Urology

Prostate cancer investigations? When would you do biopsy? Grading system used? What is TURP syndrome?

Multiparametric MRI then biopsy

-          Likert scale >3 – offer biopsy

-          Likert scale 1-2 – discuss pros and cons of biopsy

PSA – if prostatitis or UTI – postpone test for at least 6 weeks after treatment, ideally no ejaculation or vigorous exercise in last 48 hrs

Gleason grading system

-          2 most common tumour patterns across all samples are graded based on differentiation – sum of both is gleason score

International prostate symptom score

TURP syndrome

-          Irrigation fluid from operation (glycine) enters intravascular space via prostatic bed and expands it. This causes a state of fluid overload and hyponatraemia.

Epididymo-orchitis - features? Main DD? Causes in young and old? Management?

Unilateral testicular pain and swelling, urethral discharge

DD – testicular torsion!!

Young – STI Ix, old with low-risk sexual hx – MSU

If STI most likely cause – urgent referral to sexual health clinic

Unknown organism, - IM ceftriaxone single dose + doxycycline 100mg BD for 10-14 days

Enteric organism most likely cause = quinolone 14 days. If CI – co-amox 10 days

Testicular torsion - signs? USS finding? Management?

Retracted testicle, absent cremasteric reflex, horizontal lie

One cause – bell clapper deformity

USS – whirlpool sign

Urgent surgical exploration – after detorsion wrap testis in warm saline gauze and observe

• If pink colour returns – testos considered viable and both testis fixed as bell clapper often B/L

• If non-viable then orchidectomy

Hydrocele - features? Ix? Management?

        ·        Painless soft scrotal swelling

        ·        Testicle palpable, transilluminates, can get above mass  

        ·        Irreducible and no bowel sounds unlike hernia

        ·        USS if any doubt or cannot palpate testis or to exclude tumour

        ·        Infantile – repair if no spontaneous resolution by 1-2 years

        ·        Adults – cons mx

Varicocele - what is it? Features? Which side is most common? Ix?

        ·        Swollen veins in pampiniform plexus

        ·        R testicular vein → IVC and L testicular vein → L renal vein

        ·        90% on L side – think RCC – esp if doesn’t disappear on lying down

        ·        Pain worse on standing, dragging sensation, bag of worms

        ·        USS with doppler imaging

Epididymal cysts - features? Ix?

        ·        Painless lump – can’t get above, will transilluminate, posterior side of testicle, separate from body of testicle

        ·        Spermatocele if contains sperm

        ·        Top of testicle – soft, round lump

        ·        USS

Testicular cancer types? Tumour markers? Staging system?

        ·        Germ cell tumours – Seminoma and non-seminoma

        ·        Non-germ cell tumours – Leydig cell tumours and sarcomas

        ·        Can get gynaecomastia

        ·        Tumour markers in germ cell tumours – Alpha fetoprotein raised in non-seminomas, B-hcG raised in both, LDH raised in germ cell tumours  

        ·        USS 1^st line

        ·        Royal Marsden staging system

Interstitial cystitis/bladder pain syndrome - duration of sx? What does cystoscopy show?

        ·        LUTI sx 6 weeks

        ·        Cystoscopy shows Hunner lesions and granulations

Urethral stricture - causes? Features? Ix? Complications? Management?

• Causes – pelvic trauma, perineal trauma, urethral insertion of foreign bodies, gonorrhoea or chlamydia, long-term catheter

• Clinical features – chronic retention, overflow incontinence, LUTS

• Investigations – cystoscopy, urine MC&S, renal function, urodynamic testing and residual volume measurement

• Complications – calculus formation, chronic infection, prostatitis, epididymitis, renal impairment, bladder diverticula

• Treatment – internal urethrotomy, urethroplasty

BPH medical management options? How do they work?

• Alpha-1 antagonists e.g. tamsulosin decrease smooth muscle tone of prostate and bladder

• 5 alpha-reductase inhibitors e.g. finasteride – block conversion of testosterone to DHT

Priapism - Ix? Management?

• Ix – cavernosal blood gas analysis or doppler USS to differentiate between ischaemic and non-ischaemic

• Ischemic is emergency – if >4hrs – aspirate blood and inject with saline flush → if fails, inject vasoconstrictive agent and repeat every 5 mins → if fails, surgery

• Non-ischaemic can be observed

Bladder cancer types? RFs for each?

-          Transitional cell carcinoma – smoking, aniline dyes, cyclophosphamide

-          Squamous cell carcinoma – schistosomiasis, smoking