Urology

Overview A varicocele refers to dilated veins within the pampiniform plexus. The pampiniform plexus is a network of veins found in the spermatic cord that drains the testes and epididymis. Varicoceles occur most commonly in adolescent boys and may affect up to 15% of men. The vast majority (around 90%) occur on the left side. It is strongly associated with infertility and as such varicoceles are seen in around 40% of men presenting with infertility. Aetiology Varicoceles occur due to dilation of the pampiniform plexus in the scrotum. The pampiniform plexus is a network of veins found in the spermatic cord that

Overview Testicular torsion is a urological emergency, that without intervention leads to ischaemia and loss of the testis. Testicular torsion is a rare but serious condition. Successful treatment requires prompt recognition, referral and surgical intervention. It exhibits a bimodal distribution with peaks in the neonatal period and around puberty. Differential Diagnosis Whilst other diagnoses should be considered, suspicion of testicular torsion requires urgent testicular exploration Trauma Epididymo-orchitis Torsion of the epididymal appendage Testicular tumour (an association between testicular cancer and torsion has been described) Hydrocele Inguinal hernia Systemic diseases (e.g. Henoch-Schönlein purpura, Mumps) Types Testicular torsion may be intravaginal or extravaginal. Extravaginal torsion occurs in-utero and in neonates.

Overview Testicular cancer is responsible for 1% of all new cancers in men. It typically presents with a unilateral testicular mass. Incidence appears to be increasing, with approximately 3-10 cases / 100,000 men each year in the Western world. The vast majority of testicular cancers are germ-cell tumours (95%). Overall prognosis, following appropriate therapy, is good. As with all cancers, optimal management requires a multi-disciplinary approach with GPs, specialist nurses, urologists and oncologists all essential. Figures from Cancer Research UK (last accessed Nov 2021). Epidemiology There are approximately 2,300 cases of testicular cancer in the UK each year. It is the 18th most common cancer affecting

Introduction Renal colic classically refers to acute severe loin pain that occurs secondary to a urinary stone. Urinary stones, also termed urolithiasis, refer to stone formation anywhere within the urinary tract. They may be asymptomatic or cause acute loin-to-groin pain due to ureteric obstruction. Urinary stones are extremely common, men are affected up to three times more than women. The peak incidence of symptomatic urinary stones is between 40-60 years in males and late 20’s in females. Aetiology Renal colic is caused by obstruction to urinary flow within the ureter that occurs secondary to urinary stones. The majority of renal stones, approximately 80%, are composed of

Overview Renal cell carcinoma is the most common kidney cancer in adults. It accounts for around 80-85% of kidney cancers. They may be found incidentally on abdominal imaging, present symptomatically (e.g. haematuria, loin pain, loin mass, fever) or with features of paraneoplastic syndromes. In those with disease spread it may be local, particularly involving invasion of the renal vein and inferior vena cava (IVC) or distant (commonly the lungs). Management is highly dependent on the stage at diagnosis and patient-based factors. Epidemiology  In 2017, kidney cancers (overall) were the 7th most common cancer in the UK. There are around 13,000 cases of

Overview Prostate cancer is the most common malignancy affecting men in the UK. Incidence increases with advancing age and men of Black ethnicity are more commonly affected. It can affect men, trans women, non-binary (assigned male sex at birth) and some intersex patients. Localised disease is commonly asymptomatic but symptoms often develop in locally advanced and metastatic disease. Management is dependent on a multitude of factors but may involve active surveillance, androgen deprivation therapies, radiotherapy, chemotherapy and surgical intervention. Epidemiology 1 in 6 men in the UK will be diagnosed with prostate cancer in their lifetime. In the UK it is the

Overview Hydrocele refers to a collection of serous fluid between the parietal and visceral layers of the tunica vaginalis. Patients present with (typically) a non-tender scrotal swelling. Hydroceles may be associated with (communicating hydrocele) or without (non-communicating hydrocele) a patent processus vaginalis. Treatment depends on the underlying aetiology, age and symptomatic burden of the hydrocele. NOTE: In rare cases a similar condition may be seen in women where fluid accumulates in the canal of Nuck. Types There are two major types of hydrocele: communicating and non-communicating. Communicating These occur due to the failure of normal closure of the processus vaginalis. This allows the passage of

Overview Chronic prostatitis is characterised by > 3 months of urogenital pain, often associated with LUTS or sexual dysfunction. Chronic prostatitis may be categorised as: Chronic prostatitis/chronic pelvic pain syndrome: clinical features of chronic prostatitis in the absence of an identifiable bacterial infection. Chronic bacterial prostatitis: relatively uncommon, accounting for around 10% of patients with chronic prostatitis. Aetiology The aetiology of non-bacterial associated chronic prostatitis is poorly understood. Chronic prostatitis/chronic pelvic pain syndrome The aetiology remains poorly understood. Infective and inflammatory triggers may be implicated. There are suggestions that some may have a neuropathic component. Chronic bacterial prostatitis This may develop following an episode

Overview Bladder cancer is a common malignancy, in 2017 it was the 11th most common cancer in the UK. In the UK, transitional cell carcinoma is by far the most common cause (around 90%). Advancing age and smoking are significant risk factors for its development. More men than women are affected, though this appears largely due to exposure to relevant risk factors. It classically presents with painless haematuria. Management depends on staging and can involve trans-urethral resection of bladder tumour (TURBT), immunotherapy, chemotherapy, radiotherapy and cystectomy. Epidemiology There are approximately 10,300 cases of bladder cancer in the UK each year. In 2017,

Overview Benign prostatic hyperplasia (BPH) is characterised by hyperplasia resulting in lower urinary tract symptoms (LUTS). In BPH, prostatic hyperplasia (increased cell proliferation leading to enlargement) leads to urinary frequency, incomplete emptying, dribbling, hesitancy and nocturia. It may also be complicated by acute or chronic urinary retention. You may come across the term benign prostatic enlargement (BPE). This refers to a clinical finding on digital rectal examination (DRE), BPH refers to a histological diagnosis. There is increasing recognition that LUTS in males are often not secondary to BPH. An open mind should be had with regards to the underlying aetiology in

Overview Acute epididymo-orchitis is a common cause of testicular pain and swelling. It is caused by acute inflammation of the epididymis (epididymitis) that may affect the testicle (orchitis). Most commonly the aetiology is infectious through the spread of pathogens from the urethra or bladder. It may be related to urinary tract infections or sexually transmitted infections. Testicular torsion must be considered in anybody presenting with acute testicular pain, particularly in children, adolescents and younger men. If there is any diagnostic uncertainty, refer to urology / paediatric surgery. Aetiology Epididymo-orchitis is most commonly caused by sexually transmitted infections or urinary pathogens. Sexually transmitted organisms tend

Introduction Acute bacterial prostatitis refers to a an infection involving the prostate that may cause significant systemic upset. It tends to present with urinary symptoms, lower back or pelvic pain +/- symptoms of systemic infection. Urinary pathogens are often implicated, commonly Escherichia coli. Less commonly sexually transmitted infections are isolated as the cause. Aetiology E.coli is the most commonly isolated pathogen in acute bacterial prostatitis. Pseudomonas aeruginosa, Klebsiella, Enterococcus and Proteus may all be causes. Sexually transmitted infections, Chlamydia trachomatis and Neisseria gonorrhoea, are less commonly isolated. There are a number of specific scenarios to consider: Recent urethral or prostatic instrumentation (e.g. urethral catheterisation, cystoscopy or transrectal prostate biopsy): rarely acute