Urology Special Notes NMT11

symptomatology Upper urinary tract symptoms:

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

Lower urinary tract symptoms:

1- pain: vesical pain Prostatic & seminal vesical pain Urethral pain Testicular and epididymal pain varies from slight discomfort to severe agonizing pain in the supra pubic region especially with full bladder is deeply seated vague discomfort in the pelvis. 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 : frequency of 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 Its 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). 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)

urgency

Dysuria Symptoms of bladder outlet obstruction

3- Urinary incontinence

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4- Symptoms related to changes in urine Changes in urinary volume Polyuria oliguria excessive fluid intake, DM ,diabetes insipidus and high-output chronic renal failure is urine volume less than 400ml/24 hours in adults. The cause is either acute renal failure or bilateral ureteric obstruction. is urine volume less than 200ml/24hrs , the causes are o Pre-renal causes: e.g. shock and dehydration o Renal causes: e.g. toxins, drugs and renal diseases o post- renal causes:e.g bilateral renal obstruction or complete obstruction in solitary kidney If due to stones its called calcular anuria .anuria is one of the urological emergencies Pneumaturia Changes in color and contents of urine Hematuria Pyuria is passage of blood in urine the presence of pus in urine. Its either microscopic or macroscopic passage of white milky urine due to presence of lymphatic fluid or chyle (turbid) urine: due to presence of excessive phosphate crystals that precipitated in alkaline urine. passing pieces of necrotic tissues in urine. It is pathognomonic of bladder carcinoma presence of gas in urine.

anuria

Chyluria

Cloudy

Necroturia:

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 NMT11

Anomalies of kidney Classification
Anomalies of number Anomalies of volume & structure - Agenesis :bilateral or unilateral - Supernumerary kidney hypoplastic simple renal cyst polycystic kidney multicystic kidney medullary sponge kidney Ectopic (pelvic or iliac)kidney horse-shoe kidney discoid (cake-shaped) kidney sigmoid & L-shaped kidney Incomplete rotation Bifid pelvis (double pelvis) Pelvi-ureteric junction obstruction Aberrant & accessory renal arteries Renal artery aneurysm & A-V fistula

Anomalies of ascent Anomalies of shape, form & fusion

Anomalies of rotation Anomalies of renal pelvis Anomalies of renal vasculature

Simple renal (solitary) cyst

Clinical features: 1 A solitary cyst is commonly asymptomatic. 2. Intermittent dull pain in flank or back. 3. Hemorrhage in a cyst or infection will lead to acute symptoms. 4. Renal mass if the cyst is huge . Treatment: - No treatment but follow up is required. - If there is complications : percutaneous needle aspiration

Polycystic kidney
Adult type (autosomal dominant) polycystic kidney disease This is the commonest form of cystic diseases of the kidney. It affects both kidneys. 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 intracranial aneurysms.

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Clinical features: 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. Renal failure may occur after the age of 50. Investigations: Ultrasonography or CT scan is accurate in the diagnosis of polycystic kidneys. Treatment: 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. After renal failure Renal transplantation is the definitive treatment. Haemodialysis is a temporary measure until a suitable donor Is found .

Infantile type (autosomal recessive) polycystic kidney disease Very large kidneys may obstruct labour. Newborn infants with severe form of the disease may die from respiratory failure due to pulmonary hypoplasia. Renal failure.

Horseshoe kidney
More frequent in males. Pathology: 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.

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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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Anomalies of urethra

Posterior urethral valves

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. This not only leads to damage of the smooth muscle function of the bladder, but also leads to vesicoureteral reflux and renal parenchymal damage. Clinical features: The presentation depends on the degree of obstruction. The most severe forms present at birth with palpable kidneys or bladder, urinary ascites and respiratory distress from pulmonary hypoplasia. 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. Investigations: 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.

Hypospadias
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. Deficient receptors in targel cells may play a role. Clinical features: Meatus is ventrally placed and stenosed. Prepuce is deficient venterolaterally. Shaft is ventrally curved due to the presence at chordee except in the glanular variety. Scrotum is bifid in the perineal type. Associated lesionsundescended testes or upper urinary tract anomalies Patients with posterior hypospadias may have a problem with sex differentiation Investigations: Ultrasound examination to detect upper urinary tract problems. Treatment: Circumcision should not be done to hypospadiac patients because the skin of the prepuce can be used for repair. 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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Urology Special Notes NMT11

Benign prostatic hyperplasia (BPH)
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

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)

b. Obstructive symptoms i- Hesitancy: Delay instarting ii- Weak - interrupted (intermittent stream) ,may be forked iii-Sense of incomplete voiding

c. Symptoms of complications a- Retention: IAcute: due to edema and cong. Of bladder neck .., bladder still normal, Severe pain IIChronic: due to long standing obstruction Hypertrophy dilatation dilatational weakness + poor contraction Large amounts of urine are retained, may reach 1.5 L Normal bladder retains 350 650 ml urine IIIChronic retention with overflow How to differentiate from true incontinence bladder empty In chronic retention with overflow digital rectal examination full bladder Catheter U/S Pt. has a desire to micturate
N.B. Bladder trabeculation, sacculations and pulsation diverticulum may occur with chronic retention

b- Due to stasis cystitis and stone formation pain and frequency c- Reflux hydronephrosis & gradual deterioration of renal function (bilateral) N.B. Normally, detrusor muscle contraction is responsible for prevention of reflux from bladder to ureter, with dilational weakness loss of antireflex mechanism. d- 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

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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 1) Urine analysis for pus cells, hematuria, sp. Gravity (if low fixed sp. Gravity at 1010 CRF) 2) Kidney functions tests 3) PSA (prostatic specific Ag) serum level to screen prostatic cancer (Norma level: 0-4 ng/ml) 1) 2) 3) Radiological Plain x-ray to visualize stone U/S: 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 : 1- 1-blocker e.g. : doxazosin (carclua) .. DRUG OF CHOICE -block receptors in prostatic urethra relax prostate smooth muscle improve symptomsesp.frequency. 2- 5 reductase inhibitors e.g. finasteide Inhibit 5-reductase enz. Responsible for conversion of testosterone to active dihydrotestosteron which slowThe progression & decrease prostate size However,not the drug of choice because e size of prostate not directly linked to severity of Symptoms. 3- phytotherapy. 4- decongestant suppositories. surgical : Indications: failure of medical treatment or complications 1- prostatism distributing pts life with failure of medical ttt. 2- complicated case:
more than one attack of acute retention. residual urine more than 200ml. severe hematuria. complications in bladder as cystitis and stones. complications in kidney as hydronephrosis.

Methods: 1-endoscopic : - TransUrethral Resection of Prostate (TURP) : PROCEDURE OF CHOICE. - visual laser ablation of prostate (VLAP) 2-open surgey : retropubic millen's operation transvesical.

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Urology Special Notes NMT11 Prostatic cancer

Incidence
common malignant cancer in males more than 65ys

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

Pathology
Peripheral zone mainly.*

Adenocarcinoma in more than 95% of cases.*

Symptomatology
1 -asymptomatic: esp. in countries with screening test done routinely. 2 -Symptoms:
a. Irritative symptoms :
Urgency, frequency, nocturia.
Less marked than BPH (Mainly in peripheral)

b. Obstructive symptoms
Hesitancy, sense of incomplete void, weak interrupted flow

c. complication due to obstruction:

Retention, stasis (cystitis, stones),reflux.

d. Metastasis:
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 removed Due to BPH c) tumor not seen or felt but +++ PSA. nodule confined to prostate: a) in 1 lobe. b)in 2 lobes extends through capsule reach seminal vesicle. adjacent structure other than SV. N.B:
BPH arises ALWAYS from transisional zone Pr.carcinoma arises MAINLY from peripheral zone

T2 T3 T4

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Investigation:
Laboratory : 1) PSA:most importantserumtumour marker for screening & follow up. (Norma level: 0-4 ng/ml) If : suggestive of prostatic cancer. If more than 20 : bone spread. N.B. every man > 50 years should be screened yearly by PSA + digital rectal examination, Serum PSA may be also in infection (prostatitis) and benign conditions as BPH. If elevated levels ttt infection by quinolones for 6 weeks (prostate poorly absorb drug) then restimate PSA 2) urine analysis : infection , hematuria 3) kidney function test. Radiological 1) TRANSRECTAL U/S*: visualize prostate & guide biopsy. 2) u/s :hydronephrosis,. 3) x-rays : stones, bone spread, lung spread. 4) CT,MRI : asses 1ry tumour , LNs , metastasis. 5) IVP. 6) Bone scan : very important esp. if PSA more than 20. 7) BIOPSY : must be done if +++ PSA -------- ( CONFIRM DIAGNOSIS ).

Management A. Early
Organ confined (localized) AIM: Cure STANDARD:Any of the following 1) RADICAL prostatectomy: (never forget to write RADICAL) Remove prostate, S.V. + lymphadenectomy (if increased PSA) Then connect bladder to membranous Urethra( Patient remains continent to urine) 2) Radiotherapy: because tumor is radiosensitive 3) Brach therapy: inserted into prostate tissue NON-STANDARD: Watchful waiting if old age ,not fit for surgery

B. Late
T4 AIM: Palliation

1) 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)

2) TURP to relieve symptoms (Transurethral Resection in Pts with bladder outflow obstruction)

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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
1. 2. 3. 4. 5. 6. 7. Ureter:Bilateralpathology to affect renal function Urethra: Congenital or Stricture Bladder: Stricture, Congenital obstruction. Prostate: BHP, Carcinoma

pathology
Hydronephrosis Hydroureter Renal Failure Trabeculae in bladder Diverticular Elongated Prostatic urethra Later Dilatation Thick wall bladder

C/P :
Symptoms
Anuria Bladder Empty Obst. Above bladder Anuria= < 200 ml/24hr Retention Bladder Full Obst. at or below bladder

Investigation
Laboratory : 1. 2. 3. 4. Renal function test Electrolytes Na & K [Beware of Hyperkalemia] ABG Hb elective: If acute on top of chronic

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Radiological: 1. U/S: Very Important 2. X-ray 3. MR urography **N.B.: IVP is CONTRAINDICATED in Obstructive lesions

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 Specific e.g.bilharz. & TB o non-specific urethritis, prostaitis, cystitis, pyelonephritis, epididymoorchitis

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

Symptoms Profuse discharge (scanty in Chlamydia), burning micturation Investigation Urethral swab gram stained smear G-ve diplococci in PMNs, culture may be done Treatment
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....only investigation is urine analysis if male has UTI, must be investigated by U/S

Symptoms frequency& burning micturation

Acc. symptoms: ureteric pain if calculus

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 Do NOT do prostatic massage 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 Pneumonitis Spread to all body organs, Survive only in Liver Grows to Adult then move in Portal venous system to reach Vesicoprostatic Plexus in S.hematobium

pathology
Bilharzial Sandy patches- Brunn nests B. Tubercules B.Nodules B. Papillomatous Bilharzialgranulomala- B.Ulcers- Fibrosis Leukoplakia or Cystitis Glandular Malignancy SQ.Cell Carcinoma

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 Surgical

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Urology Special Notes NMT11 Urinary TB

Causes
Mycobacterium Tuberculosis [ Human 75% & Bovine 25%] Route of infection - Always 2ry Hematogenous Spread - [1ry always Asymptomatic]

1. 2. 3. 4. 5.

pathology Kidney: Extensive destruction Autonephrectomy loss of affected kidney Ureter: Spread from kidney fibrosis [Multilevel] + Shortening If Intramural part High grade reflux GOLF HOLE APPEARANCE on Cystoscopy Bladder Tubercles, Tuberculous ulcers Beaded Vas Deference Obstruction 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 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 crystalloids in urine diet Hereditary error or metabolic abnormality as GOUT ( uric acid stones) infection :Nidus formation , alter PH stasis F.B.

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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 if chronic may predispose to malignancy May cause mucosal injury hematuria

symptomatology :
Asymptomatic in largenumber of cases Loin pain ( renal stone ) or ureteric colic ( ureteric stones ) Burning micturation or difficult micturationin 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

* pus cells * RBCs *crystals :cystine , ca oxalate(COMMONEST) ,triphosphate or urate crystals *PH acidic uric acid stones alkaline triplephosphate stones *specific gravity if concentrated urine if renal failure .

1-U/S:1st investigation show site ,size ,number

,obstruction ,other kidney , Parenchymal thickness ,hydronephrosis, anuria Vs retention .

2-X-ray :radio opaque stones 85% e.g. ca oxalate BUT not show radiolucent stones e.g. uric acid stones 3- IVU :show radiolucent stones+ site
detection .

2-Kidney function test: creatinine( N 0.7 1.5 )

better than urea which change according to degree of dehydration ,liver function & diet .

- 3- Urine culture . - 4- CBC: leukocytosis 5-Metabolic workup:esp. if recurrent, multiple

4-CT :now considered the BEST investigation

excellent details .

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TREATMENT :
According to site & size
Site : 1- Kidney 2-Ureter upper -middle -lower. 3-Bladder Size: Small <5mm Moderate 5mm -2cm Large >2cm.

A)Kidney: Small :medical ttt:

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) ( )+ medical TTT Large :surgery

percutaneous nephrolithotomy (less invasive than open surgery ) .

Open surgery ( very hard or very large stone )=pyelonephrolithotomy

B)Ureteric stones :
Upper segment Small Moderate Large Medical ttt ESWL Open surgery ( urertrolithotomy ) Middle segment Medical ttt Open surgery (recent uretroscopic removal) *ESWL not done (sacroiliac shadow obscure) Lower segment Medical ttt Ueretroscopic 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 hydronephrosis . GENERAL RULES: . *for conservative management (medical ttt) there is should be - small sized stones - NO back pressure effect ( hydronephrosis ). - NO 2ry infection . - NO distal obstruction .

back

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*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 intake crystal containing diet metabolic work up

Calcularanuria :surgical emergency

D.D. :retention - NO desire - empty bladder
IVU C.I. in this case Main aim of ttt 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. :Transitional 90:10). Currently, Sq. cell carc. Has decreased owing to improved health care (Ratio Sq. :Transitional 40:60). Global ratio Sq. :Transitional 1:9

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Pathogenesis: SCC
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

TCC
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.

Pathology:
Transitional CC Gross picture Microscopic picture
Villous papillary growth Less commonly cauliflower or ulcer

Squamous CC
Cauliflower or Ulcer

Transitional cells with cellular features of Cell nests with keratin whorls & malignancy malignant features Local spread: surrounding organs, lately, reach pelvic bone . Bladder L.N.: EARLY Blood: late Local spread: ureters, prostate, sem. Vesicle, uterus, rectum L.N. Late.Because of Blood lymph.&vasc.Obstruction by
Bilh.fibrosis

Spread

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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* Wallace system for staging is based on clinical DRE or bimanual
T1palpable, mobile, NO induration T2palpable, mobile + induration T3palpable, mobile + extravesical ext. T4Fixed

Investigations:
LAB Urine analysis - RBCs >100 - Necroturia - Malignant cells - Pus cells CBC: anemia Kidney Function Tests Coag. Profile & liver function tests to exclude coag. problem causing hematuria RADIOLOGICAL US: 1 to be done Advs. Accurate
st

Non-invasive IVP (IVU) - Delineate urinary tract - May show filling defect in bladder 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

INVASIVE Cystoscopy Guided BIOPSY; most important If villous growth superf. - Complete resection + part of musculosa - Send for pathology - Free margins??

TNM Staging(for transitional CC)

TIS Ta Flat lesion with No invasion (carcinoma in situ) Villous growth into bladder with mucosal involvement only T1 Submucosal invasion T2 Musculosa invasion asup. bdeep T3 Extravesical extension amicroscopicbmacro aprostate, uterus, vagina T4 Invasion of other organs bpelvic wall, abd. wall Squamous CC are ALWAYS TTTby radical cystectomy Early diagnosis is extremely important Follow up: once weekly for 6 wksthen do cystoscopy Superficial bladder cancer Muscle invading bladder cancer

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

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Urinary diversion 1-Ureterocutaneous implantation:
1stwas made e' 2 skin opening Disadvantage : - urine leakage ( Later e' 1 skin opening urinefrousodour&skin excoriation) Currently ileal conduit -Asc. infection Esp beneficial in uremic pt.--> absorption less than ureterocolic Adv. : no leakage

2- Ureterocolic anastomosis
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 till renal 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 -

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)

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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 :6th-7th decade Usually unilateral ,bilateral in only 2% Incidence is due to : Improved diagnostic modalities eg:CT Environmental : Smoking 4%FAMILIAL 96%SPORADIC

NB.

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 Depending on nuclear shape Has prognostic value 4 grades from low to high grades

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TNM staging (2002) T0 No evidence of malignant grow Txcan't be assessed T1 7 cm (0-4cm A )& (4-7cm B) T2 7 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)

N -

N2 (multi.)

regional (paracervical&paraaortic) Other N4

N3 (fixed)

MsNo evidence of metastasis Mx Can'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.clots ureteric - 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 - Erythropoietin polycythemia - 3-cancer cachexia - PTH Hyppercalcaemia - 4-Fever of unknown origin - renin hypertension Liver dysfunction (stauffer$)

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Investigations
LAB Urine analysis CBC polycythemia Kidney functions Liver functions Alk.phosphatase 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

Management
Surgical is the mainstay of ttt A) - radical nephrectomy (open or laparoscopic) b) - 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
ORIGIN: embryonic nephrogenic tissue INCIDENCE:10% OF
CHILDHOODMALIGNANCIES Age group: peak 3-4 yrs

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

MICROSCOPIC
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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CLINICALPRESENTATION:
- 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 Wilmstumour, 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: Urine analysis: Microhematuria(50%) CBC,liver&kidney function tests Urinary catecholamines are NORMAL (Vs neuroblastom) Radiological : 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

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

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 e.g. road traffic accident , fall from height and direct kick Penetrating: e.g. stabs and gun shots Iatrogenic: e.g. during renal biopsy or percutaneous nephrostomy

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 take precautions and dont 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 doesnt 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 ). CBC serial hematocrit persistant bleeding.

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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 urinary extravasation Indications: Children with any hematuria. Adult with gross hematuria or microscopic hematuria + shock Deceleration injury. Other radiological investigations : U/S : urinary collection ( urinoma ) , size and contour of kidney Plain x-ray : 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 5 : Shattered kidney or major vascular injury ,renal pedicle avulsion.

Treatment:
1) Resuscitation ( very important ) 2) 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 :

Immediate exploratory laparotomy

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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 irrepairable laceration , pedicle injury , severe bleeding

Complications of renal injury:

Urinary extravasation : ureteric stent + folleys catheter Peri-renal abscess : drainage Delayed retroperitoneal bleeding : AV fistula due to penetrating injury Hypertension : rennin mediated due to ext. compression ( page kidney ) Renal atrophy / fibrosis Hydronephrosis

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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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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Rupture urethra
Anterior & posterior urethra rupture Posterior urethra Fracture pelvis or instrumentation Complete: Torn puboprostatic ligament Displaced bladder & prostate Superficial perinealpouch"penis, Suprapubic, perivesicalspace"deep scrotum"superficial extravasation extravasation Perineal pain Pelvic pain Bleeding per urethra Retention & extravasation of urine Stricture urethra P/R: displaced prostate 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 Anterior urethra Trauma to peritoneum Complete orIncomplete

Etiology Types

Extravasation of urine Clinical picture

Treatment

Special Thanks To our dear colleague RAMY DOSS For his great effort in preparing this note

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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.

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 1st 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.

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.

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 1st 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.

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. 1st 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. b e c a d c d c e c c d d b a 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. a e e d d d a d b c e d c d a

Urology special notes NMT11