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Urology Back to Basics The “Nuts” and Bolts James Watterson, MD FRCSC Assistant Professor, University of Ottawa Director, Ottawa Lithotripsy and Stone.

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Presentation on theme: "Urology Back to Basics The “Nuts” and Bolts James Watterson, MD FRCSC Assistant Professor, University of Ottawa Director, Ottawa Lithotripsy and Stone."— Presentation transcript:

1 Urology Back to Basics The “Nuts” and Bolts James Watterson, MD FRCSC Assistant Professor, University of Ottawa Director, Ottawa Lithotripsy and Stone Program Endourology and Laparoscopic Urological Surgery Division of Urology, The Ottawa Hospital

2 References The Medical Council of Canada –www.mcc.cawww.mcc.ca –Objectives for the Qualifying Examination MCC Objectives.doc University of Toronto Notes Campbell’s Urology

3 Objectives The Medical Council of Canada –Abdominal Mass –Adrenal Mass –Blood in Urine (Hematuria) –Gynecomastia –Ambiguous Genitalia –Infertility –Incontinence, Urine –Incontinence, Urine, Pediatric (Enuresis) –Impotence, Erectile Dysfunction –Acute and Chronic Renal Failure (Post-renal / Obstruction) –Scrotal Mass / Scrotal Pain –Urinary Tract Injuries –Dysuria and / or Pyuria –Urinary Obstruction / Hesitancy / Prostatic Cancer

4 Objectives The Medical Council of Canada –Abdominal Mass –Adrenal Mass –Blood in Urine (Hematuria) –Gynecomastia –Ambiguous Genitalia –Infertility –Incontinence, Urine –Incontinence, Urine, Pediatric (Enuresis) –Impotence, Erectile Dysfunction –Acute and Chronic Renal Failure (Post-renal / Obstruction) –Scrotal Mass / Scrotal Pain –Urinary Tract Injuries –Dysuria and / or Pyuria (UTI) –Urinary Obstruction / Hesitancy / Prostatic Cancer

5 Blood in Urine (Hematuria) Key Objective (s): Differentiate red or brown urine from hematuria, transient from persistent, and glomerular from extraglomerular hematuria

6 Hematuria Objectives Through efficient, focused, data gathering Determine whether the patient has true hematuria Diagnose the presence of urinary tract infections Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Interpret reported urinalysis findings Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract Outline a plan for investigation of patients with recurrent nephrolithiasis Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis Discuss possible strategies for the detection and prevention of urinary tract tumors

7 Hematuria Objectives Through efficient, focused, data gathering Determine whether the patient has true hematuria Diagnose the presence of urinary tract infections Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Interpret reported urinalysis findings Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract Outline a plan for investigation of patients with recurrent nephrolithiasis Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis Discuss possible strategies for the detection and prevention of urinary tract tumors

8 Hematuria Considerations Pseudohematuria –Menses –Dyes (ie. Anthrocyanin in beets, rhodamine B in drinks, candy and juices) –Hemoglobinuria (hemolytic anemia) –Myoglobinuria (rhabdomyolysis) –Drugs (rifampin, phenazopyridine) –Porphyria (brownish urine) –Laxatives (phenolphthalein) 1.Urine dipstick – if positive, indicates hematuria, hemoglobinuria, or myoglobinuria 2.Microscopy distinguishes hematuria from Hgburia or Mgburia

9 Hematuria Objectives Through efficient, focused, data gathering Determine whether the patient has true hematuria Diagnose the presence of urinary tract infections Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Interpret reported urinalysis findings Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract Outline a plan for investigation of patients with recurrent nephrolithiasis Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis Discuss possible strategies for the detection and prevention of urinary tract tumors

10 UTI History & P/E –Irritative voiding symptoms (dysuria, freq, urg, suprapubic pain, hematuria) –Fever –Flank pain Inspection of urine – Turbid –May be secondary to excessive phosphates Urinalysis –Dipstick Leukocyte esterase Nitrites –Microscopic analysis False-negative (low numbers bacteria), false-positive (normal vaginal flora; NB squamous epithelial cells indicate contamination) > 2 WBCs/HPF correlates with presence of bacteriuria RBCs lack sensitivity (40-60% cases of cystitis) but highly specific Urine culture –mid-stream vs. catheterized specimen –Traditionally, > 10 5 cfu/mL In dysuric patients, 10 2 cfu/mL of a known pathogen significant Limited sensitivity

11 Hematuria Objectives Through efficient, focused, data gathering Determine whether the patient has true hematuria Diagnose the presence of urinary tract infections Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Interpret reported urinalysis findings Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract Outline a plan for investigation of patients with recurrent nephrolithiasis Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis Discuss possible strategies for the detection and prevention of urinary tract tumors

12 Hematuria MCC Causal Conditions Transient –Urinary tract infections –Exercise induced –Stones/Crystals –Trauma –Endometriosis –Thromboembolism –Anticoagulants (similar incidence of hematuria in non-anticoagulated patients) Persistent –Extraglomerular (Urological) Renal –Tumors –Tubulointerstitial diseases (e.g polycystic kidneys, pyelonephritis) –Vascular (e.g. papillary necrosis, sickle cell disease) Collecting system –Tumors –Stones Lower urinary tract –Glomerular Isolated (e.g. IgA nephropathy, thin membrane disease) Post-infections (e.g. post-streptococcal) Systemic involvement (e.g. vasculitis, SLE)

13 Figure 3-7 Evaluation of nonglomerular renal hematuria (circular erythrocytes, no erythrocyte casts, and proteinuria). CT, computed tomography; IgA, immunoglobulin A; IVU, intravenous urography; PT, prothrombin time; PTT, partial thromboplastin time; R/O, rule out.

14 Figure 3-6 Evaluation of glomerular hematuria (dysmorphic erythrocytes, erythrocyte casts, and proteinuria). ANA, antinuclear antibody; ASO, antistreptolysin O; Ig, immunoglobulin.

15 Hematuria Diagnostic Evaluation: Is it? 1.True or False 2.Extraglomerular vs. Glomerular 1.Dysmorphic RBCs 2.Casts (RBC, WBC) 3.Proteinuria (> mg/dL or 2+ to 3+ on dipstick) 3.Gross or Microscopic 1.> 3 RBC / HPF 4.Further Urological Questions 1.Location- Renal/Ureter/Bladder/ Prostate/Urethra 2.Painful/Painless 3.Part of Stream- Initial/Terminal/Throughout ??? 4.Clots – shape of clots

16 Investigations for Hematuria History and P/E –Smoking –Other risk factors for urothelial malignancy Urine –Urinalysis / Microscopy / C & S –Cytology Upper tract –Microscopic Renal U/S –Gross CT urogram Lower tract –cystoscopy

17 Hematuria DDx VINDICATE Renal/Ureter/Bladder/Prostate/Urethra –Neoplasm.. Neoplasm.. Neoplasm –Stone –Trauma –Infection

18 Hematuria Objectives Through efficient, focused, data gathering Determine whether the patient has true hematuria Diagnose the presence of urinary tract infections Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Interpret reported urinalysis findings Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract Outline a plan for investigation of patients with recurrent nephrolithiasis Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis Discuss possible strategies for the detection and prevention of urinary tract tumors

19 UTI Treatment Principles of Antimicrobial Therapy –Effective antimicrobial therapy must eliminate bacterial growth –Antimicrobial resistance is increasing because of excessive utilization –Antimicrobial selection should be influenced by efficacy, safety, cost and compliance Lower Tract UTI – cystitis; most occur in women; 10% incidence Bacteria – E.coli causative organism in 75 – 90% of acute cystitis in young women Drug choices –TMP-SMX DS BID 3 days –Nitrofurantoin 100mg BID 3 days –Norfloxacin 400mg BID 3 days –Ciprofloxacin 500mg BID 3 days

20 UTI Treatment Recurrent Lower Tract UTI in Women –Self-start Rx –Post-coital single dose –Low dose prophylaxis 3-6 months Upper Tract UTI (Acute Pyelonephritis) –E.coli accounts for 80% of cases –Blood cultures positive in 25% –Consider U/S or CT if failure to respond after 72 hrs of therapy –Rx Uncomplicated – Cipro 500mg BID PO, Levofloxacin 500mg QD PO x 7 – 10 days Complicated – Parenteral Cipro, Levo, Amp + Gent x 7 – 10 days

21 Hematuria Objectives Through efficient, focused, data gathering Determine whether the patient has true hematuria Diagnose the presence of urinary tract infections Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Interpret reported urinalysis findings Outline significance of patient’s age, gender and life style on diagnostic possibilities Conduct an effective plan of management for a patient with hematuria Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract Outline a plan for investigation of patients with recurrent nephrolithiasis Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis Discuss possible strategies for the detection and prevention of urinary tract tumors

22 Risk Factors for Stone Disease Diet, Diet, Diet –Dehydration –High protein intake –High salt intake –Certain foods high in oxalate Occupation –Dehydration Inflammatory Bowel Disease, Gout, Hyperparathyroidism Genetics –Rarely Recurrent nephrolithiasis –Refer to urologist or nephrologist –Metabolic evaluation Serum chemistry (Lytes, BUN, Cr, Ca, Urate, PTH) 24 hour urine (Lytes, Ca, Oxalate, Uric acid, citrate, Mg, cystine)

23 Dysuria and/or Pyuria Key Objective (s): Differentiate between urinary tract infections and conditions outside the urinary tract with similar presentation; determine which infections require treatment, and select the appropriate treatment. In patients with recurring urinary tract infections, determine whether a predisposing condition may be present (e.g., stasis from obstruction, reflux).

24 Dysuria and/or Pyuria Through efficient, focused, data gathering: –Interpret urinalysis and clinical findings in order to diagnose problems external to urinary tract. –Evaluate examination findings so that problems involving the urethra or prostate are identified. –Determine whether cystitis or pyelonephritis is the more likely diagnosis. List and interpret critical clinical and laboratory findings which were key in the processes of exclusion, differentiation, and diagnosis: –Outline significance of patient's age, gender, and life style on diagnostic possibilities. –Select findings which are best for differentiating cystitis from pyelonephritis. –Describe the collection of samples to be sent for culture and sensitivity; interpret results. Conduct an effective plan of management for a patient with urinary frequency, dysuria, and/or pyuria: –Determine which patients require additional investigation and/or referral. –Determine which patients require hospitalization. –Determine which patients should be on prophylactic treatment and the type of treatment. –Select the most appropriate treatment for the underlying condition. –List conditions which predispose to urinary tract infections. Outline strategies for prevention of recurrent urinary tract infections.

25 Dysuria and/or Pyuria Dysuria = painful urination –Usually caused by inflammation –Commonly referred to the urethral meatus –Start: may indicate urethral –End (stranguria): usually bladder origin –Usually accompanied by frequency and urgency Pyuria = presence of white blood cells (WBCs) in urine –Generally indicative of infection and an inflammatory response of the urothelium to the bacterium –Bacteriuria without pyuria is generally indicative of bacterial colonization without infection –Pyuria without bacteriuria warrants evaluation for TB, stones, or cancer

26 Dysuria and/or Pyuria DDx Dysuria / Freq / Urgency >> Vesical vs. Extravesical Extravesical –Urological Urethral diverticulum / CA Prostatitis Urethritis Lower ureteral stone –Gyne Vulvovaginitis Herpes Endometriosis Ovarian / Uterine / Cervical CA –Bowel Diverticulosis Fistula Crohn’s Colon CA Vesical Bacterial cystitis Bladder tumor / CIS Bladder stone TB cystitis Radiation cystitis Nonbacterial cystitis Cyclophosphamide / ASA / NSAID / Allopurinol

27 Dysuria and/or Pyuria Evaluation Dysuria / Freq / Urgency >> Vesical vs. Extravesical History –Age, Gender, Smoking History –LUTS –PMHx (Gyne, IBD, divertic), PSHx (pelvic), PGUHx (UTI, STD, Tumor, Stone, Hematuria) Physical examination –Suprapubic tenderness –Genital exam –Rectal exam (prostate, rectum) –Pelvic exam Investigations –Urine (U/A, C&S, cytology) –Ultrasound - pelvic –Cystoscopy

28 Urinary Obstruction / Hesitancy / Prostatic Cancer Key Objective (s): Determine whether a patient has an acute obstruction any time the complaint is complete anuria or unexplained renal insufficiency

29 Urinary Obstruction / Hesitancy / Prostatic Cancer Objective (s): Through efficient, focused, data gathering: Determine whether the obstruction is acute or chronic, duration, complete or partial, and unilateral or bilateral, and site. Ask whether pain is present, site of pain (e.g., suprapubic for bladder distention, flank for renal capsule), whether it is colicky and radiates to ipsilateral testicle or labia (renal or ureteral colic), or occurs after a fluid load that increases urine output (e.g., beer drinking). Examine for tenderness, hydronephrosis, hypertension, and palpable bladder. List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis: Select ultrasonography as the diagnostic imaging tool to diagnose obstruction. List indications for other types of diagnostic imaging. Select and interpret tests of renal function; outline indications for prostate cancer screening. Conduct an effective plan of management for a patient with urinary tract obstruction: Perform catheterization of the bladder for both therapeutic and diagnostic reasons. Select patients for referral to specialized care.

30 Definitions Uremia = clinical signs and symptoms seen as a result of renal failure Azotemia = elevation of blood urea (BUN) Obstructive Uropathy = reversible or irreversible renal dysfunction due to the effects of impaired urine drainage Hydronephrosis = dilation of the renal pelvis and calyces

31 Urinary Tract Obstruction Classification Supravesical vs. Infravesical Acute vs. Chronic Unilateral vs. Bilateral Anatomical site –Intrarenal –Ureter –Bladder –Prostate –Urethra Extraluminal (LN, mass) vs. Intraluminal (stone, blood clot, fungus ball) vs. Intramural (TCC, polyp)

32 Diagnosis Clinical features Flank pain/renal colic Urinary retention or overflow incontinence Anuria or oliguria Uremia Stones Recurrent UTI Asymptomatic

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34 Complete or partial obstruction Duration; >30 days of complete obstruction results in irreversible loss of renal function Unilateral or bilateral Presence of infection Pathophysiology Factors Influencing Severity of Renal Dysfunction

35 Urinary Tract Obstruction Major Sequelae Loss of renal function Urinary tract infection / sepsis Stones

36 Urinary Tract Obstruction Diagnosis Clinical features Laboratory investigations Imaging studies

37 Laboratory investigations –Elevated BUN and Cr with bilateral ureteral or bladder outlet obstruction –Abnormal urinary indices Urinary Tract Obstruction Diagnosis

38 Imaging studies –Renal ultrasound –Intravenous pyelogram (IVP) –CT Scan –Retrograde pyelogram –Lasix renogram Urinary Tract Obstruction Diagnosis

39 Hydronephrosis may not develop if acute obstruction or if presence of perinephric fibrosis

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42 Bypass the cause of obstruction Bladder outlet obstruction –Foley catheter Renal or ureteral obstruction –Ureteral stent –Nephrostomy tube Urinary Tract Obstruction Temporary Measures

43 Percutaneous Nephrostomy Ureteral Stenting

44 Urinary Tract Obstruction Definitive Treatment Remove the cause of obstruction BPH –Pharmacotherapy (alpha-blockers) –Surgical (TURP) Stone –ESWL, ureteroscopy, percutaneous stone removal

45 Prostate Cancer Most common solid tumor in U.S. males Second leading cause of male cancer deaths Lifetime risk 1/6 Lifetime risk of a 50 year old: 50%, risk of dying 3% Risk factors –Family history: 1 st degree relative (2x) –blacks –High dietary fat Histologic Incidence rates –10-30% > 50 –50% > 80

46 Presentation Asymptomatic –(75%)  PSA –abN DRE Locally Advanced –LUTS (uncommon without met) –Hematuria –Hematospermia –Renal failure Metastatic Disease –Bony pain (osteoblastic) –Renal failure DDx Prostatic Nodule Prostate Cancer (30%) BPH Prostatits Prostatic Infarct Prostatic Calculus Tuberculous Prostatitis

47 PSA Enzyme produced by epithelial cells of prostate gland to liquify the ejaculate Elevated in: –Prostate cancer –Prostatitis –BPH –Trauma catheterization –Ejaculation

48 Screening DRE –Hypothenar eminence = benign PSA –CCFP - not recommended –US FP + Urologist – recommended –“normal” < 4 but 30% have PCa Age 50 unless 1 st degree relative or black male >>>40-45 yrs Screen between ages 50-70/75 years

49 Screening >10 15%25%50% 20%45%>75% PSA (NG/ML) DRE N AbN Probability of Finding Cancer on Biopsy According to a Man’s DRE Result and PSA Level

50 If abN DRE +/  PSA.. AND > 10 YR LIFE EXPECTANCY… TRUS + BIOPSY

51 Scrotal Mass Key Objective (s): Differentiate testicular tumor from a mass of inguinal origin (not possible to get above it, may reduce), cystic lesion (trans-illuminates), and a varicocele (easier to palpate with patient erect)

52 Scrotal Mass Objective (s): Through efficient, focused, data gathering: In boys, ask about pain, trauma, change in scrotal size, difficulty voiding Elicit history of undescended testicle, infertility, previous testicular tumor, and breast enlargement / tenderness Differentiate from condition that presents primarily with pain Perform abdominal exam including inguinal areas, and an examination of the male genitalia (erect and supine, testes, epididymis, cord, scrotal skin) including rectal examination to assess the prostate and seminal vesicles, transilluminate List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis: Select patients requiring ultrasound, CT and explain reason; order beta human chorionic gonadotrophin and alpha-fetoprotein Conduct an effective plan of management for a patient with scrotal mass: Outline management options for masses which are not testicular tumors.

53 Approach to Scrotal Masses Painful vs. painless Benign vs. malignant Etiology varies with age of patient –DDX differs between adults and children >>>Anatomical Approach

54 Anatomy Scrotal Contents: –Testes Tunica albuginea Tunica vaginalis –Epididymis –Spermatic Cord: Vas deferens Arteries: –Testicular –Cremasteric –Artery to the Vas Veins: –Pampiniform plexus Nerves: –Ilioinguinal –Genital br. Of Genitofemoral –Sympathetics

55 History Age of patient HPI –Onset (acute, insidious) –Painful vs. painless –Radiation –Aggravating Factors –Relieving Factors –LUTS PMHx PSHx Risk Factors –Recent trauma –Infection –Instrumentation of the urinary tract –Congenital anomalies –Prior history of neoplasm

56 Physical Examination Vital Signs –Temp Skin Abdominal exam Inguinal –Hernia (may reduce, unable to get above) –Lymph Nodes –Masses Penis – malignancy Scrotum –Skin –Testes: 3.5 cm Mass –Hydrocele Transillumination –Varicocele Valsalva DRE

57 Differential Diagnosis Painful –Trauma Contusion, rupture –Epididymo-orchitis –Hernia Incarcerated, strangulated –Torsion Testes Appendages Painless –Tumor Intratesticular Paratesticular –Varicocele –Hydrocele –Spermatocele –Scrotal wall malignancies SCC, sarcomas

58 Testicular Torsion Intravaginal (all age groups, puberty) Extravaginal (prenatal, neonatal) Hx: –Acute Painful scrotum –N & V –Rx to groin / abdomen –None or minimal trauma Px: –Patient appears unwell –Tender, swollen testicle –High riding, transverse lie –Scrotal erythema –No cremasteric reflex

59 Testicular Torsion If suspected clinically, surgical exploration indicated –Orchidectomy –Orchidopexy of contralateral side INV: –Transcrotal Ultrasound Duplex Doppler –Nuclear testicular blood flow scan

60 Torsion of Appendix Testis / Epididymis Appendix Testis: 2-3 mm embryol. remnant near upper pole of testis may twist on stalk --> pain O/E: local tenderness, blue dot sign

61 Epididymitis / Orchitis Hx: –More insidious onset –Fever –Recent instrumentation –Sexual activity –LUTS Px: –Painful epididymis +/- testis –Testis in normal position –Urethral discharge –+ Prehn’s sign INV: –CBC –U/A, C&S, Urethral Swab for GC / Chlamydia –TB >>May Resemble Torsion!

62 Epididymitis / Orchitis Causative –<35 years: N.gonorrhea, C.trachomatis, E.coli –>35 years: E.coli –Homosexual: E.coli –Mumps orchitis: 30% of patients with mumps Risk of infertility Rx: –Antibiotics –Bed rest –Analgesics / Anti- inflammatories –Scrotal elevation Specific Recommendations: –GC: ceftriaxone 250 mg IM Cipro 500 mg PO –NonGC: Azithromycin 1 g PO Doxycycline 100 mg BID x 7 days –E.coli: IV antibiotics if severe Fluoroquinolone x days

63 Hydrocele A collection of serous fluid in some part of the processus vaginalis, usually in the tunica More common in childhood 1% of adult males Congenital: –Processus vaginalis does not close after testicular descent Acquired: –Primary (idiopathic) vs. secondary to disease of the testis –Defective absorption, increased production, lymphatic obstruction

64 Hydrocele Hx: –Painless (unless large) –Change during day (suggests communication) –Other symptoms (secondary hydrocele) Px: –Transilluminates –Palpate testes –Hernia ? INV: –Transcrotal ultrasound if testis not palpable

65 Hydrocele Rx: –Adults: Symptomatic Cosmesis Underlying testicular pathology –Children: Most will resolve in 1 st year If persists, repair of hernia may be indicated Specifics: –Surgical –Aspiration –Sclerotherapy

66 Spermatocele Painless mass Contains fluid and spermatozoa 4 th / 5 th decades Region of caput Usually can palpate the testis separately from spermatocele Obstruction of efferent duct Mass may transilluminate

67 Spermatocele Rx: Conservative Spermatocelectomy Surgery may have negative consequences >>> delay if reproductive age

68 Varicocele Dilation of the veins of the pampiniform plexus of the spermatic cord due to absent competent venous valves in the spermatic vein 15% of males, 30% of subfertile males (multiple theories) –Elevated intratesticular temperature widely accepted Most Left-sided; May be bilateral; Right-sided only>> be suspicious! Rare prior to puberty

69 Varicocele Hx: –Painless vs. dull ache; pain never present on awakening –Discomfort increases with standing / activity over long period of time –Exaggerated with Valsalva –Infertility Px: –“ Bag of Worms”, “vascular thrill” –Gr.I: Palpable with valsalva –Gr.II: Palpable without Valsalva –Gr.III: Visible –Abdominal mass Scrotal Ultrasound

70 Varicocele Rx: –Sx’s –Cosmesis –Infertility –Ipsilateral testicular atrophy Surgical options: –Retroperitoneal –Inguinal –Subinguinal –Laparoscopic –Transvenous embolization

71 Testicular Tumors Testis CA most common malignancy in males 15 to 35 years Incidence: 3.7 / 100,000 (whites), 0.9 / 100,000 (blacks) R>L, 2-3% bilateral Risk factors: –Age ( 60) –Race –Cryptorchidism –Atrophy

72 Testicular Tumors Germ Cell tumors –Seminoma –Non-Seminomatous Embryonal carcinoma Choriocarcinoma Yolk Sac tumor Teratoma Mixed Gonadal Stromal –Leydig-cell –Sertoli-cell –Gonadoblastoma Paratesticular Secondary –RES Leukemia Lymphoma –Metastases

73 Testicular Tumors Hx: –Painless intratesticular mass (pain if hemorrhage) –May present with metastatic disease (SOB, cough, hemoptysis, abdominal bloating, GI complaints, lower limb edema) Px: –Chest (pleural effusion, wheezing, gynecomastia) –Abdominal exam (mass) –Genital exam –Nodal exam (inguinal, supraclavicular)

74 Testicular Tumors INV: –Scrotal U/S –CXR –Tumor markers BHCG AFP LDH –CT Chest / Abdo / Pelvis Rx: –Radical orchiectomy

75 Testicular Tumors Rx: –Dependent upon: Clinical stage Pathological stage Histology –Options: Surveillance XRT RPLND Chemotherapy

76 Urinary Tract Injuries Key Objective (s): Suspect trauma to bladder or posterior urethra in patients with pelvic fracture Examine for bleeding at the external urethral meatus after trauma; urethral injury necessitating urgent ascending urethrogram may be present.

77 Urinary Tract Injuries Objective (s): Through efficient, focused, data gathering: Elicit history about the nature of the injury, difficulty voiding, and blood in urine or at meatus; differentiate straddle injury from sexual abuse (straddle injuries typically are unilateral and superficial and involve the anterior portion of the genitalia in both boys and girls Examine for swelling, bruising, in males’ displacement of prostate on rectal List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis: List the most appropriate investigations used to determine the nature and severity of urinary tract injuries (e.g. retrograde urethrogram for urethral injury, CT scan for renal injury) Conduct an effective plan of management for a patient with urinary tract obstruction: Outline initial management of anterior urethral injury (e.g. 7 to 10 days of urethral catheterization and antibiotic therapy)

78 GU Trauma Accounts for 10% of ER trauma visits Associated with multi-system trauma Subtle presentations, easily overlooked Diseased GU organs susceptible to injury

79 Trauma Evaluation Airway with C-spine control Breathing Circulation (2 large bore IVs) Disability (brief neurologic exam) Expose (general survey)

80 Renal Trauma Most commonly injured organ GU tract Often in association with multi-system organ injury Blunt 80% Penetrating <20%

81 Renal Trauma

82 Renal Trauma Presentation Hematuria (gross or microscopic) –May be absent Shock (hypotension, tachycardia, oliguria) Flank mass Flank pain/tenderness

83 Imaging Need both anatomic and functional information CT Scan (with contrast) – gold standard IVP Angiography

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85 Indications for Imaging in Scenario of Possible Renal Injury Penetrating injuries Blunt injuries in association with –Gross hematuria –Shock (SBP<90 systolic) –Children regardless of degree of hematuria

86 Renal Trauma - Classification AAST Renal Injury Grading Scale

87 Renal Trauma Management ABCs Conservative for 85% of blunt trauma –Admission, bedrest, serial vital signs, CBC Indications for surgical exploration –Hemodynamic instability –Penetrating injuries –Extensive urine extravasation –“Shattered kidney” –Pedicle injury

88 Bladder Trauma

89 Classified by site –Contusion Hematuria and normal cystogram –Intraperitoneal rupture 30% –Extraperitoneal rupture 60% –Combined 10% –Concommitant urethral injury 10%

90 Bladder Trauma Clinical presentation –Extra 2X > Intraperitoneal ruptures –Suprapubic pain and tenderness –Inability to void –Pelvic fracture + gross hematuria 98% of bladder injuries have gross hematuria Mortality 20%, d/t associated injuries

91 Bladder Trauma Cystogram: Study of choice! –300 cc of contrast –3 films: plain, full (300cc), drainage (+/- oblique) IVP: –Poor; may demonstrate only 15% of bladder ruptures CT: –Bladder filled with 300cc contrast prior to CT –Difficult to assess bladder neck competence The severity of bladder injury cannot be determined by the amount of extravasation seen on any Xray study

92 Bladder Trauma - Management Extraperitoneal –Foley catheter x days –Selective Exploration and Repair Bladder neck, prostatic urethra Laparotomy Hemorrhage / clots Urethral catheter cannot be placed Penetrating –Open repair to rule out BN injury

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94 Bladder Trauma - Management Intraperitoneal –Open surgical repair Lower midline incision Avoid dissection in perivesical areas Vertical anterior cystotomy to assess bladder neck Debridement Closure in 2 layers: water-tight Suprapubic catheter Drain –Postop Antibiotics Foley x days Cystogram before catheter removal

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96 Urethral Trauma

97 Proper management crucial Majority caused by blunt injury 5% of pelvic fractures have associated posterior urethral injury 90% of posterior urethral injuries have associated pelvic fractures 10-29% of prostatomembranous urethral ruptures have bladder injury

98 Urethral Trauma Common mechanisms –Pelvic crush – membranous urethra disruption –Straddle injury – bulbous urethra –Penile fracture – pendulous urethra –Iatrogenic – false passages Classification –Anterior: pendulous, bulbous urethra –Posterior: membranous, prostatic urethra

99 Urethral Trauma Haematuria Inability to void or difficulty with voiding Blood at urethral meatus –Sensitivity % Perineal ecchymosis (classically in a “butterfly” pattern) Full bladder High riding prostate on DRE (posterior), bony fragments Pelvic fracture: esp. rami #’s

100 Urethral Trauma - Diagnosis Retrograde urethrogram: Gold standard –Oblique position –Sterile technique –Slight penile stretch –8F foley in fossa navicularis, 2cc in balloon –10-20 cc slow continuous injection –Fluoroscopy preferred –Peri-catheter if foley previously placed

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102 Posterior Urethral Injury Presentation Pelvic # Blood at the urethral meatus “High riding” prostate Scrotal swelling/ecchymosis Inability to void If potential for urethral injury exists, do not insert urethral catheter

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105 Urethral Trauma - Management Goal: control urinary drainage and minimize long-term complications Anterior: –Primary repair: penetrating injury, penile fracture –Suprapubic cystotomy: complete, blunt –Urethral catheter: partial, blunt

106 Urethral Trauma - Management Posterior: Open SPT + Delayed primary repair 3 – 6 months Primary catheter realignment –Open vs.Endoscopic –BN laceration: intrinsic sphincter mechanism crucial for continence after membranous urethra disruption (site of external sphincteric mechanism) –Rectal laceration: pelvic abscess or fistula –Long separation of prostate and bulbous urethra: difficult delayed repair

107 Impotence / Erectile Dysfunction Key Objective (s): Recognize that a psychogenic component is present in all cases. Recognize that testosterone deficiency is an uncommon cause of erectile dysfunction.

108 Impotence / Erectile Dysfunction Objective (s): Through efficient, focused, data gathering: Determine if an organic cause for impotence is likely by a medical, sexual, and social history. Exclude decreased libido, ejaculatory disorders, performance anxiety, and depression. Identify reveersible causes (recent medications – antihypertensives, antidepressants, etc) Examine for signs of vascular disease and diabetic complications (BP postural change, ankle-brachial index, pulses); examine for gynecomastia, lack of male hair distribution, small testes. List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis: Order screening tests for unrecognized systemic disease (e.g. diabetes) If hormonal cause is likely, order testosterone, LH, prolactin.

109 Impotence / Erectile Dysfunction Objective (s): Conduct an effective plan of management for a patient with urinary tract obstruction: Treat associated medical conditions; suggest lifestyle changes (smoking cessation, exercise, weight loss, diet, stress reduction) Determine therapy for impotence based on the underlying cause (e.g. if testosterone is low and LH is high, consider testosterone therapy / exclude prostate; if prolactin high, pituitary imaging/referral). Outline the effectiveness of inhibitors of phosphodiesterase type V and contraindications. Describe the role of injectable, transurethral, and vacuum devices. Select patients in need of specialized care (e.g., failed medical therapy, penile anatomic disease, pelvic/perineal trauma, vascular/neurologic assessment, endocrinopathies, psychiatric, etc.). Counsel and educate patient (+/- partner). Determine the therapy for impotence based on the underlying cause. Describe the role of specific injectable and oral medications in patients with erectile dysfunction.

110 Impotence / Erectile Dysfunction KEY POINTS: PENILE COMPONENTS AND THEIR FUNCTION DURING ERECTION Corpora cavernosa Support corpus spongiosum and glans Tunica albuginea (of corpora cavernosa) Contains and protects erectile tissue Promotes rigidity of the corpora cavernosa Participates in veno-occlusive mechanism Smooth muscle Regulates blood flow into and out of the sinusoids Ischiocavernosus muscle Pumps blood distally to hasten erection Provides additional penile rigidity during rigid erection phase Bulbocavernosus muscle Compresses the bulb to help expel semen Corpus spongiosum Pressurizes and constricts the urethra lumen to allow forceful expulsion of semen Glans Acts as a cushion to lessen the impact of the penis on female organs Provides sensory input to facilitate erection and enhance pleasure Facilitates intromission because of its cone shape

111 Impotence / Erectile Dysfunction Normal Erection –Innervation: Autonomic (SNS, PNS): cavernous nerves Somatic (sensory, motor): sensation, contraction of bulbocavernosus/ischiocavernous muscles –Nitric oxide (NO) released from nonadrenergic, noncholinergic neurotransmission and from the endothelium 1) Relaxation of smooth muscles 2) Dilation of the arterioles and arteries, increasing blood flow 3) Trapping of the incoming blood by the expanding sinusoids 4) Stretching of the tunica to its capacity, which occludes the emissary veins between the inncer circular and outer longitudinal layers and further decreases venous outflow to a minimum 5) increase in intracavernous pressure (100 mm Hg) leading to full erection “P(arasymp) to Point, S(ymp) to Shoot”

112 Erection: A Neurovascular Event

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119 Impotence / Erectile Dysfunction Erectile Dysfunction –Inability to achieve or maintain an erection sufficient for satisfactory sexual relations –Organic (90%) vs. Psychgenic Vascular Disease (70%) Medications (10%) Surgical (10%) Neurologic (5%) Endocrine (3%) Trauma (2%)

120 Erectile Dysfunction Evaluation

121 Erectile Dysfunction Evaluation – IIEF 15

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138 Erectile Dysfunction Treatment

139 Penile Disorders Tx: –Oral (phosphodiasterase type-5 inhibitors) –Penile Injection (PGE2, papavarine, phentolamine) –Intraurethral pellet (MUSE): PGE2 –Vacuum Erection Device –Penile implant

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148 Erectile Dysfunction Treatment

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155 Incontinence, Urine Key Objective (s): Contrast between the two most common causes of incontinence, stress incontinence and urgency incontinence.

156 Incontinence, Urine Objectives Through efficient, focused, data gathering Determine duration, characteristics, frequency, timing, and amount; elicit other lower urinary tract symptoms, precipitants, fluid intake patterns, changes in bowel habits or sexual function. Differentiate between stress (small amounts of leakage with exertion), urgency (involuntary associated with urge to urinate), reflex (associated neurologic deficit), and overflow incontinence (associated with urinary retention) Perform an abdominal exam, a pelvic exam, and rectal exam for prostate size List and interpret critical clinical and laboratory findings which are key in the processes of exclusion, differentiation, and diagnosis Perform urinalysis, estimate post-void residual urine. Select patients in need of cystoscopy and other specialized tests. Conduct an effective plan of management for a patient with hematuria Outline a plan of management for cystitis and urethritis. Counsel patients with stress incontinence about possible pelvic muscle exercises. For urge incontinence, discuss trial of anticholinergic medication (e.g. oxybutynin, tolterodine) Select patients for referral (e.g. neurologic conditions, genital prolapse, abnormal post-void)

157 Lower Urinary Tract Group of inter-related structures –>> efficient and low pressure bladder filling –>> low pressure urine storage with perfect continence –>> periodic voluntary urine expulsion at low pressure Functional, physiologic, and pharmacologic considerations Many different classifications –>> will present a functional and practical approach

158 Normal Lower Urinary Tract Function 2 phase concept of function Filling / Storage Emptying

159 Normal Lower Urinary Tract Function Bladder Filling / Storage –Accomodation of increasing volumes of urine at low pressures with appropriate sensation –Bladder outlet that is closed at rest and remains so during increases in intra-abdominal pressure –Absence of involuntary bladder contractions

160 Normal Lower Urinary Tract Function Bladder Emptying –Coordinated contraction of bladder smooth musculature of adequate magnitude –Lowering of resistance at the level of the smooth and striated sphincter –Absence of anatomic (as opposed to functional) obstruction

161 Voiding Dysfunction Any type of voiding dysfunction must result from an abnormality of one or more of the previous factors The Functional classification –Failure to Store Because of the bladder Because of the outlet –Failure to Empty Because of the bladder Because of the outlet

162 The Functional Classification Because of the Bladder –Detrusor Hyperactivity Suprasacral neurologic dz BOO Idiopathic Inflammation Aging –Decreased Compliance Neurologic dz (denervation) Fibrosis / inflammation Idiopathic BOO –Detrusor Hypersensitivity Neurologic Infectious Inflammation (I.C.) Psychologic Idiopathic Because of the Outlet –Stress Incontinence (Hypermobility) –Nonfunctional bladder neck/proximal urethra (ISD) Neurologic Trauma Surgery Obstetrical/Gynecologic Aging Failure to Store

163 The Functional Classification Because of the Bladder –Neurologic (sacral / peripheral nerves, pain, Herpes, DM, Tabes Dorsalis, pelvic surgery) –Myogenic (overdistention, infection, meds, fibrosis) –Psychogenic –Idiopathic –Pharmacologic Because of the Outlet –Anatomic Prostatic obstruction Bladder neck contracture Urethral stricture Urethral Compression –Functional Smooth Sphincter Dyssynergia (SCI above T6) Striated Sphincter Dyssynergia Failure to Empty

164 Evaluation of Voiding Dysfunction History Physical Urinalysis Urodynamics Radiography Cystoscopy Videourodynamics

165 Evaluation of Voiding Dysfunction History –Urologic Lower urinary tract symptoms –Storage vs. Emptying symptoms –Irritative, obstructive, pain, hematuria, incontinence (stress, urge, unconscious, continuous) –Ob/Gyn –Neurologic –Medical / Surgical –Social / Psychologic –Radiation –Pelvic Trauma

166 Evaluation of Voiding Dysfunction Incontinence History –“involuntary loss of urine” Symptom – statement of involuntary loss Sign – objective demonstration of urine loss Condition – pathophysiology underlying incontinence –Characterization of incontinence Stress – loss during coughing, sneezing, physical exertion Urge – sudden, strong urge to void Unconscious – unaccompanied by stress or urge Continuous Overflow –Length and severity of symptoms –Impact on quality of life –Associated bowel problems

167 Evaluation of Voiding Dysfunction Physical Exam –Systemic vaginal and pelvic exam Condition of mucosa Urethral hypermobility Demonstration of incontinence / SUI Vaginal prolapse –Use of bottom half of small speculum –Bimanual exam –Standing position in females with SUI / prolapse –Neurologic exam Mental status Mobility Lumbar and sacral sensory and motor –BC reflex, anal wink, knee and ankle DTR’s, perineal / perianal sensation

168 Evaluation of Voiding Dysfunction Simple Ancillary Tests –Voiding and intake diary Time, input, output, types of beverages –Incontinence Diary Stress, urge –U/A – rule out hematuria, UTI –C & S, cytology when indicated –Post void residual –Pad Test Endoscopy –Not recommended as a routine in the evaluation of incontinence –May be useful when clinically indicated Hematuria Refractory incontinence Anatomic abnormalities Prior surgery Etc.

169 Transient vs. Established Incontinence Delirium Infection Atrophic urethritis/ vaginitis Pharmaceuticals Psychological Endocrine Restricted mobility Stool Impaction

170 Transient vs. Established Incontinence Delirium Infection Atrophic urethritis/ vaginitis Pharmaceuticals Psychological Endocrine Restricted mobility Stool Impaction

171 Treatment of Voiding Dysfunction


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