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Rahul Panikker rp319@ic.ac.uk Urology MedEd Y3 Written Exam Lectures 2023SESSION STRUCTURE Aetiology History Presentation Investigations Management = Gold Standard = High YieldSESSION CONTENT • Scrotal Swellings • Testicular Torsion • Epididymitis and orchitis • Testicular Cancer • Varicocele • Hydrocele • Urinary Tract • Prostate Cancer • Benign Prostatic Hyperplasia (BPH) • Bladder Cancer • Urinary TractCalculi • Urinary TractInfection (UTI) Menti: 7845 7399 SCROTAL SWELLINGS SBA 1 A 25 yearold man presents to A+E with severe pain in his right testicle. This started an hour ago whilst he was playing rugby. On examination, the testicle is hot, red and swollen. The cremasteric reflex is absent. What is the most appropriate next step in his management? a) Ultrasound of the scrotum b) Surgical Exploration c) Urine dipstick d) Urine MC&S e) Blood cultures SBA 2 A 40 yearold man presents to his GP with a dragging feeling in his scrotum. This feeling is worse when standing up. It is also accompanied by a dull pain. On examination, there is a scrotal mass on the left, which the GP can get above. What is the most likely diagnosis? a) Varicocele b) Hydrocele c) Inguinal Hernia d) Testicular Torsion e) Testicular Cancer SBA 3 A 24 yearold male presents with right scrotal pain. He has also noticed some swelling and pain on urination. On examination, the right testicle is tender on palpation, and the cremasteric reflex is present. The patient is sexually active with many partners, though doesn’t always use protection. What is the most likely causative organism? a) E.coli b) N.gonorrhoeae c) Pseudomonas aeruginosa d) Klebsiella e) C.trachomatisApproach to Scrotal Swellings Hydrocoele often is painless but it transilluminates. Fig1. Oxford Cases in Medicine andSurgery Varicocele also goes here. It can be distinguished from hydrocoele as it usually causes a dull pain and doesnot transilluminate.Testicular Torsion Types Definition – Twistingof the testicle on the • Intra-vaginal (more common) – Twisting spermatic cord leadingto constriction of the occurswithin the tunica vaginalis vascular supply – SURGICAL EMERGENCY • Extra-vaginal (rare) – Entire testis and tunica vaginalis twist Aetiology • Bell Clapper Deformity – accounts for 90% ➢ Genetic condition where testis lacks normal attachment to tunica vaginalis and hangsfreely, predisposing to torsion • Trauma • Extra-vaginal torsion – very rareTesticular Torsion Symptoms Signs • Testicular Pain • Hot, swollen, tender testis • Sudden onset • Affected testis lies higher • Unilateral • Absent cremasteric reflex • Usually very ➢ Inner thigh is stroked severe ➢ Normal (ie. present) = • May be referred ipsilateral testicle is to either iliac pulled towards inguinal fossa canal • Nausea + Vomiting ➢ Testicular torsion = • Fever absent reflex(ie. testis not pulled towards inguinal canal) LOOK FOR RISK FACTORS • Trauma • History of Bell ClapperTesticular Torsion Investigation/Management Referral to urology for Emergency scrotal exploration to de-twist – SURGERY SHOULD NOT BE DELAYED FOR INVESTIGATION • If blood supply has been cut offfor too long – orchidectomy (ie. orchiectomy)= removal of testicle • If some blood supply was maintained – bilateral orchidopexy = permanent fixation of both testicles into their scrotums to reduce chances of further testicular torsion If surgery is not available, clinician should attempt manual de-torsion – ie. hold testicle with right thumb and forefinger and rotate clockwise 180 degrees; may need to repeat 2-3 times, depending on extent of twist Complications • Permanent loss of testicle • Infertility • Psychological implication • Recurrent torsionEpididymitis + Orchitis Definition • Epididymitis – inflammation of the epididymis • Orchitis – inflammation of the testes • Epididymo-orchitis = inflammation of epididymis and testes; historically thought to occur together but most cases are solely epididymitis Epidemiology Bimodal age distribution: • 15-30 years • >60 yearsEpididymitis + Orchitis Pathophysiology – usually infective from lower urinary tract • Males<35 yrs – likely sexual transmission • Chlamydia trachomatis (most common) • Neisseria gonorrhoeae • Males>35 yrs – enteric organisms more likely • E.coli Other causes: • Klebsiella • Mumps • Pseudomonas • Trauma • **look forprevious UTIs, recent catheterisation orbladder • Vasculitis outflow obstruction in these patients • ImmunosuppressionEpididymitis + Orchitis Clinical Features Symptoms Signs • Unilateral scrotal pain • Red and swollen on affected side • Swelling • Tender on palpation • Fever and rigors • Associated hydrocele • Symptoms secondary to underlyingcause: • Cremasteric reflex is present– ➢ UTI cause: differentiates from testicular torsion ❖ Dysuria • Prehn’s sign ispositive ❖ LUTS • When patient is supine (lying face up) ❖ Urethral discharge and scrotumis elevated,pain is ➢ Sexual transmission cause: relieved ❖ Recent history of unprotected sex • NB: poor specificity; not routinely usedEpididymitis + Orchitis Investigations/Management Management Investigation • Antibiotics • Diagnosis is typically clinical ➢ Enteric – ofloxacin • Urine ➢ STI – single dose of IM ceftriaxone and 10 ➢ Urine dipstick days of doxycycline ➢ MSUfor MC&S • Analgesia • Bloods – routine to see if infection • Conservative • Ultrasound – can confirm diagnosis if unsure ➢ Bed rest and rule out torsion ➢ Scrotal support ➢ Patients abstain from sexual activity • Surgery – may be required in patients who do not improve (suspected chronic infection)Testicular Cancer • Cancer of testicles Tumour Staging: • Most common cancer in men aged 20-40 • Stage I – confined to testes • Northern Europeans at higher risk • Stage II – infra-diaphragmatic lymph node involvement • Stage III – supra- and infra-diaphragmatic lymph node Risk factors: involvement • Cryptorchidism (ie. maldescended testes) • Stage IV – extra-lymphatic metastatic spread • Previous testicular malignancy • Positivefamily history • Klinefelter’s syndrome (ie. XXY) Testicular cancer Germcell – 95% Non-germ cell (usually benign) Seminomas Non-seminomatous Leydig cell tumours Sertoli cell tumours • Good • Bad prognosis prognosis • Metastasise earlyTesticular Cancer Presentation • PAINLESS HARD NODULAR TESTICULAR METASTATIC FEATURES MASS – unilateral • Weight loss • Associated lymphadenopathy • Gynaecomastia – most common in non • Bdue to spread to para-aortic lymph nodes seminomas due to high β-hCG levels found in retroperitoneumTesticular Cancer Investigations: • Bloods ➢ FBC ➢ U&Es ➢ LFTs Management: • Tumour markers ➢ α-fetoprotein – elevated in most non-seminomas • Most caseswill undergo orchidectomy (ie. surgical ➢ β-hcg – elevated in most non-seminomas and some seminomas removal of testis) ➢ LDH – elevated in half of germ cell tumours(ie. seminomasand non- • Chemotherapy and seminomas) radiotherapy may be used • Imaging ➢ Scrotal ultrasound in more severe disease ➢ CT scan ➢ Chest x-ray – can be done to check for mediastinal metastases • Percutaneous biopsy of scrotum – must be avoided as it can cause seeding of tumourVaricocele Dilated veins of the pampiniform plexus forming a scrotalmass Increased hydrostatic Incompetent venous pressure in the left renal vein valves • Usually occurs on left side ➢ Left testicular vein drains into left renal vein, which means there is more resistance • Left-sided varicocele → can be a sign of renal cell carcinoma caused by compression of left renal vein by tumourVaricocele Presentation Investigations • Dragging sensation • USS – confirms diagnosis • Throbbing/dull pain • Fertility analysis • Scrotal mass – feels like “bag of Management worms” • Managed conservatively • More prominent on standing – may reduce when lyingdown • Surgery can be offered ifconcerns of infertilityHydrocele Collection of fluid within tunica vaginalis that surrounds the testes Presentation • Painless • Soft fluctuant swelling • Possible to get above swelling • Transilluminates • Communicating hydroceles = opening between scrotum and No investigations usually required → belly that allows fluid to freely pass between the two areas clinical diagnosis ➢ Half ofbaby boys are born with this but it often goes away without treatment by 1 year • Non-communicating hydrocele = tunnel between scrotum • Usually managed conservatively and belly hasbeen closed, but the fluid is unable to be • Too uncomfortable → do surgery removed by scrotum SBA 1 A 25 yearold man presents to A+E with severe pain in his right testicle. This started an hour ago whilst he was playing rugby. On examination, the testicle is hot, red and swollen. The cremasteric reflex is absent. What is the most appropriate next step in his management? a) Ultrasound of the scrotum b) Surgical Exploration c) Urine dipstick d) Urine MC&S e) Blood cultures SBA 2 A 40 yearold man presents to his GP with a dragging feeling in his scrotum. This feeling is worse when standing up. It is also accompanied by a dull pain. On examination, there is a scrotal mass on the left, which the GP can get above. The mass is not trans-illuminable What is the most likely diagnosis? a) Varicocele b) Hydrocele c) Inguinal Hernia d) Testicular Torsion e) Testicular Cancer SBA 3 A 24 yearold male presents with right scrotal pain. He has also noticed some swelling and pain on urination. On examination, the right testicle is tender on palpation, and the cremasteric reflex is present. The patient is sexually active with many partners, though doesn’t always use protection. What is the most likely causative organism? a) E.coli b) N.gonorrhoeae c) Pseudomonas aeruginosa d) Klebsiella e) C.trachomatisTESTICULARTORSION: Summary slide Aetiology: History: Investigations: Twisting of the tesicle✶ SYMPTOMATIC ✶ SURGICAL EXPLORATION causing infarction Tender, hot erythematous Management: scrotum Extravaginal vs Unilateral Intravaginal ✶ T esticle twisted back → bilateral orchidopexy ✶ High-riding testicle ✶ Commoninteenage ✶ MUST BETREATEDWITHIN 6 HOUR OF years ✶ Absent cremasteric PRESENTATION ✶ EMERGENCY reflex TESTICULARTORSION VS EPIDIDYMITIS/ORCHITIS ✶ SYMPTOMATIC ✶ Dysuria ✶ High-riding testicle Tender, hot erythematous ✶ Absent cremasteric scrotum ✶ Pyrexia - infection reflex Unilateral ✶ Penile discharge - ✶ HOURS STI ✶ A FEW DAYSEpididymitis and orchitis: Summary slide Aetiology: History: Investigations: ✶ SYMPTOMATIC ✶ Urine Dip ✶ MSU for MC&S Inflammation of the epididymis or testes Tender, hot erythematous scrotum ✶ Bloods – FBC (highWCC) ✶ If < 35 yrs: Unilateral Chlamydia Imaging (only if unsure of diagnosis) trachomatis > ✶ Dysuria Neisseria ✶ Pyrexia - infection Colour Duplex USS gonorrhoeae ✶ If > 35 yrs: mainly coliforms(eg. E. ✶ Penile discharge - coli) STI Management: LESSACUTE COMPARED TO TESTICULAR ✶ Conservative → bed rest, scrotal elevation TORSION ✶ Medical → analgesia, antibiotics ✶ Surgical → testicular exploration, only if testicular torsion cannot be excluded clinicallyVaricocele: Summary slide Aetiology: History: Investigations: Dilated veins of the ✶ ASYMPTOMATIC ✶ Standing examination of the scrotum pampiniform plexus A ‘Bag ofWorms’ ✶ Fertility analysis ✶ Increasedhydrostatic pressure ✶ Incompetentvenous Management: valves ✶ Observation + reassurance Incidence increases after puberty ✶ If fertility analysis abnormal → surgical repair offered 80-90% in leftHydrocoele: Summary slide Aetiology: RISK FACTORS History: Investigations: MALE ✶ ASYMPTOMATIC ✶ Clinical Diagnosis Excessive fluid in the 1 Year of Life tunica vaginalis Scrotal swelling ✶ Communication → OPEN Increased intraperitoneal ✶ Transilluminates processusvaginalis fluide.g. ascities ✶ Non-Communicating → Inflammation/injury tothe CLOSED processus scrotum e.g. infection, vaginalis testicular torsion Management: ✶ Observation + reassurance ✶ If becomes too uncomfortable → surgical interventionTesticular Cancer: Summary slide Aetiology: RISK FACTORS History: Investigations: Cryptorchodism Ectopic testes Tumour in the testes Testicular atrophy ✶ PAINLESS ✶ Bloods – FBC, LFTs, FHx U&Es Unilateral testicular mass ✶ T umour Markers – a Seminomas – 50% fetoprotein, B hCG, LDH ✶ Lymphadenopathy Non-seminomatous ✶ Gynaecomastia ✶ T esticular ultrasound germ cell tumours – 30% ✶ Back ache ✶ CTAP Management: ✶ Surgical removal → orchiectomy ✶ Chemotherapy (MENTI CODE: ) Urinary Tract SBA 4 A 74 year old man, originally from Jamaica, presentscomplainingof problems with his urination. He often has to go to the toilet at night to relieve himself. When he does he finds it hard to start urinating,and a weak flow.There is also some dribbling after he has finished urinating.He is especially worried as his father suffered from prostate cancer. Urine dipstick is normal,but blood testsshow araised PSA.On DRE, there are no abnormalities or enlargement found. What is the next most appropriate step? a) Reassure the patient and monitor b) CT Scan c) MRI scan d) Ultrasound KUB e) Prescribe tamsulosin SBA 5 A 38 year old woman presents with severe left flank pain, associated with nausea. A urine dipstick shows haematuria, and a CT KUB shows a 9mm kidney stone in the left ureter What is the next most appropriate step in her management? a) Arrange percutaneous nephrolithotomy b) Allow to pass spontaneously c) Send for extracorporeal shockwave lithotripsy (ESWL) d) Prescribe tamsulosin e) Prescribe diclofenacBPH Vs Prostate Cancer Benign Prostatic Hyperplasia (BPH) – non-canceroushyperplasia ofthe transitional zone of prostate; peripheral zone may also be involved but to a lesser extent Prostate Cancer – majority are adenocarcinomas LUTS Symptoms are common to both! • Problems with voiding Common Risk Factors • Hesitancy • Age • Family history • Weak flow • Afro-Caribbean ethnicity • Terminal dribbling • Incomplete emptying • Problems with storage SPECIFIC TO PROSTATE CANCER • Urinary frequency • Nocturia • Haematuria (rare but possible with BPH) • Urge incontinence • FLAWS symptoms • Metastatic spreadBPH vs Prostate Cancer Investigations Urinalysis – exclude UTI + check for blood Multiparametric MRI scan of Prostate Cancer BPH prostate is now 1 line Bedside Asymmetrical hard nodular DRE Smoothly enlarged prostate investigation for Palpable midline groove prostate cancer asit is more accurate and PSA – high in both >4; it is non-specific less invasive. It is Bloods U&E’s – check impaired renal function as this will unfairly increase PSAlevel usually done before biopsy as Prostate Cancer BPH it will help locate MRI – 1 lineimaging Post-void bladder scan the areas of the Imaging Biopsy – transperinealor transrectalUS- prostate where Ultrasound guided biopsy the cancer is TNMStaging via CTCAP Prostate MRI (if cancer suspected) most likely to be.BPH Management For patients who are asymptomatic: Alpha blockers – workby relaxing the prostate and • Observe bladder neck, which allows urine to flowmoreeasily • Lifestyle changes as necessary (ie. theyhave anticholinergic effects) • Side effects =orthostatic hypotension; dizziness, fatigue, headache, impotence Medical Management – symptomatic BPH (ie. IPSS ≥8): 5a-reductaseinhibitors – workby preventing • Alpha blockers – eg. Tamsulosin, Doxazosin conversion of testosterone to dihydrotestosterone, • 5a-reductase inhibitors – eg. Finasteride thereby limiting prostate growth • Side effects =decreased libido; impotence; ejaculation issues; gynaecomastia; depression; Surgical Management – patients refractoryto medicine or with anxiety complications: • TURP – trans-urethral re-section ofthe prostate TURP syndrome = where useof hypo-osmolar irrigation in TURP can resultin triad of fluid Antimuscarinic drugs (eg. tolterodine) are given to patients with overload, hyponatraemia (dilutional) and glycine overactive bladder symptoms that is not responding to toxicity tamsulosin, finasteride etc.Prostate Cancer Management Management is based on: • PSA levels • Gleason score • TNM staging Gleason Score Low-Risk Disease: • Based on histology from biopsy • Active surveillance • Tissue samples are graded from 1-5 (5 • Lifestyle changes as necessary being most abnormal) • 2 numbers are added to make Gleason score: ➢ 1 number= gradeof mostprevalentpattern Intermediate and High-risk Disease: ➢ 2 number= gradeof 2 mostprevalent pattern • Surgery – radical prostatectomy • Radiotherapy Up to 6 = low-risk ≥8 = high-risk Metastatic Disease • Chemotherapy • Anti-hormonal agents (eg. goserelin) Bladder Cancer Definition Age >55 years Malignancy of bladder cells 4x more common in males 90% - Urothelial carcinoma RARE- Squamous cell carcinoma associated with chronic inflammation RF’s RF’s Smoking Chronic UTI’s Carcinogen exposure Schistosoma Haematobium Aromatic amines Polycyclic aromatic hydrocarbons Arsenic Painters and hairdressers Bladder Cancer Presentation PAINLESS haematuria – macroscopic/microscopic LUTS FLAWS LUTS Treated as bladder cancer until proven otherwise! Frequency Make 2WW referral if: Urgency • ≥ 60yrs with unexplained non-visible haematuria AND [dysuria OR raised Nocturia WCC] Hesitancy • ≥ 45yrs with unexplained visible haematuria without UTIor persisting Incomplete voiding despite treatment Poor streamBladder Cancer Investigations Bedside 1 Line: Urinalysis – confirms haematuria FBC Bloods ALP (will be raised if there are bony metastases from the bladder cancer), U&E’s Imaging Cystoscopy + biopsy – GOLD STANDARD (via 2WW referral) CTAP , MRI AP – exclude kidney stones, visualise bladder cancer Isotope bone scan – bony mets CXR – lung metsBladder Cancer Management Non-muscle invasive (eg. Tis, T1): • Transurethral resection ofthe bladder(TURBT) Muscle invasive (eg.T2): • Radical cystectomy • Neoadjuvant chemotherapy Metastatic/locally advanced • Chemotherapy • Symptomatic management • Palliative careUrinary Tract Infection Definition – Presence of pure growth of >10 organisms per mL of fresh MSU 2 main types: • Lower urinary tract infection – urethra or bladderinfection (urethritis/cystitis) • Pyelonephritis – kidney infection Pyelonephritis Cystitis UrethritisUrinary Tract Infection Risk Factors Causative Micro-organisms • Female • Sexual activity • Pregnancy – aspressure of • E.Coli – MOST COMMON for foetus can cause stasisof urine both lower UTI and flow pyelonephritis • Catheterisation • Klebsiella • Immunosuppression • Enterococcus • Urinary tract obstructionUrinary Tract Infection Investigations: Presentation: antibiotics– empirical st Storage symptoms 1 Line – Urine Dipstick +ve leucocytes and nitrites Normal women = 3 days of • Increased frequency nitrofurantoin or trimethoprim; send presentulture if >65 yrs or haematuria • Urgency • Dysuria MSU for MC&S – GOLD STANDARD Men = immediate 7 day prescription • Foul-smelling Identify bacteria always send urine cultureethoprim; (Pyelonephritis will have white cell casts) Acute Pyelonephritis Pregnant women = 1 line – nitrofurantoin (avoid near term); 2 • Flank pain course; treat even if asymptomatic toy • Fever Blood cultures – if systemically unwell prevent progression to acute and risk of urosepsis pyelonephritis • Malaise Urinary Tract Calculi Definition The presence of calculi within the urinary system 1 One of THREE points of narrowing: 1. Ureteropelvic junction 2. Pelvic brim (where ureters cross the iliac vessels) 3. Ureterovesicaljunction Types of Stone: o Calciumoxalate - MOST COMMON 2 o Struvite (magnesium ammoniumphosphate) o Urate/uric acid - 5% - not visible on X-ray! o Hydroxyapatite (5%) 3 Urinary Tract Calculi Risk Factors • Dehydration • High protein intake • High salt • Structural abnormalities • PMHx • FHx Epidemiology 3x more common in MALES Age group: 30-50yrs Higher prevalence in hot, dry countries Urinary Tract Calculi Presentation Initially may be asymptomatic As the calculi getsstuck…. Acute SEVEREloin to groin pain = RENAL COLIC Nausea & Vomiting Unable to lie still/writhingin pain Urinary symptoms Urgency Frequency Haematuria (85% microscopic, occasional macroscopic) Urinary Tract Calculi Investigations 1 Line: Urine Dipstick Bedside NOTE: in all women of child-bearing age → pregnancy test to exclude ectopic pregnancy FBC Bloods WBCs for UTI U&E’s, Cr,Cato check renal function Imaging GOLD STANDARD: non- contrast CT-KUB or (USS in pregnant women or children) Urinary Tract Calculi Management <5mm → leave to pass spontaneously with increased fluid intake Acute Complications Fluids Pyelonephritis <10mm → alpha-blocker (tamsulosin), if not passed after 4-6 Septicaemia weeks → surgery (diclofenac oral or PR) Obstruction Urinary (ondansetron) retention >10mm or failed therapy → surgical removal Hydronephrosis st Urine collection – • 1 line: extracorporeal shock wave lithotripsy (ESWL) collect passed stone AKI • Percutaeneous nephrostolithotomy – difficult shape stone e.g. staghorns If signs of infection – must do urgent renal decompression and Long-term prevention → high fluid intake, low salt diet and IV antibiotics due to riskof thiazide diuretics to reduce calcium stones; cholestyramine and sepsis pyridoxine to reduce oxalate stones; allopurinol and oral bicarbonate to reduce uric acid stones SBA 4 A 74 year old man, originally from Jamaica, presents complainingof problems with his urination. He often has to go to the toilet at night to relive himself. When he does he finds it hard to start urinating, and weak flow. There is also some dribblingafter he has finished urinating. He is especially worried as his father suffered from prostate cancer.Urine dipstick is normal, but blood tests show a raised PSA. On DRE, there are no abnormalities or enlargement found. What is the next most appropriate step? a) Reassure the patient and monitor b) CT Scan c) MRI scan d) Ultrasound KUB e) Prescribe tamsulosin SBA 5 A 38 year old woman presents with severe left flank pain, associated with nausea. A urine dipstick shows haematuria, and a CT KUB shows a 9mm kidney stone in the left ureter What is the next most appropriate step in her management? a) Arrange percutaneous nephrolithotomy b) Allow to pass spontaneously c) Send for extracorporeal shockwave lithotripsy d) Prescribe tamsulosin e) Prescribe diclofenacExtra Points • Acute urinary retention can cause AKI soon after. So, it is important to monitor serum creatinine for ~24 hours even after inserting catheter and draining urine. • Urinary problems in ayoung man with history of gonorrhoea is unlikely to be prostate-related. It is most likely aurethral stricture. • Functional urinary incontinence = barriers (eg. poor mobility) that prevents patient from reaching toilet in time • Radicalnephrectomy = 1 line treatment for renal cell carcinomaif no metastases as it does not respond well to chemotherapy or radiotherapy; partial nephrectomy can be done if tumour is <7cm • Renal adenocarcinomais also known as Grawitz tumourExtra Points • Torsion ofthe testicular appendage alone can occur and presents with similar symptoms but cremasteric reflex will still be present • BPH can increase the risk of UTIs due to stasis of urine flow • Urine incontinence = fluid intake and bladder retraining advice;if unsuccessful, start antimuscarinics (eg. oxybutynin, tolterodine) • Renal colic treatments: ➢ Stone of<5mm – manage expectantly ➢ Stone of of 5mmto 2cm – extra corporealshockwave lithotripsy ➢ Stone of<2cm in pregnant females – ureteroscopy ➢ Complex renal calculi and staghorn calculi – percutaneous nephrolithotomy ➢ Associated hydronephrosis – percutaneous nephrostomyExtra Points • If bladder cancer is suspected, on top of a flexible cystoscopy, a CT urogram should also ideally be done in order to rule out any upper tract disease (eg. collecting ducts), which cannot be seen on a flexible cystoscopy. These should be carried out before a biopsy to help plan it. • Ketamine is a recreational drug that is commonly associated with an inflamed bladder wall and contracted bladder, and may cause haematuria and pelvic pain.