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CHAPTER13 Renal medicine and urology
Prostatecancer
Prostate cancer is the 6th most common cancer worldwide. It is the most
common cancer aecting men making up 26% of all male cancer diagnoses
and ~10,000 men/ y die from the disease in the UK. 1 in 6 men have clinical
prostate cancer in their lifetimes and the incidence is rising.
Classication
Non- metastatic prostate cancer Can be divided into:
• Clinically localized disease— cancer thought after clinical examination to
be conned to the prostate gland
• Locally advanced disease— cancer that has spread outside the capsule of
the prostate gland but has not yet spread to other organs
Metastatic prostate cancer Cancer that has spread outside the prostate
gland to local, regional, or systemic LNs, seminal vesicles, or other body
organs (e.g. bone, liver, brain).
Riskfactors
• Age Uncommon <50y; 85% are diagnosed aged >65y
• Genetic i incidence if rst- degree relative aected
• Racial Incidence varies according to location in the world and ethnic
group. Highest rates are in men of black ethnic group in the USA—
lowest in Chinese men
• Dietary Links are proposed between prostate cancer and low intake of
fruit (particularly tomatoes) and high intake of fat, meat and Ca
Screening There is currently no screening programme in the UK.
Problems with screening:
• Incidental postmortem evidence of prostate cancer is high (875% men
>75y), very few become clinically evident, so many more men would
be found with prostate cancer by screening than would die or have
symptoms from it
• Natural history of prostate cancer is not understood— there is no
means to detect which ‘early’ cancers become more widespread
• Inadequate screening tests
• It is not clear if early treatment enhances life expectancy
• Peak incidence of morbidity and mortality is in old age (75– 79y) so
potential years of life saved by screening are small
Screeningtests
• Prostate- specic antigen (PSA) E p. 433
• Digital rectal examination (DRE) Operator- dependent, fails to detect
early prostate cancers and lacks specicity. Annual screening in the USA
and Germany has not d mortality
• Transrectal ultrasound (TRUS) Too expensive
The most eective screening regime involves rectal examination and PSA
testing followed by TRUS for suspicious lesions. Optimal screening interval
is unknown but serial screening does i detection.
Symptoms andsigns
Early cancer Symptomless. Usually detected following an incidental nding
of i PSA. Hard nodule sometimes felt in prostate on DRE.
2+
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PROSTATECANCER
Localdisease
• Prostatism
• Urinary retention
• Haematuria
• Lower extremity oedema
• On rectal examination, the prostate is hard,
non- tender, and sulci lose denition
Metastaticdisease
• Malaise
• Weight loss
• Bone pain
• Pathological fractures
Investigation
N
A digital rectal examination and a PSA test (after counsel-
• Spinal cord compression
• Ureteric obstruction may cause renal
failure
• Signs depend on site of metastases
ling) are recommended for patients with any of the following unexplained
symptoms:
• Erectile dysfunction
• Haematuria
• Lower back pain
• Any lower urinary tract symptoms
• Weight loss, especially in the elderly
• Bone pain
0 Exclude UTI before PSA testing and postpone digital rectal examination
until after the PSA test is done.
Urgent referral
N
• Rectal examination— hard, irregular prostate typical of prostate
cancer. PSA result should accompany the referral
• PSA levels are greater than the age- specic reference range
0 Consider discussion with specialist and patient ± carer before referral
for very elderly patients and those compromised by other co- morbidities.
0 Referral is not needed if the prostate is simply enlarged and the PSA is
in the age- specic reference range.
Further information forGPs
NICE (2015, updated 2017)Suspected cancer:recognition and referral.
Mwww.nice.org.uk/ guidance/ ng12
NICE (2019) Prostate cancer:diagnosis and management. M https://
www.nice.org.uk/ guidance/ ng131
Information forpatients
Cancer Research UK F 0808 800 4040 M www.cancerresearchuk.org
Macmillan Cancer Support F 0808 808 0000 M www.macmillan.org.uk
NHS Choices M www.nhs.uk/ conditions/ prostate- cancer/ psa- testing/
Prostate Cancer UK F 0800 074 8383 M https:// prostatecanceruk.org/
The National Federation of Prostate Cancer Support Groups F 0800
035 5302 M http:// tackleprostate.org
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CHAPTER13 Renal medicine and urology
Treatment ofprostatecancer
Symptomless local disease Treatment is controversial. There are 2
arguments:
Benets of treatment are
outweighed by risks
>50% of ♂ >50y who die from other causes are found postmortem to
have prostate cancer— prostate cancer kills only a small minority of men
who have it. The personal and economic cost of treating men whose cancer
would never have caused them any problems must be considered.
Options
• Watchful waiting or active surveillance Monitor with PSA and regular
rectal examination. i in PSA or size of nodule triggers active treatment.
Alarge UK trial published in 2016 has found active monitoring is as
eective as surgery and radiotherapy, in terms of survival at 10years
with less side eects. Progression rates are higher in patients with
poorly dierentiated cancer. Some men nd the uncertainty of waiting
dicult to cope with
• Radical prostatectomy Has potential for cure, but in the age group
most aected by prostate cancer, mortality is 1.4%. Other common
complications:impotence (50%), incontinence (25%)
• Radiotherapy May not be eective— persistent cancer is found in 30%
on biopsy. Brachytherapy (radioactive treatment in implanted seeds or
wires) has proven ecacy in early prostate cancer
• Hormone treatment No convincing evidence that this gives survival
benet in early disease
• Others Minimally invasive treatments, e.g. cryo- or microwave therapy
Symptomatic disease 30% 5y survival. Hormone manipulation is the
mainstay of treatment and gives 80% d in bone pain, PSA, or both and a
lower incidence of serious complications (e.g. spinal cord compression) if
treatment starts at the time of diagnosis. Options:
Luteinizing hormone- releasing hormone (LHRH) analogues e.g. goserelin— sc
injection every 4– 12wk (depending on the preparation used). Testosterone
levels d to levels of castrated men in <2mo. Side eects:impotence, hot
ushes, gynaecomastia, local bruising and infection around injection site.
When starting LHRH analogues, LH level initially i which can cause increased tumour activity or ‘are’. Counteracted by prescription of antiandrogens (e.g. utamide) for a few days before administration of the rst
dose of LHRH and concurrently for 3wk. Response in most patients lasts
for 12– 18mo.
Anti- androgens e.g. cyproterone acetate, utamide, bicalutamide. Do not
suppress androgen production completely. Used to prevent side eects due
to testosterone are during initiation of LHRH analogues, as monotherapy
(e.g. bicalutamide 150mg od), and in combination with LHRH analogues to
produce maximum androgen blockade.
Surgical castration d testosterone secretion permanently without the need
for medication. However, rarely used.
Or Aggressive treatment before spread is
the only way to ensure cure.
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TREATMENT OFPROSTATECANCER
Bony metastases In addition to hormone therapy, local radiotherapy
and corticosteroids are used for bone pain. Radioactive strontium d the
number of new sites of bone pain developed. Mean survival <5y.
Hormone- resistant disease No agreed treatment. Involve the
multidisciplinary team including urology, oncology, and palliative care.
Dexamethasone 0.5mg daily or docetaxel may be helpful.
Factors aecting prognosis of prostate cancer
Stage
Tumour Lymph nodes? Metastases?
T1 Impalpable N0 No M0 No spread
T2 Tumour completely
within the prostate gland
T3 Tumour has breached the
capsule of the prostate
T4 Spread within the pelvis
e.g. to bladder or bowel
N1 1 +ve LN <2cm
diameter
N2 >1 +ve LN or 1 LN
of 2– 5cm diameter
N3 Any +ve LN >5cm
diameter
outside the pelvis
M1 Spread outside
the pelvis
Gleason score Histological grade. Cells are graded 1– 5 the less dierentiated they are. The 2 areas of the biopsy with the highest grade cells
are added together. Low- grade tumours likely to grow slowly have low
scores (2– 4); high- grade tumours have high scores (7– 10).
Age Older patients with low- grade tumours are likely to die from something other than their prostate cancer.
PSA
• PSA >40:high chance of nodal or metastatic spread
• PSA >100:metastatic spread is very likely
Prognosis 5y survival rates for tumour stage:
• 1 or 2— tumour conned within the prostate (65– 98%)
• 3— tumour has breached the capsule of the prostate (60%)
• 4— spread to LNs, within the pelvis, or elsewhere (20– 30%)
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Further information
Hamdy FC, etal. (2016). 10- Year outcomes after monitoring, surgery, or
radiotherapy for localized prostate cancer. NEJM 371:415– 24.
NICE (2019) Prostate cancer:diagnosis and management. M https://
www.nice.org.uk/ guidance/ ng131
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CHAPTER13 Renal medicine and urology
Conditions ofthepenis
Posterior urethral valves Folds of mucosa inhibit or block
passage of urine causing urethral, bladder, ureter, and renal
pelvis dilatation.
Presentation Usually detected on antenatal USS. Can present in
neonates with urinary retention or dribbling urine + distended bladder,
UTI or uraemia, or later in childhood with recurrent UTI or incontinence.
Investigation and management MCUG conrms diagnosis. In all cases refer
to urology for surgical disruption of the valves.
Hypospadias 1 in 400 male births. The urethral meatus opens on the
ventral side of the penis. There is often hooding of the foreskin and ventral exion of the penis. Refer to urology. Treated with corrective surgery,
ideally preschool.
Non- retractile foreskin Usually noted by parents. May be history of
recurrent balanitis. Examination:foreskin adherent.
Management Age <4y— do nothing unless recurrent balanitis. If >4y
and/ or recurrent balanitis, consider treatment with topical steroids (e.g.
betamethasone 0.1% od) for 3– 4mo. If ineective, refer to paediatric surgery for circumcision.
Phimosis Foreskin obstructs urine ow. Common in small children.
Time usually obviates the need for circumcision. Treat as for nonretractile foreskin if recurrent balanitis.
Peyronie’s disease Hard lumps in the shaft of the penis. Unknown
cause. 4% ♂ >40y. 1 in 3 have pain/ bending of the penis when erect.
Associated with erectile dysfunction (E p. 754). 5% have Dupuytren’s
contracture.
Management Reassurance usually suces. No proven medical treatments.
Refer to urology for surgery if pain or severe bending on erection so that
intercourse is not possible.
Paraphimosis Foreskin is retracted then (because of oedema) unable to
be replaced. Commonly occurs in catheterized patients when the catheter
is changed.
Management Try to replace foreskin using ice packs (d swelling) and lubri-
cation (e.g. K- Y® Jelly). If unable to replace the foreskin, admit for surgery.
Balanitis Acute inammation of glans and foreskin. Common
organisms— staphylococci, streptococci, coliforms, Candida. Can occur at
any age. Most common in young boys when associated with non- retractile
foreskin/ phimosis. In elderly patients consider DM.
Management Oral antibiotics (e.g. ucloxacillin) or topical antifungals (e.g.
clotrimazole). If recurrent or secondary to phimosis consider referral for
circumcision.
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CONDITIONS OFTHEPENIS
Balanitis xerotica et obliterans Chronic brosing condition of the foreskin
which may become adherent to the glans. Treatment is with topical steroid
creams, e.g. betamethasone 0.1%. Consider referral for circumcision.
Trauma tothe foreskin Torn frenulum— seen after poorly lubricated
intercourse or if caught in a zip. No treatment required. If recurrent, consider referral for circumcision.
Erectile dysfunction E p. 754
Priapism Persistent painful erection not related to sexual desire.
Cause Medication for erectile dysfunction, idiopathic, leukaemia, sickle cell
disease, or pelvic tumour.
Management Ask the patient to climb stairs (arterial ‘steal’ phenomenon),
apply ice packs. If unsuccessful, refer to A&E for aspiration of corpora.
Rarely surgery is needed.
Erythroplasia of Queyrat Premalignant condition of glans. Moist
velvety- looking patches. Refer to urology. Treatment is surgical.
Carcinoma ofthe penis Squamous cell carcinoma (95%) or malignant
melanoma. Usually elderly men. Rare in the UK.
ManagementN Refer urgently patients with symptoms or signs of penile
cancer. These include:
• Progressive ulceration in the glans, prepuce, or skin of the penile shaft
• Mass in the glans, prepuce, or skin of the penile shaft
0 Lumps within the corpora cavernosa can indicate Peyronie’s disease,
which does not require urgent referral.
Penile discharge Associated with urethritis, e.g. due to chlamydia or
gonorrhoea. Refer to GUM clinic.
Further information
BASHH (2008) Management of balanoposthitis. M https:// www.
bashhguidelines.org/ media/ 1077/ 2062.pdf
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
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CHAPTER13 Renal medicine and urology
Testiculardisease
Testicular pain Treat the cause:
• Epididymo- orchitis
• Torsion of the testis
• Trauma and haematoma formation
Torsion ofthe testis Peak age 15– 30y. Presents with sudden- onset,
severe scrotal pain. May be associated with right iliac fossa pain, nausea,
and vomiting. Examination:tender, hard testis riding higher than contralat-
eral testis. Admit urgently to surgical/ urology team
Torsion ofthe hydatid ofMorgagni Small embryological remnant at
the upper pole of the testis. Presents similarly to torsion of the testis. Refer
as an emergency to exclude torsion of the testis.
Epididymo- orchitis Inammation of the testis and epididymis due to
infection. May occur at any age. The most common viral cause is mumps.
The most common bacterial causes are Chlamydia or gonococci (<35y) and
coliforms (>35y). Chronic infection with TB or syphilis is rare.
Presentation Acute- onset pain in testis; swelling and tenderness of testis/
epididymis; fever ± rigors; may be urethritis, dysuria and/ or i frequency.
Management May be dicult to distinguish from torsion of the testis. If in
doubt, admit for urology/ surgical opinion. Otherwise investigate and treat
for the underlying cause.
Testicular lumps and swellings Figure 13.3
Hydrocele Collection of uid in tunica vaginalis. Occurs at any age.
• 1° hydrocele— no predisposing cause in scrotum
• 2° hydrocele— reaction to pathology in testis or covering (infection,
tumour, torsion). In adults presenting with hydrocele, always consider
impalpable tumour beneath
Presentation Swelling in the scrotum. The examiner should be able to get
above swelling. Smooth surface, transilluminates, testis is within the swelling
and not palpable separately.
Management Investigation is not required in children; refer adults for USS if
testis is not palpable. Options for adults:
• Conservative management— reassurance— small hydroceles
• Tapping— may be suitable for large hydroceles where surgery is
inappropriate— 2° infection and recurrence are common
• Surgery— refer to urologist
Hydroceles in children are usually congenital. May be unilateral
or bilateral. Most resolve spontaneously in the rst year of life.
Refer to urology if persists >1y.
• Varicocele
• Testicular tumour (rarely
painful)
Hydrocele ofthe cord Arises in part of the processus vaginalis in the
spermatic cord above the testis. Rounded lump which slips up and down the
inguinal canal. No action needed.
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TESTICULARDISEASE
Can you get above the mass?
YES
Is it cystic?
YES
Is it separate from the testis?
YES
Dierential diagnosis:
• Epididymal cyst
• Spermatocele
Dierential diagnosis:
• Hydrocele (transilluminates)
• Haematocele
Referral guidelines
N
NO
Dierential diagnosis:
• Inguinal hernia extending into the scrotum
• Varicocele
• Hydrocele of the spermatic cord
NO—the testis lies
within the swelling
Any acutely
painful scrotum
should be treated
as a torsion of
the testis until
proven otherwise
NO—solid mass
Is it separate from the testis?
YES NO
Dierential diagnosis:
• Acute or chronic
epididymitis
• Torsion of hydatid of
Morgagni
Dierential diagnosis:
• Tumour
• Torsion
• Orchitis
• Gumma
• Refer urgently patients with a swelling or mass in the body of
the testis
• Consider an urgent USS in men with a scrotal mass that does not
transilluminate and/ or when the body of the testis cannot be
distinguished
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Figure13.3 Diagnosis of testicular lumps
Further information
BASHH (2010) Management of epididymo- orchitis. M https:// www.
bashhguidelines.org/ media/ 1062/ 3546.pdf
NICE (2015, updated 2017)Suspected cancer:recognition and referral. M
www.nice.org.uk/ guidance/ ng12
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CHAPTER13 Renal medicine and urology
Haematocele Damage to the testis (e.g. due to a direct blow, vasec-
tomy), can result in the testis rupturing and the tunica vaginalis lling with
blood. Refer as an emergency for urological assessment.
Varicocele Collection of varicose veins in the pampiniform plexus of the
cord and scrotum. Can be 2° to obstruction of the testicular veins in the abdomen. L > R.Associated with infertility (thought due to i temperature of
testis). Presents with a dull ache in the testis especially at the end of the day
or after exercise. Usually visible when the patient is standing. No treatment
is needed— reassure. Occasionally surgery or radiological embolization may
help if symptoms are severe.
Epididymal cyst Common and often multiple. Found in middle- aged/
elderly men. Usually presents when the patient nds a painless lump.
• Examination Smooth- walled cysts in epididymis (palpable above and
behind testis), often bilateral
• Investigation If unsure of diagnosis refer for USS
• Management Reassurance. Refer to urology if painful
Spermatocele Cyst containing sperm. Typically situated in the head of
the epididymis— more rarely in the spermatic cord. Clinically presents in
the same way as epididymal cyst. Management is the same.
Testicular gumma E p. 725
Benign testicular tumours Rare (<2% tumours). Sertoli cell aden-
omas; Leydig cell adenomas. Produce sex hormones and cause feminization/ masculinization respectively. Refer.
Testicular cancer Most common malignancy in men age 20– 34y.
Devastating disease as suerers tend to be young and t and do not expect
to be ill. Screening is not eective. Education to ensure men check their
testes for lumps regularly and present early is preferable.
Risk factors Undescended testes— bilateral undescended testis l 10× i
risk; past history of testicular cancer— 4% risk 2nd cancer.
Presentation Painless lump in testis; occasionally testicular pain or hydrocele; may present with metastases— back pain/ dyspnoea.
Management Testicular lumps are tumours until proven otherwise. Refer
for urgent urological opinion. USS can help diagnosis but do not delay referral. Denitive diagnosis is only made at biopsy. Specialist treatment depends on tumour type and extent (Table 13.10). Sperm banking is routinely
oered in case of d fertility due to treatment.
0 Children conceived by men treated for testicular cancer are not at i risk
of congenital abnormality.
Empty scrotum If the scrotum has never contained a testis, it is
hypoplastic. If the scrotum has contained a testis in the past, it is normally
developed but empty.
Causes ofan empty scrotum Undescended or retractile testis; surgical removal, e.g. for torsion, trauma, or tumour; testicular atrophy (e.g. due to
mumps or trauma); ambiguous genitalia; testicular agenesis— diagnosis of
exclusion.
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TESTICULARDISEASE
Table13.10 Types and features oftesticular cancer
Seminoma (60%) Teratoma
Typical age 30– 40y <30y
Tumour
markers
Nature of
tumour
Growth speed Slow growing Fast growing— can ×2 in size in days
Stage of
presentation
Treatment Treated with inguinal
Survival 98% 5y survival for stage 1
None β- HCG
Solid Solid/ cystic components.
90% stage 1 (tumour conned
to testis)
orchidectomy + radiotherapy
Relapses are treated with
chemotherapy.
More advanced disease
is treated with radio- or
chemotherapy
disease. Overall >85% 5y
survival
AFP
LDH— correlates with volume of
metastatic disease
40% occur within seminomas. Mixed
tumours are treated like teratomas
60% stage 1 (tumour conned to
testis)
Treatment of stage 1 disease is
with inguinal orchidectomy and
surveillance of tumour markers. 25%
relapse in <18mo
Treatment of relapses and metastatic
disease is with chemotherapy
Prognosis depends on stage and
degree of dierentiation
Carcinoma of the scrotal skin SCC or melanoma. Uncommon
<50y. Painless lump/ ulcer of the scrotal skin ± enlarged inguinal LNs. If
suspected, refer urgently to urology or dermatology.
Fournier’s gangrene Necrotizing fasciitis of the scrotal skin and/ or
penis. Patients are usually elderly and often have a hydrocoele. Starts as a
black spot and spreads rapidly. Early diagnosis is critical to survival so, if suspected admit as an acute urological emergency. Treatment is with surgical
debridement and IV antibiotics.
Undescended testis Aects 2– 3% of ♂ neonates— but
most descend during the 1st year. Refer those that do not for
surgical descent/ xation to avoid i risk of malignancy and later
infertility.
Retractile testis Usually young boys with active cremasteric
reex. No treatment needed.
Examination Scrotum is usually well developed. Try to nd the testis and
milk it down into scrotum. May be found anywhere from the scrotum to
the internal inguinal ring. If not found or you are unable to bring the testis
down into the scrotum assume it is undescended.
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Information and support forpatients withtesticular cancer
Cancer Research UK F 0808 800 4040 M www.cancerresearchuk.org
Macmillan Cancer Support F 0808 808 0000 M www.macmillan.org.uk
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