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Renal malignancy
https://t.me/med1917
ofrenal cortex
Clinical presentation: 50% = asymptomatic
• Haematuria = often painless (50%)
• Loin pain (40%) & loin mass (25%)
• Left-sided varicocele (less common)
• Signs of complications: anaemia, HTN, Cushing’s, polycythaemia,
pathological fractures (produces PTH-rp)
Chapter 15: Urology 195
Lung (cannonball mets), liver, bone, lymph nodes
Investigations:
• Hx & examination
• Urine dip: MSU and cytology
• Bloods: U&Es, anaemia, ESR, ALP, PTH, Ca
• Imaging: USS & CT = solid mass
PROGNOSIS:
(if mets <2y survival)
70% 5y survival
Management:
→ Nephrectomy/nephron-ureterectomy
→ ± Tyrosine kinase inhibitors ± immunotherapy (chemo/radio =lesseffective)
mesoderm tumour
Common presenting age: <5y
Symptoms: flank pain, abdo mass, haematuria
Management: chemo + nephrectomy
Prognosis: 80% cure rate4
Renal cysts
→ Commonly develop with age (solitary or multiple)
→ Autosomal dominant PCKD = common cause
Risk factors for renal malignancy:
1. Prolonged haemodialysis
2. Obesity, smoking, HTN, NSAIDs
3. Genetic: VHL, Birt–Hogg–Dubé
NICE guidelines
Refer anyone ≥45y on a 2ww pathway if:
• unexplained visible haematuria without UTI
• visible haematuria that persists after
successful treatment of UTI
• Often asymptomatic = found incidentally
• Mass/pain if large
• Occasionally haematuria
• PCKD causes 20% of end-stage CKD
• Simple cyst: no intervention
• Complicated cyst: further investigation & surgical intervention
Summary of causes of renal tract obstruction
Luminal Mural Extramural
• Calculi
• Clots
• Tumour
• Sloughed renal
papillae (DM,
NSAIDs)
4
NICE (2015, updated 2021) Suspected cancer: recognition and referral [NG12]
• Ureteric
stricture
(surgery, catheter,
TB)
• Tumour
• Pregnancy
• Bowel adhesions
Refer anyone ≥60y on a 2ww pathway if:
• unexplained non‑visible haematuria AND
either dysuria OR a raised white cell count on
a blood test
Consider non-urgent referral for anyone
≥60 years with:
• recurrent or persistent unexplained UTI
• Retroperitoneal fibrosis
→ 1° autoimmune
→ 2° to some drugs
(e.g. methotrexate)
Surgery
196 Chapter 15: Urology
https://t.me/med1917
Risk factors for bladder cancer:
1. Smoking
2. Age
3. Dyes/chemicals
4. FHx
5. Obesity
6. Gender (male)
7. Long‑term catheter
8. Bladder calculi
Bladder cancer
• Painless haematuria
• LUTS: voiding / obstructive symptoms
• Recurrent UTIs
1. Hx & examination – note RFs
2. Urine dip & MCS + cytology = haematuria
3. Flexible cystoscopy & biopsy = gold standard
4. USS or CT urogram to visualise kidneys
5. CT CAP with contrast / MRI for staging if cancer found
Risk factors for prostate cancer:
1. Age
2. FHx
3. Black/Afro‑Caribbean
PSA: SENSITIVE NOT SPECIFIC
= also raised in BPH & UTI
→ transurethral resection of bladder tumour (TURBT)
+ Mitomycin C ± intravesical BCG course
→ pre-op chemo + radical cystectomy or radiotherapy
Prostate cancer
• Voiding symptoms (hesitancy, poor stream, dribbling)
• ± Haematuria ± haematospermia
• Red flags: weight loss, night sweats, bone pain /
pathological fractures (ifmetastases)
1. Hx & examination → DRE: hard, craggy, irregular prostate
2. Urinalysis dip & MSU: (r/o infection)
3. Bloods: including PSA
IF abnormal DRE &/or PSA raised for age:
→ MRI + transrectal biopsy – Gleason grading
→ CT for staging
→ Bone scan if suspect mets
Surgery
1. Active surveillance: if low risk disease
2. Radical prostatectomy or radiotherapy: if localised
3. Surgical castration / androgen deprivation therapy: if metastases
4. Chemotherapy if failed radical or hormonal treatment
5
NICE (2015) Bladder cancer [NG2]
6
NICE (2019, updated 2021) Prostate cancer [NG131]
Common causes
Uterus
Ureter
Cervix
Rectum
Vagina
Anus
Pubic bone
Urethra
Clitoris
Labium minora
Labium majora
Urinary
bladder
Urinary bladder
Pubic bone
Ductus
deferens
Urethra
Penis
Epididymis
Testis
Ureter
Seminal
vesicle
Prostate
gland
Rectum
Anus
https://t.me/med1917
→ BPH
→ Prolapse
→ Post-incontinence surgery
→ Bladder calculi
→ Urethral strictures
→ Malignancy (bladder/urethral/prostatic)
→ External compression
→ Neurological disease
Clinical presentation
Chapter 15: Urology 197
Fig. 15.4 Female genitourinary anatomy.
1. Lower urinary tract symptoms (LUTS)
rapidonset
2. Acute urinary retention: suprapubic pain, palpable bladder, anuria
3. Chronic urinary retention: LUTS, renal impairment, palpable bladder,
overflow incontinence, large residual urine volume
Voiding symptoms Storage symptoms
Hesitancy
Poor flow
Post‑void dribbling
Dysuria
Frequency
Urgency ± urge incontinence
Nocturia
(bedwetting / overflow Incontinence)
(sensation of incomplete emptying)
Present in obstruction Present if bladder dysfunction
(can be 2° to chronic obstruction)
Bladder calculi
Often uric acid or calcium stones (or struvite if UTI-related)
Outlet obstruction Neurogenic retention Other
• BPH / prostate
carcinoma
• Bladder tumour
• Urethral stricture
• Prolapse (in women)
• Stroke / spinal cord injury
• Spina bifida
• Diabetes
• Augmentation cystoplasty
• Infection (UTIs)
• Dehydration
• Foreign body / catheter
• Passage of renal calculi into
bladder
Fig. 15.5 Male genitourinary anatomy.
IPSS: score/questionnaire to determine how
much symptoms impact daily life
Management of acute urinary retention:
1. ABCDE
2. Bloods: FBC, U&Es (deranged U&Es = HPCR
→ need USS KUB & urology R/V)
3. Catheter (3‑way if haematuria)
4. Full Hx and examination (including DRE &
neuro exam)
5. Monitor fluid and electrolyte balance
• LUTS: voiding & storage
• Dysuria & haematuria at end of
stream
• Lower abdo pain
• Hx & exam: abdo & pelvic + DRE
• Bloods: FBC, CRP, U&Es, Ca, PO4,
urate, glucose, VBG (HCO3)
• Urine dip & MCS – r/o infection
• Basic imaging: USS
• Specialist imaging: CT KUB
7
European Society of Urology (2021) Guidelines on bladder stones
Transurethral cystolitholapaxy
1. Cystoscope passed up urethra to
identify stones
2. Crush stones or fragment with
laser / pneumatic device
3. Bladder irrigation to remove
fragments
OR Open cystolithotomy = surgical
removal of bladder stones via a lower
abdominal incision
Bladder calculi increase risk of bladder cancer
Surgery
198 Chapter 15: Urology
https://t.me/med1917
Chronic urinary retention
Benign prostatic hyperplasia (BPH)
number of prostate cells
• Voiding symptoms ± secondary storage symptoms
• ± Haematuria
• Enlarged, smooth prostate on DRE
• Acute retention (sometimes occurs = rapid & painful)
• Symptoms: asymptomatic or LUTS, palpable
bladder, overflow incontinence, large residual
volume of urine
• Complications: UTIs, calculi, high pressure
chronic retention (HPCR) → renal impairment
& hydronephrosis
Possible complications of TURP:
Acute: bleeding, UTI
Chronic: retrograde ejaculation, impotence,
incontinence, bladder neck stenosis / urethral
stricture
1. History & examination: IPSS score & remember DRE
2. Urinalysis: dip & MCS
3. Uroflowmetry: <10ml/sec suggests obstruction
4. Bloods: including PSA
5. Transrectal USS + biopsy: definitive diagnosis
Mild Moderate Severe
1. Reassurance
2. Lifestyle
(fluid intake)
3. Follow‑up
1. Alpha blockers (e.g. tamsulosin)
= relax smooth muscle
→ SEs: retrograde ejaculation, postural
hypotension, dizziness, headache
1. TURP = gold standard
2. Other: e.g. laser/steam
3. Prostatic artery
2. ± 5-alpha-reductase inhibitors
(e.g. finasteride)
= inhibits testosterone → DHT conversion
4. Self-catheterisation /
→ pros: prostate size
→ cons: take 6w to 6m to work
→ SEs: loss of libido, impotence
3. ± Anti-cholinergics (e.g. oxybutynin/
solifenacin)
In combination with above to treat 2° storage
LUTS
treatment
embolisation
long-term catheter
Surgery
8
NICE (2010, updated 2015) Lower urinary tract symptoms in men [CG97]
Causes
https://t.me/med1917
Accidental: RTAs, falls, crush injury, blow to lower abdomen → often concurrent
pelvic # & other intra-abdo injury
Iatrogenic: complex/emergency abdominal & pelvic surgeries
Clinical presentation
• Haematuria / dysuria / inability to void
• Suprapubic tenderness
• Abdo distension / ileus / scrotal / perineal swelling
Chapter 15: Urology 199
Types of injury:
1. Contusion: bruising
2. Intraperitoneal rupture: e.g. tear at dome
of bladder
= urine into abdo cavity → peritonitis
3. Extraperitoneal rupture: e.g. posterior
tear
= urine into surrounding tissues
Diagnosis/investigations
1. Bloods
2. Retrograde cystography or CT cystography →bladder filled with
dye&scanned
Management
1. Intraperitoneal rupture: surgical repair
2. Extraperitoneal rupture: catheter until cystography shows resolution
Urethral trauma:
Causes = penile fractures, ‘straddle injuries’
e.g. bike
→ Sx: similar to bladder trauma
→ Mx: surgery if severe, catheterise & monitor
if mild
Surgery
200 Chapter 15: Urology
External view of scrotum Deep tissues
Autonomic
Muscle layer
muscles
muscles
epididymi
Tail of epididymis
Tunica albuginea
https://t.me/med1917
Anatomy of the scrotum
Summary of scrotal lump DDx
Painless lump • Testicular tumour
• Hydrocele
• Testicular torsion
• Varicocele
Painful lump
• Epididymo‑orchitis
• Epididymal cyst
• Torted hydatid of Morgagni
• Strangulated inguinal hernia
Scrotal
septum
Raphe
Cremaster
Fig. 15.6
Into inguinal canal
Eerent
ductule
Body of
Ductus
deferens
Rete
testis
Straight
tubule
Spermatic cord
s
Cremaster
muscle
Tunica vaginalis
Head of
epididymis
Seminiferous
tubule lobules
Septa (tunica
albuginea)
Dierentials of a scrotal lump
Dartos
Plexus of
testicular
veins
Ductus
deferens
Epididymis
Spermatic
cord
Tunica vaginalis: part of
peritoneum which descended
with the testes
Fig. 15.7
Testicular
artery
nerve
Lymphatic
vessel
Testis
Varicocele Hydrocele Epididymal cyst
Pathogenesis Abnormal dilation of pampiniform
plexus veins
Causes 1. Idiopathic valve
incompetence
Most = left side as left testicular vein
is longer & enters renal vein at a right
angle
2. 2° to left renal cell carcinoma:
must exclude if new
varicocele
Abnormal collection of peritoneal fluid between
parietal & visceral layers of the tunica vaginalis
1. Communicating (patent processus vaginalis)
→ congenital
→ IAP, fluid overload, dialysis
2. Non-communicating ( fluid production
or absorption)
→ tumour or trauma
→ testicular torsion
→ epididymitis
→ idiopathic
Presentation Dragging sensation / ache
Examination ‘Bag of worms’
• Disappears when lie flat
• Positive Valsalva
Usually painless Tender
• Fluctuant
• Anterior & inferior to testicle
• Can get above mass
• Transilluminates
Management9Embolisation / surgical ligation of
veins if:
1. Painful
2. Testicular atrophy or infertility
3. Child
Congenital: usually repaired if unresolved by 2y
of age
Adults: surgical repair if symptoms
Needs Ix with USS to r/o tumour
Benign fluid‑filled sac arising from
epididymis
1. Epididymal cyst: collection of clear
fluid
2. Spermatocele: collection of milky
fluid that may contain sperm due to
blocked outlet
e.g. post‑vasectomy
• Superior & posterior to testicle
• Smooth & well‑defined
• Separate to testicle
• Transilluminates if very large
1. Reassurance
2. Ix with scrotal USS if unsure
of diagnosis
3. Surgical excision if symptomatic
Surgery
9
NICE CKS (2022) Scrotal pain and swelling; Management scenarios
Epididymo-orchitis
https://t.me/med1917
• Painful swelling of epididymis ± testicle = sudden onset (h/d)
• Dysuria, sweats, fever
• Hx of UTI/STI symptoms: discharge/dysuria/LUTS
• Unilateral scrotal swelling; tender epididymis ± testicle
• Erythematous
• Phren’s sign: pain relief with elevation of hemi-scrotum
→ Can become tense & progress to form an abscess
1. Analgesia ± scrotal support
2. Antibiotics
→ STI: doxycycline ± ceftriaxone
→ UTI: ciprofloxacin
1. Hx (sexual/LUTS)
2. Examination (abdo, penis, testicles,
DRE)
3. First catch urine: MCS & STI screen
4. USS (shows blood to epididymis)
Chapter 15: Urology 201
Organisms:
STIs (chlamydia, gonococcal)
UTIs (E. coli, pseudomonas)
Rarer causes: mumps, TB, amiodarone
Top DDx = testicular torsion
Testicular torsion
• Sudden onset pain in testes = unilateral
• ± Pain in loin or groin area
• Nausea/vomiting
• Extremely tender testes = unilateral
• May be red, hot, swollen
• Testis is higher than normal & lie is transverse
• Absent cremasteric reflex
→ Scrotal exploration, detort testis & bilateral orchidopexy
→ If testis is non-viable then orchidectomy + orchidopexy of contralateral testis
Yes
Yes
Is it separate from the testis?
Can you get above it?
No
Causes of torsion:
1. Congenital abnormality: bell clapper /
undescended testes
2. Idiopathic
High insertion of tunica vaginalis to spermatic cord
enables testicular rotation
No
Inguinoscrotal hernia
Yes Yes
Transilluminates?
Epididymal cyst
Fig. 15.8 Summary of assessing a scrotal lump.
10
NICE CKS (2020) Epididymo-orchitis; Management scenario
11
European Society of Urology (2016) Guidelines on paediatric urology
No No
Tender?
Epididymitis Varicocele
Hydrocele
Transilluminates?
Epididymo-orchitis
Torsion
Cancer
YesYes
Tender?
NoNo
Cancer
Surgery
202 Chapter 15: Urology
https://t.me/med1917
Classication of testicular tumours
PRIMARY TUMOURS
NON-SEMINOMA (~50%)
→ Mixed
→ Choriocarcinoma
→ Yolk sac tumour
→ Embryonal carcinoma
→ Teratoma
Remember testicular tumours as DDx in
younger men
Risk factors for testicular tumours:
• FHx
• Undescended testes
• White ethnicity
• HIV
GERM CELL TUMOURS (~90%)
SEMINOMAS (~50%)
= from seminiferous tubules
Peak age: late teens to 30y
Spread: haematological
Marker: hCG & AFP
SECONDARY TUMOURS: lymphoma (older men), leukaemia, metastatic
Clinical presentation
• Testicular lump = solid, fixed, irregular
• ± Ache/heaviness/dragging
• ± Secondary hydrocele
• Metastatic Sx: weight loss, back pain, dyspnoea
Investigations
NON-GERM CELL TUMOURS
→ Leydig cell
→ Sertoli cell
→ Gonadoblastoma
Peak age: 30–50y
Spread: lymphatics
Marker: hCG & LDH
Secrete testosterone /
oestrogen causing
sexual characteristics /
precocious puber ty /
ambiguous genitalia at birth
• Hx & examination
• Bloods: FBC, CRP, U&Es, LFTs
• Tumour markers: AFP, LDH & hCG
• USS: confirms Dx
• CT, CXR to rule out metastases
Management
• Orchidectomy ± chemo ± radiotherapy
Surgery
Phimosis
https://t.me/med1917
1. Physiological: normal in early childhood (most resolve by 3y of age)
2. Pathological: infection (balanitis/balanoposthitis), inflammation & scarring
(balanitis xerotica obliterans)
• Pain on intercourse/erections
• Difficulty urinating – dribbling, weak stream
• Infection
• Recurrent UTIs
Paraphimosis
Chapter 15: Urology 203
1. Analgesia
2. Swelling reduction: compression, ice
3. Manual reduction
4. ‘Puncture’ technique to drain oedema (urologists only)
5. Dorsal slit (urologists only)
Peyronie’s disease
→ Oral pentoxifyline / verapamil injections
→ Surgery if stopping sexual intercourse
Priapism
High flow: arterial flow = less painful + semi-rigid (often post trauma) → ice packs
Recurrent/stuttering: painful + often self-limiting in sickle cell disease → treated
Commonly occurs when foreskin not
replaced after:
→ catheterisation
→ erection / sexual ac tivity
Risk factors for Peyronie’s: DM, HTN,
Dupuytren’s contracture, plantar fasciitis
Risk factors for priapism: SCD, leukaemia,
trauma, cocaine, cannabis, antidepressants,
pelvic tumours
Low flow / ischaemic: venous drainage = painful + rigid → aspiration ±
1. Observation (up to 4h)
2. Intracavernosal sympathomimetic (e.g. phenylephrine) ± aspiration ± shunt
12
BMJ Best Practice (2022) Paraphimosis
13
Reynard J, et al. (2019) Oxford Handbook of Urology 4e
14
BMJ Best Practice (2021) Priapism
Surgery
204 Chapter 15: Urology
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Risk factors for carcinoma of the penis:
phimosis, HPV (16 & 18), age
Carcinoma of the penis
burning, itching, ulceration, bleeding
glansectomy or partial / total
penectomy
most commonly SCC (95%)
Urethral stricture
1. Iatrogenic: e.g. catheterisation, prostatectomy
2. Previous trauma: e.g. saddle injury / pelvic fracture
3. Infection (urethritis): e.g. gonococcal/chlamydia
4. Inflammatory conditions: lichen sclerosus
Obstructive: hesitancy, poor stream, dysuria → may present as an emergency
with acute retention
Common organisms in urethritis:
Neisseria gonorrhoeae and Chlamydia trachomatis*
*Chlamydia may present as
+ reactive arthritis + uveitis)
Reiter’s triad
(urethritis
Drugs causing impotence:
• Beta‑blockers • Diuretics
• Antipsychotics • Antidepressants
Phosphodiesterase-5 inhibitors
→ take up to 4h before sex
→ still requires arousal
→ food & alcohol reduce absorption
→ no more than 1 per day
Urethritis
• Dysuria + frequency/urgency
• Discharge/itching
• Pain during sex
Antibiotics – depending on causative organism and local guidelines
1. Hx & examination
2. First catch urine: dip & MSU
3. Urethral swab: polymorphonuclear
leukocytes on microscopy
Erectile dysfunction (impotence)
Impotence = common
1. Organic causes:
→ Smoking, alcohol, diabetes (‘big 3’ organic causes)
→ Other: hypogonadism, hyper-/hypothyroidism, spinal cord lesion, MS,
hypertension, prostate radiotherapy, drugs
2. Psychogenic causes (often still achieve morning erection):
→ Rule out organic causes first
• Full sexual & psychological history
• Bloods: U&Es, LFT, glucose, lipids,
TFT
• Hormones: testosterone, LH, FSH,
prolactin
• ± Doppler scan ± nocturnal penile
tumescence testing
Contraindications for phosphodiesterase
inhibitors
• SBP <90 • Recent stroke/angina
• Concurrent nitrates • Recent MI
Surgery
1. Treat underlying cause / lifestyle factors
2. Psychological support / counselling
3. Phosphodiesterase-5 inhibitor e.g. sildenafil (Viagra)
4. Other options: vacuum expanders, tumescence devices, intracavernosal
injection, penile prosthesis
15
NICE CKS (2020) Management of erectile dysfunction; Management scenarios
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