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CHAPTER 10 Urology
382
Testicular tumours
Key facts
• Commonest malignancy in men between the ages of 18 and 40.
• Annual incidence 6 per 100 000 males per year.
• Associated with testicular maldescent.
• Increased risk is associated with higher levels of exogenous oestrogens,
either prenatally or in childhood.
• Increased level of awareness has led to more tumours being detected
on self-examination, particularly amongst younger men.
Pathological features
• Common types are seminoma and non-seminomatous germ cell
tumours (NSGCT; previously called ‘teratoma’). Lymphoma is a rare
testicular tumour.
• Seminoma.
Peak incidence 30–40y.•
Lymphatic spread more common than haematogenous.•
Lymphatic spreads to iliac and para-aortic nodes.•
• NSGCTs.
Peak incidence 20–30y.•
Haematogeneous spread most common to lungs, brain, and liver.•
• Lymphomas. Peak incidence over 60y.
• Marsden staging (after investigations and treatment).
Stage 1, confi ned to testis.•
Stage 2, abdominal nodal spread.•
Stage 3, nodal disease outside the abdomen.•
Stage 4, extralymphatic spread.•
Clinical features
• The usual presentation is with a painless testicular mass.
• Typical features are irregular, fi rm, fi xed, and does not transilluminate.
• Palpate the abdomen for intra-abdominal masses (either para-aortic
node masses or hepatomegaly).
• Check for supraclavicular lymphadenopathy and signs of lung or
neurological disease.
Diagnosis and investigation
2 Any clinically suspicious mass requires urgent testicular ultrasound scan.
Typical features are a non-homogeneous mass with increased vascularity.
• Serum tumour markers, B-HCG and AFP. Increased levels suggest
metastatic disease in NSGCTs, but may be normal in localized or
metastatic disease; very rarely elevated in seminoma even if metastatic.
• CT scan of abdomen and chest. To assess presence of metastases.
• CT brain, bone scan. Only if clinically indicated.
TESTICULAR TUMOURS
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Treatment
• Orchidectomy is carried out at the earliest opportunity; this is
performed via an inguinal approach so that the spermatic cord can be
clamped prior to mobilization of testis.
• Seminoma is radiosensitive and even widespread local disease
responds well to radiotherapy.
Stage• 1. May be treated by orchidectomy only, orchidectomy +
prophylactic iliac and para-aortic radiotherapy, or orchidectomy +
prophylactic chemotherapy.
Stages 2/3/4• . Orchidectomy + radiotherapy to involved node
groups 9 chemotherapy.
Visceral metastases are treated with a combination of •
chemotherapy and radiotherapy.
• NSGCT is chemosensitive and even widespread metastatic disease
responds well.
Stage 1• . Orchidectomy.
Stages 2/3/4• . Orchidectomy + chemotherapy; if lymphadenopathy is
still present following chemotherapy, a retroperitoneal lymph node
dissection is performed.
Prognosis
• Cure rates >95% for stage 1 tumours.
• Metastatic disease also has excellent long-time survival rates with
combination therapy.
383
CHAPTER 10 Urology
384384
Haematuria
Causes and features
May be microscopic or macroscopic.
• UTI. Commonest cause; usually associated with LUTS, particularly
cystitis.
• Renal stones. Often associated with pain (renal colic).
• Malignancy (TCT, renal adenocarcinoma, prostate adenocarcinoma).
Most likely to be macroscopic, often with few other acute symptoms.
• Post-interventional. For example, post-TURP, post-cystoscopy, post-
catheterization.
• Renal disease. For example, glomerulonephritis, vasculitis; usually
causes microscopic haematuria, is often asymptomatic, and rarely
presents as an emergency.
Complications
• Suprapubic colicky pain or acute retention of urine suggests clots in
the bladder/urethra.
• Cardiovascular collapse is rare.
Emergency management
Resuscitation
• Establish large calibre IV access if the bleed is large; give crystalloid
fl uid up to 1000mL if tachycardic or hypotensive.
• Do not catheterize without seeking senior advice if there is any
suggestion of lower urinary tract pathology or post-interventional
bleeding.
• Irrigation (‘3-way’) catheters may be used to relieve acute symptoms
of clot colic or clot retention, but should be placed by experienced
staff.
• Send blood for FBC (Hb, WCC), U&E (Na, K), group and save,
clotting.
Establish a diagnosis
• Full clinical examination. Particularly check the prostate on PR exam.
• Ultrasound kidney. To identify renal tumours, cysts.
• Cystoscopy (usually rigid, may be fl exible). To identify bladder tumours.
• CT scan abdomen. If renal tumour is suspected.
Early treatment
• Ensure all clotting abnormalities are corrected.
• Ensure fl uid balance is correct; promote an active diuresis to prevent
clot formation and retention.
• Transfuse blood only if Hb <8g/dL or the patient is symptomatic or
high risk.
• Start antibiotics according to local protocol if infection is suspected
(before cultures are available).
HAEMATURIA
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Defi nitive management
Transitional cell tumours Transurethral resection will control symptoms,
establish a diagnosis, and start treatment (see b p. 382).
Renal stones (see b p. 358)
• May pass spontaneously.
• May need endoscopic removal, lithotripsy, or percutaneous treatment.
Post-interventional Flexible cystoscopy may be required.
385385
CHAPTER 10 Urology
386386
Acute urinary retention (AUR)
Causes and features
Defi ned as a painful inability to pass urine.
Local causes
• Prostatic enlargement (BPH or carcinoma) (see b p. 362). Often
acute-on-chronic retention.
• Post-urological surgery, e.g. post-TURP, clot impaction.
• Bladder or urethral stone impaction.
• Pressure on bladder, e.g. late pregnancy, faecal impaction.
• UTI.
General causes
• Pharmacological, for example:
Anticholinergic side effects of many drugs.•
Anaesthetic drugs.•
Alcohol intoxication.•
A• -sympatheticomimetics.
• Post-non-urological surgery:
Precipitated by recent catheterization.•
Abdominal surgery with lower abdominal pain.•
Epidural or spinal anaesthesia.•
• Loss of normal neurological control:
Spinal injury (trauma, ‘slipped disc’, neurological disease).•
Epidural/spinal anaesthesia.•
Symptoms
• Suprapubic pain, inability to pass urine despite desire.
• May dribble urine in small volumes, especially if there is underlying
chronic retention.
• Palpable/percussible bladder strongly suggests pre-existing chronic
retention/lower urinary tract disease.
Signs
• Prostatic enlargement on PR examination.
• Check for signs of neurological disease.
Emergency management
Resuscitation
• Give analgesia (e.g. morphine 5–10mg IV); it will also help relaxation
and may aid spontaneous micturition.
• A warm bath may aid micturition in drug-induced retention.
• Catheterize if retention persists. 2 Seek senior advice before starting
if there are concerns about local pathology as a cause or if there is a
history of previous surgical instrumentation of the urethra.
• Suprapubic catheterization may be required for known or suspected
urethral disease or failed urethral catheterization (see b p. 210).
• Document initial urine volume passed after catheter inserted; large
volumes suggest underlying chronic retention.
ACUTE URINARY RETENTION (AUR)
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• Send urine for M,C,&S.
• Send blood for FBC (Hb, WCC), U&E (Na, K), Cr.
Establish a diagnosis
• Check medications, especially recent changes.
• Cystoscopy may be required.
• Review full clinical examination, including neurological fi ndings and
rectal examination.
Early treatment
• Monitor renal function, especially if there is underlying chronic
retention; renal function may deteriorate even after relief of the
obstruction.
• Monitor fl uid balance in fi rst 48h if there is associated chronic
retention; a secondary diuresis may occur.
• Start antibiotics according to local protocols if there is evidence
of a UTI.
Defi nitive management
Prostatic disease (see b p. 362)
• TURP may be required.
• A-blocker may enable successful trial of voiding.
387387
CHAPTER 10 Urology
388388
Acute testicular pain
Causes and features
This is an acute emergency in men of childbearing age. Torsion of the
testicle must be dealt with immediately to preserve testicular function. It
is the commonest cause for referral for acute testicular pain.
Torsion of the testicle
Key facts
• Occurs due to anatomical variants in testicular anatomy, e.g. ‘bell
clapper’ testicle with pronounced meso-orchium allowing rotation
within the tunica vaginalis.
• Peak age of incidence 12–18y.
• Torsion initially causes venous obstruction, but with prolonged
increased venous pressure, arterial compression occurs and the
testicle rapidly develops irreversible ischaemia and necrosis.
• Testicular salvage depends on the degree of torsion and time spent
torted. Speed of presentation, diagnosis, and treatment are all
important. Torsion greater than 360* lasting longer than 24h results in
near universal complete or severe atrophy.
• Spermatogenic cells are more susceptible to ischaemia than Leydig
cells. Subfertility may occur even if the testicle is macroscopically
normal after treatment.
Features
• Sudden onset of moderate to severe, constant, unilateral scrotal pain,
often with nausea, vomiting, and abdominal pain.
• May have been preceding episodes of intermittent pain that suddenly
resolved.
• The testis is globally tender, high in the scrotum, may have a transverse
axis, and be slightly enlarged. If it is infarcted, scrotal wall oedema and
tenderness may be present. Absence of ipsilateral cremasteric refl ex is
the most reliable sign.
Torsion of the testicular appendages
• Occurs in testicular appendix ‘hydatid of Morgagni’ or epididymal
appendages (e.g. cysts, ductal remnants).
• Similar features and symptoms to testicular torsion.
• The ‘blue dot sign’ is said to be pathognomonic when present.
• The testis and epididymis may be non-tender and the cremasteric
refl ex should be preserved.
Acute epididymo-orchitis
• Peak incidences vary according to cause, ages 35y and >55y.
• Common organisms include Chlamydia trachomatis, Neisseria
gonorrhoea in the young (sexually-transmitted infections (STI)).
• Escherichia coli and Proteus occur in chronic bladder outfl ow
obstruction or urinary tract instrumentation.
• One-third of male adolescents with mumps develop orchitis, which is
unilateral in 80%; a third of these testes atrophy.
ACUTE TESTICULAR PAIN
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Features
• Gradual onset of pain (hours or days).
• Dysuria, urethral discharge, and pyrexia are common.
• Tenderness and induration are localized to the epididymis and
spermatic cord in epididymitis.
• Cremasteric refl ex is preserved.
• Prehn’s sign (relief of pain with scrotal elevation).
Idiopathic scrotal oedema
• Often less painful and tender than appears.
• Swelling is mostly cutaneous and normal size and texture testicle may
be palpable with care.
Acute inguinal lymphadenopathy
• May occur secondary to lower limb, buttock, or perineal infections.
• Rarely part of systemic infection of lymphatic disorder.
Emergency management
Resuscitation Give analgesia (e.g. morphine 5–10mg IV).
Establish a diagnosis
3 Immediate surgical exploration is indicated for all cases where
the diagnosis of torsion is considered possible and the history is short (i.e.
testicular viability is still at issue).
• Testicular colour duplex ultrasound. May be used if immediately
available or where symptoms have been present for days and testicular
viability is unlikely if torted.
• Send MSU, urethral swab, chlamydia serology if suspected infection.
Defi nitive management
If a torted testicle is found at surgery:
• A viable testicle is detorted and fi xed.
• A clearly non-viable testicle is excised.
• The opposite testicle is fi xed (orchidopexy) to prevent the opposite
side torting in future.
Torsion of testicular or epididymal appendage Excise appendage.
Epididymo-orchitis
• Suspected STI, e.g. ceftriaxone 250mg IM single dose, doxycycline
100mg PO bd 7 days.
• Suspected UTI-related—ciprofl oxacin 500mg PO bd 10–14 days.
• Abscess formation may require drainage or orchidectomy.
• Treatment of acute viral orchitis is symptomatic.
389389
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Chapter 11
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Colorectal surgery
Ulcerative colitis 392
Crohn’s disease 394
Other forms of colitis 396
Colorectal polyps 398
Colorectal cancer 400
Restorative pelvic surgery 402
Minimally-invasive colorectal surgery 403
Diverticular disease of the colon 404
Rectal prolapse 406
Pilonidal sinus disease 408
Fistula-in-ano 410
Haemorrhoids 412
Acute anorectal pain 414
Acute rectal bleeding 416
Acute severe colitis 418
Post-operative anastomotic leakage 420
391
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