- •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
508 CHAPTER 13 Neuropathic bladder
The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
Neuropathic patients experience two broad categories of problems— bladder filling and emptying—depending on the balance between bladder and sphincter pressures during filling and emptying. The effects of these bladder filling and emptying problems include incontinence, retention, recurrent UTIs, and renal failure.
High-pressure sphincter
High-pressure bladder
If the bladder is overactive (detrusor hyperreflexia) or poorly compliant, bladder pressures during filling are high. The kidneys have to function against these chronically high pressures. Hydronephrosis can develop and ultimately cause renal failure.
At times the bladder pressure overcomes the sphincter pressure and the patient leaks urine (incontinence). If the sphincter pressure is higher than the bladder pressure during voiding, as in DSD, bladder emptying is inefficient (leading to retention, recurrent UTIs, or bladder calculi).
Low-pressure bladder
If the bladder is underactive (detrusor areflexia), pressure during filling is low. The bladder simply fills up—it is unable to generate enough pressure to empty causing retention and stasis of urine.
Urine leaks at times if the bladder pressure becomes higher than the sphincter pressure (incontinence), but this may occur only at very high bladder volumes or not at all.
Low-pressure sphincter
High-pressure bladder
If the detrusor is hyperreflexic or poorly compliant, the bladder will only be able to hold low volumes of urine before leaking (incontinence).
Low-pressure bladder
If the detrusor is areflexic, such that it cannot develop high pressures, the patient may be dry for much of the time. They may, however, leak urine (incontinence) when abdominal pressure rises (e.g., when coughing, rising from a seated position, or when transferring to or from a wheelchair). Their low bladder pressure may compromise bladder emptying, causing recurrent UTIs.
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510 CHAPTER 13 Neuropathic bladder
Bladder management techniques for the neuropathic patient
A variety of techniques and procedures are used to treat retention, incontinence, recurrent UTIs, and hydronephrosis in the patient with a neuropathic bladder. A variety of neurological diseases, injury, congenital malformations, and medical conditions can result in a neuropathic bladder and variable degrees of voiding dysfunction. The incidence of voiding dysfunction with some common disorders is as follows:
•Cerebrovascular accident: 20–50%
•Parkinson disease: 35–70%
•Multiple sclerosis: 50–90%
•Diabetes mellitus; 5–59%
Each of the techniques described below can be used for a variety of clinical problems. Most patients require formal urodynamic evaluation (assessment of bladder filling, sensation, capacity, and compliance), urethral evaluation, voiding studies, and external sphincter electromyography to fully document the nature of the problem and identify the best clinical management.1
Thus, a patient with a high-pressure, hyperreflexic bladder that is causing incontinence can be managed with intermittent self-catheterization, sometimes supplemented with intravesical botulinum toxin injections, or a suprapubic catheter, or by sphincterotomy with condom sheath drainage, or by deafferentation combined with a sacral anterior root stimulator (SARS). Precisely which option to choose will depend on the individual patient’s clinical problem, their hand function, their lifestyle, resources available, and other personal factors, such as body image and sexual function.
Some patients will opt for a suprapubic catheter as a simple, generally safe, generally very convenient and effective form of bladder drainage. Others wish to be free of external appliances and devices because of an understandable desire to look and feel normal. They might opt for deafferentation with a SARS. The general principles of the management of the patient with neuropathic bladder dysfunction are as follows:
•Urodynamics are essential to plan urological management.
•Control intravesical pressure (prevent high pressure to protect upper tracts).
•Spontaneous voiding with continence is possible with NDO controlled medically.
•Urinary drainage: use intermittent catheterization or an external collection appliance.
•Indwelling catheterization is to be avoided long term because of complications (UTI, urethral erosion, calculi).
•Intermittent self-catheterization is the most effective treatment for most with detrusor areflexia, but requires low storage pressure.
1 Abrams P. Cardozo L. Fall M. et al. (2002). The standardization of terminology of lower urinary tract function: report from the Standardization Sub-committee of the International Continence Society. Neurourol Urodynam 21(2):167–178.
BLADDER MANAGEMENT TECHNIQUES 511
Medical therapy
Give anticholinergics to improve urinary storage pressure and decrease involuntary contraction. Use agents such as the following:
•Oxybutynin 5 mg PO tid–qid
•Hyoscyamine 0.125 mg PO qid
•Tolterodine LA 4 mg PO qd
A-Adrenergic blockers are used to decrease internal sphincter resistance and lower voiding pressure; they are ineffective for DSD. They may help control symptoms of autonomic dysreflexia. Medications include:
•Doxazosin 2 to 8 mg PO qd
•Terazosin 2 to 5 mg PO qd–bid
•Tamsulosin 0.4 mg PO qd
•Silodosin 8 mg PO qd
Botulinum toxin injection into the detrusor for detrusor overactivity is being used. The toxin selectively blocks acetylcholine release from nerve endings but is not FDA approved for bladder use.
Typical bladder regimens reported 10–30 individual endoscopic injections of 10 units/1 mL/site (posterior wall in midline, right and left lateral walls and dome), with sparing of the trigone.
Intermittent self-catheterization (ISC)
See p. 516.
Indwelling catheters, including suprapubic tubes
See p. 132.
External sphincterotomy
Deliberate ablation or stenting of the external sphincter is used to convert the high-pressure, poorly emptying bladder due to DSD to a low-pressure, efficiently emptying bladder. This is only for males with DSD; it requires a condom catheter afterward. Indications are retention, recurrent UTIs, recurrent bladder calculi, hydronephrosis, and renal insufficiency.
Techniques
•Surgical (with an electrically heated knife or vaporizing laser). Disadvantages are irreversibility, postoperative bleeding, septicemia, and stricture formation.2
•Intrasphincteric botulinum toxin. This technique is minimally invasive and reversible. Its disadvantage is that repeated injection is required every 3–9 months. It is not FDA approved for this use.
•Stenting (e.g., UroLume, AMS Minnetonka, MN). This is a 1.5–3 cm nonmetallic mesh alloy that expands to 42 F to keep the external sphincter open.3
2 JM Reynard (2003). Sphincterotomy and the treatment of detrusor–sphincter dyssynergia: current status, future prospects. Spinal Cord 41:1–11.
3 Chancellor M, Gajewski J, Ackman CFD, et al. (1999). Long-term follow-up of the North American Multicenter UroLume Trial for the treatment of external detrusor-sphincter dyssynergia. J Urol 161:1545–1550.
512 CHAPTER 13 Neuropathic bladder
Sacral neuromodulation
Sacral and nonsacral neuromodulation using the InterStim can be attempted in cases of detrusor hyperactivity (see p. 528).
Bladder augmentation
This technique involves increasing bladder volume to lower pressure by implanting detubularized small bowel into the bivalved bladder (“clam” ileocystoplasty) (Fig. 13.2) or by removing a disc of muscle from the dome of the bladder (autoaugmentation or detrusor myectomy) and allowing the mucosa to balloon outward.
25–30 cm
A
B
Figure 13.2 A “clam” ileocystoplasty. This figure was published in McAninch JW,
Traumatic and Reconstructive Urology, p. 2287. Copyright Elsevier 1996.
BLADDER MANAGEMENT TECHNIQUES 513
An autologous tissue-engineered bladder substitute for autoaugmentation is under study.4
Indications include refractory incontinence and hydronephrosis.
Urinary diversion
In the most extreme cases, permanent urinary diversion may be necessary.
•Cystectomy with continent urinary reservoir
•Ileal or colon pouch; continent catheterizable stoma (appendix or tapered ileum) on abdomen
•Cystectomy with ileal conduit
Deafferentation
This involves division of dorsal spinal nerve roots of S2–4 (sacral rhizotomy) to convert the hyperreflexic, high-pressure bladder into an areflexic, low-pressure one. Deafferentation can be used when the hyperreflexic bladder is the cause of incontinence or hydronephrosis.
Bladder emptying can subsequently be achieved by ISC or implantation of a nerve stimulator placed on ventral roots (efferent nerves) of S2–4 to drive micturition when the patient wants to void (a pager-sized externally applied radio transmitter activates micturition) (Figs. 13.3 and 13.4).
This technique is also useful for DSD/incomplete bladder emptying causing recurrent UTIs and retention.
Figure 13.3 A sacral anterior root stimulator, used to drive micturition following a deafferentation (external components).
4 Atala A, Bauer SB, Soker S, Yoo JJ, Retik AB (2006). Tissue-engineered autologous bladders for patients needing cystoplasty. Lancet 367(9518):1241–1246.
514 CHAPTER 13 Neuropathic bladder
Figure 13.4 KUB X-ray showing the sacral electrodes positioned on the ventral roots of S2, 3, and 4.
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