Urology - miscellaneous

Question 1

Testicular cancer - risk factors and types

Answer 1

Most common malignancy in men aged 20-30 years
RF: infertility, cryptorchidism, family history, Klinefelter’s syndrome, mumps orchitis

• Germ cell tumours in 95% cases:
  1. seminomas = all ages including elderly
  2. nonseminomas = including embryonal, yolk sac, teratoma and choriocarcinoma. More aggressive and develop earlier in life
• Non germ cell include Leydig cell tumours and sarcomas

Question 2

Testicular cancer - features

Answer 2

• a painless lump is the most common presentation
• pain may also be present in a minority of men
• other include hydrocele, gynaecomastia
• AFP is elevated in around 60% of germ cell tumours
• LDH is elevated in around 40% of germ cell tumours
• seminomas: hCG may be elevated in around 20%

Question 3

Testicular cancer - Investigations and management

Answer 3

Investigations

• bloods: α-FP, β-HCG, LDH
• gold standard: ultrasound

Management

• orchidectomy
• chemotherapy and radiotherapy may be given depending on staging and tumour type

prognosis is generally excellent

Post -op monitoring: CT abdo (abdo LN mets are common)

Question 4

Hydrocele

Answer 4

Presents as a mass that transilluminates, usually possible to ‘get above’ it on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis (communicating hydrocele –> needs surgery due to risk of forming inguinal hernia)

Can also be due to trauma, inflammation, torsion, with accumulation of fluid (noncommunicating –> can wait until 3+ y/o to operate)

Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis

Question 5

Testicular torsion - definition

Answer 5

twist of the spermatic cord resulting in testicular ischaemia and necrosis.
most common in males aged between 10 and 30 (peak incidence 13-15 years)

Question 6

Testicular torsion - features

Answer 6

• pain is usually severe and of sudden onset
• pain may radiate to lower abdomen, groin or loin
• may be a/w nausea, vomiting, mild fever
• on examination there is usually a swollen, tender testis retracted upwards, sometimes in a horizontal lie. The skin may be reddened
• cremasteric reflex is lost
• Prehn’s sign negative - elevation of the testis does not ease the pain (unlike in epididymitis)

Question 7

What is bell clapper deformity?

Answer 7

A bell clapper deformity is a predisposing factor in testicular torsion in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate. Bell clapper deformity predisposes to intravaginal torsion of the testis.

Question 8

Testicular torsion - definitive management

Answer 8

If torsion is suspected, urgent exploration must be done without any other investigations
- treatment is with surgical exploration + bilateral testicular fixation. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Question 9

What investigations could be done if torsion isn’t suspected?

Answer 9

Investigations

• Bloods (including inflammatory markers)
• Urine Dip & MSSU
• Colour Doppler Ultra Sound (CDUS)? - can be used if dx of torsion is unlikely & will not cause detriment
  E.g. if long history already (24-48 hours) +/- features suggestive of epididymo-orchitis

Question 10

Torsion - complications

Answer 10

Delay in treatment results in permanent ischaemic damage

- infarction of testicle/permanent testicular damage/
loss of testicles
- Atrophy
- Loss of hormone production
- Loss of sperm production / infertility

Question 11

Epididymo-orchitis - definition

Answer 11

Epididymo-orchitis describes an infection of the epididymis +/- testes resulting in pain and swelling. It is most commonly caused by local spread of infections from the genital tract (such as Chlamydia
trachomatis and Neisseria gonorrhoeae) or the bladder

Most likely organism and age:

• Sexually active & < 35 - Gonorrhoea, Chlamydia
• Children & men > 35 - E.Coli

Question 12

Epididymo-orchitis - clinical features

Answer 12

• Fever
• unilateral scrotal swelling and pain, may radiate into groin (spermatic cord). Usually gradual and progressive.
• Erythema of scrotal skin
• Thickening of cord & epididymis
• Reactive hydrocele
• Evidence of underlying infection, eg. penile discharge
  or symptoms of urethritis / cystitis

Question 13

Epididymo-orchitis - investigations

Answer 13

Investigation

• Bloods - FBC, U&Es, CRP etc.
• UDT, urine microscopy & MSSU
• Urethral swabs
• Urine Chlamydia and Gonorrhoea
• Scrotal USS (can be done as o/p)

Question 14

Epididymo-orchitis - management

Answer 14

British Association for Sexual Health and HIV (BASHH)
For unknown organism:
ceftriaxone 500mg IM single dose, plus doxycycline 100mg PO twice daily for 10-14 days

Vital:
- if >35: Ciprofloxacin 500mg bd (14 days)
- if <35 or STI Suspected:
Doxycycline 100mg bd (14 days to cover chlamydia) & ask to visit GUM clinic for contact tracing etc.

Question 15

Differentiating torsion and infection

Answer 15

Torsion

• Pain more acute and sudden
• Pain more localised to testis
• No infective symptoms
• ve urine dip
• Lifting does not ease

Infection
- Gradual onset
- Pain more localised to epididymis
- Possibly infective symptoms
\+ve urine dip (not always)
- Lifting may ease (+ve Prehn’s sign )

Question 16

Varicocele - features

Answer 16

A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility.

Varicoceles are much more common on the left side (> 80%). Features:
•classically described as a ‘bag of worms’
•subfertility

Diagnosis
•Left: ultrasound with Doppler studies
•Right: send for immediate exploration (risk it could be a retroperitoneal mass/tumour)

In adults, spermogram + US done to monitor health of testes and need for surgery

Question 17

Renal stones - types

Answer 17

1. Calcium oxalate - Hypercalciuria is a major risk factor. Stones are radio-opaque
2. Calcium phosphate - May occur in renal tubular acidosis, high urinary pH increases supersaturation of urine. Stones are radio-opaque
3. Uric acid - product of purine metabolism. May precipitate when urinary pH low. Association with gout
4. Cysteine - Inherited recessive disorder
5. Struvite - formed from magnesium, ammonium and phosphate. Occur as a result of urease producing bacteria (and are thus associated with chronic infections eg. women with UTIs). Can present as staghorn calculi

Question 18

Renal stones - risk factors

Answer 18

• dehydration
• hypercalciuria, hyperparathyroidism, hypercalcaemia
• cystinuria
• high dietary oxalate
• renal tubular acidosis
• medullary sponge kidney, polycystic kidney disease
• beryllium or cadmium exposure

Risk factors for urate stones
• gout
• ileostomy: loss of bicarbonate and fluid results in acidic urine, causing the precipitation of uric acid

Question 19

Renal stones - clinical features

Answer 19

• loin pain: typically severe, intermittent ‘colic’ pain. The patient often is restless/moving around
• pain may radiate to groin and anteriorly
• nausea and vomiting is common
• haematuria
• dysuria
• secondary infection may cause fever

Question 20

Renal stones - investigations

Answer 20

• urine dipstick and culture
• U&E: check renal function
• FBC / CRP: look for associated infection
• calcium/urate: look for underlying causes
• also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis

Definitive investigations:
• non-contrast CT KUB should be performed on all patients, within 14 hours of admission
• ultrasound still has a role but given the wider availability of CT now and greater accuracy it is no longer recommend first-line

Question 21

Renal stones - management

Answer 21

• Stones < 5 mm will usually pass spontaneously
• NSAID is the analgesia of choice for renal colic
• Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, ureteric catheters and ureteric stent.

Non-emergency treatments:

• Shockwave lithotripsy: a shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation
• Ureteroscopy: a ureteroscope is passed retrograde through the ureter and into the renal pelvis. Indicated in when lithotripsy is CI eg. pregnant women
• Percutaneous nephrolithotomy: access is gained to the renal collecting system, then intra corporeal lithotripsy or stone fragmentation is performed

Question 22

Erectile dysfunction - causes

Answer 22

• organic: gradual onset, normal libido and lack of tumescence (blood flow and engorgement)
• psychogenic: sudden onset, decreased libido, major life events eg relationship issues, psychological problems

Risk factors:

• cardiovascular: obesity, diabetes, dyslipidaemia, metabolic syndrome, hypertension, smoking
• alcohol use
• drugs eg SSRIs, beta blockers

Question 23

Erectile dysfunction - investigations

Answer 23

• 10 year CV risk assessment
• free testosterone (morning, between 9-11)

If testosterone is low or borderline:
- repeat measurement and also get FSH, LH and prolactin levels.

Referral:

• endocrinology if hormones are deranges
• urology for a young man who has always had difficuly achieving an erection

Question 24

Erectile dysfunction - management

Answer 24

• 1st line: PDE-5 inhibitors –> sildenafil (viagra)

- 2nd line, or if sildenafil is CI, can offer vacuum erection devices (help to maintain erection by pooling blood)

Question 25

Phymosis

Answer 25

- Can be physiologic = only operate after baby comes off nappies if not causing any issues - true phymosis only if you can't expose any of glans - if pt can expose glans it's no phymosis - some patients can only expose part of the glans and when they try to pull it out there's a sticky white liquid (it's not phymosis, but Balanopreputial Adhesion) - in some cases pt has excess prepuce (not phymosis) - paraphymosis (emergency): ring around it constricts the mucosa and glans --> need urgent decompression

Question 26

Hypospadias

Answer 26

- opening of urethral meatus outside usual side (can be glans, balanopreputial sulcus, penile, scrotal, perineal) - chordee - curving of penis during erection - the baby may spray while urinating - fold os skin can stretch out of glans like a hoodie - when to investigate: pts with syndromic features, pts with hypospadias in proximal penis/scrotal/perineal, scrotal anomalies or cryptochiridism --> US KUB to rule out kidney or urological anomalies and pelvic US to rule out mullerian structures (may be female?) - when to operate: usually after 6m - 1 year old

Question 27

Cryptorchidism

Answer 27

- testis outside of scrotum (palpable or not) - when to investigate: pts with syndromic features, bilateral cases, scrotal anomalies or hypospadias --> US KUB to rule out urological anomalies and pelvic US to rule out mullerian structures (may be female?) - sometimes might need laparoscopy if testis can't be seen on US or CT to confirm if baby has a testis or not - when to operate: between 1 and 2 y/o

Question 28

Bladder Cancer - general

Answer 28

- second most common urological cancer - commonly affects males aged between 50 and 80 - other RF: smoking, chronic bladder inflammation from Schistosomiasis (SCC), exposure to some dyes in the printing and textile industry, work in rubber manufacture and use of cyclophosphamide Types - Transitional cell carcinoma (>90% of cases) - Squamous cell carcinoma ( 1-7% -except in regions affected by schistosomiasis) - Adenocarcinoma (2%) (Benign bladder tumours e.g. inverted urothelial papilloma and nephrogenic adenoma are uncommon)

Question 29

Bladder Cancer - TCC

Answer 29

- solitary lesions or multifocal - Up to 70% of TCC's have a papillary growth pattern - usually superficial and have a better prognosis - The remaining are either mixed papillary and solid growth or pure solid growths. These are more prone to local invasion have a worse prognosis - Those with T3 disease or worse have a 30% (or higher) risk of regional or distant LN metastasis

Question 30

Bladder Cancer - clinical features

Answer 30

Most patients (85%) will present with painless, macroscopic haematuria. In those patients with incidental microscopic haematuria, up to 10% of females aged over 50 will be found to have a malignancy (once infection excluded). In 20% they can have storage symptoms (polyuria, frequency, dysuria) NICE refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for bladder cancer if they are: 1. aged 45 and over and have: - unexplained visible haematuria without UTI or - visible haematuria that persists or recurs after successful treatment of UTI 2. aged 60 and over and have unexplained non-visible haematuria and either dysuria or a raised WCC

Question 31

Bladder Cancer - Staging

Answer 31

T0 = no evidence of tumour Ta = non invasive papillary carcinoma TIS = non invasive, plain (carcinoma in situ) T1 = tumour invades sub epithelial connective tissue T2 = tumour in muscularis propria T3 = tumour extends to perivesical fat T4 = tumor invades any of the following: prostatic stroma, seminal vesicles, uterus, vagina (Stage 1 = lamina propria Stage 2 = muscularis propria Stage 3 = perivisceral tissue/regional LN Stage 4 = pelvic or abdominal wall or more) ``` N1 = Single regional LN metastasis within pelvis N2 = Multiple regional LN metastasis within pelvis N3 = LN mets to the common iliac lymph nodes ``` ``` M0 = no distant mets M1 = distant mets ```

Question 32

Bladder Cancer - Ix and Mx

Answer 32

Ix - A mass sometimes be found on CT or US and abnormal filling on Intravenous pyelogram (urogram) - Cystoscopy and biopsies or TURBT for definitive diagnosis and information relating to depth of invasion. - Locoregional spread is best determined using pelvic MRI and distant disease CT scanning. - Nodes of uncertain significance may be investigated using PET CT - Urine cytology is important in the diagnosis and follow-up. A positive test without a visible mass indicated tumour of renal pelvis or ureter Mx - Those with superficial lesions may be managed using transurethral resection of bladder tumour (TURBT) - Those with recurrences or higher grade/ risk on histology may be offered intravesical chemo - Those with T2/T3 usually offered either surgery (radical cystectomy and ileal conduit)(+/- neoadjuvant chemo) or radical radiotherapy - for T4 either chemo alone or chemo + cystectomy

Question 33

Post - radical cystectomy: what happens to the urine?

Answer 33

- classically, a urterosigmoidostomy used to be done (direct urine from urter to sigmoid) but this had some complications, in particular hyperchloremic metabolic acidosis - now another technique is becoming more commonly used: studer technique --> use a segment of the ileum to create an ortotopic neobladder (anastomosing the 2 ureters to the urethra via this tube) - in cases where the ureter needs to be removed, the surgeon will use again an ileal segment and create a stoma (ureteroiliostomy) (heterotopic neobladder)