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TCD 14 Urological Diseases ZainabAjaj Haematuria Urinarytractinfections Bladdercancer UrinaryIncontinence What we will BenignProstatic cover today Hyperplasia Prostatecancer Renalcolic Renalcellcarcinoma Practicequestions OSCEs Haematuria Bloodintheurine(>3RBC/hpfonmicroscopy) Classifiedasmicroscopic(invisible)ormacroscopic(gross,frank) MaybepainfulorpainlessCauses of haematuria Obstruction(stone-renal,bladder) Neoplasm(bladder,renal,prostate) Nephriticsyndrome Inflammation(UTI) Trauma Whatinvestigationswillyou donext?Investigating haematuria Bedside:Urinedipstick-whenyoususpectnon-visiblehaematuria(e.g. renalcolicorUTI).Alsotoruleoutfoodordrugmimics. Laboratory: ● Bloods-FBC,U&Es(renalfunction),coagulation,CRP,PSA ● Midstreamurine(MSU)testformicroscopy(confirmsRBCs present),culture&sensitivity(suspectUTI) Imaging: ● CTurogramwithcontrast(renaltumours) ● Flexiblecystoscopy(bladdercancer)UrinaryTract Infection (UTI) Farmorecommoninwomenduetotheshorterlengthoftheurethra.Otherriskfactors: post-menopausalwomen,pregnancy,diabetesandimmunocompromised. E.coliisthemajorcauseofUTIs. UTIscanaffectanypartoftheurinarytract,mostcommonlyinthebladder: ● Cystitis(bladder) ● Prostatitis(prostate) ● Pyelonephritis(renalpelvis)-developloinpain,feverandsystemicallyunwell Presentation:urinaryfrequency,urgency,dysuria,nocturia,suprapubicpain,frank haematuria,unwell,fever,cloudyorsmellyurine ComplicatedUTI:UTIinthepresenceofcertainriskfactorsincludingurinarytract stones,tumours,incompletebladderemptying,indwellingcatheter,↓kidneyfunction. AlwaysassumeinmenthataUTIiscomplicated(requireatleastabladderscan)Investigations: ● Urinedipstick:Nitritesorleukocytes(nitratesaremorespecific),+ RBCs ● If+vesendMSUformicroscopy,cultureandsensitivity-notallpatientswith uncomplicatedUTIneedMSU(importantinpregnantwomen,recurrentUTIs, atypicalorunresolvingsymptoms) Management -Antibiotics: ● Nitrofurantoin(eGFR≥45-avoidifless,1stlinepregnancybutnotin3rdtrimester) orTrimethoprim ● Durationofantibiotics: - 3days:simplelowerUTIinwomen - 5-10days:womenthatareimmunocompromised,haveabnormalanatomyof renalimpairment - 7days:men,pregnantwomenorcatheterrelatedUTIs ● Encouragepatienttodrinklotsoffluid ● NICErecommendchangingcatheterforpeoplewithcatheter-relatedUTIBladder cancer ● MostcommontypeisTransitionalCellCarcinoma(90%),squamouscellcarcinoma (highinareasofschistosomiasis). ● Riskfactors:Smoking,increasingage,dyeandrubberindustry(aromaticamines) ● Presentation:painless haematuria (usuallyvisible butmaybemicroscopic) ● Diagnosis:Cystoscopy (camerathroughtheurethra intothebladder) ● Staging:TNMstaging system.T(Tumour),N(lymph node),M(metastasis)Management: ● Transurethralresectionofbladdertumour (TURBT)maybeusedfor non-muscle-invasivebladdercancer.Involvesremovingthebladdertumour duringacystoscopyprocedure. ● Intravesicalchemotherapy -givenintothebladderthroughacatheter. UsuallyusedafteraTURBTproceduretoreduceriskofrecurrence. ● IntravesicalBacillusCalmette-Guérin(BCG) -formofimmunotherapy.Giving theBCGvaccine (sameasforTB)intothebladdertostimulatetheimmune systemtoattackthebladdertumour. ● Radicalcystectomy -removingtheentirebladder.Afterremoval,there’sa fewoptionsfordrainingurine: - Urostomywithanilealconduit(mostcommon) - Continenturinarydiversion - Neobladderreconstruction - Ureterosigmoidostomy Urinary Incontinence ● Stress incontinence: involves leaking of urine when intra-abdominal pressure is raised, putting pressure on the bladder - pressure of the urine overcomes mechanisms designed to maintain continence. ➔ Triggered by acts such as coughing, laughing, sneezing or exercising that↑abdominal pressure ➔ Caused by abnormality in the anatomy of the bladder, sphincters and urethra ➔ Risk factors for stress incontinence: Women - childbirth (especially vaginal), hysterectomy. ➔ Management: pelvic floor exercises, pseudoephedrine or duloxetine (SNRI) ● Urge incontinence: involves the sudden and involuntary loss of urine associated with urgency. ➔ Risk factors for urge incontinence: recurrent UTIs, high BMI, age, smoking, caffeine ➔ Management: weight loss, avoid caffeine, antimuscarinics (e.g. oxybutynin) ● Mixed incontinence: involves both features of stress and urge incontinence● Functional incontinence: involves individual having the urge to pass urine but unable to access the necessary facilities and as a result are incontinent. ➔ Causes: Sedating medications, alcohol, dementias ● Overflow incontinence: when small amounts of urine leak without warning. When the pressure within the bladder overcomes the pressures of the outlet structures urine leaks. ➔ Causes: occurs either due to underactivity of the detrusor muscle e.g. from neurological damage or if urinary outlet pressures is too high e.g. constipationProstate DiseaseBenign Prostatic Hyperplasia (BPH) BPHisacommonconditionaffectingolder men(>50years)andtypicallypresentswith lowerurinarytractsymptoms(LUTS): ● Voidingsymptoms(obstructive):weakor intermittenturinaryflow,straining, hesitancy,terminaldribbling,incomplete emptying ● Storagesymptoms(irritative):frequency, urgencyandincontinence,nocturia ● Complications:UTI,retention,stones Internationalprostatesymptomscore(IPSS)- scoringsystemthatcanbeusedtoassessthe severityofLUTSandimpactonqualityoflifeInvestigations: ● Urinedipstick-ruleoutinfection,haematuria&otherpathology ● U&Es-especiallyifchronicretentionsuspected ● PSA -ifthereisanyobstructivesymptomsorpatientworriedaboutprostatecancer ● Urinaryfrequency-volumechart (foratleast3days) ● Digitalrectalexam(prostate):benignprostateshouldfeel smooth,symmetricaland slightlysoftwithamaintainedcentralsulcus Management: ● Watchfulwaitingissymptomsaremild/manageable ● Alpha-1antagonistse.g.tamsulosin -decreasesmoothmuscletoneoftheprostateand bladdersorapidimprovementinsymptoms.Sideeffects:dizziness,posturalhypotension, drymouth,depression ● 5alpha-reductaseinhibitorse.g.finasteride -usedtoslowenlargementofprostatebutthis takestimesosymptomsmaynotimprovefor6months.Sideeffects:erectiledysfunction (ED),reducedlibido,ejaculationproblems,gynaecomastiaTransurethralresectionofthe prostate(TURP) ● MostcommonsurgicaltreatmentofBPH. ● Involvesremovingpartoftheprostate frominsidetheurethra. ● Aresectoscopeisinsertedintothe urethra,thenprostatetissueisremoved usingadiathermyloop. ● Aimstocreateamoreexpansivespacefor urinetoflowthroughthereforeimproving symptoms. ● Complications:bleeding,infection,urinary incontinence,ED,retrogradeejeculation Prostate cancer ● Mostcommoncancerinmen.Riskfactors:Africanethnicity,BRCAmutation,age&FH. ● Majorityareadenocarcinomasleadingtoperipheralenlargement(ofprostate) ● Many prostatecancersareslowgrowinganddon’tcausedeath. ● Advancedprostatecancercommonlymetastasizes tothe lymphnodesandbones ● Localisedprostatecancerisusuallyasymptomatic- maypresentwithLUTSsimilartoBPH(weakflow, terminaldribbling,hesitancy,frequencyandnocturia) ● Mayalsopresentwithhaematuria,haematospermia, erectiledysfunction ● Advanced/metastasismaypresentwithbonepain, weightloss,spinalcordcompression ● Digitalrectalexam(prostate):hard,irregularprostate withlossofthe centralsulcusProstate specific antigen (PSA) ● PSAisaproteaseenzymeproducedbynormalandmalignantprostate epithelialcells ● AraisedlevelmayindicateprostatecancersoPSAtestingmayleadtoearlier detection ● PSAtestingmaybeunreliablewithahighrateoffalsepositives(leadtofurther unnecessaryinvasivetests) andfalsenegatives(falsereassurance) ● PSAlevelsmayalsoberaisedby:BPH,prostatitisand UTI(postponePSAtest for1monthaftertreatment),ejaculaionorvigorousexercise(ideallynotin previous48hours)andurinaryretention ● WhetherDREexamactuallycausesariseinPSAlevelsisamatterofdebate Investigations ● MultiparametricMRI(producesdetailedpictureofprostategland)isnowfirstline - Resultsreportedusinga5-pointLikertscale - Likertscore≥3offeraprostatebiopsy - Likertscore1-2thediscusspros&consofhavingbiopsy ● Prostatebiopsy-toestablishdiagnosis.Needmultipleneedlesto takesamplefromdifferentareas.Thereare2options: - Transrectalultrasound-guidedbiopsy(TRUS) - Transperinealbiopsy Mainrisks:pain,bleeding,infection,urinaryretentionandED ● Isotopebonescan-tolookforbonymetastases Gleasongradingsystem-basedonhistologyfromtheprostatebiopsy.Helpstodeterminewhat treatmentismostappropriate.Higherscore=morepoorlydifferentiated(worseprognosis) TNMstagingcanalsobeusedManagement ● MDTteam ● Watch&wait-elderly,multiplecomorbidities,lowGleasonscore ● Radiotherapy:externalbeamandbrachytherapy.Keycomplicationisproctitis (inflammationintherectum).Alsoincreasesriskofbladder&rectalcancer ● Hormonaltherapy-reducelevelofandrogens(e.g.testosterone)thatstimulate thecancertogrow.Usedincombinationwithradiotherapyoralonein advanced disease.Examples: - SyntheticGnRHagoniste.g.Goserelin(Zoladex) - Bicalutamide(blocksandrogenreceptor) - Abiraterone(androgensynthesisinhibitor - Bilateralorchidectomy-removetesticles ● Surgery-radicalprostatectomy.ErectiledysfunctionisacommoncomplicationPatientpresentswithsuddenonsetofsevere lointogroinpain Thepainisintermittent Nauseousandvomiting Whatdowethink? RenalColicRenal Colic ● Renalstones(calculi)formintherenalpelvis. ● Theymaybeasymptomaticuntiltheyirritateorgetstuckintheureter. ● Theycommonlygetstuckatthevesicouretericjunctionandureteropelvicjunction ● The2maincomplicationsare:obstruction(leadingtoAKI) orinfection ● Thetypesofstonesinclude: - Calcium(80%):calciumoxalate(commonest),calcium phosphate.Hypercalcaemiaisariskfactor. - Struvite:formstaghorncalculus(stoneformsintheshape oftherenalpelvis).MaybeseenonplainX-rayfilm. - Uricacid:notvisibleonX-rays(radio-lucent) - Cystine:semiopaque‘ground-glass’appearancePresentation: ● Severeunilaterallointogroinpain ● ‘Colicky’(fluctuatinginseverity)asthestonemoves&settles ● Nausea&vomiting ● Haematuria ● ↓Urineoutput ● Maybesepticifinfectionpresent Investigations: ● Bedside:urinedipstick(showshaematuriaandcanruleoutinfection) ● Bloods:FBC,CRP(infection),U&Es(renalfunction),serumcalcium&uricacid (identifyunderlyingcauseofstone) ● Imaging:non-contrastCTKUB(kidneys,ureters&bladder)isinitial investigationofchoice-within24hoursofpresentationbutimmediatelyifthey haveafever,onekidneyoruncertaindiagnosis. AbdominalX-raycanshow calciumstones(noturicacidstones).Management ● Analgesia:NSAIDs -intramusculardiclofenac(considerriskof cardiovascular events-IVparacetamol) ● Antiemeticsfornausea&vomiting(e.g.metoclopramide).Antibioticsforinfection. ● Stones<5mmtypicallypasswithin4weeksofsymptomonset(watch&wait) ● Stones<2cm-Extracorporealshockwavelithotripsy(ESWL):externalmachine generatesshockwaves&directsthematthestone(underXRayguidance)tobreakinto smallerpiecestomakethempasseasier ● Pregnantfemaleswithstone<2cm-Ureteroscopy:camerainsertedthroughureterinto renalpelvistobreakstonewithlaserintosmallerpieceseasiertopass ● Complexrenalcalculiandstaghorncalculi-Percutaneousnephrolithotomy: a nephroscope(smallcameraonastick)insertedviasmallincisioninpatientsback-stones identified,brokenintosmallerpieces andremovedRenal Cell Carcinoma (RCC) ● RCCsareadenocarcinomas,of whichmost(80%)areclearcellcarcinomasandmostof therestpapillary. ● Riskfactors:smoking,obesity,hypertension,familyhistory,Von-hippelLindaudisease andage ● Presentation-classictriad: - Haematuria - Flank(loin)pain - Palpablemass Othernon-specificsymptomsofcancer (fever,nightsweats,weightloss,fatigue) ● Spread:oftentoothertissuearoundkidney. “Cannonballmetastasis”inlungs-exams!!. Alsochoriocarcinoma(cancerinplacenta).ParaneoplasticsyndromesassociatedwithRCC: ● Polycythaemia–duetosecretionofunregulatederythropoietin ● Hypercalcaemia–duetosecretionof hormonethatmimicsactionofPTH(ordueto metastases) ● Hypertension–increasedreninsecretion,polycythaemiaandphysicalcompression ● Stauffer’ssyndrome–abnormalLFTswithoutlivermetastasis Staging: CT-TAP(Thorax,abdomen&pelvis)tostagethecancerusingtheTNMstagingsystem. Management: ● MDTteam ● Surgery(firstline)-forconfineddisease:partialnephrectomyortotalnephrectomy ● Ifnotfitforsurgery,considerradiofrequencyablation(percutaneous)orcryotherapy (percutaneousorlaparoscopic) ● Metastases:Tyrosinekinaseinhibitors(e.g.suntinib),anti-VEGFandcytokine immunotherapy(IFNαorIL-2)Practise Questions1)A68yearoldmanisreferredtothe2weekwaiturologyclinicwitha1month historyoffrankpainlesshaematuriaandweightloss.Therearenosymptomsof dysuria,frequencyorurgency.Hispastmedicalhistoryincludesischaemicheart disease,andCOPD.Heisanexsmoker,witha30packyearhistory.Whatisthemost likelylesion? A. Squamouscellcarcinoma B. Transitionalcellcarcinoma C. Bladderadenocarcinoma D. Cholangiocarcinoma E. Testiculartumour1)A68yearoldmanisreferredtothe2weekwaiturologyclinicwitha1month historyoffrankpainlesshaematuriaandweightloss.Therearenosymptomsof dysuria,frequencyorurgency.Hispastmedicalhistoryincludesischaemicheart disease,andCOPD.Heisanexsmoker,witha30packyearhistory.Whatisthemost likelylesion? A. Squamouscellcarcinoma B. Transitionalcellcarcinoma C. Bladderadenocarcinoma D. Cholangiocarcinoma E. Testiculartumour2)A66yearoldfemaledescribesanumberofepisodesofurinaryincontinence.She getsasuddenurgetopassurinefrom“outofnowhere”andduetoherwork,isoften unabletomakeittoatoiletintime.Shereportsdrinking3cupsofcoffeeand4cups ofteaperday.Aurinedipisnegative.Whatisthebestinitialmanagementoption? A. IntravesicalBotox B. Oxybutynin C. Bulkingagents D. Reducecaffeineintake E. Pelvicfloorexercises2)A66yearoldfemaledescribesanumberofepisodesofurinaryincontinence.She getsasuddenurgetopassurinefrom“outofnowhere”andduetoherwork,isoften unabletomakeittoatoiletintime.Shereportsdrinking3cupsofcoffeeand4cups ofteaperday.Aurinedipisnegative.Whatisthebestinitialmanagementoption? A. IntravesicalBotox B. Oxybutynin C. Bulkingagents D. Reducecaffeineintake E. Pelvicfloorexercises3)A70-year-oldgentlemanpresentswithdifficultypassingurine.Hehasexperienced increasinglypoorflowoverthepastfewmonths.HismedicationlistincludesBisoprolol, Warfarin,TamsulosinandFinasteride.Bladderscanshows770mlsofurineandacatheteris inserted.Bloodtestsareunremarkableandurinedipisnegative. Whatisthenextstepinmanagementforthispatient? A. Prostatectomy B. Transurethralresectionofbladdertumour(TURBT) C. Doxazosin D. Long-termcatheter E. Transurethralresectionoftheprostate(TURP)3)A70-year-oldgentlemanpresentswithdifficultypassingurine.Hehasexperienced increasinglypoorflowoverthepastfewmonths.HismedicationlistincludesBisoprolol, Warfarin,TamsulosinandFinasteride.Bladderscanshows770mlsofurineandacatheteris inserted.Bloodtestsareunremarkableandurinedipisnegative. Whatisthenextstepinmanagementforthispatient? A. Prostatectomy B. Transurethralresectionofbladdertumour(TURBT) C. Doxazosin D. Long-termcatheter E. Transurethralresectionoftheprostate(TURP)4)A42yearoldfemalepresentstoEDwithseverecolickylointogroinpain.Aurinedipconfirmsthe presenceofblood,andaCTKUBconfirmsthepresenceofacalculiattheleftpelvicureteric junction.Hercalciumprofileisasfollows: ● Ca3.2 (2.1-2.6) ● PO40.55 (0.8-1.4) ● PTH7(1.6-6.8) Whatisthemostlikelycompositionofheruretericcalculi? A. Urate B. Calciumoxalate C. Struvite D. Indinavir E. Cystine4)A42yearoldfemalepresentstoEDwithseverecolickylointogroinpain.Aurinedipconfirmsthe presenceofblood,andaCTKUBconfirmsthepresenceofacalculiattheleftpelvicureteric junction.Hercalciumprofileisasfollows: ● Ca3.2 (2.1-2.6) ● PO40.55 (0.8-1.4) ● PTH7(1.6-6.8) Whatisthemostlikelycompositionofheruretericcalculi? A. Urate B. Calciumoxalate C. Struvite D. Indinavir E. Cystine5)A29-yearoldmanpresentswithsuddenonsetrightflankpainthatradiatestohisgroin.Heis unabletositstillonthebedandtellsyouhesawbloodinhisurinethismorning.Hefeels nauseousbuthasnotvomitedandlastopenedhisbowelsthismorning.Onexaminationhis observationsarestable,andhehasrightflankandsuprapubictenderness,butnoguardingor rigidity.Urinedipispositiveforblood3+,protein3+andtraceleukocytes.Whatisthemost appropriateinvestigation? A. Abdominalultrasound B. Plainfilmabdominalx-ray C. Noimaging.Taketotheatreforemergencyappendectomy. D. LowdoseComputedTomographyKidney,Ureters,Bladder(CTKUB) E. ComputedTomographyoftheabdomenandpelvis(CTAP)withcontrast5)A29-yearoldmanpresentswithsuddenonsetrightflankpainthatradiatestohisgroin.Heis unabletositstillonthebedandtellsyouhesawbloodinhisurinethismorning.Hefeels nauseousbuthasnotvomitedandlastopenedhisbowelsthismorning.Onexaminationhis observationsarestable,andhehasrightflankandsuprapubictenderness,butnoguardingor rigidity.Urinedipispositiveforblood3+,protein3+andtraceleukocytes.Whatisthemost appropriateinvestigation? A. Abdominalultrasound B. Plainfilmabdominalx-ray C. Noimaging.Taketotheatreforemergencyappendectomy. D. LowdoseComputedTomographyKidney,Ureters,Bladder(CTKUB) E. ComputedTomographyoftheabdomenandpelvis(CTAP)withcontrast6)A57-year-oldladypresentstotheGPwithmildleftflankpain.Shesmokes20cigarettesa dayandiscurrentlytakingAmlodipineforhighbloodpressure.Onexamination,sheisnoted tohaveapalpablemassattheleftrenalangle.CTscanshowsa7cmmass. WhatisthemostlikelycauseoftheCTfindings? A. Phaechromocytoma B. Renalclearcellcarcinoma C. Renalmedullarycarcinoma D. Papillaryadenoma E. Neuroblastoma(Wilm’stumour)6)A57-year-oldladypresentstotheGPwithmildleftflankpain.Shesmokes20cigarettesa dayandiscurrentlytakingAmlodipineforhighbloodpressure.Onexamination,sheisnoted tohaveapalpablemassattheleftrenalangle.CTscanshowsa7cmmass. WhatisthemostlikelycauseoftheCTfindings? A. Phaechromocytoma B. Renalclearcellcarcinoma C. Renalmedullarycarcinoma D. Papillaryadenoma E. Neuroblastoma(Wilm’stumour)OSCEsUrinaryhistory: ● Storagesymptoms(irritative):frequency,urgency,incontinence,nocturia, dysuria(painonurinating) ● Voidingsymptoms:weakorintermittenturinaryflow,straining,hesitancy, terminaldribbling,incompleteemptying ● Haematuria ● Appearanceofurine:cloudy(UTI),frothy-protein(nephroticsyndrome) ● Pain:suprabubic(tenderness),lointogroin ● Systemicsymptomse.g.fever,weightloss,nightsweats,fatigue ● SH:smoking(bladdercancer,RCC),occupation(dyeindustry) Digitalrectalexam(prostateexam)-differencebetweenBPHandprostatecancer Explanationstation:Renalcolic(preventingotherepisodes-increasingfluidintake,addfresh lemonjuicetowater,avoidcarbonateddrinks,reducesaltintake,maintainnormalcalcium intake,reduceoxalaterichfoodse.g.spinach,beetroot,nuts)Resources ● https://geekymedics.com/evaluation-of-haematuria/ ● https://zerotofinals.com/surgery/urology/loweruti/ ● https://zerotofinals.com/surgery/urology/bladdercancer/ ● https://zerotofinals.com/surgery/urology/bph/ ● https://zerotofinals.com/surgery/urology/prostatecancer/ ● https://zerotofinals.com/surgery/urology/kidneystones/ ● https://zerotofinals.com/surgery/urology/renalcellcarcinoma/ ● https://www.passmedicine.com ● https://app.quesmed.com/Thank you Any Questions?