcinoma. However, it is worth noting that NICE CKS recommend NOT routinely referring men with a left sided varicoceles for an ultrasound to investigate for renal tumours.
Types of testicular cancers ?
- Seminoma (50%) (germ cell)
- Teratoma (50%) (germ cell)
- Rarely other types
Investigations for testicular cancer ?
Tumour markers (BAL):
- Beta-hCG - may be raised in teratomas and seminomas, but more often in teratomas
- Alpha-fetoprotein - may be raised in teratomas (not seminomas)
- Lactate dehydrogenase
- USS (95% sensitive)
- CT abdomen and pelvis (LNs)
Name 4 common sites for testicular cancer to metastasise to ?
Prognosis of testicular cancer ?
Good prognosis unless metastatic (>90% cure rate)
Even metastatic disease is often curable
Slightly better prognosis for seminomas
Management of testicular cancer ?
- Orchidectomy (offer testicular prosthesis)
- Chemotherapy / radiotherapy based on staging
- Monitoring post treatment with tumour markers and imaging
What is pyelonephritis ?
Infection of the renal pelvis and parenchyma
Name 3 RF’s for pyelonephritis ?
- Structural urological abnormalities
Name four common organisms that cause pyelonephritis (include most common cause) ?
- Escherichia coli is the most common cause
Presentation of pyelonephritis ?
- High fever and rigors
- Loin to groin pain
- Dysuria and urinary frequency
- Other non-specific symptoms (e.g. vomiting)
- Renal angle tenderness
Investigations for pyelonephritis ?
- Urine dipstick
- Blood and urinary cultures
- Renal USS
- CT contrast
- Dimercaptosuccinic acid (DMSA) scan - involves injecting radiolabelled DMSA, which builds up in the kidneys and when imaged using gamma cameras gives an indication of renal scarring. This is used in recurrent pyelonephritis to assess the damage.
What would a urine dipstick show in someone with pyelonephritis ?
- Leukocyte esterase (produced by neutrophils)
- Nitrite (gram negative organisms metabolise nitrates in the urine )
Management of pyelonephritis ?
- Broad spectrum antibiotics (e.g. co-amoxiclav) until culture and sensitivities are available
- Admission if systemically unwell or complicated
- IV rehydration
- Recurrent kidney infections
- Leads to scarring of the renal parenchyma
- Can result in chronic kidney disease
- Can result in abscess and/or pus in or around the kidney
- May be a role for prophylactic antibiotics
What are the different types of renal stone ?
- Calcium oxalate forms 80% of stones
- Calcium phosphate
- Uric acid (not visible on xray)
- Struvite (magnesium ammonium phosphate)
What is a staghorn calculus, what is it usually composed of, how does it form and how can they be seen ??
- Renal calculus that forms the shape of a staghorn
- The body sits in the renal pelvis with horns extending into renal calyxes
- Usually composed of struvite
- In recurrent upper urinary tract infections, the bacteria can hydrolyse the urea in urine to ammonia, creating the solid struvite
- Can be seen on plan xray films
How do renal stones present ?
- May be asymptomatic and never cause an issue
- Renal colic
- Excruciating loin to groin pain
- May have haematuria, nausea, vomiting and oliguria
- May have symptoms of sepsis if infection present (i.e. fever)
Investigations for kidney stones (highlight gold standard diagnostic test)?
- CT KUB (non-contrast scan of kidney, ureters and bladder) is gold standard for identifying stones
- Urine dipstick (haematuria in stones but also exclude infection)
- Bloods for infection, kidney function, Ca and uric acid levels.
- Renal stones may not be visible on abdominal xray
Management of kidney stones ?
- NSAIDs are usually the most effective type of analgesia (e.g. PR diclofenac)
- Antiemetic if nausea and vomiting
- Antibiotics if infection is present
- Stones less than 6mm have greater than 50% chance of passing without intervention
- Spontaneous passage can take several weeks
- Tamsulosin (an alpha-blocker) can be used to help aid spontaneous passage of stones
- Surgical Interventions in large stones or stones that do not pass
Surgical interventions for nephrolithiasis ?
Extracorporeal Shock Wave Lithotripsy:
- An external machine generates shock waves and directs them at the stone under xray guidance.
- Breaks the stone to smaller parts to make them easier to pass.
Ureteroscopy and Laser Lithotripsy:
- Camera inserted via urethra, bladder and ureter
- Stone identified
- The stone is broken up by targeted lasers
- The smaller parts are easier to pass
- Performed in theatres under 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 either be removed or broken up to small stones
One episode of renal stones predisposes patients to further episodes. What advice would you give to pts to reduce the change of a reoccurrence ?
- Increase oral fluids
- Reduce dietary salt intake
- Reduce intake of oxalate-rich foods for calcium stones (e.g. spinach, nuts, rhubarb, tea)
- Reduce intake of urate- rich foods for uric acid stones (e.g. kidney, liver, sardines)
- Limit dietary protein