Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_623_Библиотеки_им_академика_М_И_Перельмана
.pdf
The bladder 445
https://t.me/medicina_free
Mesonephric
duct
Ureter
Primitive
urogenital
sinus
membrane
Allantois
Cloacal
Mesonephric
Ureteric
Hindgut
duct
bud
Urorectal
septum
Anorectal
canal
Bladder
Phallus
Perineal
body
(a) (b) (c)
Figure44.1 Embryological development of the bladder and lower urinary tract. a: at 5weeks; b at 7weeks; c at
8weeks.
Lower urinary tract changes include bladder exstrophy, where the ureters together with the bladder trigone open directly onto the anterior abdominal wall
below the umbilicus. This is usually associated with a
failure of fusion of the pubic bones and, in men, there
is an associated epispadias (opening of the urethra on
the dorsal penile shaft rather than the glans penis).
There is often a widened pelvis with a waddling gait.
The infant is completely incontinent of urine, with
excoriation of the abdominal skin and a permanent
unpleasant ammoniacal smell of infected urine. If
the condition is untreated, the child may die of pyelonephritis, or develop a stratified squamous carcinoma of the bladder rudiment after initial
metaplastic change.
Intraperitoneal rupture
This follows a penetrating wound (e.g. a bullet wound) or
crush injury to the pelvis when the bladder is distended.
Occasionally, it occurs during transurethral resection of a
tumour, and, very rarely, the overretention may rupture spontaneously.
distended bladder of
Extraperitoneal rupture
This happens most commonly during transurethral
urological surgery, typically resection of a bladder
tumour, or evacuation of clot retention. It may also
occur by injury from a spicule of bone in a pelvic fracture or occasionally may be caused during a hernia
operation or repair of a cystocoele.
Treatment
Reconstructive surgery is highly specialist, the need
for which can usually be predicted before birth, enabling appropriate planning of the optimal time and
place of delivery. Corrective surgery is usually staged,
and may require correction of defects of formation of
the bony pelvis, as well as the urinary tract.
Rupture ofthe bladder
Bladder rupture may be either intraperitoneal or,
more commonly, extraperitoneal.
Clinical features
Intraperitoneal rupture produces the typical picture
of peritonitis with generalized abdominal pain,
marked rigidity and a silent abdomen.
Extraperitoneal rupture is associated with extraperitoneal extravasation of blood and urine producing a painful swelling that arises out of the pelvis.
When associated with pelvic fracture, differentiation
must be made from rupture of the membranous
urethra (see Chapter46), although this may not be
possible until surgical exploration is carried out.
Aurethral tear is, however, typically accompanied by
446 The bladder
https://t.me/medicina_free
anterior displacement of the prostate, which can be
detected on rectal examination.
In either circumstance, traumatic bladder rupture
causes haematuria.
Special investigations
• Computed tomography (CT) scan demonstrates
extravasation and any associated pelvic injury.
Cystography will confirm rupture.
•
•
Urethrography will demonstrate a urethral injury.
Treatment
Extraperitoneal ruptures are usually managed conservatively, with indwelling urethral (Foley
drainage of the bladder and percutaneous drainage of
the suprapubic space; larger leaks may necessitate
exploration and repair, with drainage of the retropubic space and antibiotic therapy.
Intraperitoneal ruptures are sutured and the bladder drained by means of a urethral and/or suprapubic
catheter.
1
) catheter
Diverticulum ofthe
bladder
The aetiology of diverticula of the bladder is unclear. It
is no longer assumed that they are simply secondary to
bladder outflow obstruction, and a small number are
congenital in origin. About 95% of diverticula occur in
men and this was the basis of the belief that bladder
outlet obstruction was invariably the cause. Congenital
diverticula have all the layers of the bladder wall;
acquired diverticula contain only the urothelium.
Complications
• Urinary infection because of urinary stasis.
•
Calculus formation because of a combination of
infection and stasis.
Clinical features
The majority of diverticula remain silent unless they
undergo one of the complications listed above. Some
are found incidentally during investigation of the
underlying obstructive lesion, for example a prostatic
1
Frederick Foley (1891–1966), Urologist, St Paul, MN, USA.
enlargement or urethral stricture. Occasionally, a
large, uninfected diverticulum gives the strange
symptom of double micturition (‘pis en deux’). In this
circumstance, the patient empties the bladder but a
substantial amount of the urine passes into the distensible diverticulum. No sooner does micturition
end than the diverticulum passively empties again
into the bladder, giving the surprised patient the
desire once again to empty their bladder.
Special investigations
• Ultrasound: this defines the size of the diverticulum.
• Cystoscopy: the neck and body of the diverticulum
can be visualized.
Treatment
Excision of a diverticulum is very seldom indicated.
Associated bladder outflow obstruction may require
treatment, but the diverticulum will remain.
Bladder stone
The varieties of bladder calculi are the same as renal
stones, namely phosphate, oxalate, urate and rarely
cystine (see Chapter43).
Aetiology
Bladder stones either originate in the kidney and pass
down the ureter into the bladder, where they remain
and grow, or originate de novo in the bladder. Stones
that arise in the bladder are due to the following.
Stasis and infection: bladder stones commonly
•
arise as a consequence of outflow obstruction (e.g.
urethral stricture or prostatic enlargement). They
may be secondary to an atonic bladder in a paraplegic person, and may have arisen first within a
bladder diverticulum.
Foreign body: a calculus will deposit on a long-
•
term indwelling catheter or on any foreign body
inserted into the bladder.
Clinical features
The typical triad of bladder stone symptoms is frequency, pain and haematuria. In addition, patients
sometimes complain of intermittent stopping of the
The bladder 447
https://t.me/medicina_free
urinary flow as the stone blocks the internal urinary
meatus like a ball valve, and occasionally actual
retention of urine may occur if the stone impacts in
the urethra.
•
Frequency is more troublesome during the day
than at night, probably because, in the upright
position, the stone lies over, and irritates, the bladder trigone.
•
Pain is felt in the suprapubic region, in the peri-
neum and the tip of the penis; it particularly
occurs at the end of micturition, when the bladder
contracts down upon the calculus.
Haematuria tends to occur as the last few drops of
•
urine are passed.
Special investigations
• Plain abdominal X- ray (specifically, a ‘KUB’ to show
kidneys, ureters and bladder): the majority of bladder stones are radio-
• Cystoscopy allows stones to be seen, and to be
fragmented and retrieved.
opaque and are readily visible.
Treatment
Unless the stone is very small, when there is a possibility that it will pass spontaneously, it should be
removed either by crushing with an endoscopic
lithotrite under direct vision or by endoscopic disintegration with laser.
Bladder tumours
2 Secondary: direct invasion from adjacent tumours,
that is, colorectal, renal, ovarian, uterine, prostatic
tumours.
Urothelial carcinoma
Urothelial carcinoma (UC) is most commonly found
in middlefrequently affected than women.
Aetiology
Risk factors include cigarette smoking (four- fold
increase in incidence compared to non- smoker) and
workers in the aniline dye, rubber and plastics industry, because of the excretion of carcinogens such as
β-
naphthylamine in the urine. The manufacture of
many of the more dangerous dyes and chemicals has
been abolished in most countries. In addition,
exposure to polycyclic hydrocarbons, as happens in
industries working with carbon and crude oil, has
been associated with bladder cancer. Other occupations associated with chemical exposure, such as
leather workers, hairdressers and painters, have
increased risk.
There is a high incidence of malignant change in
the exposed bladder epithelium of untreated bladder
exstrophy (see earlier in this chapter), and in the bladder infected with schistosomiasis. It can also occur in
association with longplegic patients and in the presence of bladder stones;
in these cases, characterized by chronic inflammation
and urothelial metaplasia, development of squamous
cell dysplastic change is common.
aged and elderly patients. Men are more
term catheterization in para-
Pathology
Nearly all bladder tumours are malignant. Bladder
cancer may be classified as follows, together with the
relative incidence.
1 Primary:
a Urothelial carcinoma (90%).
b Squamous cell carcinoma arising in an area of
metaplasia (7%).
c Adenocarcinoma (may occur in urachal rem-
nants) (2%).
d Neuroendocrine tumours (small cell carci-
noma) (~1%).
e Sarcomas (rare).
Pathology
Although any part of the bladder may be involved,
tumours are particularly common at the base, trigone and around the ureteric orifices. They are often
multiple, signifying a field change throughout the
urothelium with the tendency for tumours to develop
anywhere from the renal pelvis to the urethra.
Macroscopic appearance
The low- grade tumours form fine fronds, which
resemble seaweed floating in the urine. High- grade
tumours are sessile, solid growths, which infiltrate the
448 The bladder
https://t.me/medicina_free
bladder wall, then ulcerate, often with marked surrounding cystitis. Carcinoma in situ may produce a
suspicious red patch of urothelium.
Microscopic appearance
Urothelial carcinoma may be well, moderately or
poorly differentiated. Keratinizing squamous cell carcinoma or adenocarcinoma may be seen.
Spread
• Local with infiltration of the bladder wall, the
prostate, urethra or, in women, the pelvic viscera.
The ureteric orifices may be occluded, producing
hydronephrosis and ultimately renal failure.
• Lymphatic, to the obturator, iliac and para- aortic
lymph nodes.
Blood- borne spread occurs late to the liver, lungs
•
and bones.
Clinical features
Bladder cancer usually presents with painless haematuria (visible or non- visible). It may also cause
dysuria, frequency and urgency of micturition.
The patient may present with hydronephrosis
caused by ureteric obstruction or with retention of
urine caused either by clot or by tumour growth
involving the urethra. In late cases, there may be
severe pain from pelvic invasion or uraemia from
bilateral ureteric obstruction.
Examination is usually negative, but tumours
invading muscle may be palpable bimanually at the
time of cystoscopy.
Special investigations
• Urine examination usually reveals blood, either to
the naked eye or microscopically.
• Urine cytology is usually positive in high- grade
(G3 and carcinoma in situ) cancers; a positive
urine test always indicates urothelial cancer in
the urinary tract, but negative cytology does not
exclude it.
•
CT or MRI scans are done to stage high- grade can-
cers and may demonstrate ureteric obstruction or
hydronephrosis. At the same time, the presence of
pelvic bony secondaries may be revealed.
• Flexible cystoscopy under local anaesthesia in the
clinic is the most valuable investigation.
Treatment
Initial assessment of all tumours involves bimanual
examination and transurethral resection under general anaesthesia; further treatment depends on the
grade and stage of the tumour.
Staging
Staging is generally according to the TNM system (see
Chapter6). The local staging (T) involves both bimanual palpation and histological examination to ascertain the depth of invasion through the bladder wall,
and the grade of the tumour (G1, well differentiated, to
G3, poorly differentiated). Carcinoma in situ (CiS) is a
grade (G3) tumour confined to the urothelium.
high-
Low- risk non- muscle- invasive
cancers
Well- differentiated (G1 and low- grade G2) tumours
that do not invade the bladder wall (pTa) are treated
by endoscopic resection followed by intravesical
chemotherapy (mitomycin C) to prevent recurrence.
Follow- up cystoscopy is required to detect and treat
recurrence. This severity of disease has a low chance
(<5%) of progression to muscle-
invasive disease.
High- risk non- muscle- invasive
cancers
High- risk non- muscle- invasive disease (G3pTa,
G3pT1 and CiS) has a much greater chance of progression to muscle invasion (30–60%). The treatment
options are intravesical bacille Calmette–Guérin
(BCG) therapy
2
or early cystectomy.
Muscle- invasive cancers
Muscle- invasive cancers (pT2 and greater) have a
poor prognosis, with approximately 50% 5vival. Treatment is initially with platinum- based
chemotherapy if possible (depending on adequate
renal function and performance status), followed by
cystectomy or radiotherapy. After radiotherapy, cystoscopic follow- up is undertaken, with consideration
2
Léon Calmette (1863–1933), Director of the Pasteur
Institute, Paris, France. Camille Guérin (1872–1961),
Veterinary Surgeon, Lille, France.
year sur-
The bladder 449
https://t.me/medicina_free
of cystectomy if recurrence is diagnosed– so- called
‘salvage cystectomy’.
At cystectomy, the bladder and distal ureters are
removed, along with the prostate or gynaecological
organs. Urinary drainage is fashioned with either
implantation of the ureters into a tube of ileum
brought out as a stoma (an ileal conduit) or bladder
reconstruction (avoiding an external stoma), using
bowel to create a substitute bladder or reservoir that
can be catheterized.
Chemotherapy and immunotherapy may be used
for metastatic disease, but tends to be palliative rather
than curative.
Additional resources
Case 112: A gross congenital abnormality
Case 113: A bladder stone found at autopsy
Case 114: An insidious cause of lumbago
45
https://t.me/medicina_free
45
The prostate
Arthur McPhee
Learning objectives
✓ To know the causes and treatment of benign prostatic enlargement.
✓ To know about the presentation of urinary retention and its treatment.
✓ To know the causes and treatment of prostate cancer.
There are two common conditions of the prostate that
require consideration: benign enlargement and
cancer.
Benign prostatic
enlargement
Pathology
Benign prostatic enlargement is the clinical finding of
an enlarged prostate due to the underlying histological process of benign prostatic hyperplasia (BPH).
Some degree of enlargement of the prostate is
extremely common from the age of 45 onwards, but
this enlargement often produces either no or only
minor symptoms. A UK study suggested that 14% of
40–49-
year- olds, and 43% of 60–69- year- olds have
symptomatic BPH.
The prostate, like the breast and thyroid, is
composed of glandular tissue, stromal tissue and epithelium. Growth regulation in the prostate is complex
with androgens playing a role as well as multiple
growth factors from autocrine, endocrine and
Ellis and Calne’s Lecture Notes in General Surgery, Fourteenth Edition.
Edited by Christopher Watson and Justin Davies.
© 2023 John Wiley & Sons Ltd. Published 2023 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Watson/GeneralSurgery14
paracrine systems. The gland may become enlarged
during periods of change, with excessive micronodule formation and proliferation of both stromal and
epithelial tissue.
Enlargement of the lateral lobes of the prostate
results in encroachment on the prostatic urethra. The
median lobe may also enlarge as a rounded swelling
overlying the posterior aspect of the internal urinary
meatus. The three lobes may then obstruct the urethral lumen, impeding the passage of urine.
Complications ofbenign prostatic
enlargement
The obstruction to bladder outflow which results from
progressive BPH is associated with the following.
Lower urinary tract symptoms (LUTS).
•
• Bladder diverticula, which form from saccules
between muscle bands.
• Bladder stones form as a consequence of urinary
stasis, particularly in diverticula. Stone formation
occurs due to significant urinary stasis with supersaturation and eventual crystallization. These
crystals then enlarge over time to become stones,
which can eventually become too large to pass.
• Urinary infection may occur (especially after
catheterization).
• Renal impairment, with or without hydronephrosis,
a result of back- pressure on the ureters. It is commonly referred to as ‘obstructive nephropathy’.
The prostate 451
https://t.me/medicina_free
Clinical features
There are three types of symptoms that result from
prostatic hyperplasia.
•
Storage symptoms due to associated bladder
overactivity.
Voiding symptoms due to bladder outlet obstruction.
•
Symptoms of the sequelae, such as infection or
•
renal failure.
It is important to realize that LUTS such as those
associated with BPH may be due to bladder overactivity, or other conditions; indeed, they also occur commonly in women. Urinary tract infection may
exacerbate the symptoms or precipitate acute retention (see later in this chapter).
Lower urinary tract symptoms
Voiding symptoms
• Weak urinary stream.
•
Hesitancy– delay in starting to pass urine.
• Prolonged voiding.
• Intermittency– stopping and starting several times
during micturition.
•
Terminal and post- void dribbling.
• Incomplete bladder emptying and retention.
Storage symptoms
• Nocturia.
•
Frequency.
• Urgency and urge incontinence.
• Incontinence.
•
Enuresis.
Symptoms ofthe sequelae
Urinary retention
Urinary retention can present as either an acute episode, typically characterized by suprapubic pain, a
palpable bladder and the urge to pass urine, or as
chronic retention.
Chronic urinary retention has been defined as a
nonpainful bladder that remains palpable after voiding, with renal impairment a consequence. Acute- onchronic presentations may involve worsening LUTS
with small volumes of voided urine. This can be associated with episodes of incontinence (referred to as
‘overflow incontinence’) and may also present with a
degree of renal impairment.
Urinary tract infection
Urinary tract infection may occur as a consequence of
urinary stasis due to incomplete bladder emptying.
UTIs and/or renal impairment in men should result
in an assessment of bladder emptying looking for a
palpable bladder and/or enlarged prostate.
Symptoms ofrenal failure
The obstruction to the outflow of the bladder may
result in renal failure, with nausea, lethargy, drowsiness, headache and confusion.
Confusion can be a presenting symptom of either
UTI or renal impairment, and thus it is wise to examine the bladder for enlargement and to check the
serum creatinine in men with confusion.
Examination
Examination of the abdomen may reveal a large bladder, which may reach to the umbilicus or above. The
swelling has the typical globular shape of the bladder
arising from the pelvis, and is dull to percussion. If
there is acute retention, the bladder will be tender to
palpation.
On digital rectal examination, the prostate may be
enlarged. Typically, in benign enlargement, the lateral lobes are enlarged and a sulcus is palpable
between them in the midline. Palpable nodularity,
loss of palpable sulcus or a globally hard craggy mass
should raise suspicion for prostate cancer.
Special investigations
• Medication review, to identify any medication
being taken that may contribute to LUTS.
• Assessment of LUTS:
– Urinary frequency/volume chart. The patient
records when passed urine, and how much is
passed.
– International prostate symptom score (IPSS) is
a questionnaire tool for classifying the severity
of LUTS. Marks are given according to the frequency with which the patients suffers from
incomplete emptying, frequency, intermittency, urgency, weak stream, straining and
nocturia. Scores will define mild, moderate or
severely symptomatic patients.
– Urine flow rate assessment. A voided volume of at
least 150mL is required for adequate assessment
of maximum flow rate. A maximum flow rate of
452 The prostate
https://t.me/medicina_free
less than 12mL/sec indicates obstruction or weak
bladder contractility. A flow rate over 15 mL/sec
makes bladder outlet obstruction unlikely.
Urodynamics (pressure flow
used to distinguish outflow obstruction from poor
detrusor contraction, which will not improve following prostate surgery.
Urine sample:
•
– Urinalysis for the presence of leucocytes, pro-
tein, blood and glucose.
– Urine culture is performed if urinalysis is posi-
tive. Most patients with prostatic disease do
not have infected urine until the bladder and
urethra have been instrumented.
• Serum creatinine to assess renal function.
• Prostate- specific antigen (PSA) is an indicator of
prostate cancer. A PSA concentration below 4.0ng/
mL is usually deemed normal, but ageupper limits of normal may be used. Refinements
in PSA include measurement of the free/total PSA
ratio, which is over 0.15in normal men.
Ultrasound to assess post- void residual urine vol-
•
ume, retention or hydronephrosis. Normally, there
is no significant residual volume; however, in the
presence of bladder outflow obstruction, the bladder cannot be completely emptied.
assessment) can be
adjusted
In addition, anticholinergics may help symptoms of
an overactive bladder, and an afternoon loop diuretic
or oral desmopressin may help with nocturnal polyuria, but needs careful monitoring of sodium.
Surgical therapy
Surgery is offered to symptomatic patients in whom
medical therapy has failed and who have bladder outflow obstruction on flow rate and pressure/flow
assessment or have presented with urinary retention
with renal impairment or have had recurrent urinary
retention after removal of catheter.
Endoscopic prostatectomy
The prostate can be removed endoscopically by
means of an operating cystoscope, using a diathermy
cutting loop (TURP) or laser fibre (most commonly,
holmium laser prostatectomy, HoLEP). Removal of
too much gland may damage the urethral sphincter
mechanism. Newer techniques have been developed
to offer less invasive surgery to address some of the
risks surrounding erectile dysfunction and retrograde
ejaculation. Morbidity and mortality from these procedures is typically low and minimally invasive
approaches now exist even for significant prostatic
enlargement (over 100 grams).
Treatment
This depends on whether presentation is with LUTS
(nocturia, frequency, urgency, etc.) or acutely with
urinary retention (see later in this chapter).
Conservative management
If there are few symptoms, lifestyle measures, such as
well as the use of containment products (e.g. pads)
may be helpful.
Medical therapy
This is indicated for those who are moderately
symptomatic.
• Selective α
e.g. tamsulosin or alfuzosin) are the mainstay of
treatment for lower tract symptoms.
• 5α- reductase inhibition (e.g. finasteride or dutas-
teride) blocks the conversion of testosterone to its
active metabolite, dihydrotestosterone, in the
prostate. The beneficial effect may take up to
6months to appear.
- adrenergic antagonists (α- blockers,
1
Novel therapies
Newer therapies include:
Prostate artery embolization – super selective
•
catherization of the prostatic artery via a femoral
artery approach to embolize the prostate’s blood
supply causing necrosis and shrinkage.
Rezum – a transurethral steam vapour therapy,
•
causing thermal ablation of the prostate.
• Urolift – a small device like a treasury tag is
inserted through the prostatic lobe, and the
implant retracts the enlarged prostate.
• Aqua- ablation uses a high pressure jet of saline to
hydro- dissect away the obstructing prostate.
Complications ofprostatectomy
Transurethral prostatectomy and HoLEP have a low morbidity and mortality, particularly in view of the elderly
population in which surgery is usually performed.
•
Haemorrhage: primary haemorrhage is more
common with malignant glands, with large resections, and in patients on aspirin or clopidogrel.
The prostate 453
https://t.me/medicina_free
• Transurethral resection (TUR) syndrome: absorption of large volumes of the irrigating fluid through
open prostatic veins may result in hyponatraemia
and confusion.
Infection is particularly common in patients who
•
are catheterized before surgery; prophylactic antibiotics are given.
•
Retrograde ejaculation is almost certain after
TURP.
Erectile dysfunction occurs in 5–15% of patients,
•
depending on the level of preoperative potency.
•
Bladder neck stenosis, due to stricturing of the
bladder neck following resection, may occur and
presents with outflow obstruction.
•
Urinary incontinence is uncommon but may occur
if the resection is extended below the verumontanum with damage to the urethral sphincter.
•
Recurrent LUTS: late recurrence may be due to
either regrowth of an adenoma or malignant
change.
Urinary retention
Urinary retention is generally divided into acute and
chronic.
Acute retention presents with inability to pass
•
urine, suprapubic pain and a suprapubic mass.
Chronic urinary retention is a more insidious
•
process with gradual enlargement of the bladder,
dribbling incontinence and little or no pain.
However, there can be an abrupt shift to acute urinary retention referred to as ‘acuteretention’.
Causes ofurinary retention
Causes of urinary retention may be divided into general and local:
1
General causes (no organic obstruction to urinary
flow):
a Postoperative.
b
Neurological causes, such as diabetes, stroke
or spinal tumour.
Drugs, for example anticholinergics, tricyclic
c
antidepressants.
2 Local causes:
a In the lumen of the urethra, for example stone
or blood clot.
on- chronic
b In the wall, for example stricture.
c
Outside the wall, for example prostatic enlarge-
ment (benign or malignant), faecal impaction,
pelvic tumour, pregnant uterus.
General causes of retention of urine must always be
borne in mind: retention related to acute illness
(e.g. chest infection), trauma (e.g. hip fracture) or
surgery (e.g. hernia repair or haemorrhoid surgery)
is common and often selfpatient with occult bladder outlet obstruction is precipitated into retention of urine following some
other surgical procedure and it may then be necessary to proceed to prostatectomy if spontaneous
voiding is to resume.
limiting. Sometimes a
Clinical features
Acute urinary retention is typically a straightforward
diagnosis to make with the patient complaining of an
inability to void despite a strong sensation to void
with the presence of a palpable bladder typically to
the level of the umbilicus or higher. Having made the
diagnosis, it is important to consider the underlying
cause (e.g. prostatic hyperplasia), and consider any
consequences (e.g. renal impairment). For example,
there may be a history of progressive LUTS, a history
of urethral infection suggesting a stricture, or a history
of ureteric colic suggesting a stone.
Examination reveals a distended bladder. The
patient should have a digital rectal examination to
assess the prostate, and the urethra palpated and
meatus examined. Other potential causes may warrant further examination, such as neurological examination. Diagnosis can be confirmed with a portable
bladder ultrasound scanner.
The main priority is to relieve the patient’s distress
by urinary catheterization, after which more detailed
history taking and examination may proceed.
Special investigations
• Creatinine and electrolytes are measured, looking
for evidence of renal impairment.
• Ultrasound scan of the urinary tract is indicated to
look for hydronephrosis if the creatinine is raised
or there was a large residual volume.
• Serum PSA may be raised due to retention, infec-
tion and catheterization, so any measurement as a
test for prostate cancer should be delayed at least
6weeks.
454 The prostate
https://t.me/medicina_free
Treatment
Catheterization is the definitive treatment for the
symptoms of acute urinary retention, and patients
typically experience relief within minutes. Should the
patient have a high residual volume on catheterization
(more than one litre) they will need a period of observation to assess for polyuria post catheterization as
this may require admission and IV fluid replacement.
Should the creatinine and/or ultrasound scan be
abnormal, a urology assessment should be performed
prior to removal of the catheter.
Treatment with an α-
alfuzosin, should be offered to the patient before
removal of the catheter. Failure of the trial without
catheter requires replacement of the catheter; subsequent management may involve surgery, intermittent
self- catheterization, or long- term indwelling catheter
depending on the fitness of the patient.
Bladder neck obstruction
blocker, such as tamsulosin or
Prostatitis
Acute prostatitis is a bacterial infection of the prostate,
usually caused by bacteria entering the prostate from
the urinary tract either spontaneously, or after instrumentation of the urinary tract or prostatic biopsy.
Infection is usually due to faecal organisms, particularly Escherichia coli and Streptococcus faecalis.
Non-
bacterial prostatitis (chronic pelvic pain
syndrome, CPPS) does not have an identifiable cause,
although an autoimmune process after prior
sensitization, possibly by an infection, may be responsible. Not uncommonly, patients may present with
the symptoms in the absence of any inflammation
(prostatodynia).
Clinical features
In addition to asymptomatic prostatitis seen histologically in prostatic chippings at the time of resection, the
following forms of prostatitis are recognized.
Bladder neck obstruction may be due to congenital
valves in the region of the prostatic urethra and internal meatus, or failure of relaxation of the bladder
neck.
Posterior urethral valves
Congenital valves, which usually produce hydronephrosis and retention of urine in childhood. They are
usually diagnosed on antenatal ultrasound, and the
diagnosis confirmed by micturating cystourethrogram. Early treatment by surgical incision of the
valves before renal failure occurs is important.
Failure ofbladder neck relaxation
The bladder neck normally relaxes actively during
voiding. If this fails to happen, there is functional
obstruction, with lower tract obstructive symptoms
but without enlargement of the prostate. Bladder neck
obstruction can also occur as a consequence of scarring following instrumentation or prostatic surgery.
Treatment
Medical therapy with α- blockers can be offered, and if
this fails, endoscopic incision of the bladder neck is
considered.
Acute bacterial prostatitis
The patient presents with fever, rigours, perineal pain
and difficulty voiding, together with symptoms of a
urinary tract infection; acute retention of urine may
be evident. In addition, pain on ejaculation and blood
in the semen (haematospermia) may be present.
Rectal examination reveals an enlarged, exquisitely
tender prostate, and occasionally an abscess may be
palpable. Epididymitis is a common accompaniment,
owing to infection passing along the vas deferens.
A urine culture is taken in attempt to identify the
causative organism. Treatment is commenced with
an initial 2antibiotics (with trimethoprim as an alternative first
choice if fluoroquinolone antibiotics are contraindicated) which have good penetration into the prostate.
The antibiotics are reviewed in light of the sensitivities
of the micro- organism grown, but in general a prolonged course (e.g. six weeks) is required.
week course of ciprofloxacin or oflaxacin
Chronic pelvic pain syndrome
This is a common insidious problem affecting up to
9% of men. The symptoms are typically pain in the
perineum, scrotum, tip of penis or bladder, along with
pain on ejaculation or micturition. Symptoms of urinary frequency and a feeling of incomplete emptying
Соседние файлы в папке Библиотека им академика М.И. Перельмана