Phase 2

1

Urology

• Phase 2
• Kate McDonald and Rebecca Marlor

The Peer Teaching Society is not liable for false
or misleading information
2
Aims

• To understand the diagnosis, investigation and
  management of some common urological conditions

The Peer Teaching Society is not liable for false
or misleading information
3
Introduction

• Benign prostatic obstruction
• Prostate Cancer
• Urinary tract infections (UTIs)
• Acute kidney injury (AKI)
• Chronic kidney disease (CKD)

The Peer Teaching Society is not liable for false
or misleading information
4
Benign Prostatic Hyperplasia

• Definitions
• BPH Benign prostatic hyperplasia (histological)
• BPE Benign prostatic enlargement (DRE)
• BPO Benign prostatic obstruction

The Peer Teaching Society is not liable for false
or misleading information
5
Benign Prostatic Hyperplasia

• Common in elderly men (60-70 years old)
• Usually asymptomatic until late on
• Mechanism poorly understood
• Expansion of the central zone, effects both the
  glandular and connective tissue

The Peer Teaching Society is not liable for false
or misleading information
6
Benign Prostatic Obstruction
Symptoms Signs
Storage symptoms Frequency Smooth enlarged prostate on DRE, Palpable median sulcus
Urgency
Nocturia
Overflow incontinence
Voiding Terminal dribbling
Difficult initiation
Poor flow/straining
Hesitancy
Overflow incontinence
Inadequate emptying of bladder
The Peer Teaching Society is not liable for false
or misleading information
7
Benign Prostatic Obstruction

• Differential Diagnosis
• Prostate Cancer
• Urinary bladder Cancer
• Bladder stone
• Urethral stricture
• Prostatitis
• Detrusor overactivity

The Peer Teaching Society is not liable for false
or misleading information
8
Benign Prostatic Obstruction

• Investigations
• ? PSA
• Symptom questionnaire (IPSS)
• Urinalysis
• UEs (Creatinine), FBCs, LFTs

A man presents with LUTS and you think it is
probable he has BPH, what investigations would
you want to arrange?
The Peer Teaching Society is not liable for false
or misleading information
9
Benign Prostatic Obstruction

• Management
• Conservative
• Watchful waiting
• Medical
• Alpha adrenergic antagonists (Doxazosin/Tamsulosin
  )
• 5-alpha reductase inhibitors (Finasteride)
• Surgical
• TURP/prostatectomy

The Peer Teaching Society is not liable for false
or misleading information
10
Acute Urinary Retention!!
67 year old gentleman presents with 24/24
inability to pass urine (anuria) and 12/24
supra-pubic abdominal pain? You suspect he has
acute urinary retention? What are the different
causes?

• Causes
• Benign Prostatic Hyperplasia
• Prostate cancer
• Prostatitis
• Neurological (disc rupture/metastasis)
• Urethral pathology
• Pelvic mass lesions/constipation
• Anticholinergic drugs

The Peer Teaching Society is not liable for false
or misleading information
11
Acute Urinary Retention!!

• EMERGENCY!
• Check for neurological deficits!!
• Dont measure PSA
• Catheterization
• Urine output
• ? Surgery

Symptoms Signs
SUDDEN Inability to pass urine Bladder palpable and distended
Supra-pubic pain Tender supra-pubicly
Enlarged prostate
Agitation
The Peer Teaching Society is not liable for false
or misleading information
12
Chronic Urinary Retention!!

• Incomplete bladder emptying
• Often asymptomatic, but can get LUTS overflow
  incontinence, NOT painful!
• Acute on chronic retention
• Hydronephrosis bladder hypertrophy -gt chronic
  renal failure

What serious complications do we worry about?
The Peer Teaching Society is not liable for false
or misleading information
13
Chronic Urinary Retention!!

• Investigations
• Monitor UEs and urinary proteins
• Upper UT imaging
• Management
• Intermittent catheterisation
• ? Surgery

The Peer Teaching Society is not liable for false
or misleading information
14
Prostate Cancer

• Most common male cancer
• Hormonally driven - dihydrogentestosterone
• Adenocarcinoma, peripheral, ?multi-focal
• Localized
• Locally advanced
• Metastatic

The Peer Teaching Society is not liable for false
or misleading information
15
(No Transcript)
16
Prostate Cancer
Symptoms
? LUTS
Acute urinary retention
Back/perineal or testicular pain
Haematuria
Stress incontinence
? Constipation, leg swelling
Weight loss
Anorexia
Fatigue
?Bone pain pathological fractures
What would you expect to find on DRE?
DRE Asymmetrical nodular enlargement of the
prostate Hard and Craggy Loss of median sulcus
The Peer Teaching Society is not liable for false
or misleading information
17
Prostate Cancer

• Investigations
• PSA
• TRUS /- biopsy
• ?MRI/CT scan
• ? Isototope bone scan
• Gleason Grading and Clinical Staging

The Peer Teaching Society is not liable for false
or misleading information
18
Prostate Cancer
The Peer Teaching Society is not liable for false
or misleading information
19
Prostate Cancer

• Management
• Localised Prostate Cancer
• Watch and wait
• Active follow up
• Radical prostatectomy
• Radiotherapy (brachytherapy/external beam)
• Focal therapy

The Peer Teaching Society is not liable for false
or misleading information
20
Prostate Cancer

• Management
• Locally advanced Prostate Cancer
• Neoadjuvent hormonal therapy
• LHRH Agonists (Goserelin injections) hot
  flushes, lethargy, loss of sexual function
• Anti-Androgens gynaecomastia, nipple tenderness,
  sometimes retain sexual function
• Radiotherapy

The Peer Teaching Society is not liable for false
or misleading information
21
Prostate Cancer

• Management
• Metastatic Prostate Cancer
• Hormonal therapies
• Chemotherapy/radiotherapy to improve symptoms and
  disease control
• Bisphosphonates

The Peer Teaching Society is not liable for false
or misleading information
22
AKI

• Acute Renal Failure
• Abrupt onset (lt48 hours) kidney impairment
• Sustained (gt24 hours) reduction in GFR, UO or both

The Peer Teaching Society is not liable for false
or misleading information
23
eGFR

• Estimated Glomerular Filtration Rate
• Based on serum creatinine, age, sex and race
• Calculated using complicated mathematical
  equationModification of Diet in Renal Disease
  (MDRD)
• Normal lt 100 ml/min/1.73m2
• Independent risk factor for CVS disease

The Peer Teaching Society is not liable for false
or misleading information
24
AKI Classification

• NICE Kidney Disease Improving Global
  Outcome score (KDIGO)
• Officially (any of)
• Rise in serum creatinine gt 26µmol/L in 48 hours
• gt50 rise in serum creatinine within 7 days
• Fall in UO (lt0.5ml/kg/hr) for gt6 hours (adults)
  or gt8 hours (paeds)
• gt25 fall in eGFR in children and young people
  within 7 days

The Peer Teaching Society is not liable for false
or misleading information
25
AKIN Classification
Stage Serum Creatinine UO criteria
1 Increase gt 26µmol/L within 48 hours or increase gt 1.5-1.9X reference creatinine lt0.5mL/kg/hr for gt6 hours
2 Increase gt 2 -2.9 X reference creatinine lt0.5mL/kg/hr for gt12 hrs
3 Increase gt 3X reference creatinine, increase gt4mg/dl or started renal replacement therapy lt0.3mL/kg/hr gt24 hrs or anuria for 12hrs
The Peer Teaching Society is not liable for false
or misleading information
26
AKI Aetiology
RENAL
PRE RENAL
POST RENAL
The Peer Teaching Society is not liable for false
or misleading information
27
Classify the following causes..

• A Catheter blocked
• B Congestive Heart Failure
• C Haemorrhage
• D Goodpastures
• E Renal calculi
• F ACE inhibitor
• G Acute Tubular Necrosis
• H NSAIDs
• I Renal Artery Stenosis
• J BPH

PRE RENAL, RENAL or POST RENAL???
The Peer Teaching Society is not liable for false
or misleading information
28
Answers
Pre Renal Renal Post Renal
B D A
C G E
F H
H
I
The Peer Teaching Society is not liable for false
or misleading information
29
Pre renal

• COMMONEST CAUSE OF AKI
• Decreased intravascular volume
• Haemorrhage, shock, burns, DV
• Decreased effective circ volume
• CCF, cirrhosis
• Drugs
• ACE, ARB, NSAIDs
• Renal artery stenosis

The Peer Teaching Society is not liable for false
or misleading information
30
Renal

• Acute Tubular necrosis (ATN)
• Secondary to hypoperfusion/toxin
• Red cells/granular casts
• Tubular interstitial nephritis (antibiotics,
  NSAIDS)
• Acute and chronic pyelonephritis
• Glomerulonephritis
• Hepatorenal syndrome

The Peer Teaching Society is not liable for false
or misleading information
31
Glomerulonephritis

• IgA nephropathy
• Young male with recurrent haematuria after URTI
• Goodpastures
• Anti-glomerular basement membrane disease
• Haemoptysis and haematuria
• Proliferative GN
• Post strep infection
• Minimal change
• Common in paeds
• Rapidly progressive GN
• ESRF in days

The Peer Teaching Society is not liable for false
or misleading information
32
Post renal

• Intraluminal
• Calculus, clot, sloughed papilla
• Intramural
• Ureteric malignancy, stricture, post raditaion
  fibrosis, bladder ca, BPH
• Extrinsic
• Retroperitoneal fibrosis, pelvic malignancy.

The Peer Teaching Society is not liable for false
or misleading information
33
Investigation

• Urine
• Dipstick leuks, nitrites, blood, prot, glucose
• Albumincreatinine to quantify
• ?osmolality, ?culture
• Bloods
• FBC, UE, LFT, clotting, ESR/CRP
• ?blood culture, ?ABG, ?Immunology
• ECG
• Imaging
• US 1st line
• CT
• ?Renal Biopsy

The Peer Teaching Society is not liable for false
or misleading information
34
AKI Management

• TREAT CAUSE
• Assess fluid status..is the patient dehydrated?
• Low UO, JVP, poor tissue turgor, low BP, high
  pulse
• ? IV FLUIDS
• Identify and relieve any obstruction.
• Stop nephrotoxic drugs!
• Dialysis if renal function does not recover

The Peer Teaching Society is not liable for false
or misleading information
35
Case 1

• 68 year old male gen unwell fatigue, malaise,
  NV, anorexia
• Started on ramipril for HTN
• PMH IHD
• O/E Bilateral Renal Bruits
• Differentials? What investigations?
• Bloods- High urea and creatinine ? AKI
• Urine NAD

The Peer Teaching Society is not liable for false
or misleading information
36
Case 1
HYPERKALAEMIA

• Tented T waves
• Flattened P waves
• Prolonged PR
• Wide QRS
• Sine wave pattern, asystole

The Peer Teaching Society is not liable for false
or misleading information
37
Case 1

• IV Calcium (cardioprotective)
• 10 ml of 10 Ca gluconate IV
• IV Insulin glucose (increases intracellular
  uptake)
• Salbutamol nebuliser
• Patient potassium stabilises
• What next?

The Peer Teaching Society is not liable for false
or misleading information
38
Case 1

• Stop ramipril
• Find and treat cause
• CT bilateral renal stenosis, atheromatous
  changes
• Refer to vascular stents which improves BP
  control

The Peer Teaching Society is not liable for false
or misleading information
39
Chronic Renal Failure

• Kidney damage 3/12 based on findings of
  abnormal kidney structure or function
• OR
• GFRlt60mL/min/1.73m2 for gt3/12 with or without
  evidence of kidney damage.

The Peer Teaching Society is not liable for false
or misleading information
40
CKD Classification
Stage GFR (mL/min/1.73m2) Notes
1 gt90 Normal GFR evidence of renal damage
2 60-89 Slight decrease in GFR evidence of renal damage
3A 45-59 Moderate decrease in GFR evidence of renal damage
3B 30-44 Moderate decrease in GFR evidence of renal damage
4 15-29 Severe decrease in GFR evidence of renal damage
5 lt15 Established renal failure
The Peer Teaching Society is not liable for false
or misleading information
41
CKD Classification

• Evidence of Renal Damage
• Persistent microalbuminuria
• Persistent proteinuria
• Persistent haematuria
• Structural Abnormalities of the kidneys by USS eg
  ADPKD
• Positive biopsy for chronic glomerulonephritis

The Peer Teaching Society is not liable for false
or misleading information
42
CKD Classification

• Limitations
• Validated for patients with established RF
• Most elderly people are in Stage 3 by eGFR
• eGFR very dependent on diet
• Formula less accurate for higher eGFR

The Peer Teaching Society is not liable for false
or misleading information
43
Aetiology

• Vascular HTN, Renovascular disease
• Infective/Inflamm GN
• Trauma
• AI SLE, PAN
• Metabolic DM
• Iatrogenic/Idiopathic Drugs, contrast
• Neoplastic Myeloma, Renal Ca, Prostate Ca
• Congenital ADPKD, Fabrys, Alports

The Peer Teaching Society is not liable for false
or misleading information
44
Clinical Presentation

• Symptoms
• N/V, anorexia
• Peripheral neurpathy High urea
• Pruritus
• Lethary
• Confusion
• Sx of underlying cause
• Urinary sx dysuria, increased frequency,
  nocturia, terminal dribbling
• SLE rash, arthalgia, dry mouth, pleuritic chest
  pain

The Peer Teaching Society is not liable for false
or misleading information
45
Clinical Presentation

• Hx
• PMH
• DM,IHD.
• DH
• NSAIDs
• FH
• ADPKD

• O/E
• HTN
• Palpable kidneys
• Palpable bladder
• PR- enlarged prostate
• Renal or femoral bruits
• Rash
• Peripheral Oedema
• Pallor

The Peer Teaching Society is not liable for false
or misleading information
46
Investigations

• Blood
• FBC, UE, LFT, Lupus/vasculitis/myeloma screen
• Urine
• MCS, dipstick, ACR
• Imaging
• USS
• CXR, ECG
• Renal biopsy if cause unclear

The Peer Teaching Society is not liable for false
or misleading information
47
Management

• Treat reversible causes
• Obstruction?
• Avoid Nephrotoxins
• NSAIDs, Gentamicin, Li, Contrast
• Treat complications
• Dialysis/ Transplant

The Peer Teaching Society is not liable for false
or misleading information
48
Complications

• Fl uid overload
• A cidosis
• S x of uraemia (fatigue, anorexia, pruritus)
• H TN
• B one disease
• A naemia
• C VS disease
• K Hyperkalaemia

The Peer Teaching Society is not liable for false
or misleading information
49
Renal Osteodystrophy

• Manifestation of renal disease
• Pathophysiology
• Decreased activation of 1.25 vit D.
• Lower Ca abs from gut
• Increased PTH ? 2O hyperPTH
• Increased bone turnover
• Rugger jersey spine

The Peer Teaching Society is not liable for false
or misleading information
50
Assessing renal function..

• THINK is this ACUTE or CHRONIC?
• Hx Cormordity chronic
• Longstanding decrease in eGFR
• SIZE OF KIDNEYS usually small in chronic (lt9cm)
• Absence of anaemia, low calcium suggests acute

The Peer Teaching Society is not liable for false
or misleading information
51
Lower Urinary Tract Infection

• Urethritis Cystitis symptoms of UTI
• Pathophysiology
• alkaline urine
• ?urine osmolarity
• ?micturation volume,
• ? commensals
• - Majority Contamination with bowl flora (E-Coli)

The Peer Teaching Society is not liable for false
or misleading information
52
Lower Urinary Tract Infection
Symptoms Signs
Frequency Haematuria (Microscopic/Macroscopic)
Dysuria Cloudy smelly urine
Suprapubic pain during and after voiding
Strangury
Features suggestive of pyelonephritis fever,
rigors, loin pain, NV, guarding and tenderness

• Differential Diagnosis
• Urethritis (Chlamydia)
• Urethral syndrome

The Peer Teaching Society is not liable for false
or misleading information
53
Lower Urinary Tract Infection

• Investigations
• Urine dip
• MSU MCS
• If infection is complicated consider UEs, FBCs
  and blood cultures

The Peer Teaching Society is not liable for false
or misleading information
54
Lower Urinary Tract Infection

• Management
• Increase fluid intake (gt2Litres/day)
• Trimethoprim 200mg PO BD (3/7)
• Alternative Nitrofurantoin (in pregnancy) (PO)
• Ciprofloxacin and co-amoxiclav (PO)

First line antibiotic for LUTI? What about in
pregnancy?
The Peer Teaching Society is not liable for false
or misleading information
55
Acute Pyelonephritis

• Loin pain, fever and tender renal angle
• Nausea, vomitting, (Septic shock)
• Usually an ascending infection
• Complications perinephric abscesses, papillary
  necrosis, ureteric obstruction, AKI,

The Peer Teaching Society is not liable for false
or misleading information
56
Acute Pyelonephritis

• Differential Diagnosis (Pyelonephritis)
• Acute appendicitis
• Diverticulitis
• Cholecystitis
• Ruptured ovarian cyst
• Ectopic pregnancy

Differential diagnosis of acute
pyelonephritis?
ALWAYS consider in pre-menopausal women!!
The Peer Teaching Society is not liable for false
or misleading information
57
Acute Pyelonephritis

• Investigations
• Dipstick
• MSU MCS
• Renal tract USS/CT
• Pelvic examination (women)DRE (men)
• Blood cultures (if pyrexial)

Investigations for patient with
pyelonephritis?
The Peer Teaching Society is not liable for false
or misleading information
58
Acute Pyelonephritis

• Management
• ? Hospital admission
• Co-amoxiclav/Ciprofloxacin (PO)
• OR Gentamycin Cefuroxime (IV)
• Paracetamol
• Maintain high fluid intake

First line oral antibiotic treatment? IV
antibiotic treatment regime?
The Peer Teaching Society is not liable for false
or misleading information
59
MEQ

• An 80 year-old man attends his General
  Practitioner complaining of passing urine very
  frequently. His symptoms started about 5 years
  ago and have gradually worsened, so that for the
  last 12 months he has been passing urine hourly
  but never felt like his bladder was properly
  empty. During the last 2 days, he noticed some
  blood in his urine and felt hot and sweaty. This
  prompted him to seek medical advice. His GP
  diagnoses a lower urinary tract infection.
• 1. From the patients history, what condition
  may have predisposed to the development of this
  infection? (2 marks)

The Peer Teaching Society is not liable for false
or misleading information
60
MEQ

• An 80 year-old man attends his General
  Practitioner complaining of passing urine very
  frequently. His symptoms started about 5 years
  ago and have gradually worsened, so that for the
  last 12 months he has been passing urine hourly
  but never felt like his bladder was properly
  empty. During the last 2 days, he noticed some
  blood in his urine and felt hot and sweaty. This
  prompted him to seek medical advice. His GP
  diagnoses a lower urinary tract infection.
• CHRONIC URINARY RETENTION

The Peer Teaching Society is not liable for false
or misleading information
61
MEQ

• 2. List 4 other symptoms you might enquire about
  in relation to the patients chronic urinary
  problems (2 marks)
• LUTS Nocturia
• Hesistancy
• Terminal dribbling Poor urinary
  stream
• Intermittent stream
• Urgency

The Peer Teaching Society is not liable for false
or misleading information
62
MEQ

• 3. List 2 physical signs that you may expect to
  elicit on abdominal/PR exam (2 marks)
• Palpable bladder
• Enlarged prostate
• Palpable kidney

The Peer Teaching Society is not liable for false
or misleading information
63
MEQ

• 4. The patient is referred to a urologist for
  definitive treatment. In the meantime, a
  midstream specimen of urine is sent for culture.
  The results of a gram stain show a gram negative
  bacillus. List 2 possible pathogens that may be
  responsible for the patients infection. (2
  marks 1 mark per response)
• Escherichia coli (E. coli)
• Enterobacter
• Klebsiella sp.
• Pseudomonas aeruginosa
• Serratia sp.

The Peer Teaching Society is not liable for false
or misleading information
64
MEQ

• 5. The urologist recommends that the patient
  undergo an operation to relieve his chronic
  urinary symptoms. What operation is he most
  likely to have suggested? (2 marks)
• TURP (Transurethral resection of prostate)

The Peer Teaching Society is not liable for false
or misleading information
65
MEQ 2

• A 61-year-old man presents to his General
  Practitioner complaining of increasing difficulty
  in passing urine. On rectal examination the GP
  feels an enlarged hard, irregular prostate gland
  and suspects the diagnosis of carcinoma of the
  prostate. The patient is referred to the Urology
  department at the local hospital.
• State two tests that will aid confirmation of
  the diagnosis (2)
• Transrectal USS
• Prostatic biopsy
• Prostate Specific Antigen

The Peer Teaching Society is not liable for false
or misleading information
66
MEQ 2

• The results of these tests confirm prostate
  cancer.
• Give two investigations, which will assist in
  assessing the extent of the disease (2)
• Transrectal USS
• CT scan of abdomen (and chest)
• Alk phosphatase
• Serum Calcium
• Isotope bone scan
• Plain radiographs of axial skeleton

The Peer Teaching Society is not liable for false
or misleading information
67
MEQ 2

• State 3 treatments that may be used in this
  condition (3)
• Prostate surgery
• Radiotherapy
• Anti-androgen therapy
• Orchiectomy

The Peer Teaching Society is not liable for false
or misleading information
68
MEQBonus question!

• Treatment is conducted and the GP manages his
  subsequent follow up care. Three months later
  the patient becomes increasingly unwell. He
  complains increased thirst and has also noticed
  increased urinary frequency. He has become
  markedly constipated and his wife says that he is
  has become far less mentally sharp than he had
  been previously. The GP arranges admission to
  hospital.
• What is the most likely cause of these new
  symptoms? (1)
• HYPERCALCAEMIA (?bony mets)

The Peer Teaching Society is not liable for false
or misleading information
69
EMQ

• a. Amoxicillin f. Flucoxacillin
• b. Antibiotic treatment is not indicated g. Gentam
  icin
• c. Ceftazidime h. Nitrofurantoin
• d. Cephalexin i. Trimethoprim
• e. Ciprofloxacin j. Vancomycin
• A 23-year-old woman presents to her GP with a
  2-day history of urinary frequency and dysuria.
  Her last menstrual period was six weeks
  previously. She reports that she experienced
  facial swelling and wheezing when she was given
  either penicillins or cephalosporins as a
  teenager. Microscopy of her urine shows numerous
  white and red blood cells. Culture yields gt105
  /ml of a fully sensitive Escherichia coli.
• H

The Peer Teaching Society is not liable for false
or misleading information
70
EMQ

• a. Amoxicillin f. Flucoxacillin
• b. Antibiotic treatment is not indicated g. Gentam
  icin
• c. Ceftazidime h. Nitrofurantoin
• d. Cephalexin i. Trimethoprim
• e. Ciprofloxacin j. Vancomycin
• A 60-year-old man is admitted with a fever. He
  has had repeated hospital admissions over the
  preceding year for an unrelated condition, and is
  known to carry MRSA in his nose. On taking a
  history, he describes recent onset urinary
  frequency, nocturia and loin pain. An MSU is
  sent to the laboratory. Microscopy shows
  numerous white blood cells and a culture yields
  gt105 /ml of Staphylococcus aureus. This morning
  he has become hypotensive and confused.
• J

The Peer Teaching Society is not liable for false
or misleading information
71
EMQ

• a. Amoxicillin f. Flucoxacillin
• b. Antibiotic treatment is not indicated g. Gentam
  icin
• c. Ceftazidime h. Nitrofurantoin
• d. Cephalexin i. Trimethoprim
• e. Ciprofloxacin j. Vancomycin
• On admission to a residential home, a urine
  sample is sent from a 75-year-old man with a
  long-standing indwelling urinary catheter,
  because it looks cloudy and contains protein on
  dipstick. The patient is otherwise well. The
  culture yields gt105 /ml of a Pseudomonas
  aeruginosa sensitive to standard antipseudomonal
  antibiotics.
• B

The Peer Teaching Society is not liable for false
or misleading information