- •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
20 CHAPTER 1 Preliminary investigation
Urinary incontinence in adults
Definitions
Urinary incontinence (UI): involuntary loss of urine that is objectively demonstrable and is of social and/or hygienic concern (international Continence Society definition).
Stress urinary incontinence (SUI): urine loss associated with increased intra-abdominal pressure such as exertion, coughing, or sneezing. A diagnosis of urodynamic SUI is made during filling cystometry when there is involuntary leakage of urine during a rise in abdominal pressure (induced by coughing), in the absence of a detrusor contraction.
Urge urinary incontinence (UUI): sudden uncontrollable urgency, leading to leakage of urine.
Overactive bladder (OAB): urinary urgency, with or without urge incontinence, usually with frequency and nocturia, in the absence of causative infection or pathological conditions.
Overflow incontinence: increased residual or chronic urinary retention leads to urinary leakage from bladder overdistention.
Total incontinence: the continuous leakage of urine.
Functional incontinence: loss of urine related to deficits of cognition and mobility.
Mixed urinary incontinence (MUI): a combination of SUI and UUI.
•Both UUI/OAB and MUI require a perception of urgency by the patient.
•25% of women aged >20 years have UI, of whom 50% have SUI, 10–20% have pure UUI, and 30–40% have MUI.
•UI impacts psychological health, social functioning, and quality of life.
Significance of SUI and UUI
SUI occurs in women as a result of bladder neck/urethral hypermobility and/or neuromuscular defects causing intrinsic sphincter deficiency (sphincter weakness incontinence). As a consequence, urine leaks whenever urethral resistance is exceeded by an increased abdominal pressure occurring during exercise or coughing, for example.
In women, obesity, childbirth, and cystocele/uterine prolapse are common causes. In men, prostate surgery (radical prostatectomy, TURP) can result in incompetence or weakness of the external sphincter.
UUI may be due to bladder overactivity (formerly known as detrusor instability) or, less commonly, to a pathological process that irritates the bladder (infection [UTI, vaginitis, pelvic inflammatory disease], tumor [urological, gynecological], urolithiasis) or neuropathy (multiple sclerosis, CNS neoplasms, stroke). The correlation between urodynamic evidence of bladder overactivity and the sensation of urgency is poor, particularly in patients with MUI.
Symptoms resulting from involuntary detrusor contractions may be difficult to distinguish from those due to sphincter weakness. Furthermore,
URINARY INCONTINENCE IN ADULTS 21
in some patients, detrusor contractions can be provoked by coughing, thus distinguishing leakage due to SUI from that due to bladder overactivity can be very difficult. For the diagnosis of OAB, no cause can be identified.
Other types of incontinence
While SUI and especially UUI do not specifically allow identification of the underlying cause, some types of incontinence may allow a specific diagnosis to be made.
•Bed wetting in an elderly man suggests high-pressure chronic retention.
•Total incontinence suggests a fistulous communication between the bladder (usually) and vagina (e.g., due to surgical injury at the time of hysterectomy or C-section) or, rarely, the presence of an ectopic ureter draining into the vagina (in which case the urine leak
is usually low in volume, but lifelong). Total disruption of the internal and external sphincter in men and women can also cause total incontinence.
Diagnosis and management of incontinence
A basic history and physical exam along with urinalysis may identify the cause. In women, a pelvic exam must be performed (cystocele, urethral diverticulum).
Residual urine determination and urinary flow rates can be used to diagnose retention or outflow obstruction. Good flow rate with minimal postvoid residual suggests sphincteric incontinence.
•Urodynamic studies are useful where the history does not clearly indicate the cause.
•Cystometrogram measures bladder compliance, sensations, and detrusor responses to filling. It is particularly useful with urgency and urge incontinence. Documentation of detrusor hyperreflexia or detrusor instability has important therapeutic implications.
•Valsalva leak point pressure determines the intra-abdominal pressure at which urine leaks. A low leak point pressure implies intrinsic sphincter deficiency (ISD).
•Videourodynamic studies are advanced testing if basic evaluation not informative.
Further reading
Anger JT. Saigal CS. Stothers L. Thom DH. Rodriguez LV. Litwin MS (2006). Urologic Diseases of America Project. The prevalence of urinary incontinence among community dwelling men: results from the National Health and Nutrition Examination survey. J Urol 176(5):2103–2108.
Atiemo HO, Vasavada SP (2006). Evaluation and management of refractory overactive bladder.
Curr Urol Rep 7:370–375.
Wein AJ, Rackley RR (2006). Overactive bladder: a better understanding of pathophysiology, diagnosis, and management. J Urol 175:S5–S10.
22 CHAPTER 1 Preliminary investigation
Genital symptoms
Scrotal pain
Pathology within the scrotum
•Epididymitis, orchitis, epididymo-orchitis
•Torsion of the testicles
•Torsion of testicular appendages
•Testicular tumor (usually painless)
Referred pain
•Ureteric colic
•Inguinal hernia
•Nerve root irritation or entrapment (ilioinguinal or genitofemoral)
Testicular torsion
Ischemic pain is severe and often accompanied by nausea and vomiting. Torsion presents with sudden onset of pain in the hemiscrotum, sometimes waking the patient from sleep. It may radiate to the groin and/or flank. There is sometimes a history of mild trauma to the testis in the hours before the acute onset of pain.
Similar episodes may have occurred in the past, with spontaneous resolution of the pain (suggesting torsion or spontaneous detorsion). The testis is very tender. It may be high-riding (lying at a higher than normal position in the testis) and may lie horizontally due to twisting of the cord.
Torsion of testicular appendage
Pain is usually not as severe as testicular torsion, and onset can be more gradual, not usually associated with nausea/vomiting.
Epididymitis, orchitis, epididymo-orchitis
These conditions have similar presenting symptoms to those of testicular torsion. Tenderness is most commonly localized to the epididymis. Isolated orchitis is rare today. Untreated epididymitis may involve the testicle secondarily with massive swelling and diffuse tenderness. See p. 33 for advice on attempting to distinguish torsion from epididymo-orchitis.
Testicular tumor
Only 20% of patients present with testicular pain, and most often after minor trauma.
Acute presentations of testicular tumors
•Testicular swelling may occur rapidly (over days or weeks). An associated (secondary) hydrocele is common. A hydrocele, especially in a young person, should always be investigated with an ultrasound to determine whether the underlying testis is normal.
•Rapid onset (days) of testicular swelling can occur. Very rarely, patients present with advanced metastatic disease (high-volume disease in the retroperitoneum, chest, and neck, causing chest, back, or abdominal pain or shortness of breath).
GENITAL SYMPTOMS 23
•Approximately 10–15% of testis tumors present with signs suggesting inflammation (i.e., signs suggesting a diagnosis of epididymo-orchitis—a tender, swollen testis, with redness in the overlying scrotal skin and a fever).
Priapism
Priapism is painful, persistent, prolonged erection of the penis not related to sexual stimulation (see causes in Chapter 12). It can be associated with pharmacological therapies (oral and intracavernosal) for erectile dysfunction. Recurrent or “stuttering” priapism episodes are recurrent but of limited duration. There are two broad categories—low flow (most common) and high flow.
Low-flow (“ischemic”) priapism is due to hematological disease (hemoglobinopathies, sickle cell anemia, thalassemia) or infiltration of the corpora cavernosa with malignant disease, or it is medication related. The corpora cavernosa are very rigid and painful because the corpora are ischemic.
High-flow priapism is due to perineal trauma, which creates an arteriovenous fistula. There is less pain and rigidity.
Diagnosis is usually obvious from the history and examination. Characteristically, the corpora cavernosa are rigid and the glans is flaccid. In low-flow priapism of the erect penis is very tender. Examine the abdomen for evidence of malignant disease and perform a digital rectal examination to examine the prostate. If necessary, corporal blood gas can be used to sort ischemic priapism (pO2 < 30 mmHg, pCO2 > 60 mm Hg, pH < 7.25) from non-ischemic priapism (pO2 > 90 mmHg, pCO2 < 40 mmHg, pH > 7.4).