- •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
68 CHAPTER 3 Bladder outlet obstruction
Benign prostatic obstruction (BPO): symptoms and signs
Clinical practice guidelines
Such guidelines were developed to standardize the approach to diagnosis (and treatment) of men presenting with symptoms suggestive of BPH (see Box 3.1).1 Every guideline agrees that a history should be taken, an examination performed, and the severity of urinary symptoms be formally assessed using the IPSS (the International Prostate Symptom Score). This includes a measure of the “problems” caused by the patient’s symptoms (i.e., the degree to which the symptoms are troubling).
Urinary symptoms—what do they mean?
During the 1990s, the classic “prostatic” symptoms of frequency, urgency, nocturia, hesitancy, poor flow, an intermittent flow, and terminal drib- bling—traditionally said to indicate the presence of BOO due to benign prostatic enlargement—were shown to bear little relationship to prostate size, flow rate, residual urine volume, or urodynamic evidence of BOO. Age-matched elderly men and women have similar symptom scores (IPSS), despite the fact that women have no prostate and rarely have BOO.
Prostatism vs. LUTS vs. LUTS/BPH
Prostatism has thus been replaced by the expression lower urinary tract symptoms (LUTS), which avoids any implication about the cause of these symptoms. More recently, the expression LUTS/BPH has been used to describe the symptoms of BPH.
It doesn’t really matter whether you use prostatism, LUTS, or LUTS/ BPH as long as you remember that urinary symptoms may have nonprostatic causes. Try to avoid treating the prostate when the problem may lie elsewhere.
Ask specifically about the presence of the following:
•Bed-wetting suggests the presence of high-pressure chronic retention (look for distension of the abdomen due to a grossly enlarged bladder which is tense on palpation and dull to percussion).
•Marked frequency and urgency, particularly when also combined with bladder pain: look for carcinoma in situ of the bladder (urine cytology, flexible cystoscopy, and bladder biopsy).
•Macroscopic hematuria is sometimes due to a large vascular prostate, but exclude other causes (bladder and kidney cancer and stones) by flexible cystoscopy and upper tract imaging.
•Back pain and neurological symptoms (sciatica, lower limb weakness or tingling). Rarely, LUTS can be due to neurological disease.
1 Irani J, Brown CT, van der Meulen J, Emberton M (2003). A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same? Br J Urol Int 92:937–942.
BPO: SYMPTOMS AND SIGNS 69
Box 3.1 Websites for BPH clinical practice guidelines
•AUA guidelines: http://www.auanet.org/content/guidelines-and- quality-care/clinical-guidelines.cfm
•EAU guidelines: http://www.uroweb.org/files/uploaded_files/bph.pdf
•WHO (International Consensus Committee) guidelines: http:// www.who.int/ina-ngo/ngo/ngo048.htm
•Australian guidelines: http://www.health.gov.au/nhmrc/publications/ pdf/cp42.pdf
•German guidelines: http://dgu.springer.de/leit/pdf/3_99.pdf
•Singapore guidelines: http://www.urology-singapore.org.html/ guidelines_bph.htm
•Malaysian guidelines: http://www.mohtrg.gov.my/guidelines/bph98.pdf
•UK guidelines: http://www.rcseng.ac.uk/publications/
70 CHAPTER 3 Bladder outlet obstruction
Diagnostic tests in men with LUTS thought to be due to BPH
Clinical practice guidelines
Guidelines were developed as an attempt to standardize the approach to diagnosis and treatment of men presenting with symptoms suggestive of BPH1 (see Box 3.1). All agree that a history should be taken and an examination performed, and all recommend assessment of symptom severity using the IPSS (International Prostate Symptom Score). This includes a measure of the problems caused by the patient’s symptoms.
There is considerable variation among guidelines in terms of recommended diagnostic tests. High-quality guidelines (e.g., based on results of randomized trials) recommend few diagnostic tests2—urine analysis, completion of a voiding diary (frequency–volume chart) to detect the presence of polyuria and nocturnal polyuria (which may be the cause of a patient’s increased frequency or nocturia), and measurement of serum creatinine. They regard flow rate measurement and assessment of residual urine volume as optional tests.
Digital rectal examination (DRE) and PSA
DRE and PSA testing are done to detect nodules that may indicate an underlying prostate cancer and to provide a rough indication of prostate size. Size alone is not an indication for treatment, but if surgical treatment is contemplated, marked prostatic enlargement can be confirmed by transrectal ultrasound (TRUS) scan (prostate volume in the order of 100 mL or more increases the likelihood of an open prostatectomy).
Discuss the pros and cons of PSA testing with the patient.
Serum creatinine
This is a baseline measure of renal function, used to detect renal failure secondary to high-pressure urinary retention.
Post-void residual urine volume (PVR)
PVR varies considerably (by as much as 600 mL between repeat measurements) on the same or on different days.3 It cannot predict symptomatic outcome from transurethral resection of the prostate (TURP). Along with serum creatinine, it indicates whether watchful waiting is safe.
It is safe not to operate when the PVR volume is <350 mL,4,5 since the majority of men show no worsening of creatinine, no increase in PVR, and no worsening of symptoms and do not require TURP or other bladder outlet procedure.
Flow rate measurement
This is variously regarded as optional, recommended, and obligatory prior to undertaking surgical treatment for BPH. Like PVR, measured flow rate varies substantially on a given day,6 cannot distinguish between BOO and a poorly contractile bladder, and is not good at predicting the likelihood of a good symptomatic outcome after TURP.
DIAGNOSTIC TESTS IN MEN WITH LUTS 71
Pressure-flow studies
Such studies are reasonably good at predicting symptomatic outcome after TURP. However, most patients without obstruction have a good outcome, and the time, cost, and invasiveness of pressure-flow studies are perceived by most urologists as not justifying their routine use.
Renal ultrasonography
This is used to detect hydronephrosis if serum creatinine is elevated. The percentage of patients having upper tract dilatation on ultrasound according to serum creatinine is as follows: creatinine <115 mmol/L (1.5 mg/dL), 0.8%; creatinine 115–130 mmol/L (1.5–1.7 mg/dL), 9%; and creatinine >130 mmol/L (1.7 mg/dL), 33%.7
Further reading
Roehrborn CG (2008). Currently available treatment guidelines for men with lower urinary tract symptoms. Br J Urol 102:18–23.
Wei JT, Calhoun E, Jacobsen SJ (2005). Urologic diseases in America project: benign prostatic hyperplasia. J Urol 173:1256–1261.
Emberton M, Andriole GL, de la Rosette J, Djavan B, Hoefner K, Nvarette R et al. (2003). Benign prostatic hyperplasia: a progressive disease of aging men. Urol 61:267–273.
1 Roehrborn CG, Bartsch G, Kirby R, et al. (2001) Guidelines for the diagnosis and treatment of benign prostatic hyperplasia: a comparative international overview. Urology 58:642–650.
2 Irani J, Brown CT, van der Meulen J, Emberton M (2003) A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same? Br J Urol Int 92:937–942.
3 Dunsmuir WD, Feneley M, Corry DA, et al. (1996) The day-to-day variation (test–retest reliability) of residual urine measurement. Br J Urol 77:192–193.
4 Bates TS, Sugiono M, James ED, et al. (2003) Is the conservative management of chronic retention in men ever justified? Br J Urol Int 92:581–583.
5 Wasson JH, Reda DJ, Bruskewitz RC, et al. (1995) A comparison of transurethral surgery with watchful waiting for moderate symptom of benign prostatic hyperplasia. The Veterans Administration Cooperative Study Group on Transurethral Resection of the Prostate. N Engll Med 332:75–79.
6 Reynard JM, Peters TJ, Lim C, Abrams P (1996) The value of multiple free-flow studies in men with lower urinary tract symptoms. Br J Urol 77:813–818.
7 Koch WF, Ezz el Din KE, De Wildt MJ, et al. (1996) The outcome of renal ultrasound in the assessment of 556 consecutive patients with benign prostatic hyperplasia. J Urol 155:186–189.