MAGNETIC RESONANCE IMAGING

CT imaging remains the mainstay of urologic cross-sectional body imaging; however, MRI is
increasingly being applied to the genitourinary system. With constant improvements in
technology, MRI is gradually narrowing the overall resolution quality gap between it and CT. A
significant advantage of MRI is the excellent contrast resolution of soft tissue, without the need
for contrast in
Key Points: CT Imaging

The CT urogram is an excellent imaging choice to evaluate the kidney, upper tract collecting
system, and ureter. l The CT urogram is highly sensitive and specific for upper tract urothelial
carcinoma. l A renal mass in the kidney seen on CT urogram that enhances more than 15 to 20
HU is most likely a renal cancer.
l With the exception of indinavir stones, all types of urolithiasis are visible on unenhanced CT of
the abdomen and pelvis. many situations. Currently MRI is used when patients cannot be given
iodinated contrast and when tissue findings in the urinary system cannot be resolved using CT or
ultrasonography. To obtain magnetic resonance images, the patient is placed on a gantry that
passes through the bore of the magnet. When exposed to a magnet field of sufficient strength,
the free water protons in the patient orient themselves along the magnetic field’s z-axis. This is
the head-to-toe axis, straight through the bore of the magnet. A radiofrequency (RF) antenna or
“coil” is placed over the body part to be imaged. It is the coil that transmits the RF pulses through
the patient. When the RF pulse stops, protons then slowly aspirate the fluid instilled. This
maneuver should clear any obstruction of the catheter side hole by lubricant or other material.
If the catheter is in the bladder, fluid should be aspirated without resistance. If the catheter is
still within the urethra, the negative pressure produced during aspiration will cause collapse
of the urethral wall and will not permit the return of the instilled fluid.
Only when the position of the catheter has been verified should the retaining balloon be inflated,
with the amount of fluid indicated on the catheter. Most catheters do safely permit twice the
indicated amount of fluid without risk of balloon rupture. Sterile water is the preferred solution
for balloon inflation. Air is compressible and might leak, and electrolyte or glucose-based
solutions can precipitate and occlude the tubing and valve mechanism.
The catheter should be attached to a sterile closed bag system as soon as urine is draining. The
drainage bag should be placed below the level of the bladder to encourage one-way gravity flow
with the tubing as straight as possible and avoiding kinks that might impair drainage. It has been
shown that even the retention of 50 mL of urine in catheterized patients has been associated
with an increase in UTIs in up to one third of the patients (Garcia et al, 2007).
The temporal exception to this is in patients with acute urinary retention with significant bladder
distension in which rapid bladder drainage might precipitate decompression-induced hematuria
or “ex vacuo hematuria.” In these patients the catheter should be intermittently clamped and
released to permit gradual bladder decompression over 30 to 60 minutes.
If the patient is uncircumcised, at this point return the foreskin to its normal reduced position to
avoid paraphimosis. Secure the catheter to the patient, allowing for a normal range of motion
and without tension, using adhesive tape or a commercial securing device.
Female Patients
Anatomic Considerations
The female urethra is approximately 3.5 to 4 cm long. The meatus is usually in an anterior location
and the bladder neck in a posterior location in the horizontal plane, giving the urethra a slight
posterior inclination. After antiseptic preparation and sterile draping, use the nondominant hand
to spread the patient’s labia (now considered contaminated) to reveal the urethral meatus. After
lubrication, insert the tip of the catheter and gently advance using a slightly downward direction,
until about half the length of the catheter has been inserted. Check for urine return and activate
the anchoring mechanism if used. Difficulties during female catheterization may be encountered
for several reasons including the inability to locate the urethral meatus due to obesity and age-
related changes and less frequently to strictures (postsurgery, radiotherapy, neoplastic causes).
In the obese patient, the use of one or more assistants to provide labial retraction or the use of
stirrups can be helpful. In the case of postmenopausal vaginal atrophy or other conditions
resulting in the urethral meatus receding into the introitus, we suggest the following alternatives.
Holding the index and middle fingers of the nondominant hand together, slowly slide posterior
along the introitus until the urethral meatus is palpated and then proceed to slide the fingers just
distal to the inferior margin of the meatus. Using the dominant hand, pass the catheter along the
groove made by the fingers (this serves a dual purpose—it creates a posterior border with the
fingertips and provides a guide for the catheter). As the catheter tip crosses the meatus, it can
be felt with the fingertips, thus ensuring proper placement. A second maneuver is to use a vaginal
speculum to aid in the retraction and fixation of the introitus. Finally use a coudé tip catheter
angled upward and gently slide the tip along the anterior vaginal wall in the midline, until it enters
the meatus, and then advance into the bladder.

Special Considerations in Children

Whenever possible the procedure should be explained in clear and age-appropriate language to
the child. Catheterization in children is most commonly performed for drainage, performance of
voiding cystourethrogram, or obtaining urine for culture. When attempting to obtain a urine
sample for cultures, the use of a portable bladder ultrasound is recommended to ensure that an
adequate amount of urine is present in the bladder, thus minimizing the risk of unproductive
catheterization (Robson et al, 2006).
In female children the correct identification of the urethral meatus is essential to avoid
unnecessary catheter contact with the sensitive introitus, leading to discomfort and possibly loss
of cooperation by the child. The meatus is just above the superior margin of the introitus and
frequently hidden by the superior portion of the hymen. Gentle downward pressure on the upper
aspect of the hymen with a cotton ball may allow visualization of the meatus. Failing this
maneuver, the catheter tip should be inserted just above the hymen in the midline. In
uncircumcised boys, retract the foreskin only until the meatus is visible. In infants and children
younger than 3 years of age, when the normal foreskin adhesions have not yet involuted, simply
align the preputial opening with the meatus to assist catheter insertion.

Difficult Catheterization
Difficulty inserting a catheter into the bladder is most commonly due to prostatic growth,
urethral stricture(s), bladder neck contracture, or false passage from previous urethral
instrumentation. Rarely it is the result of phimosis or urethral calculi. Although these difficulties
occur mostly in men, the techniques describedherein may be applied to place a catheter
regardless of gender(Fig. 7–3).
If there is no clinical history of previous sexually transmitted infections (STIs), catheterization,
trauma, urethral surgery, or radiotherapy in an adult male over 40 years of age, the most likely
cause is prostatic enlargement. Using adequate urethral lubrication and a 16- or 18-Fr coudé tip
silicone catheter is often successful in this scenario. If multiple previously unsuccessful attempts
have been made and urethral trauma is suspected due to the appearance of a bloody urethral
discharge, a false passage or a stricture is likely. A single atraumatic attempt can be made using
a 12-Fr silicon/straight or coudé tip catheter. If this maneuver is unsuccessful, then depending on
the availability of equipment and the level of experience of the clinician, several other options
can be considered. The authors’ preference is to use a flexible cystoscope, allowing a direct visual
approach that can be both diagnostic and therapeutic and minimizes the risk of further urethral
injury. Under direct vision, the area where the false passage was created or the site of stricture
formation is identified
Histologic Features
BPH is a hyperplastic and not a hypertrophic process, that is, there is a net increase in the number
of cells and not in the size of the cells. Histologic studies document an increase in the cell number
(McNeal, 1990). In addition, thymidine uptake studies in the dog clearly indicate an increase in
DNA synthesis in experimentally induced BPH (Barrack and Berry, 1987). The term benign
prostatic hypertrophy is pathologically incorrect.
McNeal’s studies (1990) demonstrate that the majority of early periurethral nodules are purely
stromal in character.
These small stromal nodules resemble embryonic mesenchyme with an abundance of pale
ground substance and minimal collagen. It is unclear whether these early stromal nodules contain
mainly fibroblast-like cells or whether differentiation toward a smooth muscle cell type is
occurring. In contrast, the earliest transition zone nodules represent proliferation of glandular
tissue that may be associated with an actual reduction in the relative amount of stroma (Fig. 91–
8). The minimal stroma seen initially consists primarily of mature smooth muscle, not
unlike that of the uninvolved transition zone tissue. These glandular nodules are apparently
derived from newly formed small duct branches that bud off from existing ducts, leading
to a totally new ductal system within the nodule. This type of new gland formation is quite rare
outside embryonic development.
This proliferative process leads to a tight packing of glands within a given area as well as an
increase in the height of the lining epithelium. There appears to be hypertrophy of individual
epithelial cells as well. Again, the observed increase in transition zone volume with age appears
to be related not only to an increased number of nodules but also to an increase in the
overall size of the zone. During the first 20 years of BPH development, the disease may
be predominantly characterized by an increased number of nodules, and the subsequent growth
of each new nodule is generally slow. Then a second phase of evolution occurs in which there
is a significant increase in large nodules. In the first phase, the glandular nodules tend to be larger
than the stromal nodules. In the second phase, when the size of individual nodules is increasing,
the size of glandular nodules clearly predominates. There is significant pleomorphism in stromal-
epithelial ratios in resected tissue specimens. Studies from primarily small resected glands
demonstrate a predominance of fibromuscular stroma (Shapiro et al, 1992). Larger glands,
predominantly those removed by enucleation, demonstrate primarily epithelial nodules (Franks,
1976). However, an increase in stromalepithelial ratios does not necessarily indicate that this is
a “stromal disease”; stromal proliferation may well be due to “epithelial
disease.”

The Bladder’s Response to Obstruction

Current evidence suggests that the bladder’s response to obstruction is largely an adaptive one.
However, it is also clear that many lower tract symptoms in mn with BPH or prostate enlargement
are related to obstruction-induced changes in bladder function rather than to outflow
obstruction directly. Approximately one third of men continue to have significant voiding
dysfunction and mostly storage symptoms after surgical relief of obstruction (Abrams et al, 1979).
Obstruction-induced changes in the bladder are of two basic types. First, the changes that lead
to detrusor instability or decreased compliance are clinically associated with symptoms of
frequency and urgency. Second, the changes associated with decreased detrusor contractility
are associated with further deterioration in the force of the urinary stream, hesitancy,
intermittency, increased residual urine, and (in a minority of cases) detrusor failure. Acute
urinary retention should not be viewed as an inevitable result of this process. Many patients
presenting with acute urinary retention (AUR) have more than adequate detrusor function,
with evidence of a precipitating event leading to the obstruction.
Much of our knowledge of the detrusor’s response to obstruction is based on experimental
animal studies. Limited information is available on the natural history of the human bladder’s
response to obstruction. It has been demonstrated that the major endoscopic detrusor change,
trabeculation, is due to an increase in detrusor collagen (Gosling and Dixon, 1980;
Gosling et al, 1986). Severe trabeculation is associated with significant residual urine (Barry et al,
1993), suggesting that incomplete emptying may be due to increased collagen rather than
impaired muscle function. Severe trabeculation, however, is seen in fairly advanced disease. In
experimental animal models the initial response of the detrusor to obstruction is the
development of smooth muscle hypertrophy (Levin et al, 1995,
2000). It is likely that this increase in muscle mass, although an adaptive response to increased
intravesical pressure and maintained flow, is associated with significant intracellular and
extracellular changes in the smooth muscle cell that lead to detrusor instability and in some
cases impaired contractility. Obstruction also induces changes in smooth muscle cell contractile
protein expression, impaired energy production (mitochondrial dysfunction), calcium signaling
abnormalities, and impaired cell-to-cell communication (Levin et al, 1995, 2000).
There is considerable evidence that the response of the detrusor smooth muscle cell to stress
(increased load related to outlet obstruction) is not as adaptive as the response of skeletal muscle
to stress. In the latter case, a relatively normal repertoire of contractile protein genes are
upregulated and an increased number of normally organized contractile units assemble in the
muscle cell. In the detrusor smooth muscle cell, load-induced hypertrophy leads to a change in
myosin heavy chain isoform expression (Lin and McConnell, 1994; Cher et al, 1996) and to a
significant alteration in the expression of a variety of thin filament-associated proteins
(Mannikarottu et al, 2005a, 2005b, 2006). Taken together, these observations strongly suggest
that smooth muscle cells revert to a secretory phenotype in response to obstruction-induced
hypertrophy. One consequence of this phenotypic switch is increased ECM production. The
detrusor smooth muscle cell is a key contributor to the complex of symptoms associated with
prostatic obstruction. Additional research in this area is required
(Christ and Liebert, 2005).
In experimental animal models, unrelieved obstruction is associated with the development of
significant increases in detrusor ECM (collagen) (Levin et al, 1995, 2000). This also appears to be
the case in the human, although cause-and-effect relationships have not been established
(Gosling et al, 1986). In addition to obstruction-induced changes in the smooth muscle cell and
ECM of the bladder there is increasing evidence that obstruction may modulate neural-detrusor
responses as well (Steers et al, 1990, 1999; Clemow et al, 1998, 2000). Altered neural control of
micturition has been noted in aging rats, including reduced bladder contractility, impaired central
processing, and altered sensation (Chai et al, 2000).
Independent of obstruction, aging produces some of the same changes in bladder function,
histology, and cellular function (Nordling, 2002). There is suggestive evidence from animal
models that atherosclerosis and the resultant chronic bladder ischemia or hypoxia induced by
other mechanisms (e.g., increased bladder wall tension) may contribute to bladder pathology
(Tarcan et al, 1998; Azadzoi et al, 1999, 2003, 2008; Azadzoi, 2003).

Definitions
The study of epidemiology determines the distribution and determinants of diseases in man.
From this evolve the components of descriptive epidemiology, which is the description of
disease incidence, mortality and prevalence by person, place, and time, and analytical
epidemiology, which is the search for determinants of disease risk that may serve to increase
prospects for prevention (Oishi et al, 1989). Epidemiologists assess and compare rates of
diseases within one population stratified by sex, age, and other demographic and socioeconomic
parameters and between populations of different culture, ethnicity, lifestyles, and diet.
The following definitions of rates are important to understand:
l Incidence: number of diseased people per 100,000 population per year l Prevalence: number
of existing cases per 100,000 population at a distinct target date l Mortality: number of deaths
per 100,000 population per year l Fatality: number of deaths per number of diseased
Key Points: Etiology and Pathophysiology
l The development of BPH requires an intact androgen signaling pathway, but androgens do not
cause the disease. l In the absence of obvious cellular proliferation, the hyperplastic process must
be due to an imbalance between cell death and cell proliferation, leading to cell accumulation in
both the epithelial and stromal compartments. l BPH is said to be a “stromal disease,” but it
remains unclear whether the initiating events occur in the stromal compartment,the epithelial
compartment, or both. combination of clinical threshold