Urology Notes PDF

H. Keet Urology Notes Urogenital infections UTI Epidemiology - Most common bacterial infection (F > M, ratio decreases with increasing age) - Risk factor...

H. Keet Urology Notes Urogenital infections UTI Epidemiology - Most common bacterial infection (F > M, ratio decreases with increasing age) - Risk factors: - Previous UTI - Spinal cord injury - Urinary obstruction / UG abnormalities - Pregnancy - Immune compromised (DM, HIV, steroid use) Definitions - UTI: inflammatory response of urothelium to bacteria associated with bacteriuria and pyuria - Bacteriuria: presence of bacteria in urine (NB – beware contamination!) - Pyuria: presence of WBC’s in urine - Bacteria without pyuria = colonization / contamination - Pyuria without bacteria = sterile pyuria (think stones, TB, malignancy, on A/B’s) - Recurrent UTI: occurs after resolution of previous infection - Sometimes defined as 3 or more UTI’s in 12 months - Due to: - Reinfection: Different organism, variable timeframe - Persistence: Same organism, short interval Presentation and work-up - Cystitis – dysuria, frequency, urgency, suprapubic pain, haematuria - Pyelonephritis – fever, rigors, flank pain, N&V, sepsis - Urinalysis - Urine collection methods - Mid-stream urine - Catheterised specimen - Suprapubic aspiration - Uncomplicated - Female - Non-pregnant - Complicated UTI - Male - Pregnant female - Children - Structural or functional abnormality - Immunosuppression - NB! Complicated UTI = further investigation / imaging - Imaging: - KUB X-Ray à stones, abnormal gas patterns - Ultrasound à non-invasive, easy, fast, no radiation, no contrast = GOOD 1st line test - CT à best anatomical detail, can guide treatment / intervention Management - Uncomplicated cystitis - 3-7 days empiric oral antibiotics - No need for follow up if symptoms resolve 1  H. Keet - Complicated cystitis - Investigate and correct risk factors / urogenital abnormalities - 10-14 days empiric oral antibiotics (+- IV antibiotics if severe) - Recurrent UTI’s - Usually reinfection (different organism, variable time frame) - Common in females, usually no correctable cause - Investigate if risk factors present (DM, prev. stones, haematuria) - Non-medical Mx à increase fluid intake, frequent voiding, cranberry juice, treat constipation - Acute pyelonephritis - E. Coli in 80%, +- 20% can have negative urine MCS - Mild: - Urine MCS –> Oral antibiotics x 10/7 - If symptoms resolve –> rpt urine MCS after A/B’s –> Urology r/v PRN - No improvement/severe: - Urine + blood cultures –> IV antibiotics x 3-7 days –> imaging - Once afebrile –> oral A/Bs x 10/7 - Bacterial nephritis - Severe form of pyelonephritis, early renal abscess, usually responds to IV A/Bs - Emphysematous pyelonephritis - Necrotizing parenchymal and peri-renal infection caused by gas-forming organisms - DM, female > male, mortality 20-40% - NB! Emergency: IV fluids, antibiotics, +- relieve obstruction +- nephrectomy Antibiotics Pregnancy - Asymptomatic bacteriuria - Most common infectious complication of pregnancy - Complications: increased risk of pyelonephritis and sepsis à increased risk of prematurity, low birth weight, fetal death - Screening of bacteriuria - urinalysis and MCS in 1st trimester à If +, 3-7 day course based on culture - Pyelonephritis - -+-4%. of pregnant women - 75% during 3rd trimester due to hydronephrosis and urinary stasis - IV A/Bs followed by 14/7 oral A/Bs - Antibiotics - Safe: - Penicillin - Cephalosporins - Avoid: - Fluoroquinolones - Sulfonamides - Tetracyclines - Flagyl 2  H. Keet Fournier’s gangrene - Necrotising fasciitis of genitalia and perineum - Most commonly mixed bacterial growth (E. Coli most common single organism) - Spread along Dartos fascia of scrotum / penis, Colle’s fascia of perineum, Scarpa’s fascia of anterior abdominal wall - Presentation – pain, fever, sepsis, confusion, tachypnoea, tachycardia - Management – NB! Emergency! - ABC’s –> IV fluids –> bloods + cultures –> broad-spectrum antibiotics - Urgent surgical debridement - Mortality rate +-20% Prostatitis Acute Prostatitis - Uncommon acute infection of the prostate caused by uropathogens - Clinical presentation - Pyrexia and rigors - Acute pain in the lower abdomen, perineum and pelvis - Urinary difficulty or retention - Rectal examination reveals a “boggy” acutely tender prostate - Management - Admit - Bloods and urine cultures - Percutaneous suprapubic cystotomy (if in retention) - Fluroquinolones (initially IV à oral) x 6 weeks - Persistent pyrexia despite antibiotics may signify development of prostatic abscess - Fluctuant tender area in prostate on DRE - Treatment is transurethral drainage Chronic prostatitis - A small % of patients with chronic prostatitis have a true bacterial cause - Diagnosis is confirmed by microscopy and culture of prostatic fluid (obtained by doing prostatic massage) - Treated with a six-week course of a fluoroquinolone (antibiotic with best penetration into prostate) - Chronic bacterial prostatitis will not be discussed further here - Incidence - Very common (about 10% of Urological consultations in USA) - All ages but peak incidence 30-50 years - Etiology - Uncertain - Possibly due to reflux of urine into prostate -> chemically induced inflammatory prostatitis - Anxiety or stress may cause - Increased sympathetic stimulation of smooth muscle in bladder neck and prostate - Spasm of pelvic floor muscles - Above may cause outflow obstruction à intra-prostatic reflux of urine - Clinical presentation - Pain is the most important symptom - Perineum - Suprapubic region - Penis - Testes - Lower back - Pain is typically aggravated by ejaculation - Often history of previous episodes of pain - Irritative voiding symptoms - ED: common 3  H. Keet - Rectal examination: not diagnostic for this condition, but many patients have prostatic tenderness - Urine: always clear - Management - Reassurance: that serious disease (such as prostate cancer) is not present - Antibiotics - despite the fact that very few patients have true bacterial prostatitis, about 50% of patients respond symptomatically to antibiotics - Fluoroquinolone six week course at full dosage - Other treatments if non-response to antibiotics - alpha-blockers (e.g. Doxazosin - Cardura®) - striated muscle relaxants (e.g. Diazepam - Valium® - non-steroidal anti-inflammatory drugs (NSAIDs) - periodic prostatic massage - psychotherapy - Pain Clinic referral - Surgery - no place in the treatment, unless patient has concomitant symptoms from BPH - This condition is characterised by frequent recurrences, often over many years Urogenital TB - Incidence - 1% of TB cases in developed countries - 15-20% of TB cases in developing countries (commonest site of extra-pulmonary TB) - kidney = commonest site of GUTB, but almost 30% of patients with GUTB have genital TB only - in developing countries, GUTB = disease of young adults (20-40 years) - while in developed countries it affects an older population - male: female ratio = 2: 1 - Pathogenesis - Primary infection of lung or bowel -> lymphatic system + haematogenous spread to - Bones and joints - Meninges - Genitourinary tract - Renal cortex - Head of epididymis - Prostate - Organism then becomes dormant - Conditions of lowered immunity -> reactivation of disease -> clinical GUTB - Transluminal spread - Kidney à ureter à bladder - Prostate and head of epididymis à seminal vesicles, vas deferens and testis - Clinical features of urinary TB - Patients usually have either urinary or genital TB (very rare to have two together) - Disease of young adults (rare in children) - Past or family history of pulmonary TB (PTB) - "Cystitis" not responding to antibiotics = commonest presentation - Haematuria - Flank pain due to ureteric stricture -* hydronephrosis * NB, - Renal failure - if extensive bilateral renal involvement - Systemic symptoms (night sweats, weight loss) - uncommon - Clinical examination is often non-contributory - Special investigations - Urine - Classically patients have STERILE ACID PYURIA - 20% of patients with urinary TB have a secondary UTI (usually E coli) 4  H. Keet - At least three early morning urines (EMUs) sent for - Microscopy for acid-fast bacilli (AFBs = Ziehl-Neelsen(ZN) staining) - TB culture = the most important test - requires 3-6 weeks for result - Renal function tests - ESR: not elevated in GUTB - Chest X-ray - often signs of old PTB - seldom active PTB ( hydroceles (if severe may have a "missing" calix) - poor or non-function of kidney (s) - ureteric strictures (especially distal) - small bladder capacity - CT Scan - early urothelial lesions not well shown - good definition of parenchymal pathology - calcifications - inflammatory masses - abscesses - cortical scarring - shows non-functioning tissue and perinephric extension quite well - U/S - limited value for initial evaluation - useful to monitor hydronephrosis - TB ureteric strictures may rapdily become worse on antituberculosis treatment (due to fibrosis) - Radioisotope renogram - useful to determine differential renal function to decide on surgical management - Cystoscopy and bladder biopsy - done to make a histological diagnosis when strong clinical suspicion of urinary TB, but unable to make a bacteriological diagnosis - usually done under antituberculosis cover - bladder involved in 80% of cases of urinary TB - Treatment of urinary TB - Principles - Treat active disease - Make patient non-infectious as soon as possible - Preserve maximal amount of renal tissue - Medical treatment - Diagnosis must be confirmed (bacteriology or histology) before treatment is started - Patient is notified to Department of Health (who should supervise patient's treatment) - The cornerstone of antituberculous treatment = use of multidrug bactericidal treatment - 6 months regimens are effective for GUTB - The relevant drugs are combined into one tablet - Isoniazide (INH), Rifampicin, Pyrazinamide (PZA) and Ethambutol x 2 months - INH and Rifampicin x 4 months 5  H. Keet - Surgical treatment - about 50% of patients will need surgery - patients should have had at least 6 weeks of medical treatment pre-surgery - DJ stenting - may be needed if a TB ureteric stricture becomes worse on treatment - Ablative surgery - nephrectomy for poorly or non-functioning kidney (30% of patients with urinary TB) - Reconstructive surgery - ureteric reimplantation for ureteric stricture - augmentation cystoplasty for small bladder capacity Bilharzia (Schistosomiasis) - Endemic in most of Africa and Middle East - Urinary tract schistosomiasis is caused by Schistosoma haematobium (a blood fluke in humans) - Excreted ova die rapidly unless they are in contact with water (then viable × 3 weeks) - Eggs hatch in water to form miracidia - They enter the Bulinus snail host (a tropical freshwater snail) where they form sporocysts in the snail's liver - Sporocysts release cercariae into the water - penetrate skin of the human host - Reach hepatic portal veins via venous circulation where worms mature and mate - Gravid female worm reaches pelvic veins where ova are deposited under mucosa of bladder and lower ureters and then excreted into the urine - Pathology - Bladder and lower ureters have same pathology - Acute changes - viable ova and variable inflammatory infiltrate (eosinophils and plasma cells) - typical cystoscopic lesions = bilharzial papule and pseudotubercles - these changes disappear on medical treatment - Chronic changes - dead ova and fibrosis - calcification - typical cystoscopic lesions = "sandy patches" - these changes are permanent and do not disappear on medical treatment - Pathological complications - Bladder - secondary bacterial infection - bladder wall calcification - bladder calculi - small bladder capacity - squamous metaplasia - squamous carcinoma - Ureter - atony - VUR - ureteric stricture (uncommon) - renal failure (due to bilateral ureteric obstruction - uncommon) - Clinical presentation - Cercarial dermatitis ("swimmers itch") - transient urticaria due to skin penetration by cercariae - Katayama fever - rare in endemic populations - occurs in populations not previously exposed (e.g. tourists) - allergic reaction to schistosomes in liver - present with fever, jaundice and hepatosplenomegaly - Urinary schistosomiasis - classical symptom = terminal haematuria - associated frequency and dysuria - may present with complications - particularly bladder carcinoma 6  H. Keet - Diagnosis - NEEDS A HIGH INDEX OF SUSPICION IN ENDEMIC AREAS - Urine collection is very important: terminal urine - Full blood count: eosinophilia in acute phase - Serology - Schistosoma ELISA test - confirms infection has occurred, but? present? past - useful for screening - IVP/EUG - Calcifications - bladder wall - distal ureters - seminal vesicles - Dilated ureters - usually atonic (not obstructed) - erect post-micturition film shows good drainage - Filling defects in bladder - bilharzial papule - blood clots - squamous carcinoma - Small bladder capacity - Cystoscopy - only done if unsure of diagnosis or complications (such as carcinoma) suspected - typical lesions described above - diagnosis confirmed on bladder wall biopsy - Treatment - Prophylaxis - improved housing and sanitation - snail eradication - prophylactic medical treatment for high-risk groups - Medical treatment - praziquantel (Biltricide®) - 40 mg / kg as single dose or two divided doses - 600 mg tablets - treat acute infections - repeat urine microscopy one month post-treatment to confirm eradication of ova - problem of re-infection in endemic areas - Surgical treatment - course of medical treatment first - surgery for complications - cystectomy for bladder carcinoma - ureteric reimplantation for ureteric stricture Male Sexual Dysfunction Erectile dysfunction Definition - Persistent inability to achieve and/or maintain an erection sufficient enough for penetration and satisfactory sexual intercourse Physiology - Vascular Mechanism of Erection - Flaccidity: smooth muscle of corpora cavernosa contracts tonically and blood flow is minimal - Erection: arterial vasodilation occurs along with the relaxation of smooth muscle and expansion of the corpora cavernosa. There is also a reduction in venous outflow (corporal veno-occlusive mechanism) 7  H. Keet - Neurological pathways of erection - Autonomic nervous system includes S2-4 Parasympathetic fibres promoting erection and T11-L2 Sympathetic fibres promoting detumesence - Somatic nerves include the dorsal penile nerve which is a branch of the pudendal nerve - The main neurotransmitter of erection is nitric oxide (NO), which increases the production of cGMP, a relaxant of corpora cavernosa smooth muscle. The erection eases when NO release stops, phosphodiesterases degrade cGMP and the sympathetic discharge of ejaculation occurs. Aetiology: Organic vs Psychogenic Aetiology History - Medical, especially cardiac conditions - Surgical - Psychiatric - Medication, Smoking, Alcohol, Recreational drugs - Erectile dysfunction history: onset, duration, severity - Other sexual history: libido, ejaculation, orgasm, pain - Standardised Questionnaire: International Index for Erectile Function (IIEF) Examination - Blood pressure and vitals - Palpate peripheral pulses and assess for AAA - Focused neurological examination - Secondary sexual characteristics - Testis size and consistency - Assess penis for Peyronie’s plaques and other deformities, including curvature, phimosis, injuries Investigations - Blood tests: FBC, U&E, Lipid Profile, HbA1c, Thyroid function, Testosterone (if abnormal then do FSH, LH and Prolactin) 8  H. Keet - Abdominal or scrotal ultrasound if abnormalities found on examination - Specialised Evaluation: - Vascular Studies: Intracavernous vasoactive drug injection; Duplex Doppler study of the penis; Dynamic Infusion Cavernosometry and Cavernosography; Internal pudendal arteriography - Neurophysiologic Studies: Nocturnal penile tumescence and rigidity (NPTR); Bulbocavernosus reflex latency; Corpus cavernosum electromyography; Dorsal nerve conduction velocity - Audiovisual Sexual Stimulation Management - Lifestyle Modifications - Psychosexual Therapy - Drug Therapy - Vacuum Devices - Surgical Treatments Lifestyle Modifications - Stop smoking - Reduce alcohol intake - Weight loss - Exercise - Manage comorbid conditions, especially DM, HPT, hyperlipidaemia - Change chronic medications that may cause ED - Testosterone replacement therapy if needed Psychosexual Therapy - Especially for Psychogenic ED - Also useful for Organic ED as ED itself can cause psychological distress - Relationship counselling - Performance anxiety Oral Drug Therapy - PDE5 Inhibitors: Sildenafil (Viagra); Vardenafil (Levitra); Tadalafil (Cialis); Avanafil - PDE5 Inhibitors block phosphodiesterase type 5, which inactivates cyclic GMP. Thus there is an increase in levels of cyclic GMP which results in increased smooth muscle relaxation and better erection. - Sexual stimulation is required for the effects of the PDE5 inhibitors to take place as they do not induce erections. - Side effects include headache, facial flushing, nasal congestion, visual disturbances, dyspepsia - Absolute contraindications include treatment with nitrates for ischaemic heart disease, unstable angina, retinitis pigmentosa - Relative contraindications are CVA or MI in past 6 months and medications that can affect drug metabolism - PDE5 Inhibitors are often given on-demand about an hour prior to intercourse but some can be given as a daily chronic dose Intracavernosal Drug Therapy - For patients who have failed oral therapy - Vasoactive drug is injected directly into corpora cavernosa through the tunica albuginea - Use a fine needle on the lateral side of the penis to avoid the urethra ventrally and neurovasculature dorsally - Patient must be taught how to do this procedure himself at home and requires manual dexterity - Injectable Agents: - Papaverine–PDE2,3,4inhinbitor - Phentolamine–alpha-blocker - Alprostadil – Prostaglandin E1 (PGE1) - Contraindicated in bleeding disorders, sickle cell anaemia, leukaemia - Adverse effects can include pain and priapism 9  H. Keet Intraurethral Therapy - MUSE – medicated urethral system for erections - Intraurethral Alprostadil in the form of a pellet - Alternative to intracavernous injections in patients who prefer a less invasive, although less efficacious treatment - A vascular interaction between the urethra and the corpora cavernosa enables drug transfer between these structures - Application of a constriction ring at the root of the penis may improve efficacy - Adverse effects include local pain, dizziness with hypotension, urethral bleeding, and rarely urinary tract infections Vacuum Erection Devices - Used in patients who do not respond to or decline oral or local vasoactive drugs - Well-informed older patients with infrequent sexual intercourse and comorbidity requiring non-invasive, drug-free management of ED - Contraindicated in patients with bleeding disorders or on anticoagulant therapy - Consists of a plastic cylinder and vacuum pump that mechanically creates a negative pressure surrounding the penis in order to engorge it with blood - Provides passive engorgement of the corpora cavernosa, together with a constrictor ring placed at the base of the penis to retain blood within the corpora - May cause pain and numbness and possibly skin necrosis Surgical Treatments - Penile Prostheses - Malleable or Inflatable - Surgical procedure where a prosthesis is placed into the corpora cavernosa - Last step in ED treatment algorithm - Very effective - Possible complications or failure - Penile Arterial Revascularisation - Creates an arterial inflow into the corpora cavernosa thus treating arteriogenic ED 10  H. Keet Peyronie’s Disease Priapism 11  H. Keet Renal colic and Stones Epidemiology - Life-time risk:1-15% - Male> Female: gap narrowing - Whites> Asians> blacks - Uncommon before age 20 yrs - Peak incidence: 4th – 6th decades - Higher prevalence in hot, arid, dry climate Physiochemistry of stone formation - Supersaturation with stone-forming salts - Nucleation: salt precipitation & crystal formation - Crystal retention - Crystal growth to form stones Promoters & inhibitors of stone formation - Promoters - Calcium, Sodium, Oxalate, Urate, Cystine - Low urine PH - Low urine volume - Inhibitors - Citrate, Magnesium, Pyrophosphate - Tamm-Horsfall protein - Nephrocalcin, Osteopontin - Glycosaminoglycans Clinical manifestations - Renal colic - Nausea and vomiting - Hematuria - Frequency and dysuria - Hydronephrosis - Oliguria and anuria in obstruction Investigations: Laboratory - Urine dipstick: red cells, leucocytes, nitrite and PH - Urine MC&S - Blood - Septic markers: CRP, WCC - U&E - Uric acid - Calcium 12  H. Keet Investigations: Imaging - KUB X-ray - Radio-opaque stones: calcium, struvite, cystine - Radio-lucent stone: uric acid, indinivar, xanthine - Ultrasound - Identify dilatation of urinary tract - Non-contrast CT - Current gold standard - Identify presence of stone, diameter, location and density (HU) General preventive measures - Fluid intake: 3L/ day - Limit sodium intake - Normal calcium content - Limit protein intake - Decrease intake of refined sugars - Weight loss Specific approaches - Hypercalciuria: thiazide diuretics, k- citrate - Uric acid: allopurinol, alkanize urine - Oxaluria: hydration, cholestyramine, ca supplements - Hypo-citroturia: k- citrate - Cystinuria: hydration, low Na diet, alkanize urine, chelators Medical expulsive therapy - Prerequisite: - Well- controlled pain - No clinical evidence of sepsis - Normal renal function - Drugs used: - Alpha- blockers (Doxazosin/Cardura) - Calcium channel blocker (Amlodipine) - NSAIDS DJ stent - Indications: - Raised septic markers - Renal dysfunction - Intractable pain - Solitary kidney - Bilateral renal calculi Surgical management - ESWL - Laser lithotripsy - PCNL - Pyelolithotomy - Nephrectomy- nonfunctioning kidney 13  H. Keet Urinary Tract Tumours Renal cystic Disease 14  H. Keet Hydronephrosis - Definition - Dilation of the renal pelvis and calyces caused by the impairment in antegrade urine flow - Etiology - Mechanical - Congenital - Acquired - Intrinsic: trauma, inflammation and bleeding, calculi, urologic neoplasms, BPH, urethral stricture, phimosis, previous urological surgery - Extrinsic: trauma, neoplasms (uterine fibroid; colorectal, uterine, and cervical malignancies; lymphoma), aortic aneurysm, pregnancy (gravid uterus) - Functional - Neuropathic: neurogenic bladder, diabetic neuropathy, spinal cord disease 15  H. Keet - Pharmacologic: α-adrenergic agonists - Hormonal: pregnancy (progesterone decreases ureteral tone) - Investigations - Focused Hx, inquiring about pain (flank, lower abdomen, testes, labia),U/O ,medication use, pregnancy, trauma, fever, Hx of UTIs, calculi, PID, and urological surgery - CBC, electrolytes, Cr, BUN, U/A, C&S - Imaging studies (U/S is >90% sensitive and specific) - MAG3 diuretic renogram: evaluates differential renal function and demonstrates if functional obstruction exists - Treatment - Hydronephrosis can be physiologic - Treatment should be guided at improving symptoms, treating infections, or improving renal function - Urgent treatment may require percutaneous nephrostomy tube or ureteral stenting to relieve pressure Renal Transplantation 16  H. Keet Renal Cell Cancer Renal tumours 17  H. Keet Post-Obstructive Diuresis - Definition - Polyuria resulting from relief of severe chronic obstruction - >3L/24 h or >200cc/h over each of two consecutive hours - Pathophysiology - Physiologic POD secondary to excretion of retained urea, Na+,and H2O (high osmotic load) after relief of obstruction - Self-limiting; usually resolves in 48 h with PO fluids but may persist to pathologic POD - Pathologic POD is a Na+- wasting nephropathy secondary to impaired concentrating ability of the renal tubules due to: - Decreased reabsorption of NaCl in the thick ascending limb and urea in the collecting tubule - Increased medullary blood flow (solute washout) - Increased flow and solute concentration in the distal nephrons - Management - Admit patient and closely monitor hemodynamic status and electrolytes (Na+ and K+ q6-12h and replace prn; follow Cr and BUN to baseline) - monitor U/O q2h and ensure total fluid intake 3 RCC / HPF (High Power Field) - Macroscopic: Visible blood within urine sample - Important to differentiate between medical causes of hematuria vs. surgical causes - Medical: - Glomerulonephritis, Interstitial nephritis etc - Suggested by presence of Proteinuria, dysmorphic red cells, and casts within urine - Surgical: - Infectious, Inflammatory, Stones, Tumours, Trauma etc - Workup of Macroscopic Hematuria includes: (* = if indicated) - Urine Testing - MCS, Bilharzia*, TB*, Cytology* - Bloods - FBC, U&E, PSA*, INR/PTT* - Upper Tract imaging (Kidneys and Ureter) - CT IVP (Intravenous Pyelogram) - Lower Tract imaging (Bladder, Urethra) - Cystoscopy 22  H. Keet Bladder Carcinoma Overview - Subtypes: - Transitional Cell Carcinoma (TCC) (95%) - Squamous Cell Carcinoma (3-5%) - Usually secondary to chronic inflammatory conditions resulting in metaplasia, dysplasia, neoplasia response - Bilharzia, Chronic catheterisation, Bladder stones etc - Adenocarcinoma (0.5-2%) - Often arising from persistent urachal remnant - May be from adjacent locally invasive malignancy e.g. Cervix, prostate, rectum - Others (0.5%) - Sarcoma, Lymphoma, Neuroendocrine Tumours 23  H. Keet TNM Staging Neurogenic Bladder Phases of the Lower Urinary tract - Storage Phase - Bladder fills passively – detrusor muscle is relaxed - Urethral sphincter is ‘closed’ (contracted urethral and pelvic floor muscles) - Sensory afferent signalling (fullness) via hypogastric, pudendal and pelvic nerves - Motor efferent signalling (retain urine) predominantly sympathetic control - Voiding Phase - Bladder actively voids urine (detrusor contraction under conscious voluntary control) - Urethral sphincter is ‘open’ (urethral and pelvic floor muscles relaxed) - Motor efferent signalling (void urine) predominantly parasympathetic control 24  H. Keet CNS areas responsible for voluntary and involuntary control of micturation - Voluntary - Cerebral (suprapontine) areas: Controls the pontine micturition centre. Role in delaying micturition, inhibiting premature detrusor contractions and initiating voiding at appropriate time - Pontine micturation centre: controls descending signals - switches the lower urinary tract between storage and voiding phases - Involuntary - Lumbosacral cord: responsible for numerous involuntary reflexes which relax the detrusor and contract sphincter as the bladder becomes full (guarding reflex) Causes of neurogenic bladder - Supraspinal - CVA - Parkinson’s disease - Brain injury (traumatic/non- traumatic) - Hydrocephalus - Cerebral palsy - Tumours - Spinal Cord - Neural tube defects - Spinal cord injury (traumatic/non- traumatic) - Tumours - Disc disease - Transverse myelitis - Multiple sclerosis - Peripheral Nerves - Diabetes mellitus - Tabes dorsalis (neurosyphilis) - Herpes zoster - Herniated lumbar disc disease - Radical pelvic surgery Types of NGB - not always predictable and findings may evolve over time - Lesion above the pontine micturition centre - overactive and/or uninhibited bladder - Loss of voluntary inhibition of voiding and reduced awareness of filling may lead to urinary incontinence - Overactivity may lead to urge incontinence - Lesion between the pontine micturition centre & sacral spinal cord - UMN bladder (spastic bladder) - Detrusor is overactive/hyperreflexic +- detrusor-sphincter-dyssynergia (DSD) - May lead to high bladder storage pressures which may cause reflux and damage kidneys - Urge incontinence due to overactivity - Lesion of sacral cord or sacral nerve root or peripheral nerves - lower motor neuron bladder (flaccid bladder) - Underactive/flaccid detrusor with intact internal sphincter leading to chronic urinary retention. - May cause overflow urinary incontinence, urinary tract infections, bladder stones sacral lesions may also produce mixed lesions depending on which nuclei are spared Spinal shock - The initial several weeks following a spinal cord injury may be characterised by a loss of spinal cord reflexes - The lower urinary tract usually manifests as a flaccid/areflexic bladder requiring catheterisation - Resolution of spinal shock is heralded by the return of spinal cord reflexes (i.e. bulbocavernosus reflex) - At this point the patient can be assessed for the true nature of their lower urinary tract dysfunction 25  H. Keet Autonomic dysreflexia - Individuals with a neurologic level of spinal cord injury at or above T6 - Imbalanced reflex sympathetic discharge in response to noxious stimulus below the level - May lead to potentially life-threatening hypertension - Urological noxious stimuli include: - Bladder distention - Urinary tract infection - Bladder stone - Cystoscopy/instrumentation/suprapubic catheterisation - Urodynamic study Evaluation of Neurogenic Bladder - History - Voiding complaints: LUTS, incontinence, infections - Use of medications - Bladder diary - Neurological history - Physical examination - Including genitourinary exam and neurological exam - Presence of spinal reflexes - Bedside Tests - Ultrasound assessment of post- voiding residual urine volume - Ultrasound evaluation for hydronephrosis which may indicate renal damage - Urine dipstick - Non-invasive uroflowmetry – evaluate urine flow in ml/sec - Laboratory evaluation - Urine for MCS - Serum UEC – eGFR - Urodynamic study - Definitive assessment of lower urinary tract dysfunction - Invasive test and requires co- operative patient. Operator dependant. - Objective evaluation of bladder storage pressures, detrusor over/underactivity, sphincter function Management – dependent on ‘type’ of NGB - Lifestyle - Fluid schedule - Avoidance of constipation - Manage sexual function - Pharmacological - Anticholinergics to reduce bladder overactivity and therefore reduce storage pressures e.g. oxybutynin, tolterodine, solefenacin - Management of symptomatic UTIs only - Catheterisation - Self-intermittent-clean-catheterisation (SICC) - Patient self-inserts a ‘nelaton’ catheter regularly on a times basis - Flaccid bladder - SICC to facilitate emptying - Patients with overactivity +- DSD – SICC to keep storage pressures low to protect kidney - Indwelling catheter - For patients unable to do SICC (e.g. quadriplegic) - For uncontrollable incontinence - SICC may still cause UTIs but it improves self-care and independence, and reduces barriers to sexual intimacy compared to use of an indwelling catheter - Surgery - Generally for patients who fail to respond to non-invasive treatments - Intravesical injection of botulinum toxin – relaxes overactive detrusor 26  H. Keet - Bladder augmentation with small bowel – improves storage capacity and reduces pressure - Slings and artificial sphincters – for incontinence - Sacral neuromodulation – implant which stimulates sacral nerve roots to reduce detrusor overactivity Complications of Neurogenic Bladder - Recurrent UTIs - Incontinence associated dermatitis - Bladder stone formation - Chronic urinary retention – hydronephrosis, renal failure - Vesico-ureteric reflux & renal damage - Impaired social and sexual function - Autonomic dysreflexia - A bladder that is not managed well early-on, may decompensate and become difficult to manage later on Overactive Bladder - Definition - A symptom complex that includes urinary urgency with or without urgency incontinence, urinary frequency (voiding ≥8 times in a 24 hr period), and nocturia (awakening ONE or more times at night to void) - Etiology - Multiple etiologies proposed - Symptoms usually associated with involuntary contractions of the detrusor muscle - Diagnosis - The diagnostic process should document symptoms that define overactive bladder and exclude other disorders that could cause of the patient’s symptoms - Minimal requirements for the process consist of: - focused history including past genitourinary disorders and conditions - Questionnaires of LUTS for women and diaries of urination frequency, volume and pattern - P/E including genitourinary, pelvic and rectal examination - U/A to rule out hematuria and infection - In some patients, the following investigations could be considered - Post-void residual - Cystoscopy to rule out recurrent infections, carcinoma in situ and other intravesical abnormalities - Urodynamics to rule out obstruction in older men - Treatment - nonpharmacological: behaviour therapies such as bladder training, bladder control strategies, pelvic floor muscle training, fluid management, and avoidance of caffeine, alcohol - pharmacological - Anti-muscarinics: oxybutynin hydrochloride, tolterodine, solifenacin, fesoterodine, or trospium - β3-adrenoceptor agonist: mirabegron - refractory patients may be treated with neuromuscular-junction inhibition: botulinum toxin bladder injection - others - percutaneous tibial nerve stimulation (not used commonly in Canada) - sacral neuromodulation 27  H. Keet Testicular Cancer 28  H. Keet Penile Cancer Urethral Cancer 29  H. Keet Urethral Strictures 30 H. Keet 31  H. Keet Acute Scrotum Overview - Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum - True urology emergency Differential diagnosis of acute scrotum - Ischemia - Torsion of the testes or torsion of the spermatic cord - Intravaginal - Extravaginal (neonatal) - Appendiceal torsion, testis - Testicular infarction - Compressive hydrocele or hernia - Others vascular insult (cord injury, thrombosis) - Trauma - Testicular rupture - Intratesticular hematoma - Haematocele - Hernia - With or without associated testicular ischemia - Incarcerated - Strangulated - Infectious conditions - Acute epididymitis - Acute epididymo-orchitis - Abscess - Gangrenous infections /fournier’s gangrene - Inflammatory conditions - Fat necrosis , scrotal wall - Henoch schonlein purpura vasculitis of scrotal wall - Acute on chronic events - Spermatocele - Hydrocele rupture, infection - Testicular tumor with rupture, infarction or infection - Varicocele Testicular torsion - Refers to the twisting of the spermatic cord, causing ischaemia of the testicle which leads to irreversible loss of reproductive germinal tissue within hours of onset - True emergency - Missed torsion may have significant impact on the patient psychosexual, reproductive as well have medicolegal implication - Common in neonates and postpubertal boys (5-19 years) - Results from inadequate fixation of the testis to the tunica vaginalis Clinical features and diagnosis torsion - The onset of pain is usually sudden and often occurs several hours after vigorous physical activity or minor trauma - There may be associated nausea and vomiting - Another typical presentation in children is awakening with scrotal pain in the middle of the night or in the morning - On physical examination , classic finding of asymmetrically high-riding testis with the long axis of the testis oriented transversely called bell clapper deformity - The cremasteric reflex is usually absent this help to distinguish torsion with other causes of scrotal pain - Prehn’s sign relief of scrotal pain by elevating testicle: Not very reliable 32  H. Keet - Absence of signs of infection - Urinalysis normal - Imaging - If etiology of acute scrotal process is equivocal after history and physical examination, color doppler ultrasound is the diagnostic of choice - Lack of immediate access to ultrasound should not delay surgical exploration Treatment - Treatment for suspected testicular torsion is immediate surgical exploration with intraoperative detorsion and fixation of the testes - Longer periods of ischaemia more 12 hours may cause infarction requiring orchidectomy Treatment torsion appendages - Torsion of the appendix testis or epididymis present with the acute onset of scrotal pain and mass - Testis is palpable and has a normal lie - If early palpable - Blue dot sign if appendage is ecchymotic - Doppler ultrasound: normal perfused testis - Process is often self-limited - Appendage atrophy - If surgical exploration the appendage is excised and no orchidopexy needed Infections - Maybe difficult to distinguish on physical examination from torsion and trauma - Epididymitis is the most common cause of scrotal pain in adults in outpatient setting - History of sexually transmitted infection (STI), recent sexual activity - Palpation reveals induration and swelling of the involved epididymitis with tenderness - More advanced present with testicular swelling and pains with scrotal erythema and a reactive hydrocele - Urinalysis and urine culture should be performed - A urethral swab if discharge - Testicular ultrasound in acute onset to exclude a testicular torsion - Acute febrile patients with sepsis often require intravenous hydration and parenteral antibiotics and nonsteroidal anti-inflammatory - Less severe cases treated on an outpatient basis with oral antibiotics, ice and scrotal elevation Fournier’s gangrene - Is a necrotizing fasciitis of the perineum caused by mixed infections which often involves the scrotum - Treatment consists of early and aggressive surgical exploration and debridement of necrotic tissue, antibiotics and hemodynamic support Inguinal hernia - May also present as acute scrotum - Swelling involve both the scrotal contents and the groin area - An incarcerated inguinal involves bowel that is obstructed: a true surgical emergency - Groin and scrotal ultrasound or pelvic CT scans can clarify before surgery Trauma - Penetrating and blunt testicular injury - As a general principle penetrating should be surgical explored - Blunt trauma, physical findings may include swelling, tenderness, or ecchymosis - Ultrasound can determine the degree of testis injury 33  H. Keet Acute on chronic events - Testicular neoplasm - Spermatocele - Hydrocele - Scrotal physical examination reveals a firm intratesticular mass - Scrotal ultrasound shows the lesions 34  H. Keet Scrotal Masses Incontinence Urinary Incontinence - Definition: - UI is the complaint of any involuntary leakage of urine. - Urinary incontinence (UI) has a considerable social and economic impact. - The bladder tends to be an “unreliable witness” - Hence careful evaluation of the storage and voiding symptoms is necessary Storage Symptoms: (FUN) - Frequency of Micturition - >7 x during the day - Urgency- Urgency is the complaint of a sudden, compelling desire to pass urine, which is difficult to defer. - Nocturia 35  H. Keet Voiding Symptoms (WISE) - Weak Stream - Intermittency - Stranguria - Incomplete Emptying Types of urinary incontinence: - Mixed Urinary incontinence - Stress Urinary incontinence - Urge urinary incontinence - Overflow urinary incontinence - Total Urinary incontinence - Nocturnal Enuresis (see paeds) - Transient Incontinence Mixed Urinary incontinence - Most common type of incontinence - Mixture of Urge and Stress Urinary Incontinence - Symptomatic complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing. - There will be one predominant symptom. - Treat the predominant symptom first. Stress Urinary Incontinence - Stress UI is the: - Symptomatic complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. - A common cause is urethral hypermobility. - Another cause is Intrinsic Sphincter dysfunction Risk Factors: - Increased intra-abdominal and /or increased intra thoracic pressure. - Older, Female - Multiparity - Big baby - Prolonged labour - Instrumentation – forceps or suction delivery - Pelvic trauma - Musculo-skeletal disease On History: - Tease out the type of UI - Precipitating factors - Severity- how many pads are used /day - Frequency of leaks - Irritative or obstructive symptoms - Bladder diary - Past medical history- Neurological diseases - Past surgical history- incontinence surgery, hysterectomy, prostate surgery - Obstetric history - Drug history- TCAs, alpha blockers - Rule out causes of transient urinary incontinence 36  H. Keet On examination: - In lithotomy, you may see a demonstrable leak upon coughing. - Bladder neck descent on straining - Q-tip test: Place this in the urethra with lubrication and ask patient to cough. - If there is a change in angle of more than 30 degrees, this indicates urethral hypermobility - Focused Neurological exam: S2-S4 - Urine Dipstix. SUI treatment: - Treat the underlying cause of the increased intra-thoracic /abdominal pressure. - Mid urethral sling - Pelvic floor therapy - SNRI- Duloxetine used in patients unfit for surgery Urge Urinary Incontinence - Wet overactive bladder. - UDS: detrusor instability - Bladder diary will show frequent small voids with strong urge with associated incontinence - Treatment: - Anticholinergics: Oxybutynin, Mirabegron - Bladder Training - Neuromodulation - Side Effects of Drugs: parasympathetic Overflow Incontinence - This is secondary to urinary retention - This may be due to either a physiological or anatomical cause. - Physiological causes: - Neurogenic flaccid bladder - Anatomical Causes: - Urethral stricture - Enlarged prostate - Treatment - Clean intermittent catheterisation - Treat the underlying cause Total Incontinence - Causes: - Vesicovaginal fistula - Other genitourinary fistula - Intrinsic sphincter dysfunction - Ectopic Ureter - Treatment - Surgical repair of the fistula - Urinary diversion - Artificial urethral sphincter Transient Incontinence “Diappers” - Delirium - Infection - Atrophic urethritis or vaginitis - Pharmacologic - Psychogenic - Endocrine (hypercalcaemia or hyperglycaemia) - Restricted Mobility - Stool impaction 37  H. Keet Pelvic Organ Prolapse Definition: - Pelvic organ prolapse is defined as the descent of one or more of the following: anterior vaginal wall, posterior vaginal wall, and apex of the vagina (cervix/uterus) or vault (cuff) after hysterectomy. - Pelvic organ prolapse can occur in association with UI and other lower urinary tract dysfunction and may on occasion mask incontinence. - Treatment if indicated is either surgical or pessaries Urinary Retention Clinical Features - Suprapubic pain (with acute retention),incomplete emptying,weak stream - Palpable and/or percussible bladder(suprapubic) - Possible purulent/bloody meatal discharge (with UTI) - Increased size of prostate or reduced anal sphincter tone on DRE - Neurological: presence of abnormal or absent deep tendon reflexes, reduced “anal wink”, saddle anesthesia Investigations - FBC, electrolytes, Cr, BUN, U/A and urine C&S, U/S, cystoscopy, urodynamic studies, PVR Treatment - Treat underlying cause - Catheterization - Acute retention - Immediate catheterization to relieve retention; leave Foley in to drain bladder; follow-up to - Determine cause; closely monitor fluid status and electrolytes (risk of POD) - Chronic retention - Intermittent catheterization by patient may be used; definitive treatment depends on etiology - Suprapubic catheter if obstruction precludes urethral catheter - For post-operative patients with retention: - Encourage ambulation - α-blockers to relax bladder neck outlet - May need catheterization - Definitive treatment will depend on etiology Dysuria 38  H. Keet Investigations - Focused Hx and P/E to determine cause (fever, d/c, conjunctivitis, CVA tenderness, back/joint pain) - Any d/c (urethral, vaginal, cervical) should be sent for gonococcus/chlamydia testing, wet mount if - vaginal d/c - U/A and urine C&S - If suspect infection, may start empiric ABx treatment - ± Imaging of urinary tract (tumour, stones) Paediatric urology Enuresis Antenatal hydronephrosis - Epidemiology - 1-5% fetal U/S, some detectable as early as first trimester - Most common urological consultation in perinatal period and one of most common U/S abnormalities of pregnancy - Differential Diagnosis - UPJ or UVJ obstruction - Multi-cystic dysplastic kidney - VUR - PUVs (only in boys) - Duplication anomalies 39  H. Keet - Ureterocele - Ectopic ureter - Treatment - Antenatal in utero intervention rarely indicated unless evidence of lower urinary tract obstruction with oligohydramnios Posterior urethral valves - Epidemiology: the most common congenital obstructive urethral lesion in male infants - Pathophysiology: abnormal mucosal folds at the distal prostatic urethra causing varying degrees of obstruction - Clinical Presentation - antenatal: bilateral hydronephrosis, distended bladder, oligohydramnios - neonatal (recognized at birth): palpable abdominal mass (distended bladder, hydronephrosis), urinary ascites (transudation of retroperitoneal urine), respiratory distress (pulmonary hypoplasia from oligohydramnios), weak urinary stream - neonatal (not recognized at birth): within weeks present with urosepsis, dehydration, electrolyte - abnormalities, failure to thrive; rule out pyloric stenosis, which may present similarly - toddlers: UTIs or voiding dysfunction - school-aged boys: voiding dysfunction → urinary incontinence - associated findings include renal dysplasia and secondary VUR - Investigations - Most commonly recognized on prenatal U/S→ bilateral hydronephrosis, thickened bladder, dilated posterior urethra (“keyhole sign”), oligohydramnios in a male fetus - VCUG→ dilated and elongated posterior urethra, trabeculated bladder, VUR - Treatment - Immediate catheterization to relieve obstruction, followed by cystoscopic resection of PUV when baby is stable - If resection of PUV is not possible, vesicostomy is indicated Ureteropelvic junction obstruction 40  H. Keet Vesicoureteral reflux Renal Cysts/ Nephroblastoma (Wilms’ Tumour) 41  H. Keet Cryptorchidism/ Undescended/EctopicTestes UTI in children 42  H. Keet Phimosis and circumcision 43  H. Keet Hypospadias Exstrophy-epispadias complex - Definition - A spectrum of defects depending on the timing of the rupture of the cloacal membrane - Bladder exstrophy: congenital defect of a portion of lower abdominal and anterior bladder wall, with exposure of the bladder lumen - Cloacal exstrophy: exposed bladder and bowel with imperforate anus, associated with spina bifida in >50% - Epispadias (least severe): urethra opens on dorsal aspect of the penis, often associated with penile curvature - Etiology - Represents failure of closure of the cloacal membrane, resulting in the bladder and urethra opening directly through the abdominal wall - Epidemiology - High morbidity→ multiple reconstructive surgeries, incontinence, infertility, reflux - Treatment - Surgical correction at birth - Later corrections for incontinence, VUR, and low bladder capacity may be needed 44  H. Keet Trauma in urology 45  H. Keet Catheters Catheter size - French (F) gauge = circumference of catheter in mm - Men > 16-18 F - Women > 14-16 F - Macroscopic haematuria (e.g. after prostatic surgery) > 22-24 F Catheter material - Latex (rubber) - Forms encrustations, causes urethral irritability, risk of Latex allergy - Should not remain indwelling > 3 weeks - Silicone (silastic) - Inert > less urethral damage - Can remain indwelling for up to 3 months Catheter associated UTI - indwelling catheters rapidly become colonized by organisms - reach bladder via sheath of exudate that surrounds catheter in urethra and/ or via the lumen of the catheter - therefore, prophylactic antibiotics for patients with an indwelling catheter are not recommended as it encourages emergence of resistant strains of bacteria - however, if a patient with an indwelling catheter develops a symptomatic UTI (pyrexia, rigors, loin pain) > 10-14 day course of antibiotic - prophylactic antibiotics may be considered in high risk cases (e.g. prosthetic heart valve) 46  H. Keet Transurethral Catheterisation 47  H. Keet Suprapubic Cystotomy Urodynamic Studies 48  H. Keet Imaging the Urogenital Tract 49 H. Keet 50