Oncology: Urology and Genital cancers

• Urological: Prostate Cancer: Diagnosis | Treating Prostate Cancer | Bladder and Urothelial Cancer | Kidney Cancer | Testicular Cancer | Penile Cancer
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🔬 Urological, skin, head and neck cancers and sarcomas make up a large share of cancer care. Prostate cancer is the commonest cancer in men; skin cancers are the commonest cancers of all; testicular cancer is the commonest solid cancer in young men and almost always curable. The key skills are recognising red flags - visible haematuria, a changing mole, a persistent mouth ulcer, a testicular lump, a growing deep lump.
Your four questions for every patient: Which red flag is present, and what is the right urgent pathway? What are the stage and grade? What are the treatment options and their effects on function (continence, erections, speech, swallowing)? Is there a lifestyle or inherited factor to address (smoking, sun, HPV, BRCA)?

Prostate Cancer: Diagnosis

The basics: The commonest cancer in UK men - about 1 in 8 men (and 1 in 4 Black men). Many slow-growing cancers never cause harm; others are aggressive.

Risk factors:

• Age (most over 65).
• Black ethnicity.
• Family history (father or brother).
• BRCA2 (and BRCA1, Lynch).
• Obesity (aggressive disease).

Symptoms:

• Early cancer usually causes no symptoms.
• Lower urinary tract symptoms (frequency, poor flow) are usually due to benign prostatic hyperplasia, but warrant a PSA discussion.
• Advanced disease:
  • Bone pain (back, pelvis). Spinal cord compression.
  • Weight loss; anaemia. Haematuria; kidney failure (ureteric obstruction).

PSA testing (Prostate Cancer Risk Management Programme):

• Men over 50 can ask for a PSA test after informed discussion - false positives, overdiagnosis and overtreatment are common.
• Raised by: Cancer, BPH, urinary infection (wait 6 weeks), prostatitis, urinary retention, catheterisation, recent ejaculation or vigorous exercise (48 hours), DRE (minor).
• Lowered by: 5-alpha reductase inhibitors (finasteride, dutasteride - halve it).
• Refer urgently (NICE NG12) if the PSA is above the age-specific threshold, or the prostate feels malignant on rectal examination (hard, irregular, craggy).
• Targeted screening for BRCA2 carriers with a family history is being introduced.

Diagnosis:

• Multiparametric MRI first (PI-RADS score) - avoids biopsy in many and guides targeting.
• Transperineal biopsy (lower infection risk than transrectal).
• Grading: Gleason score, now grouped into ISUP grade groups 1–5.
• Risk groups (Cambridge Prognostic Groups 1–5) combine PSA, grade and stage.
• Staging: Bone scan, CT, or PSMA PET-CT for higher-risk disease.

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Treating Prostate Cancer

• Localised low-risk disease: Active surveillance - PSA, MRI and repeat biopsy; treat if it progresses. Avoids side effects for many.
• Older or frail men: Watchful waiting - treat with hormones only if symptoms develop.
• Localised intermediate or high risk - radical treatment:
  • Radical prostatectomy (often robotic) - risks: urinary incontinence, erectile dysfunction.
  • Radical radiotherapy (often with 6 months to 3 years of hormone therapy) - risks: urinary and bowel problems (radiation proctitis), erectile dysfunction.
  • Brachytherapy (seed implants) for selected patients.
• Locally advanced: Radiotherapy with long-term ADT, or surgery in selected cases.
• Metastatic hormone-sensitive disease:
  • ADT (LHRH agonist with anti-androgen flare cover, or an antagonist).
  • Plus a newer hormonal drug (abiraterone, enzalutamide, apalutamide or darolutamide), with or without docetaxel.
  • Prostate radiotherapy for low-volume metastatic disease.
• Castration-resistant disease (progressing despite low testosterone):
  • A newer hormonal drug if not already used.
  • Docetaxel, cabazitaxel.
  • Radium-223 (bone metastases).
  • Lutetium-177 PSMA therapy.
  • PARP inhibitors (olaparib) for BRCA or other DNA-repair mutations.
• Supportive care:
  • Bone health on ADT (DEXA, calcium and vitamin D, bisphosphonates); denosumab or zoledronic acid for bone metastases in castration-resistant disease.
  • Exercise; cardiovascular risk management.
  • Palliative radiotherapy for bone pain.
  • Spinal cord compression awareness - tell patients with bone metastases to report back pain or leg weakness urgently.

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Bladder and Urothelial Cancer

The basics: Usually urothelial (transitional cell) carcinoma; commoner in men and older people.

Risk factors:

• Smoking (the biggest - about half of cases).
• Occupational - aromatic amines in dyes, rubber, leather, paint, printing.
• Schistosomiasis (squamous cell carcinoma - Africa, Middle East).
• Long-term catheters and bladder stones (squamous).
• Cyclophosphamide; pioglitazone (small risk); pelvic radiotherapy.
• Lynch syndrome (upper tract urothelial cancer).

Symptoms:

• Painless visible haematuria (the classic sign).
• Irritative symptoms (frequency, urgency) - carcinoma in situ.
• Recurrent UTIs.
• Advanced: pelvic pain, leg swelling, kidney obstruction.

Referral (NICE NG12) - urgent suspected cancer pathway:

• Age 45 or over with unexplained visible haematuria (without UTI), or haematuria that persists after a UTI is treated.
• Age 60 or over with non-visible haematuria plus dysuria or a raised white count.

Investigation:

• Flexible cystoscopy.
• CT urogram (upper tracts).
• Urine cytology.

Treatment:

• Non-muscle-invasive bladder cancer (about 75%):
  • TURBT (transurethral resection).
  • Intravesical chemotherapy (mitomycin C) after surgery.
  • Intravesical BCG for high-risk disease.
  • Regular check cystoscopies (recurrence is common).
  • Cystectomy if BCG fails.
• BCG side effects: Cystitis, flu-like symptoms; rarely disseminated BCG infection (fever, liver and lung involvement - treat with anti-TB drugs).
• Muscle-invasive bladder cancer:
  • Neoadjuvant cisplatin-based chemotherapy, then radical cystectomy (with an ileal conduit or neobladder).
  • Or bladder-preserving chemoradiotherapy.
  • Adjuvant nivolumab for high-risk disease after surgery.
• Metastatic: Enfortumab vedotin with pembrolizumab; platinum chemotherapy; avelumab maintenance; FGFR inhibitors.
• Stop smoking - it reduces recurrence.

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Kidney Cancer

The basics: Mostly renal cell carcinoma (clear cell type commonest). It is increasingly found by chance on scans.

Risk factors:

• Smoking. Obesity. Hypertension.
• Long-term dialysis (acquired cystic kidney disease).
• Von Hippel–Lindau disease (bilateral, young), tuberous sclerosis, hereditary syndromes.

Features:

• The classic triad of haematuria, loin pain and a mass is a late sign.
• Weight loss; fever.
• Left-sided varicocele that doesn't empty on lying down (tumour in the left renal vein).
• Paraneoplastic syndromes:
  • Polycythaemia (EPO).
  • Hypercalcaemia (PTHrP).
  • Hypertension (renin).
  • Stauffer syndrome (abnormal LFTs without liver metastases).
  • Anaemia.
• Metastases to lung ("cannonball" nodules), bone, liver and brain.

Diagnosis: CT (contrast-enhancing solid mass); staging CT chest. Biopsy for small masses or before systemic treatment.

Treatment:

• Small renal masses (under 4 cm) - active surveillance (older people), partial nephrectomy, or ablation.
• Localised larger tumours - radical or partial nephrectomy; adjuvant pembrolizumab for high-risk disease.
• Metastatic disease:
  • Immunotherapy combinations - nivolumab with ipilimumab, or pembrolizumab or nivolumab with a TKI (axitinib, lenvatinib, cabozantinib).
  • TKIs alone (sunitinib, pazopanib, cabozantinib).
  • Removal of isolated metastases or stereotactic radiotherapy.
• Chemotherapy and conventional radiotherapy work poorly (except for bone pain).
• Benign mimics: Angiomyolipoma (contains fat - tuberous sclerosis; bleeding if large); oncocytoma; complex cysts (Bosniak classification).

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Testicular Cancer

The basics: The commonest solid cancer in men aged 15–45. Over 95% are germ cell tumours. Over 95% are cured, even with metastases.

Risk factors:

• Undescended testis (cryptorchidism), even after correction.
• Previous testicular cancer (in the other testis).
• Family history.
• Klinefelter syndrome.
• Infertility; HIV.

Features:

• Painless lump or swelling of the testis (can be a dull ache or heaviness).
• Hydrocele (examine the testis behind it).
• Gynaecomastia (hCG).
• Back pain (para-aortic lymph node spread).
• Breathlessness or cough (lung metastases).

Assessment:

• Urgent scrotal ultrasound and urgent referral (NICE NG12).
• Tumour markers (before and after surgery):
  • AFP - raised in non-seminoma; never raised in pure seminoma (if raised, treat as non-seminoma).
  • hCG - raised in choriocarcinoma, some seminomas and non-seminomas.
  • LDH - tumour burden.
• CT chest, abdomen and pelvis for staging.

Treatment:

• Radical inguinal orchidectomy (through the groin, never through the scrotum). A prosthesis is offered.
• Sperm banking before treatment.
• Seminoma - very sensitive to radiotherapy and chemotherapy. Stage I: surveillance or one dose of carboplatin.
• Non-seminoma - stage I: surveillance or 1 cycle of BEP. Metastatic: BEP (bleomycin, etoposide, cisplatin), then surgery for residual masses.

Late effects:

• Cardiovascular disease and metabolic syndrome.
• Hypogonadism; infertility.
• Bleomycin lung damage.
• Cisplatin effects on hearing, nerves and kidneys.
• Second cancers.
• Long-term follow-up and testosterone checks.

Encourage testicular self-examination.

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Penile Cancer

• Rare; mostly squamous cell carcinoma in older men.
• Risk factors: HPV Phimosis and poor hygiene (uncircumcised men). Smoking.
• Lichen sclerosus (balanitis xerotica obliterans). Immunosuppression.

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Cancers Covered in Other Chapters

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 64-year-old man asks for a PSA test. He has no symptoms; his brother had prostate cancer.
Answer: Informed discussion first.

• Explain the benefits and harms (false positives, overdiagnosis, side effects of treatment).
• If he chooses testing and PSA is raised for his age: urgent referral for MRI, then biopsy if indicated.
• Avoid testing within 6 weeks of a UTI or 48 hours of ejaculation.

2. A 72-year-old man with prostate cancer and spinal metastases has worsening back pain and leg weakness.
Answer: Metastatic spinal cord compression.

• Dexamethasone 16 mg; urgent whole-spine MRI within 24 hours (immediately if neurological signs).
• Urgent oncology and spinal surgery opinion; radiotherapy or surgery.
• See the Oncological Emergencies chapter.

3. A 50-year-old ex-smoker has visible painless haematuria. Urine culture is negative.
Answer: Suspected bladder cancer.

• Urgent suspected cancer referral - flexible cystoscopy and CT urogram.
• If non-muscle-invasive: TURBT and intravesical treatment; surveillance cystoscopy.

4. A 26-year-old has a painless hard testicular lump.
Answer: Suspected testicular cancer.

• Urgent scrotal ultrasound; AFP, hCG and LDH; urgent urology referral.
• Radical inguinal orchidectomy; sperm banking; CT staging.
• Excellent cure rates.

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Key Points

• Prostate cancer: commonest male cancer (1 in 4 Black men). PSA testing needs informed discussion; MRI comes before biopsy.
• PSA is raised by infection, retention, catheters and ejaculation; halved by finasteride.
• Low-risk prostate cancer: active surveillance. Metastatic: ADT plus a newer hormonal drug.
• Cover LHRH agonists with an anti-androgen; monitor bones and cardiovascular risk on ADT.
• Visible haematuria at 45 or over (no UTI): urgent cystoscopy and CT urogram. Smoking is the main cause of bladder cancer.
• Kidney cancer: often incidental; paraneoplastic polycythaemia, hypercalcaemia, hypertension; immunotherapy combinations for metastatic disease.
• Testicular cancer: young men, painless lump; AFP, hCG, LDH; inguinal orchidectomy; over 95% cured. AFP is never raised in pure seminoma.

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Guidelines and Further Reading

• NICE NG131: Prostate cancer - diagnosis and management
• NICE NG2: Bladder cancer - diagnosis and management
• NICE NG14: Melanoma - assessment and management
• NICE NG36: Cancer of the upper aerodigestive tract
• NICE NG12: Suspected cancer - recognition and referral
• Prostate Cancer Risk Management Programme (PSA testing guidance)
• UK NSC recommendation on targeted prostate cancer screening (2026)
• British Sarcoma Group guidelines
• Prostate Cancer UK; Action Bladder Cancer UK; Melanoma Focus
• BNF - for current doses

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