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Urology Special Notes

symptomatology

NMT11

Upper urinary tract symptoms:

Lower urinary tract symptoms:

1-

pain:

Renal pain: dull constant aching pain in the renal angle (angle between sacrospinalis &last rib). Ureteric (renal) colic: colicky pain that extends from the loin to the groin. Usually with nausea & vomiting

vesical pain

varies from slight discomfort to severe agonizing pain in the supra pubic region especially with full bladder

 

Prostatic & seminal vesical pain

is deeply seated vague discomfort in the pelvis.

Urethral pain

is burning. It occurs during micturition and is called by inflammation or stone.

is severe local pain that may radiate to lower abdomen or costo- vertebral angle.

 

2-

Symptoms related to micturition :

The normal bladder capacity is 400 ml. Frequency may be day (diurnal) or by night (nocturnal). Frequency means increase times of micturation (Normal=3-5)

 

Nocturia means: Frequency by night (normally=0-1) ,differs from Nocturnal enuresis in which there is involuntary escape of urine

 

urgency

It’s a strong sudden desire to urinate caused by hyperactivity and irritability of bladder. In most circumstances the patient is temporarily able to temporarily control urine, but loss of small amounts of urine may occur (urgency incontinence).

 

Dysuria

Painful urination is related to acute inflammation of the bladder, urethra,or prostate.

 

BPHP and urethral stricture e.g: -hesitancy & straining,-difficulty in micturation,-terminal dribbling,-sense of incompleter emptying,-Retention of urine( acute & chronic)

 

1

3-

Urinary incontinence

   

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Urology Special Notes NMT11 4- Symptoms related to changes in urine Changes in urinary volume
Urology Special Notes
NMT11
4-
Symptoms related to changes in urine
Changes in urinary volume
Changes in color and contents of urine
Polyuria
excessive fluid intake, DM ,diabetes insipidus
and high-output chronic renal failure
Hematuria
is passage of blood in urine
oliguria
is urine volume less than 400ml/24 hours in
adults. The cause is either acute renal failure
or bilateral ureteric obstruction.
Pyuria
the presence of pus in urine.
It’s either microscopic or
macroscopic
anuria
is urine volume less than 200ml/24hrs , the
causes are
Chyluria
o
Pre-renal causes: e.g. shock and
dehydration
passage of white milky urine
due to presence of lymphatic
fluid or chyle
Cloudy
o
Renal causes: e.g. toxins, drugs
and renal diseases
post- renal causes:e.g bilateral
renal obstruction or complete
obstruction in solitary kidney
If due to stones it’s called calcular anuria
o
(turbid) urine: due to presence
of excessive phosphate
crystals that precipitated in
alkaline urine.
Necroturia:
passing pieces of necrotic
tissues in urine. It is
pathognomonic of bladder
carcinoma
.anuria is one of the urological emergencies
Pneumaturia
presence of gas in urine.
Haematuria
Definition :passage of blodd in urine
Types : -frank or microscopic
-painful or painless
-total heamaturia , terminal haematuria or initial haematuria
The most common causes :
1-
urinary stones (the most)
2-
urinary tract injuries
3-
senile prostatic enlargement
4-
renal tumors
5-
bladder tumors
6-
bilharziasis
DD: red coulred urine
1-
dietary
2- drugs
3- heamoglobinuria
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Urology Special Notes

Anomalies of kidney

Classification

NMT11

       
   

Anomalies of number

- Agenesis :bilateral or unilateral

- Supernumerary kidney

Anomalies of volume & structure

- hypoplastic

- simple renal cyst

- polycystic kidney

- multicystic kidney

- medullary sponge kidney

Anomalies of ascent

Ectopic (pelvic or iliac)kidney

Anomalies of shape, form & fusion

- horse-shoe kidney

- discoid (cake-shaped) kidney

- sigmoid & L-shaped kidney

Anomalies of rotation

Incomplete rotation

Anomalies of renal pelvis

- Bifid pelvis (double pelvis)

- Pelvi-ureteric junction obstruction

Anomalies of renal vasculature

- Aberrant & accessory renal arteries

- Renal artery aneurysm & A-V fistula

Clinical features:

acute symptoms.

4.

Renal mass if the cyst is huge .

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Treatment:

- No treatment but follow up is required.

- If there is complications : percutaneous needle aspiration

intracranial aneurysms.

Simple renal (solitary) cyst

1 A solitary cyst is commonly asymptomatic.

Intermittent dull pain in flank or back.

Hemorrhage in a cyst or infection will lead to

Polycystic kidney

Adult type (autosomal dominant) polycystic kidney disease

This is the commonest form of cystic diseases of the kidney.

It is one of the leading causes of end stage renal failure.

Almost 50% have associated cysts in the liver, but liver function remains normal. Cysts of lung,

pancreas and other organs may be found. 30 to 40% of patients have

     
 
Clinical features: • • • • • Renal failure may occur after the age of

Clinical features:

Renal failure may occur after the age of 50. Investigations:

Before renal failure

Control of hypertension.

Treatment of UTI.

Low protein diet and regular check of renal functions.

If a large cyst compresses the pelvis or the upper ureter treatment is by percutaneous ultrasound-guided aspiration.

Infantile type (autosomal recessive) polycystic kidney disease

Very large kidneys may obstruct labour.

Renal failure.

Horseshoe kidney

More frequent in males. Pathology:

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NMT11

After renal failure

Renal transplantation is the

definitive treatment. Haemodialysis is a temporary measure until a suitable donor Is found .

is a temporary measure until a suitable donor Is found . Urology Special Notes First 10
is a temporary measure until a suitable donor Is found . Urology Special Notes First 10

Urology Special Notes

Urology Special Notes

First 10 years of life there are no symptoms, the kidneys are normal in function and anatomy.

From 10 to 30 years, ultrasound shows the presence of cysts, although the patient is still asymptomatic.

After 30 years, the patient may develop microscopic or gross haematuria, hypertension, urinary tract infections and fIank pain. The kidney may be palpable.

Renal function impairment with elevation of urea and creatinine begins between age 40 to 50.

Ultrasonography or CT scan is accurate in the diagnosis of polycystic kidneys. Treatment:

Newborn infants with severe form of the disease may die from respiratory failure due to pulmonary hypoplasia.

Fusion occurs early in embryonic life when the kidneys lie low in the pelvis.

Ascent of the horseshoe kidney is arrested by the isthmus being blocked against the inferior mesenteric artery.

Furthermore, normal rotation cannot occur, and each renal pelvis lies on the anterior surface or its kidney. The ureters thus ride over the isthmus which connects the lower poles. A horseshoe kidney is prone to disease because ureteral obstruction may result from angulation of the ureter as it crosses renal isthmus. Stasis favours infection and stone formation.

may result from angulation of the ureter as it crosses renal isthmus. Stasis favours infection and
may result from angulation of the ureter as it crosses renal isthmus. Stasis favours infection and

Urology Special Notes

NMT11

Clinical features:

• 1/3 of patients remain asymptomatic ,The rest develop symptoms of complications as pain, haematuria and fever.

A hydronephrotic horseshoe kidney may be palpable below the umbilicus. A very serious mistake is to excise this undiagnosed mass in an exploratory laparotomy. Before excising such a mass always check for the presence of the kidneys by ultrasound or by IVU. Investigations:

IVU reveals that the kidneys are lower in position , the lower poles are nearerto the midline than the upper poles and that the lower pole calyces point medially and lie medial to the ureter . Treatment:

Treatment Is Indicated only for complications. Division of the isthmus of the kidney is rarely required.

Idiopathic pelvic-ureteric junction(PUJ)obstruction

PUJO is a common cause of hydronephrosis in children and adolescents. It is more often seen in males with the left side predominating. Pathology:

• For an unknown reason there is failure of relaxation of the PUJ.

Obstruction to urine outflow produces hydronephrosis which may either progress or reach an equilibrium. Clinical features:

• The clinical presentation varies according to age.

• Prenatal. Ultrasonography can diagnose the condition in the foetus .

• In infants the most frequent finding is an abdominal mass.

• In children episodic intermittent flank pain which follows fluid intake. Vomiting may be present.

In adults loin pain, recurrent urinary tract infections and hypertension Investigations:

• Excretory urography shows a dilated pelvicalyceal system with abrupt contrast arrest at the pelviureteric Junction .The ureter Is either non visualised or of normal caliber.

• Retrograde or antegrade pyelography may be used for anatomical delineation of the ureter and pelvis.

• Ultrasonography is useful in advanced conditions with poor renal function.

Diuretic renography. When the diagnosis is equivocal, It assesses the ability of the pelvis to empty after the administration of frusemide . Treatment:

- Reconstructive surgery (pyeloplasty).

- Endoscopic endopyelotomy may be considered in some patientsespecially those with previous failed surgical repair.

- Nephrectomy is considered for hopeless kidney with total function loss

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Urology Special Notes NMT11 Anomalies of urethra Posterior urethral valves Hypospadias Posterior urethral valves form
Urology Special Notes
NMT11
Anomalies of urethra
Posterior urethral valves
Hypospadias
Posterior urethral valves form the most frequent
obstructive urethral lesions in infants and
newborns. They occur only in males.
Pathology:
Posterior urethral valves are found at the distal
prostatic urethra.
The valve appears as an obstructing membrane
that radiates from verumontanum
towards the membranous urethra.
During voiding. the membrane bulges into the
urethra leaving only a narrow
opening.
Hypospadias means that the urethral meatus opens
on the ventral aspect of the penis at any point from
glans penis to the perineum
This anomaly is caused by incomplete development
of the terminal part of the urethra and the corpus
spongiosum. The missing distal part of the urethra
is replaced by a fibrous band (chordae).
Etiology:
∑ Hormonal causes: Deficiency of androgens
or 5-alpha-dehydrotestoslerone reductase
enzyme during intrauterine life.
This not only leads to damage of the smooth
∑ Deficient receptors in targel cells may play a
role.
muscle function of the bladder, but
also leads to vesicoureteral reflux and renal
parenchymal damage.
Clinical features:
∑ Meatus is ventrally placed and stenosed.
• Prepuce is deficient venterolaterally.
Clinical features:
• Shaft is ventrally curved due to the presence
at chordee except in the glanular variety.
The presentation depends on the degree of
obstruction.
• Scrotum is bifid in the perineal type.
∑ The most severe forms present at birth with
palpable kidneys or bladder, urinary
ascites and respiratory distress from
pulmonary hypoplasia.
• Associated lesionsundescended testes or
upper urinary tract anomalies
∑ Patients with posterior hypospadias may
have a problem with sex differentiation
Investigations:
∑ Less severe forms present in toddlers or
during school years with recurrent urinary
tract infection or voiding dysfunction in
the form of dribbling stream or
incontinence.
Ultrasound examination to detect upper urinary
tract problems.
Treatment:
Circumcision should not be done to hypospadiac
patients because the skin of the
Investigations:
prepuce can be used for repair.
1. Voiding cystourethrography
demonstrates
dilated posterior urethra and bladder .
It may also show the presence of vesicoureteral
reflux .
2 Cystourethroscopy will visualise the valve and
hypertrophy and trabeculation of the
bladder.
Treatment:Transurethral destruction of the valves.
Plastic surgery can be performed at the age of one
year. The aim of surgery is to have
a normally functioning male organ with normally
situated meatus at tip of the glans.
The principle of surgery is to release the chordee
so that the ventral curvature of the
penis is corrected. Then a new urethra is fashioned
using neighbouring skin from the
prepuce or the penile skin.
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Incidence: 50% of males over 50 years , +++ with age Etiology: androgen dependant +

Incidence: 50% of males over 50 years , +++ with age

Etiology: androgen dependant + age dependant

BPH did not occur in experimentally castrated rats

C/P:

1-

Asymptomatic.

2-

Symptoms:

Important
Important

a. Irritative symptoms

i. Frequency: +++no. of micturition times / day

ii. nocturia

normally micturition at night 0-1 ,

if more ------ nocturia (differs from Nocturnal enuresis in

which there is involuntary escape of urine)

iii. urgency : sudden severe desire to micturate with NO escape

of urine

or: urge incontinence ( with escape of urine)

c.

Symptoms of complications Retention:

a-

I-

II-

Chronic: due to long standing obstruction

a- I- II- Chronic : due to long standing obstruction Hypertrophy dilatation III- Chronic retention with

Hypertrophy dilatation

: due to long standing obstruction Hypertrophy dilatation III- Chronic retention with overflow How to differentiate
: due to long standing obstruction Hypertrophy dilatation III- Chronic retention with overflow How to differentiate

III- Chronic retention with overflow

How to differentiate from true incontinence

digital rectal examination

∑ digital rectal examination full bladder ∑

full bladder

U/S

b-

Due to stasis

b- Due to stasis cystitis and stone formation

cystitis and stone formation

c-

Reflux

c- Reflux

ureter, with dilational weakness

d-

Due to stasis cystitis and stone formation c- Reflux ureter, with dilational weakness d- 7 www.medadteam.org

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ureter, with dilational weakness d- 7 www.medadteam.org b. i- , Catheter NMT11 Obstructive symptoms Urology

b.

i-

,

Catheter

, Catheter

NMT11

Obstructive symptoms

b. i- , Catheter NMT11 Obstructive symptoms Urology Special Notes Benign prostatic hyperplasia (BPH)
b. i- , Catheter NMT11 Obstructive symptoms Urology Special Notes Benign prostatic hyperplasia (BPH)
b. i- , Catheter NMT11 Obstructive symptoms Urology Special Notes Benign prostatic hyperplasia (BPH)

Urology Special Notes

Urology Special Notes

Benign prostatic hyperplasia (BPH)

Hesitancy: Delay instarting

ii- Weak - interrupted (intermittent stream) ,may be forked iii-Sense of incomplete voiding

Acute: due to edema and cong. Of bladder neck …

bladder still normal, Severe pain

dilatational weakness + poor contraction

Large amounts of urine are retained, may reach 1.5 L Normal bladder retains 350 – 650 ml urine

bladder empty In chronic retention with overflow

Pt. has a desire to micturate

N.B. Bladder trabeculation, sacculations and pulsation diverticulum may occur with chronic retention

pain and frequency

hydronephrosis & gradual deterioration of renal function (bilateral)

N.B. Normally, detrusor muscle contraction is responsible for prevention of reflux from bladder to

loss of antireflex mechanism.

Hematuria: due to rupture of dilated congested sub mucosal veins on enlarged gland

N.B. hematuria in any old man should be investigated because it may have serious cause

sub mucosal veins on enlarged gland N.B. hematuria in any old man should be investigated because
sub mucosal veins on enlarged gland N.B. hematuria in any old man should be investigated because
Urology Special Notes NMT11 Signs: Examined by digital rectal exam or PR Normally prostate firm
Urology Special Notes
NMT11
Signs:
Examined by digital rectal exam or PR
Normally prostate
firm consistency
Smooth surface
Symmetrical
In BPH, one or more may be abnormal
+ enlargement
Investigation:
Laboratory
Radiological
1)
Urine analysis for pus cells, hematuria, sp.
1)
Gravity (if low fixed sp. Gravity at 1010
CRF)
2)
Plain x-ray to visualize stone
U/S:
2)
3)
Kidney functions tests
PSA (prostatic specific Ag) serum level to
screen prostatic cancer
(Norma level: 0-4 ng/ml)
3)
Hydronephrosis and UB size
Residual postvoid residual volume to estimate
degree of obstruction
Transrectal U/Sbest to estimate prostate
size
IVP:
2 indications : Hematuria and Hydronephrosis
Not a good indicator of renal function
(radionucleide isotope scans are the best)
Uroflowmetry:
measure velocity of urine – important for follow up
Treatment:
Watchful waiting: in asymptomatic or minimal symptoms
medical :
surgical :
1- α1-blocker e.g. : doxazosin (carclua)
… DRUG OF CHOICE
-block αreceptors in prostatic
urethra
relax prostate smooth muscle
improve symptomsesp.frequency.
Indications: failure of medical treatment or complications
1- prostatism distributing pts life with failure of medical t
2- complicated case:
more than one attack of acute retention.
residual urine more than 200ml.
severe hematuria.
2-
5 α reductase inhibitors e.g. finasteide
complications in bladder as cystitis and stones.
complications in kidney as hydronephrosis.
Inhibit 5-αreductase enz.
Responsible for conversion of testosterone
Methods:
1-endoscopic :
to active dihydrotestosteron
which slowThe progression &
decrease prostate size
- TransUrethral Resection of Prostate (TURP) :
However,not the drug of choice because
e size of prostate not directly
linked to severity of Symptoms.
PROCEDURE OF CHOICE.
- visual laser ablation of prostate (VLAP)
2-open surgey :
3-
phytotherapy.
retropubic – millen's operation
transvesical.
4-
decongestant suppositories.
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Urology Special Notes

NMT11

Prostatic cancer

Incidence

common malignant cancer in males more than 65ys

Incidence common malignant cancer in males more than 65ys Predisposing Factors 1)+ve family history. 2) Race

Predisposing Factors

cancer in males more than 65ys Predisposing Factors 1)+ve family history. 2) Race → American Africans

1)+ve family history. 2) Race American Africans (least among Asian) 3) Genetic. 4) Environmental and diet

Pathology

Peripheral zone mainly.*

Symptomatology

a l z o n e m a i n l y . * Symptomatology ⇒

Adenocarcinoma in more than 95% of cases.*

1 -asymptomatic: esp. in countries with screening test done routinely.

2 -Symptoms:

a. Irritative symptoms :

test done routinely. 2 -Symptoms: a. Irritative symptoms : Urgency, frequency, nocturia. b. Obstructive symptoms

Urgency, frequency, nocturia.

b. Obstructive symptoms

Hesitancy, sense of incomplete void, weak interrupted flow

c. complication due to obstruction:

Retention, stasis (cystitis, stones),reflux.

d. Metastasis:

Less marked than BPH

(Mainly in peripheral)

Commonly to bones, usually osteoblastic but weak-----pathological fractures

.Examination

May be hard, nodular, asymmetrical(normally prostate is firm, smooth, symmetrical).

Normal digital rectal examination doesn't exclude the diagnosis.

Recently:TNM staging system

• T1 a & b ) normal PSA,tumour discovered accidently on microscopic examination of prostate
• T1 a & b )
normal PSA,tumour discovered accidently on microscopic examination of prostate
removed Due to BPH
c)
tumor not seen or felt but +++ PSA.
• T2
nodule confined to prostate: a) in 1 lobe.
b)in 2 lobes
• T3
extends through capsule reach seminal vesicle.
• T4
adjacent structure other than SV.
N.B:
∑ BPH arises ALWAYS from transisional zone
∑ Pr.carcinoma arises MAINLY from peripheral zone

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Investigation: Laboratory : 1) (Norma level: 0-4 ng/ml) If : suggestive of prostatic cancer. If
Investigation: Laboratory : 1) (Norma level: 0-4 ng/ml) If : suggestive of prostatic cancer. If
Investigation:
Laboratory :
1)
(Norma level: 0-4 ng/ml)
If
: suggestive of prostatic cancer.
If more than 20 : bone spread.
Serum PSA may be also
If elevated levels
restimate PSA
2)
3)
Radiological
1)
2)
3)
4)
5)
6)
7)
Management

A. Early

Organ confined (localized)

AIM: Cure

STANDARD:Any of the following

1)

write RADICAL)

RADICAL prostatectomy: (never forget to

Remove prostate, S.V. +

lymphadenectomy (if increased PSA) Then connect bladder to membranous Urethra( Patient remains continent to urine)

2)

radiosensitive

3)

Radiotherapy: because tumor is

Brach therapy: inserted into prostate tissue

NON-STANDARD:

age ,not fit for surgery

Watchful waiting if old

Urology Special Notes

NMT11

B. Late

1)

T4

AIM: Palliation

Hormonal anti-androgen Any of the

following

Pure anti-androgen

Steroidal anti-androgen

Surgical: bilateral orchidectomy

LHRH analogues (medical orchidectomy)

Estrogen: Diethylstilbestrol (but cause

thromboembolic complications esp. in old

age

add aspirin)

(Transurethral Resection in Pts with

bladder outflow obstruction)

Resection in Pts with bladder outflow obstruction) PSA : most importantserumtumour marker for screening &
Resection in Pts with bladder outflow obstruction) PSA : most importantserumtumour marker for screening &

PSA:most importantserumtumour marker for screening & follow up.

N.B. every man > 50 years should be screened yearly by PSA + digital rectal examination,

in infection (prostatitis) and benign conditions as BPH. ttt infection by quinolones for 6 weeks (prostate poorly absorb drug) then

urine analysis : infection , hematuria kidney function test.

TRANSRECTAL U/S*: visualize prostate & guide biopsy. u/s :hydronephrosis,…. x-rays : stones, bone spread, lung spread. CT,MRI : asses 1ry tumour , LNs , metastasis. IVP. Bone scan : very important esp. if PSA more than 20. BIOPSY : must be done if +++ PSA -------- ( CONFIRM DIAGNOSIS ).

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esp. if PSA more than 20. BIOPSY : must be done if +++ PSA -------- (
esp. if PSA more than 20. BIOPSY : must be done if +++ PSA -------- (
esp. if PSA more than 20. BIOPSY : must be done if +++ PSA -------- (

2)

TURP

to relieve symptoms

Urology Special Notes

NMT11

Obstructive Uropathy

DefAffection of Renal Functions due to obstruction at the POSTRENAL level

N.B.:

Prerenal = Renal blood flow Renal = Glomerular, Tubular, interstitial diseases e.g.: Glomerulonephritis Postrenal = Ureters, bladder, urethra and prostate.

Causes

Ureter:Bilateralpathology to affect renal function

Urethra: Congenital or Stricture

Bladder: Stricture, Congenital obstruction.

Prostate: BHP, Carcinoma

Congenital obstruction. ∑ Prostate : BHP, Carcinoma pathology 1. Hydronephrosis 2. Hydroureter 3. Renal Failure

pathology

1. Hydronephrosis

2. Hydroureter

3. Renal Failure

4. Trabeculae in bladder

5. Diverticular

6. Elongated Prostatic urethra

7. Later Dilatation ‘Thick wall bladder

Prostatic urethra 7. Later Dilatation ‘Thick wall bladder C/P : Symptoms Anuria Retention - Bladder Empty
C/P :
C/P :

Symptoms

Anuria

Retention

Retention

- Bladder Empty

- Bladder Full

- Obst. Above bladder

- Obst. at or below bladder

- Anuria= < 200 ml/24hr

Investigation

Laboratory :

1.

Renal function test

2.

Electrolytes Na & K [Beware of Hyperkalemia]

3.

ABG

If acute on top of chronic

If acute on top of chronic

4.

Hb ‘elective’:

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Urology Special Notes

NMT11

Radiological:

1.

U/S: Very Important

2.

X-ray

3.

MR urography

**N.B.: IVP is CONTRAINDICATED in Obstructive lesions

**N.B.: IVP is CONTRAINDICATED in Obstructive lesions Treatment: ∑ Relieve Obstruction : MOST IMPORTANT o

Treatment:

Relieve Obstruction: MOST IMPORTANT

o

Upper Obstruction: Percutanousnephrostomy

o

Lower Obstruction: Catheter orSuprapubic Cystoscopy

Dialysis: if K +++ or severe acidosis

ttt of cause when pt Stable

N.B.:

Obstructive lesions have a good prognosis, because recovery occur when once obstructionremoved Calcular anuria is anuria due to calcus [Stone] Most Common cause of Sterile Pyuria is Antibiotic use **Acute Tubular necrosis is Reversible While Acute Cortical necrosis is Irreversible

Urinary tract infections

May be:

o

o

Specific

non-specific

Urinary tract infections May be: o o Specific non-specific e.g.bilharz. & TB urethritis, prostaitis, cystitis,

e.g.bilharz. & TB

urethritis, prostaitis, cystitis, pyelonephritis, epididymoorchitis

Urethritis

May be

pyelonephritis, epididymoorchitis Urethritis May be gonococcal Non-gonococcal n.gonorrhea others,most commonly

gonococcal

Non-gonococcal

Urethritis May be gonococcal Non-gonococcal n.gonorrhea others,most commonly Chlamydia trichomatis ∑

n.gonorrhea others,most commonly Chlamydia trichomatis

n.gonorrhea others,most commonly Chlamydia trichomatis ∑ Symptoms Profuse discharge (scanty in Chlamydia),

Symptoms Profuse discharge (scanty in Chlamydia), burning micturation

Investigation Urethral swab

Treatment

micturation ∑ Investigation Urethral swab ∑ Treatment gram stained smear G-ve diplococci in PMNs, culture may

gram stained smear G-ve diplococci in PMNs, culture may be done

single dose ciprofloxcicin for gonococcal (or penicillin but not the best)

Tetracycline (doxycyclin) for non-gonococcal 10 days

**

Give together because may be mixed infection (STDs)

 

If not treated Complications as fibrosis & ejaculatory duct obstruction

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Urology Special Notes

NMT11

Cystitis

Incidence:

more in females,

why?? (short urethra, wide urethra & proximity to vagina, antibacterial nature of prostate )

80% of females will have UTI once in their life

if male has UTI, must be investigated by U/S

only

investigation is urine analysis

Symptoms frequency& burning micturation

Acc. symptoms:

ureteric pain if calculus

NB: if old with frequency :think mainly of BPH

NB: if old with frequency :think mainly of BPH

Investigation: urine analysis (main invest.), culture, U/S, plain X-ray

Treatment:trimethoprim / sulphamethoxazone(sutrim) for 5 days

Prostatitis

Types:

1. acute

2. chronic (bacterial, non-bacterial)

3. prostatodynia

Acute

Symptoms

PAIN during micturation, ejaculation, perineal pain

Frequency, urgency & dysuria

Do NOTcathetarize

help to flare infection, better do suprapubic cystoscopy

help to flare infection, better do suprapubic cystoscopy

Do NOT do prostatic massage

⇒ Do NOT do prostatic massage very tender, may lead to chronicity or systemic spread

very tender, may lead to chronicity or systemic spread

Treatment if abscess forms DRAIN via endoscopic trans-urethral route or trans-rectal

Proper antibiotic ttt for 6 weeks (because poor absorption by prostate)

Chronic

Symptoms irritation / discomfort rather than pain

Treatment antibiotics usually not effective, give analgesics, phytotherapy

Epididymoorchitis

One of the causes of acute scrotal pain

D.D. torsion of testis

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Urology Special Notes

NMT11

Pyelonephritis

Triad of

1.

Fever& Constitutional manifestations

2.

Loin Pain

3.

Urinary symptoms:aspyuria

Investigation

a. U/S: V importantto differentiate bet. Obstructed & Non-Obstructed

b. Urine analysis / Culture

c. Plain X-ray

d. IVP [NOT Contraindicated ]

Treatment

If Obstruction: Remove BUT first DRAIN Abscess [U/S guided Percutanous nephrostomy]

Antibiotics for 2 weeks, should be Strong Antibiotics ‘ Quinolones’ to avoid Chronicity

Bilharziasis

Symptoms

Itching at cercarial penetration, when reach Lungs Spread to all body organs, Survive only in Liver

system to reach Vesicoprostatic Plexus in S.hematobium

Liver system to reach Vesicoprostatic Plexus in S.hematobium Pneumonitis Grows to Adult then move in Portal

Pneumonitis Grows to Adult then move in Portal venous

pathology

Bilharzial Sandy patches- Brunn nests – B. Tubercules – B.Nodules – B. Papillomatous

Bilharzialgranulomala- B.Ulcers- Fibrosis –Leukoplakia or Cystitis Glandular – Malignancy

“SQ.Cell Carcinoma”

or Cystitis Glandular – Malignancy “SQ.Cell Carcinoma” ∑ Involved Structures Bladder [MOST COMMON] Lower end

Involved Structures Bladder [MOST COMMON]

Lower end of ureter, Bladder Neck, S.Vs [Common]

Investigation

1.

Urine analysis:

Bilharzial Ova

Hematuria [N.B.: Usually Terminal Hematuria]

Pus Cells

2.

CBC

3.

Plain X-ray

4.

U/S

5.

IVP : (if U/S show Hydronephrosis)

Complications

Bladder Neck Contructre:

Obstruction, Malignancy, 2ry Infections

Treatment

Anti Bilharzial drugs e.g.: Praziquantel

ttt of Complications

ttt of Complications Surgical

Surgical

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Urology Special Notes NMT11 Urinary TB ∑ Causes Mycobacterium Tuberculosis [ Human 75% & Bovine

Urology Special Notes

NMT11

Urinary TB

Causes

Mycobacterium Tuberculosis [ Human 75% & Bovine 25%]

Route of infection

-

Always 2ry

∑ Route of infection - Always 2ry Hematogenous Spread

Hematogenous Spread

 

-

[1ry always Asymptomatic]

pathology

1.

2.

Kidney: Extensive destruction

Ureter: Spread from kidney

Kidney : Extensive destruction Ureter : Spread from kidney ⇒ If Intramural part

If Intramural part

“Autonephrectomy” loss of affected kidney fibrosis [Multilevel] + Shortening High grade reflux GOLF HOLE APPEARANCE

“Autonephrectomy” loss of affected kidney fibrosis [Multilevel] + Shortening

High grade reflux

GOLF HOLE APPEARANCE on Cystoscopy

3.

Bladder
Bladder

Tubercles, Tuberculous ulcers

4.

Beaded Vas Deference

Beaded Vas Deference

Obstruction

5.

Prostatic Nodules [Uncommon]

Treatment

Anti tuberculus drugs: Combined for a long time [9 months] e.g.: INH, Rifampicin

ttt of Complications: Surgical AFTER Drug therapy to avoid spread

T.B Toxemia

T.B Toxemia

N.B.: TB may be present with STERILE PYURIA [No Organism growth, on Ordinary culture]

Urinary stones

Incidence:

5-15% +++ in tropical areas --- in cold countries

Etiology:

Till now true pathogenesis not known

 

SUPERSATURATION (Most important)

 

Decrease natural inhibitors of crystallization as Pyrophosphates ,Mg,& citrates

Water intake urine concentration  

Water intake

urine concentration

urine concentration

 
 
 

crystalloids in urine

diet Hereditary error or metabolic abnormality as GOUT ( uric acid stones)

diet Hereditary error or metabolic abnormality as GOUT ( uric acid stones)

infection :Nidus formation

, alter PH

 

stasis

 

F.B.

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acid stones) infection :Nidus formation , alter PH   stasis   F.B. 15 www.medadteam.org
Urology Special Notes NMT11 Pathogenesis effect : - May have no effect asymptomatic - May
Urology Special Notes
NMT11
Pathogenesis effect :
- May have no effect
asymptomatic
- May cause obstruction :according to level e.g. retention of urine , anuria , hydronephrosis
Or ureteric colic (severepain)
- May cause inflammation
- May cause mucosal injury
if chronic may predispose to malignancy
hematuria
symptomatology :
∑ Asymptomatic in largenumber of cases
∑ Loin pain ( renal stone ) or ureteric colic ( ureteric stones ) -
∑ Burning micturation or difficult micturation-
in urethra
retention of urine with severe acute pain in bladder ( suprapubic ) –
∑ Anuria ( different from retention NO desire to micturate anuria )-
∑ Hematuria may be grossly evident
***N.B .
The most common sites of impaction of calculs in ureter :
# junction between ureter & renal pelvis
# mid ureter passage of common iliac artery .
# ureterovesical junction .
Investigations :
Laboratory :
Radiology :
1- Urine analysis
( most important )
may show
1-U/S:1 st investigation
show site ,size ,number
* pus cells
* RBCs
*crystals :cystine , ca oxalate(COMMONEST)
,triphosphate or urate crystals
,obstruction ,other kidney ,
Parenchymal thickness ,hydronephrosis,
anuria Vs retention .
*PH
acidic
uric acid stones
alkaline
*specific gravity
if
if
triplephosphate stones
concentrated urine
renal failure .
2-X-ray :radio opaque stones 85% e.g. ca
oxalate
BUT not show radiolucent stones e.g. uric acid
stones
2-Kidney function test: creatinine( N 0.7 – 1.5 )
better than urea which change according to
degree of dehydration ,liver function & diet .
3- IVU :show radiolucent stones+ site
detection .
3- Urine culture .
4- CBC: leukocytosis
5-Metabolic workup:esp. if recurrent, multiple
4-CT :now considered the
excellent details .
BEST investigation
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Urology Special Notes

NMT11

TREATMENT :

According to site & size

Site :

Size:

1- Kidney 2-Ureter – upper

-middle

-lower.

Small <5mm Moderate 5mm -2cm

3-Bladder

Large >2cm.

A)Kidney:

5mm -2cm 3-Bladder Large >2cm. A)Kidney : Small : medical ttt: fluid intake ,analgesics &

Small :medical ttt:

3-Bladder Large >2cm. A)Kidney : Small : medical ttt: fluid intake ,analgesics & antispasmodic . Disolution

fluid intake ,analgesics & antispasmodic .

Disolution of uric acid stone is possible by heavy alkalinization of urine

Modaerat : extracorp.shock wave lithotripsy (ESWL) ultrasonic waves (several sessions)

( د ا ت تا ا ز )+ medical TTT

Large
Large

:surgery

ز ) + m e d i c a l T T T Large : surgery

percutaneous nephrolithotomy (less invasive than open surgery ) . Open surgery ( very hard or very large stone )=pyelonephrolithotomy

B)Ureteric stones :

 

Upper segment

Middle segment

Lower segment

Small

Medical ttt

Medical ttt

Medical ttt

Moderate

ESWL

Open surgery (recent uretroscopic removal) *ESWL not done (sacroiliac shadow obscure)

Ueretroscopic

Large

Open surgery ( urertrolithotomy )

Open surgery *ESWL not done sacrum shadow obscure & site of ovaries

C)Bladder stones:

Small :medicalttt. Moderate :cystoscopic removal or crushing Large: open surgery.(cystolithotomy)

D) urethral stones : usually require surgery or endoscopic removal because commonly

pressure

GENERAL RULES:

endoscopic removal because commonly pressure GENERAL RULES: hydronephrosis . back . * for conservative management

hydronephrosis .

because commonly pressure GENERAL RULES: hydronephrosis . back . * for conservative management (medical ttt) there

back

. *for conservative management (medical ttt) there is should be

- small sized stones

- NO back pressure effect ( hydronephrosis ).

- NO 2ry infection .

- NO distal obstruction .

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Urology Special Notes

NMT11

 

*Precautions of ESWL :

1-<2cm

2-No distal obstruction 3- Functioning kidney (to push fragments) 4-Not used for solitary kidney 5-Stone should be radio opaque 6-Not used for pregnant OR bleeding tendency .

*Percutaneous nephrolithotomy (PCNL) done if large stone, ESWLfailure, urinary obstuuction ,

cystine stone ( very hard ).

*Open surgery if failed or contraindication of ESWL or PCNL.

HOW to prevent recurrence?

Fluid intakecontraindication of ESWL or PCNL. HOW to prevent recurrence? crystal containing diet metabolic work up Calcularanuria

crystal containing dietof ESWL or PCNL. HOW to prevent recurrence? Fluid intake metabolic work up Calcularanuria : surgical

metabolic work up

Calcularanuria :surgical emergency

diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty
diet metabolic work up Calcularanuria : surgical emergency D.D. : retention - NO desire - empty

D.D. :retention

- NO desire

- empty bladder

IVU C.I. in this case Main aim of ttt

- empty bladder IVU C.I. in this case Main aim of ttt drainage of obstructed kidney.

drainage of obstructed kidney.

Bladder cancer

Commonest urologic malignancy in Egypt.

Egypt – one of the highest countries.

In the past, when Bilharziasis was wide spread; squamous cell type was much higher than transitional cell type (Ratio – Sq. :Transitional90:10).

Currently, Sq. cell carc. Has decreased owing to improved health care (Ratio – Sq. :Transitional

40:60).

Global ratio – Sq. :Transitional1:9

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Urology Special Notes

NMT11

Pathogenesis:

SCC

SCC

TCC

Chronic irritation of bladder mucosa Sq. metaplasia Neoplasia

a. Irritation by Bilh. Is due to ova penetrating mucosa + Carcinogenic metabolites

b. Irritation by stone

c. Longstanding indwelling catheter eg. In paraplegic patients

Pathology:

High risk groups & risk factors include:

1. Smoking toxic metabolites in urine.

2. Industrial chemicals esp. Aniline dyes, Petrol …. through inhalation, ingestion & contact.

3. Cancer therapeutic drug Cyclophosphamide

4. Artificial sweeteners as saccharine.

 

Transitional CC

Squamous CC

Gross picture

Villous papillary growth Less commonly cauliflower or ulcer

Cauliflower or Ulcer

Microscopic picture

Transitional cells with cellular features of malignancy

Cell nests with keratin whorls & malignant features

Spread

Local spread: surrounding organs, lately, reach pelvic bone …. Bladder

L.N.: EARLY

Blood: late

Local spread: ureters, prostate, sem. Vesicle, uterus, rectum

spread: ureters, prostate, sem. Vesicle, uterus, rectum ∑ L ate.Because of ∑ lymph.&vasc.Obstruction by

Late.Because of lymph.&vasc.Obstruction by Bilh.fibrosis

L.N.

Blood

Symptoms:

Pt > 50 yrs presenting with HEMATURIA is considered bladder carc. until proved otherwise

Characters of Hematuria: Recurrent, Profuse (± bl. clots), Painless (except if obstruction occur)

Other presentations:

Clot retention (urinary obstruction by blood clots) Renal failure: if invading both ureters (wasting, malaise, hiccough, pallor) Mass in lower abdomen

Signs:

By Digital Rectal Examination (DRE)

General examination signs of renal failure

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Urology Special Notes

NMT11

* Wallace system for staging is based on clinical DRE or bimanual

T 1 palpable, mobile, NO induration

T 2 palpable, mobile + induration

T 3 palpable, mobile + extravesical ext.

T 4 Fixed

Investigations:

 

LAB

RADIOLOGICAL

 

INVASIVE

Urine analysis

US: 1 st to be done

 

Cystoscopy Guided BIOPSY; most

- RBCs >100

Advs.

Accurate

- Necroturia

 

important If villous growth superf.

- Malignant cells

Non-invasive

 

- Pus cells

IVP (IVU)

- Complete resection + part of musculosa

CBC: anemia

- Delineate urinary tract

 

Kidney Function Tests

- May show

filling defect in bladder

- Send for pathology

Coag. Profile & liver function tests to exclude coag. problem causing hematuria

 

- Free margins??

 

nonfunctioning kidney

 

- CI in uremic pts. (renal impairment)

due to obstruction

 

CT with contrast:theMOST important

- Shows degree of invasion of bladder wall, LN metastasis, hdronephrosis

- CI in uremic pts. (bec. Contrast induced nephropathy)

 

MRI Imaging of choice in pts with renal impairment

 

TNM Staging(for transitional CC)

   

TTT

T

IS

Flat lesion with No invasion (carcinoma in situ)

 

Superficial

bladder

Transurethral resection + Intravesical chemotherapy + Immunotherapy (BCG vaccine to recurrence)

T

a

Villous growth into bladder with mucosal involvement only

T

1

Submucosal invasion

cancer

T

2

Musculosa invasion

asup.

bdeep

Muscle

 

T

3

Extravesical extension

amicroscopicbmacro

invading

 

Radical cystectomy

 

aprostate, uterus, vagina bpelvic wall, abd. wall

bladder

T 4

 

Invasion of other organs

cancer

 

Squamous CC are ALWAYS TTTby radical cystectomy

Early diagnosis is extremely important

Follow up: once weekly for 6 wksthen do cystoscopy

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Urology Special Notes

NMT11

Urinary diversion

1-Ureterocutaneous implantation: Urology Special Notes NMT11 Urinary diversion - 1 s t was made e' 2 skin opening

- 1 st was made e' 2 skin opening

- Later e' 1 skin opening

- Currently … ileal conduit Esp beneficial in uremic pt.--> absorption less than ureterocolic Adv. : no leakage

Disadvantage : - urine leakage ( urinefrousodour&skin excoriation)

Disadvantage : - urine leakage ( urinefrousodour&skin excoriation)

: - urine leakage ( urinefrousodour&skin excoriation) 2- Ureterocolic anastomosis 2 ureters are anastomosed to

2- Ureterocolic anastomosis

excoriation) 2- Ureterocolic anastomosis 2 ureters are anastomosed to sigmoid colon There is single

2 ureters are anastomosed to sigmoid colon There is single cloacafor both urine ,stool

- Advantages : patient is continent

- Disadvantages:

a-

absorption of chlorides in urinehyperchloremic metabolic acidosis Absorption of urea amonniaencephalopathy if liver impairement

b-

recurrent upper UT infections tillrenal failure

c-

Chemicals cancer colon after 10 years in 30%

d-

continenceis partial as leakage occurs during sleep or flatus

3-Rectal ,bladder

- Dividesigmoid colon colostomy{skin opening for stool} (rapidly tolerated by patient)

- 2 Ureters implanted in rectum now act as urinary bladder

NB. Rectum has poor absorptive function compared to colon

So ,Nohyperchloremic acidosis

function compared to colon So ,Nohyperchloremic acidosis 4-orthotopic urinary diversion with bladder reconstruction

4-orthotopic urinary diversion with bladder reconstruction(continent urinary

diverstion)

- Using segments of ilem or caecum or sigmoid colon

- Ureters are implanted in the new bladder with antireflux manner

- New bladder is anastomosed to bladder neck or urethra attached to skin, stoma, by continence mechanism Appendix is jmplanted within reservoir in submucosal tunnel to provide continence mechanism ,then appendix is brought to umbiculus&Catheterized every 4-6 h.

Disadv.

- Very lengthy procedure 6-12 h. - Absorption ( not done in uremic pt)

every 4-6 h. Disadv . - Very lengthy procedure 6-12 h. - Absorption ( not done

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Urology Special Notes

NMT11

Renal Neoplasm

10% Urothelial

Tr. Cell carcinoma

Sq.cell carcinoma

90% Renal parenchymal tumours

Renal cell carcinoma

Nephroblastoma

Renal cell carcinoma =Hypernephroma =Von Growitz tumor

Incidence:

commonest renal parenchymal tumour 75% of all renal neoplasm & most lethal of them

Male:female =2:1

 

Age group :6 th -7 th decade

Usually unilateral ,bilateral in only 2%

Incidence is ↑↑ due to :

Improved diagnostic modalities Environmental : ↑↑Smoking

eg:CT

NB.

4%FAMILIAL

 

96%SPORADIC

 

Risk factors:

Smoking

Von HippelLindow syndrome (cerebellar hemiangioblastoma ,Retinal Angioma)

Acquired renal cystic disease

Well understood molecular basis loss of short arm of chromosome 3{Tumour suppressor gene}

Pathology:

Gross:

usually at upper pole of kidney ,BUT may occur at ANY site variable size ,Gold yellow {++lipid}

Cutsection Mosaic (Hge,necrosis)

&

False capsule surrounding lesion

Microscopic:

ADENOCARCINOMA originating from PCTs of kidney Commonest formCLEAR CELL Type aggressive with sarcomatoid features

Gradingsystem:Fuhrman Grading system

4 grades from low to high grades

Depending on nuclear shape

Has prognostic value

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Urology Special Notes

NMT11

TNM staging (2002)

T0 No evidence of malignant grow

Txcan't be assessed

T17 cm (0-4cm …A )& (4-7cm …B)

T27 cm but confined to kidney

T3Locally advanced but conjuned to Gerota's fascia (zukercandle's fascia) a)Perinephric fat ,adrenal gland b)Malignant thrombus in I.V.C below diaphragm c)Malignan t thrombus in I.V.C above diaphragm

T4Outside fascia

N1 (single) N2 (multi.) N3 (fixed)
N1 (single)
N2 (multi.)
N3 (fixed)

N

- regional (paracervical&paraaortic)

- Other …… N4

MsNo evidence of metastasis

MxCan't be assessed

M1distant metastasis documented Metastasis sites

- Lungs (no 1)

- Liver

- Adrenal

- Bone

C/P

Classical triad (advanced case)

- Lion pain 40% of patients Cause

a) renal capsule stretch

b) passage bl.clotsureteric …

- Loin mass : irregular hard renal swelling 30%

- Hematuria painless, recurrent, profuse 50% of cases,+ NECROTURIA(passage of necrotic

tissue in urine,

differentiate

from Nocturia !!)

Other presentation

- 1-non-reducible varicocele especially left sided ± LL edema

- 2-paraneoplastic syndrome

- 3-cancer cachexia

- 4-Fever of unknown origin Liver dysfunction (stauffer$)

- 4-Fever of unknown origin Liver dysfunction (stauffer$) - Erythropoietin → polycythemia - PTH →

- Erythropoietinpolycythemia - PTH Hyppercalcaemia - renin hypertension

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Urology Special Notes

NMT11

Investigations

LAB

Urine analysis

CBC polycythemia

Kidney functions

Liver functions

Alk.phosphatase

Management

Imaging

U/S

CT with contrast (most important)

MRI with gadolinium : not nephrotoxic+ Superior in caval thrombosis

CXR (Chest x-ray) : cannon ball metastasis

Bone scan

Surgical is the mainstay of ttt

A)

b)

- radical nephrectomy (open or laparoscopic)

- nephron sparing surgery (NSS)

Or partial nephrectomy …. At local excision with leaving the largest possible amount of functioning nephron

In advanced cases: IFN, IL-2, recently tyrosine kinas inhibitors (TKI) Follow up every 6 months with lab inv. + x-ray chest

WILMS TUMOUR

up every 6 months with lab inv. + x-ray chest WILMS TUMOUR ORIGIN : embryonic nephrogenic

ORIGIN: embryonic nephrogenic tissue ORIGIN :

INCIDENCE:10% OF

ORIGIN : embryonic nephrogenic tissue INCIDENCE : 10% OF CHILDHOODMALIGNANCIES Age group: peak 3-4 yrs GROSSPICTURE

CHILDHOODMALIGNANCIES Age group: peak 3-4 yrs

: 10% OF CHILDHOODMALIGNANCIES Age group: peak 3-4 yrs GROSSPICTURE : ∑ solitary sharply demarcated,encapsulated

GROSSPICTURE:

Age group: peak 3-4 yrs GROSSPICTURE : ∑ solitary sharply demarcated,encapsulated mass bilateral

solitary sharply demarcated,encapsulated mass bilateral in 5-10 % of cases

demarcated,encapsulated mass bilateral in 5-10 % of cases MICROSCOPIC both epithelial( 1ry glomeruli & tubules )

MICROSCOPIC

mass bilateral in 5-10 % of cases MICROSCOPIC both epithelial( 1ry glomeruli & tubules )

both epithelial( 1ry glomeruli & tubules ) &Connective tissue(cartilage,fat,smooth&striated

muscles

)

- may be well differentiated (Favourable Histology FH) or poorly differentiated(Unfavourable histology UH)

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Urology Special Notes

NMT11

Urology Special Notes NMT11 CLINICALPRESENTATION : - ABDOMINAL MASS (90%of cases): smooth,firm , confined to one

CLINICALPRESENTATION:

Urology Special Notes NMT11 CLINICALPRESENTATION : - ABDOMINAL MASS (90%of cases): smooth,firm , confined to one

- ABDOMINAL MASS (90%of cases): smooth,firm, confined to one side of abdomen -VagueAbdominal pain ,Anorexia ,Malaise,Weight loss& fever -Hypertension due to renal ischemia -Associated anomalies:Aniridia,macroglossia, Neurofibromatosis, Hypospadias&cryptorchadism

DIFFERENTIALDIAGNOSIS:

Neuroblastoma: in contrast to Wilm’stumour, it

- can cross midline

- has irregular surface, Hard consistency

- urinary catecholamines are elevated -may be associated with diarrhea(VIP secretion)

OTHERS:hydronephrosis ,Multicystic dysplastic kidneys ,polycystic kidney (infantile type)

INVESTIGATIONS

 

Laboratory:

Radiological :

Urine analysis:

U/S:consistency solid Not cystic(exclude hydronephrosis& renal cystic disease) can detect liver metastasis CT Scan: v.important differentiate cystic from solid spread response to chemotherapy & radiotherapy Chest X-ray & isotope bone scan to detect metastasis

Microhematuria(50%)

 

CBC,liver&kidney function tests Urinary catecholamines are NORMAL (Vs neuroblastom)

TREATMENT:

 

Surgical exicision (Radical nephrectomy ) remains the cornerstone for treatment,withpostoperative chemotherapy.

For large unresectabletumours: preoperative chemotherapy to shrink tumour(neo-adjuvant) ,which can then be removed ,remaining tumour directed radiotherapy

then be removed ,remaining tumour directed radiotherapy PROGNOSIS : Cure in early cases now: 80% 5

PROGNOSIS:Cure in early cases

now: 80% 5 yr survival rate

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Urology Special Notes

NMT11

U.T Injuries (Renal injuries)

Incidence:

relatively rare due to:

- Well protected by ribcage & back muscle.

- Peri-renal fat cushion

- Fibrous capsule.

80% associated with Multisystem trauma

In children less developed.

So more liable to renal injuries

Etiology:

Blunt injuries: commonest

Penetrating: e.g. stabs and gun shots

Iatrogenic: e.g. during renal biopsy or percutaneous nephrostomy

e.g. road traffic accident , fall from height and direct kick

Pathology:

Bleeding can be retroperitoneal or less commonly intraperitoneal.

NB.Retroperitoneal: stop further bleeding by tamponade effect. Thus if opened in operation massive bleeding so
NB.Retroperitoneal: stop further bleeding by tamponade effect.
Thus if opened in operation
massive bleeding
so take precautions and don’t open unless necessary

C/P

 
 

History of trauma.

 

Pain and tenderness over renal area but may be obscured by organ injury.

Hematuria:gross hematuria after trauma = urinary tract injury

 

However hematuria doesn’t correlate with severity of injury 30% of renal vascular injuries are not ass. With hematuria This is due to either complete avulsion of pedicle or ureteric injury Blunt trauma + shock ( systolic BP. < 90 mmHg ) + microscopic hematuria is a good predictor of renal injury

 

Hemorrhagic shock with oliguria

Nausea , vomiting and illeus ( abd. Distention ) are very common.

Other injuries.

 

Investigations

Lab:

-

Urine analysis

hematuria ( also for medico- legal purpose ).

hematuria ( also for medico- legal purpose ).

-

CBC

serial hematocrit

serial hematocrit

- CBC serial hematocrit persistant bleeding.

persistant bleeding.

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Urology Special Notes

NMT11

Radiological:

 

-

CT scan: study of choice in stable patient

Best with contrast

 

Adv.: excellent details , depth of lacerations , hematoma , ass. Injuries , contra-lateral kidney

state , late film

state , late film

urinary extravasation

Indications: -

 

Children with any hematuria.

Adult with gross hematuria or microscopic hematuria + shock

Deceleration injury.

-

Other radiological investigations :

U/S

Plain x-ray :

:

urinary collection ( urinoma ) , size and contour of kidney

retroperitoneal hematoma

(oblit. of psoas shadow )

Ass. rib or vertebral fracture

IVU: extrvasation of contrast ?other kidney ?

Renal injury scaling system( American ass. for surgery of trauma ):

 
 

Based on CT scan or exploration

Grade 1 : contusion or sub capsular hematoma ( no lacerations ).

 

Grade 2 : cortical laceration < 1cm deep , no extravasation.

Conservative

Grade 3 : cortical laceration > 1cm deep , no extravasation.

Grade 4 : cortical laceration < 1cm deep , reaching collecting system + extravasation.

∑ Grade 4 : cortical laceration < 1cm deep , reaching collecting system + extravasation. Immediate

Immediate

Grade 5 : Shattered kidney or major vascular injury ,renal pedicle avulsion.

exploratory

Treatment:

 

laparotomy

1)

2)

Resuscitation ( very important )

Conservative : grades 1 , 2 , 3 ( i.e. most cases )

Hospitalization with bed rest and monitoring :

 

clinical

:

vital signs

Lab (CBC) : Hg & Hematocrit

Radio

:

U/S for expanding hematoma

Analgesics

 

Large fluid intake :

 

hypovolemia

Avoid cast retention

3)

Surgery :midline exploratory laparotomy

Indications :

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Urology Special Notes NMT11 major renal injury grade 4or 5 ( can be confirmed by

Urology Special Notes

NMT11

major renal injury grade 4or 5

( can be confirmed by intraoperative IVP ) Penetrating trauma

Hemodynamic instability

Expanding retroperitoneal hematoma

Midline incision ? : needmedial approach to reach renal vessel and explore other injuries.

Nephrectomy

renal vessel and explore other injuries . ∑ Nephrectomy irrepairable laceration , pedicle injury , severe

irrepairable laceration , pedicle injury , severe bleeding

Complications of renal injury:

Urinary extravasation :

Peri-renal abscess :

Delayed retroperitoneal bleeding : AV fistula due to penetrating injury

Hypertension : rennin mediated due to ext. compression ( page kidney )

Renal atrophy / fibrosis

Hydronephrosis

ureteric stent + folley’s catheter

drainage

Rupture bladder

Bladder injuries are most often from external force and are frequently associated with pelvis fractures.

-

extraperitoneal rupture . 80%

-

intraperitoneal rupture. 20%

Etiology:

1-

Fracture pelvis is the commonest cause of extraperitoneal rupture.

2-

A blow or kick to the lower abdomen, in presence of full bladder, is the commonest cause of intraperitoneal rupture.

3-

Stabs or bullets

4-

Surgical operations or cystoscopic procedures

Clinical features:

Extraperitoneal rupture:

1-

History and signs of fracture pelvis.

2-

Hypovlaemic shock.

3-

Urine starts to collect in the retropubic space giving rise to an intense desire to void.

4-

Swelling in suprapupic area.

5-

Digital rectal examination: prostate in its normal position.

6-

If not treated: irritation of anterior abdominal wall, a necrotizing phlegmon will develop

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If not treated: irritation of anterior abdominal wall, a necrotizing phlegmon will develop 28 www.medadteam.org

Urology Special Notes

NMT11

Intraperitoneal rupture:

1-

Sudden agonizing pain in suprapubic area, the pain is later replaced by dull aching pain all over the abdomen.

2-

Severe oliguria or anuria as urine collects in the peritoneal cavity.

3-

Peritonitis and if the amount of urine in the peritoneal cavity is large , shifting dullness can be elicited.

4-

Digital rectal examination: fullness of retrovesical pouch.

5-

Passing urine catheter brings no urine.

Invetigations:

1-

Ascending cystogram provides definite diagnosis by demonstrating leakage of contrast outside the bladder.

2-

X ray: fracture pelvis and hazziness over the lower abdomen.

3-

I.V.U : exclude other urinary injuries

D.D:

- Intrapelvic complete rupture of the urethra. The prostate migrate up from the pelvis and is felt higher than normal on Digital rectal examination.

Complications:

- Pelvic abscess

- Delayed peritonitis

- Partial incontinence if bladder neck is injuried

Treatment:

Emergencysurgery after proper patient resuscitation.

-

Exploration through a mid line incision and bladder tear exposed, its edges are trimmed and the defect is closed in two layers with polygalactin or chromic gut.

-

Suprapubic catheter is left in the bladder and drain is placed in retropubic space.

-

In intraperitoneal rupture, the peritoneum has to be opened to drain extravasated urine and exclude intraperitoneal injuries.

-

Antibiotics

-

Small tear with minimal extravasation on cystogram: uretral catheter for few days without the need for surgery.

-

Pelvic fracture is then treated; internal fixation of broken bone is contraindicated in the presence of urine extravasation for fear of causing osteomyelities.

-

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Urology Special Notes NMT11 Rupture urethra Anterior & posterior urethra rupture   Anterior urethra
Urology Special Notes NMT11 Rupture urethra Anterior & posterior urethra rupture   Anterior urethra

Urology Special Notes

NMT11

Rupture urethra

Anterior & posterior urethra rupture

 

Anterior urethra

Posterior urethra

 

Etiology

Trauma to peritoneum

Fracture pelvis or instrumentation

Types

Complete orIncomplete

Complete:

 

Torn puboprostatic ligament Displaced bladder & prostate

Extravasation

Superficial perinealpouch"penis, scrotum"superficial extravasation

Suprapubic, perivesicalspace"deep extravasation

of urine

Clinical picture

Perineal pain

Pelvic pain

Bleeding per urethra Retention & extravasation of urine Stricture urethra

 
 

P/R: displaced prostate

Treatment

Patient: do NOT micturate Doctor: do NOT catheter Cystostomy Cystourethrography

 

Treatment of extravasation:

Treatment of fracture pelvis

Cystostomy+antibiotics+drainage

For stricture urethra:

· Endoscopic dilatation reconstruction

 
Special Thanks To our dear colleague RAMYRAMYRAMYRAMY DOSSDOSSDOSSDOSS For his great effort in preparing this
Special Thanks
To our dear colleague
RAMYRAMYRAMYRAMY DOSSDOSSDOSSDOSS
For his great effort in preparing this
note

30

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colleague RAMYRAMYRAMYRAMY DOSSDOSSDOSSDOSS For his great effort in preparing this note 30 www.medadteam.org

Urology special notes

NMT11

MCQ

1. Bengin cyst by u/s all is correct except:

a. is smooth containing clear fluid.

b. leaves residual mass after aspiration.

c. no rapid recollection.

d. all of the above.

2.Nocturia is:

a. passage of necrotic tissue in urine. (necroturia)

b. sudden sever desire of micturation.

c. passage of urine during sleeping. (Nocturnal enuresis)

d. all of the above.

e. non of the above.

3. Regarding urinary system investigations:

a. IVP is safe in renal impairment.

b. cystogram is the most diagnostic method of urinary bladder carcinoma.

c. vesicoureteric reflux is diagnosed by MCU.

d. cystoscope of bladder carcinoma shows pseudotubercle, sandy patches and ulcerations

4. Posterior urethral valve is best diagnosed by:

a. voiding (micturating) cystourethrography.

b. ascending urethrography.

c. us.

d. IVP.

e. x-ray.

5. as regards polycystic kidney all are correct except:

a. hereditary condition.

b. infantile type is a rare condition inherited as autosomal recessive.

c. may cause renal hypertension.

d. cannot be complicated by infections (sterile condition).

6. Adult polycystic kidney:

a.

autosomal recessive

b.

usually affects 1 kidney.

C.

usually leads to renal failure.

d.

all of the above.

e.

non of the above.

1

1

Urology special notes

NMT11

7. the commonest congenital anomaly of the bladder is:

a.

paraureteric diverticulum.

b.

patent urachus.

c.

urachal cyst.

D.

ectopia vesica.

e.

septate bladder.

8. Horse shoe kidney:

a. level of block is at the level of the superior mesenteric artery.

b. isthmectomy is always indicated.

c. The renal pelvis lies medially (anteriorly).

d. all of the above.

e. non of the above.

9. Complication of rupture kidney:

a. shock.

b. renal failure if solitary kidney.

c. A-V fistula.

d. pseudohydronephrosis.

e. all of the above.

10. Renal failure:

a. is usually common due to the strong rib cage & strong back muscles.

b. penetrating injury is more common than blunt injury.

c. absence of hematuria doesn't exclude renal injury.

d. IVP is the investigation of choice for staging of injury.

e. staging usually depend on surgical exploration laparotomy.

11. About rupture urethra:

a. commonly is prostatic urethra.

b. causes bleeding per rectum.

c. fracture of pubic and ischeal rami causes rupture membranous urethra.

d. the 1 st step of treatment is usually uretheral catheterization.

12. Bladder injuries:

a. may be intrapretoneal or extrapretoneal.

b. associated with fracture pelvis.

c. ascending cystourethrography with extravasations of dye outside bladder.

d. all of the above.

e. none of the above.

2

2

Urology special notes

NMT11

13. Diagnosis of urinary bladder carcinoma:

a. the most effective diagnostic tool is cystoscopy.

b. Best assessment of penetration is by contrast enhanced CT.

c. Irregular filling defect in cystogram.

d. All of the above.

14. UTI:

a. Gonococci is the most common causative organism.

b. Stone & catheterization are the major predisposing factors.

c. More common in males.

d. All of the above.

e. Non of the above.

15. Non gonococcal urethritis is beast treated by:

a. Tetracycline.

b. Metronidazole.

c. Quinolones.

d. Penicillin.

16. Bilharziasis:

a. Commonly affects lower end of ureter.

b. Hematuria is characterized by being total hematuria. (terminal)

c. Fibrosis of urinary bladder is not common.

17. Stones:

a. Most common type of stone is uric acid. (ca oxalate)

b. Radiolucent stones are more common.

c. They are always asymptomatic.

d. All of the above.

e. Non of the above.

18. Risk factors of transitional cell carcinoma include all the following except:

a. Smoking.

b. Cyclophosphamide.

c. Pelvic irradiation.

d. Exposure to benzidine.

e. Exposure to shistosomiasis.

19. Uric acid stones:

a. Can be treated by alkalizations.

b. Are radiolucent.

c. Occur after chemotherapy in patients with leukemia or lymphoma.

d. All of the above.

e. Non of the above.

3

3

Urology special notes

NMT11

20. Stone in the lower part of the ureter may be treated by:

a. Medical ttt.

b. Endoscopic ttt.

c. Surgical removal.

d. All of the above. (Full options)

e. Non of the above.

21. As regards complications of cancer prostate:

a. Most common site for distant metastasis is vertebral column.

b. Urine retention is a late complication.

c. Most common sexual complication after prostatectomy is retrograde ejaculation.

d. All of the above.

22. Localized prostatic cancer is best treated by:

a. Brachytherapy.

b. Hormonal ttt.

c. Orchidectomy.

d. Estrogen.

e. LHRH agonist.

23. Calcular anuria:

a. urine output is < 200ml/24hrs.

b. Drainage of obstruction is 1 st line of ttt.

c. Bladder is usually empty.

d. All of the above.

e. Non of the above.

24. BPH:

a. Commonly affects old males at the age of 40.

b. May present by frequency, hesitancy, weak stream and sense of incomplete voiding.

c. Best way for examination is suprapubic abdominal examination.

25. Renal cell carcinoma:

a. Always present in the upper pole.

b. Treated by simple nephrectomy.

c. Usually present by pain, hematuria and renal mass.

26. Willm's tumor (CHOOSE THE INCORRECT).

a. It represents 10% of childhood malignancies

b. Commonly presents by abdominal mass.

c. Best investigation is CT.

d. Commonly affects children < 7 years.

e. Chemotherapy and radiotherapy don't improve prognosis.

4

4

Urology special notes

NMT11

27. Transitional cell carcinoma of the bladder:

a. Cigarette smoking increases the risk by 4 folds.

b. Superficial type is treated by TURT.

c. Radical cystectomy is indicated if muscle is invaded.

d. All of the above.

e. None of the above.

28. Squamous cell carcinoma of the bladder:

a. Is chemo and radio sensitive.

b. Superficial type is treated by TURT.

c. Radical cystectomy is always indicated.

d. All of the above.

e. None of the above.

29. Prostatic carcinoma:

a. The gland is nodular & asymmetrical by PR examination.

b. PSA is the most important tumor marker for diagnosis and follows up.

c. Bone metastasis is usually osteoblastic.

d. All of the above.

e. None of the above.

30. 1 st line of ttt in PBH:

a. Alpha blocker.

b. Hormonal ttt to decrease size of gland.

c. Estrogen.

d. Anti androgen.

e. None of the above.

ANSWERS

1. b

16. a

2. e

17. e

3. c

18. e

4. a

19. d