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Urology: Lower Urinary Tract Pathologies Jade Miller, Final Year Student University of NottinghamThanks to our partners! Learning Objectives • Understand the male urological anatomy (prostate gland, structures within the scrotum). • Recognise the red flag symptoms in scrotal pain and swelling in surgical emergencies and be able to form a list of differentials. • Recognise features of epididymitis, understand the clinical signs used to differentiate between differentials (Prehn’s sign, cremaster reflex). • Understand the mechanism and management of the surgical emergency testicular torsion. • Describe LUTS (lower urinary tract symptoms) and possible causes. • Understand the clinical features of BPH and prostate cancer, be able to differentiate the two. • Recall the medical and surgical management of BPH and prostate cancer. • Understand the epidemiology and different types of urinary incontinence. • Understand the different medications used to treat urinary incontinence as well as their common side effects. Male Reproductive System: Functions Penis: -2 dorsal cylinders (corpora Secretory Glands (seminal vesicles, cavernosa): highly vascular, prostate, bulbourethral glands): -excrete seminal fluids & nutrients to erection -1 ventral cylinder (corpus nourish sperm spongiosum): contains penile urethra Vas Deferens: -transportation of sperm to exterior -maturation of sperm Testes (seminiferous tubules, rete testis, epididymis): -production & temporary storage of sperm -synthesis & secretion of hormones: testosterone, oestrogen, oxytocinProstateAnatomyScrotum Anatomy *Some Daft Englishman Called It Testes Skin Dartos muscle External spermatic fascia Cremaster Internal spermatic fascia Tunica vaginalis (parietal and visceral layer)Scrotal PathologiesScrotal Swelling/Lump A man presents to GP with a lump in his left scrotum. What is your initial list of differentials...? PAINLESS PAINFUL *Testicular cancer *Testicular torsion Epididymal cyst Epididymitis/Epididymo-orchitis Hydrocele Strangulated inguinal hernia Varicocele C A B How could you differentiate each of these on history and examination? D F E Differentiating Scrotal Pathology Pathology Important Points in History Examination Testicular cancer • Painless • Painless lump • Change over time • Irregular, fixed, firm • Red flags: weight loss, anorexia, night sweats, back pain, dyspnoea • Secondary hydrocele (mets) • Gynaecomastia (Leydig cell tumours) • Risk factors: 20-30 yrs, infertility, cryptorchidism, FH, Klinefelter’s (XXY), mumps orchitis Epididymal cyst • Chronic onset • Smooth, well-defined, fluctuant • Painless • Transilluminate • Risk factors: PCKD, CF, von Hippel- • Separately palpable to testes Lindau syndrome • Posterior to testicle Hydrocele • Painless swelling • Painless, fluctuant • Communicating- newborn males • Transilluminates • Non-communicating- may be due to • Can ‘get above’ the mass underlying: testicular cancer, torsion, epididymo-orchitis • USS in adults to r/o underlying cancer! Varicocele • Lump + dragging sensation • Left side (80%) • Dull ache/painless • Bag of worms • Subfertility • Disappears on lying, reappears with standing/valsalva • Red flags for RCC: flank pain, haematuria, B symptomsPainful Scrotum: Case 1 Mr. Smith, a 45-year-old male, presents to the urology clinic with a complaint of acute onset of pain and swelling in his left testicle. He describes the pain as sharp and localised to the left side of his scrotum, which has been progressively worsening over the past two days. Mr. Smith denies any recent trauma to the area but reports a recent history of dysuria and frequency of urination for the past week. He also mentions a low-grade fever and mild nausea. There is no history of urethral discharge or recent sexual activity. Past medical history is unremarkable, and he denies any history of urinary tract infections or sexually transmitted infections. Baseline Obs: •Temperature: 37.8°C (100°F) Most likely diagnosis? •Blood pressure: 120/80 mmHg Key features pointing you to it? •Heart rate: 80 bpm •Respiratory rate: 16 breaths per minute •Oxygen saturation: 98% on room airWhat is the most likely causative organism in an older patient with a low-risk sexual history? a.Staphylococcus aureus b.Escherichia coli c.Klebsiella pneumoniae d.Enterococcus faecalis e.Chlamydia trachomatis What would you do OE to r/o other causes of acute, painful testicle?On Examination: Scrotal Examination: •Inspection: Left scrotal swelling and erythema. The left testicle appears enlarged compared to the right. •Palpation: Tenderness along the posterior aspect of the left testicle, overlying skin slightly warm to touch. •Cremasteric reflex is intact bilaterally. •Prehn's sign positive: lifting of the testicle alleviates pain. •Abdo SNT Genitourinary Examination: •Urethral meatus: No discharge noted •Prostate: Non-tender on DREWhy might the cremasteric reflex be absent in testicular torsion? Afferent (sensory) limb: ilioinguinal nerve (innervates skin of superomedial thigh- L1 dermatome) Efferent (motor) limb: genital branch of genitofemoral nerve (innervates cremaster muscle)So, what should we do with our patient? •Urinalysis: leukocytes & nitrites +++ •Urine MC&S: Pending •STI screen (first-void urine sample NAAT) •Scrotal Ultrasound: can be done to confirm the diagnosis and rule out other differentials like torsion. Mx: • Analgesia • Empirical Abx • Scrotal support • Abstain from sexual intercourse (contact tracing, safe sex education if STI related)Painful Scrotum: Case 2 Mr. Johnson, a 15-year-old male, presents to the emergency department with sudden- onset severe left testicular and lower abdominal pain that began approximately 2 hours ago. He describes the pain as constant and progressively worsening. He denies any recent trauma to the genital area. There is no history of dysuria, haematuria, or urinary symptoms. Mr. Johnson reports nausea and one episode of non-bilious vomiting since the onset of pain. He denies any history of similar episodes in the past. Baseline Observations: •Temperature: 37.0°C •Blood pressure: 120/70 mmHg •Heart rate: 90 bpm •Respiratory rate: 16 breaths per minute •Oxygen saturation: 99% on room airOE: •The patient appears uncomfortable and in distress due to pain. •Inspection: Left hemiscrotum swollen and erythematous, left testicle positioned higher than the right, scrotal skin appears taut. •Palpation: Left testicle exquisitely painful to touch. •Cremasteric reflex: absent on the left side. •Prehn's Sign: negative •Transillumination Test: Negative transillumination of the left hemiscrotum. •Abdo SNT with no palpable masses or organomegaly.What is the most appropriate next step in managing this patient? a)USS to confirm diagnosis- whirlpool sign b)Scrotal exploration and fixing of left testis c)Scrotal exploration and fixing of both testes d)Phone the med reg!!! e)Analgesia, supportive care & active surveillanceAs the F1 who saw this patient first, you correctly keep him NBM, prescribe analgesia, anti- emetics and arrange urgent senior review. The Urology registrar sees the patient and agrees that they need to go to theatre immediately for testicular exploration. In Theatre: 1. A scrotal incision is made to gain access to the testes 2. The left testis and spermatic cord is examined- evidence of twisting about the spermatic cord 3. The testicle is gently, manually detorsed 4. The testicle is examined to confirm restoration of blood flow. Fortunately, the testicle appears pink, with no evidence of necrosis 5. As the testis is still viable, it is fixed to the scrotal wall using sutures (orchidopexy) 6. The right testis is also fixed https://www.youtube.com/watch?v=cw3K356uuJIWhen might you need to do an orchidectomy? *Non-viable testisWhy bilateral orchidopexy? • Bell clapper deformity= risk factor for torsion • Can be bilateral • Fix both to prevent contralateral testis torting in future • Tunica vaginalis has abnormally high attachment to spermatic cord à testis free to rotateDifferentials for Testicular Torsion: • Epididymo-orchitis • Strangulated inguinal hernia • Hydrocele • Trauma • Renal colic • Torsion of the hydatid of Morgagni What is the classic examination finding with torsion of the hydatid of Morgagni?Try some Questions…..A 12-hour-old baby examined on the ward following routine delivery with no complications. The mother reports no concerns so far. On examination, he appears well. The doctor notices a soft, non-tender swelling of the left hemi-scrotum. It is anterior to and below the testicle; he is able to 'get above' it when palpating. It is transilluminable. Both testicles appear normal. Given the likely diagnosis, what is the most appropriate next step? a) Aspiration b) Reassure and monitor c) Routine surgical referral d) USS scan e) Urgent surgical referralA 50-year-old male presents to the urology clinic with complaints of a painless swelling in his left scrotum. Upon further questioning, he reports a recent diagnosis of left flank pain and haematuria. Physical examination reveals a non-tender, palpable mass in the left testicle along with dilated veins in the scrotum. Which of the following conditions is most likely responsible for the patient's scrotal findings? a) Testicular torsion b) Epididymitis c) Renal cell carcinoma d) Inguinal hernia e) Testicular traumaA 22-year-old boy attends the Emergency Department with exquisite scrotal pain. He states the pain onset one hour ago while he was playing football. He has vomited once but denies further gastrointestinal symptoms. He is sexually active. The pain settles before analgesia is given and he mentions that he has experienced 3 previous similar episodes in the last week, each resolving without intervention. Given the likely diagnosis, what is the most appropriate management? a) Ceftriaxone and doxycycline for 10-14 days b) Discharge with follow-up in urology outpatients c) Scrotal exploration and fixation of both testes d) Testicular tumour markers e) USS scanLower Urinary Tract Symptoms (LUTS)Lower Urinary Tract Symptoms (LUTS) Group the following symptoms into Storage vs. Voiding symptoms: • Terminal dribbling • Urgency • Frequency • Hesitancy • Nocturia • Weak/intermittent stream • Straining • Urinary incontinence • Incomplete emptying • Feeling the need to urinate again just after passing urineStorage Voiding • Urgency • Hesitancy • Frequency • Weak/intermittent stream • Nocturia • Straining • Urinary incontinence • Incomplete emptying • Feeling the need to urinate again just • Terminal dribbling after passing urine Which pathologies could cause these groups of symptoms? Storage Voiding • BPH • Prostate cancer • Overactive bladder • Urethral • UTI Reality stricture • Neurogenic bladder • Pelvic organ • Drugs e.g. diuretics prolapse • Drugs e.g. antimuscarinics Could it be diabetes?LUTS: Case 1 Mr. Thompson, a 65-year-old man, presents to the urology clinic with complaints of urinary symptoms that have been gradually worsening over the past few months. He reports increased frequency of urination, especially at night, along with a sensation of incomplete emptying of the bladder. Mr. Thompson also mentions a weak urinary stream and occasional dribbling at the end of urination. He denies any history of haematuria, dysuria, or urinary retention. There is no history of recent urinary tract infections. Baseline Observations: •Blood pressure: 130/80 mmHg •Heart rate: 75 bpm •Respiratory rate: 16 breaths per minute •Oxygen saturation: 98% on room air What investigations and examinations would you like to do?Examination: • Mr. Thompson appears well-nourished and comfortable at rest. • Abdo SNT, no masses or organomegaly. No suprapubic tenderness, bladder not palpable. • DRE: smooth, enlarged prostate gland with a rubbery consistency. Investigations to consider: • Bedside: Urinalysis + MSU- rule out UTI, haematuria, BM- diabetes • Bloods: FBC, U&Es, PSA • Imaging: PV bladder scan, urodynamics, flexible cytoscopyWhat score should be calculated to help guide management? a)Prostate Health Index (PHI) b)International Prostate Symptom Score (IPSS) c)Prostate Function Index (PFI) d)Edinburgh Prostate Scale e)Glasgow Prostate Severity Score•Score 20-35: severely symptomatic •Score 8-19: moderately symptomatic •Score 0-7: mildly symptomaticManagement Conservative: • watchful waiting • limit fluid intake before bedtime, avoid caffeine and alcohol • double voiding Medical: • alpha-1 antagonists e.g. tamsulosin, alfuzosin (first-line if IPSS ≥ 8) • dizziness, postural hypotension, dry mouth, depression • 5 alpha-reductase inhibitors e.g. finasteride (if significantly enlarged and considered to be at high risk of progression) • erectile dysfunction, reduced libido, ejaculation problems, gynaecomastia • ISC/LTC Which group of medications leads to a reduction in prostate volume? Surgical: • TURP (transurethral resection of the prostate)FinasterideWhich of the following is true regarding finasteride? a)Pregnant women shouldn’t handle crushed or broken tablets b)Should be taken with fatty foods to enhance absorption c) Should be avoided in prostate cancerA 72-year-old man is having an elective trans-urethral resection of prostate (TURP) for benign prostatic hyperplasia under spinal anaesthesia. Forty minutes into the procedure he develops headache and visual disturbances. A venous blood gas is sent off, and the main abnormality noted is severe hyponatremia. What is the cause of this presentation? a) Irrigation with glycine b) Oxygen deprivation c) Side effect of spinal anaesthesia d) Too much intravenous normal saline e) Vasovagal responseLUTS: Case 2 Mr. Adams, an 87-year-old Afro-Caribbean man, presents to the urology clinic with concerns about his recent health. He reports a gradual onset of urinary symptoms, including increased frequency, hesitancy, and a weak urinary stream over the past few months. Additionally, he mentions occasional episodes of nocturia and haematuria. Mr. Adams denies any history of urinary tract infections or urinary retention. He also reports occasional lower back pain but attributes it to aging and physical exertion. There is no family history of prostate cancer. What are the red flags here? Baseline obs: unremarkable Examination: Abdo: SNT, bladder not palpable. DRE: enlarged prostate gland, firm & irregular nodules, loss of the median sulcusWhat areas are the most common sites of metastasis for prostate cancer? • Lymph nodes • Kidney • Bladder • Lung • Brain • Liver • Bones • HeartInitial investigations: • PSA • Multiparametric MRI • Trans-rectal Biopsy • Bone scan, PET-CT (mets) What scores are calculated from the MRI and biopsy respectively? Likert score Gleason score• Mr Adams’ Likert score comes back as 4 à most appropriate next step? • needs trans-rectal biopsy • What if his Likert score was <3? • discuss pros and cons of biopsy with pt Complications of TRUS biopsy: •sepsis: 1% of cases •pain: lasting ≥ 2 weeks in 15% and severe in 7% •fever: 5% •haematuria and rectal bleedingGleason score a + b = c Low (≤ 6) vs intermediate (7) vs high risk (8-10) Mr Adams’ Gleason score comes back as 4 + 5 = 9 Bone scan: widespread metastatic diseaseMr Adams’ case is discussed at the next MDT meeting. 87y M PMH CHF, IHD, T2DM PSA 230, ALP 300 Likert score 4 Gleason score 4+5=9 Bone scan showing widespread metastatic disease Age-adjusted upper limits for PSA (PCRMP) How do you think Mr Adams should be managed? *Most likely palliation due to older age, significant comorbidities, widespread cancerManagement of Prostate Cancer Active Surveillance (PSA, MRI): • Low risk cancer, low impact on life expectancy Medical Management: • Hormone therapy (anti-androgen) e.g. GnRH agonists (Goserelin), GnRH antagonists (degarelix), androgen receptor blockers (bicalutamide), androgen synthesis inhibitors (abiraterone) • Radiotherapy • Chemotherapy with docetaxel Surgical Management: • Radical prostatectomy • Bilateral orchidectomy (surgical castration)à to rapidly reduce testosterone levelsRadical Prostatectomy Common side effect? Erectile dysfunctionA 53-year-old man comes in asking for a prostate-specific antigen (PSA) test as his brother has recently been diagnosed with prostate cancer. You conduct a digital rectal examination and advise him that his prostate does not feel enlarged. After further discussion, you agree to do the test. Which one of the following is true regarding timing for PSA testing and ensuring that a reliable result is obtained? a) PSA testing can be done within 2 weeks following a prostate biopsy b) PSA testing can be done after abstaining from ejaculation and vigorous exercise for 48 hours c) PSA testing can be done after abstaining from ejaculation or vigorous exercise for 12 hours d) PSA testing can be done within 1 week following a urinary tract infection e) PSA testing can be done within 24 hours following digital rectal examinationNICE advise that, as PSA levels may be increased, testing should not be done within at least: •6 weeks of a prostate biopsy •4 weeks following a proven urinary infection •1 week of digital rectal examination •48 hours of vigorous exercise •48 hours of ejaculationA 78-year-old man is brought to the emergency department due to difficulty passing urine. On examination, the patient has a distended bladder - a catheter is inserted and a residual volume of 880ml is drained. The patient also reports pain in their upper back over the spinal vertebrae. Past medical history includes metastatic prostate cancer, for which treatment was started last week. This presentation is suspected to be a complication of their management. What prostate cancer treatment is the patient likely receiving? a) Bicalutamide (non-steroidal anti-androgen) b) Bilateral orchidectomy c) Degarelix (GnRH antagonist) d) Goserelin (GnRH agonist) e) Prostate radiotherapyUrinary Incontinence "A 55-year-old female reports sudden and intense urges to urinate, Stress Incontinence often resulting in leakage before reaching the toilet. She experiences this multiple times throughout the day and night." "A 40-year-old female notices urine leakage when coughing, Functional Incontinence laughing, or sneezing. She describes this as a frequent occurrence, particularly during physical activities or when lifting heavy objects." Mixed Incontinence "A 65-year-old male complains of both sudden urges to urinate and leakage during activities such as coughing or laughing.” "A 65-year-old male reports difficulty initiating urination and a weak Urge Incontinence urinary stream. He often experiences dribbling of urine throughout the day and night, with a sensation of incomplete bladder emptying." "An 80-year-old female with mobility issues due to arthritis struggles to reach the toilet in time. Despite assistance, she frequently Overflow Incontinence experiences urine leakage between scheduled bathroom visits." Risk factors for Urinary Incontinence: • Advancing age (particularly elderly females) • Previous pregnancy and childbirth • High BMI • Hysterectomy • Family history History: -Stress vs urge symptoms -Storage vs voiding symptoms requency -Associated symptoms/SR (dysuria, haematuria, prolapse sx, atrophic vaginitis, bowel habits) rgency -Red flags (fever weight loss, night sweats, back pain) -PMH (co-morbidities, parity, birth history, menopausal status) octuria -DH (diuretics, antimuscarinics) -FH -SH (caffeine, alcohol, fluid intake before bed, mobility/independence, housing environment) -Effect on QoLInitial investigations • Bladder diaries (minimum of 3 days, work & leisure days) • Vaginal examination to exclude pelvic organ prolapse and ability to initiate voluntary contraction of pelvic floor muscles ('Kegel' exercises) • Urine dipstick and culture • Urodynamic studiesManagement Urge Incontinence Conservative: • Fluid intake advice, avoid caffeine and alcohol, avoid excessive intake before bed, prevent dehydration, smoking cessation • Bladder retraining (minimum 6 weeks) Medical: • Antimuscarinics 1 line (oxybutynin, tolterodine, darifenacin) • Mirabegron (beta-3-agonist)- frail patients Invasive: • Intravesical Botox • Sacral neuromodulation • Augmented Cystoplasty • Urinary diversion (urostomy) What are the Common Antimuscarinic Side Effects?Which of the following is a contraindication to using Mirabegron? a)High cholesterol b)High blood pressure c) Poor glycaemic control d)BMI >35 e)Severe asthmaManagement Stress Incontinence Conservative: • Fluid intake advice, avoid caffeine and alcohol, avoid excessive intake before bed, prevent dehydration, smoking cessation, avoid heavy lifting • Pelvic floor exercises (at least 8 contractions performed 3 times per day for a minimum of 3 months) Medical: • Duloxetine (if surgical procedures declined) Surgical: • Retropubic mid-urethral tape proceduresA 39-year-old man presents to the GP with urinary incontinence. He mentions that sometimes he notices 'small dribbles of urine' passing when he does not want them to. He has not noticed any association with the timing of symptoms and says there is no association with coughing/sneezing. His only past medical history includes a fractured wrist 5 years ago and treatment for gonorrhoea 6 months ago. Given this man's presentation what is the most likely diagnosis? a) Stress urinary incontinence b) Urethral stricture c) Urge urinary incontinence d) Mixed urinary incontinence e) Functional urinary incontinenceA 75-year-old woman presents with urinary incontinence. She describes a sudden and very intense need to pass urine which is often followed by incontinence. She has a past medical history of Alzheimer's disease and closed-angle glaucoma. What is the preferred treatment? a)Darifenacin b)Duloxetine c) Mirabegron d)Oxybutynin e)TolterodineThank You For Listening!@supta_uk @SUPTAUK www.supta.uk