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Urology for the Exam
ClassificationMacroscopic (Frank, visible)
Dipstick Microscopic
72 yr old man with haematuria
What relevant history will you elicit?
Macroscopic, painless, complete, first episode
No urinary symptoms
PMH
No relevant drug history or allergies
Smoker
No relevant occupational history
No Travel
Move on to examination
72 year old …
What investigations?
MSU, dipstick
U&Es, creatinine
IVU
Cystoscopy
What is the most common diagnosis?
Ca Bladder
What are the DD
Aetiology
Urological
Cancer
Renal cell carcinoma (RCC)
Upper tract TCC
Bladder carcinoma
Prostate carcinoma
Other
Stones
Infection
Inflammation
Benign prostatic hyperplasia (large)
Nephrological (Glomerular)
Glomerular vs Urological
Glomerular haematuria: suspect if
Microscopic
Age < 40yrs
Associated
Proteinuria
BP
Creatinine
Urological haematuria: suspect if
Macroscopic
Age >50yrs
Pain
Haematuria clinic
History
Smoking
Occupation
Painful or painless
Other LUTS
Family history
Travel
Drugs
Allergies
Examination
BP
Abdominal mass
Varicocele
Leg swelling
Assess prostate by digital rectal examination (male)
Size
Texture
Haematuria clinic -investigations
Blood-FBC-U&E
Urine-Culture & sensitivity-Cytology
Radiology-Ultrasound-IVU/ CT
Endoscopy-Flexible cystoscopy
IVU
IVU -principles
Plain KUB film 1st
i.v. contrast agent
Film at 15 mins
Stones
Space occupying lesions
Filling defects
Hydronephrosis
Detects
Flexible cystoscopy
Urine cytology
IVU Ultrasound
Urine culture
Bladder cancer
Appearance on flexible cystoscopy
Bladder cancer -epidemiology
5th most common cancer in E&W
12,500 new cases & 5000 deaths per year
M:F 3:1
90% are transitional cell carcinoma (TCC)
Smoking 3x
Occupational exposure
20 yr latent period
Aniline dyes
Polycyclic aromatic amines
Staging of TCC Bladder
Bladder cancer -staging
•75% are superficial•Ta•T1
•5% are Tis•20% are muscle-invasive
•T2•T3•T4
TUR bladder tumour
•Superficial TURBT•Separate deep TUR of muscle•After clearance, EUA•Single intravesical instillation of mitomycin C
Bladder cancer -histological grading
Grade 1
Grade 2 Grade 3
Normal urothelium
Bladder cancer -Tis
Normal urothelium Tis
Treatment
Superficial TCC (Non muscle invasive)
TURBT
Intravesical Mitomycin/ Epirubicin
Intravesical BCG for Cis
Muscle invasive disease
Radical Cystectomy + Ileal conduit
Radiotherapy
Treatment of bladder cancer
High risk superficial TCC
•Check cystoscopies•Intravesical chemotherapy/immunotherapy
Low risk superficial TCC
•Check cystoscopies
Muscle-invasive TCC
• Radical•Cystectomyor•Radiotherapy
Muscle-invasive bladder cancer
Implication
Best scenario
Mobile tumour, no proven metastases at diagnosis, radical Rx
Overall 5-year survival=50%
Further investigation
CT chest, abdomen, pelvis
Bladder
Tumour
Treatment of muscle-invasive bladder cancer
TCC
No/mobile mass
No metastases
No/mobile mass
LN metastases
Fixed mass
Visceral metastases
Radical cystectomy
Radical radiotherapy
Downstaging chemotherapy +/-cystectomy /radiotherapy
Palliative Chemotherapy /radiotherapy
Radical cystectomy
Ileal conduit Orthotopic bladder reconstruction
Renal cell carcinoma (RCC)
2,300 deaths per yr
3% of adult cancers
M:F 2:1
30% metastases on presentation
Aetiology
Smoking
Obesity
RCC
RCC -spread
Perinephric spread
Lymph node metastases
IVC spread toright atrium
RCC -paraneoplastic syndromes
Erythrocytosis
Hypercalcaemia
Hypertension
Pyrexia of unknown origin
RCC -radiology
Ultrasound IVU
CT
Non-metastatic RCC -standard treatment
Radical nephrectomy(removal of kidney, adrenal, surrounding fat, upper ureter)
Normal retroperitoneum
After left nephrectomyAfter right nephrectomy
RCC -radical nephrectomy
Metastatic RCC - treatment
Tyrosine kinase inhibitors
Sunitinib
Immunotherapy
Interferon alpha
Palliative radiotherapy
Brain & bone metastases
Palliative selective embolisation
Bone metastases
Kidney (haematuria)
Upper tract TCC
Only 5% of all malignancies of upper urinary tract
Renal pelvis > ureter
Ureteric tumours
Most in distal 1/3
1/3 are associated with bladder TCC
Aetiology
Smoking
Phenacetin abuse
Balkan’s nephropathy
Upper tract TCC -initial Investigation
IVU
Filling defect
Ureteric stricture
Retrograde pyelogram
Uretroscopy (Rigid/flexible)
Biopsy
Washings for cytology
Retrograde-principles
Retrograde -upper tract TCC
Upper tract TCC -standard treatment
Nephro-ureterectomy (kidney, fat, ureter, cuff of bladder)
Who gets them?
Men 3:1
Middle aged 20-50
Warm climates / summer
Affluent nations / individuals
Obsese & weight gain
Family history
Diet and fluids
Social class / occupation
Which are the common stones?
Calcium oxalate 70-80%
Calcium phosphate 10%
Uric acid 5%
Struvite (infection) 5%
(Magnesium Aluminium Phosphate)
Cystine 1-2%
Why treat stones?
Pain
Bleeding
Obstruction
Infection
Renal damage
Nuisance of admission & treatment
Acute presentation
Sudden onset of flank to groin pain
Colicy
Unable to get comfortable
Nausea/vomiting
Pain may migrate as stone moves down
Haematuria
Usually not this ‘typical’ presentation
Consider differential diagnoses
Leaking AAA
Pancreatitis
Perforation/ulcers
Bowel obstruction
Inflamed/infected/infarcted bowel
Ectopic pregnancy
UTI, MI, chest infection, trauma
Exclude differential diagnoses
Good history & thorough examination
Bloods including amylase
Urinalysis & MSU
Urine pregnancy test
AXR, erect CXR
Further imaging as appropriate
Management
Analgesia – voltarol 100mg PR, iv opiates
Antiemetics – cyclizine 50mg iv
Consider antispasmodic – buscopan iv
Fluids if dry or vomiting (but may worsen pain)
Alpha blocker to relax ureter
CT KUB or USS if fever (nephrostomy)
Renal colic secondary to stone
History-Pain-Frank haematuria
(occasionally)
Examination-Loin tenderness
Investigation-Urine dipstick
(usually positive for blood)-Serum creatinine-IVU
(if satisfactory renal function)-Spiral CT
(if renal impairment)
Who has a high risk of recurrence?
Multiple or bilateral stones
Strong family history
Chronic enteric disorders
Metabolic disorders
Gout
Struvite stones / chronic urinary infections
High body weight / BMI
IVU -ureteric stone
STONE URINE
BLOOD
INVESTIGATION
-Ca-Phosphate-Urate
-pH-Culture & sensitivity-Cystine-24 hour urine for
CalciumOxalateCitrate
-Chemical analysis
Recurrent urinary tract calculi
Prostate
Bladder outflow obstruction (BOO) -Causes
Physical
Urethra
Phimosis
Stricture
Prostate
Benign
Malignant
Bladder neck
Dynamic
Prostate
Bladder neck
Neurological
Bladder outflow obstruction -Physical
Bladder outflow obstruction
Phimosis
Urethralstricture
Benign prostatichyperplasia (BPH)
[physical presence of prostatic tissue]
Physical
Bladder outflow obstruction -Dynamic
•Sympathetic smooth muscular tone(mediated principally by α1 receptors)
Bladder outflow obstruction -Neurological
Lumbar vertebralspine
Sacrum
Cauda equina
Spinal cord
-Neurological
Lower motor neurone
Low detrusor pressure
Large residual urine
(S2, 3, 4)
Reduced perianal sensationLax anal tone
Lower urinary tract symptoms (LUTS)
Filling (storage;irritative)
Frequency
Nocturia
Urgency
Urge incontinence
Enuresis
Voiding (obstructive)
Hesitancy
Poor flow
Straining to void
Post micturition dribbling
Feeling of incomplete bladder emptying
LUTS are not disease specific
Urinary retention
Acute
Painful with residual urine <1000 ml
Chronic – Poor detrusor function
Painless with residual urine >1500 ml
Acute on chronic
Painful with large residual urine
Investigations
Initial
Bloods
Serum creatinine
? PSA
Urine
Flow rate (non-invasive)
Further
Urodynamics (invasive)
If
Equivocal flow rate
Recurrent/persistent LUTS post surgery for BOO
Neurological
Ultrasound of kidneys & ureters
if serum creatinine
Flow meter
Flow rate
-Normal-Suggestive of Benign Prostatic Obstruction (BPO)-Suggestive of Urethral Stricture
Three fundamental aspects of BPH
Prostate volume is only partially linked with BOO and LUTS
BPO -treatment options
Watchful waitingor
Pharmacotherapy
Pharmacotherapyor
Surgery
Mild/moderate LUTS Moderate/severe LUTS
Act quickly
Take 6 months to work
More effective in larger prostates
Rx of BPH-pharmacotherapy
Rx of BPH-pharmacotherapy
Uro-selective α-blockersUro-selective α-blockers 5α-reductase inhibitors5α-reductase inhibitors
Surgical treatment of BPO
Transurethral resection of prostate (TURP)
Prostate chips
Testicular Pathology
Torsion Testis
Hydrocele
Epididymal cyst
Testicular tumours
What could it be?
Hydrocele
Epididymal cyst
Spermatocele
Epididymo-orchitis
Testicular cancer
Varicocele
Hernia
Hydrocele
Varying size
Fluctuant
Tansilluminant
Can get above swelling
Testis may not be palpable – US needed to check testis
Surgical intervention (? aspiration)
Epididymal Cyst
Epididymal Cyst
Can be confused with hydrocele
More firm than a hydrocele
Transilluminant
Fluctuant
Testis usually palpable seperately
Usually arises from the head of the epididymis
Surgical excision if indicated
Varicocele
Varicocele
Dragging sensation
Fluctuant swelling extending into the cord
“bag of worms” feeling
Disappears when lying down
May be associated with sub-fertility
Surgical intervention only if pain, sub-fertility or small testis
Testicular tumours
Usually younger men (< 50 years)
Hard , painless swelling in the testis
Heavy testis
Associated features:atrophic testisundescended testisinfertility
Testicular tumours
Germ cell tumourSeminomaTeratoma
Non-germ cell tumourSertoli cell tumourLeydig cell tumour
Seminoma Testis
Teratoma testis
Teratoma testis
What to do if suspicious lump
TWWor if not sure
Urgent US of testis (within 1-2 days)
Alpha fetoprotein, Beta HCG and LDH
Take home message: ANY LUMP IN THE BODY OF TESTS IS TO BE REFERRED AS TWW
Acute Testicular Pain
Causes:
Torsion testis (<45 years, acute onset pain,
Epididymo-orchitis
Obstructed hernia
Ureteric calculus
Ruptured aortic aneurysm (> 60 years, pale, sweating, hypotension – usually left side)
Torsion Testis
Undescended Testicle