Urology Laz Overview Prostate and Bladder - PowerPoint Presentation

Slide1

Slide2

Urology

Laz

Slide3

Overview

Prostate and Bladder

Urinary Incontinence

Acute Urology: Calculi and Torsion

Scrotal Masses

DISCLAIMER

:

MedED

does not represent the ICSM Faculty or Student Union. This lecture series has been designed and produced by students. We have made every effort to ensure that the information contained is accurate and in line with Learning Objectives featured on SOFIA, however this guide should not be used to replace formal ICSM teaching and educational materials.

Slide4

SBA 1

A 67-year-old man has been urinating around 12-14 times per day over the past 6 months. His stream is ‘weak’ and often takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him?

A

Oxybutynin

B

Solifenacin

C Tamsulosin

D Nitrofurantoin E Co-trimoxazole

Slide5

SBA 2

A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost some weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis?

A

Pyelonephritis

B

Glomerulonephritis

C Bladder CancerD Prostate Cancer

E Ureteric Stone

Slide6

SBA 3

An 80-year-old man has had considerable difficulty urinating. He goes about 10-12 times per day, including at night, and has described his stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which first-line investigation should be used to confirm the diagnosis?

A  

PSA

B  

Acid phosphatase

C  MRI ScanD  

Transrectal ultrasound guided biopsy E  Isotope bone scan

Slide7

Lower Urinary Tract Symptoms: FUND HIPS

Definition

:

a group of symptoms involving the bladder, urinary sphincter, urethra and prostate gland (in men).

Storage/Irritative

F

requency

UrgencyNocturiaDysuriaVoiding/Obstructive

H

esitancy

I

ncomplete emptying

P

oor stream

S

training

Others: terminal dribbling, overflow incontinence

Slide8

Benign Prostatic Hyperplasia

Definition

:

slowly progressive hyperplasia of the

periurethral

(transitional) zone

of the prostate gland.Symptoms and Signs

FUND HIPSSevere pain (if ACUTE retention)DRE - smoothly enlarged prostate with a palpable midline grooveInvestigations

Usually unnecessary

U&Es – check for ↓ renal function

Ultrasound of urinary tract

Epidemiology

VERY COMMON – most common cause of LUTS in men

Slide9

Benign Prostatic Hyperplasia - Management

EMERGENCY

(acute urinary retention)

CATHETERISE!

Conservative

(if mild)

Watchful waiting (because patients are old)

Medicala-blockers (e.g. tamsulosin)5a-reductase inhibitors (e.g. finasteride)

Surgical

Transurethral resection of the prostate (TURP)

Open prostatectomy

Slide10

Prostate Cancer

Symptoms and Signs

FUND HIPS

Symptoms of

malignancy

Bone pain

Cord compression

FLAWSParaneoplastic (e.g. hypercalcaemia)DRE – asymmetrical hard nodular prostate

Investigations

PSA –

low

specificity

MRI

–

FIRST LINE

Transrectal Ultrasound-guided Biopsy

LFTs/bone profile – check for metastatic effects

Slide11

Bladder Cancer

Background

Most bladder cancers are

transitional cell carcinomas

Rarely, they can be squamous cell carcinomas

Risk Factors

Dye stuffs

Pelvic irradiationSmoking Chronic UTIs Schistosomiasis

Symptoms

Painless macroscopic

haematuria

FUND (

not

HIPS)

FLAWS

Investigations

Cystoscopy

with biopsy

CT/MRI for staging

Slide12

SBA 1

A 67-year-old man has been urinating around 12-14 times per day over the past 6 months. His stream is ‘weak’ and often takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him?

A

Oxybutynin

B

Solifenacin

C Tamsulosin

D Nitrofurantoin E Co-trimoxazole

Slide13

SBA 1 - Answer

A 67-year-old man has been urinating around

12-14 times per day

over the past 6 months. His

stream is ‘weak’

and often

takes a long time to get going. After he has finished urinating, he does not feel fully empty and often dribbles a little bit. DRE reveals a

smoothly enlarged prostate gland with a palpable midline sulcus. A diagnosis of benign prostatic hyperplasia is made. He is eager to avoid surgery if possible. Which treatment would be best for him? A OxybutyninB SolifenacinC Tamsulosin

D

Nitrofurantoin

E

Co-

trimoxazole

Slide14

SBA 2

A 75-year-old owner of a dye factory has experienced 4 episodes of ‘bright red’ blood in his urine over the past 2 weeks. He does not feel any pain when urinating. He has also noticed that he has lost weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis?

A

Pyelonephritis

B

Glomerulonephritis

C Bladder CancerD Prostate Cancer

E Ureteric Stone

Slide15

SBA 2 - Answer

A 75-year-old owner of a

dye factory

has experienced

4 episodes of ‘bright red’ blood in his urine

over the past 2 weeks. He

does not feel any pain when urinating. He has also noticed that he has lost weight recently despite not changing his eating habits or exercise levels. What is the most likely diagnosis? A

PyelonephritisB GlomerulonephritisC Bladder CancerD Prostate Cancer E Ureteric Stone

Slide16

SBA 3

An 80-year-old man has had considerable difficulty urinating. He goes about 10-12 times per day, including at night, and has described his stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which first-line investigation should be used to confirm the diagnosis?

A  

PSA

B  

Acid phosphatase

C  MRI scanD  

Transrectal ultrasound guided biopsy E  Isotope bone scan

Slide17

SBA 3 - Answer

An 80-year-old man has had considerable difficulty urinating. He goes about

10-12 times per day

, including

at night

, and has described his

stream as being very poor. He has also experienced lower back pain over the last 6 weeks. On digital rectal examination, an asymmetrically enlarged, nodular prostate gland is palpated. Which investigation is most likely to provide a definitive diagnosis?

A  PSA B  Acid phosphatase C  MRI ScanD  Transrectal ultrasound guided biopsy

E  

Isotope bone scan

Slide18

SBA 4

A 43-year-old woman presents to her GP having wet herself several times since the birth of her third child, 4 months ago. Whenever she laughs or coughs, a little bit of urine leaks out without her control. Which type of incontinence does she have?

A  

Functional incontinence

B  

Stress incontinence

C  Urge incontinence D  

Overflow incontinence E  Double incontinence

Slide19

SBA 5

A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become overwhelmed by the feeling of needing to urinate. Before she can even think about finding a toilet, she has wet herself. Which type of incontinence is this?

A  

Functional incontinence

B  

Stress incontinence

C  Urge incontinence

D  Overflow incontinence E  Double incontinence

Slide20

Urinary Incontinence

Definition

:

the unintentional loss of urine

.

STRESS

Physical movement/activity (e.g. coughing, laughing) places a ‘stress’ on the bladder

Due to poor closure of the bladderChildbirth is a risk factor URGEUrine leaks as you feel a sudden, intense urge to urinateDue to detrusor overactivity

Other types

:

Functional

– individual is aware of the need to urinate, but are unable to get to the bathroom in time due to physical/mental reasons

Overflow

– involuntary release of urine from an overfull bladder, in the absence of any need to urinate

Niche Causes of Incontinence

Normal pressure hydrocephalus

Cord compression

Covered

in MedED

Neuro Lectures

Slide21

SBA 4

A 43-year-old woman presents to her GP having wet herself several times since the birth of her third child, 4 months ago. Whenever she laughs or coughs, a little bit of urine leaks out without her control. Which type of incontinence does she have?

A  

Functional incontinence

B  

Stress incontinence

C  Urge incontinence D  

Overflow incontinence E  Double incontinence

Slide22

SBA 4 - Answer

A 43-year-old woman presents to her GP having wet herself several times since the

birth of her third child

, 4 months ago. Whenever she

laughs or coughs

, a little bit of urine leaks out without her control. Which type of incontinence does she have?

A  Functional incontinence B  Stress incontinence

C  Urge incontinence D  Overflow incontinence E  Double incontinence

Slide23

SBA 5

A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become overwhelmed by the feeling of needing to urinate. Before she can even think about finding a toilet, she has wet herself. Which type of incontinence is this?

A  

Functional incontinence

B  

Stress incontinence

C  Urge incontinence

D  Overflow incontinence E  Double incontinence

Slide24

SBA 5 - Answer

A 65-year-old woman has wet herself several times over the past 3 months. She says that she will be going about her usual daily activities and will suddenly become

overwhelmed by the feeling of needing to urinate

. Before she can even think about finding a toilet,

she has wet herself

. Which type of incontinence is this?

A  Functional incontinence

B  Stress incontinence C  Urge incontinence D  Overflow incontinence E  Double incontinence

Slide25

SBA 6

A 42-year-old man presents with severe pain in his right flank. He adds that the pain moves towards his right groin. Although he is writhing around in pain, no abnormalities are detected on abdominal examination.

Urine Dipstick: + blood

Which investigation would you do next?

A  

Renal ultrasound

B  Cystoscopy

C  CT-KUB D  MRI E  Urine MC&S

Slide26

SBA 7

Which type of urinary tract stone is most common?

A

Magnesium ammonium phosphate

B

Calcium oxalate

C

CysteineD Urate E

Hydroxyapatite

Slide27

SBA 8

A 13-year-old boy is brought to A&E with sudden-onset pain and swelling in his scrotum, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to vomit. On examination, his right

hemiscrotum

is red and swollen. What is the most appropriate first step in his management?

A  

Doppler ultrasound of the testes

B  CT Scan

C  Exploratory surgery D  Empirical antibiotics E  Abdominal X-ray

Slide28

Urinary Tract Calculi

Definition

:

crystal deposition within the urinary tract. AKA

nephrolithiasis

.

Types of Stone

CALCIUM OXALATE – most commonMagnesium ammonium phosphateUrate Cysteine Causes

Idiopathic

Metabolic (e.g.

hypercalcaemia

,

hyperuricaemia

)

Risk Factors

Low fluid intake

Structural urinary tract abnormalities

Epidemiology

3 x more common in MEN

Symptoms and Signs

Often

asymptomatic

SEVERE

loin to groin pain

Nausea and vomiting

NOTE: consider

leaking AAA

(especially in the elderly)

Slide29

Urinary Tract Calculi - Investigations & Management

Investigations

Urine dipstick (microscopic

haematuria

)

Non-contrast CT-KUB

– GOLD STANDARD

Ultrasound U&Es – check renal function ManagementANALGESIA< 5 mm diameter – allow to pass spontaneously

> 5 mm diameter

–

SURGERY

Ureteroscopic

lithotripsy

Extracorporeal Shockwave Lithotripsy (ESWL)

Percutaneous

Nephrolithotomy

(PCNL)

EMERGENCY

: any signs of an obstructed

and infected

kidney requires

urgent nephrostomy

to relieve the obstruction is necessarily

Slide30

Testicular Torsion

Definition

:

twisting or torsion of the spermatic cord results in disruption of the blood supply to the testicle. A

SURGICAL EMERGENCY

.

Epidemiology

Boys and young menSymptoms and SignsSudden-onset severe hemiscrotal painNausea and vomiting Swollen and erythematous scrotum

Management

EXPLORATORY SURGERY

(within 6 hours)

Both

testicles are fixed in place

Necrotic tissue may need removal

Duplex Ultrasound

Differential Diagnosis

Epididymo-orchitis

Strangulated inguinal hernia

Slide31

SBA 6

A 42-year-old man presents with severe pain in his right flank. He adds that the pain moves towards his right groin. Although he is writhing around in pain, no abnormalities are detected on abdominal examination.

Urine Dipstick: + blood

Which investigation would you do next?

A  

Renal ultrasound

B  Cystoscopy

C  CT-KUB D  MRI E  Urine MC&S

Slide32

SBA 6 - Answer

A 42-year-old man presents with

severe pain in his right flank

. He adds that the pain

moves towards his right groin

. Although he is writhing around in pain, no abnormalities are detected on abdominal examination.

Urine Dipstick: + bloodWhich investigation would you do next? A  

Renal ultrasound B  Cystoscopy C  CT-KUB D  MRI E  Urine MC&S

Slide33

SBA 7

Which type of urinary tract stone is most common?

A

Magnesium ammonium phosphate

B

Calcium oxalate

C

CysteineD Urate E

Hydroxyapatite

Slide34

SBA 7 - Answer

Which type of urinary tract stone is most common?

A

Magnesium ammonium phosphate

B

Calcium oxalate

C

CysteineD Urate E

Hydroxyapatite

Slide35

SBA 8

A 13-year-old boy is brought to A&E with sudden-onset pain and swelling in his scrotum, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to vomit. On examination, his right

hemiscrotum

is red and swollen. What is the most appropriate first step in his management?

A  

Doppler ultrasound of the testes

B  CT Scan

C  Exploratory surgery D  Empirical antibiotics E  Abdominal X-ray

Slide36

SBA 8 - Answer

A

13-year-old boy

is brought to A&E with

sudden-onset pain and swelling in his scrotum

, which began an hour ago whilst playing a football match. After arriving at hospital, he begins to

vomit. On examination, his right

hemiscrotum is red and swollen. What is the most appropriate first step in his management? A  Doppler ultrasound of the testes B  CT Scan C  Exploratory surgery

D  

Empirical antibiotics

E  

Abdominal X-ray

Slide37

SBA 9

A 50-year-old man has developed a swollen scrotum that has been bothering him for the past 2 weeks. The swelling is uncomfortable but not painful. On examination, the left

hemiscrotum

is enlarged, fluctuant and non-tender. It is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis?

A  

Varicocoele

B  Hydrocoele

C  Testicular tumour D  Epididymal cyst E  Indirect inguinal hernia

Slide38

SBA 10

A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘bag of worms’, and is uncomfortable but not painful. On examination, the patient’s scrotum looks normal when lying down, however, the left

hemiscrotum

becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis?

A  

Indirect inguinal hernia

B  Direct inguinal hernia

C  Hydrocoele D  Varicocoele E  Epididymal cyst

Slide39

SBA 11

A 21-year-old man visits his GP complaining that his scrotum feels ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with

orchidopexy

. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to?

A

Inguinal

B FemoralC

Para-aortic D IliacE Mesenteric

Slide40

Hydrocoele

Definition

:

an excessive collection of serous fluid in

the

tunica vaginalis

.Epidemiology

Very young boys (< 1 yr)Older menCausesIdiopathicInfection

Trauma

Tumour

Symptoms and Signs

Usually asymptomatic swelling

Can get above the swelling

Transilluminates

Swelling cannot be separated from testicle

Investigations

Ultrasound - exclude tumour

Testicular tumour markers

Urine dipstick/MSU – check for infection

Slide41

Varicocoele

Definition

:

dilated veins of the

pampiniform plexus

forming a scrotal mass

.Background

More common on the LEFT (80-90%)Associated with infertilitySymptoms and Signs

Usually asymptomatic

Scrotum feels like a ‘

bag of worms

’

Swelling may reduce when lying down

Slide42

Epididymitis and Orchitis

Definition

:

inflammation of

the epididymis or testes

.

Causes

< 35 yrs: Chlamydia and Gonococcus> 35 yrs: Coliforms (e.g. Enterobacter, Klebsiella) Others: mumps, Candida

Epidemiology

Most common in 20-30

yr

olds

Symptoms and Signs

Painful, swollen and tender testis/epididymis

NOTE

: less acute onset than torsion

Penile discharge (if STI)

Fever

Enquire about sexual history

Investigations

Urine dipstick

Urine MC&S

Bloods (FBC, CRP)

Slide43

Testicular Cancer

Background

Commonest malignancy in males between 20-40 yrs

Risk Factors:

maldescended testes

Types

Seminoma - 50%

Non-Seminoma (e.g. teratoma) – 30%Others: Sertoli and Leydig cell tumours

Symptoms

Painless, hard testicular mass

Testicular swelling/discomfort

Backache (metastasis to

para-aortic

nodes)

Investigations

Tumour Markers

a

-fetoprotein

b

-

hCG

Lactate Dehydrogenase

Testicular Ultrasound

CT – allows staging

Slide44

Differential Diagnosis of Scrotal Mass

Slide45

Differential Diagnosis of Scrotal Mass - Illustration

Slide46

SBA 9

A 50-year-old man has developed a swollen scrotum that has been bothering him for the past 2 weeks. The swelling is uncomfortable but not painful. On examination, the left

hemiscrotum

is enlarged, fluctuant and non-tender. It is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis?

A  

Varicocoele

B  Hydrocoele

C  Testicular tumour D  Epididymal cyst E  Indirect inguinal hernia

Slide47

SBA 9 - Answer

A

50-year-old man

has developed a

swollen scrotum

that has been bothering him for the past 2 weeks. The swelling is uncomfortable but

not painful. On examination, the left hemiscrotum is enlarged, fluctuant and non-tender. It

is possible to get above the swelling, however, the left testicle cannot be distinguished from the swelling. When a pen torch is shone on the swelling, it illuminates brightly. What is the most likely diagnosis? A  Varicocoele B  Hydrocoele

C  

Testicular tumour

D  

Epididymal cyst

E  

Indirect inguinal hernia

Slide48

SBA 10

A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘bag of worms’, and is uncomfortable but not painful. On examination, the patient’s scrotum looks normal when lying down, however, the left

hemiscrotum

becomes swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis?

A  

Indirect inguinal hernia

B  Direct inguinal hernia

C  Hydrocoele D  Varicocoele E  Epididymal cyst

Slide49

SBA 10 - Answer

A 30-year-old man has developed a swollen scrotum that he first noticed a week ago. He adds that the swelling feels like a ‘

bag of worms

’, and is uncomfortable but

not painful

. On examination, the patient’s scrotum looks

normal when lying down, however, the left hemiscrotum becomes

swollen when he stands up. The GP can get above the swelling and distinguish it from the testicle. What is the most likely diagnosis? A  Indirect inguinal hernia B  Direct inguinal hernia C  Hydrocoele

D  

Varicocoele

E  

Epididymal cyst

Slide50

SBA 11

A 21-year-old man visits his GP complaining that his scrotum feels ‘heavier than usual’. On examination, a firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with

orchidopexy

. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to?

A

Inguinal

B FemoralC

Para-aortic D IliacE Mesenteric

Slide51

SBA 11 - Answer

A

21-year-old man

visits his GP complaining that his scrotum feels ‘

heavier than usual

’. On examination, a

firm, non-tender lump can be palpated at the base of the right testicle. The patient had an undescended testicle as a child, which was corrected with orchidopexy. Testicular cancer is suspected and a CT scan is requested to assess for spread. Which group of lymph nodes does testicular cancer spread to?

A InguinalB FemoralC Para-aortic D IliacE

Mesenteric

Slide52

Think carefully…

A 32-year-old man presents with a 2-week history of frequent urination and excessive thirst. He has also noticed that he feels much weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient?

A  

Tented T waves

B  

Absent P waves

C  

ST elevation D  J waves E  U waves

Slide53

Think carefully…

A 32-year-old man presents with a 2-week history of

frequent urination

and

excessive thirst

. He has also noticed that he feels much

weaker than usual, and is struggling to complete his usual gym routine. He has been to see his GP once before because his blood pressure was high

on multiple occasions, however, he did not return to receive treatment. His blood pressure is measured again and it is 184/94 mm Hg. What would you expect to see on the ECG of this patient?A  Tented T waves B  Absent P waves C  

ST elevation

D  

J waves

E  

U waves

Slide54

Thank you for listening!

Feedback:

https://tinyurl.com/LazUrology

Questions:

lpr114@ic.ac.uk