- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
492 CHAPTER 12 Erectile function and ejaculation
Retrograde ejaculation
Definition
This is a failure of adequate bladder neck contraction, resulting in the propulsion of sperm back into the bladder on ejaculation.
Etiology
It is secondary to damage or dysfunction of the bladder neck sphincter mechanism.
Underlying causes may be neurological (spinal cord injury; neuropathy associated with diabetes mellitus; nerve damage after retroperitoneal surgery) or anatomical disruption following transurethral resection of ejaculatory ducts (for obstruction), bladder neck incision (BNI), transurethral resection of the prostate (TURP), or open prostatectomy.
It may also occur as a result of selective A-blocker therapy for BPH (particularly tamsulosin).
Incidence
Retrograde ejaculation following TURP or open prostatectomy occurs in 9 out of 10 men and after BNI in 1–5 in 10 men.
Presentation
Dry ejaculation (failure to expel ejaculate fluid from the urethral meatus) and cloudy urine (containing sperm) in the first void after intercourse are the presenting symptoms.
Investigation
The presence of >10–15 sperm per high-powered field in a post-ejac- ulate mid-stream urine specimen confirms the diagnosis of retrograde ejaculation.
Treatment
Medical therapy is initiated in men wishing to preserve fertility and is only effective in patients who have not had bladder neck surgery. Oral adrenergic drugs may be used to increase the sympathetic tone of the bladder neck smooth muscle sphincter mechanism. Drugs include ephedrine sulfate (25–50 mg qid), pseudoephedrine (60 mg qid), or imipramine (25 mg bid).
Therapy is often given for 7–10 days prior to a planned ejaculation (coordinated with the partner’s ovulation). Alternatively, sperm retrieval may be attempted. Oral sodium bicarbonate and adjustment of fluid intake are initiated to optimize urine osmolarity and pH and to enhance sperm survival.
Sperm are collected by gentle urine centrifuge and washed in insemination media in preparation for intrauterine insemination (IUI) or in vitro fertilization (IVF) treatments.
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494 CHAPTER 12 Erectile function and ejaculation
Peyronie’s disease
Definition
This is a benign penile condition characterized by curvature of the penile shaft secondary to the formation of fibrous tissue plaques within the tunica albuginea. It is also called “a disease of aging tissue in a patient with a youthful libido.”
Epidemiology
Prevalence is ~1%, predominantly affecting men aged 40–60 years (average age, 53 years).
Pathophysiology
Scar formation in the tunica albuginea known as plaque is believed to arise as a result of buckling trauma. Dorsal penile plaques are most common (66%).
The corpus cavernosum underlying the lesion cannot lengthen fully on erection, resulting in penile curvature. It may be associated with distal flaccidity or an unstable penis (due to cavernosal fibrosis). The disorder has two phases:
•Active phase (1–6 months): painful erections and changing penile deformity
•Quiescent phase (9–12 months): disease “burns out.” Pain disappears with resolution of inflammation, and there is stabilization of the penile deformity.
Etiology
The exact cause is unknown. It is likely that repeated minor trauma during intercourse causes microvascular injury and bleeding into the tunica, resulting in inflammation and fibrosis (exacerbated by transforming growth factor-B[TGF-B]).
Autoimmune disease processes have also been suggested, and there is a reported familial predisposition.
Presentation
Patients experience pain and curvature of the erect penis. There is a hard area (plaque) on the penis, as well as erectile dysfunction (30–40%) and penile shortening.
Associated disorders
These include Dupuytren’s contractures (40%), plantar fascial contracture, tympanosclerosis, previous trauma, diabetes mellitus, and arterial disease.
Evaluation
A full medical and sexual history is taken. Patient’s photographs of the curvature are useful. Assess the location and size of the plaque (is it tender?).
Color Doppler US is used to assess vascular abnormalities, whereas contrast-enhanced MRI is indicated for complex and extensive cavernosal fibrosis.
PEYRONIE’S DISEASE 495
Management
Early disease with active inflammation (<3 months, penile pain, changing deformity) benefits most from medical therapy. Surgery is indicated for a stable, significant deformity (preventing intercourse).
Concomitant erectile dysfunction can be treated conventionally (oral or intracavernosal medications; vacuum device; penile implant).
Medical treatments
These consist of vitamin E (200 mg tid) for 3 months; tamoxifen (20 mg bid) for 3 months; or colchicine (500 mg tid) for 6 weeks.
Nesbit procedure
The penis is degloved via a circumglandular incision. An artificial erection is induced by intracavernosal saline injection. On the opposite side of maximal deformity, an ellipse is excised (a width of 1 mm is taken for every 10° of penile curvature) and then closed with sutures.
Success rates are 88–94%. Warn the patient that penile shortening of 2–3 cm frequently occurs.
Penile plication
This involves placement of soft permanent sutures in parallel rows along the convex side of the penile shaft. Penile shortening of 0.4–1.5 cm is reported in 40% of patients.
Pain at the site of tunical suture placement is reported in roughly 12%.
Plaque incision and grafting
This involves incision of plaque with venous patch insertion to lengthen the affected side (and minimize penile shortening). Other grafts reported include nonautologous grafts of dermis, porcine small intestinal submucosa (SIS) or pericardium, or autografts of dermis or rectus abdominis fascia.
Success rates are 75–96%.
Adverse effects include erectile dysfunction in 5–12% of patients.
Penile implant
When significant deformity is coupled with resistant or worsening impotence, placement of an inflatable penile prosthesis with intraoperative “molding” of the deformity is an effective way of treating both problems.