Urology

Dr. Faraaz de Belder Ex-Surgical House Officer Leeds

Important bits

Kidneys
Tubes Bladder Outflow Tract

You can and will get problems at each point.

Case 1

45 yo man with sudden onset right sided loin to groin pain. Nausea, vomiting, in pain. Diabetic, smoker. WCC 15 Neut 9 Hb 14 CRP 140
Ur 10 Cr 100

Stones

Stones:

-Acute, sudden onset LOIN TO GROIN pain

Colicky HAEMATURIA 90% radioopaque

Rule out AAA, appendix, ectopic Investigation: CT KUB

MCC: Calcium oxalate

Hurt like hell because they are spikey

Nidus for infection! Stones >6mm are unlikely to pass-ureteric diameter

Stones < or equal 4mm will pass

Where's the stone?

Where's the stone?

Renal: Loin pain. COLICKY pain= impacted PUJ Ureter: Severe colicky loin to groin, nausea, vomiting Bladder: Suprapubic pain, terminal haematuria, dysuria

Practical points as a HO

Bloods: FBC U&E CRP

Imaging: CT KUB/USS KUB

Rx: Pain relief! NSAIDs (e.g. diclofenac)

Urology: If >6mm, signs of obstruction or pyelo. Rx: Percutaneous nephrostomy Lithotripsy

Hydronephrosis

Good Bad

Case 2

You are called to see an old chap who is in extreme abdominal discomfort. Abdomen is diffusely tender. Ballotable mass extending to umbilicus
Tachycardic, hypotensive.

U&Es Ur 20 Cr 250

Hydronephrosis

ALWAYS A POST RENAL CAUSE

-Stone -Mass (?compressing ureter, bladder) -Post renal cause

Tips for a HO

Bladder scan-High volume = bladder outflow

Empty bladder = ureteric obstruction Put a drip up and a tube down (sorry anaesthetists) Cannula in, catheter down

COUDE tip catheter for big prostates!

?PR for a big prostate Always consider retention in elderly ado pain-can't always tell you what's up.

INFECTIONS

Case 3

24 year old female with history of dysuria and frequency Urine dip: Leukocytes ++ Nitrites + Blood +

UTI

Likely cystitis
Coliform Need to exclude pyelonephritis. Check temp and WCC

Ix: Always send MSU for + urine dip

Rx: Trimethoprim 200mg PO BD 3/7 supply Alternatives: Nitrofurantoin, amoxicillin, TMP-SMX

Negative urine dip but symptomatic? Send MSU and treat anyway.

Men shouldn't get UTIs=?abnormal KUB-arrange USS

What is a urine dip?!

We all know the basics

NitrItes: Coliforms convert urine nitrates to nitrites.

Leukocytes: WCC. Some sort of infection/inflammation SG: How concentrated the urine is (therefore how dry are they?)

Case 4

18 year old fresher comes in with painful urination, normal urine dip.

Urethritis

In males=STI in exams.
Arrange chlamydia/gonococcal PCR Empirical therapy: Cefuroxime + doxy/azithro

Cancers

Case 4

60 year old leather worker presents with painless haematuria, shortness of breath and a persistent temperature of 38.0 degrees.
Bloods: Hb 7.0, WCC 10.5 Plats 700 CRP 200

Renal Cell Carcinoma

Painless haematuria + older = Cancer until proven otherwise

Leather/clothes/petroleum workers=Aniline dyes/hydrcarbons Smokers.

Derived from renal tubular epithelium-adenocarcinoma

Spreads everywhere (liver, lungs cannonballs, bone) Rx: Local= Nephrectomy (70% 5 year survival) Mets=Palliative radio + chemo

Bladder Cancer

MOST COMMON urological cancer

Transition cell usually. Worms or stones cause squamous cell cancers. Spreads everywhere. Do a transurethral resection/cystoscopy intracystic chemo.

Prostates

BPH vs Prostate Cancer: the big conundrum

Benign Prostatic HYPERTROPHY PSA rises in cancer not BPH BPH Sx: Hesistancy + poor stream. Dribbling, retention, stale urine smell Rx: Tamsulosin and TURP

PR: 'Smooth enlarged prostate'

Prostatic Cancer:

Most common male cancer. 52% localised to prostate on presentation.

Sx: Pale, bony pain, atraumatic fractures, 'hard craggy prostate', raised PSA Bony mets common: 'Sclerotic lesions'
Rx: Radical radiotherapy, prostatectomy, brachytherapy

The Interesting Stuff!!

The life of a surgical HO.

Brutal. On calls are gargantuan. 250 patients, 8 wards, two bleeps, SHO somewhere, one FY1. Young, sick patients. High turnover. Stuffs you will see.....

1.) Renal failure (in all shapes and forms)

2.) Hyperkalaemia (6.0-7.0) 3.) Pain 4.) Sepsis, sepsis, sepsis 5.) Acute LVF

6.) Acute abdomens/perfs

Case 5
(True Story)

It is 4AM. The hospital is exploding, you are bleeped about: 90 year old demented, blind man admitted from nursing home with delirium.

Pulled out five (!) cannulas overnight.

You have been called because BP is now 80/40

Urine output is nil.

Obs: Hr 100 BP 80/40 Temp 37.8 RR 14 Sats 95% room air Bloods taken at 0100: Ur 14 Cr 300 (not known previous renal failure)

Take control.

Establish how urgent this is: Deteriorating patient. ACUTE KIDNEY INJURY
Is this prerenal, renal or postrenal?

Prerenal: Is the patient dry? Sepsis

Renal: Hardest to diagnose ?exclusion as F1 Postrenal: Easy, bladder scan and catheter

Plan of action:
Drip up, tube down. 1500Mls of volplex bolused. Thick pea soup out of catheter Diagnosis: Urosepsis with prerenal/postrenal failure.

Prerenal:
Ur is raised in proportion to Cr because of increased reabsorbtion

Not enough fluid going to kidney.

Sepsis, hypovolaemia, cardiac failure

Renal
Drug induced Glomerulonephritis Interstitial Nephritis

Case 6

It is hour 10 of a 12 hour long day. You are chasing bloods.

JS 30/12/1954 Day 3 post Whipples Hb 10.5 WCC 10 Plat 300

Ur 4.5 Cr 90 K 7.1 Na 145

CRP 90 ALT 150 ALP 300 Bili 5

Hyperkalaemia

You will get called about this during your first week on call!

Do not panic. Rarely causes arrythmias.

Check drugs, cross off spiro/K+ containing fluids

<6.0=Do nothing 6.0-7.0=ECG + salbutamol nebs+ insulin/dex >7.0=All of above + calcium gluconate

Final slide!

Some tips:

Get good at cannulas, now. Aim to get all your invasive stuff done before midnight.

Aim to get a sleep on nights.

Learn to be autonomous Sick patients are sick: they trump EDANS, chasing, etc

Trust YOUR judgement.

500ml bolus =