Question 1 of 63

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A 67 year old man presents with recurrent episodes of haematuria, typically at the
end of the urinary stream, he has been suffering from occasional fevers and has
noticed pus on the urethral meatus on occasion. On examination the prostate has
no discernable masses but is tender. What is the most likely cause?

Prostatitis

Cystitis

BPH

Prostate cancer

Nephritis

This is most likely prostatitis and the bleeding at the end of micturition suggests a
distal problem. Treatment is usually with prolonged courses of antibiotics.

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Benign prostatic disease

BPH is increasingly common with advancing age and is present in 50% over the
age of 60 and nearly 90% of men by the age of 90. It occurs as a result of
hyperplasia of the periurethral glands in the transitional zone of the prostate.
Androgens play a role in the development and progression of BPH. Testosterone
diffuses into prostatic and stromal cells. Within epithelial cells it binds to the
androgen receptor. In prostatic stromal cells, a small proportion binds directly to
the androgen receptor, the majority binds to the 5 alpha reductase type II receptor
on the nuclear membrane. This is converted to dihyroxytestosterone and then
binds to the androgen receptor. Dihydroxytestosterone has even greater affinity for
the androgen receptor than testosterone does. The end result is stimulation of
these cells and proliferation.
 This proliferative activity results in varying degrees of obstruction and results in
lower urinary tract obstructive symptoms. The clinical diagnosis of BPH thus
comprise a degree of lower urinary tract symptoms, palpable prostatic
enlargement and evidence of impaired voiding on urodynamic assessment.
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Presentation
Some patients have minimal symptoms, yet, on examination, have a palpable
bladder and obstructive post renal failure. LUTS can be divided into two main
groups; obstructive symptoms with voiding that include hesitancy, poor stream,
straining, prolonged micturition and dribbling; others develop irritation symptoms
which include pain during bladder filling, frequency, urgency and nocturia. Some
present with retention and haematuria.

Diagnosis
Abdominal and rectal examination
Symptoms scoring
Urodynamic studies ( a post void volume of >100ml is significant)

Management
Conservative
Alpha adrenergic antagonists. These block the action of noradrenaline on prostatic
smooth muscle causing relaxation and improved bladder emptying.
5 alpha reductase inhibitors. Finasteride blocks the enzyme 5 alpha reductase
which inhibits the conversion of testosterone to DHT. This in turn reduces
intracellular activity and decreases prostatic volume
Surgery- TURP is the gold standard. Occasionally, an open retropubic
prostatectomy may be considered for a large gland.

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Question 2 of 63
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A 15 year old boy develops sudden onset of pain in the left hemiscrotum. He has
no other urinary symptoms. On examination, the superior pole of the testis is
tender and the cremasteric reflex is particularly marked. What is the most likely
underlying diagnosis?

Epididymo-orchitis

Torsion of the testis

Torsion of a testicular hydatid

Viral orchitis

Testicular malignancy

The cremasteric reflex is usually preserved when the torsion affects the
appendage only.

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Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years.
Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell
tumours may essentially be divided into:

Tumour
Tumour type Key features markers Pathology
 Tumour
Tumour type Key features markers Pathology

Seminoma Commonest AFP usually Sheet like

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subtype normal lobular

(50%) HCG elevated patterns of
Average in 10% cells with
age at seminomas substantial
diagnosis = Lactate fibrous
40 dehydrogenase; component.
Even elevated in Fibrous septa
advanced 10-20% contain
disease seminomas lymphocytic
associated (but also in inclusions
with 5 year many other and
survival of conditions) granulomas
73% may be seen.

Non seminomatous Younger age at AFP elevated in Heterogenous

germ cell tumours presentation up to 70% of texture with
(42%) =20-30 years cases occasional
Teratoma Advanced disease HCG elevated ectopic tissue
Yolk sac tumour carries worse in up to 40% of such as hair
Choriocarcinoma prognosis (48% at cases
Mixed germ cell 5 years) Other markers
tumours (10%) Retroperitoneal rarely helpful
lymph node
dissection may be
needed for
residual disease
after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more

uniform than teratomas
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(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb090b.jpg)
Image sourced from Wikipedia
(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org
/images_eMRCS/swb090b.jpg)
/wiki/Seminoma)

Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis

Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
 Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
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Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require
retroperitoneal lymph node dissection.

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the
testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea
or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which
resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Most common in males aged between 10 and 30 (peak incidence 13-15
years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then
both testis should be fixed as the condition of bell clapper testis is often
bilateral.

Hydrocele
Presents as a mass that transilluminates, usually possible to 'get above' it
on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
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Question 3 of 63
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A 22 year old man is involved in a road traffic accident. He is found to have a pelvic
fracture. While on the ward the nursing staff report that he is complaining of lower
abdominal pain. On examination, you find a distended tender bladder. What is the
most likely diagnosis?

Bladder rupture

Ureter injury

Urethral injury

Clot retention

Prostate rupture

Pelvic fractures may cause laceration of the urethra. Urinary retention, blood at the
urethral meatus and a high riding prostate on digital rectal examination are the
typical features.

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Lower genitourinary tract trauma

Most bladder injuries occur due to blunt trauma

85% associated with pelvic fractures
Easily overlooked during assessment in trauma
Up to 10% of male pelvic fractures are associated with urethral or bladder
injuries

Types of injury
 Urethral injury Mainly in males
Blood at the meatus (50% cases)
There are 2 types:
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i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma,
blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing
retroperitoneal haematomas as they may make
examination difficult)

- Investigation: ascending urethrogram

- Management: suprapubic catheter (surgical
placement, not percutaneously)

External genitalia Secondary to injuries caused by penetration,

injuries (i.e., the penis blunt trauma, continence- or sexual pleasure-
and the scrotum) enhancing devices, and mutilation

Bladder injury rupture is intra or extraperitoneal

presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void:
always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the
bladder through a Foley catheter indicates
bladder injury
investigation- IVU or cystogram
management: laparotomy if intraperitoneal,
conservative if extraperitoneal

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Question 4 of 63
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A 32 year old male presents with a swollen, painful right scrotum after being
kicked in the groin area. There is a painful swelling of the right scrotum and the
underlying testis cannot be easily palpated. What is the best course of action?

Inguinal orchidectomy

Scrotal orchidectomy

Scrotal exploration

Testicular USS

Testicular aspiration

Acute haematocele: tense, tender and non transilluminating mass. The testis will
need surgical exploration to evacuate the blood and repair any damage.

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Scrotal swelling

Differential diagnosis

Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on

examination
Cough impulse may be present
May be reducible

Testicular Often discrete testicular nodule (may have associated

tumours hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required
 Acute epididymo- Often history of dysuria and urethral discharge
orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
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Infections with other gram negative organisms may be

associated with underlying structural abnormality

Epididymal cysts Single or multiple cysts

May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on
examination

Hydrocele Non painful, soft fluctuant swelling

Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young
men

Testicular torsion Severe, sudden onset testicular pain

Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by
elevation
Urgent surgery is indicated, the contra lateral testis should
also be fixed

Varicocele Varicosities of the pampiniform plexus

Typically occur on left (because testicular vein drains into
renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles
may affect fertility

Management
Testicular malignancy is always treated with orchidectomy via an inguinal
approach. This allows high ligation of the testicular vessels and avoids
exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children
can be difficult to elicit. Intermittent torsion is a recognised problem. The
treatment is prompt surgical exploration and testicular fixation. This can be
achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about
testicular function of infertility then surgery or radiological management can
be considered.
 Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying
pathology is a patent processus vaginalis and therefore an inguinal
approach is used in children so that the processus can be ligated. In adults
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a scrotal approach is preferred and the hydrocele sac excised or plicated.

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Question 5 of 63
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A 34 year old woman from Chad presents with continuous dribbling incontinence
after having her 2nd child. Apart from prolonged labour the woman denies any
complications related to her pregnancies. She is normally fit and well. What is the
most likely diagnosis?

Vesicovaginal fistula

Stress urinary incontinence

Overactive bladder syndrome

Colovesical fistula

Pudendal neuropathy

Vesicovaginal fistulae should be suspected in patients with continuous dribbling

incontinence after prolonged labour and from an area with limited obstetric
services.

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Urinary incontinence

Involuntary passage of urine. Most cases are female (80%). It has a prevalence of
11% in those aged greater than 65 years. The commonest variants include:
Stress urinary incontinence (50%)
Urge incontinence (15%)
Mixed (35%)

Males
Males may also suffer from incontinence although it is a much rarer condition in
men. A number of anatomical factors contribute to this. Males have 2 powerful
 sphincters; one at the bladder neck and the other in the urethra. Damage to the
bladder neck mechanism is a factor in causing retrograde ejaculation following
prostatectomy. The short segment of urethra passing through the urogenital
diaphragm consists of striated muscle fibres (the external urethral sphincter) and
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smooth muscle capable of more sustained contraction. It is the latter mechanism

that maintains continence following prostatectomy.

Females
The sphincter complex at the level of bladder neck is poorly developed in females.
As a result the external sphincter complex is functionally more important, its
composition being similar to that of males. Innervation is via the pudendal nerve
and the neuropathy that may accompany obstetric events may compromise this
and lead to stress urinary incontinence.

Innervation
Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic
nerves. Autonomic nerves travel in these nerve fibres too. Bladder filling leads to
detrusor relaxation (sympathetic) coupled with sphincter contraction. The
parasympathetic system causes detrusor contraction and sphincter relaxation.
Overall control of micturition is centrally mediated via centres in the Pons.

Stress urinary incontinence

50% of cases, especially in females.
Damage (often obstetric) to the supporting structures surrounding the
bladder may lead to urethral hypermobility.
Other cases due to sphincter dysfunction, usually from neurological
disorders (e.g. Pudendal neuropathy, multiple sclerosis).

Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary
passage of urine during episodes of raised intra-abdominal pressure.

Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of
urine. When the sphincter completely fails there is often to continuous passage of
urine.

Urge incontinence
In these patients there is sense of urgency followed by incontinence. The detrusor
muscle in these patients is unstable and urodynamic investigation will
demonstrate overactivity of the detrusor muscle at inappropriate times (e.g.
Bladder filling). Urgency may be seen in patients with overt neurological disorders
and those without. The pathophysiology is not well understood but poor central
and peripheral co-ordination of the events surrounding bladder filling are the main
processes.

Assessment
Careful history and examination including vaginal examination for cystocele.
 Bladder diary for at least 3 days
Consider flow cystometry if unclear symptomatology or surgery considered and
diagnosis is unclear.
Exclusion of other organic disease (e.g. Stones, UTI, Cancer)
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Management
Conservative measures should be tried first; Stress urinary incontinence or mixed
symptoms should undergo 3 months of pelvic floor exercise. Over active bladder
should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered oxybutynin (or
solifenacin if elderly) if conservative measures fail.
In women with detrusor instability who fail non operative therapy a trial of sacral
neuromodulation may be considered, with conversion to permanent implant if
good response. Augmentation cystoplasty is an alternative but will involve long
term intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be
undertaken. Where cystocele is present in association with incontinence it should
be repaired particularly if it lies at the introitus.

NICE guidelines
Initial assessment urinary incontinence should be classified as stress/urge
/mixed.
At least 3/7 bladder diary if unable to classify easily.
Start conservative treatment before urodynamic studies if a diagnosis is
obvious from the history
Urodynamic studies if plans for surgery.
Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
Urge incontinence: Bladder training >6/52, if fails for oxybutynin
(antimuscarinic drugs) then sacral nerve stimulation.
Pelvic floor exercises offered to all women in their 1st pregnancy.

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Question 6 of 63
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A 23 year old man presents with severe loin to groin pain. Imaging demonstrates a
2mm left sided calculus in the distal ureter, renal function is normal. What is the
most appropriate course of action?

Arrange for ureteroscopy and stone extraction

Arrange for open ureterotomy and stone extraction

Arrange for a percutaneous nephrolithotomy

Arrange for extracorporeal shock wave lithotripsy

Arrange to review the patient in 2 weeks with a KUB x-ray

Rate of stone passage

Stone size Chances of stone passage

1mm 85%

2-4mm 75%

5-7mm 60%

Distally sited stones are more likely to pass spontaneously than proximally sited
ones.

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Management of renal stones

Urolithiasis will affect up to 15% of the worldwide population. The development of

sudden onset loin to groin pain which is colicky in nature is a classic feature in the
 history. It is nearly always associated with haematuria that is either visible or non-
visible but detectable on urine dipstick testing. Where the diagnosis is suspected
the most sensitive and specific investigation is helical, non-contrast, computerised
tomographic (CT) scanning.
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Management
Most renal stones measuring less than 5mm in maximum diameter will typically
pass within 4 weeks of symptom onset(1)(2). More urgent treatment is indicated in
the presence of ureteric obstruction, renal developmental abnormalities such as
horseshoe kidney and previous renal transplant. Ureteric obstruction together with
infection is a surgical emergency and the system must be decompressed. Options
include nephrostomy tube placement or ureteric stent placement via cystoscopy.

In the non-emergency setting the preferred options for treatment of stone disease
include extracorporeal shock wave lithotripsy (ESWL), percutaneous
nephrolithotomy (PCNL) and ureteroscopy (URS). These minimally invasive options
are the most popular first line treatments. Open surgery remains an option in a few
selected cases.

Extracorporeal shock wave lithotripsy

A shock wave is generated external to the patient. Internally, cavitation bubbles
and mechanical stress lead to stone fragmentation. The passage of shock waves
can occasionally result in the development of solid organ injury. Fragmentation of
larger stones may result in the development of ureteric obstruction. The procedure
can be uncomfortable for patients and analgesia is often required during the
procedure and afterwards. ESWL is contra-indicated in pregnant females and
patients with significant vascular calcification.

Ureteroscopy
A ureteroscope is passed retrograde via the urethra and bladder, into the ureter and
renal pelvis. Laser or pneumatic fragmentation (lithoclasty) is performed using the
ureteroscope and stone fragments are extracted(3). In some cases a stent is left in
situ after the procedure.

Percutaneous nephrolithotomy
In this procedure percutaneous access is gained to the renal collecting system.
Once access is achieved, endoscopic intra-corporeal lithotripsy, lithoclasty or laser
stone fragmentation is performed and stone fragments removed.

Therapeutic selection

Renal stones

Size First line option

Less than 5mm and asymptomatic Watchful waiting

 Less than 10mm ESWL

10 20mm ESWL or ureteroscopy

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Greater than 20mm (including staghorn calculi) PCNL

Ureteric stones

Size First line option

Less than 5mm Watchful waiting

5-10mm ESWL

10-20mm Ureteroscopy

Reference
1. Bultitude M, Rees J. Management of renal colic. BMJ. 2012;345(7872):18.
2. Shah TT, Gao C, Peters M, Manning T, Cashman S, Nambiar A, et al. Factors
associated with spontaneous stone passage in a contemporary cohort of patients
presenting with acute ureteric colic: results from the Multi-centre cohort study
evaluating the role of Inflammatory Markers In patients presenting with acute
ureteric . BJU Int. 2019 Apr.
3. BAUS. Ureteroscopy (Telescopic surgery for stone removal) (Internet). BAUS
patient information leaflet. 2017 (cited 2019 Jun 27). p. 16. Available from:
https://www.baus.org.uk/userfiles/pages/files/Patients/Leaflets/Ureteroscopy for
stone.pdf
4. BAUS. Percutaneous nephrolithotomy (keyhole surgery for kidney stones). BAUS
patient information leaflet. 2017. p. 16. Available from: https://www.baus.org.uk
/userfiles/pages/files/Patients/Leaflets/PCNL.pdf
5. NICE. Renal and ureteric stones: assessment and management. NICE
Guide[NG118]. 2019;(January):112.

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Question 7 of 63
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A 42 year old man underwent a vasectomy at the surgical clinic. He is reviewed at

the request of his general practitioner. On examination he has a small rounded
nodule adjacent to the vas. What is the most likely underlying diagnosis?

Haematoma

Sperm granuloma

Varicocele

Hydrocele

Epididymal cyst

Sperm granulomas are a common sequelae of vasectomy and are smooth round
lumps adherant to the vas. They may be safely left alone.

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Vasectomy

Vasectomy is a commonly performed technique for achieving permanent

sterilisation. It has a failure rate of 1 in 2000 and is conveniently performed under
local anaesthesia.
Reversal success rates are approximately 55% if performed within 10 years of the
procedure. For the purposes of counseling the procedure should be deemed
permanent.

Procedure
Small bilateral incisions and formal dissection of the vas is the standard
technique. A technique involving the use of haemostats for skin puncture is used
in the 'no scalpel'
technique. It is not necessary to routinely send the vas for histology.
 Controversies
Be wary of performing the procedure in childless, single men under age 30.
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Risks
Following the procedure between 12 and 52% of men reported chronic scrotal
pain. Of which 5.2% sought help. Haematomas and sperm granulomas may also
occur.

Follow up
Viable sperm may persist following surgery. Clearance should not be granted until
a negative sperm sample is available. This is usually taken after 12-16 weeks post
procedure (and preferably after 24 ejaculates). Recanalisation may occur in 0.04%
of cases.In a small minority of men, non-motile sperm persist after vasectomy. In
such cases, 'special clearance' to stop contraception may be given when less than
10,000 non-motile sperm/mL are found in a fresh specimen examined at least 7
months after vasectomy.
The risks of STI's are unchanged.

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Question 8 of 63
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A 32 year old male presents with a swollen right scrotum which has developed
over 3 weeks after being kicked in the groin area. There is a non tense swelling of
the right scrotum and the underlying testis cannot be easily palpated. A dipstick is
positive for nitrates only. What is the most likely diagnosis?

Epididymo-orchitis

Testicular torsion

Torsion of testicular appendage

Hydrocele

Haematocele

Haematoceles develop over minutes/ hours and occur after the event

This is a secondary hydrocele which occurs in patients aged 20-40 years. It

develops over days/ weeks and there may not be a tense swelling. The underlying
testis is NOT palpated therefore indicating a hydrocele. Causes include trauma,
infection and tumour.

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Scrotal swelling

Differential diagnosis
 Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on
examination
Cough impulse may be present
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May be reducible

Testicular Often discrete testicular nodule (may have associated

tumours hydrocele)
Symptoms of metastatic disease may be present
USS scrotum and serum AFP and β HCG required

Acute epididymo- Often history of dysuria and urethral discharge

orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be
associated with underlying structural abnormality

Epididymal cysts Single or multiple cysts

May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on
examination

Hydrocele Non painful, soft fluctuant swelling

Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young
men

Testicular torsion Severe, sudden onset testicular pain

Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by
elevation
Urgent surgery is indicated, the contra lateral testis should
also be fixed

Varicocele Varicosities of the pampiniform plexus

Typically occur on left (because testicular vein drains into
renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles
may affect fertility

Management
 Testicular malignancy is always treated with orchidectomy via an inguinal
approach. This allows high ligation of the testicular vessels and avoids
exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

can be difficult to elicit. Intermittent torsion is a recognised problem. The

treatment is prompt surgical exploration and testicular fixation. This can be
achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about
testicular function of infertility then surgery or radiological management can
be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying
pathology is a patent processus vaginalis and therefore an inguinal
approach is used in children so that the processus can be ligated. In adults
a scrotal approach is preferred and the hydrocele sac excised or plicated.

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Question 9 of 63
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Which of the following renal stone types is most radiodense on a plain x-ray?

Calcium phosphate

Calcium oxalate

Uric acid

Struvite

Cystine

Calcium phosphate stones are the most radiodense stones, calcium oxalate
stones slightly less so. Uric acid stones are radiolucent (unless they have calcium
contained within them).

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Renal stones

Type of Percentage of
stones Features all calculi
 Type of Percentage of
stones Features all calculi

Calcium Hypercalciuria is a major risk factor (various 85%

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oxalate causes)
Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate
forms complexes with calcium making it more
soluble
Stones are radio-opaque (though less than
calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to
which calcium oxalate binds

Cystine Inherited recessive disorder of 1%

transmembrane cystine transport leading to
decreased absorption of cystine from
intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain
sulphur

Uric acid Uric acid is a product of purine metabolism 5-10%

May precipitate when urinary pH low
May be caused by diseases with extensive
tissue breakdown e.g. malignancy
More common in children with inborn errors of
metabolism
Radiolucent

Calcium May occur in renal tubular acidosis, high 10%

phosphate urinary pH increases supersaturation of urine
with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase
risk of stone formation (types 2 and 4 do not)
Radio-dense stones (composition similar to
bone)

Struvite Stones formed from magnesium, ammonium 2-20%

and phosphate
Occur as a result of urease producing bacteria
(and are thus associated with chronic
infections)
Under the alkaline conditions produced, the
crystals can precipitate
Slightly radio-opaque
 Effect of urinary pH on stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as
purine metabolism will produce uric acid. Then the urine becomes more alkaline
(alkaline tide). When the stone is not available for analysis the pH of urine may
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help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium phosphate Normal- alkaline >5.5

Calcium oxalate Variable 6

Uric acid Acid 5.5

Struvate Alkaline >7.2

Cystine Normal 6.5

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Question 10 of 63
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An 83 year old man with a long standing staghorn calculus presents with recurrent
haematuria and investigation shows a mass of the left renal pelvis. Of the lesions
listed below, the diagnosis is:

Squamous cell carcinoma

Adenocarcinoma

Transitional cell carcinoma

Sarcoma

Transitional metaplasia

SCC of the kidney usually arises in an area of chronic inflammation such as a

staghorn calculus. They are rare.

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Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to
arise from the proximal convoluted tubule. They are usually solid lesions, up to
20% may be multifocal, 20% may be calcified and 20% may have either a cystic
component or be wholly cystic. They are often circumscribed by a pseudocapsule
of compressed normal renal tissue. Spread may occur either by direct extension
into the adrenal gland, renal vein or surrounding fascia. More distant disease
usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are
more commonly affected than females and sporadic tumours typically affect
patients in their sixth decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin
 pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less
than 10% have the classic triad of haematuria, pain and mass.

Investigation
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Many cases will present as haematuria and be discovered during diagnostic work
up. Benign renal tumours are rare, so renal masses should be investigated with
multislice CT scanning. Some units will add an arterial and venous phase to the
scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be
undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory

before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent
oncological results to total radical nephrectomy. Partial nephrectomy may also be
performed when there is inadequate reserve in the remaining kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may
be performed via a laparoscopic or open approach. Preoperative embolisation is
not indicated nor is resection of uninvolved adrenal glands. During surgery early
venous control is mandatory to avoid shedding of tumour cells into the circulation.

Patients with completely resected disease do not benefit from adjuvant therapy
with either chemotherapy or biological agents. These should not be administered
outside the setting of clinical trials.

Patients with transitional cell cancer will require a nephroureterectomy with

disconnection of the ureter at the bladder.

References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update.
European Urology 2010 (58): 398-406.

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Question 11 of 63
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A 20 year old male notices a mild painful swelling of his right scrotum. He also
complains of abdominal pain. Clinically, the patient is found to have a swollen right
testicle. Apart from a supraclavicular node, there is no obvious lymphadenopathy.
What is the best course of action?

Orchidectomy via a scrotal approach

Tru cut biopsy of the testis

FNAC of the testis

Orchidectomy via an inguinal approach

Administration of antibiotics

The patient is likely to have a teratoma which has metastasized to the

supraclavicular nodes. There is suspicion of spread to the para-aortic nodes due to
the abdominal pain. He will need orchidectomy and combination chemotherapy.
There is no role for orchidectomy via scrotal approach in malignancy.

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Scrotal swelling

Differential diagnosis

Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on

examination
Cough impulse may be present
May be reducible
 Testicular Often discrete testicular nodule (may have associated
tumours hydrocele)
Symptoms of metastatic disease may be present
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

USS scrotum and serum AFP and β HCG required

Acute epididymo- Often history of dysuria and urethral discharge

orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be
associated with underlying structural abnormality

Epididymal cysts Single or multiple cysts

May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on
examination

Hydrocele Non painful, soft fluctuant swelling

Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young
men

Testicular torsion Severe, sudden onset testicular pain

Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by
elevation
Urgent surgery is indicated, the contra lateral testis should
also be fixed

Varicocele Varicosities of the pampiniform plexus

Typically occur on left (because testicular vein drains into
renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles
may affect fertility

Management
Testicular malignancy is always treated with orchidectomy via an inguinal
approach. This allows high ligation of the testicular vessels and avoids
exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children
can be difficult to elicit. Intermittent torsion is a recognised problem. The
 treatment is prompt surgical exploration and testicular fixation. This can be
achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about
testicular function of infertility then surgery or radiological management can
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying
pathology is a patent processus vaginalis and therefore an inguinal
approach is used in children so that the processus can be ligated. In adults
a scrotal approach is preferred and the hydrocele sac excised or plicated.

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Question 12 of 63
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A 28 year old man presents with pain in the testis and scrotum. It began 10 hours
previously and has worsened during that time. On examination, he is pyrexial, the
testis is swollen and tender and there is an associated hydrocele. What is the most
likely diagnosis?

Torsion of testicular hydatid

Torsion of the testis

Testicular seminoma

Acute epididymo-orchitis

Torsion of the spermatic cord

The onset is relatively slow for torsion and the presence of fever favors epididymo-
orchitis.

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Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years.
Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell
tumours may essentially be divided into:

Tumour
Tumour type Key features markers Pathology
 Tumour
Tumour type Key features markers Pathology

Seminoma Commonest AFP usually Sheet like

gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

subtype normal lobular

(50%) HCG elevated patterns of
Average in 10% cells with
age at seminomas substantial
diagnosis = Lactate fibrous
40 dehydrogenase; component.
Even elevated in Fibrous septa
advanced 10-20% contain
disease seminomas lymphocytic
associated (but also in inclusions
with 5 year many other and
survival of conditions) granulomas
73% may be seen.

Non seminomatous Younger age at AFP elevated in Heterogenous

germ cell tumours presentation up to 70% of texture with
(42%) =20-30 years cases occasional
Teratoma Advanced disease HCG elevated ectopic tissue
Yolk sac tumour carries worse in up to 40% of such as hair
Choriocarcinoma prognosis (48% at cases
Mixed germ cell 5 years) Other markers
tumours (10%) Retroperitoneal rarely helpful
lymph node
dissection may be
needed for
residual disease
after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more

uniform than teratomas
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb090b.jpg)
Image sourced from Wikipedia
(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org
/images_eMRCS/swb090b.jpg)
/wiki/Seminoma)

Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis

Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
 Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require
retroperitoneal lymph node dissection.

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the
testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea
or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which
resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Most common in males aged between 10 and 30 (peak incidence 13-15
years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then
both testis should be fixed as the condition of bell clapper testis is often
bilateral.

Hydrocele
Presents as a mass that transilluminates, usually possible to 'get above' it
on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
 Next question 
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Question 13 of 63
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What is the most useful test for a 5 year old who has vesicoureteric reflux in whom
there are concerns about the potential of renal scarring?

Intravenous urogram

Renal CT scan

DMSA scan

Micturating cystourethrogram

Retrograde ureterogram

Although MAG 3 renograms may provide some information relating to the

structural integrity of the kidney, many still consider a DMSA scan to be the gold
standard for the detection of renal scarring (which is the main concern in PUJ
obstruction and infections).

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Functional renal imaging

DMSA scan
Dimercaptosuccinic acid (DMSA) scintigraphy
DMSA localises to the renal cortex with little accumulation in the renal papilla and
medulla. It is useful for the identification of cortical defects and ectopic or
aberrant kidneys. It does not provide useful information on the ureter of collecting
system.

Diethylene-triamine-penta-acetic acid (DTPA)

This is primarily a glomerular filtration agent. It is most useful for the assessment
of renal function. Because it is filtered at the level of the glomerulus it provides
useful information about the GFR. Image quality may be degraded in patients with
 chronic renal impairment and derangement of GFR.

MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily
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secreted by tubular cells rather than filtered at the glomerulus. This makes it the
agent of choice for imaging the kidneys of patients with existing renal impairment
(where GFR is impaired).

Micturating cystourethrogram (MCUG scan)

This scan provides information relating to bladder reflux and is obtained by filling
the bladder with contrast media (via a catheter) and asking the child to void.
Images are taken during this phase and the degree of reflux can be calculated

Intra venous urography

This examination is conducted by the administration of intravenous iodinated
contrast media. The agent is filtered by the kidneys and excreted and may provide
evidence of renal stones or other structural lesions. A rough approximation of renal
function may be obtained using the technique. But it is not primarily a technique to
be used for this purpose. With the advent of widespread non contrast CT scan
protocols for the detection of urinary tract calculi it is now rarely used.

PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of
malignancy.

References
Davis A et al. Investigating urinary tract infections in children. BMJ 2013
(346):35-37.

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Question 14 of 63
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A 56 year old man presents with urinary symptoms and on investigation is found to
have a 2cm nodule in the left lobe of the prostate. Imaging with whole body MRI
and pelvic CT/MRI demonstrates a likely cancer with no distant disease and no
nodal metastasis. What is the most appropriate course of action?

Robotic prostatectomy

Open prostatectomy

Transvesical prostatectomy

Prostatic biopsy

Radical pelvic radiotherapy

Prostate cancers are typically biopsied prior to treatment.

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Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the
condition each year. Up to 9,000 will die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging.
 PSA Test
The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients
with benign disease and some with localised prostate cancer. False positives may
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be due to prostatitis, UTI, BPH, vigorous DRE.

The percentage of free: total PSA may help to distinguish benign disease from
cancer. Values of <20% are suggestive of cancer and biopsy is advised.

Pathology
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple
biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most
dominant grade (on scale of 1-5) and 2 for second most dominant grade
(scale 1-5). The two added together give the Gleason score. Where 2 is best
prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra
prostatic spread to the seminal vesicles is associated with distant disease.

Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy
possible. However, radiation proctitis and rectal malignancy are late
problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the
standard treatment for localised disease. The robot is being used
increasingly for this procedure. As well as the prostate the obturator nodes
are also removed to complement the staging process. Erectile dysfunction
is a common side effect. Survival may be better than with radiotherapy (see
references).
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic
cancers usually show some degree of testosterone dependence. 95% of
testosterone is derived from the testis and bilateral orchidectomy may be
used for this reason. Pharmacological alternatives include LHRH analogues
and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that
active surveillance is the preferred option for low risk men. It is particularly
suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores,
with < 10 mm of any core involved.

Candidates for active surveillance should:

have had at least 10 biopsy cores taken
have at least one re-biopsy.

If men on active surveillance show evidence of disease progression, offer radical

treatment. Treatment decisions should be made with the man, taking into account
co-morbidities and life expectancy.
 References
1. Prostate cancer pathway. NICE.(http://guidance.nice.org.uk/IPG424)
2. Sooriakumaran P et al. Comparative effectiveness of radical prostatectomy and
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radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ

2014 (348):13. This study shows that in men with localised disease survival was
greater in those offered surgery.

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Question 15 of 63
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 

A 22 year old man presents with an aching pain and discomfort in his right testicle.
He has felt systemically unwell for the preceding 48 hours. On examination, there
is tenderness of the right testicle. He has an exaggerated cremasteric reflex. What
is the correct course of action?

Scrotal exploration via a scrotal approach

Testicular inspection via an inguinal approach

Administration of antibiotics

Fine needle aspiration cytology

Reassure and discharge

This is likely to represent epididymo-orchitis, this is usually due to infection with

gonorrhoea or chlamydia in this age group. In addition to treatment with antibiotics
contact tracing and appropriate swabs should also be performed.

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Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years.
Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell
tumours may essentially be divided into:

Tumour
Tumour type Key features markers Pathology
 Tumour
Tumour type Key features markers Pathology

Seminoma Commonest AFP usually Sheet like

gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

subtype normal lobular

(50%) HCG elevated patterns of
Average in 10% cells with
age at seminomas substantial
diagnosis = Lactate fibrous
40 dehydrogenase; component.
Even elevated in Fibrous septa
advanced 10-20% contain
disease seminomas lymphocytic
associated (but also in inclusions
with 5 year many other and
survival of conditions) granulomas
73% may be seen.

Non seminomatous Younger age at AFP elevated in Heterogenous

germ cell tumours presentation up to 70% of texture with
(42%) =20-30 years cases occasional
Teratoma Advanced disease HCG elevated ectopic tissue
Yolk sac tumour carries worse in up to 40% of such as hair
Choriocarcinoma prognosis (48% at cases
Mixed germ cell 5 years) Other markers
tumours (10%) Retroperitoneal rarely helpful
lymph node
dissection may be
needed for
residual disease
after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more

uniform than teratomas
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb090b.jpg)
Image sourced from Wikipedia
(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org
/images_eMRCS/swb090b.jpg)
/wiki/Seminoma)

Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis

Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
 Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require
retroperitoneal lymph node dissection.

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the
testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea
or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which
resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Most common in males aged between 10 and 30 (peak incidence 13-15
years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then
both testis should be fixed as the condition of bell clapper testis is often
bilateral.

Hydrocele
Presents as a mass that transilluminates, usually possible to 'get above' it
on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
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Question 16 of 63
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A 3 month old boy is brought to the clinic by his mother who has noticed a swelling
in the right hemiscrotum. On examination, there is a firm mass affecting the right
spermatic cord distally, the testis is felt separately from it. What is the most likely
diagnosis?

Inguino scrotal hernia

Rhabdomyosarcoma

Leydig cell tumour

Torsion of testicular hydatid

Hydrocele

Rhabdomyosarcoma are paratesticular tumours with a bimodal distribution.

Because the mass is felt separate to the testis, this is the more likely diagnosis.
5% of testicular tumors
Most often arises in distal portion of spermatic cord and may invade testis
of surrounding tissues
60% occur in the first 2 decades of life
Bimodal age distribution - 3-4 months - 16 years
Arises from mesenchymal tissue - 90% embryonal variant (better prognosis)
- 30% - 50% have metastasis (usually lymph node) at diagnosis

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Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years.
Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell
tumours may essentially be divided into:
 Tumour
Tumour type Key features markers Pathology
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Seminoma Commonest AFP usually Sheet like

subtype normal lobular
(50%) HCG elevated patterns of
Average in 10% cells with
age at seminomas substantial
diagnosis = Lactate fibrous
40 dehydrogenase; component.
Even elevated in Fibrous septa
advanced 10-20% contain
disease seminomas lymphocytic
associated (but also in inclusions
with 5 year many other and
survival of conditions) granulomas
73% may be seen.

Non seminomatous Younger age at AFP elevated in Heterogenous

germ cell tumours presentation up to 70% of texture with
(42%) =20-30 years cases occasional
Teratoma Advanced disease HCG elevated ectopic tissue
Yolk sac tumour carries worse in up to 40% of such as hair
Choriocarcinoma prognosis (48% at cases
Mixed germ cell 5 years) Other markers
tumours (10%) Retroperitoneal rarely helpful
lymph node
dissection may be
needed for
residual disease
after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more

uniform than teratomas
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(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb090b.jpg)
Image sourced from Wikipedia
(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org
/images_eMRCS/swb090b.jpg)
/wiki/Seminoma)

Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis

Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
 Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
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Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require
retroperitoneal lymph node dissection.

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the
testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea
or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which
resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Most common in males aged between 10 and 30 (peak incidence 13-15
years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then
both testis should be fixed as the condition of bell clapper testis is often
bilateral.

Hydrocele
Presents as a mass that transilluminates, usually possible to 'get above' it
on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
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Question 17 of 63
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A 39 year old man notices a swelling in his left hemiscrotum. On examination he

has a left sided varicocele. The ipsilateral testis is normal on palpation. What is the
most appropriate course of action?

Scrotal exploration and ligation of the varicocele

Abdominal ultrasound

Scrotal ultrasound

Left orchidectomy

Discharge

A left sided varicocele is a recognised presenting sign of a renal tumour occluding

the renal vein (into which the left testicular vein drains). An abdominal ultrasound
should be undertaken to exclude this. Surgery for uncomplicated varicocele is
usually unnecessary.

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Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to
arise from the proximal convoluted tubule. They are usually solid lesions, up to
20% may be multifocal, 20% may be calcified and 20% may have either a cystic
component or be wholly cystic. They are often circumscribed by a pseudocapsule
of compressed normal renal tissue. Spread may occur either by direct extension
into the adrenal gland, renal vein or surrounding fascia. More distant disease
usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are
more commonly affected than females and sporadic tumours typically affect
 patients in their sixth decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin
pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less
than 10% have the classic triad of haematuria, pain and mass.
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Investigation
Many cases will present as haematuria and be discovered during diagnostic work
up. Benign renal tumours are rare, so renal masses should be investigated with
multislice CT scanning. Some units will add an arterial and venous phase to the
scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be
undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory

before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent
oncological results to total radical nephrectomy. Partial nephrectomy may also be
performed when there is inadequate reserve in the remaining kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may
be performed via a laparoscopic or open approach. Preoperative embolisation is
not indicated nor is resection of uninvolved adrenal glands. During surgery early
venous control is mandatory to avoid shedding of tumour cells into the circulation.

Patients with completely resected disease do not benefit from adjuvant therapy
with either chemotherapy or biological agents. These should not be administered
outside the setting of clinical trials.

Patients with transitional cell cancer will require a nephroureterectomy with

disconnection of the ureter at the bladder.

References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update.
European Urology 2010 (58): 398-406.

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Question 18 of 63
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A 47-year-old woman presents with loin pain and haematuria. Urine dipstick
demonstrates:

Blood ++++

Nitrites POS

Leucocytes +++

Protein ++

Urine culture shows a Proteus infection. An x-ray demonstrates a stag-horn

calculus in the left renal pelvis. What is the most likely composition of the renal
stone?

Xanthine

Calcium oxalate

Struvite

Cystine

Urate

Stag-horn calculi are composed of struvite and form in alkaline urine

(ammonia producing bacteria therefore predispose)

Renal stones on x-ray

cystine stones: semi-opaque
urate + xanthine stones: radio-lucent

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Renal stones: imaging

The table below summarises the appearance of different types of renal stone on
x-ray

Type Frequency Radiograph appearance

Calcium oxalate 40% Opaque

Mixed calcium 25% Opaque

oxalate/phosphate stones

Triple phosphate stones* 10% Opaque

Calcium phosphate 10% Opaque

Urate stones 5-10% Radio-lucent

Cystine stones 1% Semi-opaque, 'ground-glass'

appearance

Xanthine stones <1% Radio-lucent

*stag-horn calculi involve the renal pelvis and extend into at least 2 calyces. They
develop in alkaline urine and are composed of struvite (ammonium magnesium
phosphate, triple phosphate). Ureaplasma urealyticum and Proteus infections
predispose to their formation

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Question 19 of 63
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A 32 year old male presents with a swollen, painful right scrotum after being
kicked in the groin area 1 hour ago. There is a painful swelling of the right scrotum
and the underlying testis cannot be easily palpated. What is the most likely
explanation?

Hydrocele

Haematocele

Epididymo-orchitis

Orchitis

Epididymal cyst

Acute haematocele: tense, tender and non transilluminating mass post trauma. A
chronic haematoma causes a blood clot to surround the testis. The blood clot
hardens and contracts causing a hard mass which may be indistinguishable from
a tumour. Therefore the testis will need surgical exploration.

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Scrotal swelling

Differential diagnosis

Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on

examination
Cough impulse may be present
May be reducible
 Testicular Often discrete testicular nodule (may have associated
tumours hydrocele)
Symptoms of metastatic disease may be present
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USS scrotum and serum AFP and β HCG required

Acute epididymo- Often history of dysuria and urethral discharge

orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be
associated with underlying structural abnormality

Epididymal cysts Single or multiple cysts

May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on
examination

Hydrocele Non painful, soft fluctuant swelling

Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young
men

Testicular torsion Severe, sudden onset testicular pain

Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by
elevation
Urgent surgery is indicated, the contra lateral testis should
also be fixed

Varicocele Varicosities of the pampiniform plexus

Typically occur on left (because testicular vein drains into
renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles
may affect fertility

Management
Testicular malignancy is always treated with orchidectomy via an inguinal
approach. This allows high ligation of the testicular vessels and avoids
exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children
can be difficult to elicit. Intermittent torsion is a recognised problem. The
 treatment is prompt surgical exploration and testicular fixation. This can be
achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about
testicular function of infertility then surgery or radiological management can
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be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying
pathology is a patent processus vaginalis and therefore an inguinal
approach is used in children so that the processus can be ligated. In adults
a scrotal approach is preferred and the hydrocele sac excised or plicated.

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Question 23 of 63
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A 56 year old man is admitted with severe loin to groin pain associated with
haematuria. He was well until 1 week ago when he was unwell with diarrhoea and
vomiting. What is the most likely cause?

Ureteric calculus

Renal cancer

Pyelonephritis

Prostatitis

Prostate cancer

Ureteric stones may develop in a background of dehydration.

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Renal stones

Type of Percentage of
stones Features all calculi
 Type of Percentage of
stones Features all calculi

Calcium Hypercalciuria is a major risk factor (various 85%

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oxalate causes)
Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate
forms complexes with calcium making it more
soluble
Stones are radio-opaque (though less than
calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to
which calcium oxalate binds

Cystine Inherited recessive disorder of 1%

transmembrane cystine transport leading to
decreased absorption of cystine from
intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain
sulphur

Uric acid Uric acid is a product of purine metabolism 5-10%

May precipitate when urinary pH low
May be caused by diseases with extensive
tissue breakdown e.g. malignancy
More common in children with inborn errors of
metabolism
Radiolucent

Calcium May occur in renal tubular acidosis, high 10%

phosphate urinary pH increases supersaturation of urine
with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase
risk of stone formation (types 2 and 4 do not)
Radio-dense stones (composition similar to
bone)

Struvite Stones formed from magnesium, ammonium 2-20%

and phosphate
Occur as a result of urease producing bacteria
(and are thus associated with chronic
infections)
Under the alkaline conditions produced, the
crystals can precipitate
Slightly radio-opaque
 Effect of urinary pH on stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as
purine metabolism will produce uric acid. Then the urine becomes more alkaline
(alkaline tide). When the stone is not available for analysis the pH of urine may
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help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium phosphate Normal- alkaline >5.5

Calcium oxalate Variable 6

Uric acid Acid 5.5

Struvate Alkaline >7.2

Cystine Normal 6.5

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Question 20 of 63
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A 56 year old man is admitted with acute retention of urine. He has had a recent
urinary tract infection. An USS shows bilateral hydronephrosis. What is the best
course of action?

Antegrade ureteric stents

Retrograde ureteric stents

Urethral catheter

Bilateral nephrostomy

Suprapubic catheter

Establishing bladder drainage will often correct the situation. These patients often
have a significant diuresis with associated electrolyte disturbance. The urethral
route should be tried first.

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Hydronephrosis

Causes of hydronephrosis

Unilateral: PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

Bilateral: SUPER
Stenosis of the urethra
 Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis
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Investigation
USS- identifies presence of hydronephrosis and can assess the kidneys
IVU- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
If renal colic suspected: non contrast CT scan (majority of stones are
detected this way)

Management
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty

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Question 21 of 63
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A 25 year old man is admitted with left sided loin pain that radiates to his groin.
His investigations demonstrate a 9mm left sided calculus within the proximal
ureter. His renal function is normal. What is the most appropriate course of action?

Arrange a percutaneous nephrolithotomy

Arrange extra corporeal shock wave lithotripsy

Review the patient in 4 weeks with KUB x-ray on arrival

Arrange for ureteroscopy and stent insertion

Arrange for open ureteric stone extraction

For ureteric stones with a maximum diameter of less than 10mm the first-line
treatment is extracorporeal shock wave lithotripsy (ESWL). If ESWL fails or if the
stone is impacted in the upper ureter then ureteroscopy can be performed.

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Management of renal stones

Urolithiasis will affect up to 15% of the worldwide population. The development of

sudden onset loin to groin pain which is colicky in nature is a classic feature in the
history. It is nearly always associated with haematuria that is either visible or non-
visible but detectable on urine dipstick testing. Where the diagnosis is suspected
the most sensitive and specific investigation is helical, non-contrast, computerised
tomographic (CT) scanning.

Management
Most renal stones measuring less than 5mm in maximum diameter will typically
pass within 4 weeks of symptom onset(1)(2). More urgent treatment is indicated in
the presence of ureteric obstruction, renal developmental abnormalities such as
 horseshoe kidney and previous renal transplant. Ureteric obstruction together with
infection is a surgical emergency and the system must be decompressed. Options
include nephrostomy tube placement or ureteric stent placement via cystoscopy.
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In the non-emergency setting the preferred options for treatment of stone disease
include extracorporeal shock wave lithotripsy (ESWL), percutaneous
nephrolithotomy (PCNL) and ureteroscopy (URS). These minimally invasive options
are the most popular first line treatments. Open surgery remains an option in a few
selected cases.

Extracorporeal shock wave lithotripsy

A shock wave is generated external to the patient. Internally, cavitation bubbles
and mechanical stress lead to stone fragmentation. The passage of shock waves
can occasionally result in the development of solid organ injury. Fragmentation of
larger stones may result in the development of ureteric obstruction. The procedure
can be uncomfortable for patients and analgesia is often required during the
procedure and afterwards. ESWL is contra-indicated in pregnant females and
patients with significant vascular calcification.

Ureteroscopy
A ureteroscope is passed retrograde via the urethra and bladder, into the ureter and
renal pelvis. Laser or pneumatic fragmentation (lithoclasty) is performed using the
ureteroscope and stone fragments are extracted(3). In some cases a stent is left in
situ after the procedure.

Percutaneous nephrolithotomy
In this procedure percutaneous access is gained to the renal collecting system.
Once access is achieved, endoscopic intra-corporeal lithotripsy, lithoclasty or laser
stone fragmentation is performed and stone fragments removed.

Therapeutic selection

Renal stones

Size First line option

Less than 5mm and asymptomatic Watchful waiting

Less than 10mm ESWL

10 20mm ESWL or ureteroscopy

Greater than 20mm (including staghorn calculi) PCNL

Ureteric stones

Size First line option

 Less than 5mm Watchful waiting

5-10mm ESWL
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10-20mm Ureteroscopy

Reference
1. Bultitude M, Rees J. Management of renal colic. BMJ. 2012;345(7872):18.
2. Shah TT, Gao C, Peters M, Manning T, Cashman S, Nambiar A, et al. Factors
associated with spontaneous stone passage in a contemporary cohort of patients
presenting with acute ureteric colic: results from the Multi-centre cohort study
evaluating the role of Inflammatory Markers In patients presenting with acute
ureteric . BJU Int. 2019 Apr.
3. BAUS. Ureteroscopy (Telescopic surgery for stone removal) (Internet). BAUS
patient information leaflet. 2017 (cited 2019 Jun 27). p. 16. Available from:
https://www.baus.org.uk/userfiles/pages/files/Patients/Leaflets/Ureteroscopy for
stone.pdf
4. BAUS. Percutaneous nephrolithotomy (keyhole surgery for kidney stones). BAUS
patient information leaflet. 2017. p. 16. Available from: https://www.baus.org.uk
/userfiles/pages/files/Patients/Leaflets/PCNL.pdf
5. NICE. Renal and ureteric stones: assessment and management. NICE
Guide[NG118]. 2019;(January):112.

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Question 22 of 63
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A 73 year old man has previously undergone a prostatectomy to treat prostate

cancer. On review, his PSA has risen to 55 and he has developed pain in his lower
back. Imaging shows osteosclerotic lesions in L4 and L3. What is the best
treatment strategy?

Posterior spinal fusion

Vertebral body reconstruction

Bisphosphonates and radiotherapy

Androgen suppression, bisphosphonates and radiotherapy

Radiotherapy alone

In men with metastatic bone lesions from prostate cancer, the best outcomes are
achieved with androgen suppression. Radiotherapy can also produced marked
palliation. A 2010 Cochrane review has clearly demonstrated added benefit, in
terms of symptom control, from the addition of a bisphosphonate.

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Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the
condition each year. Up to 9,000 will die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
 Digital rectal examination
Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging.
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PSA Test
The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients
with benign disease and some with localised prostate cancer. False positives may
be due to prostatitis, UTI, BPH, vigorous DRE.
The percentage of free: total PSA may help to distinguish benign disease from
cancer. Values of <20% are suggestive of cancer and biopsy is advised.

Pathology
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple
biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most
dominant grade (on scale of 1-5) and 2 for second most dominant grade
(scale 1-5). The two added together give the Gleason score. Where 2 is best
prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra
prostatic spread to the seminal vesicles is associated with distant disease.

Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy
possible. However, radiation proctitis and rectal malignancy are late
problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the
standard treatment for localised disease. The robot is being used
increasingly for this procedure. As well as the prostate the obturator nodes
are also removed to complement the staging process. Erectile dysfunction
is a common side effect. Survival may be better than with radiotherapy (see
references).
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic
cancers usually show some degree of testosterone dependence. 95% of
testosterone is derived from the testis and bilateral orchidectomy may be
used for this reason. Pharmacological alternatives include LHRH analogues
and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that
active surveillance is the preferred option for low risk men. It is particularly
suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores,
with < 10 mm of any core involved.

Candidates for active surveillance should:

have had at least 10 biopsy cores taken
have at least one re-biopsy.
 If men on active surveillance show evidence of disease progression, offer radical
treatment. Treatment decisions should be made with the man, taking into account
co-morbidities and life expectancy.
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References
1. Prostate cancer pathway. NICE.(http://guidance.nice.org.uk/IPG424)
2. Sooriakumaran P et al. Comparative effectiveness of radical prostatectomy and
radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ
2014 (348):13. This study shows that in men with localised disease survival was
greater in those offered surgery.

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Question 24 of 63
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A 55 year old man presents with an episode of frank haematuria and on

investigation is found to have a T2 transitional cell carcinoma of the bladder. His
staging investigations are negative for metastatic disease. What is the most
appropriate treatment?

Radical cystectomy

Palliative radiotherapy

Intravesical BCG

Intravesical mitomycin C

Intravesical cisplatin

T2 lesions in a young fit patient are best managed surgically. Up to 25 % patients

may develop perioperative complications. However, palliative treatments and
intravesical chemotherapy (which does NOT include cisplatin) are not used
curatively in this situation.

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Bladder cancer

Bladder cancer is the second most common urological cancer. It most commonly
affects males aged between 50 and 80 years of age. Those who are current, or
previous (within 20 years), smokers have a 2-5 fold increased risk of the disease.
Exposure to hydrocarbons such as 2-Naphthylamine increases the risk. Although
rare in the UK, chronic bladder inflammation arising from Schistosomiasis
infection remains a common cause of squamous cell carcinomas, in those
countries where the disease is endemic.

Benign tumours
 Benign tumours of the bladder including inverted urothelial papilloma and
nephrogenic adenoma are uncommon.

Bladder malignancies
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Transitional cell carcinoma (>90% of cases)

Squamous cell carcinoma ( 1-7% -except in regions affected by
schistosomiasis)
Adenocarcinoma (2%)

Transitional cell carcinomas may arise as solitary lesions, or may be multifocal,

owing to the effect of 'field change' within the urothelium. Up to 70% of TCC's will
have a papillary growth pattern. These tumours are usually superficial in location
and accordingly have a better prognosis. The remaining tumours show either
mixed papillary and solid growth or pure solid growths. These tumours are typically
more prone to local invasion and may be of higher grade, the prognosis is therefore
worse. Those with T3 disease or worse have a 30% (or higher) risk of regional or
distant lymph node metastasis.

TNM Staging

Stage Description

T0 No evidence of tumour

Ta Non invasive papillary carcinoma

T1 Tumour invades sub epithelial connective tissue

T2a Tumor invades superficial muscularis propria (inner half)

T2b Tumor invades deep muscularis propria (outer half)

T3 Tumour extends to perivesical fat

T4 Tumor invades any of the following: prostatic stroma, seminal vesicles,

uterus, vagina

T4a Invasion of uterus, prostate or bowel

T4b Invasion of pelvic sidewall or abdominal wall

N0 No nodal disease

N1 Single regional lymph node metastasis in the true pelvis (hypogastric,

obturator, external iliac, or presacral lymph node)

N2 Multiple regional lymph node metastasis in the true pelvis (hypogastric,

obturator, external iliac, or presacral lymph node metastasis)
 Stage Description

N3 Lymph node metastasis to the common iliac lymph nodes

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M0 No distant metastasis

M1 Distant disease

Presentation
Most patients (85%) will present with painless, macroscopic haematuria. In those
patients with incidental microscopic haematuria, up to 10% of females aged over
50 will be found to have a malignancy (once infection excluded).

Staging
Most will undergo a cystoscopy and biopsies or TURBT, this provides histological
diagnosis and information relating to depth of invasion. Locoregional spread is
best determined using pelvic MRI and distant disease CT scanning. Nodes of
uncertain significance may be investigated using PET CT.

Treatment
Those with superficial lesions may be managed using TURBT in isolation. Those
with recurrences or higher grade/ risk on histology may be offered intravesical
chemotherapy. Those with T2 disease are usually offered either surgery (radical
cystectomy and ileal conduit) or radical radiotherapy.

Prognosis

T1 90%

T2 60%

T3 35%

T4a 10-25%

Any T, N1-N2 30%

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Question 25 of 63
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A 56 year old lady reports incontinence mainly when walking the dog. A bladder
diary is inconclusive. What is the most appropriate investigation?

Intravenous urography

Urodynamic studies

Flexible cystoscopy

Micturating cystourethrogram

Rigid cystoscopy

Urodynamic studies are indicated when there is diagnostic uncertainty or plans for
surgery.

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Urinary incontinence

Involuntary passage of urine. Most cases are female (80%). It has a prevalence of
11% in those aged greater than 65 years. The commonest variants include:
Stress urinary incontinence (50%)
Urge incontinence (15%)
Mixed (35%)

Males
Males may also suffer from incontinence although it is a much rarer condition in
men. A number of anatomical factors contribute to this. Males have 2 powerful
sphincters; one at the bladder neck and the other in the urethra. Damage to the
bladder neck mechanism is a factor in causing retrograde ejaculation following
prostatectomy. The short segment of urethra passing through the urogenital
 diaphragm consists of striated muscle fibres (the external urethral sphincter) and
smooth muscle capable of more sustained contraction. It is the latter mechanism
that maintains continence following prostatectomy.
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Females
The sphincter complex at the level of bladder neck is poorly developed in females.
As a result the external sphincter complex is functionally more important, its
composition being similar to that of males. Innervation is via the pudendal nerve
and the neuropathy that may accompany obstetric events may compromise this
and lead to stress urinary incontinence.

Innervation
Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic
nerves. Autonomic nerves travel in these nerve fibres too. Bladder filling leads to
detrusor relaxation (sympathetic) coupled with sphincter contraction. The
parasympathetic system causes detrusor contraction and sphincter relaxation.
Overall control of micturition is centrally mediated via centres in the Pons.

Stress urinary incontinence

50% of cases, especially in females.
Damage (often obstetric) to the supporting structures surrounding the
bladder may lead to urethral hypermobility.
Other cases due to sphincter dysfunction, usually from neurological
disorders (e.g. Pudendal neuropathy, multiple sclerosis).

Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary
passage of urine during episodes of raised intra-abdominal pressure.

Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of
urine. When the sphincter completely fails there is often to continuous passage of
urine.

Urge incontinence
In these patients there is sense of urgency followed by incontinence. The detrusor
muscle in these patients is unstable and urodynamic investigation will
demonstrate overactivity of the detrusor muscle at inappropriate times (e.g.
Bladder filling). Urgency may be seen in patients with overt neurological disorders
and those without. The pathophysiology is not well understood but poor central
and peripheral co-ordination of the events surrounding bladder filling are the main
processes.

Assessment
Careful history and examination including vaginal examination for cystocele.
Bladder diary for at least 3 days
Consider flow cystometry if unclear symptomatology or surgery considered and
diagnosis is unclear.
 Exclusion of other organic disease (e.g. Stones, UTI, Cancer)

Management
Conservative measures should be tried first; Stress urinary incontinence or mixed
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symptoms should undergo 3 months of pelvic floor exercise. Over active bladder
should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered oxybutynin (or
solifenacin if elderly) if conservative measures fail.
In women with detrusor instability who fail non operative therapy a trial of sacral
neuromodulation may be considered, with conversion to permanent implant if
good response. Augmentation cystoplasty is an alternative but will involve long
term intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be
undertaken. Where cystocele is present in association with incontinence it should
be repaired particularly if it lies at the introitus.

NICE guidelines
Initial assessment urinary incontinence should be classified as stress/urge
/mixed.
At least 3/7 bladder diary if unable to classify easily.
Start conservative treatment before urodynamic studies if a diagnosis is
obvious from the history
Urodynamic studies if plans for surgery.
Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
Urge incontinence: Bladder training >6/52, if fails for oxybutynin
(antimuscarinic drugs) then sacral nerve stimulation.
Pelvic floor exercises offered to all women in their 1st pregnancy.

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Question 26 of 63
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Which of the following procedures represents the optimal operative procedure for
testicular cancer?

Lords procedure

Orchidectomy via a scrotal approach

Orchidectomy via inguinal approach

Orchidectomy via a combined inguino-scrotal approach

None of the above

Testicular tumours metastasise to Para aortic nodes and thus an inguinal rather
than scrotal approach should be used. There are two main operations that are
termed Lords procedure; one is for fissure in ano and the other is a procedure for
hydrocele.

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Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years.
Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell
tumours may essentially be divided into:

Tumour
Tumour type Key features markers Pathology
 Tumour
Tumour type Key features markers Pathology

Seminoma Commonest AFP usually Sheet like

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subtype normal lobular

(50%) HCG elevated patterns of
Average in 10% cells with
age at seminomas substantial
diagnosis = Lactate fibrous
40 dehydrogenase; component.
Even elevated in Fibrous septa
advanced 10-20% contain
disease seminomas lymphocytic
associated (but also in inclusions
with 5 year many other and
survival of conditions) granulomas
73% may be seen.

Non seminomatous Younger age at AFP elevated in Heterogenous

germ cell tumours presentation up to 70% of texture with
(42%) =20-30 years cases occasional
Teratoma Advanced disease HCG elevated ectopic tissue
Yolk sac tumour carries worse in up to 40% of such as hair
Choriocarcinoma prognosis (48% at cases
Mixed germ cell 5 years) Other markers
tumours (10%) Retroperitoneal rarely helpful
lymph node
dissection may be
needed for
residual disease
after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more

uniform than teratomas
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(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb090b.jpg)
Image sourced from Wikipedia
(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org
/images_eMRCS/swb090b.jpg)
/wiki/Seminoma)

Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis

Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
 Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
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Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require
retroperitoneal lymph node dissection.

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the
testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea
or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which
resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Most common in males aged between 10 and 30 (peak incidence 13-15
years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then
both testis should be fixed as the condition of bell clapper testis is often
bilateral.

Hydrocele
Presents as a mass that transilluminates, usually possible to 'get above' it
on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
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Question 27 of 63
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A 22 year old man is involved in a road traffic accident. He is found to have a pelvic
fracture. While on the ward the nursing staff report that he is complaining of lower
abdominal pain. On examination, you find a distended tender bladder and blood at
the urethral meatus. What is the best management?

10 Ch foley urethral catheter

Suprapubic catheter

16 Ch foley urethral catheter

18 Ch coude tip urethral catheter

Pain relief and review in 1 hour

This patient has possible urethral injury based on the history. Urethral
catheterisation is contraindicated in this situation.

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Lower genitourinary tract trauma

Most bladder injuries occur due to blunt trauma

85% associated with pelvic fractures
Easily overlooked during assessment in trauma
Up to 10% of male pelvic fractures are associated with urethral or bladder
injuries

Types of injury
 Urethral injury Mainly in males

Blood at the meatus (50% cases)

There are 2 types:
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i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma,
blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing
retroperitoneal haematomas as they may make
examination difficult)

- Investigation: ascending urethrogram

- Management: suprapubic catheter (surgical
placement, not percutaneously)

External genitalia Secondary to injuries caused by penetration,

injuries (i.e., the penis blunt trauma, continence- or sexual pleasure-
and the scrotum) enhancing devices, and mutilation

Bladder injury rupture is intra or extraperitoneal

presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void:
always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the
bladder through a Foley catheter indicates
bladder injury
investigation- IVU or cystogram
management: laparotomy if intraperitoneal,
conservative if extraperitoneal

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Question 28 of 63
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A 72 year old man presents with lower urinary tract symptoms. On digital rectal
examination, benign prostatic hyperplasia is suspected. Which of the following
treatments is associated with a reduction in the risk of urinary retention?

Alfuzosin

Finasteride

Prazosin

Tamsulosin

Terazosin

5 alpha reductase inhibitors reduce the risk of urinary retention.

In the PLESS study, data show a reduction in the risk of urinary retention although
the absolute risk reduction was small.

Reference
McConnell J et al. The effect of finasteride on the risk of urinary retention and the
need for surgical intervention amongst men with benign prostatic hyperplasia. N
Engl J Med 338:557-563

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Benign Prostatic Hyperplasia

Benign prostatic hyperplasia occurs via an increase in the epithelial and stromal
cell numbers in the peri-urethral zone of the prostate. BPH is very common and
90% of men aged over 80 will have at least microscopic evidence of benign
prostatic hyperplasia. The causes of BPH are still not well understood, but the
importance of androgens remains appreciated even if the exact role by which they
induce BPH is elusive.
 Presentation
The vast majority of men will present with lower urinary tract symptoms. These will
typically be:
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Poor flow
Nocturia
Hesitancy
Incomplete and double voiding
Terminal dribbling
Urgency
Incontinence

Investigation
Digital rectal examination to assess prostatic size and morphology.
Urine dipstick for infections and haematuria.
Uroflowmetry (a flow rate of >15ml/second helps to exclude BOO)
Bladder pressure studies may help identify detrusor failure and whilst may
not form part of first line investigations should be included in those with
atypical symptoms and prior to redo surgery.
Bladder scanning to demonstrate residual volumes. USS if high pressure
chronic retention.

Management
Lifestyle changes such as stopping smoking and altering fluid intake may
help those with mild symptoms.
Medical therapy includes alpha blockers and 5 α reductase inhibitors. The
former work quickly on receptor zones located at the bladder neck.
Cardiovascular side effects are well documented. The latter work on
testosterone metabolising enzymes. Although they have a slower onset of
action, the 5 α reductase inhibitors may prevent acute urinary retention.
Surgical therapy includes transurethral resection of the prostate and is the
treatment of choice in those with severe symptoms and those who fail to
respond to medical therapy. More tailored bladder neck incision procedures
may be considered in those with small prostates. Retrograde ejaculation
may occur following surgery. The change in the type of irrigation solutions
used has helped to minimise the TURP syndrome of electrolyte
disturbances.

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Question 29 of 63
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A 17 year old man is referred to the urology clinic. As a child he was diagnosed as
having a right sided PUJ obstruction. However, he was lost to follow up. Over the
past 7 months he has been complaining of recurrent episodes of right loin pain. A
CT scan shows considerable renal scarring. What is the most useful investigation?

DMSA scan

MAG 3 renogram

CT scan of the kidney

CT KUB

Renal USS

In patients with long standing PUJ obstruction and renal scarring the main
diagnostic question is whether the individual has sufficient renal function to
consider a pyeloplasty or whether a primary nephrectomy is preferable. Since the
CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the
investigations listed both a DMSA and MAG 3 renogram will allow assessment of
renal function. However, MAG 3 is superior in the assessment of renal function in
damaged kidneys (as it is subjected to tubular secretion).

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Functional renal imaging

DMSA scan
Dimercaptosuccinic acid (DMSA) scintigraphy
DMSA localises to the renal cortex with little accumulation in the renal papilla and
medulla. It is useful for the identification of cortical defects and ectopic or
aberrant kidneys. It does not provide useful information on the ureter of collecting
system.
 Diethylene-triamine-penta-acetic acid (DTPA)
This is primarily a glomerular filtration agent. It is most useful for the assessment
of renal function. Because it is filtered at the level of the glomerulus it provides
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useful information about the GFR. Image quality may be degraded in patients with
chronic renal impairment and derangement of GFR.

MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily
secreted by tubular cells rather than filtered at the glomerulus. This makes it the
agent of choice for imaging the kidneys of patients with existing renal impairment
(where GFR is impaired).

Micturating cystourethrogram (MCUG scan)

This scan provides information relating to bladder reflux and is obtained by filling
the bladder with contrast media (via a catheter) and asking the child to void.
Images are taken during this phase and the degree of reflux can be calculated

Intra venous urography

This examination is conducted by the administration of intravenous iodinated
contrast media. The agent is filtered by the kidneys and excreted and may provide
evidence of renal stones or other structural lesions. A rough approximation of renal
function may be obtained using the technique. But it is not primarily a technique to
be used for this purpose. With the advent of widespread non contrast CT scan
protocols for the detection of urinary tract calculi it is now rarely used.

PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of
malignancy.

References
Davis A et al. Investigating urinary tract infections in children. BMJ 2013
(346):35-37.

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Question 30 of 63
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Which of the following statements is false in relation to renal adenocarcinoma?

They account for over 75% cases of renal tumours

Renal biopsy should be performed in all cases considered for radical

nephrectomy

They typically spread via the haematogenous route

Patients with completely resected T2 disease should not receive adjuvant

chemotherapy

Partial nephrectomy gives equivalent oncological outcomes in patients

with T1 disease

Routine chemotherapy is not effective in patients with renal adenocarcinoma

and should not be used following R0 resections.

Routine renal biopsy should not be performed in cases for nephrectomy. Most
cases of malignancy can be accurately classified on imaging.

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Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to
arise from the proximal convoluted tubule. They are usually solid lesions, up to
20% may be multifocal, 20% may be calcified and 20% may have either a cystic
component or be wholly cystic. They are often circumscribed by a pseudocapsule
of compressed normal renal tissue. Spread may occur either by direct extension
 into the adrenal gland, renal vein or surrounding fascia. More distant disease
usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are
more commonly affected than females and sporadic tumours typically affect
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patients in their sixth decade.

Patients may present with a variety of symptoms including; haematuria (50%), loin
pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less
than 10% have the classic triad of haematuria, pain and mass.

Investigation
Many cases will present as haematuria and be discovered during diagnostic work
up. Benign renal tumours are rare, so renal masses should be investigated with
multislice CT scanning. Some units will add an arterial and venous phase to the
scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be
undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory

before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent
oncological results to total radical nephrectomy. Partial nephrectomy may also be
performed when there is inadequate reserve in the remaining kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may
be performed via a laparoscopic or open approach. Preoperative embolisation is
not indicated nor is resection of uninvolved adrenal glands. During surgery early
venous control is mandatory to avoid shedding of tumour cells into the circulation.

Patients with completely resected disease do not benefit from adjuvant therapy
with either chemotherapy or biological agents. These should not be administered
outside the setting of clinical trials.

Patients with transitional cell cancer will require a nephroureterectomy with

disconnection of the ureter at the bladder.

References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update.
European Urology 2010 (58): 398-406.

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Question 31 of 63
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A 73 year old lady is undergoing chemotherapy for treatment of acute leukaemia.

She develops symptoms of renal colic. Her urine tests positive for blood. A KUB
x-ray shows no evidence of stones. If a stone were present, what type could it be?

Calcium oxalate stone

Calcium phosphate stone

Cystine stone

Struvite

Uric acid stone

Chemotherapy and cell death can increase uric acid levels. In this acute setting the
uric acid stones are unlikely to be coated with calcium and will therefore be
radiolucent.

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Renal stones

Type of Percentage of
stones Features all calculi
 Type of Percentage of
stones Features all calculi

Calcium Hypercalciuria is a major risk factor (various 85%

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oxalate causes)
Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate
forms complexes with calcium making it more
soluble
Stones are radio-opaque (though less than
calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to
which calcium oxalate binds

Cystine Inherited recessive disorder of 1%

transmembrane cystine transport leading to
decreased absorption of cystine from
intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain
sulphur

Uric acid Uric acid is a product of purine metabolism 5-10%

May precipitate when urinary pH low
May be caused by diseases with extensive
tissue breakdown e.g. malignancy
More common in children with inborn errors of
metabolism
Radiolucent

Calcium May occur in renal tubular acidosis, high 10%

phosphate urinary pH increases supersaturation of urine
with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase
risk of stone formation (types 2 and 4 do not)
Radio-dense stones (composition similar to
bone)

Struvite Stones formed from magnesium, ammonium 2-20%

and phosphate
Occur as a result of urease producing bacteria
(and are thus associated with chronic
infections)
Under the alkaline conditions produced, the
crystals can precipitate
Slightly radio-opaque
 Effect of urinary pH on stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as
purine metabolism will produce uric acid. Then the urine becomes more alkaline
(alkaline tide). When the stone is not available for analysis the pH of urine may
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help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium phosphate Normal- alkaline >5.5

Calcium oxalate Variable 6

Uric acid Acid 5.5

Struvate Alkaline >7.2

Cystine Normal 6.5

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Question 32 of 63
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From the list below, which drug is known to cause haemorrhagic cystitis?

Rifampicin

Methotrexate

Dexamethasone

Leflunomide

Cyclophosphamide

Cyclophosphamide is metabolised into a toxic metabolite acrolein. The effects

may be attenuated by administration of large volumes of intravenous fluids and
mesna (which neutralises the metabolite). The condition may be managed initially
by bladder catheterisation and irrigation.

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Haematuria

Causes of haematuria

Trauma Injury to renal tract

Renal trauma commonly due to blunt injury
(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures

Infection Remember TB
 Malignancy Renal cell carcinoma (remember paraneoplastic
syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell
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carcinoma, can occur anywhere along the urinary

tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC

Renal disease Glomerulonephritis

Stones Microscopic haematuria common

Structural Benign prostatic hyperplasia (BPH) causes

abnormalities haematuria due to hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma

Coagulopathy Causes bleeding of underlying lesions

Drugs Cause tubular necrosis or interstitial nephritis:

aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants

Benign Exercise

Gynaecological Endometriosis: flank pain, dysuria, and

haematuria that is cyclical

Iatrogenic Catheterisation
Radiotherapy; cystitis, severe haemorrhage,
bladder necrosis

Pseudohaematuria For example following consumption of beetroot

References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
/aetiology.html
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Question 33 of 63
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A 73 year old man presents with haematuria. Investigations demonstrate a

localised, high risk, prostatic cancer. His co-morbidities include COPD and
ischaemic heart disease. His staging investigations show no evidence of
metastatic disease. What is the best course of action?

Transvesical prostatectomy

Radical prostatectomy

External beam radiotherapy

Chemotherapy alone

Chemical orchidectomy

The co-morbidities of this patient make a surgical approach a less favorable

option. Radical radiotherapy offers a more favorable alternative.

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Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the
condition each year. Up to 9,000 will die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
 MRI/ CT and bone scan for staging.

PSA Test
The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients
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with benign disease and some with localised prostate cancer. False positives may
be due to prostatitis, UTI, BPH, vigorous DRE.
The percentage of free: total PSA may help to distinguish benign disease from
cancer. Values of <20% are suggestive of cancer and biopsy is advised.

Pathology
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple
biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most
dominant grade (on scale of 1-5) and 2 for second most dominant grade
(scale 1-5). The two added together give the Gleason score. Where 2 is best
prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra
prostatic spread to the seminal vesicles is associated with distant disease.

Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy
possible. However, radiation proctitis and rectal malignancy are late
problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the
standard treatment for localised disease. The robot is being used
increasingly for this procedure. As well as the prostate the obturator nodes
are also removed to complement the staging process. Erectile dysfunction
is a common side effect. Survival may be better than with radiotherapy (see
references).
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic
cancers usually show some degree of testosterone dependence. 95% of
testosterone is derived from the testis and bilateral orchidectomy may be
used for this reason. Pharmacological alternatives include LHRH analogues
and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that
active surveillance is the preferred option for low risk men. It is particularly
suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores,
with < 10 mm of any core involved.

Candidates for active surveillance should:

have had at least 10 biopsy cores taken
have at least one re-biopsy.

If men on active surveillance show evidence of disease progression, offer radical

treatment. Treatment decisions should be made with the man, taking into account
 co-morbidities and life expectancy.

References
1. Prostate cancer pathway. NICE.(http://guidance.nice.org.uk/IPG424)
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2. Sooriakumaran P et al. Comparative effectiveness of radical prostatectomy and

radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ
2014 (348):13. This study shows that in men with localised disease survival was
greater in those offered surgery.

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Question 34 of 63
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Which of the following does not cause red urine?

Rifampicin

Phosphaturia

Beetroot

Rhubarb

Blackberries

Phosphaturia causes cloudy urine.

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Haematuria

Causes of haematuria

Trauma Injury to renal tract

Renal trauma commonly due to blunt injury
(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures

Infection Remember TB
 Malignancy Renal cell carcinoma (remember paraneoplastic
syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

carcinoma, can occur anywhere along the urinary

tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC

Renal disease Glomerulonephritis

Stones Microscopic haematuria common

Structural Benign prostatic hyperplasia (BPH) causes

abnormalities haematuria due to hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma

Coagulopathy Causes bleeding of underlying lesions

Drugs Cause tubular necrosis or interstitial nephritis:

aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants

Benign Exercise

Gynaecological Endometriosis: flank pain, dysuria, and

haematuria that is cyclical

Iatrogenic Catheterisation
Radiotherapy; cystitis, severe haemorrhage,
bladder necrosis

Pseudohaematuria For example following consumption of beetroot

References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
 /aetiology.html

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Question 35 of 63
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A 22 year old man is participating in vigorous intercourse and suddenly feels a

snap and his penis becomes swollen and painful. The admitting surgeon suspects
a penile fracture. Which of the following is the most appropriate initial
management?

MRI scan of the penis

Immediate surgical exploration

CT scan of the penis

USS of the penis

Cystogram

Suspected penile fractures should be surgically explored and the injury repaired.

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Penile fracture

Penile fractures are a rare type of urological trauma that may be encountered. The
injury is usually in the proximal part of the penile shaft and may involve the urethra.
A classically history of a snapping sensation followed by immediate pain is usually
given by the patient (usually during vigorous intercourse). On examination there is
usually a tense haematoma and blood may be seen at the meatus if the urethra is
injured.
When there is a a strong suspicion of the diagnosis the correct management is
surgical and a circumferential incision made immediately inferior to the glans. The
skin and superficial tissues are stripped back and the penile shaft inspected.
Injuries are usually sutured and the urethra repaired over a catheter.
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C 7%
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E 8.7%

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Question 36 of 63
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A 35-year-old female is admitted to hospital with hypovolaemic shock. CT

abdomen reveals a haemorrhagic lesion in the right kidney. Following surgery and
biopsy this is shown to be an angiomyolipomata. What is the most likely
underlying diagnosis?

Neurofibromatosis

Budd-Chiari syndrome

Hereditary haemorrhagic telangiectasia

Von Hippel-Lindau syndrome

Tuberous sclerosis

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Tuberous sclerosis

Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance.

Like neurofibromatosis, the majority of features seen in TS are neuro-cutaneous

Cutaneous features
depigmented 'ash-leaf' spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum: butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen

Neurological features
developmental delay
 epilepsy (infantile spasms or partial)
intellectual impairment
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Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata

*these of course are more commonly associated with neurofibromatosis. However

a 1998 study of 106 children with TS found café-au-lait spots in 28% of patients

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C 16%
D 28.5%
E 36.7%

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Question 37 of 63
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A 43 year old lady with episodes of recurrent urinary tract sepsis presents with a
staghorn calculus of the left kidney. Her urinary pH is 7.8. A KUB x-ray shows a
faint outline of the calculus. What is the most likely stone composition?

Struvite

Calcium phosphate

Calcium oxalate

Uric acid

Cystine

Chronic infection with urease producing enzymes can produce an alkaline urine
with formation of struvite stone.

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Renal stones

Type of Percentage of
stones Features all calculi
 Type of Percentage of
stones Features all calculi

Calcium Hypercalciuria is a major risk factor (various 85%

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oxalate causes)
Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate
forms complexes with calcium making it more
soluble
Stones are radio-opaque (though less than
calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to
which calcium oxalate binds

Cystine Inherited recessive disorder of 1%

transmembrane cystine transport leading to
decreased absorption of cystine from
intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain
sulphur

Uric acid Uric acid is a product of purine metabolism 5-10%

May precipitate when urinary pH low
May be caused by diseases with extensive
tissue breakdown e.g. malignancy
More common in children with inborn errors of
metabolism
Radiolucent

Calcium May occur in renal tubular acidosis, high 10%

phosphate urinary pH increases supersaturation of urine
with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase
risk of stone formation (types 2 and 4 do not)
Radio-dense stones (composition similar to
bone)

Struvite Stones formed from magnesium, ammonium 2-20%

and phosphate
Occur as a result of urease producing bacteria
(and are thus associated with chronic
infections)
Under the alkaline conditions produced, the
crystals can precipitate
Slightly radio-opaque
 Effect of urinary pH on stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as
purine metabolism will produce uric acid. Then the urine becomes more alkaline
(alkaline tide). When the stone is not available for analysis the pH of urine may
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help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium phosphate Normal- alkaline >5.5

Calcium oxalate Variable 6

Uric acid Acid 5.5

Struvate Alkaline >7.2

Cystine Normal 6.5

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Question 38 of 63
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Which of the following treatments is not utilized in the treatment of overactive

bladder syndrome?

Sacral neuromodulation

Botulinum toxin injections

Bladder drill

Oxybutinin

Colposuspension

Overactive bladder syndrome is very common and first line management includes
the use of anticholinergics and bladder drill whereby voiding is deferred. Refractory
cases can be treated with SNS or botulinum toxin injections. A Burch
Colposuspension is used to treat stress urinary incontinence.

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Urinary incontinence

Involuntary passage of urine. Most cases are female (80%). It has a prevalence of
11% in those aged greater than 65 years. The commonest variants include:
Stress urinary incontinence (50%)
Urge incontinence (15%)
Mixed (35%)

Males
Males may also suffer from incontinence although it is a much rarer condition in
men. A number of anatomical factors contribute to this. Males have 2 powerful
sphincters; one at the bladder neck and the other in the urethra. Damage to the
 bladder neck mechanism is a factor in causing retrograde ejaculation following
prostatectomy. The short segment of urethra passing through the urogenital
diaphragm consists of striated muscle fibres (the external urethral sphincter) and
smooth muscle capable of more sustained contraction. It is the latter mechanism
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that maintains continence following prostatectomy.

Females
The sphincter complex at the level of bladder neck is poorly developed in females.
As a result the external sphincter complex is functionally more important, its
composition being similar to that of males. Innervation is via the pudendal nerve
and the neuropathy that may accompany obstetric events may compromise this
and lead to stress urinary incontinence.

Innervation
Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic
nerves. Autonomic nerves travel in these nerve fibres too. Bladder filling leads to
detrusor relaxation (sympathetic) coupled with sphincter contraction. The
parasympathetic system causes detrusor contraction and sphincter relaxation.
Overall control of micturition is centrally mediated via centres in the Pons.

Stress urinary incontinence

50% of cases, especially in females.
Damage (often obstetric) to the supporting structures surrounding the
bladder may lead to urethral hypermobility.
Other cases due to sphincter dysfunction, usually from neurological
disorders (e.g. Pudendal neuropathy, multiple sclerosis).

Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary
passage of urine during episodes of raised intra-abdominal pressure.

Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of
urine. When the sphincter completely fails there is often to continuous passage of
urine.

Urge incontinence
In these patients there is sense of urgency followed by incontinence. The detrusor
muscle in these patients is unstable and urodynamic investigation will
demonstrate overactivity of the detrusor muscle at inappropriate times (e.g.
Bladder filling). Urgency may be seen in patients with overt neurological disorders
and those without. The pathophysiology is not well understood but poor central
and peripheral co-ordination of the events surrounding bladder filling are the main
processes.

Assessment
Careful history and examination including vaginal examination for cystocele.
Bladder diary for at least 3 days
 Consider flow cystometry if unclear symptomatology or surgery considered and
diagnosis is unclear.
Exclusion of other organic disease (e.g. Stones, UTI, Cancer)
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Management
Conservative measures should be tried first; Stress urinary incontinence or mixed
symptoms should undergo 3 months of pelvic floor exercise. Over active bladder
should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered oxybutynin (or
solifenacin if elderly) if conservative measures fail.
In women with detrusor instability who fail non operative therapy a trial of sacral
neuromodulation may be considered, with conversion to permanent implant if
good response. Augmentation cystoplasty is an alternative but will involve long
term intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be
undertaken. Where cystocele is present in association with incontinence it should
be repaired particularly if it lies at the introitus.

NICE guidelines
Initial assessment urinary incontinence should be classified as stress/urge
/mixed.
At least 3/7 bladder diary if unable to classify easily.
Start conservative treatment before urodynamic studies if a diagnosis is
obvious from the history
Urodynamic studies if plans for surgery.
Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
Urge incontinence: Bladder training >6/52, if fails for oxybutynin
(antimuscarinic drugs) then sacral nerve stimulation.
Pelvic floor exercises offered to all women in their 1st pregnancy.

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Question 39 of 63
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A 65 year old man presents with significant lower urinary tract symptoms and is
diagnosed as having benign prostatic hyperplasia. Which of the following drug
treatments will produce the slowest clinical response?

Tamsulosin

Alfuzosin

Doxazosin

Finasteride

Terazosin

5 alpha reductase inhibitors have a more favorable side effect profile than α
blockers.

Alpha blockers have a faster onset of action (but lower reduction of complications
from BPH) than 5 α reductase inhibitors.

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Benign Prostatic Hyperplasia

Benign prostatic hyperplasia occurs via an increase in the epithelial and stromal
cell numbers in the peri-urethral zone of the prostate. BPH is very common and
90% of men aged over 80 will have at least microscopic evidence of benign
prostatic hyperplasia. The causes of BPH are still not well understood, but the
importance of androgens remains appreciated even if the exact role by which they
induce BPH is elusive.
 Presentation
The vast majority of men will present with lower urinary tract symptoms. These will
typically be:
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Poor flow
Nocturia
Hesitancy
Incomplete and double voiding
Terminal dribbling
Urgency
Incontinence

Investigation
Digital rectal examination to assess prostatic size and morphology.
Urine dipstick for infections and haematuria.
Uroflowmetry (a flow rate of >15ml/second helps to exclude BOO)
Bladder pressure studies may help identify detrusor failure and whilst may
not form part of first line investigations should be included in those with
atypical symptoms and prior to redo surgery.
Bladder scanning to demonstrate residual volumes. USS if high pressure
chronic retention.

Management
Lifestyle changes such as stopping smoking and altering fluid intake may
help those with mild symptoms.
Medical therapy includes alpha blockers and 5 α reductase inhibitors. The
former work quickly on receptor zones located at the bladder neck.
Cardiovascular side effects are well documented. The latter work on
testosterone metabolising enzymes. Although they have a slower onset of
action, the 5 α reductase inhibitors may prevent acute urinary retention.
Surgical therapy includes transurethral resection of the prostate and is the
treatment of choice in those with severe symptoms and those who fail to
respond to medical therapy. More tailored bladder neck incision procedures
may be considered in those with small prostates. Retrograde ejaculation
may occur following surgery. The change in the type of irrigation solutions
used has helped to minimise the TURP syndrome of electrolyte
disturbances.

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Question 40 of 63
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A parent brings her 4 year old child to the surgical clinic. She has noticed an
intermittent swelling in the right scrotum that is worse in the evening. On
examination he has a soft fluctuant swelling in the right scrotum that cannot be
separated from the testis. It transilluminates when a pen torch is held against it.
What is the best course of action?

Ligation of patent processus vaginalis via inguinal approach

Ligation of patent processus vaginalis via a scrotal approach

Jaboulay procedure via scrotal approach

Lords procedure via scrotal approach

Aspiration

In children, a hydrocele is most commonly due to a persistent processus vaginalis.

The swelling is intermittent and in most cases that are diagnosed in infancy the
hydrocele resolves. Cases that persist beyond two years of age are best managed
surgically and the surgical approach is usually made via the inguinal canal where
the patent processus is identified and ligated.

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Scrotal swelling

Differential diagnosis

Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on

examination
Cough impulse may be present
May be reducible
 Testicular Often discrete testicular nodule (may have associated
tumours hydrocele)
Symptoms of metastatic disease may be present
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USS scrotum and serum AFP and β HCG required

Acute epididymo- Often history of dysuria and urethral discharge

orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be
associated with underlying structural abnormality

Epididymal cysts Single or multiple cysts

May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on
examination

Hydrocele Non painful, soft fluctuant swelling

Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young
men

Testicular torsion Severe, sudden onset testicular pain

Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by
elevation
Urgent surgery is indicated, the contra lateral testis should
also be fixed

Varicocele Varicosities of the pampiniform plexus

Typically occur on left (because testicular vein drains into
renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles
may affect fertility

Management
Testicular malignancy is always treated with orchidectomy via an inguinal
approach. This allows high ligation of the testicular vessels and avoids
exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children
can be difficult to elicit. Intermittent torsion is a recognised problem. The
 treatment is prompt surgical exploration and testicular fixation. This can be
achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about
testicular function of infertility then surgery or radiological management can
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be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying
pathology is a patent processus vaginalis and therefore an inguinal
approach is used in children so that the processus can be ligated. In adults
a scrotal approach is preferred and the hydrocele sac excised or plicated.

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Question 41 of 63
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A 55 year old man has multiple stones within the renal pelvis, including one
measuring 25mm in diameter. What is the most appropriate course of action?

Arrange a nephrectomy

Arrange a percutaneous nephrolithotomy

Arrange for lithotripsy

Conservative management

Arrange for ureteroscopy and stone extraction

The intervention of choice for renal pelvis stones greater than 20mm is PCNL. This
stone is highly unlikely to pass spontaneously and ureteroscopy for a stone of this
size would be extremely time-consuming.

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Management of renal stones

Urolithiasis will affect up to 15% of the worldwide population. The development of

sudden onset loin to groin pain which is colicky in nature is a classic feature in the
history. It is nearly always associated with haematuria that is either visible or non-
visible but detectable on urine dipstick testing. Where the diagnosis is suspected
the most sensitive and specific investigation is helical, non-contrast, computerised
tomographic (CT) scanning.

Management
Most renal stones measuring less than 5mm in maximum diameter will typically
pass within 4 weeks of symptom onset(1)(2). More urgent treatment is indicated in
the presence of ureteric obstruction, renal developmental abnormalities such as
horseshoe kidney and previous renal transplant. Ureteric obstruction together with
 infection is a surgical emergency and the system must be decompressed. Options
include nephrostomy tube placement or ureteric stent placement via cystoscopy.

In the non-emergency setting the preferred options for treatment of stone disease
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include extracorporeal shock wave lithotripsy (ESWL), percutaneous

nephrolithotomy (PCNL) and ureteroscopy (URS). These minimally invasive options
are the most popular first line treatments. Open surgery remains an option in a few
selected cases.

Extracorporeal shock wave lithotripsy

A shock wave is generated external to the patient. Internally, cavitation bubbles
and mechanical stress lead to stone fragmentation. The passage of shock waves
can occasionally result in the development of solid organ injury. Fragmentation of
larger stones may result in the development of ureteric obstruction. The procedure
can be uncomfortable for patients and analgesia is often required during the
procedure and afterwards. ESWL is contra-indicated in pregnant females and
patients with significant vascular calcification.

Ureteroscopy
A ureteroscope is passed retrograde via the urethra and bladder, into the ureter and
renal pelvis. Laser or pneumatic fragmentation (lithoclasty) is performed using the
ureteroscope and stone fragments are extracted(3). In some cases a stent is left in
situ after the procedure.

Percutaneous nephrolithotomy
In this procedure percutaneous access is gained to the renal collecting system.
Once access is achieved, endoscopic intra-corporeal lithotripsy, lithoclasty or laser
stone fragmentation is performed and stone fragments removed.

Therapeutic selection

Renal stones

Size First line option

Less than 5mm and asymptomatic Watchful waiting

Less than 10mm ESWL

10 20mm ESWL or ureteroscopy

Greater than 20mm (including staghorn calculi) PCNL

Ureteric stones

Size First line option

 Less than 5mm Watchful waiting

5-10mm ESWL
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10-20mm Ureteroscopy

Reference
1. Bultitude M, Rees J. Management of renal colic. BMJ. 2012;345(7872):18.
2. Shah TT, Gao C, Peters M, Manning T, Cashman S, Nambiar A, et al. Factors
associated with spontaneous stone passage in a contemporary cohort of patients
presenting with acute ureteric colic: results from the Multi-centre cohort study
evaluating the role of Inflammatory Markers In patients presenting with acute
ureteric . BJU Int. 2019 Apr.
3. BAUS. Ureteroscopy (Telescopic surgery for stone removal) (Internet). BAUS
patient information leaflet. 2017 (cited 2019 Jun 27). p. 16. Available from:
https://www.baus.org.uk/userfiles/pages/files/Patients/Leaflets/Ureteroscopy for
stone.pdf
4. BAUS. Percutaneous nephrolithotomy (keyhole surgery for kidney stones). BAUS
patient information leaflet. 2017. p. 16. Available from: https://www.baus.org.uk
/userfiles/pages/files/Patients/Leaflets/PCNL.pdf
5. NICE. Renal and ureteric stones: assessment and management. NICE
Guide[NG118]. 2019;(January):112.

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Question 42 of 63
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A 16 year old boy presents with renal colic. His parents both have a similar history
of the condition. His urine tests positive for blood. A KUB style x-ray shows a
relatively radiodense stone in the region of the mid ureter. What is the most likely
composition of the stone?

Calcium phosphate stone

Uric acid stone

Struvite stone

Cystine stone

Calcium oxalate stone

Cystine stones are associated with an inherited metabolic disorder.

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Renal stones

Type of Percentage of
stones Features all calculi
 Type of Percentage of
stones Features all calculi

Calcium Hypercalciuria is a major risk factor (various 85%

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oxalate causes)
Hyperoxaluria may also increase risk
Hypocitraturia increases risk because citrate
forms complexes with calcium making it more
soluble
Stones are radio-opaque (though less than
calcium phosphate stones)
Hyperuricosuria may cause uric acid stones to
which calcium oxalate binds

Cystine Inherited recessive disorder of 1%

transmembrane cystine transport leading to
decreased absorption of cystine from
intestine and renal tubule
Multiple stones may form
Relatively radiodense because they contain
sulphur

Uric acid Uric acid is a product of purine metabolism 5-10%

May precipitate when urinary pH low
May be caused by diseases with extensive
tissue breakdown e.g. malignancy
More common in children with inborn errors of
metabolism
Radiolucent

Calcium May occur in renal tubular acidosis, high 10%

phosphate urinary pH increases supersaturation of urine
with calcium and phosphate
Renal tubular acidosis types 1 and 3 increase
risk of stone formation (types 2 and 4 do not)
Radio-dense stones (composition similar to
bone)

Struvite Stones formed from magnesium, ammonium 2-20%

and phosphate
Occur as a result of urease producing bacteria
(and are thus associated with chronic
infections)
Under the alkaline conditions produced, the
crystals can precipitate
Slightly radio-opaque
 Effect of urinary pH on stone formation
Urine pH will show individual variation (from pH 5-7). Post prandially the pH falls as
purine metabolism will produce uric acid. Then the urine becomes more alkaline
(alkaline tide). When the stone is not available for analysis the pH of urine may
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help to determine which stone was present.

Stone type Urine acidity Mean urine pH

Calcium phosphate Normal- alkaline >5.5

Calcium oxalate Variable 6

Uric acid Acid 5.5

Struvate Alkaline >7.2

Cystine Normal 6.5

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Question 43 of 63
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A 68 year old man has a TCC of the bladder. He has a right hydronephrosis
detected on ultrasound and deteriorating renal function. A DMSA scan shows a
non functioning left kidney. At cystoscopy the ureteric orifice cannot be readily
accessed. What is the best course of action?

Insertion of antegrade ureteric stent

Insertion of retrograde ureteric stent

Cystectomy and ileal conduit

Radiotherapy

Instillation of intravesical BCG

Antegrade ureteric stents pass from the kidney to the bladder

Retrograde stents pass from the bladder to the kidney

A TCC occluding the ureteric orifice will obscure its identification during surgery,
so that passage of a retrograde stent is difficult. Therefore passage of a stent
from the renal pelvis is preferable.

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Hydronephrosis

Causes of hydronephrosis

Unilateral: PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
 Calculi
Tumours of renal pelvis
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Bilateral: SUPER
Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis

Investigation
USS- identifies presence of hydronephrosis and can assess the kidneys
IVU- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
If renal colic suspected: non contrast CT scan (majority of stones are
detected this way)

Management
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty

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Question 44 of 63
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A 24 year old man presents with a persistent and unwanted erection that has been
present for the previous 6 hours. On examination the penis is rigid and tender.
Aspiration of blood from the corpus cavernosa shows dark blood. Which of the
following is the most appropriate initial management?

Discharge the patient home and review in 12 hours

Admit the patient to hospital and review in 12 hours

Aspirate further blood from the corpus cavernosa in an attempt to

decompress

Use a trucut needle to induce an arteriovenous shunt

Administer intracavernosal adrenaline 1 in 500 concentration

Low flow priapism is a urological emergency. Aspiration of bright red blood is more
reassuring and may indicate high flow priapism that may be actively monitored.
Low flow priapism should be decompressed with aspiration of blood from the
corpus cavernosum.

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Penile erection

Physiology of erection

Autonomic Sympathetic nerves originate from T11-L2 and

parasympathetic nerves from S2-4 join to form pelvic
plexus.
Parasympathetic discharge causes erection, sympathetic
discharge causes ejaculation and detumescence.
 Somatic Supplied by dorsal penile and pudendal nerves. Efferent signals
nerves are relayed from Onufs nucleus (S2-4) to innervate
ischiocavernosus and bulbocavernosus muscles.
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Autonomic discharge to the penis will trigger the veno-occlusive mechanism which
triggers the flow of arterial blood into the penile sinusoidal spaces. As the inflow
increases the increased volume in this space will secondarily lead to compression
of the subtunical venous plexus with reduced venous return. During the
detumesence phase the arteriolar constriction will reduce arterial inflow and
thereby allow venous return to normalise.

Priapism
Prolonged unwanted erection, in the absence of sexual desire, lasting more than 4
hours.

Classification of priapism

Low flow Due to veno-occlusion (high intracavernosal pressures).

priapism Most common type
Often painful
Often low cavernosal flow
If present for >4 hours requires emergency treatment

High flow Due to unregulated arterial blood flow.

priapism Usually presents as semi rigid painless erection

Recurrent Typically seen in sickle cell disease, most commonly of

priapism high flow type.

Causes
Intracavernosal drug therapies (e.g. for erectile dysfunction>
Blood disorders such as leukaemia and sickle cell disease
Neurogenic disorders such as spinal cord transection
Trauma to penis resulting in arterio-venous malformations

Tests
Exclude sickle cell/ leukaemia
Consider blood sampling from cavernosa to determine whether high or low
flow (low flow is often hypoxic)

Management
Ice packs/ cold showers
If due to low flow then blood may be aspirated from copora or try
intracavernosal alpha adrenergic agonists.
 Delayed therapy of low flow priapism may result in erectile dysfunction.

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Question 45 of 63
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A 43 year old female has undergone a renal transplant 12 months previously. Over
the past few weeks there have been concerns about deteriorating renal function.
What is the most useful investigation?

MAG 3 renogram

DMSA scan

Intravenous KUB urogram

Renal CT scan

Micturating cystourethrohram

Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent

imaging of renal function and is often used in investigating failing transplants.

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Functional renal imaging

DMSA scan
Dimercaptosuccinic acid (DMSA) scintigraphy
DMSA localises to the renal cortex with little accumulation in the renal papilla and
medulla. It is useful for the identification of cortical defects and ectopic or
aberrant kidneys. It does not provide useful information on the ureter of collecting
system.

Diethylene-triamine-penta-acetic acid (DTPA)

This is primarily a glomerular filtration agent. It is most useful for the assessment
of renal function. Because it is filtered at the level of the glomerulus it provides
useful information about the GFR. Image quality may be degraded in patients with
chronic renal impairment and derangement of GFR.
 MAG 3 renogram
Mercaptoacetyle triglycine is an is extensively protein bound and is primarily
secreted by tubular cells rather than filtered at the glomerulus. This makes it the
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agent of choice for imaging the kidneys of patients with existing renal impairment
(where GFR is impaired).

Micturating cystourethrogram (MCUG scan)

This scan provides information relating to bladder reflux and is obtained by filling
the bladder with contrast media (via a catheter) and asking the child to void.
Images are taken during this phase and the degree of reflux can be calculated

Intra venous urography

This examination is conducted by the administration of intravenous iodinated
contrast media. The agent is filtered by the kidneys and excreted and may provide
evidence of renal stones or other structural lesions. A rough approximation of renal
function may be obtained using the technique. But it is not primarily a technique to
be used for this purpose. With the advent of widespread non contrast CT scan
protocols for the detection of urinary tract calculi it is now rarely used.

PET/CT
This may be used to evaluate structurally indeterminate lesions in the staging of
malignancy.

References
Davis A et al. Investigating urinary tract infections in children. BMJ 2013
(346):35-37.

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Question 46 of 63
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A 34-year-old man from Zimbabwe is admitted with abdominal pain to the

Emergency Department. An abdominal x-ray reveals urinary bladder calcification.
What is the most likely cause?

Schistosoma mansoni

Sarcoidosis

Leishmaniasis

Tuberculosis

Schistosoma haematobium

Schistosoma haematobium causes haematuria

Schistosomiasis is the most common cause of bladder calcification worldwide.

Schistosoma mansoni typically resided in the colon from where it is excreted.

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Schistosomiasis

Schistosomiasis, or bilharzia, is a parasitic flatworm infection. The following types

of schistosomiasis are recognised:
Schistosoma mansoni and Schistosoma intercalatum: intestinal
schistosomiasis
Schistosoma haematobium: urinary schistosomiasis

Schistosoma haematobium
 This typically presents as a 'swimmer's itch' in patients who have recently returned
from Africa. Schistosoma haematobium is a risk factor for squamous cell bladder
cancer
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Features
Frequency
Haematuria
Bladder calcification

Management
Single oral dose of praziquantel

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Question 47 of 63
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A 13 month old boy is brought to the paediatric clinic by his mother who is
concerned that his testis are not palpable. On examination his testis are not
palpable either in the scrotum or inguinal region and cannot be visualised on
ultrasound either. What is the most appropriate next stage in management?

Laparoscopy

Re-assess at 5 years of age

Re-assess at 13 years of age

Administration of testosterone

Administration of cyproterone acetate

Impalpable testes are an indication for laparoscopy. Ultrasound is a relatively

unhelpful tool in evaluating cryptorchid patients and most experienced paediatric
surgeons would not use it pre-operatively. They may be associated with an intra-
abdominal location. Whilst it is reasonable to defer orchidopexy for retractile testis
completely absent testes should be investigated further.

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Cryptorchidism

A congenital undescended testis is one that has failed to reach the bottom of the
scrotum by 3 months of age. At birth up to 5% of boys will have an undescended
testis, post natal descent occurs in most and by 3 months the incidence of
cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the
maldescent is unknown. A proportion may be associated with other congenital
defects including:

Patent processus vaginalis

 Abnormal epididymis
Cerebral palsy
Mental retardation
Wilms tumour
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Abdominal wall defects (e.g. gastroschisis, prune belly syndrome)

Differential diagnosis
These include retractile testes and, in the case of absent bilateral testes the
possibility of intersex conditions. A retractile testis can be brought into the
scrotum by the clinician and when released remains in the scrotum. If the
examining clinician notes the testis to return rapidly into the inguinal canal when
released then surgery is probably indicated.

Reasons for correction of cryptorchidism

Reduce risk of infertility
Allows the testes to be examined for testicular cancer
Avoid testicular torsion
Cosmetic appearance

Males with undescended testis are 40 times as likely to develop testicular cancer
(seminoma) as males without undescended testis
The location of the undescended testis affects the relative risk of testicular cancer
(50% intra-abdominal testes)

Treatment
Orchidopexy at 6- 18 months of age. The operation usually consists of
inguinal exploration, mobilisation of the testis and implantation into a dartos
pouch.
Intra-abdominal testis should be evaluated laparoscopically and mobilised.
Whether this is a single stage or two stage procedure depends upon the
exact location.
After the age of 2 years in untreated individuals the Sertoli cells will degrade
and those presenting late in teenage years may be better served by
orchidectomy than to try and salvage a non functioning testis with an
increased risk of malignancy.

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Question 48 of 63
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Which of the following would be most consistent with a histologically aggressive

form of prostate cancer?

FIGO stage 1 disease

FIGO stage IV disease

EuroQOL score of 5

Gleason score of 2

Gleason score of 10

Prostate cancer is histologically graded using the Gleason score (see below). A
score of 10 is consistent with a histologically aggressive form of the disease. The
FIGO staging system is used to stage gynaecological malignancy. The EuroQOL
score is a quality of life measurement tool.

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Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the
condition each year. Up to 9,000 will die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
 MRI/ CT and bone scan for staging.

PSA Test
The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients
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with benign disease and some with localised prostate cancer. False positives may
be due to prostatitis, UTI, BPH, vigorous DRE.
The percentage of free: total PSA may help to distinguish benign disease from
cancer. Values of <20% are suggestive of cancer and biopsy is advised.

Pathology
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple
biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most
dominant grade (on scale of 1-5) and 2 for second most dominant grade
(scale 1-5). The two added together give the Gleason score. Where 2 is best
prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra
prostatic spread to the seminal vesicles is associated with distant disease.

Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy
possible. However, radiation proctitis and rectal malignancy are late
problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the
standard treatment for localised disease. The robot is being used
increasingly for this procedure. As well as the prostate the obturator nodes
are also removed to complement the staging process. Erectile dysfunction
is a common side effect. Survival may be better than with radiotherapy (see
references).
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic
cancers usually show some degree of testosterone dependence. 95% of
testosterone is derived from the testis and bilateral orchidectomy may be
used for this reason. Pharmacological alternatives include LHRH analogues
and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that
active surveillance is the preferred option for low risk men. It is particularly
suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores,
with < 10 mm of any core involved.

Candidates for active surveillance should:

have had at least 10 biopsy cores taken
have at least one re-biopsy.

If men on active surveillance show evidence of disease progression, offer radical

treatment. Treatment decisions should be made with the man, taking into account
 co-morbidities and life expectancy.

References
1. Prostate cancer pathway. NICE.(http://guidance.nice.org.uk/IPG424)
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

2. Sooriakumaran P et al. Comparative effectiveness of radical prostatectomy and

radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ
2014 (348):13. This study shows that in men with localised disease survival was
greater in those offered surgery.

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Question 49 of 63
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A 44 year old man is referred to the clinic because of a swelling and discomfort in
the right scrotum. This is present most of the time and he is otherwise well with no
urinary symptoms. On examination, he has a soft, fluctuant swelling in the right
scrotum that transilluminates easily. An ultrasound is performed that confirms that
the underlying testicle is structurally normal. What is the best course of action?

Ligation of patent processus vaginalis via inguinal approach

Ligation of patent processus vaginalis via a scrotal approach

Jaboulay procedure via scrotal approach

Lords procedure via inguinal approach

Aspiration and injection of sclerosant

Adult hydroceles are less commonly due to the persistence of embryonic remnants
and therefore can be managed via a scrotal approach. Both the Lords and
Jaboulay procedures are reasonable options. However, only a scrotal approach
should be adopted.

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Scrotal swelling

Differential diagnosis

Inguinal hernia If inguinoscrotal swelling; cannot 'get above it' on

examination
Cough impulse may be present
May be reducible
 Testicular Often discrete testicular nodule (may have associated
tumours hydrocele)
Symptoms of metastatic disease may be present
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USS scrotum and serum AFP and β HCG required

Acute epididymo- Often history of dysuria and urethral discharge

orchitis Swelling may be tender and eased by elevating testis
Most cases due to Chlamydia
Infections with other gram negative organisms may be
associated with underlying structural abnormality

Epididymal cysts Single or multiple cysts

May contain clear or opalescent fluid (spermatoceles)
Usually occur over 40 years of age
Painless
Lie above and behind testis
It is usually possible to 'get above the lump' on
examination

Hydrocele Non painful, soft fluctuant swelling

Often possible to 'get above it' on examination
Usually contain clear fluid
Will often transilluminate
May be presenting feature of testicular cancer in young
men

Testicular torsion Severe, sudden onset testicular pain

Risk factors include abnormal testicular lie
Typically affects adolescents and young males
On examination testis is tender and pain not eased by
elevation
Urgent surgery is indicated, the contra lateral testis should
also be fixed

Varicocele Varicosities of the pampiniform plexus

Typically occur on left (because testicular vein drains into
renal vein)
May be presenting feature of renal cell carcinoma
Affected testis may be smaller and bilateral varicoceles
may affect fertility

Management
Testicular malignancy is always treated with orchidectomy via an inguinal
approach. This allows high ligation of the testicular vessels and avoids
exposure of another lymphatic field to the tumour.
Torsion is commonest in young teenagers and the history in older children
can be difficult to elicit. Intermittent torsion is a recognised problem. The
 treatment is prompt surgical exploration and testicular fixation. This can be
achieved using sutures or by placement of the testis in a Dartos pouch.
Varicoceles are usually managed conservatively. If there are concerns about
testicular function of infertility then surgery or radiological management can
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be considered.
Epididymal cysts can be excised using a scrotal approach
Hydroceles are managed differently in children where the underlying
pathology is a patent processus vaginalis and therefore an inguinal
approach is used in children so that the processus can be ligated. In adults
a scrotal approach is preferred and the hydrocele sac excised or plicated.

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Question 50 of 63
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A 33 year old man presents with a painless lump in his left testis. USS and blood
tests are suspicious for teratoma. What is the most appropriate next step?

Orchidectomy via an inguinal approach

Orchidectomy via a scrotal approach

Fine needle aspiration cytology of the lesion

Core biopsy of the lesion

Incisional biopsy of the lesion

Do not biopsy suspected testicular cancer

Oncological orchidectomy is routinely performed via an inguinal approach to avoid

contamination of another lymphatic field.

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Testicular disorders

Testicular cancer
Testicular cancer is the most common malignancy in men aged 20-30 years.
Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell
tumours may essentially be divided into:

Tumour
Tumour type Key features markers Pathology
 Tumour
Tumour type Key features markers Pathology

Seminoma Commonest AFP usually Sheet like

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subtype normal lobular

(50%) HCG elevated patterns of
Average in 10% cells with
age at seminomas substantial
diagnosis = Lactate fibrous
40 dehydrogenase; component.
Even elevated in Fibrous septa
advanced 10-20% contain
disease seminomas lymphocytic
associated (but also in inclusions
with 5 year many other and
survival of conditions) granulomas
73% may be seen.

Non seminomatous Younger age at AFP elevated in Heterogenous

germ cell tumours presentation up to 70% of texture with
(42%) =20-30 years cases occasional
Teratoma Advanced disease HCG elevated ectopic tissue
Yolk sac tumour carries worse in up to 40% of such as hair
Choriocarcinoma prognosis (48% at cases
Mixed germ cell 5 years) Other markers
tumours (10%) Retroperitoneal rarely helpful
lymph node
dissection may be
needed for
residual disease
after
chemotherapy

Image demonstrating a classical seminoma, these tumours are typically more

uniform than teratomas
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(https://d2zgo9qer4wjf4.cloudfront.net/images_eMRCS/swb090b.jpg)
Image sourced from Wikipedia
(https://d2zgo9qer4wjf4.cloudfront.net
(http://en.wikipedia.org
/images_eMRCS/swb090b.jpg)
/wiki/Seminoma)

Risk factors for testicular cancer

Cryptorchidism
Infertility
Family history
Klinefelter's syndrome
Mumps orchitis

Features
A painless lump is the most common presenting symptom
Pain may also be present in a minority of men
Other possible features include hydrocele, gynaecomastia
 Diagnosis
Ultrasound is first-line
CT scanning of the chest/ abdomen and pelvis is used for staging
Tumour markers (see above) should be measured
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Management
Orchidectomy (Inguinal approach)
Chemotherapy and radiotherapy may be given depending on staging
Abdominal lesions >1cm following chemotherapy may require
retroperitoneal lymph node dissection.

Prognosis is generally excellent

5 year survival for seminomas is around 95% if Stage I
5 year survival for teratomas is around 85% if Stage I

Benign disease

Epididymo-orchitis
Acute epididymitis is an acute inflammation of the epididymis, often involving the
testis and usually caused by bacterial infection.
Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea
or chlamydia are the usual infections.
Amiodarone is a recognised non infective cause of epididymitis, which
resolves on stopping the drug.
Tenderness is usually confined to the epididymis, which may facilitate
differentiating it from torsion where pain usually affects the entire testis.

Testicular torsion
Twist of the spermatic cord resulting in testicular ischaemia and necrosis.
Most common in males aged between 10 and 30 (peak incidence 13-15
years)
Pain is usually severe and of sudden onset.
Cremasteric reflex is lost and elevation of the testis does not ease the pain.
Treatment is with surgical exploration. If a torted testis is identified then
both testis should be fixed as the condition of bell clapper testis is often
bilateral.

Hydrocele
Presents as a mass that transilluminates, usually possible to 'get above' it
on examination.
In younger men it should be investigated with USS to exclude tumour.
In children it may occur as a result of a patent processus vaginalis.
Treatment in adults is with a Lords or Jabouley procedure.
Treatment in children is with trans inguinal ligation of PPV.
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Question 51 of 63
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A 75 year old man presents with locally advanced carcinoma of the prostate and
vertebral body metastasis with impending spinal cord compression. Which of the
following agents (if used in isolation) carries the greatest risk of worsening his
symptoms in the short term?

Surgical orchidectomy

Cyproterone acetate

Luteinising hormone releasing hormone analogues

Flutamide

None of the above

LHRH analogues may cause flare of metastatic disease and anti androgens should
be administered to counter this. Surgical orchidectomy reduces testosterone levels
within 8 hours (but fails to reduce adrenal androgen release). Cyproterone and
flutamide are androgen blockers that may be considered as add on therapy to
reduce the risk of tumour flare when commencing treatment with LH RH
analogues.

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Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the
condition each year. Up to 9,000 will die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
 Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
Digital rectal examination
Trans rectal USS (+/- biopsy)
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MRI/ CT and bone scan for staging.

PSA Test
The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients
with benign disease and some with localised prostate cancer. False positives may
be due to prostatitis, UTI, BPH, vigorous DRE.
The percentage of free: total PSA may help to distinguish benign disease from
cancer. Values of <20% are suggestive of cancer and biopsy is advised.

Pathology
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple
biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most
dominant grade (on scale of 1-5) and 2 for second most dominant grade
(scale 1-5). The two added together give the Gleason score. Where 2 is best
prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra
prostatic spread to the seminal vesicles is associated with distant disease.

Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy
possible. However, radiation proctitis and rectal malignancy are late
problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the
standard treatment for localised disease. The robot is being used
increasingly for this procedure. As well as the prostate the obturator nodes
are also removed to complement the staging process. Erectile dysfunction
is a common side effect. Survival may be better than with radiotherapy (see
references).
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic
cancers usually show some degree of testosterone dependence. 95% of
testosterone is derived from the testis and bilateral orchidectomy may be
used for this reason. Pharmacological alternatives include LHRH analogues
and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that
active surveillance is the preferred option for low risk men. It is particularly
suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores,
with < 10 mm of any core involved.

Candidates for active surveillance should:

 have had at least 10 biopsy cores taken
have at least one re-biopsy.

If men on active surveillance show evidence of disease progression, offer radical

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treatment. Treatment decisions should be made with the man, taking into account
co-morbidities and life expectancy.

References
1. Prostate cancer pathway. NICE.(http://guidance.nice.org.uk/IPG424)
2. Sooriakumaran P et al. Comparative effectiveness of radical prostatectomy and
radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ
2014 (348):13. This study shows that in men with localised disease survival was
greater in those offered surgery.

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Question 52 of 63
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A 23 year old woman is admitted with loin pain and a fever, she has noticed
haematuria for the past week accompanied by dysuria, this was treated empirically
with trimethoprim. What is the most likely cause?

Stone disease

Cystitis

Pyelonephritis

Renal cancer

Detrusor instability

This is most likely pyelonephritis and partially treated cystitis is a common cause.

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Haematuria

Causes of haematuria

Trauma Injury to renal tract

Renal trauma commonly due to blunt injury
(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures

Infection Remember TB
 Malignancy Renal cell carcinoma (remember paraneoplastic
syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell
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carcinoma, can occur anywhere along the urinary

tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC

Renal disease Glomerulonephritis

Stones Microscopic haematuria common

Structural Benign prostatic hyperplasia (BPH) causes

abnormalities haematuria due to hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma

Coagulopathy Causes bleeding of underlying lesions

Drugs Cause tubular necrosis or interstitial nephritis:

aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants

Benign Exercise

Gynaecological Endometriosis: flank pain, dysuria, and

haematuria that is cyclical

Iatrogenic Catheterisation
Radiotherapy; cystitis, severe haemorrhage,
bladder necrosis

Pseudohaematuria For example following consumption of beetroot

References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
/aetiology.html
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Question 53 of 63
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A 58 year old man has an episode of painless frank haematuria whilst undergoing
a 24 urine collection for investigation of hypertension. What is the most likely
cause?

Renal adenocarcinoma

Neuroblastoma

Transitional cell carcinoma of the ureter

Squamous cell carcinoma of the bladder

Phaeochromocytoma

These tumours may often have paraneoplastic effects such as hypertension.

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Haematuria

Causes of haematuria

Trauma Injury to renal tract

Renal trauma commonly due to blunt injury
(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures

Infection Remember TB
 Malignancy Renal cell carcinoma (remember paraneoplastic
syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell
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carcinoma, can occur anywhere along the urinary

tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC

Renal disease Glomerulonephritis

Stones Microscopic haematuria common

Structural Benign prostatic hyperplasia (BPH) causes

abnormalities haematuria due to hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma

Coagulopathy Causes bleeding of underlying lesions

Drugs Cause tubular necrosis or interstitial nephritis:

aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants

Benign Exercise

Gynaecological Endometriosis: flank pain, dysuria, and

haematuria that is cyclical

Iatrogenic Catheterisation
Radiotherapy; cystitis, severe haemorrhage,
bladder necrosis

Pseudohaematuria For example following consumption of beetroot

References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
/aetiology.html
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Question 54 of 63
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A 56 year old man is involved in a road traffic accident. He is found to have a pelvic
fracture. He reports that he has some lower abdominal pain. He has peritonism in
the lower abdomen. The nursing staff report that he has not passed any urine. A
CT scan shows evidence of free fluid. What is the most likely diagnosis?

Membranous urethral injury

Bladder rupture

Bladder contusion

Bulbar urethral injury

Urinary tract infection

A pelvic fracture and lower abdominal peritonism should raise suspicions of

bladder rupture (especially as this man cannot pass urine).

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Lower genitourinary tract trauma

Most bladder injuries occur due to blunt trauma

85% associated with pelvic fractures
Easily overlooked during assessment in trauma
Up to 10% of male pelvic fractures are associated with urethral or bladder
injuries

Types of injury
 Urethral injury Mainly in males

Blood at the meatus (50% cases)

There are 2 types:
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i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma,
blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing
retroperitoneal haematomas as they may make
examination difficult)

- Investigation: ascending urethrogram

- Management: suprapubic catheter (surgical
placement, not percutaneously)

External genitalia Secondary to injuries caused by penetration,

injuries (i.e., the penis blunt trauma, continence- or sexual pleasure-
and the scrotum) enhancing devices, and mutilation

Bladder injury rupture is intra or extraperitoneal

presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void:
always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the
bladder through a Foley catheter indicates
bladder injury
investigation- IVU or cystogram
management: laparotomy if intraperitoneal,
conservative if extraperitoneal

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Question 55 of 63
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A 52 year old male with hypercalcaemia secondary to primary hyperparathyroidism

presents with renal colic. USS demonstrates ureteric obstruction due to a stone.
Multiple attempts at stone extraction are performed. However, the stone could not
be removed. He is now septic with a pyrexia of 39.5 oc and he has been given
antibiotics. What is the best course of action?

Cystoscopy and insertion of ureteric stent

Laparotomy and ureteric exploration

Insertion of nephrostomy

Laparoscopic ureteric exploration

Lithotripsy

The likely scenario is that this man has developed a calculus causing ureteric
obstruction. The stagnant column of urine can become colonised and infected. An
infected obstructed system is one of the few true urological emergencies. A
nephrostomy is needed as the stone could not be removed.

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Hydronephrosis

Causes of hydronephrosis

Unilateral: PACT
Pelvic-ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis
 Bilateral: SUPER
Stenosis of the urethra
Urethral valve
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Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis

Investigation
USS- identifies presence of hydronephrosis and can assess the kidneys
IVU- assess the position of the obstruction
Antegrade or retrograde pyelography- allows treatment
If renal colic suspected: non contrast CT scan (majority of stones are
detected this way)

Management
Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: Nephrostomy tube
Chronic upper urinary tract obstruction: Ureteric stent or a pyeloplasty

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Question 56 of 63
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A 75 year old lady reports urinary incontinence when coughing and sneezing. She
has had 2 children with no complications. She has no significant past medical
history and is on no medications. What is the most appropriate initial
management?

Trial of sacral neuromodulation

Urodynamic studies

Pelvic floor exercises for 3 months

Bladder drill training for 6 weeks

Administration of oxybutinin

A diagnosis of stress incontinence is obvious from the history, therefore there is no

need for a bladder diary or urodynamic studies. Pelvic floor exercises would be the
first line management.

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Urinary incontinence

Involuntary passage of urine. Most cases are female (80%). It has a prevalence of
11% in those aged greater than 65 years. The commonest variants include:
Stress urinary incontinence (50%)
Urge incontinence (15%)
Mixed (35%)

Males
Males may also suffer from incontinence although it is a much rarer condition in
men. A number of anatomical factors contribute to this. Males have 2 powerful
 sphincters; one at the bladder neck and the other in the urethra. Damage to the
bladder neck mechanism is a factor in causing retrograde ejaculation following
prostatectomy. The short segment of urethra passing through the urogenital
diaphragm consists of striated muscle fibres (the external urethral sphincter) and
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smooth muscle capable of more sustained contraction. It is the latter mechanism

that maintains continence following prostatectomy.

Females
The sphincter complex at the level of bladder neck is poorly developed in females.
As a result the external sphincter complex is functionally more important, its
composition being similar to that of males. Innervation is via the pudendal nerve
and the neuropathy that may accompany obstetric events may compromise this
and lead to stress urinary incontinence.

Innervation
Somatic innervation to the bladder is via the pudendal, hypogastric and pelvic
nerves. Autonomic nerves travel in these nerve fibres too. Bladder filling leads to
detrusor relaxation (sympathetic) coupled with sphincter contraction. The
parasympathetic system causes detrusor contraction and sphincter relaxation.
Overall control of micturition is centrally mediated via centres in the Pons.

Stress urinary incontinence

50% of cases, especially in females.
Damage (often obstetric) to the supporting structures surrounding the
bladder may lead to urethral hypermobility.
Other cases due to sphincter dysfunction, usually from neurological
disorders (e.g. Pudendal neuropathy, multiple sclerosis).

Urethral mobility:
Pressure not transmitted appropriately to the urethra resulting in involuntary
passage of urine during episodes of raised intra-abdominal pressure.

Sphincter dysfunction:
Sphincter fails to adapt to compress urethra resulting in involuntary passage of
urine. When the sphincter completely fails there is often to continuous passage of
urine.

Urge incontinence
In these patients there is sense of urgency followed by incontinence. The detrusor
muscle in these patients is unstable and urodynamic investigation will
demonstrate overactivity of the detrusor muscle at inappropriate times (e.g.
Bladder filling). Urgency may be seen in patients with overt neurological disorders
and those without. The pathophysiology is not well understood but poor central
and peripheral co-ordination of the events surrounding bladder filling are the main
processes.

Assessment
Careful history and examination including vaginal examination for cystocele.
 Bladder diary for at least 3 days
Consider flow cystometry if unclear symptomatology or surgery considered and
diagnosis is unclear.
Exclusion of other organic disease (e.g. Stones, UTI, Cancer)
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Management
Conservative measures should be tried first; Stress urinary incontinence or mixed
symptoms should undergo 3 months of pelvic floor exercise. Over active bladder
should have 6 weeks of bladder retraining.
Drug therapy for women with overactive bladder should be offered oxybutynin (or
solifenacin if elderly) if conservative measures fail.
In women with detrusor instability who fail non operative therapy a trial of sacral
neuromodulation may be considered, with conversion to permanent implant if
good response. Augmentation cystoplasty is an alternative but will involve long
term intermittent self catheterisation.
In women with stress urinary incontinence a urethral sling type procedure may be
undertaken. Where cystocele is present in association with incontinence it should
be repaired particularly if it lies at the introitus.

NICE guidelines
Initial assessment urinary incontinence should be classified as stress/urge
/mixed.
At least 3/7 bladder diary if unable to classify easily.
Start conservative treatment before urodynamic studies if a diagnosis is
obvious from the history
Urodynamic studies if plans for surgery.
Stress incontinence: Pelvic floor exercises 3/12, if fails consider surgery.
Urge incontinence: Bladder training >6/52, if fails for oxybutynin
(antimuscarinic drugs) then sacral nerve stimulation.
Pelvic floor exercises offered to all women in their 1st pregnancy.

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C 63.5%
D 7.6%
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E 7.7%

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Question 57 of 63
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A 72 year old man presents with haematuria which is recurrent. On investigation, a

retrograde pyelogram shows multiple ureteric filling defects and the renal pelvis is
irregular. What is the most likely cause?

Squamous cell carcinoma of the renal pelvis

Transitional cell carcinoma

Adenocarcinoma of the kidney

Retroperitoneal sarcoma

Retroperitoneal fibrosis

TCC of the renal pelvis may seed down the ureter.

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Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to
arise from the proximal convoluted tubule. They are usually solid lesions, up to
20% may be multifocal, 20% may be calcified and 20% may have either a cystic
component or be wholly cystic. They are often circumscribed by a pseudocapsule
of compressed normal renal tissue. Spread may occur either by direct extension
into the adrenal gland, renal vein or surrounding fascia. More distant disease
usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are
more commonly affected than females and sporadic tumours typically affect
patients in their sixth decade.
Patients may present with a variety of symptoms including; haematuria (50%), loin
pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less
 than 10% have the classic triad of haematuria, pain and mass.

Investigation
Many cases will present as haematuria and be discovered during diagnostic work
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up. Benign renal tumours are rare, so renal masses should be investigated with
multislice CT scanning. Some units will add an arterial and venous phase to the
scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be
undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory

before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent
oncological results to total radical nephrectomy. Partial nephrectomy may also be
performed when there is inadequate reserve in the remaining kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may
be performed via a laparoscopic or open approach. Preoperative embolisation is
not indicated nor is resection of uninvolved adrenal glands. During surgery early
venous control is mandatory to avoid shedding of tumour cells into the circulation.

Patients with completely resected disease do not benefit from adjuvant therapy
with either chemotherapy or biological agents. These should not be administered
outside the setting of clinical trials.

Patients with transitional cell cancer will require a nephroureterectomy with

disconnection of the ureter at the bladder.

References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update.
European Urology 2010 (58): 398-406.

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D 7.1%
E 9.5%

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Question 58 of 63
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Why is a 73 year old lady receiving a course of intravesical BCG therapy?

Bladder tuberculosis

Transitional cell carcinoma of the bladder

Adenocarcinoma of the bladder

Squamous cell carcinoma of the bladder

Rhabdomyosarcoma of the bladder

Transitional cell carcinoma of the bladder may be treated with intravesical BCG
therapy.

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Haematuria

Causes of haematuria

Trauma Injury to renal tract

Renal trauma commonly due to blunt injury
(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures

Infection Remember TB
 Malignancy Renal cell carcinoma (remember paraneoplastic
syndromes): painful or painless

Urothelial malignancies: 90% are transitional cell

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carcinoma, can occur anywhere along the urinary

tract. Painless haematuria.
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC

Renal disease Glomerulonephritis

Stones Microscopic haematuria common

Structural Benign prostatic hyperplasia (BPH) causes

abnormalities haematuria due to hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
Vascular malformations
Renal vein thrombosis due to renal cell carcinoma

Coagulopathy Causes bleeding of underlying lesions

Drugs Cause tubular necrosis or interstitial nephritis:

aminoglycosides, chemotherapy
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants

Benign Exercise

Gynaecological Endometriosis: flank pain, dysuria, and

haematuria that is cyclical

Iatrogenic Catheterisation
Radiotherapy; cystitis, severe haemorrhage,
bladder necrosis

Pseudohaematuria For example following consumption of beetroot

References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
 /aetiology.html

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B 55.7%
C 10%
D 11.6%
E 6.1%

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Question 59 of 63
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A 52 year old man falls off his bike. He is found to have a pelvic fracture. On
examination, he is found to have perineal oedema and on PR the prostate is not
palpable. What is the most likely underlying problem?

Bulbar urethral rupture

Bladder outflow obstruction

Bladder rupture

Bladder contusion

Membranous urethral rupture

A pelvic fracture and highly displaced prostate should indicate a diagnosis of

membranous urethral rupture.

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Lower genitourinary tract trauma

Most bladder injuries occur due to blunt trauma

85% associated with pelvic fractures
Easily overlooked during assessment in trauma
Up to 10% of male pelvic fractures are associated with urethral or bladder
injuries

Types of injury
 Urethral injury Mainly in males
Blood at the meatus (50% cases)

There are 2 types:

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i.Bulbar rupture
- most common
- straddle type injury e.g. bicycles
- triad signs: urinary retention, perineal haematoma,
blood at the meatus
ii. Membranous rupture
- can be extra or intraperitoneal
- commonly due to pelvic fracture
- Penile or perineal oedema/ hematoma
- PR: prostate displaced upwards (beware co-existing
retroperitoneal haematomas as they may make
examination difficult)

- Investigation: ascending urethrogram

- Management: suprapubic catheter (surgical
placement, not percutaneously)

External genitalia Secondary to injuries caused by penetration,

injuries (i.e., the penis blunt trauma, continence- or sexual pleasure-
and the scrotum) enhancing devices, and mutilation

Bladder injury rupture is intra or extraperitoneal

presents with haematuria or suprapubic pain
history of pelvic fracture and inability to void:
always suspect bladder or urethral injury
inability to retrieve all fluid used to irrigate the
bladder through a Foley catheter indicates
bladder injury
investigation- IVU or cystogram
management: laparotomy if intraperitoneal,
conservative if extraperitoneal

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Question stats

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Question 60 of 63
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A 38 year old man is investigated and found to have a left sided renal mass.
Imaging demonstrates a 5cm renal tumour invading the left renal vein. There is no
evidence of distant disease. What is the most appropriate course of action?

Renal biopsy

Radical nephrectomy

External beam radiotherapy

Combined chemoradiotherapy

Neoadjuvent chemotherapy

Renal tumours that are operable are nearly always managed surgically in the first
instance. It is not common practice to biopsy prior to surgery. They are not usually
radiosensitive.

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Renal tumours

Renal cell carcinoma

Renal cell carcinoma is an adenocarcinoma of the renal cortex and is believed to
arise from the proximal convoluted tubule. They are usually solid lesions, up to
20% may be multifocal, 20% may be calcified and 20% may have either a cystic
component or be wholly cystic. They are often circumscribed by a pseudocapsule
of compressed normal renal tissue. Spread may occur either by direct extension
into the adrenal gland, renal vein or surrounding fascia. More distant disease
usually occurs via the haematogenous route to lung, bone or brain.
Renal cell carcinoma comprise up to 85% of all renal malignancies. Males are
more commonly affected than females and sporadic tumours typically affect
patients in their sixth decade.
 Patients may present with a variety of symptoms including; haematuria (50%), loin
pain (40%), mass (30%) and up to 25% may have symptoms of metastasis.Less
than 10% have the classic triad of haematuria, pain and mass.
gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

Investigation
Many cases will present as haematuria and be discovered during diagnostic work
up. Benign renal tumours are rare, so renal masses should be investigated with
multislice CT scanning. Some units will add an arterial and venous phase to the
scan to demonstrate vascularity and evidence of caval ingrowth.

CT scanning of the chest and abdomen to detect distant disease should also be
undertaken.

Routine bone scanning is not indicated in the absence of symptoms.

Biopsy should not be performed when a nephrectomy is planned but is mandatory

before any ablative therapies are undertaken.

Assessment of the functioning of the contra lateral kidney.

Management
T1 lesions may be managed by partial nephrectomy and this gives equivalent
oncological results to total radical nephrectomy. Partial nephrectomy may also be
performed when there is inadequate reserve in the remaining kidney.

For T2 lesions and above a radical nephrectomy is standard practice and this may
be performed via a laparoscopic or open approach. Preoperative embolisation is
not indicated nor is resection of uninvolved adrenal glands. During surgery early
venous control is mandatory to avoid shedding of tumour cells into the circulation.

Patients with completely resected disease do not benefit from adjuvant therapy
with either chemotherapy or biological agents. These should not be administered
outside the setting of clinical trials.

Patients with transitional cell cancer will require a nephroureterectomy with

disconnection of the ureter at the bladder.

References
Lungberg B et al. EAU guidelines on renal cell carcinoma: The 2010 update.
European Urology 2010 (58): 398-406.

Next question 

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B 55.5%
C 7.1%
D 9.4%
E 9%

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Question 61 of 63
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A 49 year old man presents with a single episode of haematuria. Investigations

demonstrate adenocarcinoma of the prostate gland. Imaging shows T2 disease
and no evidence of metastasis. What is the best treatment option?

Chemotherapy alone

Radical prostatectomy

Trasvesical prostatectomy

TURP

External beam radiotherapy

In a young patient with local disease only a radical prostatectomy is the best
chance of cure. Radiotherapy may be given instead but has long term sequelae
(and inferior survival outcomes). A transvesical prostatectomy is a largely
historical operation performed for BPH before TURP was established.

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Prostate Cancer

Prostate Cancer
This is a common condition and up to 30,000 men are diagnosed with the
condition each year. Up to 9,000 will die in in the UK from the condition per year.

Diagnosis
Early prostate cancers have few symptoms.
Metastatic disease may present as bone pain.
Locally advanced disease may present as pelvic pain or with urinary symptoms.
Prostate specific antigen measurement
Digital rectal examination
 Trans rectal USS (+/- biopsy)
MRI/ CT and bone scan for staging.

PSA Test
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The normal upper limit for PSA is 4ng/ml. However, in this group will lie patients
with benign disease and some with localised prostate cancer. False positives may
be due to prostatitis, UTI, BPH, vigorous DRE.
The percentage of free: total PSA may help to distinguish benign disease from
cancer. Values of <20% are suggestive of cancer and biopsy is advised.

Pathology
95% adenocarcinoma
In situ malignancy is sometimes found in areas adjacent to cancer. Multiple
biopsies needed to call true in situ disease.
Often multifocal- 70% lie in the peripheral zone.
Graded using the Gleason grading system, two grades awarded 1 for most
dominant grade (on scale of 1-5) and 2 for second most dominant grade
(scale 1-5). The two added together give the Gleason score. Where 2 is best
prognosis and 10 the worst.
Lymphatic spread occurs first to the obturator nodes and local extra
prostatic spread to the seminal vesicles is associated with distant disease.

Treatment
Watch and wait- Elderly, multiple co-morbidities, low Gleason score
Radiotherapy (External)- Both potentially curative and palliative therapy
possible. However, radiation proctitis and rectal malignancy are late
problems. Brachytherapy is a modification allowing internal radiotherapy.
Surgery- Radical prostatectomy. Surgical removal of the prostate is the
standard treatment for localised disease. The robot is being used
increasingly for this procedure. As well as the prostate the obturator nodes
are also removed to complement the staging process. Erectile dysfunction
is a common side effect. Survival may be better than with radiotherapy (see
references).
Hormonal therapy- Testosterone stimulates prostate tissue and prostatic
cancers usually show some degree of testosterone dependence. 95% of
testosterone is derived from the testis and bilateral orchidectomy may be
used for this reason. Pharmacological alternatives include LHRH analogues
and anti androgens (which may be given in combination).
In the UK the National Institute for Clinical Excellence (NICE) suggests that
active surveillance is the preferred option for low risk men. It is particularly
suitable for men with clinical stage T1c, Gleason score 3+3 and PSA density
< 0.15 ng/ml/ml who have cancer in less than 50% of their biopsy cores,
with < 10 mm of any core involved.

Candidates for active surveillance should:

have had at least 10 biopsy cores taken
have at least one re-biopsy.

If men on active surveillance show evidence of disease progression, offer radical

 treatment. Treatment decisions should be made with the man, taking into account
co-morbidities and life expectancy.

References
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1. Prostate cancer pathway. NICE.(http://guidance.nice.org.uk/IPG424)

2. Sooriakumaran P et al. Comparative effectiveness of radical prostatectomy and
radiotherapy in prostate cancer: observational study of mortality outcomes. BMJ
2014 (348):13. This study shows that in men with localised disease survival was
greater in those offered surgery.

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D 21.1%
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Question 62 of 63
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 

A 32 year old lady suffers from severe left sided abdominal pain, that radiates to
her groin. As part of her evaluation the nurses identify microscopic haematuria on
dipstick. What is the explanation?

Staghorn calculus

Ureteric calculus

Transitional cell carcinoma of the ureter

Adenocarcinoma of the ureter

Cystitis

Ureteric calculi will often present with loin pain radiating to the groin. It is usually
severe. There may be macroscopic or microscopic haematuria. The absence of
haematuria on dipstick testing should prompt investigations for alternative
diagnoses. The best investigation is a non contrast CT scan. CT changes
consistent with stone or recent stone passage include evidence of stone,
perinephric stranding, ureteric oedema or hydronephrosis.

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Haematuria
 Causes of haematuria

Trauma Injury to renal tract

gathered by dr. elbarky, for free, not intended for profit by anybody elsewhere

Renal trauma commonly due to blunt injury

(others penetrating injuries)
Ureter trauma rare: iatrogenic
Bladder trauma: due to RTA or pelvic fractures

Infection Remember TB
References
Http://bestpractice.bmj.com/best-practice/monograph/316/overview
Malignancy Renal cell carcinoma (remember paraneoplastic
/aetiology.html syndromes): painful or painless
Urothelial malignancies: 90% are transitional cell
carcinoma, can occur anywhere along the urinary
tract. Painless haematuria. Next question 
Squamous cell carcinoma and adenocarcinoma:
rare bladder tumours
Prostate cancer
Penile cancers: SCC
Display my notes on this topic

Renal
 disease
   Glomerulonephritis
     

Stones Microscopic haematuria common

Save my notes
Structural Benign prostatic hyperplasia (BPH) causes
abnormalities haematuria
Question due
statsto hypervascularity of the
prostate gland
Cystic renal lesions e.g. polycystic kidney disease
A 12.5%
Vascular malformations
B 64.2%
Renal vein thrombosis due to renal cell carcinoma
C 8.3%
Coagulopathy
D Causes bleeding of underlying lesions
6%
E 9.1%
Drugs Cause tubular necrosis or interstitial nephritis:
aminoglycosides, chemotherapy
64.2% of users answered this question correctly
Interstitial nephritis: penicillin, sulphonamides,
and NSAIDs
Anticoagulants
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Benign Exercise
Search term Go
Gynaecological Endometriosis: flank pain, dysuria, and
haematuria that is cyclical

Iatrogenic Catheterisation
 

Question 63 of 63
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A 78 year old man has a long history of nocturia, urinary frequency and terminal
dribbling. He was admitted with urinary retention and was catheterised. On
removal of the catheter he has noticed some haematuria. What is the most likely
cause?

Transitional cell carcinoma of the bladder

Squamous cell carcinoma of the bladder

Polycystic kidney disease

Renal cell carcinoma

Benign prostatic hyperplasia

The symptoms are typical for prostatic disease.

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Benign prostatic disease

BPH is increasingly common with advancing age and is present in 50% over the
age of 60 and nearly 90% of men by the age of 90. It occurs as a result of
hyperplasia of the periurethral glands in the transitional zone of the prostate.
Androgens play a role in the development and progression of BPH. Testosterone
diffuses into prostatic and stromal cells. Within epithelial cells it binds to the
androgen receptor. In prostatic stromal cells, a small proportion binds directly to
the androgen receptor, the majority binds to the 5 alpha reductase type II receptor
on the nuclear membrane. This is converted to dihyroxytestosterone and then
binds to the androgen receptor. Dihydroxytestosterone has even greater affinity for
the androgen receptor than testosterone does. The end result is stimulation of
these cells and proliferation.
This proliferative activity results in varying degrees of obstruction and results in
lower urinary tract obstructive symptoms. The clinical diagnosis of BPH thus
 comprise a degree of lower urinary tract symptoms, palpable prostatic
enlargement and evidence of impaired voiding on urodynamic assessment.

Presentation
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Some patients have minimal symptoms, yet, on examination, have a palpable

bladder and obstructive post renal failure. LUTS can be divided into two main
groups; obstructive symptoms with voiding that include hesitancy, poor stream,
straining, prolonged micturition and dribbling; others develop irritation symptoms
which include pain during bladder filling, frequency, urgency and nocturia. Some
present with retention and haematuria.

Diagnosis
Abdominal and rectal examination
Symptoms scoring
Urodynamic studies ( a post void volume of >100ml is significant)

Management
Conservative
Alpha adrenergic antagonists. These block the action of noradrenaline on prostatic
smooth muscle causing relaxation and improved bladder emptying.
5 alpha reductase inhibitors. Finasteride blocks the enzyme 5 alpha reductase
which inhibits the conversion of testosterone to DHT. This in turn reduces
intracellular activity and decreases prostatic volume
Surgery- TURP is the gold standard. Occasionally, an open retropubic
prostatectomy may be considered for a large gland.

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A 14%
B 9.1%
C 6.9%
D 6.5%
E 63.4%