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Urology DDr Aeron AlvaradoceHeader slide ● Urinary retention: Causes, management ● Benign prostatic hyperplasia: Symptoms, treatment options ● Prostate cancer: Risk factors, diagnosis, staging, and management ● Kidney stones: Types, presentation, management ● Urinary tract infections: Diagnosis, treatment, complications ● Hematuria: Evaluation and differential diagnosisQuestion 1 A 86-year male on a orthopaedic What is the most appropriate immediate ward post NOF surgery under management? general anaesthesia has not passed urine for 10 hours and has become more delirious. The nursing staff are A) Abdominal XR patient is complaining of some. The B) Septic 6 screen abdominal discomfort and he is unable to pass urine when he tries. C) Start tamsulosin D) Insert a urinary catheter A bladder scan which shows 500ml. His observations are stable. E) Increase the patient’s analgesia some suprapubic tenderness onor palpation.Answer 1 A 86-year male on a orthopaedic What is the most appropriate ward post NOF surgery under immediate management? general anaesthesia has not passed urine for 10 hours and has become more delirious. The nursing staff are A) Abdominal XR patient is complaining of some. The B) Septic 6 screen abdominal discomfort and he is unable to pass urine when he tries. C) Start tamsulosin D) Insert a urinary catheter A bladder scan which shows 500ml. His observations are stable. E) Increase the patient’s analgesia some suprapubic tenderness onor palpation.Urinaryretention Inability to voluntarily empty the bladder (fully or partially) - acute or chronic Obstructive: - BPH, prostate cancer, urethral strictures (recurrent UTIs), blood clots, stones (bladder/urethral), severe constipation, tumours, organ prolapse Medications: - Opioids, anaesthesia, anticholinergics Other: - Neurological (spinal cord, diabetes), psychological Urinaryretention Symptoms: inability to void, LUTS (dribble, weak stream), recurrent UTIs, abdominal discomfort Assessment: examination/history, PSA, U&Es, bladder scan, urinalysis, urodynamic studies, cystogram Complications: UTIs, bladder stones, hydronephrosis (kidney impairment) Treatment: - Acute = urinary catheterisation - Chronic = BPH treatment, surgery (urethral stricture, organ prolapse), medication review, lifestyle/urinating habitsQuestion 2 A 75 year old male has been experiencing progressively Given the likely diagnosis, what is the most worsening weak urinary flow, appropriate management at this stage? straining and post-void dribbling for 18 months. His GP refers him to a urology clinic and performs aA)PR Watchful waiting examination and some tests. B) Transurethral resection of prostate (TURP) PR examination: large, smoothC) Start Finasteride and Tamsulosin prostate D) Start Tamsulosin Urinalysis: NAD E) Start Oxybutynin PSA 1.3 (1.0 - 1.5 normal)Answer 2 A 75 year old male has been experiencing progressively Given the likely diagnosis, what is the most worsening weak urinary flow, appropriate management at this stage? straining and post-void dribbling for 18 months. His GP refers him to a urology clinic and performs A) Watchful waiting an PR examination and some B) Transurethral resection of prostate (TURP) tests. C) Start Finasteride and Tamsulosin PR examination: large, smooth prostate D) Start Tamsulosin E) Start Oxybutynin Urinalysis: NAD PSA 1.3 (1.0 - 1.5 normal)Question 3 What piece of information is most important to inform the The same patient as question 2 is patient of? started on tamsulosin for BPH. A) He is at an increased risk of developing prostate A 75 year old male has been experiencing cancer. progressively worsening weak urinary flow, B) U&Es should be monitored routinely. straining and post-void dribbling for 18 months. C) Tamsulosin increases his risk of falls via postural His GP refers him to a urology clinic and hypotension. performs an PR examination and some tests. D) Due to being of caucasian ethnicity he had an increased risk of developing BPH than black PR examination: large, smooth prostate ethnicity. E) Tamsulosin increases his risk of gynaecomastia. Urinalysis: NAD PSA 1.3 (1.0 - 1.5 normal)Answer 3 The same patient as question 2 is started on What piece of information is most important to inform tamsulosin for BPH. the patient of? A 75 year old male has been experiencing progressively A) He is at an increased risk of developing prostate worsening weak urinary flow, straining and post-void cancer. dribbling for 18 months. His GP refers him to a urology B) U&Es should be monitored routinely. clinic and performs an PR examination and some tests. C) Tamsulosin increases his risk of falls via PR examination: large, smooth prostate postural hypotension. D) Due to being of caucasian ethnicity he had an Urinalysis: NAD increased risk of developing BPH than black ethnicity. PSA 1.3 (1.0 - 1.5 normal) E) Tamsulosin increases his risk of gynaecomastia.Benign prostate hyperplasia Non-cancerous enlargement of the prostate gland in older men causing lower urinary tract symptoms (LUTS). Black > Caucasian > Asian LUTS: - Obstructive: weak, straining, hesitancy, incomplete voiding, post-void dribble - Irritative: urgency, frequency, urge incontinence - Complications: UTI, acute retention, bladder stones, kidney damage Benign prostate hyperplasia Investigations: - International prostate symptom score (IPSS) questionnaire - impact of LUTS on life - Score 20-35: severely symptomatic - Score 8-19: moderately symptomatic - Score 0-7: mildly symptomatic - DRE (enlarged but smooth) - Urinalysis (?blood, ?infection) - Post-void bladder scan - PSA - U&Es - Cystoscopy Treatment: - Watchful waiting - Alpha-1-blocker (relaxes prostate/urethra muscles): tamsulosin - 5-Alpha reductase (shrink prostate): finasteride - Combination of A1B and 5AR - Anticholinergic (if overactive bladder symptoms): tolterodine - Transurethral resection of prostate (TURP) - TURP syndrome: fluid overload & hypoNa (agitation, confusion)Question 4 A 60-year old male presents to the GP What is the most important first with strain incontinence for the pastinvestigation for this patient? months. On further questioning he has noted some unintentional weight loss. DRE reveals a large craggy A) PSA prostate. Abdomen is SNT. B) Transrectal urethral guided biopsy C) Transperineal biopsy D) Abdominal US E) Multiparametric MRIAnswer 4 A 60-year old male presents What is the most important first to the GP with strain investigation for this patient? incontinence for the past 6 months. On further A) PSA questioning he has noted some unintentional weight B) Transrectal urethral guided biopsy loss. DRE reveals a large C) Transperineal biopsy D) Abdominal US craggy prostate. Abdomen is E) Multiparametric MRI SNT.Question 5 The same patient has a Where is the most common location for diagnosis of prostate cancer prostate cancer metastasis? confirmed. A) Brain B) Liver A 60-year old male presents to C) Femur the GP with strain incontinence D) Lungs for the past 6 months. On E) Lumbar spine further questioning he has noted some unintentional weight loss. DRE reveals a large craggy prostate. Abdomen is SNT.Answer 5 The same patient has a Where is the most common location diagnosis of prostate cancer for prostate cancer metastasis? confirmed. A) Brain A 60-year old male presents to B) Liver C) Femur the GP with strain incontinence D) Lungs for the past 6 months. On E) Lumbar spine further questioning he has noted some unintentional weight loss. DRE reveals a large craggy prostate. Abdomen is SNT.Prostate cancer Commonest cancer in men, adenocarcinoma, peripheral zone (>70%) Spread to bones: spine (L>T>C) and lymph nodes Androgen dependant RF: age, HFx, Black African/Caribbean, BRCA (2>1) Presentation: asymptomatic, LUTS, advanced disease (weight loss, bone pain) Investigations: - DRE: craggy, asymmetrical and firm - PSA (non-specific) - Multiparametric MRI (first-line investigation if suspected): Likert scale (1-5: suspicion) - Biopsy (confirms diagnosis, perform based on Likert scale): transrectal US or transperineal (lower infection risk) - Gleason grading (histology) - CT staging Isotope bone scan: looks for bony metastasis Prostate cancer TNM staging: - TX – unable to assess size - T1 – too small to be felt on examination or seen on scans - T2 – contained within the prostate - T3 – extends out of the prostate - T4 – spread to nearby organs - N0 = no nodes, N1 = at least 1 node - M0 = no mets, M1 = at least 1 met Treatment: - Surgery (radical prostatectomy) - External beam radiotherapy or brachytherapy (radioactive metal seeds into prostate) - SE: proctitis - Hormone therapy - reduce androgen levels (SE: ED, osteoporosis, fatigue) - Androgen-receptor blocker (bicalutamide) - GnRH agonist (goserelin)Question 6 An 18M is brought into the ED What is the most appropriate initial after a crash while go-karting. management? He is complaining of severe, 10/10 pain in his groin not A) Urgent CT Abdomen relieved by oral morphine. On B) Urgent urological exploration examination there is abdominal bruising, and he is C) USS testes scan D) NBM, routine CT KUB exquisitely tender in the E) IV Morphine PRN scrotum which is swollen, with associated nausea and vomiting.Question 6 An 18M is brought into the ED What is the most appropriate initial after a crash while management? go-karting.He is complaining of severe, 10/10 pain in his groin A) Urgent CT Abdomen not relieved by oral morphine. B) Urgent urological exploration On examination there is abdominal bruising, and he is C) USS testes scan D) NBM, routine CT KUB exquisitely tender in the E) IV Morphine PRN scrotum which is swollen, with associated nausea and vomiting. Testicular torsion - Note this is a *clinical diagnosis* - Trauma/ high-energy event may precede - Typical findings on imaging: Whirlpool sign on USS testes - - On examination classically: - Unilateral swollen, horizontal testes on affected side. - Loss of cremasteric reflex - Nausea + Vomiting (from pain) Torsion vs epididymitis Persistent pain despite the elevation of the testicle (negative Prehn's sign) Management: Urgent surgical exploration for definitive managementQuestion 7 A 65M presents to his GP What is a key side effect that the GP needs complaining of relationship to counsel the patient on? difficulties. On further questioning he reveals that he A) Side effect is unable to get sexually B) Nausea and vomiting aroused. He has an intact desire response and normal C) Skin rash D) Blood pressure drops bloods at the GP. E) Bleeding The GP prescribes him a medication to take as needed.Question 7 A 65M presents to his GP What is a key side effect that the GP needs complaining of relationship to counsel the patient on? difficulties. On further questioning he reveals that he A) Side effect is unable to get sexually B) Nausea and vomiting aroused. He has an intact desire response and normal C) Skin rash D) Blood pressure drops bloods at the GP. E) Bleeding The GP prescribes him a medication to take as needed. Erectile dysfunction The inability to achieve or maintain a sufficient erection for sexual performance. Need to exclude psychological dysfunction, medication side effects, pathology (injury, trauma, vascular disease) Complication of: poorly-controlled diabetes, peripheral vascular disease, cerebral function, previous pelvic or urological surgeries. Management options: psychosexual therapy, oral phosphodiesterase inhibitors (PDE5i-s) , vacuum aids, intra-cavernosal injections, and the use of prostheses.Question 8 A 23M presents to his GP with What is the most appropriate next step? a new hard painless lump in his testicle. This lump has A) Outpatient USS testes grown over the past 3 months B) Refer to Same Day Emergency Care for and is not associated with any review other symptoms. C) CT TAP The GP explains the diagnosis D) Reassure and review in 6 months and further management E) Urgent 2-week wait urology referralQuestion 8 A 23M presents to his GP with What is the most appropriate next step? a new hard painless lump in his testicle. This lump has A) Outpatient USS testes grown over the past 3 months B) Refer to Same Day Emergency Care for and is not associated with any review other symptoms. C) CT TAP The GP explains the diagnosis D) Reassure and review in 6 months and further management E) Urgent 2-week wait urology referral Testicular cancer The most common solid cancer in young men (20-45) Differential diagnoses: Epididymal cyst; Hydro/Varicocoeles; Epididymitis and Testicular torsion. 2ww referral: Painless testicular lump with change in size or texture. Bloods: (alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), and lactate dehydrogenase (LDH) levels) Imaging: USS Testes, CT TAP if suspecting mets Common sites of metastases: first spreads to the para-aortic lymph nodes, and can also spread to the lymph nodes of the lungs, liver, bones and brain. (Follows the lymphatic drainage of testes, ascending in a stepwise manner)Question 9 A 65M presents to SDEC clinic What is a complication that the doctor after being referred by his GP. needs to counsel the patient on? He describes an increased in testicular size and heaviness. A) Increased risk of infertility B) Possible loss of testicle On examination you see an enlarged scrotum, with a C) Increased pain unilaterally enlarged left D) Haematospermia testicle. This testicle has an E) Increased testicle size overlying baggy mass, with visible veins.Question 9 A 65M presents to SDEC clinic What is a complication that the doctor after being referred by his GP. needs to counsel the patient on? He describes an increased in testicular size and heaviness. A) Increased risk of infertility B) Possible loss of testicle On examination you see an enlarged scrotum, with a C) Increased pain unilaterally enlarged left D) Haematospermia testicle. This testicle has an E) Increased testicle size overlying baggy mass, with visible veins. Varicocoele Visible and/or palpable enlargement of scrotal veins. (Bag of worms appearance) Faulty valves in the testicular veins- blood pools and enlarges the veins in the testicles. Note left sided varicocoeles - ?compression from left renal vein from cancer Management: Conservative- watch and wait; embolization of scrotal veins; surgical repair of veins Varicocoele Visible and/or palpable enlargement of scrotal veins. (Bag of worms appearance) Faulty valves in the testicular veins- blood pools and enlarges the veins in the testicles. Note left sided varicocoeles - ?compression from left renal vein from cancer Management: Conservative- watch and wait; embolization of scrotal veins; surgical repair of veins What is the most appropriate treatment option? Question 10 A) NSAID and reassurance A 30M presents to A&E with ongoing B) Watchful waiting pain in their flanks that comes in C) Admit for observation D) Extracorporeal shockwave lithotripsy (ESWL) waves, and frank haematuria. E) Urgent referral to urology for surgical intervention You note on their past medical history he had previously been seen by his GP for recurrent kidney stones which resolved with NSAIDs. An USS KUB is performed which shows and enlarged urinary tract extending up into the kidneys. A XR KUB is performed which shows:Question 10 A 30M presents to A&E with What is the most appropriate treatment ongoing right-sided pain in option? their flanks that comes in waves, and frank haematuria. A) NSAID and reassurance You note on their past medical B) Watchful waiting C) Admit for observation history he had previously been D) Extracorporeal shockwave lithotripsy seen by his GP for recurrent kidney stones. An USS KUB is (ESWL) performed which shows and E) Urgent referral to urology for enlarged urinary tract surgical intervention extending up into the kidneys. A XR KUB is performed which shows: Kidneystones Stones in the urinary tract; usually kidneys. Present with Sx of renal/ureteric colic +/- frank haematuria. Conservative Mx: NSAIDs >> IV Paracetamol>> Opioids Watchful waiting for *asymptomatic* stones <5mm; or >5mm if safety-netted For renal stones >5mm and for intervention: Abbreviations: PCNL = percutaneous nephrolithotomy; SWL = shockwave lithotripsy; URS= ureteroscopy. Kidneystones Stones in the urinary tract; usually kidneys. Present with Sx of renal/ureteric colic +/- frank haematuria. Conservative Mx: NSAIDs >> IV Paracetamol>> Opioids Watchful waiting for *asymptomatic* stones <5mm; or >5mm if safety-netted For renal stones >5mm and for intervention: Abbreviations: PCNL = percutaneous nephrolithotomy; SWL = shockwave lithotripsy; URS= ureteroscopy. SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching