ChapFM.qxd 6/7/06 9:19 PM Page i ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 ChapFM.qxd 6/7/06 9:19 PM Page iii Consultant Urological Surgeon, Edith Cavell Hospital, Peterborough Consultant Urological Surgeon, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading ChapFM.qxd 6/7/06 9:19 PM Page iv Blackwell Publishing Ltd 2006BMJ Books is an imprint of the BMJ Publishing Group, used under licence Blackwell Publishing Inc., 350 Main Street, Malden, Massachusetts 02148–5020, USABlackwell Publishing Ltd, 9600 Garsington Road, Oxford OX4 2DQ, UKBlackwell Publishing Asia Pty Ltd, 550 Swanston Street, Carlton, Victoria 3053, Australia The right of the Author to be identified as the Author of the Work has been asserted in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording and/or otherwise, except as permitted by the UK Copyright,Designs and Patents Act 1988, without the prior written permission of the publisher.
First published 1997Second edition 2006 Library of Congress Cataloging-in-Publication DataABC of urology / edited by Chris Dawson, Hugh N. Whitfield. — 2nd ed.
"BMJ Books."Includes bibliographical references and index.
ISBN-13: 978-1-4051-3959-5ISBN-10: 1-4051-3959-5 1. Urology. 2. Genitourinary organs — Diseases. I. Dawson, Chris, MBBS.
II. Whitfield, Hugh N.
[DNLM: 1. Urologic Diseases — diagnosis. 2. Urologic Diseases — therapy. 3. Genital Diseases, Male — diagnosis. 4. Genital Diseases, Male — WJ 140 A134 2006] ISBN-13: 978-1-4051-3959-5ISBN-10: 1-4051-3959-5 A catalogue record for this book is available from the British Library Cover image of a urinary tract x-ray is courtesy of Sovereign, ISM/Science Photo Library Set in 9/11 pts New Baskerville by Newgen Imaging System Pvt., Ltd, Chennai, IndiaPrinted and bound in Singapore by C.O.S. Printers Pte Ltd Commissioning Editor: Eleanor LinesEditorial Assistant: Vicky PittmanDevelopment Editor: Sally Carter / Vicki DonaldProduction Controller: Debbie Wyer For further information on Blackwell Publishing, visit our website:www.blackwellpublishing.com The publisher's policy is to use permanent paper from mills that operate a sustainable forestry policy, and which has beenmanufactured from pulp processed using acid-free and elementary chlorine-free practices. Furthermore, the publisher ensuresthat the text paper and cover board used have met acceptable environmental accreditation standards.
Blackwell Publishing makes no representation, express or implied, that the drug dosages in this book are correct. Readers musttherefore always check that any product mentioned in this publication is used in accordance with the prescribing informationprepared by the manufacturers. The author and the publishers do not accept responsibility or legal liability for any errors in thetext or for the misuse or misapplication of material in this book.
ChapFM.qxd 6/7/06 9:19 PM Page v Introduction to urology Hugh N Whitfield Bladder outflow obstruction
Jyoti Shah Adam Jones Subfertility and male sexual dysfunction
Stephanie Symons Management of urinary tract infection in adults
Philippa Cheatham Chris Dawson Derek Fawcett Renal and testis cancer
Paul K Hegarty Urinary tract stone disease
Hugh N Whitfield Common paediatric problems
Asif Muneer ChapFM.qxd 6/7/06 9:19 PM Page vi Specialist Registrar in Urology, Harold Hopkins Department of Senior Registrar in Urology, The Armed Forces Hospital, Al- Urology, Royal Berkshire Hospital, Reading Khoud, Sultanate of Oman Chris Dawson
Consultant Urological Surgeon, Edith Cavell Hospital, Specialist Registrar in Urology, Northwick Park Hospital, Consultant Urological Surgeon, Harold Hopkins Department Specialist Registrar in Urology, Edith Cavell Hospital, of Urology, Royal Berkshire Hospital, Reading Paul K Hegarty
Hugh N Whitfield
Specialist Registrar Urology, Great Ormond Street Hospital, Consultant Urological Surgeon, Harold Hopkins Department of Urology, Royal Berkshire Hospital, Reading Adam Jones
Consultant Urological Surgeon, Harold Hopkins Department Specialist Registrar in Urology, Edith Cavell Hospital, of Urology, Royal Berkshire Hospital, Reading Asif Muneer
Specialist Registrar in Urology, Harold Hopkins Department of
Urology, Royal Berkshire Hospital, Reading
ChapFM.qxd 6/7/06 9:19 PM Page vii There have been considerable technical and scientific innovations since the publication of the first edition of the ABC of Urologynearly 10 years ago. The time is therefore right for the publication of this revised second edition.
Acknowledging the progress made in each area of urology we felt that it was appropriate for us to take on an editorial role and invite specialist authors each to contribute to their area of expertise. Each chapter has been completely rewritten and contains upto date information contributed by an expert in the field. We hope that this edition will be the more authoritative as a result.
The ABC of Urology remains a useful introduction to the subject for surgeons training for the MRCS and will also provide a source of information for medical students. The style of each chapter also means that this book will prove a useful resource for nursing andancillary staff dealing with patients with urological problems.
We remain indebted to the staff of Blackwell Publishing without whose efforts this revised edition would not have been possible.
Chris Dawson and Hugh N Whitfield ChapFM.qxd 6/7/06 9:19 PM Page ix Introduction to urologyHugh N Whitfield Urological disorders account for about one third of all surgical Subspecialties in urology
admissions to hospital. Urological pathology is also a common reason for patients to present in primary care. Although few urological conditions are immediately life threatening, many may have a profound effect on the patient's quality of life.
As with all other medical and surgical specialties, Paediatric urology subspecialisation has occurred within urological practice.
Evidence in the confidential enquiry into perioperative deaths(CEPOD) highlighted that transurethral prostatectomy, theoperation performed most often in urological departments, isassociated with a significantly lower mortality when performedby surgeons who undertake more than 50 such procedures ayear. Most urologists will undertake core urology and willsubspecialise in one or two of the component parts of urology.
One common theme is that urological surgery requiresspecialised urological nursing to be effective Urodynamic disorders Problems of bladder outflow obstruction secondary to benignprostatic hypertrophy constitute about one third of cases inurological practice. Other urodynamic disorders occur inpatients with neurological disorders of many kinds. Themanagement of patients with urinary incontinence may alsobe included under this heading, although urogynaecologistsare now taking over a considerable part of this workload.
Prostate and bladder cancer are the two most commonmalignant diseases that present to urologists. The numbers ofrenal and testicular cancers that are being found seems to beincreasing. All patients with malignant diseases now come under A robotic laparoscopy system the care of a multidisciplinary team that consists of urologists,oncologists, radiologists, and histopathologists. Urologicaloncologist nurses have an increasing role to play in thecounselling and follow-up of patients with malignant disease.
In most urological departments with five or more urologists,one urologist will have a subspecialty interest in stone disease.
The need for expensive technology dictates that the mostcomprehensive care for patients with stone disease can beprovided only in centres with an onsite lithotripter andequipment for endoscopic treatments, including lasers.
Such a capital investment can be justified only for apopulation base of 750 000–1 000 000.
Paediatric urologists are responsible for managing congenitalanomalies that need urological reconstruction. In adult practice,urethral stricture disease remains a challenge. After radicalcystectomy for bladder cancer, some patients with incontinencecan be offered a reconstructive procedure that may beperformed by an oncological or reconstructive surgeon. A few ChapFM.qxd 6/7/06 9:19 PM Page x Introduction to urology patients with intractable urological incontinence may also beoffered a reconstructive procedure. Uncommon problemsinvolving the ureters also may require a reconstructiveprocedure, with the small intestine used to substitute for theureter.
Paediatric urology Paediatric urological disorders are managed best by those withspecial expertise in the investigation, surgery, and nursing ofchildren. The regulations that surround the care of childrenare creating a situation in which it is increasingly difficult foran adult urologist to undertake any paediatric urology. This isnot always appropriate, as the small number of paediatricurologists, at least in the United Kingdom, should be devoting Balanitis and phimosis in a 5 year old boy. Reproduced with permission their time to problems more complex than phimosis and from Dr P Marazzi/Science Photo Library undescended testicle, which can be managed very well bynon-specialists.
The role of the urologist in the management of erectiledysfunction and subfertility is changing. With the advent of oralagents to treat most patients with erectile dysfunction, much ofthis component of urology has been taken on by primary care Male factor infertility
doctors. Urologists who subspecialise in andrology may be more Some centres have a combined clinic, in which a involved in the surgery of patients with severe Peyronie's gynaecologist and urologist see both partners at the disease and those who request gender reassignment.
Gynaecologists are now undertaking much of the care of men with subfertility, although surgery for vasal Renal transplantation blockage and varicocoele remain the remit of urologists In most centres, dedicated transplant surgeons are responsiblefor renal transplantation. Urologists become involved only incases in which patients have postoperative ureteric problems orrenal stone disease.
Changes in urological practice In the last 10 years many changes have resulted in aconsiderable shift in the scope of urological care. Moreeffective medical treatment for benign prostatic hyperplasia Ratio of urologists to population
has resulted in a reduction in the number of operationsrequired for this common problem. As mentioned above, specialists from other disciplines are playing an increasing role in the management of andrological disorders and of urodynamic disorders in women.
Laparoscopic surgery is performed increasingly within urology. The dilemma arises to decide whether laparoscopic surgeons will remain organ and pathology based or technique based.
As the requirement for urological specialists to perform surgery is diminishing, the training of urologists must adapt to accommodate these changes. Just starting in the UnitedKingdom is a two stage system; a three year training in coreurology to produce a "consultant urologist" will start afterbasic surgical training. The scope of the surgery thatconsultant urologists undertake will be limited. Those whowish to become urological surgeons will have to hope thatmanpower calculations show a need before they undertake afurther period of training for two or three years in a urologicalsurgical subspecialty. Currently, the United Kingdom has alower ratio of urologists per head of the population than anyother developed country.
ChapFM.qxd 6/7/06 9:19 PM Page xi Introduction to urology Philosophy of urology The investigation and treatment of patients with urological Participants in shared care
disorders tends to be minimally invasive. The urologicalequivalent of diagnostic laparotomy seldom, if ever, is needed.
Urological surgeon General practitioner Most of even the most major urological surgical procedures may be performed laparoscopically. This will become the Continence nurses standard in the next few years.
Stoma therapists The pharmaceutical industry is anticipating an increase in the proportion of medically treated urological disorders: from5% to 15% over the next 10 years. With an ageing populationand increased expectation for quality of life, the demand formedical and surgical urological care is likely to increase.
Manpower predictions for training purposes will becomeincreasingly complex.
Shared care between urologists and primary care doctors is Participants in multidisciplinary teams
common and effective. Integration with other healthcareprofessionals—such as district nurses, physiotherapists, Urological surgeons Oncologists radiographers, and urology nurse practitioners based in hospitals—also has a pivotal role. One recent example of close Histopathologists collaboration is the setting up of multidisciplinary tumour group meetings to manage patients with urological cancers.
Nurse oncologists The provision of urological health is likely to shift in the next few years. The role of the "independent sector" in theprovision of non-oncological urology is unclear, and the lattermay become the "Cinderella" of the specialty.
Urologists have a reputation for innovation. Although innovations can be of great benefit to patients—for example,extracorporeal shock wave lithotripsy—the recent history of Urological provision is changing
urology is littered with examples of technologies that have been More care based in community introduced with great enthusiasm by their protagonists but Emergency care provided by emergency departments of district abandoned after a short time. The advent of a scrutinising general hospitals Elective surgery for oncology available at centres that provide committee from the National Institute for Clinical Excellence care for populations of about 1 million people should act to hold back those who are overenthusiastic.
Chap01.qxd 6/7/06 9:06 PM Page 1 1 Urological evaluationHugh N Whitfield Urological complaints Differentiation between urological and
non-urological causes of non-specific
The most common urological complaints that trigger the symptoms can be made only after basic
need for referral to a primary care doctor or urological surgeon can be divided into those referable to the lowerurinary tract and those referable to the upper urinary tract.
Although a careful history may be diagnostic in patients with,for example, renal colic or testicular torsion, very oftennon-specific features are more difficult to unravel.
Obstructive symptoms Irritative symptoms Erectile dysfunction and sexual problems The bladder has been described as an unreliable witness.
Urinary incontinence Pain Sensory innervation is mediated largely through parasymapathetic nerves, with pain from overdistension mediated through the sympathetic nervous system. The precision with which the site and cause of symptoms in thelower and upper urinary tracts can be identified from thisautonomic innervation is limited. Similar symptoms may occuras the result of different pathology. The art of urological evaluation on the basis of symptoms depends on understanding how much reliance can be placed on the patient's account of different symptoms and symptom complexes. This also depends Intermittent stream on the ability of the doctor to phrase questions so that the Terminal dribbling patient is clear about their meaning.
Hesitancy of micturition can be a reliable symptom. The patient
can quantify accurately a delay in initiation of the urinarystream. Using quite crude analogies, most men can describe Burning on micturition whether their urinary stream is fast or slow—that is, strong or Daytime frequency weak. A man's ability to write his initials with his urine on the wall behind a urinal indicates a strong stream, whereas a stream Urge incontinence that dribbles onto his toes obviously is weak. Patients can confirmif their urinary stream is intermittent, and this is a goodindicator of obstruction. A feeling of incomplete bladderemptying correlates poorly with objective findings on ultrasound.
A burning sensation on micturition is common in patients witha lower urinary tract infection. A similar sensation can occur in the absence of infection, however, and infection can occur inthe absence of any discomfort.
The term "dysuria" is often applied to a burning sensation on micturition, but it means different things to different people and Volume and type of fluid is best avoided. Urgency of micturition may be sensory or motorin origin, but when a history is taken, it is hard to distinguishbetween the two—although the underlying pathologies are verydifferent. Patients with urgency feel as if they may leak urine ifthey are not able to reach a lavatory imminently. The sensationof needing to pass urine again just after micturition—strangury—is the urological equivalent of tenesmus. In the urinary tract, thesymptom is not diagnostic for any one pathology.
Frequency of micturition
When patients are asked to describe their urinary frequency,
they have every opportunity for an unhelpful and lengthy reply.
The number of times a patient wakes to pass urine at night is a
Recording frequency of micturition on a "time and volume" chart can be value that most people can identify accurately. A single episode ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap01.qxd 6/7/06 9:06 PM Page 2 of nocturia is within normal limits. More than this number becomes increasingly important.
Daytime urinary frequency is subject to so many variables Urinary leakage is more common in women than that it almost is unhelpful—except to know whether such A severe degree of urge incontinence will probably frequency provokes an adverse effect on the patient's lifestyle.
cause a larger volume of urine loss than the mostsevere stress incontinence Some women are unable to identify how they leak To establish the circumstances under which urine loss occurs is Urinary leakage during sexual intercourse occurs important. Neither men nor women are entirely continent. In men, a small urinary leakage at the end of the stream (alsoknown as "post-micturition dribble") is so common that it doesnot constitute an abnormality. Many women—young and old—leak a little urine on coughing. The degree of a patient'sfastidiousness will dictate their response to minor degrees ofurinary loss of this kind.
The single most important question to follow a complaint of urinary incontinence is "What protection do you need tocope with the leakage?" If the loss of urine needs no more thana change of underwear, further investigation is unlikely to beworthwhile, but referral for consideration of pelvic floorexercises may be beneficial to the patient.
When a stone enters the intramural
ureter, patients often describe strangury,
and, in men, discomfort may be felt at
Renal and ureteric colic
the tip of the penis
The pain from a stone that is moving within the urinary tract isamong the most severe pains that patients may experience.
Stones may move within the renal collecting system, and, insuch cases, the pain is likely to be felt mainly in the loin. Whena stone moves into the ureter, the pain may radiate into theiliac fossa and the scrotum or labia. The site of the pain,however, is not a very reliable indicator of the site of the stone.
If a urinary tract infection is suspected the
presence of nitrites and red cells on dipstick
testing can be useful, although not
unequivocal, confirmatory evidence
Lower urinary tract infections do not cause a fever, whichoccurs only when a urinary infection is in a solid organ (kidney,prostate, or testis) or if the patient has an obstructed andinfected urinary tract. The latter is an emergency that needsimmediate nephrostomy drainage (under local anaesthesia). Ifan infected and obstructed kidney is suspected, urgentultrasound (to confirm hydronephrosis) should be followed by Ideally, antibiotics should not be
prescribed until a urine culture has
Erectile dysfunction presents as an inability to initiate or sustain
an erection sufficient to enable vaginal penetration and
subsequent orgasm. The presence of nocturnal or early
morning erections makes an organic cause of erectile
dysfunction less likely.
Retrograde ejaculation occurs commonly in men after transurethral resection of the prostate and sometimes in thosewho have taken a adrenergic blockers. Failure of ejaculationmay occur after sympathectomy or retroperitoneal surgery, as the sympathetic pathways to the prostate and seminal vesiclesare interrupted. Premature ejaculation occurs most often as a functional problem.
Much of the genitourinary tract is hidden from view. This dictates that many decisions on management are usually possible only at a second outpatient visit, when the results of baseline investigations are available.
Male genitalia including scrotal contents. Reproduced from Adler M, et al.
ABC of sexually transmitted infections. 5th edition. Oxford: Blackwell If a lax scrotum lies between the thighs, the scrotal contents Publishing, 2004, and adapted from the Sexually transmitted infections: can be delivered painlessly for examination by taking and history taking and examination CD published by the Wellcome Trust, 2003.
Chap01.qxd 6/7/06 9:06 PM Page 3 Urological evaluation pulling on a fold of scrotal skin. The testes appear withoutdiscomfort. The testes and epididymes can be identifiedseparately.
If epididymal infection is present or testicular torsion is suspected, the examination must be extremely gentle to avoidcausing pain. Observation of the colour of the scrotal wall mayreveal hyperaemia. The absence of a cremasteric reflex The patient's external genitalia should be
contraction when the scrotum, or the area close to the scrotum, examined with the patient in the supine
is touched is also an important sign to elicit. The loss of this and erect positions to identify pathologies
such as hernia and varicocele
reflex is not diagnostic of one pathology, but its presence isstrongly against a diagnosis of torsion.
Examination of the penis should include assessment of the degree to which the prepuce can be retracted. The externalurethral meatus must be identified: in patients with hypospadias and epispadias, the meatus will be sited Anal sphincter tone abnormally. If an attempt is made to pull the sides of the Anal sphincter contractility meatus apart, the presence of meatal stenosis can be identified.
Peri-anal sensation The shaft of the penis is palpated to identify fibrous plaques of Prostate—size, surface, symmetry, and consistency Peyronie's disease, which usually are found dorsally.
To avoid causing the patient discomfort, rectal examination is
performed best with the patient in the left lateral position. The
examiner's finger should be inserted while the patient exhales
to encourage maximum relaxation of the anal sphincter. The
tone of the anal sphincter is noted, and in patients with
incontinence as a result of weakness of the sphincter, it is
helpful to ask the patient to contract their anal sphincter.
Perianal sensation can be tested in the distribution of the S2,
S3, and S4 segments—the spinal segments responsible for the
main motor and sensory innervation of the bladder.
Examination of the prostate per rectum provides only a rough estimate of the size: the prostate can be categorised as small,medium, or large. The consistency of the prostate can bedescribed as soft, firm, or hard; the surface as smooth orirregular; and the lateral lobes as symmetrical or asymmetrical.
Although malignant prostates classically are hard, no precise correlation exists between any of the features described and aspecific pathology. Although patients find examination of the prostate uncomfortable, only a bad examination technique, anal pathology, or inflamed prostate will cause significantdiscomfort or pain.
Initial investigations Dipstick urine testing
S2, S3, and S4 segments are responsible for the main motor and sensory Readily available and frequently used, dipstick testing of urine is innervation of the bladder a very inaccurate investigation. The presence of white cells andnitrites is only a rough guide to the presence of infection,although the absence of nitrites in the urine normally is enoughto rule out an infection and the need for urine microscopy.
Microscopic haematuria may be intermittent, but the presence of blood cells in the urine normally should prompt referral for Urine cytology Biochemistry further investigation, and it now is considered unnecessary to confirm the presence of red cells by urine microscopy.
Urodynamics Radiology Nuclear medicine Many laboratories now use an automated method to identifyred and white cells in the urine. The numbers of each that canbe considered normal are considerably higher than thenumbers regarded as normal when urine microscopy is used.
These values must be recognised, particularly for red cells, toprevent inappropriate referrals.
Culture of a midstream specimen
of urine is the only way to identify
patients whose symptoms truly
Although some automation is used for the analysis of urine result from infection
cytology, the final arbiter is microscopy—the accuracy of which
Chap01.qxd 6/7/06 9:06 PM Page 4 depends on the expertise of the cytopathologist. Althoughalternatives to microscopy to identify malignant cells in urinehave been introduced, none can reproduce the accuracy of theexpert eye.
Renal function is measured better by serum creatinine than by
blood urea, the latter being influenced by the degree of
hydration and rate of metabolism. The extent of reserve renal
function means there must be a loss of two thirds of overall renal function before levels of serum creatinine increase.
Measurements of sodium, potassium, and chloride electrolytes are the other baseline biochemical tests of relevance.
Ultrasound examinations are used extensively now in the
investigation of renal, ureteric, bladder, prostatic, and scrotal
pathology. They may be regarded as an extension of
examination. Whether an ultrasound examination is undertaken
by an ultrasonographer, radiologist, or urologist, the person who
undertakes the examination has the advantage of seeing the
images in real time, while the doctor has only a few still images.
The report thus is of prime importance, and the skill of the
person who undertakes the examination is paramount.
Limitations of ultrasound vary in different situations.
KidneyIn the kidney, ultrasound is better than computed tomographyat identifying renal cysts, but it may fail to distinguish betweenparapelvic cysts and hydronephrosis. Although renal stones maygive the classic appearance of a bright echo with a blackshadow behind, this is not always the case. Ultrasound is a poorway of screening for renal stones. Assessment of the size of astone using ultrasound is not very accurate. On occasions, if astone fills the renal pelvis or the entire collecting system, it ispossible to miss it on ultrasound. If the patient is obese,ultrasound becomes more difficult.
BladderThe bladder is seen easily on transabdominal ultrasound, andvolume measurements are easy and accurate. Intravesical Renal ultrasound showing pelvi-caliceal and upper ureteric dilatation pathology, such as tumours and stones, can be seen best whenthe bladder is full.
ProstateTransrectal ultrasound of the prostate has transformedunderstanding of prostatic anatomy and pathology. Biopsies ofthe prostate and placement of radioactive seeds inbrachytherapy are always undertaken with ultrasound imaging.
ScrotumThe scrotal contents are one of the few sites in urologicalpractice where examination is easy. Differentiation between thenormal epididymis and testis is accurate, and the vas can bepalpated. In the presence of a tense hydrocele or inflammation,examination becomes more difficult and ultrasound may beworthwhile.
UreterUreteric dilatation can be identified, but the cause is muchmore difficult to define. A stone at the lower end of the uretermay be identified by using the full bladder as an acousticwindow.
Ultrasound showing dilatated ureter Chap01.qxd 6/7/06 9:06 PM Page 5 Urological evaluation Urodynamic investigations of the upper urinary tract are notcommonly performed. Assessment of the function of the lower urinary tract can be made by a number of investigations: Plain abdominal x ray Urinary flow rate is a basic measurement that is obtained Intravenous urogram easily and non-invasively Assessment of bladder capacity and the size of the residual Retrograde ureterogram urine volume is made readily by cheap bladder scanners or Antegrade ureterogram Computed tomography more expensive ultrasound machines Magnetic resonance imaging To add sophistication to a urodynamic assessment, bladder Isotope renogram pressures can be measured with a urethral catheter during Isotopic glomerular filtration rate bladder filling and emptying Isotope bone scan Further information is afforded by performing a pressure or flow assessment under fluoroscopic imaging.
Intravenous urography (combined with renal ultrasound)
remains the investigation of choice in patients with painless
Debate continues over whether
haematuria. New low osmolarity contrast media cause severe intravenous urography is better than
allergic reactions in less than 0.02% of patients.
computed tomography for the
investigation of patients with renal colic
The use of computed tomography has increased in urological
practice—often at the expense of increased doses of radiation.
Computed tomography remains the investigation of choice for
identification of renal masses. The rapid speed of the
investigation offers advantages, but interpretation of images
may need considerable investment of time at a sophisticated
workstation that can format images in a wide variety of ways.
Magnetic resonance imaging
Magnetic resonance imaging has been adopted as the
investigation of choice in the staging of prostate cancer. The
same investigation can be helpful if used on bone settings to
interpret areas of increased isotope uptake on a bone scan.
Positron emission tomography
Positron emission tomography is not available widely. It is not
used routinely yet in urology.
Dynamic isotope renography that uses mercaptoacetylglycine
(MAG3) as the radiopharmaceutical is the most accurate
method of identifying upper urinary tract obstruction and also
shows differential renal function. Static renography with
dimercaptosuccinic acid (DMSA) will identify renal scarring
and differential renal function. The most accurate
measurement of glomerular filtration rate is obtained by using
an ethylenediaminetetraacetic acid (EDTA) clearance
Axial coloured magnetic resonance image scan of a patient with prostate technique. Isotope bone scans are used in uro-oncology to cancer. With permission from Du Cane Medical Imaging Ltd/ identify bony metastatic disease.
Science Photo Library Chap02.qxd 7/7/06 4:45 PM Page 6 2 Bladder outflow obstructionJyoti Shah Bladder outflow obstruction is most commonly the result of Symptoms of bladder outflow obstruction
benign prostatic hyperplasia, which expands the transition zoneof the prostate. This is part of the normal ageing process, and 10% of men in their 40s and up to 90% of men aged 80 years will have symptoms that are attributed to benign prostatic hyperplasia. Other causes of bladder outflow obstruction Intermittent stream Terminal dribbling include urethral stricture, bladder neck obstruction, and Incomplete emptying bladder neck dyssynergia.
Levels of prostate specific antigen adjusted for age
Normal range (ng/ml)
The assessment of a man with bladder outflow obstruction begins with a history. Traditionally, symptoms have been divided into irritative (related to storage of urine) and obstructive (voiding symptoms). The severity of symptoms can be quantified by the use of numerical symptoms scoring sheetssuch as the International prostate symptom score (IPSS).
Alternative tests for prostate specific antigen
Prostate specific antigen exists in two forms in serum—free and bound to circulating proteins All men should undergo a general physical examination that A greater proportion of prostate specific antigen is includes examination of the external genitalia. The cornerstone protein-bound in patients with prostate cancer than in of the physical examination in patients with possible urological those with benign prostatic hyperplasia, which results problems, however, is a digital rectal examination. This allows in decreased free: total prostate specific antigen ratio estimates of the size and consistency of the prostate gland.
General cut off for prostate cancer is 0.15 (15%), below which the probability of cancer is high Alternative assay for complexed prostate specific antigen measures the amount of prostate specificantigen that is protein bound Density calculated by dividing level of prostate specific Urine should be sent for microscopy and culture to exclude a antigen by volume of prostate gland urinary tract infection. Haematuria should alert the doctor to Prostate biopsy advocated in patients with ratio 0.15 other urological pathology that requires further evaluation.
Serum electrolytes should also be requested. After discussion Refers to rate of change of prostate specific antigen with the patient, an assay for prostate specific antigen should be requested, although this remains controversial.
Patients with prostate cancer are thought to have more Prostate specific antigen is a glycoprotein that is secreted by rapidly increasing levels of prostate specific antigen the epithelial cells that line the prostatic acini. Any disease than those who do not have prostate cancer An increase of 0.75 ng/ml a year suggests a higher process that interferes with the basement membrane of these risk of malignancy cells will result in elevated levels of prostate specific antigen.
International prostate symptom score
Symptoms of benign prostatic hyperplasia over past month
Sensation that bladder is not empty after urinating
Need to urinate within two hours of previous urination Need to stop and start again several times while urinating Find it difficult to postpone urination Have a weak urinary stream Need to strain to urinate Number of times during night awakened by need to urinate Scores are totalled: 7 or less mild symptoms; 8 19 moderate symptoms; 20 35 severe symptoms.
ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap02.qxd 7/7/06 4:45 PM Page 7 Bladder outflow obstruction The low specificity of assays for prostate specific antigen meansthat many researchers have developed alternative tests.
One of the most important investigations in patients suspected of having bladder outflow obstruction is Obstructed bladder outflow measurement of the rate of urine flow and the volume of Urethral stricture residual urine after the bladder is emptied. Normal bladderfilling occurs up to a volume of 300–500 ml. The normalbladder, in the absence of outlet obstruction, empties tocompletion with a maximum flow rate of 15 ml/second. Apoor flow rate is not proof of obstruction as a similar picturecan be caused by detrusor failure.
A large residual volume (300 ml) represents chronic retention of urine, with a risk of upper tract dilatation in cases of high pressure chronic retention. The kidneys of patients with Typical traces produced in uroflowmetry in normal men, those with bladder residual volumes 200 ml should thus be evaluated by outflow obstruction, and those with a stricture Watchful waiting
Not all patients with bladder outflow obstruction secondary to
benign prostate hyperplasia need intervention. Their annual
risk of developing acute urinary retention is 1–2%. As long as
their symptoms are not bothersome and no complications of
benign prostatic hyperplasia are present, observation is
Plant extracts that contain saw palmetto are popular with men
who have benign prostatic hyperplasia, although little evidence
supports their use.
Blockers such as tamsulosin, doxazosin, and alfuzosin relax prostatic smooth muscle and have a rapid onset of action.
If they are going to produce a benefit, they will do so withinfour weeks of treatment being started. They can improve flowrates, although the improvement rarely is enough to restore theflow rate to the normal unobstructed range. The main sideeffect of blockers is reductions in blood pressure, which can Plant extracts that contain extracts of saw palmetto are often used to treat result in dizziness. They are therefore best taken before the benign prostatic hyperplasia. With permission from Jim Steinberg/ patient goes to bed. Retrograde ejaculation can occur with Science Photo library blockers. This is reversible when the drugs are stopped.
The 5-reductase inhibitors (finasteride and dutasteride) must be taken for 3–6 months before they produce an effect.
They are more effective in patients with large prostate glands(50 g) and will reduce prostate volume by about 20%,thereby improving symptoms. The main side effects are lossof libido and erectile dysfunction, which occurs in 3% ofpatients.
Since the medical therapy of prostatic symptoms study (MTOPS) was undertaken, some evidence has shown that blockers in combination with 5-reductase inhibitors aremore effective in managing symptoms than either treatment "The evidence supporting combination therapy [for benign
alone. Together, they also reduce the risk of acute urinary prostatic hyperplasia] in selected patients is so strong that
retention and the need for surgery for benign prostatic I expect to see major changes in medical practice in the
Leroy M Nyberg Jr
Director of the urology program,
National Institute of Diabetes and
Digestive Kidney Diseases
In the current climate, surgery is used for men who have failed Adapted from NIH news release
medical pharmacological treatment or have had complications such as acute urinary retention.
Chap02.qxd 7/7/06 4:45 PM Page 8 Transurethral resection of prostate Complications of transurethral resection of the prostate
This operation remains the gold standard for patients with benign prostatic hyperplasia. Most procedures involve a 1–2 daystay in hospital and provide improvement in symptom scores and flow rates. Although the complication rate is low, patients Retrograde ejaculation must be counselled adequately for this form of surgery.
Erectile dysfunction Transurethral incision of prostate Transurethral resection syndrome Repeat TURP needed Men with mild to moderate symptoms and a small prostateoften have an elevated bladder neck. Such men will benefitfrom one or two incisions of the prostate from the uretericorifices to the level of the verumontanum at the 5 o'clock and 7 o'clock positions. This operation is faster than transurethral resection of the prostate, and rates of retrograde ejaculationare lower (25%).
Reduced blood loss Decreased incidence of transurethral resection syndrome Ability to perform the procedure as daycase surgery Laser therapy Reduced rate of retrograde ejaculation The two main laser therapies use neodymium-doped yttriumaluminium garnet (Nd:Yag) and holmium-doped yttrium aluminium garnet (Holmium Yag) lasers. Both cause Absence of tissue for pathological evaluation coagulative necrosis of the prostate tissue under direct vision Long term results not known with a cystoscope or ultrasound.
Photo selective vaporization of prostate with green light laserGreen light laser energy is absorbed by tissues and vessels richin blood with only superficial penetration, which decreases Green light laser has a wavelength
postoperative irritative symptoms. The result is an almost of 532 nm and is in the visible
bloodless operation that is performed as daycase surgery, with green part of spectrum
symptom improvement lasting up to five years. The mean timeof catheterisation after the operation is 14 hours. At follow upat one year, the rate of retrograde ejaculation is 36% and the Cumulative reoperation rate
reoperation rate is 2.2%.
after transurethral microwave
therapy is 7%
Transurethral microwave therapyMicrowave hyperthermia can be delivered to the prostatethrough transurethral catheters under local anaesthesia. Somereports have been made of improved symptom scores aftertransurethral microwave therapy, although the rate ofpostoperative urinary tract infections is high. This is possiblybecause patients are catheterised for longer after high-energymicrowave therapy (average 1–2 weeks).
High intensity focused ultrasoundHigh intensity focused ultrasound is delivered through anultrasound probe in the rectum. This heats the prostate andresults in coagulative necrosis. This technique is less effectivefor bladder neck enlargement and median lobe enlargementand provides some improvement in symptom scores.
Transurethral needle ablation of the prostateThis technique uses interstitial radiofrequency to heat prostatetissue, which results in coagulative necrosis. As with highintensity focused ultrasound, transurethral needle ablation isineffective for men who have large median lobes and highbladder necks. Some subjective and objective improvementoccurs after transurethral needle ablation, although durabilityof the improvement is unknown.
Prostate stentsIntraurethral prostate stents that are placed with a flexiblecystoscope under local anaesthetic are an excellent option formen who are elderly and need intervention but are high risk Chap02.qxd 7/7/06 4:45 PM Page 9 Bladder outflow obstruction candidates for anaesthesia. They are placed in the prostaticfossa but tend to be covered with urothelium within six months.
They also can migrate and become heavily calcified.
This technique uses a special catheter that results in dilatation Transurethral resection of prostate remains the gold standard of the prostatic fossa. The technique is used in men who have treatment for bladder outflow obstruction as a result of benign small prostates and provides relief of symptoms.
prostatic hyperplasia Many minimally invasive techniques still need to be compared with transurethral resection of the prostate through randomised studies to provide data on durability, cost-effectiveness, and long This technique now is used only when the prostate is too large to be enucleated with endoscopic techniques. In general,prostate glands larger than 100 g are considered suitable foropen prostatectomy.
Urethral stricture Acquired urethral strictures are fibrotic narrowings of theurethra composed of collagen and fibroblasts. This restricts theflow of urine and may cause proximal urethral dilatation andbladder hypertrophy. A history of sexually transmitted diseases,urethral trauma, or previous catheterisation may be suggestiveof urethral stricture. The trace produced by uroflowmetry in apatient with a urethral stricture is indicative of a stricture.
Treatment depends on the location, length, and degree of the urethral stricture. Options include dilatation, urethrotomy,or reconstruction for more complex or recurrent strictures.
Bladder neck dysfunction Bladder outflow obstruction as a result of bladder neckdysfunction is also called bladder neck dyssynergia. Thiscondition is almost exclusively found in young and middle agedmen. Digital rectal examination tends to show a small andnormal prostate gland. The condition is characterised byincomplete opening of the bladder neck during voiding, whichproduces an obstructed trace with urodynamics.
Medical treatment in the form of a blockers can relieve symptoms, although definitive treatment consists of bladderneck incision under cystoscopic vision. This carries a 15–50%risk of retrograde ejaculation, however, and requires careful Endoscopic review of a tight bulbar urethral stricture, through which a consideration in young fertile men.
guide wire is about to be passed before a urethrotomy Chap03.qxd 6/7/06 9:08 PM Page 10 3 Urinary incontinenceHelen Zafirakis-Hegarty Urinary incontinence is defined as the involuntary leakage of Causes of stress urinary incontinence
urine. The prevalence increases with age to about 14% in Weakness of pelvic floor muscles (often as a result of childbirth) women and 13% in men aged 65–74 years. Various types of Intrinsic sphincter deficiency urinary incontinence exist.
Damage of voluntary urethral sphincter (for example, after Stress urinary incontinence is the involuntary leakage of transurethral resection of prostate) urine from the urethra in association with exertion or effort, Collagen disorders such as coughing and sneezing. Detrusor overactivity describes the involuntary contraction of the bladder and is usuallyassociated with the symptom of urgency. Leakage of urineassociated with this type of problem is known as urgeincontinence. This generally is divided into neurogenic or non-neurogenic types. Patients with mixed incontinence often havefeatures of stress and urge incontinence, usually with one typebeing predominant.
Neurogenic and non-neurogenic detrusor overactivity
Overflow incontinence is caused by chronic retention of urine as a result of a non-painful bladder that is palpable on Thought to be the result of intrinsic examination after voiding. Extraurethral incontinence implies Multiple sclerosis problems within the bladder wall leakage of urine through a fistula or an ectopic ureter. Patients Spinal cord injury typically void normally and are incontinent between voids (also known as paradoxical incontinence) The diagnosis andmanagement of vesicovaginal fistula is covered in more detailat the end of this chapter.
A detailed clinical history is of vital importance to establish thetype of incontinence on the basis of symptoms and duration.
The severity should be quantified in terms of the number ofpads required by day and night. An assessment of quality of lifewill also determine the need for referral to a urologist. Inquiryinto the past medical history should include questions related to frequency of urinary infections, parity, previous pelvic surgery, such as hysterectomy, and details of any drugs being taken.
Examination should include a physical examination as well as a neurological examination. The abdomen should be Examination or investigation
examined for a palpable bladder and scars from previous surgery. In women, examination of the perineum should look for atrophic vaginitis or signs of pelvic floor prolapse (such as cystocele, rectocele, vaginal vault, and uterine prolapse).
Women should be asked to cough repeatedly with a full bladderto try to demonstrate stress urinary incontinence. An idea of pelvic floor strength can be gained by asking the patient tocontract the pelvic floor while the examiner inserts two digits in the vagina—pelvic floor strength can be graded subjectively as weak, normal, or strong. In men, signs of phimosis or urethral meatal stenosis should be sought, and a digital rectal examination is mandatory to examine the prostate.
Urine analysis should be performed routinely in all patients.
Further assessment can be performed by asking the patient to fill in a frequency or volume voided chart, which may be performed in primary care before referral. Other investigations include pad testing, uroflowmetry (with or without assessmentof post micturition residual volume), and full urodynamics.
Flow diagram of assessment of incontinence ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap03.qxd 6/7/06 9:08 PM Page 11 Urinary incontinence Typical recording fromvideourodynamic assessment Conservative treatment of stress incontinence
Urodynamic studies examine the physiological behaviour of the bladder during filling and voiding. Small pressure transducing Pelvic floor training can be easily taught to patients and iseffective in up to 50% of patients catheters are placed into the rectum and urethrally into the It is normally taught by a physiotherapist or specialist nurse using bladder. The bladder is filled with normal saline at body vaginal cones of various sizes or biofeedback devices Exercises may need to be done regularly for a prolonged period Vesical pressure (Pves) is calculated by subtracting the if maximum benefit is to be obtained abdominal pressure (P Devices that passively stimulate the pelvic floor are also available abd—actually the pressure measured by the probe in the rectum) from the detrusor pressure (P Other non-surgical treatments include urethral plugs, topical oestrogen replacement, or agonists During the filling phase, detrusor pressure is monitored to look Duloxetine—a serotonin and noradrenaline reuptake inhibitor— for signs of detrusor overactivity. Stress incontinence can be was licensed for treatment of stress incontinence in September provoked by asking the patient to cough during filling or by 2004 and can be used in primary care other provocative manoeuvres, include rapid filling andpostural changes. The bladder capacity is recorded, andbladder compliance can also be determined from the changein detrusor pressure per unit volume.
During voiding, the detrusor pressure at maximum flow rate is recorded. The resulting flowmetry curve can also help inthe diagnosis of obstruction.
Videourodynamics is similar to the above test, but it also Management of mixed urinary incontinence
uses contrast medium for bladder filling and can show Clear understanding of main troublesome symptoms is vital, as is anatomical abnormalities. This normally is reserved for patients urodynamic assessment with mixed incontinence or assessment of stress urinary Conservative measures to control symptoms should be tried first incontinence before surgery.
Specialist care usually is preferable Adequate bladder drainage is needed by: Intermittent self-catheterisationLong term catheterisation The treatment of incontinence ranges from non-surgical Bladder outflow surgery measures, such as pelvic floor training and biofeedback, to pharmacological methods, and surgery. Incontinence nurse practitioners are extremely useful allies in the non-surgical Urinary fistulae need careful assessment followed by surgicalrepair treatment of incontinence. Patients should also be made awareof support groups and organisations available for the various Usual practice is to treat the predominant symptoms first.
forms of incontinence.
Chap03.qxd 6/7/06 9:08 PM Page 12 Surgical management of stress incontinence
Surgical management of stress incontinence in women
A variety of surgical treatments exist for women with stress incontinence. The choice depends on the patient's age and Submucosal or periurethral injection treatment uses a bulkingagent injected into the bladder neck or proximal urethra to parity, the degree of bladder neck mobility, previous surgery, increase urethral resistance. It is suitable only for patients with and patient preference. Adequate preoperative assessment by a minimal bladder neck mobility; the effects are temporary in most specialist is mandatory, and the patient must understand that more than one procedure may be needed.
Slings are very popular in patients with stress incontinence In men with sphincter damage, pelvic floor exercises may caused by intrinsic weakness of the sphincter, as well as those have a role in the first instance, but the surgical treatment of with considerable bladder neck mobility. Tension free vaginaltape especially is popular, with more than 700 000 cases having choice is insertion of an artificial urethral sphincter. This been performed with excellent results. Transobturator tapes also involves placing an inflatable cuff around the urethra and a are available and are approved by the National Institute for reservoir of fluid and a pump system normally in the scrotum.
Clinical Excellence. These can be done under general or local In its resting position, the cuff is inflated, which promotes anaesthetic. Sling procedures can also employ donated or continence. The patient activates the sphincter to allow the fluid to move back into the reservoir, which deflates the cuff Birch colposuspension and vaginal obturator shelf procedure are open procedures with excellent long term results. They are the and allows voiding to take place. The reservoir refills the cuff gold standard for patients with considerable mobility of the over a few minutes. This procedure should be performed only bladder neck. The procedure involves mobilisation of the vagina in specialist centres.
on either side of the bladder neck and suturing of theendopelvic fascia to the pectineal ligament or obturator fascia.
Management of detrusor instability
This prevents descent of the bladder during straining The mainstays of treatment for incontinence related to urgeare bladder retraining and antimuscarinic drugs. Pelvic floorexercises may also be useful as part of bladder retraining, whichinvolves teaching the patient to try to increase the timebetween voids. Antimuscarinic drugs inhibit the strength andfrequency of unstable bladder contractions, thus reducingurgency and incontinence. They also allow the bladder to holdmore volume. Treatment may be limited by side effects such asdry mouth and blurred vision. A number of such drugs areavailable, and the patient may have to try a number of these insequence to provide the best results with the minimum of sideeffects.
Pressure regulating balloon reservoir Intractable urge incontinence may be treated with intravesical instillation of botulinum toxin, which is gaining inpopularity. This treatment is not available in all centres, and the duration of effect is variable.
Surgical management for detrusor instability involves bladder augmentation with a piece of bowel (clam cystoplasty)or bladder myomectomy. These procedures often lead toincomplete bladder emptying and need intermittent self- catheterisation. As a result, these procedures are undertakenonly after much consideration.
Vesicovaginal fistula Artificial urinary sphincter Vesicovaginal fistula is uncommon in the developed world.
Most cases seen by urologists result from injury duringgynaecological surgery. Three quarters of all such fistulae occurafter abdominal or vaginal hysterectomy. Previous surgery tothe uterus and a history of endometriosis or pelvicradiotherapy all are known to increase the risk of vesicovaginalfistula. In the developing world, vesicovaginal fistulae morecommonly result from prolonged labour and trauma duringchildbirth.
Patients who develop vesicovaginal fistulae after pelvic surgery normally present with urinary leakage through thevagina within 7–10 days. In patients with more serious injury,immediate postoperative complications—such as paralytic ileus,flank tenderness, or haematuria—may develop. The lattersymptoms are suggestive of ureteric obstruction orureterovaginal fistula. Fistulae after pelvic radiotherapy may notdevelop for a number of years after the original insult.
Chap03.qxd 6/7/06 9:08 PM Page 13 Urinary incontinence The presenting features of vesicovaginal fistula may vary from a watery vaginal discharge to continuous incontinenceduring the night and day. The appearance of any symptoms ofincontinence after recent pelvic surgery should raise suspicionabout the development of a vesicovaginal fistula.
A complete examination of the patient is needed to establish the presence of vesicovaginal fistula. Often an acutepresentation of a vesicovaginal fistula will be apparent vaginallyas an area of inflammation and erythema. A more longstandingfistula may be seen as a small opening in the vaginal wall. On occasions, more than one fistulous track may be present, andthe "three swab" test may be useful.
Three swab test for diagnosis of vesicovaginal fistula
Three separate sponge swabs are placed into the vagina one The bladder is then filled with a coloured agent such as methylene blue, and the swabs are removed after 10 minutes Discolouration of only the lowest swab suggests that urine has come down the vagina—as a result of a low urethral fistula orfrom back flow into the introitus A ureterovaginal fistula will cause the uppermost swab to become wet but not discoloured, as the urine will have come from theureter above the level of the bladder A vesicovaginal fistula normally is confirmed when the topmost swab is wet and stained blue by fluid leaking from bladder intovagina Three swab test. Adapted from Chapple C, Turner Warmick R, BJU Int Radiological imaging with an intravenous urogram is useful 2005;95:193–214 with permission of the publishers, Blackwell Publishing to rule out associated ureterovaginal fistulae and also may showobstruction to the ureter or urine extravasation into the retroperitoneum. Cystoscopy and examination under anaesthesia is essential to assess mobility of tissues and to plan Abrams P, Blaivas JG, Stanton SL, Andersen JT. Thestandardization of terminology of lower urinary tract function: any subsequent surgical repair. Retrograde ureterography can report from the standardization subcommittee of the also be performed at the same time if the intravenous urogram International Continence Society. Neuro Urol Urodynam is unhelpful.
Spontaneous closure of small vesicovaginal fistulae has been Smith GL, Williams G. Vesicovaginal fistula. BJU Int 1999;83:554 –70.
reported if the bladder is drained with a catheter, but most Chapple C, Turner Warwick R. Vesico-vaginal fistula. BJU Int patients will need to undergo a surgical repair. A full discussion 2005;95:193 –214.
Huang WC, Zinman LN, Bihrle W. Surgical repair of of the range of operations available is beyond the scope of this vesicovaginal fistulas. Urol Clin N Am 2002; 29:709 –23.
chapter, but articles of interest are listed as further reading.
Chap04.qxd 7/7/06 4:49 PM Page 14 4 Urological emergenciesAdam Jones Several urological emergencies can present to medical Causes of urinary retention
professionals other than specialist urologists.
Benign prostatic hyperplasia Prostatic carcinoma Retention of urine Urethral stricture Pelvic mass (especially in women) Retention of urine can occur acutely or chronically. Acute Urinary tract infection retention is characterised by an acute onset of suprapubic discomfort associated with the desire, but inability, to urinate. It Neurological Postoperative pain or immobility is typically seen in men, when the cause is usually obstructive:for example, benign prostatic hyperplasia, prostate cancer, orurethral stricture. It can occur in women, when a pelvic massshould be excluded. Other causes of acute retention are urinarytract infection, constipation, and neurological disorders.
Urethral catheterisation is straightforward and will relieve the
patient's symptoms instantly. For patients with a history of
urethral stricture or previous traumatic catheterisations,
Important points about catheterisation
however, care needs to be taken. If any resistance is felt, do not Record the volume of urine drained on initial catheterisation persist but seek help from an experienced colleague.
Suprapubic catheterisation may be needed.
Catheterisation in the presence of urinary tract infection can precipitate sepsis In male trauma patients, consider urethral rupture (blood at the Acute retention of urine usually occurs in one of two settings: meatus, perineal bruising, and possible high riding prostate) Out of the blue— Typically, these patients have little in the way of preceding symptoms in the lower urinary tract andwould have a smaller residual volume (perhaps 900 ml). Atrial without catheter with or without preceding blockersmay be justified.
After pre-existing deterioration—Retention merely represents an "end of the road" phenomenon. In this scenario, andcertainly in patients with residual volumes much greater than900 ml, the chance of a long lasting successful trial without Predisposing causes of acute urinary retention
catheter is limited, and they should probably proceed totransurethral resection of the prostate.
Out of the blue
Constipation, postoperative Deteriorating lower urinary tract Chronic urinary retention develops over time and is pain, and prolonged car symptoms for some time painless. The classic presentation is in an older man whodevelops nocturnal enuresis, which occurs as a consequence of overflow and probably is related to relaxation of the restingsphincter pressure during sleep.
Chronic retention can be associated with chronic renal failure. In this case, initial catheterisation is essential; however, itmay be followed by postobstructive diuresis, and careful fluidbalance will be required if this occurs. Management includes dailymonitoring of creatinine and electrolytes, weight, and posturalblood pressures. In patients with chronic retention, with orwithout renal failure, trial without catheter is not appropriate, andpatients should proceed to transurethral resection of the prostateif they are medically fit or one of the less invasive alternatives suchas laser or microwave prostatectomy. In patients with significantmedical problems, options include prostatic stenting, intermittentself-catheterisation, or long term catheterisation.
Renal colic presents with severe pain that often is described asthe patient's worst ever pain. Typically, this starts in the flankand radiates around the abdomen, and it can radiate into thetestes in men and the labia in women. When a patient describes the position of pain from renal colic, they will adopt a Distended bladder ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5
Chap04.qxd 7/7/06 4:49 PM Page 15 Urological emergencies classic hand position, with their palm overlying the kidney,their fingers pointing posterior, and the thumb pointinganterior down towards the umbilicus.
If a patient uses this classic hand position, this is almost diagnostic of renal colic in itself. Unlike the pain of peritonitis,which is also severe, the patients do not lie still and, typically,are restless and cannot get comfortable in any position.
Abdominal examination is frequently unremarkable, but this may help to exclude other differential diagnoses: forexample, acute appendicitis, diverticulitis, salpingitis, andruptured abdominal aortic aneurysm. If urinalysis does notshow microscopic haematuria, an alternative diagnosis shouldbe strongly considered.
Patients should have an intravenous urogram or computed tomography urogram, depending on local preference. Theinitial management is symptomatic, with analgesics such asdiclofenac and antiemetics.
Intravenous urogram The chances of a renal calculus passing spontaneously largely depend on its size. Calculi 4 mm in size should be calculus in the regionof the mid-ureter treated conservatively, as 90% will pass spontaneously. Fifty per opposite L3 on the cent of calculi of 4–6 mm will pass spontaneously, but only control film (top), 10–20% of those 6 mm will pass spontaneously. Intervention delayed nephrogram thus is required only for stones that are highly unlikely to pass on the right comparedwith the left (middle), spontaneously, for stones that should pass spontaneously but do dilated obstructed not over a period of several weeks, and for those that cause ureter on later films continuous symptoms. Most stones can be treated by extracorporeal shockwave lithotripsy or ureteroscopy andbasketing or fragmentation by a variety of methods.
One absolute indication for intervention is the case of an obstructed infected system. Affected patients typically are Conservative management of ureteric calculi
unwell, with a history of rigors and pyrexia. They need urgentpercutaneous nephrostomy, although this intervention itself can precipitate a septic crisis. To avoid missing an obstructed infected system, a diagnosis of "pyelonephritis" should be made in hospital, with an ultrasound or intravenous urogram to Conservative initially as 90 % will pass spontaneously 50 % pass spontaneously Intervention likely as only 10 % will pass spontaneously Testicular torsion Any man who presents with an acute onset of testicular painshould be considered as having testicular torsion. The peak agefor this is in adolescence; it is rare in men older than 30 years.
The main differential diagnoses are torsion of the hydatid ofMorgagni (which typically occurs in younger children),epididymitis (which is usually caused by Chlamydia in youngermen and is related to urinary tract infections in older men),and, rarely, testicular tumours.
Younger children localise pain poorly, so the testes always should be examined—especially in younger children whopresent with abdominal pain. The classic presentation fortesticular torsion is a sudden onset of pain that typically wakesthe patient at night and is associated with abdominaldiscomfort and possibly vomiting.
On examination, the testis is usually very tender and often is riding high or lying abnormally as a result of shortening ofthe cord via the torsion. The golden rule is that if any doubtexists, the patient should have a scrotal exploration, as the Testicular torsion showing necrosis of affected testis blood supply to the testis is completely cut off in torsion andthe testis will die in about six hours.
Priapism is characterised by a persistent painful erectionunrelated to sexual desire. Priapism may be divided into lowflow and high flow. Low flow priapism is a urological
Chap04.qxd 7/7/06 4:49 PM Page 16 emergency, whereas high flow priapism is not. High flow Some causes of priapism
priapism usually has a preceding history of perineal trauma.
The aspirated blood also can be sent for blood gas analysis to Intracavernosal pharmacotherapy for erectile dysfunction Leukaemia, sickle cell disease, or pelvic tumour see if the blood is arterial or venous in origin. Oral terbutaline Penile or spinal cord trauma may also be helpful, especially in the primary care setting.
Idiopathic causes Other conservative measures may be successful, such as askingthe patient to climb the stairs (the "arterial steal" syndrome) orapplying ice packs.
If these measures fail and, certainly if the erection has been present for more than four hours, the patient should bereviewed in hospital and the corpora should be aspirated with abutterfly needle and syringe. This is done on the lateral aspectof the penis to avoid the neurovascular bundles dorsally andthe urethra ventrally. If this fails, slow infusion of an agonistsuch as phenylephrine is the next step unless the initialaspiration reveals bright red blood, which would suggest apenile arteriovenous shunt. If this still fails, the patient willneed surgery, starting with a Winter shunt to createcommunication between the corpora cavernosa and corpusspongiosum of the glans penis.
Paraphimosis is swelling of the glans penis and a failure of theforeskin to protract over the glans having been previouslyretracted. It usually occurs in the setting of a mild phimosis,where the foreskin is a little tight.
Most commonly, it occurs in elderly catheterised patients or in younger men after an early sexual experience. The tightretracted foreskin causes the glans to swell, with subsequentswelling of the foreskin itself.
To reduce the foreskin, the oedema needs to be squeezed out of the glans penis by gentle but persistent pressure on theglans for several minutes. This can be helped by using a penilering block with 1% plain lignocaine. Once the size of the glansis reduced, the retracted foreskin can be pulled back to itsnormal position. Should this procedure fail, the patient willneed to have the restricting "ring" of the prepuce incised undera general anaesthetic, which will allow the foreskin to be pulledforward again. Elective circumcision almost always should beperformed several weeks later.
Spinal cord compression Isotope bone scan with thoracic andlumbar metastases Spinal cord compression is an acute medical emergency. Itoften presents to urologists because metastatic prostate canceris one of the most common causes.
Symptoms often are rapidly progressive and irreversible, so prompt diagnosis is essential. Unfortunately, the classic Specific symptoms of spinal cord compression to elicit
presentation is rather non-specific, with the patient often Altered sensation or paraesthesia in legs described as "off his legs".
Leg weakness or difficulty walking Urinary incontinence or retention Perianal sensation often is the first sensation lost, and this Faecal incontinence can be associated with loss of the bulbocavernosal reflex. Thisreflex is seen visually as contraction of the anus on stroking the Associated with these symptoms may be signs of: perianal skin or squeezing the glans penis. Decreased anal tone Decreased muscle tone in the lower limbs may be associated with this. An urgent magnetic resonance scan Abnormal sensation is the investigation of choice, and, if spinal cord compression is "Sensory level:" this is shown by "wiggling" an examining finger confirmed, urgent neurological advice should be sought.
down the patient's midline starting at the jugular notch and Intravenous corticosteroids should be given and urgent spinal moving inferiorly. The sensory level at which the patient notices decompression or radiotherapy performed.
a change in sensation corresponds roughly to the level at which In patients with cord compression secondary to prostate the spinal cord compression is present cancer who are not already on hormone ablation, this may alsobe a case for an emergency orchidectomy.
Chap04.qxd 7/7/06 4:49 PM Page 17 Urological emergencies Top 10 tips for urological Jones A, Turner K, Handa A. Surgical emergencies:urological emergencies. Student BMJ 2000;8:268–269.
If urethral catheterisation is not straightforward, do not force Rosenstein D., McAninch JW. Urologic emergencies. Med Clin it—seek experienced help.
North Am 2004;88:495–518.
Always record the immediate post-catheterisation residual Keoghane SR, Sullivan ME, Miller MA. The aetiology, pathogenesis and management of priapism. BJU Int volume, as this may influence subsequent management If an older patient develops nocturnal enuresis, always Reynard JM, Barua JM. Reduction of paraphimosis the simple suspect chronic retention.
way—the Dundee technique. BJU Int 1999;83:859–860.
In patients with pelvic trauma, remember the possibility of a Shah J, Whitfield HN. Urolithiasis through the ages. BJU Int ruptured urethra.
Obstruction and infection in a kidney are urological Beware renal colic on the left side in older men—consider a The photograph showing paraphimosis is with permission from ruptured abdominal aortic aneurysm Raynard JM. BJU Int 1999;83:859–600.
Any testicular pain in a young man is torsion until proved Priapism needs to be corrected rapidly to avoid ischaemic fibrosis of the penis.
Do not rush paraphimosis reduction. Persistent pressure is needed on the swollen glans for several minutes todecompress it.
Do not forget spinal cord compression in a patient with a known primary cancer that has a strong tendency tometastasise to the bone (prostate and kidney, as well asbreast, bronchus, and thyroid).
Chap05.qxd 7/7/06 4:48 PM Page 18 5 Subfertility and male sexual dysfunctionStephanie Symons Subfertility is defined as failure to conceive after regularunprotected sexual intercourse over a period of one year.
About 15% of couples are thought to be affected by infertility:50% as a result of factors in the woman, 20% as a result offactors in the man and 30% as a result of factors in the manand woman. This chapter considers only male subfertility.
Male fertility is a complex process that requires an intact endocrine axis, successful spermatogenesis, satisfactory spermdelivery to the woman's genital tract, and sperm capable ofpenetrating the woman's ova. The causes for male subfertility arenumerous and can affect any one of these processes. Clinicalassessment of subfertile men is aimed at identifying any reversiblecause for subfertility and excluding significant underlyingpathology. Assessment should also identify causes of subfertilitythat are suitable for treatment with assisted reproductivetechniques. In cases of subfertility that are not reversible orcannot be managed by assisted reproductive techniques, artificialinsemination by donor sperm or adoption can be advised.
Initial assessment of subfertile men must include careful history, physical examination, and semen analysis. A sexualhistory provides details of erectile or ejaculatory dysfunctionand abstinence. Past medical and surgical history should Spermatozoa penetrating an ovum during fertilisation. With permissionfrom Eye of Science/Science Photo Library elucidate previous genitourinary infections and trauma, as wellas cryptorchidism or torsion. Attention should also be paid tothe use of drugs and the woman's reproductive history. General Causes of male factor infertility
physical examination may give clues to an underlyingchromosomal abnormality, and examination of the genitals can identify hypogonadism, absent testes or vas deferens, and Pituitary disease penile anomalies such as hypospadias and chordee.
Hypogonadotropic hypogonadism Semen analysis is the cornerstone of the assessment of Excess of androgens subfertile men. Semen should be produced by masturbation Disorders of spermatogenesis
after three days of abstinence and must be examined within two Chromosomal disorders hours of collection. Two separate samples are usually analysed, and, in most cases, the results of semen analysis guide further Testicular torsion investigation and treatment.
Sertoli cell only Subfertile men should be managed further by a multidisciplinary team in specialist fertility centres at which Sperm delivery disorders
cryopreservation of sperm is available. Men with normal results Congenital bilateral absence of vas deferens after semen analysis may need to be counselled about the Ductal obstruction timing of intercourse and avoidance of lubricants. The female Erectile dysfunction partners of normospermic men may need further evaluation.
Ejaculatory dysfunction In men with an absent or low volume ejaculate, the question Penile anatomical disorders
is whether the patient has retrograde ejaculation, obstructedejaculatory ducts, or failure of emission. In the absence of Sperm function disorders
obstructed ejaculatory ducts, azoospermic men with testicular Immunological infertility failure or absent vas deferens will need genetic counselling Ultrastructural abnormalities of sperm about chromosomal abnormalities. Reduced numbers of sperm,known as oligospermia, is an indication for hormone studies.
Levels of testosterone, follicle stimulating hormone, andluteinising hormone should be checked in men with 5–10million sperm/ml to exclude a treatable endocrine cause. A WHO criteria for normal seminal fluid analysis (2002)
diagnosis of primary testicular failure may also be established.
If further assessment by testicular biopsy is required, some Sperm concentration 20 million/ml sperm should be cryopreserved, as this avoids a second Sperm motility 50% progressive or 25% rapidly progressive operation to retrieve sperm if assisted reproduction is to be Morphology (strict criteria) 15% normal forms undertaken. Varicocelectomy and antisperm antibody testing Vitality 75% live are not advised, as no evidence shows that varicocelectomy White blood cells 1 million/ml ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap05.qxd 7/7/06 4:48 PM Page 19 Subfertility and male sexual dysfunction increases male fertility and no treatment is effective againstantisperm antibodies. If varicocelectomy is required, this maybe performed by open ligation, laparoscopic ligation, orradiological embolisation.
Assisted reproductive techniques have revolutionised the treatment of couples affected by subfertility. Intrauterineinjection of sperm can be used in men with problems withdelivery of sperm into the woman's reproductive tract, such asretrograde ejaculation and severe hypospadias. In vitrofertilisation is used in combination with female superovulationand ova harvesting when reasonable volumes of good qualitysperm can be extracted from the man. Fertile sperm areretrieved from the epididymis in such men by microsurgical orpercutaneous sperm aspiration—percutaneous epididymalsperm extraction or testicular sperm extraction. In cases ofsevere male factor subfertility, however, intracytoplasmic sperm Testicular exploration and sperm extraction injection has become the technique of choice.
Intracytoplasmic sperm injection involves the injection of a single spermatozoon into an ovum retrieved for in vitrofertilisation. A single spermatozoon can be harvested in nearlyall men from the epididymis or testis, even in cases of testicularfailure. Most couples affected by severe male factor subfertilitycan therefore now be treated with intracytoplasmic sperminjection. Factors that relate to the woman, such as age, have aconsiderable impact on the success rates of intracytoplasmicsperm injection, which have been recorded as up to 33%.
Erectile dysfunction The subcellular understanding of erectile function has produceda revolution in its treatment. From a vascular standpoint, normalmale erection depends on three integrated processes: Arterial inflow to the penis increases, filling the sinusoids of the corpora cavernosa Cavernosal smooth muscle relaxation aids arterial inflow Subsequent compression and elongation of the subtunical veins drain the corpora cavernosa decrease venous outflowand aid rigidity.
Intracytoplasmic sperm injection. Reproduced from Braude P, Rowell P.
Assisted conception. In Braude P, Taylor A (eds). ABC of subfertility. Oxford: Evaluation of men with erectile dysfunction must include a Blackwell Publishing, 2004. careful history to elucidate psychogenic causes. Risk factors forcardiovascular disease are also now known to be the mostimportant risk factors for physiological erectile dysfunction.
Risk factors for erectile dysfunction
Patients should be advised to stop smoking and should undergoscreening for hypertension, hypercholesterolaemia, diabetes, Most important risk factors
Additional risk factors
and renal disease. Hormone evaluation should include early Psychological factors morning free testosterone in patients with diminished sexual Cardiovascular disease interest or suspected hypogonadism. In patients with low levels Diabetes mellitus Neurological disorders of testosterone, the results should be confirmed and luteinising Drug side effects Hormonal disorders hormone, follicle stimulating hormone, and prolactin should Excessive alcohol be assessed to exclude prolactinoma before secondary referral.
Oral agents for erectile dysfunction have reduced the urologist's role in this area. Most patients with erectiledysfunction can now be treated within the community with one Comparisons of phosphodiesterase inhibitors
of the phosphodiesterase inhibitors. These drugs differ from each other in terms of onset of action and half life, but theirefficacy seems to be equal.
Patients should be advised to take phosphodiesterase inhibitors about one hour before sexual intercourse is desired, although some drugs, such as tadalafil, may produce potency over a much longer period. Sexual stimulation is needed to Duration (hours) 4 potentiate the effect of these drugs, and failure to respond to them often is a result of a lack of understanding of this fact.
Initial failure should not be an endpoint in itself, and the facial flushing, facial flushing, patient should be encouraged to try again on up to five or six dyspepsia, nasal dyspepsia, nasal dyspepsia, nasalcongestion occasions, with increasing doses of drugs where appropriate.
Chap05.qxd 7/7/06 4:48 PM Page 20 It may also be useful to try more than one phosphodiesterase Intracavernosal injection of prostaglandin E
inhibitor before deciding that the drugs are not going to be of Once the correct dose is established by titration against the desired effect, the patient is taught good injection technique The drug of choice is determined by individual patient The injection is placed laterally into the base of the penis, preference. Phosphodiesterase inhibitors are contraindicated in avoiding the urethra ventrally and the neurovascular bundle patients who are using nitrates, because of the risk of profound hypotension. Patients with intermediate or high risk cardiac Complications including pain and fibrosis at the injection site status should be referred to a cardiologist before their erectile and priapism should be outlined to the patient dysfunction is treated. Patients who do not respond tophosphodiesterase inhibitors should have the opportunity tosee a urologist.
Patients who fail on oral treatments for erectile dysfunction can be treated with intracavernosal pharmacotherapy, a vacuumdevice, or insertion of a penile prosthesis. Intracavernosalinjection of prostaglandin E1 remains one of the most reliableways of gaining an erection, although many patients find self-injection disagreeable. The use of a vacuum device is lessinvasive than intracavernosal injection. For patients who willnot respond to other treatment for erectile dysfunction, apenile prosthesis is considered. Prostheses can be divided intomalleable, inflatable, or non-inflatable types. Insertion of aprosthesis requires strict asepsis under a general anaesthetic,and infection remains the most important complication. Aninfected penile prosthesis should be removed.
Patient places flaccid penis into device Air is withdrawn, creating a vacuum that draws blood into the penis and results in an erection Erection is maintained by placing constriction band around the base of the penis Peyronie's disease The symptomatic incidence of Peyronie's disease is thought tobe 1%. Affected men present with pain and deformity onerection, a palpable penile plaque, and, in many cases, erectiledysfunction. Peyronie's disease is associated with Dupuytren'scontracture and a history of penile trauma. Minor injury to thetunica albuginea is thought to lead to trapping of fibrin and anexcess cytokine reaction that causes disordered healing andfocal loss of elasticity. Clinically, the disease undergoes acuteand chronic phases. During the acute phase, which can last up to two years, the erectile deformity may worsen, so it isimportant to resist surgical intervention during this time.
Various medical treatments have been tried for Peyronie's disease, but none has been shown to be effective, althoughpatients may ask to try one of these.
In patients whose deformity prevents intercourse, surgical intervention is needed. The penile curvature is corrected byexcision and plication of the contralateral tunica (Nesbittprocedure) or excision and grafting at the plaque site (Lueprocedure). The Nesbitt operation causes penile shortening,while the Lue procedure risks erectile dysfunction.
Treatments tried in patients with Peyronie's disease
Extracorporeal shock wave lithotripsy Injections of verapamil Vitamin E therapy Para-aminobenzoate tablets Curvature of penis in Peyronie's disease Chap05.qxd 7/7/06 4:48 PM Page 21 Subfertility and male sexual dysfunction Clinical picture of androgen decline in ageing men
In recent years, interest has grown in the concept of androgen Decreased sexual desire and erectile quality Decreased intellectual capacity (depression or fatigue) decline in the ageing male, which is known as "andropause." Decreased lean body mass Androgen decline in the ageing male is relatively common, and Decreased bone mineral density the cause is thought to be multifactorial. It is characterised by Decreased body hair and skin alterations reduced levels of androgen in the serum, with or without Decreased visceral fat changes in androgen receptor sensitivity. Androgen deficiency Increase in abnormal sleep patterns can affect multiple organ systems and result in significantreduction in quality of life, including sexual function. Clinically,it is important to differentiate between the ageing male who has symptomatic hypogonadism, who may require treatment,and the ageing male without symptoms, who does not.
National Institute for Clinical Excellence. Fertility:assessment Symptomatic patients with low levels of testosterone in serum and treatment for people with fertility problems. London: NationalInstitute for Clinical Excellence, 2004. Available at can be treated with a variety of forms of testosterone to maintain levels within the physiological range. Liver function, accessed 24 Jan 2006).
lipids, and levels of prostate specific antigen should be American Urological Association. Erectile dysfunction. The monitored regularly in patients started on androgen management of erectile dysfunction: an update. American Urologoical replacement therapy. Androgens are absolutely contraindicated Association, 2005. Available at: www.auanet.org/guidelines/ in men with definite or suspected prostate or breast cancer.
edmgmt.cfm (last accessed 24 Jan 2005).
Urciuoli R, Cantisani TA, Carlinil M. Prostaglandin E1 for treatment of erectile dysfunction. Cochrane Library. Issue 2.
The diagrams showing the technique for intracavernosal pharmacotherapy Oxford: Update Software, 2005.
were adapted from a leaflet published by Pharmacia and Upjohn. The Morales A, Morley JE, Heaton JPW. Practical approach toandropause (ADAM) and androgen therapy. Presented at the photograph showing testicular exploration and sperm extraction is 99th Annual Meeting of the American Urological Association, courtesy of Suks Minhas, and the photograph of Peyronie's disease is San Francisco, CA, 8–13 May 2004.
courtesy of Mr David Ralph.
Chap06.qxd 6/7/06 9:10 PM Page 22 6 Management of urinary tract infection in adultsPhilippa Cheatham Features of urinary tract infections
Urinary tract infection is bacterial invasion of the urothelium that Urinary tract infection is common, particularly in women Urinary tract infection may be less common in men because the results in an inflammatory response. A complicated urinary extra urethral length prevents bacterial colonisation of the infection carries a moderate to high risk of sepsis, with significant morbidity and mortality. Risk factors for this should alert the doctor Cystitis produces symptoms of frequency, urgency, dysuria, and to an increased risk of severe or complicated infection. Bacteriuria is a bacterial urinary tract infection that occurs without any of the Local symptoms may be absent, particularly in elderly people, usual symptoms. Antibiotic resistance is increasing, so sensitivities who may present only with increasing confusion Urine often has an offensive odour should be confirmed on cultures from midstream urine samples.
Underlying functional or anatomic disorders must be excluded Common urinary bacterial pathogens Ascending infection causes pyelonephritis, which typicallypresents with fever, loin pain, and malaise Most urinary infection is ascending. Bowel organisms, whichcolonise the perineum, displace commensal organisms and Risk factors for complicated urinary tract infection
ascend into the bladder. The number of bacteria in the bladder Urinary tract instrumentation is critical to the development of urinary tract infections. Most bacteria are Gram negative bacilli. Escherichia coli is the most Febrile urinary tract infection common organism in both sexes. In young women, Symptoms for 7 days Immunosuppression Staphylococcus saprophyticus is the second most common urinary Infection with drug resistant pathogen and is almost always related to sexual activity.
History of stone disease Recent hospitalisation Functional or structural The process of bacterial cell adhesion is the key to urinary tractinfection. Bacterial adhesins produced by pili on the bacterialsurface are important in pathogenesis: for example, the P Common urinary bacterial pathogens
fimbriae possessed by E coli. The specific adhesins determine Escherichia coli Klebsiella spp the degree and site of invasion. Adhesion of bacteria to the Staphylococcus saprophyticus Providencia spp epithelium is followed by proliferation, invasion, and initiation Streptococcus faecalis Citrobacter spp Proteus spp Serratia spp of the inflammatory process. Protective glycoprotein layers that Pseudomonas spp Enterococcus faecalis cover the urothelium are broken down, promoting colonisationof the exposed deeper layers. Patients susceptible to urinarytract infection also have increased carriage of adhesive bacteria in the large intestine, perineum, introitus, and prepuce.
infection symptoms Management of urinary tract infection in women Urinary tract infection is extremely common in women, as theshort urethral length permits easy bacterial colonisation of the Abdominal x ray of kidneys, ureters, and bladder bladder. At least 20% of women can expect to experience aurinary tract infection in their lifetime.
Diagnosis and investigation
Infection of the lower urinary tract may be diagnosed by
Treat current infection initially dipstick urine analysis. The dipstick is frequently positive for blood because of inflammation of the bladder wall. Theleucocyte esterase test detects pus cells in the urine. Bacteria in Check sensitivity and the urine that reduce nitrate to nitrite are detected by the change antibiotic if nitrate reductase test. Protein is also often detected.
Reasons for negative culture from midstream urine in
presence of cystitis symptoms
Abdominal x ray of Flow rate and measure kidneys, ureters, and Irritative symptoms not due to infection Abdominal x ray of Renal tract ultrasound kidneys, ureters, and Urinary dilution following high fluid intake Renal tract ultrasound Specimen collection in early stages of urinary tract infection Infection partially treated with antibiotics Specimen stored for too long so organisms not cultured Diagnosis and investigation of urinary tract infections ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap06.qxd 6/7/06 9:10 PM Page 23 Management of urinary tract infection in adults A midstream urine sample should be sent for microscopy Midstream urine samples
and culture to confirm the presence of bacteria and pyuria.
The midstream urine sample should thus be collected before True urinary tract infections, rather than contaminations, are present with 105 bacterial forming colonies/ml of midstream antibiotics are started. The laboratory will also test for sensitivity to antibiotics.
Many patients with infective urinary symptoms have lower counts Once the infection has been treated, a repeat midstream Presence of more than one type of organism suggests urine sample should be sent for culture to confirm that the organism has been eradicated. If haematuria persists after theinfection has been treated. this should be investigatedaccordingly.
Single episodes of documented infection in otherwise Antibiotic sensitivity testing
normal women need no special investigations, but repeatedepisodes of cystitis in women need to be investigated. Regular This is becoming increasingly important as the number of resistant organisms increases urine cultures will help identify women with abacterial cystitis, If bacteria present on urine culture are not sensitive to the as well as differentiating those with recurrent bacterial cystitis, antibiotic initially prescribed, an alternative needs to be which is the result of bacterial persistence or reinfection.
Reinfection is responsible for 95% of recurrent urinary tract Local knowledge of the bacterial uropathogens and their infections in women. An on demand facility for midstream sensitivity is crucial to minimising the likelihood of prescribing urine samples, at which the patient can drop in a urine sample an ineffective antibiotic to the general practice when they are symptomatic, will increasethe success of accurate categorisation.
Cystoscopy—with a flexible scope using local anaesthetic or rigid cystoscopy under general anaesthetic—permits Categories of women with cystitis symptoms according to
visualisation of the bladder wall. A plain x ray of the kidneys, ureters, and bladder and a renal ultrasound examination will exclude upper tract abnormalities including stones. An Bacteria always present in urine Bacteria sometimes present in urine ultrasound of the bladder combined with uroflowmetry will Bacteria never present in urine detect a residual volume and show the flow rate profile. A tighturethral meatus in women can result in poor bladder drainageand urinary infection. When obstructive symptomspredominate, a cystoscopy and urethral dilatation may improveflow and prevent further infection.
Uncomplicated urinary tract infections usually respond to a
course of three days of oral antibiotics. Patient compliance with
respect to completing the course at the correct dose maximises
treatment success and minimises development of resistance. If
urinary tract infections are related to sexual activity, a single
dose of an antibiotic may be taken after sexual intercourse.
Long term low dose antibiotic prophylaxis is an option for
those who continue to suffer recurrent attacks despite taking
Prevention is better than cure. Lifestyle advice should be given
to reduce the frequency of attacks.
Endoscopic view of prostatic urethra and bladder neck. Provided by Mr H N Other inflammatory conditions that give rise to a similar symptom complex of frequency, urgency, dysuria, andsuprapubic pain can be misdiagnosed as recurrent lowerurinary tract infections. Patients who present with persistent Prevention of urinary tract infections in women
symptoms or no growth on urine culture should therefore be Maintaining adequate fluid intake referred to a urologist for further investigation. In both men Ensuring that bladder is fully empty and women, the possibility of bladder carcinoma mimicking Emptying bladder before and after sexual intercourse symptoms of infection should be excluded by urine cytology Avoiding constipation analysis, as well as cystoscopy and biopsy if necessary. Other Wearing cotton underwear inflammatory conditions include trigonitis and interstitial Avoid using vaginal deodorants and perfumed toiletries in baths Rubber diaphragms and some spermicidal creams can aggravate cystitis. The midstream urine sample is usually free of infection, although infection can coexist. The trigone at the base of the Cranberry juice may have a definite antibacterial effect bladder is oestrogen dependant. In perimenopausal orpostmenopausal women, inflammation of the trigone as a resultof hormonal deficiency can result in irritative symptoms thatmimic urinary infection. The trigone seems inflamed oncystoscopy, but the rest of the bladder has a normal appearance.
Chap06.qxd 6/7/06 9:10 PM Page 24 Causes of urinary tract infections in men
Pregnancy is associated with bacteriuria, so symptomatic urinary tract infection is common. Hormones of pregnancy cause Local obstructive causes including urethral stricture, highbladder neck and an obstructive prostate can be detected at ureteric relaxation. Pressure of the fetal head in the pelvis compresses the ureters, with physiological hydronephrosis Urethrotomy, bladder neck incision or transurethral resection of almost inevitable as pregnancy progresses. Urinary alkalinity, the prostate can be arranged respectively if necessary.
which would encourage growth of Gram negative organisms, Bladder stones form in stagnant urine, when obstruction may also be a relevant predisposing factor to urinary tract prevents drainage. They can often be detected with a KUB x-ray.
infection in pregnancy. Ascending infection that results in acute Cystoscopy will also reveal if bladder stones are present. Stonescause infection and infection can exacerbate further stone pyelonephritis can thus easily occur. Urinary infection therefore should be taken seriously in pregnancy, as it can result in Transrectal prostate needle biopsy carries a risk of complications, premature delivery and perinatal mortality. Women are including urinary tract infection. Prophylactic antibiotics pre and screened for bacteriuria at the first prenatal visit and post biopsy are given to reduce the risk of bacteraemia resulting throughout pregnancy. If present, it should be treated with in life threatening sepsis.
antibiotics that are not contraindicated in pregnancy.
Management of urinary tract The only two antibiotics to penetrate the prostate are
infections in men trimethoprim and ciprofloxacin, which should be
remembered when the most appropriate antibiotic is
selected in men with urinary tract infections
Urinary tract infection is less common in men. A single urinarytract infection needs full investigation, as described for women.
Recurrent infection is more commonly the result of bacterialpersistence than reinfection. Prostatitis and epididymo-orchitiscan be associated with urinary tract infections in men and oftenrequire a prolonged course of antibiotics (4–6 weeks). Digitalrectal examination to assess for a tender painful prostate, aswell as examination of the external genitalia to assess fortenderness of the testes and epididymi, should therefore alwaysbe performed in men.
Upper urinary tract infection Acute pyelonephritis is defined as inflammation of the renalparenchyma and renal pelvis. The diagnosis is usually madeclinically on the basis of loin pain, fever, chills, and generalmalaise. Vomiting is not uncommon. Lower urinary tractsymptoms may be minimal at presentation. If the patient ispyrexial, blood cultures should be arranged as well as urinecultures. Prompt renal ultrasound imaging should beperformed primarily to exclude obstruction. Anatomicalabnormalities and renal stones may be detected. Intravenousurogram or computed tomography are alternativeinvestigations. Treatment includes intravenous antibiotics,intravenous hydration, analgesia, and an antiemetic if necessary.
Intravenous antibiotics are usually given for 24–48 hours. Oralantibiotics should then be continued for 10–14 days. Thepatient may take several weeks to return to normal health.
Most cases of upper urinary tract infection Infection in presence of obstructed are caused by Gram negative bacteria,predominantly Escherichia coli. Courtesy of CDC/Peggy S Hayes An infected obstructed upper urinary tract is a urologicalemergency and is potentially life threatening. If this isconfirmed on imaging, prompt decompression is essential.
Percutaneous drainage of the kidney under local anaestheticwith a nephrostomy tube can be performed in the radiologydepartment. Alternatively, retrograde placement of a uretericstent can be done in theatre. In ill patients, nephrostomydrainage is preferable. The cause of obstruction can be dealtwith at a later date, when the sepsis has resolved and thepatient is well again.
Chap07.qxd 7/7/06 4:46 PM Page 25 7 Prostate cancerChris Dawson Prostate cancer is the most common cancer in men in the United Kingdom and accounts for 20% of cancers in men overall but only 13% of deaths from cancer in men. Survival at five years in men diagnosed with prostate cancer in Englandand Wales has more than doubled in the last 20 years.
Percentage of change The risk of developing prostate cancer is linked to age, and most cases are diagnosed in men aged 70–79 years. The stage at presentation has changed dramatically over the last 20 years,with more cases being localised at presentation.
Symptoms and signs Change in presentation of prostate cancer Early prostate cancer produces no specific symptoms, so most Raised prostate specific antigen men present with lower urinary tract symptoms of benign and/or abnormal digital rectal exam prostatic hyperplasia (see Chapter 2). About 10% of patientswho undergo surgery for benign prostatic hyperplasia will be found to have prostate cancer after histological examination of with guided prostate biopsies the prostate.
Men referred with lower urinary tract symptoms shouldundergo a full history and clinical examination. The latter Monitor prostate specific antigen T stage Gleason Score should always include digital rectal examination of the prostate.
Further transrectal ultrasonography computed tomography or The use of levels of prostate specific antigen has led to with guided prostate biopsies if required magnetic resonance imaging more frequent diagnosis of early prostate cancer. Considerable Isotope bone scan if prostate specific antigen >10 ng/ml debate surrounds its use in patients with suspected prostatecancer, as the overall accuracy of the test varies between 64%and 90% in published studies.
Localised disease Many urological departments have started to use age specific reference ranges for levels of prostate specific antigen rather than absolute cut-off values for normal or abnormal Active surveillance Radiotherapy with or Active surveillance if levels. Use of these age specific reference ranges may detect Radical prostatectomy without hormone therapy prostate cancer at an early stage in younger men and reduce the number of unnecessary biopsies in older men.
The standard test for prostate specific antigen measures the total amount of the antigen in the bloodstream, but it exists in Diagnosis and management of prostate cancer different states. Most prostate specific antigen in serum isbound to protein, but a proportion exists free in thebloodstream. The proportion of free prostate specific antigen Counselling patients who request a prostate specific
reduces in patients with prostate cancer. The proportion of free antigen test
prostate specific antigen can be measured, and this can be Although the test for prostate specific antigen itself is expressed as a ratio of the level of total prostate specific innocuous, the consequences of an increased level of antigen. A free to total prostate specific antigen ratio of 25% prostate specific antigen may be more considerable in men with a total level of 4–10 ng/ml has been shown to A level of prostate specific antigen higher than the age detect 95% of cancers while avoiding 20% of unnecessary specific reference range requires a transrectal ultrasound and biopsy of the prostate, as long as no contraindications exist Similarly, the amount of prostate specific antigen bound to The biopsy procedure has known complications of haematuria, protein (complexed prostate specific antigen) can be haemospermia, and rectal bleeding. Important complications, measured. Complexed prostate specific antigen is more stable including septicaemia, have been reported but are rare in extracted blood samples and may give more reliable results A biopsy positive for cancer will lead to a discussion about than levels of free prostate specific antigen.
treatment options for prostate cancer A negative biopsy does not exclude prostate cancer, and the
Age specific reference values for prostate specific antigen
patient will often need further surveillance of their levels of prostate specific antigen and biopsies later if the levels should rise further ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap07.qxd 7/7/06 4:46 PM Page 26 The indications for transrectal ultrasound and biopsy of the prostate are an abnormal finding on digital rectal examinationof the prostate or an increased level of prostate specific antigen.
Role of screening for prostate cancer Although screening with prostate specific antigen for prostate Transrectal ultrasound scan cancer has not been adopted in the United Kingdom, this test showing prostate cancer (arrow) remains an important diagnostic tool in many cases. In men bulging anteriorly through who present without lower urinary tract symptoms, the patient must be counselled fully before the test for prostate specificantigen is performed.
A recent review of screening for prostate cancer concluded that prostate cancer remains a major health problem but: The natural history is unknown The screening test is inefficient No agreement exists about effective treatment Screening may lead to a reduction in quality of life Screening has not been proved to reduce mortality from Radical treatment may incur risks and long term side effects Whether screening is cost effective is unknown.
Transrectal ultrasonography machine (left) and biopsy equipment (right).
The biopsy gun is designed to be operated one-handed and features an Management of prostate cancer integral safety device to prevent accidental firing. Also shown in the figure islocal anaesthetic ready to inject around the prostate using a spinal needle.
The use of cassettes (shown in yellow to right of picture) and sponges to Staging prostate cancer
transport the biopsies in formalin greatly assists the pathology staff Before a decision can be made about management, the cancermust be staged with the TNM classification system and given aGleason score. Most prostate cancers are heterogeneous, andvarious degrees of histological differentiation will be seen downthe microscope. The two most common patterns are given a TNM classification for prostate cancer
score of 1 to 5 (with 5 being the most poorly differentiated).
This is expressed most commonly as, for example, "Gleason 4 3." These values are added together to give a Gleason sum No evidence of primary tumour score, which would be "7" in the example above.
Tumour is neither palpable nor visible by imaging Tumour in 5% prostate chips at transurethral Computed tomography and magnetic resonance imaging resection of the prostate are often used to stage prostate cancer in order to determine Tumour in 5% prostate chips at transurethral the presence of extracapsular spread or distant metastasis, resection of the prostate which might preclude intervention with radical therapy.
Tumour found at prostate biopsy or detected Studies, however, have shown that these imaging methods through levels of prostate specific antigen may be of limited value. The resolution of computed Palpable tumour or visible on transrectal ultrasound Involves one lobe tomography is too low to be able to distinguish abnormalities Involves both lobes within the prostate gland, the state of the prostatic capsule, or Tumour extends through prostatic capsule the presence or absence of disease outside the prostate gland.
Involves one or both sides Magnetic resonance imaging seems to be of limited value Involves seminal vesicles overall in clinically localised prostate cancer. The use of anendorectal magnetic resonance coil can help predictextracapsular penetration or involvement of the seminalvesicles. Computed tomography and magnetic resonanceimaging, however, may have a role in evaluating the status oflymph nodes in patients at risk of involvement of the lymphnodes, who are suitable for radical surgery or radiotherapy.
An isotope bone scan should be performed to exclude metastases in patients who are undergoing radical therapy, inthose with a Gleason sum score 7, or when a clinical suspicionof metastases exists. Most doctors would omit such a scan inpatients with a level of prostate specific antigen 10 ng/ml anda Gleason sum score 7.
Localised prostate cancer Gleason 3 pattern of prostate cancer (magnification 20) (left) andGleason 5 pattern of prostate cancer (20) (right). Note the marked Active surveillance preserves quality of life by the avoidance of cytological atypia, nuclear pleomorphism, and lack of gland formation significant complications associated with other treatments. This compared with the Gleason 3 pattern Chap07.qxd 7/7/06 4:46 PM Page 27 may be suitable for patients at low risk (low levels of prostate Management options for localised prostate
specific antigen, low Gleason sum score, and stage T1 or T2).
cancer (stage T1 or T2)
Patients are seen in the outpatient department at intervals ofthree to six months and are monitored through levels of Active surveillance Radical prostatectomy prostate specific antigen. If the time to doubling of levels of External beam radiotherapy prostate specific antigen is less than three years or if the patient has any signs of clinical progression, active treatment should be High intensity focused ultrasound pursued. Newer strategies for active surveillance include repeat biopsies every two years if radical treatments are still appropriate.
Radical prostatectomy has advanced considerably in the last few
years, but it remains a procedure with important potential
complications, particularly erectile dysfunction, which has been
reported in 10–80% of cases. Most surgeons now use a "nerve
Active surveillance versus radical prostatectomy
sparing" approach to dissection around the prostate to A recent study that compared active surveillance with radical maximise the chance of potency. Incontinence is much less of a prostatectomy showed—after 10 years of follow up—a reduction in problem after radical surgery compared with external beam distant metastases, local progression, cancer specific death, andoverall mortality in patients who underwent radical prostatectomy.
radiotherapy, but it may occur in up to 15% of cases.
Active surveillance thus perhaps is suited best to patients whose lifeexpectancy is reduced for other reasons External beam radiotherapy
Developments in radiotherapy techniques, such as conformal
radiotherapy, have increased the precision of radiotherapy and
Complications of external beam radiotherapy
allowed dose escalation. Treatment is often combined withandrogen deprivation therapy.
The incidence of long term erectile dysfunction after external beam radiotherapy is similar to that with radical prostatectomybut does not occur immediately Incontinence after radiotherapy occurs less commonly than with Brachytherapy involves the implantation of permanent radical prostatectomy radioactive seeds into the prostate. It offers a number of Bowel dysfunction (bleeding, passing mucus, and frequent bowel potential advantages over radical prostatectomy and external action) is a common acute complication of external beamradiotherapy and may become chronic in about 5% of cases beam radiotherapy but is limited to patients at low risk withsmall glands (50 cm3).
Most patients report a worsening of lower urinary tract symptoms after brachytherapy, and about 5% will developurinary retention. This technique therefore is not suitable forpatients with significant lower urinary tract symptoms at Potential advantages of brachytherapy over radical
presentation. Furthermore, if transurethral resection of the prostatectomy or external beam radiotherapy
prostate is needed after brachytherapy, it may be very difficult Usually performed as a day case procedure and also is more likely to lead to postoperative incontinence.
Risk of long term incontinence is low (about 1%) Erectile dysfunction may be preserved in the long term, although some studies show that up to 50% of patients potent before High intensity focused ultrasound and cryotherapy
brachytherapy may develop erectile dysfunction over five years These two treatments are mentioned for completeness but arestill largely experimental. High intensity focused ultrasound isundergoing clinical trials in the United Kingdom, and furtherdata on safety and efficacy are awaited. Cryotherapy is availablein some urological departments for the treatment of localisedprostate cancer. Details on this technique are available throughthe further reading.
In most men with a life expectancy of more than 10 years, this
option is unlikely to be appropriate. Treatment with hormones
puts off the day when definitive treatment is required, while
adding considerably to the morbidity. This option therefore is
most appropriate for men with a life expectancy less than 10
years or when this is the patient's preference.
Locally advanced prostate cancer In general, the treatment of patients in this category (stage T3or T4 but without evidence of distant metastases) is withradiotherapy or hormones, or both. Active surveillance also is Ultrasound prostate biopsy—active surveillance is an option in elderly menwith advanced prostate cancer. Some strategies for active surveillance an option in older men and those with significant comorbidity include repeat biopsies every two years if radical treatments are suitable.
and reduced life expectancy.
With permission from Dr P Marazzi/Science Photo Library Chap07.qxd 7/7/06 4:46 PM Page 28 Metastatic prostate cancer Symptoms and signs of spinal cord compression
Patients with metastatic prostate cancer cannot be cured. The May present de novo Can present with numbness or paraesthesiae, "off legs," "falls," emphasis of treatment is to control the extent and activity of or "urinary difficulty" the tumour by suppressing the levels of testosterone to castrate Prevention is better than cure—once lost, function is rarely levels or by using androgen receptor blocking agents.
In patients with asymptomatic, small volume, bony metastases, active surveillance is an option, but complicationsrelated to the cancer, such as urinary obstruction and bone Management of spinal cord compression
fractures, are reduced in patients who take hormone therapy.
Patients with advanced metastases, particularly those at risk of Admit for bed rest High doses of prednisolone spinal cord compression, should be offered immediate Urgent magnetic resonance imaging of spine hormone therapy.
Admission to radiotherapy centre for radiotherapy Customarily, an antiandrogen, such as cyproterone acetate, Start hormone therapy with antiandrogen if patient is not is prescribed for one week before and three weeks after the first already on hormone therapy dose of luteinising hormone releasing hormone analogue toprevent a transient stimulation of tumour growth. Luteinisinghormone releasing hormone agonists act by initially stimulating luteinising hormone releasing hormone, so they produce a surge of testosterone. The latter may lead to spinal cordcompression by bone metastases or urinary retention.
Laparoscopic radical prostatectomy has been performed since In most cases, the development of hormone resistant clones The procedure has a steep learning curve of cancer cells means that the prostate cancer will eventually The procedure seems to have results similar to those with open become resistant to first line therapy. This will be apparent radical prostatectomy (functional results and cancer control) but from successive rises in the levels of prostate specific antigen with faster convalescence and quicker return to normal activity and, in some cases, the development of new bone metastases on the isotope bone scan.
Second line therapy can be given by the addition of an Robotic radical prostatectomy (for example, with the da Vinci system) provides greater manual dexterity than is possible with antiandrogen such as bicalutamide. Third and fourth line standard laparoscopic approaches therapies are available, but most patients in this category will The operator performs the procedure from a console and looks succumb to their disease. Palliative chemotherapy may be through binoculars at three dimensional view of the operative considered for hormone refractory disease.
Recent guidelines suggest that patients with prostate cancer Movement of the handles at the consoles determines the that is metastatic and resistant to hormone treatment, even if movement of laparoscopic instruments placed within the pelvis asymptomatic, benefit from treatment with a bisphosphonate, This procedure is said to be easier to learn than the standardlaparoscopic procedure such as zoledronic acid, to reduce the risk from, and time todevelopment of, events such as bone pain, fracture, and spinal cord compression. Radiotherapy and strontium provide Proteomics is the study of protein expression and protein effective pain relief for bony metastatic disease.
Further study in this area may provide new markers for early detection of prostate cancer, assessment of the cancer's aggressiveness, monitoring after treatment, or predictingoutcome after treatment In the terminal phases of metastatic prostate cancer, the patientand his carers recognise that the disease is progressing despitetreatment and that the patient is reaching the end of his life.
The focus in this phase moves towards quality of life and Melia J. The burden of prostate cancer, its natural history, palliation of symptoms where appropriate. The involvement of information on the outcome of screening and estimates of ad an oncology nurse specialist and particularly a local palliative hoc screening with particular references to England and Wales.
care team at this stage is invaluable.
BJU International 2005;93(Suppl 3);4–15.
Dawson C. Is radiological imaging worthwhile in patients with clinically localised prostate cancer? In: Dawson C, Muir G, eds.
The evidence for urology. Harley: TfM Publishing, 2005.
Bill-Axelson A, Holmberg L, Ruutu M, Haggman M, Andersson S-O, Bratell S, et al. Radical prostatectomy versus watchfulwaiting in early prostate cancer. N Engl J Med 2005;352:1977–84 Scattoni V, Montorsi F, Picchio M, Roscigno M, Salonia A, Rigatti P, et al. Diagnosis of local recurrence after radicalprostatectomy. BJU International 2004;93:680–8.
The pictures of Gleason 3 and 5 prostate cancers were kindly supplied by Rees J, Patel B, Macdonagh R, Persad R. Cryosurgery for prostate Dr E Astall, consultant histopathologist, Peterborough and Stamford cancer. BJU International 2004;93, 710–4.
Hospitals Foundation Trust.
Chap08.qxd 6/7/06 9:13 PM Page 29 8 Bladder cancerDerek Fawcett Adenomacarcinoma and squamous cell carcinoma
In the western world, bladder cancer is commonly a neoplasm In areas of endemic schistosomiasis (caused by Schistosomahaematobium), most bladder cancers are squamous cell cancers, of the transitional cells that line the urinary tract (transitional although this parasitic infection may produce transitional cell cell cancers). It is predominantly environmental in origin, being caused by carcinogens excreted in the urine. Bladder Squamous cancers also may occur in older women with chronic cancer is more common in men than women (3:1).
urinary tract infection and may present in bladder diverticulae Workers in some occupations have an acknowledged risk of Adenocarcinoma of the bladder classically arises in a urachal bladder cancer—for example, those in the rubber industry and remnant, from areas of metaplasia, or from direct invasion fromthe colon those who handle aniline dyes. Industrially related cases of The bladder is also the site of rarer tumours, including bladder cancer are decreasing now that regulations are in force phaeochromocytomas and rhabdomyosarcomas (in children) to prevent the use of known carcinogens.
If bladder adenocarcinoma is detected, a primary site outside the Specific aromatic amines (such as 2-naphthylamine and bladder should be excluded before assuming a primary bladder nitrosamines) are highly carcinogenic for the bladder and have been identified in cigarette smoke. Sadly, evidence supports theidea that many bladder cancers are related to cigarette smokingand are thus self-induced. Doctors in primary care have animportant role in communicating the message that smoking Important signs and symptoms
causes cancers of the bladder, as well as other organs.
Macroscopic haematuria never must be ignored On a daily basis, we breathe many other environmental Patients with macroscopic haematuria must be referred at the carcinogens that may also predispose to the development of time of first presentation Recurrent microscopic or dipstick haematuria in patients of bladder cancer.
either sex older than 40 years should be referred Symptoms and signs of bladdercancer Haematuria—the cardinal sign of bladder cancer—is classicallypainless and commonly is intermittent. All patients withmacroscopic haematuria should be referred for investigation.
An exception can be made in young women with a provedurinary tract infection, but these patients should also bereferred for investigation if the haematuria persists despitetreatment of the infection.
Macroscopic haematuria has a risk of 20–25% of cancer (bladder, renal, and prostatic) and the risk of detecting similarcancers in patients with microscopic haematuria is around 4%.
Occasionally, bladder cancer presents with infection or is foundincidentally on ultrasound. Investigation of microscopichaematuria is controversial, but currently the recommendationis that persistent evidence of haematuria on microscopy ordipstick testing in patients older than 40 years should bereferred for investigation.
Primary carcinoma in situ rarely presents with haematuria.
It may present with irritative symptoms.
Papillary transitional cell carcinoma Investigation of patients withsuspected bladder cancer All patients with bladder cancer should be managed byurologists who are part of a multidisciplinary team associatedwith a cancer network.
Most patients now are seen in specialist haematuria clinics. Fibre
optic cystoscopy under local anaesthetic will be the initial
investigation. This may show a classic papillary tumour (fronded
Sessile transitional cell and like seaweed) or a tumour that is more broad based (sessile) and less papillary and solid looking, which may be invasive.
ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap08.qxd 6/7/06 9:13 PM Page 30 Transitional cell cancer stages: G1—well differentiated (left), G2—moderately differentiated (centre), and G3—poorly differentiated (right) Specimens of urine will be taken for culture and cytology, and imaging of the urinary tract will be arranged. Cytology ofthe urine may be affected by the instrumentation of the urinarytract, so samples for cytology should be sent before thecystoscopy is performed.
Some debate remains about the ideal imaging method for
patients with haematuria and suspected bladder cancer.
Traditionally, the intravenous pyelogram is the standard, but it
must be complemented with ultrasound to exclude mass lesions
of the kidney. Ultrasound alone is almost certainly inadequate.
Cytology of voided urine Cross sectional imaging (computed tomography or magnetic showing a clump of resonance imaging) is reserved for staging muscle invasive bladder cancer.
The definitive diagnosis is made on biopsy, which is commonly
taken with a rigid cystoscope or resectoscope under Impalpable before and after resection anaesthesia. Bladder muscle must be included in the biopsy to Palpable before but not after resection exclude or confirm muscle invasion—the single most important Palpable before and after resection prognostic feature of bladder cancer.
Involving a neighbouring organ Bimanual examination under anaesthesia is essential in the assessment of bladder cancer, as the clinical stage or categorywill become apparent. A palpable mass after resection is a good guide to arranging computed tomography or magneticresonance imaging before the results of biopsies are known.
Confined to urothelium; basement membrane not breached Histological types and gradingTransitional cell and squamous cell cancers of the bladder are Invasion into lamina propria Superficial (invasive) described by histopathologists in three grades: G1 (well Overtly malignant cells form a layerthat replaces urothelium differentiated, G2 (moderately differentiated), and G3 (poorlydifferentiated). These grades represent the overall level of Invasion into muscularis propria dedifferentiation from normal histology and architecture. Theyhave prognostic value and different treatment pathways.
Deep invasion into muscularis propria (detrusor) Microscopic extravesical spread StagingClinical staging (T category) is established by bimanual Macroscopic extravesical spread examination at cystoscopy and biopsy under anaesthetic.
Involves neighbouring organ Pathological staging is determined by the histopathologist after Involved lymph nodes
examination of the biopsy. It is denoted by the prefix "p." Nodal disease indicates a very poor prognosis. The TNM Biopsies can be staged only up to stage pT2a, as staging higher classification classifies it as follows: than this requires a whole specimen from cystectomy.
N1: single node 2 cm N2: single node 2 cm, multiple nodes 5 cm N3: 5 cm Treatment of bladder cancer Superficial bladder cancer (pTa and pT1)
The TNM classification classifies soft tissue or bony metastases as The overall aim of treatment in superficial bladder cancer (pTa and pT1) is preservation of the bladder and achievement of a M1: presence of metastases normal life expectancy by detecting progression and preventingrecurrence. This is achieved in most cases by a combination oftreatment and surveillance (check or review cystoscopy).
Chap08.qxd 6/7/06 9:13 PM Page 31 cystoscopy under local cystoscopy under local Simple recurrence: Simple recurrence: in six months under in six months under local anaesthesia local anaesthesia Multiple recurrence: Multiple recurrence: six hours for all six hours for all mitomycin C x 6 and mitomycin C x 6 and in 6-8 weeks under in 6-8 weeks under general anaesthesia general anaesthesia If confirmed, BCG x 6 If confirmed, option of BCG x 6 and check High risk group
High risk group
general anaesthesia general anaesthesia Presence of
If upstaged, follow carcinoma in situ
If upstaged, follow carcinoma in situ
Include carcinoma Include carcinoma appropriate protocol in situ protocol in muscle invasive bladder in situ protocol in treatment decision treatment decision Management of pTa bladder cancer Management of pT1 bladder cancer Newly diagnosed superficial bladder cancer is resected under general anaesthesia (transurethral resection of bladdertumour). A single instillation of mitomycin C is given into thebladder within 6–24 hours of resection. In patients withsuperficial bladder cancer, the instillation of mitomycin Cwithin a few hours of resection significantly reduces theincidence of recurrent disease at three months.
The use of intravesical BCG as a non-specific immune stimulant is now standard practice in patients with high gradesuperficial bladder cancer (pTa G3, pT1 G3, or pTis). It is Common side effects of treatment with
given in a course of weekly instillations for six weeks.
Symptoms severe enough to require antituberculous Bladder irritability: treatment can occur in up to 6% of patients. Systemic infection with BCG has been responsible for several deaths.
It must be recognised that pT1 disease is already showing invasive potential and has a significant risk of progression. The overall intention of treatment is preservation of the bladder and achievement of normal life expectancy.
Poorly differentiated tumours (pT1 G3) are always subject to repeat biopsy to confirm the stage. If confirmed, intravesical immunotherapy is indicated (six instillations of BCG). If muscle Granulomatous prostatitis invasion is detected, the protocol for pT2 tumours is followed.
Widespread pT1 G3 tumour associated with carcinoma in situ is a dangerous situation, and serious consideration shouldbe given to early radical cystectomy. Cross sectional imagingshould be performed before radical surgery is considered.
Carcinoma in situ
Although classified as superficial bladder cancer, carcinoma in
situ is a completely different type of disorder that carries a high
risk of progression to muscle invasive, and hence life
threatening, bladder cancer. The prime intention of treatment
is to eradicate the changes by immunotherapy, maintain
surveillance, and predict and prevent progression to
Carcinoma in situ of the urinary bladder (pTis) is traditionally included under the heading of superficial bladdercancer, because it is superficial and the basement membrane isnot breached. It is at the end of the spectrum of dysplasia ofthe urothelium. The cells, however, cytologically are malignant,and the tumour may progress rapidly to muscle invasive cancer.
pT1 G3 bladder tumour Chap08.qxd 6/7/06 9:13 PM Page 32 Postoperative pathology Option of ileal conduit or reconstruction reviewed at multidisciplinary discussed with patient if appropriate Follow-up or adjuvant Transurethral resection of bladder tumour Patient receives three cycles of gemcitabine + cisplatin Intravesical mitomycin C or methotrexate, vinblastine, doxorubicin and cisplatin not given if suspicion of Computed tomography after chemotherapy Histology and imaging muscle invasive tumour and cystectomy six weeks later reviewed at multidiciplinary team meeting and treatment Abdominal pelvic computed options decided (may differ tomography scan arranged if not a transitional cell before next appointment Patient receives 60 Gy external beam radiation carcinoma bladder cancer) Initially one month follow- if tumour thought to be therapy (curative intent)or 21 Gy external beam up, then every three months radiation therapy (palliative) for one year, then extended to every 4-6 months as per clinical decision Eventually, yearly follow-up Patient referred to oncology and appropriatespecialists for symptom control and support Management of muscle invasive bladder cancer Complications of urinary division
Traditionally, BCG is given in weekly instillations for six weeks followed by a check cystoscopy and biopsy at three Electrolyte and acid-base balance Hyperchloraemic metabolic acidosis months. Debate remains as to whether BCG prevents Can lead to electrolyte abnormalities, osteomalacia, altered liver progression of carcinoma in situ to invasive bladder cancer.
metabolism, renal stones, and abnormal drug metabolism Widespread primary carcinoma in situ is very dangerous, Deterioration in renal function—may result, for example, from and serious consideration should be given to early radical chronic retention or infection in neobladders or stenosis of cystectomy, instead of attempting to conserve the bladder by uretero-ileal junction in an ileal conduit.
the use of BCG. Rarely, carcinoma in situ may metastasise Bone disease—from chronic acidosis without an apparent "tumour" in the bladder.
Impairment of growth and development (in children) Mucus production in intestinal segments used in diversion or Muscle invasive bladder cancer (pT2 and pT3)
Muscle invasive bladder cancer is a life threatening disease that Development of stones requires meticulous staging and treatment planning. In patients Rupture (in orthotopic neobladders) with reasonable life expectancy and localised disease, the Tumour formation—exact risk of development of intention of treatment is cure, but in elderly people, palliation adenocarcinoma in intestinal segment used for reconstruction ordiversion unknown may be a preferable strategy.
Primary surgeryPrimary surgery is the treatment of choice if the patient is fit.
In men, surgery comprises cystoprostatectomy and pelvic nodedissection, but in women it needs anterior pelvic clearance,with a hysterectomy, salpingo-oophorectomy, and upper thirdvaginectomy. Mortality should be 2%. Such surgery should becarried out only in centres that perform large amountsroutinely. In patients unfit for surgery or who prefer to avoidsurgery, external beam radiotherapy is an alternative.
Neoadjuvant and adjuvant chemotherapyThe role of neoadjuvant chemotherapy remains uncertain, butdownstaging achieved with neoadjuvant chemotherapy seems tolead to a better outcome. Adjuvant chemotherapy has littleevidence in its favour and is of doubtful value.
Urinary diversion after bladder removalBladder removal is followed by a cutaneous diversion (ilealconduit) or by orthotopic or ectopic bladder reconstruction(neobladder). In the early 1950s, Bricker introduced theconcept of interposing a section of small bowel between theureters and skin as a conduit (ileal conduit). This allowed theconstruction of a larger and non-stenosing stoma over which abag could be fitted. The ileal conduit has remained themainstay of urinary diversion after cystectomy ever since.
Efforts to create a replacement urinary reservoir have led tothe creation of orthotopic reservoirs that are attached to thenative urethra, thus allowing urine to be expressed in thenormal way.
"Studer" type orthotopic neobladder Chap08.qxd 6/7/06 9:13 PM Page 33 Palliative care in bladder cancer
If death from bladder cancer is inevitable, priority must be given to preventing death from locally recurrent disease and Oosterlink W, Lobel B, Jakse G, Malmström P-U, Stöckle M, Sternberg C, et al. Guidelines on bladder cancer. Eur Urol 2002; the associated misery of bleeding and strangury.
The old surgeon's prayer "Pray it not be my tongue or my Gerharz EW, Turner WH, Kalble T, Woodhouse CRJ. Metabolic bladder" is indicative of the misery that bladder cancer causes and functional consequences of urinary reconstruction with in its late stages. Pain, bleeding, strangury, and fistulation are bowel. BJU International 2003;91:143–9.
typical end stage problems in all types of pelvic cancer. In the Meyer J-P, Fawcett D, Gillatt D, Persad R. Orthotopic neobladder presence of incurable disease, various methods can be used to reconstruction—what are the options? BJU International 2005;96:493–7.
reduce the incidence of these symptoms.
Studer UE, Varol C, Danuser H. Surgical atlas—orthotopic ileal A team approach—with urologist, clinical oncologist, neobladder. Br J Urol 2004: 93; 183–93.
palliative care doctor, clinical nurse specialists, and pain controlteam—should provide a multidisciplinary approach topalliation. This requires use of good symptom relief with paincontrol, palliative radiotherapy, or palliative chemotherapy: allof which aim to improve the quality of life and reduce pain and I thank Nicky Sillwood Clinical Nurse Specialist in Uro-Oncology, Harold Hopkins Department of Urology, Royal Berkshire Hospital, and Natalie Urinary diversion or even cystectomy are justified as Scott-Young, special reader in histopathology, Royal Berkshire Hospital,Reading. The line drawing of the Studer type orthotopic neobladder is palliative measures for bleeding, pain, and fistulation. Good adapted from Studer UE, et al. BJU Int 2004;93:183–93. With permission of practice is to consider the possible consequences of late local the publishers, Blackwell Publishing.
recurrence when deciding the initial treatment strategies atpresentation.
Bladder cancer (new or end stage) that presents with bilateral ureteric obstruction and acute renal failure isparticularly difficult to manage for the admitting team.
Nephrostomies can be easily inserted to prevent immediatedeath, but patients rarely survive more than a few weeks andallowing death at presentation occasionally may be anappropriate decision.
Chap09.qxd 6/7/06 9:14 PM Page 34 9 Renal and testis cancerPaul K Hegarty Presentation
The classic triad of flank pain, haematuria, and palpable mass
Paraneoplasia is a clinical or biochemical disturbance associated
with malignant tumours not related directly to invasion by the
thankfully now is rare. Such a presentation usually denotes a primary tumour or metastasis
locally advanced cancer. A paraneoplasia is found in 20% ofcases, which is why renal cell carcinoma previously was knownas the "physician's disease." Rank order of paraneoplastic processes in renal cell
Diagnosis of renal cell carcinoma begins with a full history and examination. Although most varicoceles arise in the absence ofany other condition, a newly developed varicocoele on the left side in the presence of a left renal tumour implies renal vein Raised erythrocyte sedimentation rate involvement, usually at a stage where the primary tumour is palpable. A full blood count; erythrocyte sedimentation rate; and serum calcium, liver, and renal profiles all are indicated to exclude any of the associated paraneoplastic conditions.
Abnormal results of liver function test Raised levels of serum calcium Raised levels of haemoglobin The diagnosis of renal cell carcinoma is largely radiological, with biopsy seldom used. Ultrasonography allows diagnosis of many renal tumours nowadays and is particularly good at Stauffer's syndrome: abnormal liver function test and raised distinguishing solid masses from simple cysts. Ultrasound also provides good imaging to determine involvement of theinferior vena cava. Staging of renal cell carcinoma is primarilyby high quality abdominal computed tomography. A chest x ray TNM classification of renal cancer (1997)
is usually sufficient to stage the thorax. Magnetic resonance imaging can be used when venous involvement is suspected orthe patient is allergic to intravenous contrast medium. Three 7 cm confined to kidney 7 cm confined to kidney dimensional computer reconstruction of computed Into adrenal or perinephric fat not Gerota's fascia tomography or magnetic resonance imaging is essential for Involvement of the vena cava below diaphragm planning surgery nephron-sparing surgery.
Involvement of the vena cava above diaphragm Beyond Gerota's fascia One regional node Knudson and Strong proposed that a gene product that could More than one regional node suppress tumour development must be involved in Distant metastases carcinogenesis. They suggested that mutation or inactivation ofboth alleles of this "tumour suppressor gene" would be neededfor the evolution of cancer. They thus proposed a "two hit"theory of carcinogenesis. Their hypothesis has been proved fora number of cancers, including renal cell carcinoma. VonHippel-Lindau disease is an autosomal dominant disorder thatoccurs in one per 36 000 population. Half of such casesdevelop renal cell carcinoma.
The gene for Von Hippel-Lindau disease is a tumour suppressor gene on chromosome 3. It contains three exons and Computed tomogram of theabdomen with intravenous encodes a protein of 213 amino acids. Loss of its activity favours contrast demonstrating tumour growth. Abnormalities in the gene for Von Hippel- tumour arising from right Lindau disease are evident in 75% of sporadic cases of renal kidney and tiny left kidney cell carcinoma. Furthermore, mutation of p53 has beenreported in 6–40% of cases of renal cell carcinoma and maycorrelate with tumour grade and stage.
Van Hippel Lindau protein Features of Von Hippel-Lindau disease
Altered hypoxia inducible factor I Phaeochromocytoma Retinal angiomata Vascular endothelial growth factor Hemangioblastomas of the brain stem, cerebellum, or spinal Neovascularity of tumour Pancreatic cysts and adenocarcinoma Epididymal cystadenoma Proposed pathway of effect of loss of Von Hippel-Lindau gene activity Endolymphatic sac tumour in ear (0.5%) ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap09.qxd 6/7/06 9:14 PM Page 35 Renal and testis cancer Innovation in laparoscopy allows total
and partial nephrectomy to be
The growth rate and risk of metastasis of small renal tumours informed with minimal invasion
(3 cm diameter) that are discovered incidentally are low.
They may be managed by observation in unfit patients or thosewith short life expectancy.
SurgeryRemoval of all of the tumour currently offers the best chance of cure. Traditionally, open radical nephrectomy was indicated Used to be reserved for patients with bilateral for all cases without metastasis. Partial nephrectomy allows tumours, solitary kidney tumours, and currentor possible future renal impairment preservation of ipsilateral renal function.
Increasingly offered to patients with normal Open nephrectomy remains necessary for large primary contralateral renal function tumours or those with involvement of the inferior vena cava.
Nephrectomy may also be performed to "debulk" the tumourload before immunotherapy with interferon.
AblationSmall cancers may be treated by cryotherapy or radiofrequencyablation. These tumours need to be imaged clearly and aretargeted best if they are on the periphery of the kidney. Thesemethods hold great promise but must be proved to matchstandard surgery in oncological control.
Adjuvant therapyChemotherapy—Renal cell cancer is resistant to chemotherapy.
Renal cancer cells express transmembrane proteins that activelypump out large hydrophobic compounds, including several of Right radical nephrectomy specimen. Note the adrenal the cytotoxic drugs.
gland superomedially and tumour extension into the Immonotherapy—Various immunotherapeutic regimens have inferior vena cava and contralateral vein been described, with combined complete and partial responsesat best of up to 30%. Interferon alpha and, more commonly,interleukin 2 are used to treat metastatic disease, especially Classification of testis cancer
after debulking of the primary tumour with surgery. Patients Germ cell tumours
who may be amenable to immunotherapy tend to have non- bulky pulmonary or soft tissue metastases, or both. Patients Non-seminomatous germ cell tumours with bony metastases respond poorly to immunotherapy.
Non-germ cell tumours (5–6%)
Radiotherapy—Radiation is used for symptomatic bone or brain metastases.
Leydig cell tumours Sertoli cell tumours (very rare) Lymphoma (secondary tumour) Cancer of the testis is the commonest cancer occuring in menaged between 15 and 35 years. The lifetime risk is one in 500.
Non-seminomatous germ cell tumour
High rates of cure in patients with testis cancer are the Non-seminomatous germ cell tumour occurs typically in men result of modern multidisciplinary treatments. They are aged 20–35 years unrivalled in patients with other solid tumours. These enviable Histological types comprise embryonal carcinoma, teratoma, results are dependent on the doctor and rely on a team choriocarcinoma, and yolk sac elements alone or mixed approach that combines urological surgery, chemotherapy, and More aggressive and less chemosensitive and radiosensitive than Early presentation is the patient factor that determines cure In the presence of seminoma and non-seminomatous elements,the clinical behaviour is regarded as non-seminomatous germ rates. Symptomatic delay has a proved negative impact on cell tumour.
disease stage, treatment outcome, and mortality.
Most cases of testis cancer present with a scrotal mass or
discomfort. Advanced cases can present with back pain, Classic seminoma occurs typically in men in their 30s respiratory compromise, or neurological deficit. Examination Relatively slow growing and chemosensitive and radiosensitive should not be restricted to the scrotum; it should include the Anaplastic type has greater mitotic activity, with higher rate of abdomen and supraclavicular fossa.
Spermatocytic type often occurs in men older than 50 years and has a low metastatic potential Alpha fetoprotein is raised in embryonal carcinoma,teratocarcinoma, yolk sac tumour, or combined tumours but notwith pure choriocarcinoma or pure seminoma. Human chorionic Chap09.qxd 6/7/06 9:14 PM Page 36 Prognosis of testis cancer based on marker levels
Human chorionic gonadotrophin (IU)
gonadotrophin is raised in all patients with choriocarcinoma,40–60% with embryonal carcinoma, and 5–10% with pure Royal Marsden Hospital's staging system
seminoma (apparently produced by the syncytiotrophoblast-likegiant cells that occur in some seminomas). Lactate dehydrogenase is found in seminomas and non-seminomatous Tumour confined to testis germ cell tumours in proportion to the disease stage. Placental Regional nodes 2 cm alkaline phosphate is a fetal isoenzyme; its levels are raised in Regional nodes 2–5 cm 40% of patients with advanced seminoma.
Regional nodes 5 cm Levels of markers before treatment correlate with prognosis. Normalisation of levels of markers after treatment cannot be equated with the absence of residual disease.
Between 10% and 20% of patients who receive combined TNM classification of testis tumours (1997)
systemic chemotherapy for bulky metastatic disease andsubsequently undergo retroperitoneal dissection of the lymph nodes have a histologically confirmed viable tumour despite No evidence of primary tumour having normal preoperative levels of markers.
Carcinoma in situ Tumour limited to testis and epididymis without vascularor lymphatic invasion The Royal Marsden Hospital's system of staging requires cross Tumour limited to testis and epididymis with vascular or sectional imaging of the abdomen, usually with computed lymphatic invasion, or tumour extending through tunica tomography. If the abdomen is involved, imaging should albuginea with involvement of tunica vaginalis include the thorax, otherwise a plain chest x ray will suffice.
Tumour invades spermatic cord Tumour invades scrotum No regional lymph node metastasis Initial treatment is urgent radical orchidectomy. This is performed Metastasis with a lymph node mass 2 cm and five or through an inguinal incision. The testis and cord are delivered fewer positive nodes and isolated from the wound. The spermatic cord is ligated at the Metastasis with a lymph node mass 2 cm but 5 cm in deep ring. A non-absorbable suture facilitates future identification diameter, or more than five positive nodes in the event of retroperitoneal dissection of the lymph nodes Metastasis with a lymph node mass 5 cm in greatestdimension being indicated. If the diagnosis is in doubt, the spermatic cord isplaced in a soft clamp before the isolated testis is bivalved.
Sperm bank facilities should be made available before the Treatment according to tumour type and stage
operation. Orchidectomy allows tissue diagnosis to guide furthertreatment if necessary. In stage I seminoma, the primary Non-seminomatous germ cell
tumour's size is an independent risk factor for subsequent relapse. Negative prognostic factors include presence oflymphatic or vascular invasion. In non-seminomatous germ cell tumours, the absence of yolk sac elements or the presence of dissection of the lymph nodes embryonal cell carcinoma worsens prognosis.
Abdominal computed tomography can be performed before or after surgery. Patients who present with symptomatic or retroperitoneal dissection of extralymphatic metastases (stage IV) may need emergency chemotherapy, with orchidectomy deferred until their overall status has improved.
Chemotherapy orchidectomy Subsequent management depends on the type and stage of the tumour. Retroperitoneal dissection of the lymph nodesvirtually removes the chance of relapse in the abdomen. About25% of patients with clinical stage I non-seminomatous germcell tumours have microscopic retroperitoneal lymph nodeinvolvement. Men with this clinical diagnosis can be offeredprimary retroperitoneal dissection of the lymph nodes,chemotherapy, or close surveillance of markers and imaging.
Treatment of residual mass on imaging after chemotherapy is Walsh PC, Retik AB. Campbell's urology. Philadelphia, PA: controversial and requires multidisciplinary input. The main Saunders, 2002.
complications of retroperitoneal lymph node dissection are loss Chisholm GD. Nephrogenic ridge tumors and their syndrome.
Ann N Y Acad Sci 1874:230;403–23.
of anterograde ejaculation and lymphocoele formation. Recent Knudson AG, Strong LC. Mutation and cancer: a model for advances in laparoscopic surgery are exploring its application Wilm's tumor of the kidney. J Natl Cancer Inst 1972;48:313–24.
to this retroperitoneal operation.
Chap10.qxd 6/7/06 9:15 PM Page 37 10 Urinary tract stone diseaseHugh N Whitfield Differential diagnosis of ureteric colic
Ten per cent of the population in the United Kingdom may expect to have an episode of stone disease during their lifetime.
The upper urinary tract is affected in most cases.
Bladder stones are found in a small proportion of men with Leaking aortic aneurysm bladder outflow obstruction. The incidence in children remainshigh in some developing countries.
The prevalence of renal stones varies; it also correlates with affluence. A "stone belt" can be traced across India, Pakistan,and North America. The prevalence of stones changes with ageand is lower in women, although the male:female ratio isbecoming more equal.
Absence of pain does not indicate
absence of chronic obstruction, which
can cause irreversible renal damage
Renal stones may be suspected because of loin pain. The mostsevere pain occurs when stones are moving. Paradoxically,therefore, large stones that are in the kidney and not movingmay cause less discomfort than smaller stones that are moving.
In some patients, pain is provoked by exercise. Asymptomaticstones often are found during radiographic or ultrasoundimaging for unrelated reasons.
Advantages of intravenous urography over
When stones are moving out of the kidney into and down the More readily available ureter, the acute colicky pain is second to none in its severity.
Less irradiation When a ureteric stone has been present for 72 hours, the Easy to interpret acute pain subsides and the patient has relatively few symptoms.
Shows ureteric anatomy better Chronic ureteric obstruction is dangerous, because the lack ofsymptoms may lull the patient (and an ill informed medicaladviser) into a false sense of security. A stone that is lodged inthe intramural ureter causes strangury and discomfort that isfelt at the tip of the penis in men.
However renal stones are diagnosed initially, treatment can be
Advantages of computed tomography over
planned only after an intravenous urogram, which enables the relation of the stone to the pelvicaliceal system to be identified.
The management of large or bilateral renal stones, or both, No risk of contrast allergy depends on the patient's overall and differential renal function.
High specificity Glomerular filtration rate is measured most accurately by an Shows other pathology isotopic plasma clearance method with the use of Not contraindicated in patients with diabetes who are taking metformin ethylenediaminetetraacetic acid (EDTA). Differential renalfunction can be assessed by static or dynamic renograms withdimercaptosuccinic acid (DMSA) or mercaptoacetylglycine(MAGIII), respectively.
Debate continues about the best imaging method to be used in
patients who present with suspected acute renal or ureteric
Percentage of ureteric stones that pass spontaneously
colic. Intravenous urography and computed tomography have Size of stone (mm)
Stones that pass spontaneously (%)
their own advantages and disadvantages. Conservativeexpectant management of a ureteric stone thought to be small enough to pass spontaneously can only be pursued safely if the patient is monitored with the use of renographic methods.
ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap10.qxd 6/7/06 9:15 PM Page 38 Renal stones
Five options for the treatment of renal stones exist:
Conservative management—Conservative management of small renal stones has been advocated. The only good randomisedtrial, however, has provided evidence to suggest that suchstones are treated better with extracorporeal shockwavelithotripsy. Staghorn calculi also may be asymptomatic;conservative management has been shown to becontraindicated unless comorbidity is very considerable.
Extracorporeal shockwave lithotripsy—This method is effective for treating kidney stones 2 cm in maximum diameter, aslong as no obstruction to the passage of stone fragments ispresent. Ninety-nine per cent of patients can tolerate theprocedure after no more than a non-steroidal anti- Bilateral staghorn calculi inflammatory drug. More than one treatment session may beneeded in patients with large or hard stones. The larger thestone, the greater the risk that fragments will cause ablockage in the ureter that has to be relieved endoscopically.
Retrograde renoscopy—A laser fibre can be introduced through a flexible fibre optic ureterorenoscope, which is introducedthrough the urethra and bladder, and up the ureter to therenal collecting system. Stones 1 cm in diameter can bedisintegrated.
Percutaneous nephrolithotomy—Stones 2 cm in diameter may be treated by percutaneous nephrolithotomy. Underfluoroscopic control, a track with a diameter of about 1 cm isdilated transparenchymally into the collecting system.
Disintegrating devices, which can be introduced through a view from a calyx of a stone in nephroscope, are used to break the stone into fragments that can be evacuated through the track.
Open surgery—This is needed infrequently. Staghorn stones, in which the bulk of the stone lies within calices rather than withinthe renal pelvis, are treated best by open surgery. Kidneys thatcontribute 10% of overall renal function should usually beremoved. Extensive perirenal fibrosis is usually encountered,which makes such a nephrectomy impossible laparoscopically.
Five options for the management of ureteric stones exist. The
decision depends on the severity and length of time of the
symptoms, the size and site of the stone, evidence of renal
functional impairment, and, sometimes, on the patient's
domestic or work plans.
Conservative management—Most stones 5 mm in maximum diameter are likely to pass spontaneously and should be allowed to do so. Best practice, however, demands thatconservative management is monitored renographically everytwo weeks. This is difficult to achieve. Patients often areadvised to drink copious volumes of fluid to "flush the stonethrough." No evidence shows that this helps, and, for goodreasons, this approach may be counterproductive. Stones willpass down the ureter when the ureter peristalses. In thepresence of an obstruction, diuresis will provoke uretericdilatation and reduce peristalsis. Anticholinergic drugs, suchas hyosine, similarly will be ineffective.
Extracorporeal shockwave lithotripsy—This has been advocated for ureteric stones, when imaging is possible radiographicallyor by ultrasound. This approach is less successful for uretericstones than renal stones and is possible only at urologicalcentres that have a static rather than mobile lithotripter.
Endoscopic ureterolithotomy—With or without stone disintegration, this is a safe and effective method ofmanaging ureteric stones that need intervention.
Chap10.qxd 6/7/06 9:15 PM Page 39 Urinary tract stone disease Open surgery—This is indicated very rarely for ureteric stones.
If associated ureteric pathology, such as stricture, is present,open surgery may be the only solution.
Laparoscopy—Does not play any important role in the Risk factors for people who form stones of
management of uteric stone disease.
Male sex Low urinary volume Causes and prevention of renal stones Hyperoxaluria Increased urinary pH The need for metabolic screening in people who produce stones is controversial. Some people advocate screening only in people with recurrent stones. As 80% of people who produce Hypocitraturia Hypomagnesuria their first stone will have a recurrence within 10 years, however,this distinction can be regarded as irrelevant. Patients whorecently have experienced an episode of renal colic are wellmotivated to do whatever is possible to prevent another similarepisode. Appropriate preventative measures can berecommended only when the results of metabolic screening forstones are available.
Analysis of the composition of a stone is a useful start.
Serum levels of uric acid and corrected serum levels of calciumshould be measured. Collection of urine for 24 hours is neededto measure excretion of calcium, oxalate, uric acid, and citrate.
Most stones are composed of calcium oxalate. Many predisposing factors exist: the most common is low intake offluid. Patients who work in hot environments, those who take alot of exercise, and people who fly long distances are at General dietary advice for people who
considerably increased risk. People who form stones should aim form stones of calcium oxalate
to have a urine output of two litres a day and need to drink Maintain urine volume of two litres a day enough to ensure this is achieved.
Reduce intake of oxalate Idiopathic hypercalciuria is a frequent finding. If this Aim for intake of calcium of 750 mg/day persists despite appropriate dietary changes and fluid intake, Consume no added salt treatment with a thiazide diuretic can be helpful.
Consume a diet high in fibre Raised levels of uric acid in the blood or urine are important causes of stone formation. If a reduction in proteinintake is not enough to correct the biochemistry, allopurinol should be given. Recurrence of stones composed of uric acid Whitfield HN, W F Hendry WF, Kirby RS, Duckett JW (eds).
should be preventable, except in patients with an ileostomy, Textbook of genitourinary surgery. Oxford: Blackwell Science, 1998.
who have an increased risk of urate stones because of their Whitfield HN. The management of ureteric stones. Part I: acidic urine, which cannot be made more alkaline.
diagnosis. BJU Int 1999;84:8:911–5.
Urinary infection may cause large stones composed of triple Whitfield HN. The management of ureteric stones. Part II: (calcium, magnesium, and ammonium) phosphate, particularly therapy. BJU Int 1999;84:8:916–21.
in women with organisms that split urea. Recurrence of stones Whitfield HN. Stone disease. In: Gerharz EW, Emberton M, caused by infection can be prevented if the stone is removed O'Brien T, (eds) Classic papers in urology. Oxford: Isis MedicalMedia, 2000; pp 295–315.
completely and the urine is kept sterile.
Biochemical abnormalities in urine caused by excessive dietary intake of some foods or fluids can be treated effectivelyby dietary changes. Patients are often unaware of the dietaryrisk factors. Congenital causes of stones—for example,cystine—are uncommon. Advice from a nephrologist is needed.
Chap11.qxd 6/7/06 9:16 PM Page 40 11 Common paediatric problemsA R Prem Phimosis is the most common reason for circumcision,although recurrent balanitis is also an indication. Circumcision Possible indications for circumcision for
may also be performed for religious or social reasons.
patients with phimosis
At birth, adhesions are present between the glans penis and foreskin, but separation begins to occur immediately and Recurrent infection under foreskin Appreciable restriction to urine flow continues thereafter. The prepuce normally becomes retractileafter the age of two years, but many adolescent boys retain someadhesions. Preputial adhesions are a common reason for referralto a urologist, but adhesions are normal and should be treatedonly if "physiological phimosis" persists into adolescence andcauses problems with masturbation or sexual intercourse. A non-retractile foreskin is free of symptoms and self-limiting, andcircumcision is not needed. Parents often say that the prepuce Sites of undescended testis
"balloons" when the child urinates, but this is a sign of a non- Inguinal canal (80%) retractile foreskin rather than phimosis. Careful examination will Intra-abdominal (19%) show that the urethral meatus is visible through the narrowed preputial opening, and, with time, this opening widens to allow the foreskin to retract normally. True or "pathologic phimosis" is rare, but it may cause appreciable problems in childhood or Contralateral scrotum adolescence. Treatment usually is circumcision, althoughalternative treatments, such as preputioplasty or application ofsteroid creams, may be needed.
Main findings on laparascopy to locate
Undescended testis an impalpable testis
The incidence of undescended testis ranges from 3.4% to 5.8% Blind ending spermatic vessels aboveinternal inguinal ring but no testis in full term boys but decreases to 0.8% in boys aged about one Intra-abdominal testis year. Why testes fail to descend into the scrotum is unclear, but Cord structures that enter internal ring recent evidence suggests that descent occurs in two distinctphases and that androgens may have an important role,possibly acting via the genitofemoral nerve. An undescendedtestis can be classified by its location in the upper scrotum,superficial inguinal pouch, inguinal canal, or abdomen. In 80% Fertility of an undescended testis
of cases, the undescended testis will be palpable in the inguinal becomes compromised after the
canal. Patients with undescended testes have two major age of two years
concerns: increased incidence of testicular cancer andheightened risk of subfertility.
For treatment purposes, the main distinction that needs to be made is whether the testis is palpable. If the testis is palpable inthe inguinal canal, an orchidopexy should be carried out. Thecorrect timing of orchidopexy has been debated. Spontaneousdescent of undescended testis is rare after the age of one year.
Every attempt should be made to locate an impalpable testis. Ultrasound, computed tomography, and magneticresonance imaging have been used, but laparoscopy is thecurrent investigation of choice. If blind ending spermaticvessels are noted, further evaluation is not needed; the patientand parents should be counselled and hormonal replacementand a testicular prosthesis may be needed. If the testis is intra-abdominal in a prepubertal child, orchidopexy should beperformed as soon as possible. If an intra-abdominal testis isdetected after puberty, orchidectomy should be performed, asthe testis is incapable of spermatogenesis and the risk ofmalignancy is up to 10 times higher than in a normal testis. Ifthe cord structures enter the internal ring, inguinal explorationis warranted. In boys with bilateral undescended testis in whomneither testis is palpable, chromosomal and endocrineevaluation is needed.
Inguinal exploration of undecended testis ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap11.qxd 6/7/06 9:16 PM Page 41 Common paediatric problems Retractile testis Retractile testis is common in general practice and is oftenconfused with undescended testis. The key to distinguishing aretractile testis from an undescended testis is to show that thetestis can be delivered into the scrotum. A retractile testis willstay in the scrotum after the cremaster muscle has beenoverstretched, whereas a low undescended testis willimmediately pop back to its undescended position after beingreleased. If any doubt exists, the child should be seen in followup for a repeat examination. If doubt exists as to whether thetestis is retractile or undescended, referral for a urologicalopinion should be arranged.
Right sided vesicoureteric junction Vesicoureteric junction reflux reflux with gross hydronephrosis Reflux stops spontaneously in a large proportion of patients,although the degree of resolution is inversely proportional tothe severity of the reflux. For children with reflux of grades I-II,antibiotic prophylaxis is the recommended initial treatment. In all children with reflux of grades III-V and those with persistent reflux despite a trial of observation on prophylactic antibiotics, surgical correction is recommended. Dysfunctional voiding as a result of bladder instability should be treated with In the neonatal period, reflux is likely to be the result of anatomical abnormalities; the incidence of reflux is equal inthe sexes. In later childhood, the condition predominantlyoccurs in girls with voiding disturbances. Much evidence showsthat reflux should not be considered in isolation and that 4 Calices
dysfunctional voiding has a large role in the development of A vicious cycle of symptoms may also exist, because reflux may lead to infection, which itself may lead to bladderinstability, dysfunctional voiding, and further reflux. Thesethree elements thus should be considered equally in thetreatment of reflux. Reflux alone is now believed not to lead torenal damage—infection also must be present. Many urologistsbelieve that renal damage occurs early in the natural course of Grading of vesicoureteric reflux the disease, and in many cases it is not progressive.
Recent advances in management of reflux
Past treatment for reflux centred on ureteric reimplantation Recently, endoscopic injection of tetrafluoroethylene polymer (Teflon) into the submucosa of the ureter has been used withsome success Concern about the risks of migration of particles of tetrafluoroethylene polymer has prevented universal acceptanceof the technique Mid-penile hypospadias Other agents, such as bovine crosslinked collagen, autologous chondrocytes, dextranomer plus hyaluronic acid, copolymer andpolydimethylsiloxane, have been suggested for injection Success rates vary between 65% and 90% Hypospadias is a congenital condition that affects three in 1000male infants and results in underdevelopment of the urethra.
The penis may be deviated by chordee, and the urethral Mid-penile hypospadias—urethral opening opening may be situated anywhere from the perineum to the Chap11.qxd 6/7/06 9:16 PM Page 42 glans on the ventral surface (in contrast to epispadias in whichthe opening is on the dorsal surface).
The child should be referred for urological assessment and surgical treatment. The ideal age for surgery is 6–12 months.
Neonatal hydronephrosis Fetal urinary tract anomalies are common; they occur in Hypospadias surgery—transverse preputial 0.2–0.9% of all pregnancies. Hydronephrosis accounts for more than 50% of these anomalies. Antenatal hydronephrosis may becaused by ureteropelvic junction obstruction, ureterovesicaljunction obstruction, multicystic kidney, primary obstructivemegaureter, vesicoureteral reflux, or posterior urethral valves.
In cases of mild unilateral hydronephrosis (15 mm in diameter) with normal appearing renal parenchyma, further The use of routine ultrasound examination in pregnancy has
prenatal follow up is seldom useful, and surgery is unnecessary.
identified a number of fetuses with hydronephrosis. Postnatal
A postnatal check is important to confirm the hydronephrosis evaluation and management depends on the severity and
laterality of hydronephrosis
In cases of moderate unilateral hydronephrosis (15–19 mm), ultrasound and a micturating cystogram shouldbe performed at two months and subsequently at intervals ofsix months. Surgery also is unlikely to be needed in these cases.
In cases of severe unilateral hydronephrosis (20 mm), ultrasound, a micturating cystogram, and an isotopic renal scanshould be performed at one month. Severe unilateralhydronephrosis is most likely eventually to need surgery.
In neonates with severe bilateral hydronephrosis, ultrasound and a micturating cystogram should be performed Presentation of pelviureteric obstruction
within one week. Early surgery is often indicated.
Obstruction of the pelviureteric junction may occur at any time (before birth, in childhood, or in adulthood) Infants typically present with an abdominal mass Obstruction of pelviureteric junction Older children may have abdominal pain The condition often presents with haematuria after fairly minor The essential defect seems to be an aperistaltic segment of ureter, from which the normal musculature is congenitallyabsent. The role of "aberrant" vessels in causing obstructionrecently has been questioned. These vessels are usually normalvariants, often pass behind the ureter, and are not generallythought to cause obstruction.
It is usually diagnosed by intravenous urography, which shows delay in appearance of contrast on the affected side anddilated renal pelvis and calices. The ureter, when seen, is usuallynot dilated. Differential renal function and confirmation ofobstruction should be obtained with isotope renography.
Surgery is indicated for obstructive symptoms, stone formation, recurrent urinary infection, or progressive renalimpairment. Pyeloplasty is the treatment of choice, but if theaffected kidney possesses 10% of total renal function,nephrectomy should be performed. Minimally invasive alternativetechniques include antegrade endopyelotomy and laparoscopicpyeloplasty. Laparoscopic pyeloplasty is becoming the treatmentof choice, and open procedures usually are reserved for patientsin whom laparoscopic surgery is contraindicated.
Congenital obstruction of left Common paediatric tumours pelvi-ureteric junction Wilms' tumourWilms' tumour (nephroblastoma) is the most common primarymalignant renal tumour of childhood. It typically affects youngchildren (median age 3.5 years), with more than 80% of thepatients being identified before the age of five years. The most common presentation of Wilms' tumour is an abdominal mass, About 15% of children with Wilms' tumour have congenital although haematuria is the presenting feature in up to 15% of abnormalities, including musculoskeletal and other cases. Wilms' tumour is usually diagnosed with ultrasound, genitourinary anomalies (4.4%) Bilateral disease is seen in 5–7% of children with Wilms' tumour computed tomography, or magnetic resonance imaging.
Chap11.qxd 6/7/06 9:16 PM Page 43 Common paediatric problems Wilms' tumour is treated by radical nephrectomy; chemotherapy is usually given after surgery, with the exactprotocol depending on the stage of the disease. Radiotherapy is Rickwood AMK. Medical indications for circumcision. BJU Int needed only if residual tumour has been left behind at surgery Elder JS. Abnormalities of the genitalia in boys and their surgical and for patients with lymphatic and pulmonary metastases.
management. In: Walsh PC, Retik AB, Vaughn ED, Wein AJ, eds.
Neoadjuvant chemotherapy is beneficial for patients with Campbell's urology. Philadelphia, PA: Saunders, 2002:2334–52.
Kolon TF, Patel RP, Huff DS. Cryptoorchidism: diagnosis, treatment and long-term prognosis. Urol Clin N Am Renal cell carcinoma Austin JC, Cooper CS. Vesicoureteral reflux: surgical approaches.
This tumour is rare in children and is not usually diagnosed Urol Clin N Am 2004;31:543–57.
until confirmed by histological examination of a presumedWilms' tumour. Some tumours are chemosensitive, andradiotherapy may be needed for microscopic residual disease,but radical nephrectomy remains the mainstay of treatment.
RhabdomyosarcomaThis sarcoma commonly presents with lower urinary tractsymptoms, particularly haematuria or urinary retention.
Tumours of the vagina may cause a foul vaginal discharge, andpelvic tumours may cause a large mass.
Rhabdomyosarcoma is treated effectively with chemotherapy. The role of radical surgery is diminishing andcurrently is reserved for children who fail to respond tochemotherapy or develop a pelvic relapse.
Chap12.qxd 6/7/06 9:18 PM Page 44 12 Genitourinary traumaAsif Muneer Trauma is defined as a morbid condition of the body producedby external violence. The genitourinary structures mostcommonly involved are the kidneys and testicles.
Renal trauma is the most common genitourinary injury andaccounts for 1–5% of all trauma. The incidence of renal traumais higher in men than women. The availability of highresolution imaging modalities and staging of trauma has led toa reduction in the need for surgical intervention and thusincreased renal preservation.
Mechanism of injury
The mechanism of injury may be blunt trauma or penetrating
injuries. Blunt trauma most often occurs as a result of road
traffic accidents. The remaining cases are attributed to assaults,
falls, and contact sports.
Penetrating renal injuries occur as a result of gunshot and stab wounds. The highest rates are within urban areas as aresult of gang violence and street crime. These account forsevere and unpredictable injuries. The passage of a bulletthrough the abdomen can result in multiple organ injuries, Computed tomography scan showing significant injury after blunt renal with significant renal parenchymal destruction. Gunshot wounds are classified as high velocity and low velocity. Lowvelocity gunshot wounds produce a blast effect that results in Classification of renal injuries
damage to the tissues. High velocity gunshot wounds causemore associated injuries.
Description of injury
Contusion or non-expanding subcapsular haematoma Several classification systems have been used over the years Non-expanding perirenal haematoma according to the morphological findings and clinical course.
Cortical laceration 1 cm The most widely accepted classification system is that of the Cortical laceration 1 cm American Association for the Surgery of Trauma, which Laceration through corticomedullary junction into collecting classifies renal injuries on a scale of 1–5.
systemorSegmental artery or vein injury with contained haematoma Diagnosis
All patients with trauma need an initial assessment that
Shattered kidney or renal pedicle injury or avulsion includes securing the airway, control of external bleeding, andcardiovascular resuscitation. This should follow the criteria of Simplified classification of haemorrhagic shock
the advanced trauma and life support system.
The history from a conscious patient or witness (in the case of a severely injured patient) may indicate a major renal injury.
Direct blows to the flank or an event that involved rapid deceleration lead to a high index of suspicion. The type and size of the weapon and the velocity of the gunshot are valuable points of information if available. If the patient is conscious, Decreased Decreased any pre-existing renal pathology or renal dysfunction should be documented, as they may complicate even minor renal injuries.
Normal or Decreased Decreased Decreased Physical examination involves assessment of haemodynamic stability. The presence of shock may be determined with a simplified classification that involves blood loss, heart rate, blood pressure, pulse pressure, respiratory rate, and mental state. Other signs that indicate an underlying renal injury include fractured ribs, flank ecchymoses or abrasions, abdominal tenderness, or distension associated with flank pain.
Urinalysis is a basic test in the evaluation of patients with Major renal injuries may occur without haematuria
trauma. Microscopic haematuria in the trauma setting is definedas more than five red blood cells per high powered field; ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Chap12.qxd 6/7/06 9:18 PM Page 45 Genitourinary trauma macroscopic haematuria is blood readily visible in a urine Indications for further radiological imaging in patients with
specimen. The degree of haematuria, however, does not always blunt renal trauma
correlate with the magnitude of the renal trauma.
Not all injuries need imaging for further assessment. Large studies have concluded that patients with blunt trauma and Computed tomography microscopic haematuria without shock are unlikely to have a Computed tomography if significant renal injury and thus do not need imaging. The stable or intravenous preferred imaging method for stable patients with renal trauma urogram on table if unstable is computed tomography.
Most blunt injuries are managed conservatively. Life
threatening haemodynamic instability or grade 5 injuries,
however, are an absolute indication for surgical exploration.
The overall exploration rate after blunt trauma is 10%. Most
explorations ultimately lead to a nephrectomy, depending on
the nature and severity of the injury. Reconstruction, in the
In patients with renal trauma, computed tomography is a more
form of renorraphy, can be performed in some cases at surgery.
sensitive and specific method than other imaging methods, such
The presence of a normal functioning kidney on the as intravenous pyelography, ultrasound, and angiography
contralateral side must be established; this is usually achievedwith a one shot intravenous pyelogram before surgery.
Laparotomy is usually needed to explore intraperitoneal Non-operative management of patients with renal trauma
non-renal injuries—such as occur after penetrating trauma to involves bed rest and adequate hydration; 5% of patients fail
the bowel, liver, or spleen. Although these organs require repair or resection, the simultaneous presence of a non-expanding retroperitoneal haematoma is best managed byleaving it undisturbed.
Follow up involves serial measurements of blood pressure and renal function. The use of radiological imaging during Complications of renal trauma
follow up depends on whether reconstruction or conservative management is used.
Calculus formation Paediatric renal trauma Abscess formation Chronic pyelonephritis Hypertension (Page kidney) The kidneys lie lower in children than in adults and are Arteriovenous fistula protected less well by the abdominal muscles and lower ribs.
Children therefore are more susceptible to blunt renal trauma.
A full history and examination are essential to evaluate the mechanism of injury and any pre-existing renal disease. Unlikein adults, the absence of hypotension is an unreliable sign inchildren, as significant loss of blood still can be associated witha relatively stable blood pressure.
Ultrasound can be used as an imaging method in children Testicular injuries are common during aggressive sports and
who are stable, but computed tomography is mandatory to motor vehicle crashes because of the vulnerable position of the
accurately stage the injury.
Testicular injuries Testicular injuries can be classified as blunt and penetratinginjuries. Blunt traumas that arise from kicks or straddle injuriescompress the testis against the lower border of the pubic boneand can result in minor contusion or complete rupture of thetunica albuginea. Significant testicular injuries present with aswollen tender scrotum. Ultrasound assessment can be used todifferentiate between testicular contusion or rupture, but theaccuracy is limited.
Testicular trauma in the absence of significant scrotal swelling
can be managed conservatively. Early scrotal exploration is
needed in cases of testicular rupture, and devitalised tissue is
removed, with repair of the tunica albuginea. Non-viable
testicles are removed by orchidectomy.
Penetrating trauma to the testicle may be secondary to a gunshot wound or stabbing. Debridement of non-viable tissue isundertaken, with an attempt to preserve as much testicular Testicular rupture Chap12.qxd 6/7/06 9:18 PM Page 46 tissue as possible. When the testicle cannot be conserved, Classic presentation of penile fracture
orchidectomy is performed. Broad spectrum antibiotics areneeded, and the tetanus status of the patient must be checked.
Severe pain Rapid detumescence Penile swelling as a result of rupture of the tunica albuginea that covers the corpora cavernosa.
Extreme angulation of the erect penis during sexualintercourse accounts for most penile fractures. The classichistory is diagnostic, and the tear in the tunica sometimes canbe palpated. In uncertain cases, magnetic resonance imaging ofthe penis will differentiate between a complete tunical tear andintracavernosal haematoma. A tunical tear needs immediateexploration of the penis to evacuate the haematoma and repairthe injury.
Early repair of penile fracture maintains erectile function
and prevents late onset penile curvature
Rapid detumescence and penile swelling accompany a penile fracture Urethral injuries In men, the urethra is divided into posterior and anterior Posterior urethra comprises
membranous and prostatic urethra;
segments by the urogenital diaphragm. Posterior urethral anterior urethra consists of bulbar and
injuries most commonly occur as a result of pelvic fractures sustained in road traffic accidents, falls from a height, andcrush injuries. The injury can range from a stretch orcontusion injury to complete disruption of the posteriorurethra. Anterior urethral injuries are rarely associated with Patients who need realignment and
pelvic fractures but can occur after road traffic accidents, falls, delayed urethroplasty for urethral
injuries are usually referred to a
or straddle type injuries that involve a blunt blow to the perineum. Iatrogenic injury to the urethra secondary toendoscopic trauma and instrumentation is the most commoncause of urethral stricture.
Presence of blood at the urethral meatus should lead to a high
index of suspicion of an underlying urethral injury. Retrograde
urethrography should be performed before catheterisation of
the urethra is tried. If a urethral injury is diagnosed by
retrograde urethrography, a suprapubic catheter is inserted.
Initial diagnosis and management should focus on avoiding
Penetrating injuries to the anterior urethra can be repaired by
primary anastomosis over a urethral catheter. Anterior urethral
injuries associated with stricture formation can be managed with
endoscopy for short strictures or urethroplasty for longer
strictures. Management of posterior urethral injuries is more
complex and must take into account associated injuries. If the
patient is stable and can tolerate the lithotomy position, delayed
primary end to end urethroplasty can be done within two weeks.
Alternatives are realignment, which can be performed as an
open or endoscopic procedure, or delayed urethroplasty.
Iatrogenic trauma and direct blunt trauma account for mostcases of bladder rupture. As the bladder has intraperitoneal Urethrogram showing urethral rupture and extraperitoneal components, the degree of bladderdistension at the time of injury determines whether anintraperitoneal or extraperitoneal leak is likely. The site ofbladder rupture governs the subsequent management.
Chap12.qxd 6/7/06 9:18 PM Page 47 Genitourinary trauma Gross haematuria occurs in up to 82% of patients, along withlower abdominal tenderness. Retrograde cystography will Weiss RM, George NJR, O'Reilly PH. Comprehensive urology. St Louis, MO: Mosby, 2000.
confirm if the rupture is intraperitoneal or extraperitoneal.
Blunt extraperitoneal rupture can be managed safely by
catheter drainage, ensuring that the catheter does not get
blocked by clots. Most ruptures heal within 10 days.
Intraperitoneal rupture can be complicated by peritonitis as a
result of a urinary leak and must always undergo surgical
exploration with repair of the bladder laceration.
Daws_Index.qxd 6/7/06 9:21 PM Page 49 investigations 6–7 surgical intervention 7–9 adhesins, bacterial 22 alpha fetoprotein 35, 36 bone scans, isotope 5, 26 anal sphincter examination 3 androgen deficiency 21 bulbocavernosal reflex loss 16 andrology xandropause 21 calcium oxalate 39 carcinogenesis, two hit hypothesis 34 antibiotics 2, 23, 24, 46 carcinogens, industrial 29 antimuscarinic drugs 12 antisperm antibody testing 18–19 bladder trauma 47 aromatic amines 29 arterial steal syndrome 16 urethral 14, 17, 46 assisted reproductive techniques 19 bacterial cell adhesion 22 neoadjuvant 32, 43 bacterial pathogens 22 renal cancer 35, 43 bacteriuria screening 24 rhabdomyosarcoma 43 balloon dilatation of prostatic fossa 9 testicular cancer 36 BCG (bacille Calmette–Guérin), intravesical 31, 32 children x, 40–3 benign prostatic hyperplasia 6, 14 testicular torsion 15 biofeedback training 11 bisphosphonates 28 choriocarcinoma 35, 36 chromosomal abnormalities, cigarette smoking 29 circumcision 16, 40 clam cystoplasty 12 computed tomography (CT) 5 detrusor overactivity 10, 12 prostate cancer staging 26 detrusor pressure 11 testicular cancer 36 congenital anomalies ix, 42 creatinine, serum levels 4 cremasteric reflex 3 crush injuries 46 ultrasound examination 4 cyproterone acetate 28 bladder cancer ix, 29–33 carcinoma in situ 31–2 cystography, retrograde 47 investigations 29–30 cystoplasty, clam 12 metastases 30, 32 cystoprostatectomy 32 muscle invasive 32 cystoscopy 13, 30 palliative care 33signs/symptoms 29 detrusor instability management 12 detrusor overactivity 10, 12 superficial 30–2 detrusor pressure 11 diet, stone disease 39 UTI differential diagnosis 23 dimercaptosuccinic acid (DMSA) 5 dipstick testing 2, 3, 24 dysfunction/dyssynergia 6, 9 bladder outflow obstruction 6–9 ABC of Urology Second Edition Edited by Chris Dawson and Hugh N Whitfield 2006 Blackwell Publishing Ltd. ISBN: 978-1-405-13959-5 Daws_Index.qxd 6/7/06 9:21 PM Page 50 surgical reconstruction 45 ultrasound examination 4 see also renal entries retrograde 2, 7, 9, 18, 19 emergencies, urological 14–17 lactate dehydrogenase 36 laparoscopic surgery x, xi endopyelotomy, antegrade 42 prostate cancer 28 endoscopy, urethral strictures 46 examination 3, 24 ultrasound examination 4 undescended testis 40 laparotomy, intraperitoneal injuries 45 epididymo-orchitis 24 laser therapy, bladder obstruction 8 erectile dysfunction x, 2, 18 lithotripsy ix, 15, 38 subfertility 19–20 Escherichia coli 22 luteinizing hormone-releasing hormone agonists 28 extracorporeal shockwave lithotripsy 15, 38 magnetic resonance imaging (MRI) 5 extraurethral incontinence 10, 11 prostate cancer staging 26 fertility problems x, 18–19, 40 mercaptoacetylglycine (MAG3) 5 bladder cancer 30, 32 immunotherapy 35isotope bone scans 26 genitalia, external 2–3 prostate cancer 16, 28 genitourinary tract examination 2–3 spinal cord compression 16, 17 glomerular filtration rate measurement 5 testicular cancer 36 gunshot injuries 44, 45 microwave hyperthermia 8 micturating cystogram 42 bladder cancer 29 bladder trauma 47 microscopic 15, 29, 44, 45 rhabdomyosarcoma 43 myomectomy, bladder 12 haemodynamic stability 44 needle ablation, transurethral of prostate 8 healthcare professionals xi hormone therapy, prostate cancer 27 pelviureteric junction obstruction 42 human chorionic gonadotrophin renal cancer 35, 43 hydatid of Morgagni 15 hydronephrosis 2, 41 nephrolithotomy, percutaneous 38 nephrostomy, percutaneous 2, 15 hypercalciuria 39 bladder cancer 33 hypospadias 19, 41–2 nephrostomy drainage 2, 24 Nesbitt operation 20 vesicovaginal fistula risk 12 nocturnal enuresis 17nuclear medicine 5 nurse practitioners, specialist xi, 11 immunotherapy, renal cancer 35incontinence nurse practitioners xi, 11 obstructive symptoms 1 infertility x, 18–19 interleukin 2 (IL-2) 35 International prostate symptom score testicular trauma 46 intracavernosal haematoma 46 intracavernosal pharmacotherapy 20 overflow incontinence 10, 11 intracytoplasmic sperm injection 19investigations 3–4 in-vitro fertilisation (IVF) 19 irritative symptoms 1 paediatric disorders x, 40–3 infections 2, 15, 17, 24 obstruction 17, 24 bladder cancer 33 percutaneous drainage 24 prostate cancer 28 Daws_Index.qxd 6/7/06 9:21 PM Page 51 paradoxical incontinence 10 reconstruction procedures ix–x rectal examination 3, 24 pelvic clearance, anterior 32 5-reductase inhibitors 7 pelvic floor training 11, 12 renal calculi/stones 15, 37 pelvic fractures 46 investigations 37 pelvic node dissection 32 pelviureteric junction obstruction 42 penile prostheses 20 renal cancer/renal cell carcinoma 34–5 penile ring block 16 arteriovenous shunt 16 aspiration of corpora 16 renal colic 2, 14–15, 17 renal transplantation x renal trauma 44–5 Peyronie's disease 3, 20 renal ultrasound 24 renography, dynamic isotope/static 5 phosphodiesterase inhibitors 19–20 renoscopy, retrograde 38 photo selective vaporization of prostate retroperitoneal haematoma 45 with green light laser 8 retroperitoneal lymph node dissection 36 positron emission tomography (PET) 5 rhabdomyosarcoma 43 pregnancy, urinary tract infection 24 road traffic accidents 44, 46 prepuce, adhesions 40 robotic surgery, prostate cancer 28 priapism 15–16, 17prostaglandin E1, intracavernosal injection 20 salpingo-oophorectomy 32 examination 2–3 examination 3, 24 medical therapy of symptoms 7 ultrasound examination 4 self-catheterisation, intermittent 12 surgical intervention 7–9 semen analysis 18 ultrasound examination 4 volume reduction 7 sexual dysfunction 2 see also benign prostatic hyperplasia prostate cancer ix, 25–8 active surveillance 26–7 sperm extraction 19 investigation 25–6 spinal cord compression 16, 28 laparoscopic surgery 28 Staphylococcus saprophyticus 22 locally advanced 27 metastases 16, 28 palliative care 28 stone disease ix, 2, 37–9 robotic surgery 28 investigations 37 metabolic screening 39 symptoms/signs 25 urine retention 14 stone composition 39 prostate-specific antigen (PSA) 6–7, 25 strangury 1, 2, 37 prostatic fossa, balloon dilatation 9 stress incontinence 10, 11 surgical management 12 pyelography, intravenous 30 subfertility x, 18–19 pyelonephritis 15, 24 undescended testis 40 support groups 11surgery x radiofrequency ablation, renal cancer 35 renal cell carcinoma 34 examination 3, 24 intra-abdominal 40 renal cancer metastases 35 renal cell carcinoma 43 Daws_Index.qxd 6/7/06 9:21 PM Page 52 testes (contd.) ultrasound examination 4 urinary diversion 32, 33 testicular cancer 15, 35–6 urinary incontinence 2, 10–13 assessment 10–11 undescended testis 40 reconstruction procedures ix–x testicular torsion 3, 15, 17 surgical management 12 testosterone therapy 21 treatment 11–12 tetrafluoroethylene polymer ureteral injection 41 three swab test 13 urinary tract, upper TNM classification 26 transurethral incision of the prostate 8 urinary tract infection 22–4 transurethral microwave therapy 8 differential diagnosis 23 transurethral needle ablation of the prostate 8 transurethral resection of the prostate 8, 9 management 22–4 recurrent 23stone disease 39 bladder cancer 30 high intensity focused 8, 27 hydronephrosis 42 dipstick testing 2, 3, 22 renal cell carcinoma 34 midstream sample 22, 23 residual volume 7 submucosal tetrafluoroethylene retention 7, 14, 27 polymer injection 41 rhabdomyosarcoma 43 ultrasound examination 4 voiding dysfunction 41 ureteric calculi/stones 4, 15, 37 urodynamic disorders ix, x investigations 37 urodynamic investigations 5, 11 urography, intravenous 5, 13 ureteric stents 24 urological complaints 1 ureterography, retrograde 13 urological evaluation 1–5 ureterolithotomy, endoscopic 38 urological practice x urology nurse practitioners xi, 11 catheterisation 14, 17, 46 vacuum devices 20 varicocelectomy 18–19 strictures 6, 9, 14, 46 vesical pressure 11 underdevelopment 41 vesicoureteric junction reflux 41 urethral meatus 3 vesicovaginal fistula 10, 12–13 videourodynamics 11 Von Hippel-Lindau disease 34 urethral sphincter, artificial 12urethrography, retrograde 46 Wilms' tumour 42–3 urethroplasty, urethral strictures 46urge incontinence 10, 12 zoledronic acid 28
The Effects of Serum Testosterone, Estradiol, and SexHormone Binding Globulin Levels on Fracture Risk inOlder Men Erin S. LeBlanc, Carrie M. Nielson, Lynn M. Marshall, Jodi A. Lapidus,Elizabeth Barrett-Connor, Kristine E. Ensrud, Andrew R. Hoffman, Gail Laughlin,Claes Ohlsson, and Eric S. Orwoll, for the Osteoporotic Fractures in Men StudyGroup Bone and Mineral Unit (E.S.L., C.M.N., L.M.M., J.A.L., E.S.O.), Oregon Health and Science University,Portland, Oregon 97239; Department of Family and Preventive Medicine (E.B.-C., G.L.), University ofCalifornia, San Diego, San Diego, California 92093; Departments of Medicine and Epidemiology &Community Health (K.E.E.), University of Minnesota and Department of Medicine (K.E.E.), VeteransAffairs Medical Center, Minneapolis, Minnesota 55417; Department of Medicine (A.R.H.), StanfordUniversity, Palo Alto, California 94305; and Department of Internal Medicine (C.O.), Center for BoneResearch at the Sahlgrenska Academy, SE-416 85 Go¨teborg, Sweden
The MTACAdult Performance ProgramFive Reflections and Reviews Jennifer Griest, Alison Edwards, Gwen Churchill, Lynn Kidder and Yasmin Haddadi What exactly is Adult Performance?" participants may be considered for the Adult Performance Recital at the State Convention. I was asked this question quite often during the past year as the