Master Specialist Urology (URO5931)
for DHA Speciality

Core Concepts

Specialist Urology encompasses the diagnosis and management of diseases of the male and female urinary tracts, alongside the male reproductive system. Core areas include urologic oncology (prostate, bladder, kidney, testis), benign prostatic hyperplasia (BPH), urolithiasis (stones), urinary tract infections (UTIs), urinary incontinence, male infertility, and erectile dysfunction. A strong understanding of anatomy, physiology, and pathophysiology is crucial, with an emphasis on distinguishing urgent from non-urgent conditions for prompt management.

Clinical Presentation

• Haematuria:
  • Macroscopic (visible) or microscopic. Painless suggests malignancy (bladder, kidney); painful suggests stones, infection.
• Lower Urinary Tract Symptoms (LUTS):
  • Storage: Frequency, urgency, nocturia, urge incontinence (e.g., Overactive Bladder, UTI, BPH).
  • Voiding: Hesitancy, weak/intermittent stream, straining, incomplete emptying (e.g., BPH, urethral stricture).
• Pain:
  • Renal Colic: Acute, severe flank pain radiating to groin (suggests urolithiasis).
  • Suprapubic: Bladder distension, cystitis.
  • Testicular: Acute (torsion, epididymitis); Chronic (varicocele, hydrocele, tumour - often painless).
• Scrotal Mass/Swelling: Acute (torsion, epididymitis) vs. Chronic (hydrocele, varicocele, spermatocele, tumour).
• Urinary Incontinence: Stress (leakage with exertion), Urge (leakage with urgency), Mixed, Overflow (due to chronic retention).
• Erectile Dysfunction (ED) & Male Infertility: Inability to achieve/maintain erection; difficulty conceiving (often asymptomatic apart from primary issue).

Diagnosis (Gold Standard)

While history and physical are foundational, specific gold standards/primary diagnostics include:

• Prostate Cancer: Transrectal Ultrasound (TRUS)-guided prostate biopsy.
• Bladder Cancer: Cystoscopy with Transurethral Resection of Bladder Tumour (TURBT).
• Renal Cell Carcinoma: Contrast-enhanced CT Abdomen/Pelvis.
• Urolithiasis: Low-dose unenhanced Computed Tomography of the Kidneys, Ureters, and Bladder (CT KUB).
• Urethral Stricture: Retrograde Urethrogram (RUG).
• Testicular Torsion: Clinical diagnosis; urgent surgical exploration is definitive. Doppler ultrasound supportive.
• Benign Prostatic Hyperplasia (BPH): International Prostate Symptom Score (IPSS), Digital Rectal Exam (DRE), PSA, Uroflowmetry with Post-Void Residual (PVR).
• Urinary Incontinence (complex cases): Urodynamic studies (cystometry).

Management (First Line)

• Benign Prostatic Hyperplasia (BPH):
  • Medical: Alpha-blockers (e.g., Tamsulosin), 5-alpha reductase inhibitors (e.g., Finasteride).
  • Surgical: Transurethral Resection of the Prostate (TURP), Holmium Laser Enucleation of the Prostate (HoLEP).
• Urolithiasis:
  • Conservative: Hydration, Alpha-blockers (for small distal ureteral stones).
  • Interventional: Extracorporeal Shockwave Lithotripsy (ESWL), Ureteroscopy (URS) with laser, Percutaneous Nephrolithotomy (PCNL) for large/complex stones.
• Prostate Cancer:
  • Localised: Active Surveillance (low risk), Radical Prostatectomy, External Beam Radiotherapy.
  • Advanced: Androgen Deprivation Therapy (ADT).
• Bladder Cancer:
  • Non-Muscle Invasive: TURBT + Intravesical Chemotherapy (Mitomycin-C) or Immunotherapy (BCG).
  • Muscle Invasive: Radical Cystectomy with urinary diversion.
• Renal Cell Carcinoma (RCC): Partial or Radical Nephrectomy (localised disease). Targeted therapies for advanced.
• Overactive Bladder (OAB): Lifestyle modifications, Pelvic Floor Muscle Training, Anticholinergics (e.g., Solifenacin), Beta-3 agonists (e.g., Mirabegron).
• Stress Urinary Incontinence (SUI): Pelvic Floor Muscle Training. Surgical: Mid-urethral slings (TVT/TOT).
• Erectile Dysfunction (ED): Lifestyle changes, Phosphodiesterase-5 (PDE5) inhibitors (e.g., Sildenafil, Tadalafil).
• Acute Testicular Torsion: Urgent surgical exploration and detorsion with bilateral orchidopexy.