Urology
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Urolithiasis
Doctor Instruction:
You are a Junior Doctor working in the Emergency Department. Your next patient is Anna – a 30-year-old female presenting with loin pain. Please take a history and perform an appropriate examination.
Patient History:
Anna Jones, a 30-year-old female, social worker
You are coming in today as you have had a sudden constant right loin pain radiating to the right groin in the past two days. You describe this as a severe sharp/dull pain. It is between 8-10/10 pain score. You tried ibuprofen and paracetamol with only little relief. No obvious trigger.
You feel nauseous but no vomiting. When it is painful, you do feel a bit hot and sweaty. No recorded temperature. You noticed pain passing urine (cannot see any blood), otherwise, no urinary symptoms. Urine output is normal – you last passed urine was yesterday. No labial/ anterior thigh pain. Bowels open normally with no loose stool or constipation (no blood). You have a regular male partner and are sexually active and you use a Mirena coil for contraception.
Ideas, Concerns, Expectations:
You think this is appendicitis, as your mum had this before. You are worried that your appendix might burst, which happened to your mum, who had emergency surgery. You hope to have your appendix removed as soon as possible and have your pain well-controlled.
Past Medical History:
Obesity
Hypertension
No previous history of renal stones
No past surgical history.
Drug History:
Ramipril 1.25mg OD
The Mirena coil was inserted two years ago.
NKDA
Family History:
Appendicitis from mother
Social History:
Lives with partner in a flat
Works as a social worker
Smoke five cigarettes a day for the past five years
Drink occasionally during special events
Independent at home
Examination Finding
The patient appears in agony, often twisting the body.
Right loin to groin tenderness, the abdomen is otherwise soft with no signs of peritonism. Right renal angle tenderness.
Bowel sound normal.
Genital examination is normal.
Differentials
Urolithiasis
UTI, e.g. pyelonephritis
Urinary Tract obstruction
Hydronephrosis
GI/ gynaecological pathologies e.g. acute appendicitis, ectopic pregnancy, ovarian cyst …etc.
Dissection of aortic aneurysm
Investigations
Bedside:
Basic observations
Urine dipstick – may show haematuria in urolithiasis, nitrite/ leucocyte positive in infection, pH (> 7: urea-splitting organism, e.g. Proteus spp, <5: uric acid stones)
Urine MCS
Urine Pregnancy Test
Bloods:
Routine Bloods e.g. U&E (measure renal function), FBC/CRP (infection), Calcium (hypercalcaemia), bHCG (ectopic pregnancy), coagulation screen if intervention is required/planned.
Imaging
Non-contrast CT KUB within 24 hours – the gold standard for diagnosing renal stones (first-line)
USS KUB (alternative to CT, e.g. pregnant women, young adults and children) If negative, low dose non-enhanced CT scan or MRI scan should be considered
Abdominal XR – calcium-based stone can be present on imaging; uric acid stones are radiolucent
Special Test:
If a stone is obtained, e.g. by encouraging the patient to attempt and catch the stone using a filter for analysis, the stone should be analysed to guide cause and reduce the risk of recurrence.
Management
Urolithiasis can be managed as an inpatient or urgent outpatient, depending on whether the pain is controlled. Other indications for hospital admission: signs of infection, increased risk of AKI e.g. solitary/ nonfunctioning/ transplanted kidney, poor fluid intake due to N+V, anuria, diagnostic uncertainty.
Consider referring children and young people with ureteric/renal stones to a paediatric nephrologist or urologist for assessment and metabolic investigations.
Conservative:
NSAIDs e.g. IM/PR diclofenac, followed by IV paracetamol and then opioids if pain is uncontrolled.
Antiemetics e.g. prochlorperazine, metoclopramide, cyclizine
Rehydration therapy e.g. IV fluids, encourage oral fluid intake
Watchful waiting for asymptomatic patients with <5mm stones (50-80% chance passing by itself), 5-10mm stones may be suitable with consent and informed discussion on possible risks and benefits. It can take several weeks to pass.
Medical:
Empirical antibiotics if indicated for infection
Tamsulosin (an alpha blocker) to aid stone passage if the stone is located distally with optimal size between 5mm -10mm.
Surgical ( >10mm stone or stone that does not pass by itself or in complete obstruction, infection, or pain cannot be tolerated):
The choice of procedure depends on the size of the stone, age, anatomy, contra-indication, and history of failed previous procedures.
Extracorporeal shock wave lithotripsy (ESWL) – shock wave to break the stone into smaller parts to pass.
Ureteroscopy and Laster Lithotripsy – stone is broken down by laser to pass, assisted by using a telescope.
Percutaneous nephrolithotomy under GA – nephroscope is inserted via the patient’s back towards the kidney and ureter, where stones are broken down and removed (for >2cm stone/ staghorn calculi and cystine stone).
Open/laparoscopic surgery (reserved for complicated cases e.g. multiple stones).
Percutaneous nephrostomy tube or stenting may be performed under specialist guidance.
Prevention
Encourage good oral fluid intake (2-3 litres per day in adults or 1-2 litres for children).
Add fresh lemon juice to water as citric acid binds to calcium in the urine, reducing the formation of stones.
Avoid carbonated drinks, which can lead to calcium oxalate formation.
Reduce salt intake as high consumption causes hypercalciuria.
Eat a healthy diet and maintain a normal weight.
Maintain normal calcium level and do not restrict calcium intake as less calcium binding to oxalate in the GI tract promotes hyperoxaluria, increases the risk of stone formation, and low calcium can affect bone health.
Avoid oxalate-rich food e.g. black tea, nuts, spinach, beetroot, to prevent calcium oxalate stones.
Avoid purine-rich food, e.g. spinach, sardines, liver, and anchovies, to prevent uric acid stones.
Potassium citrate reduces the risk of calcium oxalate, cysteine stones, uric acid stones +/- thiazide diuretics - reducing the risk of calcium oxalate.
Viva Questions:
Where does the ureteric colic most commonly happen in the urinary tract?
Commonly at the vesicoureteral junction (VUJ). Other locations: pelvic ureteric junction (PUJ) and where it crosses the pelvic brim.
What are the complications of kidney stones?
Obstruction leading to AKI, Infection e.g. pyelonephritis, ureteric stricture, increased risk of renal cell carcinoma and upper tract urothelial carcinoma in older age group (55-69), renal calyx rupture.
What are the different types of renal stones?
Calcium oxalate (most common), calcium phosphate, uric acid (not visible on XR), struvite (associated with infection), cysteine
What are the risk factors for urinary tract stones/urolithiasis?
Anatomy e.g. horseshoe kidney, stricture, family history, hypertension, gout, hyperparathyroidism, dehydration, immobilisation, metabolic disorder, diet, obesity...etc.
What is staghorn calculus?
Staghorn calculus is a stone formed in the renal pelvis with horns extending into renal calyces. It is associated with struvite and recurrent upper urinary tract infections.
Name the causes of hypercalcaemia.
Calcium supplementation, hyperparathyroidism, cancer i.e. breast CA, lung CA, myeloma, dehydration.
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Acute Prostatitis
Doctor Instruction:
You are a Junior Doctor working in General Practice. Your next patient is a 65-year-old gentleman, Logan Freeman, presenting with groin pain. Please take a history and perform an appropriate examination.
Patient History:
James Newman, a 65-year-old gentleman, retired.
You are coming in today as you have been experiencing worsening left groin pain in the last two days, which started quite quickly. You describe the pain as a constant burning sensation. It is located deep down the groin and localised there. You rate the pain 6/10. The pain is worsened when you open your bowels and is relieved by taking ibuprofen.
You also have pain while urinating with increased urinary frequency since the past week. You do not have urine retention, but the stream has been slow. You do not use a urinary catheter. No blood from urine currently (settled from recent prostate biopsy last week).
You are currently experiencing unexplained weight loss and night sweats - which you went to see a urologist for possible prostate cancer. You have been told that you have a raised prostate marker. You will soon find out the results from the recent prostate biopsy they did last week. You can't remember if you were given prophylactic antibiotics.
You feel hot and cold, but you haven't taken a temperature yet, so you are unsure if you have a fever. You feel tired. You have muscle aches all around the body, and you do not feel great at all!
You are currently happily married for 30+ years. Your last sexual intercourse was a long time ago - God knows! You are slightly constipated, but you are opening your bowel without any major issues.
No rashes. No SOB. No diarrhoea. No penile discharge. No issues with the testicles.
Ideas, Concerns, Expectations:
You think this might be related to your prostate. You are worried that you have prostate cancer and hope the cancer is not spreading. You would like to get treatment as soon as possible.
Past Medical History:
Benign prostatic hyperplasia
Hypercholesterolemia
Transrectal prostatic biopsy for suspected prostate cancer one week ago
Drug History:
Tamsulosin
Atorvastatin
NKDA
Family History:
Nil
Social History:
You stopped smoking a month ago, as you have been told to quit by the urologist - but you used to smoke ten cigarettes/per day for 20+ years.
You drink 5-10 units of alcohol per week.
You live with your wife in a bungalow.
You are managing well independently at home.
You are retired, but you used to work as a voice actor.
Examination Findings:
Digital rectal exam: warm, tender and enlarged prostate; a small nodular mass can be felt at the left side of the prostate gland.
Testicular / penis exam normal.
Abdominal examination normal.
No renal angle tenderness.
No obvious inguinal lymphadenopathy
Differentials:
Acute prostatitis (bacterial/ non-bacterial) - likely due to an infective cause from a recent prostatic biopsy
Cystitis / UTI
Prostate pain syndrome
Urinary tract stones
Prostatic abscess
Underlying prostate malignancy
Investigations:
Observations
Urine dipstick testing - infection
Urine MC&S
Chlamydia and gonorrhoea NAAT testing
Consider Bloods: FBC, U&Es, CRP, Blood culture + other baseline bloods
Consider transrectal ultrasound to rule out prostatic abscess/ cysts / seminal vesicle obstruction
Consider the 4-glass / 2-glass test in chronic prostatitis
PSA should have been done before the investigation for prostatic cancer. Prostate biopsy in the past six weeks can raise PSA levels and affect results. Other factors that raise PSA level is vigorous exercise, ejaculation, prostate stimulation in DRE...etc.
Management:
Conservative:
Analgesia e.g. paracetamol, NSAIDs
Laxative for pain from bowel movement
Psychological treatment e.g. CBT/ anti-depressants
Medical:
Antibiotics if less than six months of symptoms/history of infection, e.g. ciprofloxacin 500mg BD for 14 days. After 14 days, review antibiotic treatment effectiveness.
Consider admission for those who are acutely ill/ in septic shock...etc. for IV antibiotics
Contact tracing if the disease is sexually transmitted + GUM clinic
Avoid further rectal examination to prevent the spreading of infection
Alpha-blockers e.g. tamsulosin to relax smooth muscle and improve symptoms
Surgical:
Consider a urinary catheter if retention of urine
Surgical intervention e.g. aspiration transrectal /perineal under US guidance for prostatic abscess
Viva Questions:
Explain the pathophysiology of prostatitis.
Prostatitis, prostate gland inflammation, stems from infections (bacterial, chronic) or non-infectious factors (autoimmunity, nerve dysfunction). Infections trigger immune responses, pain, and tissue damage. Bacteria can persist within the prostate, causing long-term inflammation. Non-infectious cases involve immune reactions and nerve sensitization, leading to pelvic pain. Immune cells release cytokines, worsening symptoms. Nerve dysfunction contributes to heightened pain perception.
What is the national institute of health chronic prostatitis symptom index?
The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) is a standardized questionnaire designed to assess the severity of symptoms and impact on quality of life in individuals with chronic prostatitis or chronic pelvic pain syndrome. It evaluates urinary, pain, and quality of life domains, aiding in diagnosis and treatment evaluation.
What are the complications of prostatitis?
Complications of prostatitis can include recurrent infections, abscess formation within the prostate, urinary retention, and impaired sexual function. Chronic prostatitis might lead to long-term pain, decreased quality of life, and psychological distress. In some cases, the infection could spread to other parts of the urinary tract or bloodstream, causing more serious infections. It's essential to promptly diagnose and manage prostatitis to prevent these potential complications.
What are the bacterial vs non-bacterial causes of prostatitis?
Prostatitis can arise from bacterial infections, where pathogens infiltrate the prostate gland through various routes, causing inflammation and discomfort. On the other hand, non-bacterial prostatitis occurs without evident infection. This form could result from autoimmune reactions, nerve dysfunction, or pelvic muscle tension.
What are the risk factors of prostatitis?
Risk factors for prostatitis include urinary tract infections, prior prostate infections, catheter use, unprotected anal intercourse, bladder outlet obstruction, and an enlarged prostate. Certain medical procedures involving the urinary tract, like biopsies, can also elevate the risk. Lifestyle factors, such as stress, sedentary habits, and poor diet, may contribute. Age and a family history of prostate conditions could increase susceptibility.
What are the common pathogens associated with bacterial prostatitis?
Common pathogens linked to bacterial prostatitis include Escherichia coli (E. coli), which frequently originates from urinary tract infections. Other bacteria like Klebsiella, Proteus, Enterococcus, and Pseudomonas species can also cause infection. These pathogens often reach the prostate through the urethra or bloodstream. Identification of the specific bacteria is important for targeted antibiotic treatment.
What are the common side effects of fluoroquinolones?
Common side effects of fluoroquinolone antibiotics include gastrointestinal symptoms like nausea, vomiting, and diarrhea. They can also lead to central nervous system effects such as headache, dizziness, and confusion. Tendon-related issues like tendonitis and tendon rupture, especially in the Achilles tendon, are a concern. Moreover, fluoroquinolones may cause photosensitivity reactions, skin rashes, and allergic reactions. Some individuals might experience alterations in blood sugar levels or electrolyte imbalances.
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Epididymo-orchitis
Doctor Instruction:
You are currently a senior surgical doctor on call. You are asked to see Alan, a 25-year-old professional tennis player, complaining of scrotal swelling. Please take a history and perform a relevant examination.
Patient History:
Alan Gee - a 25-year-old male - professional tennis player.
It's all a bit embarrassing, but your right testicle has swollen up gradually. You noticed it last night when you looked; though you couldn't see clearly, it seemed a bit red. You haven't noticed any change in size with coughing, straining or standing for prolonged periods.
It's stopped you from playing tennis since it's really sore. The pain started last night and is a deep sharp pain at about six out of 10. Does not radiate anywhere. You've tried ibuprofen, which has somewhat reduced the pain, but it's still there. This is associated a dragging or heavy sensation down below.
On direct questioning, you admit you've had some discharge from your penis for the last week that's white and thick. It is sore when you're passing urine. You feel a little feverish but you haven't taken a temperature to confirm. You have had no difficulty swallowing, indigestion, or weight loss.
When asked directly, you mention you are quite sexually active with 2 female partners at the moment. You try to always use condoms, but you will have the odd two or three times when you don't remember.
Ideas, Concerns, Expectations:
Though you’re concerned about not being able to play tennis and having to take time off, what you’re worried the most about is if this might affect your fertility. You ask the doctor if you’re going to need surgery.
Past Medical History:
Appendicectomy 5 years ago.
Drug History:
None.
NKDA.
Family History:
Bowel cancer (father at age 50).
Social History:
You are a professional tennis player and train 4 days a week, which involves a lot of running and physical activity.
You don't smoke and drink two bottles of wine weekly, each spread over 3-4 days.
You're an active and independent man and live by yourself.
Examination Findings:
Pulse 104bpm.
Swollen, red, warm right scrotum
Right testis tender to palpation, especially around the posterior aspect
Prehn's sign positive (relief upon elevation of the scrotum)
Cremasteric reflex intact
No hernias can be felt
Differentials:
Epididymo-orchitis (testis + epididymis swollen and tender in sexually active young man, Prehn’s sign)
Other possible differentials for swollen, tender scrotum include trauma and cellulitis.
To rule out testicular torsion (possible given active young man but pain more severe & acute, typically cremasteric reflex -ve + younger age)
Investigations:
Bedside:
Urine dipstick, MC&S
NAAT testing (chlamydia/ gonorrhoea)
Swab of urethral discharge for culture and sensitivities including gonorrhoea
Consider testing for mumps if suspected e.g.. saliva swap, serum antibodies (IgM acute infection / IgG previous infection or vaccination)
Bloods:
FBC/ CRP (infection)
Baseline Bloods e.g. U&Es, LFT, Bone Profile
Blood culture
Imaging:
Ultrasound (if unclear diagnosis, to assess for torsion/ tumour)
Management:
Consider admission for IV antibiotics for those acutely unwell/ septic
Those high risk of STIs should be referred to genitourinary medicine (GUM)
Two-week antibiotic course depending on suspected pathogen e.g. doxycycline for STI, ciprofloxacin if E.coli - as per local guidelines
Bed rest
Scrotal elevation
Analgesia
Contact tracing if sexually transmitted infection
Abstain from intercourse
Reduce physical activity
Supportive underwear
Safety net
Viva Questions:
Explain the pathophysiology of epididymo-orchitis.
Epididymo-orchitis involves inflammation and infection of the epididymis and testicle. It's usually caused by bacteria entering the urinary or reproductive tract. The bacteria trigger an immune response, causing swelling, pain, and tissue damage in the affected area. Symptoms include testicular pain, swelling, fever, and sometimes discharge. Prompt medical attention is necessary for diagnosis and treatment with antibiotics to prevent complications and potential fertility issues.
Which pathogens most commonly cause epididymo-orchitis?
The most common pathogens responsible for causing epididymo-orchitis are bacteria. Among these, Escherichia coli (E. coli), a bacterium commonly found in the gastrointestinal tract, is a frequent cause. Additionally, sexually transmitted infections (STIs) such as Chlamydia trachomatis and Neisseria gonorrhoeae can also lead to epididymo-orchitis, particularly in younger sexually active individuals. These infections can ascend from the urethra and cause inflammation and infection in the epididymis and testicle.
What are the complications of epididymo-orchitis?
Complications of epididymo-orchitis include abscess formation, chronic pain, scrotal abnormalities, and potential infertility if left untreated or not managed properly. Early and appropriate treatment with antibiotics can help prevent these issues.
If a urine dipstick revealed a positive leucocyte and negative nitrites, what does this mean?
A positive leukocyte result means there are white blood cells in the urine, suggesting inflammation. A negative nitrite result indicates certain bacteria aren't present. This combination might indicate an early infection, non-typical bacteria, or a non-bacterial cause of inflammation in the urinary tract. Further evaluation is needed for an accurate diagnosis.
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Benign Prostatic Hyperplasia
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is 65-year-old Henry, who did not state a reason for attendance. Please take a history and perform a relevant examination.
Patient History:
You were somewhat embarrassed about attending today, and the receptionist wanted to ask you what you were booking for which was awfully inappropriate!
You've been waking up at night to go to the loo for the past month. You even have to wee during the day more frequently (usually, you'd only go 2 or 3 times and never at night, now, it's close to 5 or 6 times in the day and once/twice at night). You often get a sudden urge to go to the toilet or feel like you might wee yourself (it's terribly embarrassing!), but you haven't had any accidents. Or at least not yet.
You wouldn’t say it hurts to pass urine, and you’ve never seen any blood or cloudiness in your wee. You don’t have any tummy pain and no fever.
You do notice you're straining to start urinating, but you've had that and the poor flow for a good couple of months now. It certainly is just the next step in the ageing process. You have noticed some dribbling at the end as well, and occasionally a feeling like you haven't done a great job emptying your bladder. Overall you need major plumbing service!
You haven't had any weight loss. You have had some back pain, but that's been going on for years with your arthritis. You don't believe it has worsened at all recently.
Ideas, Concerns, Expectations:
You think this is just a natural part of the ageing process. You knew it was coming, but you just can't manage when you always have to know where the nearest toilet is. You're just unable to go out and play golf like you normally do, and it's incredibly embarrassing when the hour strikes and you're mid-conversation with a friend. You have to suddenly conjure up a reason to dash and find the nearest place to urinate. (You start to get emotional and cry). You’ve even once had to do it out in the park! You want the doctor to find a solution for this because you simply cannot carry on with your life this way.
Past Medical History:
Arthritis
High blood pressure.
Drug History:
Oral Paracetamol and ibuprofen PRN.
Topical Ibuprofen gel PRN.
Indapamide.
NKDA.
Family History:
No history of kidney problems in your family.
Social History:
You live in a bungalow alone and only leave the house for shopping and golf.
You don't have any family who visits (your only daughter lives in New Zealand with her husband – she sends you the most beautiful postcards, but you really wish she'd come and visit you more often).
You've never smoked since you used to work in the army, and you drink the occasional beer or lager but nothing extreme.
If asked about caffeine, you love your coffee; you've always been drinking several cups since your army days.
Examination Findings:
No abdominal or suprapubic tenderness, masses or organomegaly.
If mentioned DRE = a non-tender, smooth, elastic, and firm enlarged prostate with the median sulcus palpable.
Differentials:
Benign Prostatic Hyperplasia (lower urinary tract symptoms (LUTS) in the presence of examination findings in an elderly male)
Prostatic cancer (important to exclude, less likely given examination findings and negative red flags)
Prostatitis (typical history involves pelvic pain, fever and dysuria with tender enlarged prostate)
UTI (no fever or dysuria, however)
Bladder cancer (typically haematuria with normal prostate)
Detrusor weakness/instability
Neurological conditions e.g. MS, spinal cord injury
Investigations:
Bedside:
Urine dipstick (infection, blood)
Patient voiding diary (quantify severity)
International Prostate Symptom Score (IPSS) to assess the severity
Bloods:
PSA (non-specific, though very elevated levels e.g. x10 are highly indicative of cancer)
U&E (associated renal impairment)
Imaging/ Special Tests:
Bladder USS and post-void residual volume
Flow rate measurement & urodynamic studies
Cystoscopy ± biopsy
Management:
Conservative:
Lifestyle modifications e.g. physical activity, decrease fluid intake before bedtime, moderate consumption of alcohol and caffeine, and following a timed voiding schedule.
Intermittent self-catheterisation if BPH is causing frequent retention, UTI or renal failure.
Medical:
Alpha-blockers e.g. tamsulosin
5-alpha reductase inhibitors e.g. finasteride
Surgery:
Transurethral resection of the prostate (TURP)
Holmium laser enucleation of the prostate (HoLEP)
UroLift procedure
Viva Questions:
What is Benign Prostatic Hyperplasia?
Benign Prostatic Hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland in men. As the prostate grows, it can squeeze the urethra, leading to urinary symptoms such as frequent urination, difficulty starting and maintaining a steady stream, and a feeling of incomplete emptying. BPH is common with aging and is not linked to prostate cancer. Treatment options include lifestyle changes, medications, and, in severe cases, surgery.
What are the drawbacks of the PSA test for diagnosing prostate cancer?
Drawbacks of the PSA test, particularly false positives, include elevated levels due to benign conditions (BPH, prostatitis), age-related increases, medications, recent activities (ejaculation, exercise), variability in levels, and the potential for unnecessary anxiety and invasive procedures. Careful consideration and informed discussions with healthcare providers are essential for interpreting results accurately.
What is an IPSS score?
The IPSS score, or International Prostate Symptom Score, is a questionnaire used to assess the severity of urinary symptoms in men with benign prostatic hyperplasia (BPH). It helps quantify issues such as incomplete emptying, frequency, intermittency, urgency, weak stream, and nocturia. Scores range from 0 to 35, with higher scores indicating more severe symptoms. The IPSS assists healthcare professionals in evaluating and managing BPH-related symptoms.
What do we mean by Lower Urinary Tract Symptoms (LUTS), and how can we classify them?
Lower Urinary Tract Symptoms (LUTS) encompass storage symptoms (frequency, urgency, nocturia, urge incontinence) and voiding symptoms (weak stream, intermittency, hesitancy, incomplete emptying, straining). LUTS can affect both men and women, often indicating conditions like BPH or urinary tract infections. The International Prostate Symptom Score (IPSS) is a tool to assess and quantify the severity of LUTS.
What should you warn Henry about before starting him on an alpha blocker like tamsulosin?
Before starting tamsulosin, patients should be warned about potential side effects, including:
Orthostatic Hypotension: Causing dizziness, especially when standing up.
First Dose Effect: Advised to take the initial dose at bedtime to minimize blood pressure drop.
Driving Precautions: Caution when driving or operating machinery due to potential dizziness.
Adverse Effects: Common side effects like headache, nasal congestion, and abnormal ejaculation.
How do alpha-blockers and 5-alpha reductase inhibitors work? Which one works over a longer period?
Alpha-blockers (e.g., tamsulosin) quickly relieve BPH symptoms by relaxing muscles around the prostate, improving urine flow. 5-alpha reductase inhibitors e.g. finasteride shrink the prostate over time by reducing hormone-related growth. While alpha-blockers offer faster relief, 5-alpha reductase inhibitors have a more sustained effect, gradually reducing prostate size. Combining both may provide comprehensive short-term and long-term benefits.
What do you know about TURP syndrome?
TURP syndrome, or Transurethral Resection of the Prostate syndrome, is a potential complication of the surgical procedure TURP, commonly used to treat benign prostatic hyperplasia (BPH). It occurs when excessive amounts of irrigation fluid used during the surgery are absorbed into the bloodstream, leading to electrolyte imbalances. Symptoms can include confusion, nausea, seizures, and, in severe cases, cardiac issues. Close monitoring and prompt medical intervention are essential to manage TURP syndrome.
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Prostate Cancer
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is 70-year-old John, who came in for a routine check-up. He has a past medical history of hypertension, for which he is taking amlodipine. Please take a general history and perform a relevant examination.
Patient History:
John Doe, a 70-year-old male, retired.
(The purpose of this interview is for you to discuss your urological complaint. You spend the first few minutes discussing blood pressure, but after a few minutes of building rapport, you should interject to discuss your urinary problems)
You're here for your routine check-up, and you have to say things have been going great! Your blood pressure has been fine, with your average readings at about 145/90. The lovely lady or nurse who took your blood pressure just before you came in here was very happy with your BP when she checked it – it was a good 135/80.
You haven't had any problems with your vision and haven't had to go to the hospital for anything. Thankfully no heart attacks or strokes!
(You cut off the doctor) – you just remembered that your previous doctor said blood pressure can affect your kidneys, right?
Well, you've noticed some kidney problems for the past month. You've been visiting the toilet more often, even at night sometimes. You often get a sudden urge to go to the toilet or feel like you might wee yourself, but you haven't had any incontinence. You also sweat a lot, especially at night.
There's no pain when passing urine, though you have to strain. You can sometimes see blood in your urine. You don't have any tummy pain and no fever. Your stream is okay, you suppose (you don’t properly understand what this means), and you don’t get any dribbling.
When the doctor mentions it, you notice that you're buckling your belt a bit tighter, possibly from losing some weight. You don't have any balances at home to weigh yourself anyways. If asked directly, mention you have had some focal lower back pain for the past month.
Ideas, Concerns, Expectations:
You're quite pleased to be here and think you're doing fine. The weeing problem is somewhat of a nuisance, but you remember your father having similar problems when he was older, so this must be a part of growing older, like those back pains. You'd like to be on your jolly way and head back home in time for the game!
Past Medical History:
High blood pressure
Drug History:
Amlodipine 10mg daily
NKDA
Family History:
Your father died of cancer at the age of 60 - you don't remember what it is.
Social History:
You live at home with your son and are frequently visited by your three daughters.
You're an independent man who always remembers to take your pills at the right time without anyone's help.
You've smoked 10 cigarettes daily since you were 15 but don't drink alcohol.
You hate the taste of coffee but drink a cup of tea every day after meals.
Examination Findings:
No abdominal or suprapubic tenderness, masses or organomegaly.
If mentions DRE = asymmetric, nodular prostate with obliteration of the median sulcus.
Differentials:
Prostatic cancer (elderly man with FH of ?prostate Ca associated with weight loss and back pain)
Prostatitis (typical history involves pelvic pain, fever and dysuria with tender enlarged prostate)
To rule out UTI
Bladder cancer (typically haematuria with normal prostate)
Detrusor weakness/instability
Neurological conditions e.g. MS, spinal cord injury
Investigations:
Bedside:
Urine dipstick (infection, blood)
Patient voiding diary (quantify severity)
International Prostate Symptom Score (IPSS) to assess the severity
Bloods:
PSA (non-specific, though very elevated levels e.g. x10 are highly indicative of cancer)
U&E (associated renal impairment)
LFT (raised ALP may indicate metastasis, baseline before hormone therapy)
Imaging/ Special Test:
Multiparametric MRI (usually first line, results reported on 1-5 Likert scale)
Transrectal US-guided or transperineal biopsy (confirms the diagnosis and Gleason grading)
Technetium-99 bone scan (locate bony metastases)
Bladder USS and post-void residual volume
Flow rate measurement & urodynamic studies
Management:
MDT approach
Depends on risk stratification (involving PSA, Gleason score and staging)
Watchful waiting = if asymptomatic/unsuitable. Annual PSA and management of urinary symptoms.
Active surveillance = if low risk and localised. 6 monthly PSA. Annual DRE. Repeat MRI in 1yr.
Radical treatment = if intermediate or high risk. Radical prostatectomy or radiotherapy (external beam or brachytherapy).
Hormone therapy = if metastases. Chemotherapy or Androgen deprivation therapy either medically (GnRH analogues) or surgically (bilateral orchidectomy).
Palliative +/- radiotherapy, bisphosphonates.
Viva Questions:
How would you counsel a patient about the PSA test?
Explanation: Describe what PSA is—a protein produced by the prostate gland. Elevated levels can sometimes indicate prostate issues, but not always cancer.
Purpose: Discuss that the PSA test helps in detecting potential prostate problems, including cancer, at an early stage.
Pros and Cons: Explain that while the test can identify issues early, it might also yield false positives or negatives. Elevated levels could indicate non-cancerous conditions, and normal levels might not rule out cancer.
Risk and Benefits: Discuss the risks of unnecessary treatment due to false-positive results and the benefits of early detection and potential life-saving interventions.
Individualized Decision: Encourage the patient to make an informed decision based on their risk factors, age, and personal preferences after understanding the test's limitations and potential implications.
Follow-up: Emphasize the importance of discussing with their healthcare provider, considering their medical history, family history, and understanding the potential next steps based on test results.
Regular Monitoring: For those at higher risk, such as those with a family history of prostate cancer, discuss the importance of regular screening.
Is there currently a screening programme for prostate cancer?
In the UK, there isn't a nationwide screening program for prostate cancer. The PSA test is available through the NHS, but routine population-wide screening isn't recommended. Men aged 50 and over can discuss the test's risks and benefits with their healthcare provider for an informed decision.
What might be the cause of back pain in Jack’s case?
Back pain can be a symptom of advanced prostate cancer. Prostate cancer that has metastasized or spread to the bones, particularly the spine, can cause bone pain, including the lower back. The cancer weakens the bones, leading to pain, fractures, and spinal cord compression. However, it's important to note that back pain is a common issue and often not related to cancer. Many cases of back pain are due to muscular or skeletal problems, injury, or other non-cancerous causes.
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Lower Urinary Tract Infection (LUTI)
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is Jim – a 51-year-old man who complains of pain during urination. Please take a history and perform a relevant examination.
Patient History:
Jim Lock - a 51-year-old male - retired teacher.
You started experiencing pain when you urinated three days ago. This started quite suddenly, and the pain has been getting worse. You rate the pain 6/10. You describe the pain as burning. You do feel quite uncomfortable in the area below your belly button. You do not have any groin/loin pain.
You have noticed feeling quite feverish – today recorded 37.6 C. You have also been going to the toilet to empty your bladder more frequently than usual. You also sometimes have a sudden urge to urinate. Therefore, you always ensure a toilet nearby when you go outside. You also sometimes find it difficult to start urine, and the flow also seems to be slower compared to 1 year ago.
No discharge/haematuria/hesitancy/weight loss/nocturia. Not sexually active/ no pain in testicles.
Ideas, Concerns, Expectations:
You recently have been with a new partner and have been sexually active. You have always used barrier contraceptives. You think you have received AIDs from your new partner. You are very concerned about this as you heard many people have died of AIDS in the past. You are thinking of ending the relationship because of this. You hope to find out what is going on and seek treatment as soon as possible.
Past Medical History:
Type 2 Diabetes
Drug History:
Metformin, allergic to penicillin > rash
Family History:
Father has prostate cancer.
Social History:
Smoker – non-smoker
Alcohol – 3-4 pints of lager per week.
Occupation – retired teacher
Live alone.
Examination Findings:
Abdominal discomfort/ tenderness in the suprapubic region
Warm + sweats on palpation
No costovertebral angle tenderness
Enlarged prostate with central sulcus during PR if done (no tenderness / abnormal lumps)
Differentials:
Urinary tract infection (Lower)
STI
Things to rule out BPH/ Stones/ Prostate, Bladder or Renal Cancer/ stricture / Prostatitis
Investigations:
Bedside:
Observation
PR examination / testicular exam
Mid-stream Sample with Urine dipstick - White cells, Haematuria, Nitrites
Urinalysis - microscopy, culture if needed
STI screen
Bloods:
FBC – infection
CRP – infection
U&E & Creatinine – assess renal function
LFT – baseline
PSA
Consider blood culture – infection/ suspect sepsis
Imaging:
Consider CT KUB (non-contrast) – rule out stones if any features of nephrolithiasis or suspected complications
Consider US KUB - as with CT, also useful for assessing urodynamics, especially if recurrent
Management:
Conservative:
Patient Education
Better control of risk factors e.g. diabetes
To discourage sexual intercourse until recovered and to continue barrier contraception until the STI screen tested negative for both
Ensure fluid intake and personal hygiene behaviours
MDT approach
Paracetamol to treat fever
Medical:
Consult local guidelines for antibiotic treatment but in general:
In men - 7 days of nitrofurantoin or trimethoprim
In non-pregnant women - 3 days of nitrofurantoin or trimethoprim for simple LUTI
In pregnant women - 7 days of trimethoprim (avoid in first trimester) or nitrofurantoin (avoid from third trimester) or amoxicillin or cefalexin
Catheter-associated - 7 days of nitrofurantoin or trimethoprim
If severe, treat using sepsis 6, and treat any complications e.g. severe pyelonephritis
Safety netting advice e.g. return if worsening symptoms, no improvement, or pain spreads to back (Pyelonephritis)
Viva Questions:
What is the significance of an asymptomatic bacteriuria in elderly patients?
In the absence of signs/symptoms or consequences, these do not need to be treated. A urine dipstick in patients from care homes does not hold as much clinical significance if they are asymptomatic.
What is the significance of an asymptomatic bacteriuria in a pregnant patient?
It is associated with pre-term labour & low birth weight and therefore has consequences, so therefore requires treatment.
What are some common risk factors of UTIs?
Gender (women are more susceptible).
Sexual activity.
Urinary tract abnormalities.
Menopause.
Urinary tract obstructions.
Catheter use.
Weakened immune system.
Age (especially in the elderly).
Dehydration.
Personal hygiene practices.
Explain the Pathophysiology of UTI
UTIs result from bacteria, often E. coli, entering the urethra and ascending to the bladder. Factors like sexual activity, catheter use, or urinary tract obstructions contribute. Cystitis (bladder infection) causes typical symptoms, while untreated cases may progress to pyelonephritis (kidney infection) or sepsis.
What are the differences between Upper vs Lower UTI in Presentation?
Lower UTI is the most common & presents with a low fever, dysuria, increased frequency & suprapubic pain/discomfort.
Upper UTI can present with symptoms of a lower UTI, but also may have costovertebral angle tenderness, high fever, nausea/vomiting, rigors and increased malaise/myalgia.
What are the common pathogens causing UTIs?
The most common pathogens causing UTIs are bacteria, with Escherichia coli being the primary culprit. Other common bacteria include Staphylococcus saprophyticus, Klebsiella pneumoniae, Proteus mirabilis, and Enterococcus faecalis.
What information does a urine dip provide?
Nitrites (assess for nitrogen metabolising bacteria), leukocytes (assess infection), blood, urobilinogen, glucose, bilirubin, ketones, specific gravity, pH and protein
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Pyelonephritis
Doctor Instruction:
You are currently a senior surgical doctor on call. Your next patient is Jane – a 35-year-old woman presenting with a fever. Please take a history and perform a relevant examination.
Patient History:
Jane Doe - a 35-year-old female - office worker.
You have been feeling unwell for the past few days. Today you took a temperature which was found to be 38.0 degrees C as you had some shivering. Before the fever started, you remember developing a sudden worsening back pain on the lower left side which is associated with nausea and vomiting (no blood or faecal matter – just food). Pain comes in waves and is sharp – rating it a 7/10 pain score. Your urine also looks darker than usual and smells nasty, with blood in it. You have been going to the toilet more often than usual. You feel unwell. You currently have a poor appetite.
Not known to use a catheter. No diarrhoea. No cough. No breathlessness. No flu-like symptoms. No weight loss. No night sweats. Haven't eaten anything abnormal lately.
Ideas, Concerns, Expectations:
You have no idea what is going on. You think you have an infection but do not know what might be causing it. It might be renal stones. You are concerned because of not feeling your usual self. You want to receive some antibiotics.
Past Medical History:
High BMI, diabetes type 2 + renal stones (no known urological problems/ procedure in the past) + HIV (positive)
Drug History:
Metformin NKDA
Family History:
Renal stones
Social History:
You live alone in a flat.
Ex-smoker – used to smoke 10 cigarettes a day for 10 years.
You do not drink.
You currently work as an office worker.
Examination Findings:
Renal angle tenderness (left) + suprapubic tenderness without guarding.
No obvious lymphadenopathy.
Differentials:
Pyelonephritis
Cystitis / Urethritis
Renal stones / hydronephrosis / post renal problems
LUTI
Pelvic inflammatory disease/ gynae problems
Investigations:
Bedside:
Observations
Pregnancy test (to rule out pregnancy/ectopic)
Urine Dipstick /MSU
Bloods:
Blood sugar level, hba1c (diabetes control due to being a risk factor, FBC/ CRP (raised WBC/ CRP in infection) + U&E (renal function) + LFT / bone profile (baseline / rule out any liver pathology causing high temperature), blood culture
Imaging/Special Test:
CT KUB (if diagnosis in doubt/ no improvement after 72 hours of treatment/ deterioration)
USS KUB (post-renal/ structural abnormalities/ stones)
Consider MRI ( in pregnancy/children where renal infection, masses and urinary obstruction are suspected)
Consider MCUG (to identify reflux)
Consider intravenous pyelogram (small kidneys/ ureteric/ caliceal dilatation/blunting with cortical scarring)
Consider renal biopsy (to exclude papillary necrosis – risk is increased )
For recurrent/ chronic pyelonephritis, consider DMSA (to check for scarring and renal damage)
Management (Pyelonephritis):
Conservative:
Rest, hydration, analgesia, /anti-pyrexetics / safety netting / patient education
Admit (indication: pregnant women, severe vomiting, relapse of symptoms, inadequate access to follow-up, social issues, non-concordance with treatment, uncertain diagnosis, oliguria/ anuria, urinary tract obstruction, severe pain, dehydration, inability to take fluids/ medication, signs of sepsis, co-morbidities e.g. diabetes)
Withhold nephrotoxic medications in acute pyelonephritis
Medical:
Antibiotics e.g. cefalexin/ co-amoxiclav/ trimethoprim/ ciprofloxacin. (avoid ciprofloxacin/trimethoprim in pregnancy)
Initiate sepsis 6
Severe cases: dialysis / renal transplantation
Surgery:
If the patient does not respond well to treatment, consider renal abscess or kidney stone causing an obstruction. Consider urology referral - surgery to drain renal/perinephric abscesses / to relieve obstructions causing infection e.g. stones / stenting
Prevention:
Consider prophylactic treatment for those who have symptomatic infection >=3x a year e.g. trimethoprim
Viva Questions:
Explain the pathophysiology of pyelonephritis.
Bacterial Entry: Bacteria, commonly Escherichia coli, enter the urinary tract, often from the urethra, and ascend towards the kidneys. These bacteria multiply, causing infection.
Inflammation of Renal Tissue: The bacteria invade the renal parenchyma, leading to inflammation in the renal pelvis and the kidney tissue.
Release of Inflammatory Mediators: This invasion triggers an immune response, leading to the release of inflammatory mediators, causing damage to the renal tissues.
Obstruction or Reflux: Factors like urinary tract obstructions or vesicoureteral reflux (backward flow of urine from the bladder to the kidneys) can contribute to the persistence and severity of the infection.
Symptoms: Patients experience symptoms like fever, chills, flank pain, abdominal pain, nausea, vomiting, and urinary symptoms like frequent urination and pain during urination.
Complications: Without proper treatment, pyelonephritis can lead to abscess formation, sepsis, kidney damage, and potential scarring of renal tissue.
What are the risk factors of pyelonephritis?
Urinary Tract Abnormalities: Structural issues like kidney stones, blockages, or conditions that cause urine to flow backward towards the kidneys (vesicoureteral reflux) increase the risk.
Urinary Tract Obstructions: Conditions that hinder normal urine flow, such as an enlarged prostate, tumors, or strictures, can raise the likelihood of infection.
Catheter Use: Individuals with urinary catheters are at a higher risk due to the potential for introducing bacteria into the urinary tract.
Gender: Women have a higher susceptibility due to shorter urethras, which make it easier for bacteria to enter the urinary tract.
Pregnancy: Changes in the urinary tract during pregnancy can increase the risk of urinary tract infections, including pyelonephritis.
Weakened Immune System: Conditions or treatments that compromise the immune system, such as diabetes, HIV/AIDS, chemotherapy, or certain medications, can elevate susceptibility to infections.
Recurrent Urinary Tract Infections: Individuals with a history of frequent UTIs are at a higher risk of developing pyelonephritis.
What are the most common pathogens causing urinary tract infections?
The most common pathogens causing urinary tract infections (UTIs) include:
Escherichia coli (E. coli): E. coli is the most prevalent bacteria responsible for the majority of urinary tract infections.
Staphylococcus saprophyticus: Particularly common in young sexually active females, this bacterium is another frequent cause of UTIs.
Klebsiella pneumoniae: This bacterium is known to cause UTIs, particularly in individuals with a compromised immune system.
Proteus mirabilis: Commonly found in complicated UTIs, this bacterium is known to form kidney stones and contribute to recurrent infections.
Enterococcus species: Enterococci are becoming more prevalent as causative agents of UTIs, especially in healthcare settings.
What are the complications of pyelonephritis?
Sepsis: The infection can spread to the bloodstream, causing sepsis, a severe and life-threatening condition.
Kidney Scarring: Prolonged or recurrent infections can lead to scarring of kidney tissue, potentially affecting kidney function.
Kidney Abscess: Formation of abscesses in the kidney, leading to localized collections of pus.
Chronic Kidney Disease (CKD): Severe or untreated pyelonephritis can contribute to the development of chronic kidney disease.
High Blood Pressure (Hypertension): Kidney damage due to persistent infection can lead to hypertension.
Renal Papillary Necrosis: A rare but severe complication causing the death of kidney tissue.