Urology Summary

Bladder and urethra

Bladder cancer

Pathophysiology

o 90% Transitional cell carcinoma (TCC)

o 10% Squamous cell carcinoma/adenocarcinoma

 Pathology:

o 80% non-muscle invasive bladder cancer (NMIBC)

o 20% MIBC

 Can affect anywhere from renal pelvis to bladder

-urothelioma staging: T1 subepithelial invasion, T2 invades muscle, T3 invades perisvesical tissue, T4

invades prostate/uterus/vagina; N1 is single node <2cm, N2 is either single node between 2cm and
5cm or mulriple nodes <5cm, N3 is >5cm

 Risk Factors:

o SMOKING (50% can be attributed to this)

o Occupational (exposure to chemicals e.g. paints, inks, dyes, textiles)

o Cyclophosphamide chemo, pelvic radiation, analgetics

o Indwelling catheters, spinal cord injury

o Chronic inflammatory damage e.g. stone disease

o Male:female 3:1

 Prognosis generally poorer for women and black people

Presentation

 Classical:

o Painless macroscopic haematuria (~80% cases, bladder cancer until proven otherwise)

 Urgency, frequency, dysuria (indicates muscle invasion)

 More advanced:

o Bone pain from metastases

o Flank pain from ureteral obstruction

Investigations

 Confirmed via biopsy (via cystoscopy)

 Intravenous urogram to visualise entire length of tract:

 Cystourethroscopy and examination under anaesthesia for all suspected cancers

 Bimanual palpation to determine extent/characteristics of malignancy

Management

o Trans-urethral resection of bladder tumour (TURBT)

o Single dose intra-vesical chemo

o Long-term cystoscopic follow-up

radical cystectomy (bladder + prostate/bladder + uterus + urethra + ovairies), then urinary diversion

o Radio can improve symptoms if metastatic

o Chemo

 Survival:

o Low grade superficial >90% 5yr

o High grade invasive 50%

Transitional cell carcinoma

Pathophysiology

 Risk Factors:

o Male

o Increasing age

o Smoking

o Phenacetin ingestion

 Pathology:

o Often multifocal, sometime bilateral

o Papillary 80%, non papillary 20% (mostly malignant)

Presentation

 Visible haematuria (80%)

 Flank pain “clot colic”

 Can be asymptomatic, diagnosed w/ synchronous bladder tumour)

Diagnosis

 CT urogram (or Renal USS + IVP)

 Cystoscopy +/- retrograde pyelogram

 Urine cytology if necessary

 Flexible ureterenoscopy + biopsy

 Staging:
o CT chest abdo pelvis

Treatment

o Radical nephro-ureterectomy

o Percutaneous, segmental or ureterenoscopic resection/laser ablation

o chemotherapy

o Palliative surgery/arterial embolization/radiotherapy for haematuria

Infections

-simple cystitis presents with dysuria, urinary frequency, suprapubic pain and it can be due to
infective or non-infective causes. E. coli, Klebsiella and Proteus species, cause most infections.

-chronic cystitis leads to different bladder abnormalities and malignant transformations

Disorders of bladder function

-overactive bladder is a symptomatic diagnosis

-detrusor overactivity is the presence of involuntary detrusor contractions. It might be neurogenic

(e.g. in supra-sacral lesions), non-neurogenic (e.g. in direct bladder stimulation, or due to
obstructions) or idiopathic.

Prostate gland
Benign disorders of prostate gland

-E. coli, Klebsiella and Proteus most often cause acute bacterial prostatitis. Symptoms include an
enlarged and painful prostate. The inflammation may also become chronic

-benign prostate hyperplasia causes obstructive symptoms like urinary frequency, nocturia,
hesitancy, straining and incomplete emptying. This can lead to infections, stones and obstructive
uropathy. Diagnosis is done with flow rate, residual urine, transrectal ultrasound, urodynamic studies
and digital-rectal examination. Treatment can be conservative, pharmacological (α-blockers, 5-alpha-
reductase inhibitors,…) and surgical (open prostatectomy, transurethral resection).

Prostate Cancer

Pathophysiology

 Most common malignancy in males,

most frequent cause of all cancer deaths

 Risk factors:

o Age

o Scandinavia

o Diet (animal fat)

o Obesity

o Genetic (increased risk if 1st degree relative affected)

 Pathology:
o Adenocarcinoma (glandular epithelium) 95%

o 80% arise in peripheral zone

Presentation

 Usually >60 (peak 65-75), can be younger

 Mostly asymptomatic

 Emptying symptoms (poor stream, hesitancy, nocturia, incomplete emptying)

 Sometimes acute retention

 Can present w/ bone symptoms, ureteric obstruction

Diagnosis

 Bloods:

o PSA (total and free)

 Trans-rectal ultrasound (TRUS) w/ guided needle biopsy

 Bone scan if symptomatic OR PSA >20 ug/L

 MRI staging (if high risk disease?)

Treatment
-active surveillance, radical prostatectomy, hormonal treatment

Male genitalia
Urethra

-hypospadias: the urethra opens on the ventral aspect of the penis

-types: glandular (urethra on the underside of the glans)
penile (urethra opens onto the penile shaft)
complete (opens on the base of the penis)

-inflammation of the urethra in gonorrhea, chlamydia, ureaplasma, mycoplasma

-trauma: iatrogenic trauma due to cuts, catheters

blunt force injury of a fall leading to compression
treatment: divert the urine

Fractured pelvis with rupture of urethra, pelvis can be minimally or grossly displaced

-complications of urethral injuries:

-stricture: is a common result. It’s a circumferential scar due to trauma or infection and it causes
obstruction. Complications can be infections, abcesses, sterility and cancer due to chronic
inflammation. It can be treated with intermittent dilation, internal visual urethrotomy and
urethroplasty (has the best long term results).

-impotence: is caused by damage to the neurovascular bundle of the penis or the pelvic autonomic
nerves

-impaired ejaculation: damage to the sympathetic nerves may cause paralysis of the bladder neck
and seminal vesicles resulting in retrograde or dry ejaculation
-incontinence: happens if the bladder neck has been denervated or destroyed, or if there is injury to
the sphincters

-urethral carcinoma: can be primary or secondary (due to cancer elsewhere in the urinary tract). Risk
factors include urethral strictures, chronic irritation due to catherisation, infections and external
beam radiotherapy. Urethral diverticula and recurrent UTIs also increase the risk of cancer.
Usually patients present with locally advanced disease (macroscopic hematuria, obstruction, pain,
discharge).
Diagnosis is done with imaging, urethroscopy and biopsy.
Treatment includes surgery and local radiotherapy.

Penis

-circumcision due to phimosis (inability to retract prepuce) can be done because of physiological or
pathological (due to balanoposthitis xerotica obliterans  lichen sclerosus) phimosis.

-acute balantoposthitis occurs due to E.coli, Proteus, Haemophilus

-Peyronie’s disease: development of fibrous tissue plaques in buck’s fascia leading to penile
curvature during erection. It can be painful and can can erectile dysfunction. It can be treated non-
surgically or surgically.

-ejaculatory failure can be due to premature ejaculation (either due to psychological reasons or
hypersensitivities), anejaculation (in spinal cord injury or blocking of ducts) and retrograde
ejaculation (in DM, precious surgeries)

-erectile dysfunction: due to anatomical (micropenis, peyronie’s), vasculogenic (cardiovascular

disease, DM), neurogenic (MS, Parkinson’s), drug induced (antihypertensive, antidepressive),
hormonal (hypogonadism, hypo/hyperthyroidism), trauma (penile and pelvic fractures) and
psychogenic reasons
Treatment goes over lifestyle modifications, psychosexual counselling, drugs, intracavernosal
injections to vascular operations.

-priapism is prolonged unwanted erection due to hematological (sickle cell disease, EPO use),
neurological (spinal cord or brain injury), pharmacological agents or idiopathic reasons.

-cancer: precancerous lesions on the penis include Bowen’s disease, condyloma and paget’s disease.
Diagnosis is done with a punch biopsy, excisional biopsy
Treatment is excision, partial amputation and radiotherapy

Testicle

-congenital anomalities include ectopic testicles, incomplete descent (either abdominal, inguinal,
emergent, high retractible or low retractible.
Complications include torsion (extravaginal, intravaginal, both with sudden pain, redness and
swelling, treatment is through surgery and testis might be removed completely), infertility and
cancer.
Diagnosis is made by inspection and palpation in most cases. CT can help find the exact location.
Treatment includes orchidopexy and waiting for descent. Orchidopexy should be performed early
before the age of 3 to avoid infertility and the increasing risk of cancer.

-varicocele is a physiological dilation of the venous plexus. It can depress spermatogenesis and lead
to atrophy. Ligation of the veins either macroscopically or laparoscopically or robotically.
-hydrocele is fluid accumulation in the tunica vaginalis, which may be idiopathic, primary or
secondary due to lymphobstruction. In neonates a hydrocele is associated with hernias. In adults it
may hint to a tumor. It can be tapped but only surgical correction is curative

-cysts are separate from the testis, can be tense on palpation, could be single or multiple, can be
asymptomatic requiring only follow up and surgery can be performed

-trauma: testis can be easily injured. Clots should be evacuated from the testis.

-inflammation: viruses (coxsackie, mumps) usually cause acute orchitis. Acute epididymitis is caused
by bacterial infections from the urinary tract and it is usually caused by E.coli and chlamydia.
Chronic orchitis occurs in syphilis and granulomatous orchitis. Orchidectomy is a good treatment due
to the possibility of cancer. Chronic epididymitis can be caused by tuberculosis or a seminal
granuloma after vasectomy.

-orchialgia: is a psychiatric syndrome of pain in the testicle when there is no organic cause.

-cancer: there a different risk factors for testicular cancer like being Caucasian, previous cancers,
inguinal hernias, subfertility, cryptorchidism and family history. Most cancers arise from germ cells.
There are teratocarcinomas (with benign or malignant forms) embryonal carcinomas, epidermoid
cysts and tumors arising from gonadocytes and spermatocytes.
Non-germ cell tumors include leydig cell tumors (leading to precocious puberty), sertoli cell tumors
(cause gynecomastia and are rare), lymphomas and small cell origin (which commonly metastasize).

Investigations include ultrasound, tumor markers, exploration and CT scans.

Treatment includes monitoring, platinum based chemotherapy, radiotherapy and surgery.

Male infertility

-history taking is a crucial point

-semen analysis: volume from 1-8ml, sperm density and motility (1 x 10 6/ml), morphology (doubtful
relevance), antibodies in seminal plasma or cervical mucus
-grossly raised FSH is a strong negative predictor to spermatogenesis
-testis biopsy

-infertility is defined as the failure to conceive after regular unprotected sex for 18 months. It can be
classified in non-obstructive, obstructive and coital.

-non-obstructive can be due to chromosomal abnormalities (klinefelter), genetic defectcs (cystic

fibrosis)
-obstructive causes can be congenital (intratesticular, absent vas deferens, different cysts) and
acquired (post-surgical, post infective)
-treatment includes assisted fertility, reconstruction, surgery
-coital includes anorgasmia (usually psychological), premature ejaculation, anejaculation, retrograde
ejaculation

-vasectomy: both partner must consent, can be performed under local or general anesthesia, a
segment can be resected or needle cautery is performed. Complications include haematoma,
infections, pain in the scrotum and sperm granuloma. Reversal of the vasectomy is also possible by
attaching the ends back together.