Urology

most common cancer in men
mostly adenocarcinomas and are androgen dependent.
Advanced types will spread to lymph nodes and bone

increasing age, FHx, black, tall stature, anabolic steroids

can be ASx, or can present with lower urinary tract sx [LUTS] like hesitancy, frequency, dribbling, weak flow

bone pain seen in metastatic disease

others: haematuria, erectile dysfunction, weight loss, cauda equina

will feel firm and hard. Asymmetrical, irregular with loss of central sulcus

2WW referral needed

epithelila cells of prostate produce PSA which helps thin the thick semen into liquid after ejaculation. Very unspecific test, can lead to false positives which leads to excessive invasive procedures or false negatives

prostate cancer, BPH, prostatitis, UTI, vigorous exercise [cycling], recent ejaculation

Multiparametric MRI is first line where results are reported on Likert scale [1-5, 4-5 being probable cancer]

next step is a prostate biopsy via methods like transrectal US guided biopsy [TRUS], transperineal biopsy

If metastasis is suspected, radioactive isotope can be given via IV and then a gamma camera is used after to take pictures. Lesions will have darker areas

Can also use histology [Gleason grading system] and TNM staging

specific to prostate cancer to help determine Tx.

the greater the gleason score, the more poorly differentiated so the worse prognosis.

Score consists of two numbers: score of the most prevalent and 2nd most prevalent pattern in biopsy. Scores are from 1-5 and the total of the two scores is your Gleason score. 8 or more is high risk

MDT. if low risk, surveillance and early waiting approach with biopsies being taken regularly to determine if radical Tx is needed.

Can use external beam radiotherapy, brachytherapy, hormone therapy in combination [Bicalutamide, GnRH agonists]

Surgical methods include radical prostatectomy, transurethral prostatectomy

most common type of kidney tumour, mostly adenocarcinomas

Clear cell 80% of the time, papillary 15%, chromophobe 5%

Wilms tumour is seen in children under 5yrs old

tends to spread to tissues around the kidney, within Gerota’s fascia [encloses the kidney and adrenal gland]. Can spread to renal vein and then into IVC.

Cannonball metastases is the classic feature in metastatic renal cell carcinoma

smoking, obesity, HPTN, end stage renal failure, von hippel-Lindau disease, tuberous sclerosis

Triad: haematuria, flank pain, palpable mass

pyrexia, varicocele may be seen

Paraneoplastic features: polycythaemia, hypercalcaemia, HPTN, Stauffer’s syndrome [liver dysfunction w / o any tumour invasion]

Age over 45yrs with unexplained haematuria w / o UTI = 2WW

CT imaging to see alongside TNM staging.

Stage 1: less than 7cm
Stage 2: more than 7cm, confined to kidney
Stage 3: local spread but confined to Gerotas fascia
Stage 4: spread beyond Gerotas fascia

Surgical first line: partial [if less than 7cm] or total nephrectomy

if not suitable for surgery,
arterial embolisation [stop blood flow to kidney], percutaneous cryotherapy, radiofrequency ablation

arises from germ cells in testes. Non germ cell tumours are rarer.

Germ cell tumours can be divided into seminomas and non-seminomas

undescended testes, male infertility, FHx, crypto-orchidism, increased height

painless lump usually on testes

non- tender, hard, irregular, not fluctuant or transilluminant.

Can see gynaecomastia particularly in Leydig cell tumour due to increased oestradiol levels

Scrotal US is initial investigation

Seminomas you may see hCG elevation. In non-seminomas, you may see alpha fetoprotein and beta hCG levels elevated. Stage with CT scan

Lymphatics, Lung, Liver, Brain

depends on seminoma or non-seminoma

usually orchidectomy, chemo / radiotherapy depending on staging and tumour types

transitional cell carcinoma [90%]
Squamous cell carcinoma [5%]
Adenocarcinoma [2%]

SMOKING, increasing age, aromatic amines [DYE WORKERS], Schistosomiasis infection

painless, macroscopic haematuria

over 45yrs old with unexplained visible haematuria without UTI or persisting after Tx of UTI

over 60yrs old with microscopic haematuria AND dysuria / increased WCC

Flexible cystoscopy

TURBT [transurethral resection of bladder]

Pelvic MRI / PET CT for locoregional spread

if superficial, TURBT

if recurrences or higher staging, intravesical chemotherapy. Can use intravesical BCG vaccination as immunotherapy.

If invasive / T2 staging: surgery via radical cystectomy or radical radiotherapy

Urostomy with an ileal conduit is the most common method

Continent urinary diversion

Neobladder reconstruction

Ureterosigmoidostomy

Usually squamous cell carcinoma of epithelium of inner glans [95%]

Other types include: basal cell, sarcomas, melanomas, urethral carcinomas

HPV 6, 16, 18
phimosis
Smoking
lichen sclerosis
HIV
PUVA Tx previously

circumcision is protective

Palpable / ulcerating lesion on glans / foreskin / shaft or scrotum can be seen. Can see painless discharge / bleeding.
Inguinal lymphadenopathy in 30-60% BUT this does not mean its malignant

Specialist referrral centre if suspicious.
Test for HIV.
Then take penile biopsy. if confirmed, inguinal lymphadenopathy checked via PET-CT to see spread. If this is also confirmed, then CT of chest / abdomen / pelvis is needed for TNM staging

Superficial, non-invasive: use topical chemotherapy [5-fluorouracil], repeat biopsy and long-term surveillance.

Otherwise, surgical like local excision, partial glansectomy or total with reconstruction. Alongside neoadjuvant chemo and radiotherapy

time of onset, associated sx like pain, any previous episodes

site, size, shape, symmetry, skin changes, scars

tenderness, temperature, transillumination

CAMPFIRE: consistency, attachment, mobility, pulsation, fluctuation, irreducibility, regional lymph nodes, edge

unable to “get above” an inguinal hernia, like unable to palpate a superior surface. Cough may exacerbate swelling and it may disappear upon lying flat

Need to assess for strangulation and obstruction

inflammation of the epididymis and testicles, usually a result of an infection [E.coli in men above 35yrs and STIs in men under 35yrs]

indwelling catheters, gay sex, known STI contact

gradual onset from mins to hrs of UNILATERAL:

testicular pain / swelling, urethral discharge seen in STI causes. Dragging / heavy sensation, tenderness on palpation.

Fever / sepsis

Urine dipstick to confirm infection and then sent for microscopy, culture and sensitivities. Important to tell if STI cause or non-STI cause
NAAT testing for STI on 1st pass urine.

Bloods and saliva swab for PCR testing if mumps is suspected

US for torsion / tumour differentials

Conservative: analgesia, abstain from sex, less physical activity

Medical: if E.coli, give ciprofloxacin 14 days / Levofloxacin 10 days [Quinolones]. SEs: tendon dmg / rupture, lower seizure threshold

STI causes have different medication, usually a combination of Doxycycline and IM ceftriaxone

the accumulation of fluid within the tunica vaginalis

causes: epididymo-orchitis, testicular torsion, testicular tumours

Communicating: caused by patency of the processus vaginalis, allowing peritoneal fluid to drain into the scrotum. Usually more common in newborn males, resolves within a few months

Non-communicating: caused by excessive fluid production within the tunica vaginalis

Soft non tender swelling of hemi scrotum. Usually inferior and anteriorly below the testicle.

Swelling is confined to the scrotum, able to get above the mass.

Transilluminates

If infantile hydrocele do not spontaneously resolve by 1-2yrs of age, repair them.

Adults, refer urgently for testicular US to exclude underlying causes like a tumour

Enlargement of the veins within the scrotum. Usually on LHS but can be bilaterally

increasing age, taller stature [increases length of venous structures], lower BMI

Venous insufficiency: incompetent / absent valves in spermatic veins, leading to retrograde blood flow

Nutcracker syndrome: compression of left renal vein leads to varicocele

can be an incidental finding, ASx

can experience a dull, aching pain that is exacerbated by prolonged standing / physcial activity. Heaviness / dragging sensation in scrotum. May be infertility / subfertility

Will see enlargement of affected hemiscrotum, prominent / visible veins, “bag of worms” sensation, testicular atrophy

Dubin Amelar Classification

Grade 1: not detectable on o / e, only visible by US
Grade 2: detectable on palpation, not on inspection, may see mild sx
Grade 3: visible on inspection and palapation, most likely will present with sx

Conservative: observe, regular follow up every 6-12 months for ASx varicocele

Surgical management: ligation, radiological embolisation, laparoscopic varicocelectomy

twisting of spermatic cord with rotation of the testicle: A urological emergency, delays lead to ischaemia and necrosis which leads to infertility

Bell clapper deformity: where the testicle is not fixed posteriorly to the tunica vaginalis, leading to a horizontal position. This can lead to rotation within the tunica vaginalis.

if in suspicion, escalate to senior urology opinion

acute, rapid onset of unilateral testicular pain with abdominal pain and vomiting. Often triggered by activity like sports.

Firm, swollen testicle and elevated. Absent cremasteric reflex. Prehns sign, abnormal testicular lie,

Test via elevating the scrotum to see if it relieves pain. +ve test if it does, epididymitis may be associated with this.

Scrotal US may show whirlpool sign to confirm diagnosis. BUT do not delay Tx by doing investigations

NBM, prepare for surgery. Analgesia as required.

Surgical exploration of scrotum with orchiopexy [fixing position of testicles] or orchidectomy [if delays / necrosis present]

not available on the NHS for religious / cultural reasons

May reduce penile cancer / UTI risk / risk of acquiring STIs

Indications: phimosis, recurrent balanitis, balanitis xerotica obliterans, paraphimosis

Hard stones, usually calcium oxalate, that is formed in the renal pelvis, where the urine collects before travelling down the ureter.

Most commonly get stuck in the vesico-ureteric junction

Calcium oxalate is the most likely [opaque in Xray]. Calcium phosphate is next most common. Mixture of two can be seen as well.

Rarer causes include: urate stones, cystine stones, xanthine stones

not visible on xray. These are due to a product of purine metabolism. May precipitate when urinary pH low or can be caused by disease with extensive tissue breakdown like malignancy.

these are produced by bacteria and so are associated with infection. Classic appearance is the staghorn calculus in the renal pelvis “antlers of the deer stag”.

associated with cystinuria which is an inherited autosomal recessive condition. Leads to decreased absorption of cystine in the intestines and renal tubule leading to multiple stones to form.

Radiodense

Post meal, pH will fall as purine metabolism will produce uric acid, pH then begins to rise in response. When stones are not available for analysis, pH of urine can help determine which stone was present. Most of them are acidic, struvate is alkaline

dehydration, hypercalciuria, hyperparathyroidism, hypercalcaemia, cystinuria, high dietary oxalate, renal tubular acidosis, medullary sponge kidney, PCKD, Beryllium / Cadmium exposure

Gout / ileostomy are RFs for urate stones

Drug causes: loop diuretics, steroids, acetazolamide, theophylline

Thiazides can prevent stones, they increase distal tubular calcium resorption

Renal colic pain: unilateral loin to groin pain that can be excruciating. Fluctuates in severity, “colicky”

Px often restless due to pain

May see haematuria, n / v, reduced urine output, sx of infection / sepsis

Initial is CT KUB for diagnosing kidney stones.

Urine dipstick, bloods can be used to check for infection and kidney function

If less than 5mm, watchful waiting to see that they will pass naturally.
5-10mm = shockwave lithiotripsy
> 20mm = percutaneous nephrolithotomy

NSAIDs are best analgesia like IM diclofenac, if CI = use IV paracetamol. Antiemetics for n / v, ABx as required. Tamsulosin recommended for stones in distal region

If there is ureteric obstruction and infection, surgical emergency so nephrostomy tube or utereic catheters and a stent can be surgically placed.

one episode predisposes px to further episodes.
Recommended to up oral intake, add fresh lemon juice [citric acid binds to urinary calcium], avoid carbonated drinks [phosphoric acid promotes calcium oxalate formation], reduce salt intake, reduce oxalate / purine rich food, limit protein

persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance

Can be organic or psychogenic cause

Increasing age, CVS disease RFs [obesity, DM, HPTN, smoking], alcohol use, SSRIs, beta blockers

All men have their 10yr CVS risk calculated by measuring lipid and fasting glucose serum levels

Measure free testosterone levels at 9-11am. If low, repeat testing + FSH / LH / Prolactin as well. If this is also abnormal, refer to endo

if young, refer to urology

PDE-5 inhbitiors [slidenafil / viagra] is prescribed to everyone if there are no CI.

Vaccuum erection devices can also be used

very common, affecting men over 50yrs old
Caused by hyperplasia of the stromal and epithelila cells of the prostate, usually presenting with LUTS

age is the biggest risk factor, other one is ethnicity [black, white, asian]

Voiding sx [strain, hesitancy, weak flow, dribbling, intermittency, incomplete emptying]

Storage sx [urgency, frequency, nocturia]

DRE will show an enlarged prostate. International prostate sx score [IPSS] to assess severity of LUTS, anything above 20 is severe.
Bedside tests involve taking urine dipstick for complications, and urinary frequency volume charts

Tamsulosin to relax smooth muscle and improve sx. [SE: postural hypotension]
5 alpha reductase inhibitors like finasteride is next line to gradually reduce the size of prostate. Works by reducing dihydrotestosterone levels in prostate tissue, takes a long time for effects to be seen. [SE:: sexual dysfunction]

Transurethral resection of prostate via diathermy loop. Complication is TURP syndrome. Other methods include: transurethral electrovaporisation of prostate, holmium laser enucleation of prostate or open prostatectomy

Irrigation with large volumes of glycine is absorbed when prostatic venous sinuses are open during resection. This results in hyponatraemia, hyperammonia. This leads to visual disturbances, CNS / resp. systemic sx

rapid onset of sx, usually from E.coli mostly.

when sx last for at least 3 months. Can be due to infection or no infection [chronic pelvic pain syndrome]

recent UTI, urogenital instrumentation, intermittent bladder catheterisation, recent prostate biopsy

Acute: fever, myalgia, nausea, fatigue, sepsis

Chronic [3 months of]: pelvic pain, LUTS, sexual dysfunction, pain with bowel movement, tender / enlarged prostate on examination

urine dipstick testing to confirm infection. Then use urine microscopy, cultures, and sensitivities for the causative organism and sensitivities.

NAAT testing for STIs on first pass urine

Chronic: tamsulosin, analgesia, psycholgical Tx if indicated, ABx if there is a history of infection

Acute: hospital admission if septic. 14 day course of quinolone, consider screening for STI

person suddenly within hours becomes unable to voluntarily pass urine. Most common urological emergency that increases with age

secondary to BPH, other urethral obstructions [strictures, calculi, cystocele, masses], medications [anticholinergics, tricyclic antidepressants, antihistamines, opioids, BZDs], there can also be a neurological cause

inability to pass urine, lower abdominal discomfort, pain / discomfort, maybe in confusional state.

O / E: palpable distended bladder, lower abdominal tenderness

urine sample for urinalysis and culture. check U&Es for kidney injury.

Bladder US will show more than 300cc to confirm diagnosis

decompress bladder via catheterisation

treat reversible causes like UTI and refer if needed

kidneys may increase diuresis due to the loss of their medullary concentration gradient. This leads to volume depletion and worsening of AKI. Needs IV fluids. to fix this and time to re-equilibriate

painless, insidious

High pressure retention: leads to impaired renal function and bilateral hydronephrosis

Decompression haematuria: after catheterisation, the rapid decrease in pressure causes haematuria

necrotising fasciitis that affects the perineum. It is a urological emergency. Basically affects the whole area of the perineum except the testes / epididymis

Group A streptococcus, Clostridia perfringes, E.coli

DM, excess alcohol intake, poor nutritional state, excess steroid use, haematological malignancies, recent trauma to the perineal region

severe pain + pyrexia. often non-specific until significant deterioration that does not seem like cellulitis. Will see crepitus, skin necrosis, haemorrhagic bullae, sensory loss of the area

Will often enter septic shock

mostly clinical, if suspected then taken for immediate surgical exploration

take bloods and cultures for cause. CT imagine can show fascial swelling and soft tissue gas

Laboratory risk indicator for necrotising fasciitis. Anything 6 or above is enough to confirm the diagnosis

Urgent surgical debridement is needed with tissue being sent for histology and cultures & sensitivities.

intermittent: removed after draining urine
Foley catheter: the standard 2 way
Corde tip catheter: helps to navigate past an obstruction
3-way catheter: for irrigation and drainage
Suprapubic catheter: through abdomen and straight into bladder

urinary retention due to obstruction, neurogenic bladder, surgery prep, output monitoring in acutely unwell px, bladder irrigation to wash out clots, delivery of meds like for chemotherapy

used to see if a px can manage without a catheter. Monitor via urine output and US bladder scan to see the residual urine left in bladder.
If they fail, insert another catheter

key complication, send urine sample
if no sx, no ABx needed
if sx, then 7 days of ABx and change catheter as soon as possible

infection of the kidneys, often as a result of an ascending UTI that has spread from the bladder to the kidneys

80% E coli
others: klebsiella, pseudomonas, enterobacter species, fungal candida species

females [urethra is smaller], reduced urine flow causes [stones, BPH, neuropathic bladder], vesico-ureteric reflex, catheter use, pregnancy, immunosuppression

fever, n / v, flank [unilateral] pain

haematuria, foul smelling urine, malaise, confusion

o / e: tenderness over loin, signs of shock from urosepsis [key complication of pyelonephritis]

empirical ABx: cefalexin / ciprofloxacin for 10-14 days, or depending on sensitivities

recurrent episodes of infection in kidneys. leads to scarring of the renal parenchyma, leading to CKD and ESRF

can use dimercaptosuccinic acid [DMSA] scans to see for kidney’s function

inflammation of the glans penis and can extend to the underside of the foreskin, balanoposthitis.

Very common: candidiasis, dermatitis

Common: bacterial, anaerobic

rarer: lichen planus or lichen sclerosus [balanitis xerotic obliterans]

mostly clinical, based on Hx and o / e

if suspected, swab for microscopy and culture. Biopsy can be done if in doubt

Mostly conservative: gentle saline washes, wash under foreskin, use 1% hydrocortisone if severe.

Specific tailored ABx depending on sensitivities

tying / cutting of the vas deferens

not immediately effective. Needs semen analysis at 12 weeks for check for effectiveness, before having unprotected sex

persistent penile erection >4hrs and NOT associated with sexual stimulation

can be ischaemic or non-ischaemic

idiopathic, sickle cell / haemoglobinopathies, erectile dysfunction meds, medications [anti-hypertensives, anti-coagulants, antidepressants], cocaine / cannabis / ecstasy, trauma

persistent erection over 4 hours long, pain localised to other penis, Often a history of either haemoglobinopathy or certain medications

Cavernosal blood gas analysis to differentiate between ischaemic / non ischaemic. Will see lower pH and pO2 with high pCO2 in ischaemic.

Doppler US can be an alternative and FBC / toxicology for the causes

medical emergency
First line is aspiration of blood from cavernosa and injection of saline flush to clear viscious blood that has pooled.
If this fails, intracavernosal injection of vasoconstrictive injection like phenylephrine at 5 minute intervals

all fails, surgery

when one or both kidneys becomes stretched and swollen as a result of a build up of urine inside them

PACT: pelvic-ureteric obstruction, aberrant renal vessels, calculi, tumours of renal pelvis

SUPER: stenosis of urethra, urethral valve, prostatic enlargement, extensive bladder tumour, retro peritoneal fibrosis

US is first line to confirm presence of hydronephrosis and can assess the kidneys.

if renal colic, CT KUB for calculi

remove obstruction, drain urine. Can use nephrostomy tube or stents

chronic condition causing inflammation of the bladder. Leads to LUTS and suprapubic pain

more than 6 weeks of: suprapubic pain [worse when full, better by emptying], frequency of urination, urgency

Urinalysis, Swabs, Cystoscopy may see Hunner lesions [red inflammed patches] and granulations

Conservative: diet changes, stop smoking, pelvic floor exercises, bladder retraining, CBT

Medical: analgesia, anticholinergics, Mirebegron, Ciclosporin, Intravesical meds directly into the bladder

Surgical: can use BOTOX, neuromodulation, augmentation of bladder, cystectomy

unable to pull forward retracted foreskin over the glans. Gradually the glans becomes increasingly oedamatous due to reduced venous return. Leads to vascular enlargement of distal penis.

Untreated, can lead to ischaemia and infection which is a urological emergency

phimosis, indwelling urethral catheter, poor hygiene, prior paraphimosis

Analgesia prior to reduction.

ASAP reduction either via manually via force with lubircant jelly OR Dundee technique of a needle puncture to drain oedematous fluid before manually doing glans reduction

Definitive is to arrange a circumcision

narrowing of the distal foreskin leading to inability to retract it. It is associated with balanitis xerotica obliterans. If severe, circumcise

Gonococcal: N. Gonorrhoea

Non-gonococcal: C. trachomatis, M. genitalium, T. vaginalis

younger than 25, gay sex, previous STI, new recent sexual partner or multiple partners in last year

dysuria, penile irritation, discharge

Take a good sexual history, screening and notify partners if needed

First void sent for NAAT for STIs

MSU dipstick sent for microscopy and sensitivities

Abstain from sex for 7 days after ABx course. Counsel for condom use, contact tracing

Gonococcal: ceftriaxone 1g IM + Azithromycin 1g PO

Non-gonococcal: doxycycline 100mg PO BD for 7 days

OR Azithromycin 1g PO single dose

Minor trauma leads to inflammation which leads to fibrotic healing, which disrupts normal tissue architecture. Fibrotic plaques form which leads to painful shortening and curvature of the penis. Also can cause reduced blood flow or erectile dysfunction

increasing age, DM, ischaemic heart disease, HPTN, beta blockers / PPIs / antidepressants / antihistamines, dupuytrens

PDE5 inhibitors or intracavernosal injections of vasoactive meds or vaccuum erection pumps: to improve sexual function

Surgical: tunical plications is most common, plaque incision / grafting, penile prosthesis for severe cases

urological emergency, needs prompt surgical intervention. Traumatic rupture of corpus cavernosa and tunica albuginea in erect penis. Usually due to blunt trauma where partner has slipped or fell on an erect penis

Careful history of MOA. Popping snapping sensation with penile swelling, discoloration, aubergine sign

Haematoma may be palpable

analgesia and then surgical exploration to evacuate the haematoma.

Abstain from sex for 6-8 weeks

Simple: well define, homogenous

Complex: complicated structure, risk of malignancy, staged by Bosniak system

increasing age, smoking, HPTN, male gender, genetic [PCKD, tuberous sclerosis, von hippel-Lindau]

usually incidental finding. if cyst ruptures, flank pain and haematuria

px with PCKD, uncontrolled HPTN and flank mass

if ASx and simple, no Tx
if sx and simple, analgesia and needle aspiration

Complex cysts depend on Bosniak classification and may need surgical intervention

congenital absence of one or both testes in the scrotum, due to failure of testes to descend during development.

can be true undescended, ectopic or ascending

prematurity, low birth weight, having other abnormalities of genitalia like hypospadias, having a first degree relative

will report the testes unable to be felt or seen. Needs testes examination which can be difficult in children

refer to paediatrician

if undescended after 3 months after initial consultation, surgery via laparoscopy like ochidectomy or 2 step procedure.

if atropic, remove testes

impaired fertility due to temperature differences, testicular cancer risk 2-3x, torsion

congenital defect causing urethral meatus to be located at an abnormal site, usually the underside of the penis

will see abnormal urinary flow or penile curvature. Ventral direction

Surgical urethroplasty to bring the meatus to the glands and straighten the penis. Dorsal foreskin can be circumcised or reconstructed