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Two red flag symptoms in urology: haematuria and testicular lumps Mr Erik Mayer, Consultant Surgeon

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Contents

− Referral Guidelines

− Diagnostics

− Differential Diagnosis

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Haematuria

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Causes of Haematuria

– Infection (cystitis, prostatitis).

– Tumour (renal cell, Wilms' tumour, bladder, prostate).

– Trauma.

– Inflammation (glomerulonephritis, IgA nephropathy, Henoch-Schonlein purpura, systemic lupus erythematosus).

– Structural (calculi, polycystic kidney disease).

– Haematological.

– Surgery.

– Toxins (NSAIDs, sulphonamides, cyclophosphamide).

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Why the NICE Guidance?

– UK has worse survival than other countries

– New guidance to broaden (lower threshold) for

referral – actually more confusing

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NICE Guidance 6

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‘Unexplained’

Unexplained Symptoms or signs that have not led to a

diagnosis being made by the healthcare professional in

primary care after initial assessment (including history,

examination and any primary care investigations)

– Primary care investigations:

– History/examination

– Bloods

– BP

– Urine Dipstick/culture

– Urine cytology

– Ultrasound

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• Dipstick versus microscopy (high-false negative rate)

• Trace versus 1+ (Trace considered negative)

• Haemolysed versus non-haemolysed (No difference)

• Persistence NVH is defined as 2 out of 3 dipsticks positive for NVH.

• Haematuria does not result from anti-coagulants or anti-platelets

Non-visible Haematuria

• Exclude UTI and/or other transient cause.

• Plasma creatinine/eGFR.

• Measure proteinuria on a random sample.

Send urine for protein:creatinine ratio

(PCR) or albumin:creatinine ratio (ACR)

on a random sample

• Blood pressure

Visible Haematuria

• Exclude UTI and/or other

transient cause.

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Bladder TCC

80% of patients with a bladder tumour will present with painless

visible haematuria

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Lessons Learnt

– Bladder cancer most frequent diagnosis after NO

DIAGNOSIS and UTI – 1 in 20 risk for Non-visible

haematuria and 1 in 5 risk for Visible haematuria

– Cancer diagnosis in 1 in 4 for Visible Haematuria and

1 in 10 for Non-visible Haematuria

– Ultrasound or IVU alone would have missed 50% of

upper tract tumours

– Cystoscopy recommended for all patients

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Projected Age-standardised Rates

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Risk Factors

– Smoking

– 37% of bladder cancers in the UK are linked to

tobacco smoking

– Bladder cancer risk is 73-80% lower in ex-smokers

who quit 25 years previously

– Aromatic Amines

– Production of dyes, rubber, and textiles

– Hairdressers/Barbers

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Increases risk ('sufficient' or

'convincing' evidence) – Aluminium production

– 4-Aminobiphenyl

– Arsenic and inorganic arsenic compounds

– Auramine production

– Benzidine

– Chlornaphazine

– Cyclophosphamide

– Magenta production

– 2-Naphthylamine

– Painting

– Rubber production industry

– Schistosoma haematobium

– Tobacco smoking

– ortho-Toluidine

– X-radiation, gamma-radiation

– 4-Chloro-ortho-toluidine

– Coal-tar pitch

– Coffee

– Dry cleaning

– Engine exhaust, diesel

– Hairdressers and barbers (occupational exposure)

– Pioglitazone

– Printing processes

– Soot

– Textile manufacturing

– Tetrachloroethylene

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May increase risk ('limited' or

'probable' evidence)

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Routes to Diagnosis

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Stage 1 Stage 2 Stage 3 Stage 4 Stage unknown

Stage

Percentage of tumour stages by presentation route, Bladder, 2012-2013

Death certificate only & unknown

Emergency presentation

Other managed

GP referral

Two week wait

Screen detected

Presentation route

Perc

enta

ge

of

dia

gno

ses

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Bladder Cancer (C67 D090 D414): 2002-2006 Five-Year Relative Survival (%) by Stage, Adults Aged 15-99, Former Anglia Cancer Network

Prepared by Cancer Research UK Original data source: The National Cancer Registration Service, Eastern Office. Personal communication. http://ecric.org.uk/

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Haematuria

– Visible versus Non-visible

– Painful or painless

– Initial/mid/end/throughout

– Trauma

– Previous history

Dysuria/smelly urine

Pain on ejaculation

Haematuria/haematospermia

STD’s/UTI’s

Previous urological history/surgery

Family history of urinary tract malignancy/stones

Smoker

Occupation

(Sexual history)

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Haematuria

– 2WW pathway

– Typically one stop:

– Investigations:

– Urine Culture/Urine Cytology

– US KUB or CT IVU

– Flexible Cystoscopy

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Flexible Cystoscopy

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Rate is no different to background incident rate

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Urgent (2WW) referral

Urgent referral is required for:

– All adult patients with painless visible haematuria.

– Patients >50 years with unexplained non-visible

haematuria (Greater than trace)

– Patients >40 years with recurrent/persistent UTI

associated with haematuria.

– Symptoms of UTI with persistent sterile pyuria >50

years old

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Take home messages

– 2WW Referral for haematuria very acceptable

– As Urologists we try and funnel most through one-

stop haematuria clinic as best environment for

diagnosis of several pathologies

– Two patient groups to be wary of:

– Squamous Cell Carcinoma and long-term

catheters (spinal cord injury patients)

– Female with recurrent UTIs

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Take home messages

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Male vs. Female

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Male

s

Fe

male

s

Male

s

Fe

male

s

Male

s

Fe

male

s

Male

s

Fe

male

s

Male

s

Fe

male

s

Male

s

Fe

male

s

Screen detected Two week wait GP referral Other managed Emergency presentation

Death certificate

only &

unknown

Presentation route and sex

Percentage of presentation routes and sex by tumour stage, Bladder, 2012-2013

Stage unknown

Stage 4

Stage 3

Stage 2

Stage 1

Stages

Perc

enta

ge o

f dia

gno

ses

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Testicular lumps

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Referral Guidelines

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Diagnosis

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Diagnostics

– History

– Clinical Examination

– Genitals

– Abdomen

– Supraclavicular Lymphadenopathy

– Urine Dipstick & Pregnancy Test

– Tumour Markers

– Ultrasound

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History

Symptoms

• Hard, painless lump

- Partner detection

• 5-10% scrotal pain

• - Intra-tumoural haemorrhage

- Trauma brings attention to abnormality

• Metastatic

- Weight loss

- Shortness of Breath

- Back/abdominal pain

- Neck lumps

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Key Points in a Scrotal Mass History

– The Lump

– How was it detected (in the bath etc.)?

– How long has it been there?

– Is it changing in size?

– Painful or painless

– Sexual history – Any recent STIs

– Any lower urinary tract symptoms

– Any recent testicular trauma

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Key points continued

− Any abdominal or neck lumps (lymphadenopathy)

− Any SOB or abdominal pain

− PMH

− Previous orchidopexy/maldescent of testicle

− Have they had testicular US scan before/been encouraged to regularly self examine

− FH of testicular Cancer

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Clinical Examination

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Which tumour markers might be raised in testicular cancer?

A. CA 19-9, CA 125

B. CEA, B-HCG

C. AFP, B-HCG, LDH

D. CA 125, AFP

E. None of the above

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Tumour Markers

AFP - raised in 50-70% of NSGCT – May be elevated with:

– hepatic dysfunction, cirrhosis, and – drug or alcohol abuse

- normal <10ng/mL – βhCG - raised in:

• 100% Choriocarcinoma • 60% Embryonal carcinoma • 55% Teratocarcinoma • 25% Yolk Cell Tumour • 7% Seminomas

- normal <5mIU/mL – False positive elevations - marijuana use – LDH- ↑in 30% to 80% of pure seminoma and 60% of

nonseminomas.

Useful in diagnosis, risk stratification & monitoring

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Ultrasound

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What I discuss with the patient

− Diagnosis

− Prognosis

− CxR/CT scan/tumour markers

− Need for Surgery as first line treatment

− Testicular Prosthesis

− Fertility/Sperm Storage

− Possible further treatment

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Headline Statistics

– Affects 7 in 100,000 men

– Most common solid cancer in men 20-45

– Rare below 15 and above 60

– Responsible for just over 1% of all male cancers.

– Estimated that the lifetime risk of developing testicular cancer in 2012 is 1 in 195 for men in the UK.

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European Age-Standardised Incidence Rates per 100,000

Population, Males, Great Britain

Headline Statistics

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Headline Statistics European Age-Standardised Mortality Rates per

100,000 Population, Males, UK

One-, Five- and Ten-Year Net Survival (%), Adults Aged 15-99, England & Wales

1-Year Survival (%)

5-Year Survival (%)

10-Year Survival (%)

Men

Net Survival 99.1 98.3 98.2

95% LCL 99.1 98.3 98.2

95% UCL 99.1 98.3 98.2

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Operating is not always best for the patient

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Orchidectomy: Inguinal vs. Scrotal approach

– Meta-analysis

– Scrotal violation → ↑ local recurrence from 0.4 – 2.9%

Capelouto et al., 1995

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Prosthesis

– Infection risk

– Think Chemotherapy

– Long-term safety

– Cosmesis/Migration

– About 25% uptake

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Sperm Storage

– Andrology Lab - Hammersmith

– Hep B/C, HIV & CMV screening

– No desperate need to do pre-op although is recommended in

EAU guidelines (3 samples/3 day abstinence)

– Cost associated after year one

– Collecting and freezing the samples can cost between £200

and £400. Then you pay about £300 a year to store them

– Standard storage period 10 years

– Quality of the sperm not guaranteed

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Further Treatment

– Oncological outcomes – overall survival

– Reducing burden of follow-up

– Minimising ‘overtreatment’ and treatment related morbidity

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So it’s NOT Cancer

Most testicular lumps are NOT cancer. At a testicular clinic at the Queen Elizabeth Hospital in Birmingham, only 76 cancers were found out of 2,000 men seen with a testicular lump. This means that fewer than 4 in every

100 testicular lumps (4%) are cancer

The awkward Scrotum

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Differential Diagnosis

– Any cause of scrotal lump/pain

– Testicular torsion

– Torted hydatid of Morgagni

– Epididymal cyst(s)

– Hydrocoele

– Varicocoele

– Epididymitis (orchitis)

– Hernia

– Adenomatoid Tumour

Other findings on Ultrasound

Microlithiasis

Varicocoele

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Microlithiasis

– Common – up to 10% men referred for Ultrasound

– Increasingly detected with higher frequency US

– Is it Premalignant?

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Varicocele – Abnormal dilatation of the testicular

veins in the pampiniform plexus

– 2-22% incidence of normal men, and

25% of infertile men

– Typically pain coming on when standing/

ambulating

– No pain at night

– 90% Left and 10% bilateral

o 10 cms longer and into renal vein.

o ‘nutcracker effect’ left renal vein

between the aorta and SMA.

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Varicocoele

– Consider underlying cause if:

• Sudden onset of varicocoele

• Right sided varicocoele

• Does not collapse on being supine

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– Grade 0:

– subclinical varicocoele.

– Grade 1:

– palpable only with valsalva.

– Grade 2:

– Clinically palpable in upright position.

– Grade 3:

– Gross varicocoele with ‘bag of worms’ visible through skin.

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Varicocoeles and fertility

– Varicocoeles do not cause infertility

– Routine testing of semen parameters not

required

– Do not require treatment unless associated

with abnormal semen parameters and low

testicular volume in the context of infertility

– Always consider female infertility factors

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Treatment

– Treatment Conservative/embolisation/ ligation

– Be guarded about outcome

– Natural History may demonstrate improvement

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Torsion

– Testicular torsion

– Torsion of a testicular appendage (appendix testis, Hydatid of Morgagni)

– Torsion

– Acute testicular pain (unilateral)

– Radiation to lower abdomen

– Nausea & vomiting

– Negative urine dipstick

– Main investigation is scrotal exploration

– (Ultrasound)

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Torsion

− Immediate referral to A&E

− No investigation needed

− Scrotal exploration, untwisting of testicle and bilateral 3-point

fixation with non-absorbable sutures in adult, dartos pouch in

children

− Warm ischaemia time 6 hours

− Torted Hydatid of Morgagni – conservative treatment an option

if diagnosis clear

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Infection

–Acute epididymitis/Epididymo-orchitis

– Bacterial

– In older men, UTI organisms

– In younger men, Chlamydia and Gonococcus

History

– Examination; tender swelling of epididymis +/- secondary

hydrocoele

– 21 days of appropriate antibiotic but warn patient that swelling

may persist >6 weeks

– Scrotal support

– Patient typically ends up with repeat ultrasound

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Follow-up Ultrasound

– Epididymal/Testicular abscess

– Testicular infarction

– Underlying tumour

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Infection

–Orchitis

Can be extension of epididymorchitis

Viral

• Mumps, ?other viruses

• History of parotitis

• Supportive measures – analgesia, bed rest

• Steroids? Tunical incision

If bilateral, mumps orchitis post-puberty may lead to

atrophy and subfertility

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Epididymal cysts and hydroceles

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Aetiology

Epididymal Cyst

– Possible results from

epididymal tube

obstruction

Hydrocoele

-Excess fluid production

Inflammation

Tumours

-Decreased fluid absorption

Post treatment for varicocoele

-Congenital

Patent Processus Vaginalis

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Clinical Appearance

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Epididymal Cyst

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Management

Epididymal Cyst

– Conservative

- Why not to operate:

– Pain does not improve

– Pain can be made worse

– Recurrence

– Epididymal obstruction

Hydrocoele

– Conservative

– Aspiration

– Aspiration + Sclerotherapy

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Inguino-scrotal Hernia

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Take Home Messages

− Scrotal Lumps and Bumps can be difficult to confidently

diagnose

− Always get an Ultrasound (urgent vs. routine)

− If in doubt 2WW referral

− Elements of managing new testicular cancer patient

− Benign scrotal pathology can generally be managed

conservatively

− Except torsion

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