- •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
384 CHAPTER 8 Stone disease
Kidney stones: medical therapy (dissolution therapy)
Uric acid and cystine stones are potentially suitable for dissolution therapy. Calcium within either stone type reduces the chances of successful dissolution.
Uric acid stones
Urine is frequently supersaturated with uric acid (derived from a purinerich diet—i.e., animal protein). Half of patients who form uric acid stones have gout. The other 50% do so because of a high protein and low fluid intake (Western lifestyle). In patients with gout, the risk of developing stones is ~1% per year after the first attack of gout.
Uric acid stones form in concentrated, acid urine. Dissolution therapy is based on hydration, urine alkalinization, allopurinol, and dietary manipulation—the aim being to reduce urinary uric acid saturation.
The patient should maintain a high fluid intake (urine output 2–3 L/day) and alkalinize the urine to pH 6.5–7 (sodium bicarbonate 650 mg 3 or 4 times daily or potassium citrate 30–60 mEq/day, equivalent to 15–30 mL of a potassium citrate solution 3 or 4 times daily).
In those with hyperuricemia or urinary uric acid excretion >1200 mg/ day, add allopurinol 300–600 mg/day (inhibits conversion of hypoxanthine and xanthine to uric acid). Dissolution of large stones (even staghorn calculi) is possible with this regimen.
Cystine stones
Cystinuria is an inherited kidney and intestinal transepithelial transport defect for the amino acids cystine, ornithine, lysine, and arginine, (“COLA”) leading to excessive urinary excretion of cystine. It has autosomal recessive inheritance, with prevalence of 1 in 700 being homozygous (i.e., both genes defective). It occurs equally in both sexes. About 3% of adult stone formers are cystinuric and 6% of stone-forming children.
Most cystinuric patients excrete about 1 g of cystine per day, which is well above the solubility of cystine. Cystine solubility in acid solutions is low (300 mg/L at pH 5, 400 mg/L at pH 7). Patients with cystinuria present with renal calculi, often in their teens or 20’s. Cystine stones are relatively radiodense because they contain sulfur atoms.
The cyanide nitroprusside test will detect most homozygote stone formers and some heterozygotes (false positives occur in the presence of ketones).
Treatment of existing stones and prevention of further stones
The aim is to do the following:
-Reduce cystine excretion (dietary restriction of the cystine precursor amino acid methionine and also of sodium intake to <100 mg/day)
-Increase solubility of cystine by alkalinization of the urine to >pH 7.5, maintenance of a high fluid intake, and use of drugs that convert cystine to more soluble compounds.
KIDNEY STONES: MEDICAL THERAPY (DISSOLUTION THERAPY) 385
D-penicillamine, N-acetyl-D-penicillamine, and mercaptopropionylglycine bind to cystine—the compounds so formed are more soluble in urine than cystine alone. D-penicillamine has potentially unpleasant and serious side effects (allergic reactions, nephrotic syndrome, pancytopenia, proteinuria, epidermolysis, thrombocytosis, hypogeusia).
Therefore, it is reserved for cases where alkalinization therapy and high fluid intake fail to dissolve the stones.
Treatment for failed dissolution therapy
Cystine stones are very hard and are therefore relatively resistant to ESWL. Nonetheless, for small cystine stones, a substantial proportion will still respond to ESWL. Flexible ureteroscopy (for small) and PCNL (for larger) cystine stones are used where ESWL fragmentation has failed.
386 CHAPTER 8 Stone disease
Ureteric stones: presentation
Ureteric stones usually present with sudden onset of severe flank pain that is colicky (waves of increasing severity are followed by a reduction in severity, but it seldom goes away completely). It may radiate to the groin as the stone passes into the lower ureter.
Approximately 50% of patients with classic symptoms for a ureteric stone do not have a stone confirmed on subsequent imaging studies, nor do they physically ever pass a stone.
Examination
Spend a few seconds looking at the patient. Ureteric stone pain is colicky—the patient moves around, trying to find a comfortable position. The patient may be doubled-up with pain.
Patients with conditions causing peritonitis (e.g., appendicitis, a ruptured ectopic pregnancy) lie very still: movement and abdominal palpation are very painful.
Pregnancy test
Arrange for a pregnancy test in premenopausal women (this is mandatory in any premenopausal woman who is going to undergo imaging using ionizing radiation). If positive, refer to a gynecologist; if negative, obtain imaging to determine whether the patient has a ureteric stone.
Dipstick or microscopic hematuria
Many patients with ureteric stones have dipstick or microscopic hematuria (and, more rarely, macroscopic hematuria), but 10–30% have no blood in their urine.1,2 The sensitivity of dipstick hematuria for detecting ureteric stones presenting acutely is ~95% on the first day of pain, 85% on the second day, and 65% on the third and fourth days.2 Therefore, patients with a ureteric stone whose pain started 3–4 days ago may not have blood detectable in their urine.
Dipstick testing is slightly more sensitive than urine microscopy for detecting stones (80% vs. 70%) because blood cells lyse, and therefore disappear, if the urine specimen is not examined under the microscope within a few hours. Both ways of detecting hematuria have roughly the same specificity for diagnosing ureteric stones (~60%).
Remember, blood in the urine on dipstick testing or microscopy may be a coincidental finding because of non-stone urological disease (e.g., neoplasm, infection) or a false-positive test (no abnormality is found in ~70% of patients with microscopic hematuria, despite full urological investigation).
1 Luchs JS, Katz DS, Lane DS, et al. (2002). Utility of hematuria testing in patients with suspected renal colic: correlation with unenhanced helical CT results. Urology 59:839.
2 Kobayashi T, Nishizawa K, Mitsumori K, Ogura K (2003). Impact of date of onset on the absence of hematuria in patients with acute renal colic. J Urol 170:1093–1096.
URETERIC STONES: PRESENTATION 387
Temperature
The most important aspect of examination in a patient with a ureteric stone confirmed on imaging is to measure their temperature. If the patient has a stone and a fever, they may have infection proximal to the stone. This is considered a urological emergency.
A fever in the presence of an obstructing stone is an indication for urine and blood culture, intravenous fluids and antibiotics, and nephrostomy drainage if the fever does not resolve within a matter of hours.