Urology

Flow, obstruction and the tract that reached keyhole surgery first.

• Urology manages the urinary tract and the male reproductive organs: stones and the obstructed kidney, bladder and prostate cancers, retention and its causes, and the scrotal emergencies where hours decide organs.
• Its master rule is the one about pressure: an obstructed urinary system that becomes infected must be drained, and the obstructed infected kidney is one of surgery's true drop-everything emergencies.
• The specialty operates from inside as much as outside: cystoscopy, ureteroscopy and transurethral resection made it endoscopic decades before laparoscopy reached the abdomen.
• Its cancers teach oncology's whole spread of tempos: bladder cancer surveilled and resected repeatedly, prostate cancer managed across decades, and testicular cancer cured briskly in young men.

Ultrasound

• Loin pain with fever

  “Colicky right loin pain radiating to the groin, now with rigors and a temperature of 38.9: CT shows a 7 mm stone in the ureter and a swollen kidney above it.”

  • Stone pain alone is managed expectantly or electively; stone pain with fever is a different disease: infection above an obstruction, under pressure, seeding the bloodstream.
  • The kidney's version of cholangitis follows the same law: antibiotics are cover, drainage is treatment, and the drain cannot wait for office hours.
  • Two routes decompress: a retrograde ureteric stent from below, or a percutaneous nephrostomy from above, chosen by stability, anatomy and availability.

  Live it as a case Percutaneous nephrostomy

• The man who cannot pass urine

  “Twelve hours of inability to void, agonising suprapubic fullness, in a 74-year-old with years of hesitancy and nocturia he never mentioned.”

  • Acute retention is treated first, explained second: the catheter is analgesia, diagnosis and treatment in one tube, and the residual volume gets written down.
  • Ask what set it off: constipation, anticholinergics and opioids, infection, alcohol, or simply prostatic progression finally crossing the line.
  • The kidneys report the chronicity: high-pressure chronic retention shows itself in creatinine and hydronephrosis, and its relief brings a diuresis that needs watching.

  Live it as a case TURP (transurethral resection of the prostate)

• Painless visible haematuria

  “A 68-year-old smoker reports two episodes of frank blood in the urine, painless, now clear again and hoping it was nothing.”

  • Painless visible haematuria is bladder cancer until proven otherwise, and 'it went away' is the disease's favourite trick: intermittency reassures patients and should not reassure clinicians.
  • The haematuria clinic answers it in one visit: flexible cystoscopy for the bladder, upper tract imaging for the kidneys and ureters, cytology as an adjunct.
  • Smoking and occupational dye exposure are the classic risk factors: the urothelium is a field exposed to everything the kidneys filter.

  Live it as a case Transurethral resection of bladder tumour

• The raised PSA

  “A fit 66-year-old's health check returns a PSA of 8.2: no symptoms, a worried patient, and a decision tree with decades on its branches.”

  • PSA is prostate-specific, not cancer-specific: infection, retention, instrumentation and size all raise it, so the number starts a pathway rather than making a diagnosis.
  • MRI before biopsy is the modern sequence: the scan targets the biopsy and spares some men biopsy altogether.
  • Grade and stage set the tempo: much low-grade disease is watched on active surveillance, deliberately and safely, while higher-grade disease meets surgery or radiotherapy.

  Live it as a case

• The acute scrotum

  “A 15-year-old woken by sudden severe left testicular pain, vomiting once: the testis rides high and tender, the reflex absent.”

  • Torsion is first on the list until it is off the list, and it comes off the list in theatre, not on a scan report: the twisted cord is strangling the testis on a timer measured in hours.
  • The classic story is short and sudden; epididymitis's story is slower with urinary symptoms; but overlap is common and the tie-break goes to exploration.
  • Ultrasound is for the cases where the story has already made torsion unlikely: ordering it to 'confirm' a likely torsion spends the organ's minutes on a queue.

  Live it as a case