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Chapter 10
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Urology
Symptoms and signs in urology 354
Investigations of urinary tract disease 356
Urinary tract stones 358
Obstruction of the ureter 360
Benign prostatic hyperplasia 362
Stricture of the urethra 364
Scrotal swellings 366
Disorders of the foreskin 368
Common conditions of the penis 370
Erectile dysfunction 372
Adenocarcinoma of the kidney 374
Transitional cell tumours 376
Adenocarcinoma of the prostate 378
Carcinoma of the penis 380
Testicular tumours 382
Haematuria 384
Acute urinary retention (AUR) 386
Acute testicular pain 388
353
CHAPTER 10 Urology
354
Symptoms and signs in urology
Symptoms
Pain
• May be located over the site of pathology, e.g. testes.
• May radiate in accordance with innervation of the structure involved.
Kidney pain• . In the renal angle (between the lower border of the
12th rib and the spine).
Ureteric pain• . Between the renal angle and the groin.
Bladder pain• . In the suprapubic region.
Prostatic pain• . In the perineum, but may radiate along the urethra to
the tip of the penis.
• May be related to function, e.g. suprapubic pain exacerbated by
bladder fi lling.
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
• Refers to a group of symptoms that typically affect the ageing male.
• Often caused by bladder outfl ow obstruction related to prostatic
enlargement.
• Includes symptoms related to both voiding and storage.
• Voiding symptoms. Poor urine fl ow, 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.
SYMPTOMS AND SIGNS IN UROLOGY
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Causes• . Overfl ow incontinence from chronic retention, fi stulation
(commonly between bladder and vagina), gross sphincter
disturbance resulting from surgery or neurological disease.
Male sexual dysfunction
• Erectile dysfunction (ED), commonly known as impotence.
Inability to attain and maintain an erection adequate for satisfactory •
sexual intercourse.
There are degrees of ED.•
Men with incomplete ED respond more satisfactorily to treatment.•
The majority of cases have an organic basis.•
All cases have a degree of psychogenic involvement.•
Twenty per cent of cases are primarily psychogenic.•
• Premature ejaculation.
More common in younger men.•
Invariably has a psychogenic basis.•
Often associated with performance anxiety.•
• Loss of libido.
Loss of normal sex drive.•
Either psychogenic or related to hypogonadal states.•
Haemospermia
• Presence of blood in ejaculate.
• Rarely associated with signifi cant pathology.
Signs
Inspection
Examination of the penis must include retraction of the foreskin (if possible) and inspection of the glans and external meatus for signs of infection,
infl ammation, or tumour.
Palpation
• Tenderness in the renal angle or a palpable loin mass may indicate
renal pathology.
• Suprapubic dullness to percussion is an indication of a bladder mass or
full of urine.
• Check for testicular asymmetry, masses, or tenderness
(underdevelopment, tumours, and infection).
• Intrascrotal mass may include the testis (e.g. hydrocele) or be separate
from it (e.g. epididymal cyst).
• Do a digital rectal examination to determine the size, consistency,
regularity, and symmetry of the prostate.
355
CHAPTER 10 Urology
356
Investigations of urinary tract disease
Laboratory investigations
Urinalysis
• Dipstick analysis for blood, leucocytes, protein, nitrites, and glucose.
Nitrites, blood, and leucocytes—infection.•
Blood—microscopic haematuria.•
Protein, leucocytes—intrinsic renal disease.•
• Microbiology, cytology for presence of urinary infection or
malignant cells. Midstream urine (MSU) specimens are required for
bacteriological culture; take care to avoid contamination
particularly in women.
• Matched urine and serum biochemistry to assess glomerular function,
e.g. matched osmolarities, sodiums, and potassiums.
Blood
• Serum creatinine levels. Provides a crude assessment of overall renal
function.
• Creatinine (Cr) clearance (requires 24h urine collection and
measurement of serum creatinine).
Cr clearance (mL/min) = u x v/p
where u is urine Cr concentration, v is 24h urine volume, p is plasma Cr
concentration.
• Serum prostate-specifi c antigen (PSA). Indicator of prostate disease.
Interpreted according to age-specifi c reference range.•
High levels are found in benign prostatic hyperplasia, prostate •
cancer, acute retention, and urinary infection.
• Sex hormone measurements. Occasionally useful in the assessment of
male sexual dysfunction and infertility.
Radiology investigations
Ultrasound
• Renal and bladder scans. For haematuria and urinary tract infection
(UTI).
• Transrectal ultrasound scan. Measures prostate accurately and allows
systematic biopsy for detection of cancer.
• Scrotal ultrasound. Evaluates acute scrotum from a suspected testicular
cancer.
Intravenous urogram (IVU)
• Provides greater functional information than ultrasound.
• Provides superior imaging of the ureter.
CT
• Pre- and post-contrast scans provide some functional information with
regard to arterial and venous blood fl ow and excretory function of the
kidneys.
• Vital for the staging of renal, bladder, and testicular cancers.
INVESTIGATIONS OF URINARY TRACT DISEASE
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MRI
• Provides greater accuracy than CT in assessment of the prostate
capsule and seminal vesicles.
• Sensitive test for the presence of bone metastases.
Isotope bone scan
• Demonstrates abnormal area of bone turnover.
• A useful screening test for the presence of bone metastases.
• Plain fi lms are taken to aid interpretation if the site or pattern of hot
spots is indeterminate.
Isotope renography
• Provides anatomical and functional information about the kidneys.
• Dimercaptosuccinate (DMSA) scan provides an image of functioning
renal parenchymal tissue.
• 99m
Tc-mercaptoacetyltriglycine (MAG3) renogram provides dynamic
information regarding excretion from the kidneys and determines
whether or not obstruction is present.
Endoscopy
Flexible cystoscopy
• Examines urethra and bladder.
• Performed using local anaesthetic gel.
• There is limited potential for intervention.
Rigid cystoscopy Under GA, permits biopsy and resectoscope allows
resection of tissue.
Ureteroscopy
• Rigid and fl exible ureteroscopes provide access to the ureter and
pelvicalyceal system.
• Allows the passage of instruments and laser fi bres for the treatment of
stones and upper tract tumours.
357
CHAPTER 10 Urology
358
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-fi ve per cent 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 per cent of all calculi.
• Commonly occur against a background of chronic urinary infection and
may grow rapidly.
• ‘Staghorn’ calculi (fi ll the calyceal system) are a form of struvite.
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.
• Diffi cult to treat due to extremely hard consistency.
Other stones Xanthine, pyruvate, and other stones; 1% of all calculi.
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 infl ammation.
• Iliac fossa tenderness if the calculus has passed into the distal ureter.
Investigations
• Basic tests.
Raised WCC and CRP suggest superadded infection (should be •
confi rmed by MSU); raised Cr suggests renal impairment.
URINARY TRACT STONES
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Stones often visible on plain abdominal X-ray (‘kidneys/ureters/•
bladder’ (KUB)).
Serum calcium, phosphate, and uric acid.•
24h urine for calcium, phosphate, oxalate, urate, cystine, and •
xanthine.
• Advanced tests.
Non-contrast spiral 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 100mg PR; antiemetic, e.g. metoclopramide
10mg IV; IV fl uids.
• 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.
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.•
• Percutaneous nephrolithotomy (PCNL).
For stones in the renal pelvis or calyces and occasionally for stones •
in the upper ureter.
Percutaneous track into the renal pelvis using fl uoroscopic •
guidance.
Nephroscope is inserted and the calculus visualized.•
Removed either in total or, if large, following fragmentation.•
• Endoscopic treatment.
Ureteroscope is inserted and the stone visualized.•
Stone is fragmented using ultrasound, electrohydraulic •
intracorporeal lithotripsy, or laser.
• Open nephrolithotomy/ureterolithotomy. For large staghorn calculi or
complex stones, e.g. above ureteric stricture.
Prevention of recurrence
• Increase oral fl uid 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).
• Thiazide diuretics (for idiopathic hypercalciuria).
359
CHAPTER 10 Urology
360
Obstruction of the ureter
(See Fig. 10.1)
Key facts
pelvicalyceal dilatation).
Pathological features Hydronephrosis can be unilateral or bilateral.
Unilateral
• Extramural.
• Intramural.
Bilateral
• All causes of unilateral obstruction may cause bilateral hydronephrosis.
• Congenital posterior urethral valve.
• Congenital or acquired urethral stricture.
• Benign enlargement of the prostate.
• Locally advanced prostate cancer.
• Large bladder tumours.
• Gravid uterus.
Clinical features
• Loin pain.
• Fever and/or rigors (if complicated by infection).
• Symptoms and signs of renal failure (if obstruction longstanding).
Investigation and diagnosis
• Serum biochemistry and haematology.
• MSU.
• KUB X-ray/IVU.
• Ultrasound scan and/or CT scan.
• Isotope renogram.
• Retrograde pyelogram.
Complications
• Infection, pyonephrosis.
• Hypertension.
• Renal failure.
Ureteric obstruction leads to hydronephrosis (ureteric and
Aberrant vessels at the PUJ.•
Extrinsic tumour. Carcinoma of the cervix, prostate, large bowel, or •
retroperitoneal endometriosis.
Idiopathic retroperitoneal fi brosis.•
Post-radiation fi brosis.•
Retrocaval ureter.•
Abdominal aortic aneurysm.•
Transitional cell carcinoma of the renal pelvis or ureter.•
Urinary calculi.•
Ureteric stricture.•
Aperistaltic segment. Almost always congenital.•
OBSTRUCTION OF THE URETER
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Treatment
3 Emergency presentation
• Emergency treatment is indicated if there are signs of infection,
established renal failure, uncontrollable symptoms.
• Treatment is drainage of the kidney via a percutaneous nephrostomy
or retrograde ureteric stent.
Elective presentation
• Defi nitive treatment is directed at the underlying cause. Possible
interventions include:
Treatments of calculi (see • b p. 358).
Ureteric stenting (unilateral or bilateral).•
Ureterolysis and ureteric transfer (for retroperitoneal fi brosis).•
Prostatic resection.•
Bladder drainage using a urethral or suprapubic catheter.•
• In cases where renal function cannot be restored, a nephrectomy is
performed to avoid infective complications.
1. Pelviureteric junction
2. Mid ureter (lower retroperitoneum
and pelvic brim)
361
3. Vesicoureteric junction
4. Bladder neck
Fig. 10.1 Commonest sites of renal stone impaction. 1, pelviureteric junction;
2, pelvic brim; 3, vesicoureteric junction.
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