Key Facts

Urology is a diverse surgical specialty covering benign and malignant conditions of the urinary tract in both sexes, and the male reproductive system. The specialty encompasses emergency conditions (testicular torsion, urinary retention, urosepsis) and complex cancer surgery.

Epidemiology

Prostate cancer is the most common cancer in men in the UK (~52,000 cases/year). Bladder cancer affects ~10,000/year, kidney cancer ~13,000/year, and testicular cancer ~2,400/year. Renal stones affect approximately 10-15% of the UK population during their lifetime. Benign prostatic hyperplasia affects up to 80% of men by age 80.

Aetiology

Urological conditions arise from:

• Malignancy: Genetic predisposition, smoking (bladder, renal), age (prostate), cryptorchidism (testicular)
• Stone disease: Dehydration, hypercalciuria, hyperuricaemia, metabolic disorders
• Obstruction: BPH, strictures, malignancy
• Infection: Ascending UTI, epididymo-orchitis, pyelonephritis
• Functional: Overactive bladder, stress incontinence, neurogenic bladder

Pathophysiology

The urinary system functions to filter blood, maintain electrolyte balance, and excrete waste. Obstruction at any level (renal pelvis to urethra) leads to upstream dilatation and potential renal damage. The lower urinary tract depends on the coordination of detrusor contraction and sphincter relaxation for normal voiding, under autonomic and somatic nervous system control.

Storage LUTS

• Frequency, urgency, nocturia, urge incontinence
• Overactive bladder (OAB) — idiopathic or neurogenic

Voiding LUTS

• Hesitancy, poor stream, intermittency, terminal dribbling
• Straining, incomplete emptying
• Acute urinary retention — painful, unable to void

Haematuria

• Visible (macroscopic) — always requires investigation
• Non-visible (microscopic) — investigate if aged ≥60 or symptomatic
• Painless haematuria — suspect malignancy until proven otherwise

Urological Emergencies

• Testicular torsion: acute scrotal pain, <6-hour surgical window
• Acute urinary retention: painful, catheterise urgently
• Urosepsis: UTI with systemic sepsis
• Renal colic: loin-to-groin pain, haematuria

Red Flags

• Painless visible haematuria — urgent cancer investigation
• Acute scrotal pain — testicular torsion until proven otherwise
• Bilateral ureteric obstruction with rising creatinine — emergency nephrostomy/stenting
• Priapism >4 hours — urological emergency

Bedside

• Urine dipstick: Haematuria, nitrites, leucocytes, glucose
• Post-void residual (bladder scan): Assess voiding efficiency
• IPSS (International Prostate Symptom Score): Standardised LUTS assessment
• Flow rate (uroflowmetry): Peak flow <10 mL/s suggests obstruction

Bloods

• PSA: Prostate cancer screening/monitoring (normal <4 ng/mL age-adjusted)
• U&Es: Renal function, especially in obstruction
• FBC: Anaemia (haematuria, CKD), polycythaemia (RCC)
• Calcium: Hypercalcaemia in RCC or stone disease

Imaging

• USS renal tract: First-line for upper tract assessment
• CT KUB (non-contrast): Gold standard for renal stones
• CT urogram (with contrast): Investigate haematuria — detect upper tract TCC
• MRI pelvis (multiparametric): First-line for suspected prostate cancer (NICE NG131)
• Flexible cystoscopy: Investigate visible haematuria — detect bladder tumours

Special Tests

• Urodynamic studies: Complex LUTS, neurogenic bladder
• Prostate biopsy (TRUS or transperineal): After positive MRI (PI-RADS ≥3)
• Urine cytology: Adjunct in high-grade bladder cancer surveillance
• Metabolic stone screen: 24-hour urine collection for recurrent stone formers

Non-pharmacological

• Watchful waiting: Mild LUTS (IPSS <8)
• Lifestyle measures: Fluid management, bladder training, caffeine reduction
• Pelvic floor exercises: Stress incontinence, post-prostatectomy incontinence

Pharmacological

• Alpha-blockers: Tamsulosin 400mcg OD — relax prostatic smooth muscle (LUTS/BPH)
• 5-alpha reductase inhibitors: Finasteride 5mg OD — reduce prostate volume (>30cc prostate)
• Antimuscarinics: Oxybutynin 2.5-5mg BD/TDS or solifenacin 5-10mg OD — overactive bladder
• Mirabegron: 50mg OD — beta-3 agonist for OAB (alternative to antimuscarinics)
• MET (medical expulsive therapy): Tamsulosin 400mcg OD for ureteric stones 5-10mm

Surgical/Interventional

• TURP: Gold standard for BPH causing retention/refractory LUTS
• HoLEP: Holmium laser enucleation — size-independent, lower retreatment rate
• Radical prostatectomy: Curative for localised prostate cancer
• Radical cystectomy + ileal conduit: Muscle-invasive bladder cancer
• Nephrectomy: Partial (nephron-sparing) or radical for RCC
• ESWL, ureteroscopy, PCNL: Graduated approach to stone management

Referral Criteria

• Visible haematuria (any age) — urgent 2WW referral
• Non-visible haematuria aged ≥60 — urgent referral
• Raised PSA — urology referral per age-specific thresholds
• Acute retention not responding to TWOC — urology

• Prostate cancer: 10-year survival >95% for localised disease; metastatic disease median survival 2-3 years
• Bladder cancer: 5-year survival ~50% overall; >90% for non-muscle-invasive, ~50% for muscle-invasive
• Renal cell carcinoma: 5-year survival ~70% (localised), ~12% (metastatic)
• Testicular cancer: Overall cure rate >95%, even with metastatic disease
• BPH: Progressive if untreated; ~30% of men will eventually require surgical intervention

IPSS (International Prostate Symptom Score)

Stone Management by Size and Location

Haematuria Investigation Pathway