ESSENTIAL UROLOGY FOR MEDICAL STUDENTS, Lecture notes of Urology

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ESSENTIAL UROLOGY FOR MEDICAL

STUDENTS

Nishanth Krishnananthan

Assistant Professor Charles Chabert

‘Build it, and they will come’

Dr Chabert is a urological surgeon with an interest in minimally invasive surgery and diseases of the prostate gland. His practice is located at John Flynn Hospital, St Vincent’s Hospital and Lismore Base Hospital. He is also an assistant professor at Bond University.

Assistant Professor Charles Chabert

As a final year medical student at Bond University, it was a pleasure working with Dr Chabert in Urology, and my experiences and knowledge attained have been reflected in this book, which I hope will serve as a tool for all medical students. It contains the essential Urology facts that a student must know in a clear and concise format, so enjoy reading.

Nishanth Krishnananthan

CHAPTER 1

Acute Scrotal Pain

Acute Scrotal Pain is the presenting symptom for a wide spectrum of surgical conditions which may present in adolescents to adults. The aim of evaluation is to identify testicular torsion due to the threat of irreversible testicular ischemia and subsequent infarction.

Differential Diagnoses

1. Testicular Torsion (16.0–39.5%)^1 **2. Torsion of Testicular Appendages

3. Epididymo-orchitis
4. Testicular Trauma
5. Testicular Neoplasm(s)**

TESTICULAR TORSION (TT)

IMPORTANT  Acute scrotal swelling in children indicates torsion of the testis until proven otherwise^2. Definition:

- Twisting or rotation of the testis on the axis of the spermatic cord. - Surgical emergency as it causes strangulation of the gonadal blood supply with subsequent testicular necrosis and atrophy - Torsion can be partial or complete (vary from 180-720°) Incidence: - Neonates/young adolescents (12-18, with a peak at 14), but can occur at any age. The prevalence is 1 in 4000 males less than 25 yrs old^3. Types:

• Extravaginal (the whole cord and its investing layers twist, 5% of all torsions^4 ). More commonly associated with the neonatal age group.
• Intravaginal usually occurs in older children (also referred to as the Bell Clapper Deformity). Causes :
• Bell-Clapper Deformity (12% of all males^5 ), a congenital abnormality in which the testicle lacks the normal attachment to the tunica vaginalis (permitting increased mobility) and rests transversely within the scrotum.
• Other: physical/sexual activity, trauma (4-8%^6 ).

Presentation:

1. Clinical features
   • Acute unilateral severe sudden onset testicular pain.
   • Nausea and vomiting (1/3 of patients, higher in paediatric population) 7
   • Abdominal pain (20-30%)^8
   • Fever (16%)^9
   • Urinary frequency (4%)^10
2. Physical examination
   • Asymmetrically high-riding testis on the affected side with horizontal lie.
   • Diffuse testicular tenderness
   • Testicular oedema + scrotal erythema
   • Ipsilateral loss of the cremasteric reflex.
   • Prehn's sign negative i.e. scrotal elevation relieves pain in epididymitis but not torsion.
3. Complications: Infarction, Infertility, Infection. Diagnosis:

• Clinical
• Colour Doppler Ultrasound (94% sensitivity, 96% specificity.) 11 Treatment:
• Urgent surgical de-torsion and fixation (orchidopexy) of both testicles due to risk of contralateral torsion in the future
• A salvage rate of 90-100% is found in patients who undergo de-torsion within 6 hours of onset of pain - the viability rate falls to 20% and 50% after 12 hours; and 0-10% if de-torsion is delayed greater than 24 hours^12.

TORSION OF TESTICULAR APPENDAGES (TTA)

Definition:

• The appendix testis (Hydatid of Morgangni), a mullerian duct remnant located at the superior pole of the testicle, is the most common appendage to undergo torsion (92%)^13. Incidence:
• 7-14 y.o. (80%), with a mean age of 10.6^14. Presentation :

1. Clinical features:

• Acute/Subacute onset of testicular pain (less severe and more gradual in onset when compared to Testicular Torsion)  Pain at superior pole of testicle.
• Patients may endure pain for several days before seeking medical attention.
• Absence of systemic symptoms (nausea/vomiting) and urinary symptoms.

2. Physical examination:

• Localised tenderness (upper pole of the testis)
• Blue dot sign  paratesticular nodule. Seen in 21% of people^15 (mainly light- skinned boys, or children due to their thin scrotal skin).
• Normal vertical lie Diagnosis:

1. Mainly clinical.
2. Testicular Ultrasound (TU)

• Cremasteric reflex is intact.
• Prehn’s sign is positive
• Scrotal oedema is present in 50% of cases^25
• Enlarged inguinal lymph nodes

3. Complications:

• Scrotal abscess, pyocele, testicular infarction, chronic epididymitis, infertility, cutaneous fistulisation. Diagnosis:

1. Mainly Clinical
2. Full Blood Count (FBC)  Leukocytosis
3. Urine M/C/S (Pyuria) + Urethral Swab Culture
4. Colour Doppler Ultrasonography (CDU) : sensitivity of 91-100% for epididymitis +/- orchitis^26 Treatment:

• Antibiotics i.e. Ceftriaxone + Doxycycline for Chlamydia/Gonorrhoea Trimethoprim-Sulfamethoxazole to cover coliforms in Pre-pubertal boys^27
• Analgesics + NSAIDS
• Scrotal support + elevation + bed rest.
• Pain generally self resolving (one week)
• Surgery considered for complications.

SUMMARY

Acute Scrotum Condition Age Cause Onset Tenderness Cremasteric Reflex

Treatment

Testicular Torsion

12 - 18 Bell-Clapper deformity

Acute Diffuse Negative Surgical de-torsion

TTA 7 - 14 Structural predisposition

Acute/ Subacute

Localised (upper pole)

Positive Bed rest + Scrotal elevation

Epididym o-orchitis

18 - 50 C.Trachomatis, E-coli, Viral

Insidious Epididymal Positive Antibiotics

NOTES

Burgher LCDR SW, Acute scrotal pain , Emerg Med Clinics of North America 1998;16(4):781-809.

J.David, S.Yale, I.Goldman, Urology: Scrotal Pain , PubMed, April 2003; 1(2): 159–160, last viewed June 2010.

S.Young, M.South, Acute Scrotal Pain or Swelling, The Royal Children’s Hospital Melbourne, April 2010, last viewed June 2010. http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5196

Siegel MJ. The acute scrotum. Radiol Clin North Am. 1997;35:959– 976

L.Galejs, E.Kass, Diagnosis and Treatment of the Acute Scrotum, American Family Physician, Feb 1999,

J.Brenner, A.Ojo, A.Middleman, G.Fleisher, M.Torchia, Evaluation of scrotal pain or swelling in children and adolescents, UpToDate, Sept 2008

Dugani S., Lam D, Toronto Notes 2009, Mcgraw Hill Professional; Canada, 2009

CHAPTER 2

Prostate Specific Antigen (PSA)

Prostate specific antigen is a serine protease produced specifically by the prostate. It can be increased by inflammation, benign prostatic hyperplasia (BPH), or by cancer of the prostate.

Role in Body

PSA liquefies the seminal fluid.

PSA Test

PSA is a blood test used to detect early prostate cancer (increased in 25-92% of people^1 ); however elevation of PSA is not specific for cancer; it can also be increased due to inflammation or BPH. Causes for an elevated PSA include:  BPH (increased in 30-50% of people^2 )  Recent rectal examination, prostate massage, prostatitis, UTI, urinary catherization,  Acute urinary retention, ejaculation and acute renal failure. Evaluation of different aspects of PSA allows improvements in the utility of the test. These include:  Age specific value  Median value  Free-total ratio  Velocity, increase the utility of the test  PSA density

1. Age- Reference values + Median values.

Age Median PSA Normal Range 40-49 0.7ng/ml 0-2.5ng/ml 50-59 0.9ng/ml 0-3.5ng/ml 60-69 1.4ng/ml 0-4.5ng/ml 70+ 0-6.5ng/ml

2. Free-Total ratio PSA is bound to alpha 1 antichymotrypsin in plasma. When produced by malignant disease, it has a higher affinity for this protein than benign produced PSA. As a result, there is an inverse correlation between F/T ratio and prostate cancer risk.  Risk of CAP is 55% if F/T ratio <10%  Risk of CAP 7% if F/T ratio >25%^3

NOTES

REFERENCES

(1,2) D.Provan, A.Krentz, Oxford Handbook of Clinical and Laboratory Investigation, 2002, UK, p 90.

(3,4) The Cancer Council Queensland, The Early Detection Of Prostate Cancer in General Practice: Supporting Patient Choice , 2007, last viewed on March 2010.

(5) S.Brosman, Prostate Specific Antigen , E-medicine Urology, April 2009, last viewed on March 24 2010.

(6) S.Parpart, A.Rudis, A. Schreck, N.Dewan, P.Warren, Sensitivity and Specificity in Prostate Cancer Screening Methods and Strategies , Georgia Institute of Technology, April 2007. Agabegi, E. Agabegi, Step up to medicine: Second edition, Lippincott Williams & Wilkins, USA, 2008, p. 289.

(7) M. Longmore, I.Wilkinsons, T. Turmezei, C.Chueng, Oxford Handbook of Clinical Medicine: Seventh Edition , 2007, New York, p. 607,681.

(8) J. Reynard, S.Brewster, S.Biers, Oxford Handbook of Urology: 1st^ edition, 2006, UK, p. 194-198.

(Table) C.Chabert, Laparoscopic Urology Australia, 2010. <http://www.laparoscopicurology.org/Default.aspx?ContentPageName=BPH Enlarged Prostate>

S.Freedland, M.O’Leary, D.Rind, Measurement of prostate specific antigen , UpToDate, Oct 2008, last viewed on March 24 2010.

National Cancer Institute of Health, Prostate-Specific Antigen (PSA) Test, U.S. National Institutes of Health, March 2009, last viewed on March 2010. http://www.cancer.gov/cancertopics/factsheet/Detection/PSA

 Bladder calculi The presence of these complications requires to bladder outlet surgery.

Prognosis

The prognostic features for BPH progression are:

1. PSA>1.
2. Prostate Volume>40cc
3. Age>
4. PVR>150mls.

Clinical assessment includes an abdominal examination and a digital rectal examination (DRE). A DRE should be done to assess prostate size and consistency, to detect nodules, indurations, and asymmetry. The prostate is usually smooth, rubbery and symmetrically enlarged in patients with BPH (median sulcus remains palpable).

Investigations

Investigating BPH includes combining History and DRE with Urinalysis, Blood tests, Imaging and occasionally a cystoscopy.

1. DRE: Assess prostate size, consistency and detect nodules, indurations, and asymmetry, all of which raise suspicion for malignancy.
2. Urinalysis : assess for the presence of blood, leukocytes, bacteria, protein, or glucose.
3. Urine M/C/S : assess for infection.
4. Urine flow studies : Evaluate max flow rate combined with post-void residual volume determination.
5. Prostate Specific Antigen : Refer to PSA testing in booklet.
6. Ultrasound KUB : useful for helping determine prostate size and screening upper tracts.
7. Cystoscopy : Allows bladder outlet assessment and exclusion of intra-vesicle pathology.
8. TRUS Prostate : may be required for the exclusion of prostate cancer in the presence of persistent elevation of PSA levels.

Treatment

Treatment for BPH involves conservative measures, pharmacological treatments or surgical interventions depending on the severity of symptoms and degree of bother.

1. Patients with mild symptoms/minimal bother.  Watchful waiting - 40% of patients improve spontaneously.^7 Includes lifestyle changes (e.g. evening fluid restriction, reducing consumption of mild diuretics such as caffeine and alcohol, planned voiding).  Herbal Therapies: Saw Palmetto^8
2. Medical treatment  Alpha-1-adrenergic antagonists (e.g. tamsulosin/Flomax, Doxazosin) reduce stromal smooth muscle tone. SEs: orthostatic hypotension and dizziness.  5-Alpha-reductase inhibitors (e.g. finasteride and dutasteride) decrease the conversion of testosterone to DHT (dihydrotestosterone). It is the second line

medical treatment and has greater efficacy when combined with Alpha-1 blockers.^9 SEs: Impotence, decreased libido. 3 Surgical Treatments   Green Light Laser Prostatectomy : Minimally invasive option with lower incidence of complications when compared to TURP.  TURP (Transurethral resection of the prostate).  Open Prostatectomy

REFERENCES

(1) Andrology Australia URL: <www.andrologyaustralia.org>

(2) McNeal JE, Redwine EA, Freiha FS, Stamey TA. Zonal distribution of prostatic adenocarcinoma. Correlation with histologic pattern and direction of spread. Am J Surg Pathol. Dec 1988;12(12):897-

(3,4) R. Leveillee, V.Patel, V.Bird, C.Moore, Prostate Hyperplasia, Benign , in E-medicine, June 2009, last viewed March 2010. http://emedicine.medscape.com/article/437359-overview

(5) Dugani S., Lam D, Toronto Notes 2009, Mcgraw Hill Professional; Canada, 2009 G.Cunningham, D.Kadmon, M.O’Leary, D.Rind, Epidemiology and pathogenesis of benign prostatic hyperplasia, UpToDate, Oct 2008.

(6) Barry, MJ, Fowler, FJ Jr, O'Leary, MP, et al. The American Urological Association Symptom Index for Benign Prostatic Hyperplasia. J Urol 1992; 148:1549. Lippincott Williams and Wilkins

(7) URL: http://www.nutrition2000.com/Q&A_BPH.cfm

(8) G.Cunningham, D.Kadmon, M.O’Leary, D.Rind, Medical treatment of benign prostatic hyperplasia, UpToDate, Oct 2008.

(9) American Urological Association Education and Research, Inc., 2003, last viewed March 2010. <http://www.auanet.org/content/guidelines-and-quality-care/clinical-guidelines/main-reports/bph- management/chapt_1_appendix.pdf>

(Image) C.Chabert, Laparoscopic Urology Australia, 2010. <http://www.laparoscopicurology.org/Default.aspx?ContentPageName=BPH Enlarged Prostate>

McConnell JD, Roehrborn CG, Bautista OM, Andriole GL Jr, Dixon CM, Kusek JW, The long-term effect of doxazosin, finasteride, and combination therapy on the clinical progression of benign prostatic hyperplasia , N Engl J Med. Dec 18 2003;349(25):2387-

G.Gerber, Enlarged Prostate, in E-medicine Health, March 2009, last viewed March 2010. http://www.emedicinehealth.com/enlarged_prostate

McConnell JD, Bruskewitz R, Walsh P, et al. The effect of finasteride on the risk of acute urinary retention and the need for surgical treatment among men with benign prostatic hyperplasia. Finasteride Long-Term Efficacy and Safety Study Group. N Engl J Med. Feb 26 1998;338(9):557-

F.Gardiner, Prostate Enlargement Fact Sheet, Andrology Australia, March 2006. http://www.andrologyaustralia.org/docs/Factsheet_ProstateEnlargement.pdf

G.Cunningham, D.Kadmon, M.O’Leary, D.Rind, Clinical manifestations and diagnosis of benign prostatic hyperplasia, UpToDate, Aug 2008.

Madersbacher S, Marszalek M, Lackner J, Berger P, Schatzl G. The long-term outcome of medical therapy for BPH. Eur Urol. Jun 2007; 51(6):1522-33.

P. Kumar, M. Clark, Kumar and Clark: Clinical Medicine Sixth edition, Elsevier Saunders, United Kingdom, 2006, p. 685.

G.Cunningham, D.Kadmon, M.O’Leary, D.Rind, Surgical and other invasive therapies of benign prostatic hyperplasia , UpToDate, March 2008.

APPENDIX

(1) C.Chabert, Laparoscopic Urology Australia