Urology

Prostate cancer
Risk factors ➢ PSA isn’t specific for prostate cancer but it’s
• Increasing age useful in follow-up & monitoring TTT
➢ Before PSA test, men should NOT have:
• Male, black Afro-Caribbean - An active UTI
• 1st degree relative with prostate cancer - Ejaculated in the past 48h
Presentation - Exercised vigorously in the past 48h
• Lower urinary tract symptoms (LUTS) are NOT specific for - Had a prostate biopsy in the last 6 weeks

prostate cancer
• LUTS include voiding or obstructing symptoms such as hesitancy, urgency, poor and/or intermittent stream,
straining, prolonged micturition, feeling of incomplete bladder emptying, dribbling
Investigation
• Initial → DRE (hard, irregular & nodular) + PSA Biopsy-related prostatitis
• Normal ⟶ E. coli
- ≥2 ng/ml at age 40-49 years
• Immunocompromised ⟶ Pseudomonas aeruginosa
- ≥3 ng/ml at age 50-69 years
- ≥5 ng/ml at age 70 years or older
• Definitive → Biopsy Leuprolide is a GnRH analog:

Management • If used in pulsatile fashion → agonist

➢ Leuprolide, used in a continuous manner • If used in a continuous fashion → antagonist

Local disease Locally invasive Metastatic

• Raised PSA on screening • Hematuria • Bone metastasis → hypercalcemia → thirst

• LUTS • Hematospermia • Bone pain or sciatica
• UTI • Obstruction of ureters, • Paraplegia 2ry to spinal cord compression
causing loin pain, anuria, • LN enlargement
symptoms of AKI or CKD • Lethargy (anemia, uremia)
• Weight loss
➢ KUB US
➢ MRI

Metastatic spinal cord compression

➢ An oncological emergency and an urgent MRI should be requested within 24h
➢ 20% of patients with spinal metastasis
Features
• Neurological symptoms like radicular pain, limb weakness, difficulty in walking, sensory loss or bladder or
bowel dysfunction
• Neurological signs of spinal cord or cauda equina compression

➢ DO NOT confuse between metastatic spinal cord compression and spinal • Spinal metastasis + symptoms of
metastasis. Spinal metastasis presents with pain in the thoracic or upper decompression → MRI
cervical spine, progressive lumbar spine pain or nocturnal spinal pain • Spinal metastasis WITHOUT symptoms
of compression→ Isotope scan
preventing sleep. Spinal metastasis isn’t considered emergency

➢ Most frequent sites for metastasis for prostate cancer are bone (by hematogenous spread) and lymph nodes of
the obturator fossa, internal, external and common iliac arteries and presacral regions
• Prostate cancer → Bone + LN
• Testicular cancer → LN + Lungs
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 Urology
Benign Prostatic Hyperplasia (BPH)
➢ An old male complaining of LUTS
➢ DRE reveals a large, firm and smooth prostate CYSTITIS= *suprapubic pain, dysuria, urgency, frequency, hematuria - Nitrites and
Leucocytes in urine...

Interstitial cystitis
Features
• Recurrent suprapubic pain
• Worsened by bladder filling
• Relieved by voiding but returns when bladder fills again
• LUTS: urine frequency, urgency & nocturia
• In women, symptoms are often worse during menstruation
Investigation
• Cystoscopy, to exclude bladder malignancy
- 10% have Hunner’s ulcers, they’re reddened mucosal areas
associated with small vessels radiating towards a central scar
- Glomerulations (petechial red areas)
Management
• 1st line
- Bladder training
- Pelvic floor relaxation techniques (avoid pelvic floor exercises)
- Avoid triggers like coffee, citrus fruits or smoking which can exacerbate symptoms
- Analgesics such as NSAIDs
• 2nd line
- Amitriptyline
- Oxybutynin
- Gabapentin

Pyogenic cystitis
- LUTS
- Fever
- Nitrates and leukocytes in urine

Bladder stones are rare in women

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 Urology
Bladder cancer
➢ Mostly transitional cell carcinoma ➢ Whenever you see painless, gross
hematuria in an elderly male, you should
➢ Presents with painless visible hematuria
immediately be thinking of cancer
Risk factors
• Smoking – the major cause
• Occupational exposure (industrial plants processing paint, dye (aniline), metal and petroleum products)
• Male Urosepsis post bladder catheterization: Do septic screen which includes blood and urine cultures FBC
• Increasing age CRP lactate and imaging

Investigations of Hematuria
• After a UTI has been excluded or treated, all patients with persistent microscopic or macroscopic hematuria
require investigation of their upper tracts, bladder and urethra bladder ca, melanoma, pancreatic ca, ovarian ca, laryngeal ca,
breast lump--> 2WW referral

- >40 + frank hematuria → Cystoscopy, CTU (CT-urography) & cytology

- >40 + non-visible hematuria OR <40 + hematuria (malignancy less likely) → CT-KUB for stones
- For renal and ureteric malignancy → CTU
Ultrasound is used in cases of suspected renal calculi only if the patient is pregnant.

• CTU is faster than US or IVU in detecting renal and ureteric tumors. However, it carries a higher radiation
dose and is more expensive. CTU also detects some bladder tumors, but may overcall bladder wall
hypertrophy as tumor and will miss flat CIS and urethral pathology so it cannot replace cystoscopy
>45 Y with painless hematuria - 2WW urology referral

D/Dx:
Varicocele 1. Renal stones - could be painless or in this scenario background of unilateral back pain. Inv: NCCT KUB
2. Bladder cancer - smoker, weight loss, painless. Inv: Cystoscopy
3. RCC - Abdominal Mass +ve, flank pain. Inv: CTU
➢ Abnormal enlargement of the testicular veins
➢ Incompetent valves of the internal spermatic veins lead to retrograde blood flow, vessel dilatation and
tortuosity of the pampiniform plexus
➢ > 80% on the left side, the left testicular vein opens at a right angle to the left renal vein
➢ 2ry varicocele can be caused by a kidney tumor (causing obstruction of the left testicular vein)
Features
• Classically described as a bag of worms
• Subfertility (due to elevated scrotal temperature
which affects spermatogenesis)
• Usually asymptomatic (rarely causes pain, if so →
scrotal heaviness)
• Swelling from varicocele may demonstrate cough
impulse like hernia and they also tend to
disappear when lying down (gravity allows
drainage of the pampiniform plexus)
Diagnosis
➢ Scrotal doppler US is diagnostic
Management
• Usually conservative → Reassure
• Surgery is occasionally considered if there’s
significant ongoing pain, debatable in managing
fertility

➢ Newly diagnosed varicocele over the age of 40 years is very suggestive of RCC

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 Urology
Testicular torsion
Retracted affected testis, sudden onset pain <6 hours =testicular torsion

Key features Other investigations

• Severe sudden onset testicular pain • Color doppler US ⟶ reduced arterial blood
• Usually affects adolescents and young males (<20 years) flow in testicular artery
• Radionuclide scanning ⟶ decreased
• Possible history of trauma
radioisotope uptake
• Could be recurrent ⟶ testis twisting and then spontaneously
resolving ➢ If the clinical suspension is high, surgical
• On examination testis is tender and pain not eased by intervention should not be delayed for the
sake of further investigations
elevation
DD
- In testicular torsion ⟶ lifting the testis up over the • Mumps orchitis
symphysis increases pain - 70% unilateral
- In epididymitis ⟶ usually relieves pain - A week-history of parotitis
Management
➢ Urgent exploratory surgery (detorsion & orchidopexy) is needed to prevent ischemia of the testicle within 6h

Epididymo-orchitis
➢ An infection of the epididymis with or without an infection of the testes resulting in pain and swelling
➢ Most commonly caused by local spread of infections from the genital tract (e.g. chlamydia & gonorrhea)
where there’s a retrograde spread from the prostatic urethra and seminal vesicles
➢ It also could be caused by non-sexually transmitted organism causing UTI (e.g. E. coli)
Features
➢ Epididymo-orchitis in men VS. Salpingitis in women
• Unilateral scrotal pain and swelling
• Tenderness is usually localized to epididymis (may help distinguish from testicular torsion)
• Urethral discharge may be present, but urethritis is often asymptomatic
• Leukocytes & nitrates positive (e.g. E. coli)
• Fever and rigors in severe cases
• Tenderness may be relieved by elevating the scrotum
⟶ +ve Prehn’s sign
Management
➢ Antibiotics

Reiter’s syndrome [AUC]

1. Urethritis
2. Arthritis
3. Conjunctivitis
➢ Triggered by chlamydia infection, and usually in conjugation with HLA-B27
Simple UTI+non-pregnant woman+age below 65= no urine culture needed. Just do UA and then commence antibiotics if needed.

When to take culture:

* Pregnant woman
* Above 65 years of age
* Symptoms persist despite antibiotic therapy
* Recurrent urinary tract infections
* Has a urinary catheter
* Abnormalities of the genitourinary tract
* Renal impairment
* Haematuria

When to refer:

* Men with upper urinary tract infection

* Poor response to treatment
* Recurrent infections
* Pyelonephritis
* Persistent haematuria
* Unusual organisms detected

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to perform imaging: 4
* Fever which persists for more than 48 hours despite giving antibiotics (renal abcess?)
* Recurrent episodes
* Suspected stone
* Patients with diabetes mellitus or in an immunocompromised state
 Urology
Testicular cancer
➢ Germ cell tumor mostly
1. Seminoma ⟶ the most common
2. Non-seminoma
➢ Usually present at earlier age (30-34 years old)
Risk factors
• Cryptorchidism (undescended testis), increases the risk 10 times higher ⟶ Orchidopexy at age 6 months
Features
• Painless lump in the body of the testis ⟶ the most common presentation
Diagnosis
• US is the 1st line ⟶ [This should be first line for any scrotal lump]
• CT ⟶ for staging
• Tumor markers ⟶ LDH (seminoma), B-HCG or AFP (non-seminoma)
Complications • No biopsy for testicular cancer for fear of
➢ 2ry spread to the para-aortic LN rather than the inguinal LN seeding
➢ Metastasis is rare, if happens ⟶ LNs, lungs • Enlarged scrotum ⟶ Hydrocele
• Enlarged testis ⟶ Testicular cancer

Epididymal cyst
➢ Derived from the collecting tubules of the epididymis and contains clear fluid
➢ They develop slowly, lie within the scrotum & often multiple (multiloculated)
➢ Most common cause of scrotal swelling seen in primary care
Features - Epididymal cyst ⟶ behind and above
• Painless - Hydrocele ⟶ anterior and below

• Lie behind and above the testis

➢ Epididymal cyst feels as a separate swelling
Diagnosis from testis. However, in hydrocele, testis feels
➢ US as a free-floating mass in scrotum
Management
• Usually supportive but surgical removal may be attempted for larger or symptomatic cysts

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 Urology
Nephrolithiasis
Risk factors
• Dehydration
• Hypercalcemia (either due to hyperparathyroidism or sarcoidosis -raised vitamin D produced by
macrophages-)
• ADPKD
• Gout ⟶ uric acid stones
• Loop diuretics ⟶ Ca excretion ⟶ hypercalciuria
Features
• Sudden onset flank pain, radiating to the loin/groin
• Nausea and vomiting • Renal colic + joint pain ⟶ uric acid stone
• Hematuria (painful) • Triad of gout = arthritis + nephrolithiasis + tophi
Types
• Ca oxalate ⟶ most common
• Uric acid (radiolucent)
• Struvite stone (staghorn stone) ⟶ alkaline urine (infection with urease producing bacteria, proteus &
klebsiella)
• Cysteine ⟶ a child with recurrent episodes of renal colic
Renal colic pain management: 1st line : NSAIDS. - - > IV
Investigations PARACETAMOL - - > if C/I : OPIOID(tramadol)

• Initial ⟶ X-ray
• If suspect a radio-lucent stone ⟶ US
• Most accurate ⟶ non-contrast CT
- It can also exclude other causes of acute abdomen (e.g. ruptured AAA)
Management
• <5 mm ⟶ manage conservatively by increasing fluid intake ➢ Ca stones ⟶ Thiazide diuretics
➢ Uric acid stones ⟶ K citrate
• 5-10 mm ⟶ medical therapy using CCB, analgesics and steroids
with increased fluid intake ➢ Besides increasing fluid intake, patient
• 10 mm – 2 cm ⟶ ESWL or uteroscopy (using dormia basket) can be treated with:
• >2 cm (large and complex stone) ⟶ percutaneous 1. Tamsulosin (relaxes the bladder
neck)
nephrolithotomy
2. Diclofenac (NSAID)
• Staghorn ⟶ surgery

An urgent percutaneous nephrostomy or uretic stent (JJ) may be needed

1. Infection + obstruction (fever, tender loin & pyuria)
2. Urosepsis (altered mental state, systolic blood pressure ≤ 100 mmHg, respiratory rate >22 breath/min)
3. Intractable pain or vomiting
4. Impending AKI (azotemia or elevated creatinine and BUN)
5. Obstruction in a solitary kidney
6. Bilateral obstructing stones

➢ For ureteral stones Urgent (hydronephrosis, AKI...) : Stent or Nephorostomy ........Definitive : Ureteroscopy or ESWL
- <5 mm → conservative
- >5 mm → CCB and Tamsulin, most pass in 48h, if not → ESWL or ureteroscope
- Larger stones, multiple or complex → percutaneous nephrolithotomy

Loin pain + Stone + Hydronephrosis = depends on size

loin pain + stone + Hydronephrosis + features of AKI/fever = Needs decompression ( Stenting/Nephrostomy)

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 Urology
Post-op ureteric injury
➢ May present in the first few days following surgery but it may also be delayed by weeks
➢ One of the most serious complications during gynecological & abdominal surgeries
➢ Ureter could be divided, ligated, angulated by a structure or damaged by a diathermy
Features
• Ileus (due to urine in the peritoneal cavity)
• Fever
• Flank pain (if the ureter has been ligated) ➢ Any investigation involving contrast media CANNOT
be given in case of impaired renal function
• Abdominal pain
• Abdominal distension
• Retroperitoneal urinoma (a collection of urine)
• Urinary leakage (vaginally or via abdominal wound)
Investigations
• Intravenous urography (IVU)
- Shows an obstructed ureter, extravasation of the dye from the site of injury or hydronephrosis
- The best imaging modality to evaluate the continuity of the ureter in cases of ureteral injury after an
operation
• Renal US
- Best non-invasive method to visualize the kidney
- Best when renal function is impaired
- Shows hydronephrosis or retroperitoneal urinomas. However, it CANNOT assess the ureteric continuity
• CT with contrast
• Retrograde urethrogram

Vesicovaginal fistula
➢ A continuous involuntary discharge of urine into the vaginal vault
➢ A possible complication after gynecological procedures (hysterectomy)
➢ A 3-swab test could identify a vesicovaginal fistula
- 3 gauze swaps placed into the vagina using a speculum (top, middle &bottom)
- Blue dye is inserted to the bladder by passing through a catheter
- Catheter is removed and the patient is asked to walk around for an hour without urinating
- Then, swabs are taken and evaluated for blue dye

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 Urology
Hypothalamospinal: Autonomic regulation ( erectile dysfunction )
Syphilis Mesolimbic: Reward, motivation, addiction
Cerebellothalamic: Movement coordination
Nigrostriatal: Motor control (Parkinsons link)
➢ An STI caused by Treponema pallidum Nigrofrontal: Cognitive functions and decision-making

➢ More common in homosexuals

➢ Acquired syphilis is characterized by primary, secondary and tertiary features
Incubation period
• Around 3 weeks • Single painless genital ulcer → Syphilis
Features • Single painful ulcer → Ducreyi
1. Primary features • Multiple painful ulcers → HSV
- Chancre, painless ulcer at the site of sexual contact
- Local non-tender lymphadenopathy
- In women, they’re found on the vulva, labia and can also be found on the cervix or within the anal canal
2. Secondary features
- Appears 6 weeks after beginning of the primary lesion but may overlap or not appear for several months
- Systemic symptoms: fever, lymphadenopathy, headache, malaise
- A generalized polymorphic rash often affect the palms, soles and face
- Papules enlarge into condylomata lata (pink or grey discs) in moist warm areas
3. Tertiary features
- Gummas (granulomatous lesions can occur in any organ but most commonly affect bone and skin)
- Cardiovascular syphilis → ascending aortic aneurysms, AR
- Neurological syphilis → tabes dorsalis, dementia
Investigations
• Visible ulcer or infected LN → (GP → PCR // GUM physician → Dark field microscopy)
• Healed ulcer → Serology (VDRL, TPHA or treponemal antibody absorption)
Management
➢ Benzathine penicillin + oral azithromycin
• Certain strains of Chlamydia can cause painless ulcer
+ lymphogranuloma venereum
DD of rash on palms and soles
• Classically found un Africa, India and Caribbean
1. 2ry Syphilis by Treponema pallidum • Outbreaks are possible in MSM
2. Hand, foot, mouth disease by Coxsackie virus
3. Rocky mountain spotted fever by rickettsia

Genital Herpes Simplex

➢ May be asymptomatic, or may remain dormant for months or even years
➢ When symptoms occur after infection, they tend to be severe
➢ It can be a chronic, lifelong infection
➢ Mostly caused by HSV-1 (most common cause of both orolabial and genital herpes)
Presentation
• Flu-like prodrome, followed by grouped vesicles/papules around genitals
• They burst and form shallow ulcers
• Dysuria is often present
Investigations
• NAAT (nucleic acid amplification test)
• PCR & viral culture
• Recurrent/atypical genital ulcers with -ve culture or PCR → Anti-HSV antibodies
Management
• Oral acyclovir

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 Urology
Genital warts
➢ Benign epithelial skin tumors commonly seen as cauliflower-like growths
➢ Most commonly caused by HPV 6 & 11
➢ Around 30% can resolve spontaneously
➢ Transmitted by sexual intercourse • HPV 16 & 18 are responsible for most cervical
cancers in the UK
➢ IP: 6 weeks to several months
Management
• Solitary, keratinized warts → Gardasil, protects against HPV 6,11, 16 & 18
• Multiple, non-keratinized → Podophyllotoxin
• Ablative (e.g. cryotherapy & excision under anesthesia)

TURP $
• Occurs when irrigation fluid enters the systemic circulation. It’s caused by venous destruction and
absorption of the irrigation fluid and it can be life threatening
• Characterized by dilutional hyponatremia
• Managed by fluid restriction

Purple urine bag $

• Resulted from co-existent UTI
• One of the most common causing bacteria is Providencia stuartii
• Managed by betadine lavage of the urethra and catheter change

Infected indwelling urinary catheter

- Action ⟶ Change the catheter
- If symptoms of UTI ⟶ Antibiotics

- Due to detrusor overactivity but in cases where antimuscarinics

Urge incontinence
- “when I have to go to the toilet, I really have to go” are contraindicated like SVT,
Glaucoma : MIRABEGRON (beta 3
/overactive bladder
- “sometimes urine passes before reaching the toilet” agonist) is choice
(OAB)
Treatment → Bladder retraining, antimuscarinics (Oxybutynin, tolterodine or darifenacin)
- Leaking small amounts of urine when coughing or laughing
- Usually with a history of many vaginal deliveries as this would weaken the pelvic
Stress incontinence floor muscles
Treatment → Pelvic floor exercise, tension-free vaginal tape, retropubic mid-urethral tape
procedures, Duloxetine
Mixed incontinence - A mix of both stress and urge incontinence

- Involuntary release of urine from an overfull urinary bladder, often in the absence of
any urge to urinate
Overflow
- Occurs in patients who have blockage of the bladder outlet (BPH, prostate cancer or
incontinence
narrowing of the urethra) or when the muscle that expels urine from the bladder is
too weak to empty the bladder normally
- Opening between vagina and urethra
Urethrovaginal
- Continual leakage of urine from the vagina
fistula
- Vagina would have a foul smelling

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