Urology

Symptomology and methods of physical

examination of urological diseases
Symptomology of urological diseases
■ The basic symptoms of kidney and urinary tract
diseases :
■ Quantitative changes in urine
■ Qualitative changes in urine
■ Pain (renal colic)
■ Urination disorder
■ Lose weight
■ Hyperthermia (chill, fever)
■ Urethral discharge
■ Ejaculation disorders
■ Erection disorders
■ Changes in spermatogenesis
 Quantitative changes in urine

■ The normal range for 24-hour urine volume is

800 to 2,000 milliliters
■ Diuresis depends on the amount of fluid taken
and the amount of food consumed
■ Normal urine specific gravity 1005-1025
■ Quantitative changes in urine:

■ Anuria - nonpassage of urine, in practice is defined as

passage of less than 100 ml of urine in a day;
■ Oliguria - low output of urine, less than 500ml/day;
■ Polyuria - increased production and passage of urine, more
than 2000ml/day;
■ Causes of oliguria/anuria:
1. Prerenal
■ Hypovolemia - bleeding, loss of water and electrolytes
■ Cardiovascular Failure - Heart Failure, Hepato-Renal Syndrome
■ Acute impairment of blood circulation in the kidney - kidney
artery or vein occlusion, shock, collapse
2. Renal
■ Prolonged haemodynamic disorders
■ Toxemia - hemolysis, myolysis, medication
■ Parenchymal kidney diseases - acute interstitial nephritis, rapidly
progressive glomerulonephritis, vasculitis, etc.
3. Postrenal - mechanical obstruction of the upper
urinary tract with stones, cancer, ligation of the
lower segments of the ureter during gynecological
operations
■ Polyuria also develops during oligoanuria
■ After removing urinary tract obstruction and restoring
urine passage, during renal functional recovery - the
phase of polyuria
 Qualitative changes in urine
■ Haematuria - presence of red blood cells in the
urine. (The presence of 3 or less RBCs per
high-power field is normal)
■ Microhaematuria - erythrocytes are detected only
through a microscope.
■ Macrohaematuria - different intensity of blood-stained
urine.
■ Reasons: Cancers, inflammatory and urolithiasis,
traumatic injury, anticoagulants
Erythrocytes in the urine during bladder cancer
■ Types of haematuria:
■ Initial haematuria – blood at beginning of micturition
■ Terminal haematuria - blood seen at end of micturition
■ Total hematuria - blood visible throughout micturition
■ During intensive haematuria, blood clots may form
■ Different-shaped - from the urethra or prostate (in men)
■ Wormlike shaped - coming from upper urinary tract
■ When blood clots are obstructed in the urinary tract,
macrohematuria is accompanied by pain.
■ Proteinuria
■ Presence of proteins in the urine >0,033 gr/L.
■ True proteinuria - because of the kidney
■ Functional
■ Neonatal physiological proteinuria; orthostatic albuminuria;
transitory- after severe anemia, burns, traumas, physical activity,
consuming protein foods
■ Organic
■ The protein is filtered through the damaged membranes of the
glomerulus
■ Kidney pathology - nephritis, glomerulonephritis, pregnant
nephropathy
■ False proteinuria – non-renal
■ The presence of leukocytes, erythrocytes, bacteria in the urine
■ Different diseases of the urinary tract - urolithiasis, inflammatory,
tuberculosis, tumors
■ Pyuria
■ Presence of leykocites in the urine
■ It is marked in inflammatory diseases of the urinary
organs(pyelonephritis, tuberculosis, cystitis, urethritis,
prostatitis)
■ Myoglobinuria
■ Presence of myoglobin in the urine
■ Develops during the long time pressure (Crush
syndrome)
■ Cylindruria
■ The presence of renal cylinders in the urine
■ Occurs in nephritis, glomerulonephritis, when using
nephrotoxic drugs
1. True cylindruria - Hyaline, granular, waxy
2. False cylindruria- uric acid salts, myoglobin, bacteria
Urological diseases are mainly characterized by
hyaline cylinders
■ Bacteriuria
■ The presence of bacteria in urine
■ Normally the urine is sterile
■ Bacterioscopy reveals the presence of
microorganisms
■ Bacteriological test determines the type and
number of microorganisms
■ Pneumaturia
▪ Excretion of gases with urine
■ Reasons:
■ Instrumental examinations (cystoscopy,
catheterization)
■ Fistulas between the urinary tract and digestive
tract
Bacteriuria. Gram-negative bacilli of Escherichia
coli
■ Lipuria
■ The presence of fat in the urine
■ Visually: the presence of fat on the surface of the urine
■ Reason: Fatty embolisms of the renal capillaries after
fracture of the long bones (etc. femur)
■ Chyluria
■ The presence of chyle in the urine
■ Urine color and consistency is like milk
■ Reason: Inflammatory and tumor processes, traumatic
fistulas between the urinary system and large lymph
ducts
■ Hydatiduria
■ Blend of echinococcus small vesicles with urine after
opening hydatid cyst in the urinary tract
■ Fecaluria
■ The presence of feces in the urine
■ Reason: Urinary bladder-rectal fistula in cancerous
diseases
 Pain
■ Kidney pain
■ Localization: In the lumbar region in the costovertebral corner,
laterally to the sacrospinal muscle and below the XII rib.
■ Irradiation: Towards the umbilical cord, inguinal region, testis and
labium.
■ According to the intensity:
■ Dull pain - In inflammatory, urolithiasis, cystic and cancerous
diseases.
■ Post-urinating pain in the kidney area – vesicoureteral
reflux
■ Offensive pain – renal colic.

■ It develops unexpectedly during acute obstruction of the

urinary tract(stone, colt...). Elevated renal pressure is
transmitted through the pelvic baroreceptors to the
central nervous system, where it transforms like pain.
Reflexive spasm of the renal blood vessels further
increases the intensity of the pain.
■ Swelling and enlargement of renal parenchyma causes stretching
fibrotic capsule rich in pain receptors and an even greater
increase in pain intensity.
■ The patient is restless, trying to get a comfortable position,
changing pulse, blood pressure, body temperature.
■ Positive Pasternack sign- pain is elicited by light stroke of the
area of the back overlying the kidney
■ Kidney colic should be differentiated with the
following conditions:
1. Acute cholecystitis
2. Pankreatitis
3. Gastric ulcer perforation
4. Retroperitoneal and intercostal neuralgia
■ Pain of intraperitoneal origin is rarely of an offensive nature
■ Pain of intraperitoneal origin is characterized by irradiation
of the arm and diaphragm
■ Patients with intraperitoneal pain prefer lying motionless
■ Ureteral pain
■ Reason: Obstruction with stone or blood clot
■ Obstruction increases the internal pressure of the ureter, developing
hyperperistalsis and spasm of smooth muscles.
■ Upper 1/3 obstruction of the ureter:
■ Irradiation of pain in upper half of abdomen

■ Differentiation is needed : Cholecystitis, pancreatitis, gastric ulcer

■ Middle 1/3 obstruction of the ureter:

■ Irradiation of pain in lower half of the abdomen and small pelvis,
testis, labium
■ Lower 1/3 obstruction of the ureter:
■ Frequent urination, urinary urgency, discomfort in the suprapubic
area, pain along the ureteral tube
■ Urinary bladder pain
■ Reasons: Bladder stretching during acute urinary retention;
Inflammatory, stone and cancerous diseases.
■ In bacterial or interstitial cystitis, pain is present when the
bladder is full and disappear completely or partially after
urinating.
■ Prostate pain
■ Reason: Extension of the prostate capsule as a result of
inflammation.
■ Localization: Lower abdominal, inguinal, perineal, rectal
areas.
■ Often accompanied by urinating disorders
■ Penile pain
■ Reasons: Paraphimosis, Balanopostitis, Tumors, Trauma.
■ The pain during penile erection basically marked during the
Peyronie’s disease and Priapism.
■ Scrotal pain
■ Reasons:
■ Orchiepididymitis, varicocele, tumor, hydrocele (Dull
pain).
■ Testicular torsion, trauma, infection of the hair follicle
or testicle, Fournier’s gangrene (acute pain).
„Acute scrotum“
 Acute scrotum differential diagnosis

Torsion testis Torsion of epididymal Epididymitis Orchitis Trauma

cyst

Testicular cancer Hydrocele Spermatocele Varicocele

 Urination disorders
■ Urination disorder - dysuria
■ Normally an adult urinates 4-5 times a day, Vol.
Approx. 200-250 ml.
■ Urination disorders
■ Pollakiuria
■ Stranguria
■ Nocturia
■ Urinary incontinence
■ Urinary retention
■ Pollakiuria
■ Urinary frequency.
■ Characteristic of lower urinary tract and prostate
diseases.
■ A small amount of urine is excreted on urination
■ It is often accompanied by imperative need to urinate.
■ It may occur after large amount of fluid intake, in
diabetes and chronic kidney diseases, however, output
urine volume is not small at this time.
■ Stranguria
■ Difficulty in micturition in which urine is passed only
drop by drop with pain and tenesmus
■ Caused by urinary bladder pathologies
■ Spasmodic contraction of urinary bladder, small
amounts of urine, imperative need to urinate.
■ Nocturia
■ Frequent urinate at night.
■ Prostate hyperplasia, diabetes mellitus, cardiovascular
failure.
■ Urinary incontinence (stress, imperative, paradoxical, enuresis)
■ Stress incontinence
■ Urinary incontinence during physical tensing (coughing, laughing,
sneezing...), intra-abdominal pressure increases and in case of
functional failure of the sphincter, involuntary urination occurs.
■ Mostly in women with weakening pelvic muscle and bladder
sphincter tone, due to the vaginal or uterine prolapse.
■ During menopause, when hormonal changes cause functional
discoordinate of the detrusor and sphincter, which leads to stress
incontinence.
■ In men: After radical prostatectomy due to damage to the urethral
sphincter.
Stress incontinence
■ Imperative urinary incontinence
■ Involuntary urination due to an imperative urge to urinate - at this
time occurs sudden emergence need to urnate, the patient is
unable to reach the toilet and retention urine.
■ Reasons: Cystitis, neurogenic urinary bladder, infra-vesical
obstruction.
■ Paradoxical urinary incontinence(Ischuria)
■ Involuntary urination during chronic retension.
■ Large amounts of residual urine and streched urinary bladder in
prostate hyperplasia causes detrusor and sphincter failure. These
cause nonpassage of urine, or decreased output of urine and
involuntary urination.
■ Enuresis
■ Involuntary urination while asleep.
■ 13-20% of 5-year-old children, 5% of 10-year-old children. By 15
years of age 1 to 2 percent continue to wet the bed. Under 15 is
considered physiologically.
■ In other cases, it is a symptom of other diseases of the urinary
tract.
 Lose weight
■ In advanced case inoperable tumors of the urinary tract organs.

Temperature rise
■ Inflammatory and cancerous diseases of the organs of the urinary
system.
■ High temperature(38-40°C) occurs: Acute pyelonephritis,
paranephritis, acute prostatitis, acute orchiepididymitis.
■ Urinary tract obstruction, vesicoureteral reflux in infected urine
conditions cause a sudden chill and rise in temperature.
■ The subfebrile temperature is associated with urinary tract
tuberculosis, chronic orchiepididymitis, a kidney tumor.
 Genital symptoms
■ Urethrorrhagia
■ refers to urethral bleeding in the absence of urine, associated with
urethral cancer, traumatic injury.
■ Prostatorrhea
■ Is the emission of prostatic secretions during straining associated
with urination or defecation. Occurs in chronic bacterial prostatitis or
during prolonged restraint from sex life.
■ Spermatorrhoea
■ abnormally frequent and involuntary nonorgasmic emission of
semen, during severe spinal cord injury.
■ Hematospermia
■ Presence of blood in ejaculation; It may be accompanied by
prostatitis, prostate tuberculosis or cancer.
 Ejaculation disorders
■ Absence of ejaculate or retrograde ejaculation (semen enters the
bladder).
■ Reasons:
■ Deficiency of androgens

■ Sympathetic denervation

■ Pharmacological agents

■ Bladder neck and prostate surgery

 Erectile dysfunction
■ 20% of men over the age of 60 complain of
sexual disorders, low libido, erectile dysfunction.
 Changes in spermatogenesis
■ Aspermatism - The absence of seminal secretion
■ Azoospermia - Semen contains no sperm
■ Oligospermia - Semen with a low concentration of sperm (less
than 30%)
■ Teratozoospermia – The presence of increased percentage of
abnormal sperm (more than 70%)
■ Necrospermia - The presence of motionless, dead
spermatozoa
■ Hematospermia - The presence of blood in the sperm
 Physical examinations of the urogenital
system
Inspection
■ Anterior abdominal wall and lumbar-spine area

■ Asymmetry - Large-sized hydronephrosis, polycystic kidney,

renal tumor.
■ Swelling and hyperthermia of lumbar-spine area – perinephric
infection, abscess.
■ Urinary bladder

■ Outline of urinary

bladder filled with urine

during urinary retention.
■ Inspection of scrotum

Scrotal skin cysts

Hypospadias
■ Inspection of scrotum

Scrotal abscess Hydrocele

Varicocele
■ Inspection of scrotum

Scrotal hematoma (traumatic)

Scrotal Elephantiasis (Lymph duct

obstruction)
Varicocele Hydrocele
■ Penis inspection

Phimosis Paraphimosis

Balanitis Herpes ulcers

■ Penis inspection

Penis cancer Meatal stenosis

Hypospadias
Palpation
■ Palpate for kidneys

■ Normally only the lower pole can be felt when breathd deeply.

■ Bimanual palpation : Evaluating kidney size, shape, elasticity,

location, pain.
 Bimanual palpation Diseases
Enlaged kidney 1. Compensatory hypertrophy in the
absence or atrophy of the second
kidney
2. Hydronephrosis
3. Cancer
4. Kidney cyst
5. Policystic kidney disease

Nodular or thick 1. Policystic kidney disease

2. Cancer

Bimanally kidney-free palpation of tissue 1. Retroperitoneal tumor

mass 2. Spleen
3. Bowel cancer, abscess
4. Enlarged gall bladder
5. Pancreatic cyst
■ Urinary bladder palpation
■ Surface of the bladder filled with urine during acute or chronic
urinary retention
■ Scrotal palpation
Evaluating:
■ The presence, number, size, density, pain of the testicle.
■ Structure, size of the epididymis and interconnection with the
testicles.
Diagnoses:
■ Hydrocele
■ Hematocele
■ Varicocele
■ Cryptorchidism
■ Orchitis, orchiepididymitis
■ Testicular cyst, tumor
■ Testicular torsion
Testis, cord Palpation
The method of self-examination
■ Male genital palpation
■ Evaluating Cavernous bodies and urethral elasticity
■ Fibroblastic induration of the penis may be established
(Peyronie’s disease, tumor, periurethritis).
■ Palpation of inguinal region
■ Enlargement of lymph nodes: Inflammation of the penis or
scrotum; Penis, scrotal skin, female distal urethral tumor.
■ Supraclavicular region
■ Left-sided lymph nodes may have metastases from the
testicles and prostate (Virchow or Troisier nodes)
Percussion
■ Kidneys
■ Front and back percussion: In terminal hydronephrosis,
when the kidney is unable to palpate because of its soft
consistency.
■ To identify progressive hemorrhagic masses in the kidney
injury, when palpation fails because of muscle spasms.
■ Urinary bladder
■ Evaluating urinary bladder’s fullness, in case of at least
150ml of urine existence in it
Auscultation
■ Diagnosis of renal arterial hypertension, stenosis of renal artery,
arteriovenous fistula, atherosclerotic lesion of the abdominal aorta.
Digital rectal exam of men
■ Sphincter and anus
■ Anal sphincter tone relaxation indicates changes in urinary
bladder sphincter and detrusor, neurogenic disease.
■ Should be excluded: Anus stenosis, internal hemorrhoids,
rectal fistula, polyp, tumor, what may become the
secondary cause of urinate disorders.
■ Prostate
■ Normal size 3,0X4,0X2,0 sm., weight 18-20 gr.

■ By digital rectal exam:

■ The right lob of the prostate

■ The left portion of the prostate

■ Interlobar duct

■ Evaluating size, elasticity, consistency,

■ Stone density - prostate cancer

Digital rectal exam for prostate
■ Prostate Massage and Prostate Secretion
■ Prostate secretion mixes with sperm and is an important site for
sperm motility.
■ With digital rectal massage it is possible to get prostate secretion.

■ Normally prostate secretion contains:

■ Lecithin granules

■ Small amounts of epithelial cells

■ Rarely corpora amylacea

■ Rarely sperm

■ Bacteriological examination of prostate secretion - Necessary

method of diagnosing prostate inflammatory diseases.
■ Prostate rectal massage is not recommended during acute urethral
discharge, acute prostatitis, urinary retention, prostate cancer.
■ Seminal vesicles
■ Seminal vesicles are located behind the urinary bladder base
and are deviated to the lower peak
■ Rectal examination is unable, If there is no deviation distally
 Female genital system
■ Diseases of the female genital system may be occured by symptoms
typical of diseases of the urinary organs.
■ Inspection

■ Palpation

■ Vaginal examination
 Pediatric urology and anomalies
Embryogenesis
■ Human genitourinary system develops from the urogenital ridge on the
dorsal surface of the embryo. The latter is further differentiated into the
urinary and genital systems.
■ During pregnancy, the kidney goes through three successive stages of
development : Pronephros, mesonephros and metanephros.
■ Pronephros is a dysfunctional structure and soon degenerates.
■ Mesonephros is a temporary excretory organ. The greater part of it also
degenerates, a part (ureteric bud) produces ureter. Its termination (The
wolffian duct) produces an epididymis, ductus deferens, seminal vesicle and
ejaculatory duct in men.
■ Metanephrosis becomes the definitive kidney. In the formation of the
metanephrosis takes part:
■ Mesonephrotic ureteric bud - Upcoming pelvis and urethra;
■ Arounding mesodermic area – Upcoming glomerular apparatus and
tubular system.
■ The definitive kidney then migrates upward and takes its place in the lumbar
region.
■ Metanephros opens in the urogenital sinus, from
which the urinary bladder and urethra arise.
■ The following basic structures are involved in genital
embryogenesis :
■ Undifferentiated gonads 🡪 The testicles in the male
and the ovaries in the female.
■ The formed gonads then migrate from the abdominal cavity
to the pelvis (female) and scrotum (male).
■ Paramesonephric (the Mullerian) ducts 🡪 The uterus
and cervix, fallopian tubes.
■ Mesonephric (the Wolffian) ducts 🡪 Epididymis,
ductus deferenses, seminal vesicles and ejaculatory
duct.
■ Phimosis - is a condition in which the foreskin cannot be
retracted from around the tip of the penis.
■ Treatment: Circumcision (Indication: Recurrent infections,
difficulty urinating); Short frenum correction (Frenulotomy).
■ Paraphimosis - is a condition in which the foreskin can no
longer be pulled forward over the tip of the penis.
■ Often iatrogenic: after catheterization.

■ Causes severe pain.

■ Circulatory failure can lead to necrosis of the head and

foreskin of the penis.
■ Emergency is needed : Manual correction if unsuccessful, an
emergency dorsal slit should be performed, or circumcision.
 Paraphimosis
Phimosis

Short frenum
It is necessary to differentiate the phimosis in children
with long foreskin
Cryptorchidism
■ Is the absence of at least one testicle from the scrotum.
■ Types: (1) A testis retention at the level of the abdomen,
inguinal canal or outer inguinal ring; (2) Thigh, penodorsal or
epipfascial ectopia.

Descending of the testis to the

scrotum during embryogenesis
■ Cryptorchidism is reported in 1.8-2% of children under
1 year of age.
■ The movable (retractile) testicle is the type of
cryptorchidism - The movable testicle with a very short
spermatic cord easily returns toward the external
inguinal ring and canal.
■ Increased risk of infertility and testicular cancer
■ Diagnosis - Physical Examination, Ultrasonography,
Magnetic Resonance Imaging.
■ Treatment:
■ Hormone therapy (human chorionic gonadotropin).
■ Surgery treatment: Orchidopexy (to move a testicle
in the scrotum).
 Diagnosis of Cryptorchidism

• Inspection, palpation
• Ultrasonography, ct, mri
• Laparoscopy
Other anomalies of the urethra, urinary
bladder, and external genitals
Hypospadias
Epispadias
Micropenis
Congenital penile curvature
Duplication of urethra
Ectopic urinary bladder
Ambiguous genitals
Ambiguous genitals
Hypospadias
■ Abnormal localization of the urethral opening on the ventral
surface of the penis, scrotum or perineum.
■ Classification by localization : Distal (glanular, coronal,
subcoronal), midshaft, proximal (penoscrotal, scrotal, perineal)
■ Evaluating:
■ External urethral orifice diameter, shape, location;
■ Penis size, curved erectile penis, inflammatory changes;
■ Existence of other congenital anomalies of the genitourinary
system;
■ Treatment:
■ Surgical treatment needed: (1) Midshaft and proximal
hypospadias, (2) distal hypospadias,
if it is accompanied by penile fracture the and
Meatal stenosis.
■ Surgery: Correction of curved penis,
formation of new external urethral orifice and
put the external urethral orifice on top of the
pennis.
Epispadias
■ Localization of the external urethral orifice on the
dorsal surface of the penis.
■ Rare malformation of the penis than
hypospadias.
■ Often accompanied by urinary bladder exstrophy.
■ It is characterized by penile curvature and
urinary incontinence.
■ The treatment is surgical : Curvature correction,
reconstruction of the external urethral orifice.
 Hypospadias

Epispadias and urinary bladder exstrophy

 Micropenis
Hormonal causes : Deficiency of gonadotropins, 5-alpha
reductase deficiency, decreased androgen sensitivity,
Klinefelter syndrome, Idiopathic, ...

Micropenis due to excess weight

Urinary incontinence

■ In children urinary incontinence problem solve on reaching of 2 years age,

and when they reach the age of 4, they control nighttime urinary retention
■ Classification:
■ Enuresis – Normal urination, implemented at an inappropriate and
socially inaccessible time and place.
■ Monosymptomatic enuresis - Involuntary urination at night in sleeping
children; do not wake the liquid; has a genetic tendency.
■ Primary nocturnal enuresis - Occurs after birth and the dry period does
not exceed 6 months.
■ Secondary nocturnal enuresis - Starts after a dry period of 6 months.
■ Nocturnal polyuria, enuresis - Enuresis + according to diary of urination,
the amount of urine produced at night exceeds the functional volume of
the bladder.
■ Daytime anuresis- If the bladder is completely emptied and the urethral
and bladder function is normal, then, due to an inattention, daytime can
occur.
■ Urinary incontinence related:
■ Anatomical defects of the urinary tract - Ectopic ureter,
ureterocele, Prune-Belly syndrome, urinary bladder
exstrophy, epispadias, rear urethral valve, Cloacal
anomalies.
■ With neurogenic disorders – Spinal cord disruption,
Caudal regression syndrome, myelomeningocele, other
C.N.S. disorders.
■ Functional incontinence of urine - Non-neuropathic
bladder-sphincter dysfunction(Imperative urination
syndrome and Dysfunctional voiding); Often associated
with recurrent urinary tract infections.
■ Diagnosis: Anamnesis, examination, urinalysis,
ultrasonography, voiding diary, urodynamic testing,
cystourethrography, urethrocystoscopy.
Dilatation of the upper urinary tract
■ Fetal hydronephrosis
■ By the 16th week of pregnancy, fetal hydronephrosis can
be diagnosed.
■ Reasons:

■ Vesicorenal reflux,

■ Ureteropelvic junction obstruction,

■ Megaureter,

■ Urethral valve,

■ Multicystic dysplastic kidney.

■ Diagnosis - Ultrasonography, voiding cystourethrography,

renal scintigraphy, excretory urography.
■ Treatment – Cause correction.
Ureteropelvic junction obstruction
Ureteropelvic junction obstruction
Pyeloplasty
Pyeloplasty
Excretory urography Miction
cystourethrography
Urinary reflux
■ Backflow of urine in the urinary
bladder or in the renal pelvis:
Vesicoureteral or vesicorenal
reflux.
■ The incidence of vesicoureteral
reflux in the kindergarten and
school age girls is 14-29% in
boys 30%.
■ The basic manifestation is
recurrent upper urinary tract
infections.
■ Advanced case reflux causes
hypertension, kidney failure.
■ Diagnosis - Ultrasonography, voiding cystourethrography,
renal scintigraphy, excretory urography.
■ The goal of treatment is to prevent infectious complications
and progressive impairment of renal function.
■ Methods of treatment - Conservative, surgical (depending on
age and reflux grade).
Renal anomalies
Quantitative renal abnormality
■ Renal agenesis - Condition in which one (unilateral) or both
(bilateral) fetal kidneys fail to develop.
■ Supernumerary kidney

Right renal agenesis Partially merged left extra kidney

Renal anomaly of position

■ Dystopia - Pelvic, lumbar, iliac,

thoracal, crossed.
■ Nephroptosis (Abnormally moving
kidney). It differs from dystopia
with ureteral length.
Renal anomalies of shape

■ The horseshoe kidney -

Kidneys become attached together
at the lower end or base
■ S-shaped kidney,

■ L-shaped kidney,

■ Pancake (discoid) kidney,

The horseshoe kidney

Volumetric and structural renal abnormalities
■ Renal hypoplasia- Small kidney(congenital)

In clinical practice it is often difficult to differentiate from

acquired atrophy.
■ Renal cysts
■ Mylticystic kidney - The kidney consists of irregular
cysts of varying sizes
■ Unilateral anomaly
■ Acquired
■ Reason: Absence of ureter or dull ending.
■ Polycystic kidney disease - development and growth of
multiple cysts within the kidney
■ Bilateral anomaly
■ Genetic, congenital
■ Progressive renal failure
■ Simple kidney cyst – this kind of cysts are often
unilateral and do not require treatment unless they
cause symptoms or impaired kidney function
Multicystic kidney (ultrasonography)
Polycystic kidney (computed tomography)
Simple cyst of the right kidney(computed tomography)
Anomalies of kidney rotation
■ Complete, incomplete, reversed
Renal pelvicalyceal system anomalies
■ Calyceal diverticulum

■ Hydrocalycosis

■ Megacalycosis

■ Unipapillary kidney

■ Extrarenal pelvis or calyces

■ Funnel-shaped pelvis

■ Duplication of renal pelvis

Renal vascular abnormalities
■ Additional or multiple blood vessels

■ May cause ureteropelvic segment obstruction

■ Renal artery aneurysm

■ Renal arterio-venous fistula

Multiple arteries of the right

kidney
Ureteral anomalies
■ Quantitative anomalies
■ Often concurring with quantitative renal
abnormalities.
■ Even a normal kidney may have a duplicated ureter
■ Ureters can be attached independently to the
bladder or to each other at different levels.
Incomplete duplicated ureter Complete duplicated ureter. Also
(Y-shaped) left side ectopic ureteral orifice.
■ Anomalies of ureteral endings
■ Lateral ectopy – Ureteral orifice opens on the lateral wall
of the bladder.
■ An ectopic ureteral orifice may open into the urinary
bladder neck, urethra, vagina, uterus, In men - into the
prostate part of the urethra, seminal vesicles, into the
ejaculatory duct, and into the epididymis.
■ Ureterocele
■ Narrowed ureteral orifice and pushed it into the
bladder lumen.
■ It may be related to the duplicated ureter.

■ Urinary Rare anomalies:

■ Rolled ureter,

■ Ureteral diverticulum,

■ Ureteric valve.
■ Ureteropelvic segment obstruction
■ One of the most common pathologies.

■ It may be related to the presence of an accessory renal

blood vessel, which often joins the kidney to the lower
pole and causes pressure on the ureteropelvic segment.
■ Ureter locational anomalies
■ Retrocaval ureter
Urinary bladder anomalies
■ Ectopic urinary bladder

■ The bladder has no anterior wall and the bladder mucosa

joins the abdominal skin in the suprapubic area
■ It is more common in boys and is always accompanied by
an epispadias.
 Spina bifida, myelomeningocele

Stretching and compression of the spinal nerves causes urination

disorders, disruption of renal motor-evacuatory function.
Urogenital tract infections
Urinary tract infections
Introduction
⚫ Upper urinary tract infections :
◦ Pyelonephritis
⚫ Lower urinary tract infections
◦ Cystitis
◦ Urethritis
◦ Prostatitis
Urinary tract infections
⚫ Uncomplicated
⚫ Complicated
◦ Factors: Functional or anatomical anomaly of
the urinary tract, gender (male), pregnancy,
great age, diabetes, immunosuppression,
urologic infections in childhood, prolonged
catheterization, hospital-acquired infections,
late (> 7 days) detection.
General symptoms of urinary tract
infection
⚫ Dysuria, frequent urination
⚫ Hematuria
⚫ Fever
⚫ Nausea / vomiting
⚫ Pain
Urinary tract infections
Objective examination data
⚫ Physical examination:
◦ Palpation-induced pain in the lumbar region
(pyelonephritis)
◦ Urethral discharge (urethritis)
◦ Pain during digital rectal exam (prostatitis)
⚫ Laboratory studies : Urinalysis
◦ + Leukocyte esterase
◦ + Nitrites
● Gram-negative infection sign
◦ + Leukocytes
◦ + Erythrocytes
 Urinary tract infections
Bacteriological studies
⚫ Urine culture = >105 CFU/mL
⚫ The most common causes of cystitis,
prostatitis, pyelonephritis
◦ Escherichia coli
◦ Staphylococcus saprophyticus
◦ Proteus mirabilis
◦ Klebsiella
◦ Enterococcus
⚫ The most common causes of urethritis
● Chlamydia trachomatis
● Neisseria Gonorrhea
Determination of probable localization of urinary tract
infections by urine portion
Acute pyelonephritis
⚫ Infectious inflammation of the renal
parenchyma and pelvicalyceal system
⚫ The classic triad:
● Fever
● Chilling
● Pain in the lumbar region
Acute obstructive pyelonephritis
Methods of elimination of obstruction
Retrograde ureteral
stenting

Percutaneous
nephrostomy
Acute pyelonephritis
Complications
Renal abscess
Renal abscess: Percutaneous drainage
Acute pyelonephritis
Complications
Pyonephrosis
Acute pyelonephritis
Complications
Emphysematous pyelonephritis

Renal parenchyma destruction and gases in the retroperitoneum

🡪 Emergency nephrectomy
Renal parenchyma atrophy resulting from frequent,
recurrent infections
Acute bacterial cystitis

Frequent attacks of symptoms

of acute cystitis, which does not
obey standard treatment 🡪 A
cystoscopy is needed to
exclude the tumor.
Chronic cystitis
⚫ Recurrent bacterial infection
⚫ Urinary bladder concrements
⚫ Chemical impact (for example,
chemotherapy for tumors)
⚫ Interstitial cystitis - Inflammatory
infiltration of unknown etiology into the
submucosa.
Classic cystoscopic image of interstitial cystitis
Urethritis
⚫ Primary - Mostly sexually transmitted infection
⚫ Secondary - Result of prolonged catheterization
⚫ According to the pathogen
◦ Gonococcal
◦ Non-gonococcal (chlamydia)
⚫ The main symptoms : Urethral discharge,
dysuria
⚫ Treatment - According to the pathogen
 Prostatitis
⚫ Prostatitis syndrome - Pain of varying intensity and
non-clear localization in the penis, perineum, scrotum,
lumbar region; Urination disorders
⚫ Acute bacterial prostatitis - Hospitalization and intensive
antibiotic therapy are needed to prevent sepsis.
⚫ Prostate abscess - Surgical drainage with a perineal or
rectal approach is required
⚫ Chronic prostatitis/Chronic pelvic pain syndrome –
Complicated, long-lasting inflammatory disease; Complex
treatment is needed
Epididymitis and Orchitis
⚫ Acute or chronic
⚫ Infection caused by mostly catarrhal causes
⚫ It may be a complication of viral parotitis
⚫ It may be a manifestation of Tuberculosis
⚫ It is necessary to differentiate with the testicular tortion
⚫ Treatment – Bed rest, testis elevation,
anti-inflammatory and antibacterial therapy.
Balanitis and balanoposthitis
⚫ Balanitis - Inflammation of the foreskin of
the penis
⚫ Balanoposthitis – Inflammation of the
foreskin and the head of penis
⚫ Diabetes mellitus
Tuberculosis of the genitourinary
system
⚫ Mycobacterium tuberculosis hematogenous spread
from the lung.
⚫ Damages the kidney (abscess,), Ureter (stricture +
hydronephrosis), urinary bladder (sclerosis), testis and
epididymis (chronic orchiepididymitis)
⚫ Important clinical signs : Hematuria and sterile pyuria.
 Distal stricture of the left
Tuberculous calcification of the ureter due to tuberculosis
left kidney
Urinary bladder
tuberculosis.
Cystoscopic image
Urinary tract stone disease
 Epidemiology
• 3:1 men:women (~7% men/ 3% women)
• Most common in the 3-5th decade of life (70%)
• All urologic patients 30%
• Congenital attitude(renal tubular acidosis,
hyperparathyroidism, cystinuria, sarcoidosis, Crohn’s
disease,...)
• Climate (mountain, desert, tropics)
• Season of the year (the warmest months)
• Life style (mostly seated)
• Medications : Protease inhibitors, some diuretics,
classes of medication that cause diarrhea,...
 Localization
• Kidney
– Calyce
– Pelvis
• Ureter
– Upper 1/3
– Middle 1/3
– Lower 1/3
• Urinary bladder
 Pathophysiology
• Three basic factors are needed when forming
a concrement:
1. Urinary supersaturation
2. Lack of citrate and pyrophosphate - natural concrement
anti-producing substances
3. Obstracles of urine flow
• Ingredients:
1. 75% calcium Oxalate
2. 10% struvites (often ”Staghorn”): ss associated with
infection
3. 10% uric acid stones/urates (x-ray negative)
 Critical size of the concrement
• ~ 90% of the 5mm size stones in the lower
segment of the ureter are expelled
spontaneously
• 15% of the 5-8 mm stones are expelled
spontaneously
• 95% of >8mm stones cause obstruction and
require lithotripsy or surgery
• 75% of the stones localize in the distal third of
the ureter
 Localization of site of obstruction
• Renal calyce
• Anatomical constrictions
of the ureter
 Clinical manifestations
• Pain
– Colic: Of calyces, pelvis, hyperperistaltis of
smooth muscles of the ureter
– Dull: Extension of renal capsule
• ± Hematuria
• Nausea, vomiting
• Dysuria
 Laboratory studies
• Urine pH
– pH> 7.6: Urease-producing bacterial infection
is doubtful.
– pH< 5: Often associated with uric acid / urate
stones.
• Urinalysis: Hematuria, leukocyturia,...
• Serum creatinine
 Diagnosis

• Ultrasonography
– Non-invasive
– In pregnant women !
• Review and Excretory Urography
• Computed tomography
– Modern ”Gold Standard”
 The right renal and
ureteral
concrements(review
urography)

Left: Phlebolith
კენჭი
(calcification within a
vein)

ფლებოლითი
Bilateral staghorn
calculi
Computed
tomography.
Right renal
concrement
 Ultrasonography. The
renal pelvicalyceal system
is dilated due to the
ureteral concrement.

In the same patient:

Dilatation of the ureter
and a concrement (arrow)
with characteristic
acoustic shade.
 Treatment
• Pain control: Opioids, nonsteroidal
anti-inflammatory drugs
• Obstruction + infection: Emergency case!
• Hospitalization showings:
– Obstruction + infection
– Pain, Which does not controled by treatment
– Non stop vomiting, severe dehydration
– Hypercalcemic crisis
– The only kidney concrement
 Treatment

1 Conservative
1 Remote (extracorporeal) shock wave
lithotripsy
1 Endoscopic (ureterorenoscopy)
1 Endoscopic (percutaneous)
1 Open surgery
 Kidney stones
> 2 cm 1. Percutaneous nephrolitholapaxy
2. Extracorporeal shock wave lithotripsy + Ureteric stenting
3. Nephrolithotomy

1 – 2 cm 1. Extracorporeal shock wave lithotripsy + Ureteric

stenting
2. Flexible ureterorenoscopy

< 1 cm 1. Flexible ureterorenoscopy

2. Extracorporeal shock wave lithotripsy
Conservative treatment

Stone
• Stone size<5მმ
• Lower 1/3 of
ureter
• Absence of
obstruction
 Extracorporeal shock wave
lithotripsy
• Focused shock waves
• Radiological / echoscopic control
Mechanism of
extracorporeal shock
wave lithotripsy
 Ureteroscopy
• Concrements of lower
segment of ureter
• Breaking ways
– Laser
– Mechanical
– Ultrasound
Ureteroscope
 Percutaneous nephrolitholapaxy
(PNL)
• Nephroscopic
manipulation
• Breaking of the
concrement and
extraction of the
fragments by a
nephrostomic catheter
Nephrolithotomy
Open surgery, PNL, URS

Lithotripsy
 Control
• Metabolic analysis
• Serum calcium Prevention
• Complete metabolic
analysis is needed in •Fluids
recurrent, complicated, • High-fiber diet
bilateral, and X-ray
negative stones. • Animal proteins
• Salt
• Sugar
• Alcohol
 Urinary bladder concrements
• Pathophysiology, treatment differs from kidney
stones
• Almost always in older men
• Most often it is a complication of other urological
pathologies :
– Infravesical obstruction (prostatic hyperplasia)
– Chronic infection (Proteus)
– Prolonged catheterization
Urinary bladder
concrement
?
Abdominal / pelvic review
radiography. Giant,
calcified fibrinoid in uterus
resembles urinary bladder
concrement.
 Urinary bladder concrements
Treatment

Transurethral
cystolitholapaxy

Suprapubic cystolithotomy
UROLOGICAL TUMORS
UROLOGICAL TUMORS
⚫ Prostate cancer
⚫ Urinary bladder cancer
⚫ Kidney cancer
⚫ Testicular cancer
UROLOGICAL TUMORS
STATISTICS IN EUROPE
Prostate cancer
Epidemiology
 PROSTATE CANCER
⚫ The most common cancer among men
⚫ The second leading cause of cancer death for
men, left behind lung cancer
⚫ Risk factors:
◦ Racial, ethnicity
◦ Hereditary load
◦ Nutrition, hormonal status...
 Anatomy of the prostate
CZ Central Zone B
PZ Peripheral Zone
bladder
PPS Preprostatic
VAS VAS
Sphincter SV SV
PPS
U Urethra
V Verumontanum
U
ED Ejaculatory CZ CZ
Duct
ED ED
VAS Vas urethra V
SV Seminal vesicles urethra
PZ PZ
B Bladder

80% of prostate cancer develops in the peripheral zone

 PROSTATE CANCER
PATHOPHYSIOLOGY
⚫ Adenocarcinoma
⚫ Increases with androgen
stimulation
⚫ Spread
◦ Localized (not exceeding
prostate borders)
◦ Locally distributed
(beyond the capsule)
◦ Generally distributed
PROSTATE CANCER
CLINICAL MANIFESTATIONS
⚫ Localized - Mostly asymptomatic
⚫ Locally distributed - Symptoms of lower
urinary tract, urinary retention,
hemospermia...
⚫ Generally distributed - Lumbar or bone pains,
anuria due to urinary tract blockage, general
cachexia and anemia.
 PROSTATE CANCER
DIAGNOSIS

Digital rectal exam Transrectal ultrasonography

 PROSTATE CANCER
DIAGNOSIS
Prostate-specific antigen(PSA)
• Protein produced by normal prostate cells
• During prostate pathology, it appears in the blood
• 3 main diseases, that cause PSA increase in blood:
• Inflammatory diseases of the prostate
• Benign prostatic hyperplasia
• Prostate cancer
 PSA

PSA (ng/ml) % Prostate cancer

< 0,5 7%
0,6 – 1,0 10 %
1,1 – 2,0 17 %
2,1 – 3,0 24 %
3,1 – 4,0 27 %
 PROSTATE CANCER
DIAGNOSIS

Transrectal prostate biopsy

 PROSTATE CANCER
DIAGNOSIS

Computed tomography
 PROSTATE CANCER
DIAGNOSIS

Skeletal scintigraphy(metastasis?)
PROSTATE CANCER
TREATMENT
⚫ Active observation – In low risk-patients
⚫ Radical prostatectomy (open,
laparascopic, robotic)
⚫ Radiotherapy (external or brachytherapy)
⚫ Hormone therapy (androgenic blockade,
surgical or medication castration) –
Generally distributed cancer
⚫ Chemotherapy - Hormone-refractory
cancer
Radical prostatectomy open surgery
Laparascopic radical
prostatectomy
Robot-assisted radical prostatectomy
Brachytherapy - radioactive capsules are
implanted in the prostate tissue
URINARY BLADDER CANCER
⚫ 90% - Transitional cell
⚫ 10% - Squamous cell carcinoma...
⚫ Superficial - CIS, Ta, T1
⚫ Invasive - T2-T4
⚫ Risk factors: Tobacco, amine paints...
 Grades of urinary bladder cancer
სტადია დახასიათება
Ta Includes mucosa
CIS Carcinoma insitu (superficial, agressive)
T1 Invasion into the submucosal layer
T2 Invasion into the muscular layer
T2a In the inner half
T2b In the outer half
T3 Invasion outside the muscular layer
T3a Microscopic
T3b Macroscopic (extravesical mass)
T4 Invasion into the nearby organs
T4a Prostate, vagina, uterus
T4b Pelvic wall, anterior wall of abdomen
Grades of urinary bladder cancer

Non-invasive Invasive
URINARY BLADDER CANCER
SYMPTOMS
⚫ Dysuria
⚫ Hematuria
⚫ Differential diagnosis: Infectious and
inflammatory diseases, prostate
pathology, Concrements, upper urinary
tract tumors
⚫ In all cases, cystoscopy is needed
Fluorescence cystoscopy facilitates the detection of tumor
growth.
Conventional and fluorescence cystoscopy
URINARY BLADDER CANCER
TREATMENT. TRANSURETHRAL
RESECTION
Urinary bladder cancer Grade

Non-invasive in muscle Invasive in muscle

Ta T1 Cis T2 – T4

Mucosa

Submucosa
+ Chemotherapy
TUR Cystectomy

Muscle layer
URINARY BLADDER CANCER
TREATMENT. RADICAL CYSTECTOMY

In men: Urinary bladder, In women: Urinary bladder,

prostate, seminal vesicles, uterine with appendages,
distal segments of the vagina (partially), distal
ureters segments of the ureters
RADICAL CYSTECTOMY
URINE DERIVATION
RENAL CELL CARCINOMA
⚫ 80-90% of kidney cancers
⚫ Other tumors - 10-20%
⚫ Extensive use of ultrasound and
CT studies has increased the
incidence of asymptomatic
tumors found in the kidney.
⚫ The classic triad (pain, hematuria,
tumor mass in the lumbar region)
rarely found today.
Risk factors

Tobacco

Excess weight (especially in women)

Inherited (Von Hippel-Lindau syndrome:

Multiple tumors)
Arterial hypertension
Kidney failure, dialysis
Cadmium, lead…
Renal cell carcinoma
- >70% asymptomic !!!
Accidentally discovered

- Advanced case:
• Pain
• Macrohematuria
• Palpable tumor
• Varicocele
• Lose weight
• Hypercalcemia
• Anemia

-20-30% are already metastasized at diagnosis

- Most commonly metastasized: in lungs, lymph nodes, liver and
bones.
Kidney cancer diagnosis
KIDNEY CANCER DIAGNOSIS
Kidney cancer diagnosis
Kidney cancer diagnosis
 RENAL CELL CARCINOMA
DIFFERENTIAL DIAGNOSIS

Renal cyst Renal angiomyolipoma

RENAL CELL CARCINOMA
COMPLICATION: THROMB INTO THE INFERIOR
VENA CAVA
 RENAL CELL CARCINOMA
TREATMENT
• Radical nephrectomy (laparascopic, open surgery)
• Partial nephrectomy (laparascopic, open surgery)
RADICAL NEPHRECTOMY
PARTIAL NEPHRECTOMY
Renal cell carcinoma
Alternative methods of treatment

Cryoablation

Radiofrequency ablation
Renal cell carcinoma
Symptomatic treatment
⚫ Chemotherapy is ineffective
⚫ Immunotherapy (interferon, tyrosine kinase
inhibitors, m-Tor inhibitors, antibodies) – In
correctly selected, with metastasized, patients
after surgical treatment
TESTICULAR CANCER
⚫ 1-1.5% of cancers in men
⚫ 5% of urologic tumors
⚫ It is most common at the age of 30-40
⚫ When diagnosed, 1-2% are bilateral
⚫ Epidemiological risk factors:
◦ Cryptorchidism
◦ Genetic disorders (Klinefelter Syndrome)
◦ Family history
◦ Infertility in anamnesis
TESTICULAR CANCER
⚫ Classification
◦ Seminoma
◦ Non-seminoma cancer
● Choriocarcinoma
● Yolk sac tumor
● Teratoma
● Mixed type
 TESTICULAR CANCER
⚫ Clinical manifestations
◦ Painless palpable formation
◦ Scrotal pain
◦ 10% are identified as acute orchitis
◦ Metastasizes to the lymph nodes, in the retroperitoneal space (place of
embryonic origin of testis!)
⚫ Oncomarkers
◦ Alpha-fetoprotein
● Increases in 50-70% of non-monomers
● Does not increase during seminoma
◦ β-chorionic gonadotropin
● Increases in 40-60% of non-seminomas
● Increases in 30% of seminomas
◦ Lactate dehydrogenase
● Less specific
● Often increased during seminomas
Palpation of the testis and funicle
Method of self-examination of testis
Testicular cancer. Computed
tomography
Retroperitoneal mass (lymph nodes)
 TESTICULAR CANCER
TREATMENT
The primary intervention
in all types is radical
orchiectomy (high
hemicastration)

After orchiectomy (according to

grade and risk):
1. Chemotherapy
2. Nerve-saving retroperitoneal
lymphadenectomy
3. Active observation
Testicular cancer
Retroperitoneal lymphadenectomy
 TESTICULAR CANCER

Lance Armstrong – An American former professional road

racing cyclist
Metastatic testicular cancer was detected at 25 years of
age. He has been in active sport for 10 years after
treatment. He is now 34 years old