29 - Toronto Notes 2011 - Urology

u Urology Samir Bidnur, Yooah Krakowsky and Debonh Sasgea, chapter editors Alaina Garbens and Modupe Oyeumt. associate editors Adam Gladwish, EBM editor Dr. Armando Lorenzo, Dr. Keith Jarvi and Dr. Sender Henchom, staff editors Basic Anatomy Review ................... 2 Scrotal Mass........................... 27 Abdominal Wall Anatomy of Scrotum Genito-Urinary Tract Anatomy Penis Anatomy Varicocele Spermatocele Hydrocele Testicular Torsion Inguinal Hernia Hematocele Common Presenting Problems ............. 3 Hematuria Scrotal Complaints Urinary Retention Dysuria Voiding Dysfunction ..................... 5 Penile Complaints ...................... 29 Peyronie's Disease Priapism Paraphimosis Phimosis Erectile Dysfunction (ED) Premature Ejaculation Voiding Failure to Store: Urinary Incontinence Failure to Void: Urinary Retention Benign Prostatic Hyperplasia (BPH) Urethral Stricture Neurogenic Bladder Post Obstructive Diuresis (POD) Trauma ............................... 32 Infectious and Inflammatory Diseases...... 10 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Urinary Tract Infections (UTI) Recurrent/Chronic Cystitis Interstitial Cystitis (Painful Bladder Syndrome) Acute Pyelonephritis Prostatitis/Prostatodynia Epididymitis and Orchitis Urethritis Urethral Syndrome Female Factors Male Factors Stone Disease ......................... 15 Approach to Renal Stones Calcium Stones Uric Acid Stones Struvite Stones Cystine Stones Urological Neoplasms ................... 18 Approach to Renal Mass Benign Renal Neoplasms Malignant Renal Neoplasms Carcinoma of the Renal Pelvis and Ureter Bladder Carcinoma Prostatic Carcinoma (CaP) Prostate Specific Antigen (PSA) Testicular Tumours Penile Tumours Toronto Notes 2011 Renal Trauma Bladder Trauma Urethral Injuries Pediatric Urology ....................... 36 Congenital Abnormalities Nephroblastoma (Wilm's Tumour) Cryptorchidism/Ectopic Testes Disorders of Sexual Differentiation Circumcision Enuresis Selected Urological Procedures ........... 40 Bladder Catheterization Cystoscopy Radical Prostatectomy Transurethral Resection of the Prostate (TURP) Extracorporeal Shock Wave Lithotripsy (ESWL) Common Medications ................... 43 Antibiotics Erectile Dysfunction Benign Prostatic Hyperplasia Prostatic Carcinoma Continence Agents References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Urology Ul U2 Urology Basic Anatomy Review Toronto Notes 2011 Basic Anatomy Review Above Arcuate Line _ "!i¥='i'- L- , . Fascia 11!::.!2::! ,..-----External Oblique r ' . }; ' Abdominus Fascia ,..----- Extra peritoneal Fat ,..------ Peritoneum Below Arcuate Lin e)--Inferior Epigastric Artery --.._____Skin \..__ Superficial Fascia \..__ External Oblique - ----"="="";._ '--Internal Oblique --Transversus Abdominus .._____Transversalis Fascia '------ Extraperitoneal Fat '------ Peritoneum Figure 1. Midline Cross-Section of Abdominal Wall External spermatic fascia Cremaster muscle Internal spermatic fascia Pampiniform plexus Tunica vaginalis Dartos fascia Figure 2. Anatomy of Scrotum Minor Major calyx Pararenal fat Renal sinus Renal pelvis Renal vein Renal artery Abdominal aorta IVC Ureter Gonadal artery and vein Renal papilla Renal column Renal pyramid Renal capsule (Gerota's fascia) Ureter Internal iliac artery and vein External iliac artery and vein Internal pudenal artery Common penile artery © Krista Shapton 2010 Male Pelvic Vasculature Detrusor Trigone Base detrusor Uretero-vesicular junction Prostate Prostatic urethra Posterior urethra Periurethral striated muscle-"2!rn.:.;...-Membranous urethra Rhabdosphincter (external Bulbar urethra : } sphincter, striated muscle) ' Anterior urethra Spongy (penile) urethra © Sandra Tavares 2007 Figure 3. Essential Genito-Urinary Tract Anatomy ©June Li 2010 Figure 4. Cross Section of the Penis Common Presenting Problems Toronto Notes 2011 Urology U3 Common Presenting Problems Hematuria Classification (see Nephrology. NP6) Tabla , . Etiology of Hematuria by Aga Group B-20 Glomerulonephritis, llTI, cong..ital anomalies 2()..40 un, stones, bladder tumour 4[)..60 Male: bladder tumour, stones, UTI Female: lJTI, stones, bladder tumour >60 Male: BPH, bladder tumour, un Female: bladder tumour, un Etiology Tabla 2. Etiology of Hamaturia by Typa bleeding Dyes (beets. rhodemine B in candy and juicesl Hemoglobin (hemolytic anemial Myoglobin (rhebdomyolysis) Drugs (rifaiJ'1lin. phenazopyridine. pyridium. phenytoin) Porphyria Laxatives (phenolphthalein) AnticoiiiJII!nts Coagulation defects Sickle cell dsease Neoplasms Leukemia Ttmnboembolism Stone Trauma Renal cell carcinoma cell carcinoma Wilm's tumour Glomerulonephritis Stone Tumour Uretlritis Polyps Foreign body Uretlnl sbicture Tuberculosis Infarct Polycystic kidneys Arteriovenous malloiTIIiltion History • full history, inquire about timing of macroscopic hematuria in urinary stream • initial: anterior urethra • terminal: bladder neck and prostatic urethra • total: bladder and/or above Investigations • gross hematuria and symptomatic hematuria require full workup • CBC (rule out anemia, leukocytosis), electrolytes, creatinine, BUN • urine studies: • urinalysis (casts, crystals, cells) • culture and sensitivity • cytology • imaging: • CT/IVP to investigate upper tracts (ultrasound alone is not sufficient) • cystoscopy to investigate lower tract (possible retrograde pyelogram) • microscopic hematuria defined as more than two red blood cells (RBC) per high-power field (HPF) (see Figure 5) Acute Management of Severe Bladder HemoiThage • manual irrigation via catheter with normal saline to remove clots • continuous bladder irrigation (CBI) using large (22-26 Fr) 3-way Foley to help prevent clot formation • cystoscopy if bleeding quite active: • identify resectable tumours • coagulate obvious sites ofbleeding • refractory bleeding: • continuous intravesical irrigation with 1% alum (aluminum potassium sulfate) solution as needed • intravesical instillation of 1% silver nitrate solution • intravesical instillation of 1-4% formalin (need general anesthesia) • embolization or ligation ofiliac arteries • cystectomy and diversion rarely Cammon urologic CIIUUS of h111111lwi1 c., be grossly classified 115: TIBUIIIII Infection Tumoun; Ston11 U4 Urology Common Presenting Problems ,, , The CUA guidelines advise: Repeat initial urine microacopy if history of llflllhral tnurna. IXlln:isa, or me11181. lmmedim rllhi!Tal to nephrology if 1111y of: proteinuria, -1' craatinine, rad cell casts or clysmorphic RBCs Toronto Notes 2011 I >Z RBC,IHPF I I Urinalysis and urine C&S I • • • 1. Rule out and treat benign causes {i.e. Ull) 2. If accompanied by d1J1111orphic RBC, or 1' Cr, evalum for primary renal disease ,, , If neither 1 or 2, urologic evaluation required • Uppllf Tr-ct I-Fni Opt- Urothtllial Cell Carcinoma {UCCI Riak Stratification l'yela!Jam- Traditional option and widely available, but use i$ decreasing. Reasollllble sensitivity for UCC, but poor sensitivity for RCC. + + HIGH RISK Smoking hi&lory Occupational chamictlllCPosura Gross hematuria >4Dyn old Hx of &!Drage voiding &ymptoms Hx of recurrent lJTI's Ultrunnd - Superior to IVP for 8VIIIuation of renal piUllllChyma and renal cysts. Urnillld sensitivity for UCC and small renal masses. UIS alone is not sullicilllt for uppar tract imaging. •... CT - Optimallllst for renal parenchyma, calculi ll1d infections, but less Complsta &valuation and mora expentiv& thllll lltruound. Involves elqiDIUre to l'lldiation and inlnMIIIDUS CDIIII'IIl 1. Urine cytology 2. Upper tract imaging LOW RISK 1. Urine cytology 2. Uppar tract imaging +1 +ve I TreatUCC +1111 i 3. Cysto.copy 3. Cysto.copy I I .,. ..... .. .... Follow up Urinalysis, cytology, and BP at 6, 12, 24, 36 months Figure 5. Workup of Asymptomatic Microscopic Hematuria Based on AUA Guidelines Scrotal Complaints • see Scrotal Mass, U27 Urinary Retention ------------------------------------------ • see Failure to Void, U6 Dysuria Differential Diagnosis Tabla 3. Differential Diagnosis of Dysuria Infectious urstllilis, 11'05f81itis, epididymitis, vestibulitis cervicitis, wlvovaginitis, perineal inllanmatiorilnfaelion, TB, Naaplum Renal cell, bladder, prostate, penis, vagiiiiWulva, BPH C.lcul Bladder stone, ureteral stone, kidney stone lnlll11mltory Seronegilliw arthropathie& (Riileliw arthritis: arthritis, uwitis, u181hritisl, drug &ide llf!ect&, autoimmune disorders, chronic pelvic pain synctome (CPPSI. in1elslitial cystitis Hormllllll Endometriosis, hypoeslnlgenism TraUIIII Catheter insertion. post-coillll cyslitis (honaymoon cystitisI Plychagenic Somalimlion disorder, MOD, stress/anxiety disorder Othar Conteel sensitivity, foreign body Approach • focused history and physical to determine cause (fever, discharge, CVA tenderness, conjunctivitis, back/joint pain) • urine dip, C&S, R&M • any discharge {urethral, vaginal, cervical) should be sent for gonococcus/chlamydia testing; wet mount if vaginal discharge • if suspect infection, may start empiric antibiotic treatment • ±imaging of urinary tract (tumour, stones) Urology US Voiding Dysfunction Toronto Notes 2011 Voiding Dysfunction • see GY36 for relevant female topics Voiding • two phases oflower urinary tract function: 1. Storage phase - bladder filling and urine storage • accommodation and compliance • no involuntary contraction 2. Voiding phase - bladder emptying • coordinated detrusor contraction • synchronous relaxation of outlet sphincters • no anatomic obstruction • voiding dysfunction can therefore be classified as: • failure to store - due to bladder or outlet • failure to void - due to bladder or outlet • three types of symptoms: storage (formerly known as irritative), voiding (formerly known as obstructive), post-void Failure to Store: Urinary Incontinence ------ Definition • involuntary leakage of urine Etiology • urgency incontinence: • detrusor overactivity: • CNS lesion, inflammation/infection (cystitis, stone, tumour), bladder neck obstruction (tumour, stone), BPH • decreased compliance of bladder wall: • CNS lesion, fibrosis • sphincter/urethral problem • stress urinary incontinence (SUI): • urethral hypermobility • weakened pelvic floor allows bladder neck and urethra to descend with increased intra-abdominal pressure • urethra is pulled open by greater motion of posterior wall of outlet relative to anterior wall • associated with childbirth, pelvic surgery, aging, levator muscle weakness • intrinsic sphincter deficiency (ISD) • pelvic surgery, neurologic problem, aging and hypoestrogen state • intrinsic sphincter deficiency and urethral hypennobility can co-exist • F:M=2:1 • more frequent in the elderly, affecting 5-15% of those living in the community and 50% of nursing home residents Table 4. Urinary Incontinence: Types and Treatments Type Urga Involuntary leakage of urile Involuntary leakage of IJ'ine preceded by a strong, suddan increases in sudden Ullle to void inlnHibdominal pressure Etialagy Bladder {detrusor overactivity) Dilgnollis Hisloly Urudynamics Stress Ovarllaw Mixed Involuntary leakage of urine whan inti'IIV8Sical pressure axceads urethral pressure Urinary leakage associated with Ul'llencv and increased inlnHibdominal pressure Urethrs/Sphilcter weakness, Obslruction, neuropathy post1)artum pelvic {diabetes, MS. musculature W8ilkn8Ss antic:holinal'llic drugs) Combination of bladder and sphilcter issues History History Urodynamics Stras1 Test (hBw patient bear downfcough) • • Urgancy • Nocturia • OV.uria Thilit Frequent Urgant Ni{#rtlime Di8Comfort 't' C.usn of 11enn•1• Urinary DIAPERS Delirium lnflammatiorVInfection A1rophic Phllllllllcautic:lllr,/Psyc:hologiclll Epidemiology • variable prevalence in women: 25-45% Dalililio1 F•iluN to Store Urinlry Tract Sr.-1111 (WTSJ (irritlltift) History Urodymmics Stress Test Excns uriu output Resbicted mobiity/Retention Stool impaction U6 Urology ...... , ·}-----------------, Voiding Dysfunction Toronto Notes 2011 Table 4. Urinary Incontinence: Types and Treatments (continued) Type Urge Sims Owlflow Traatmlllt Lifestyle Bladder habit training Weight loss, LWestyle Clllheterillllion tD IIVDid organ damage Traat Wlderlying cause Urge Incant!- Traidnnlnt 8ewanl of lllticholinerqic side effects including delirium and urinary retention. Batox Medications: Anticholin&rgics (1Diterodine Kegel's exercises Bulking agents Surgary (slings, lVOT, Miud Combination of management of urge and stress incontinence artificial sphinctn) oxybutynin (Ditropan"J. trospium (Trosec1111. soiW&nacin TCAs Neuromodulation Failure to Void: Urinary Retention .._,, ,}-----------------, Acute vs. Chronic llatlntlon Acute retention is 1 medical emergency chlllllllimd by pain and 11111ril with nonnal bladder volume and Acuta ovardillantion lead Ill bllddar rupture. Chi'Oilic retention can be asymptomlllic grwdy incnaud bladder voUnl 1nd detrusor hypertrophy foUowed by atony (IIIII). ------------------ Etiology • outflow obstruction: • bladder neck or urethra - calculus, clot, foreign body, or neoplasm • prostate - BPH, prostate cancer, prostatitis • urethra - stricture. phimosis, traumatic disruption • bladder innervation: • spinal cord - injury, disc herniation, multiple sclerosis • stroke •DM • post-pelvic surgery • pharmacologic: • anticholinergics •narcotics • antihypertensives (ganglionic blockers, methyldopa) • over-the-counter cold medications containing ephedrine or pseudoephedrine (e.g. Sudafed•) • antihistamines (e.g. Benadryl•, Nytol•, Sominex•) • psychosomatic substances (e.g. ecstasy) Clinical Features • • • • palpable and/or percussible bladder (suprapubic) possible purulent/bloody meatal discharge DRE - size of prostate, anal sphincter tone neurological- presence of abnormal deep tendon reflexes, saddle sensation, etc. Investigations • CBC, electrolytes, Cr, BUN, urine R&M, C&S, ultrasound, cystoscopy, urodynamic studies, post void residual (PVR) scan Treatment • guiding principles are to treat underlying cause of retention and use least invasive treatment possible • catheterization: • contraindicated in trauma patient unless urethral disruption has been ruled out • acute retention: immediate catheterization to relieve retention, leave Foley in to drain bladder, follow up to determine cause • chronic retention: intermittent catheterization by patient is commonly used; definitive treatment depends on etiology • suprapubic cystotomy • for post-operative patients with retention: • encourage ambulation • alpha-blockers to relax bladder neck • may need catheterization • definitive treatment will depend on etiology Toronto Nota 2011 Voicling Dyafunction UroiOBf U7 Benign Prostatic Hyperplasia (BPH) _ _ _ _ _ _ __ J Definition • hyperplasia ofstroma and epithelium in periurethral area ofprostate (transition zone) see Pigure6 • tone ofprolltlrtic smooth muscle cells plays a role in addltlon to hyperplasla. Anterior 11r1111 lillll"'"""n "'"" ---= / ZIJfl8 Etiology • etiology unknown • androgen dihydrotestosteront: (DHT) required (converted from testosterone by 5-alpha reductase) • possible role ofimpaired apoptosis, estrogens, ather growth factors Epidemiology • age-related. extremely common (SO% of50 year olds, 80% of80 year olds) • 2596 of men will require treatment Clinical Features • result from outlet obstruction and compensatory changes In detrusor functl.on • voiding symptoms: • hesitancy, straining. weak/interrupted stres.m. incomplete bladder emptying • decreased flow rates may be seen on uroflowmetry • due to outflow obstruction and/or impaired detrusor contractility • storage symptoms: • urgency, frequency, nocturia, urgency incontinence • thought to be due to detrusor overactivity and deaeased compliance • prostate Is llllOOth, rubbery and symmetrically enlarged on DRE • complications: • retention • overflow incontinence • hydronephrosis and renal compromise • infection • gross hematuria •bladderstones Centnllzxn l'llripherlllzxn EjiiCUIIIlny zona C Meog'-' Brilllley Figure I. Cr.....Saellon af ProsbdB lt' AIIAPrDitllli Syqmn Scllre FUIIIWJIE Urgency NDC!uria WMkelrelm lnterm-cy llnlining ineo.,.-811 ._..g of Each '"fll1piGm graded out"' 5. D-7 - Milcly wymp!DmllliG B-19- Modlrmly aymp!CIIIIIIic 20.J5-SIIVIfllly Nata; Dy.ril. nut ilcludad in 1100111 but ia cammanly._illlcl with BPH Investigations • history • a&&ess LUTS and effect on quality ofUfe, may include self-administered questionnaires (AUA symptom and impact score) • physical exam: DRE • urinalysis to exclude UTI • c.reatinine to assess renal function ± renal ultrasound to assess for hydronephrosis • prostate-specific antigen (PSA) trJ rule out malignancy (iflife apectancy >10 years) • umflowmetryto measure flow rate (optional) • bladder ultrasowtd to determme post-void residual urine (optional) • cystoscopy prior trJ potential surgical management • biopsy ifsuspicious for malignancy Treatment • conservative for those with mild symptoms: • watcltful waiting - 5096 of patients improve spontaneously • includes Ufestyle changes (e.g. evening fluid restriction, planned voiding) • medical treatment • a-adrenergl.c antagunlsts - reduce stromal smooth muscle tone [e.g. terazosln (Hytrln-}, doxazosin (cardura•), tamsulosin (Plomax"), alfuzosin (Xatral-)1 • 5-a reductase inhibitor- blocks conversion of testosterone to DHT; acts on the epithelial component of the prostate- reduces prostate size [e.g. finasteride (Proscar"), dutasteride (Avodart")] • combination shown to be synergistic (see sidebar) • transurethral resection ofprostate (TURP): • see Seleded UrolDgical Procedures, U40 • open prostatectomy: • for large prostates or associated problems (e.g. bladder stones) • suprapubic (transvesically to deal with bladder pathology) • retropubic (through the prostatic capsule) om.inimallylnvasivetherapy: • prostatic stents, microwave therapy, laser ablation, water-induced thermotherapy, cryotherapy, ¥ intensity focuaed ultrasound (HIFU) and transurethral neeclli: ablation (TUNA) ..... , llpprmdllltlll'roltlta 1181 20 4:C - ct.ltnut 25t:e-pUn 50 t:e -lem111 75 t:e - oranga I 00 cc - grapefnjt ..... ,, Alllalm INIAiill11 fur IPH S...ry • Rafnlctoty urilll'f rellntion • Rac..,.n UTI1 • Rac....-.d hamaturlll Nfrll:lory111 mediDII trlltmlnt • ._,.. !IIIIa out Cllhar CIUIM) • 8lu11M US Urology Voiding Dysfunction Urethral Stricture . ,.... ., .........,..... • Lilt-Tim E1lld rlllmllmlil. hlllridl, Definition IIIIUPSI Trill} • M>F .. c.n-....n..., ...... aii:ll ,....... .,.,..,..s,.,... NfJM2003; 349:2387-2398 lllwly:lllnlt:lnilld, daubla-bmdad, cantralllld trill witllllll!l of 4.5 YIIIJ. Pllilnll: 3047 plliiiD Nth BPH IAignld Ill pil1:abo 7371. doxlzalin 7561 fillllllride (n • 768), « conDilali:ln 1lllrapy (n= 786). Melli age 62.6. CIII'IIIIMIM 11811mant-... dllllllllil \15. finulaide Vi. cantinllillll111arapy. Main D*-: Clnical J1R9111ion dainad 11: fim ocamnce ol111 inl:niue IMI'bae lile of 111 IIIII fiu pcin1s in 1lla AUA sympiDm ara, ICUIII LriiBy lllention.llllli Toronto Notes 2011 nmrert lrinlly111ct irluclim, ar llirwy imlli1R:a. .... The &-¥r • • l!ldLEtion il CINTII81i¥e incidence rlclinicll 1Dpllc:lllofar daomlin- lft(P<0.001L fillllllride- 34!1 llld combinetioolMrlpy- &8'11IP<0.001). Comnltion thenill¥- lillie IAIIiclive thui eitller daaain [P<O.OOII artilllstwidl (P<O.OOII IIane. 111111-na sV!bltdifnl:e daaain llld fillllllridaalln. l:.l:luiJn: long·term cantinlliJn 1herapywilh daaain llld fillllllrida ofll¥8111 clinicaiii'UQIIIIion othlrigl jRitllic h¥Perpln &igniic:antlt ll1llll thui diltr811mint witb li1llar • decrease in urethral calibre due to scar formation in urethra (may also involve corpus spongiosum) Etiology • congenital- failure of normal canalization • may cause bilateral hydronephrosis • trauma: • instrumentation (most common) • external trauma (e.g. burns, straddle injury) • other: foreign body, removal ofinflated Foley catheter, etc. • infection: • long-term indwelling catheter • balanitis xerotica obliterans (lichen sclerosis or chronic progressive sclerosing dermatosis of the male genitalia) causes meatal stenosis Clinical Features • voiding symptoms (obstructive symptoms) • urinary retention • related infections: recurrent UTI, secondary prostatitis/epididymitis Investigations • laboratory findings • flow rates <10 ml/s (normal-20 ml/s) on uroflowmetry • urine culture usually negative, but may show pyuria • radiologic findings • retrograde urethrogram, voiding cystourethrogram (VCUG) will demonstrate location • urethroscopy Treatment • urethral dilatation: • temporarily increases lumen size by breaking up scar tissue • healing will often reform scar tissue and recreate stricture • visual internal urethrotomy (VIU): • endoscopically incise stricture without skin incision • cure rate 50-8096 with single treatment, <50% with repeated courses • open surgical reconstruction: • complete stricture excision ± anastomosis, ± urethroplasty depending on location and size of stricture Neurogenic Bladder Definition • a malfunctioning urinary bladder due to a deficiency in some aspect of its innervation 4C. Gf Bllldder Capacity (35()-500 cc; J'ed$: (Agtj + 2) X 30) Neurophysiology ComplillnCI[minimal A Pmsur..tA Table 5. Efferent Syrnpatlnmc, Parasympathetic, and Somatic Nerve Supply Volume) Conlraclility (vDiuniBry and &u&lllinad) Cooperation of bladder and sphincter Nam Fibrn Sympathetic Somlllic Parasympathetic Narve rucrt& in micluritiDII: "12·3-4 Dlpe tile •inl orr t,.lloor.· S1111ma11: Nllll'lllrllllmittlr T11111t Kay Recaplara T10-LZ SZ-S4 SZ-S4 Noradrenuline Acetylcholile Acetylcholile Trigone, internal sphincter, proximal LR!hra Adrenergic {all External s!ilincter Nicotinic Muscarinic (MZ. M31 Detrusor • receptors in the bladder wall and mucosa relay information to pontine micturition centre (PMC) and activate micturition reflex • the PMC sends excitatory/inhibitory signals to regulate micturition reflex (normally inhibited by cortical input) • micturition: stimulation of sacral parasympathetic neurons (bladder contraction); inhibition of sympathetic (IS relaxation) and sacral somatic neurons (ES relaxation) • urine storage: inhibition of sacral parasympathetic neurons (bladder relaxation) aided by sympathetic activation (bladder relaxation, IS contraction); stimulation of sacral somatic neurons (ES contraction ) • voluntary action of external sphincter (pudendal n. S2-S4) can inhibit urge to urinate • cerebellum, basal ganglia, thalamus, and hypothalamus all have input at PMC Toronto Notes 2011 Urology U9 Voiding Dysfunction Classification of Neurologic Voiding Dysfunction • lesion above PMC [e.g. stroke, tumour, multiple sclerosis (MS)]: neurogenic detrusor over activity (detrusor hyperreflexia) • loss of voluntary inhibition of voiding • intact pathway inferior to PMC maintains coordination ofvoiding episodes • lesion of spinal cord [e.g. MS, arteriovenous malformation (AVM)]: detrusor sphincter dyssynergia (DSD) • loss of coordination between detrusor and sphincter (ie. detrusor contracts on closed sphincter and vice versa) • component of detrusor overactivity as well • lesion of sacral cord or peripheral efferents (e.g. trauma, diabetes, disc herniation): detrusor atony/areflexia • flaccid bladder which fails to contract • may progress to poorly compliant bladder with high pressures • peripheral autonomic neuropathy: deficient bladder sensation -+ increasing residual urine -+ decompensation (e.g. DM, neurosyphilis, herpes zoster) • muscular lesion: can involve detrusor, smooth/striated sphincter Neuro-Urologic Evaluation • history and physical exam (urologic and general neurologic) • urinalysis, renal profile • imaging: intravenous pyelogram (IVP), U/S to rule out hydronephrosis and stones • cystoscopy • urodynamic studies: • uroflowmetry - assess flow rate, pattern • filling cystometrogram (CMG) - assess capacity, compliance, detrusor overactivity • voiding cystometrogram - pressure-flow study, assess bladder contractility and extent of bladder outflow obstruction • EMG - helps ascertain presence of coordinated or uncoordinated voiding, allows accurate diagnosis of DSD • video study- x-ray contrast to visualize bladder/bladder nec.k/urethra during CMG Treatment • goals of treatment: • maintenance oflow pressure storage and emptying system with minimal tubes and collecting devices is necessary to • prevent renal failure • prevent infections • prevent incontinence or achieve social continence • treatment options: depends on status of bladder and urethra • bladder hyperactivity-+ medications to relax bladder (see Incontinence, US) • if refractory: - botulinum toxin injections into bladder wall - occasionally augmentation cystoplasty • flaccid bladder-+ clean intermittent catheterization (CIC) Autonomic Dysreflexia • exaggerated sympathetic nervous system response to visceral stimulation below the lesion in spinal cord injury patients • lesion is usually above T6/T7 • stimulation includes instrumentation, distention or stimulation of bladder, urethra or rectum • symptoms include: hypertension, headache, reflex bradycardia, sweating, anxiety, piloerection • vasoconstriction below lesion, vasodilation above lesion • treatment: remove noxious stimulus (e.g. insert catheter), parenteral ganglionic or a-blockers, nifedipine (prophylaxis during cystoscopy) Post Obstructive Diuresis (POD) -------------------------- Definition • polyuria resulting from relief of severe chronic obstruction • >3 U24 hrs or >200 cclhr over each of two COlllleCutive hours Pathophysiology • ranges in severity: physiologic to pathologic process • physiologic POD occurs secondary to excretion of retained urea, sodium, and water (high osmotic load) after relief of obstruction • self-limiting, usually resolves in 48 hrs with PO fluids but sometimes can continue even after having reached euvolemic status (i.e. pathologic POD) ...... '' "Spillll •hack" earty phase foUowing cord injury m111ilesl$ qlllonic bladder. UIO Urology Voiding Dysfunction/Infectious and In11ammatory Diaeaaes Toronto Notes 2011 • pathologic POD is a sodium-wasting nephropathy that occurs secondary to an impaired concentrating ability ofthe renal tubules due to: • decreased reabsorption of sodium chloride in the thick ascending limb and urea in the collecting tubule • increased medullary blood flow (solute washout) • increased flow and solute concentration in the distal nephron Management • admit patient and closely monitor hemodynamic status and electrolytes • monitor urine output (U/0) q2h and ensure total fluid intake <U/0 by replacing every 1 cc U/0 with 0.5 cc 1/2 NS IV (PO fluids if physiologic POD) • avoid glucose-containing fluid replacement (can cause iatrogenic diuresis) • check Na and K q6-12h and replace prn • follow creatinine and BUN to baseline Infectious and Inflammatory Diseases Urinary Tract Infections (UTI) ---------------------------- • for UTis during pregnancy, see Obstetrics, OB18 Definition • greater than 100,000 bacterialml- midstream urine • if symptomatic, 100 bacterialml may be significant Classification • uncomplicated: lower urinary tract infection in a setting of functionally and structurally normal urinary tract • complicated: pyelonephritis and/or structural/functional abnormality • unresolved bacteriuria = urinary tract is not sterilized during therapy (most commonly due to resistant organisms or noncompliance) • recurrent UTI • bacterial persistence = urine cultures become sterile during therapy but resultant reinfection of the urine by the same organisms • reinfection= new infection with new pathogen (80% of recurrent UTls) Source • • • • ascending (most common) - GI organisms hematogenous (TB, perinephric abscess) lymphatic direct (inflammatory bowel disease, diverticulitis) Risk Factors • stasis and obstruction: • residual urine in poorly flushing system, e.g. posterior urethral valves, reflux, medication (anticholinergics), BPH, urethral stricture, cystocele • foreign body: • introduce pathogen or act as nidus of infection • e.g. catheter, instrumentation • decreased resistance to organisms: • diabetes, malignancy, immunosuppression • other factors: • trauma, anatomic variance (congenital), female (short urethra) Clinical Features • • • • Cystitis: c....IEEPS IIJeiJsrelle sp. E. coli (90%), o1her G1111m-negalives Enterococci Proteus minlbilis. aprophytiw., s. s. storage symptoms (frequency, urgency, dysuria) voiding symptoms (hesitancy, post-void dribbling, dysuria) hematuria pyelonephritis: more severe symptoms (including constitutional symptoms, CVA tenderness) Organisms • routine cultures (see sidebar) • non-routine cultures: • tuberculosis (TB) • Chlamydia trachomatis • Mycoplasma (Ureaplasma urealyticum) • fungi (Candida) Toronto Notes 2011 Infectious anclln1lammatory Diaeaaes Indications for Investigations • persistence of pyuria/symptoms after adequate therapy • severe infection with an increase in creatinine • recurrent/persistent infections • atypical pathogens (urea splitting organisms) Investigations • midstream urine R&M, C&S • dipstick: leukocytes ± nitrites ± hematuria • microscopy: >5 WBC/HPF in un-spun urine or >10 WBC/HPF in spun urine, bacteria, ±WBCcasts • Gram stain: GN bacilli, GP cocci,> 1 bacterium/oil immersion field • culture and sensitivity: midstream, catheterized or suprapubic aspirate • hematuria workup - urine cytology; ultrasound, cystoscopy • CT scan if indicated Treatment • confirm diagnosis • identify organism and treat (TMP/SMX, fluoroquinolones, nitrofurantoin, cephalosporins) • for mild infections 3 day course is sufficient (for treatment details see Common Medications, U43) • establish predisposing cause (if any) and correct • if febrile, consider admission with IV therapy and rule out obstruction Recurrent/Chronic Cystitis • incidence of bacteriuria in females: • pre-teens: 1 %; late teens: 4%; 30-50 years: 6% • assess predisposing factors as described above • possible relation to intercourse (postcoital antibiotics), perineal colonization • investigations may include cystoscopy, ultrasound, CT • antibiotic prophylaxis if >3 or 4 episodes per year in females Etiology • unknown: • theories: increased epithelial permeability, autoimmune, neurogenic • associations: severe allergies, irritable bowel syndrome (IBS), fibromyalgi.a Treatment • daily low-dose prophylaxis (nitrofurantoin, TMP/SMX) • lifestyle changes (limit caffeine intake, increase fluid/water intake, smoking cessation) • post-menopausal women: consider topical or systemic estrogen therapy • no treatment for asymptomatic UTI except in pregnant women or patients undergoing urinary tract instrumentation Interstitial Cystitis (Painful Bladder Syndrome) Definition • chronic urgency, frequency± pain without other reasonable causation Etiology • unknown: • theories: increased epithelial permeability, autoimmune, neurogenic, defective glycosaminoglycan (GAG) layer overlying mucosa • associations: severe allergies, irritable bowel syndrome (IBS), fibromyalgi.a Epidemiology • prevalence: -20/100,000 • 90% of cases are in females • mean age at onset is 40 years Classification • non-ulcerative (more common) -younger to middle-aged • ulcerative - middle-aged to older Urology Ull Ul2 Urology Infedioua and ln1lammatory Diseases Toronto Notes 2011 Diagnosis • required criteria: • glomerulations (submucosal petechiae) or Hunner's ulcers on C}'!l:oscopic examination • pain associated with the bladder or urinary urgency • negative urinalysis, C&S Differential Diagnosis • UTI, vaginitis, bladder tumour • radiation/chemical cystitis • eosin.ophilic:/TB cystitis • bladder calculi Treatment • patient empowerment (diet, lifestyle) • pentosan polysulfate (Elmiron•) • low dose amitriptyline • bladder hydrodistention (also diagnostic) under general anesthesia • intravesical dimethylsulfoxide (DMSO) or Cystistat• • surgery (augmentation cystoplasty and urinary diversion ± cystectomy) Acute Pyelonephritis ------------------------------------ • see Infectious Diseases, ID21 Definition • infection of the renal parenchyma with local and systemic manifestations Etiology • ascending (usually GN bacilli) or hematogenous route (usually GP cocci) • causative microorganisms: E. coli (most common), Klebsiella, Proteus, Pseudomonas, Enterococcus jaecalis, Enterobacter, S. Aureus, S. saphrophyticus • common underlying causes of pyelonephritis: stones, strictures, prostatic obstruction, vesicoureteric reflux, neurogenic bladder, catheters, DM, sickle-cell disease, PCKD, immunosuppression, post-renal transplant, instrumentation, pregnancy Clinical Features • rapid onset (hours - day) • LUTS including frequency, urgency, hematuria • fever, chills, nausea, vomiting, myalgia, malaise • CVA tenderness or exquisite flank pain • dysuria is not a symptom of pyelonephritis without concurrent cystitis ,, MacroBID has poor tissue penetration and 1h818fm is not usad to treat pyelonephritis (raquil'lll post-renal Investigations • urine R&:M, C&S (see Urinary Tract InfoctWns, UIO) • blood • CBC + differential: leukocytosis, left shift • imaging - indicated if suspect complicated pyelonephritis or symptoms do not improve with 72 hours oftreatment • Abdo/pelvic U/S • IVP • Cystoscopy • CT Treatment • may treat as outpatient if hemodynamically stable, ciprofloxacin PO x 7-14 days or cotrimoxazole (TMP/SMX) POx 14 days • severe or non-resolving: admit, hydrate and treat with ampicillin IV and gentamycin IV • emphysematous pyelonephritis: emergency nephrectomy • stone obstruction: admit and emergency stenting or percutaneous nephrostomy tube Toronto Notes 2011 Infectious anclln1lammatory Diaeaaes Urology U13 Prostatitis/Prostatodynia .... ', Prostlllic masuga may cMJse IIXIrllme 18ndem81Ri and incraaed risk af inducing sepsis, abscess or apididymo- • most common urologic diagnosis in men <50 years • incidence 10-30% • acute bacterial, chronic bacterial, abacterial subtypes Tabla &. Comparison of tlla Thraa Types of Prostatilil E1ialagy Type 1: Acute Bill:tlriill Pramtitis Type II: Chronic Bill:tBrill Prwliltitis Type Ill: Chronic Pelvic Pail Syndrome {AHc:IBriil] KEEPS (see U10 sidebar]: 811% E. coli Ascending urethral infection and reiiUK into prostatic ducts 01tan associated with autlst abmuctian {BPHJ, recent cystascapy, prostatic biopsy Most ilfections occur in 1he peripheral mne (see Figure 61 Recurrent e.xacerblllions of acute prostatitis signs and symptoms Recurrent UTI with same organism Divided into inflammlllory and non-inflammlllory subtypes lntraprostatic reflux of urine ± urethral hypertonia Multilactorial (immunologicaL neuropathic, neuroendocrine, psychosocial) AcLIIe onset fiNer, chills, malaise Rectal, lower back and perineal pain Storagellld voiding WTS Hematuria asymptomlllic with normal prostate on DRE Pelvic pain, storage LUTS, ejaculatory pain, postejaculatory pain lnmtigllions RectaiiiDUIIl Urine C&S: 4 specimens Enlarged, tender, warm prostate Colony counts in EPS and VB3 Urine C&S: 4specimens should exceed those of initial and VB1 [voided bladder urine): ilitial (urethra] midstream by 10times (suggests VB2: midstraern (bladder) prostate as bacterial source] EPS (eJC!li!!SSed prosta1ic secretions): {prostate] not usually performed VB3: post-massageiDRE (prostate) UrineR&M Blood CBC, C&S Tl'1lltmllnt Supportive measures (an!Viretics, analgesics, stool softeners) PO llllibiotics 1raat for wks 1D prevent Admission criteria: sepsis, urimry retention, immunodeficiency IV antibiotics {ampicillin and gentamicin) asevere Mid-stream urine C&S at 1and 3 months post antibiotic therapy Avoid clllheterillllion due to risk of bacteremia llld systemic infection Small drainage calhBtar may be inserted a obstruction suspected Extended course of antibiotics (3-4 months) Ruoracp.linolones, TMP/SMX or doxycydina; addition of an a-blockar may reduce symptoms DREwriabla Urine C&S negative on serial specimens Prostate biopsy (rarely performed) shows histological inflammation Trial of antibiotic therapy fluoroquinolone or doxycycline if Chlamydia fnlchomtltis is suspected a -blocker to relieve sphincter spasms, NSAIDs llld supportive measuras for symptomatic llllillf Epididymitis and Orchitis Etiology • infection: • <35 years - gonorrhea or Chlamydia tradwmatis • >35 years+ penetrative anal intercourse- GI organisms {esp. E. coli) • mumps infection may involve orchitis after parotiditis • other rare causes: • TB • syphilis • granulomatous (autoimmune) in elderly men • amiodarone (non-infectious cause, involves only head of epididymis) • note: epididymitis is much more common than orchitis Risk Factors • UTI, unprotected sexual contact • instrumentation/catheter • reflux • increased pressure in prostatic urethra (straining. voiding. heavy lifting) may cause reflux of urine along vas deferens -+ sterile epididymitis .... ' ,I If unsura b81w8an diagnosas of epididymitis and torsion: vo to OR. Ramambar: torsion >6 tn has poor prognosil. U14 Urology ...... , •t-----------------, Prehn'• 1ign: pain may be relieved with elevation oftesticlel i1 epididymitis but not in testicular 1Drsion. Poor sii1Sitivity, e5p&ciaUy in children. Infedioua and ln1lammatory Diseases Toronto Notes 2011 Clinical Features • sudden onset scrotal pain and swelling ± radiation along cord to flank • scrotal erythema and tenderness • fever • storage symptoms, purulent discharge • reactive hydrocele Investigations • urinalysis (pyuria), urine C&S • ± urethral. discharge: Gialil stain/culture • if diagnosis uncertain, must do: • colour-flow Doppler ultrasound • nuclear medicine scan • examination under anesthesia Treatment • rule out toraion • antibiotics: • N. gono"heae or C. trachomatis - cefixime 400 mg PO once followed by azithromycin 1 g single dose or doxycycline 100 mg bid x 10 days • coliforms- broad spectrum antibiotics (Septra•, Cipro•) x 14 days • scrotal support, ice, analgesia Complications • if severe -+ testicular atrophy • 30% have persistent infertility problems Urethritis • common causes: infectious, inflammatory (e.g. reactive arthritis) Tabla 7. lnfactious Urethritis: Gonococcal vs. Non-Gonococcal Gunococc;al Reactin Artllriti1 (furm•ly llnawn • Clusatiw= DI'Qinillm Neisseria gononheae Usually Chlamydia tr.Jchomatis Diagn111il History of sexual conlact, yellow purulent discharge, irritcrtiva L.l1TS Gram slain (GN diplococci}, urine PCR allll/or culture from urethral specimen Hirtory of sexual contact. mucoid whitish purulent discharge, ± initaliva UJTS Gram slain demonstrates >4 PMN/oil immersion field, no evidence of N. gonon11eae, urine PCR ami/or culture from urethral specimen Cllfildme 400 mg PO DDCI orCeftrixune 125 mg IM once AND treat for Chlamydia trachomatis Azithrumydn 1 gPO DDCI or doxycycline 100 mg PO bid x 7 days Wer"• Synclrom•l Urethritis, Uveitis ll1d Arthritis (Cin"t pee, 188, clln"t climb a 1nlll} Urethral Syndrome • dysuria in females with consistently sterile urine cultures or low bacterial counts • some have bacterial urethrocystitis (C. trachomatis or other organisms) and require antimicrobial treatment • treat: tetracycline or erythromycin • rule out: vaginitis, cancer, interstitial cystitis, psychological etiologies Toronto Notes 2011 Stone Disease Urology U15 Stone Disease Incidence • prevalanceof2-3% • male:female = 3:1, peak incidence 30-50 years of age • recurrence rate: 10% at one year, 50% at 5 years, 60-80% lifetime Clinical Features • urinary obstruction -+ upstream distention -+ pain • flank pain from renal capsular distention (non-colicky) • severe waxing and waning pain radiating from flank to groin, testis, or tip of penis due to stretching of collecting system or ureter (ureteral colic) • writhing, never comfortable, nausea, vomiting, hematuria (90% microscopic), diaphoresis, tachycardia, tachypnea • occasionally symptoms oftrigonal irritation (frequency, urgency) • bladder stones result in: storage and voiding LUTS, terminal hematuria, suprapubic pain • ff fever, rule out concurrent pyelonephritis or obstruction Differential Diagnosis of Renal Colic • acute ureteral obstruction (other causes): • UPJ obstruction • sloughed papillae • clot colic from gross hematuria • acute abdominal crisis - biliary, bowel, pancreas, abdominal aortic aneurysm (AAA) • gynecological- ectopic pregnancy, torsion/rupture of ovarian cyst, pelvic inflammatory disease (PID) • pyelonephritis (fever, chills, pyuria) • radiculitis (Ll) -herpes zoster, nerve root compression Location of Stones • calyx • may cause flank discomfort, recurrent infection or persistent hematuria • may remain asymptomatic for years and not require treatment • pelvis • tend to cause obstruction at ureteropelvic junction (UPJ) • staghom calculi (renal pelvis and one or more calyces) • often associated with infection that will not resolve until stone is cleared • ureter • <5 mm diameter will pass spontaneously in 75% of patients Stone Pathogenesis • supersaturation of stone constituents (at appropriate temperature and pH) • stasis, low flow and low volume of urine (dehydration) • crystal formation and stone nidus • loss of inhibitory factors: • citrate (forms soluble complex with calcium) • magnesium (forms soluble complex with oxalate) • pyrophosphate • Tamm-Horsfall glycoprotein Risk Factors • hereditary: RTA, G6PD, cystinuria, :xanthinuria, oxaluria, etc. • dietary excess: Vitamin C, oxalate, purines, calcium • dehydration (especially in summer months) • sedentary lifestyle • medications: thiazide • UTI (with urea-splitting organisms) • myeloproliferative disorders • GI disorders: IBD • hypercalcemia disorders: hyperparathyroidism, sarcoidosis, histoplasmosis, etc. ..... ,, Ttle four narrowest passaae pointJ for upper tract IIIDnn ara: 1. UPJ z. Palvic brim 3. Under vas dafarantlbroad Hgamant 4.lNJ Ul6 Urology Stone Disease Toronto Notes 2011 Approach to Renal Stone -------------------------------- Urvent Intervention requirad if: 1. Solilllry kidney 2. Bilateral stones 3. lnllllctable pain or 4. Acuta renal faiure Figura "1. Approach to Ranll Stone ,,_._, ________________ IWB CT Rdiollllllll ladiolluclllt Calcium Uric Acid lndinavir Calcium lndinavir Struvita Cystine Struvita Cystine Uric Acid .... . ,, lndiemon• for •dndsahln bl huspibll: l.lntractBIH pain 2.1nlrBctllble vomiting 3. Fever (sugglllll infection) 4. Compromised renal function 5. Singla kidney with UI&!Billl obstructionlbilatellll obstructing stones .... ,.., If aptic, IJilllnl uramric mnt or percutaneous neplns1Dmy should be considerad. ..._,, _._________________ lndicatiana far Pwcut.Moua • Size >2.5 em • Staghom • UPJ obstruction • Caiyl;1111l diverticulum • Cystine stonas (poor1y friQIIIIIIlld wilt1 ESWLJ Investigations • screening labs • CBC -+ elevated WBC in presence of fever suggests infection • electrolytes, Cr, BUN -+ to assess renal function • urinalysis: R&M (WBCs, RBCs, crystals), C&S • imaging • kidneys, ureters, bladders (KUB) x-ray • to differentiate opaque from non-opaque stones (e.g. uric acid, indinavir) • 90% of stones are radiopaque • crscan • no contrast; good to distinguish radiolucent stone from soft tissue filling defect • abdominal ultrasound • may demonstrate stone (difficult in ureter) • may demonstrate hydronephrosis • IVP (not usually done) • anatomy of urine collecting system, degree of obstruction, extravasation • cystoscopy for suspected bladder stone • strain all urine -+ stone analysis • if recurrent stone formers, conduct metabolic studies • serum electrolytes, Ca, P04> uric acid, creatinine and urea • PTH ifhypercalcemic • 24 hour urine x 2 for creatinine, Ca. P04> uric acid, Mg, oxalate, citrate Treatment -Acute • medical • analgesic (Tylenol #3•, DemeroJ•, morphine)± antiemetic • NSAIDs help lower intra-ureteral pressure (e.g. Ketoralac) • alpha-blockers: increase rate of spontaneous passage in distal ureteral stones • ± antibiotics for UTI • IV fluids if vomiting (note: IV fluids do NOT promote stone passage) • interventional: if obstruction endangers patient (i.e. sepsis, renal failure) • ureteric stent (via cystoscopy) • percutaneous nephrostomy (image-guided) • admit if necessary - see sidebar Treatment - Elective • medical • conservative if stone <5 mm and no complications • fluids to increase urine volume to >2 Uday (3-4 L if cystine) • specific to stone type (Table 8) Toronto Notes 2011 Stone Disease Urology U17 • interventional Bliclcyll o-IIDiian a till Tlllllnt II UnllniS.. J. !im 2007; 1119:1183-117 •kidney • stent if stone is 1.5-2.5 em • extraoorporeal shockwave lithotripsy {ESWL} if stone <2.5 crn • percutaneous nephrolithotomy if stone >2.5 em (see sidebar Ul6) a-blockln lilellpy. liDs.- MBIJNE (JiruaJV 1966111 DctuiJer • ureter 2005),111e C4clillll8 Carmi SMh lilnry, Er.tiASE U1110 1111111u aladnlric diiiiJIIe of llbllrldl pwmd 111111u Anrul Mallilu a1111u An.Aaiacillliall (2002., 21Xl5) Wife ..medfll'lillnm idlhlled in l'llillll: 11 studin 11'1! llill:tian crD!i1 (n=l11). Ttatmllrt rqad from Bdlys ID 6Willis. ..... Giani: lnc:idlncl al dillll Lnlllll Rlnl • ESWL is the primary modality oftreatment • ureteroscopy (extraction or fragmentation) if - failed ESWL - ureteric stricture - reasonable alternative for distall/3 of ureter open ureterolithotomy (very rare) • bladder • transurethral cystolitholapaxy • remove outflow obstruction (TURP or stricture dilatation} 1IIIUII: J.lminillrltian 11111 a-ilb:brwM!I CGISIMiiw1llltmlli inmued incidence oftiDnl - QIIIS8Miiw blltnwlt Ilana bv 4411 (M 1:11.31-1.51, p<0.001). Cabiar. a-blac:lil!lhlnpr isiiDIICilled v.rith igJilll:lnltf incmud lllH al clllll uretnl slllne Prevention • dietary modification: • increase tluid (>2 L/day}, potassium intake • reduce animal protein, oxalate, sodium, sucrose, and fructose intake • avoid high-dose vitamin C supplements • medications: • thiazide diuretics for hypercalciuria • allopurinol for hyperuricosuria • potassium citrate for hypodtraturia .... ,' Al1hough hypercalciuria i5 a risk fac!Dr for stone formation. dacraasing diallry calcium is NOT recommended 1o prevent stone formlllion. Low dista!y calcium IIIIIs 1o incnaasad lllCBID absorption and higher Lilla levels of calcium OJIIIIII!I. Table B. Stone Classification Type of Slana Cllci1111 [7§..15%) Uric Acil [5-10%) Efiolagy Hypercalciuria Hyparuricosuria [25% of pati8111s with Ca stones) Hyperoxaluria (<5% of patients) Hypocitraturia [12% of patients) Other causes: • Hypomagn8S8111ia - associlll8d with hyperoxama and hypocitraturia • High dietary sodium • Decreased uril'lll'f proteins Uric acid in low volume, Infection with urea-splitting acidi: urine with ahigh uric acid organisms [Proteus, Pseudomonas. concentnrtion: Provid8nciB, KJebsialle. o Hyperuricosuria alone Mycoplasme, Satratia, S. autBUS) o Low urimry pH, low ume volume results in alkaline urinary pH and (e.g. Gl water loss) precipitation of struvit8 • Drugs (ASA, thiazides) ammonium jhlsphata) • Diet [pume rich red meats) o Hyperuricosuria with hyperuricemia o Gout o High rate of cell tumover or cal daldh gdemia, cytDtaxic drugs) Autosomal recessive defect in small bowel mucosal absorption and ranal tubular absorption of dilasic amino acids results in "COLA" in urine [cystine, omithine,lysine, .-giline) Kay faatulll Radiopa!J!e on KUB Rerllcing dietary calcium is NOT an effective method of preventiol\"' tr8irtrnent Radiolucent on KUB Radiopaque on CT Acidic urine Perpetuates UTI because stone harbours organism S1one and all forei!J1 bodies roost be clecnd to avoid racurrenca Associated with staghom calculi Positive urine dip and cultures Note: E. coli infection does nat cause stnrvite stones Aggressive stone disease seen in children and young allllts Recurrent stone formation, family hi&tory Often staghom calculi Faintly radiopaque on KUB Positive urine sodium nitroprusside test. urine clr'Dnnatogrephy for cystine Trennent Fluids to incn!llse urine volume lncreesed fluid intake Alkalinillltion of urine to pH 6.5 to 7 (bicarbonate. potassium drate) ± allopurinol Shockwave lithotripsy not effective Complete stone clearance Antibiotics for 6weeks Regular follow up urine Increased fluid intake (3-4L of urimt/davl Alkalinize urine (bicarbonate, pota&&ium citratu), Penicillaminl1/ a-MPG or Captopril (form compktx with cystine) Shockwave lithotripsy not effective to >2Uday stones: celulose Matica/ if slons <5 mm For pha&phate, orthoph05phate for and no complications absorptive causes ProcadJrai/Sutg For calcium oxalate stones: thiazides, tTNtmant ifstons ± potassium citnlte, ± alopurinol >5 mm orpresence of Calcium struvite- antibiotics (stone complications (see U76) must be removed to treat infection) StruYita [5-1 0%) Cystine [1 %) Ul8 Urology Urological Neoplamu Toronto Notes 2011 Urological Neoplasms Approach to Renal Mass .. Cystic • IUllnlso1.11d I I .. Hypoechoic No calcification Thin wall Dense Calcified Septated Sbip CT* CT (exclude angiomvolipoma) Angiography Possible aspiration or biopJY I • SUI'lllrf .. Solid I I • Surveillance I I ... ... la!'llemass (>1.5cm) Small mass (<1.5cm) I SUI'lllrf I I I I Possible surveillance I I Figure I. Workup of a Renal Mass •MRI DCCISionally pe!fonned I conlnlll corrnindit*d Benign Renal Neoplasms ..._----------------, Tabllra• Scl11n1U. AuiD&omal dominant JYndrume chnellrized by mantel retardation, epilePJY, adenoma sebaceum •nd other hllmar111111a. ea- Gf Enlllrpd ICIIInep SIIAPE Sclerodanna HIV nephropalhy Amyloidosis Polycvstic kidniiY diuas• Endocrinopllthy' (diabeles) RENAL CYSTS • simple cysts • very common - up to 50% at age 50 • usually incidental finding on abdominal imaging • classification of cysts (i.e. simple and complex) • Bosniak classification is used to stratify for risk of malignancy based on cyst features, see Table 9 • polycystic kidney disease • autosomal recessive - massive kidneys with early renal failure in children • associated with hepatic disease • autosomal dominant - progressive bilateral disease leading to hypertension and renal failure • associated with hepatic cysts and cerebral aneurysms • medullary sponge kidney • dilatations of the collecting ducts • usually benign course, but predispose to calcium phosphate stones • von Hippel-Lindau syndrome • renal cysts, cerebellar and retinal hemangioblastomas, pancreatic and epididymal cysts • 30-40% incidence of renal cell carcinoma Table 9. B01niak Classification of Renal Cysts Features Risk of Malig111ncy Simple cyst Round, no septalions, no calcifiCiltions, no solid component N99rzero Minimally complex cyst Thin septillion, calcifications, hyperdense on CT Minimal 3 Con1llex cyst ThickEr septatians, thicker and mere irregular walls, measurable enhancement Moderate. surgical intervention usually necessaiY 4 Clearly malignanl Class 3plus enhancing sllft-tissue components Near certain Cl11s 2 Toronto Notes 2011 Urological Neoplasms Urology U19 Table 10. B•ign Renal Masses Epidlllliolagy Less than 1'!1. of alkllt renal tumours Renal Oncocylllm1 llen1l Ad1110m1 3-7% of renal tumours. More common in males Incidence increases with age Found in 7-23% of all autopies F>M M:F=3:1 211% associill8d with tuberous sclerosis (especially multiple, recurrent) Dilgnasis Clonal neoplasm consisting of fat. smooth musde and blood vessels May extend into 11!1181 vein and become symptomatic Spherical, capsLJIIllld with possible cenlnll scar HistDiogically organized aggregates of eosinophilic cells originating from intercalated calls uf collecting diet Small cortical lesions <1 em Majority are solitary but can be multifocal Histologically organized cells with no atypia which may exhibit bisornv of chromosomes 7 and 11 R:idml diagnosis Negative attenuation {-ZO HU) on CT is pathognomonic Rare presentation of hematuria, flank pain and palpable mass (same as RCC) lncidml finding on CT although difficult to distinguish from RCC Biopsy may be performed to rule out malignancy lncidml finding on CT Rarely syrl1llomatic Controversy as tD whelher this represents benign or preofllalignant neoplasm Benign course although excision warranted if inCillllsad risk uf rupture and retroperitoneal bleed (large size, pregnancy, previous bleed) Follow with serial UIS PartiaVradical nephrectomy for large masses High intensity focused ultrasound (HIFU) or radiufrequency ablation (RFA) for smeller masses PartiaVradical nephrectornv if mass >3cm lkla tD increased risk of mlll8stllsis Malignant Renal Neoplasms RENAL ADENOCARCINOMA [Renal Cell Carcinoma (RCC)] Etiology • cause unknown • originates from proximal convoluted tubule epithelial cells • risk factors: smoking (results in 2x increased relative risk), cadmium exposure, employment in leather industry • familial incidence seen with von Hippel-Lindau syndrome Epidemiology • eighth most common malignancy (accounts for 3% of all newly diagnosed cancers) • 85% ofprimary malignant tumours in kidney • male:female = 3:1 • peak incidence at 50-60 years of age Pathology • histological subtypes: clear, granular, spindle cell, papillary, chromophobe Clinical Features • usually asymptomatic- frequently diagnosed incidentally by U/S or CT • poor prognostic indicators: weight loss, weakness, anemia, bone pain • local effects: classic "too late triad" found in 10-15%: • gross hematuria 50% • flank pain <50% • palpable mass <30% • was called the "internist's tumour" because of paraneoplastic symptomatology, now called the •radiologist's tumour· because of incidental diagnosis imaging • systemic effects: paraneoplastic syndromes (10-40% ofpatients) • hematopoietic disturbances: anemia, polycythemia, raised ESR • endocrinopathies: hypercalcemia (increased vitamin D hydroxylation), erythrocytosis (increased erythropoietin), hypertension (increased renin), production of other hormones (prolactin, gonadotropins, TSH, insulin and cortisol) • hepatic cell dysfunction - "Stauffer's syndrome": abnormal liver function tests, decreased WBC count, fever, areas ofhepatic necrosis; no evidence of metastases; reversible following removal ofprimary tumour • hemodynamic alterations: systolic hypertension (due to AV shunting), peripheral edema (due to caval obstruction) • metastases: seen in 15% of new cases • bone, brain, lung and liver most common sites Investigations • routine labs fur paraneoplastic syndromes (CBC, ESR, LFTs) • urinalysis (60-75% have hematuria) • renal ultrasound (solid vs. cystic lesion) • CT scan (to distinguish solid vs. cystic lesion and to determine extent and operability) • IVP (mass lesion): no longer routinely done • angiography: no longer routinely done ... , , rumour may invade ranal vaint and inferior vana (may mull in IICiiBI, hllpetic dysfunction, right lllrilll tumour, and pulmonary .-nbolil. U20 Urology Urological Neoplamu 1'oroDio 2011 Methods of Spread • direct. venous, lymphatic Staging • Involves cr, cheat .x-ray.liver euzymes and functions, bone &can Table 11. 111M Clllllflcatlon of Renal Adellocarclnoma T N M Tl ; tllnOW' <1 em. cedined to P8l1ll pnnchyma l1s; <4em T1b: 4-7 em NO: na regional nadas Ml: na evidence af IIIBIIIIalis TZ: limDUr >7 em. cadinad to ranal p111111chyma T3: tllnOW' axl8nds no Dlljor vails or achnal. but nat bawand GIJDilis fla:ia T3a: itto arRI1fll cr sills fat T3b: irto rellllll VIii or infnllillphlli!JIIIIic IVC 13c: illo supradillphl'llfllllic IVC Figure 9. RCC Stegi1g N1: IIIBIIIIalii1D 8 <Zem node, M1: pra8IIIC8 af liltlm 11181881111il NZ: IIIBIIIIalii1D 8 node bll\W8tll Zand 5em cr miAtipla nadas <Zem Nl: nada >5 em T4: limDUr 8ld8ndl ba'jOIII Gllllla's fiiiCil Treatment • surgical: • radical nephrectomy: en bloc removal of kidney, tumour, .ipsilateral adrenal gland (in upper pole tumours) and intact Gerota's capsule md paraaortic lymphadenectomy • partial nephrectomy: <4 em tumour or solitary kidney/bilateral tumours • surgical removal ofsolitary metastasjs may be considered • radiation for palliation - painful bony lesiona • chemotherapy: NOT effi:ctive • advanced stage: • anti-angiogenesis (anti-VEGF) • anti-tyrosine kinase: sunit:inib • anti-ll.2: dacllzwnab (Zenapu-) Prognosis • stage at diagnosis is the most important predictor of survival: • T 1 - 5-yeauurvival is 90-10096 • T2-T3 - 5-year survival is approximately 6096 • 5-year survival of patients presenting with metastasis is 0-2096 Carcinoma of the Renal Pelvis and Ureter Epidemiology • rare. a.ccounb for 496 ofall urothclial cancers • frequently multifocal, 2-596 are bilateral • M:F=3:1 • relative lncldence- bladder:renal:ureter = 100:10:1 RJ:CII-...-d &rgery is 1ha only lllflctivl inlllwnti111 fur RCC; chllmDihlrapy i1 NOT uRIU. .... , lliffllltlllilll DillgHIIIil of Aling Dafllct • lkD1halial ctll cninal'lll (diffa1111i118 and CT an) • Uric acid lllllnl (dlfallll'llilllll viii cytology and CT sctn) • Blaod clat • l'lpll.., niCilllil • • GBJ Wlbl1 from 1111 pruduc;ing orgllli11111 Pathology • papillary urothelial cell carcinoma (UCC); 8596 (othen include squamous cell. adenocarcinoma) • UCC of kidney md ureter are histologically similar to bladder UCC Risk Factors • smoking • chemical exposure (industrial dyes and solvents) • ll!lalgesic abuse (acetaminophen, ASA, and phenacetin) • Balkan nephropathy (chronic interstitial nephropathy in countries such as Serbia, Montenegro. Romania. Bulgaria) Clinical Features • gross pe.inle&s hemeturila (70-9096 of patients) • microsoopic hematuria • flank pain • dysuria • flank mass caused by tumour or associated hydronephrosis (10-2096 of patients) Investigations • cystoscopy and retrograde pyelogram: CT scan, radiolucent filling defect on IVP/CT urogram Treatment • radical ureteronephrectomy with cuff of bladder • dlstal ureterectomy for dlstal ureteral tumours Toronto Notes 2011 Urology U21 Urological Neoplasms Bladder Carcinoma Etiology • unknown, but exposure to environmental and occupational carcinogens plays a role • risk factors: • smoking (main factor- implicated in 60% of new cases) • chemicals: naphthylamines, benzidine, tryptophan, phenacetin metabolites • cyclophosphamide • prior history of radiation treatment to the pelvis • Schistosoma hematobium infection (associated with SCC) • chronic irritation: cystitis, chronic catheterization, bladder stones, (associated with SCC) Epidemiology • 2nd most common urological malignancy • male:female = 3:1, white:black = 4:1 • mean age at diagnosis is 65 years Pathology • classification: • urothelial cell carcinoma (UCC) >90% • squamous cell carcinoma (SCC) 5-7% • adenocarcinoma I% • others <I% • stages of urothelial cell carcinoma at diagnosis: • superficial papillary (75%) -+ >80% overall survival • 15% ofthese will progress to invasive UCC • the majority of these patients will have recurrence • invasive (25%} -+ 50-60% 5-year survival • 85% have no prior history of superficial UCC (i.e. de novo) • 15% have occult metastases at diagnosis -lymph nodes, lung, peritoneum, liver • carcinoma in situ-+ flat, non-papillary erythematous lesion characterized by d)'liplasia confined to urothelium • more aggressive, poorer prognosis • usually multifocal • may progress to invasive UCC Clinical Features • hematuria (key symptom: 85-90% at the time of diagnosis) • pain (50%) • clot retention (17%) • asymptomatic (20%) • storage urinary symptoms - consider carcinoma in situ • palpable mass on bimanual exam -+ likely muscle invasion • obstruction of ureters -+ hydronephrosis and uremia (nausea, vomiting and diarrhea) • metastases • hepatomegaly, lymphadenopathy, bone lesions • lower extremity lymphedema if local advancement or lymphatic spread Investigations • urinalysis, urine C&S, urine cytology • ultrasound • CT scan with contrast or intravenous pyelogram (IVP) -+ look for filling defect • C}'litoscopy with bladder washings (gold standard) • biopsy to establish diagnosis and to determine depth of penetration (although cold punch biopsy can be transurethral. resection is standard) • new advances with specific bladder tumour markers (e.g. NMP-22, BTA, Immunocyt, FDP) Grading • Grade 1: well-differentiated (10% invasive) • Grade 2: moderately differentiated (50% invasive) • Grade 3: poorly differentiated (80% invasive) Staging • for invasive disease: CT or MRI, chest x-ray, liver function tests (metastatic work-up) ',, The "field d81act"tlleory helps to explain why UCC has multiple lesions and has I high rec1J111111Ce rata. The antira uruthalium [ptlvis to bladder) il bath8d in can:inogens. U22 Urology Urological Neoplamu 1'oroDio 2011 Tebl11112. DIM Clestificmun uf Bladd• T N M Tt: mnirrvasive papililwy Cll'tftlma N slalus: as fllr 11!11111 cell carcdlma M status: ulur renal eel carciloma T11: caciloma ilsitu !CIS); flatlllnull' Tl: 1111111111' iiMidas &Ubmucau,/IIIID prapria '121: 111rncu iiMidas superficial mu&dll T2b: 111mu inwdes deep IIIIIIZ T3: 1111111111' iiMidBS ptrivesical fal T41: q.cent 11g111 ilwlv1lnant; prasteta, Ullnls arVIIIJinll T4b: lldjlced argan invalvamant; pelvic Will II' Bbdlri& wall PalvicWIIIor Abdominal Will Fnltlat8 I I .. ]§ 0 F"1111•r• 10. Urutllaill Call Clln:inoma Gf Bladdar Treatment • superfida.l (non muscle invas1ve) disease: Tis, Ta, Tl • transurethral resection ofbladder tumour (TURBT) ± &lDgle dose or maintenance intnwesical chemo/immuno-therapy (e.g. BCG, mitomycin C) to decrease recurrence rate • high grade disease - TURBT + lilllinlx:nance BCG OR cystectomy in select patients • invasive disease: T2a, T2b, T3 • radical cystectomy + pelvic lymphadenectomy with urinary divezsion (e.g. lleoconduit Figure II) or irradiation for small tumours • advanced/metastatic disease: T4a, T4b, N+, M+ • initial combmatlon systemlc chemotherapy ± Irradiation ± surgery Prognosis • depends on size, number oflesions, recurrence and presence of CIS: • stage Tl- 90% at 5 years • stage T2 - 55% f"llglr& 11.1JeGCOndUit • stage T3 - 2096 • stage T41N+IM+ - <5% Prostatic Carcinoma (CaP) Etiology • notknown • risk factors • increased inddence in persons of African descent • famlly history • 1st degree relative = 2xrisk • 1st and 2nd degree relatives = 9x risk • high dietary fat increases risk by 2x • cJgarette smoking Epidemiology • most prevalent cancer in males • third leading cause of mole cancer deaths (following lung and colon) • lifetime risk of a SO y.o. man for CaP is 5096, and risk of death from CaP is 3% • 75% diagnosed between ages of 60 and 85 and mean age at diagnosis is 72 Toronto Notes 2011 Urological Neoplasms ', Pathology .... •t-----------------, • adenocarcinoma • >95% • often multifocal • urothelial cell carcinoma (4.5%) • associated with UCC of bladder • not hormone-responsive • endometrial (rare) • carcinoma of the utricle DHJ.rentill DilgJMil of 1 Proltltic Nodule • l'nlstm cane• {30%) • Benign prostatic hypurplaia • • • • Anatomy (see Figure 6) • 60-70% ofnodules arise in the peripheral zone • 10-20% arise in the transition zone • 5-10% arise in the central zone Clinical Features • usually asymptomatic • most commonly detected by DRE, elevated PSA, or as an incidental finding on transurethral resection of the prostate (TURP) • DRE: hard irregular nodule or diffuse dense induration involving one or both lobes • PSA: see Prostate Specific Antigl!n, U24 • locally advanced disease: • storage and voiding LUTS (uncommon without spread) • suspect with LUTS, incontinence ± back pain • metastatic disease: • bony metastasis to axial skeleton is very common (osteoblastic) • visceral metastasis is less common with liver, lung and adrenal metastases occurring most frequently • leg pain and edema with nodal metastasis obstructing lymphatic and venous drainage Methods of Spread • local invasion • lymphatic spread to regional nodes • obturator > iliac > presacrallpara-aortic • hematogenous dissemination occurs early ,.._I'IMience GIJNUSI* CA blulll: Study MS cloeed emtv as olijectiues were nwt. lb&ra-1 MAIIIIMI TldL£1ian (P<0.001) in prM1111:1 rl pnllllll CA in 1111 filu1lrill gnllf [18\ incidallctl COITptlld 1D pllcllllo p t [24ll. inciclanca], but 1r1 ilcrnsa i11111 proporb al lhose Glide tuncus !Gleason score 1-101 N M M: distant metastasis T2: palpable, confined ID prostate T2a: tumour involving less than alobe T2b: tumour involving less than or equal to 1 lobe T2c: tumour involving bath lobes M1a: nonregionallymph nodes M1b: bone(s] M1c: lither site(sl with or without bona disease plecebol. The njorityal11mlurs in bath graups 118\lwera bcdz8d di181M(T1 11 T2). The firasleride group •lso lad a sigliicdy higher inciclanca ai1111UII swmpiDms 'dlll11111 pliabo graup. Cancbioll: MIIIIIMII 55 who took filllllaride for 7\'IIIIW8nl 25\lals lblv1D dMop pniSIIt8 CA 1otbu plaeebotJQUP. h_.'dla t:IIIC8IS ilthlfinllllridl grDUpWINaf I higi.Qlllll. ..... ,•t-----------------, , Co•idtntiona In lnt.rprdn1 Prostata Biopsy Renlts • GI8QOn ISCOI'll6 for two moe!: prN!minant patmms ar. l"'ported {e.g. 3+4 = Gleason sum Nota: 4+2 not equal to 3+3 despite equivalent Gleason sum) • Billlbnl "'· ...... itvolvement • %of core and number of cores involved T3: tumour extEnds through prostate Cl!pSule T31: IIX!nlcapsular IIXIIInsion (unilateral or bilatel'lll] T3b: tumour invadng sami1111l vesicle(s] T4: tumour invades adjacent structures (besides seminal vesicles] Table 14. Prostate Cancer MDrtality Risk GIBuon Score S1llly: Alll'lllanimd, plabo· caolraled IM!dy designed Ill del2mine l'lllelber tJultmart witli mllllarida Cldd IIIla lila ]R'IIIIence II prostm CA during 1711111 period. ,..._ 11.882lTII!Iv.illl . . . . rilkalpniSIItl CA (55 YIIJIIIIIQI 11 oldlt AtriCIII-Anwican, or 11st d'fBI relllive hlwi1Q pniSIIt8 CAl witli 11'1111TT111 ORE and 1 PSA IMI rl g 111tniWIN 17-,..r period. N: spread ID 11!1jianal T1: dinically undetectable normal ORE and TilUS T1a: tumour incidiiiTIBI histologic findilg in < 5% of tissue res!!Cted lymph nodes T1 b: tumour incidental histologic findilg in > 5% of tissue resected nc: tumour identified by neelle biopsy (because of elevated PSA IMII; tumours found in 1or bath lobes by needle biopsy but nat palpable or l'llliably visible by imaging Stage n.l'rlllllll c-l'nlnnllllll 1111 tiV1l NUf 21103; 349:21&-224 Finllllrid1 (51TO"dly) vs. piiCiba Tabla 13. Staging of PrDitate Cancer (TNM 2002) PSA Efllct rl Sllftun IIIII Villlllil E• lilt all'lallllllc-ud .... c-n. S.lnm IIIII Vlllmil ECa.-l'llldln Trill (SB£CT) lippnwl SM, Kltil EA et al..IA.WI2009; 301(1):39-51 llllllldr. Rlndomilld, pB:.bo canlrallid 1rillwitll 35,5331TIIII \'Onin E.l8ilrliL111 +villmin E, or pllcebo. c.t•ian: Sllaniln Dlvillmin E, IIana Ill in combinltian lithe dalllllld f1lnriMDns lllld. cill nat pmant pniSIIt8 elncl' in lllis pilldltion al Nlltiwly haallhy 111811. lhin DRE PSA elevated in the majority of patients with CaP transrectal ultrasound (TRUS) -+ size and local staging TRUS-guidedneedle biopsy bone scan may be omitted in untreated CaP with PSA < 10 ng/ml CT scanning to assess metastases T l'nlstatitis l'nlstatic infarct l'nllllllic: calculus Tuben:ulous prostatitis Qlled. t2'J.v.lli1e. Investigations • • • • • • Urology U23 Low Rilk Madlll'lllt lhk [if any of fallowing) High Rilk [if any of fuiiDWi1g) <10 10-20 >20 <7 7 8-10 pT1-2a pT2b-T2c pT3/4 U24 Urology Urological Neoplamu Wi:ll ,......,_WIIr:WWiiliq il Early,....... c.. NEJM m; 352:1 m-84. .....: To dellnnina whether aut, lldical praslllldDmy improved 1118 llniwl in lTIIII with 11011-invlliw pnllllta CIIICir II compnd ID . 695 lllmWIIIPI1JIIIeeM. 111rolld iam 14 CIJ'ils lll1lllld Swldlll.linllad bllwlln 1989ltld 199!.1ncmian criteri• incUd8d being undlr lila of 75, n!JMt ......,....lliln: diiQIIOMd pn1111ta CIIIC8t sllg8 T2 or lels.l'ltholagr hiiiiiD show Ilk allllldnlltt or llmlur. l'ltialb W8A1 rlnllolriy lllignad 011811:1 bail ID llillltr en iiiiiiMnlion grnup {TIIicll proslllaCIDmy) or r:an1RA Wliling). The PriniiV llllpoint rl1he study was IMmll lTIGitJity u ID p!IJIIIts C111C8t with IICDIIdlty 1ndpaia lllkln ID be local prl9lllian and dilllnt 1111111111111. ADiiyliiWIS perflmnld on 111 inllniiiHD-trllt belil. The lelltNe risk IRR) rllocll protpeSiion •nd dislllnl llllllslllsll for 1118 inlllvmion 0.33 {p<O.OOllltld D.OO {p<O.DliiiiPiclivlly, II compnd 1D 1118 COIIIJol Qroup. The Nlllivl risk II derrtll d11111D poe11t1 CII1C8r in lila irrbrMnliorr c:..:u-llrldicel ptOSIIIIcbrmy retb:el1he risk rl dlltlr clJ11Dprillllll Cllll*' in 111111 with 11011-invlliw, WIIIID rnodllllaly dilllnrnlilfld Ullourt, • compll8d ID Wlldrlul Wliq. The lelltNe risk rl bodllocll iiiVISiorr 111d 1he spread rldillld111111S1111s-dsolianificarrlti decnued with lilly lldicll prostaiiCtDrTiy Toronto Notes 2011 Treatment • Tl (small well-differentiated CaP are associated with slow growth rate) • if young consider radical prostatectomy, brachytherapy or radiation • follow in older population {cancer death rate up to 10%) ·T2 • radical prostatectomy or radiation (70-85% survival at 10 years) or brachytherapy • T3, T4 • staging lymphadenectomy and radiation or hormonal treatment • N >0 or M >0 (see Common Medications, U43) • requires hormonal therapy/palliative radiotherapy for metastases • bilateral orchiectomy- removes 90% of testosterone • GnRH agonists [e.g.leuprolide (Lupron• or Eligard•), goserelin (Zolada-)] • estrogens [e.g. diethylstilbestrol (DES)] • antiandrogens [bicalutamide (Casodcx•)] • local irradiation of painful secondaries or half-body irradiation • chemotherapy regimens that include docetaxel may improve survival in advanced prostate cancer that is no longer responsive to hormone therapy Table 15. Treatment Options for Localized Prostate Cancer Wlll:hful Waiting (Active Surveillance) Low grade cisease or short life expecllllcy ( <5-10 y); good follow-(Jp Disease pragression 81'1ChythM'IpJ Low volume, low PSA (< 10), low grade Erectile dyshr.ction (5D%),? long term effectiveness ExtamaiB_. Locally advanced disease, older patients Radiation practitis (S'lf.), erectile dysfunction (51l%), risk of rectal cancer Young patients (<65 y), hilt! grade disease Incontinence (11l%), erectile dysfunction (3D-51l%) Tharapy • Otlrar options includl high irt1n1ity foms11 '*n!IOUnd {HIFll), hormonlllllllltion Prognosis • stage T 1-T2: excellent, comparable with normal life expectancy • stage T3-T4: 40-70% survival at 10 years • stage N+ and/or M+: 40% survival at 5 years • prognostic factors: tumour stage, tumour grade, PSA value, PSA doubling time Prostate Specific Antigen (PSA) • enzyme produced by epithelial cells of prostate gland to liquify the ejaculate • leaks into circulation and is present at <4 ng/mL • measured total serum PSA is a combination of free (unbound) PSA ( 15%) and compl.exed PSA (85%) It' In PSA testing, tlink "free and auy": increased free/total nrtio suggeslli b111ign cauu of high PSA. ,,., c - ot lnt:r11uad PSA BPH, pnnibditis, i&ehsmirl/ infarction. acute urinary retention, Pf1)5lllhl biopsy/allgflfY, prolllrtic; masua-. urllh111l c:am...rimtion, TRUS, 111nal faiiU111, bypass Ql1lft.. radia1ion therapy; a normal DRE does NOT significantly llrnll1 PSA. Screening Prostate Cancer: PSA and ORE AUA Best Practice Statement, 2009 Update • PSA may be elevated in prostate cancer and many other conditions; it is not specific to prostate cancer • currently mixed evidence concerning effect of PSA screening on mortality (ERSPC and PLCO trials - see sidebar) • population-based, routine screening not recommended • must discuss risk factors, test characteristics, risk of over-detection and over-treatment, treatment and active surveillance options • well-informed patients can elect to undergo PSA test and DRE • the decision to proceed to prostate biopsy should be based primarily on PSA and DRE results, but should take into account multiple factors (free and total PSA, patient age, PSA velocity, PSA density, family history, ethnicity, prior biopsy history and comorbidities) Strategies to Increase Specificity of PSA • age-related cut-off values Table 16. Nonnal PSA Value by Aga Group Serum PSA Concentndian {IIJ'l) 411-49 <2.5 50-59 <3.5 60-li9 <4.5 70-79 <6.5 JE st al..li1AM 1193; 270{71:86()..4. Toronto Notes 2011 Urological Neoplasms • free-to-total PSA ratio: • complexed PSA increases in prostate cancer, decreasing the percentage of the free fraction • <10% free PSA suggestive of cancer, >20% free suggests benign cause • PSA velocity: • change of>0.75 nglmUyear associated with increased risk of cancer • PSA density: • PSA divided by prostate volume as found on TRUS • >0.15 nglmUg associated with increased risk of cancer Other Uses for PSA (AUA Bast Practice Statement, 2009 Update) • therapeutic decision making: patients with serum PSA levels <10.0 nglmL are most likely to respond to local therapy • work-up: bone scans are generally not necessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 nglmL unless the history or clinical examination suggests bony involvement • disease monitoring: serum PSA should fall to a low level following radiation therapy, high intensity focused ultrasound and cryotherapy and should not rise on successive occasions. PSA should remain undetectable following radical prostatectomy • outcome prediction: in patients with metastatic disease receiving androgen suppression therapy, failure to achieve a PSA nadir of <4.0 nglmL seven months after initiation of therapy is associated with a very poor prognosis (median survival: one year) Testicular Tumours Etiology (Risk Facton) • cryptorchidism, atrophy, sex hormones, HIV infection, infertility • family history; personal history of testis cancer Epidemiology • rare, but most common in young adults (17-37 years of age) • high cure rate • any solid testicular mass in young patient - must rule out malignancy • slightly more common in right testis (corresponds with slightly higher incidence of right-sided cryptorchidism) • 2-3% bilateral (simultaneously or successively) Pathology • primary: • 1% of all malignancies in males • most common solid malignancy in males aged 15-34 years • undescended testicle has increased risk (10-40:x) of malignancy • 95% are germ cell tumours (all are malignant) • seminoma (35%) classic, anaplastic, spermatocytic • nonseminomatous germ cell tumours (NSGCT) embryonal cell carcinoma (20%), teratoma (5%), choriocarcinoma (<1 %), yolk sac («1%), mixed cell type (40%) • 5% are non-germ cell tumours (usually benign) (testosterone, precocious puberty), Sertoli (gynecomastia, decreased libido) • secondary: • male >50 years of age • usually a lymphoma • metastases (e.g. lung. prostate, GI) Clinical Features • • • • • • • • • • painless testicular enlargement (painful if intratesticular hemorrhage or infarction) firm, non-tender mass dull heavy ache in lower abdomen, anal area or scrotum associated hydrocele in 10% coincidental trauma in 10% infertility (rarely presenting complaint) gynecomastia due to secretory tumour effects metastatic disease related back pain supraclavicular and inguinal nodes abdominal mass (retroperitoneal lymph node metastases) Urology U25 ....... lullllllizlll bnpunlludy NEJM2001; 3611:13211-8 .....: To detamina 1111 lfficlcy of prollllaspdic dg8n ll'SAiscraaq ill impi'Mig Mllllllftivll in ........,..!dan: 1821611 IIQI!d SG-74 were remilldbltwelll1994- Z!l04 m prDIIltS CIIICIIr. patients E!JropB counlrin 111d p!IIIIICtiwly mild and IIIMimniltd llllilhlr 1 ar cantral group. Scr.ning conlind of a PSA 1M talren MY 4 Y8ll1 {i llld cut-dlfor bicl!liY was at 3ri;Pri TllliMnt rl conlimld i)RIIIIII was laft1o the guidlines rlaldi courty. The prin'llry anll-poirt was IMII1111101111ity. 11111(zad on Ill iniiOOon-1o-SCRIIn IIIIis. 11116: Median fliiMo\QJ time WIS 9yem, and 1lle incidence rl prostate Clf1Cel ill the sa-eerilq Pf was8.2\n. l8'l. in ill canlrDI ThalliiiiM risk al dllth il llfliUP n. canlrDiwu 0.80 IP<D.15I. The lllltiiiD ria IVClJclionwas0.71 group, trnslB; lila needed to sa.n r/1410 IIIII a rurlie! 11l8dld 1o 11111 r/48. c:.I1111Dnl: T1'11111of PSAsa.ningwullill 1D !Xdarallillive riskllllb:tion aiM1ollllll rl50 at 74 {MbthiiTlljority rl benefit se111 in m111 aged SG-611. 1lle increaled rill ridilgllllil was spcdf iiCflllld in group, ltld clii1D the ildolad CUll afmany prDIIltS Clnalll, !hill flct nut be lliren irQ considlndion. Fur1her Wjy is Wlll3llled 11 examine 1lle aptimll llml ofPSA Uldttnsholds 1D 1*11fon!ll1111 the optimall1llfllff 1D IHIICI thlrisbri!MIIdilgnlllilandllllJCIIdprDIIltll c:m:ur nutD!y. .._n ', , On:ltiapoy SurgiCIII dNC:unt (orchiopexy) of undescended testis does nat reduce the rill!: of mlllignlllncy. It can however, r.duc1 the rilk of infertility lllld physical axarn. U26 Urology . ..,., , .-----------------, Testlll nl acroblm hlva lymphlllic drain11Q8, lllenlfore 1rans-scrotalllppi'08ch for biopsy or orchieciDmy shoolei be avoided. ..,., , ..-----------------· AorU is •11111 Left: Lsft testicle drains iniD the pr. and pnaortic nodes. IVC ie on thlllight: Right testicle draits in to the IJII111CIMIII nod11. ..,., , .-----------------, . SUging Clinical- CXR metatases), mllbrs for staging AFP. LDH), CT abdomenfpelvis lymphadenoplllhy) • Stage 1: disease limited to testis, epididymis or lji&ITTIIIlic cord • Stage II: diseasa limited to the rvtroperitoneld nodn • Stage Ill: diuase m.tutlltic to supradiaptngmatic: nodal or visceral Urological Neoplamu Methods of Spread • local spread follows lymphatics: • right -+ medial, paracaval, anterior and lateral nodes • left -+ left lateral and anterior paraaortic nodes • "cross-over" metastases from right to left are fairly common, but they have not been reported from left to right • hematogenous most commonly to lung, liver, bones and kidney Investigations • diagnosis is established by railical inguinal orchidectomy • tumour markers: • beta-hCG and AFP are positive in 85% of non-seminomatous tumours • pre-orchidectomy elevated marker levels return to normal post-operatively if no secondaries • beta-hCG positive in 7% of seminomas, AFP never elevated with seminoma • testicular ultrasound {hypoechok area within tunica albuginea =high suspicion oftesticular cancer) • evidence of testicular microlithiasis is not a risk factor fur testicular cancer • needle aspiration contraindicated Management • orchiectomy for all stages • adjuvant therapies as per Figure 12 Tentoma Embryonal CA Germinal cell . .-----------------, RPLIIIP can ba perform ad in a niiVI sparing fashion, preserving niMII of the hypogestric plaxus to maintain antegl"lde ejaculation. Mixed cell type Yolk sac CA l'lthologic {Ill orchiectomy) • T1 :tumour confined to tosli$ and epididymis, no vascui.-Jlymphl.tic: illllll$ion • T2: tumour extends beyond tunica albuginea or vascular/lymphatic illllll$ion • T3: tumour involves spermatic cord • T4: blmour invadll scrorum • T4a: tumour invlldes spermatic cord • T4b: tumour invedes acrollll WilD ... , , Toronto Notes 2011 Epithulium Chorio CA 90% Staga I Surveillance 10% 40% 20% 20% Staga 11+111 Staga I Stage II Staga II ./ ./ ./ Ralialion RPI.JIID• Chemothlnpy ± ? ./ ./ ./(residual mass) ./ ./ Figura 12. Management of Tll'licular Cancer 1 APLND = retruperilmeai-IIXIe dillectiln Adapted from Dr. MAS Jewett Prognosis • 99% cured with stage I, stage ll disease • 70-80% complete remission with advanced disease Penile Tumours • rare (<1% of cancer in males in U.S.), most common in 6th decade Benign • cyst, hemangioma, nevus, papilloma Pre-malignant • balanitis xerotica obliterans, leukoplakia, Buschke-Lowenstein tumour (large condyloma) Pre-invasive Cancer • carcinoma in situ (CIS): • Bowen's disease -+ crusted, red plaques on the shaft • erythroplasia of Queyrat -+ velvet red, ulcerated plaques on the glans • treatment options: local excis.ion, laser, radiation, topical5-fluorouracil Malignant • risk factors: • chronic inflammatory disease • STI • phimosis • uncircumcised penis • 2% of all urogenital cancers • squamous cell (>95%), basal cell, melanoma, Paget's disease ofthe penis (extremely rare) • definitive diagnosis requires full thickness biopsy oflesion Toronto Notes 2011 Urological Neoplasms/Scrotal Mlllll Urology U27 Table 17. TNM Staging for Penile Carcinoma T N M Tx: prinary 1ll1l0ur can nat be assessed N1: metastasis in a single superficial, node M: presence {+I or absence (01 of distant metastasis (lung. liver, bone, brainI TO: no evidence of primary tumour T.: CIS N2: melil&lil5is in or bilahral superficial lymph nodes Ta: non-iiMISive carciloma N3: metastasis in deep inguinal or pelvic lymph noda(sl unilateral T1: tumour invades subspithelial coniiiCiive tissue (Buck's and lla1Ds fascial T2: tumour invades carpus cavemosurn (throu!ll tunica albugineaI or T3: tumour invades urethra or prostate T4: tumour invades D1her adjacent structures • lymphatic spread (superficial/deep inguinal nodes-+ iliac nodes) »hematogenous Treatment • wide surgical excision with tumour-free margins (dependent on extent and area of penile involvement) ± lymphadenectomy Scrotal Mass • see Common Presenting Problems, U3 Tabla 1B. Differentiating batwaan Scrotal Mauas Di&renti.. gf a Benign krvtal MIIR Condition Pain Pllpalian Tol'lion + Diffuse tenderness + + + Epididymal tenderness Present cremaster reflex, positive Prehn's sign Diffuse tenderness PrasiJTI: cremaster reflex. positive Prehn's sign Epididymitia On:hitis H1111atocllla Additional Findnp Absent cremaster reflex. negative Prehn's siiJI, EMERGENCY! Diffuse tenderness No transillumillltion HydiiiCIII Testis not separable from hydrocele, cord palpable Transilumination SparmlltDcela Testis separable from spermatocele, cord palpable Transilumination Bagofwonns No transillumillltion Testis separable from hernia, cord nat palpable, cou!ll impulse may transmit, may be reducible No transillummon lllricoclll lndn=ct lnguilal - (+ htnmgulatedl Tumaur - (+ hemorrhagicI Hard lump/nodule HIS IllS llydrucale Infection Sperm {spermatocele I llaod {hlmlltacll•l lnlllslirm (hamial TDI'Iion lome veins lvaricocelel Idiopathic: .... ,·}-----------------, , Vuic:ec:ale Gl'lldilg Grade 1: l'lllpeblti only with valsalva manaevre Grade 2: Palpable without VIIIIIIIVII Grade 3: Visible through scrotal skin .... ,·}-----------------, , lndicllions for Tl'8ltnlent vf Vuic:ec:ale • Impaired sparm or qullllity • Pail or dulache llffectinv of life • Affected testis fails to grow in lldalascants • Cosm.tic indications (especially in lldalascantsl U28 Urology Scrotal Mass Toronto Notes 2011 Table 19. Benign Scrotal Masses Type Vlricocele Sp•IIIIIDc:lla Hv*acell Dllilitian Diatatian and toltuosity of piiiXU& A benign, sperm filled epididymal rBtention cyst Twisting of the testicle Protrusion of abdominal Collection of serous fluid contenlli through the inguinal that resulbi tom a dsf8ct or causilg wnous occlusion irritation in the tunica vaginalis and engorgement as well as canal into the scrotum artaial ischemia and irllrction Etiolagy • 10%ofmen • Due to incorJ1)elent valves in the testicular vains • 90% left sided Wtiple theories, ncluding: • Distal obstruction • Aranysmal dilations of the epididymis • Agglutinal!d genn cells • Usually idioplllhic • Found in 5-111% testicular tumOUIS • Associated with traLIIII!/ infection • Communicatilg: patent processus vaginalis, changas size during day (peds) • Non-communicating: nonpatent processus vaginal is (adlltl • • • • • TlllUIIlll, Cryptarchidism, "Ball dapper dafonnity" Many occur in sleep (50%) Necrosis of in 5-6 hoUIS • Indirect (through internal ring, oftEn into scrotum)congenillll • Direct (through IIXtemal ring. rarely into scrotum)abdominal muscle weakness • Non-tender, cystic mJISS • Transilluminates • Non-tender, inlrascn!lal mass • Cystic • Transilluminates • Acute onset severe scrotsl pail, swelling • Gl upsets cases • Retracted and transverse testicle (horizontal lie) • Negative Phren's sign • Absent cramastaric reflex • A small bulge in the groin that may increase in size and disappear when lying down • Can present as aswollen or enlarged scrotum • Discomfurt or shlrp pain espacially when straining. lilting. or exercising • Physical exam • U/S to r/o tumour • U/S • Conservative • Needle drainage • Surgical • Emergency manual detorsion (rotate outward) with electiva bilateral orchiopexy • Falure of manual delllrsion: surgical delllrsion with orchiopexy • Orchiectomy if poor prognosis • "Bag of wonns", Phylical Eum • Oftan painless • Pulsatas with valsalva Hislllry/ IIYelligati- • Physical exam • vasava T1111tment • U/S to r/o tumour • CanseJVBtive • Consentalive • Surgical ligation of testicular • Avoid needle aspiration as it Cllllead to infection, wins • Perculllleous vein occlusion reaccumulation and spilling (balloon, sclerosing agents) of irrilllting spenn within • Repair may improve sperm scrotum count/motility 50·75%. • Excisa symptomatic TIISiicullr To11i1111 l1111uinll Hamil • History 111d physical colour ftow Doppler probe over • Invagination of the scrotum testicular artery • Valsalva • Decrease uptake on 99m Tcpertechnetate scintillation scan (doughnut sign) • Surgical repair TORSION OF TESTICULAR APPENDIX • twisting of testicular/epididymal vestigial appendix • often <16 years of age Signs and Symptoms • clinically similar to testicular torsion • "blue dot sign· - blue infarcted appendage seen through scrotal skin (can usually be palpated as small, tender lump) • point tenderness over the superior-posterior portion of testicle Treatment • analgesia - most will subside over 5-7 days • surgical exploration and excision if diagnosis uncertain or refractory pain HEMATOCELE • trauma with bleed into tunica vaginalis • ultrasound helpful to exclude fracture of testis which requires surgical repair Treatment • ice packs, analgesics, surgical repair 'IbroDlo Nota 2011 Peaile Com.plainb Urology U29 Penile Complaints Payronia's Disease Definition • benign curvature of penile shaft secondary to fibrous thickening of tumca albuginea • commonly on donal surface resulting in upward curvature of erect penis - may occur at any site Etiology • exact etiology unknown • trauma/repeated mk:rotrauma -+ inflammation -+ fibrosis • familial predisposition • relllted to diabetes mellitus, vascular disease, autoimmunity, Dupuytren's contracture • role of vitamin E deficiency. beta-blockade, elevated serotonin Clinical Features • penile curvature andlor pain with erection • penile shortening and poor erection distal to plaque Tralltment • depends on pain and interference with intercourse • watchful waiting (spontaneous resolution in up to SO%) • vitamin E, potassium paraaminabenzoate (potaba) -limited efficacy • intralesional verapamll • surgery if stable disease, slgnlftcant deformity AND failed medl.cal. therapy • exdsion ofplaque ± prosthesis Priapism UROLOGICAL EMERGENCY Definition • prolonged unwanted erection lasting >4 hours • tumescence (swelling) of corpora cavernosa (often painful) with flaccid glans penis (no corpora spongioswn involvement) Classlnc:atlon • low-flow (most common): reducedlabsent cavemosal blood flow-+ hypoxia. acidosis -+ischemia • high-How: unregulated a.rtJ:rial flow with normal tissue oxygenation Etiology • primary - 60% idiopathic • secondary: • thromboembolic - including sickle cell, thalassemia, total parenteral nutrition, dlalf!lll, leukemia, solid tumours • neurogenic- spinal cord injury, autonomic neuropathy • traumatic - cavemosal artery laceration, arterio-venous fistula • medication- intracavernosal drug injection (e.g. triple lllix), alpha-blockers, anticoagulants. antidepressant&. antipsychotics, anxiolytia, • reaeational drugs - cocaine, marijuana. alcohol Treatment • treat reversible causes (e.g.leukophorms ifleukemia, treat sickle cell crisis) • high flow often self-limited - observation vs. a.rtJ:rial embolization • lowflow: 1. urgent via needle aspiration of blood 2. phenylephrine injection into the corpora cavernosa ql0-15min 3. ahunt creation between cavemosum and spongiosum ifno response within I hour Complications • erect:lle dysfunction due to corporal fibrosis iftreatment delayed (50%) • 9096 risk if>24 hours 1. Fillraus plaqua Z. Tmic:a lllbuailel 3. CG!pus I:IW8I'IIOIUm 4.Budt'•fQc;ia 5. CGfpus _,.angiost.m &. Uralhr1 c J ... Li 201 a Figura 13. Payronia'a .. U30 Urology Penile Complaints Toronto Notes 2011 Paraphimosis UROWGICAL EMERGENCY Definition • foreskin caught behind glans leading to edema -+ unable to reduce foreskin Treatment • squeeze edema out ofthe glans with manual pressure (analgesia required) • pull on foreskin with fingers while pushing on glans with thumbs • if fails, perform dorsal slit or circumcision • elective circumcision for definitive treatment (paraphimosis tends to recur) Complications • infection, glans ischemia, gangrene Phimosis Definition • inability to retract foreskin over glans penis • may be caused by balanitis (infection of glans), often due to poor hygeine or congenital • normal congenital adhesions separate naturally by 1-2 years of age Treatment • circumcision, dorsal slit, proper hygiene (trial of topical corticosteroids in children) Complications • balanoposthitis (inflammation of prepuce), paraphimosis, penile cancer Erectile Dysfunction (ED) ------------------------------------- Definition • consistent (>3 months duration) or recurrent inability to obtain or maintain an adequate erection for sexual performance Physiology • erection involves the coordination of psychologic, neurologic, hemodynamic, mechanical and endocrine components • nerves: sympathetic (Tll-12), parasympathetic (52-4), somatic [dorsal penile/pudendal nerves (S2-4)] Erections POINT AND SHOOT parasympa1hetics = point; and sympathlllict/lomatiCI = sboat • erection ("POINT") • parasympathetics -+ release ofnitric oxide (NO) -+ increased cGMP levels within corpora cavernosa leading to: 1. arteriolar dilatation 2. sinusoidal smooth muscle relaxation -+ increased arterial inflow and compression of penile venous drainage (decreased venous outflow) • emission ("SHOOT") • sensory afferents from glans • secretions from prostate, seminal vesicles, and ejaculatory ducts enter prostatic urethra (sympathetics) • ejaculation ("SHOOT") • bladder neck closure (sympathetic) • spasmodic contraction of bulbo-cavernosus and pelvic floor musculature (somatic) • detumescence • sympathetic nerves, norepinephrine, endothelin-1 -+ arteriolar and sinusoidal constriction -+ penile flaccidity Classification Table 28. Classification of Erectile Dysfunction Fsyt:hoganic: Proportion 011141t Fn=quenc:y Variation Age Organic Risk Fac:tDrs fHTN, DM, Dyslipidemia] Nocbi'111VAM aractian Organic: 111% 90% Sudden Gradual Sporadic 'IIIith partner 111d circumstance Younger All circumstances No No organic risk fac!Drs Old• Risk fac!Drs present Present Absent Toronto Notes 2011 Penile Complaints Urology U31 Etiology (.. IMPOTENCE'") • • • • • • • • • Iatrogenic: pelvic surgery/pelvic radiation Mechanical: Peyronie's, post-priapism Psychological: depression, stress, anxiety, PTSD, widower syndrome Occlusive vascular: arterial (hypertension, diabetes, smoking, hyperlipidemia, peripheral vascular disease, smoking), venous (impaired vena-occlusion) Trauma: penile/pelvic Extra factors: renal failure, cirrhosis, COPD, sleep apnea, malnutrition Neurogenic: CNS (e.g. Parkinson's, multiple sclerosis, spinal cord injury, spina bifida, stroke), PNS (e.g. diabetes, peripheral neuropathy) Chemical: antihypertensives, sedatives, antidepressants, antipsychotics, anxiolytics, anti-androgens (including 5-alpha reductase inhibitors), statins, GnRH agonists, illicit drugs Endocrine: diabetes, hypogonadism, hyperprolactinemi.a, hypo/hyperthyroid Diagnosis • complete history (sexual, medical, and psychosocial) • self-administered questionnaires (International Index of Erectile Function, Sexual Health Inventory for Men Questionnaire, ED Intensity Scale, ED Impact Scale) • focused physical exam, including vascular and neurologic examinations • lab investigations - based on clinical picture • risk factor evaluation: fasting blood glucose or HbAlc, cholesterol profile • other: TSH, CBC, urinalysis • hypothalamic-pituitary-gonadal axis evaluation: testosterone (free and total), prolactin, lli, FSH • usually unnecessary to do further testing except in certain situations • specialized testing • non-invasive: • nocturnal penile tumescence monitor • invasive (rarely done): • intracavemous injection of papaverine or PGE1 - rule out significant arterial or venous impairment • Doppler studies pre- and post-papaverine injection - cavernosal anatomy and arterial flow evaluation (penile-brachial index <0.6 suggestive ofvascular cause} • angiography of pudendal artery post papaverine injection -post-traumatic ED evaluation only fur possible vascular reconstruction • dynamic cavernosometry and cavemosography- to evaluate leakage from penile veins Treatment • must fully inform patient/partner of options, benefits and complications • non-invasive: • lifestyle changes (alcohol, smoking), psychological (sexual counseling and education) • change precipitating medications • minimally invasive: • oral medication (see Common Medications, U43) • sildenafil (V!agra•), tadalafil (Cialis•), vardenafil (Levitra•): inhibits phosphodiesterase type 5 • rarely used - yohimbine: a-blocker that is best fur psychogenic ED - trazodone: serotonin antagonist and reuptake inhibitor • androgen replacement therapy: if hypogonadism • vacuum devices: draw blood into penis via negative pressure, then put ring at base of penis once erect • MUSE: Male Urethral Suppository for Erection - vasoactive substance (PGE1) capsule into urethra • invasive: • intracorporal vasodilator injection/self-injection • triple therapy (papaverine, phentolamine, PGE1) or PGE1 alone • complications include priapism (overdose}, thickening of tunica albuginea at site of repeated injections (Peyronie's plaque) and hematoma • implants (last resort): malleable or inflatable • vascular surgery: microvascular arterial bypass and venous ligation (investigational} ... , , THiolilanme deficiem:y ia an uncommon cause of ED. PDE-5 inhibitoR are contn.indica1ed in patienlli on nitnrtllf/nitravlyl;erin due to savere hypotension. U32 Urology Penile Complaint:a!I'rauma Toronto Notes 2011 Premature Ejaculation ---------------------------------- Definition • occurrence of ejaculation prior to when one or both partners desire it • primary premature ejaculation • never experienced sexual activity without the presence of premature ejaculation • secondary premature ejaculation • the individual once had acceptable ejaculatory control, but now experiences premature ejaculation, not associated with a general medical condition Epidemiology • 30-70% prevalence • most common sexual dysfunction reported in men 18-30 years old, associated with secondary impotence in men 45-65 years old Investigations • indicated by history and physical • testosterone levels if in conjunction with impotence Treatment • • • • • must rule out and treat any associated general medical conditions (ie. fear of angina) often thought to be due to psychological factors; identify and address specific stressors referral to psychiatry, couples counseling or sex therapy SSRis have been found to be effective in some cases clomipramine (daily or PRN 4-6 hours before intercourse) Trauma • see Emergency Medicine. ER14 Renal Trauma Etiology • blunt (80%, motor vehicle collision (MVC), assaults, falls) vs. penetrating (20%, stab wounds and gunshots) History • mechanism of injury Physical Exam • ABCs, renal vascular injury -+ shock mandating resuscitation • upper abdominal/flank tenderness, flank contusions, lower rib/vertebral transverse process fracture suggests blunt trauma Investigations • urinalysis: hematuria- requires workup but degree does not correlate with the severity of injury • imaging: cr (contrast triphasic) if patient stable -look for renal laceration, extravasation of contrast, retroperitoneal hematoma. and associated intra-abdominal organ injury Staging • • • • • I: contusion/hematoma II: <1 em laceration without urinary extravasation III: >1 em laceration without urinary extravasation IV: urinary extravasation V: shattered kidney or avulsion of pedicle Classification According to Severity • minor: contusions and superficial lacerations/hematomas - 90% of all blunt traumas, surgical exploration seldom necessary • major: laceration that extends into medulla and collecting system, major renal vascular injury, shattered kidney Management • microscopic hematuria + isolated well-staged minor injuries -+ no hospitalization • gross hematuria + contusion/minor lacerations -+ hospitalize, bedrest, repeat CT ifbleeding persists Toronto Notes 2011 Urology U33 Trauma • surgical intervention: • absolute indications: hemorrhage and hemodynamic instability • relative indications • non-viable tissue and major laceration • urinary extravasation • vascular injury • expanding or pulsating peri-renal mass • laparotomy for associated injury Outcome • follow up with ultrasound or CT before discharge, and at 6 weeks • hypertension in 5% of renal trauma Bladder Trauma • blunt (MVC, falls, and crush injury) vs. penetrating trauma to lower abdomen, pelvis, or perineum • blunt trauma is associated with pelvic fracture in 97% of cases Clinical Features • abdominal tenderness, distention, and inability to void • may be peritoneal signs or symptoms • associated injuries including pelvic and long bone fractures are common • hemodynamic instability due to extensive blood loss in the pelvis • suprapubic discomfort and/or tenderness Investigations • urinalysis - gross hematuria in 90% • imaging • cystogram and post-drainage film for extravasation Claulflcatlon • contusions: no urinary extravasation, damage to mucosa or muscularis • intraperitoneal ruptures: often involve the bladder dome • extraperitoneal ruptures: involve anterior or lateral bladder wall in full bladder Treatment • penetrating trauma: surgical exploration • contusion: urethral catheter until hematuria completely resolves • extraperitoneal bladder perforations: typically non-operative with foley insertion • surgery if. infected urine, rectallvaginal perforation, bony spike into bladder or iflaparatomy for concurrent injury • intraperitoneal rupture usually requires surgical repair and suprapubic catheteri2ation Complications • complications of bladder injury itself are rare • mortality is around 20%, and is usually due to associated injuries rather than bladder rupture Urethral InJuries Etiology • posterior urethra: common site of injury is junction ofmembranous and prostatic urethra due to blunt trauma, MVCs, peMc fracture • shearing force on fixed membranous and mobile prostatic urethra • anterior urethra: straddle injury can crush bulbar urethra against pubic rami • other causes: iatrogenic (instrumentation, prosthesis insertion), penile fracture, masturbation with urethral manipulation • always look for associated bladder rupture Clinical Features • blood at urethral meatus • high riding prostate on digital exam • sensation of voiding without urine output • swelling and butterfly perineal hematoma • distended bladder • penil and/or scrotal hematoma Investigations • do not perform cystoscopy or catheteri2ation before retrograde urethrography if urethral trauma suspected • retrograde urethrography- demonstrates extravasation and location of injury ',.._---------------, , AUpatients with suspected urethral injury should undergo retrograde Ul'llhragram {RUG). U34 Urology ..,., , •t----------------. Do not csthmrim if IIISPIC! umh111l injury. Trauma/Infertility Toronto Notes 2011 Treatment • simple contusions - no treatment • partial urethral disruption: • very gentle attempt at catheterization by urology staff or urology resident • with no resistance to catheterization- Foley x 2-3 weeks • with resistance to cathetemation - suprapubic cystostomy or urethral catheter alignment in OR • periodic flow rates/urethrograms to evaluate fur stricture formation • complete disruption: • immediate repair if patient stable, delayed repair if unstable (suprapubic tube in interim) Infertility Definition • failure to conceive after one year of unprotected, properly timed intercourse • incidence: • 15% of all couples - investigate both partners • 1/3 female, 1/3 male, 1/3 combined problem • primary (has never conceived before) vs. secondary (has conceived before) Female Factors • see Gptecology, GY21 Male Factors Male Reproduction • hypothalamic-pituitary-testicular axis (HPTA): GnRH from hypothalamus acts on anterior pituitary stimulating release of LH and FSH • LH acts on Leydig (interstitial) cells -+ testosterone synthesis/secretion • FSH acts on Sertoli cells -+ structural and metabolic support to developing spermatogenic cells • FSH and testosterone support germ cells (responsible for spermatogenesis) • sperm route: epididymis -+ vas deferens -+ ejaculatory ducts -+ prostatic urethra Etiology • idiopathic (25% infertile males) • endocrine (see Endocrinology, E48) • hypothalamic-pituitary-testicular axis (2-3%) • e.g. Kallmann's syndrome, excess prolactin, excess androgens, excess estrogens • testicular • varicocele (35-40% infertile males) • tumour • congenital (Klinefelter's triad: small, firm testes, gynecomastia and azoospermia) • post-infectious (epididymo-orchitis, STis, mumps) • uncorrected torsion • cryptorchidism ( <5% of cases) • obstructive • iatrogenic (vasectomy, hernia repair, hydrocelectomy, orchidopexy) • infectious (gonorrhea, chlamydia) • trauma • congenital (absence of vas deferens, cystic fibrosis) • bilateral ejaculatory duct obstruction, epididymal obstructions • Kartagener's syndrome • retrograde ejaculation secondary to bladder/prostate surgery • medications (chemotherepeutics, GnRH agonists, anabolic steroids) • drugs (marijuana. cocaine, tobacco, alcohol} • increased testicular temperature (sauna. hot baths, tight pants or underwear) • chronic disease: liver, renal History • medical history (past illness, diabetes, trauma, CF, genetic syndromes) • surgical history (orchidopexy, cryptorchidism, prostate) • fertility history (pubertal onset, previous pregnancies, duration of infertility, treatments) • sexual history (erection/ejaculation, timing, frequency, STis) • family history • medications (e.g. nitrofurantoin, cimetidine, sulfasalazine, spironolactone, alpha-blockers) • social history (alcohol, tobacco, cocaine, anabolic steroids) • occupational exposures Toronto Notes 2011 Infertility Urology U35 Physical Exam • general appearance (sexual development. gynecomastia) • scrotal exam (size, consistency and nodularity of testicles; palpation of cord; DRE) Investigations • semen analysis (SA) at least 2 specimens over several weeks • hormonal evaluation - indicated with abnormal semen analysis (rare to be abnormal with normal SA) • testosterone for evaluation ofHPA • FSH measures state of sperm production • serum LH and prolactin are measured iftestosterone or FSH are abnormal • genetic evaluation • chromosomal studies (Klinefelter's Syndrome - XXY) • genetic studies (Y-chromosome microdeletion, CF gene mutation) • immunologic studies (antisperm antibodies in ejaculate and blood) • testicular biopsy • scrotal U/S (varicocele, testicular size) • vasography (assess patency of vas deferens) Treatment • lifestyle • regular exercise, healthy diet • eliminate lifestyle habits described above • medical • endocrine therapy (see E48) • treat retrograde ejaculation • discontinue anti-sympathomimetic agents, may start a-adrenergic stimulation (phenylpropanolamine, pseudoephedrine, or ephedrine) • treat underlying infections • surgical • varicocelectomy (if indicated) • vasovasostomy (vasectomy reversal) • epididymovasostomy • transurethral resection of blocked ejaculatory ducts • assisted reproductive technologies (ART) - refer to infertility spectalist • sperm washing + intrauterine insemination (niT) • in vitro fertilization (IVF) • intracytoplasmic sperm injection (ICSI) Figure 14. Infertility Workup ..... , ! WHO GuidlliNarmll 11111111 V.I• Volum1: 2·5 ml • Concenlnltion: > 20 million sperm/ml • Morphology: 30'lla nonmlll forms • Motility: >SO'lla adeqlll!e forward J11V11111$$ion • complltl in 20 minutn • pH: 7.2·7.8 • WBC: < 1oper high p - field or <10' WBCfml. semen . ..... , ! Mutation of Cystic Fibrosis Transmembrane Conductance Regulator {CFTR) gene associated with congenilll bilabnllabunc1 of vas dlf1r1ns {CBAVD)Ind epididymal cysts, aven if patient manif8sts no symptoms of CF. ..... , ! Common Ter.....lour on Sem1111lylil: • Teratospemnia: Abnormal morphology • AsthlnDSpiiTTlil: Abnormal motility • Oligospermia: Demased sperm count • Amospermia: Ablant Jpann in wman • Mixed types, i.e. oligoiSihenospermill U36 Urology Pediatric Urology Toronto Notes 2011 Pediatric Urology Congenital Abnormalities ,, , Majority of antenatal hydronaphrosas resolve during pregnancy or wilhin the first yaar of lifa. • • • • not uncommon; 1/200 have congenital abnormalities of the GU tract UTI is the most common presentation postnatally hydronephrosis is the most common finding antenatally six common presentations of congenital urological abnormalities: 1. ANTENATAL HYDRONEPHROSIS • 1 in 500 fetal U/S -detectable on U/S as early as :first trimester • most common urological consultation in perinatal period • can be unilateral or bilateral • important to examine the rest of the GU system for anomalies • differential diagnosis • UPJ or UVJ obstruction • multi-cystic kidney • reflux • posterior urethral valves • duplication anomalies • antenatal in utero intervention rarely indicated unless posterior urethral valves 2. POSTERIOR URETHRAL VALVES (PUV) • the most common obstructive urethral lesion in male infants • abnormal mucosal folds at the distal prostatic urethra causing varying degrees of obstruction • most commonly recognized on prenatal ultrasound examination -+ bilateral hydronephrosis, thickened bladder, oligohydramnios Clinical Presentation -depends on age and severity • antenatal: bilateral hydronephrosis, distended bladder, oligohydramnios • neonatal (recognized at birth): palpable abdominal mass (distended bladder, hydronephrosis), ascites (transudation of retroperitoneal urine), respiratory distress (pulmonary hypoplasia resulting from oligohydramnios) and features of oligohydramnios • neonatal (not recognized at birth): within weeks present with urosepsis, dehydration, electrolyte abnormalities, failure to thrive • toddlers: presents with urinary infections or voiding dysfunction • school-aged boys: voiding dysfunction -+ urinary incontinence Associated Findings • oligohydramnios - due to low intrauterine production of urine • renal dysplasia - due to high pressure reflux • pulmonary hypoplasia secondary to oligohydramnios Diagnosis • VCUG -+ dilated and elongated posterior urethra, reflux Treatment • immediate catheterization to relieve obstruction, followed by cystoscopic resection of PUV 3. UPJ OBSTRUCTION • the most common congenital defect of the ureter (but can be secondary to tumour, stone, etc.) • M:F=2:1 • 40% bilateral • unclear etiology: adynamic segment of ureter, stenosis, strictures, aberrant blood vessels -+ extrinsic compression Clinical Presentation • symptoms depend on severity and age at diagnosis (mostly asymptomatic :finding on antenatal UIS) • infants: abdominal mass, urinary infection • children: pain, vomiting. failure to thrive • some cases are diagnosed after puberty and into adulthood Diagnosis • antenatal U/S most common, Doppler U/S, IVP, and renal scan± furosemide Urology U37 'IbroDlo Nota 2011 Treatment • surgical correction (pyeloplasty), consider nephrectomy if< 1596 renal function Prognosis • good since usually unilateral di&ease 4. VESICOURETERAL RER.UX (WR) • common condition wherein urine p111111es retrograde from the bladder through the UVJ into the ureter • incidence ranges from 1-18.5% in normal children • present in up to 70% ofchildren with UTI • 85% ofVUR occurs in females but a male presenting with UTI has a hlgher lilaillhood ofhavmg VUR • common cause ofantenatal hydronephrosis • 30-5096 of children with reflux will have renal scarring • common causes: trigonal weakness, lateral insertion ofthe uretErs, short submucosal segment (all part of"primary refluxj • many other causes including secondary reflux, infravesical obstruction, iatrogenic, secondary to ureteric abnormalities (e.g. ureterocele, ectopic ureter. or duplication), and secondary to cystitis Presentation • UTI, urosepsl.s • pyelonephritis • pain on voiding • symptoms ofrenal fiillure (uremia, hypertension) • diagnosis and staging lB done wing VCUG ± U/S Complications • pyelonephritis • hydroureter/hydronephrosis Treatment (sea sidebar for grading) • many cbildren •outgrow" reflux (60% of primary reflux) • annual renal UIS and VCUGIRNC to monitor; renal scan ifswspect new renal scar (episode of pyelonephritis) • treatment Is dependent on the grade: • medical (grade I-III) - goal is to keep urine free ofinfection to prevent renal damage wbile waiting for cbild to ·outgrow" their reflux • long term antibiotic propbylms at half the treatment dose for half the treatment time (TMP/ SMX, amoxicillin, or nitrofurantoin) • surgical (ureteroneocystostomy± ureteroplasty) or subureteral injection of Dc:Hux- or ..... '.' VUR Gredlna IMted an C\'lflllnlll lirwul: ureters GDv fil lirwull: unrbn and pt11vislil lraulll: uratJn and pcilvis fill with SGIIII dilltatian Gm.. IV: lnblrs, Pllvil and with S. .cant dllllldiDII lrau V: Inters, Pllvis and cllycas Iii with major dilatalion and 1Qr1uosily Gla!Ur Coronal" Sl.koronal Macroplastique• • indications: - failure of medical management - new renal scars - breakthrough infections - high grade reflux (grade IV or V - not an absolute indication) • prognosis depends on degree of damage at the time of diagnosis Dilllll Penile 5. HYPOSPADIAS • a condition in which the urethral meatus opens on the ventral side ofthe penis. promnal. to the glans penis • very common; 1/300 live male births • multifa.ctorial genetic mode ofinheritance • white »black • may be associated with chordee, intersex states, undescended t2sticles or inguinal hernia • depending on the severity, there may be difficulty directing the urinary stream or infertility Oong-term) • treatment Is surgical correction - optimal repair before 2 years old • circumcision should be deferred because the foreskin may be utllized in the correction •· J --..- ' - .· • . .. ·. SQ'IJIII Perileal Figura 15. Clluilicetio• af (*•ccam far 75%) ..... '' r::l-cRIJ-m_cisa_pdl _ _ nm_with_.- - - - , U38 Urology Pediatric Urology Toronto Notes 2011 6. EPISPADIAS-EXSTROPHY COMPLEX • rare: incidence 1/30,000, 3:1 male to female predominance • epispadias-exstrophy complex: a spectrum of defects - depends on the timing of the rupture of the cloacal membrane • bladder exstrophy (congenital absence of a portion oflower abdominal and anterior vesical wall, with eversion of bladder) • several variants • cloacal exstrophy (vesicointestinal fissure) • most severe • exposed bladder, bowel and colon with imperforate anus • associated with spina bifida in >50% • epispadias • least severe • urethra opens on dorsal penis • high morbidity -+ incontinence, infertility, reflux Etiology • represents failure of closure of the cloacal membrane, resulting in the bladder and urethra opening directly through the abdominal wall Treatment • surgical correction at birth, later corrections for incontinence, increasing bladder capacity and vesicoureteral reflux may be needed Naphroblastoma (Wilm's Tumour) --------------------- • arises from abnormal proliferation of metanephric blastoma • 5% of all childhood cancers, 5% bilateral • average age of incidence is 3 years • 1/3 hereditary (autosomal dominant) and 2/3 sporadic • familial form associated with other congenital abnormalities and gene defects Clinical Features • abdominal mass: large, firm, unilateral (most common presentation- 80%) • hypertension (60%) • flank tenderness • microscopic hematuria • nausea/vomiting Treatment • always investigate contralateral kidney • treatment of choice is radical nephrectomy ± radiation ± chemotherapy Prognosis • generally good; overallS-year survival about 80% • metastatic disease may respond well Cryptorchidism/Ectopic Tastes ..._,, Normal Tntlcullr Develop..lllt ond Deeclllt in Uloro Znd Mlllllb- Tnticle begins to form 4th Month - Begins to take Dl1 its normal and mi{J'It86 from its origin at the kidney to the internal inguinal ring 7th Month - The tntis, surroundld in peritoneal caverinv. begins to descend through the intimal ring, inguinal conal and external ring to terminate in the scrotum • definition: testes located abnormally somewhere along the normal path of descent (prepubic > external inguinal ring > inguinal canal > abdominal) • ectopic testis (testis found outside its normal path of descent} is rare • incidence: • 2.7% of full term newborns • 0.7%-0.8% at 1 year old • differential diagnosis: • retractile testes • atrophic testes • intersex state (bilateral impalpable testes) Treatment • undescended testes should be brought down to monitor for malignancy and preserve fertility (better in less than 1 year of age) • hormonal therapy (hCG or LH may facilitate their descent -+ not proven) • surgical -+ orchiopexy Toronto Notes 2011 Pediatric Urology Urology U39 Prognosis • • • • untreated bilateral cryptorchidism -100% infertility treated bilateral: 60-70% fertility rate (dependent on the age at the time of surgery) treated/untreated unilateral: fertility is still less than the general population risk of malignancy is 10-40x increased in undescended testes; this risk does not decrease with surgical descent, but monitoring is made easier • increased risk of testicular torsion (always perfonn bilateral orchiopexy for prevention if doing orchiopexy for torsion) Disorders of Sexual Differentiation Definition and Classification • genitalia that do not have a normal appearance based on the chromosomal sex ofthe child due to the undermasculinization of genetic males or the virilization ofgenetic females • considered a social emergency • four major categories 1. 46XY DSD • defect in testicular synthesis of androgens • androgen resistance in target tissues • palpable gonad 2.46XXDSD • most due to congenital adrenal hyperplasia (21-hydroxylase deficiency most common enzymatic defect) -+ shunt in steroid biosynthetic pathway leading to excess androgens 3. ovotesticular DSD 4. mixed gonadal dysgenesis (46 XY/45 XO most common karyotype) • presence ofY chromosome -+ partial testis determination to varying degrees Diagnosis and Treatment • thorough maternal and family history needed • other fonns of abnormal sexual development: • maternal medication or drug use in pregnancy -+ maternal hyperandrogenemia • parental consanguinity • physical exam: palpable gonad(= chromosomal male), hyperpigmentation, evidence of dehydration, hypertension, stretched phallus length, position of urethral meatus • chromosomal evaluation - sex karyotype • laboratory test:s: • plasma 17-OH-progesterone (after 36 hours of life) -+ increased in 21-hydroxylase deficiency (CAH) • plasma 11-d.eoxycortisol-+ increased in deficiency • basal adrenal steroid levels • serum testosterone and DHT pre- and post-hCG stimulation (2,000 IU/day for 4 days) • serum electrolytes • ultrasound of adrenals, gonads, uterus, and fallopian tubes • endoscopy and genitography of urogenital sinus • sex assignment (with extensive family consultation) • must consider capacity for sexually functioning genitalia in adulthood and psychologic impact • reconstruction of external genitalia - between 6-12 months • long term psychological guidance and support for both patient and family Circumcision Definition • removal of some or all of the foreskin from the penis Epidemiology • 30% worldwide • frequency varies depending on geographic location, religious affiliation, socioeconomic classification Medical Indications • phimosis • definitive treatment of paraphimosis Contraindication& • unstable or sick infant • congenital genital anomalies (hypospadias) • family history of bleeding disorders warrants laboratory investigation prior to circumcision . . Chailillflll' l'mdllll !Willi... Codnne lhllllllse .\)sf /lev 21m; {21:!m336Z lie.._.: 11Msl'8'.iiaw llVIUIIalllle llac:tiwllla ll'lllllflly 11'111 cirann:ililn fur p!IIVIOOng aapitian llf HN in h..._. nwl. Th••lylld dill ilfllllnlfnllllldomilld canllaled trBls ID assess tile elicacy rJ 1111le citlm:ilion far HIV aaPiition in IMI1 in Alric:a \Wiich begin il2002. Clncbinl: Thill'lllli&w lwld lti'Dng INidance tt11t ITIIIIIcll mae circlm:iliill rab:ls 111e ICqUilililn ti HN by mllllblllwlen m 11'111 24 11111-.tof HIVIIII ....... whl h111 So with 1111: AMIINIIIpill JW4 21108; 300(141:1674-84. lie.._.: TIMslnlllll-nlylis mminad 15 IU!ia (u= 53 561) tt1lt qiJIIItitDI\' ..rinld the 1110eiltion bllval1111le liluncilion lll1d HNJS11111101111 men who hive ret willl men (MSMI. llulll: n. Dddll ti baing HlV-plllitM Will IIIII lignificlntlv 1owar in c:irwmcilad MSM. Thl•ocidion HN ciMicliollll'lll but notllllistic:att sigriCIIII. Mill ciriJlmcilion hid I paiiClivl UlllCillion l'liGI HN in lllldes II MSM Clllllucfld before 1he ti hijllf IICtiva lnliulrMII1falpy. Clncbinl: This lllliylis fOII'Id insl&ient INid..:elllll male ciMiclioll llglinst HN inllctiDn or Dtlm Slll. llcMMt the pndlctiwellwct ti ll'lle circn:iiorl in MSM Wli11 aJnduclld Wore 11!1 n of lil#t active antirelnMnlllhen!rt supports f1llfw imllqltion rl male cin:oou:ilian fur HlV preverOin III'DIIg MSM. U40 Urology Pediatric Urology/Selected Urological Procedures Toronto Notes 2011 Complications • bleeding • infection • phimosis, skin bridges • fistula • glans injury • penile sensation deficits Enuresis • see Pediatrics. Pl2 Selected Urological Procedures Bladder Catheterization SbipiiiiMIIIiq 11111r in IIIII Sldl •111111r CaiMIIrialion (-... VIII• in Cb:ll lledcilts.i•l 1. Ellpllin pnx:adura 1D lhll pllilnt and on1.111 na cantnilllicltianl (blood IIIIIWIU, ICIOIII hlmltDml, pelvic frlcbn, !Mgll-ridng proelatll 2. Ensur8 you hlv8 cdllltr •nd tit, idoclile jllly tllll:1111811r 1Dpa wilhiiiiiiiCh Ill till bldlill 3. wpatiant don 11011-s!Brile glowlllld fiiiiCt foralkil 4. Insert 10·15ml of ldocU!e ielll' iiiD LRIInl meQJI tnd Pnc:fl p8lils for • • mindls 5. Open kllnd piiQJ patilllt'&legl 6. lbi . . giMs 7. coHua ball in IIQeplic B. Open lubricllltand dispel ontol:llilllllr1nly 9. ofwllar lnd callacling ..,nm !Dcttflltlr 10. l'lllc:efenestJDd dnipe Mr pubic regiorund pro*lll11iQ111 11.1imp]JIIIile lllllftv.ntlumdominlnl hind. hold llld purpaticUir to IIIII pltielts body (this bind is now nan-lleriel 12. C.• glms ponil in ciwlurrl)lion 13. LJJbriCIII tip of clllllltr, irlllrl iiiD lllllnl meQis tnd IIMrlce to 1lle IMI of111e IIIIIIDIIII inllltion port 14. Wd fGI rebln of llile ido colecling w Ab:ll.,.. • catheter size measured by the French {Fr) scale- circumference in mm • each 1 mm increase in diameter = approximately 3 Fr increase {standard size 16-18 Fr) Continuous Catheterization • indications: • accurate monitoring of urine output • relief of urinary retention due to medication, neurogenic bladder or intravesical obstruction • temporary therapy for urinary incontinence • perineal wounds • clot removal {24-28 Fr) for continuous bladder irrigation {CBI) • post-operative Intermittent Catheterization • indications: • post-void residual volume measurement • to obtain sterile diagnostic specimens for urinalysis/cultures • management of neurogenic bladder or chronic urinary retention Causes of Difficult Catheterizations and Treatment • patient discomfort - use sufficient lubrication {± xylocaine) • collapsing catheter -lubrication as above ± firmer catheter (silastic catheter) • meatal/urethral stricture - dilate with progressively larger catheters/balloon catheter • BPH - use catheter as angled tip can help navigate around prostate • urethral disruption/obstruction -filiform catheter or suprapubic catheterization • anxious patient - anxiolytic medication praalll w 15. !Moe urine is bling, ilftllle llllllaan l'litiiCIUt •lowilu Cl1ilullrlrnulrlel 16. pul Clllletlll bac:t lnd llpe ID patient's 111igh f1lpG the cltfllter, not 1ht callacling $'jSIImUing) 17.11aduceforllkintop!MIIIplla;Mmolis Complications of Catheterization • infection - UTI • meatal/urethral trauma Contraindications • urethral trauma: blood at the meatus of the urethra, scrotal hematoma, pelvic fracture, and/or high riding prostate Cystoscopy Objective • endoscopic inspection of the lower urinary tract {urethra, prostate, bladder neck, walls and dome, and ureteral orifices) using irrigation, illumination, and optics • scopes can be flexible or rigid Indications • hematuria • LUTS (irritative or obstructive) • urethral and bladder neck strictures • stones • bladder tumour surveillance • evaluation of upper tracts with retrograde pyelography (ureteric:: stents, catheters) Toronto Notes 2011 Selected Urological Procedures Complications • during procedure • infection, bleeding, anesthetic-related • perforation (rare) • post-procedure (short-tenn) • epididymo-orchitis (rare) • urinary retention • post-procedure (long-term) • stricture Radical Prostatectomy Objective • the removal of the entire prostate and prostatic capsule via a lower midline abdominal incision, laparoscopically or robotically • internal iliac and obturator vessel lymph nodes may also be dissected and sent for pathology (dependent on risk: clinical stage, grade, PSA) • seminal vesicle vessels are also ligated Indications • treatment for localized prostate cancer Complications • immediate (intraoperative) • blood loss • rectal injury • ureteral injury (extremely rare} • perioperative • lymphocele fonnation • late • moderate to severe urinary incontinence (3-10%) • mild urinary incontinence (20%) • erectile dysfunction (-50%, depending on whether one, both, or neither of the neurovascular bundles are involved in extracapsular extension of tumour) Transurethral Resection of the Prostate (TURP) Objective • to partially resect the periurethral area ofthe prostate (transition zone) to decrease symptoms of urinary tract obstruction • accomplished via a cystoscopic approach using an electrocautery loop, irrigation (glycine}, and illumination Indications • • • • • • obstructive uropathy (large bladder diverticula, renal insufficiency) refractory urinary retention recurrent UTis recurrent gross hematuria bladder stones intolerance/failure of medical therapy Complications • acute: • intra- or ext:raperitoneal rupture ofthe bladder • rectal perforation • incontinence • incision of the ureteral orifice (with subsequent reflux or ureteral stricture) • hemorrhage • epididymitis • sepsis • transurethral resection syndrome (also called "post-TURP syndrome·) • caused by absorption of a large volume of the hypotonic irrigation solution used, usually through perforated venous sinusoids, leading to a hypervolemic hyponatremic state • characterized by dilutional hyponatremia, confusion, nausea, vomiting, hypertension, bradycardia, visual disturbances, CHF, and pulmonary edema • treat with diuresis and (if severe) hypertonic saline administration Urology U41 U42 Urology Selected Urological Procedures Toronto Notes 2011 • chronic: • retrograde (>75%} • erectile dysfunction (5-1 0% risk increases with increasing use of cautery) • incontinence (<1%) • urethral stricture • bladder neck contracture Extracorporeal Shock Wave Lithotripsy (ESWL) Objective • to treat renal calculi, proximal calculi, and midureteral calculi which cannot pass through the urinary tract naturally • shockwaves are generated and focused onto stone -+ fragmentation, allowing stone fragments to pass spontaneously and less painfully Indications • potential first-line therapy for renal and ureteral calculi less than 2.5 em in size • individuals with calculi in solitary kidney • individuals with hypertension, diabetes or renal insufficiency Contraindication& • acute urinary tract infection or urosepsis • bleeding disorder or coagulopathy • pregnancy • obstruction clistal to stone Complications • bacteriuria • bacteremia • post-procedure hematuria • ureteric obstruction (by stone fragments) • peri-nephric hematoma Toronto Notes 2011 Urology U43 Common Medications Common Medications Tabla 21. Antibiotics Duration of TNIIImant Umililti-ID Uu Simple uncomplicated cystitis Recunent cystitis Pyelonephritis Prostatitis Epididynitiil/architis (Gremilegative organism) 3 days Stevens.Jolrlson syndrome ?Salety in last 2 weeks of pregnancy Resistalce 20% in the community nilrufunrrtoin Simple uncomplicated cystitis Recunent cystitis 7 days Contnindicated in nmal failure Pulmonary toxicity/fibrosis ciproflox.acin Cystitis Pyelonephritis 3 days 7-14 days ?Safety in pregnancy Achilles tendon rupture genlllmicin Severely ill patients with pyelaneplritis, prostatitis Dnlg TMP/SMX LDI'(lll!rm as prophylaxis 14 days 4-awusb Zweeks Only IV Nephllllllxic Ototoxic Tabla 22. Erectile Dysfunction Medications Dnlg Cia• Machlnilm sildenalil (V'IIgraat) tadalafil (Cialisllt) vardenalil (l..evitra"l Phosphodiastarase 5 inhibiiDr Selectiva irtlibition of PDE5 (enzyme which degrades cGMP) Leads to sinusoidal smooth muscle relaxation and erection alprostadi (MUSE: Male Unrtlnl Suppository fur Erection) Prostaglandin E1 Activation of cAMP. relaxing sinusoidlll smooth muscle Local release (capsule inserted intD urethra) ED Penile Presyncope alprostadi (intracavemosal iljection) triple therapy also used: papaverine, phentolamine, See above See above ED Thickening of tunica albuginea at site of repeated injections (Peyronie's plaque) Painful erection Hematoma Contrainrlcated if Hx of priapism, or in conditions predisposing to priapism lndi:ltion ED when some erection present Sevara hypotansion Contraindicated if Hx of priapism. or in conditions predisposing to priapism (leukemia, myelofibrosis, polycythemia, sickle cell disease) Contlllindicatad with nilllltas pan PGE1 Tabla 23. B•ign Prostatic Hyperplasia Medications Dnlg Clus Machanism lndiCition tei8ZOSin (llytrin"l dDXIIZOSin (Callba"l tamsulosin (Aornax®) Alpha 1blockers Alpha-adrenergic anlllgonists reduce stromlll smooth muscle tone Reduce dynamic component of bladder outlat obstruction BPH finasteride dutasteride (Avodartilt) 5 alpha-reductase inhibiiDr Blocks convarsion of tastosterone to DHT Reduces static corqlOilent of bladder outlet obstruction Reduces prostatic volume BPH Alpha 1a selactiva Alpha 1a selactiva Presyncope Leg edema Ratrograde ejaculation Headache Asthenia Nasal congestion Saxual dysfunction PSA decreases Naill: AI alpt.-IIIDCbrs diMllopad far 81'11 hiVIlsimillr afli:lcy. '-a(.llph•1sala:IMI11Q811!1 hM 111 impnMld sida lllact pmfila. Tabla 24. Prostatic Carcinoma Medications Drug Class Machanilm lldic:ation Advasa Elfacts leuprolide (Luprnnllt, 8igard"), goserelin (Zolad!lt8 ) GnRH agonist ntially stimulates LH. increasing testosterone and causing "flare" {clinically: i'lcreased bone pain), later causes low testosterone CaP (N>D, M>D) Hot flashes *diethylstilbestrol (DES) Estrogens Hlibit LH and cytotoxic effect on tumour cells As above *cyproterone acetate Steroidel antiandrogen with DHT for iltracellular receptors: 1. Prevent flare produced by GnRH agonist 2. Use for compiBIB androgen blockade 3. May preserve patency As above ftutamide bicalutamide (Caso£Ex®) Nort-steroidal antiandrogen As above As above Hepatotoxic: AST/ALT monitoring *ketoconazole, spironolactone Steroidogenesis inhibiiDrs Blocks multiple enzymes in steroid pathway, including adrenal androgens As above Gl syrl1IIDrns Hyperkalemia Gynecomastia Headache Decreased libido Increased risk of cardiovascular events U44 Urology Toronto Notes 2011 Common MedicationsJR.eferenc:es Tabla 25. Continanca Agents Drug Clus oxybutynin AntispiiSIIlDiic lndl:lllion lmibillactian Df ACh an smaD1h muscle oxybutynin {Ditropan<») tolterodine {Detro18 ) trospium [Trosec18) Anticholilergic (Vesicaraa) lkge incontinence + urgency + frequency llecreeses frequency of unirllibited detrusor contraction lliminishes initial urge to void Muscarinic receptor antagonist lkge incontinence + Selective for bladder urgency + frequency Increases bladder vo.,me llecraases detrusor pressure Dry mouth Blurred visim Canstipatian Supraventricular tachycardia As above dlllilenacin {Enablat') imipramine Tricyclic llllidelftSSBnt Sympathomimetic sff8cts: urinary sphincter conlnlction Stress and urge incontinence As abDW Weight gain Anticholinergic elfects: Orthostatic hypotension detrusor relaxation Prolonged PR interval Nlllt: AIIIIIIH:IMJiilwgics 11111J11ily lfllctiw and liq acting fmmulllilns (llllrollA1 111d Ditropln XL8)111 balblr IDiarrllld. Nln IIIISCII'inic t.l3 rapiDr spaciic IHJIIIIIy Efficacious iiS older drugs, hllwever, ACTs bued 111 helcl-111·/nml compuisan to lang acting furmulllilns n llglds lsallenlcin. References G.... lnfllrnlti111 AnuriCillllrulogical Allocillli1111. http;'/wwau111111..D19'guidainlrl Amll'iC111 Aao1:i1ticr1 of Ftmily Phy$icia11$. hllp;'/wtow.Mfp.tqiafpl2002041 W158UIIm Ferri F. Practical Glide ID tt. Clll oftt.lllldical plliant (&thad.) ZW6. St Lllil: Mosby. Galdmln I, Ausialo D. Cecil Tlldbook of Medicine (22nd ad.] 2004. Salnlars (EIIaviar). MIICflrlme MI House lllicer Series: Uralogy. 13rd ad.] ZWI. UAJincotl Ylfllllllli & TaiiiQIIo EA. McAnilch JN. Srrith's Glmllll Uralogy.(l&th ad.)2004. McGraw-Hill Companies, Uralogy Clilnnal Wein AJ, Kavoussi Ul, Novick AC, l'lrlin AW rnd Cl'eteTs CA. Campbelrs Urology. 19th ed.] PhilldeliJ!il: WB Saunders Co. c-llll'rlllllllingl'n6ll• Colirn RA 111d llrailn RS. Micrascapic hamablia. Naw Englrnd Joumal II Mldicine.2003;348:2330-2338 MoriDnAR,IIilsm EAand Wil11111 JWI.. Nephrology: l.lnwlligltion lndtnlllrrWit!IIICIUIIIII kilhlyiiDIIBL CMAJ 166(2):213-218,Jan 2002 Teichnan JMH. Acute -.nal colic ln1m c•lcuiJs. New England Joumalcl Madicile. 2004;350:684·693 Uralagi:ll Ern.Jn:ia Galejs LE. Dilgnolis and treatmrnt ol the IICUII scra11rn. Americ:lln Ftmily l'hyan. 1991;51(41:817-24 Medialions Bii-Axelson A, Holmberg I, llwtu M, et. al. Radical Proslnc:tomyversus Waiting il Early l'rosllte Cancer. NEJM. ZW5; 352: 1977·84. Common Medications: Gray J (Edi1mj. Therapeutic Choicas (4th ld). Canadiln Phlrmacirls Allocilltion, Dttawa. 2003. Micramadax heellh catlll8rias. v.ww.micnlmedax.com Rini B. HIIIIIi S.llale*l!l J. et.al Bevaciarmab Pl.ile Cornplllll with Interferon Alta MDII!Ihmpy in l'ltientJ with Metn111ic Renal Cell Can:incml: CALGB !11206. J. Cln. One. 2008; 26: 5422-28.

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