u

Urology
Samir Bidnur, Yooah Krakowsky and Debonh Sasgea, chapter editors

Alaina Garbens and Modupe Oyeumt. associate editors Adam Gladwish, EBM editor Dr. Armando Lorenzo, Dr. Keith Jarvi and Dr. Sender Henchom, staff editors
Basic Anatomy Review ................... 2
Abdominal Wall Anatomy of Scrotum Genito-Urinary Tract Anatomy Penis Anatomy

Scrotal Mass........................... 27
Varicocele Spermatocele Hydrocele Testicular Torsion Inguinal Hernia Hematocele

Common Presenting Problems ............. 3
Hematuria Scrotal Complaints Urinary Retention Dysuria

Penile Complaints ...................... 29
Peyronie's Disease Priapism Paraphimosis Phimosis Erectile Dysfunction (ED) Premature Ejaculation

Voiding Dysfunction ..................... 5
Voiding Failure to Store: Urinary Incontinence Failure to Void: Urinary Retention Benign Prostatic Hyperplasia (BPH) Urethral Stricture Neurogenic Bladder Post Obstructive Diuresis (POD)

Trauma ............................... 32
Renal Trauma Bladder Trauma Urethral Injuries

Infectious and Inflammatory Diseases...... 10
Urinary Tract Infections (UTI) Recurrent/Chronic Cystitis Interstitial Cystitis (Painful Bladder Syndrome) Acute Pyelonephritis Prostatitis/Prostatodynia Epididymitis and Orchitis Urethritis Urethral Syndrome

Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Female Factors Male Factors

Pediatric Urology ....................... 36
Congenital Abnormalities Nephroblastoma (Wilm's Tumour) Cryptorchidism/Ectopic Testes Disorders of Sexual Differentiation Circumcision Enuresis

Stone Disease ......................... 15
Approach to Renal Stones Calcium Stones Uric Acid Stones Struvite Stones Cystine Stones

Selected Urological Procedures ........... 40
Bladder Catheterization Cystoscopy Radical Prostatectomy Transurethral Resection of the Prostate (TURP) Extracorporeal Shock Wave Lithotripsy (ESWL)

Urological Neoplasms ................... 18
Approach to Renal Mass Benign Renal Neoplasms Malignant Renal Neoplasms Carcinoma of the Renal Pelvis and Ureter Bladder Carcinoma Prostatic Carcinoma (CaP) Prostate Specific Antigen (PSA) Testicular Tumours Penile Tumours

Common Medications ................... 43
Antibiotics Erectile Dysfunction Benign Prostatic Hyperplasia Prostatic Carcinoma Continence Agents

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Toronto Notes 2011

Urology Ul

U2 Urology

Basic Anatomy Review

Toronto Notes 2011

Basic Anatomy Review
Above Arcuate Line
r

, .

Abdominus L - Fascia ' }; ' ,..----- Extra peritoneal Fat . ,..------ Peritoneum
External spermatic fascia Cremaster muscle Internal spermatic fascia Tunica vaginalis Dartos fascia

"!i¥='i'-

11!::.!2::! ,..-----External Oblique

_

Fascia

Below Arcuate Lin e)--Inferior Epigastric Artery --.._____Skin \..__ Superficial Fascia \..__ External Oblique - ----"="="";._ '--Internal Oblique --Transversus Abdominus .._____Transversalis Fascia '------ Extraperitoneal Fat '------ Peritoneum

Pampiniform plexus

Figure 1. Midline Cross-Section of Abdominal Wall

Figure 2. Anatomy of Scrotum

Renal vein Renal artery Abdominal aorta IVC Ureter Gonadal artery and vein Internal iliac artery and vein External iliac artery and vein Internal pudenal artery Common penile artery Detrusor Trigone Base detrusor

Minor Major calyx Pararenal fat Renal sinus Renal pelvis Ureter

Renal papilla Renal column Renal pyramid Renal capsule (Gerota's fascia)

Uretero-vesicular junction

© Krista Shapton 2010

Male Pelvic Vasculature

Prostate Prostatic urethra Posterior urethra Periurethral striated muscle-"2!rn.:.;...-Membranous urethra Rhabdosphincter (external Bulbar urethra : } sphincter, striated muscle) ' Anterior urethra Spongy (penile) urethra

© Sandra Tavares 2007

Figure 3. Essential Genito-Urinary Tract Anatomy

©June Li 2010 Figure 4. Cross Section of the Penis

Toronto Notes 2011

Common Presenting Problems

Urology U3

Common Presenting Problems
Hematuria
Classification (see Nephrology. NP6)
Tabla , . Etiology of Hematuria by Aga Group
B-20 2()..40
4[)..60

Glomerulonephritis, llTI, cong..ital anomalies

un, stones, bladder tumour
Male: bladder tumour, stones, UTI Male: BPH, bladder tumour, un Female: lJTI, stones, bladder tumour Female: bladder tumour, un

>60
Etiology

Tabla 2. Etiology of Hamaturia by Typa
bleeding Dyes (beets. rhodemine B in candy and juicesl Hemoglobin (hemolytic anemial Myoglobin (rhebdomyolysis) Drugs (rifaiJ'1lin. phenazopyridine. pyridium. phenytoin) Porphyria Laxatives (phenolphthalein)

AnticoiiiJII!nts Coagulation defects Sickle cell dsease Neoplasms Leukemia Ttmnboembolism

Stone Trauma Renal cell carcinoma cell carcinoma Wilm's tumour

Stone Tumour

Glomerulonephritis

Uretlritis Polyps Foreign body Uretlnl sbicture

Cammon urologic CIIUUS of h111111lwi1 c., be grossly classified 115:
TIBUIIIII

Infection Tumoun;

Ston11

Tuberculosis

Infarct
Polycystic kidneys Arteriovenous malloiTIIiltion

History • full history, inquire about timing of macroscopic hematuria in urinary stream • initial: anterior urethra • terminal: bladder neck and prostatic urethra • total: bladder and/or above Investigations • gross hematuria and symptomatic hematuria require full workup • CBC (rule out anemia, leukocytosis), electrolytes, creatinine, BUN • urine studies: • urinalysis (casts, crystals, cells) • culture and sensitivity • cytology • imaging: • CT/IVP to investigate upper tracts (ultrasound alone is not sufficient) • cystoscopy to investigate lower tract (possible retrograde pyelogram) • microscopic hematuria defined as more than two red blood cells (RBC) per high-power field (HPF) (see Figure 5) Acute Management of Severe Bladder HemoiThage • manual irrigation via catheter with normal saline to remove clots • continuous bladder irrigation (CBI) using large (22-26 Fr) 3-way Foley to help prevent clot formation • cystoscopy if bleeding quite active: • identify resectable tumours • coagulate obvious sites ofbleeding • refractory bleeding: • continuous intravesical irrigation with 1% alum (aluminum potassium sulfate) solution as needed • intravesical instillation of 1% silver nitrate solution • intravesical instillation of 1-4% formalin (need general anesthesia) • embolization or ligation ofiliac arteries • cystectomy and diversion rarely

U4 Urology

Common Presenting Problems

Toronto Notes 2011

,, ,

I I

>Z RBC,IHPF
Urinalysis and urine C&S

The CUA guidelines advise: Repeat initial urine microacopy if history of llflllhral tnurna. IXlln:isa, or me11181. lmmedim rllhi!Tal to nephrology if 1111y of: proteinuria, -1' craatinine, rad cell casts or clysmorphic RBCs

1. Rule out and treat benign causes {i.e. Ull) 2. If accompanied by d1J1111orphic RBC, or 1' Cr,
evalum for primary renal disease

,, ,

If neither 1 or 2, urologic evaluation required

• • •

I I

Uppllf Tr-ct I-Fni Opt l'yela!Jam- Traditional option and widely available, but use i$ decreasing. Reasollllble sensitivity for UCC, but poor sensitivity for RCC.

Urothtllial Cell Carcinoma {UCCI Riak Stratification

Ultrunnd - Superior to IVP for 8VIIIuation of renal piUllllChyma and renal cysts. Urnillld sensitivity for UCC and small renal masses. UIS alone is not sullicilllt for uppar tract imaging.

HIGH RISK Smoking hi&lory Occupational chamictlllCPosura Gross hematuria >4Dyn old Hx of &!Drage voiding &ymptoms Hx of recurrent lJTI's Complsta &valuation

+

LOW RISK 1. Urine cytology
2. Uppar tract imaging

+

CT - Optimallllst for renal parenchyma,
calculi ll1d infections, but less
inlnMIIIDUS CDIIII'IIl

and mora expentiv& thllll lltruound. Involves elqiDIUre to l'lldiation and

• ...

+ve

+1
3. Cysto.copy

I
+1111


TreatUCC

I

.,.

1. Urine cytology 2. Upper tract imaging
3. Cysto.copy

i

I

.....

....

..

Follow up Urinalysis, cytology, and BP at 6, 12, 24, 36 months

Figure 5. Workup of Asymptomatic Microscopic Hematuria Based on AUA Guidelines

Scrotal Complaints
• see Scrotal Mass, U27

Urinary Retention
------------------------------------------

• see Failure to Void, U6

Dysuria
Differential Diagnosis
Tabla 3. Differential Diagnosis of Dysuria
Infectious
Naaplum C.lcul
urstllilis, 11'05f81itis, epididymitis, vestibulitis cervicitis, wlvovaginitis, perineal

inllanmatiorilnfaelion, TB,

Renal cell, bladder, prostate, penis, vagiiiiWulva, BPH Bladder stone, ureteral stone, kidney stone Seronegilliw arthropathie& (Riileliw arthritis: arthritis, uwitis, u181hritisl, drug &ide llf!ect&, autoimmune disorders, chronic pelvic pain synctome (CPPSI. in1elslitial cystitis Endometriosis, hypoeslnlgenism Catheter insertion. post-coillll cyslitis (honaymoon cystitisI Somalimlion disorder, MOD, stress/anxiety disorder Conteel sensitivity, foreign body

lnlll11mltory

Hormllllll
TraUIIII Plychagenic Othar

Approach
• focused history and physical to determine cause (fever, discharge, CVA tenderness, conjunctivitis, back/joint pain) • urine dip, C&S, R&M • any discharge {urethral, vaginal, cervical) should be sent for gonococcus/chlamydia testing; wet mount if vaginal discharge • if suspect infection, may start empiric antibiotic treatment • ±imaging of urinary tract (tumour, stones)

BPH • decreased compliance of bladder wall: • CNS lesion. inflammation/infection (cystitis. post-void Failure to Store: Urinary Incontinence Definition • involuntary leakage of urine ------ Etiology • urgency incontinence: • detrusor overactivity: • CNS lesion. Urinary Incontinence: Types and Treatments Type Dalililio1 Excns uriu output Resbicted mobiity/Retention Stool impaction Urga Stress Ovarllaw Involuntary leakage of urine whan inti'IIV8Sical pressure axceads urethral pressure Mixed Urinary leakage associated with Ul'llencv and increased inlnHibdominal pressure Involuntary leakage of urile Involuntary leakage of IJ'ine preceded by a strong. MS. Storage phase .bladder filling and urine storage • accommodation and compliance • no involuntary contraction 2. aging and hypoestrogen state • intrinsic sphincter deficiency and urethral hypennobility can co-exist Epidemiology • variable prevalence in women: 25-45% • F:M=2:1 F•iluN to Store Urinlry Tract Sr. suddan increases in sudden Ullle to void inlnHibdominal pressure Etialagy Bladder {detrusor overactivity) Hisloly Urudynamics Urethrs/Sphilcter weakness. fibrosis • sphincter/urethral problem • stress urinary incontinence (SUI): • urethral hypermobility • weakened pelvic floor allows bladder neck and urethra to descend with increased intra-abdominal pressure • urethra is pulled open by greater motion of posterior wall of outlet relative to anterior wall • associated with childbirth. tumour).uria Thilit Frequent Urgant Ni{#rtlime Di8Comfort 't' C. Voiding phase .usn of 11enn•1• Urinary DIAPERS Delirium lnflammatiorVInfection A1rophic Phllllllllcautic:lllr.bladder emptying • coordinated detrusor contraction • synchronous relaxation of outlet sphincters • no anatomic obstruction • voiding dysfunction can therefore be classified as: • failure to store ./Psyc:hologiclll • more frequent in the elderly.Toronto Notes 2011 Voiding Dysfunction Urology US Voiding Dysfunction • see GY36 for relevant female topics Voiding • two phases oflower urinary tract function: 1. musculature W8ilkn8Ss antic:holinal'llic drugs) History Combination of bladder and sphilcter issues History Urodynamics Dilgnollis Stras1 Test (hBw patient bear downfcough) History Urodymmics Stress Test . bladder neck obstruction (tumour. affecting 5-15% of those living in the community and 50% of nursing home residents Table 4. aging.due to bladder or outlet • failure to void .-1111 (WTSJ (irritlltift) • • Urgancy • Nocturia • OV. stone. voiding (formerly known as obstructive). pelvic surgery. Obslruction.due to bladder or outlet • three types of symptoms: storage (formerly known as irritative). levator muscle weakness • intrinsic sphincter deficiency (ISD) • pelvic surgery. neurologic problem. stone). neuropathy post1)artum pelvic {diabetes.

Urinary Incontinence: Types and Treatments (continued) Type Urge Lifestyle Bladder habit training Sims Owlflow LWestyle Clllheterillllion tD IIVDid organ damage Traat Wlderlying cause Miud management of urge and Traatmlllt Weight loss.U6 Urology Voiding Dysfunction Toronto Notes 2011 . Kegel's exercises Bulking agents Surgary (slings. prostatitis • urethra . post void residual (PVR) scan Treatment • guiding principles are to treat underlying cause of retention and use least invasive treatment possible • catheterization: • contraindicated in trauma patient unless urethral disruption has been ruled out • acute retention: immediate catheterization to relieve retention. phimosis. definitive treatment depends on etiology • suprapubic cystotomy • for post-operative patients with retention: • encourage ambulation • alpha-blockers to relax bladder neck • may need catheterization • definitive treatment will depend on etiology . Chi'Oilic retention can be asymptomlllic grwdy incnaud bladder voUnl 1nd detrusor hypertrophy foUowed by atony (IIIII). ultrasound. ecstasy) . Chronic llatlntlon Clinical Features • • • • palpable and/or percussible bladder (suprapubic) possible purulent/bloody meatal discharge DRE . follow up to determine cause • chronic retention: intermittent catheterization by patient is commonly used. Batox Medications: Anticholin&rgics (1Diterodine oxybutynin stress incontinence artificial sphinctn) (Trosec1111.g.... electrolytes.calculus. ------------------ Etiology • outflow obstruction: • bladder neck or urethra . Sominex•) • psychosomatic substances (e. ·}-----------------. urine R&M... lVOT. leave Foley in to drain bladder.. . Table 4. urodynamic studies.injury._. or neoplasm • prostate .g. Combination of Urge Incant!. Sudafed•) • antihistamines (e. Acute vs.BPH. saddle sensation.stricture. traumatic disruption • bladder innervation: • spinal cord . multiple sclerosis • stroke •DM • post-pelvic surgery • pharmacologic: • anticholinergics •narcotics • antihypertensives (ganglionic blockers. Cr. foreign body.size of prostate. cystoscopy. disc herniation. Acute retention is 1 medical emergency chlllllllimd by pain and 11111ril with nonnal bladder volume and Acuta ovardillantion lead Ill bllddar rupture. Benadryl•. C&S. clot.g.. trospium TCAs Neuromodulation Failure to Void: Urinary Retention .}-----------------. etc.Traidnnlnt 8ewanl of lllticholinerqic side effects including delirium and urinary retention.presence of abnormal deep tendon reflexes. prostate cancer. Investigations • CBC. soiW&nacin (Ditropan"J. methyldopa) • over-the-counter cold medications containing ephedrine or pseudoephedrine (e. anal sphincter tone neurological. Nytol•. BUN.

evening fluid restriction._.Modlrmly aymp!CIIIIIIic 20.. U40 • open prostatectomy: • for large prostates or associated problems (e._.reatinine to assess renal function ± renal ultrasound to assess for hydronephrosis • prostate-specific antigen (PSA) trJ rule out malignancy (iflife apectancy >10 years) • umflowmetryto measure flow rate (optional) • bladder ultrasowtd to determme post-void residual urine (optional) • cystoscopy prior trJ potential surgical management • biopsy ifsuspicious for malignancy Treatment • conservative for those with mild symptoms: • watcltful waiting .. 80% of80 year olds) • 2596 of men will require treatment lt' Centnllzxn l'llripherlllzxn EjiiCUIIIlny zona C Meog'-' Brilllley Figure I.5096 of patients improve spontaneously • includes Ufestyle changes (e. tamsulosin (Plomax").n UTI1 • Rac. urgency incontinence • thought to be due to detrusor overactivity and deaeased compliance • prostate Is llllOOth..Saellon af Clinical Features • result from outlet obstruction and compensatory changes In detrusor functl...g. straining. terazosln (Hytrln-}.ril. frequency.. llpprmdllltlll'roltlta 1181 20 4:C . nocturia.ry • Rafnlctoty urilll'f rellntion • Rac. water-induced thermotherapy... planned voiding) • medical treatment • a-adrenergl. doxazosin (cardura•). acts on the epithelial component of the prostate.d hamaturlll Nfrll:lory111 mediDII trlltmlnt • .....g.Toronto Nota 2011 Voicling Dyafunction UroiOBf U7 Benign Prostatic Hyperplasia (BPH) _ _ _ _ _ _ __ J Definition • hyperplasia ofstroma and epithelium in periurethral area ofprostate (transition zone) see Pigure6 • tone ofprolltlrtic smooth muscle cells plays a role in addltlon to hyperplasla.c antagunlsts ..ltnut 25t:e-pUn 50 t:e -lem111 75 t:e .m.g of out"' 5.inimallylnvasivetherapy: • prostatic stents... alfuzosin (Xatral-)1 • 5-a reductase inhibitor. Cr. Dy.Milcly wymp!DmllliG • hydronephrosis and renal compromise • infection • gross hematuria •bladderstones Investigations B-19.reduce stromal smooth muscle tone [e. !IIIIa out Cllhar CIUIM) • 8lu11M . Each '"fll1piGm graded D-7 .reduces prostate size [e.. finasteride (Proscar"). dutasteride (Avodart")] • combination shown to be synergistic (see sidebar) • transurethral resection ofprostate (TURP): • see Seleded UrolDgical Procedures._illlcl with BPH • history • a&&ess LUTS and effect on quality ofUfe... nut ilcludad in 1100111 but ia cammanly.-. weak/interrupted stres..grapefnjt .J5-SIIVIfllly Nata. estrogens. incomplete bladder emptying • decreased flow rates may be seen on uroflowmetry • due to outflow obstruction and/or impaired detrusor contractility • storage symptoms: • urgency..ct. .g.. extremely common (SO% of50 year olds. microwave therapy.blocks conversion of testosterone to DHT.. ather growth factors Epidemiology • age-related. ¥ intensity focuaed ultrasound (HIFU) and transurethral neeclli: ablation (TUNA) ..oranga I 00 cc . Etiology • etiology unknown 11r1111 Anterior ---= lillll"'"""n "'"" / ZIJfl8 • androgen dihydrotestosteront: (DHT) required (converted from testosterone by 5-alpha reductase) • possible role ofimpaired apoptosis. Alllalm INIAiill11 fur IPH S. laser ablation. rubbery and symmetrically enlarged on DRE • complications: • retention • overflow incontinence ProsbdB AIIAPrDitllli Syqmn Scllre FUIIIWJIE Urgency NDC!uria WMkelrelm lnterm-cy llnlining ineo..-811 ...g. may include self-administered questionnaires (AUA symptom and impact score) • physical exam: DRE • urinalysis to exclude UTI • c.on • voiding symptoms: • hesitancy. cryotherapy. bladder stones) • suprapubic (transvesically to deal with bladder pathology) • retropubic (through the prostatic capsule) om. .

.... .. ... c. etc.lloor.. « conDilali:ln 1lllrapy (n= 786).llllli nmrert Clinical Features • voiding symptoms (obstructive symptoms) • urinary retention • related infections: recurrent UTI..... Melli age 62. secondary prostatitis/epididymitis lft(P<0... ar llirwy imlli1R:a. Gf Bllldder Capacity (35()-500 cc...l:luiJn: long·term cantinlliJn 1herapywilh daaain llld fillllllrida ofll¥8111 clinicaiii'UQIIIIion othlrigl jRitllic h¥Perpln &igniic:antlt ll1llll thui diltr811mint witb li1llar 1Dpllc:lllofar daomlin- Investigations • laboratory findings • flow rates <10 ml/s (normal-20 ml/s) on uroflowmetry • urine culture usually negative.tA Volume) Conlraclility (vDiuniBry and &u&lllinad) Cooperation of bladder and sphincter Nam Fibrn Sympathetic Somlllic Parasympathetic S1111ma11: Nllll'lllrllllmittlr T11111t Kay Recaplara T10-LZ SZ-S4 SZ-S4 Noradrenuline Acetylcholile Acetylcholile Trigone. M31 Detrusor "12·3-4 Dlpe tile •inl orr t. removal ofinflated Foley catheter.. hlllridl. Parasympathetic.6..n..&8'11IP<0.. thalamus. J'ed$: (Agtj + 2) X 30) Neurophysiology Table 5. ± urethroplasty depending on location and size of stricture Neurogenic Bladder Definition • a malfunctioning urinary bladder due to a deficiency in some aspect of its innervation 4C. straddle injury) • other: foreign body. basal ganglia. IS contraction).. Pllilnll: 3047 plliiiD Nth BPH IAignld Ill pil1:abo 7371. 111111-na sV!bltdifnl:e daaain llld fillllllridaalln.. cantralllld trill witllllll!l of 4.. aii:ll . proximal LR!hra External s!ilincter Adrenergic {all Nicotinic Muscarinic (MZ. finulaide Vi.US Urology Voiding Dysfunction Toronto Notes 2011 .. stimulation of sacral somatic neurons (ES contraction ) • voluntary action of external sphincter (pudendal n......5 YIIIJ.OOII IIane.... IIIIUPSI Trill} • Lilt-Tim E1lld rlllmllmlil. 349:2387-2398 lllwly:lllnlt:lnilld.....001). The &-¥r • • l!ldLEtion il CINTII81i¥e incidence rlclinicll LriiBy lllention. burns..34!1 llld combinetioolMrlpy.... S2-S4) can inhibit urge to urinate • cerebellum. Comnltion thenill¥.. and Somatic Nerve Supply ComplillnCI[minimal A Pmsur.001L fillllllride...lillie IAIIiclive thui eitller daaain [P<O. inhibition of sympathetic (IS relaxation) and sacral somatic neurons (ES relaxation) • urine storage: inhibition of sacral parasympathetic neurons (bladder relaxation) aided by sympathetic activation (bladder relaxation... Efferent Syrnpatlnmc. • infection: • long-term indwelling catheter • balanitis xerotica obliterans (lichen sclerosis or chronic progressive sclerosing dermatosis of the male genitalia) causes meatal stenosis NfJM2003.s. cantinllillll111arapy.failure of normal canalization • may cause bilateral hydronephrosis • trauma: • instrumentation (most common) • external trauma (e. ICUIII lrinlly111ct irluclim. <50% with repeated courses • open surgical reconstruction: • complete stricture excision ± anastomosis..g. ... but may show pyuria • radiologic findings • retrograde urethrogram. ..· Narve rucrt& in micluritiDII: • receptors in the bladder wall and mucosa relay information to pontine micturition centre (PMC) and activate micturition reflex • the PMC sends excitatory/inhibitory signals to regulate micturition reflex (normally inhibited by cortical input) • micturition: stimulation of sacral parasympathetic neurons (bladder contraction). Main D*-: Clnical J1R9111ion dainad 11: fim ocamnce ol111 inl:niue IMI'bae lile of 111 IIIII fiu pcin1s in 1lla AUA sympiDm ara.. voiding cystourethrogram (VCUG) will demonstrate location • urethroscopy Treatment • urethral dilatation: • temporarily increases lumen size by breaking up scar tissue • healing will often reform scar tissue and recreate stricture • visual internal urethrotomy (VIU): • endoscopically incise stricture without skin incision • cure rate 50-8096 with single treatment. internal sphincter... . .. doxlzalin 7561 fillllllride (n • 768).OOII artilllstwidl (P<O.. CIII'IIIIMIM 11811mant-.. .. l:. and hypothalamus all have input at PMC . dllllllllil \15. Urethral Stricture Definition • decrease in urethral calibre due to scar formation in urethra (may also involve corpus spongiosum) • M>F Etiology • congenital.n-. daubla-bmdad...

DM. smooth/striated sphincter Neuro-Urologic Evaluation • history and physical exam (urologic and general neurologic) • urinalysis. US) • if refractory: . trauma.assess capacity.. multiple sclerosis (MS)]: neurogenic detrusor over activity (detrusor hyperreflexia) • loss of voluntary inhibition of voiding • intact pathway inferior to PMC maintains coordination ofvoiding episodes • lesion of spinal cord [e. pattern • filling cystometrogram (CMG) .. '' "Spillll •hack" earty phase foUowing cord injury m111ilesl$ qlllonic bladder. headache.pressure-flow study. nifedipine (prophylaxis during cystoscopy) .Toronto Notes 2011 Voiding Dysfunction Urology U9 Classification of Neurologic Voiding Dysfunction • lesion above PMC [e. detrusor overactivity • voiding cystometrogram . disc herniation): detrusor atony/areflexia • flaccid bladder which fails to contract • may progress to poorly compliant bladder with high pressures • peripheral autonomic neuropathy: deficient bladder sensation -+ increasing residual urine -+ decompensation (e. arteriovenous malformation (AVM)]: detrusor sphincter dyssynergia (DSD) • loss of coordination between detrusor and sphincter (ie.g. usually resolves in 48 hrs with PO fluids but sometimes can continue even after having reached euvolemic status (i. urethra or rectum • symptoms include: hypertension. vasodilation above lesion • treatment: remove noxious stimulus (e. pathologic POD) ... insert catheter).assess flow rate. sodium. sweating. reflex bradycardia. MS.x-ray contrast to visualize bladder/bladder nec. and water (high osmotic load) after relief of obstruction • self-limiting.helps ascertain presence of coordinated or uncoordinated voiding. compliance. stroke. detrusor contracts on closed sphincter and vice versa) • component of detrusor overactivity as well • lesion of sacral cord or peripheral efferents (e. diabetes.g.botulinum toxin injections into bladder wall . renal profile • imaging: intravenous pyelogram (IVP).g. piloerection • vasoconstriction below lesion. assess bladder contractility and extent of bladder outflow obstruction • EMG .occasionally augmentation cystoplasty • flaccid bladder-+ clean intermittent catheterization (CIC) Autonomic Dysreflexia • exaggerated sympathetic nervous system response to visceral stimulation below the lesion in spinal cord injury patients • lesion is usually above T6/T7 • stimulation includes instrumentation.e. anxiety. distention or stimulation of bladder..k/urethra during CMG Treatment • goals of treatment: • maintenance oflow pressure storage and emptying system with minimal tubes and collecting devices is necessary to • prevent renal failure • prevent infections • prevent incontinence or achieve social continence • treatment options: depends on status of bladder and urethra • bladder hyperactivity-+ medications to relax bladder (see Incontinence. neurosyphilis.g.g. herpes zoster) • muscular lesion: can involve detrusor. parenteral ganglionic or a-blockers. U/S to rule out hydronephrosis and stones • cystoscopy • urodynamic studies: • uroflowmetry . allows accurate diagnosis of DSD • video study. Post Obstructive Diuresis (POD) Definition • polyuria resulting from relief of severe chronic obstruction • >3 U24 hrs or >200 cclhr over each of two COlllleCutive hours -------------------------- Pathophysiology • ranges in severity: physiologic to pathologic process • physiologic POD occurs secondary to excretion of retained urea. tumour.

CVA tenderness) Organisms • routine cultures (see sidebar) • non-routine cultures: • tuberculosis (TB) s. storage symptoms (frequency. perinephric abscess) lymphatic direct (inflammatory bowel disease.midstream urine • if symptomatic. s. cystocele • foreign body: • introduce pathogen or act as nidus of infection • e. e.GI organisms hematogenous (TB. reflux. post-void dribbling.UIO Urology Voiding Dysfunction/Infectious and In11ammatory Diaeaaes Toronto Notes 2011 • pathologic POD is a sodium-wasting nephropathy that occurs secondary to an impaired concentrating ability ofthe renal tubules due to: • decreased reabsorption of sodium chloride in the thick ascending limb and urea in the collecting tubule • increased medullary blood flow (solute washout) • increased flow and solute concentration in the distal nephron Management • admit patient and closely monitor hemodynamic status and electrolytes • monitor urine output (U/0) q2h and ensure total fluid intake <U/0 by replacing every 1 cc U/0 with 0.g. OB18 ---------------------------- Definition • greater than 100. E. o1her G1111m-negalives Enterococci Proteus minlbilis. IEEPS IIJeiJsrelle sp. malignancy.5 cc 1/2 NS IV (PO fluids if physiologic POD) • avoid glucose-containing fluid replacement (can cause iatrogenic diuresis) • check Na and K q6-12h and replace prn • follow creatinine and BUN to baseline Infectious and Inflammatory Diseases Urinary Tract Infections (UTI) • for UTis during pregnancy. immunosuppression • other factors: • trauma.. diverticulitis) Risk Factors • stasis and obstruction: • residual urine in poorly flushing system.000 bacterialml.. dysuria) hematuria pyelonephritis: more severe symptoms (including constitutional symptoms. BPH. coli (90%). posterior urethral valves. anatomic variance (congenital).. catheter.. urgency. dysuria) voiding symptoms (hesitancy.g. urethral stricture. medication (anticholinergics). • Chlamydia trachomatis • Mycoplasma (Ureaplasma urealyticum) • fungi (Candida) . female (short urethra) Clinical Features • • • • Cystitis: c. see Obstetrics. aprophytiw.. 100 bacterialml may be significant Classification • uncomplicated: lower urinary tract infection in a setting of functionally and structurally normal urinary tract • complicated: pyelonephritis and/or structural/functional abnormality • unresolved bacteriuria = urinary tract is not sterilized during therapy (most commonly due to resistant organisms or noncompliance) • recurrent UTI • bacterial persistence = urine cultures become sterile during therapy but resultant reinfection of the urine by the same organisms • reinfection= new infection with new pathogen (80% of recurrent UTls) Source • • • • ascending (most common) . instrumentation • decreased resistance to organisms: • diabetes.

000 • 90% of cases are in females • mean age at onset is 40 years Classification • non-ulcerative (more common) -younger to middle-aged • ulcerative . TMP/SMX) • lifestyle changes (limit caffeine intake. U43) • establish predisposing cause (if any) and correct • if febrile. perineal colonization • investigations may include cystoscopy.middle-aged to older .a Epidemiology • prevalence: -20/100. ±WBCcasts • Gram stain: GN bacilli. cephalosporins) • for mild infections 3 day course is sufficient (for treatment details see Common Medications. autoimmune. autoimmune. fibromyalgi. 30-50 years: 6% • assess predisposing factors as described above • possible relation to intercourse (postcoital antibiotics). late teens: 4%. irritable bowel syndrome (IBS). consider admission with IV therapy and rule out obstruction Recurrent/Chronic Cystitis • incidence of bacteriuria in females: • pre-teens: 1 %. irritable bowel syndrome (IBS). neurogenic. ultrasound. fluoroquinolones. frequency± pain without other reasonable causation Etiology • unknown: • theories: increased epithelial permeability. defective glycosaminoglycan (GAG) layer overlying mucosa • associations: severe allergies. neurogenic • associations: severe allergies. catheterized or suprapubic aspirate • hematuria workup . ultrasound. smoking cessation) • post-menopausal women: consider topical or systemic estrogen therapy • no treatment for asymptomatic UTI except in pregnant women or patients undergoing urinary tract instrumentation Interstitial Cystitis (Painful Bladder Syndrome) Definition • chronic urgency. GP cocci. CT • antibiotic prophylaxis if >3 or 4 episodes per year in females Etiology • unknown: • theories: increased epithelial permeability.a Treatment • daily low-dose prophylaxis (nitrofurantoin. nitrofurantoin.urine cytology. cystoscopy • CT scan if indicated Treatment • confirm diagnosis • identify organism and treat (TMP/SMX. C&S • dipstick: leukocytes ± nitrites ± hematuria • microscopy: >5 WBC/HPF in un-spun urine or >10 WBC/HPF in spun urine. bacteria. increase fluid/water intake.> 1 bacterium/oil immersion field • culture and sensitivity: midstream.Toronto Notes 2011 Infectious anclln1lammatory Diaeaaes Urology Ull Indications for Investigations • persistence of pyuria/symptoms after adequate therapy • severe infection with an increase in creatinine • recurrent/persistent infections • atypical pathogens (urea splitting organisms) Investigations • midstream urine R&M. fibromyalgi.

Aureus. Enterococcus jaecalis. vomiting. PCKD. vaginitis. S. strictures. C&S (see Urinary Tract InfoctWns. prostatic obstruction. vesicoureteric reflux. malaise • CVA tenderness or exquisite flank pain • dysuria is not a symptom of pyelonephritis without concurrent cystitis Investigations • urine R&:M. urgency.Ul2 Urology Infedioua and ln1lammatory Diseases Toronto Notes 2011 Diagnosis • required criteria: • glomerulations (submucosal petechiae) or Hunner's ulcers on C}'!l:oscopic examination • pain associated with the bladder or urinary urgency • negative urinalysis. lifestyle) • pentosan polysulfate (Elmiron•) • low dose amitriptyline • bladder hydrodistention (also diagnostic) under general anesthesia • intravesical dimethylsulfoxide (DMSO) or Cystistat• • surgery (augmentation cystoplasty and urinary diversion ± cystectomy) Acute Pyelonephritis • see Infectious Diseases. Klebsiella.indicated if suspect complicated pyelonephritis or symptoms do not improve with 72 hours oftreatment • Abdo/pelvic U/S • IVP • Cystoscopy • CT . S. Proteus. DM. bladder tumour • radiation/chemical cystitis • eosin. Enterobacter. nausea. left shift • imaging .day) • LUTS including frequency. immunosuppression.ophilic:/TB cystitis • bladder calculi Treatment • patient empowerment (diet. hematuria • fever. ciprofloxacin PO x 7-14 days or cotrimoxazole (TMP/SMX) POx 14 days • severe or non-resolving: admit. saphrophyticus • common underlying causes of pyelonephritis: stones. instrumentation. UIO) • blood • CBC + differential: leukocytosis. pregnancy Clinical Features • rapid onset (hours . hydrate and treat with ampicillin IV and gentamycin IV • emphysematous pyelonephritis: emergency nephrectomy • stone obstruction: admit and emergency stenting or percutaneous nephrostomy tube . neurogenic bladder. post-renal transplant. MacroBID has poor tissue penetration and 1h818fm is not usad to treat pyelonephritis (raquil'lll post-renal Treatment • may treat as outpatient if hemodynamically stable.. myalgia. chills. ID21 ------------------------------------ Definition • infection of the renal parenchyma with local and systemic manifestations Etiology • ascending (usually GN bacilli) or hematogenous route (usually GP cocci) • causative microorganisms: E. catheters. C&S Differential Diagnosis • UTI. coli (most common). sickle-cell disease. Pseudomonas.

prostatic biopsy Most ilfections occur in 1he peripheral mne (see Figure 61 AcLIIe onset fiNer.. Comparison of tlla Thraa Types of Prostatilil Type 1: Acute Bill:tlriill Pramtitis E1ialagy KEEPS (see U10 sidebar]: 811% E. Prostlllic masuga may cMJse IIXIrllme 18ndem81Ri and incraaed risk af inducing sepsis. analgesics. stool softeners) PO llllibiotics 1raat for wks 1D prevent Admission criteria: sepsis.. involves only head of epididymis) • note: epididymitis is much more common than orchitis . warm prostate Colony counts in EPS and VB3 Urine C&S: 4specimens should exceed those of initial and VB1 [voided bladder urine): ilitial (urethra] midstream by 10times (suggests VB2: midstraern (bladder) prostate as bacterial source] EPS (eJC!li!!SSed prosta1ic secretions): {prostate] not usually performed VB3: post-massageiDRE (prostate) UrineR&M Blood CBC. abacterial subtypes Tabla &.gonorrhea or Chlamydia tradwmatis • >35 years+ penetrative anal intercourse.linolones. tender. recent cystascapy. TMP/SMX or doxycydina. voiding. postejaculatory pain lnmtigllions RectaiiiDUIIl Urine C&S: 4 specimens Enlarged. addition of an a-blockar may reduce symptoms DREwriabla Urine C&S negative on serial specimens Prostate biopsy (rarely performed) shows histological inflammation Tl'1lltmllnt Trial of antibiotic therapy fluoroquinolone or doxycycline if Chlamydia fnlchomtltis is suspected a -blocker to relieve sphincter spasms. unprotected sexual contact • instrumentation/catheter • reflux • increased pressure in prostatic urethra (straining. E. ejaculatory pain. chronic bacterial. C&S Supportive measures (an!Viretics. ' .. lower back and perineal pain Storagellld voiding WTS Hematuria .. immunodeficiency IV antibiotics {ampicillin and gentamicin) asevere Mid-stream urine C&S at 1and 3 months post antibiotic therapy Avoid clllheterillllion due to risk of bacteremia llld systemic infection Small drainage calhBtar may be inserted a obstruction suspected Extended course of antibiotics (3-4 months) Ruoracp. Ramambar: torsion >6 tn has poor prognosil.GI organisms {esp.Toronto Notes 2011 Infectious anclln1lammatory Diaeaaes Urology U13 Prostatitis/Prostatodynia • most common urologic diagnosis in men <50 years • incidence 10-30% • acute bacterial.. urimry retention. coli Ascending urethral infection and reiiUK into prostatic ducts 01tan associated with autlst abmuctian {BPHJ. coli) • mumps infection may involve orchitis after parotiditis • other rare causes: • TB • syphilis • granulomatous (autoimmune) in elderly men • amiodarone (non-infectious cause.xacerblllions of acute prostatitis signs and symptoms Recurrent UTI with same organism Type Ill: Chronic Pelvic Pail Syndrome {AHc:IBriil] Divided into inflammlllory and non-inflammlllory subtypes lntraprostatic reflux of urine ± urethral hypertonia Multilactorial (immunologicaL neuropathic.. malaise Rectal. chills. '.I If unsura b81w8an diagnosas of epididymitis and torsion: vo to OR. Risk Factors • UTI. NSAIDs llld supportive measuras for symptomatic llllillf Epididymitis and Orchitis Etiology • infection: • <35 years . psychosocial) asymptomlllic with normal prostate on DRE Pelvic pain. abscess or apididymo Type II: Chronic Bill:tBrill Prwliltitis Recurrent e. neuroendocrine. storage LUTS. heavy lifting) may cause reflux of urine along vas deferens -+ sterile epididymitis .

± initaliva UJTS Gram slain demonstrates >4 PMN/oil immersion field. purulent discharge • reactive hydrocele Investigations • urinalysis (pyuria). Poor sii1Sitivity. reactive arthritis) Tabla 7. trachomatis . inflammatory (e. gonon11eae. no evidence of N. clln"t climb a 1nlll} History of sexual conlact.g. must do: • colour-flow Doppler ultrasound • nuclear medicine scan • examination under anesthesia Treatment • rule out toraion • antibiotics: • N. Clinical Features • sudden onset scrotal pain and swelling ± radiation along cord to flank • scrotal erythema and tenderness • fever • storage symptoms. ice. discharge: Gialil stain/culture • if diagnosis uncertain. psychological etiologies . cancer. irritcrtiva L. Prehn'• 1ign: pain may be relieved with elevation oftesticlel i1 epididymitis but not in testicular 1Drsion. .Jchomatis Hirtory of sexual contact. •t-----------------.al Clusatiw= DI'Qinillm Neisseria gononheae Usually Chlamydia tr.. analgesia Complications • if severe -+ testicular atrophy • 30% have persistent infertility problems Urethritis • common causes: infectious. yellow purulent discharge. urine PCR ami/or culture from urethral specimen Azithrumydn 1 gPO DDCI or doxycycline 100 mg PO bid x 7 days Diagn111il Reactin Artllriti1 (furm•ly llnawn • Urethritis. urine C&S • ± urethral.U14 Urology Infedioua and ln1lammatory Diseases Toronto Notes 2011 . interstitial cystitis.. urine PCR allll/or culture from urethral specimen Cllfildme 400 mg PO DDCI orCeftrixune 125 mg IM once AND treat for Chlamydia trachomatis Wer"• Synclrom•l Urethral Syndrome • dysuria in females with consistently sterile urine cultures or low bacterial counts • some have bacterial urethrocystitis (C.broad spectrum antibiotics (Septra•. trachomatis or other organisms) and require antimicrobial treatment • treat: tetracycline or erythromycin • rule out: vaginitis. Uveitis ll1d Arthritis (Cin"t pee.cefixime 400 mg PO once followed by azithromycin 1 g single dose or doxycycline 100 mg bid x 10 days • coliforms. e5p&ciaUy in children. Non-Gonococcal Gunococc. lnfactious Urethritis: Gonococcal vs. gono"heae or C.. mucoid whitish purulent discharge. 188.l1TS Gram slain (GN diplococci}.. Cipro•) x 14 days • scrotal support..

never comfortable. purines. oxaluria.. chills. oxalate. or tip of penis due to stretching of collecting system or ureter (ureteral colic) • writhing. G6PD. terminal hematuria. cystinuria. vomiting.. rule out concurrent pyelonephritis or obstruction Differential Diagnosis of Renal Colic • acute ureteral obstruction (other causes): • UPJ obstruction • sloughed papillae • clot colic from gross hematuria • acute abdominal crisis . suprapubic pain • ff fever. • dietary excess: Vitamin C. pancreas. . pelvic inflammatory disease (PID) • pyelonephritis (fever. tachycardia. diaphoresis.Toronto Notes 2011 Stone Disease Urology U15 Stone Disease Incidence • prevalanceof2-3% • male:female = 3:1. etc. nausea. 60-80% lifetime Clinical Features • urinary obstruction -+ upstream distention -+ pain • flank pain from renal capsular distention (non-colicky) • severe waxing and waning pain radiating from flank to groin. low flow and low volume of urine (dehydration) • crystal formation and stone nidus • loss of inhibitory factors: • citrate (forms soluble complex with calcium) • magnesium (forms soluble complex with oxalate) • pyrophosphate • Tamm-Horsfall glycoprotein Risk Factors • hereditary: RTA. torsion/rupture of ovarian cyst. Under vas dafarantlbroad H gamant 4.ectopic pregnancy. :xanthinuria. hematuria (90% microscopic). Palvic brim . sarcoidosis.. nerve root compression Location of Stones • calyx • may cause flank discomfort.biliary. Ttle four narrowest passaae pointJ for upper tract IIIDnn ara: 1.. . abdominal aortic aneurysm (AAA) • gynecological. testis. urgency) • bladder stones result in: storage and voiding LUTS. histoplasmosis. pyuria) • radiculitis (Ll) -herpes zoster. recurrent infection or persistent hematuria • may remain asymptomatic for years and not require treatment • pelvis • tend to cause obstruction at ureteropelvic junction (UPJ) • staghom calculi (renal pelvis and one or more calyces) • often associated with infection that will not resolve until stone is cleared • ureter • <5 mm diameter will pass spontaneously in 75% of patients Stone Pathogenesis • supersaturation of stone constituents (at appropriate temperature and pH) • stasis. calcium • dehydration (especially in summer months) • sedentary lifestyle • medications: thiazide • UTI (with urea-splitting organisms) • myeloproliferative disorders • GI disorders: IBD • hypercalcemia disorders: hyperparathyroidism. etc.. tachypnea • occasionally symptoms oftrigonal irritation (frequency. peak incidence 30-50 years of age • recurrence rate: 10% at one year. bowel. 50% at 5 years.lNJ z. UPJ 3.

.Ul6 Urology Stone Disease Toronto Notes 2011 Approach to Renal Stone -------------------------------- Urvent Intervention requirad if: 1. Singla kidney with UI&!Billl obstructionlbilatellll obstructing 2.. RBCs. Bilateral stones 3.g. Ca.1nlrBctllble vomiting stones • no contrast... bladders (KUB) x-ray • to differentiate opaque from non-opaque stones (e. Ca. sepsis.5 em • Staghom • UPJ obstruction • Caiyl. creatinine and urea • PTH ifhypercalcemic • 24 hour urine x 2 for creatinine._ .Elective • medical • conservative if stone <5 mm and no complications • fluids to increase urine volume to >2 Uday (3-4 L if cystine) • specific to stone type (Table 8) wilt1 ESWLJ .. Fever (sugglllll infection) 4.._.1111l diverticulum • Cystine stonas (poor1y friQIIIIIIlld Treatment . Approach to Ranll Stone . Cr. lndiemon• for •dndsahln bl huspibll: l. BUN -+ to assess renal function • urinalysis: R&M (WBCs. Acuta renal faiure Figura "1.. morphine)± antiemetic • NSAIDs help lower intra-ureteral pressure (e.Moua • Size >2. ureters. Treatment -Acute • medical • analgesic (Tylenol #3•. P04> uric acid. conduct metabolic studies • serum electrolytes. Mg.. uric acid. . Compromised renal function 5. oxalate. renal failure) • ureteric stent (via cystoscopy) • percutaneous nephrostomy (image-guided) • admit if necessary ..g. Solilllry kidney 2. crystals). extravasation • cystoscopy for suspected bladder stone • strain all urine -+ stone analysis • if recurrent stone formers. . citrate . lnllllctable pain or 4. indinavir) • 90% of stones are radiopaque Rdiollllllll ladiolluclllt Uric Acid lndinavir lndinavir IWB Struvita Cystine Calcium CT Calcium Struvita Cystine Uric Acid • crscan .. C&S • imaging • kidneys._. .._________________ lndicatiana far Pwcut.lntractBIH pain .see sidebar If aptic. ________________ Investigations • screening labs • CBC -+ elevated WBC in presence of fever suggests infection • electrolytes.. DemeroJ•. P04> uric acid. degree of obstruction.e. 3. IJilllnl uramric mnt or percutaneous neplns1Dmy should be considerad.. Ketoralac) • alpha-blockers: increase rate of spontaneous passage in distal ureteral stones • ± antibiotics for UTI • IV fluids if vomiting (note: IV fluids do NOT promote stone passage) • interventional: if obstruction endangers patient (i.. _. good to distinguish radiolucent stone from soft tissue filling defect • abdominal ultrasound • may demonstrate stone (difficult in ureter) • may demonstrate hydronephrosis • IVP (not usually done) • anatomy of urine collecting system.

Low dista!y calcium IIIIIs 1o incnaasad lllCBID absorption and higher Lilla levels of calcium OJIIIIII!I. Gl water loss) precipitation of struvit8 • Drugs (ASA.5 crn • percutaneous nephrolithotomy if stone >2. 21Xl5) Wife .Toronto Notes 2011 • interventional Stone Disease Urology U17 Bliclcyll o-IIDiian a till Tlllllnt II UnllniS.31-1..reasonable alternative for distall/3 of ureter open ureterolithotomy (very rare) • bladder • transurethral cystolitholapaxy • remove outflow obstruction (TURP or stricture dilatation} liDs.' Al1hough hypercalciuria i5 a risk fac!Dr for stone formation. tTNtmant ifstons ± potassium citnlte. oxalate..MBIJNE (JiruaJV 1966111 DctuiJer U 1110 1111111u aladnlric diiiiJIIe of a-blockln lilellpy. and fructose intake • avoid high-dose vitamin C supplements • medications: • thiazide diuretics for hypercalciuria • allopurinol for hyperuricosuria • potassium citrate for hypodtraturia . cytDtaxic drugs) Radiolucent on KUB Radiopaque on CT Acidic urine Perpetuates UTI because stone harbours organism S1one and all forei!J1 bodies roost be clecnd to avoid racurrenca Associated with staghom calculi Positive urine dip and cultures Note: E. Satratia. .medfll'lillnm idlhlled in l'llillll: 11 studin 11'1! llill:tian crD!i1 (n=l11).rith igJilll:lnltf incmud lllH al clllll uretnl slllne Prevention • dietary modification: • increase tluid (>2 L/day}.111e C4clillll8 Carmi SMh lilnry. Pseudomonas...QIIIS8Miiw blltnwlt Ilana bv 4411 (M 1:11. a-blac:lil!lhlnpr isiiDIICilled v. Cabiar. S. ± alopurinol >5 mm orpresence of Calcium struvite. dacraasing diallry calcium is NOT recommended 1o prevent stone formlllion. Ttatmllrt rqad from Bdlys ID 6Willis. .tiASE llbllrldl pwmd 111111u Anrul Mallilu a1111u An.-giline) Uric acid in low volume.ureteric stricture . thiazides) ammonium jhlsphata) • Diet [pume rich red meats) o Hyperuricosuria with hyperuricemia o Gout o High rate of cell tumover or cal daldh gdemia. 1119:1183-117 •kidney • stent if stone is 1.5 to 7 (bicarbonate. Penicillaminl1/ a-MPG or Captopril (form compktx with cystine) Shockwave lithotripsy not effective Trennent Fluids to incn!llse urine volume to >2Uday Matica/ if slons <5 mm For stones: celulose pha&phate. coli infection does nat cause stnrvite stones Kay faatulll Aggressive stone disease seen in children and young allllts Recurrent stone formation. potassium drate) ± allopurinol Shockwave lithotripsy not effective Complete stone clearance Antibiotics for 6weeks Regular follow up urine . J. potassium intake • reduce animal protein.5 em • extraoorporeal shockwave lithotripsy {ESWL} if stone <2.failed ESWL . omithine..... Er...lysine. Aaiacillliall (2002.15%) Hypercalciuria Hyparuricosuria [25% of pati8111s with Ca stones) Hyperoxaluria (<5% of patients) Hypocitraturia [12% of patients) Other causes: • Hypomagn8S8111ia . p<0.5 em (see sidebar Ul6) • ureter • ESWL is the primary modality oftreatment • ureteroscopy (extraction or fragmentation) if . !im 2007. low ume volume results in alkaline urinary pH and (e. urine clr'Dnnatogrephy for cystine Increased fluid intake (3-4L of urimt/davl Alkalinize urine (bicarbonate.. pota&&ium citratu).antibiotics (stone complications (see U76) must be removed to treat infection) lncreesed fluid intake Alkalinillltion of urine to pH 6. o Hyperuricosuria alone Mycoplasme. concentnrtion: Provid8nciB. autBUS) o Low urimry pH.001).51.associlll8d with hyperoxama and hypocitraturia • High dietary sodium • Decreased uril'lll'f proteins Radiopa!J!e on KUB Rerllcing dietary calcium is NOT an effective method of preventiol\"' tr8irtrnent Uric Acil [5-10%) StruYita [5-1 0%) Cystine [1 %) Autosomal recessive defect in small bowel mucosal absorption and ranal tubular absorption of dilasic amino acids results in "COLA" in urine [cystine. sucrose. KJebsialle. Giani: lnc:idlncl al dillll Lnlllll Rlnl 1IIIUII: J. sodium. family hi&tory Often staghom calculi Faintly radiopaque on KUB Positive urine sodium nitroprusside test. . orthoph05phate for and no complications absorptive causes ProcadJrai/Sutg For calcium oxalate stones: thiazides. Infection with urea-splitting acidi: urine with ahigh uric acid organisms [Proteus.lminillrltian 11111 a-ilb:brwM!I CGISIMiiw1llltmlli inmued incidence oftiDnl .. Table B.5-2. Stone Classification Type of Slana Efiolagy Cllci1111 [7§.g. 2005)..

.Ul8 Urology Urological Neoplamu Toronto Notes 2011 Urological Neoplasms Approach to Renal Mass Cystic .11d I I Hypoechoic No calcification Thin wall • Dense Calcified Septated . • • ea.Gf Enlllrpd ICIIInep SIIAPE Sclerodanna HIV nephropalhy • Amyloidosis Polycvstic kidniiY diuas• Endocrinopllthy' (diabeles) • • very common . no calcifiCiltions. la!'llemass (>1.. • simple cysts . Tabllra• Scl11n1U.up to 50% at age 50 • usually incidental finding on abdominal imaging classification of cysts (i.5cm) I I I SUI'lllrf • I I Surveillance • I I SUI'lllrf Possible surveillance Figure I. no septalions. simple and complex) • Bosniak classification is used to stratify for risk of malignancy based on cyst features. pancreatic and epididymal cysts • 30-40% incidence of renal cell carcinoma Table 9.e.. see Table 9 polycystic kidney disease • autosomal recessive . cerebellar and retinal hemangioblastomas._----------------. thicker and mere irregular walls. I I I I Small mass (<1.5cm) .massive kidneys with early renal failure in children • associated with hepatic disease • autosomal dominant .. no solid component Thin septillion.progressive bilateral disease leading to hypertension and renal failure • associated with hepatic cysts and cerebral aneurysms medullary sponge kidney • dilatations of the collecting ducts • usually benign course.. hyperdense on CT ThickEr septatians.. but predispose to calcium phosphate stones von Hippel-Lindau syndrome • renal cysts. epilePJY. AuiD&omal dominant JYndrume chnellrized by mantel retardation. B01niak Classification of Renal Cysts Cl11s Features Round. adenoma sebaceum •nd other hllmar111111a. surgical intervention usually necessaiY Near certain Simple cyst 2 3 4 Minimally complex cyst Con1llex cyst Clearly malignanl . CT (exclude angiomvolipoma) Sbip CT* Angiography Possible aspiration or biopJY I . Workup of a Renal Mass •MRI DCCISionally pe!fonned I conlnlll corrnindit*d Benign Renal Neoplasms RENAL CYSTS .. measurable enhancement Class 3plus enhancing sllft-tissue components Risk of Malig111ncy N99rzero Minimal Moderate. Solid .. IUllnlso1. calcifications.

bone pain • local effects: classic "too late triad" found in 10-15%: • gross hematuria 50% • flank pain <50% • palpable mass <30% • was called the "internist's tumour" because of paraneoplastic symptomatology. now called the •radiologist's tumour· because of incidental diagnosis imaging • systemic effects: paraneoplastic syndromes (10-40% ofpatients) • hematopoietic disturbances: anemia. papillary. lung and liver most common sites Investigations • routine labs fur paraneoplastic syndromes (CBC. brain. gonadotropins. fever. hypertension (increased renin). granular.Toronto Notes 2011 Table 10. no evidence of metastases. B•ign Renal Masses Urological Neoplasms Urology U19 Renal Oncocylllm1 Epidlllliolagy llen1l Ad1110m1 Incidence increases with age Found in 7-23% of all autopies Less than 1'!1. flank pain and palpable mass (same as RCC) Benign course although excision warranted if inCillllsad risk uf rupture and retroperitoneal bleed (large size. ESR. peripheral edema (due to caval obstruction) • metastases: seen in 15% of new cases • bone.. chromophobe Clinical Features • usually asymptomatic. insulin and cortisol) • hepatic cell dysfunction . capsLJIIllld with possible cenlnll scar HistDiogically organized aggregates of eosinophilic cells originating from intercalated calls uf collecting diet lncidml finding on CT although difficult to distinguish from RCC Biopsy may be performed to rule out malignancy M:F=3:1 Small cortical lesions <1 em Majority are solitary but can be multifocal Histologically organized cells with no atypia which may exhibit bisornv of chromosomes 7 and 11 lncidml finding on CT Rarely syrl1llomatic Controversy as tD whelher this represents benign or preofllalignant neoplasm PartiaVradical nephrectornv if mass >3cm lkla tD increased risk of mlll8stllsis PartiaVradical nephrectomy for large masses High intensity focused ultrasound (HIFU) or radiufrequency ablation (RFA) for smeller masses Malignant Renal Neoplasms RENAL ADENOCARCINOMA [Renal Cell Carcinoma (RCC)] Etiology • cause unknown • originates from proximal convoluted tubule epithelial cells • risk factors: smoking (results in 2x increased relative risk). More common in males F>M 211% associill8d with tuberous sclerosis (especially multiple. cystic lesion and to determine extent and operability) • IVP (mass lesion): no longer routinely done • angiography: no longer routinely done .. cystic lesion) • CT scan (to distinguish solid vs. rumour may invade ranal vaint and inferior vana (may mull in IICiiBI. TSH. erythrocytosis (increased erythropoietin).-nbolil. smooth musde and blood vessels May extend into 11!1181 vein and become symptomatic Dilgnasis R:idml diagnosis Negative attenuation {-ZO HU) on CT is pathognomonic Rare presentation of hematuria. anemia. employment in leather industry • familial incidence seen with von Hippel-Lindau syndrome Epidemiology • eighth most common malignancy (accounts for 3% of all newly diagnosed cancers) • 85% ofprimary malignant tumours in kidney • male:female = 3:1 • peak incidence at 50-60 years of age Pathology • histological subtypes: clear. decreased WBC count. polycythemia. production of other hormones (prolactin. cadmium exposure. raised ESR • endocrinopathies: hypercalcemia (increased vitamin D hydroxylation). spindle cell. hllpetic dysfunction. previous bleed) Follow with serial UIS Spherical. and pulmonary . . areas ofhepatic necrosis. pregnancy. right lllrilll tumour. . weakness. reversible following removal ofprimary tumour • hemodynamic alterations: systolic hypertension (due to AV shunting). LFTs) • urinalysis (60-75% have hematuria) • renal ultrasound (solid vs. of alkllt renal tumours 3-7% of renal tumours."Stauffer's syndrome": abnormal liver function tests.frequently diagnosed incidentally by U/S or CT • poor prognostic indicators: weight loss. . recurrent) Clonal neoplasm consisting of fat.

. a.x-ray. 2-596 are bilateral • M:F=3:1 • relative lncldence. tllnOW' <1 em. Risk Factors • smoking • chemical exposure (industrial dyes and solvents) • ll!lalgesic abuse (acetaminophen.ing orgllli11111 Treatment • radical ureteronephrectomy with cuff of bladder • dlstal ureterectomy for dlstal ureteral tumours . N1: IIIBIIIIalii1D 8 <Zem M1: pra8IIIC8 af liltlm 11181881111il NZ: IIIBIIIIalii1D 8 node bll\W8tll Zand 5em cr miAtipla nadas <Zem Nl: nada >5 em Figure 9. . .. lymphatic • Involves cr..liver euzymes and functions. tumour.painful bony lesiona • chemotherapy: NOT effi:ctive • advanced stage: • anti-angiogenesis (anti-VEGF) • anti-tyrosine kinase: sunit:inib • anti-ll. <4em T1b: 4-7 em TZ: limDUr >7 em.5-year survival is approximately 6096 • 5-year survival of patients presenting with metastasis is 0-2096 Carcinoma of the Renal Pelvis and Ureter Epidemiology • rare. and phenacetin) • Balkan nephropathy (chronic interstitial nephropathy in countries such as Serbia..ccounb for 496 ofall urothclial cancers • frequently multifocal. cedined to P8l1ll pnnchyma l1s.ipsilateral adrenal gland (in upper pole tumours) and intact Gerota's capsule md paraaortic lymphadenectomy • partial nephrectomy: <4 em tumour or solitary kidney/bilateral tumours • surgical removal ofsolitary metastasjs may be considered • radiation for palliation . bone &can Table 11.2: dacllzwnab (Zenapu-) Prognosis • stage at diagnosis is the most important predictor of survival: • T 1 .U20 Urology Urological Neoplamu 1'oroDio 2011 Methods of Spread Staging • direct. RCC Stegi1g T4: limDUr 8ld8ndl ba'jOIII Gllllla's fiiiCil Treatment • surgical: • radical nephrectomy: en bloc removal of kidney.-d &rgery is 1ha only lllflctivl inlllwnti111 fur RCC. cheat . chllmDihlrapy i1 NOT uRIU. venous. adenocarcinoma) • UCC of kidney md ureter are histologically similar to bladder UCC .5-yeauurvival is 90-10096 • T2-T3 .bladder:renal:ureter = 100:10:1 RJ:CII-... ASA. Montenegro. Pathology • papillary urothelial cell carcinoma (UCC). niCilllil Investigations • cystoscopy and retrograde pyelogram: CT scan. Bulgaria) Clinical Features • • • • lliffllltlllilll DillgHIIIil of Aling Dafllct • lkD1halial ctll cninal'lll (diffa1111i118 and CT an) • Uric acid lllllnl (dlfallll'llilllll viii cytology and CT sctn) • Blaod clat • gross pe. but nat bawand GIJDilis fla:ia T3a: itto arRI1fll cr sills fat T3b: irto rellllll VIii or infnllillphlli!JIIIIic IVC 13c: illo supradillphl'llfllllic IVC NO: na regional nadas Ml: na evidence af IIIBIIIIalis node.inle&s hemeturila (70-9096 of patients) microsoopic hematuria flank pain dysuria flank mass caused by tumour or associated hydronephrosis (10-2096 of patients) • l'lpll. radiolucent filling defect on IVP/CT urogram • • GBJ Wlbl1 from 1111 pruduc.. 8596 (othen include squamous cell. 111M Clllllflcatlon of Renal Adellocarclnoma T N M Tl . cadinad to ranal p111111chyma T3: tllnOW' axl8nds no Dlljor vails or achnal. Romania.

Toronto Notes 2011 Urological Neoplasms Urology U21 Bladder Carcinoma Etiology • unknown. de novo) • 15% have occult metastases at diagnosis -lymph nodes. white:black = 4:1 • mean age at diagnosis is 65 years Pathology • classification: • urothelial cell carcinoma (UCC) >90% • squamous cell carcinoma (SCC) 5-7% • adenocarcinoma I% • others <I% • stages of urothelial cell carcinoma at diagnosis: • superficial papillary (75%) -+ >80% overall survival • 15% ofthese will progress to invasive UCC • the majority of these patients will have recurrence • invasive (25%} -+ 50-60% 5-year survival • 85% have no prior history of superficial UCC (i. vomiting and diarrhea) • metastases • hepatomegaly. peritoneum.implicated in 60% of new cases) • chemicals: naphthylamines. liver function tests (metastatic work-up) . bladder stones.consider carcinoma in situ • palpable mass on bimanual exam -+ likely muscle invasion • obstruction of ureters -+ hydronephrosis and uremia (nausea. resection is standard) • new advances with specific bladder tumour markers (e. (associated with SCC) Epidemiology • 2nd most common urological malignancy • male:female = 3:1.e.g. chest x-ray. Grading • Grade 1: well-differentiated (10% invasive) • Grade 2: moderately differentiated (50% invasive) • Grade 3: poorly differentiated (80% invasive) Staging • for invasive disease: CT or MRI. BTA. The antira uruthalium [ptlvis to bladder) il bath8d in can:inogens. The "field d81act"tlleory helps to explain why UCC has multiple lesions and has I high rec1J111111Ce rata. tryptophan. non-papillary erythematous lesion characterized by d)'liplasia confined to urothelium • more aggressive. chronic catheterization. phenacetin metabolites • cyclophosphamide • prior history of radiation treatment to the pelvis • Schistosoma hematobium infection (associated with SCC) • chronic irritation: cystitis. lung. benzidine. urine C&S. but exposure to environmental and occupational carcinogens plays a role • risk factors: • smoking (main factor. urine cytology • ultrasound • CT scan with contrast or intravenous pyelogram (IVP) -+ look for filling defect • C}'litoscopy with bladder washings (gold standard) • biopsy to establish diagnosis and to determine depth of penetration (although cold punch biopsy can be transurethral. poorer prognosis • usually multifocal • may progress to invasive UCC Clinical Features • hematuria (key symptom: 85-90% at the time of diagnosis) • pain (50%) • clot retention (17%) • asymptomatic (20%) • storage urinary symptoms . Immunocyt. bone lesions • lower extremity lymphedema if local advancement or lymphatic spread Investigations • urinalysis.. lymphadenopathy. liver • carcinoma in situ-+ flat. NMP-22. FDP) '.

N+.1JeGCOndUit • stage T3 .g.l (non muscle invas1ve) disease: Tis. flatlllnull' Tl: 1111111111' iiMidas &Ubmucau.U22 Urology Urological Neoplamu 1'oroDio 2011 Tebl11112. T2b. Urutllaill Call Clln:inoma Gf Bladdar Treatment • superfida. T4b.<5% Prostatic Carcinoma (CaP) Etiology • notknown • risk factors • increased inddence in persons of African descent • famlly history • 1st degree relative = 2xrisk • 1st and 2nd degree relatives = 9x risk • high dietary fat increases risk by 2x • cJgarette smoking Epidemiology • most prevalent cancer in males • third leading cause of mole cancer deaths (following lung and colon) • lifetime risk of a SO y.g. ]§ F"1111•r• 10.o. pelvic Will II' Bbdlri& wall PalvicWIIIor Abdominal Will I I 0 Fnltlat8 .cent 11g111 ilwlv1lnant. Tl • transurethral resection ofbladder tumour (TURBT) ± &lDgle dose or maintenance intnwesical chemo/immuno-therapy (e. recurrence and presence of CIS: • stage Tl. Ta.90% at 5 years • stage T2 .TURBT + lilllinlx:nance BCG OR cystectomy in select patients • invasive disease: T2a. number oflesions./IIIID prapria '121: 111rncu iiMidas superficial mu&dll T2b: 111mu inwdes deep IIIIIIZ T3: 1111111111' iiMidBS ptrivesical fal T41: q. mitomycin C) to decrease recurrence rate • high grade disease . DIM Clestificmun uf Bladd• T N M Tt: mnirrvasive papililwy Cll'tftlma N slalus: as fllr 11!11111 cell carcdlma M status: ulur renal eel carciloma T11: caciloma ilsitu !CIS).2096 • stage T41N+IM+ . prasteta. man for CaP is 5096. and risk of death from CaP is 3% • 75% diagnosed between ages of 60 and 85 and mean age at diagnosis is 72 . T3 • radical cystectomy + pelvic lymphadenectomy with urinary divezsion (e.55% f"llglr& 11. BCG.. M+ • initial combmatlon systemlc chemotherapy ± Irradiation ± surgery Prognosis • depends on size. Ullnls arVIIIJinll T4b: lldjlced argan invalvamant. lleoconduit Figure II) or irradiation for small tumours • advanced/metastatic disease: T4a.

882lTII!Iv.Toronto Notes 2011 Urological Neoplasms Urology U23 Pathology • adenocarcinoma • >95% • often multifocal • urothelial cell carcinoma (4.-l'llldln Trill (SB£CT) lippnwl SM. Prostate Cancer MDrtality Risk Low Rilk Madlll'lllt lhk [if any of fallowing) 10-20 7 High Rilk [if any of fuiiDWi1g) >20 8-10 PSA GIBuon Score <10 <7 Stage pT1-2a pT2b-T2c pT3/4 . itvolvement • %of core and number of cores involved Table 14._ 11. U24 • locally advanced disease: • storage and voiding LUTS (uncommon without spread) • suspect with LUTS..IA. c-n. piiCiba Investigations • • • • • • DRE PSA elevated in the majority of patients with CaP transrectal ultrasound (TRUS) -+ size and local staging TRUS-guidedneedle biopsy bone scan may be omitted in untreated CaP with PSA < 10 ng/ml CT scanning to assess metastases nwt.... The njorityal11mlurs in bath graups 118\lwera bcdz8d di181M(T1 11 T2).l8ilrliL111 +villmin E. or as an incidental finding on transurethral resection of the prostate (TURP) • DRE: hard irregular nodule or diffuse dense induration involving one or both lobes • PSA: see Prostate Specific Antigl!n.. confined ID prostate T2a: tumour involving less than alobe T2b: tumour involving less than or equal to 1 lobe T2c: tumour involving bath lobes T3: tumour extEnds through prostate Cl!pSule T31: IIX!nlcapsular IIXIIInsion (unilateral or bilatel'lll] T3b: tumour invadng sami1111l vesicle(s] T4: tumour invades adjacent structures (besides seminal vesicles] M: distant metastasis M1a: nonregionallymph nodes M1b: bone(s] M1c: lither site(sl with or without bona disease plecebol. 349:21&-224 Methods of Spread • local invasion • lymphatic spread to regional nodes • obturator > iliac > presacrallpara-aortic • hematogenous dissemination occurs early S1llly: Alll'lllanimd.rentill DilgJMil of 1 Proltltic Nodule • l'nlstm cane• {30%) • Benign prostatic hypurplaia '. pB:.v. . . • • • • l'nlstatitis l'nlstatic infarct l'nllllllic: calculus Tuben:ulous prostatitis Anatomy (see Figure 6) • 60-70% ofnodules arise in the peripheral zone • 10-20% arise in the transition zone • 5-10% arise in the central zone Clinical Features • usually asymptomatic • most commonly detected by DRE.. cill nat pmant pniSIIt8 elncl' in lllis pilldltion al Nlltiwly haallhy 111811.WI2009. Co•idtntiona In lnt. DHJ.. . .Qlllll. ...•t-----------------. 301(1):39-51 llllllldr.lnm IIIII Vlllmil ECa.... Staging of PrDitate Cancer (TNM 2002) T N M N: spread ID 11!1jianal T1: dinically undetectable normal ORE and TilUS T1a: tumour incidiiiTIBI histologic findilg in < 5% of tissue res!!Cted lymph nodes T1 b: tumour incidental histologic findilg in > 5% of tissue resected nc: tumour identified by neelle biopsy (because of elevated PSA IMII.. IIana Ill in combinltian lithe dalllllld f1lnriMDns lllld. incontinence ± back pain • metastatic disease: • bony metastasis to axial skeleton is very common (osteoblastic) • visceral metastasis is less common with liver. plabo· caolraled IM!dy designed Ill del2mine l'lllelber tJultmart witli mllllarida Cldd IIIla lila ]R'IIIIence II prostm CA during 1711111 period. The firasleride group •lso lad a sigliicdy higher inciclanca ai1111UII swmpiDms 'dlll11111 pliabo graup... . •t-----------------.. c.bo canlrallid 1rillwitll 35. but 1r1 ilcrnsa i11111 proporb al lhose Tabla 13. rilkalpniSIItl CA (55 YIIJIIIIIQI 11 oldlt AtriCIII-Anwican. .. ..t•ian: Sllaniln Dlvillmin E. .5331TIIII \'Onin E. Rlndomilld. lung and adrenal metastases occurring most frequently • leg pain and edema with nodal metastasis obstructing lymphatic and venous drainage Efllct rl Sllftun IIIII Villlllil E• lilt all'lallllllc-ud .5%) • associated with UCC of bladder • not hormone-responsive • endometrial (rare) • carcinoma of the utricle . blulll: Study MS cloeed emtv as olijectiues were Glide tuncus !Gleason score 1-101 inciclanca]. l"'ported {e. h_.'dla t:IIIC8IS ilthlfinllllridl grDUpWINaf I higi. elevated PSA.rprdn1 Prostata Biopsy Renlts • GI8QOn ISCOI'll6 for two moe!: prN!minant patmms ar.. lhin 17-. n.l'rlllllll c-l'nlnnllllll 1111 tiV1l NUf 21103.. Cancbioll: MIIIIIMII 55 who took filllllaride for 7\'IIIIW8nl 25\lals lblv1D dMop pniSIIt8 CA 1otbu plaeebotJQUP.g.001) in prM1111:1 rl pnllllll CA in 1111 filu1lrill gnllf [18\ incidallctl COITptlld 1D pllcllllo p t [24ll.illl . or 11st d'fBI relllive hlwi1Q pniSIIt8 CAl witli 11'1111TT111 ORE and 1 PSA IMI rl g 111tniWIN Qlled.. tumours found in 1or bath lobes by needle biopsy but nat palpable or l'llliably visible by imaging T2: palpable. 3+4 = Gleason sum Nota: 4+2 not equal to 3+3 despite equivalent Gleason sum) • Billlbnl "'· . Kltil EA et al. lb&ra-1 MAIIIIMI TldL£1ian (P<0._I'IMience GIJNUSI* CA Finllllrid1 (51TO"dly) vs.. S.r period. or pllcebo.lli1e. t2'J.

PSA velocity... test characteristics.. masua-. pnnibditis. The lelltNe risk rl bodllocll iiiVISiorr 111d 1he spread rldillld111111S1111s-dsolianificarrlti decnued with lilly lldicll prostaiiCtDrTiy 81'1ChythM'IpJ ExtamaiB_.rimtion.5 <3..removes 90% of testosterone • GnRH agonists [e.. but should take into account multiple factors (free and total PSA. bypass Ql1lft..OOllltld D.. older patients Disease pragression Erectile dyshr.. prior biopsy history and comorbidities) Strategies to Increase Specificity of PSA • age-related cut-off values Table 16. 111rolld iam 14 CIJ'ils lll1lllld Swldlll. radia1ion therapy.. hilt! grade disease • Otlrar options includl high irt1n1ity foms11 '*n!IOUnd {HIFll).. prolllrtic. lldical praslllldDmy improved 1118 llniwl in lTIIII with il Early.ction (5D%).4..OO {p<O.1ncmian criteri• incUd8d being undlr lila of 75.. The PriniiV llllpoint rl1he study was IMmll lTIGitJity u ID p!IJIIIts C111C8t with IICDIIdlty 1ndpaia lllkln ID be local prl9lllian and dilllnt 1111111111111... l'ltialb W8A1 rlnllolriy lllignad 011811:1 bail ID llillltr en iiiiiiMnlion grnup {TIIicll proslllaCIDmy) or r:an1RA Wliling).5 JE st al.)..see sidebar) • population-based..l'ltholagr hiiiiiD show Ilk allllldnlltt or llmlur.. PSA value.. . The Nlllivl risk II derrtll d11111D poe11t1 CII1C8r in lila irrbrMnliorr 11011-invlliw pnllllta CIIICir II compnd ID . II compnd 1D 1118 COIIIJol Qroup. diethylstilbestrol (DES)] • antiandrogens [bicalutamide (Casodcx•)] • local irradiation of painful secondaries or half-body irradiation • chemotherapy regimens that include docetaxel may improve survival in advanced prostate cancer that is no longer responsive to hormone therapy Table 15. The lelltNe risk IRR) rllocll protpeSiion •nd dislllnl llllllslllsll for 1118 inlllvmion 0... good follow-(Jp Low volume.33 {p<O.. PSA doubling time Prostate Specific Antigen (PSA) • enzyme produced by epithelial cells of prostate gland to liquify the ejaculate • leaks into circulation and is present at <4 ng/mL • measured total serum PSA is a combination of free (unbound) PSA ( 15%) and compl.. 2009 Update • PSA may be elevated in prostate cancer and many other conditions. ... patient age. 352:1 m-84... n!JMt Treatment • Tl (small well-differentiated CaP are associated with slow growth rate) • if young consider radical prostatectomy.g. Treatment Options for Localized Prostate Cancer Wlll:hful Waiting (Active Surveillance) Low grade cisease or short life expecllllcy ( <5-10 y).5 <4. low grade Locally advanced disease.DliiiiPiclivlly. U43) • requires hormonal therapy/palliative radiotherapy for metastases • bilateral orchiectomy. i&ehsmirl/ infarction. Nonnal PSA Value by Aga Group Serum PSA Concentndian {IIJ'l) 411-49 50-59 60-li9 70-79 It' In PSA testing. <2. acute urinary retention. erectile dysfunction (3D-51l%) c:... it is not specific to prostate cancer • currently mixed evidence concerning effect of PSA screening on mortality (ERSPC and PLCO trials . WIIIID rnodllllaly dilllnrnlilfld Ullourt. 695 lllmWIIIPI1JIIIeeM. a normal DRE does NOT significantly llrnll1 PSA. 270{71:86(). c..5 <6. risk of rectal cancer Incontinence (11l%).ot lnt:r11uad PSA BPH. comparable with normal life expectancy • stage T3-T4: 40-70% survival at 10 years • stage N+ and/or M+: 40% survival at 5 years • prognostic factors: tumour stage. erectile dysfunction (51l%).li1AM 1193. PSA density.. family history. tumour grade.. goserelin (Zolada-)] • estrogens [e. T4 • staging lymphadenectomy and radiation or hormonal treatment • N >0 or M >0 (see Common Medications.:u-llrldicel ptOSIIIIcbrmy retb:el1he risk rl dlltlr clJ11Dprillllll Cllll*' in 111111 with 11011-invlliw. Pf1)5lllhl biopsy/allgflfY..? long term effectiveness Radiation practitis (S'lf.. treatment and active surveillance options • well-informed patients can elect to undergo PSA test and DRE • the decision to proceed to prostate biopsy should be based primarily on PSA and DRE results.linllad bllwlln 1989ltld 199!.. routine screening not recommended • must discuss risk factors. 111nal faiiU111. TRUS.: To dellnnina whether aut.. urllh111l c:am.lliln: diiQIIOMd pn1111ta CIIIC8t sllg8 T2 or lels. . hormonlllllllltion Prognosis • stage T 1-T2: excellent.g.U24 Urology Wi:ll . low PSA (< 10).... .exed PSA (85%) Screening Prostate Cancer: PSA and ORE AUA Best Practice Statement. • compll8d ID Wlldrlul Wliq. ADiiyliiWIS perflmnld on 111 inllniiiHD-trllt belil. tlink "free and auy": increased free/total nrtio suggeslli b111ign cauu of high PSA. Tharapy Young patients (<65 y).leuprolide (Lupron• or Eligard•). ethnicity. risk of over-detection and over-treatment. c . brachytherapy or radiation • follow in older population {cancer death rate up to 10%) ·T2 • radical prostatectomy or radiation (70-85% survival at 10 years) or brachytherapy • T3._WIIr:WWiiliq Urological Neoplamu Toronto Notes 2011 NEJM m.

2\n.75 nglmUyear associated with increased risk of cancer • PSA density: • PSA divided by prostate volume as found on TRUS • >0.80 IP<D. >20% free suggests benign cause • PSA velocity: • change of>0....Z!l04 m Epidemiology • rare. Pathology • primary: • 1% of all malignancies in males • most common solid malignancy in males aged 15-34 years • undescended testicle has increased risk (10-40:x) of malignancy • 95% are germ cell tumours (all are malignant) • seminoma (35%) classic.0 nglmL unless the history or clinical examination suggests bony involvement • disease monitoring: serum PSA should fall to a low level following radiation therapy. lung.. teratoma (5%). atrophy. . lullllllizlll bnpunlludy NEJM2001. 11111(zad on Ill iniiOOon-1o-SCRIIn IIIIis. c:.15I. sex hormones._n Testicular Tumours Etiology (Risk Facton) • cryptorchidism. Sertoli (gynecomastia. ltld clii1D the ildolad CUll afmany prDIIltS Clnalll. precocious puberty). but most common in young adults (17-37 years of age) • high cure rate • any solid testicular mass in young patient ...: To detamina 1111 lfficlcy of prollllaspdic dg8n ll'SAiscraaq ill impi'Mig prDIIltS CIIICIIr.Pri TllliMnt rl conlimld i)RIIIIII was laft1o the guidlines rlaldi courty... lila needed to sa...!dan: 1821611 IIQI!d SG-74 were remilldbltwelll1994. !hill flct nut be lliren irQ considlndion... Scr..ning conlind of a PSA 1M talren MY 4 Y8ll1 {i llld cut-dlfor bicl!liY was at 3ri. 3611:13211-8 .I1111Dnl: T1'11111of PSAsa. Mllllllftivll in .g. 2009 Update) • therapeutic decision making: patients with serum PSA levels <10. infertility • family history. decreasing the percentage of the free fraction • <10% free PSA suggestive of cancer. It can however. l8'l. r. On:ltiapoy SurgiCIII dNC:unt (orchiopexy) of cryptorchidism) • 2-3% bilateral (simultaneously or successively) undescended testis does nat reduce the rill!: of mlllignlllncy.duc1 the rilk of infertility lllld physical axarn. The lllltiiiD ria IVClJclionwas0. GI) Clinical Features • • • • • • • • • • painless testicular enlargement (painful if intratesticular hemorrhage or infarction) firm. 11116: Median fliiMo\QJ time WIS 9yem. Fur1her Wjy is Wlll3llled 11 examine 1lle aptimll llml ofPSA Uldttnsholds 1D 1*11fon!ll1111 the optimall1llfllff 1D IHIICI thlrisbri!MIIdilgnlllilandllllJCIIdprDIIltll c:m:ur nutD!y.. personal history of testis cancer E!JropB counlrin 111d p!IIIIICtiwly mild and IIIMimniltd llllilhlr 1 ar cantral group. non-tender mass dull heavy ache in lower abdomen.. yolk sac («1%).Toronto Notes 2011 Urological Neoplasms Urology U25 • free-to-total PSA ratio: • complexed PSA increases in prostate cancer.... canlrDiwu 0. HIV infection. mixed cell type (40%) • 5% are non-germ cell tumours (usually benign) (testosterone. and 1lle incidence rl prostate Clf1Cel ill the sa-eerilq Pf was8.. The prin'llry anll-poirt was IMII1111101111ity.. prostate.0 nglmL are most likely to respond to local therapy • work-up: bone scans are generally not necessary in patients with newly diagnosed prostate cancer who have a PSA <20.0 nglmL seven months after initiation of therapy is associated with a very poor prognosis (median survival: one year) . PSA should remain undetectable following radical prostatectomy • outcome prediction: in patients with metastatic disease receiving androgen suppression therapy. choriocarcinoma (<1 %).71 group. failure to achieve a PSA nadir of <4. decreased libido) • secondary: • male >50 years of age • usually a lymphoma • metastases (e. 1lle increaled rill ridilgllllil was spcdf iiCflllld in group..15 nglmUg associated with increased risk of cancer . patients Other Uses for PSA (AUA Bast Practice Statement. anal area or scrotum associated hydrocele in 10% coincidental trauma in 10% infertility (rarely presenting complaint) gynecomastia due to secretory tumour effects metastatic disease related back pain supraclavicular and inguinal nodes abdominal mass (retroperitoneal lymph node metastases) .must rule out malignancy • slightly more common in right testis (corresponds with slightly higher incidence of right-sided '. high intensity focused ultrasound and cryotherapy and should not rise on successive occasions. in ill canlrDI ThalliiiiM risk al dllth il llfliUP n. anaplastic.n r/1410 IIIII a rurlie! 11l8dld 1o 11111 r/48. trnslB.ningwullill 1D !Xdarallillive riskllllb:tion aiM1ollllll rl50 at 74 {MbthiiTlljority rl benefit se111 in m111 aged SG-611. spermatocytic • nonseminomatous germ cell tumours (NSGCT) embryonal cell carcinoma (20%).

radiation. . mllbrs for staging AFP. ./ .U26 Urology Urological Neoplamu Toronto Notes 2011 .-Jlymphl. Paget's disease ofthe penis (extremely rare) • definitive diagnosis requires full thickness biopsy oflesion . ..tic: illllll$ion • T2: tumour extends beyond tunica albuginea or vascular/lymphatic illllll$ion • T3: tumour involves spermatic cord • T4: blmour invadll scrorum • T4a: tumour invlldes spermatic cord • T4b: tumour invedes acrollll WilD 90% Staga I Surveillance Ralialion . RPLIIIP can ba perform ad in a niiVI . .-----------------. basal cell.. but they have not been reported from left to right • hematogenous most commonly to lung.tutlltic to supradiaptngmatic: nodal or visceral Mixed cell type Yolk sac CA Chorio CA l'lthologic {Ill orchiectomy) • T1 :tumour confined to tosli$ and epididymis. papilloma Pre-malignant • balanitis xerotica obliterans./ RPI. Figura 12./ . Methods of Spread • local spread follows lymphatics: • right -+ medial. topical5-fluorouracil Malignant • risk factors: • chronic inflammatory disease • STI • phimosis • uncircumcised penis • 2% of all urogenital cancers • squamous cell (>95%). laser.. anterior and lateral nodes • left -+ left lateral and anterior paraaortic nodes • "cross-over" metastases from right to left are fairly common... hemangioma. most common in 6th decade Benign • cyst. SUging Clinical. CT abdomenfpelvis lymphadenoplllhy) • Stage 1: disease limited to testis. Chemothlnpy 1 . .-----------------.-----------------· . .S.. leukoplakia.ion./ . AFP never elevated with seminoma • testicular ultrasound {hypoechok area within tunica albuginea =high suspicion oftesticular cancer) • evidence of testicular microlithiasis is not a risk factor fur testicular cancer • needle aspiration contraindicated Management • orchiectomy for all stages • adjuvant therapies as per Figure 12 Tentoma Embryonal CA Germinal cell Epithulium IVC ie on thlllight: Right testicle draits in to the IJII111CIMIII nod11. Management of Tll'licular Cancer APLND = retruperilmeai-IIXIe dillectiln Adapted from Dr. AorU is •11111 Left: Lsft testicle drains iniD the pr.. . lllenlfore 1rans-scrotalllppi'08ch for biopsy or orchieciDmy shoolei be avoided. . Testlll nl acroblm hlva lymphlllic drain11Q8. paracaval. . nevus. liver. ulcerated plaques on the glans • treatment options: local excis../(residual mass) .CXR metatases).-----------------.. stage ll disease • 70-80% complete remission with advanced disease Penile Tumours • rare (<1% of cancer in males in U.. sparing fashion. MAS Jewett Prognosis • 99% cured with stage I./ ./ 10% Staga 11+111 40% Staga I ./ 20% Stage II 20% Staga II .JIID• ± ? .).. Buschke-Lowenstein tumour (large condyloma) Pre-invasive Cancer • carcinoma in situ (CIS): • Bowen's disease -+ crusted. LDH). red plaques on the shaft • erythroplasia of Queyrat -+ velvet red. melanoma. and pnaortic nodes.. no vascui. . epididymis or lji&ITTIIIlic cord • Stage II: diseasa limited to the rvtroperitoneld nodn • Stage Ill: diuase m. bones and kidney Investigations • diagnosis is established by railical inguinal orchidectomy • tumour markers: • beta-hCG and AFP are positive in 85% of non-seminomatous tumours • pre-orchidectomy elevated marker levels return to normal post-operatively if no secondaries • beta-hCG positive in 7% of seminomas. .. preserving niMII of the hypogestric plaxus to maintain antegl"lde ejaculation...

. cord nat palpable. brainI superficial lymph nodes T1: tumour invades subspithelial coniiiCiive tissue (Buck's and lla1Ds fascial cavemosurn (throu!ll tunica albugineaI N3: metastasis in deep inguinal or pelvic lymph noda(sl unilateral T2: tumour invades carpus or T3: tumour invades urethra or prostate T4: tumour invades D1her adjacent structures • lymphatic spread (superficial/deep inguinal nodes-+ iliac nodes) »hematogenous Treatment • wide surgical excision with tumour-free margins (dependent on extent and area of penile involvement) ± lymphadenectomy Scrotal Mass • see Common Presenting Problems..tic indications (especially in lldalascantsl .: CIS Ta: non-iiMISive carciloma N2: melil&lil5is in or bilahral M: presence {+I or absence (01 of distant metastasis (lung. TNM Staging for Penile Carcinoma T Tx: prinary 1ll1l0ur can nat be assessed N N1: metastasis in a single superficial.(+ hemorrhagicI Hard lump/nodule Idiopathic: . .. + + + + EMERGENCY! Present cremaster reflex. positive Prehn's sign No transillumillltion Transilumination Transilumination No transillumillltion No transillummon Epididymitia On:hitis H1111atocllla HydiiiCIII SparmlltDcela lllricoclll HIS IllS llydrucale Infection Sperm {spermatocele I llaod {hlmlltacll•l lnlllslirm (hamial TDI'Iion lome veins lvaricocelel lndn=ct lnguilal . cord palpable Bagofwonns Di&renti.. . life Vuic:ec:ale Gl'lldilg Grade 1: l'lllpeblti only with valsalva manaevre Grade 2: Palpable without VIIIIIIIVII Grade 3: Visible through scrotal skin . liver.·}-----------------. Differentiating batwaan Scrotal Mauas Condition Tol'lion Pain Pllpalian Diffuse tenderness Epididymal tenderness Diffuse tenderness Diffuse tenderness Testis not separable from hydrocele.Toronto Notes 2011 Urological Neoplasms/Scrotal Mlllll Urology U27 Table 17. U3 Tabla 1B.. bone.. cou!ll impulse may transmit. .(+ htnmgulatedl Testis separable from hernia. may be reducible Tumaur .·}-----------------. lndicllions for Tl'8ltnlent vf Vuic:ec:ale • Impaired sparm or qullllity • Pail or dulache llffectinv of • Affected testis fails to grow in lldalascants • Cosm. node M TO: no evidence of primary tumour T. gf a Benign krvtal MIIR Additional Findnp Absent cremaster reflex.. cord palpable Testis separable from spermatocele.. negative Prehn's siiJI. positive Prehn's sign PrasiJTI: cremaster reflex.

tender lump) • point tenderness over the superior-posterior portion of testicle Treatment • analgesia . Phylical Eum • Oftan painless • Pulsatas with valsalva • Non-tender.blue infarcted appendage seen through scrotal skin (can usually be palpated as small. rarely into scrotum)abdominal muscle weakness Etiolagy • 10%ofmen • Due to incorJ1)elent valves in the testicular vains • 90% left sided Wtiple theories. lilting.U28 Urology Scrotal Mass Toronto Notes 2011 Table 19. • Excisa symptomatic • Conservative • Needle drainage • Surgical TORSION OF TESTICULAR APPENDIX • twisting of testicular/epididymal vestigial appendix • often <16 years of age Signs and Symptoms • clinically similar to testicular torsion • "blue dot sign· . surgical repair . changas size during day (peds) • Non-communicating: nonpatent processus vaginal is (adlltl • Non-tender. cystic mJISS • Transilluminates • Acute onset severe scrotsl pail.most will subside over 5-7 days • surgical exploration and excision if diagnosis uncertain or refractory pain HEMATOCELE • trauma with bleed into tunica vaginalis • ultrasound helpful to exclude fracture of testis which requires surgical repair Treatment • ice packs. or exercising IIYelligati. oftEn into scrotum)congenillll • Direct (through IIXtemal ring. swelling • Gl upsets cases • Retracted and transverse testicle (horizontal lie) • Negative Phren's sign • Absent cramastaric reflex • A small bulge in the groin that may increase in size and disappear when lying down • Can present as aswollen or enlarged scrotum • Discomfurt or shlrp pain espacially when straining.• Physical exam • vasava • Physical exam • U/S to r/o tumour • U/S to r/o tumour • U/S • History 111d physical colour ftow Doppler probe over • Invagination of the scrotum testicular artery • Valsalva • Decrease uptake on 99m Tcpertechnetate scintillation scan (doughnut sign) • Emergency manual detorsion (rotate outward) with electiva bilateral orchiopexy • Falure of manual delllrsion: surgical delllrsion with orchiopexy • Orchiectomy if poor prognosis • Surgical repair T1111tment • CanseJVBtive • Consentalive • Surgical ligation of testicular • Avoid needle aspiration as it Cllllead to infection. analgesics. "Ball dapper dafonnity" Many occur in sleep (50%) Necrosis of in 5-6 hoUIS • Indirect (through internal ring. ncluding: • Distal obstruction • Aranysmal dilations of the epididymis • Agglutinal!d genn cells Hislllry/ • "Bag of wonns". wins • Perculllleous vein occlusion reaccumulation and spilling (balloon. Cryptarchidism. Benign Scrotal Masses Type Vlricocele Diatatian and toltuosity of piiiXU& Sp•IIIIIDc:lla A benign. inlrascn!lal mass • Cystic • T ransilluminates • • • • • TlllUIIlll. sperm filled epididymal rBtention cyst Hv*acell TIISiicullr To11i1111 l1111uinll Hamil Dllilitian Twisting of the testicle Protrusion of abdominal Collection of serous fluid contenlli through the inguinal that resulbi tom a dsf8ct or causilg wnous occlusion irritation in the tunica vaginalis and engorgement as well as canal into the scrotum artaial ischemia and irllrction • Usually idioplllhic • Found in 5-111% testicular tumOUIS • Associated with traLIIII!/ infection • Communicatilg: patent processus vaginalis. sclerosing agents) of irrilllting spenn within • Repair may improve sperm scrotum count/motility 50·75%.

potassium paraaminabenzoate (potaba) -limited efficacy • intralesional verapamll • surgery if stable disease. therapy • exdsion ofplaque ± prosthesis • depends on pain and interference with intercourse • watchful waiting (spontaneous resolution in up to SO%) Priapism UROLOGICAL EMERGENCY Definition • prolonged unwanted erection lasting >4 hours • tumescence (swelling) of corpora cavernosa (often painful) with flaccid glans penis (no corpora spongioswn involvement) Classlnc:atlon • low-flow (most common): reducedlabsent cavemosal blood flow-+ hypoxia.Budt'•fQc. CGfpus _. total parenteral nutrition.g.. anticoagulants. phenylephrine injection into the corpora cavernosa ql0-15min 3. acidosis -+ischemia 1. Fillraus plaqua Z. leukemia. a.leukophorms ifleukemia. Li 201 a . Tmic:a lllbuailel 3. antipsychotics. alcohol Treatment • treat reversible causes (e. autonomic neuropathy • traumatic ..observation vs.m &. triple lllix).60% idiopathic • secondary: • thromboembolic . Payronia'a • high-How: unregulated a. treat sickle cell crisis) • high flow often self-limited .including sickle cell.g.may occur at any site Etiology • exact etiology unknown • trauma/repeated mk:rotrauma -+ inflammation -+ fibrosis • familial predisposition • relllted to diabetes mellitus.plainb Urology U29 Penile Complaints Payronia's Disease Definition • benign curvature of penile shaft secondary to fibrous thickening of tumca albuginea • commonly on donal surface resulting in upward curvature of erect penis .cal.angiost. slgnlftcant deformity AND failed medl. . solid tumours • neurogenic. Dupuytren's contracture • role of vitamin E deficiency. autoimmunity. marijuana. dlalf!lll. beta-blockade.rtJ:rial embolization • lowflow: 1. thalassemia.cocaine. alpha-blockers.intracavernosal drug injection (e. • reaeational drugs .spinal cord injury. arterio-venous fistula • medication.ia 5. urgent via needle aspiration of blood 2.cavemosal artery laceration.rtJ:rial flow with normal tissue oxygenation Etiology • primary . elevated serotonin Clinical Features • penile curvature andlor pain with erection • penile shortening and poor erection distal to plaque Tralltment • vitamin E. Figura 13. Uralhr1 c J . antidepressant&. vascular disease. CG!pus I:IW8I'IIOIUm 4. ahunt creation between cavemosum and spongiosum ifno response within I hour Complications • erect:lle dysfunction due to corporal fibrosis iftreatment delayed (50%) • 9096 risk if>24 hours ..'IbroDlo Nota 2011 Peaile Com. anxiolytia.

U30 Urology Penile Complaints Toronto Notes 2011 Paraphimosis UROWGICAL EMERGENCY Definition • foreskin caught behind glans leading to edema -+ unable to reduce foreskin Treatment • squeeze edema out ofthe glans with manual pressure (analgesia required) • pull on foreskin with fingers while pushing on glans with thumbs • if fails. somatic [dorsal penile/pudendal nerves (S2-4)] Erections POINT AND SHOOT parasympa1hetics = point. penile cancer Erectile Dysfunction (ED) ------------------------------------- Definition • consistent (>3 months duration) or recurrent inability to obtain or maintain an adequate erection for sexual performance Physiology • erection involves the coordination of psychologic. gangrene Phimosis Definition • inability to retract foreskin over glans penis • may be caused by balanitis (infection of glans). paraphimosis. often due to poor hygeine or congenital • normal congenital adhesions separate naturally by 1-2 years of age Treatment • circumcision. sinusoidal smooth muscle relaxation -+ increased arterial inflow and compression of penile venous drainage (decreased venous outflow) • emission ("SHOOT") • sensory afferents from glans • secretions from prostate. dorsal slit. norepinephrine. Classification of Erectile Dysfunction Fsyt:hoganic: Organic: Proportion 011141t Fn=quenc:y Variation Age Organic Risk Fac:tDrs 111% Sudden Sporadic 'IIIith partner 111d circumstance Younger No organic risk fac!Drs 90% Gradual All circumstances No Old• Risk fac!Drs present fHTN. Dyslipidemia] Nocbi'111VAM aractian Present Absent . hemodynamic. seminal vesicles. arteriolar dilatation 2. mechanical and endocrine components • nerves: sympathetic (Tll-12). neurologic. proper hygiene (trial of topical corticosteroids in children) Complications • balanoposthitis (inflammation of prepuce). parasympathetic (52-4). and ejaculatory ducts enter prostatic urethra (sympathetics) • ejaculation ("SHOOT") • bladder neck closure (sympathetic) • spasmodic contraction of bulbo-cavernosus and pelvic floor musculature (somatic) • detumescence • sympathetic nerves. DM. endothelin-1 -+ arteriolar and sinusoidal constriction -+ penile flaccidity Classification Table 28. and sympathlllict/lomatiCI = sboat • erection ("POINT") • parasympathetics -+ release ofnitric oxide (NO) -+ increased cGMP levels within corpora cavernosa leading to: 1. glans ischemia. perform dorsal slit or circumcision • elective circumcision for definitive treatment (paraphimosis tends to recur) Complications • infection.

tadalafil (Cialis•). ED Intensity Scale. U43) • sildenafil (V!agra•).based on clinical picture • risk factor evaluation: fasting blood glucose or HbAlc. smoking). post-priapism Psychological: depression. venous (impaired vena-occlusion) Trauma: penile/pelvic Extra factors: renal failure. peripheral neuropathy) Chemical: antihypertensives. multiple sclerosis.and post-papaverine injection . antipsychotics. urethra • invasive: • intracorporal vasodilator injection/self-injection • triple therapy (papaverine.g. spina bifida. cholesterol profile • other: TSH.rule out significant arterial or venous impairment • Doppler studies pre. CBC. . prolactin. phentolamine. Sexual Health Inventory for Men Questionnaire. hyperlipidemia. vardenafil (Levitra•): inhibits phosphodiesterase type 5 • rarely used .vasoactive substance (PGE1) capsule into PDE-5 inhibitoR are contn.indica1ed in patienlli on nitnrtllf/nitravlyl. lli. spinal cord injury. diabetes.a. FSH • usually unnecessary to do further testing except in certain situations • specialized testing • non-invasive: • nocturnal penile tumescence monitor • invasive (rarely done): • intracavemous injection of papaverine or PGE1 . medical.erin due to savere hypotension..to evaluate leakage from penile veins . smoking. IMPOTENCE'") • • • • • • • • • Iatrogenic: pelvic surgery/pelvic radiation Mechanical: Peyronie's. illicit drugs Endocrine: diabetes. then put ring at base of penis once erect • MUSE: Male Urethral Suppository for Erection . sleep apnea. PTSD.yohimbine: a-blocker that is best fur psychogenic ED . anxiolytics. and psychosocial) • self-administered questionnaires (International Index of Erectile Function. including vascular and neurologic examinations • lab investigations .. hypo/hyperthyroid Diagnosis • complete history (sexual. anxiety. Treatment • must fully inform patient/partner of options. stress.trazodone: serotonin antagonist and reuptake inhibitor • androgen replacement therapy: if hypogonadism • vacuum devices: draw blood into penis via negative pressure. diabetes. PGE1) or PGE1 alone • complications include priapism (overdose}.Toronto Notes 2011 Penile Complaints Urology U31 Etiology (. .g. stroke). widower syndrome Occlusive vascular: arterial (hypertension. statins. GnRH agonists. thickening of tunica albuginea at site of repeated injections (Peyronie's plaque) and hematoma • implants (last resort): malleable or inflatable • vascular surgery: microvascular arterial bypass and venous ligation (investigational} . benefits and complications • non-invasive: • lifestyle changes (alcohol. psychological (sexual counseling and education) • change precipitating medications • minimally invasive: • oral medication (see Common Medications.cavernosal anatomy and arterial flow evaluation (penile-brachial index <0. hypogonadism. Parkinson's. peripheral vascular disease. ED Impact Scale) • focused physical exam. THiolilanme deficiem:y ia an uncommon cause of ED. cirrhosis. hyperprolactinemi. PNS (e. sedatives. malnutrition Neurogenic: CNS (e. anti-androgens (including 5-alpha reductase inhibitors). COPD. antidepressants.. urinalysis • hypothalamic-pituitary-gonadal axis evaluation: testosterone (free and total). smoking).6 suggestive ofvascular cause} • angiography of pudendal artery post papaverine injection -post-traumatic ED evaluation only fur possible vascular reconstruction • dynamic cavernosometry and cavemosography.

surgical exploration seldom necessary • major: laceration that extends into medulla and collecting system. not associated with a general medical condition Epidemiology • 30-70% prevalence • most common sexual dysfunction reported in men 18-30 years old.requires workup but degree does not correlate with the severity of injury • imaging: cr (contrast triphasic) if patient stable -look for renal laceration. falls) vs. associated with secondary impotence in men 45-65 years old Investigations • indicated by history and physical • testosterone levels if in conjunction with impotence Treatment • • • • • must rule out and treat any associated general medical conditions (ie. extravasation of contrast. retroperitoneal hematoma. stab wounds and gunshots) History • mechanism of injury Physical Exam • ABCs. lower rib/vertebral transverse process fracture suggests blunt trauma Investigations • urinalysis: hematuria. bedrest. major renal vascular injury. but now experiences premature ejaculation. assaults. ER14 Renal Trauma Etiology • blunt (80%. renal vascular injury -+ shock mandating resuscitation • upper abdominal/flank tenderness. fear of angina) often thought to be due to psychological factors. penetrating (20%. motor vehicle collision (MVC). flank contusions. couples counseling or sex therapy SSRis have been found to be effective in some cases clomipramine (daily or PRN 4-6 hours before intercourse) Trauma • see Emergency Medicine. and associated intra-abdominal organ injury Staging • • • • • I: contusion/hematoma II: <1 em laceration without urinary extravasation III: >1 em laceration without urinary extravasation IV: urinary extravasation V: shattered kidney or avulsion of pedicle Classification According to Severity • minor: contusions and superficial lacerations/hematomas . shattered kidney Management • microscopic hematuria + isolated well-staged minor injuries -+ no hospitalization • gross hematuria + contusion/minor lacerations -+ hospitalize.U32 Urology Penile Complaint:a!I'rauma Toronto Notes 2011 Premature Ejaculation Definition ---------------------------------- • occurrence of ejaculation prior to when one or both partners desire it • primary premature ejaculation • never experienced sexual activity without the presence of premature ejaculation • secondary premature ejaculation • the individual once had acceptable ejaculatory control. identify and address specific stressors referral to psychiatry. repeat CT ifbleeding persists .90% of all blunt traumas.

bony spike into bladder or iflaparatomy for concurrent injury • intraperitoneal rupture usually requires surgical repair and suprapubic catheteri2ation Complications • complications of bladder injury itself are rare • mortality is around 20%. and crush injury) vs. masturbation with urethral manipulation • always look for associated bladder rupture Clinical Features • blood at urethral meatus • high riding prostate on digital exam • sensation of voiding without urine output • swelling and butterfly perineal hematoma • distended bladder • penil and/or scrotal hematoma Investigations • do not perform cystoscopy or catheteri2ation before retrograde urethrography if urethral trauma suspected • retrograde urethrography. pelvis. . . falls. infected urine. and at 6 weeks • hypertension in 5% of renal trauma Bladder Trauma • blunt (MVC.demonstrates extravasation and location of injury '. distention.. AUpatients with suspected urethral injury should undergo retrograde Ul'llhragram {RUG)._---------------. prosthesis insertion).Toronto Notes 2011 Trauma Urology U33 • surgical intervention: • absolute indications: hemorrhage and hemodynamic instability • relative indications • non-viable tissue and major laceration • urinary extravasation • vascular injury • expanding or pulsating peri-renal mass • laparotomy for associated injury Outcome • follow up with ultrasound or CT before discharge. and inability to void • may be peritoneal signs or symptoms • associated injuries including pelvic and long bone fractures are common • hemodynamic instability due to extensive blood loss in the pelvis • suprapubic discomfort and/or tenderness Investigations • urinalysis . rectallvaginal perforation. or perineum • blunt trauma is associated with pelvic fracture in 97% of cases Clinical Features • abdominal tenderness. damage to mucosa or muscularis • intraperitoneal ruptures: often involve the bladder dome • extraperitoneal ruptures: involve anterior or lateral bladder wall in full bladder Treatment • penetrating trauma: surgical exploration • contusion: urethral catheter until hematuria completely resolves • extraperitoneal bladder perforations: typically non-operative with foley insertion • surgery if. MVCs.gross hematuria in 90% • imaging • cystogram and post-drainage film for extravasation Claulflcatlon • contusions: no urinary extravasation.. penile fracture. and is usually due to associated injuries rather than bladder rupture Urethral InJuries Etiology • posterior urethra: common site of injury is junction ofmembranous and prostatic urethra due to blunt trauma. penetrating trauma to lower abdomen. peMc fracture • shearing force on fixed membranous and mobile prostatic urethra • anterior urethra: straddle injury can crush bulbar urethra against pubic rami • other causes: iatrogenic (instrumentation.

anabolic steroids) • occupational exposures .U34 Urology Trauma/Infertility Toronto Notes 2011 . hernia repair. frequency. cocaine. renal History • medical history (past illness. previous pregnancies.no treatment • partial urethral disruption: • very gentle attempt at catheterization by urology staff or urology resident • with no resistance to catheterization. GnRH agonists. epididymal obstructions • Kartagener's syndrome • retrograde ejaculation secondary to bladder/prostate surgery • medications (chemotherepeutics.. CF. timing.Foley x 2-3 weeks • with resistance to cathetemation . chlamydia) • trauma • congenital (absence of vas deferens. secondary (has conceived before) Female Factors • see Gptecology. tobacco. nitrofurantoin. prostate) • fertility history (pubertal onset. treatments) • sexual history (erection/ejaculation. firm testes. Do not csthmrim if IIISPIC! umh111l injury. gynecomastia and azoospermia) • post-infectious (epididymo-orchitis. Treatment • simple contusions .. duration of infertility.g.. alpha-blockers) • social history (alcohol.. spironolactone. genetic syndromes) • surgical history (orchidopexy. properly timed intercourse • incidence: • 15% of all couples . diabetes. GY21 Male Factors Male Reproduction • hypothalamic-pituitary-testicular axis (HPTA): GnRH from hypothalamus acts on anterior pituitary stimulating release of LH and FSH • LH acts on Leydig (interstitial) cells -+ testosterone synthesis/secretion • FSH acts on Sertoli cells -+ structural and metabolic support to developing spermatogenic cells • FSH and testosterone support germ cells (responsible for spermatogenesis) • sperm route: epididymis -+ vas deferens -+ ejaculatory ducts -+ prostatic urethra Etiology • idiopathic (25% infertile males) • endocrine (see Endocrinology. sulfasalazine. Kallmann's syndrome. delayed repair if unstable (suprapubic tube in interim) Infertility Definition • failure to conceive after one year of unprotected. trauma. •t----------------. 1/3 combined problem • primary (has never conceived before) vs. . excess androgens. hot baths. STis. excess prolactin. tight pants or underwear) • chronic disease: liver.g. STis) • family history • medications (e. cryptorchidism.investigate both partners • 1/3 female. E48) • hypothalamic-pituitary-testicular axis (2-3%) • e. cystic fibrosis) • bilateral ejaculatory duct obstruction. alcohol} • increased testicular temperature (sauna. hydrocelectomy. anabolic steroids) • drugs (marijuana. cocaine. 1/3 male. orchidopexy) • infectious (gonorrhea. cimetidine.suprapubic cystostomy or urethral catheter alignment in OR • periodic flow rates/urethrograms to evaluate fur stricture formation • complete disruption: • immediate repair if patient stable. mumps) • uncorrected torsion • cryptorchidism ( <5% of cases) • obstructive • iatrogenic (vasectomy. tobacco. excess estrogens • testicular • varicocele (35-40% infertile males) • tumour • congenital (Klinefelter's triad: small.

pseudoephedrine. oligoiSihenospermill Figure 14.e.. semen .Toronto Notes 2011 Infertility Urology U35 Physical Exam • general appearance (sexual development.indicated with abnormal semen analysis (rare to be abnormal with normal SA) • testosterone for evaluation ofHPA • FSH measures state of sperm production • serum LH and prolactin are measured iftestosterone or FSH are abnormal • genetic evaluation • chromosomal studies (Klinefelter's Syndrome . Infertility Workup .. ! Treatment • lifestyle • regular exercise. testicular size) • vasography (assess patency of vas deferens) . consistency and nodularity of testicles. ... or ephedrine) • treat underlying infections • surgical • varicocelectomy (if indicated) • vasovasostomy (vasectomy reversal) • epididymovasostomy • transurethral resection of blocked ejaculatory ducts • assisted reproductive technologies (ART) . .XXY) • genetic studies (Y-chromosome microdeletion..8 • WBC: < 1oper high p .lour on Sem1111lylil: • Teratospemnia: Abnormal morphology • AsthlnDSpiiTTlil: Abnormal motility • Oligospermia: Demased sperm count • Amospermia: Ablant Jpann in wman • Mixed types.2·7. .. healthy diet • eliminate lifestyle habits described above • medical • endocrine therapy (see E48) • treat retrograde ejaculation • discontinue anti-sympathomimetic agents.. . may start a-adrenergic stimulation (phenylpropanolamine. . CF gene mutation) • immunologic studies (antisperm antibodies in ejaculate and blood) • testicular biopsy • scrotal U/S (varicocele...field or <10' WBCfml. aven if patient manif8sts no symptoms of CF. ! WHO GuidlliNarmll 11111111 V... ! Common Ter.I• Volum1: 2·5 ml • Concenlnltion: > 20 million sperm/ml • Morphology: 30'lla nonmlll forms • Motility: >SO'lla adeqlll!e forward J11V11111$$ion • complltl in 20 minutn • pH: 7. gynecomastia) • scrotal exam (size... palpation of cord. i.. DRE) Investigations • semen analysis (SA) at least 2 specimens over several weeks • hormonal evaluation ...refer to infertility spectalist • sperm washing + intrauterine insemination (niT) • in vitro fertilization (IVF) • intracytoplasmic sperm injection (ICSI) Mutation of Cystic Fibrosis Transmembrane Conductance Regulator {CFTR) gene associated with congenilll bilabnllabunc1 of vas dlf1r1ns {CBAVD)Ind epididymal cysts.

U36 Urology Pediatric Urology Toronto Notes 2011 Pediatric Urology Congenital Abnormalities • • • • not uncommon.) • M:F=2:1 • 40% bilateral • unclear etiology: adynamic segment of ureter. stenosis. hydronephrosis). strictures. etc. 1/200 have congenital abnormalities of the GU tract UTI is the most common presentation postnatally hydronephrosis is the most common finding antenatally six common presentations of congenital urological abnormalities: . oligohydramnios • neonatal (recognized at birth): palpable abdominal mass (distended bladder. ascites (transudation of retroperitoneal urine). UPJ OBSTRUCTION • the most common congenital defect of the ureter (but can be secondary to tumour. reflux Treatment • immediate catheterization to relieve obstruction. followed by cystoscopic resection of PUV 3.due to low intrauterine production of urine • renal dysplasia . stone. failure to thrive • toddlers: presents with urinary infections or voiding dysfunction • school-aged boys: voiding dysfunction -+ urinary incontinence Associated Findings • oligohydramnios .. POSTERIOR URETHRAL VALVES (PUV) • the most common obstructive urethral lesion in male infants • abnormal mucosal folds at the distal prostatic urethra causing varying degrees of obstruction • most commonly recognized on prenatal ultrasound examination -+ bilateral hydronephrosis. IVP. failure to thrive • some cases are diagnosed after puberty and into adulthood Diagnosis • antenatal U/S most common.due to high pressure reflux • pulmonary hypoplasia secondary to oligohydramnios Diagnosis • VCUG -+ dilated and elongated posterior urethra. Doppler U/S. distended bladder. vomiting. 1. aberrant blood vessels -+ extrinsic compression Clinical Presentation • symptoms depend on severity and age at diagnosis (mostly asymptomatic :finding on antenatal UIS) • infants: abdominal mass. electrolyte abnormalities. respiratory distress (pulmonary hypoplasia resulting from oligohydramnios) and features of oligohydramnios • neonatal (not recognized at birth): within weeks present with urosepsis. oligohydramnios Clinical Presentation -depends on age and severity • antenatal: bilateral hydronephrosis. dehydration. urinary infection • children: pain. and renal scan± furosemide . Majority of antenatal hydronaphrosas resolve during pregnancy or wilhin the first yaar of lifa. . thickened bladder. ANTENATAL HYDRONEPHROSIS • 1 in 500 fetal U/S -detectable on U/S as early as :first trimester • most common urological consultation in perinatal period • can be unilateral or bilateral • important to examine the rest of the GU system for anomalies • differential diagnosis • UPJ or UVJ obstruction • multi-cystic kidney • reflux • posterior urethral valves • duplication anomalies • antenatal in utero intervention rarely indicated unless posterior urethral valves 2.

. amoxicillin. SQ'IJIII Perileal Figura 15. ·. undescended t2sticles or inguinal hernia • depending on the severity. short submucosal segment (all part of"primary refluxj • many other causes including secondary reflux. urosepsl.5% in normal children • present in up to 70% ofchildren with UTI • 85% ofVUR occurs in females but a male presenting with UTI has a hlgher lilaillhood ofhavmg VUR • common cause ofantenatal hydronephrosis • 30-5096 of children with reflux will have renal scarring • common causes: trigonal weakness. there may be difficulty directing the urinary stream or infertility Oong-term) • treatment Is surgical correction .ctorial genetic mode ofinheritance • white »black • may be associated with chordee. .. Pllvil and with S..or . or nitrofurantoin) • surgical (ureteroneocystostomy± ureteroplasty) or subureteral injection of Dc:Hux.s • pyelonephritis • pain on voiding • symptoms ofrenal fiillure (uremia. to the glans penis • very common..koronal Dilllll Penile • a condition in which the urethral meatus opens on the ventral side ofthe penis.breakthrough infections .' . lateral insertion ofthe uretErs. hypertension) • diagnosis and staging lB done wing VCUG ± U/S Complications • pyelonephritis • hydroureter/hydronephrosis Treatment (sea sidebar for grading) • many cbildren •outgrow" reflux (60% of primary reflux) • annual renal UIS and VCUGIRNC to monitor.'IbroDlo Nota 2011 Urology U37 Treatment • surgical correction (pyeloplasty).UX (WR) • common condition wherein urine p111111es retrograde from the bladder through the UVJ into the ureter • incidence ranges from 1-18.g.. ectopic ureter. ----.. consider nephrectomy if< 1596 renal function Prognosis • good since usually unilateral di&ease 4...· . promnal. VUR Gredlna IMted an C\'lflllnlll lirwul: ureters GDv fil lirwull: unrbn and pt11vislil lraulll: uratJn and pcilvis fill with SGIIII dilltatian '..failure of medical management . ureterocele. Clluilicetio• af (*•ccam far 75%) r::l-cRIJ-m_cisa_pdl _ _ nm_with_... .goal is to keep urine free ofinfection to prevent renal damage wbile waiting for cbild to ·outgrow" their reflux • long term antibiotic propbylms at half the treatment dose for half the treatment time (TMP/ SMX. secondary to ureteric abnormalities (e.. iatrogenic. HYPOSPADIAS Sl.. VESICOURETERAL RER. intersex states.cant dllllldiDII lrau V: Inters. . IV: lnblrs.new renal scars . or duplication).optimal repair before 2 years old • circumcision should be deferred because the foreskin may be utllized in the correction •· • J --.not an absolute indication) • prognosis depends on degree of damage at the time of diagnosis 5. '' . infravesical obstruction.' Gm. 1/300 live male births • multifa. renal scan ifswspect new renal scar (episode of pyelonephritis) • treatment Is dependent on the grade: • medical (grade I-III) . Pllvis and cllycas Iii with major dilatalion and 1Qr1uosily Gla!Ur Coronal" Macroplastique• • indications: . and secondary to cystitis Presentation • UTI.high grade reflux (grade IV or V .

unilateral (most common presentation.Tnticle begins to form 4th Month . EPISPADIAS-EXSTROPHY COMPLEX • rare: incidence 1/30.80%) • hypertension (60%) • flank tenderness • microscopic hematuria • nausea/vomiting Treatment • always investigate contralateral kidney • treatment of choice is radical nephrectomy ± radiation ± chemotherapy Prognosis • generally good. inguinal conal and external ring to terminate in the scrotum Deeclllt in Uloro .. firm. later corrections for incontinence.000.Begins to take Dl1 its normal and mi{J'It86 from its origin at the kidney to the internal inguinal ring 7th Month .The tntis. infertility. 3:1 male to female predominance • epispadias-exstrophy complex: a spectrum of defects . begins to descend through the intimal ring.U38 Urology Pediatric Urology Toronto Notes 2011 6.7% of full term newborns • 0. with eversion of bladder) • several variants • cloacal exstrophy (vesicointestinal fissure) • most severe • exposed bladder.._. surroundld in peritoneal caverinv.. increasing bladder capacity and vesicoureteral reflux may be needed Naphroblastoma (Wilm's Tumour) --------------------- • arises from abnormal proliferation of metanephric blastoma • 5% of all childhood cancers. Normal Tntlcullr Develop. reflux Etiology • represents failure of closure of the cloacal membrane.depends on the timing of the rupture of the cloacal membrane • bladder exstrophy (congenital absence of a portion oflower abdominal and anterior vesical wall. overallS-year survival about 80% • metastatic disease may respond well Cryptorchidism/Ectopic Tastes • definition: testes located abnormally somewhere along the normal path of descent (prepubic > external inguinal ring > inguinal canal > abdominal) • ectopic testis (testis found outside its normal path of descent} is rare • incidence: • 2. 5% bilateral • average age of incidence is 3 years • 1/3 hereditary (autosomal dominant) and 2/3 sporadic • familial form associated with other congenital abnormalities and gene defects Clinical Features • abdominal mass: large. bowel and colon with imperforate anus • associated with spina bifida in >50% • epispadias • least severe • urethra opens on dorsal penis • high morbidity -+ incontinence.lllt ond Znd Mlllllb. resulting in the bladder and urethra opening directly through the abdominal wall Treatment • surgical correction at birth..8% at 1 year old • differential diagnosis: • retractile testes • atrophic testes • intersex state (bilateral impalpable testes) Treatment • undescended testes should be brought down to monitor for malignancy and preserve fertility (better in less than 1 year of age) • hormonal therapy (hCG or LH may facilitate their descent -+ not proven) • surgical -+ orchiopexy .7%-0.

: 11Msl'8'... 46XY DSD • defect in testicular synthesis of androgens • androgen resistance in target tissues • palpable gonad 2.iiaw llVIUIIalllle llac:tiwllla ll'lllllflly 11'111 cirann:ililn fur p!IIVIOOng aapitian llf HN in h. and fallopian tubes • endoscopy and genitography of urogenital sinus • sex assignment (with extensive family consultation) • must consider capacity for sexually functioning genitalia in adulthood and psychologic impact • reconstruction of external genitalia . but monitoring is made easier • increased risk of testicular torsion (always perfonn bilateral orchiopexy for prevention if doing orchiopexy for torsion) Disorders of Sexual Differentiation Definition and Classification • genitalia that do not have a normal appearance based on the chromosomal sex ofthe child due to the undermasculinization of genetic males or the virilization ofgenetic females • considered a social emergency • four major categories 1. Chailillflll' l'mdllll !Willi.. hypertension._. {21:!m336Z lie. Clncbinl: This lllliylis fOII'Id insl&ient INid._..\)sf /lev 21m. nwl..000 IU/day for 4 days) • serum electrolytes • ultrasound of adrenals. Clncbinl: Thill'lllli&w lwld lti'Dng INidance tt11t ITIIIIIcll mae circlm:iliill rab:ls 111e ICqUilililn ti HN by mllllblllwlen m 11'111 24 11111-. Codnne lhllllllse . llcMMt the pndlctiwellwct ti ll'lle circn:iiorl f1llfw imllqltion rl male cin:oou:ilian fur HlV preverOin III'DIIg MSM. Mill ciriJlmcilion hid I paiiClivl UlllCillion Medical Indications • phimosis • definitive treatment of paraphimosis Contraindication& • unstable or sick infant • congenital genital anomalies (hypospadias) • family history of bleeding disorders warrants laboratory investigation prior to circumcision l'liGI HN in lllldes II MSM Clllllucfld before 1he ti hijllf IICtiva lnliulrMII1falpy. whl h111 So with 1111: AMIINIIIpill JW4 21108. Dddll ti baing HlV-plllitM Will IIIII lignificlntlv 1owar in c:irwmcilad MSM. position of urethral meatus • chromosomal evaluation . lie. stretched phallus length. this risk does not decrease with surgical descent. llulll: n.. evidence of dehydration.Toronto Notes 2011 Pediatric Urology Urology U39 Prognosis • • • • untreated bilateral cryptorchidism -100% infertility treated bilateral: 60-70% fertility rate (dependent on the age at the time of surgery) treated/untreated unilateral: fertility is still less than the general population risk of malignancy is 10-40x increased in undescended testes... 300(141:1674-84.:elllll male ciMiclioll llglinst HN inllctiDn or Dtlm Slll.46XXDSD • most due to congenital adrenal hyperplasia (21-hydroxylase deficiency most common enzymatic defect) -+ shunt in steroid biosynthetic pathway leading to excess androgens 3.: TIMslnlllll-nlylis mminad 15 .. ovotesticular DSD 4. in MSM Wli11 aJnduclld Wore 11!1 n of lil#t active antirelnMnlllhen!rt supports . hyperpigmentation._..eoxycortisol-+ increased in deficiency • basal adrenal steroid levels • serum testosterone and DHT pre. socioeconomic classification IU!ia (u= 53 561) tt1lt qiJIIItitDI\' . gonads.sex karyotype • laboratory test:s: • plasma 17-OH-progesterone (after 36 hours of life) -+ increased in 21-hydroxylase deficiency (CAH) • plasma 11-d. mixed gonadal dysgenesis (46 XY/45 XO most common karyotype) • presence ofY chromosome -+ partial testis determination to varying degrees Diagnosis and Treatment • thorough maternal and family history needed • other fonns of abnormal sexual development: • maternal medication or drug use in pregnancy -+ maternal hyperandrogenemia • parental consanguinity • physical exam: palpable gonad(= chromosomal male).. Th••lylld dill ilfllllnlfnllllldomilld canllaled trBls ID assess tile elicacy rJ 1111le citlm:ilion far HIV aaPiition in IMI1 in Alric:a \Wiich begin il2002.rinld the 1110eiltion bllval1111le liluncilion lll1d HNJS11111101111 men who hive ret willl men (MSMI..and post-hCG stimulation (2. religious affiliation.between 6-12 months • long term psychological guidance and support for both patient and family . . uterus. Thl•ocidion HN ciMicliollll'lll but notllllistic:att sigriCIIII...tof HIVIIII Circumcision Definition • removal of some or all of the foreskin from the penis Epidemiology • 30% worldwide • frequency varies depending on geographic location.

ICIOIII hlmltDml.ntlumdominlnl hind. Insert 10·15ml of ldocU!e ielll' iiiD LRIInl meQJI tnd Pnc:fl p8lils for • • mindls 5.use sufficient lubrication {± xylocaine) • collapsing catheter -lubrication as above ± firmer catheter (silastic catheter) • meatal/urethral stricture . Wd fGI rebln of llile ido colecling lledcilts. prostate. not 1ht callacling $'jSIImUing) 17.UTI • meatal/urethral trauma Contraindications • urethral trauma: blood at the meatus of the urethra.dilate with progressively larger catheters/balloon catheter • BPH .circumference in mm • each 1 mm increase in diameter = approximately 3 Fr increase {standard size 16-18 Fr) 1. catheters) . hold llld purpaticUir to IIIII pltielts body (this bind is now nan-lleriel 12.use catheter as angled tip can help navigate around prostate • urethral disruption/obstruction -filiform catheter or suprapubic catheterization • anxious patient .Mmolis Cystoscopy Objective • endoscopic inspection of the lower urinary tract {urethra. Open lubricllltand dispel ontol:llilllllr1nly 9.. and/or high riding prostate w Ab:ll. giMs 7. LJJbriCIII tip of clllllltr. ofwllar lnd callacling . Pl2 Selected Urological Procedures Bladder Catheterization SbipiiiiMIIIiq 11111r in IIIII Sldl •111111r CaiMIIrialion (-. Ellpllin pnx:adura 1D lhll pllilnt and on1. illumination. irlllrl iiiD lllllnl meQis tnd IIMrlce to 1lle IMI of111e IIIIIIDIIII inllltion port 14. !Moe urine is bling.1imp]JIIIile lllllftv. idoclile jllly tllll:1111811r 1Dpa wilhiiiiiiiCh Ill till bldlill 3.• glms ponil in ciwlurrl)lion 13. neurogenic bladder or intravesical obstruction • temporary therapy for urinary incontinence • perineal wounds • clot removal {24-28 Fr) for continuous bladder irrigation {CBI) • post-operative Intermittent Catheterization • indications: • post-void residual volume measurement • to obtain sterile diagnostic specimens for urinalysis/cultures • management of neurogenic bladder or chronic urinary retention Causes of Difficult Catheterizations and Treatment • patient discomfort . and optics • scopes can be flexible or rigid Indications • hematuria • LUTS (irritative or obstructive) • urethral and bladder neck strictures • stones • bladder tumour surveillance • evaluation of upper tracts with retrograde pyelography (ureteric:: stents.i•l Continuous Catheterization • indications: • accurate monitoring of urine output • relief of urinary retention due to medication. Ensur8 you hlv8 cdllltr •nd tit. wpatiant don 11011-s!Brile glowlllld fiiiiCt foralkil 4. pelvic fracture. Open kllnd piiQJ patilllt'&legl 6. C.. pelvic frlcbn..nm !Dcttflltlr 10. scrotal hematoma. pul Clllletlll bac:t lnd llpe ID patient's 111igh f1lpG the cltfllter.... bladder neck. VIII• in Cb:ll • catheter size measured by the French {Fr) scale.11aduceforllkintop!MIIIplla. walls and dome. lbi . coHua ball in IIQeplic B. l'lllc:efenestJDd dnipe Mr pubic regiorund pro*lll11iQ111 11.111 na cantnilllicltianl (blood IIIIIWIU. !Mgll-ridng proelatll 2. and ureteral orifices) using irrigation. skin bridges • fistula • glans injury • penile sensation deficits Enuresis • see Pediatrics.. . ilftllle llllllaan l'litiiCIUt •lowilu Cl1ilullrlrnulrlel 16.U40 Urology Pediatric Urology/Selected Urological Procedures Toronto Notes 2011 Complications • bleeding • infection • phimosis.anxiolytic medication Complications of Catheterization • infection . praalll w 15.

and pulmonary edema • treat with diuresis and (if severe) hypertonic saline administration . nausea.Toronto Notes 2011 Complications Selected Urological Procedures Urology U41 • during procedure • infection. both. renal insufficiency) refractory urinary retention recurrent UTis recurrent gross hematuria bladder stones intolerance/failure of medical therapy Complications • acute: • intra. or neither of the neurovascular bundles are involved in extracapsular extension of tumour) Transurethral Resection of the Prostate (TURP) Objective • to partially resect the periurethral area ofthe prostate (transition zone) to decrease symptoms of urinary tract obstruction • accomplished via a cystoscopic approach using an electrocautery loop. grade. hypertension. PSA) • seminal vesicle vessels are also ligated Indications • treatment for localized prostate cancer Complications • immediate (intraoperative) • blood loss • rectal injury • ureteral injury (extremely rare} • perioperative • lymphocele fonnation • late • moderate to severe urinary incontinence (3-10%) • mild urinary incontinence (20%) • erectile dysfunction (-50%. visual disturbances. depending on whether one. CHF. laparoscopically or robotically • internal iliac and obturator vessel lymph nodes may also be dissected and sent for pathology (dependent on risk: clinical stage.or ext:raperitoneal rupture ofthe bladder • rectal perforation • incontinence • incision of the ureteral orifice (with subsequent reflux or ureteral stricture) • hemorrhage • epididymitis • sepsis • transurethral resection syndrome (also called "post-TURP syndrome·) • caused by absorption of a large volume of the hypotonic irrigation solution used. bradycardia. usually through perforated venous sinusoids. leading to a hypervolemic hyponatremic state • characterized by dilutional hyponatremia. confusion. bleeding. and illumination Indications • • • • • • obstructive uropathy (large bladder diverticula. anesthetic-related • perforation (rare) • post-procedure (short-tenn) • epididymo-orchitis (rare) • urinary retention • post-procedure (long-term) • stricture Radical Prostatectomy Objective • the removal of the entire prostate and prostatic capsule via a lower midline abdominal incision. vomiting. irrigation (glycine}.

and midureteral calculi which cannot pass through the urinary tract naturally • shockwaves are generated and focused onto stone -+ fragmentation.U42 Urology • chronic: Selected Urological Procedures Toronto Notes 2011 • retrograde (>75%} • erectile dysfunction (5-1 0% risk increases with increasing use of cautery) • incontinence (<1%) • urethral stricture • bladder neck contracture Extracorporeal Shock Wave Lithotripsy (ESWL) Objective • to treat renal calculi. proximal calculi. allowing stone fragments to pass spontaneously and less painfully Indications • potential first-line therapy for renal and ureteral calculi less than 2. diabetes or renal insufficiency Contraindication& • acute urinary tract infection or urosepsis • bleeding disorder or coagulopathy • pregnancy • obstruction clistal to stone Complications • bacteriuria • bacteremia • post-procedure hematuria • ureteric obstruction (by stone fragments) • peri-nephric hematoma .5 em in size • individuals with calculi in solitary kidney • individuals with hypertension.

including adrenal androgens As above As above Hepatotoxic: AST/ALT monitoring Gl syrl1IIDrns Hyperkalemia Gynecomastia *ketoconazole. B•ign Prostatic Hyperplasia Medications Dnlg tei8ZOSin (llytrin"l dDXIIZOSin (Callba"l tamsulosin (Aornax®) Clus Alpha 1blockers Alpha 1a selactiva Alpha 1a selactiva Machanism Alpha-adrenergic anlllgonists reduce stromlll smooth muscle tone Reduce dynamic component of bladder outlat obstruction lndiCition BPH Presyncope Leg edema Ratrograde ejaculation Headache Asthenia Nasal congestion finasteride dutasteride (Avodartilt) 5 alpha-reductase inhibiiDr Blocks convarsion of tastosterone to DHT Reduces static corqlOilent of bladder outlet obstruction Reduces prostatic volume BPH Saxual dysfunction PSA decreases Naill: AI alpt. prostatitis ?Safety in pregnancy Achilles tendon rupture Only IV Nephllllllxic Ototoxic Tabla 22.Toronto Notes 2011 Common Medications Urology U43 Common Medications Tabla 21.-IIIDCbrs diMllopad far 81'11 hiVIlsimillr afli:lcy. goserelin (Zolad!lt8 ) *diethylstilbestrol (DES) *cyproterone acetate Class GnRH agonist Machanilm ntially stimulates LH. 8igard"). Antibiotics Dnlg TMP/SMX Simple uncomplicated cystitis Recunent cystitis Pyelonephritis Prostatitis Epididynitiil/architis (Gremilegative organism) Simple uncomplicated cystitis Recunent cystitis Duration of TNIIImant Umililti-ID Uu Stevens. polycythemia. M>D) Hot flashes Headache Decreased libido Estrogens Steroidel antiandrogen As above As above Increased risk of cardiovascular events ftutamide bicalutamide (Caso£Ex®) Nort-steroidal antiandrogen Steroidogenesis inhibiiDrs As above Blocks multiple enzymes in steroid pathway. Prevent flare produced by GnRH agonist 2. '-a(. relaxing sinusoidlll smooth muscle Local release (capsule inserted intD urethra) See above lndi:ltion ED when some erection present Sevara hypotansion Contraindicated if Hx of priapism.Jolrlson syndrome ?Salety in last 2 weeks of pregnancy Resistalce 20% in the community 3 days LDI'(lll!rm as prophylaxis 14 days 4-awusb Zweeks nilrufunrrtoin ciproflox. May preserve patency with lldic:ation Advasa Elfacts CaP (N>D.acin genlllmicin 7 days 3 days 7-14 days Contnindicated in nmal failure Pulmonary toxicity/fibrosis Cystitis Pyelonephritis Severely ill patients with pyelaneplritis. Prostatic Carcinoma Medications Drug leuprolide (Luprnnllt. Erectile Dysfunction Medications Dnlg sildenalil (V'IIgraat) tadalafil (Cialisllt) vardenalil (l. phentolamine. myelofibrosis.. Prostaglandin E 1 ED pan See above ED PGE1 Thickening of tunica albuginea at site of repeated injections (Peyronie's plaque) Painful erection Hematoma Contrainrlcated if Hx of priapism. Tabla 24. increasing testosterone and causing "flare" {clinically: i'lcreased bone pain). sickle cell disease) Contlllindicatad with nilllltas Penile Presyncope alprostadi (MUSE: Male Unrtlnl Suppository fur Erection) alprostadi (intracavemosal iljection) triple therapy also used: papaverine. or in conditions predisposing to priapism (leukemia. later causes low testosterone Hlibit LH and cytotoxic effect on tumour cells DHT for iltracellular receptors: 1.evitra"l Cia• Phosphodiastarase 5 inhibiiDr Machlnilm Selectiva irtlibition of PDE5 (enzyme which degrades cGMP) Leads to sinusoidal smooth muscle relaxation and erection Activation of cAMP. or in conditions predisposing to priapism Tabla 23. Use for compiBIB androgen blockade 3. spironolactone .llph•1sala:IMI11Q811!1 hM 111 impnMld sida lllact pmfila.

'/wwau111111. Novick AC. Campbelrs Urology. c-llll'rlllllllingl'n6ll• Colirn RA 111d llrailn RS.Jn:ia Galejs LE. Naw Englrnd Joumal II Mldicine. Kavoussi Ul. http.51(41:817-24 Medialions Bii-Axelson A. McGraw-Hill Companies.Mfp. Nln IIIISCII'inic t. ACTs bued 111 helcl-111·/nml compuisan to lang acting furmulllilns n References G . Cln. Galdmln I. Radical Proslnc:tomyversus Waiting il Early l'rosllte Cancer. hllp.al Bevaciarmab Pl. Common Medications: Gray J (Edi1mj. llwtu M.com Rini B. ZW5. 1991.lllldical plliant (&thad. et.] ZWI.eferenc:es Tabla 25.ww.U44 Urology Common MedicationsJR.. Continanca Agents Drug Clus Toronto Notes 2011 lndl:lllion oxybutynin AntispiiSIIlDiic lmibillactian Df ACh an smaD1h muscle lkge incontinence + oxybutynin {Ditropan<») tolterodine {Detro18 ) trospium [Trosec18) (Vesicaraa) Anticholilergic llecreeses frequency of unirllibited detrusor contraction lliminishes initial urge to void Muscarinic receptor antagonist lkge incontinence + Selective for bladder urgency + frequency Increases bladder vo. Acute -.ile Cornplllll with Interferon Alta MDII!Ihmpy in l'ltientJ with Metn111ic Renal Cell Can:incml: CALGB !11206. New England Joumalcl Madicile. MIICflrlme MI House lllicer Series: Uralogy. 26: 5422-28. al. Salnlars (EIIaviar). HIIIIIi S. Practical Glide ID tt.'/wtow. v.. .. 2004.] 2004. Nephrology: l. Srrith's Glmllll Uralogy.2003. Holmberg I. J. et.] PhilldeliJ!il: WB Saunders Co. Micramadax heellh catlll8rias.lnwlligltion lndtnlllrrWit!IIICIUIIIII kilhlyiiDIIBL CMAJ 166(2):213-218. UAJincotl Ylfllllllli & TaiiiQIIo EA.micnlmedax.(l&th ad.tqiafpl2002041 W158UIIm Ferri F. Clll oftt.Jan 2002 Teichnan JMH. 352: 1977·84.D19'guidainlrl Amll'iC111 Aao1:i1ticr1 of Ftmily Phy$icia11$.) ZW6.. hllwever. Ausialo D. Uralogy Clilnnal Wein AJ. 13rd ad.)2004.. 2008.348:2330-2338 MoriDnAR. McAnilch JN.l3 rapiDr spaciic llglds lsallenlcin. 19th ed. Therapeutic Choicas (4th ld). One.IIilsm EAand Wil11111 JWI. IHJIIIIIy Efficacious iiS older drugs. 2003. Cecil Tlldbook of Medicine (22nd ad. Americ:lln Ftmily l'hyan.nal colic ln1m c•lcuiJs.llale*l!l J. Canadiln Phlrmacirls Allocilltion. lnfllrnlti111 AnuriCillllrulogical Allocillli1111. NEJM.350:684·693 Uralagi:ll Ern. Dilgnolis and treatmrnt ol the IICUII scra11rn. St Lllil: Mosby. Micrascapic hamablia. l'lrlin AW rnd Cl'eteTs CA.me llecraases detrusor pressure Sympathomimetic sff8cts: urgency + frequency Dry mouth Blurred visim Canstipatian Supraventricular tachycardia As above dlllilenacin {Enablat') imipramine Tricyclic llllidelftSSBnt urinary sphincter conlnlction Anticholinergic elfects: Stress and urge incontinence As abDW Weight gain Orthostatic hypotension detrusor relaxation Prolonged PR interval Nlllt: AIIIIIIH:IMJiilwgics 11111J11ily lfllctiw and liq acting fmmulllilns (llllrollA1 111d Ditropln XL8)111 balblr IDiarrllld.. Dttawa.

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