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Urology Back to Basics
The “Nuts” and Bolts
James Watterson, MD FRCSC
Assistant Professor, University of Ottawa
Director, Ottawa Lithotripsy and Stone Program
Endourology and Laparoscopic Urological Surgery
Division of Urology, The Ottawa Hospital
References
• The Medical Council of Canada
– www.mcc.ca
– Objectives for the Qualifying Examination
• MCC Objectives.doc
• University of Toronto Notes
• Campbell’s Urology
Objectives
• The Medical Council of Canada
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Abdominal Mass
Adrenal Mass
Blood in Urine (Hematuria)
Gynecomastia
Ambiguous Genitalia
Infertility
Incontinence, Urine
Incontinence, Urine, Pediatric (Enuresis)
Impotence, Erectile Dysfunction
Acute and Chronic Renal Failure (Post-renal / Obstruction)
Scrotal Mass / Scrotal Pain
Urinary Tract Injuries
Dysuria and / or Pyuria
Urinary Obstruction / Hesitancy / Prostatic Cancer
Objectives
• The Medical Council of Canada
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Abdominal Mass
Adrenal Mass
Blood in Urine (Hematuria)
Gynecomastia
Ambiguous Genitalia
Infertility
Incontinence, Urine
Incontinence, Urine, Pediatric (Enuresis)
Impotence, Erectile Dysfunction
Acute and Chronic Renal Failure (Post-renal / Obstruction)
Scrotal Mass / Scrotal Pain
Urinary Tract Injuries
Dysuria and / or Pyuria (UTI)
Urinary Obstruction / Hesitancy / Prostatic Cancer
Blood in Urine (Hematuria)
Key Objective (s):
Differentiate red or brown urine from hematuria, transient
from persistent, and glomerular from extraglomerular
hematuria
Hematuria
Objectives
Through efficient, focused, data gathering
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Determine whether the patient has true hematuria
Diagnose the presence of urinary tract infections
Differentiate between glomerular and extraglomerular hematuria by examination of urine
sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
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Interpret reported urinalysis findings
Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria
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Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
Outline a plan for investigation of patients with recurrent nephrolithiasis
Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
Discuss possible strategies for the detection and prevention of urinary tract tumors
Hematuria
Objectives
Through efficient, focused, data gathering
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Determine whether the patient has true hematuria
Diagnose the presence of urinary tract infections
Differentiate between glomerular and extraglomerular hematuria by examination of urine
sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
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Interpret reported urinalysis findings
Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria
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Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
Outline a plan for investigation of patients with recurrent nephrolithiasis
Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
Discuss possible strategies for the detection and prevention of urinary tract tumors
Hematuria
Considerations
• Pseudohematuria
– Menses
– Dyes (ie. Anthrocyanin in beets, rhodamine B in drinks, candy and
juices)
– Hemoglobinuria (hemolytic anemia)
– Myoglobinuria (rhabdomyolysis)
– Drugs (rifampin, phenazopyridine)
– Porphyria (brownish urine)
– Laxatives (phenolphthalein)
1. Urine dipstick – if positive, indicates hematuria, hemoglobinuria,
or myoglobinuria
2. Microscopy distinguishes hematuria from Hgburia or Mgburia
Hematuria
Objectives
Through efficient, focused, data gathering
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Determine whether the patient has true hematuria
Diagnose the presence of urinary tract infections
Differentiate between glomerular and extraglomerular hematuria by examination of urine
sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
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Interpret reported urinalysis findings
Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria
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Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
Outline a plan for investigation of patients with recurrent nephrolithiasis
Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
Discuss possible strategies for the detection and prevention of urinary tract tumors
• History & P/E
UTI
– Irritative voiding symptoms (dysuria, freq, urg, suprapubic pain, hematuria)
– Fever
– Flank pain
• Inspection of urine – Turbid
– May be secondary to excessive phosphates
• Urinalysis
– Dipstick
• Leukocyte esterase
• Nitrites
Limited sensitivity
– Microscopic analysis
• False-negative (low numbers bacteria), false-positive (normal vaginal flora;
NB squamous epithelial cells indicate contamination)
• > 2 WBCs/HPF correlates with presence of bacteriuria
• RBCs lack sensitivity (40-60% cases of cystitis) but highly specific
• Urine culture
– mid-stream vs. catheterized specimen
– Traditionally, > 105 cfu/mL
• In dysuric patients, 102 cfu/mL of a known pathogen significant
Hematuria
Objectives
Through efficient, focused, data gathering
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Determine whether the patient has true hematuria
Diagnose the presence of urinary tract infections
Differentiate between glomerular and extraglomerular hematuria by examination of urine
sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
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Interpret reported urinalysis findings
Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria
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Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
Outline a plan for investigation of patients with recurrent nephrolithiasis
Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
Discuss possible strategies for the detection and prevention of urinary tract tumors
Hematuria
MCC
Causal Conditions
• Transient
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Urinary tract infections
Exercise induced
Stones/Crystals
Trauma
Endometriosis
Thromboembolism
Anticoagulants (similar incidence of hematuria in non-anticoagulated patients)
• Persistent
– Extraglomerular (Urological)
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Renal
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Collecting system
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Tumors
Tubulointerstitial diseases (e.g polycystic kidneys, pyelonephritis)
Vascular (e.g. papillary necrosis, sickle cell disease)
Tumors
Stones
Lower urinary tract
– Glomerular
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Isolated (e.g. IgA nephropathy, thin membrane disease)
Post-infections (e.g. post-streptococcal)
Systemic involvement (e.g. vasculitis, SLE)
Figure 3-7 Evaluation of nonglomerular renal hematuria (circular erythrocytes, no erythrocyte casts, and proteinuria). CT, computed tomography; IgA, immunoglobulin A; IVU,
intravenous urography; PT, prothrombin time; PTT, partial thromboplastin time; R/O, rule out.
Figure 3-6 Evaluation of glomerular hematuria (dysmorphic erythrocytes, erythrocyte casts, and proteinuria). ANA, antinuclear antibody; ASO,
antistreptolysin O; Ig, immunoglobulin.
Hematuria
Diagnostic Evaluation: Is it?
1.
2.
True or False
Extraglomerular vs. Glomerular
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2.
3.
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Dysmorphic RBCs
Casts (RBC, WBC)
Proteinuria (>100-300 mg/dL or 2+ to 3+ on dipstick)
Gross or Microscopic
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4.
> 3 RBC / HPF
Further Urological Questions
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2.
3.
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Location- Renal/Ureter/Bladder/ Prostate/Urethra
Painful/Painless
Part of Stream- Initial/Terminal/Throughout ???
Clots – shape of clots
Investigations for Hematuria
• History and P/E
– Smoking
– Other risk factors for urothelial malignancy
• Urine
– Urinalysis / Microscopy / C & S
– Cytology
• Upper tract
– Microscopic
• Renal U/S
– Gross
• CT urogram
• Lower tract
– cystoscopy
Hematuria
DDx
• VINDICATE
• Renal/Ureter/Bladder/Prostate/Urethra
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Neoplasm.. Neoplasm.. Neoplasm
Stone
Trauma
Infection
Hematuria
Objectives
Through efficient, focused, data gathering
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Determine whether the patient has true hematuria
Diagnose the presence of urinary tract infections
Differentiate between glomerular and extraglomerular hematuria by examination of urine
sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
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Interpret reported urinalysis findings
Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria
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Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
Outline a plan for investigation of patients with recurrent nephrolithiasis
Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
Discuss possible strategies for the detection and prevention of urinary tract tumors
UTI
Treatment
• Principles of Antimicrobial Therapy
– Effective antimicrobial therapy must eliminate bacterial growth
– Antimicrobial resistance is increasing because of excessive utilization
– Antimicrobial selection should be influenced by efficacy, safety, cost and
compliance
• Lower Tract UTI – cystitis; most occur in women; 10% incidence
• Bacteria – E.coli causative organism in 75 – 90% of acute cystitis in young women
• Drug choices
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TMP-SMX DS BID 3 days
Nitrofurantoin 100mg BID 3 days
Norfloxacin 400mg BID 3 days
Ciprofloxacin 500mg BID 3 days
UTI
Treatment
• Recurrent Lower Tract UTI in Women
– Self-start Rx
– Post-coital single dose
– Low dose prophylaxis 3-6 months
• Upper Tract UTI (Acute Pyelonephritis)
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E.coli accounts for 80% of cases
Blood cultures positive in 25%
Consider U/S or CT if failure to respond after 72 hrs of therapy
Rx
• Uncomplicated – Cipro 500mg BID PO, Levofloxacin 500mg QD PO x 7 – 10 days
• Complicated – Parenteral Cipro, Levo, Amp + Gent x 7 – 10 days
Hematuria
Objectives
Through efficient, focused, data gathering
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Determine whether the patient has true hematuria
Diagnose the presence of urinary tract infections
Differentiate between glomerular and extraglomerular hematuria by examination of urine
sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
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•
Interpret reported urinalysis findings
Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria
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Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
Outline a plan for investigation of patients with recurrent nephrolithiasis
Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
Discuss possible strategies for the detection and prevention of urinary tract tumors
Risk Factors for Stone Disease
• Diet, Diet, Diet
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Dehydration
High protein intake
High salt intake
Certain foods high in oxalate
• Occupation
– Dehydration
• Inflammatory Bowel Disease, Gout, Hyperparathyroidism
• Genetics
– Rarely
• Recurrent nephrolithiasis
– Refer to urologist or nephrologist
– Metabolic evaluation
• Serum chemistry (Lytes, BUN, Cr, Ca, Urate, PTH)
• 24 hour urine (Lytes, Ca, Oxalate, Uric acid, citrate, Mg, cystine)
Dysuria and/or Pyuria
Key Objective (s):
Differentiate between urinary tract infections and conditions outside the
urinary tract with similar presentation; determine which infections require
treatment, and select the appropriate treatment.
In patients with recurring urinary tract infections, determine whether a
predisposing condition may be present (e.g., stasis from obstruction, reflux).
Dysuria and/or Pyuria
• Through efficient, focused, data gathering:
– Interpret urinalysis and clinical findings in order to diagnose problems external to urinary tract.
– Evaluate examination findings so that problems involving the urethra or prostate are identified.
– Determine whether cystitis or pyelonephritis is the more likely diagnosis.
• List and interpret critical clinical and laboratory findings which were
key in the processes of exclusion, differentiation, and diagnosis:
– Outline significance of patient's age, gender, and life style on diagnostic possibilities.
– Select findings which are best for differentiating cystitis from pyelonephritis.
– Describe the collection of samples to be sent for culture and sensitivity; interpret results.
• Conduct an effective plan of management for a patient with urinary
frequency, dysuria, and/or pyuria:
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Determine which patients require additional investigation and/or referral.
Determine which patients require hospitalization.
Determine which patients should be on prophylactic treatment and the type of treatment.
Select the most appropriate treatment for the underlying condition.
List conditions which predispose to urinary tract infections.
• Outline strategies for prevention of recurrent urinary tract infections.
Dysuria and/or Pyuria
• Dysuria = painful urination
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Usually caused by inflammation
Commonly referred to the urethral meatus
Start: may indicate urethral
End (stranguria): usually bladder origin
Usually accompanied by frequency and urgency
• Pyuria = presence of white blood cells (WBCs) in urine
– Generally indicative of infection and an inflammatory response of the
urothelium to the bacterium
– Bacteriuria without pyuria is generally indicative of bacterial colonization
without infection
– Pyuria without bacteriuria warrants evaluation for TB, stones, or cancer
Dysuria and/or Pyuria
DDx
Dysuria / Freq / Urgency >> Vesical vs. Extravesical
• Extravesical
– Urological
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Urethral diverticulum / CA
Prostatitis
Urethritis
Lower ureteral stone
– Gyne
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Vulvovaginitis
Herpes
Endometriosis
Ovarian / Uterine / Cervical CA
– Bowel
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Diverticulosis
Fistula
Crohn’s
Colon CA
• Vesical
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Bacterial cystitis
Bladder tumor / CIS
Bladder stone
TB cystitis
Radiation cystitis
Nonbacterial cystitis
• Cyclophosphamide / ASA /
NSAID / Allopurinol
Dysuria and/or Pyuria
Evaluation
Dysuria / Freq / Urgency >> Vesical vs. Extravesical
• History
– Age, Gender, Smoking History
– LUTS
– PMHx (Gyne, IBD, divertic), PSHx (pelvic), PGUHx (UTI, STD, Tumor, Stone,
Hematuria)
• Physical examination
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Suprapubic tenderness
Genital exam
Rectal exam (prostate, rectum)
Pelvic exam
• Investigations
– Urine (U/A, C&S, cytology)
– Ultrasound - pelvic
– Cystoscopy
Urinary Obstruction / Hesitancy /
Prostatic Cancer
Key Objective (s):
Determine whether a patient has an acute obstruction any time the complaint is
complete anuria or unexplained renal insufficiency
Urinary Obstruction / Hesitancy / Prostatic Cancer
Objective (s):
Through efficient, focused, data gathering:
•Determine whether the obstruction is acute or chronic, duration, complete or partial, and unilateral or bilateral,
and site.
•Ask whether pain is present, site of pain (e.g., suprapubic for bladder distention, flank for renal capsule), whether
it is colicky and radiates to ipsilateral testicle or labia (renal or ureteral colic), or occurs after a fluid load that
increases urine output (e.g., beer drinking).
•Examine for tenderness, hydronephrosis, hypertension, and palpable bladder.
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis:
•Select ultrasonography as the diagnostic imaging tool to diagnose obstruction.
•List indications for other types of diagnostic imaging.
•Select and interpret tests of renal function; outline indications for prostate cancer screening.
Conduct an effective plan of management for a patient with urinary tract obstruction:
•Perform catheterization of the bladder for both therapeutic and diagnostic reasons.
•Select patients for referral to specialized care.
Definitions
• Uremia = clinical signs and symptoms seen as a result of
renal failure
• Azotemia = elevation of blood urea (BUN)
• Obstructive Uropathy = reversible or irreversible renal
dysfunction due to the effects of impaired urine drainage
• Hydronephrosis = dilation of the renal pelvis and calyces
Urinary Tract Obstruction
Classification
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Supravesical vs. Infravesical
Acute vs. Chronic
Unilateral vs. Bilateral
Anatomical site
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Intrarenal
Ureter
Bladder
Prostate
Urethra
• Extraluminal (LN, mass) vs. Intraluminal (stone, blood
clot, fungus ball) vs. Intramural (TCC, polyp)
Diagnosis
Clinical features
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Flank pain/renal colic
Urinary retention or overflow incontinence
Anuria or oliguria
Uremia
Stones
Recurrent UTI
Asymptomatic
Pathophysiology
Factors Influencing Severity of Renal Dysfunction
• Complete or partial obstruction
• Duration; >30 days of complete obstruction results
in irreversible loss of renal function
• Unilateral or bilateral
• Presence of infection
Urinary Tract Obstruction
Major Sequelae
• Loss of renal function
• Urinary tract infection / sepsis
• Stones
Urinary Tract Obstruction
Diagnosis
• Clinical features
• Laboratory investigations
• Imaging studies
Urinary Tract Obstruction
Diagnosis
• Laboratory investigations
– Elevated BUN and Cr with bilateral ureteral or bladder
outlet obstruction
– Abnormal urinary indices
Urinary Tract Obstruction
Diagnosis
• Imaging studies
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Renal ultrasound
Intravenous pyelogram (IVP)
CT Scan
Retrograde pyelogram
Lasix renogram
Hydronephrosis may not develop if acute obstruction or if presence of
perinephric fibrosis
Urinary Tract Obstruction
Temporary Measures
• Bypass the cause of obstruction
• Bladder outlet obstruction
– Foley catheter
• Renal or ureteral obstruction
– Ureteral stent
– Nephrostomy tube
Percutaneous Nephrostomy
Ureteral Stenting
Urinary Tract Obstruction
Definitive Treatment
• Remove the cause of obstruction
• BPH
– Pharmacotherapy (alpha-blockers)
– Surgical (TURP)
• Stone
– ESWL, ureteroscopy, percutaneous stone removal
Prostate Cancer
• Most common solid tumor in U.S. males
• Second leading cause of male cancer deaths
• Lifetime risk 1/6
• Lifetime risk of a 50 year old: 50%, risk of dying 3%
• Risk factors
– Family history: 1st degree relative (2x)
– blacks
– High dietary fat
• Histologic Incidence rates
– 10-30% > 50
– 50% > 80
Presentation
• Asymptomatic
– (75%) h PSA
– abN DRE
• Locally Advanced
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LUTS (uncommon without met)
Hematuria
Hematospermia
Renal failure
DDx Prostatic Nodule
• Prostate Cancer (30%)
• BPH
• Prostatits
• Prostatic Infarct
• Prostatic Calculus
• Tuberculous Prostatitis
• Metastatic Disease
– Bony pain (osteoblastic)
– Renal failure
PSA
• Enzyme produced by epithelial cells of prostate
gland to liquify the ejaculate
• Elevated in:
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Prostate cancer
Prostatitis
BPH
Trauma
• catheterization
– Ejaculation
Screening
• DRE
– Hypothenar eminence = benign
• PSA
– CCFP - not recommended
– US FP + Urologist – recommended
– “normal” < 4 but 30% have PCa
Age 50 unless 1st degree relative or black male >>>40-45 yrs
Screen between ages 50-70/75 years
Screening
Probability of Finding Cancer on Biopsy According to a Man’s
DRE Result and PSA Level
PSA (NG/ML)
2-4
4-10
>10
N
15%
25%
50%
AbN
20%
45%
>75%
DRE
• If abN DRE +/ h PSA.. AND > 10 YR LIFE
EXPECTANCY…
TRUS + BIOPSY
Scrotal Mass
Key Objective (s):
Differentiate testicular tumor from a mass of inguinal origin (not possible to
get above it, may reduce), cystic lesion (trans-illuminates), and a varicocele
(easier to palpate with patient erect)
Scrotal Mass
Objective (s):
Through efficient, focused, data gathering:
• In boys, ask about pain, trauma, change in scrotal size, difficulty voiding
• Elicit history of undescended testicle, infertility, previous testicular tumor, and breast enlargement / tenderness
• Differentiate from condition that presents primarily with pain
• Perform abdominal exam including inguinal areas, and an examination of the male genitalia (erect and supine,
testes, epididymis, cord, scrotal skin) including rectal examination to assess the prostate and seminal vesicles,
transilluminate
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis:
•Select patients requiring ultrasound, CT and explain reason; order beta human chorionic gonadotrophin and
alpha-fetoprotein
Conduct an effective plan of management for a patient with scrotal mass:
• Outline management options for masses which are not testicular tumors.
Approach to Scrotal Masses
• Painful vs. painless
• Benign vs. malignant
• Etiology varies with age of patient
– DDX differs between adults and children
• >>>Anatomical Approach
Anatomy
• Scrotal Contents:
– Testes
• Tunica albuginea
• Tunica vaginalis
– Epididymis
– Spermatic Cord:
• Vas deferens
• Arteries:
– Testicular
– Cremasteric
– Artery to the Vas
• Veins:
– Pampiniform plexus
• Nerves:
– Ilioinguinal
– Genital br. Of Genitofemoral
– Sympathetics
History
• Age of patient
• HPI
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Onset (acute, insidious)
Painful vs. painless
Radiation
Aggravating Factors
Relieving Factors
LUTS
• PMHx
• PSHx
• Risk Factors
– Recent trauma
– Infection
– Instrumentation of the
urinary tract
– Congenital anomalies
– Prior history of
neoplasm
Physical Examination
• Vital Signs
– Temp
• Skin
• Abdominal exam
• Inguinal
– Hernia (may reduce, unable
to get above)
– Lymph Nodes
– Masses
• Penis
– malignancy
• Scrotum
– Skin
– Testes:
• 3.5 cm
• Mass
– Hydrocele
• Transillumination
– Varicocele
• Valsalva
• DRE
Differential Diagnosis
• Painful
– Trauma
• Painless
– Tumor
• Intratesticular
• Paratesticular
• Contusion, rupture
– Epididymo-orchitis
– Hernia
• Incarcerated,
strangulated
– Torsion
• Testes
• Appendages
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Varicocele
Hydrocele
Spermatocele
Scrotal wall
malignancies
• SCC, sarcomas
Testicular Torsion
• Intravaginal (all age groups,
puberty)
• Extravaginal (prenatal,
neonatal)
• Hx:
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Acute Painful scrotum
N&V
Rx to groin / abdomen
None or minimal trauma
• Px:
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Patient appears unwell
Tender, swollen testicle
High riding, transverse lie
Scrotal erythema
No cremasteric reflex
Testicular Torsion
• If suspected clinically,
surgical exploration
indicated
– Orchidectomy
– Orchidopexy of
contralateral side
• INV:
– Transcrotal Ultrasound
• Duplex Doppler
– Nuclear testicular blood
flow scan
Torsion of Appendix Testis / Epididymis
•Appendix Testis: 2-3 mm embryol. remnant near upper pole of
testis
•may twist on stalk --> pain
•O/E: local tenderness, blue dot sign
Epididymitis / Orchitis
• Hx:
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More insidious onset
Fever
Recent instrumentation
Sexual activity
LUTS
• Px:
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Painful epididymis +/- testis
Testis in normal position
Urethral discharge
+ Prehn’s sign
• INV:
– CBC
– U/A, C&S, Urethral Swab for
GC / Chlamydia
– TB
• >>May Resemble Torsion!
Epididymitis / Orchitis
• Causative
– <35 years: N.gonorrhea,
C.trachomatis, E.coli
– >35 years: E.coli
– Homosexual: E.coli
– Mumps orchitis:
• 30% of patients with mumps
• Risk of infertility
• Rx:
– Antibiotics
– Bed rest
– Analgesics / Antiinflammatories
– Scrotal elevation
• Specific Recommendations:
– GC:
• ceftriaxone 250 mg IM
• Cipro 500 mg PO
– NonGC:
• Azithromycin 1 g PO
• Doxycycline 100 mg BID x 7
days
– E.coli:
• IV antibiotics if severe
• Fluoroquinolone x 10-14 days
Hydrocele
• A collection of serous fluid in some part of the processus
vaginalis, usually in the tunica
• More common in childhood
• 1% of adult males
• Congenital:
– Processus vaginalis does not close after testicular descent
• Acquired:
– Primary (idiopathic) vs. secondary to disease of the testis
– Defective absorption, increased production, lymphatic obstruction
Hydrocele
• Hx:
– Painless (unless large)
– Change during day
(suggests
communication)
– Other symptoms
(secondary hydrocele)
• Px:
– Transilluminates
– Palpate testes
– Hernia ?
• INV:
– Transcrotal ultrasound if
testis not palpable
Hydrocele
• Rx:
– Adults:
• Symptomatic
• Cosmesis
• Underlying testicular
pathology
– Children:
• Most will resolve in 1st
year
• If persists, repair of
hernia may be indicated
• Specifics:
– Surgical
– Aspiration
– Sclerotherapy
Spermatocele
• Painless mass
• Contains fluid and
spermatozoa
• 4th / 5th decades
• Region of caput
• Usually can palpate the testis
separately from spermatocele
• Obstruction of efferent duct
• Mass may transilluminate
Spermatocele
• Rx:
• Conservative
• Spermatocelectomy
• Surgery may have
negative consequences
>>> delay if reproductive
age
Varicocele
• Dilation of the veins of the pampiniform plexus of the spermatic
cord due to absent competent venous valves in the spermatic
vein
• 15% of males, 30% of subfertile males (multiple theories)
– Elevated intratesticular temperature widely accepted
• Most Left-sided; May be bilateral; Right-sided only>> be
suspicious!
• Rare prior to puberty
Varicocele
• Hx:
– Painless vs. dull ache; pain never
present on awakening
– Discomfort increases with standing
/ activity over long period of time
– Exaggerated with Valsalva
– Infertility
• Px:
– “Bag of Worms”, “vascular thrill”
–
–
–
–
Gr.I: Palpable with valsalva
Gr.II: Palpable without Valsalva
Gr.III: Visible
Abdominal mass
• Scrotal Ultrasound
Varicocele
• Rx:
–
–
–
–
Sx’s
Cosmesis
Infertility
Ipsilateral testicular atrophy
• Surgical options:
–
–
–
–
–
Retroperitoneal
Inguinal
Subinguinal
Laparoscopic
Transvenous embolization
Testicular Tumors
• Testis CA most common malignancy in males 15 to 35 years
• Incidence: 3.7 / 100,000 (whites), 0.9 / 100,000 (blacks)
• R>L, 2-3% bilateral
• Risk factors:
–
–
–
–
Age (<10, 15-35, >60)
Race
Cryptorchidism
Atrophy
Testicular Tumors
• Germ Cell tumors
– Seminoma
– Non-Seminomatous
•
•
•
•
•
Embryonal carcinoma
Choriocarcinoma
Yolk Sac tumor
Teratoma
Mixed
• Paratesticular
• Secondary
– RES
• Leukemia
• Lymphoma
– Metastases
• Gonadal Stromal
– Leydig-cell
– Sertoli-cell
– Gonadoblastoma
Testicular Tumors
• Hx:
– Painless intratesticular mass (pain if hemorrhage)
– May present with metastatic disease (SOB, cough, hemoptysis,
abdominal bloating, GI complaints, lower limb edema)
• Px:
–
–
–
–
Chest (pleural effusion, wheezing, gynecomastia)
Abdominal exam (mass)
Genital exam
Nodal exam (inguinal, supraclavicular)
Testicular Tumors
• INV:
– Scrotal U/S
– CXR
– Tumor markers
• BHCG
• AFP
• LDH
– CT Chest / Abdo / Pelvis
• Rx:
– Radical orchiectomy
Testicular Tumors
• Rx:
– Dependent upon:
• Clinical stage
• Pathological stage
• Histology
– Options:
•
•
•
•
Surveillance
XRT
RPLND
Chemotherapy
Urinary Tract Injuries
Key Objective (s):
Suspect trauma to bladder or posterior urethra in patients with pelvic fracture
Examine for bleeding at the external urethral meatus after trauma; urethral
injury necessitating urgent ascending urethrogram may be present.
Urinary Tract Injuries
Objective (s):
Through efficient, focused, data gathering:
•Elicit history about the nature of the injury, difficulty voiding, and blood in urine or at
meatus; differentiate straddle injury from sexual abuse (straddle injuries typically are
unilateral and superficial and involve the anterior portion of the genitalia in both boys
and girls
• Examine for swelling, bruising, in males’ displacement of prostate on rectal
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis:
•List the most appropriate investigations used to determine the nature and severity of
urinary tract injuries (e.g. retrograde urethrogram for urethral injury, CT scan for renal
injury)
Conduct an effective plan of management for a patient with urinary tract obstruction:
• Outline initial management of anterior urethral injury (e.g. 7 to 10 days of urethral
catheterization and antibiotic therapy)
GU Trauma
• Accounts for 10% of ER trauma visits
• Associated with multi-system trauma
• Subtle presentations, easily overlooked
• Diseased GU organs susceptible to injury
Trauma Evaluation
•
•
•
•
•
Airway with C-spine control
Breathing
Circulation (2 large bore IVs)
Disability (brief neurologic exam)
Expose (general survey)
Renal Trauma
• Most commonly injured organ GU tract
• Often in association with multi-system organ
injury
• Blunt 80%
• Penetrating <20%
Renal Trauma
Renal Trauma
Presentation
• Hematuria (gross or microscopic)
– May be absent
• Shock (hypotension, tachycardia, oliguria)
• Flank mass
• Flank pain/tenderness
Imaging
• Need both anatomic and functional information
• CT Scan (with contrast) – gold standard
• IVP
• Angiography
Indications for Imaging in Scenario of Possible
Renal Injury
• Penetrating injuries
• Blunt injuries in association with
– Gross hematuria
– Shock (SBP<90 systolic)
– Children regardless of degree of hematuria
Renal Trauma - Classification
• AAST Renal Injury Grading Scale
Renal Trauma
Management
• ABCs
• Conservative for 85% of blunt trauma
– Admission, bedrest, serial vital signs, CBC
• Indications for surgical exploration
–
–
–
–
–
Hemodynamic instability
Penetrating injuries
Extensive urine extravasation
“Shattered kidney”
Pedicle injury
Bladder Trauma
Bladder Trauma
• Classified by site
– Contusion
• Hematuria and normal cystogram
–
–
–
–
Intraperitoneal rupture 30%
Extraperitoneal rupture 60%
Combined 10%
Concommitant urethral injury 10%
Bladder Trauma
• Clinical presentation
–
–
–
–
Extra 2X > Intraperitoneal ruptures
Suprapubic pain and tenderness
Inability to void
Pelvic fracture + gross hematuria
• 98% of bladder injuries have gross hematuria
• Mortality 20%, d/t associated injuries
Bladder Trauma
• Cystogram: Study of choice!
– 300 cc of contrast
– 3 films: plain, full (300cc), drainage (+/- oblique)
• IVP:
– Poor; may demonstrate only 15% of bladder ruptures
• CT:
– Bladder filled with 300cc contrast prior to CT
– Difficult to assess bladder neck competence
The severity of bladder injury cannot be determined by
the amount of extravasation seen on any Xray study
Bladder Trauma - Management
• Extraperitoneal
– Foley catheter x 10-14 days
– Selective Exploration and Repair
•
•
•
•
Bladder neck, prostatic urethra
Laparotomy
Hemorrhage / clots
Urethral catheter cannot be placed
• Penetrating
– Open repair to rule out BN injury
Bladder Trauma - Management
• Intraperitoneal
– Open surgical repair
•
•
•
•
•
•
•
Lower midline incision
Avoid dissection in perivesical areas
Vertical anterior cystotomy to assess bladder neck
Debridement
Closure in 2 layers: water-tight
Suprapubic catheter
Drain
– Postop
• Antibiotics
• Foley x 10-14 days
• Cystogram before catheter removal
Urethral Trauma
Urethral Trauma
• Proper management crucial
• Majority caused by blunt injury
• 5% of pelvic fractures have associated posterior urethral
injury
• 90% of posterior urethral injuries have associated pelvic
fractures
• 10-29% of prostatomembranous urethral ruptures have
bladder injury
Urethral Trauma
• Common mechanisms
–
–
–
–
Pelvic crush – membranous urethra disruption
Straddle injury – bulbous urethra
Penile fracture – pendulous urethra
Iatrogenic – false passages
• Classification
– Anterior: pendulous, bulbous urethra
– Posterior: membranous, prostatic urethra
Urethral Trauma
• Haematuria
• Inability to void or difficulty with voiding
• Blood at urethral meatus
– Sensitivity 33-100%
• Perineal ecchymosis (classically in a “butterfly”
pattern)
• Full bladder
• High riding prostate on DRE (posterior), bony
fragments
• Pelvic fracture: esp. rami #’s
Urethral Trauma - Diagnosis
• Retrograde urethrogram: Gold standard
–
–
–
–
–
–
–
Oblique position
Sterile technique
Slight penile stretch
8F foley in fossa navicularis, 2cc in balloon
10-20 cc slow continuous injection
Fluoroscopy preferred
Peri-catheter if foley previously
placed
Posterior Urethral Injury
Presentation
•
•
•
•
•
Pelvic #
Blood at the urethral meatus
“High riding” prostate
Scrotal swelling/ecchymosis
Inability to void
If potential for urethral injury exists,
do not insert urethral catheter
Urethral Trauma - Management
Goal: control urinary drainage and minimize long-term
complications
• Anterior:
– Primary repair: penetrating injury, penile fracture
– Suprapubic cystotomy: complete, blunt
– Urethral catheter: partial, blunt
Urethral Trauma - Management
Posterior:
• Open SPT + Delayed primary repair 3 – 6 months
• Primary catheter realignment
– Open vs.Endoscopic
– BN laceration: intrinsic sphincter mechanism crucial for
continence after membranous urethra disruption (site of
external sphincteric mechanism)
– Rectal laceration: pelvic abscess or fistula
– Long separation of prostate and bulbous urethra: difficult
delayed repair
Impotence / Erectile Dysfunction
Key Objective (s):
Recognize that a psychogenic component is present in all cases.
Recognize that testosterone deficiency is an uncommon cause of erectile
dysfunction.
Impotence / Erectile Dysfunction
Objective (s):
Through efficient, focused, data gathering:
• Determine if an organic cause for impotence is likely by a medical, sexual, and social history.
• Exclude decreased libido, ejaculatory disorders, performance anxiety, and depression.
• Identify reveersible causes (recent medications – antihypertensives, antidepressants, etc)
• Examine for signs of vascular disease and diabetic complications (BP postural change, ankle-brachial index,
pulses); examine for gynecomastia, lack of male hair distribution, small testes.
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis:
• Order screening tests for unrecognized systemic disease (e.g. diabetes)
• If hormonal cause is likely, order testosterone, LH, prolactin.
Impotence / Erectile Dysfunction
Objective (s):
Conduct an effective plan of management for a patient with urinary tract obstruction:
• Treat associated medical conditions; suggest lifestyle changes (smoking cessation, exercise,
weight loss, diet, stress reduction)
• Determine therapy for impotence based on the underlying cause (e.g. if testosterone is low and LH
is high, consider testosterone therapy / exclude prostate; if prolactin high, pituitary
imaging/referral).
• Outline the effectiveness of inhibitors of phosphodiesterase type V and contraindications.
• Describe the role of injectable, transurethral, and vacuum devices.
• Select patients in need of specialized care (e.g., failed medical therapy, penile anatomic disease,
pelvic/perineal trauma, vascular/neurologic assessment, endocrinopathies, psychiatric, etc.).
• Counsel and educate patient (+/- partner).
• Determine the therapy for impotence based on the underlying cause.
• Describe the role of specific injectable and oral medications in patients with erectile dysfunction.
Impotence / Erectile Dysfunction
KEY POINTS: PENILE COMPONENTS AND THEIR FUNCTION DURING ERECTION
•
•
•
•
•
•
•
Corpora cavernosa
Support corpus spongiosum and glans
Tunica albuginea (of corpora cavernosa) Contains and protects erectile tissue
Promotes rigidity of the corpora cavernosa
Participates in veno-occlusive mechanism
Smooth muscle
Regulates blood flow into and out of the sinusoids
Ischiocavernosus muscle
Pumps blood distally to hasten erection
Provides additional penile rigidity durin
rigid
erection phase
Bulbocavernosus muscle
Compresses the bulb to help expel semen
Corpus spongiosum
Pressurizes and constricts the urethra lumen to
allow forceful expulsion of semen
Glans
Acts as a cushion to lessen the impact of the penis on
female organs
Provides sensory input to facilitate erection and
enhance pleasure
Facilitates intromission because of its cone shape
Impotence / Erectile Dysfunction
• Normal Erection
– Innervation:
Autonomic (SNS, PNS): cavernous nerves
Somatic (sensory, motor): sensation, contraction of
bulbocavernosus/ischiocavernous
muscles
– Nitric oxide (NO) released from nonadrenergic, noncholinergic
neurotransmission and from the endothelium
•
•
•
•
1) Relaxation of smooth muscles
2) Dilation of the arterioles and arteries, increasing blood flow
3) Trapping of the incoming blood by the expanding sinusoids
4) Stretching of the tunica to its capacity, which occludes the emissary veins
between the inncer circular and outer longitudinal layers and further decreases
venous outflow to a minimum
• 5) increase in intracavernous pressure (100 mm Hg) leading to full erection
“P(arasymp) to Point, S(ymp) to Shoot”
Erection: A Neurovascular Event
Impotence / Erectile Dysfunction
• Erectile Dysfunction
– Inability to achieve or maintain an erection sufficient for satisfactory
sexual relations
– Organic (90%) vs. Psychgenic
•
•
•
•
•
•
Vascular Disease (70%)
Medications (10%)
Surgical (10%)
Neurologic (5%)
Endocrine (3%)
Trauma (2%)
Erectile Dysfunction
Evaluation
Erectile Dysfunction
Evaluation – IIEF 15
Erectile Dysfunction
Treatment
Penile Disorders
• Tx:
–
–
–
–
–
Oral (phosphodiasterase type-5 inhibitors)
Penile Injection (PGE2, papavarine, phentolamine)
Intraurethral pellet (MUSE): PGE2
Vacuum Erection Device
Penile implant
Erectile Dysfunction
Treatment
Incontinence, Urine
Key Objective (s):
Contrast between the two most common causes of
incontinence, stress incontinence and urgency incontinence.
Incontinence, Urine
Objectives
Through efficient, focused, data gathering
•
•
•
Determine duration, characteristics, frequency, timing, and amount; elicit other lower urinary
tract symptoms, precipitants, fluid intake patterns, changes in bowel habits or sexual
function.
Differentiate between stress (small amounts of leakage with exertion), urgency (involuntary
associated with urge to urinate), reflex (associated neurologic deficit), and overflow
incontinence (associated with urinary retention)
Perform an abdominal exam, a pelvic exam, and rectal exam for prostate size
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
•
•
Perform urinalysis, estimate post-void residual urine.
Select patients in need of cystoscopy and other specialized tests.
Conduct an effective plan of management for a patient with hematuria
•
•
•
•
Outline a plan of management for cystitis and urethritis.
Counsel patients with stress incontinence about possible pelvic muscle exercises.
For urge incontinence, discuss trial of anticholinergic medication (e.g. oxybutynin,
tolterodine)
Select patients for referral (e.g. neurologic conditions, genital prolapse, abnormal post-void)
Lower Urinary Tract
• Group of inter-related structures
– >> efficient and low pressure bladder filling
– >> low pressure urine storage with perfect continence
– >> periodic voluntary urine expulsion at low pressure
• Functional, physiologic, and pharmacologic considerations
• Many different classifications
– >> will present a functional and practical approach
Normal Lower Urinary Tract Function
• 2 phase concept of function
• Filling / Storage
• Emptying
Normal Lower Urinary Tract Function
• Bladder Filling / Storage
– Accomodation of increasing volumes of urine at low
pressures with appropriate sensation
– Bladder outlet that is closed at rest and remains so
during increases in intra-abdominal pressure
– Absence of involuntary bladder contractions
Normal Lower Urinary Tract Function
• Bladder Emptying
– Coordinated contraction of bladder smooth musculature of
adequate magnitude
– Lowering of resistance at the level of the smooth and
striated sphincter
– Absence of anatomic (as opposed to functional) obstruction
Voiding Dysfunction
• Any type of voiding dysfunction must result from an
abnormality of one or more of the previous factors
• The Functional classification
– Failure to Store
• Because of the bladder
• Because of the outlet
– Failure to Empty
• Because of the bladder
• Because of the outlet
The Functional Classification
Failure to Store
• Because of the Bladder
– Detrusor Hyperactivity
•
•
•
•
•
Suprasacral neurologic dz
BOO
Idiopathic
Inflammation
Aging
– Decreased Compliance
•
•
•
•
Neurologic dz (denervation)
Fibrosis / inflammation
Idiopathic
BOO
– Detrusor Hypersensitivity
•
•
•
•
•
Neurologic
Infectious
Inflammation (I.C.)
Psychologic
Idiopathic
• Because of the Outlet
– Stress Incontinence
(Hypermobility)
– Nonfunctional bladder
neck/proximal urethra (ISD)
•
•
•
•
•
Neurologic
Trauma
Surgery
Obstetrical/Gynecologic
Aging
The Functional Classification
Failure to Empty
• Because of the Bladder
– Neurologic (sacral / peripheral nerves,
pain, Herpes, DM, Tabes Dorsalis, pelvic
surgery)
– Myogenic (overdistention, infection,
• Because of the Outlet
– Anatomic
•
•
•
•
Prostatic obstruction
Bladder neck contracture
Urethral stricture
Urethral Compression
meds, fibrosis)
– Psychogenic
– Idiopathic
– Pharmacologic
– Functional
• Smooth Sphincter Dyssynergia
(SCI above T6)
• Striated Sphincter Dyssynergia
Evaluation of Voiding Dysfunction
•
•
•
•
•
•
History
Physical
Urinalysis
Urodynamics
Radiography
Cystoscopy
Videourodynamics
Evaluation of Voiding Dysfunction
• History
– Urologic
• Lower urinary tract symptoms
– Storage vs. Emptying symptoms
– Irritative, obstructive, pain, hematuria, incontinence (stress, urge,
unconscious, continuous)
–
–
–
–
–
–
Ob/Gyn
Neurologic
Medical / Surgical
Social / Psychologic
Radiation
Pelvic Trauma
Evaluation of Voiding Dysfunction
• Incontinence History
– “involuntary loss of urine”
• Symptom – statement of involuntary loss
• Sign – objective demonstration of urine loss
• Condition – pathophysiology underlying incontinence
– Characterization of incontinence
•
•
•
•
•
Stress – loss during coughing, sneezing, physical exertion
Urge – sudden, strong urge to void
Unconscious – unaccompanied by stress or urge
Continuous
Overflow
– Length and severity of symptoms
– Impact on quality of life
– Associated bowel problems
Evaluation of Voiding Dysfunction
• Physical Exam
– Systemic vaginal and pelvic exam
•
•
•
•
Condition of mucosa
Urethral hypermobility
Demonstration of incontinence / SUI
Vaginal prolapse
– Use of bottom half of small speculum
– Bimanual exam
– Standing position in females with SUI / prolapse
– Neurologic exam
• Mental status
• Mobility
• Lumbar and sacral sensory and motor
– BC reflex, anal wink, knee and ankle DTR’s, perineal / perianal sensation
Evaluation of Voiding Dysfunction
• Simple Ancillary Tests
– Voiding and intake diary
• Time, input, output, types of beverages
– Incontinence Diary
• Stress, urge
–
–
–
–
U/A – rule out hematuria, UTI
C & S, cytology when indicated
Post void residual
Pad Test
• Endoscopy
– Not recommended as a routine in the evaluation of incontinence
– May be useful when clinically indicated
•
•
•
•
•
Hematuria
Refractory incontinence
Anatomic abnormalities
Prior surgery
Etc.
Transient vs. Established Incontinence
•
•
•
•
•
•
•
•
Delirium
Infection
Atrophic urethritis/ vaginitis
Pharmaceuticals
Psychological
Endocrine
Restricted mobility
Stool Impaction
Transient vs. Established Incontinence
•
•
•
•
•
•
•
•
Delirium
Infection
Atrophic urethritis/ vaginitis
Pharmaceuticals
Psychological
Endocrine
Restricted mobility
Stool Impaction
Treatment of Voiding Dysfunction