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UROLOGY FOR

MEDICAL STUDENTS
Doc. MUDr. Milan Hora, Ph.D. Faculty of Medicine in Pilsen Charles University in Prague University Hospital in Pilsen Department of Urology

copyright Faculty of Medicine in Pilsen, Charles University, 2002 - 2009

Hora M: Urology for medical students

UROLOGICAL SYMPTOMS
Lower urinary tract symptoms (LUTS) Irritative symptoms Frequency - normal adult voids five or six times per day, with a volume approximately 300 ml with each void, often voiding = polakisuria (lat.) Nocturia - frequent passage of urine during the night (nocturnal frequency) Urgency - an overwhelming desire to pass urine immediately Urge incontinence - wetting when voiding cannot be instituted quickly enough Dysuria - pain on voiding, that is usually caused by inflammation Stranguria - an uncontrollable and often painful desire to pass urine which results in little or no urine being voided. It is often a feature of bladder or lower ureteric calculi
Pis-en-deux = sense of incomplete bladder emptying and the desire to return to the toilet shortly afterwards to void again

Obstructive symptoms Decrease force of urination Hesitancy = a delay in the start of micturition Intermittency - involuntary starting-stopping of the urinary stream Terminal dribbling = difficult for the patient to cut off the stream after voiding P.S. Hesitancy, a reduced urinary stream and terminal dribbling are the hallmark of bladder outflow obstruction. Frequency, nocturia, urgency and urge incontinence may occur in the absence of outflow obstruction but are often seen in patients with obstruction and secondary bladder instability. Dribbling may occurs several minutes after cessation of voiding = post-micturition dribbling, usually as a result of trapping of urine in the urethra (e.g. urethral stricture) Spraying and "forking" of the urinary stream suggest the possibility of the urethral or meatal stricture Straining the use of abdominal musculature to urinate = a symptom of bladder outlet obstruction Other symptoms Incontinence - stress i., urge i., overflow i. - see bellow (special question) Haematuria = blood in the urine Gross or microscopic The chemical detection of blood in the urine is based on the peroxidase-like activity of haemoglobin. False-positive dipstick readings most often result from contamination of urine specimen with menstrual blood. The presence of clots usually indicates a more significant degree of haematuria - Beetroot and some drugs (e.g. pyridium, rifampicin) may also colour the urine. - All cases of haematuria must be investigated! - Bleeding occurring at the end of the stream suggest an origin in the bladder neck - Spontaneous bleeding from urethra independent of voiding = uretrorrhagia - Heavy bleeding from any source will result in the passage of clots and may cause clot retention but, if these clots are long, thin and worm-like, they are likely to have arisen in the upper urinary tract and the have shaped by passage down the ureter.

Hora M: Urology for medical students

The association of pain with the haematuria is important, since the bleeding caused by urothelial tumours is most commonly painless whilst painful haematuria is more suggestive of an inflammatory or calculous lesion.

Differential diagnosis and evaluation of haematuria Haematuria of renal origin is frequently associated with casts in the urine and almost always associated with significant proteinuria. Even significant haematuria of urologic origin does not elevate the protein concentration in the urine into 100-300mg/dl range or 2+ to 3+ range on dipstick.
Erythrocytes arising from glomerular diseased are typically dysmorphic and show a wide range of morphologic alteration. Conversely, erythrocytes arising from tubulointerstitial renal disease and of urologic origin uniformly have a round shape. Erythrocyte morphology is more easily determined through phase contrast microscopy.

Glomerular haematuria - see nephrology Nonglomerular haematuria can be cause by nearly all urological diseases (the most often causes: UTI, urolithiasis, urological tumours, BPH) Investigation: - history, physical examination including DRE (digital rectal examination) - mid stream urine test - ultrasonography - by finding on the former investigations are indicated next examination, if it is negative, IVU and urethrocystoscopy is performed, if negative, patient is controlled in 3 months interval Treatment: - by the basic diagnosis (e.g. TURT of bladder tumour) - anticoagulant therapy (Warfarin) - vitamin K or, if acute, frozen blood plasma Enuresis = urinary incontinence that occurs during sleep Prostatodynia = pain of prostate Sexual dysfunction Loss of libido Erectile dysfunction Failure to ejaculate (ejaculatory dysfunction - mainly anejaculation = aspermia) Absence of orgasm Premature ejaculation Haemospermia = blood in the semen Patient has to be investigated to exclude mainly prostate cancer and testicular tumour. Faecuria and Pneumaturia Bubbles of gas (pneumaturia) and faecal particles in the urine (faecuria) are an indication that there is a pathological connection (fistula) between the intestine and bladder (diverticulitis, carcinoma of sigmoid colon, m. Crohn, rarely bladder carcinoma). The presence of gas alone in the urine may occasionally be the result of gas-fermenting organism in the bladder; this is most likely to occur in the sugar-laden urine of diabetics.

Hora M: Urology for medical students

Urethral discharge The most common symptom of venereal infection

SPECIALISED METHODS OF UROLOGICAL DIAGNOSIS


History Clinical examination A renal mass arises from the loin, is palpable bimanually, is ballottable and moves with respiration, it is usually possible to "get above" an enlarged kidney (in contrast to an enlarged spleen or liver) Digital rectal examination - see BPH, prostatitis and prostate cancer

Fig. bimanual palpation of the kidney Laboratory investigation Urine analysis This is best performed on a mid-stream specimen of urine. After cleansing the external urethral meatus, the first 20 ml or so of urine (containing bacteria and cells from urethra) are discharged before collecting the next part of the voided urine in a sterile container. Chemical tests "Dipstick" = a strip coated with chemicals for measuring the urine pH and for detecting the presence of glucose, protein or blood; bilirubin, urobilinogen, ketones and nitrites can also be detected. The urine pH Varies between 4.5 and 8.0 Persistently alkaline urine (pH > 8.0) suggest infection with urea-splitting organism such as Proteus mirabilis Protein The amount of protein in the urine is normally less than 100 mg/24 h. Dipstick will only detect levels greater than 300 mg/l Transient proteinuria (e.g. UTI) or persistent (glomerulopathia) Glycosuria Usually diabetes mellitus, rarely renal glycosuria Microscopy = microscopical examination of urine directly of the urinary sediment studied after centrifugation Red blood cells = see haematuria
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White blood cells Epithelial cells Casts - from glomerular disorders (hyaline or cellular) Crystals - related to stone disease Bacteria - Gram stain should be performed; if tuberculosis is suspected, the urinary sediment should be stained using the Ziehl-Nielsen methods Ova schistosomiasis Culture The specimen should be plated out promptly or refrigerated until processing to prevent multiplication of bacteria after voiding. Significant infection is present if there are more than 100 000 (= 105) organism/ml, whilst counts less than 10 000 (=103)/ml suggest contamination. Antibiotic sensitiveness is determined using culture plates with antibiotic discs that inhibit the growth of susceptible organisms. If tuberculosis is suspected, three early morning samples of urine (EMU) are taken and cultured on Lwenstein-Jensen medium. Blood tests Renal function studies the plasma urea (normal range 2,3-6,9 mmol/l) and creatinine (normal range 50-120 mol/l) creatinine clearance (normally 100-140 ml/min) - closely approximates to the glomerular filtration rate (GFR) Haematology Anaemia - tumours, renal impairment White blood cell count - may raised in infections ESR - elevated in certain disorders - tumours, retroperitoneal fibrosis Other tests PSA - see BPH and prostate cancer Diagnostic imaging Plain abdominal X-ray (KUB) The KUB (a plain X-ray to include the kidneys, ureters and bladder) is useful to detect: - radio-opaque urinary calculi (90% of calculi) unless they overlie areas of the bony skeleton - soft tissue masses in the renal areas and pelvis - gallstones (10%) - pelvic phleboliths - calcified lymph nodes - sclerotic deposits in prostate cancer (osteoplastic metastases - for other tumours are more typical osteolythic metastases)

Fig. plain X-ray of pelvis with cystolithiasis Fig. plain X-ray with multiple left nephrolithiasis Intravenous urography (IVU) - after a plain film, iodine-containing contrast medium (Telebrix) is injected intravenously and serial films are taken to follow its excretion by the kidneys - the nephrogram phase - on the initial film 1-3 minutes after injection, contrast medium is in the glomeruli and proximal tubules so that a clear image of the renal outline is obtained - the pyelogram phase - subsequent excretion of contrast medium outlines the collecting systems, renal pelvis, ureter and bladder, showing any structural abnormalities or filling defects - the procedure may be complicated by allergic reaction to the contrast medium, ranging in severity from a mild urticarial rash to anaphylactic shock Ultrasound - The most frequently used radiological techniques in urological disorders - almost all urological out-patient department are able to perform ultrasound immediately after physical examination - Colour-flow Doppler techniques - measuring blood flow

Hora M: Urology for medical students

Fig. Ultrasonography of the kidney with a tumour 81 x 73 mm (T2)

Fig. Ultrasonography of the kidney with hydronephrosis

Fig. Colour-flow Doppler of blood supply of the kidney

Hora M: Urology for medical students

Fig. Transrectal ultrasonography of prostate in two plains (sagittal and transversal) CT scanning (computed tomography) Multidetector spiral CT it enables reconstructions in different planes and biphasic CT angiography

Fig. Biphasic CT angiography of the left kidney. PET/CT Combination of positive emission tomography and CT. It allows precise localisation of tumours.

Hora M: Urology for medical students

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Fig. PET/CT with metastases of kidney cancer to the soft tissue around the right hip joint. MRI (magnetic resonance imaging)

Fig. MRI coronary plain with kidneys with bilateral simple renal cyst Arteriography - Renal arteriography is used in diagnosis of renal vascular disorders, renal tumours and renal trauma; therapeutic embolisation of the renal artery can be performed at the same time to control bleeding from the kidney. - Iliac arteriography is useful for assessing the pelvic tumours or trauma, and therapeutic embolisation of the internal iliac artery is occasionally used for uncontrollable bladder haemorrhage, pelvic trauma, and priapism. Other radiological techniques Antegrade pyelogram - contrast medium is injected via a small-bore needle passed into the collecting systm under local anaesthetic or via a percutaneous nephrostomy Ascending ureterogram - using a catheter inserted into the ureteric orifice at cystoscopy Uretrography (ascending and descending) - contrast medium is instilled directly into urethra (ascending uretrography), contrast medium is passed out and is are performed micturition cystogram (it can demonstrate vesicourethral reflux) and descending uretrography. Uretrography is useful for diagnosis of urethral stricture mainly. Lymphography - following injection of contrast medium into a lymphatic in the foot is used to demonstrate the iliac and para-aortic nodes in pelvic malignancy; nowadays, it has been replaced by CT scanning Radionuclide studies
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Renal scintigraphy It is useful mainly for dynamic diagnosis - upper urinary tract obstruction, assessing of renal function of both kidneys. Bones scintigraphy It is most widely used in the detection of bony metastases from prostatic, bladder and renal carcinoma. Urodynamic studies See special question.

SPECIALISED METHODS OF UROLOGICAL TREATMENT


CATHETERISATION Catheters are used mainly therapeutically to relieve urinary retention. Types and sizes of catheters Material: - soft silicon coated latex (silicon is highly resistant to incrustation) - it can be introduced up to 4 weeks - 100% silicon - it can be introduced up to 8 weeks (it is better, but more expensive) Types of catheters: 1. One way catheter - for dilatation of urethral stricture, to discover residual urine (better it is performed by ultrasound), to introduce contrast medium into the bladder 2. Two way catheter = self-retaining balloon catheter = Foley catheter 3. Three way catheter - for irrigation (lavage) of bladder (by bleeding to bladder after prostatectomy, due to bladder tumour) Division by a tip of catheter: Nelaton - straight round tip Tiemann - curved pointed tip Size of catheters: French scale = Charrie scale = circumference in mm diameter is size in F (Ch) divided by (= 3.14) e.g. catheter 18 F has diameter 6 mm

Fig. two way (Foley) Nelaton catheter (upper) and one way rigid Tiemann catheter.

Fig. Fulfilled balloon in Foley catheter. Balloon fixes catheter in the bladder. Technique of passing of catheter in men: 1. sterilisation of glans penis

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2. introducing of anaesthetic gel to the urethra 3. the catheter is passed to the urethra by sterile clamp without being touch by the unsterile hand 4. balloon of catheter is filled with 5-10 ml with sterile water ENDOSCOPY Two types of endoscopes: 1. rigid 2. flexible - examination is more difficult, an endoscope is more expensive, through this endoscope can be passed only flexible instruments, but for patient is this flexible endoscopy more pleasant Panendoscopy = uretroscopy and cystoscopy = endoscopy of urethra and urinary bladder Ureteroscopy - endoscopy of ureter Ureterorenoscopy - endoscopy of ureter and renal pelvis too Endoscopic operations Lithotripsy - disintegration of stone in bladder and ureter Transurethral resection of prostate (TURP = TUPE) and bladder tumour (TURT) Nephrostomy To the dilated renal pelvis is introduced under ultrasound and/or radiological control catheter (= percutaneous nephrostomy).
Percutaneous nephrostomy step by step: Needle puncture of dilated renal pelvis under X-ray or/and ultrasonography control Guide wire passed down needle Dilatation of channel over guide wire "pig-tail" catheter inserted over guide wire

Fig. Scheme of introduction of percutaneous nephrostomy. Nephroscopy It is used mainly for treatment of stones = nephrolitholapaxy BIOPSY Prostate biopsy Indication: suspicion on prostate cancer It is performed transrectal (or transperineal) under mainly ultrasound control

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Biopsy of kidney It is done under ultrasonography or CT control. Mainly used in nephrology, biopsy for kidney tumour is indicated rarely.

RENAL FAILURE
For details see nephrology Acute renal failure Oliguria = a daily urine output of less than 500 ml in adult Anuria = absence of urine formation (< 100 ml/day) Aetiology - Pre-renal - Renal - Post-renal ("urological") - it is more often in solitary kidney - ureteric occlusion - stone, ureteral tumour, retroperitoneal fibrosis, retroperitoneal tumours, the small pelvis tumours = anuria - bladder outlet obstruction (e.g. BPH, prostate cancer) = urinary retention Treatment of urological causes of ARF 1st step: Subvesical obstruction - permanent catheter or epicystostomy Ureteric occlusion - catheterisation of ureter(s), nephrostomy Definitive treatment follows investigation and definition of basic cause (e.g. uretroscopy and tripsy of ureteral stones, prostatectomy )

Fig. Double loop ureteral stent Chronic renal failure See nephrology CONGENITAL ANOMALIES OF URINARY AND GENITAL TRACT CONGENITAL ANOMALIES OF THE UPPER URINARY TRACT Many congenital anomalies become manifest only in the older children or adult

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The vast majority of babies with urinary obstruction and worst cases of reflux can now be diagnosed antenatally using ultrasound Renal anomalies - shape, number Unilateral renal agenesis No ureter, and the appropriate half of the trigone of the bladder is missing Bilateral renal agenesis the absence of foetal urine leads to oligohydramnions treatment is not appropriate Malrotation Renal pelvis face forward Renal ectopia = a kidney that has incompletely ascended and remains lower than normal

Fig. left sacral dystopia

Fig. CT of the dystopic right kidney

Crossed ectopia - the kidney is located on the opposite side Fused kidney Horseshoe kidney - the two kidneys are joined across the midline at their lower poles

Calyceal abnormalities Hydrocalyx and hydrocalycosis


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Congenital infundibular stenosis or extrinsic compression from a vessel Megacalyx = congenital maldevelopment of the kidney Fullness of the renal pelvis but no obstruction is present Calyceal diverticulum Pelvi-ureteric junction obstruction hydronephrosis The cause Intrinsic obstruction Lower pole blood vessels Diagnosis - wash-out IVU (diuresis urography with furosemide) Management - surgical pyeloplasty (open or laparoscopic/retroperitoneoscopic)

Fig. Scheme of the hydronephrosis of the right kidney due to accessorial renal vessels to the lower pole

Fig. IVU hydronephrosis of the right kidney

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Fig. Scheme of dismembered pyeloplasty Dysplastic, hypoplastic and cystic diseases of the kidney Renal dysplasia = histological diagnosis Multicystic kidney = severe renal dysplasia The kidney is composed of a mass of cysts loosely held together by fibrous stroma Occasionally bilateral = incompatible with life Treatment - nephrectomy Renal hypoplasia = a small kidney with normal renal tissue, no dysplasia and normal ureter Infantile polycystic disease A rare autosomal recessive The children tend to die from renal or respiratory failure in the few days of life Adult polycystic disease An autosomal dominant Typically present in the 3rd and 4th decades with hypertension, renal impairment or large palpable kidney Treatment is directed to the management of the hypertension and the renal failure
Multilocular cystic kidney - it is benign renal tumour by up-to-date knowledge

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Fig. Adult polycystic kidney CT and specimen of kidneys at operation Medullary sponge kidney Dilatation and cyst formation of the distal collecting tubules nephrocalcinosis Simple cyst Rarely in children, extremely common in older patient - it suggest, that they are acquired disease Treatment - none, only huge cysts - laparoscopic ablation

CONGENITAL ANOMALIES OF THE URETER Duplication of the upper urinary tract - the kidney is drained by two separate ureters - the upper pole ureter drains the upper group of calyces - the lower ureter the middle and lower calyces Simple partial duplication (ureter fissus) The two ureters can join anywhere to give little more than a bifid pelvis or two ureters meeting just outside the bladder Simple complete duplication (ureter duplex) The two ureters enter the bladder separately The ureter from upper pole opens inferiorly and medially to the lower pole ureter The lower pole ureter often has a more direct course through the bladder wall and may be reflux - some form of operation (re-implantation) is usually necessary The upper pole ureter Can be ectopic on the low trigonum of bladder, at the bladder neck, within the proximal urethra, even outside of bladder, male - ejaculatory duct, seminal vesicle, vas, female vagina, vulva Treatment - heminephrectomy May be end as a balloon dilatation = ureterocele Treatment - TUR discision or re-implantation

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Fig. duplex kidney (bridge of parenchyma in the middle part of the kidney), duplication of ureter is invisible

Fig. Left ureter fissus (left) and ureter duplex Simple ureterocele Small "smile" incision along the lower edge of the ureterocele using a diathermy needle Excising the ureterocele and re-implantation

Fig. Duplex ureter, upper part of the kidney with megaureter due to ureterocele

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Fig. Discision of the ureterocele

Fig. Discision of the ureterocele Retrocaval ureter The right ureter passes behind vena cava Treatment - division of ureter and re-anastomosis lateral to the cava Megaureter Megaureter should be defined as an abnormal ureteral width (either segmental or along the whole ureteral length) Classification of megaureters (congenital but acquired as well): Refluxing m-s Primary Due to short or absent intravesicle ureter (see vesicoureteral reflux)
Congenital paraurethral diverticulum

Secondary Subvesical obstruction (posterior urethral valve, urethral stricture, neuropathic bladder, BPH) Obstructed m-s Primary = intrinsic ureteral obstruction - ureterocele, ectopic megaureter, ureteral valve
or stricture, functional obstruction

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Secondary Ureteral lesion - ureteral stricture, postoperative Extrinsic lesion - tumour, retroperitoneal fibrosis, posttraumatic, vascular compression Nonrefluxing and nonobstructed m-s Primary = idiopathic Secondary - diabetes insipidus, uroinfection, postoperative Treatment - by basic cause, see special chapters

CONGENITAL ANOMALIES OF THE LOWER URINARY TRACT ANOMALIES OF THE BLADDER AND URACHUS ORIGIN Bladder extrophy = part of spectrum of defects in which there are failure of fusion of the lower abdomen, genitalia and pelvic bone - the defect range form isolated epispadias to complex anomalies involving the bladder - the bladder mucosa lies exposed on the lower abdominal wall with the bladder neck and the urethra laid open - secondary inflammatory changes with squamous metaplasia, cystitis chronica and fibrosis - the prostate and testes are normally developed Treatment - complicated surgical correction Anomalies of urachal origin Extremely rare - patent urachus, urachal cyst, urachal diverticulum Vesicoureteral reflux VUR is primary due to short insufficient ureterovesical junction or secondary due to elevation of intravesical pressure (subvesical obstruction, neuropathic bladder). Treatment of primary VUR: conservative in mild forms, surgical in complicated cases (re-implantation of ureters). Bladder diverticulum = a protrusion of mucosa through a weak point in the bladder muscle Treatment - open surgical excision ANOMALIES OF THE URETHRA Posterior urethral valve The most common form of outflow obstruction in boys due to subvesical obstruction: the bladder is thickened, trabeculated and usually sacculated from the long-standing, severe obstruction. The upper tracts are dilated and the kidney damaged to a variable degree Treatment: endoscopical valve ablation ANOMALIES OF THE PENIS Hypospadia A common genital anomaly (1:400 male births) The meatus opens ventrally anywhere from normal site to as far back as the perineum and is associated with a hooded (ventrally-deficient) prepuce There can be a downward curvature of the penis on erection due to ventral chordee Treatment - surgical

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Epispadia See bladder extrophy. As an isolated anomaly only in boys - the meatus opens dorsally. CONGENITAL ANOMALIES OF TESTIS AND SPERMATIC CORD Infantile hydrocele A processus vaginalis remains open, it result in a hydrocele A conservative approach may be justified for the first years, because a very narrow processus may close off spontaneously up to age of 3 years Varicocele in children Varicocele is a dilatation of the pampiniform plexus of the left testis, caused by failure of the venous valve system in the testicular (internal spermatic) vein. The internal spermatic vein drains into the renal vein. On the right side it empties into the vena cava. It is rarely seen before puberty, after which it is reported to occur in over 15% of males. Possible consequences of varicocele are testicular damage ( infertility), hormonal dysbalance ( hypotestosteronemia) 99% the left side (testicular vein go to the renal vein). Treatment: surgical
subinguinal microscopical varicocelectomy = ligation of dilated veins of pampiniform plexus = the best procedure laparoscopic varicocelectomy can be performed too open varicocelectomy - inguinal approach

Cryptorchismus (Undescended testis) = testis can not be found in scrotum Classification of cryptochrismus: rectractile, ectopic, truly undescended, absent testis: Retractile testis - testis is normal and can reach to the bottom of the scrotum Ectopic testis - left the normal path of absent, is found in the perineum, upper thigh, base of the penis on in superficial inguinal pouch and cannot be pushed down into the scrotum Truly undescended testis (retentio testis) = one that has stopped in the normal path of descent Possible positions - intra-abdominal, inguinal (canalicular), emergent, high scrotal, mid-scrotal Absent testis - 5% of the testes, that are not palpable Optimal age for surgery Surgery should be performed by the age of 2 years Retractile testes - no operation Hormonal treatment HCG or LHRH - better result with retractile testes Malignancy risk 7.5 times increased risk of malignancy in an undescended testis The risk is reduced if orchidopexy is performed before the age of 8 years INTERSEX = ambiguous genitalia. The commonest - virilising congenital adrenal hyperplasia. Causes of intersex: I. Gonadal dysgenesis Turner syndrome (45X0), Klinefelter's syndrome (47XXY), true hermaphroditism, mixed gonadal dysgenesis (masaic XX, XY) II. Male pseudohermaphroditism
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Androgen resistance syndrome (testicular feminisation), testosterone biosynthetic defect, 5-reductase deficiency III. Female psedohermaphroditism Virilising congenital adrenal hyperplasia URINARY TRACT INFECTION IN ADULTS Incidence UTI (urinary tract infection) - common, affecting all ages and both sexes the most common but one infections (the first - breath infections) clinical syndromes associated with UTI: septicaemia (urosepsis) renal infection pyelonephritis pyonephrosis renal abscess peri- et paranephric abscess cystitis - bacterial, abacterial prostatitis urethritis epididymitis, epididymo-orchitis Methods of introducing UTI: ascending infection - via urethra to bladder, reflux of infected urine up to ureter and/or spread of organisms along peri-ureteric lymphatics infection via a fistula (e.g. vesico-colic) heamatogenous infection (via renal artery) Aetiology and pathogenesis the urinary tract is normally sterile above the distal urethra the chiefly defence mechanisms: hydrokinetic = the dilution of bacteria by the flow of urine mucosal = mainly secretion of immunoglobulin A (Ig A) and phagocytic capability of the urothelium itself Factors predisposing to infection: UTI - commoner in women: due to shorter urethra opening of urethra at the vaginal vestibule, which is readily contaminated with faecal organism in many young women, infection are precipitated by sexual intercourse, bacteria-laden secretion from the perineum entering the urethra during sexual activity (so called honeymoon cystitis) In either sex UTI may develop: Incomplete bladder emptying (residual urine) due to outflow obstruction (BPH, urethral stricture ) Bladder diverticula Neuropathic bladder Upper urinary tract stasis due to obstruction of ureter, megaureter, stones

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Vesico-ureteric reflux interferes with both ureteric and bladder emptying and is commonly accompanied by infection Calculi, bladder tumours and foreign bodies (e. g. catheters) are predispose to infection, as may instrumentation of the urinary tract Factors that suppress the immune response (diabetes mellitus, cytotoxic or immunosuppressive agents) Common urinary pathogens: I. Ascending infection Bacteria - Gram-negative

- Escherichia coli - klebsiella spp - proteus spp - pseudomonas spp - Gram-positive cocci - streptococcus faecalis - staphylococcus aureus - chlamydia trachomatis - L-organism - ureaplasma urealyticum, mycoplasma hominis Fungi - candida spp II. Haematogenous infection Bacteria - mycobacterium tuberculosis Fungi Parasites - schistosoma spp Viruses - cytomegalovirus, adenovirus type 11

Clinical manifestation Symptoms Lower UTI - Voiding symptoms - frequency, urgency, micturition with discomfort, burning sensation (= dysuria) - Occasionally haematuria Upper UTI - loin pain -Systemic disturbance - fever, sweating, rigors - Some patients have lower UTI as well (often upper UTI follow lower UTI) Physical signs Fever and tachycardia Tenderness in the loin and in the suprapubic region Diagnosis the presence of pus cells on microscopy the presence of significant number (over 105 per ml) of organism in a mid-stream specimen of urine (MSU) microbiology laboratories determines antibiotic sensitivities specialised microbiological techniques may be required in certain circumstances (e. g. Tuberculosis, fungal infection, viral infection) Further investigation cystitis in young sexually active women investigation is not required for the first attack unless it is accompanied by haematuria or loin pain investigation is indicated in this group of women for recurrent infections, in older women, pregnant women, children, men, diabetes mellitus, neuropathy, known urinary stones or

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urinary tract anomaly urinary tract ultrasound, if indicated IVU, blood count, the serum urea and creatinine Treatment Antibiotics commonly used to treat UTI: Nitrofurantoin Co-trimoxazol (sulfamethoxazol + trimethoprim) and trimethoprim alone Ampicillin, amoxycillin, co-amoxycillin (clavulic acid + amoxicillin) Gentamicin Quinolones (norfloxacin, ciprofloxcin) Cefalosporins High fluid intake and regular emptying of the bladder to promote hydrostatic clearance of bacteria Attention to personal hygiene for women with recurrent infection In patients with collections of infected urine or pus (e.g. pyonephrosis, perinephric abscess) drainage is usually required UPPER URINARY TRACT INFECTIONS Acute renal infection Most result from ascending infection (75% of patients have preceding lower-tract symptoms) Some they are result of haematogenous spread There is important to distinguish between infection alone and infection combined with upper-tract obstruction; the latter combination may lead to rapid obstruction of renal tissue unless prompt drainage of the obstructed kidney is established Pathology Acute pyelonephritis = acute inflammation of the pelvic epithelium, with bacteria entering the collecting duct and fornices to produce inflammation of the renal parenchyma Renal carbuncle = an abscess in the renal parenchyma and is usually due to haematogenous spread of organisms (Typically staph. aureus from foil, infected infusion site, contaminated needles in drug addicts) Pyonephrosis Infection within an obstructed kidney rapid destruction of kidney Perinephric abscess It result form any of the above infective processes Initially, the infection is confined by Gerotas fascia (= perinephric abscess), but may rupture through this (= paranephric abscess) and to reach the skin (in Petits lumbar triangle), the psoas muscle or the bowel; it may even rupture through the diaphragm to reach the pleura and lungs Clinical symptoms Loin pain, fever, tachycardia, scoliosis in sever cases Mass may be palpable in the loin Septicaemia and shock

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Investigation Urine should be examined for pus cells and bacteria (urine culture), blood culture (all patients with pyrexia or clinical suspicious of septicaemia) Ultrasound urinary tract, liver, spleen, a plain abdominal X-ray, chest X-ray, IVU Management septicaemic patient: rapid intravenous fluid replacement intravenous hydrocortisone or methylprednisolone parenteral bactericid antibiotics Subsequent management depend on the pattern of infection, basic treatment is are antibiotics: Acute pyelonephritis antibiotics for 7-14 days, guided by the result of urine culture and sensitivity Renal carbuncle drainage by aspiration of the abscess under ultrasound or CT control by open surgery Pyonephrosis Drainage by percutaneous nephrostomy or with a ureteric catheter passed retrogradely from the bladder at cystoscopy After improvement ascendant pyelography or descendent pyelography (nephrostogram) identification of obstruction renal scintigraphy determines remaining renal function treatment of obstruction (e. g. ureteroscopy for ureterolithiasis, nephrectomy if kidney function is by scintigraphy under 10 (15) %) Perinephric abscess surgical drainage or nephrectomy, if function in the affected kidney is very poor Chronic pyelonephritis = combination of renal scarring and urinary infection it may follow vesico-ureteric reflux and infection repeated episodes of acute pyelonephritis differential diagnosis of other types of interstitial nephritis or hypoplasia of kidney is difficult Treatment Eradication of infection to prevent further renal damage. Nephrectomy, if: renal function is under 10 (15) % sever secondary hypertension Xantogranulomatous pyelonephritis = the result of granulomatous reaction within kidney to chronic infection Treatment nephrectomy LOWER URINARY TRACT INFECTIONS Acute bacterial cystitis usually result of ascending bacterial infection from the perineum particularly common in women (due to short urethra) clinical features:
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Frequency and urgency of micturition with dysuria There may be suprapubic pain, urine often has a fishy smell or may be bloodstained (= haemorrhagic cystitis) Association of loin pain and fever suggest spread of infection to the kidney (acute pyelonephritis) Management: MSU (including urine culture) before treatment to confirm the diagnosis Antibiotics for a 5 days period this can be changed, if necessary, on the basis of antibiotics sensitivity tests Analgetics and spasmolytics (the best in combination e.g. Algifen Liva) Resolution of symptoms MSU to repeat at 2 weeks and at 3 months to ensure eradication of infection Chronic and recurrent bacterial cystitis Clinical symptoms similar to acute cystitis Histologically cystic changes (cystitis cystica) and squamous metaplasia Treatment In women self-help advice Increase fluid intake Pass urine every 2 hours Regular washing of the vulva and vaginal introitus Wipe from front to back after bowel actions Empty the bladder after sexual intercourse (if the symptoms are precipitated by sex) If infection antibiotics Long-term low dose antibiotics (6-12 months), e. g. furantoin 100 mg daily, trimethoprim 100 mg twice daily, co-trimoxazol one tablet (480 mg) one or twice daily Immunotherapy e. g. Uro-Vaxom In women, whose infections are precipitated by sexual intercourse, voiding and single dose of antibiotics after intercourse may be prevent infection developing Abacterial cystitis Trauma, toxic drugs (e. g. severe haemorrhagic cystitis is caused by cyclofosfamid), chemicals, irradiation, viruses and related organism such as chlamydia trachomatis Interstitial cystitis Special type of chronic abacterial cystitis. Well recognise syndrome of unknown aetiology. Diagnosis and treatment are very complicated. ASYMPTOMATIC BACTERIURIA 1-2% schoolgirls, 3-5% of adult women, 0.5% schoolboy, 0.5% of adult male Management Exclude some abnormalities of the urinary tract Active treatment pregnant women due to 30% risk of developing acute pyelonephritis Other treatment is doubtful

URINARY TRACT INFECTION IN CHILDREN See paediatric medicine

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Two special problems: 1. Symptoms of urinary infection in small children may be non-specific 2. Collection of urine, particularly in small girls, may be difficult By coincidence UTI a anomalies of urinary tract - 3 groups of children with UTI: 1. Anomalies, which can be lead to rapid deterioration in renal function - reflux, obstruction 2. Relatively harmless anomalies - duplication of upper tract, bladder anomalies 3. Normal urinary tract INFECTION OF MALE GENITAL TRACT Result UTI or may occur in isolation Prostatitis It is called newly as chronic pelvic pain syndrome, because inflammation is a cause of disease in only a part of cases. 1. acute or chronic bacterial infection 2. non-bacterial prostatitis (absence of bacterial growth) 3. prostatodynia without objective evidence of inflammation or infection Clinical features In adult men of all ages Pain in the perineum, sacrum, suprapubic area and groins Urinary symptoms with frequency, urgency of micturition and dysuria Pain on ejaculation, heamospermia In acute prostatitis often fever, sweating, rigors (shake due to elevation of temperature) Spread of infection down the vas deferens can lead to concurrent epididymitis Investigation DRE (digital rectal examination) in acute prostatitis prostate feels enlarged and boggy, exquisitely tender, fluctuant abscess may be palpable In other types of prostatitis sign are less florid with variable enlargement and tenderness; prostate often feels firm similar as a prostate cancer Culture of fractionated urine specimen Culture of expressed prostatic secretion obtain after prostatic massage Bacterial prostatitis E. coli, other faecal organism, staph. albus Non-bacterial prostatitis some patient chlamydia trachomatis PSA, transrectal ultrasound and if indicated prostate biopsy to exclude prostate cancer Management Bacterial prostatitis antibiotics for at least 3 weeks (6-12 weeks) Abscess Drainage transurethrally by resection of overlying prostatic tissue to de-roof the abscess Prostatectomy in older patient Transrectal incision Non-bacterial prostatitis et prostatodynia treatment is less satisfactory Antibiotics help in some patient, possibly by eradicating undetected chlamydia Anti-inflammatory agents (indometacin) Mild sedatives (e. g. diazepam)

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Acute epididymitis rare before puberty but is seen in all other age group infection may reach the epididymis via the bloodstream or by retrograde spread from the prostatic urethra and seminal vesicles predisposing factors: UTI, STD (sexually-transmitted diseases), instrumentation of urethra Clinical features the onset is often sudden, with pain a rapidly progressive swelling of the scrotum, fever and rigors in severe cases there is often a history of dysuria, suggesting urinary infection, recent instrumentation of the urethra Investigation: microscopy and culture of the urine, culture of any urethral discharge, ultrasound Treatment bed rest, scrotal support, analgesia, antibiotics - quinolones, cephalosporins, cotrimoxazol, doxycycline if complications = abscess formation: drainage or orchiectomy Chronic epididymitis (ChE) This usually follows repeated attacks of acute epididymitis but may be an occasional complication of vasectomy. Tuberculosis is important as a cause of ChE and was quite common before the introduction of modern anti-tuberculous chemotherapy. It is usually secondary infection elsewhere in the genitourinary tract. In the tropics, chronic epididymitis my complicate schistosomiasis and filariasis. Typically - slowly progressive swelling of the epididymis with little pain Examination - hard irregular swelling involving the epididymis. In advance cases of tuberculous ChE - cutaneous fistulae developed from rupture of "cold" abscesses. Treatment: antibiotics for 6 weeks, in tuberculous CHE antituberculous chemotherapy, if indicated epididymectomy or orchiectomy Orchitis only as a viral illnesses - mumps, infectious mononucleosis, rubella, coxackie virus bacterial - only as a part of epididymo-orchitis GENITOURINARY TUBERCULOSIS (GU TBC) 3-5% of tuberculosis mycobacterium tuberculosis or bovine strains reach urinary tract via bloodstream from a primary focus elsewhere, usually in the lungs GU TBC may manifest itself years after primary infection Clinical features Frequency and dysuria, loin pain (from upper tract obstruction), haematuria and symptoms from genital involvement, non-specific symptoms (lethargy, malaise, anorexia) Pathological changes Kidney and ureter Erosion of renal papilla (in early lesion)

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Pyocalyx from fibrous obstruction at neck of calyx Complete replacement of renal tissue by caseous debris (autonephrectomy) Bladder fibrosed and contracted bladder Genitalia tuberculous epididymitis Investigation On a routine MSU sterile pyuria Since tubercle bacilli are scanty in the urine, they are best detected in the first early-morning specimen of urine Ziehl-Nielsen stain of urine acid-fast bacilli Culture on special (Lwenstein-Jensen) medium for 6 weeks PCR detection Stay of urogenital tract ultrasonography, IVU Management Combination of chemotherapy (triple isoniazid, rifampicin, pyrazinamid) for 6 month Chemotherapy lead to accelerated fibrosis reconstructive surgery (pyeloplasty, reimplantation of ureter, augmentation cystoplasty with ileum, ablative surgery nephrectomy for non-functioning kidney, epididymectomy) SCHISTOSOMIASIS (BILHARZIA) Endemic in Africa, the Middle East, the Far East, parts of South America Disease is caused by a trematode fluke, whose natural life cycle involve 3 stages (larval, snail, adult) Urinary tract is affected by schistosoma haematobium Pathology Penetration of human skin in water systemic infection (liver, pelvic veins) deposit ova into bladder wall intensive inflammatory reaction within bladder wall calcification of the lesion, fibrosis, shrinkage of the bladder, squamous metaplasia and progress to squamous carcinoma Clinical symptoms Frequency, sever dysuria, haematuria, small capacity of bladder In Egypt schistosomiasis affects 35% of the population Investigation Identification of schistosomal eggs in biopsies of the bladder or in the urine Serological test Ultrasonography, IVU, cystoscopy with biopsy Management Treatment of acute infestation praziquantel, metrifonate Surgery augmentation cystoplasty for bladder contraction re-implantation of ureter for lower ureter fibrosis total cystectomy with urinary diversion for cancer

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OAB (OVER ACTIVE BLADDER) OAB is definition established on symptoms only. OAB is defined a urgency with or without urge urinary incontinence without any disease explains these symptoms. Prevalence of OAB is 17 %. Symptoms: frequency 8 or more in 24 hours, nocturia 2 and more per night, urgency, urgent urinary incontinence. Treatment: For more details see neuropathic bladder (bladder training, pharmacotherapy, intravesical application of botulotoxine; rarely neuromodulation and neurostimulation). INCONTINENCE Incontinence is the involuntary loss of urine. It is a distressing and socially disabling condition that affects 5% of the population, with women affected more than men (8% and 3% respectively). Classification of incontinence Via the urethra (urethral incontinence) or from an abnormal extra-urethral route (fistula vesico-vaginalis, ectopic ureter opening into vagina). Urethral incontinence: a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Insensible incontinence e. Post-micturition dribbling Urge incontinence This is involuntary loss of urine associated with a strong desire to void. It may be due to either sensory or motor dysfunction of the bladder. Sensory urgency may be associated with intravesical pathology (e.g. UTI, interstitial cystitis, bladder calculi, bladder tumours), but in some patient there is no demonstrable problem and psychological factors may be involved. Motor urge incontinence due to uninhibited detrusor contractions may be neuropathic (= detrusor hyper-reflexia) or non-neuropathic (detrusor instability); detrusor instability may be secondary to bladder outflow obstruction or idiopathic. Stress incontinence This is involuntary loss of urine during activities which produce a rise in intra-abdominal pressure (e.g. coughing, straining, or lifting). Common in women, often the result of obesity, multiparity, childbirth. In men, sphincter weakness may follow prostatectomy, pelvic fracture. Two basic types: hypermobility of urethra descendus of urethra makes impossible a transfer of intraabdominal pressure on the urethra, only on bladder ISD (intrinsic sphincter dysfunction)

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Fig. normal urethra

Fig. descensus of urethra

Overflow incontinence This occurs from an overdistended bladder when the intravesical pressure exceeds the urethral closure pressure. It is invariably due to chronic retention of urine secondary either to bladder outflow obstruction or to an unobstructed acontractile bladder (= ischiuria paradoxa). Insensible incontinence This may occur in neurological disorders that interrupt the sensory pathways from the bladder and is often the result of detrusor hyper-reflexia. Patients with cerebral degeneration may be incontinent without warning because either they have no awareness of a full bladder or they have lost the usual social inhibitions. In these patients, loss of cortical appreciation above the pontine micturition centre result in reflex voiding when the bladder is full.
Post-micturition dribbling = the loss of a small amount of urine after voiding has finished and it is not synonymous with terminal driblling (= difficulty to cut off the stream after voiding due to outflow obstruction). It occurs predominantly in men. It is occasionally associated with underlying urological disease (urethral diverticulum or stricture).

Assessment of incontinent patient History Physical examination Investigations frequency volume chart, USG, IVU, urine culture, urodynamic studies Management of incontinence Urge incontinence Urgency is in a new terminology OAB (overactive bladder). Sensory u. i. Treatment of local intravesical pathology; if this is ineffective or no cause is found, management is along the same lines as for idiopathic detrusor instability. Motor u. i. Relieving of outflow obstruction Persisting symptoms after surgery other forms of treatment Bladder training Encouraging the patient to void by the clock, gradually increasing the interval between voids. Drug therapy Agents with anticholinergic and/or smooth muscle relaxant properties see neuropathic bladder. Hydrostatic bladder distension Under a general anaesthetic
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Surgical treatment Mainly augmentation clam ileocystoplasty see neuropathic bladder. Stress incontinence Non-operative measure In women with minor degrees of SI Pelvic floor exercises Weight reduction Smoking cessation -adrenergic stimulants
Electrical stimulation of the pelvic floor muscles using external electrodes (pelvic faradism)

Local or systemic oestrogens in atrophic vaginitis Vaginal pessary in an associated cystocele (but surgical repair it preferred) Operative measures If the above measures fail Many operative techniques have been described, but the aim is to elevate and support the bladder neck, returning it to its normal position above the pelvic floor muscles. Colposuspension secundum Burch sutures placed in the lateral vaginal fornices, are hitched to the back of the symphysis pubis, thus elevating and supporting bladder neck. Only for hypermobility of urethra. Sling operations urethra is elevated and compressed subvesically with sling. For both types of SI. TVT Tension free Vaginal Tape TOT TransObturator Tape now preferred method o injectables (silicone, collagen, teflon)

Fig. colposuspension sec. Burch

Fig. TOT

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Fig. principle of sling operation (TVT) elevation and compression of urethra Stress incontinence in men Mainly following operation of prostate (TURP, radical prostatectomy) Treatment: sling operation (compression of bulbar urethra) or artificial urinary sphincter Combined stress and urge incontinence The first step: to correct detrusor instability. If incontinence persists surgery for sphincter weakness. Overflow incontinence Due to chronic retention the bladder outflow obstruction should be relieved by prostatectomy (in men) or urethral dilatation/urethrotomy (in women). If the bladder still fails to empty after relief of outflow obstruction or if an atonic detrusor is the primary problem bladder emptying can often be improved by cholinergic agents (e.g. betanechol), by anticholinesterases (e.g. distigmine) or by suprapubic compression (Cred manoeuvre) and abdominal straining. Clean intermittent self-catheterisation (CISC) the best bladder emptying. Insensible incontinence Due to cerebral degeneration. Resolution: External drainage device (e.g. penile sheath), absorbent padding, permanent urethral catheter. Post-micturition dribbling It is usually seen in men. I. Urethral pathology (stricture, diverticulum) this should be treated II. No urethral abnormality the patient should be encouraged to milk the urethra manually after voiding to ensure that is empties completely.

NOCTURNAL ENURESIS Primary NE the patient has never been dry at night Secondary NE bedwetting develops in an individual who has previously been dry at night Primary enuresis In the infant, micturition is a reflex event. As the child grow older, voluntary control is gradually exerted over this reflex and the child becomes aware of the sensation of bladder fullness. Daytime continence is normally achieved by 18-24 months. The development of night-time control is more variable - 2/3 of children dry by age of 3. About 2% of children
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remain wet at night after the age of 15. In these children is often: family history of bedwetting, psychological factors. Urinary infection should be excluded in all patients, but additional investigations are not warranted under the age of 5 unless there are accompanying urinary symptoms. After the age of 5, an IVU or ultrasound is necessary to exclude urinary tract abnormalities. If no abnormality is found: Bladder training during the day Fluid restriction before bedtime Lifting the child when the parents go to bed Some patient: Anticholinergic drug Synthetic ADH analogues (e.g. desmopressin) Imipramin reducing the depth of sleep and inhibiting the bladder directly An enuresis alarm = small detector worn in the pants during the night which trigger an audible
alarm to wake the child as leakage occurs. Eventually, the bladder becomes conditioned to appreciate bladder fullness and to wake and pass urine before leakage occur.

For the 2% of patients whose bedwetting persist beyond adolescence, a formal urodynamic assessment is helpful. Many of these patients have detrusor instability. Secondary enuresis It develops at any age and should be fully investigated. It is due to UTI, chronic retention, neurological disorders URINARY FISTULAE = abnormal communication between epithelial surfaces the result of trauma, infection, tumours, surgery, radiotherapy. Vaginal urinary fistulae, vesico-intestinal fistulae, urethral fistulae. Treatment mainly reconstructive surgery. URODYNAMIC STUDIES = several specialised tests for assessing disorders of function of urinary tract Lower urinary tract The bladder and urethra act as a functional unit for storage and expulsion of urine, and both should be assessed when dealing with voiding disorders UROFLOWMETRY Voiding urinary flow rate = the volume of urine passed in a certain time and is expressed as millilitres per second Age (years) Male (ml/s) Female (ml/s) 16-45 > 25 > 30 46-55 > 15 > 25 56-80 > 15 > 12 - The peak urinary flow rate varies with age and between the sexes CYSTOMETRY = measurement of the intravesical pressure during artificial filling of bladder and is recorded as a tracing (cystometrogram)

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Two fine urethral catheters are passed into the bladder one to fill the bladder and the other to measure the intravesical pressure The total pressure in the bladder is the sum of the pressure produced by the bladder wall itself (detrusor pressure) and the intra-abdominal pressure The intra-abdominal pressure is measured simultaneously via a fluid-filled catheter in the rectum or vagina detrusor function can be evaluated during bladder filling (= cystometry) and during voiding when the urine flow rate is also recorded (pressure-flow study = P-Q study) using contrast medium to fill the bladder, bladder and the urethral activity can be seen on fluoroscopy and it can be recorded alongside the pressure tracings on video-tape (= video-cystourethrography)

URETHRAL-PRESSURE PROFILE if a fine catheter with side opening near its tip is perfused and slowly withdrawn along the urethra, the pressure to maintain a constant flow will vary according the activity of the urethral wall Assessment of the function of the urethral muscles from the bladder neck to the external meatus ELECTROMYOGRAPHY (EMG) further information about the activity of the urethral sphincter an electrode is stick closely to anus normally, electrical activity increases gradually as the bladder fills and then ceases as the sphincter relaxes during voiding Disadvantage of EMG: intrinsic urethral sphincter cannot be examined
Upper urinary tract the main value of upper tract urodynamics is in diagnosis of upper urinary tract obstruction = antegrade perfusion studies (Whitaker test) this Whitaker test is replaced with wash-out techniques (IVU or renal scintigraphy with furosemide)

NEUROPHATIC BLADDER DISORDERS The bladder and urethra act as single functional unit under complex neurological control for the storage and expulsion of urine. Lesions at any point in the neurological pathway can disturb the continence-voiding mechanism so that bladder dysfunction is a common feature in many neurological disorders

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Fig. Neurogenic supply of urinary bladder and sphincter Common causes of neuropathic bladder dysfunction Cerebral lesions CVA, Parkinsonism, dementia Spinal lesions trauma, multiple sclerosis, compression (tumours, abscess) Peripheral nerve lesions - pelvic surgery, diabetes mellitus Classification of neurovesical dysfunctions The clinical picture in an individual patient can be interpreted on the basis of changes in detrusor and urethral function as measured objectively by urodynamic studies. Functional classification of neuropathic urinary bladder disorders: Detrusor disorders hyperactive (detrusor hyper-reflexia) hypoactive (underactive - detrusor hyporeflexia of areflexia) Sphincter disorders hyperactive hypoactive (urethral sphincter incompetence). Detrusor-sphincter dyssynergia is dys-coordination of detrusor and sphincter activity The nature of these changes depends largely on the site of the lesion in the neurological pathway rather than on the underlying cause. Lesion may, however, be incomplete and produce a missed picture so it is necessary to define the changes in detrusor and urethral function separately. Effect of lesions at different levels on bladder and urethral function:

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1. lesions of sacral cord or peripheral nerves Both detrusor and urethra are underactive. 2. lesion of supra-sacral cord Loss of inhibitory impulses causes detrusor overactivity; urethra often overactive and uncoordinated with detrusor contraction (dyssynergia) 3. lesions above pons Loss of cerebral inhibition may produce overactive detrusor. Detrusor and urethral activity remain coordinated. Functional consequences of neuropathic bladder disorders: 1. incontinence detrusor hyper-reflexia urethral underactivity underactive detrusor but incompetent urethral sphincter (e.g. stress incontinence) 2. retention detrusor hyper-reflexia + urethral overactivity (detrusor-sphincter dyssynergia) underactive detrusor; sphincter normal or overactive In addition to effect on bladder function, upper tract dilatation (megaureters) may also occur in patients with high intravesical pressures due to detrusor hyper-reflexia and detrusorsphincter dyssynergia. There may be accompanying vesico-ureteric reflux, especially in children with congenital lesions of the spinal cord. The transmission of high pressures to the kidney may lead to renal damage and chronic renal failure which was, until recent yeasrs, the commonest cause of death in patients with spinal cord injury. Assessment of neuropathic bladder disorders History Investigations Urine culture, blood urea and creatinine, blood glucose level IVU, ultrasound (including measurement of residual urine) Micturating cystography (to detect vesico-ureteric reflux) Urodynamic studies Principles of management Management depends on accurate diagnosis I. Incontinence Detrusor hyper-reflexia The same treatment is indicated in OAB and in urge incontinence. Drug with anticholinergic and/or smooth muscle relaxant properties Anticholinergic (parasympatolytic) drugs: Oxybutynin, fesoterodin, propiverin, trospium, tolterodin, solifenacin, darifenacin Side effects: dry mouth, blurred vision Intravesical application of botulotoxine Other treatment modalities are uncommon Neuromodulation and neurostimulation Augmentation cystoplasty (a segment of bowel usually ileum is incorporated into the bladder) II. Incompetent sphincter -adrenergic drugs
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duloxetine inhibition of re-uptake of serotonine and noradrenaline in CNS surgery to bladder neck the same techniques used for genuine stress incontinence see bellow artificial urinary sphincter

III. Retention of urine = underactive detrusor or detrusor-sphincter dyssynergia Atonic detrusor Cred manoeuvre emptying of the bladder by abdominal straining and suprapubic pressure Drugs with a stimulant action on smooth muscle (e.g. bethanechol) or anticholinesterase activity (e.g. distigmine Ubretid) CISC = clean intermittent self-catheterisation Urethral overactivity -adrenergic blockers see BPH striated muscle relaxants (e.g. baclofen) sphincterotomy CISC = clean intermittent self-catheterisation permanent urethral catheter Special features of individual disorders Spinal injuries Although the eventual activity of the detrusor and urethra depend on the level of the spinal lesion, there is an initial period of spinal shock below the lesion which leads to paralysis of the detrusor with retention of urine. Immediate management of spinal shock Overdistension of the bladder must be prevented to avoid permanent impairment of detrusor contractility. The best regime: intermittent catheterisation (every 4-6 hours) or suprapubic catheter (epicystostomy) or indwelling catheter risk of complications e.g. infection, urethral stricture, penile abscess, fistula Bladder drainage is continued until period of spinal shock has passed Subsequent management The rate of return of detrusor activity after spinal injury is variable but some activity is usually evident 4-5 weeks after injury. Sacral cord injury Spontaneous or induced detrusor contraction does not reappear, and effective bladder emptying depends on abdominal straining and suprapubic pressure (Cred manoeuvre) (P.S. sacral spinal cord segment centre of micturition in level of S2-4) Suprapubic cord lesion A trial of voiding is attempted, measurement of residual bladder urine by ultrasound. Urological complications of spinal cord injury in the longer term: treatment of urological complications (e.g. UTI, megaureters, renal failure, calculi) Regular urological follow-up including period evaluation of the urinary tract by IVU or/and ultrasound, urine culture, blood creatinine Other common diseases lead to neuropathic bladder Spina bifida

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Compression of the spinal cord or cauda equina o A prolapsed intervertebral disc, spinal stenosis, spinal tumours (primary or secondary) Diabetes mellitus Multiple sclerosis Pelvic surgery and pelvic radiotherapy Cerebral disorders a stroke, Parkinsons disease, dementia, cerebral tumours URINARY TRACT CALCULI (UROLITHIASIS) Incidence, aetiology 2-3% of population common in Europe, North America, Japan high intake of refined carbohydrate and animal proteins with low intake of crude fibre southern Africa - native Africans - a very low incidence X white sellers - a high incidence much more in administrative and sedentary personnel, more common in any professional groups, particularly in doctors, less common in people with active physical occupations most patients present in early adults life (a peak incidence around 28 years) second peak at 55 years - mainly result of infective stones in women male : female ratio 4:1 The pathogenesis The basic mechanism of stone formation remain unknown X we known a number of factors as predisposing to stone formation Metabolic abnormalities Stone form in the urine when solute concentrations reach supersaturation ( crystallisation) A. low urine volumes (dehydration) B. diseases result in excess urinary excretion of calcium, oxalate, amino-acids (e.g. cystine), urate idiopathic hypercalciuria, hyperoxaluria, hyperuricosuria, hyperparathyreoidism, cystinuria C. deficient of inhibitors of crystallisation in the urine citrate, pyrophosphate, magnesium Anatomical abnormalities Gross a.a., abnormalities of microanatomy Urinary tract infection (UTI) Typical infective stones - large "staghorn" calculi made of struvite (calcium magnesium ammonium phosphate = "triple" phosphate) Proteus - product an enzyme, urease, which split urinary urea to form ammonium ions, resulting in a rise in urinary pH Idiopathic stone formation 5-10% of all stone formers Most - calcium oxalate, alkaline urine Clinical features renal colic - severe pain radiating from loin to groin pain renders the patient nauseated, sweaty and pale, causes restless, may produce hypotension differential diagnosis

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left renal colic in elderly - abdominal aortic aneurysm Paralytic ileus, constipation Investigation history clinical examination laboratory investigation stone analysis incidence of stone types: pure calcium oxalate 45% calcium oxalate + phosphate 25% "triple" phosphate (infective) 20% uric acid 5% calcium phosphate 3% cystine 3% Calcium oxalate monohydrate = whewellite Calcium oxalate dihydrate = weddellite Magnesium ammonium phosphate = struvite Calcium phosphate = apatite Uric acid = uricite Investigation in the acute phase Plain abdominal film (plain X-ray KUB - kidney, ureters, bladder) Ultrasonography IVU (intravenous urogram or urography) = IVP (pyelography) Management of acute episode spasmoanalgetics opiates prostaglandin synthetase inhibitors - indometacin, diclofenac 60% of all stones pass spontaneously (half of these within 48 hours) 30% stones require surgical removal 10% may be followed expectantly

Surgery is indicated: Large stones (> 5mm) Infection with severe obstruction Failure of conservative measures To correct anatomical abnormalities Treatment of renal calculi Dissolution Uric acid stones can be dissoluted by alkalisation of urine (Uralyt-U = kalii citras + natrii citras). ESWL (extracorporeal shock wave lithotripsy) First developed in Germany 1982

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Aiming shockwaves from a spark generator, piezo-electric disk or electromagnetic plate directly onto the stone under X-ray or ultrasound control The shockwaves, generated in a water cushion, pass through the skin into the kidney and disintegrate the stone in situ The patient must then pass the powdered stone fragments down the ureter over next days and weeks - 20% patients developed renal colic, rarely sepsis, 5-10% requires further operative intervention to remove these Sedo-analgesia Stones greater 2 cm diameter - insertion of a ureteric stent before ESWL minimise the risk of ureteric obstruction Unsuitable for ESWL - very large stones, "staghorn" calculi, cystine stones Percutaneous nephrolithotomy (percutaneous stone removal) Indication Large ("staghorn") calculi too bulky for ESWL Stones which have failed respond to ESWL Operative technique The kidney is punctured under X-ray (or ultrasound) control with a needle A tract is dilated into the kidney using graduated dilators up to diameter 1 cm (30 French gauge) Stone removal is accomplished under direct vision within the kidney using nephroscope and a variety of grasping instruments A large stones (> 1cm) need to be broken before they can be removed (an ultrasound probe, electrohydraulic probe, LASER) Conventional open surgery Indications: very large staghorn calculi which cannot be treated by ESWL and which prove refractory to percutaneous surgery to correct any anatomical abnormalities which predisposed to stone formation (e.g. pelvi-ureteric junction obstruction, ureteric stricture) Techniques: pyelolithotomy - stones are removed via renal pelvis nephrolithotomy - to pick out calyceal fragments (Incision into the renal parenchyma bleeds profusely so the renal artery must be dissected out and clamped to achieve haemostasis) Management of ureteric calculi 60% of all ureteric calculi will pass spontaneously Only 30% will require surgical removal Surgical treatment is indicated: Stone is considered too large to pass spontaneously (> 7mm diameter) Stones causing obstruction which is impairing renal function (mainly in solitary kidney) Proximal infection combined with obstruction ESWL Most ureteric calculi, especially in the upper or lower third of ureter (middle third - pelvic bone -X-ray focusing is impossible) Failure of ESWL is an indication for endoscopic (or open) removal Technique of ESWL for upper ureteric calculi: ESWL in situ

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"push-bang" treatment - stones is endoscopically pushed back into the kidney before ESWL

Fig. Scheme of ESWL Ureteroscopy = endoscopic stone removal under direct vision with stone basket (Dormia) sometimes combined with diathermy incision of the ureteric orifice, large ureteric calculi - disintegration and fragments are retrieved individually

Fig. Scheme of ureteroscopy and nephroscopy

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Fig. Ureteroscopy with ureteral stone in Dormia basket Ureterolithotomy Conventional open surgery = extraperitoneal approach, longitudinal incision of ureter, removing of stone,
suture of incision, drainage of the peri-ureteric area

Minimally invasive surgery (laparoscopic or retroperitoneoscopic approach)

Fig. Open ureterolithotomy.

Fig. Open pyelolithotomy.

Bladder calculi Stones form de novo in the bladder due to bladder outflow obstruction (BPH, carcinoma of prostate), in diverticula, on foreign bodies (including catheters) and more rarely stones passed down the ureter which have lodged and enlarged in the bladder The classical picture: Sudden cessation (interruption) of the urinary stream during voiding Haematuria Frequency, dysuria, stranguria Suprapubic, groin, penile pain UTI (urinary tract infection) Surgery for bladder calculi:

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Removal of stones endoscopical procedure Small stones may be washed out via a cystoscope Large stones need to be broken into fragments before removal with urinary ultrasound or hydraulic lithotripsy litholapaxy - crushing instrument (lithotrite) = stone is gripped in the jaws, crushed into pieces and
washed out

cystolithotomy = open removal for stones which cannot bez crushed


suprapubic incision, opening of the bladder vault (= sectio alta), direct removal of the stone

Relief of the underlying cause for the stone formation (Usually bladder outflow obstruction - mainly BPH - stone removal is combined with TURP or open prostatectomy)

Fig. Endoscope for tripsy of cystolithiasis.

Fig. Tripsy of cystolithiasis with Ho:YAG laser. BENIGN PROSTATIC HYPERPLASIA (N 40) The prostate enlarges in most men after the age of 40 but the degree of obstruction produced is highly variable By the age of 70: 75% of men have benign nodular hyperplasia but only 10-15% require prostatectomy for relief of obstructive symptoms

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Pathology The prostate is composed of glandular tissue within a fibromuscular stroma and its activity is regulated both by androgens and estrogens. From the age of 40 onwards, areas of glandular and fibromuscular proliferation develop in the inner prostatic glands. These areas coalesce to form an adenoma and, as this enlarges, the outer zone of glands is compressed to form a false "surgical" capsule. The exact cause of these changes is not known but may be related to an imbalance between estrogenic and androgenic activity. As the prostate enlarges, it may compress the urethral lumen and cause obstruction to the flow of urine. There is, however, a poor correlation between prostatic size and the severity of the obstruction. Clinical features Symptoms of outflow obstruction = "prostatism" (= LUTS - lower urinary tract symptoms) irritative symptoms Extreme frequency of urination during day (polakisuria) at night (nocturia) Urgency = a sudden, very strong desire to urinate that may lead to loss of urine (incontinence) if micturition is not possible Suprapubic pain Obstructive symptoms Hesitancy Slow stream, interrupted stream Terminal dribbling Urinary retention Complications Retention of urine with ischiuria paradoxa Recurrent urinary tract infection (UTI) Stone formation Chronic retention of urine with megaureters with subsequent renal failure Bladder diverticulum Haematuria Clinical assessment PSA (the serum prostate-specific antigen) - blood must be taken before digital rectal examination (DRE) PSA in cancer usually rises, especially in the presence of metastases Normal level does not entirely exclude malignancy Normal value < 4 ng/ml, 4-10 grey zone (prostate cancer and BPH too), >10 tumour is very suspicious DRE - provides an approximate assessment of the size of prostate and helps differentiate BPH from prostate cancer Transabdominal ultrasonography of kidney, bladder, prostate and residual urine after voiding or/and IVU TRUS (transrectal ultrasonography) in special cases MSU (mainly culture of urine) Laboratory - serum creatinine Uroflowmetry Urodynamic study of lower urinary tract (pressure-flow study) - if indicated for differential diagnosis neurogenic bladder from BPH

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Differential diagnosis BPH and prostate cancer - see question prostate cancer as well PSA DRE TRUS Sextant transrectal ultrasonography guided biopsy Treatment I. watchful waiting If the symptoms are not bothersome. II. Medical - Only uncomplicated BPH -adrenergic blocking agent alfuzosin, doxazosin, tamsulosin, terazosin Inhibition of contraction of muscle in the bladder neck and prostatic capsule They improve urinary flow rates and decrease urinary frequency in part of patients Side effect - mainly postural hypotension Inhibitors of the enzyme 5--reductase finasteride or dutasteride 5--reductase converts testosterone to its metabolite dehydrotestesterone (DHT) In prostate act only DHT Reduction of prostate volume Plant extracts Principle of effect is unknown III. Surgical Indication - BPH with complications - Ineffective medical treatment Prostatectomy = removal of the obstructive adenoma from within "surgical" capsule of the prostate, leaving the compressed outer portion of the gland behind TURP = transurethral resection of prostate Open prostatectomy (transvesical or rarely retropubic) Very large prostate (over 70 g) Associated abnormalities in the bladder (e.g. diverticula, big bladder stones) Retrograde ejaculation is almost inevitable after prostatectomy and the patients should always be informed of this IV. Minimally invasive treatment of BPH (an alternative to prostatectomy) HIFU (High-Intensity Focused Ultrasound) TUMT (transurethral microwave thermotherapy) or hyperthermic therapy Vaporisation methods - PVP photoselective vaporisation with green light laser (532 nm) - plasmakineitc vaporisation bipolar instruments HoLEP enucleation of prostate with Ho:YAG laser V. Permanent indwelling catheter Patient presenting in retention and deemed unfit for prostatectomy

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UROONCOLOGY Number of cases of urological tumours in men in Czech Republic in 2005 top ten (percentage and total number per year). 30 % of malignancies are urological. 1. C61 2. C33, 34 3. C18 4. C19-21 5. C64-66, 68 6. C67 7. C16 8. C25 9. C43 10. C32 prostate lung colon rectosigma kidney urinary bladder stomach pancreas melanoma of skin larynx 17% 4846 16% 4632 9% 2622 8% 2124 7% 1742+79+37+16 6% 1827 3% 919 3% 901 3% 894 2% 454

PENILE CANCER (C 60) Uncommon, incidence about 0.5 - 1 per 100000 in year. Rare under age of 45 years. Rare in circumcised at birth (Jews and other religious groups) smegma is carcinogenic (also to the female cervix) Tumour arises as a warty growth or ulcer on the gland penis or in the coronal sulcus. This is usually hidden by the foreskin and the presenting symptom may be pain, bleeding or a foul-smelling discharge (mainly by phimosis). Histologically - usually a squamous carcinoma Early spread occurs via lymphatics to the inguinal nodes. Nodal enlargement, however, may be due to secondary infection rather than tumour involvement. Diagnosis: Biopsy of tumour, status of nodes - clinical examination of inguinal nodes, PET/CT, chest X-ray. Staging T category: Ta non-invasive tumour T1 sub-epithelial invasion T2 infiltration of corpus spongiosum or cavernosum T3 infiltration of urethra and prostate T4 infiltration of other organs N category N0 or N+ M category - M0 or M+ Treatment Ta, T1 Local resection, circumcision, glansectomy, local radiotherapy

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Fig. Glansectomy operation and status 2 months after operation T2-3 Partial amputation of penis Total amputation of penis - more advanced tumours, involving the shaft of the penis, with reconstruction of urethra as a perineal uretrostomy Emasculinisation in involving of scrotal skin, removal of scrotum and scrotal contents as well, supplementation of androgens is necessary

Fig. partial amputation of penis

Fig. Total amputation of penis with perineouretrostomy

T4 If surgery is not possible in advance disease, palliative local radiotherapy should be offered + suprapubic epicystostomy.

Fig. Extremely advanced penile cancer

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N+ (inguinal node enlargement in carcinoma of the penis) Enlarged inguinal nodes - we "wait-and-see" and we reassess nodes at 6-8 weeks - if they are still palpable - block lymph node dissection (inguinal lymphadenectomy) and adjuvant chemotherapy or actinotherapy PROSTATE CANCER (C 61) Incidence The commonest cancer in men (in mortality is fist lung cancer) the majority of men affected are between 65 and 85 years, rare before the age of 50 Aetiology - causes are unknown Pathology Small foci of prostatic carcinoma are common at autopsy in elderly asymptomatic men (50-60 years 37%, over 80 years 77%) these latent cancers are much commoner than overt clinical disease and their exact relationship to progressive disease are unknown typically, prostatic carcinoma arises in the periphery of the posterior part of prostate which has a different embryological origin from the more central site of benign prostatic hyperplasia (BPH) the majority of tumours are adenocarcinoma, which vary from well differentiated (Gleason score 2-4) to anaplastic (Gleason score 10) The Gleason system = histopatological grading (range 2 to 10) Spread and staging staging is performed by TNM classification Spread: Direct local extension may involve penetration of the prostatic capsule and involvement of adjacent structures (e.g. seminal vesicles, lower ureters) Lymphatic spread to pelvic lymph nodes - common in advanced tumours Haematogenous spread - chiefly to the axial skeleton (particularly the lumbar spine and pelvis) Clinical features Symptoms Due to subvesical obstruction (= local symptoms) "prostatism" (= LUTS - lower urinary tract symptoms) - 70% Acute retention - 25% haematuria - 5%, uraemia - 5%, anuria - 1% Symptoms due to generalisation (metastases) bone back pain - 15% Also: weight loss and fatigue, perineal pain, haemospermia, constipation, paraplegia Diagnosis DRE (digital rectal examination) Initial cancer - a small nodule Later cancer - hard and irregular PSA (the serum prostate-specific antigen) - see BPH Transrectal ultrasound (TRUS)
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to spot small tumours to assess extracapsular spread to facilitate needle biopsy of suspicious areas Biopsy histological confirmation of the diagnosis is essential before commencing treatment Performing: transrectally (or transperineally) by TRU-CUT needle by ultrasound guidance TURP some carcinomas are discovered incidentally following prostatectomy for a clinical benign gland Verification of tumour by biopsy - we perform staging of tumour CT scanning or MRI - magnetic resonance imaging staging of lymph nodes (N category in TNM system) X the most accurate method of nodal staging is to remove the pelvic lymph nodes surgically (pelvic lymphadenectomy) bone scintigraphy - 99mTc - labelled isotope the main site of blood-borne metastases is the skeleton when scanned by a gamma camera the metastases produce "hot spot" a chest X-ray - to exclude pulmonary metastases liver function test - abnormal ultrasound of the liver Ultrasound or intravenous urography state of urinary tract Treatment of prostate cancer depend on the grade and stage of tumour, the age and clinical condition of the patient staging of T category: T1 - no palpable tumour (verified only by biopsy performed for elevation of PSA or by incidentally by TURP) T2 - tumour confined within the prostate T3 - extension beyond the capsule T4 - fixed to neighbouring structures Locally confined carcinoma T1-2N0M0 Radical prostatectomy (RAPE) following preliminary pelvic lymphadenectomy with frozen section biopsy to exclude pelvic node metastases RAPE is performed only in patients with life expectancy over 10 years (carcinoma prostate is slowly growing tumour) Life expectancy under 10 years - no treatment, only follow-up RAPE = total removal of the prostate, seminal vesicles and distal vasa deferentia with subsequent anastomosis of the bladder neck to membranous urethra. RAPE is performed through open or laparoscopic approach (including robot assisted RAPE). Complication of RAPE - incontinence 2%, erectile dysfunction 30-50% (due to damage of neurovascular bundle with cavernous nerves), aspermia (dry ejaculation) 100%

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Fig. Scheme of radical prostatectomy

Fig. Preservation of neurovascular bundle (NVB) in radical prostatectomy

Fig. Laparoscopic radical prostatectomy 4 or 5 ports are used.

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Radiotherapy (external beam or brachytherapy) - Alternative to RAPE in patients refusing RAPE, in poor clinical condition (e.g. severe form of IHD) Locally extensive carcinoma T3-4NXM0 in locally advances disease, the pelvic lymph nodes are involved in at least 50% of patients pelvic irradiation or/with immediate hormonal manipulation palliative TURP (transurethral resection of prostate) - obstructive symptoms or retention of urine Metastatic carcinoma TXNXM1 Hormonal manipulation Patients with symptomatic metastases - immediate hormonal manipulation Patients with asymptomatic metastases - hormone therapy can be delayed until symptoms appear or given at the outset to try and delay progression of the disease, clinical trials are currently in progress to try to answer this question Castration (classical surgical c. = bilateral orchiectomy or chemical c. = LHRH analogues) GnRH analogues (gondadotropin-releasing hormone analogues = LHRH luteinizing hormone-releasing hormone) - buserelin, goserelin, leuprorelin - subcutaneous depot injection (monthly or ever 3 months) = equivalent of orchiectomy 2. Anti-androgens (AA) block extragonadal sources of testosteron (about 10-20% of androgens) from adrenal glands AA only lead to elevation of testosterone (mainly non-steroidal) lower efficacy clinical advantage - maintenance of libido and potency two types of AA: steroidal - cyproteron acetate pure (non-steroidal) - flutamide 3. Total androgen blockade (TAB) = combination of orchiectomy (surgical or chemical) with antiandrogens TAB is more effective than orchiectomy only mainly in patients with "minimal diseases" (few metastases) Intermittent androgen blockade - under clinical trials The duration of response to hormonal therapy averages 18 months, although prolonged periods are seen in some patients. No response to hormonal therapy and relapse after an initial response to hormones - the outlook is poor: estramustin phosphate (combination of oestrogen and cytostatic agent) - can be effective in about 40% Chemotherapy - mainly docetaxel, but low efficacy Other patients with hormone-resistant disease - palliation of symptoms, usually pain from skeletal metastases Opiate analgesia 89 Stroncium given intravenously Local radiotherapy Other complications Ureteric obstruction resulting in megaureters and in renal impairment - insertion of double-J stent or percutaneous nephrostomy
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Bowel obstruction - du to a prostatic carcinoma encircling the rectum - this may require a colostomy Spinal cord compression by an extradural metastatis demand urgent surgical decompression Prognosis Depend on stage of disease UROTHELIAL TUMOURS Bladder tumours (C 67) Urinary tract - specialised waterproof (transitional) epithelium 70% superficial - 2/3 recurrence, 10-15% of recurrence is invasive 30% primary invasive Incidence about 20 per 100000 of the population per year (Czech Rep. total 18, male 27, female 9) wide geographical variation in incidence - common in the industrialised world, undeveloped countries only in bilharzial areas Aetiology cigarette smoking industrial carcinogens associated diseases - schistostomiasis (bilharsiosis), chronic inflammation, pelvic radiation Pathology transitional cell carcinoma 90% special form - carcinoma in situ (CIS, TIS) squamous carcinoma 5-8% (usually following long-standing inflammation or infestation by schistosomiasis) adenocarcinoma 1-2% staging of T category: superficial tumor - tumor is confined to epithelium (Ta) or invasion only of subepithelial connective tissue (T1) invasive tumour - invasion of bladder muscle (T2), beyond bladder wall (T3) or invasion to other organs (T4) grading = histological differentiation - G1 well differentiated, G2 moderately, G3 poorly

Clinical features classical symptom is painless haematuria - 70-90% cystitis, bladder outflow obstruction, renal pain, renal failure, non-specific symptoms (weight loss, anaemia, PUO) incidental finding - 10% Investigation urine analysis including urine cytology for malignant cells

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intravenous urography ultrasonography cystoscopy CT or MRI - when radical surgery is planned

Treatment Superficial tumour (Ta-1) TURT (transurethral resection of tumour) under anaesthesia

Fig. TURT Low risk tumour - only follow-up (regular endoscopic follow-up) High risk tumour (T1, G3, large and/or multiple tumours, recurrence) - intravesical immunotherapy (BCG) or intravesical chemotherapy (epirubicin, mitomycin C ) Comment: BCG = Bacille-Calmette-Gurin = attenuated strain of Mycobacterium bovis Invasive tumour (T2-3) Radical cystectomy (lower ureters, bladder, prostate and urethra by men or lower ureters, bladder, gynaecological organs by women) with urinary diversion: orthotopic ileal or colonic neo-bladder - the best choice, only when urethra is tumour free and adjuvant radiotherapy isn't planned ileal conduit sigma-rectum pouch (ureterosigmoidestomy) heterotopic neo-bladder with continent stoma (self-catheterisation)

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Fig. Scheme of radical cystectomy in man and in woman

Fig. Ureteroileostomy

Fig. Orthotropic neobladder

Patient refusing radical surgery or contraindicated for surgery - radiotherapy (external beam 40-60 Gy) and systemic chemotherapy T3 or G3 - adjuvant radio- and chemotherapy Advanced tumour (T4) Extremely poor prognosis. Palliative radiotherapy. Carcinoma in situ Intravesical immunotherapy and by non-respondents radical cystectomy Metastatic bladder cancer Systemic chemotherapy or only symptomatic therapy (analgesics, urinary diversion by nephrostomy) 5-year survival Carcinoma in situ 3-40%, Ta 90-95%, T1 40-75%, T2 55%, T3 30-40%, T4 5-10% Urothelial tumours of renal pelvis (C 65) and ureter (C 66)

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Rare. Treatment nephroureterectomy, in small tumours laser ablation or resection. KIDNEY TUMOURS (C 64) Incidence world standard 15 per 100000 inhabitants per year (Czech Rep.- the highest incidence of kidney tumour all over the world - total 23, male 29, female 17) Aetiology unknown - cigarette smoking in 40% familiar in M. von Hippel-Lindau, tuberous sclerosis Pathology renal cell carcinoma (RCC) = adenocarcinoma - over 90% of kidney tumours clear RCC - about 90% papillary RCC 5-8% chromophobe 2% unclassified 2% oncocytoma Benign epithelial tumours, about 5% of kidney tumours angiomyolipoma Benign mesenchymal tumours, about 5% of kidney tumours nephroblastoma (Wilms' tumour) - predominantly in children staging is performed by TNM classification grading = histological differentiation - G1 well differentiated, G2 moderately, G3 poorly

Clinical features local symptoms haematuria, loin pain, palpable mass, all three symptoms together = classic triad varicocele symptoms due to metastases bone pain or pathological fractures respiratory symptoms or pathological chest X-ray metastases in brain - neurological symptoms paraneoplastic syndromes - fatigue, weight loss, anaemia, hepatopathy, fever, neuropathy incidental finding by ultrasonography or CT performed due to cholecystolithiasis 40% Investigation Laboratory, ultrasonography, chest X-ray, CT or MRI, angiography of renal artery, bone scan.- Newly PET/CT. Treatment of RCC Local tumours Resection of tumour per lumbotomy or laparoscopically Less than 4 cm, in carefully selected cases in bigger tumour as well Bilateral tumours Tumour of solitary kidney
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Fig. Scheme of kidney resection Radical nephrectomy (open or laparoscopic) Tumours over 4 cm = removal of the kidney, adrenal gland, surrounding perinephric fat within Gerota's fascia, upper ureter, enlarged para-aortic nodes Metastatic kidney cancer Solitary metastasis - radical nephrectomy combined with removal of the metastasis (e.g. lobectomy for pulmonary secondary) Multiple metastases chemotherapy (inhibitors of angiogenesis sunitinib, sorafenib, bavacizumab, temsirolimus) only partial remission in about 40 %, symptomatic therapy Radiological embolisation of renal artery - relieving local symptoms without resort to surgery (in gross haematuria) Prognosis The overall 5-year survival rate 30-50% Better prognosis - low stage (T1) and grade (G1-2), incidentally founded tumours Treatment of the other histological types of kidney tumours Oncocytoma - resection of tumour ("nephron" sparing surgery) or nephrectomy Angiomyolipoma - 4cm only follow-up (watch and waiting) - > 4 cm - risk of spontaneous rupture with retroperitoneal bleeding - resection of tumour or nephrectomy Nephroblastoma - radical nephrectomy and adjuvant chemo- and radiotherapy - in specialised centres of paediatric oncology (Czech Republic - Praha, Motol)

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TESTICULAR TUMOURS (TUMOURS OF THE TESTIS) (C 62) Incidence Relatively rare, only 1-2% of male malignant tumours (in Czech Republic 1,4%) the commonest neoplasm in men aged 25-34 world standard 3,5 per 100000 inhabitants per year (Czech Rep. total 3,9, male 7,0, female 0) Aetiology 10% a history of testicular maldescent (7,5 times greater risk) Histological classification I. primary neoplasm A. Germinal neoplasm - 90-95% of all testicular neoplasm 1. seminoma 2. embryonal carcinoma 3. teratoma 4. choriocarcinoma 5. yolk sac tumor
B. Nongerminal tumor Leydig cell tumor Sertolli cell tumor adenocarcinoma of the rete testis mesenchymal tumor II. secondary tumor - metastases, lymphoma III. paratesticular neoplasms

Staging Staging is performed by specialised system; TNM classification is not commonly used stage I - diseases confined to testis stage II - infradiafragmatic node involvement II A < 2 cm, II B 2-5 cm, II C > 5 cm stage III - supradiafragmatic node involvement stage IV - extralymphatic disease Clinical features the usual presentation - a nodule or painless swelling of one gonad testicular self-examination - diagnosis can occur earlier in approximately 10% - acute pain in approximately 10% - manifestation due to metastases a neck metastases - supraclavicular lymph node metastases (LNM) respiratory symptoms (cough, dyspnoe, haemoptysis) - pulmonary metastases gastrointestinal disturbation (anorexia, nausea, vomiting) - reetroperitoneal LNM lumbal back pain - bulky retroperitoneal disease involving the psoas muscle or nerve roots jaundice - hepatic metastases bone pain - skeletal metastases gynecomastia - 5% of germinal tumors (HCG, prolactin, androgens, estrogens) Spread Testicular tumours spread mainly via the lymphatics

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Lymphatic spread occurs initially to para aortic nodes (the testicular lymphatics accompany the testicular artery to its origin from the abdominal aorta) Only choriocarcinoma mainly via the bloodstream, in other types late The commonest sites of distant haematogenous metastases are the lungs and liver Tumour markers AFP (-fetoprotein) -HCG (beta-human chorionic gonadotrophin) for differential diagnosis, to monitor progress during and after treatment high marker levels after removal of the primary testicular tumour = probably metastatic disease
Elevation of markers by different types of tumour: seminoma - 15% HCG, 0% AFP teratoma - 0% HCG, 20% AFP choriocarcinoma - 100% HCG yolk sac tumor - 50% HCG, 20% AFP

Initial management of a suspected tumour Clinical examination, ultrasonography, tumour markers (blood taking for tumour markers is essential pre-operatively!), chest X-ray Prompt exploration of the testis (in 24 hours) through the inguinal canal (to avoid interference with the superficial lymphatics of the scrotum which drain to the inguinal nodes) In case of doubt about the diagnosis at operation - frozen section biopsy Staging protocol post-operative markers chest X-ray ultrasonography of retroperitoneum CT (or MRI) of the abdomen (mainly retroperitoneum - assessment of involvement of para-aortic nodes), the chest and mediastinum, newly PET/CT sperm banking (chemotherapy produce profound impairment of spermatogenesis which may not recover after treatment) Treatment Seminoma Extremely sensitive to radiotherapy Stage I - prophylactic radiotherapy (30 Gy) to the para-aortic and ipsilateral pelvic lymph nodes Stage II A, II B - radiotherapy (35 Gy) - the field is extended to contralateral pelvic nodes Stage II C - IV - chemotherapy - combination regime Radiotherapy is reserved for treatment of individual tumour masses Non-seminoma Stage I Surveillance (tumour markers, CT scan) - low risk tumour (no presence of venous or lymphatic invasion in the spermatic cord, well-differentiated tumour) Retroperitoneal lymphadenectomy Negative histology - surveillance Positive histology - re-staging as stage II Chemotherapy 2-3 cycles

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Mainly PVB (cisplatin, vinblastin, bleomycin) 5 days in the three weeks cycles Stage II - IV Chemotherapy is continued until complete remission (it is seen in 87% of patients) Residual mass after chemotherapy - excision ("second look" lymphadenectomy) - 80% fibrous tissue or mature teratoma, only 20% residual malignancy - additional chemotherapy should be given Prognosis - cure rates exceed 90% BENIGN DISEASE OF MALE GENITALIA Balanitis B. is inflammation of the foreskin; such inflammation usually affects the glans penis and the tissue behind the foreskin (balanoposthitis). All men with balanitis should have their urine tested for glucose. Treatment: Careful washing behind foreskin. If indicated local treatment - see dermatovenerology. All patients should be re-examined carefully after treatment of acute phase and, if they have phimosis, offered circumcision Phimosis = Tightness of the foreskin which prevents it from being retracted fully over the glans penis. An infant's foreskin is normally adherent to the glans penis until the age of one. Over one year of age we perform forcibly separation of the foreskin and glans. Children with tight foreskin and adults with acquired phimosis - circumcision Paraphimosis This condition is caused by pulling a tight foreskin (phimosis) back over the glans penis. Typically this occurs when the penis is erect during intercourse or masturbation, but it may occur after instrumentation of the urethra. Subsequently, the foreskin cannot be pulled forward again and, as a result, the glans penis swells considerably, making reduction of the foreskin even more difficult. Treatment: Conservative - under a regional local anaesthetic block. The glans penis and tissue distal to the constricting ring of foreskin are gently squeezed for a few minutes to reduce the oedema. The glans penis is then pulled firmly forwards to elongate it as much as possible and the foreskin "eased" forwards over the glans. Circumcision follows within 6-8 weeks. Surgical - emergency circumcision

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Fig. circumcision

Fig. paraphimosis

Lichen sclerosus et atrophicus = Flat-topped white papules which coalesce to form white patches without infiltration. The end stages may resemble very thin parchment of tissue paper. On the penis this condition occurs as balanitis xerotica obliterans, which may lead to urethral stenosis and shrinkage of the prepuce. Conservative treatment - see dermatovenerology Genital warts (condylomata accuminata) They are caused by human papilloma virus (HPV). In moist areas, the warts may be more hypertrophic and giant warts occasionally develop (Buschke-Lwenstein tumours). Treatment: local podophyllin, electrocautery, cryotherapy, LASER cautery Hydrocele a) Congenital = persistent processus vaginalis testis in children Treatment: inguinal approach, transection of processus vaginalis and ligation of central stump (Adelaide operation) b) Acquired A hydrocele consists of a collection of fluid within the tunica vaginalis. Although i may occur within the spermatic cord (= spermatocele), it is most often seen surrounding the testis. A cause of chronic hydrocele is usually unknown, and it is usually afflicts men post age 40 years. An acute hydrocele may develop rapidly secondary to epididymitis, orchitis, local injury, radiotherapy. Therapy of chronic hydrocele: surgery - hydrocele sac is open and wall of sac is resected (operation sec. Bergmann), everted (Jaboulay) over testis or stitched to testis (Lord)

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Fig. Operation of hydrocele sac was resected, now it is everted and stitched Varicocele
See too chapter CONGENITAL ANOMALIES OF TESTIS AND SPERMATIC CORD - Varicocele in children

Varicocele is a dilatation of the pampiniform plexus of the left testis, caused by failure of the venous valve system in the testicular (internal spermatic) vein. The internal spermatic vein drains into the renal vein. On the right side it empties into the vena cava.

Fig. The left testicular (gonadal) vein drained to the renal vein It is rarely seen before puberty, after which it is reported to occur in over 15% of males. Possible consequences of varicocele are testicular damage ( infertility), hormonal dysbalance ( hypotestosteronemia) 99% the left side (testicular vein go to the renal vein). Treatment: - subinguinal microscopical varicocelectomy = ligation of dilated veins of pampiniform plexus = the best procedure - laparoscopic varicocelectomy can be performed too - open varicocelectomy - inguinal approach

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Fig. Scheme of subinguinal varicocelectomy Spermatocele = A painless cystic mass containing sperm. It lies just above and posterior to the testis but is separate form it. Most spermatoceles are less than l cm in diameter, only occasionally quite large. The cause is not clear. Treatment: none, only large s-s are excised Torsion of the testicle (torsion of the spermatic cord) TT is an uncommon affliction that is almost completely limited to prepubertal males. It causes strangulation of the blood supply to the testis. Unless treatment is given within 3 or 4 hours, testicular atrophy may occur. Clinical finding: Sudden pain in one testicle, followed by swelling of the organ, reddening of the scrotal skin, lower abdominal pain, and nausea and vomiting. Differential diagnosis: acute epididymitis, torsion of the appendices of the testis and epididymis, acute mumps orchitis, trauma If the dif. dg. is unclear (It is called as a syndrome of acute scrotum), surgical exploration has to be indicated! Treatment: acute surgical exploration and surgical fixation of both testes, if testis is necrotic, orchiectomy has to be performed Torsion of the appendices of the testis and epididymis On the upper poles of both the testis and epididymis there are small vestigial appedages that may be sessile or pedunculated. The latter type may spontaneously undergo torsion, which leads to an inflammatory reaction followed by ischemic necrosis and absorption. This phenomenon usually affects boys up to age 16 years. Clinical finding and differential diagnosis is as in torsion of the testicle Treatment: surgical excision of appendix Penile fracture See genitourinary trauma URETHRAL STRICTURE (US) Clinical symptoms Slow urinary stream and any of the typical symptoms of outflow obstruction may be present (see BPH)

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Aetiology Congenital meatal stenosis (e.g. with coronal hypospadias), bulbar stricture Acquired Traumatic Perineal trauma Ruptured urethra from pelvic injuries Urethral instrumentation = iatrogenic damage - the most often cause of US Infective - urethritis gonococcal, non-specific, tuberculosis Inflammatory - balanitis xerotica obliterans (meatal stricture) Neoplastic - transitional cell carcinoma, squamous carcinoma Investigation Case history, UFM, MSU, laboratory (serum creatinine) Urethrogram (ascendent urethrography with subsequent descendent urethrography) Ultrasound of urethra IVU - status of bladder (diverticulum, stones) and upper urinary tract (megaureters) urethrocystoscopy Treatment Optical urethrotomy = cutting the stricture with an endoscopic cold knife (or with LASER) under direct incision urethroplasty (open reconstruction) For dense fibrotic stricture or recurrent stricture after urethrotomy Short stricture - excision and end-to-end re-anastomosis Longer stricture - reconstruction with tissue transfer = "onlay" urethroplasty With alive patch from prepuce (intact vasculature of the patch) With buccal mucosal graft Urethral stent Regular dilatation of urethra with catheter - in patient unable underwent urethroplasty URETRITIS Gonorrhoea - see dermatovenerology Non-gonococcal urethritis (NGU) Possible causative organism in NGU Chlamydia trachomatis - 50-60% Others - 5-10% - trichomonas vaginalis, ureaplasma urealyticum, gardnerella vaginalis, candida albicans, herpes simplex, viral warts Unknown (non-specific urethritis, NSU) 30-45% Symptoms are seen exclusively in men and there is usually a mucous discharge with mild dysuria. Treatment: Antibiotics: - deoxymycoin 100 mg 1-0-0 for 10 days or 2 weeks - azithromycine (Sumamed 500 mg 1-0-0 for 3 days)

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The sexual partner must be investigated and treated as well. NGU does not occur as a clinical entity in women but it presumed on the basis of sexual contact with a male sufferer and the culture of chlamydia from cervical swabs. DISEASE OF ADRENAL GLAND Details see endocrinology. Primary hyperaldosteronism - 70% an aldosteron producing adrenal adenoma arising from the zona glomerulosa = Conn's syndrome - 30% idiopathic, bilateral adrenal hyperplasia - mainly in young to middle-aged women Clinical signs: - hypertension sodium retention with increase in intracelular fluid - hypokalaemia - + weakness, tetany, nocturia, constipation Treatment of adenoma- adrenalectomy - see below Cushing's syndrome Causes:
1. 2. 3. administration of steroids to treat other diseases basophil or chromophobe adenoma of the pituitary (Cushing's disease) ectopic ACTH production

4. adrenal tumours (adenoma or carcinoma)


Symptoms: - weight gain, centripetal obesity, moon face, buffalo lump - hypertension (82%) - fatigability, weakness - amenorrhoea - hirsutismus, striae, thin skin, ecchymoses - oedema - back pain, osteoporosis - personality changes, headaches

Treatment:
Conservative treatment - see endocrinology Pituitary tumours - see neurosurgery

Urological treatment: Adrenal tumours - see below Hyperplastic adrenals - bilateral adrenalectomy After bilateral adrenalectomy, the patient requires glucocorticoids and mineralocorticoids supplements for life Phaeochromocytoma = Tumour of the adrenal medulla which produce pressor agents (adrenaline, noradrenaline). It has been called the "ten per cent tumours": 10% of phaeochromocytomas are extra-adrenal 10% are bilateral 10% are malignant 10% are multiple Treatment - surgical removal Other types of primary adrenal tumours are rare
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Metastases to adrenal are reported in 10% of all malignancies. Technique of adrenalectomy Open surgery (through laparotomy or lumbotomy) is replaced by minimally invasive surgery (= laparoscopic or retroperitoneoscopic). Surgery can be hazardous in patient with phaeochromocytoma, since handling of the tumour may release large quantities of catecholamine into the circulation resulting in severe, acute hypertension. For this reason, all patients should be receiving - and -blockers for at least 72 hours before surgery. During surgery, intravenous - and -blockers should be used in the event of sudden hypertension, and vasodilatator agents such as sodium nitroprusside may also be used to lower blood pressure. Pressor agents and intravenous fluid replacement are important in the event of "rebound" hypotension after tumour removal.

Fig. Abdomen of patient following left adrenalectomy (5 ports) for adenoma. DISEASE OF RETROPERITONEUM Nearly all diseases of retroperitoneum cause ureteric obstruction Upper urinary tract obstruction
Whatever the cause, prolonged or severe obstruction of the upper urinary tract results in functional impairment of the obstructed kidney. It is important to recognise obstruction and to treat i promptly to avoid irreversible damage to the kidney. Obstruction, which is relieved promptly, may result in a return to normal renal function. Pathophysiology When a ureter is obstructed, continuing urine production results in distension above the site of the obstruction. This, in turn, causes a rise on intra-ureteric pressure. This pressure is transmitted via the papillae of the kidney to the nephrons and negates the filtration gradient in the glomeruli. If this situation persisted, all obstructed kidneys would cease functioning completely within a short time. Ureteric dilatation This occur progressively with chronic obstruction of the upper tract; the ureteric muscle becomes at first hypertrophic and then, later, floppy and atonic.

Clinical features - Acute obstruction - loin pain, it can radiate into groin (cf. ureteric colic), haematuria - Chronic obstruction - it may be totally silent! However, most patients have occasional episodes of loin pain. Diagnosis - ultrasound, IVU, CT Causes of ureteric obstruction See chapter congenital anomalies of upper urinary tract - obstructed secondary megaureters extrinsic lesion

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Causes of extrinsic obstruction - vascular lesion - benign disorders of the female reproductive system - gastrointestinal diseases - retroperitoneal tumours - retroperitoneal fibrosis Vascular lesion ILIAC OR AORTIC ANEURYSMS - direct compression or peri-aneurysmal fibrosis Treatment - ureterolysis or ureteric intubation
The right ureter is often dilated in women, especially in those who have had children. The right ovarian vein at S1 level very occasionally produces genuine ureteric obstruction resection and ligation of the veins retrocaval ureter

Benign disorders of the female reproductive system PREGNANCY commonly results in dilatation of the ureter, often on the right side. This is partly due to hormonal changes resulting in atony, but the enlarged uterus may compress the ureters and cause genuine obstruction. uterine prolaps Gastrointestinal diseases ANY INFLAMMATORY CONDITION of the gastrointestinal tract (appendicitis, Crohn's disease, diverticulum disease) may obstruct a ureter that lies in close proximity to the inflamed bowel. Treatment: usually resolved with treatment of primary condition, ureterolysis may be necessary in some cases. GASTROINTESTINAL TUMOURS invades directly to the ureter Retroperitoneal tumours Primary retroperitoneal tumours (benign and malignant) are rare Secondary retroperitoneal tumours: 1. direct invasion of tumour e.g. rectosigmoid cancer, tumour arise from ovary, cervix, uterus 2. metastases to retroperitoneal lymph nodes - e.g. testicular tumour, tumours of prostate, bladder, colon, lymphomas Treatment: 1. treatment of primary tumours 2. if impossible - urinary diversion - ureteric splinting with double loop stent - nephrostomy - ureteroileostomy - (ureterolysis and re-implantation of ureter aren't indicated, if primary tumours is untreatable) Retroperitoneal fibrosis (M. Ormond) - RPF 1. Secondary - one-third - secondary to malignancy, irradiation, postoperative, drugs (methysergid, drugs) 2. Idiopathic - 2/3

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Whatever the cause, the ureters become involved in a fibrotic plaque of tissue which pulls them towards the midline and obstructed them. The process may also produce obstruction of the blood vessels to the lower limbs and pelvis. Typically, the clinical picture is of a man (twice as commonly as women of idiopathic RPF) 40-60 years old with backache, a vague systemic illness and signs of renal functional impairment. There are few physical signs other than those associated with hypertension, chronic renal failure or venous occlusion. DIAGNOSIS: Laboratory - often a normochromic, normocytic anaemia - raised levels of urea and creatinine - ESR of often markedly raised USG IVU or retrograde uretreopyelography (if is renal failure) renography to determine the degree of functional impairment of each kidney Abdominal CT - a peri-aortic plaque of fibrosis involving the ureters If there is any question of malignant RPF, CT guided-needle biopsy may be performed TREATMENT: The initial treatment is to improve renal function by ureteric stents or percutaneous nephrostomy. Since renal function has returned to stable levels, definitive treatment should be instituted. This involves laparotomy and complete freeing of both ureters from renal pelvis to bladder from the fibrotic process (ureterolysis). To prevent recurrent obstruction the ureters are the wrapped in omentum and remain intraperitoneal. Systemic steroids are useful, when the ESR is raised. The dose of steroid can be titrated against the ESR to keep the disease under optimum control. Notes to treatment Retrograde cystoscopic insertion of ureteric catheter. For long-term derivation, double-loop ("pig-tail") ureteric stent. GENITOURINARY TRAUMA - 10-15% of all patients with abdominal injuries have associated genitourinary trauma (GUT) - trauma to the loin or lower ribs, trauma to the pelvis and direct blow to the perineum or genitalia - blunt trauma: the commonest - road traffic accidents, sporting injuries - penetrating injury: knife wounds - the most important indicator of urinary tract trauma is the presence of blood in urine (6070% patients with renal injuries and in all patients with bladder or urethral injuries) Renal injuries Mechanism of injury - Blunt trauma in over 90% of cases; the remaining being due to penetrating wounds (gunshot). - Blunt trauma probably causes its damage by crushing the relatively immobile kidney between the mobile anterior ends of the lower ribs and the upper lumbar spine. This is often associated with brushing in the flank, signs of a retroperitoneal haematoma and fractures of the lower ribs or transverse processes of the lumbar vertebrae. Investigation USG and/or CT, if indicated: IVU, angiography

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Types of renal injuries: 1. contusion of kidney 2. parenchymal tear (renal capsule and collecting system are intact) subcapsular haematoma 3. parenchymal and capsular tear - perirenal haematoma 4. laceration of parenchyma into collecting system, capsule is intact massive haematuria 5. combination of parenchymal, capsular and collecting duct tear massive haematuria, perirenal haematoma and urinoma as well 6. renal pedicle avulsion - only microscopic haematuria, perirenal haematoma, IVU afunction of kidney, diagnosis - angiography 1. and 2. = minor injury, 3. - 6. serious trauma

Fig. renal injury a (1) to f (6)

Fig. CT - Trauma of the left kidney type 5 - parenchymal, capsular and collecting duct tear, leakage urine with contrast fluid in front of the kidney. Specimen at operation nephrectomy was performed. Management of renal trauma - the main aim of management is to preserve renal function Surgery: in only 10% Indications for surgery in renal trauma:
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1. 2. 3. 4.

expanding retroperitoneal haematoma with signs of progressive blood loss severe urinary extravasation on IVU or CT proven renal pedicle or arterial injury penetrating renal trauma (high probability of multiple organ damage)

It should be performed through an abdominal incision to allow a full laparotomy with inspection of all intraabdominal viscera - sutura of laceration - excision of devitalised areas of kidney - to close the collecting system - vascular injury - delicate arterial reconstruction or, more likely, nephrectomy Conservative treatment - bed rest, sedation, laboratory measurement of haemoglobin, creatinine, urea, electrolytes - fluids intravenously - ultrasonography (or CT) controls Ureteric injuries Uncommon - due to external trauma, usually a penetrating injury, or may occasionally result from closed hyperextension injuries of the spine. The commonest cause, however, is iatrogenic damage during the course of intra-abdominal surgery (gynaecological - hysterectomy, adnexectomy, surgical - rectosigmoid cancer)
Treatment = surgical: 1. deliberation of ureter from stitch 2. ureterorrhaphia (end-to-end anastomosis of ureter) 3. ureterocystoneoanastomosis (UCNA) = reimplantation of ureter 4. Boari bladder flap 5. transureteroureterostomy 6. ileal replacement of ureter 7. nephrectomy

Bladder injuries Anatomical note: the bladder base is fixed, whilst the dome of the bladder is very mobile and thin, supported only by peritoneum. At its fundus the bladder is so poorly supplied with muscle that it is possible under certain circumstances to get spontaneous rupture of the bladder. This tends to occur when the bladder is overdistended (alcohol intake, straining at stool, childbirth, protracted vomiting). Intraperitoneal rupture of the bladder Typically, it occurs when a full bladder is compressed by an external force, e.g. a seat belt during a motor accident or a direct blow to the lower abdomen. Less commonly, it may occur as a result of a penetrating suprapubic injury piercing a full bladder. Rupture may also be produced by a surgeon working endoscopically within the bladder, e.g. during resection of a urothelial tumour. Diagnosis: cystoradiography - intraperitoneal contrast fluid leakage Treatment: Immediate surgical repair: laparotomy, evacuation of all blood and urine from the peritoneal cavity and
suture of the rupture in the dome of the bladder. The peritoneal cavity and prevesical space should be drained and the bladder drained with a urethral catheter.

Extraperitoneal rupture of the bladder

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This is usually associated with fracture of the pelvis. However, only 10% of pelvic fracture result in bladder damage, probably due to the fact that the empty bladder is rarely injured. Extraperitoneal rupture may also result from endoscopic perforation of the bladder wall or prostatic cavity.
Extravasation in extraperitoneal rupture results in blood and urine tracking up to anterior abdominal wall between transversalis fascia and the peritoneum to cause suprapubic swelling and induration. If neglected, this becomes painful, red and tender and is associated with sings of toxaemia.

Diagnosis: cystoradiography - prevesical contrast fluid leakage Treatment: - minor degree of extravasation can be treated simply by urethral catheterisation for a week or so, if needed, prevesical drainage can be performed - more major ruptures - exploration, suture of bladder and drainage of perivesical space and urethral catheter inserted into the bladder for a minimum period of 10 days Urethral injuries Injuries to the female urethra are very rare; only injuries to the male urethra will be consider here. Injuries to the anterior urethra - usually solitary - frequently caused by instrumentation with catheters of cystoscope Diagnosis - uretroscopy or uretrography Treatment - minor injuries - simple urethral catheterisation for a + or 2 weeks - more major injuries - - immediate repair of damaged urethra by open surgery - if primary repair is not possible, a suprapubic catheter (epicystostomy) should be inserted and the damage repaired at a later date Rupture of bulbar urethra This has traditionally been attributed to the "straddle injury" typified by the mythical fall astride a manhole cover. Nowadays, it is far more likely to occur as a result of a direct kick to the perineum or a fall astride a bicycle crossbar. Diagnosis and treatment - see injuries of anterior urethra Rupture of prostatomembranous urethra Like extraperitoneal rupture of the bladder, rupture of the membranous urethra is usually associated with fractured and gross disruption of the pelvic ring. Such trauma almost invariably damages the pelvic nerve plexuses as well as the urethra and this often results in the patient becoming impotent in the long term (see andrology - erectile dysfunction). Typically, the patient has a fractured pelvis, is bleeding from urethral meatus and cannot pass urine. An IVU is mandatory in this situation to exclude other injuries to the urinary tract and usually shows a "teardrop" bladder displaced upwards in the pelvis and compressed at its base by haematoma. The prostate is impalpable on DRE, having swung upwards and forwards. Diagnosis: ascended uretrography + IVU

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Fig. IVU: complete rupture of the membranous urethra, bladder is dislocated by hematoma cranially. Hematoma of perineum of the same patient. Treatment: Conservative treatment - partial rupture or rupture without dislocation - epicystostomy for 3 weeks, then descended uretrography, if normal, epicystostomy is removed, if there is stricture - internal uretrotomy, in case of recurrent stricture - bulboprostatoanastomosis Acute surgery - major dislocation of urethra, associated injury of rectum, pelvis, uncontrolled bleeding: exploration of the retropubic space, evacuation of haematoma and "railroad" or urethral catheter into the bladder (="realignment") - in 6-12 weeks bulboprostatoanastomosis is performed Injury to the penis Simple cutaneous injuries to the penis such as the typical "zipper" injury - suture or circumcision. A torn frenulum - elongation of frenulum = discision and suture (=frenuloplasty). More radical skin loss over the penis as that caused by "vacuum cleaner" injuries my require either skin grafts or burying of the penis in scrotal skin Fracture of penis = the erect penis is bent acutely during intercourse. Fracture may be associated with an audible crack as the tunica albuginea ruptures. There is immediate detumescence and swelling of the penis, often with visible deformity. Treatment: conservative In some cases - immediate exploration and repair of the defect in the tunica albuginea

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Fig. occlusion of venous and lymphatic drainage with metal ring used for masturbation. Relatively frequent trauma of the penis. Ring was divided with pincers. Injuries to the scrotum and testes Mainly direct blows Avulsion of scrotal skin - skin grafting, or the exposed testes may need to be implanted into pockets of the skin fashioned in the thighs, later being reconstructed into a neoscrotum. Disruptive injuries to the testes - unusual, mainly because of their mobility within the scrotum. However, the presence of a large haematoma in the scrotum should alert the urologist to the possibility of a haematocele or rupture of the testis and it may be helpful to confirm the diagnosis before surgical exploration using scrotal ultrasound. Treatment - early surgical exploration is advisable to preserve testicular function if at all possible Any scrotal injury incurs the risk of developing Fournier's gangrene. If signs of infection with skin necrosis appear, aggressive treatment should be instituted with antibiotics and, if necessary, radical skin debridement. ANDROLOGY Erectile dysfunction Definition: ED is the inability to achieve and maintain a penile erection sufficient for satisfactory sexual performance. Prevalence of all forms ED (minimal, moderate, complete) about 20%. Incidence increases with age. Causes psychogenic - 15% anxiety, fear of failure, depression, marital conflict, misinformation organic - 85% diabetes mellitus atherosclerosis occlusive disease of penile arteries including risk factors - smoking, hypertension, hyperlipidemia radical operation and radiotherapy in small pelvis for cancer of prostate, rectum, bladder

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spinal cord injury, multiple sclerosis many other diseases

Fig. Scheme of erection. Section of penis, left side normal status, right side erection dilated cavernous artery (in centre), dilatated cavernous tissue, compressed drainage veins Diagnosis Case history, physical examination, laboratory (mainly glycaemia, lipidogram, testosterone) In selective cases: colour duplex ultrasonography of penile arteries Treatment 1. psychogenic - psychosexual therapy 2. Organic lifestyle change - regular exercise, a healthy diet, smoking cessation, alcohol in moderation only oral agents: sildenafil (Viagra Pfizer), Tadalafil (Cialis Lilly), Verdenafil apomorphin (Uprima Abbott) many other non-specific drugs intracavernous injection of PGE1 (prostaglandin) - patient apply himself PGE1 intracavernously with diabetic syringe at home 10 minutes before sexual intercourse vacuum constriction device = plastic cylinder connected to vacuum generating source. After the penis is engorged by the negative pressure, a constricting ring is applied to the base to maintain the erection. To avoid injury, the ring should not be left in place for longer than 30 minutes. penile prosthesis Male infertility approximately one couple in ten are infertile investigation for infertility are instituted after 1 (-2) year(s) of unproductive intercourse male factors alone are responsible for infertility in one-third of couples and contribute to problem in a further third Investigation

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Clinical history Physical examination Laboratory investigation seminal analysis - by masturbation after 5 days' sexual abstinence normal semen parameters: volume 2-5ml colour grey-yellow sperm density 20-200 million/ml (= normozoospermia) motility > 50% abnormal forms < 50% abnormal findings aspermia - no semen azoospermia - no sperms in semen oligozoospermia - sperm density < 20 million/ml asthenozoospermia - motility < 50% teratozoospermia - abnormal forms > 50% OAT = oligo-astheno-teratozoospermia hormonal studies plasma levels of FSH, LH, testosterone, prolactin FSH (follicle-stimulating hormone) - controls spermatogenesis LH (luteinizing hormone) - controls secretion of testosterone by Leydig cell the combination of small testes, asoospermia and grossly elevated FSH levels suggests primary testicular failure (X obstructive azoospermia normal testes a normal FSH) chromosomal studies Distribution of patients by diagnostic category after full evaluation varicocoele 38% idiopathic 25% obstruction 13% normal 10% cryptorchidism 9% antisperm antibodies 2,5% ejaculatory dysfunction 1% drug use 1% endocrinopathy 1% white blood cell in sperm 1% Others - sexual dysfunction, testicular failure, genetic, ultrastructural, Sertoli-cell-only, cancer, heat, radiation exposure, systemic illness, testicular cancer Treatment 1. treatment of basic disorders - e.g. varicocelectomy, hormonal replacement therapy, orchidopexis 2. reproductive assistance Obstructive azoospermia - reconstructive surgery - possible in few patients = vasovasostomy, epididymovasostomy ICSI + SMART testicular azoospermia (Sertolli-cell only syndrome) - arteficial (heterologous) intrauterine insemination (IUI) with donor sperm Oligozoospermia 10-20mil/ml - IVF

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Severe oligozoospermia OAT Retrograde ejaculation

- SMART (mainly TESE) + ICSI - semen processing and ICSI - alkalisation and centrifugation of urine + IVF

Micromanipulation techniques = with oocyt and spermatozoa IVF - in vitro fertilization, oocyt is gain by needle aspiration under ultrasound control ICSI - intracytoplasmatic sperm injection SMART - sperm micro-aspiration retrieval techniques MESA - microsurgical epididymal sperm aspiration TESA - testicular sperm aspiration TESE - testicular sperm extraction

Fig. ICSI sperm is injected into the oocyt with micro-pipette Priapism priapism is defined as a persistent, painful erection which is not associated with an appropriate sexual desire pathophysiology high-flow - excessive arterial input, 10%, mainly trauma of penis low-flow - blocked venous drainage, 90% prolonged sexual excitation (e.g. prolonged masturbation) drug (often in overdose) - anticoagulants, phenothiazines, marijuana, antihypertensives idiopathic hematological diseases - sickle-cell anaemia, leukaemia malignant infiltration of penis Treatment Low-flow priapism Treatment must be started in 6 hours. 1. aspiration of cavernous blood 2. intracavernous application of -sympatomimetics (adrenaline) 3. shunt procedures - shunt between corpora cavernosa et corpus spongiosum (= low presure space) Over 50% patient after treatment of priapism suffer from erectile dysfunction due to ischaemia of cavernous tissue

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Fig. Scheme of corporoglandular shunt with scalpel No. 11 High-flow priapism - Radiologically controlled embolisation of the internal pudendal artery or open surgery excision of fistula or ligature of cavernous artery The Aging Male Subjects high on the theme the aging male are mainly hormonal effects of male aging, sexuality, osteoporosis, body composition and social aspects Important theme is supplementation with testosterone in man with recognised androgen deficiency, so called PADAM (Partial Androgen Deficiency in Aging Male) Clinical symptoms of PADAM: Decrease in libido (sex drive), erectile dysfunction Lack of energy Decrease in strength and/or endurance Lost of height Decreased enjoyment of life Patient is sad and grumpy Deterioration in ability to play sports Falling asleep after dinner Deterioration in work performance Osteoporosis Diagnosis of PADAM - laboratory - serum concentration of testosterone Treatment - supplementation of testosterone Peyronie's disease = a fibrotic process of unknown aetiology which affects the tunica albuginea and corpora cavernosa it is consider analogous to Dupuytren's contracture in the hand the plaque prevents the tunica albuginea from expanding during erection, resulting in erectile deformity of penis extensive plaques of fibrosis may result in ED Treatment - difficult, often unsuccessful UROLOGICAL EMERGENCY Renal colic - see urolithiasis Urosepsis - see urinary tract infection Priapism - see andrology paraphimosis, penile fracture, torsion of testicle (syndrom of acute scrotum) - see benign disease of male genitalia Subrenal anuria - see disease of retroperitoneum, renal failure
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Clot retention of bladder - see urological symptoms Treatment: 1. laboratory blood transfusion, if indicated 2. To stop anticoagulant therapy (e.g. Warfarin), vit. K or fresh blood plasma + prevention of tromboembolic disease with low molecular heparin 3. permanent three way catheter - aspiration of clot from bladder, continual lavage of bladder with sterile physiological solution 4. investigation - ultrasound, IVU 5. definite treatment by basic cause (e.g. TURT of bladder tumour ) Fournier's gangrene This is an infection of the scrotal skin caused by the synergistic action of several strains of bacteria (aerobic Gram-negative rods, Gram-positive cocci and anaerobic bacteria, especially Bacteroides fragilis). The infection causes gangrene of the scrotal skin. This condition is rare but is usually caused by an underlying problem such as diabetes mellitus, peri-anal sepsis or peri-urethral abscess. Treatment is by intensive antibiotic therapy (aminoglycosides, penicilin and metronidazole) with careful debridement of devitalised skin. Skin grafting may be required once the infection has been eradicated and can be accomplished by rotation flaps from adjacent areas or by free grafts.

Fig. Fourniers gangrene before and after surgery.

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