UROLOGY
Dr. soad Abdeltwab
• At the end of lecture all student should be able to:
• Explain common urological disorders.
• Discriminate different signs and symptoms for urological
disorders.
• Describe treatment measures and surgical management
for urological disorders.
Symptoms and signs in urology
Symptoms
Pain
• . In the renal angle (between the lower border of the
Kidney pain12th rib and the spine).
• . Between the renal angle and the groin. Ureteric pain
• . In the suprapubic region. Bladder pain
• . In the perineum, but may radiate along the urethra to
Prostatic pain
At the tip of the penis.
• May be related to function, e.g. suprapubic pain
exacerbated by bladder filing
Symptoms and signs in urology
cont’
• Haematuria (macroscopic)
• Frequently a sinister symptom of malignant disease,
especially the bladder when it is normally painless.
• When associated with painful voiding, it is usually due to
bladder infection or stones
Lower urinary tract symptoms
• Includes symptoms related to both voiding and storage.
• Voiding symptoms. Poor urine flow, hesitancy, post-
micturition dribbling.
• Storage symptoms. Frequency, nocturia, urgency, urge
incontinence.
• International prostate symptom score (IPSS) is a validated
• questionnaire to estimate the patient’s perception of
severity of symptoms.
Urinary incontinence
Affects women more commonly than men.
• Stress incontinence. Urine leakage that occurs at times of
increased, intravesical pressure, e.g. during coughing,
sneezing, lifting.
• Results from incompetence of urethral sphincter and
bladder neck mechanism; usually related to pregnancy and
childbirth.
Urge incontinence. Urine leakage that occurs in
association with a strong desire to void.
• Urine leaks from the bladder before the patient is able to
reach a toilet.
• Usual cause is overactivity of the detrusor muscle.
• May be idiopathic or secondary to other bladder disease.
• Stress and urge incontinence frequently coexist
Insensible urine leakage
•. Occurs without any associated symptoms.
• Urine leaks from the bladder continuously and the patient
is sometimes unaware.
Urinary tract stones
Key facts
• Prevalence of stones in the population is around 3%; ♂ >
♀.
• The commonest reason for emergency urological
admissions.
• Peak presentation in the summer months.
• Most common age of presentation of urinary calculi is 20–
50y.
• Ninety per cent of urinary calculi are radio-opaque.
Aetiology
• Metabolic. Hyperparathyroidism, idiopathic hypercalciuria,
disseminated malignancy, sarcoidosis, hypervitaminosis D.
• Familial metabolic causes. Cystinuria, errors of purine
metabolism,
hyperoxaluria, hyperuricuria, xanthinuria.
• Infection.
• Impaired urinary drainage, e.g. medullary sponge kidney,
pelviureteric
junction (PUJ) obstruction, ureteric stricture, extrinsic
obstruction
Pathological features
Calcium stones
• Seventy-five percent of all urinary calculi.
• Usually combined with oxalate or phosphate, are sharp,
and may cause symptoms, even when small.
Triple phosphate stones (‘struvite stones’)
• Compounds of magnesium, ammonium, and calcium
phosphate.
• Fifteen percent of all calculi.
• Commonly occur against a background of chronic urinary
infection and may grow rapidly.
Pathological features
Uric acid stones
• As a consequence of high levels of uric acid in
the urine.
• Five per cent of all urinary stones; radiolucent
Cystine stones
• Relatively rare; 1–2% of all cases.
• Difficult to treat due to extremely hard
consistency.
Clinical features
• ‘Ureteric/renal colic’. Severe, intermittent, stabbing pain
radiating from loin to groin.
• Microscopic or, rarely, frank haematuria.
• Systemic symptoms such as nausea, vomiting,
tachycardia, pyrexia.
• Loin or renal angle tenderness due to infection or
inflammation.
• Iliac fossa tenderness if the calculus has passed into the
distal ureter
Investigations
• Basic tests.
• Raised WC and CRP suggest superadded infection;
raised Cr suggests renal impairment.
• plain abdominal X-ray (‘kidneys/ureters/
bladder’ (KUB)).
• Serum calcium, phosphate, and uric acid.
• 24h urine for calcium, phosphate, oxalate, urate, cystine
• Non-contrast CT is the gold standard for locating stones
and assessing evidence of complications.
• IVU will locate stones and show any proximal obstruction.
• Renal ultrasound scan for hydronephrosis
Treatment
Acute presentations (renal colic, ureteric obstruction)
• Analgesia, e.g. diclofenac; antiemetic, e.g.
metoclopramide ; IV fluids.
• Small stones (<0.5cm) may be managed expectantly as
most will pass
spontaneously.
• Emergency treatment with percutaneous nephrostomy
and/or ureteric stent insertion is necessary if either pain or
obstruction is persistent.
Treatment
Elective presentations
• Extracorporeal shock wave lithotripsy (ESWL).
Focused, externally generated electrohydraulic or ultrasonic
shock waves.
• Targeted onto the calculus using ultrasound, X-ray, or a
combination.
• Causes stone disintegration and the fragments are then voided.
Treatment
• Percutaneous nephrolithotomy (PCNL).
• Endoscopic treatment.
1. • Ureteroscope is inserted and the stone visualized.
2. • Stone is fragmented using ultrasound, electrohydraulic
intracorporeal lithotripsy, or laser.
• Open nephrolithotomy/ureterolithotomy. For large calculi
or complex stones, e.g. above ureteric stricture.
Prevention of recurrence
• Increase oral fluid intake and reduce calcium intake.
• Correct metabolic abnormalities.
• Treat infection promptly.
• Urinary alkalization, e.g. sodium bicarbonate 5–10g/24h
PO in water (mainly for cystine and urate stones).
Obstruction of the ureter
• Key facts
• Ureteric obstruction leads to hydronephrosis (ureteric and
pelvicalyceal dilatation).
• Pathological features Hydronephrosis can be unilateral or
bilateral.
Clinical features
• Loin pain.
• Fever
• Symptoms and signs of renal failure (if obstruction
longstanding).
Investigation and diagnosis
• Serum biochemistry and haematology.
• KUB X-ray/IVU.
• Ultrasound scan and/or CT scan.
• Isotope renogram.
• Retrograde pyelogram.
Complications
• Infection.
• Hypertension.
• Rénal failure.
Treatment
• Treatment is drainage of the kidney via a percutaneous
nephrostomy or retrograde ureteric stent.
Benign prostatic hyperplasia
Key facts
• Benign prostatic hyperplasia (BPH) is a non-malignant
enlargement of the prostate gland. There is an increase in
both stromal and glandular components.
• Incidence of BPH is about 25% in age 40–60y, 40% in
over 60s.
• Commonest cause of lower urinary tract symptoms
(LUTS) in middle-aged and elderly men.
Pathological features
Aetiology is largely unknown.
Symptoms
• Storage symptoms, such as frequency, urgency, nocturia,
and incontinence.
• Voiding symptoms, including hesitancy, poor stream,
intermittency,
terminal dribble, and abdominal straining.
• infection may cause dysuria and haematuria.
• Possible palpable bladder if chronic retention.
Complications of BPH
• LUTS.
• Haematuria.
• UTI.
• Stone formation.
• Acute retention of urine.
• Chronic retention of urine.
• incontinence.
• Obstructive renal failure.
Diagnosis and investigations
• Prostate symptom score to assess severity.
• Digital rectal examination and assess for malignancy.
Basic investigations
• Serum creatinine, urinalysis in all patients.
• Urine flowmetry and residual volume estimation in those
considered for intervention
Advanced investigations
• Cystoscopy. To exclude bladder disease.
• Transrectal ultrasound and guided biopsy. If concern over
underlying malignancy.
• Renal ultrasound
Surgical treatment
• Reserved for those with any of the complications or
symptoms not responding to medical therapy.
• Surgical options include:
• Transurethral resection of the prostate (TURP), the most
commonly performed procedure for BPH.
• Open retropubic prostatectomy.
• Transurethral incision in the prostate (TUIP).
• Bladder neck incision.
• Laser ‘prostatectomy’.
• Microwave thermotherapy ablation of the prostate.
Adenocarcinoma of the kidney
Key facts
• Accounts for 2% of all cancers.
• Incidence is 2–5 per 100 population.
• ♂:♀, 3:1.
Clinical features
• May be asymptomatic
• Symptoms include painless haematuria, groin pain,
awareness of a mass arising from the flank.
• Chest symptoms and bone pain may be present with
metastases to these sites.
• Positive family history
Treatment
• Surgical management
• Medical therapy
• Used for metastatic disease e.g. Biological therapy
Transitional cell tumours
Key facts
• Transitional cell tumours (TCT) may affect any part of the
urinary epithelium (renal pelvis, ureter, bladder, or very
rarely, urethra).
• progression may occur from benign to more malignant
forms with time.
Clinical features
• The majority of cases present with painless haematuria.
• Other features are painful micturition, renal colic due to
blood clot, disturbance of urinary stream, retention of urine
Diagnosis and investigation
Urine cytology May reveal malignant cells; if there are
malignant cells, TCC or carcinoma in situ will probably be
present.
Cystoscopy
• Usually carried out using a fibre optic flexible cystoscope
and local anaesthetic gel.
• Images the bladder and urethra; suspect lesions usually
require transurethral resection under GA for diagnosis
Transurethral resection
Upper tract imaging
Treatment
Superficial TCT
• Remove; completed by endoscopic resection.
Carcinoma in situ
• Immunotherapy with intravesical BCG is effective in 60% of
cases.
• Needs close endoscopic surveillance with regular bladder biopsy.
Invasive TCC
• Muscle-invasive tumours
• radical cystectomy (combined
with a urinary diversion via an ileal conduit) or radical radiotherapy.
Squamous cell and adenocarcinoma
• Radical cystectomy.
• Usually resistant to radiotherapy and chemotherapy
Thank you
