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