Urology For Undergraduate 2021

Urology
For Undergraduates
By
Staff Members of Urology Department
Faculty of Medicine, Assiut University
Revised Fifth Edition

2021
“Urology for Undergraduates”
Revised Fifth Edition
The fifth edition aimed to make the subject of urology easy and simple
for the undergraduate medical student. It has been subjected to little
beneficial addition, minimal required change, minor necessary
correction and trivial proper re-arrangement.
Preface of the Fifth Edition
Welcome to the 5th edition of “Urology for Undergraduates”. This
book targets the common urologic disorders presented for the
undergraduate medical students. Moreover, it has been prepared to be a
beneficial urologic guide for the general practitioners and other
specialists.
New topics were addressed in this edition; urologic symptoms &
focused examination, Fournier's gangrene, circumcision, nocturnal
enuresis and urinary catheters. A list of abbreviations is added. The text
has been thoroughly revised to be simple, concise, clear and updated. It
has been provided with the advanced diagnostic and therapeutic tools for
urologic diseases with preservation of the basic knowledge in the
meanwhile.
Knowledge does not gain its benefit unless it is actually applied. A
common mistake is to spend more time absorbing knowledge without
gaining the skill of how to use it clinically or convey it to an examiner.
Other useful resources available to you are your patients, your fellows
and your seniors.
All staff members of the Urology Department of Assiut Faculty of
Medicine present this version with great pleasure inviting any criticism,
comments or suggestions.
Staff members
Urology Department of Assiut Faculty of Medicine
2021
CONTENTS
Topic Page Topic Page
Urologic symptoms 1-6 Andrology: 51-57
Focused urologic examination 7-11 - Male subfertility ------------------------ 51
Urologic investigations: 12-16 Varicocele ------------------------------ 52
- Urine analysis-------------------------------- 12 - Erectile dysfunction -------------------- 53
- Semen analysis------------------------------ 13 - Peyronie's disease---------------------- 54
- Urologic imaging---------------------------- 14 - Ejaculatory disorders ------------------ 54
Genito-urinary infections: 17-26 - Andrologic emergencies--------------- 54
- Non specific genito-urinary infections--- 17 - Circumcision----------------------------- 55
- Genito-urinary tuberculosis---------------- 22 Voiding dysfunction and neuro-urology: 58-60
- Schistosomiasis of the urinary tract------- 25 - Overactive bladder---------------------- 58
Obstructive uropathy: 27-33 - Urinary incontinence------------------- 59
- Hydronephrosis ------------------------------ 27 - Nocturnal enuresis---------------------- 60
- Bladder outlet obstruction------------------ 30 - Neuropathic bladder-------------------- 60
- Benign prostatic hyperplasia --------------- 31 Genito-urinary tumors: 61-68
- Urethral stricture ---------------------------- 33 - Renal tumors---------------------------- 61
Urolithiasis: 34-40 - Bladder cancer-------------------------- 63
- Renal stones---------------------------------- 36 - Prostate cancer-------------------------- 65
- Ureteral stones------------------------------- 37 - Testicular tumors----------------------- 67
- Bladder stones------------------------------- 39 Renal transplantation: 69
- Urethral stones------------------------------ 40 Urologic catheters: 70-73
Urinary tract trauma: 41-44 - Urethral catheters----------------------- 70
- Renal trauma-------------------------------- 41 - Ureteric catheters----------------------- 72
- Bladder trauma----------------------------- 43 - Percutaneous nephrostomy tube------ 73
- Urethral trauma---------------------------- 44 - Percutaneous cystostomy tube-------- 73
Genito-urinary congenital anomalies: 45-50 - Guide wires 73
- Upper urinary tract anomalies----------- 45
- Lower urinary tract anomalies----------- 47
- Testicular maldescent--------------------- 49
Abbreviations
Abbreviation Term Abbreviation Term
ADH Antidiuretic hormone NSGCT Non seminomatous germ
AFP Alpha fetoprotein cell tumor
BOO Bladder outlet obstruction OAB Overactive bladder
BPH Benign prostatic hyperplasia PCa Prostate cancer
CBC Complete blood count PCN Percutaneous nephrostomy
CIC Clean intermittent catheterization PCR Polymerase chain reaction
CIS Carcinoma in situ PDE-5 Phosphodiesterase type 5
CRF Chronic renal failure PE Premature ejaculation
DD Differential diagnosis PNL Percutaneous nephrolithotomy
DRE Digital rectal examination PSA Prostate specific antigen
ED Erectile dysfunction PVR Post voiding residue
ESR Erythrocytic sedimentation rate RBCs Red blood corpuscles
FSH Follicle stimulating hormone RCC Renal cell carcinoma
GFR Glomerular filtration rate RUG Retrograde urethrography
HCG Human chorionic gonadotropin SCC Squamous cell carcinoma
HIV Human immunodeficiency virus SWL Shock wave lithotripsy
HLA Human leuckcyte antigens TB Tuberculosis
HPF High power field TCC Transitional cell carcinoma
ICSI Intracytoplasmic sperm insertion TOT Transobturator tape
INH Isoniazid TRUS Transrectal ultrasound
IUI Intrauterine insemination TUR Transurethral resection
IV Intravenous TURBT Transurethral resection of
IVC Inferior vena cava bladder tumor
IVU Intravenous urography TURP Transurethral resection of
KUB Kidney ureter bladder the prostate
LDH Lactic dehydrogenase TVT Tension free vaginal tape
LH Leutinizing hormone UDS Urodynamic study
LHRH Leutinizing hormone releasing UMNL Upper motor neurone lesion
hormone UPJ Uretro pelvic junction
LUTS Lower urinary tract symptoms URS Ureteroscopy
MSCT Multislice computed tomography U/S Ultrasound
MRI Magnetic resonance imaging UTI Urinary tract infection
MRU Magnetic resonance urography VCUG Voiding cystourethrogram
NE Nocturnal enuresis VIU Visual internal urethrotomy
NSAIDs Non steroidal anti- inflammatory VUR Vesicoureteric reflux
drugs WHO World health organization
UROLOGIC SYMPTOMS
Intended learning outcomes:
- To know all the urologic symptoms, their causes and how to analyze them
through history taking in order to reach a provisional diagnosis
- To focus in particular on flank pain, anuria, acute urinary retention and hematuria
UROLOGIC SYMPTOMS
UROLOGIC SYMPTOMS
Urologic symptoms are classified into:
I- Upper urinary tract symptoms II- Lower urinary tract symptoms (LUTS)
III- Urine changes IV- Male genital symptoms
V- Uremic manifestations VI- Extraurologic symptoms related to urologic disorders
I- Upper urinary tract symptoms:
 Flank pain. The most common
 Renal swelling. As a urologic symptom, it denotes huge enlargement of the kidney/s e.g.
hydronephrosis, polycystic kidney disease and Wilms' tumor. Essentially, it is a flank swelling
unless the kidney is ectopic.
 Oliguria and anuria.
 Polyuria. It is the excessive production of urine more than 3 liters per 24 hours in adults. It
results in painless frequent micturition. The volume of urine per void is normal or even
increased. It can be caused by diabetes mellitus, diabetes insipidus, chronic renal failure, post-
obstructive diuresis, compulsive water intake and use of diuretics.
 Discharge of urine, pus or blood from a renal or ureteric fistula or sinus. It can be post-surgical,
post-traumatic or rarely spontaneous.
FLANK PAIN:
The flank comprises the loin with the ipsilateral iliac fossa. Any flank pain is presumed to be
urological in origin, however non-urologic causes should be considered.
 Urologic causes of flank pain:
 Renal and ureteric stones: this is the most common cause. It may be chronic dull aching pain
especially in cases of renal stones. On the other hand, stone migration leads to hyperperistalsis
of the pelvicalyceal system (renal colic) or the ureter (ureteric colic). Colic is felt as severe
intermittent pain of sudden onset and sudden offset.
According to site of stone, pain may radiate to the suprapubic region, ipsilateral groin, scrotum,
testis, labia and urethra down to the tip of the penis. It may be associated with hematuria,
dysuria, urgency, frequency and GIT symptoms (nausea, vomiting and abdominal distension).
 Infection: as acute pyelonephritis, infected hydronephrosis, pyonephrosis, renal abscess and
perinephric abscess. Pain can be throbbing in nature with pus under tension.There is associated
fever and local loin tenderness.
 Ureteropelvic junction obstruction and ureteric stricture: Pain is usually chronic & dull aching
due to distension of renal capsule. It may be precipitated or accentuated by diuresis.
 Renal or ureteric tumors: Pain is considered a late presentation for upper urinary tract tumors.
It is usually preceded by hematuria in cases of urothelial tumors.
 Blood clots from any upper urinary tract site may produce colicky pain during their passage.
 Other causes e.g. cystic diseases of the kidney, vesicoureteric reflux and nephroptosis.
 Differential diagnosis of renal pain (Non-urologic causes of flank pain):
Usually, they are not associated with urine changes or LUTS.
 Myo-skeletal causes e.g.: muscle spasm, sprain or inflammation, rib fracture and disc prolapse.
Pain is provoked or relieved by certain body positions, trunk movements, coughing, sneezing
and respiration. It may radiate to the lower limbs.
1
UROLOGIC SYMPTOMS
 Gastro-intestinal causes e.g.: irritable bowel syndrome (abdominal distension and change in
bowel habits), cholecystitis (fatty dyspepsia and jaundice) and appendicitis (rebound tenderness
at the right iliac fossa and psoas spasm).
 Gynecological causes in females e.g.: torsion of an ovarian cyst and ectopic pregnancy
 Basal pleurisy: pain related to respiration, associated with other symptoms as dyspnea & cough.
 Herpes zoster: Pain is severe and the diagnosis is revealed by appearance of specific eruption
along the course of the intercostal nerves.
OLIGURIA AND ANURIA:
Oliguria is urine output of less than one ml/Kg/hour in infants, 0.5 ml/ Kg/ hour in children and
400 ml/24 hours in adults, while anuria is cessation of urine production resulting in urine
output less than 100 ml/24 hours in adults. Anuria represents a variant of acute renal failure.
Causes of oliguria & anuria:
 Pre-renal= mostly a medical problem leading to decrease urine filtration due to decreased renal
blood flow and subsequently decreased filtering pressure as in:
- Hypovolemia, hypotension and shock (e.g. repeated vomiting, severe diarrhea, massive
bleeding and cardiogenic & neurogenic shock).
- Bilateral renal vein thrombosis or bilateral renal artery occlusion.
 Intra-renal= intrinsic medical renal problem with injury to the glomeruli or renal tubules by:
- Inflammation as acute glomerulo-nephritis.
- Acute tubular necrosis: either ischemic (due to prolonged uncorrected shock) or toxic (due to
toxins or nephrotoxic drugs).
 Post-renal (obstructive anuria) = surgical problem entailing complete & bilateral ureteral
obstruction or complete obstruction of the ureter of a solitary kidney. The causes include:
- Bilateral ureteral or renal stones (calcular anuria): It is the most common.
- Advanced malignancy compressing or infiltrating both ureters as bladder cancer, advanced
prostate cancer, uterine cancer and retroperitoneal malignancies.
- Iatrogenic bilateral ureteral obstruction after:
i- Gynecological and obstetric surgeries e.g. hysterectomy.
ii- Abdomino-perineal surgeries e.g. for rectal carcinoma.
Associated findings:
 Manifestations correlated to the cause:
 Pre-renal causes  History of massive bleeding and shock.
 Renal causes  Hematuria and hypertension with glomerulonephritis.
 Post-renal causes  History of renal pain, urolithiasis or pelvic surgery.
 Uremic manifestations due to increase of the waste products in blood with elapse of time
Investigations include:
 ↑ serum creatinine, ↑ blood urea, hyperkalemia (↑ serum K+) and acidosis
 Ultrasonic findings: The bladder is empty. The kidneys appear obstructed in post-renal type
Treatment entails:
 Prevention by e.g. rapid management of hypovlemia & shock and avoid nephrotoxic drugs
 Urgent dialysis in certain situations e.g. neglected cases with marked hyperkalemia
 Temporary kidney drainage by ureteric catheter, JJ ureteric stent or PCN
 Treatment of the obstructive cause in obstructive anuria as soon as the patient can tolerate
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UROLOGIC SYMPTOMS
II- Lower urinary tract symptoms (LUTS):

1. Storage LUTS (irritative symptoms)
They are caused by irritative bladder pathology e.g. bladder stone, ulcer, inflammation,
diverticulum and cancer.
Storage LUTS include:
 Increased frequency of micturition: > 8 times / 24 hours.
 Nocturia (nocturnal frequency): > one time / night.
 Urgency: sudden severe compelling desire to micturate that cannot be deferred.
 Urge incontinence: involuntary urine leakage associated with urgency.
2. Voiding LUTS (obstructive)
They are caused by either any cause of bladder outlet obstruction (e.g. urethral meatus
stenosis, urethral stone, urethral stricture, BPH and large blood clots) or neuropathic
bladder due to failure of the bladder to pump urine out.
Obstructive LUTS include:
- Hesitancy = difficulty to start micturition that requires some time or effort or both
- Intermittency = interrupted stream (loss of stream continuity)
- Weak stream = stream is feeble and not projecting well
- Narrow stream (of narrow caliber)
- Terminal dribbling
- Sense of incomplete evacuation of the bladder
- Straining during voiding
- Acute retention of urine: It is the maximal obstructive form of LUTS.
3. Pain:
 Suprapubic pain: due to different bladder pathologies e.g. acute bacterial cystitis and
anterior bladder wall tumor. It can be caused by GIT diseases (e.g. pelvic colitis) and
gynecologic diseases (e.g. pelvic inflammatory disease & ectopic pregnancy).
 Urethral pain: usually is expressed as burning micturition (dysuria). It is due to
inflammation (urethritis & cystitis), stones (urethral, bladder & intramural ureteric) and
bladder ulcer or cancer.
 Low back, perineal or peri-anal pain: may be caused by different diseases including
prostatic and urethral pathologies e.g. stones, inflammations (urethritis, prostatitis &
prostatic abscess) and prostatic congestion or cancer.
4. Urethral discharge: It is detected in the clothes and not related to the act of micturition.
Its amount, color and associated symptoms should be assessed. It includes:
 Mucous, muco-purulent and purulent discharge: in cases of urethritis, urethral
diverticulum and around a fixed urethral catheter.
 Seminal discharge: due to prostatic congestion, prostatitis and sexual excitation.
 Blood: It is termed bleeding per urethra. The main cause is urethral trauma.
5. Swelling:
 Suprapubic (bladder) swelling: mostly due to chronic urine retention.
 Perineal or penile swelling: due to urine and/or blood extravastion after urethral trauma
or penile fracture.
6. Lower urinary tract fistulae and sinuses: The cause can be congenital, inflammatory,
post-traumatic (accidental or surgical) or neoplastic e.g.
 Vesico-cutaneous (suprapubic), vesicovaginal, vesicouterine, vesicorectal or
ureterovaginal.
 Urachal congenital umbilical vesico-cutaneous urinary fistula or urachal umbilical sinus.
 Urethro-cutaneous perineal or penile sinus or fistula & urethrovaginal or urethrorectal fistula
3
UROLOGIC SYMPTOMS
ACUTE URINARY (URINE) RETENTION:

It is the inability to pass urine in spite of severe painful desire to void with full urinary bladder.
Etiology:
1- Stone impacted in the urethra or bladder neck. 2- Urethral trauma with complete rupture.
3- Prostatic diseases as benign prostatic hyperplasia (BPH) and prostatic abscess or cancer.
4- Neuropathic bladder e.g. after spinal cord injuries (usually painless without desire).
5- Occasional causes of acute urine retention e.g.:
- Reflex urinary retention due to severe painful perineal and anal conditions e.g. after surgeries
for piles or anal fissure - Phimosis - Hysterical retention - Obstructed Foley catheter
- Acute urethritis and impermeable urethral stricture - Bladder neck or prostatic cancer
Evaluation includes: A- History of:
- Inability to micturate with severe desire and agonizing supra-pubic pain.
- History suggesting the cause e.g. recent renal colic (migrating stone), old males (BPH) or recent
surgery (anal, perianal and spine surgery).
B- Clinical examination:
- Supra-pubic fullness, tenderness and dullness, without palpable supra-pubic mass. A palpable
bladder means acute on top of chronic urinary retention.
- Signs of the cause: e.g. palpable urethral stone or phimosis
- Digital rectal examination (DRE) may show:
> Palpable stone at the membranous urethra > Prostatic tenderness in prostatic abscess
> Benign Prostatic Hyperplasia > Tender cystic bladder by bimanual examination
- Abdominal U/S: It confirms bladder fullness and may detect a bladder neck stone or growth. It
detects bladder clots (in clot retention).
C- Differential diagnosis:
- Clot retention: in massive hematuria the bladder is full of urine and clots.
- Chronic urine retention: although the patient is voiding, the bladder is still distended and
palpable without pain or tenderness. The patient may develop acute on top of chronic retention.
- Anuria: no desire for micturition since the bladder is empty with the risk of uremia.
Management includes: 1- Emergent relief of acute urinary retention (first aid measure) using:
- Nelaton urethral catheter. It is contraindicated in urethral trauma, urethral stones and urethritis.
- Percutaneous cystostomy can be inserted if urethral catheterization fails or is contraindicated.
- Insertion of Foley urethral catheter under anesthesia may be occasionally resorted to.
2- Treatment of the cause: later on when it is appropriate
III- Urine changes includes: urine turbidity and / discoloration due to e.g.
 Hematuria
 Pyuria (macroscopic or gross): in urinary tract infection (UTI) e.g. pyelonephritis and cystitis.
 Crystaluria: e.g. phosphaturia and less commonly oxaluria or uricosuria.
 Necroturia: whitish or pinkish necrotic tissue pieces pass with urine in advanced bladder cancer.
 Pneumaturia: the passage of gases in urine due to fistula (e.g. vesico-intestinnal or vesico-colic),
UTI with gas-forming organisms (especially in diabetics) or after recent urologic instrumentation.
 Discolored urine as in: pseudomonas infection (greenish), jaundice (brownish or olive green) and
some administered foods or drugs (e.g. reddish with beet roots and rifampicin).
 Bad unpleasant smell of urine: due to UTI by E.coli or urease producing micro-organisms.
4
UROLOGIC SYMPTOMS
HEMATURIA:
It is the presence of more than three RBCs / HPF in urine sediment after centrifugation. It may be
microscopic or macroscopic (gross). The etiology of hematuria includes:
1. Glomerular hematuria due to e.g. glomerulonephritis (e.g. post-streptococcal), IgA nephropathy
and systemic lupus erythematosus.
2. Non-glomerular hematuria can be caused by any urologic pathology e.g. urolithiasis, infections,
trauma, BPH, polycystic kidney disease and tumors of the urinary tract.
3. Post-urologic open or endoscopic surgery as primary, reactionary or secondary hemorrhage.
4. Coagulation & bleeding disorders and anticoagulant therapy.
5. Cyclic hematuria (menstrual bleeding mixed with urine) in vesicouterine fistula and endometriosis
of the bladder or ureter. Evaluation of a case of hematuria includes:
A- History of:
 Any possible cause e.g. trauma, operations and exposure to bilharziasis.
 Relation of hematuria to the act of micturition. It may be:
- Initial (at the start of micturition followed by clear urine) due to a lesion at the posterior urethra or
bladder neck.
- Terminal (at the end of micturition preceded by clear urine) due to bladder lesion e.g. bilharziasis.
- Total (the whole urine is red) due to bladder or upper urinary tract lesions.
 Color of urine: bright red urine means fresh bleeding and brownish urine means old bleeding.
 Presence of clots confirms true hematuria and may cause obstructive LUTS up to clot retention.
The shape of clots may point to the origin of bleeding. Thread-like clots are of renal or ureteral
origin, while discoid clots are mostly of urinary bladder lesions.
 Associated pain helps in localization of the pathology e.g. renal pain with upper urinary tract
lesions and painful micturition with bladder lesions.
 Painless hematuria is present in e.g. BPH, transitional cell carcinoma (TCC) of urinary bladder,
glomerulonephritis and bleeding tendencies.
 Bleeding from other sites suggests a systemic cause.
B- Clinical examination:
- General examination: To detect any other bleeding sites and systemic effects of blood loss e.g.
pallor, tachycardia and hypotension.
- Abdominal examination for renal swellings and clot retention.
- DRE for e.g. BPH and bladder tumor. - Inspection of a sample of voided urine
C- Differential diagnosis:
 Total red discoloration of urine due to e.g. some drugs (as rifampicin), foods (as beet roots). The
onset and offset are clearly related to the causative ingested material. The discolored urine is not
turbid, with no clots or urologic manifestations.
 Bleeding per urethra which means blood trickling from the urethra without voiding due to a
urethral lesion or trauma distal to the urinary sphincters. Blood is detected at the external urethral
meatus and the clothes.
 Contamination by menstrual bleeding, thus urine analysis is better avoided during menses.
D- Investigations:
 Urine analysis (essential):
- It confirms the diagnosis by detection of RBCs.
- The cause of hematuria may be detected e.g. bilharzial ova, bacteria and crystals.
- It differentiates between glomerular hematuria (dysmorphic RBCs, proteinuria and RBCs casts)
and non-glomerular hematuria (eumorphic RBCs).
 Abdominal U/S (essential) can detect urologic lesions e.g. renal or bladder stones or tumors.
 Further specific investigations include e.g. checking the bleeding profile, urine cytology,
cystoscopy, uretero-renoscopy and renal biopsy.
5
UROLOGIC SYMPTOMS
E- Treatment of hematuria: entails treatment of the cause besides:

 Simple general measures: e.g. bed rest, good hydration and hemostatic drugs.
 With massive hematuria: hospitalization, vital signs monitoring and blood transfusion.
 For clot retention: Evacuation of clots using Nelaton catheter followed by continuous bladder
irrigation using three-way Foley catheter.
 Specific measures to stop massive bleeding e.g. hemostatic dose of radiotherapy in bladder cancer
and angio-embolization in renal trauma or tumors.
IV- Male genital symptoms include:
> Subfertility > Erectile dysfunction (ED) > Ejaculatory disorders
> Scrotal conditions either:
- Pain: referred (from the upper urinary tract) or due to local cause (as testicular torsion, trauma,
mumps or epididymitis)
- Swelling e.g. epididymo-orchitis, hydrocele, varicocele, spermatocele, hernia or testicular
tumor.
- Empty scrotum e.g. testicular maldescent - Scrotal sinus e.g. posterior TB epididymal sinus
> Position of the external urethral meatus at an abnormal site e.g. hypospadias or epispadias.
> Penile & preputial conditions e.g. [penile curvature or (chordee ventral, dorsal or lateral),
micropenis, concealed penis, priapiasm and Peyronie's disease] & {phimosis, paraphimosis and
deficient prepuce}.
V- Uremic manifestations
Mild cases are asymptomatic (discovered incidentally) or show non-specific symptoms as
headache, lack of concentration, anorexia and easy fatigability.
The symptoms of renal failure include:
 Lack of concentration (an early symptom).
 Headache and blurring of vision.
 Easy fatigability, tachypnea and palpitation (due to anemia, acidosis and hypertension)
 Gastrointestinal manifestations (Early: anorexia & dyspepsia. Late: dry mouth, metallic taste,
nausea, vomiting, hiccup & abdominal distension)
 Bleeding tendency (late) e.g. epistaxis and hematemesis.
 Body itching (late).
VI- Extraurologic symptoms related to urologic disorders
 GIT symptoms:
- Acute pyelonephritis and ureteric colic may be associated with nausea, vomiting, distension
and generalized abdominal pain.
- Huge renal swellings produce GIT pressure symptoms.
- Neuropathic bladder is commonly associated with chronic constipation.
 Constitutional symptoms: Acute bacterial infections of the kidney, prostate, epididymis and
testis can produce toxemia, bacteremia and septicemia resulting in fever, palpitation and
anorexia.
 Symptoms of urologic tumors' metastases:
- Bones: Pain is localized, severe and irresponsive to analgesics. Lately bone swelling, nerve
compression and pathologic fracture may occur.
- Brain: Headache, projectile vomiting, visual disturbances, convulsions.
- Chest: Persistent dry cough, dyspnea, hemoptysis and chest pain.
- Liver: right hypochondrial pain and jaundice.
- Generalized symptoms as weight loss, low grade fever, anorexia, pallor, malignant cachexia
and paraneoplastic syndrome.
6
FOCUSED UROLOGIC
EXAMINATION
To be able to perform and elicit findings through:
- loin examination
- male external genital examination
- digital rectal examination.
FOCUSED UROLOGIC EXAMINATION

Examination of a urologic patient is classic and routine. What is peculiar is loin, male external
genitalia and digital rectal examinations.
Loin examination
The loin is the anatomical region with the following boundaries:
> Superiorly: the lower border of the last rib > Inferiorly: the iliac crest
> Posteriorly: the later border of sacrospinalis muscle > Anteriorly: the mid-axillary line
The renal (costo-vertebral) angle lies between the lower border of the last rib and the lateral border of
sacrospinalis (erector spinae) muscle. Loin examination is conducted through:
 Inspection in sitting and lateral positions for e.g. scars, incisional hernias, swellings and sinuses.
 Palpation in supine and sitting positions for e.g.
tenderness, rigidity and swellings.
 Percussion for shifting dullness or any palpable swelling.
Bimanual palpation of the loin:
 The kidney is palpated while the patient is breathing
slowly and deeply.
 The left hand is placed posteriorly; its index overlies the
last rib on the right side while its little finger overlies the
last rib on the left side. The tips of the other three fingers
(the thumb is not employed) stop at the lateral border of
the sacrospinalis muscle i.e. in the renal angle. The left Bimanual examination for the
hand only pushes anteriorly for renal ballottement. right kidney
 The right hand is placed anteriorly starting below the level
of the umbilicus and moved towards the costal margin. On the right side, it is parallel to the costal
margin. On the left side, it is perpendicular to the costal margin.
Signs characterizing a renal swelling:
 Site: retroperitoneal, so it is best felt at the renal angle unless the kidney is ectopic.
 Border: is always rounded and never sharp.
 The swelling disappears below the costal margin so that one can insinuate the hand between the
swelling and the costal margin unless the swelling is huge. The part of the renal swelling which is
palpable represents its lower part that lies below the costal margin i.e. the upper part is concealed.
 Shape: reniform or oval.
 Movement and mobility:
- Up and down with respiration (within the paranephric space). This can be restricted or lost in
pyonephrosis, infiltrating renal tumors or recurrent cases.
- Renal ballottement is antero-posterior movement within the perinephric space. When the left
hand pushes the swelling anteriorly, the swelling is felt by the right hand and then returns back to
the left hand. Ballottement is lost when a disease affects the perinephric space and fat (e.g.
perinephritis, pyonephrosis, infiltrated by renal tumor) or previous renal surgery (adhesions). A
huge renal swelling has no space for ballottement and it is felt by both hands at the same time
which is called renal contact.
 All renal swellings are dull on percussion. However, a band of colonic resonance can be detected
over the swelling.
 Differential diagnosis of renal swelling:
I- Parietal loin swellings:
˃ Move antero- posteriorly with respiration.
˃ Persist or become more prominent on abdominal wall muscles contraction.
˃ May overlie the costal margin.
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II- Intra-abdominal swellings:

˃ Liver: Right sided, felt anteriorly, with sharp border, the hand cannot be insinuated between
the swelling and the costal margin and always dull on percussion.
˃ Spleen: Left sided, felt anteriorly, with sharp notched border, the hand cannot be insinuated
between the swelling and the costal margin, always dull on percussion and the direction of
movement is toward the right iliac fossa.
˃ Colon: on right or left side, sausage shape, ill defined borders and resonant on percussion.
˃ Retroperitoneal swellings: irregular shape & surface, firm to hard in consistency and not
ballottable (fixed to the posterior abdominal wall).
III- Different types of renal swellings:
Abdominal sonography (is now considered a bedside test) can easily distinguish each type of
these swellings which include:
- Hydronephrosis - Simple renal cysts
- Infected hydronephrosis - Polycystic kidney diseases
- Pyonephrosis - Renal tumors
Male external genitalia examination:

The informed and consenting patient should be examined by both hands in both standing and supine
positions.
I- Penis and urethra:
 The prepuce normally conceals the glans completely and the preputial opening is not narrow. It
may be abnormal in e.g. phimosis (narrow), hypospadias and epispadias (deficient).
 The external urethral (urinary) meatus normally appears as a dry vertical slit situated at the tip
of the glans with two lips that can be separated apart to see inside. It may be abnormally e.g.
stenosed, located ventrally (hypospadias) or located dorsally (epispadias).
 The glans is normally conical in shape and flaccid with the meatus at its tip. Abnormally, it may
be e.g. inflamed (balanitis), flat with the meatus (hypospadias) or fistula at its undersurface.
 The penile shaft is normally flaccid straight (without curvature), with identifiable ventral corpus
spongiosum, smooth surface (without induration) and no tenderness. The penile size is age related.
The lower normal length of the stretched penis is 1.9 cm in infants and 7 cm in adults.
 Abnormally, the penis may be e.g. small sized (micropenis), buried below the surface of the
prepubic skin (with obesity) or bowed (with chordee).
II- Scrotum, testes, epididymes and spermatic cords:

 The scrotum normally has two compartments with an apparent median raphe in between, and
corrugated pliable skin. Some of the scrotal lesions include e.g. scrotal sinus, bifid scrotum,
Fournier gangrene and different skin diseases.
 The testis normally lies at the bottom of the scrotum. It has oval shape, smooth surface, firm
consistency and a characteristic testicular sensation. The testicular size is age related with no
significant difference between the two testes. The testis is covered by tunica vaginalis; which has
two layers (parietal and visceral) with minimal potential space in between. Abnormally, the testis
may be e.g. agenetic, ectopic, inflamed, swollen and torsed.
 The epididymis is a ribbon-like structure that normally lies posterior to the testis. A laterally
situated palpable sulcus separates the testis from the epididymis. The epididymis has a head
(caput) behind the upper pole of the testis, body (corpus) and tail (cauda). It may be anteverted
(anterior to the testis), inflamed or the site of tuberculous scrotal sinus.
 The spermatic cord has two parts; scrotal and inguinal. The scrotal part is available for palpation.
The spermatic cord is normally soft except the cord-like vas deferens. Lesions that can be detected
include e.g. varicocele, thickened or beaded vas, lipoma and encysted hydrocele of the cord.
8
III-Differential diagnosis of inguino-scrotal swellings:

Examination should be directed towards identification of swelling:
 Origin: the scrotal neck test differentiates between pure inguinal swellings (all above the scrotal
neck), pure scrotal swellings (all below the scrotal neck) and inguino-scrotal swellings (above,
below and distending the scrotal neck).
 Consistency: the bipolar fluctuation test detects cystic swellings (hydroceles) present in this
mobile part. Gurgling sensation is present in hernias containing intestine (enterocele), while
doughy sensation is present in hernias containing omentum (omentocele).
 Relation to the testis: the testis may be separable from the swelling (e.g. acquired inguinal
hernia and encysted hydrocele of the cord), the seat of the swelling (testicular abscess or tumor)
or concealed by the swelling with lesions involving the surrounding tunica vaginalis (e.g. vaginal,
infantile & congenital hydroceles and congenital inguinal hernia).
 Variation in size: the swelling may be constant in size (e.g. infantile hydrocele and epididymal
swellings), with marked instant variation in size (e.g. hernias) or with slow & gradual
variation in size over the day (e.g. congenital hydrocele or varicocele).
Inguinoscrotal swellings include e.g.:

 Hydrocele: It is abnormal clear fluid collection between the two layers of the processus
vaginalis at the inguinoscrotal region related to the testis and/or the spermatic cord.
Normally, the processus vaginalis is obliterated from the internal inguinal ring to the upper pole of
testis, leaving a small potential space that surrounds the testis (tunica vaginalis). Hydroceles if not
complicated usually present as chronic cystic painless swellings and they include:
1. Congenital (communicating) hydrocele: It is inguino-scrotal swelling surrounding the testis
and spermatic cord with a minute communication between its sac and the peritoneal cavity.
Thus it slowly evacuates and refills. It is the only type of hydrocele that shows variation in size.
2. Infantile (non-communicating) hydrocele: It simulates the congenital type without
communication with the peritoneal cavity; so there is no variation in size.
3. Encysted hydrocele of the cord: The unobliterated part of the processus vaginalis is isolated
from both the peritoneal sac and the testis. It may be scrotal, inguinal or inguinoscrotal. The
testis is not involved in the swelling.
4. Hydrocele of hernial sac: It is primarily an inguinal swelling (outside the cord) due to fluid
accumulation in a closed hernial sac without any visceral content.
5. Vaginal hydrocele: It is a pure scrotal swelling surrounding the testis. It may be primary
(with no detectable cause) or secondary (due to e.g. epididymo-orchitis, testicular tumor and
ligation of lymphatics during varix ligation or inguinal hernia repair).
Different anatomical types of hydrocele
Special clinical tests for vaginal hydrocele:

- Pinching of the parietal layer of tunica vaginalis in minimal vaginal hydrocele.
- Positive trans-illumination test due to the clear nature of the fluid. In pyocele, hematocele or
chylocele trans-illumination is negative.
- Scrotal ultrasonography is mandatory when the testis cannot be clinically evaluated to exclude
testicular malignancy or atrophy.
9
Treatment of hydrocele:
- Conservative management: in neonates and infants waiting for spontaneous resolution over the
first year. Surgery is indicated with persistence of hydrocele.
- Surgical excision of the sac in all types of hydrocele. However in uncomplicated vaginal
hydrocele, eversion of the parietal layer of the tunica vaginalis is enough.
- Treatment of the cause: in cases of secondary vaginal hydrocele.
 Inguinal hernia: It may be congenital (with patent processus vaginalis and the testis is one of
the contents) or acquired (with a new peritoneal hernia sac and the testis is outside). If
uncomplicated, it shows characteristic signs; namely expansile impulse on cough and
reducibility. It may be complicated by irreducibility, obstruction or strangulation, so it needs
repair as soon as possible.
 Varicocele: It is an inguinoscrotal diffuse compressible cord swelling and its size increases with
straining and decreases in supine position. It may also present with subfertility or dragging scrotal
pain. It is usually left sided and may be bilateral.
 Spermatocele: It is an epididymal cyst with unclear fluid containing sperms. Thus it is a pure
scrotal swelling related to the upper pole of the testis (forming with the testis an 8-shaped
figure). It varies in size and sometimes it resembles a third testis.
 Testicular tumor: It is usually a painless firm testicular swelling with loss of the characteristic
testicular sensation. It may be associated with rapidly formed vaginal hydrocele or hematocele.
Digital rectal (anorectal) examination:
Keeping the patient privacy, digital rectal examination (DRE) begins by inspection of the perineum
and ends by inspection of the examining finger after doing bimanual examination. The steps include:
I) Positioning:
The informed and consenting patient acquires one of the following positions:
* Supine position (with bilateral semi-flexion of both hip and knee joints and supported heels) is the
most frequently used in urologic practice.
* Left lateral position * Knee-elbow position.
II) Inspection for:
 Normal corrugation around the anal orifice. Loss of corrugations is present if the external anal
sphincter is atonic. This raises the possibility of neuropathic bladder.
 Perianal & perineal (abscess, sinus or fistula) and any discharge (pus, mucus, urine or feces)
 Discharge, prolapsed piles or rectal prolapse.
 Signs of trauma e.g. perineal urinary extravasation and hematoma.
 Scar of previous operation (e.g. urethroplasty) or skin disease (e.g. tinea cruris)
III) Finger introduction:
 The hands should be gloved and the examining right index finger well lubricated.
 The bulb of the index finger is applied to the anal verge in a light or superficial palpation manner
to test for any tenderness or spasm.
 The pressure is increased (deep palpation) till the anal sphincter is relaxed, then the distal phalanx
is flexed to be gently introduced into the anal canal.
 Proceed to introduce the middle phalanx to reach the prostate region, then the proximal phalanx to
reach the bladder base.
 DRE is not routine in children, and if indicated the right little finger is used.
10
 Findings by DRE (both normal and abnormal findings):

1. Anal sphincter tone:
Actually there is great anatomical and functional similarity between the anal and urethral
sphincters. They share the same source of nerve supply. Each sphincter has two components;
one is involuntary and the other is voluntary.
There is a normal degree of gripping or resistance to the examining finger by the anal sphincter
tone. The anal tone normally may be:
- Spontaneous:
- Voluntary: It is obtained by the intentional contraction of the sphincter after asking the
patient to squeeze the examining finger during DRE as if the patient is trying to hold flatus.
It is resorted to when the spontaneous gripping is doubtful or seems to be absent or weak.
- Reflex (the bulbocavernosus reflex): It is provoked by (squeezing the glans) or by gentle
controlled traction on an indwelling catheter if the patient is catheterized.
This anal tone may be abnormally:
- Lost or ↓ in lower motor neuron lesions, direct trauma to the sphincter and in the elderly.
- Exaggerated in uncooperative patient, upper motor neuron lesions, painful perianal
conditions and anal canal stenosis
2. The membranous urethra: a stone or catheter can be felt in the midline below the prostate.
3. Prostate: A normal prostate is not tender, has smooth flat surface & rubbery consistency and
its base is easily reached. The soft base of the bladder is felt above. The prostate has two lateral
sulci (between the lateral prostatic edges and the soft rectum) and a median furrow (bilobed).
DRE signs of benign prostate enlargement include:
- convexity of surface = ↑ of antero-posterior dimension.
- exaggeration of the lateral sulci = ↑ of antero-posterior and the transverse dimensions.
- difficulty or failure to reach the prostate base = ↑ of cephalo-caudal dimension
In acute prostatitis and prostatic abscess, the prostate is extremely tender and the patient
cannot tolerate DRE.
In prostate cancer, signs of malignancy include nodular surface, hard consistency obliteration
of one or both lateral sulci, obliteration of the median furrow and frozen pelvis. There is no
tenderness unlike bladder cancer.
4. Bladder base is:
- normally soft, with smooth surface and not tender.
- tender in acute bacterial cystitis, acute urine retention and bladder cancer
- indurated, firm with irregular surface in posterior wall bladder cancer.
5. The seminal vesicles are normally impalpable. They may be palpable with obstruction,
bilharzial affection or malignant involvement.
6. The rectum: the examining finger is rotated around to detect any rectal pathology e.g. rectal
polyp or cancer.
IV) Bimanual examination: It is an essential step of DRE to assess the bladder between the
examining finger (in the rectum) and the left hand (at the supra-pubic region). It helps to detect:
- Cystic bladder mass (urine) in chronic urine retention or huge bladder diverticulum.
- Solid bladder mass (cancer) which is usually tender. It may be mobile or fixed.
V) Inspection of the examining finger for blood, pus or mucus.
11
UROLOGIC
INVESTIGATIONS
- To address the normal findings of urine analysis.
- To be able to identify various abnormalities in urine analysis report and to know
their causes.
- To know the normal values of semen analysis, and to be able to identify various
abnormalities in it.
- To list the various imaging modalities used to investigate the urinary tract.
- To be familiar with the normal appearance of the urinary tract on ultrasonography,
KUB X-ray and IVU.
UROLOGIC INVESTIGATIONS
URINE ANALYSIS
It is a standard and routine investigation for every urologic patient. The standard method of urine
sampling is the mid-stream catch. Urine should be examined:
Physically (by naked eye):
 Color: Normally, it varies from light to dark yellow according to its concentration. Many foods,
medications, metabolic products, and infections may produce abnormal color.
 Aspect: Normally, urine is transparent. Common causes of cloudy or turbid urine include
phosphaturia, pyuria and hematuria.
By dipstick testing:
 Specific gravity: It varies from 1.001 to 1.035.
- A specific gravity less than 1.008 is regarded as dilute. Conditions that decrease specific gravity
include increased fluid intake, diuretics and diabetes insipidus.
- A specific gravity greater than 1.020 is considered concentrated. Conditions that increase
specific gravity include decreased fluid intake, dehydration (owing to fever, vomiting and
diarrhea), diabetes mellitus and excreted contrast material.
- A fixed specific gravity of 1.010 is a sign of renal insufficiency, either acute or chronic.
 Reaction (pH): It varies from 4.5 to 8.
- Normally, urine is acidic with an average pH of 5.5-6.5.
- Alkaline urine predisposes to UTI. In the meanwhile, UTI with a urea-splitting organism renders
urine pH greater than 7.5.
- Urinary pH is usually acidic in patients with uric acid and cystine lithiasis. Urine alkalinization is
an important line of therapy of such stones.
 Blood: Positive dipstick for blood indicates the presence of hemoglobin in urine.
 Leukocytes: Leukocyte esterase activity indicates the presence of pus cells (pyuria) in urine.
 Nitrites: normally, are not present in urine. Its presence strongly suggests bacteriuria.
 Protein: Although healthy adults excrete 80 to 150 mg of protein in the urine daily, the qualitative
detection of proteinuria should raise the suspicion of an underlying renal (glomerular,
tubulointerstitial or vascular) disease. Proteinuria can also occur following strenuous exercise.
 Glucose and Ketones: Normally, almost all the glucose filtered by the glomeruli is reabsorbed.
Detection of glucose and ketones is useful in screening for diabetes mellitus.
 Bilirubin: Normal urine contains traces of urobilinogen and no bilirubin. Bilirubin appears in urine
in obstructive and hepatocellular jaundice. Urobilinogen increases in hemolytic conditions.
Microscopically: (for urine sediment after centrifugation)
 RBCs: The normal count in centrifuged urine is 0-3 RBCs / HPF. Increase in this count means
hematuria. RBCs derived from the glomeruli are distorted (dysmorphic). Those derived from
tubular bleeding and the lower down urinary tract have a normal shape (eumorphic).
 Pus cells (dead leukocytes): Normally, a count of < 10 pus cells / HPF is accepted.
 Epithelial cells: are commonly observed with no clinical significance e.g. due to contamination
from the anterior urethra in males or the introitus in females.
 Bacteria: The presence of five bacteria / HPF reflects about 105 colony forming units/ mL. This is
the standard level to diagnose UTI in a clean-catch specimen.
 Crystals: Calcium oxalate, uric acid and cystine may be detected in acidic urine. Calcium
phosphate and triple-phosphate may be detected in alkaline urine.
 Parasites and ova: e.g. trichomonas vaginalis and bilharzial ova.
 Urinary casts: A cast is a protein coagulum formed in the renal tubule casting the shape of the
tubule. The protein matrix traps tubular luminal contents.
12
Urinary casts include:

1) Hyaline casts: contain only mucoproteins and are seen after exercise, heat exposure, and in
pyelonephritis or chronic renal disease.
2) RBC casts: contain trapped erythrocytes and are diagnostic of glomerular bleeding, most
often due to glomerulonephritis.
3) Leukocyte (WBC) casts: in acute pyelonephritis & acute glomerulonephritis.
Special urine samples for:
 UTI: Culture and sensitivity
 Bladder cancer: Cytology
 Retrograde ejaculation: Post-coital voided urine.
 Daily (24- hour) urine output of protein, calcium, oxalate, uric acid, phosphates and creatinine
SEMEN ANALYSIS
 Indications:
1. Male subfertility: the chance of conception decreases as the semen quality declines, however
fertility does not reach zero. 2- Varicocele (for assessment and follow up).
3- Hemospermia. 4- Premarital assessment of fertility.
 Methods of obtaining a semen specimen: Masturbation (recommended) or coitus interruptus.
 Abstinence period: 3 to 5 days from the last ejaculation.
 The specimen is examined macroscopically, microscopically and biochemically.
 The following table shows the normal semen parameters according to the WHO:
Parameter WHO WHO Abnormalities
1999 2010
Color White opalescent Yellowish or reddish brown
Physical Volume (mL) ≥2 ≥ 1.5 Low ejaculate volume
criteria Liquefaction Coagulates and liquefies No coagulation
within 20 minutes Prolonged liquefaction
pH 7.35-7.50 ≥ 7.2 acidic
Sperm concentration Oligospermia:
≥ 20 ≥ 15
(million/mL) (low sperm concentration)
Total sperm count Azospermia:
≥ 40 ≥ 39
(million) (no detectable sperm)
Sperm Progressive motility Asthenospermia (decreased %
≥ 50 ≥ 32
criteria (%) of progressively motile sperms)
Vitality (%) Necrospermia:
≥ 75 ≥ 58
(increased % of dead sperms)
Normal morphology Teratospermia:
≥ 30 ≥4
(%) (increased % of abnormal forms)
leukocytes Leukocytospermia (pyospermia)
<1
Cells (million/mL)
RBCs 0 Hemospermia
 Abnormal semen analysis should be repeated twice or thrice over a period of several weeks to
confirm abnormalities present in the first specimen.
 Hemospermia is a symptom however the presence of even a single RBC in semen is considered
hemospermia. It may be idiopathic. It can be caused by prostatic congestion or (inflammations,
trauma or tumors) of organs involved in the process of ejaculation e.g. TB of the prostate or seminal
vesicles and prostate cancer.
 Acidic semen and absence of fructose are encountered in bilateral ejaculatory duct obstruction.
13
UROLOGIC IMAGING
This includes a wide spectrum of procedures with different technical aspects such as:
A- Ultrasonography (U/S):
It is cheap, rapid, real-time, safe, radiation free, easily performed and widely available. It provides a
good tool for patients' follow up, guidance of needle biopsies and insertion of draining tubes.
However, it is operator dependent requiring experience and direct contact to the area under
examination. It includes:
i. Abdominal ultrasonography: It is actually a bed-side test and can be considered a part of the
routine abdominal clinical examination. It can assess:
 Kidneys: site, size, echogenicity, stones, obstruction, cysts, tumors and perinephric
collections.
 Ureters: They can be traced by ultrasound if they are dilated.
 Bladder: It should be full at examination to detect stones, masses and intramural ureteric
stone. Lastly, it evaluates post-void residual (PVR) urine.
 Other abdominal organs (e.g. the liver, gall bladder & uterus) and intra-abdominal collections
or masses.
Normal sonographic appearance of the:

kidney (left) and urinary bladder (right)
ii. Scrotal ultrasonography evaluates:
 Scrotal masses; cystic (e.g. hydrocele) or solid, benign or malignant
 Color duplex ultrasonography is used in cases of varicocele (detects venous dilation and
venous reflux) and testicular torsion.
iii. Penile color duplex ultrasonography in cases of erectile dysfunction.
iv. Trans-rectal ultrasonography (TRUS) evaluates:
 The prostate: volume, suspicious foci, stones or abscess. It can guide prostatic biopsy
 Seminal vesicles and ejaculatory ducts for e.g. obstruction.
B- Plain X-Ray of the urinary tract or KUB (kidney, ureter, bladder) film:
It requires prior bowel preparation and carries the risk of ionizing radiation, so it must be avoided
during pregnancy. Colonic gases may obscure findings and details.
14
KUB film can show:

i. Bones:
 Normally bones are used as landmarks for the urinary tract:
- The renal pelvis lies opposite the second lumbar
transverse process
- The middle ureter lies opposite the sacro-iliac joint
- The posterior urethra lies opposite the symphysis
pubis.
 Urologically related bone abnormalities include e.g.
spine deformities (as scoliosis and sacral agenesis),
fractures (as pelvis or spine fracture) and metastases
(osteolytic or osteosclerotic).
ii. Radio-opaque shadows:
 Radio-opaque stones. Opacities that may be confused
with stones include pelvic phleboliths (small, round,
have lucent center, usually below the ischial spines) and
calcified lymph nodes.
 Abnormal calcifications e.g. TB renal calcification and Normal KUB film
linear bladder/ureteral bilharzial calcification.
 Foreign bodies as urologic stents (e.g. JJ stent) and metal clips.
iii. Renal soft tissue shadow normally appears just lateral to the psoas shadow. The psoas
shadow can be obscured by retroperitoneal masses (e.g. hugely enlarged kidney) or collections
(pus or blood).
C-Abdominal computed tomography (CT): It shows both the urinary tract and other abdominal
organs. It uses ionizing radiation as KUB and IVU however with higher doses. Thus, these three
modalities are contraindicated during pregnancy.
i. Non-contrast CT: It can detect both radio-lucent & radio-opaque stones and determine their
densities. It shows the site and shape of the kidneys irrespective to their function e.g. ectopic and
horse-shoe kidneys.
ii. Contrast CT:
- Contrast media are water soluble tri-iodinated benzoic acid compounds, administered
intravenously and excreted by the kidneys.
- Their adverse reactions are hypersensitivity and nephro-toxicity. So, they are
contraindicated in cases of contrast hypersensitivity, renal impairment and diabetics
receiving metformin.
- Preparation: It needs prior good hydration and normal serum creatinine.
- Indications include:
1. Genitourinary tumors; diagnosis, staging and follow up.
2. Urinary tract trauma; mainly renal and ureteric trauma.
3. Obstruction; uretero-pelvic junction obstruction and ureteric stricture.
15
D- Intravenous urography (IVU):

 It has been largely replaced by CT since it cannot assess
renal cortical lesions, non-functioning renal unit, acutely
obstructed kidney during renal colic or other organs.
 It is still valid in assessment of upper urinary tract
obstruction (uretero-pelvic junction obstruction and ureteric
stricture) and if CT is not available. It is actually widely
available at any center that has an x- ray unit including the
operative theater.
E- Other urologic contrast studies:
 Retrograde urethrography to detect urethral stricture or
urethral rupture.
 Retrograde cystography to detect bladder rupture.
Normal IVU
 Voiding cystourethrography to detect vesico-ureteral
reflux (VUR) and posterior urethral valve.
 Retrograde uretero-renography (intra-operatively) to detect ureteric injury, localize ureteric
stricture and at the start of percutaneous nephrolithotomy.
 Antegrade nephrostography (through a percutaneous nephrostomy tube) to define the site of
obstruction.
F- Magnetic Resonance Imaging (MRI) includes:
 Magnetic resonance urography replaces CT in cases with pregnancy and studies with IV contrast
in renal impairment and contrast hypersensitivity.
 Multiparametric MRI can be used for assessment of genitourinary tumors especially prostate
cancer.
 The patient should put off any metallic object. Moreover, the procedure is contraindicated with
claustrophobia and any intra-corporeal metallic prosthetic implant.
G-Renal scintigraphy (radio-isotope scan) determines the differential (split) renal function and
confirms upper urinary tract obstruction. It is permissible with renal impairment; however it is
firmly contraindicated during pregnancy.
16
GENITO-URINARY
INFECTIONS
- To describe the etiology, pathology, clinical manifestations, complications, diagnosis
and treatment for patients with non specific infections of genito-urinary tract.
- To describe the pathology, clinical presentation, complications, diagnostic modalities
and treatment for patients with genito-urinary TB.
- To describe the pathology, clinical presentation, complications, diagnosis and
treatment for patients with urinary bilharziasis.
GENITO-URINARY INFECTIONS
NON-SPECIFIC GENITO-URINARY INFECTIONS

Definitions:
 Urinary tract infection (UTI) is an inflammatory response of the urinary tract to microbial
invasion. It may be complicated or uncomplicated UTI.
 Uncomplicated (simple) UTI is one occurring in a patient with a structurally and functionally
normal urinary tract. It responds quickly to a short course of antibiotics.
 Complicated UTI is one occurring in the presence of an underlying anatomical or functional
abnormality (e.g. incomplete bladder emptying due to BPH). It takes longer time to respond to
antibiotic treatment with increased risk of recurrence.
 Bacteriuria is the presence of bacteria in urine, either asymptomatic or symptomatic.
 Pyuria is the presence of white blood cells (WBCs) in urine (detected by dipstick test) or more
than 10 WBCs / HPF in sediment of centrifuged urine. Pyuria is mainly caused by bacterial
infection.
 Bacteriuria without pyuria indicates the presence of bacterial colonization of the urine, rather than
the presence of active infection.
 Pyuria without bacteriuria (sterile pyuria) may occur with urinary stones, carcinoma in situ of the
bladder and urinary TB infection.
Causative organisms:
A- Bacterial
 Gram negative bacilli: E. coli is the most common pathogen and represents more than 80% of all
UTI. Others include klebsiella and proteus. Pseudomonas aeruginosa is present in complicated UTI.
 Gram positive cocci e.g. streptococci and staphylococci.
B- Non-bacterial: They are commonly sexually transmitted e.g.chlamydia trachomatis, ureaplasma
urealyticum and trichomonas vaginilis.
Routes of entry:
1. Ascending: it is the most common route for UTI e.g. renal infection due to reflux of infected urine.
2. Other routes include hematogenous (from a septic focus), lymphatic and direct spread (from
neighboring organs).
Natural defense mechanisms against UTI include complete periodic emptying of the urinary bladder,
antegrade ureteral peristalsis, non refluxing vesico-ureteral junction and acidic pH of urine.
Risk factors for UTI:

1. Urinary tract obstruction (urinary stasis) e.g. by stones, strictures, BPH.
2. Foreign bodies e.g. indwelling catheters, urinary stents and stones.
3. Vesico-ureteral reflux.
4. Neuropathic bladder.
5. Urinary diversion e.g. ureterosigmoidostomy.
6. Gender: Females are more liable essentially due to short straight urethra.
7. Systemic factors e.g. DM, renal failure and immuno-suppression.
8. Organism factors including its virulence and number.
The diagnosis of UTI is based on symptomatology, urinalysis, and urine culture findings. Urine culture
is the gold standard for the diagnosis of bacterial UTI. Treatment is usually indicated if >10 5 colony
forming unit/mL in a patient with symptomatic UTI, particularly with associated pyuria.
Most cases of simple UTI do not require additional investigations. High grade fever, recurrent UTI,
pregnancy and systemically ill patients are some indications that require further investigations e.g. total
leukocytic count (leukocytosis), abdominal U/S, KUB film, abdominal CT, assessment of post void
residual urine, voiding cystourethrography and urodynamic studies.
17
1) ACUTE PYELONEPHRITIS
It is a clinically diagnosed disease due to acute inflammation and infection process of the pelvi-
calyceal system and renal parenchyma.
Clinical diagnosis:
1. High grade fever with acute onset and associated with rigors.
2. Severe flank pain and tenderness.
3. Other symptoms as malaise, vomiting, irritative LUTS and turbid urine.
Investigations:
1. Abdominal U/S: It is mostly within normal, but it may show mildly enlarged edematous
kidney and renal stones.
2. Urine analysis shows microscopic pyuria and bacteriuria.
3. Urine culture & sensitivity specifies the infecting organism and the appropriate antimicrobial
therapy. However its result takes 3-5 days.
Complications:
1. Septicemia up to septic shock.
2. Renal or perinephric abscess.
3. Chronic pyelonephritis.
Treatment:
a. Drug treatment: prompt treatment is essential to prevent complications.
1. Antimicrobials: empiric broad spectrum parenteral antibiotic therapy (e.g. ceftriaxone) is
started until the result of culture and sensitivity tests is obtained. Oral antimicrobials are used
and continued thereafter.
2. Symptomatic treatment e.g. anti-pyretics, analgesics and anti-emetics.
3. Intra-venous fluids: if there is vomiting or hypotension.
b. Hospitalization is indicated in pregnancy, solitary kidney and immune-compromised patients.
Obstructive pyelonephritis requires ureteric stenting.
2) CHRONIC PYELONEPHRITIS
It is a radiologic and pathologic disease due to chronic cortico-medullary inflammation and scarring
(fibrosis) of the kidney.
Diagnosis:
1. The presentation may be asymptomatic, mild renal pain or by
complication(s).
2. Abdominal U/S: Smaller sized kidney, irregular outline,
increased echogenicity and irregular calyceal dilatation with
non-dilated pelvis.
3. Urine analysis may show proteinuria, pyuria and bacteriuria.
Sonographic appearance of
Complications:
chronic pyelonephritis
1. Renal hypertension. 2. Renal stones.
3. Renal function loss that may lead to chronic renal failure if bilateral or in a solitary kidney.
Treatment:
 Pathogen specific antibiotic.
 Chronic suppressive therapy (long term use of a low-dose regimen of antimicrobials).
 Nephrectomy may be carried out for unilateral poorly functioning kidney complicated by
hypertension, persistent renal pain or persistent pyuria.
18
3) PYONEPHROSIS: It may result from:

a) Acute infection of a preexisting hydronephrosis:
 Here it better to be described as infected hydronephrosis.
 It presents by severe renal pain, high grade fever, rigors and toxemia.
 There is renal angle tenderness and the kidney if palpable is cystic.
 Abdominal U/S: the kidney is enlarged, hydronephrotic with internal echoes.
 Treatment: IV antibiotics and IV fluids, followed by
urgent insertion of percutaneous nephrostomy (PCN).
b) Chronic infection (which was not promptly treated) with
concomitant obstruction of the infected kidney:
- The kidney is enlarged and tender but less than the case
of infected hydronphrosis.
- Fever is also lower and not of high grade.
- Infection may extend to the perinephric fat and result in
perinephric abscess. Sonographic appearance of
- The renal tissue is destroyed leading to loss of renal pyonephrosis
function and ultimately, it may indicate nephrectomy.
- If bilateral, it leads to chronic renal impairment and failure.
4) RENAL & PERI-NEPHRIC ABSCESS
Etiology: The organism that underlies such condition may come from:
 Urinary tract (gram negative bacilli) in most cases.
 Blood (staphylococcus organism) from a distant site.
Clinical picture:
 Fever (high grade) and rigors.
 Throbbing renal pain and severe renal tenderness with reflex rigidity.
 Peri-nephric abscess may be additionally associated with:
- bulging of the renal angle when it extends posteriorly.
- reflex muscle spasm leading to scoliosis (concavity toward the affected side) and flexion of
the ipsilateral thigh (psoas spasm).
Investigations:
 Abdominal U/S shows the collected pus, its amount and condition of the kidney(s). It is
beneficial to follow up and evaluate the response of medical treatment.
 KUB may show scoliosis, renal stone(s) and ipsilateral pleural effusion.
 CT. scan is indicated if medical treatment fails.
 Laboratory investigations include urine analysis (pyuria, bacteriuria) and blood count
(leukocytosis). Culture of urine, blood and drained pus reveals the causative organism and its
antimicrobial susceptibility.
Treatment:
1. Hospitalization.
2. Medical treatment by broad spectrum IV antibiotics, IV fluids together with symptomatic
treatment e.g. anti-pyretics and analgesics.
3. Follow up for fever, pain and abscess size.
4. Drainage is indicated in large abscesses or after failure of medical treatment.
19
5) CYSTITIS
 Acute bacterial cystitis is due to ascending infection especially in women (e.g. honey-moon
cystitis) and girls.
 Symptoms: irritative LUTS (frequent voiding of small volumes, dysuria & urgency) and
suprapubic pain. Gross hematuria and fever are infrequent.
 Signs are non specific.
 Urinalysis: pyuria and bacteriuria ± microscopic hematuria.
 Additional imaging (e.g. abdominal U/S) and urine culture are indicated in febrile patients, when
symptoms persist or renal pain co-exits.
 Treatment: unless complicated, trimethoprim-sulphamethoxasole or quinolones for 3-5 days is
sufficient.
 Cystitis persists in the presence of bladder outlet obstruction, neuropathic bladder, bladder stone,
bladder diverticulum or infection with (atypical or specific microorganism).
6) URETHRITIS
 It is mainly a sexually transmitted disease in men.
 Urethritis is either acute or chronic & gonococcal or non-gonococcal. The causative organism is
revealed by examination of the urethral discharge. If the discharge is scanty, use a urethral swap.
 The presentation includes urethral pain, dysuria, urethral discharge and painful ejaculation.
 Complications:
- Acute (acute urinary retention & acute prostatitis and epididymo-orchitis).
- Chronic (urethral stricture & infertility due to obstruction of the ejaculatory ducts).
 Treatment considerations:
- Treatment should be started immediately covering both gonococcal and non-gonococcal types
(dual therapy).
- Sexual partner should be simultaneously treated.
- Sexual abstinence is highly recommended till cure.
- Urethral catheterization and instrumentation are contraindicated.
- Acute retention of urine - if occurred- requires insertion of a suprapubic percutaneous
cystostomy tube.
The following table summarizes the main differences between:
Gonococcal and non- gonococcal urethritis
Differentiating Gonococcal Non-gonococcal
points urethritis urethritis
Causative agent Niesseria gonorrhea Chlamydia trachomatis, Ureaplasma
(Gram -ve intracellular diplococci). urealyticum or Trichomonas vaginalis
Incubation period 3-10 days 1-5 weeks
Urethral discharge Profuse, yellowish & purulent Scanty, mucoid or muco-purulent
Single dose of : Azithromycin (one gm, single oral
Treatment Ceftriaxone (one gm, IM) or dose) or Doxycycline (100 mg twice
Cefixime (400 mg, oral) daily for 7-10 days)
20
8) ACUTE EPIDIDYMO-ORCHITIS
It is commonly due to infection spreading through the lumen of the vas secondary to urethritis,
cystitis, urethral catheterization or instrumentation. It affects the epididymis firstly then it may
progress to the testis. Orchitis may be caused specifically by mumps (viral infection).
Diagnosis:
 Acute severe scrotal pain associated with tender swelling.
 History pointing to the source of infection e.g. urethral discharge and irritative LUTS.
 Constitutional symptoms e.g. fever, rigors, malaise….etc.
 The epididymis and the testis are swollen, tender and lately appear as one inflamed structure
with redness and edema of the overlying scrotal skin.
 It should be differentiated from other causes of acute scrotum; mainly testicular torsion.
Complications: abscess formation, recurrence & chronicity and testicular atrophy (especially with
mumps orchitis) that may risk fertility.
Treatment:
 Antibiotics for two weeks e.g. quinolones or ceftriaxone.
 Bed rest, testicular support, ice packs, anti-inflammatory, antipyretic and analgesic drugs.
 Any form of urethral instrumentation should be avoided.
9) FOURNIER GANGRENE
It represents a state of spontaneous fulminant gangrene of the male external genitalia
 It is a necrotizing fasciitis of the genitalia and perineum leading to necrosis and gangrene of
infected tissues. It is unusual for the testes or deeper penile tissues to be involved.
 This is one of the most dramatic, rapidly progressing and life threatening infections in medicine.
 Both aerobic and anaerobic organisms grow rapidly in a synergistic fashion.
 It may follow even a trivial accidental or surgical local trauma or urethral instrumentation
especially in diabetics.
 Diagnosis:
- It is a clinical one and based on awareness of
the condition.
- There is marked local pain and tenderness in a
very ill feverish patient.
- Crepitation may be present, indicating the
presence of subcutaneous gas produced by
gas-forming organisms.
- In a matter of hours, areas of necrosis
(blackish discoloration with offensive odor)
may develop (at the scrotum, penile shaft skin Fournier gangrene:
and perineum) and spread to involve adjacent an early stage (left) and a late stage (right)
tissues (e.g., the lower abdominal wall).
 Treatment:
- Hospitalize and monitor meticulously the vital signs (risk of septic shock).
- Without delay, start IV fluids, take blood for culture and administer oxygen.
- Parenteral broad-spectrum antibiotics to cover both (gram-positive & gram-negative bacteria)
and both (aerobes and anaerobes).
- A suprapubic catheter is inserted to divert and monitor urine output.
- Emergent and extensive debridement of necrotic tissue.
- Later skin coverage of the bare areas is carried out
21
GENITO-URINARY TUBERCULOSIS (TB)

It is usually secondary to extra-urologic primary tuberculous focus e.g. lungs or GIT. The causative
organism is mycobacterium tuberculosis; an acid fast bacillus. It is usually caught by inhalation and
spreads hematogenously to the urinary tract with a latent period of 7-15 years. However in rare cases,
acute diffuse systemic dissemination of tuberculous bacilli can result in fatal miliary TB.
RENAL TUBERCULOSIS
 Hematogenous spread causes granuloma formation in the renal cortex, associated with caseous
necrosis of the renal papillae
 Spillage of this caseous material into the pelvicalyceal system releases bacilli into the urine and
leaves cavitations leading to deformity of the calyces.
 Rupture of caseous lesions outside the kidney causes perinrphric cold abscess.
 This is followed by healing, fibrosis and calcification, which causes destruction of renal
architecture, uretero-pelvic junction (UPJ) obstruction and autonephrectomy.
URETERAL TB
 It is an extension of the disease from the kidney.
 TB affects all layers of the ureter which becomes thick walled, slightly dilated and non-tortuous
(pipe stem ureter).
 Stricture occurs at UPJ, middle ureter and sometimes the whole ureter becomes strictured with
subsequent hydronephrosis.
TB of the urinary bladder
 Bladder lesions are secondary to renal tuberculosis starting at the ureteral orifices.
 The mucosa shows TB ulcers (rare, superficial with irregular outline).
 Fibrosis around the ureteral orifices may cause vesico-ureteral reflux (VUR).
 When the disease spreads to the muscle, fibrosis results in contracted bladder.
Male genital TB
 Genital TB is more common than urinary TB. It is common in the third and fourth decades.
 Hematogenous spread (from a primary focus in the gastro-intestinal tract or the lungs) affects the
epididymis and the prostate.
 Subsequently the epididymis infects the vas deferens and the testis causing indurated swollen
epididymis, thickened beaded vas and secondary vaginal hydrocele. In neglected cases, posterior
scrotal epididymal sinus may develop.
 Likewise, the prostate infects the seminal vesicles. Prostatic nodule/s, hemospermia, ejaculatory
duct obstruction and low ejaculate volume are some of the sequels.
Complications of genito-urinary TB:
1. Secondary bacterial infection.
2. Stone formation.
3. UPJ obstruction or ureteric stricture with subsequent hydronephrosis and pyonephrosis.
4. VUR.
5. Renal hypertension.
6. Renal function loss up to chronic renal failure.
7. Chronic bladder ulceration and hematuria.
8. Contracted bladder.
9. Genital sinus or urinary fistula (spontaneous or after surgical intervention).
10. Male subfertility.
22
Clinical presentation of genito-urinary TB:

 Symptoms are generally chronic, intermittent and non-specific.
 TB can stand behind any genito-urinary symptom.
 Complications represent the usual form of presentation.
 Clinically genito-urinary TB should be suspected in the following situations:
- History of any extra-urologic TB e.g. pulmonary TB.
- Chronically toxic patient (anorexia, pallor, loss of weight, night sweating).
- The characteristic thickened beaded vas and posterior scrotal sinus.
- Genital sinus and urinary fistula after surgical intervention.
- UTI treatment failure with the current broad spectrum antibiotics.
- Sterile pyuria with highly acidic urine.
- Afebrile renal or perinephric abscess as fever is rare in GU tuberculosis.
Investigations:
I- Laboratory:
 Tuberculin test: It is a good negative test.
 Ziehl-Neelsen staining of 3-5 early morning urine samples to detect acid-fast bacilli. Although it
has low sensitivity, it is very specific and good positive test.
 Culture of urine, semen or any discharge on Lowenstein-Jensen or Dorset-egg media which
takes more than 4 weeks.
 Polymerase Chain Reaction (PCR) for blood, urine, semen or sinus discharge. It is highly
sensitive, specific and rapid.
II- Radiological:
 Ultrasonography:
- Abdominal ultrasonography: may reveal cavitary lesions, cortical abscesses, hydronephrosis or
lately (cortical scarring, perinephric
abscess and urinary stones).
- TRUS assesses the prostate, seminal
vesicles and ejaculatory ducts.
 KUB film may show mottled renal
calcification (pathognomonic) and
calcified bladder.
 IVU or CT with contrast may show:
- Renal cavitary lesions, irregular calyces
(moth-eaten kidney) or localized
hydrocalycosis (due to infundibular
stenosis).
- Hydronephrosis due to UPJ obstruction,
ureteric stricture or VUR.
- Pipe-stem ureter (mildly dilated,
stretched, non-tortuous ureter/s). It is KUB: IVU:
a pathognomonic sign. Mottled TB Pipe-stem
- Non-excreting kidney. renal calcification tuberculous ureter
- Contracted bladder is suggestive of extensive bladder TB.
23
III- Cystoscopy in case of TB may show:

 Hyperemic bladder mucosa with tubercles & ulcers.
 Gapping (golf-hole) ureteral orifice/s.
 Low bladder capacity (contracted bladder).
 Biopsy can be taken from bladder lesions.
Treatment:
It aims to:
 make the patient non-infectious
 preserve the renal function
 manage any co-morbid condition.
Treatment includes:
I- Medical treatment (anti-tuberculous drugs):
 Chemotherapy for 4-6 months is the mainstay of
treatment. It includes a combination of isoniazid (INH),
rifampicin and pyrazinamide.
Retrograde cystogram:
 In resistant cases drug sensitivity testing may be resorted
Contracted bladder due to
to. Ethambutol and streptomycin are two other optional chronic TB with bilateral VUR
anti-tuberculous drugs.
 The patient should be clinically and radiologically monitored during treatment and followed up
after completion of treatment.
II- Surgical treatment:
A- Primary measures:
- Anti-tuberculous drugs must be started once the diagnosis is confirmed and should continue for
at least 4-6 weeks before surgical intervention.
- Drainage of any perinephric collection or abscess with concomitant drainage of the kidney (by
JJ ureteral stent) may be indicated.
B- Reconstructive surgery for:
- UPJ obstruction:
→ pyeloplasty.
- Ureteral stricture:
→ endoscopic (dilatation & stenting) or uretero-neocystostomy (ureteric re-implantation).
- VUR:
→ ureteric re-implantation with an anti-reflux technique.
- Contracted bladder:
→ augmentation cystoplasty by an isolated ileal segment; a procedure called ileo-cystoplasty.
- Subfertility:
→ assisted reproductive techniques may be resorted to.
C- Excisional or ablative surgery:
- Symptomatic non-functioning kidney: nephro-ureterectomy, both the kidney and the whole are
to be excised since they represent a shelter for the organism.
- Persistent epididymal sinus: epididymectomy. However, If both the epididymis and testis are
involved, both mandate excision as one mass.
24
SCHISTOSOMIASIS OF THE URINARY TRACT

Urinary schistosomiasis (bilharziasis) is a parasitic infestation caused by the trematode Schistosoma
haematobium.
The disease has two stages; active with actively laying eggs that can cross from veins to the lumen and
inactive when the adult worms die and there is a host reaction to the submucosal entrapped eggs.
Ova which pass with urine continue the life cycle of the parasite and leave microscopic abrasions in
the mucosal layer causing hematuria.
Tissue reaction includes granuloma formation (hypertrophic lesions), fibrosis (atrophic lesions), egg
calcification (dystrophic calcification) and metaplasia (precancerous lesions).
Bilharziasis of the urinary bladder
 The urinary bladder is the most common urinary organ to be involved and heaviest to be affected.
 Hypertrophic bladder lesions: early foreign body reaction leads to increase vascular supply
resulting in nodules, polyps, von Brunn’s nests and granulomata.
 Atrophic bladder lesions: Healing by fibrosis hinders the blood supply resulting in ischemic
changes that include:
- Mucosa: sandy patches, ground glass mucosa, calcific plaques and chronic bladder ulcer/s.
- Bladder neck contracture (bladder neck obstruction due to extensive fibrosis at the
submucosa and musculosa)
- Contracted bladder (marked reduction of bladder capacity due to heavy ova deposition that
extends to the perivesical fat) with subsequent VUR.
 Metaplastic lesions (precancerous):
- Squamous metaplasia (leukoplakia) may progress to squamous cell carcinoma.
- Glandular metaplasia (cystitis glandularis) may progress to adenocarcinoma.
Bilharziasis of the ureter
 The lower third is the most commonly affected site.
 Healing by fibrosis and calcification of submucosal ova leads to ureteric stricture and subsequent
hydroureter (dilated & tortuous) and hydronephrosis.
 Secondary infection and ureteric stone formation may take place.
 Bilateral affection may eventually produce chronic renal impairment.
Other sites of bilharziasis are rare including the prostate (nodules), seminal vesicles (calcification),
and perineal urethra (mass or water-cane fistula).
Clinical picture includes:

 Schistosomal dermatitis (swimmer's itch) is the first clinical sign due to cercarial skin penetration.
 Acute schistosomiasis (active stage) is concomitant with the onset of ova deposition producing
several manifestations mainly terminal hematuria, painful micturition and increased urinary
frequency. Other rare manifestations may be diarrhea, abdominal pain, cardiac disturbances and
mental weakness.
 Chronic schistosomiasis (inactive stage = stage of complications) can produce:
- Irritative LUTS from e.g. bladder ulcer, secondary infection, contracted bladder or even bladder
cancer.
- Obstructive LUTS from bladder neck contracture, polyps or cancer.
- Post-voiding pain and suprapubic dull aching pain signify constant bladder wall pathology
(chronic ulcer or cancer).
- Hematuria (terminal or total) from e.g. ureteric stones, bladder ulcer or cancer.
- Renal pain, swelling and/or uremic manifestations due to ureteric stricture, stone/s or VUR.
- Examination may reveal different signs e.g. renal swelling, suprapubic tenderness, bladder base
tenderness or mass, prostatic nodule/s and palpable seminal vesicles.
25
Investigations for schistosomiasis and its complications:

1. Urine analysis: Detection of ova with terminal spines is diagnostic of active infestation.
Microscopic hematuria is usually evident.
2. Serologic tests can aid in the diagnosis of infection especially in chronic inactive cases where egg
excretion is uncommon.
3. Radiological investigations: mainly for the diagnosis of complications.
a. Abdominal ultrasonography for the detection of:
- Echogenic bladder growth/s
- Hydronephrosis and hydroureter.
b. KUB film can show:
- Bilharzial calcifications of the bladder & ureter/s (linear)
and the seminal vesicles (honey-comb appearance).
- Secondary stones: radio-opaque ureteric or bladder stones.
c. Intravenous urography or CT with contrast:
- Hydronephrosis and hydroureters due to ureteral strictures,
ureteral stones, vesico-ureteral reflux or basal bladder
cancer.
- Filling defects on cystography in hypertrophic or
malignant lesions. KUB: Bladder calcification
- Contracted bladder.
4- Cystoscopy:
- Sandy patches and ground glass mucosa have
characteristic cystoscopic pictures.
- Bladder nodules, polyps, granulomata, ulcers,
leukoplakia and bladder cancer may be detected and
indicate trans-urethral resection (TUR) biopsy.
- Bladder neck obstruction may cause bladder wall
trabeculations, diverticula and secondary stones.
Treatment:
I- Medical: oral treatment in the active stage:
 Praziquantel is the current drug of choice in a single dose
of 40 mg/kg. It is active against all schistosomal species.
 Alternatively, Mirazid can be used in a dose of 600 mg
daily for six days. IVU: Bilateral dilated tortuous
II- Endoscopic: ureters due to bilharzial
ureteral strictures
 TUR and biopsy for any bladder growth, ulcers or
leukoplakia. Leukoplakia mandates follow up as it is a
precancerous condition.
 Bladder neck incision for bladder neck contracture
 Endoscopic ureteric dilation for ureteric stricture
 Endoscopic treatment of bladder or ureteric stones.
III- Surgical:
 Ureteric reimplantation or Boari bladder flap for complicated ureteric stricture.
 Radical cystectomy for bladder cancer with appropriate urinary diversion.
 Augmentation cystoplasty for contracted bladder.
26
OBSTRUCTIVE UROPATHY
- To know the causes and sequelae of hydronephrosis.
- To describe clinical presentation, diagnostic modalities and treatment for patients
with hydronephrosis.
- To describe the etiology, pathology, complications, diagnosis and treatment of
bladder outlet obstruction, benign prostatic hyperplasia and urethral stricture.
The urinary tract is divided on both anatomical and functional basis into:
 The upper urinary tract: includes both kidneys and ureters (paired structures)
 The lower urinary tract: includes the bladder and urethra (solitary structures)
Obstruction means impedance of flow. When it affects urine it is termed obstructive uropathy. Thus,
obstructive uropathy can affect:
 The upper urinary tract resulting in stasis and accumulation of urine in the kidney
(hydronephrosis), in the ureter (hydroureter) or in both (hydro-ureteronephrosis)
 The lower urinary tract and is called bladder outlet obstruction and primarily produces LUTS
and if neglected, it results in upper urinary tract obstruction. Actually, the bladder outlet is the
pathway of urine from the bladder neck till the exterior so it includes the whole urethra, the
external urethral meatus and the prepuce as well.
HYDRONEPHROSIS
It is dilatation of the pelvi-calyceal system of the kidney.
Causes:
I) Upper urinary tract obstruction (Organic obstruction):
A) Renal pelvis obstruction by e.g.
1. Renal pelvic stone/s.
2. Ureteropelvic junction (UPJ) obstruction:
 Congenital UPJ obstruction.
 Post-traumatic: either accidental trauma or
iatrogenic trauma (due to injury of UPJ during renal
surgery).
B) Ureteral obstruction:
1. Causes in the ureteral lumen: Stones are the most
common.
2. Causes in the ureteral wall (ureteral stricture):
 Inflammatory: e.g. bilharzial and tuberculous.
 Traumatic: e.g. iatrogenic after ureteroscopy or
due to trauma during pelvic or abdominal surgeries.
 Radiotherapy IVU: Right UPJ obstruction
 Neoplastic: primary ureteral tumor or tumor
infiltration from bladder, prostate, uterus or colon malignancies.
3. Causes outside the ureter (extrinsic obstruction): e.g. gravid uterus, uterine cervix fibroids,
enlarged lymph nodes and retroperitoneal fibrosis.
II) Vesico-ureteric reflux = VUR (Functional obstruction):

It is the abnormal backflow or regurgitation of urine from the bladder into the ureter and up to the
kidney. Its causes include:
 Primary reflux: due to congenital defective uretero-vesical junction that normally acts as a
valve. This is commonly present in children especially in the presence of complete ureteral
duplication. Recurrent urinary tract infection is the most common presentation of primary
VUR.
 Secondary reflux: due to increased intravesical pressure in cases of bladder outlet
obstruction, neuropathic bladder and contracted bladder. Secondary reflux usually produces
bilateral hydro-ureteronephrosis.
 Iatrogenic: after e.g. JJ ureteral stenting or ureteric reimplantation without anti-reflux
technique.
27
Clinical manifestations of hydronephrosis:

 Asymptomatic & accidentally discovered hydronephrosis: e.g. during abdominal
ultrasound examination for any reason.
 Renal pain: It is due to stretch of the renal capsule or increased pressure inside the
pelvicalyceal system. With VUR, renal pain may be experienced during voiding.
 Renal swelling: It is cystic in consistency with oblong shape, lobulated surface, rounded
borders and free mobility.
 Gastro-intestinal manifestations as pressure symptoms from huge hydronephrosis.
Complications of hydronephrosis:
 Decreased renal function: The presence of obstruction or reflux results in increased
pressure inside the pelvicalyceal system leading to ischemia and subsequent renal
parenchymal atrophy. In advanced bilateral cases, renal failure can occur.
 Secondary infection → Infected hydronephrosis.
 Secondary stone formation.
 Increased susceptibility to trauma.
Investigations:
I- Laboratory investigations:
 Urine analysis: pyuria and bacteriuria.
 Serum creatinine: is elevated in advanced bilateral cases or in a solitary kidney
II- Abdominal ultrasonography is the primary imaging modality that may show:
 Kidneys: pelvicalyceal dilatation, renomegaly and decreased cortical thickness.
 Dilated ureter in cases of ureteric obstruction or VUR.
 Bladder: post-voiding residual urine and diffuse wall thickening (secondary VUR).
 The cause of hydronephrosis e.g. renal pelvic stone or basal bladder tumor.
Sonographic appearance of hydronephrosis:

The renal pelvis and calyces are dilated
III- Imaging for detection of the cause and level of obstruction:
 KUB film to detect radio-opaque renal or ureteric stones.
 Non-contrast MSCT of the urinary tract to detect all types of urinary stones, the level and
the extrinsic causes of ureteric obstruction.
 CT urography or IVU to detect UPJ obstruction, ureteric stricture and ureteric
duplication. It also gives an idea about the function of the kidneys.
 MRU when the use of contrast material is contraindicated e.g. pregnancy, impaired renal
function and contrast hypersensitivity.
 Voiding cysto-urethrography to detect VUR.
 Retrograde ureterography (intra-operative through a ureteric catheter) and antegrade
nephrostography (through an already present PCN) to detect the level of obstruction.
28
 Radiological signs of hydronephrosis include:

 Concomitant dilatation of the renal pelvis and calyces
 The minor calyces lose their cupping & become flat, clubbed and lastly become ballooned.
 The site of obstruction shows localized narrowing and proximal dilatation of the uretero-renal
unit. The ureter below the site of obstruction is normal and may not be visualized.
 In chronic ureteric obstruction, the ureter becomes dilated, kinked & tortuous.
 The excreted dye is stagnant and lasts for a long time to be drained.
 Methods for functional evaluation of the hydronephrotic kidney/s:
 Cortical thickness (by U/S): As the renal cortex atrophies and gets thinner, its function gets
less with more loss of its job.
 Contrast secretion (on CT urography or IVU) signifies reversible function.
 Renal scintigraphy (radio-isotope scan): is the most accurate method to determine the
differential (split) renal function (GFR of each kidney). Diuretic renogram is also utilized to
confirm the presence of upper tract obstruction.
 Per-cutaneous nephrostomy (PCN): Daily urine output ≥ 200 ml of clear concentrated urine
means a reasonably functioning kidney.
 Lines of treatment of hydronephrosis:
1. Urgent drainage of urine: using a temporary maneuver to overcome critical situations of
urosepsis or uremia.
 Indications: a) Infected hydronephrosis
b) Decompensated renal function with bilateral hydronephrosis or
hydronephrotic solitary kidney.
 Methods: a) PCN or JJ stent in cases of upper tract obstruction.
b) Indwelling urethral catheter in cases of VUR.
2. Treatment of the cause: whenever the hydronephrotic kidney is still functioning and the
patient is not decompensated i.e. not in renal failure.
3. Renal replacement therapy:
 Indication: when the renal function is irreversibly lost and cannot be improved in a
decompensated patient.
 Methods: Dialysis or renal transplantation.
4. Nephrectomy: for unilateral hydronephrosis with irreversibly lost function in the presence of
a normal contralateral kidney.
 Treatment of ureteral stricture:
 Endoscopic treatment for passable stricture by dilatation or endoureterotomy followed
by ureteral stenting.
 Open surgery for non-passable stricture and after failure of endoscopy:
* Lower third ureter: ureteroneocystostomy (ureteral reimplantation) or
Boari’s bladder flap.
* Middle and upper third ureter: Resection reanastomosis for short stricture and
ileal loop replacement of the ureter for long stricture.
* Ureteropelvic junction obstruction: pyeloplasty.
 Treatment of VUR:
 Conservative measures as frequent bladder voiding and prophylactic low dose antibiotics if
without recurrent UTI. An episode of UTI should be treated with appropriate antibiotics.
 Cystoscopic injection of a biocompatible bulking agent to produce ureteral orifice
coaptation in cases with primary VUR.
 Treatment of the cause of secondary VUR e.g. bladder outlet obstruction.
 Ureteroneocystostomy with anti-reflux measure in complicated cases.
29
BLADDER OUTLET OBSTRUCTION

Causes of BOO:
 Prepuce: e.g. phimosis.
 External urethral meatal stenosis: in an orthotopic or a hypospadiac meatus.
 Urethra: e.g. urethral stricture, stones or valve.
 External urethral sphincter: spasm due to painful anal or perianal conditions.
 Prostate: e.g. BPH, prostatic abscess or cancer.
 Bladder neck obstruction (by fibrosis).
 Others: e.g. prolapsed ureterocele and uterine cervix fibroid or cancer.
Pathologic effects of BOO:
 The bladder exerts more effort and the detrusor muscle hypertrophies.
 The bladder mucosa is pushed in between the muscle bundles & outpouches to diverticula.
 Lately, the bladder begins to fail and its contractility decreases (bladder decompensation or
failure). Thus the following complications may take place:
- UTI and bladder stone formation due to urinary stasis
- Accumulation of post-voiding residual urine up to chronic urine retention.
- Overflow urinary incontinence occurs when the pressure inside the bladder exceeds the
increased infravesical resistance.
- 2 ry VUR with subsequent bilateral hydro-uretero-nephrosis and renal function impairment.
Symptoms:
 Obstructive LUTS include hesitancy, intermittency, terminal dribbling, sense of incomplete
bladder evacuation and straining during voiding.
 Acute urine retention is the maximal obstructive presentation.
 Overflow (paradoxical or false) incontinence.
 Symptoms of urologic complications e.g. burning micturition due to infection or stone formation
or symptoms of uremia.
 Symptoms of non-urologic complications due to chronic straining e.g. hernias and piles.
Signs:
 Signs of the cause e.g. phimosis, narrow external urethral meatus, palpable urethral stone,
indurated urethra at the site of stricture and enlarged prostate.
 Marked suprapubic tenderness in acute urine retention.
 In chronic retention, the bladder is palpable and shows dullness on suprapubic percussion. On
DRE, a cystic bladder mass denotes chronic urine retention or bladder diverticulum. Wet meatus is
observed with overflow incontinence.
 Palpable kidneys, signs of uremia, hernias or piles in neglected cases.
Investigations:
 Abdominal ultrasound for detection of e.g. residual urine, bladder wall thickening, bladder stones
or diverticula and hydro-ureteronephrosis.
 Investigations for detection of the cause e.g. KUB (urethral stone), retrograde urethrography
(urethral stricture), VCUG (posterior urethral valve) and TRUS (prostate pathology).
 Urine analysis (UTI) and serum creatinine (especially in bilateral hydronephrosis).
 Urodynamic studies: They objectively document the obstruction and quantify its degree.
Treatment:
 Treatment of the cause is the main line e.g. TURP for BPH.
 Treatment of complications e.g. secondary bladder stones.
 Drainage of the bladder by either urethral catheter or percutaneous cystostomy in:
- Acute retention of urine
- Chronic urine retention + impaired renal function, unresolving UTI or overflow incontinence
30
BENIGN PROSTATIC HYPERPLASIA (BPH)

The prostate gland is composed of glandular epithelial, smooth muscle, and fibrous components. BPH
is a histopathological term denoting hyperplasia of one or more of these components.
The actual etiology of BPH is uncertain. The prevalence of BPH increases with age. About 50% of
men aged 50 years and 80% over the age of 80 years have a histologic evidence of BPH.
BPH may be symptomatic or asymptomatic, may or may not cause clinical prostatic enlargement and
may or may not cause BOO.
Clinical picture:
A. Irritative and/or obstructive LUTS particularly:
 Increased urinary frequency at night (nocturia) occurs firstly & later it becomes diurnal as well.
 Urgency and urge incontinence.
 Hesitancy, intermittency, weak stream and straining during voiding.
B. Manifestations of complications including:
 Burning micturition occurs secondary to UTI, bladder stones or diverticulum.
 Hematuria: It is total profuse hematuria up to clot retention.
 Acute retention of urine.
 Overflow incontinence in cases of neglected chronic urinary retention.
 Uremic manifestations due to reflux and bilateral hydro-uretero-nephrosis.
 Hernia (mostly inguinal) and secondary piles due to chronic straining.
C. Digital rectal examination (DRE) for:
 Evaluation of the tone of the anal sphincter to exclude any associated neurologic disorders.
 Palpation of the prostate: Normally, the prostate has a flat smooth surface, rubbery consistency
and two lateral lobes with a median furrow in between.
In BPH, the surface becomes convex with exaggerated lateral sulci.
 Rough estimation of the degree of prostatic enlargement:
1st degree: the examining finger easily reaches the bladder base.
2nd degree: the examining finger reaches the bladder base with difficulty.
3rd degree: the examining finger cannot reach the bladder base.
 There is no correlation between the prostatic size and the presence or severity of symptoms.
Median lobe enlargement of the prostate can produce significant symptoms although mostly not
amenable for palpation.
D. Neurological examination is mandatory to exclude any associated neurologic defect that may be
primarily responsible for lower urinary tract dysfunction.
Differential diagnosis:
- Neuropathic bladder and other causes of BOO.
- Concomitant prostate or bladder cancer should be excluded.
Investigations:
A. Basic investigations:
 Urine analysis to detect UTI and hematuria.
 Serum creatinine to exclude renal insufficiency.
 Serum prostate-specific antigen to exclude prostate cancer.
 Abdominal U/S for detection of associated bladder pathology (cancer, stone or diverticulum),
PVR and hydro-uretero-nephrosis.
 KUB film for detection of radio-opaque stones and osteosclerotic prostate cancer metastases.
 Uroflowmetry may show low flow rate, interrupted curve or increased voiding time.
B. Trans-rectal ultrasound (TRUS) and TRUS guided biopsy if prostate cancer is suspected.
31
C. Other urodynamic studies (cystometry):

- They objectively (together with uroflowmetry) verify and document the obstruction.
- They help in differentiating BOO (due to BPH or else) from neuropathic bladder (the main
DD). Neuropathic bladder is suspected in e.g. cerebro--vascular stroke, spinal surgery & DM.
- Uroflowmetry in both BOO and neuropathic bladder show low urine flow rate. However,
voiding cystometry shows the high intra-vesical voiding pressure with BOO and the low intra-
vesical voiding pressure with poor bladder contractility in neuropathic bladder.
D. Urethrocystoscopy whenever bladder cancer is suspected e.g. in cases in which the cause of
hematuria or burning micturition is unexplained.
Treatment:
1. Watchful waiting: for patients with mild symptoms and no complications.
It includes patient reassurance, periodic monitoring and lifestyle modifications (as decreasing fluid
intake before bedtime, moderating caffeine and alcohol, avoidance of exposure to cold and
maintaining a time-voiding schedule).
2. Medical treatment: for patients with bothersome symptoms but uncomplicated.
It includes α1 adrenergic blockers, 5α-reductase inhibitors or combination of both.
α1 adrenergic blockers 5α-reductase inhibitors

Mechanism of action block α1 adrenergic receptors of inhibit conversion of testosterone to its
smooth muscles of the bladder active form; dihydrotestesterone
neck and prostate
Effect reduce the tone of prostatic shrinkage of prostatic epithelium leading
smooth muscles to reduction of the size of the prostate
Onset of clinical effect rapid (hours or days) delayed (weeks or months)
Side effects postural hypotension, headache loss of libido, erectile dysfunction and
and retrograde ejaculation low ejaculate volume
Examples doxazocin, tamsulosin and finastride, dutastride
silodosin
3. Surgical treatment: for patients with complications or failed medical treatment. Prior fixation of
an indwelling urethral catheter is required to manage recurrent acute retention till operation and in
cases of gross pyuria, overflow incontinence or renal impairent due to reflux.
 Transurethral resection of the prostate (TURP): it is the standard treatment. It carries the
advantages of being less invasive while resecting and performing hemostasis under vision. In
cases of prolonged resection time for a huge prostate, there is a risk of TUR syndrome
(hypervolemia and dilutional hyponatremia).
 Open transvesical prostatectomy (TVP): it has few limited indications e.g. very huge prostate,
concomitant large bladder stone or large bladder diverticulum. It entails enucleation of the
hyperplastic part of the prostate leaving the peripheral zone within the prostatic capsule. Neither
TURP nor open prostatectomy eliminates the possibility of future prostate cancer.
 Other treatment options for the critically ill patient, e.g. laser prostatectomy for patients who
cannot stop anticoagulant therapy.
32
URETHRAL STRICTURE
It is abnormal narrowing or loss of distensibility of the urethra that significantly impedes urine flow.
Causes:
 Post-inflammatory: e.g. following gonococcal urethritis.
 Post-traumatic: e.g. falling astride can result in bulbar urethral stricture.
 Iatrogenic: after urethral catheterization, instrumentation or surgery.
Diagnosis:
 History: -urethral discharge, trauma or instrumentation. -Obstructive LUTS.
 Examination sometimes detects induration at the site of stricture.
 Abdominal U/S may detect significant post-voiding residue.
 Uroflowmetry: This is a non-invasive test to assess the degree of obstruction and improvement
after treatment. It illustrates abnormal voiding pattern and reveals low flow rate.
 Retrograde urethrography is the main diagnostic method to delineate the stricture.
 Urethroscopy: is used for both diagnosis and endoscopic treatment.
Differential diagnosis
-Other causes of bladder outlet obstruction as BPH.
-Neuropathic bladder which may require neurologic and urodynamic assessment.
Treatment depends upon many variables and it includes:-
1. Urgent percutaneous cystostomy insertion for temporary urinary diversion in cases
complicated with urine retention, renal impairment due to upper tract dilatation, acute
epididymo-orchitis, periurethral suppuration or urethral fistula.
2. Visual internal urethrotomy (VIU) for passable short uncomplicated anterior urethral
stricture by endoscopic incision of the stricture.
3. Urethroplasty for impassable or complicated strictures and failed VIU. It implies excision of
the strictured segment and bridging the defect by direct reanastomosis, local skin flap or buccal
mucosal graft.
Retrograde urethrography showing

stricture at the bulbar urethra
33
UROLITHIASIS
- To describe the etiology, clinical manifestations, complications, diagnostic
modalities, and treatment plans for renal, ureteric and bladder stones.
- To be able to detect urinary tract stones on ultrasonography, KUB X-ray and CT.
UROLITHIASIS
UROLITHIASIS
A urinary calculus is an aggregate of crystalloid material/s excreted in urine. Internationally,
urolithiasis is the third common urological disease after urinary tract infections and prostatic diseases.
Etiology:
 Urinary stasis due to anatomical or functional obstruction.
 Urinary tract infections can cause phosphate stones (in alkaline urine).
 Metabolic causes: hypercalciuria, hyperoxaluria, hyperuricosuria, cystinuria and hypocitraturia.
 Low urinary output (low fluid intake & hot weather) and chronic diarrhea.
 Diet with e.g. high animal protein, excessive salt and low calcium.
Any formed stone/s may subsequently:
 Stay at the original site of formation (dormant) or its size may grow.
 Migrate along the urinary tract to be expelled.
 Impact at an anatomically narrow site.
Pathologic effects of urinary stones:

 Obstructive uropathy (upper or lower, acute or chronic).
 Urinary tract infection (as a foreign body or a result of stasis).
 Urothelial irritation (acute: hematuria, chronic: squamous metaplasia).
 Recurrence of stone after spontaneous passage or treatment.
Methods of detection of stones:

1. Clinical: for palpable urethral stones or rarely for giant bladder stones by DRE.
2. KUB shows most urinary stones (radio-opaque). Few stones cannot be detected (radiolucent).
3. Ultrasonography reveals both radio-opaque and radiolucent stones as hyper-echoic objects with
acoustic shadow.
4. Non-contrast multislice CT is the best modality for detection of urinary stones of any type or
size in a more or less three-dimensional fashion.
5. MRI may be resorted to during pregnancy despite its low sensitivity.
6. Endoscopic detection during intervention and treatment.
Investigations for detection of the cause of stone formation:
 To detect anatomical or functional obstruction e.g.:
- IVU or CT urography to detect UPJ obstruction and ureteral stricture.
- Sonography (post-voiding residue) and urodynamics in cases of BOO or neuropathic bladder.
 Urine analysis and culture to detect UTI.
 Metabolic evaluation:
- Urine analysis for urine pH and type of the excreted crystals.
- 24 hour urine sample for evaluation of daily urine output and concentrations of stone forming
substances.
- Serum level of calcium, phosphorus, uric acid and parathormone.
- Stone analysis for any retrieved stone or stone fragments.
34
UROLITHIASIS
Modalities of treatment of urolithiasis:

A- Expectant treatment: for spontaneous expulsion of renal or ureteric stone.
 Indications: single small (5 mm or less) unilateral stone with normal contralateral kidney in a
compliant patient with normal renal function.
 Contraindications: solitary kidney, distal obstruction and active UTI.
B- Shock wave lithotripsy (SWL) entails non-invasive disintegration of renal or ureteric stones
without anesthesia except in young children. The stone fragments are left for spontaneous
expulsion. The patient is maintained on medical treatment and follow-up to monitor stone clearance
and detect complications. Further SWL sessions may be required.
 Contraindications:
- Active UTI and infected stones that may lead to septicemia.
- Obstruction distal to the stone/s.
- Bleeding disorders unless corrected.
- Pregnancy.
- Aortic or renal artery aneurysm which may rupture.
 Complications of SWL:
- Persistent renal colic concomitant with passage of gravels.
- Ureteral obstruction by stone fragments (steinstrasse).
- Acute pyelonephritis.
- Hematuria.
- Intrarenal and/or perinephric hematoma.
C- Endoscopic treatment:
Stone disintegration (lithotripsy) and/or extraction using an appropriate endoscope under anesthesia:
 Retrograde endoscopy through the external urethral meatus gives access to the whole urinary tract.
 Percutaneous access can be used to approach renal or bladder stones.
D- Open or laparoscopic surgical treatment is limited to special situations e.g.:
 Stones not suitable for SWL or endoscopic treatment as huge stones.
 Associated pathology requiring surgery as UPJ obstruction or huge BPH with secondary stone/s.
 Failure of endoscopic access to the stone.
 Conversion to surgery if URS is complicated by e.g. ureteric perforation
E- Prevention of stone recurrence:
 Periodic follow up by abdominal U/S for early detection of new recurring stone/s.
 Increase oral fluid intake to prevent urine super-saturation with crystallizing material.
 Diet modifications as: ↓ chocolate, mangoes, strawberry, tomatoes & spices etc. in oxalate stones.
↓ protein intake for uric acid and urate stones.
↑ citrate intake.
 Prompt treatment of urinary tract infection.
 Changing the pH of urine by alkalinization of urine for stones formed in acidic urine (uric acid,
oxalate and cystine stones) and acidification of urine for calcium phosphate and infection stones.
 Surgical treatment of underlying cause e.g.
- Any distal obstruction e.g. UPJ obstruction, ureteric stricture or BPH.
- Primary hyperparathyroidism by parathyroidectomy.
35
UROLITHIASIS
RENAL STONES
Clinical manifestations:
 Accidentally discovered on abdominal US or KUB for any medical indication.
 Flank dull aching renal pain or renal colic is the most common presentation.
 Urine turbidity due to hematuria, pyuria or crystalluria.
 Gastro-intestinal manifestations mostly nausea, vomiting and distension.
 Manifestations of complications:
- Fever due to acute pyelonephritis or infected hydronephrosis.
- Obstructive anuria and manifestations of acute renal failure.
- Renal swelling with advanced hydronephrosis.
- Manifestations of uremia in cases of solitary kidney or bilateral renal stones.
Investigations:
 Serum creatinine especially prior the use of any contrast material.
 Abdominal ultrasonography is diagnostic for the stones and evaluates the kidney site, size, degree
of hydronephrosis, cortical thickness & echogenicity.
 KUB film reveals about 90 % of renal stones.
 Non-contrast multislice CT for detection of stone/s and evaluation of the anatomy of the urinary
tract without contrast.
 IVU or CT urography provides functional assessment of the kidneys and offers detailed anatomy of
the pelvicalyceal systems and ureters.
 Radio-isotope scan to evaluate the function of any non-excreting kidney.
Sonographic appearance KUB: KUB: Bilateral staghorn

of renal pelvis stone Left renal pelvis renal stones
stone
Treatment:
A- Expectant treatment:
- High oral fluid intake, NSAIDs and anti-spasmodics.
- Chemolysis of uric acid stones by urine alkalinization.
B- SWL:
- Indications: single or multiple stone/s with stone burden ≤ 2 cm in a compliant patient with
normal renal function in the absence of distal obstruction.
- Bilateral renal stones and stone in solitary kidney necessitate ureteric stenting before SWL to
avoid obstructive anuria.
36
UROLITHIASIS
C- Percutaneous nephrolithotripsy (PNL):

- It is indicated for stones larger than 2 cm or after failure of SWL.
- Percutaneous access to the stone is obtained (in prone position) under fluoroscopic or ultrasonic
guidance.
- The created tract is dilated to accommodate the nephroscope.
- Subsequent disintegration and extraction of stone/s & stone fragments is carried out.
D- Retrograde endoscopic stone disintegration: using a flexible or rigid ureteroscope to access and
manipulate a renal stone in cases with bleeding tendency or stones in an ectopic pelvic kidney.
E- Open or laparoscopic surgery:
- Renal stone/s can be extracted through a renal pelvic incision (pyelolithotomy) or a parenchymal
incision (nephrolithotomy). Pyelo-nephrolithotomy can be used for multiple or branched stone/s.
- With irreversible renal damage, polar (partial) or simple (total) nephrectomy may be carried out.
URETERAL STONES
Origin of ureteral stones:
 Migrating stones from the kidney represent > 90 % of ureteric stones.
 Secondary ureteral stones are formed in the ureter above a ureteric stricture.
Clinical presentation:
 Renal pain: is the most common symptom and it may be:
- colicky pain due to stone migration with subsequent ureteral hyper-peristalsis.
- dull aching pain due to renal capsule distention by the back pressure.
- throbbing pain due to acute pyelonephritis or infected hydronephrosis.
- referred pain to e.g. the ipsilateral testis & hemi-scrotum in males.
- associated with GIT symptoms as nausea, vomiting and distension.
 Hematuria: Microscopic or gross hematuria.
 Irritative LUTS as increased frequency, urgency or burning micturition with descending infection or
intra-mural ureteric stones
 Manifestations of complications:
- Fever with acute pyelonephritis or infected hydronephrosis.
- Obstructive (calcular) anuria with solitary kidney or in bilateral stones.
- Chronic renal function loss.
- Renal mass (late and rare) that may be hydronephrosis or pyonephrosis.
Renal colic:
It is a common medical emergency caused by obstruction and subsequent hyper-peristalsis of a calyx,
renal pelvis or ureter due to stones, passage of crystals or blood clots. Association of colic with
burning micturition, increased frequency, turbid urine, hematuria, oliguria or even anuria points to a
urologic problem. Renal colic should be differentiated from:
 Appendicular colic: it is associated with fever and psoas spasm. The pain begins at the umbilicus
then the right iliac fossa with tenderness, rebound tenderness and localized rigidity at Mcburney
point. CBC reveals leukocytosis.
 Biliary colic: The pain and tenderness are at the right hypochondrium and pain radiates to right
shoulder. It may be associated with fatty dyspepsia or jaundice. Abdominal U/S may reveal gall
bladder stones.
 Intestinal colic: at any site all over the abdomen. It may be associated with other GIT symptoms e.g.
diarrhea, tenesmus, offensive and bloody stools.
 Acute gynecologic or obstetric condition: (e.g. complicated ovarian cyst and ectopic pregnancy) in
females with e.g. menstrual disturbances. Abdominal U/S usually helps in diagnosis with normal
appearance of the urinary tract.
37
UROLITHIASIS
Renal colic is treated by parentral NSAIDs, antispasmodics and fluids. Ureteric stenting is required if
colic is persistent or associated with anuria or oliguria.
Investigations:
 Ultrasonography: It can show :
- upper ureteric stone or
intramural lower ureteric stone.
- the degree of hydronephrosis,
cortical thickness and associated
renal stones.
- the condition of the other
kidney.
 KUB film: It can detect 90% of the
stones which are radio-opaque.
 Non-contrast multislice CT: It is
very sensitive for detection of
ureteral stones of any type or size. KUB: Left upper
KUB: Left lower
It is the preferred modality of
ureteric stone ureteric stone
imaging for diagnosis of ureteric
stones even during renal colic or with impaired renal function where contrast studies are
contraindicated.
 IVU or CT urography offers the detailed anatomy of the ureter (e.g. ureteric stricture and
duplication) and provides functional assessment of the kidneys.
Treatment:
A- Expectant treatment:
In addition to analgesics and good hydration, alpha adrenergic blockers have the potential to
enhance expulsion of small (< 5 mm) lower ureteric stones (stone expulsive therapy).
B- SWL:
 The suitable stone size ranges from 5 to 15 mm.
 The preferred site of stone is the upper third of the ureter.
 SWL is not a treatment option for:
- Radiolucent ureteric stones (cannot be localized).
- middle ureteric stones that overlie bones (difficult in localization).
- lower ureteric stones during female child bearing period (ovarian injury).
C- Ureteroscopy (URS):
 It is a retrograde endoscopic procedure where a semi-rigid or flexible ureteroscope is
introduced through the urethra, ureteric orifice up to the ureteric stone. Then the stone is
extracted if small or disintegrated and extracted if large.
 It is indicated for ureteric stones from 5 to 15 mm and after failure of expectant treatment or
SWL.
 The preferred site of stone is the lower and middle thirds of the ureter.
 URS indicated (can be carried out) in cases with bilateral ureteric stones, radiolucent stones,
ureteral stricture or even impaired renal function.
 Ureteric stones can be intentionally pushed or may migrate accidentally to the kidney during
URS. In this case, a ureteric stent should be inserted prior to instant PNL or delayed SWL.
D- Ureterolithotomy (by open surgery or laparoscopy) is resorted to in:
 Large or multiple stones (>1.5 cm).
 Presence of ureteral stricture that cannot be manipulated by URS.
 Failure of stone access or complicated URS e.g. by perforation of the ureter.
38
UROLITHIASIS
BLADDER STONES
Origin of vesical stones:
 Migrating renal or ureteral stones.
 Primary stones: formed inside a normal bladder, mainly in children.
 Secondary stones: formed due to predisposing factors as: BOO (e.g. BPH or urethral stricture),
neuropathic or augmented bladder, retentive bladder diverticulum and vesical foreign body (e.g.
neglected JJ stent or non absorbable sutures).
Clinical presentations:
 Irritative LUTS in the form of increased frequency (usually diurnal & related to posture and
exertion), urgency or urge incontinence.
 Burning during and / or after micturition.
 Pain at the tip of the penis: children usually pinch and squeeze the glans.
 Turbid urine by blood (hematuria; terminal or total), pus (pyuria) or crystals.
Complications:
 Total painful hematuria.
 Acute retention of urine, if the stone impacts at the bladder neck or the urethra.
 Squamous metaplasia (precancerous) in long standing stones.
Investigations:
1- Ultrasonography is the best diagnostic method for:
- detection of the stone/s whether radio-opaque or radio-lucent.
- estimation of post-voiding residual urine if present.
- diagnosis of other pathologies as bladder diverticulum, and
renal stones.
2- KUB film: can diagnose only radio-opaque stones.
3- Pelvi-abdominal CT in cases with upper urinary tract stones or
dilatation. Sonographic appearance
Treatment (no medical treatment for bladder stone/s): of bladder stone
1- Endoscopic treatment:
* Litholapaxy: only in adults for stones ≤ 2.5 cm using
the visual lithotrite for mechanical stone crushing.
* Transurethral cystolithotripsy: can be used in
children and for stones even more than 2.5 cm using
either ultrasonic, pneumatic or laser lithotripsy.
* Percutaneous cystolithotripsy: through a suprapubic
port (bypassing the urethra) for any stone size.
2- Open surgery (cystolithotomy) is indicated in:
- Giant bladder stone/s.
- Stone/s in a bladder diverticulum.
- Concomitant huge BPH indicating TVP.
3- Treatment of the primary cause in secondary bladder
KUB: Bladder stone
stones to prevent recurrence.
39
UROLITHIASIS
URETHRAL STONES
Origin of urethral stones:
Usually the stone is migrating from above i.e. from either the kidney or the ureter.
 Marked obstructive LUTS up to acute urinary retention.
 The stone is usually palpable on clinical examination
(including DRE for posterior urethral stones)
 The stone may be seen peeping from the external urethral
meatus
 Sometimes the stone is palpable by the patient.
Investigations:
 KUB shows radio-opaque stones.
 Abdominal U/S may detect the urethral stone in the posterior
urethra and other urinary tract stones. It also verifies acute
urinary retention.
 Non-contrast CT for non-palpable radiolucent urethral
stones.
Treatment: (no medical treatment or open surgery)

a) Stone at the fossa navicularis:
It may need ventral meatotomy before extraction. KUB: Posterior urethral stone
b) Urethral stones at other sites of the urehra: pointed to by the arrow
Urethroscopy is carried out for stone:
- visualization
- in-situ disintegration if impacted
- push–back to the bladder where stone disintegration can
be carried out.
c) If the patient is in acute retention and not ready for operation:
A temporary percutaneous cystostomy is inserted. Insertion of a urethral catheter is
contraindicated unless the stone is removed
40
URINARY TRACT TRAUMA
- To describe the etiology, mechanisms, clinical presentation and complications of
trauma to the kidneys, bladder and urethra.
- To be able to spot the patients with suspicion of urinary tract trauma and to be
oriented with their appropriate management.

General principles:
 On dealing with a traumatized patient, priorities should be directed to airway (A), bleeding (B),
circulation (C) then deficit of bones and nervous system (D) which are life threatening.
 The kidneys, ureters, bladder and posterior urethra are deeply seated inside the body and well
protected. Thus, they require either a major blunt trauma or a penetrating trauma to be injured. So,
multiple organ injury is mostly the rule in association with urinary tract trauma.
 Disruption of any part of the urinary tract leads to urine extravasation which is peculiar to urinary
tract trauma. Urine either produces collection (urinoma), leakage (urinary fistula), chemical tissue
reaction or infection.
 New onset of hematuria after any trauma denotes urinary tract involvement. However, absence of
hematuria does not exclude urinary tract affection.
RENAL TRAUMA
Predisposing factors:
1. Malposition e.g. ectopic pelvic kidney which is liable to iatrogenic trauma during pelvic surgery or
accidental injury with pelvic trauma.
2. Pre-existing renal pathology e.g. hydronephrosis, renal stones or tumors.
Mechanisms and etiology:

 Direct trauma: e.g. penetrating traumas (stab-wounds and gun shots) and iatrogenic injuries.
 Indirect trauma: Blunt trauma with fracture of the last two ribs can injure the underlying kidney.
 Acceleration-deceleration movement may lead to avulsion of the kidney with a major vascular
trauma.
Grading: (by abdominal CT):

A- Minor traumas include:
 subcapsular hematoma and
 any cortical laceration not reaching the pelvi-calyceal system.
B- Major renal traumas include:
 deep cortico-medullary laceration trauma extending to the pelvi-calyceal system (with subsequent
urine extravasation) and
 renal pedicle vascular injuries.
 History of trauma.
 Hematuria: It is a major symptom or sign. It is not related to the type or grade of renal trauma e.g.
renal vascular avulsion may lack hematuria, while minor trauma may present with profuse total
hematuria.
 Local manifestations of trauma as loin pain & tenderness (especially with rib fractures) and skin
wound (in penetrating injuries).
 General manifestations e.g. pallor, tachycardia or shock.
41
Investigations in case of renal trauma aim to:

- detect renal trauma
- assess the grade and the effect of trauma
- evaluate the contralateral kidney
- assess other abdominal organs with concomitant trauma.
These investigations include:
 Abdominal Ultrasonography is a preliminary tool to detect perinephric or intraperitoneal urine
collection or hematomas.
 Pre and post contrast abdominal CT is the cornerstone for detection, grading of the renal trauma
and evaluation of other abdominal organs in a hemodynamically stable patient. It is indicated in:
- Presence of perinephric collection or hematoma detected by U/S.
- Adult patients with macroscopic hematuria.
- Pediatric patients even with microscopic hematuria.
 Intravenous urography: if CT scan is not available. It also can be carried out inside the operative
theatre for rapidly admitted hemodynamically unstable patients requiring immediate exploration.
 Laboratory investigations: urine analysis, blood grouping, hematocrite value, and serum
creatinine.
Complications of renal trauma:
 Hematuria
 Retroperitoneal hematoma.
 Urine extravasation (urinoma).
 Perinephric suppuration due infection of perinephric
hematoma or urinoma.
 Loss of kidney function due to e.g. renal artery
thrombosis, renal pedicle avulsion or major renal
trauma necessitating nephrectomy. Abdominal CT with contrast:
 Renal hypertension may develop lately due to Left renal trauma
ischemia of the kidney.
Management:
I- Conservative treatment: is the main line of treatment in most of the cases by:
 Hospitalization and strict follow up of vital signs and degree of hematuria
 Supportive treatment including bed rest, intravenous fluid infusion & blood transfusion and
prophylactic antibiotics.
 Serial abdominal U/S and hematocrite value to detect any ongoing bleeding.
II- Surgical exploration: for (drainage of urinoma or hematoma, hemostasis & repair) is indicated in:
 Hemodynamic instability even without prior CT scan.
 Failure of conservative treatment e.g. deterioration of vital signs, declining hematocrite value,
expanding hematoma and deepening hematuria.
 During exploration for other trauma in poly-traumatized patient.
III- Angio-embolization can be done in certain cases of iatrogenic vascular injury.
IV- Nephrectomy is indicated as a life-saving measure or if trauma is beyond repair.
42
BLADDER TRAUMA
Predisposing factors:
 Normal bladder: in children (abdominal) and in adults (when it is full).
 Chronic urinary retention due to bladder outlet obstruction or neuropathic bladder.
 Pathologic bladder as in bladder cancer.
Mechanism and etiology:
1. Accidental trauma:
 Blunt trauma e.g. animal kicks and motor car accidents.
 Penetrating trauma e.g. stab wounds and fire-arm injuries.
 With pelvic fracture, pubic bone fragments can injure the bladder.
2. Iatrogenic:
 Urologic e.g. during litholapaxy and TUR of a bladder tumor.
 Non urologic e.g. gynecological, obstetric and general pelvic surgery.
Types of bladder trauma:
1. Bladder contusion and laceration: without severing the whole thickness of bladder wall (no urine
extravasation). At most, there is some hematuria.
2. Bladder rupture (perforation): there is a wound that involves all vesical wall thickness with
urine extravasation which may be:
i- Extraperitoneal: Infected urine may produce pelvic abscess.
ii- Intraperitoneal: more dangerous. It can cause chemical peritonitis (by sterile urine), septic
peritonitis (by infected urine) and elevated blood urea & serum creatinine (by reabsorption).
 History of trauma whether accidental or surgical.
 The patient is usually unable to void.
 Hematuria is nearly a consistent sign even microscopic.
 Trauma manifestations as local pain, ecchymosis, hematoma, external wounds & suprapubic bulge.
 Abdominal rigidity due to peritonitis in cases of intraperitoneal bladder rupture.
 Urine leakage or collection after pelvic surgery or vaginal delivery.
Investigations:
 Abdominal ultrasound can detect intraperitoneal as well as perivesical fluid collections.
 KUB film evaluates bones e.g. pelvic fracture.
 Retrograde (ascending) cystography (after exclusion of concomitant urethral injury): It is
mandatory to verify or rule out bladder rupture (contrast extravasation).
 Urine analysis shows microscopic hematuria. Blood urea and serum creatinine may be elevated in
cases of intraperitoneal bladder rupture.
Treatment:
I- Conservative treatment: by fixation of a Foley’s catheter and
follow up. It is indicated in cases of bladder contusion or
laceration and some cases of extra-peritoneal bladder rupture
(when extravasation and hematuria are minimal).
II- Surgical treatment is indicated in:
 Intra-peritoneal bladder rupture.
 Penetrating bladder injury.
 Failure of conservative treatment e.g. persistent deep
hematuria. Retrograde cystogram:
 Iatrogenic injuries if detected intraoperatively. Intraperitoneal bladder rupture
 Concomitant injuries indicating abdominal exploration. (dye extravastion)
43
URETHRAL TRAUMA
Mechanism and etiology:
1-Accidental trauma:
a. Blunt trauma of:
i. Bulbar urethra due to perineal trauma: straddle injury (falling astride).
ii. Posterior urethra due to pelvic fracture. Shearing mechanism results in pelvic fracture
distraction injury (urethral avulsion).
b. Penetrating trauma: e.g. gun shots or knives. It can involve any part of the urethra.
2-Iatrogenic injuries: e.g. penetrating injuries during urethral instrumentation (false passage).
The main sequel of urethral trauma is urethral stricture. There are some basic differences between
trauma of the posterior and anterior urethra shown in the following table:
Anterior urethral trauma Posterior urethral trauma
minor trauma without bone
Nature of trauma major trauma causing pelvic fracture
fracture
Concomitant bladder injury absent common
can be affected with damage of the
Urinary continence not affected.
external sphincter.
Urine extravasation and in the perineum, then to scrotum, inside the pelvis and the pelvic
blood collection around the penis and up to hematoma displaces the prostate
anterior abdominal wall. upwards.
Clinical picture:
 History of trauma in the form of falling astride, urethral instrumentation or pelvic fracture with pain
at the site of injury.
 Bleeding per urethra is a sure sign of urethral trauma.
 Acute urine retention with urethral avulsion.
 Swelling at the perineum, scrotum, around the penis or suprapubic region.
 On DRE with posterior urethral injury, the prostate may not be felt being pushed upwards by the
accumulating pelvic hematoma (high riding prostate).
Investigations:
 KUB film reveals any pelvic fracture.
 Retrograde (ascending) urethrography is essential
for diagnosis. The presence of dye extravasation means
urethral rupture which can be partial (the dye can reach
the bladder) or complete (the dye does not reach the
bladder).
Treatment:
 Immediate management at time of trauma:
- Insertion of percutaneous cystostomy tube for
urine diversion and relief of acute retention.
- Alternatively, insertion of a Foley's catheter under
anesthesia and urethroscopic guidance can be tried Retrograde urethrogram:
in cases of partial urethral rupture to prevent urine urethral injury
extravastion and permit spontaneous urethral (notice dye extravasation)
healing. In cases of complete rupture the passage of Foley's catheter achieves primary
urethral realignment.
 Delayed management (after three months) for any residual urethral stricture:
- Visual internal urethrotomy only in anterior urethral stricture.
- Open surgery (urethroplasty).
44
GENITO-URINARY
CONGENITAL ANOMALIES
- To list the congenital anomalies of the kidneys, ureters, urinary bladder, urethra
and the testes.
- To address the clinical presentation and diagnosis of different renal anomalies.
- To be able to diagnose hypospadias, epispadias and bladder exstrophy clinically,
and to be oriented with their appropriate management.
- To know the types of testicular maldescent and how to diagnose and treat them.
GENITO-URINARY CONGENITAL ANOMALIES
UPPER URINARY TRACT ANOMALIES

I- Renal agenesis:
 Unilateral renal agenesis: The solitary kidney usually acquires compensatory hypertrophy and so
long it is healthy, no special precautions are taken.
 Bilateral renal agenesis: is incompatible with life.
II- Hypoplastic kidney:
 It is usually asymptomatic and accidentally discovered at any age. Symptoms arise from
complications e.g. infection, stone formation & renal hypertension.
 On abdominal ultrasonography the kidney is normal in all aspects except the small size. The other
kidney usually shows compensatory hypertrophy.
 Abdominal CT confirms the anatomy of the hypoplastic kidney, while radio-isotope renal scan
assesses its function.
 Differential diagnosis (small sized kidney):
1. Chronic pyelonephritis. 2. Chronic glomerulonephritis.
3. Renal tuberculosis. 4. Renal artery stenosis
 Treatment: Nephrectomy may be indicated in cases of renal hypertension or recurrent UTI.
III- Anomalies of renal ascent and fusion:
 Normally, the kidney develops in the fetal pelvis then it ascends
cranially with medial rotation along its longitudinal axis. Ultimately,
each kidney lies just below the diaphragm with its upper pole more
medial than its lower pole.
 Any aberration from this process results in abnormalities in kidney
site (ectopy), orientation (malrotation) and/or separation (fusion).
 Such anomalous kidneys may be asymptomatic and accidentally
discovered, though they are more liable to obstruction, infection,
stone formation and surgical trauma. Moreover, surgery carries the
risk of trauma to the anomalous renal vasculature.
 Examples of these anomalies include: IVU: Ectopic pelvic right
A. Ectopic kidney: kidney
- It may be pelvic, iliac or low lumbar and always with malrotation.
- It may be palpable in the suprapubic region or iliac fossa.
- It can be detected by abdominal U/S, CT or IVU.
B. Horse-shoe kidney
- It is the most common of all renal fusion anomalies.
- There are two distinct malrotated renal moieties on either side of
the middle line connected at the lower poles by a
parenchymatous or fibrous isthmus. The inferior mesenteric
artery obstructs ascent of the isthmus.
- On IVU or CT urography characteristic signs of horseshoe
kidney include:
>Bilateral low sited malrotated kidneys.
>The lower poles are more medial than the upper poles; thus the IVU: Horse-shoe kidney
two longitudinal renal axes if extended meet downwards toward the pelvis.
>Calyces have an end-on appearance or even look medially as an evidence of malrotation.
>The renal pelves are anterior and the upper ureters cross in front of the isthmus producing
flower-en-vas appearance.
C. Crossed renal ectopia: The kidney crosses the midline towards the side opposite its ureteric
orifice. This anomaly may be unilateral or bilateral, with or without fusion of both kidneys.
45
IV. Congenital cystic kidney diseases include:

A. Autosomal Dominant (adult) Polycystic Kidney Disease (ADPKD):
It runs in families and usually presents after the age of 40 years being responsible for 10% of
end stage renal failure cases. It may be associated with cystic disease in other organs e.g. lung,
liver and epididymis.
Clinical picture (uncomplicated cases):
 Dull aching renal pain.
 Bilateral renal swellings which are firm (never cystic) with nodular surfaces.
 Positive family history and screening of other family members is mandatory.
Investigations:
 Abdominal ultrasonography is the superior tool for diagnosis which reveals bilateral
innumerable renal cysts of variable sizes with subsequent enlargement of both kidneys.
 Serum creatinine.
 Abdominal CT scan or MRI may be indicated in complicated cases.
Sequelae and complications:
 Renal hypertension that predisposes to heart failure.
 Progressive renal insufficiency.
 Infection of the cysts.
 Hematuria: It may be profuse and fatal.
 An associated cerebral aneurysm may lead to fatal intra-cranial hemorrhage.
Management:
 Conservative management entails regular follow up, appropriate dietary regimen, life
style modification, control of hypertension and treatment of UTI.
 Surgical cysts deroofing may be indicated with infection or persistent pain.
 End stage renal failure is treated by regular dialysis or renal transplantation.
B. Autosomal Recessive (Infantile) Polycystic Kidney Disease (ARPKD):
Presentation and diagnosis:
 Obstructed labor due to bilateral huge renomegaly.
 Failure to thrive due to renal and/or hepatic insufficiency.
 Bilateral flank masses with distended abdomen.
 Abdominal U/S reveals markedly enlarged echogenic kidneys since cysts are microscopic.
Complications: include renal, hepatic and respiratory failure. The infant commonly dies in the
first few months.
C. Multicystic dysplastic kidney: It is a non-hereditary unilateral cystic renal dysplasia due to
early fetal ureteral obstruction. U/S reveals multiple numerable cysts with no cortical tissue.
VII- Anomalies of the pelvis and ureter:
1. Uretero-pelvic junction (UPJ) obstruction.
2. Retro-caval (circumcaval) ureter: The right ureter passes behind
(around) the inferior vena cava.
3. Bifid renal pelvis
4. Double ureter (complete or incomplete duplication).
5. Ectopic ureteral insertion into the:
- vas deferens that may lead to epididymo-orchitis.
- vagina that may lead to urinary incontinence.
- urethra that may lead to urinary incontinence in females only.
6. Ureterocele: cystic dilatation of the distal ureter as it drains and
bulges into the bladder. IVU: Bilateral incompletely
7. Primary vesicoureteral reflux. duplicated ureters
46
LOWER URINARY TRACT ANOMALIES

I- HYPOSPADIAS:
It is a congenital anomaly of the male external genitalia in which:
 The external urethral meatus is ventral and proximal to its normal site anywhere from the glans to
the perineum. Accordingly hypospadias may be glanular, coronal, sub-coronal, distal penile, mid-
penile, proximal penile, penoscrotal, scrotal or perineal.
 The urethral plate is the roof of the deficient unfolded urethra. This mucosal patch extends from
the ventral external meatus till the tip of the glans.
 The prepuce (foreskin) is present as a dorsal hood and is deficient ventrally except in the rare
cases of megameatus intact prepuce.
 Ventral curvature (chordee) of the penile shaft is common especially with more proximal meatus.
 Associated genital anomalies include:
- Pin hole meatus especially when the meatus is more distal.
- Testicular maldescent; unilateral or bilateral.
- Bifid scrotum in scrotal or perineal hypospadias.
- Genital ambiguity (pseudohermaphrodite) occurs in some cases of perineal hypospadias with
bilateral undescended testes, bifid scrotum and micropenis. Karyotyping (chromosomal
analysis) is mandatory to settle the genetic gender.
- Congenital inguinal hernia
 Extra-genital anomalies include e.g. cardiac defects, cleft palate and polydactyly.
Different types of Distal penile Scrotal

hypospadias hypospadias hypospadias
Management:
 The child should not be circumcised since the prepuce may be used in repair.
 The ideal age of repair is 6–18 months.
 Micropenis (< 2cm) needs hormone therapy before repair to achieve a reasonable penile size.
 Goals of surgical repair include:
- Correction of penile curvature (orthoplasty).
- Reconstruction of the deficient urethra (urethroplasty) with slit shaped meatus (meatoplasty)
and cone shaped glans (glansplasty).
- Appropriate skin coverage of the penis.
- Treatment of associated genital anomalies: Pin-hole meatus rarely necessitates dorsal
meatotomy as a separate step. Congenital hernia and undescended testis have to be managed
firstly. Bifid scrotum requires scrotoplasty.
 The repair is usually a single stage procedure. However, severe degree/s of hypospadias and cases
with failed primary repair may require a two-staged procedure. If local tissues are deficient or
scarred, tissue flaps (e.g. prepuce) or grafts (e.g. buccal mucosa) can be used.
47
II- EPISPADIAS:
It is a congenital anomaly where the external urethral meatus is dorsal and proximal to its normal
site. It may be glanular, penile or penopubic. The following table summarizes the main differences
between hypospadias and epispadias. Surgical repair is best carried out by the age of 6-18 months.
Urinary incontinence if present, should be managed at the age 4-6 years (age of toilet training).
Hypospadias Epispadias
Incidence Common (1/300) Rare (1/100,000)
Gender Boys only Both boys and girls
Affected part of urethra Anterior male urethra only Whole urethra can be affected
Urinary continence preserved Preserved with continent
(incomplete) epispadias, or
lost with incontinent (complete)
epispadias
Meatus, urethral plate, ventral dorsal
penile curvature and
preputial deficiency
III- BLADDER EXSTROPHY:
It is a rare very complex anomaly characterized by:
 Deficient anterior abdominal wall with separation of the recti
muscles and symphysis pubis
 The lower abdomen shows the exposed posterior bladder wall
as a mucosal patch without overlying skin.
 The ureteric orifices are visible and spurt urine.
 The bladder neck is opened together with complete epispadias.
 In males, bilateral inguinal hernias are mostly present. Penopubic epispadias
 In females, the vagina is anteriorly displaced.
Management of bladder exstrophy is challenging and requires
staged and multiple interventions to cope with its multiple
Umbilical cord
defects. It should be started as early as possible at the neonatal stump
period in specialized centers. Incontinence is the most
challenging issue to be treated. Excision of the bladder and
urinary diversion is considered as the last resort.
IV- Posterior urethral valve:
 It is an important cause of bladder outlet obstruction in boys.
 It can result in chronic urinary retention, bilateral vesico- Bladder exstrophy
ureteral reflux, UTI and chronic renal failure. (in a male neonate )
 Prenatal diagnosis by abdominal ultrasound during pregnancy detects most of the cases that show
(bilateral fetal hydro-ureteronephrosis with constantly full bladder)
 Postnatal diagnosis is confirmed by voiding cystourethrogram (VCUG).
 Treatment is by endoscopic fulgration of the valve once it has been diagnosed.
48
TESTICULAR MALDESCENT
Incidence: This disorder may be unilateral or bilateral affecting about 3-5 % of full term boys and
30 % of premature and low birth weight babies. The incidence declines to only 1 % at age
of 6 months due to spontaneous descent.
Classification of testicular maldescent (cryptorchidism or hidden testis):
1. Undescended testis (incompletely descended or on-course testis): Testicular descent is
arrested anywhere along its normal pathway i.e.:
- intra-abdominal: This abdominal testis is impalpable
- inguinal canal: This inguinal testis is mostly palpable
- external inguinal ring: This palpable testis is called subinguinal or high scrotal testis
2. Ectopic testis (off-course testis): The testis has already passed the external inguinal ring, but
deviated to a position outside its normal pathway.
3. Retractile testis: The testis is retracted up by intermittent hyperactive cremasteric reflex. The
testis can be brought down to the bottom of the scrotum by the examiner and stay there.
Consequences:
 Impaired spermatogenesis: An undescended testis is exposed to the body temperature which
affects spermatogenesis (the exocrine function). Irreversible changes in the germinal epithelium
begin after the age of one year. In bilateral cases, sub-fertility is usually the rule. The hormonal
(endocrine) function of the testis remains normal, so that secondary sexual characters develop
normally even in bilateral cases.
 Increased risk of testicular trauma, torsion and tumors.
Clinical evaluation:
 The child is assessed in a warm room with warm examiner's hands in both the classic supine and
crossed frog-leg positions.
 Start by inspection of the scrotum that is underdeveloped and collapsed in all cases of empty
scrotum except retractile testis.
 The examiner should inhibit the cremasteric reflex by placing the non-dominant hand at the
groin region.
 The groin region is to be “milked” towards the scrotum in an attempt to move the testis into the
scrotum. A retractile testis can generally be brought into the scrotum, where it will remain until a
cremasteric reflex (provoked by touching the inner thigh skin) retracts it into the groin.
 The external genitalia, perineum and groins should be examined for ectopic testis and other
associated anomalies as inguinal hernia and hypospadias.
 Sites of testicular ectopy include the:
- superficial inguinal pouch to be anterior to the inguinal canal. It is called ectopic inguinal testis
and it is the most common type
- perineum (ectopic perineal testis)
- suprapubic region (peripenile testis)
- ipsilateral femoral triangle (femoral canal). It is called femoral testis
- contralateral scrotal compartment (trans-scrotal testis)
 Empty scrotum whether unilateral or bilateral means that one or both testes are not present inside
in cases of:
- testicular maldescent
- agenetic testis or testes.
- orchidectomy
 According to clinical examination, the testis may be:
- Impalpable (abdominal undescended, agenetic or atrophic inguinal)
- Palpable (normally descended, retractile, ectopic, or inguinal undescended)
49
The testis is a mobile and slippery structure so it needs employment of the two hands to encompass
and palpate it. Actually, this bimanual examination is required for palpation of the kidney (during
loin examination), the bladder (during DRE) and scrotum and its contents (for vaginal hydrocele by
bipolar fluctuation test & for varicocele during Valhalla's maneuver)
Bimanual examination
planned for palpation
of the testis in case of
testicular maldescent
Investigations:
 Laparoscopy is the most beneficial for detection of the abdominal (impalpable) testis.
 No benefit of any imaging modality such as ultrasound, CT scan & MRI due to high false
negative results.
 In cases with (unilateral impalpable testis associated with hypospadias) or cases with (bilateral
impalpable testes), karyotyping (chromosomal analysis) is essential for gender assignment.
Treatment:
 No intervention before the age of six months for the possibility of spontaneous descent in
about 65% of cases. The optimal time for intervention begins from the age of 6- 12 months and
should not exceed the second year of life.
 Retractile testes need annual follow up for the possibility of testicular ascent (acquired
undescended testis).
 Hormonal treatment in the form of human chorionic gonadotrophins (HCG) or gonadotropin
releasing hormone analogues. It is better to be avoided and it is only rarely indicated in bilateral
undescended testes.
 Open surgery (orchiolysis & orchiopexy) is indicated for palpable testes i.e. for all types of
ectopic testes, inguinal and high scrotal undescended testes.
 Laparoscopy is indicated for the impalpable testis which may be absent or intra-abdominal. The
latter is managed laparoscopically as one or single stage (laparoscopic orchiolysis & orchiopexy)
or in two stages (Fowler-Stephens technique) if the testicular vessels are short.
 Orchidectomy may be rarely performed if the testis is atrophied and the other testis is normal or
there is suspicion of malignancy.
Conditions in which Is the Is the Is the What is required
the testis is not at its testis testis scrotum for management
scrotal sac present? palpable? empty? and medical care?
Agenetic testis NO NO YES Meticulous care after any testis present
If for tumor  chemo- radiotherapy
Surgically excised NO NO YES
If for torsion  Fix the other testis
Undescended abdominal YES NO YES Laparoscopy and proceed
Undescended inguinal YES YES YES Open orchiolysis and orchiopexy
Ectopic YES YES YES Open orchiolysis and orchiopexy
Retractile YES YES YES / NO Follow up for testicular re-ascent
50
ANDROLOGY
- To describe the etiology, diagnostic modalities and treatment plans for patients
with (male subfertility & varicocele), (erectile dysfunction & Peyronie's disease),
and (ejaculatory disorders).
- To be able to diagnose various andrologic emergencies and to be oriented with
their appropriate management.
- To know the indications, techniques and complications of circumcision.
ANDROLOGY
ANDROLOGY
Andrology addresses male subfertility, erectile dysfunction, ejaculatory disorders & some andrologic
emergencies
A- MALE SUBFERTILITY
Subfertility is failure to conceive after one year of a regular unprotected intercourse.
Etiology: A- Pre-testicular (hormonal) causes e.g.:
Hypothalamic and pituitary disorders as (↓ FSH, ↓ LH, ↑ prolactin), hypo- or hyperthyroidism.
B- Testicular causes:
 Congenital as testicular (agenesis or maldescent), chromosomal aberrations (e.g. Klienfelter
syndrome) and sperm disorders (e.g. immotile cilia syndrome and Sertoli-cell only syndrome).
 Inflammatory: e.g. mumps orchitis after puberty and testicular abscess.
 Varicocele.
 Chronic exposure to heat.
 Orchidectomy for e.g. testicular (trauma, torsion or cancer) or prostate cancer treatment.
 Testicular exposure to irradiation or systemic chemotherapy.
C- Post-testicular causes:
 Failure of proper intra-vaginal deposition of semen due to erectile dysfunction, ejaculatory
disorders (e.g. retrograde ejaculation) and severe degrees of hypospadias and epispadias.
 Genital tract obstruction or ablation as: ejaculatory duct obstruction, bilateral congenital absence
of vasa deferentia, TB (of the vas and/or epididymis) and surgical trauma to the genital tract
(after e.g. inguinal hernia repair, radical cystectomy and prostatectomy).
 Immunologic: As anti-sperm anti-bodies disorders in e.g. neglected testicular torsion or trauma.
Evaluation:
A- History addresses type of subfertility (primary or secondary), duration, contraceptive measures,
previous operations (e.g. hernia operations or vasectomy), radiation exposure, chemotherapy, etc.
B- Relevant physical examination.
C- Female partner evaluation is conducted by the gynecologist.
D- Semen analysis: is mandatory.
E- Other investigations are individualized e.g.:
 Hormonal assay: FSH, LH, prolactin and testosterone.
 Semen culture and sensitivity test in cases of leukocytospermia.
 Karyotyping to detect chromosomal aberrations.
 Immunologic tests to detect antisperm antibodies.
 Scrotal duplex ultrasound in cases of varicocele.
 TRUS detects seminal vesicles and ejaculatory ducts obstruction.
 Pelvic MRI in cases of obstructive azoospermia.
 Testicular biopsy: to retrieve sperms for assisted reproductive techniques. It also differentiates
primary testicular failure (absent or defective spermatogenesis) from obstructive azoospermia
(presence of mature sperms).
Treatment: A- Treatment of the primary cause either:
 Medically e.g., treatment of increased semen viscosity by mucolytics, hormonal treatment in
cases of disturbed hormonal profile and PDE-5 inhibitors for ED.
 Surgically e.g. varicocele ligation, hypospadias repair and TUR of veru-montanum for
ejaculatory duct obstruction.
B- Assisted reproductive techniques (ART) as:
* intrauterine insemination (IUI) * in-vitro fertilization (IVF) * intracytoplasmic sperm injection
(ICSI). * Semen may be preserved (semen banking) for future use in some cases e.g. before
orchidectomy & chemotherapy for testicular tumor.
51
ANDROLOGY
VARICOCELE
It means abnormal dilatation, elongation & tortuousity of pampiniform plexus of testicular veins. It is
present in about 15-20% of all males and 40% of infertile males. The right internal spermatic vein
drains directly into the inferior vena cava while the left vein drains into the left renal vein.
Etiology (Types):
 Primary (idiopathic) varicocele: is mostly due to deficient or defective venous valves that allow
reflux. It is more common on the left side. Isolated left varicocele is present in about 80% of cases.
It is more common than secondary varicocele.
 Secondary varicocele: rare, caused by obstruction of the gonadal veins (compression, thrombosis or
infiltration) by a retroperitoneal mass such as renal tumor and lymphoma.
Pathologic effect:
 Varicocele may affect spermatogenesis by thermal effect (↑ of intra-testicular temperature to reach
the body temperature) and/or reflux of metabolites from the suprarenal gland. It produces "stress
semen pattern" that consists of Oligospermia, Asthenospermia and Teratospermia (OAT syndrome).
 In neglected cases, the testis may become atrophied.
 The varicocele is rarely complicated by venous thrombosis or rupture.
Symptoms:
 Varicocele may be asymptomatic & discovered during routine examination e.g. on proposal to
military or gymnastic schools.
 Primary varicocele has an insidious onset and is more common in early adulthood. It may occur in
adolescence (adolescent varicocele). Secondary varicocele has a rapid onset and should be
suspected in older ages and right sided varicocele.
 Symptoms are: 1. Failure of conception (subfertility): the most common presentation.
2. Dragging testicular pain that increases on prolonged standing and exertion.
3. Painless soft scrotal lump.
Examination: (in both standing and supine positions).
- According to the size of dilated veins in the standing position, three
degrees are recognized:
* 1st degree: the dilated veins are palpable on straining i.e.
on Valsalva’s maneuver).
* 2nd degree: the dilated veins are palpable without straining.
* 3rd degree: the dilated palpable veins become visible.
ry
- In supine position, the size of dilated veins ↓ in 1 varicocele.
- In secondary varicocele, the size of the dilated veins does not change Left varicocele;
with the Valsalva maneuver or in supine position. It is usually 3rd degree
accompanied by other varicosities in the lower limbs and the perineum
- In long standing varicocele, the testis may be atrophic (soft and small).
Investigations: 1. Semen analysis may be normal or show stress pattern.
2. Scrotal color duplex U/S can show reflux & degree of venous dilatation.
3. Abdominal U/S, CT and MRI to detect the cause of secondary varicocele.
Treatment indications: 1. Subfertility with semen stress pattern 2. Concomitant testicular atrophy
3. Persistent scrotal pain exaggerated by exertion and relieved by rest.
4. Adolescent varicocele.
Treatment lines:
1. Varicocele (varix) ligation is the standard treatment through:
-Open surgery: subinguinal, inguinal or high venous ligation (no trans-scrotal ligation)
-Laparoscopic (high) venous ligation may be indicated in bilateral cases.
2. Radiographic occlusion (sclerotherapy) especially in recurrent varicocele.
52
ANDROLOGY
B- ERECTILE DYSFUNCTION (ED)

It is the persistent inability to attain and maintain an erection sufficient for satisfactory intercourse. It is
reported by about 50% of 40-70 year-old men.
Erection is a neurovascular phenomenon under hormonal control. It includes penile arterial dilatation
(increase inflow) with veno-occlusive mechanism (decrease and cessation of outflow).
Risk factors for erectile dysfunction include: smoking, diabetes mellitus, obesity and
hypercholesterolemia.
Etiology:
 Vasculogenic (arterial insufficiency and/or venous leakage) e.g. with hypertension and DM.
 Neurogenic e.g. cerebrovascular stroke and spinal cord disorders.
 Hormonal e.g. in hypogonadism.
 Drug-induced (reversible): antihypertensives, antidepressants, anti-psychotics, antiandrogens,
antihistamines and recreational drugs (heroin, cocaine, and methadone).
 Radical pelvic surgeries e.g. for bladder, prostate and rectal cancer.
 Structural as penile curvature & fracture, priapism and Peyronie’s disease.
 Psychogenic.
History should address:
 the duration, course and severity of the problem
 The presence of morning erection and what about libido (desire)
 vascular risk factors as diabetes mellitus, hypertension, smoking, sedentary life and concomitant
ischemic heart disease
 etiologic factors as trauma of the spine, radical pelvic surgery or cerebro-vascular strokes
 drug intake as a cause of ED or a treatment of ED
Physical examination should include the genital, vascular and neurological systems.
Laboratory testing is required for blood glucose, lipid profile and total serum testosterone.
Specialized diagnostic tests:
 Office test: Intracavernous vasodactive drug (vasodilator) injection to induce erectile response.
 Penile duplex ultrasound (also with local vasoactive drug injection) to detect arterial insufficiency
and/or venous leakage.
Treatment:
First line
A- Oral drugs: Phosphodiesterase-5 (PDE-5) inhibitors:
- They are administered 30-60 minutes before the desired act. Sildenafil and Vardenafil are
short acting and their absorption is affected by fatty meal. However, Tadalafil is long acting
and is not influenced by food.
-Side effects include headache, flushing, nasal congestion and dizziness.
- Nitrates absolutely contraindicate using PDE-5 inhibitors. Antihypertensives α-drenergic
blockers may result in additive drop of the blood pressure and orthostatic hypotension.
B- Vacuum constriction device: It provides passive engorgement of the corpora cavernosa.
Its undesired events include penile pain, numbness, bruising and inability to ejaculate.
Second line: Intracavernous injection of vasoactive drugs:
- Drugs like prostaglandin E1 (Alprostadil) and papaverine are self injected at the desired time.
- Side effects include penile pain, mild hypotension, priapism and penile fibrosis.
Third line: Penile prosthesis:
- This entails surgical intracavernous implantation of semirigid or inflatable prosthesis.
- It is the last resort when other lines of treatment fail.
- Its main complications are mechanical failure, erosion and infection. The latter mostly
necessitates extraction of the prosthesis.
53
ANDROLOGY
PEYRONIE’S DISEASE
It is a benign penile condition characterized by fibrous tissue plaques within the tunica albuginea that
confines the corpora cavernosa. It affects about 1% of men aged 40–60 years. This disorder has two
phases:
 Active phase (1–6 months): painful erections and changing penile deformity.
 Quiescent phase: Pain disappears with stabilization of the penile deformity.
Clinical picture:
 Penile hard area/s (plaque/s) especially on the dorsal aspect.
 Penile pain and curvature especially during erection.
 Penile shortening.
 Erectile dysfunction in about 30–40%.
Treatment:
 Early disease may benefit from medical therapy (e.g. vitamin E and colchicine).
 Concomitant erectile dysfunction can be treated conventionally (oral therapy, intracavernosal
medications, vacuum device or penile prosthesis).
 Surgery is indicated to repair stable, significant penile deformity and shortening.
C- EJACULATORY DISORDERS
The ejaculatory disorders include:
 Premature ejaculation: It is the inability to control ejaculation for a sufficient time before or
during vaginal penetration.
 Retrograde ejaculation is caused by bladder neck incompetence due to e.g. DM, TURP and
alpha blockers.
 Delayed ejaculation and anejaculation are mainly due to neurogenic causes.
 Painful ejaculation due to e.g. prostatitis and prostatic calculi.
 Low ejaculate volume may be due to improper sample collection, retrograde ejaculation,
obstruction of ejaculatory ducts and hypogonadism.
 Hemospermia may be idiopathic or due to e.g. prostate cancer and genital TB.
D- ANDROLOGIC EMERGENCIES
Andrologic emergencies include:
1- Phimosis
It is inability to retract the prepuce due to narrow preputial opening or adherence of the prepuce to the
glans. It may be congenital or may be acquired due to preputial inflammation (posthitis).
Clinical picture:
 The infant or the child is straining, agonized or crying during the act of micturition.
 Narrow and interrupted urine stream.
 Ballooning of the prepuce during voiding.
Complications: Acute retention of urine and chronic balano-posthitis
Treatment: Circumcision.
54
ANDROLOGY
2- Paraphimosis
It is the formation of a constricting ring when the prepuce is
retracted and neglected behind the glans penis. This leads to
glanular venous congestion, edema and ischemia with subsequent
gangrene and sloughing if not urgently managed.
Prevention: This is an iatrogenic complication encountered after
manipulation of the prepuce for e.g. examination of the urethral
meatus or urethral instrumentation. So, never leave the prepuce Manual reduction of the
retracted behind the glans. prepuce in a case of
Treatment: paraphimosis
1. Trial of manual reduction of the prepuce.
2. Dorsal slit (release incision) at 12 o’clock position if manual reduction failed.
3. Circumcision can be done electively later on.
CIRCUMCISION
Definition:
It means excision of the prepuce (foreskin). It can be done under local or general anesthesia. It is an
elective procedure and should only be done when the risk of complications is negligible. It can be
safely done as early as 40 day-old.
Indications: - Traditional - Phimosis - Paraphimosis
- Urinary tract anomalies as primary VUR to minimize recurrence of UTI.
Contraindications:
 Before repair of hypospadias or epispadias: Circumcision is only allowed as a part of repair.
 Before correction of any bleeding disorder e.g. hemophilia.
 Local skin disease e.g. inflammation, edema and rash.
 Huge inguino-scrotal swellings e.g. hernia and hydrocele.
 Micropenis and concealed penis
Operative techniques: (vary according to the available devices, experience and operator preference.)
 Surgical dissection and excision: although it is difficult, yet it is safe.
 Excision of the overstretched prepuce after being clamped by bone cutting clamp. It is a blind
maneuver that carries an actual risk of glans injury.
 Other modalities employ the use of glans covers (e.g. cones and bells of different sizes) to excise
the prepuce with the glans being shielded.
Postoperative care:
 A nonadhesive dressing is applied for few hours.
 Short-term use of antibiotic, analgesic and anti-inflammatory drugs.
 The penis may be bruised and swollen, and this resolves spontaneously over a week or two.
Complications and their management:
Although circumcision is a simple operation, it carries the risk of serious complications including:
 Bleeding: Most frequently from the frenular artery on the ventral surface of the penis. If local
pressure does not stop the bleeding, any bleeding vessel should be carefully sutured.
 Wound infection and skin necrosis: mostly reassurance of the parents is all that is needed.
 Urethrocutaneous fistula: It results from direct injury or suturing of the urethra. It should not be
repaired before 3 months.
 Glans injury: It is the most troublesome complication as it entails partial or complete glans
amputation by the bone cutting clamp. Meatal stenosis may result.
 Concealed glans by cross union of penile skin that completely hides the glans when the technique is
sutureless. It needs surgical dissection and excision of the excess skin.
55
ANDROLOGY
3- Hair tie
This is an occasional emergency where fallen hair/s
encircles the coronal sulcus, and is spontaneously tied
thus it constricts the glans. This is encountered in
infants, young boys and those who are mentally
retarded. It requires urgent untying and removal.
If neglected, the glans becomes edematous, congested
and ischemic. It may lead to urethro-cutaneous fistula or
even necrosis and sloughing of the glans.
Hair tie around the coronal sulcus
4- Priapism
It is prolonged and oftenly painful erection without sexual stimulus that lasts > four hours, which
predominantly affects the corpora cavernosa. Potential sequelae include ischemia and fibrosis of the
cavernous tissue which may result in erectile dysfunction.
Types: 1. Ischemic (veno-occlusive or low flow priapism): The corpora cavernosa are rigid, tender
and patients report pain. It is the commonest type.
2. Non-ischemic (arterial or high flow priapism): the penis is neither fully rigid nor painful
with no risk of tissue damage.
Causes: 1. Idiopathic: 35%
2. Drugs: e.g. intracavernosal injections to treat ED, antipsychotics, anticoagulants, β
adrenergic blockers, alcohol and recreational drugs.
3. Medical diseases as:
-Blood disorders (thrombo-embolic): thalassemia, sickling disease & leukaemia.
-Neurogrnic disorders: spinal cord lesions, multiple sclerosis & spinal anesthesia.
-Malignant infiltration of corpora cavernosa from e.g. bladder cancer.
4. Scorpion bite.
5. Trauma: penile or perineal injury resulting in cavernosal artery laceration or
arteriovenous fistula formation (non-ischemic or high flow type).
Treatment:
a. Urgent drainage and wash of the entrapped cavernosal blood with intra-corporal injection of
vasoconstrictor drugs e.g. ephedrine.
b. Surgical shunts: To drain the corpus cavernosum either into the corpus spongiosum (corporo-
corporal shunt) or into the great saphenous vein (corporo-venous shunt).
5- Penile fracture
It is traumatic rupture of corporal tunica albuginea of an erect penis.
Symptoms: 1. History of cracking sound followed by detumescence of the erect penis.
2. Intense penile pain and swelling.
3. Rarely, bleeding per urethra that indicates associated urethral injury.
Signs: 1. Penile bruising & egg-plant deformity due to hematoma formation.
2. The tunical defect may be palpable.
3. Blood spots at the external urethral meatus denote urethral injury.
Investigations are rarely used to document the diagnosis:
1. Penile MRI in some doubtful cases.
2. Retrograde urethrography in suspected urethral injury.
Complications: 1. ED due to fibrosis or spongio-cavernous fistula.
2. Penile shaft curvature (chordee).
Treatment: 1. Immediate surgical repair for early cases. Penile fracture
2. Conservation for late cases that are neglected for ≥ one week.
56
ANDROLOGY
6- Testicular torsion
It is the twisting of the testis and its cord that strangulates testicular blood supply.
Types:
1. Extravaginal: torsion of the testis with its tunica vaginalis (in the neonatal period).
2. Intravaginal: torsion of the testis within the tunica vaginalis (in older children).
Pathology:
 Torsion of the spermatic cord interrupts the blood flow to the testis and
epididymis.
 The direction of torsion is from lateral to medial (towards the midline).
 Testicular salvage is possible if the duration of torsion is less than six
hours.
 After ≥ 24 hours, testicular necrosis develops in most patients.
 If neglected, the interrupted testicular-blood barrier permits formation
of antisperm-antibodies causing subfertility.
 The contralateral testis is also liable for torsion. Testicular torsion
Symptoms: - Sudden attack of severe scrotal pain (acute scrotum).
- Gastro-intestinal symptoms may follow the testicular pain.
- Scrotal swelling then occurs.
Signs: - Enlarged tender high-riding testis (shortened spermatic cord) with no fever.
- Absent cremasteric reflex.
- The epididymis may be palpable anterior or lateral to the testis.
Investigations:
 Scrotal color duplex ultrasonography: documents decreased or absence of testicular blood flow.
 Urine analysis: microscopic pyuria suggests acute epididymitis
Treatment:
1. Manual detorsion by outward rotation of the testis as a first aid measure.
2. Urgent surgical exploration:
- If the testis is still viable, orchiopexy is done after detorsion.
- If the testis is irreversibly damaged, orchidectomy is carried out.
- Orchiopexy of the contra-lateral testis is mandatory.
7- Other Causes of Acute Scrotum

Acute scrotum - like acute abdomen – means any acute painful scrotal condition.
Differential diagnosis of acute scrotum (besides testicular torsion):
 Testicular torsion.
 Acute epididymitis and acute epididymo-orchitis (usually with fever, history of UTI and increased
vascularity by color duplex U/S).
 Complicated inguinal hernia (history of hernia ± intestinal obstruction).
 Mumps orchitis (history of parotitis and the epididymis is free).
 Torsion of testicular appendages (with insignificant consequences).
57
VOIDING DYSFUNCTION
AND NEURO-UROLOGY
- To know the types of urinary incontinence, how to differentiate between them
and the broad lines of their treatment.
- To describe the etiology, clinical presentation, diagnostic modalities and
treatment plans for patients with nocturnal enuresis, overactive bladder and
neuropathic bladder.
VOIDING DYSFUNCTION AND NEURO-UROLOGY

Lower urinary tract function can be divided into urine storage and urine emptying:
 Storage depends on bladder capacity, sensation, compliance and stability (absence of undesired
contractions), sphincteric function and pelvic floor support.
 Emptying depends on detrusor muscle contraction, sphincteric relaxation & urethral patency.
Neuro-anatomy of micturition:
 Parasympathetic input is derived from S 2, 3, 4. It stimulates detrusor contraction and inhibits
contraction of the internal sphincter smooth muscle to start a micturition reflex.
 Sympathetic input arises from T 11, 12 and L 1, 2, 3. It inhibits bladder contraction and induces
internal sphincteric contraction; thus it is responsible for bladder storage.
 Somatic input from S 2, 3, 4 via the pudendal nerve stimulates the striated muscle of the voluntary
external urethral sphincter.
 Suprasacral centers (spinal cord, pons and cerebral cortex) input inhibits the autonomically
controlled micturition reflex.
OVERACTIVE BLADDER (OAB)

It is a symptom syndrome that includes urgency, with or without urge incontinence, usually associated
with frequency and nocturia. OAB can affect males and females.
Etiology:
 Idiopathic is the most common cause in women.
 Secondary to BOO mostly in males (e.g. BPH).
 Neuropathic: usually with lesions above sacral micturition center (UMNL).
Diagnosis:
 History and physical examination for::
- Identification of the symptom syndrome.
- Detection of any underlying condition (BOO, any neurologic disease and DM).
- Thorough neurological assessment.
 Urine analysis, urine culture and abdominal U/S to exclude pathologies that may produce
symptoms similar to OAB i.e. DD of OAB as: UTI, bladder stones and bladder cancer.
 Urodynamic studies: to detect uninhibited detrusor contractions and to exclude BOO.
Treatment:
 Treatment of the cause if present.
 Behavioral treatment:
- Lifestyle interventions including decrease fluid intake, weight loss and avoidance of irritants (as
smoking, caffeine and spicy food)
- Bladder training and pelvic floor exercises.
 Pharmacological treatment:
- Antimuscarinics (e.g. oxybutynin, tolterodine, and solifenacin) are the main treatment.
Common side effects are dry mouth, constipation, dizziness, visual impairment and headache.
- Other new drugs e.g. propiverine (mixed antimuscurinic & Ca2+ antagonistic actions) and
Mirabegron (beta-3 adrenergic agonists).
 Surgical treatment for refractory cases includes intravesical botulinum injections, neuro-
modulation (sacral or tibial nerve stimulation) and augmentation cystoplasty.Voiding diary to
58
URINARY INCONTINENCE
It means “any involuntary loss of urine”. It has hygienic, social and/or economic impacts. Its types include:
 Stress incontinence: It is incontinence that is related to sudden increase in intra-abdominal pressure (e.g.
coughing, sneezing and straining). It mainly affects the female population. Its main risk factor is
multiparity especially with vaginal deliveries.
 Urge incontinence: here incontinence is accompanied by or immediately preceded by urgency. It is
caused by irritative bladder pathologies (e.g. infection, stone or cancer) or as a part of OAB syndrome.
 Mixed incontinence: It comprises both stress and urge incontinence
 Overflow incontinence: Urine leaks in case of chronic urinary retention (due to BOO or neuropathic
bladder). The latter may underlie UTI, stone formation, hydro-ureteronephrosis and renal impairment.
 Continuous incontinence: It is the complaint of continuous urine leakage due to sphincteric deficiency
(empty bladder) which may be congenital (e.g. exstrophy-epispadias complex), neurologic (e.g. spinal
dysraphism) or traumatic (e.g. after TURP or TVP).
 Nocturnal enuresis (NE): It means the escape of urine during sleep (bedwetting).
 Postmicturition dribbling: It is the complaint of urine dribbling that occurs after voiding (due to
pooling of urine in the male bulbous urethra).
 Extraurethral incontinence as vesicovaginal fistula and ectopic ureter.
Evaluation:
1. History should include:
 Timing, number of episodes, severity and precipitating factors.
 Other LUTS and genito-urinary conditions.
 Medical history especially for neurologic disorders and previous spine or pelvic surgery.
 Obstetric history in females.
2. Physical examination should include:
 Abdominal examination for palpable bladder that indicates chronic urinary retention.
 Neurologic examination focusing on perineal sensation and lower limbs function.
 DRE to evaluate the anal sphincter tone and bulbo-cavernosus reflex as well as the prostate.
A cystic bladder swelling due to high post-voiding residue can be detected by bimanual examination.
 Vaginal examination to demonstrate stress incontinence and any pelvic organ prolapse.
3. Voiding diary to record frequency & volume of voided urine, incontinent episodes, pad usage and fluid
intake.
4. Urinalysis to exclude UTI and abdominal sonography to evaluate the bladder, PVR and upper urinary
tract.
5. Urodynamic studies to objectively evaluate the process of bladder filling and emptying.
6. Urethrocystoscopy to exclude any urethral or bladder irritative or obstructive pathology.
Treatment:
1. If there is any organic cause of incontinence it should be treated.
2. For stress urinary incontinence:
 Conservative treatment includes pelvic floor exercises and biofeedback to strengthen the levator ani and
striated sphincter in mild to moderate cases
 Synthetic midurethral slings include Tension free Vaginal Tape (TVT) & Trans-Obturator vaginal Tape
(TOT) as minimally invasive procedures in severe cases or failure of conservative treatment in moderate
cases.
3. For sphincteric deficiency treatment includes endoscopic injection of bulking materials into the bladder
neck, open bladder neck reconstruction and artificial urethral sphincter. Other lines include clean
intermittent catheterization (CIC) for overflow incontinence) and urinary diversion (after failure of
reconstructive trials)
59
NOCTURNAL ENURESIS (NE)

Its prevalence is about 15 % at age of 7 years and declines to about 1 % by the age of 15 years. Its
types include:
 Primary NE (never been dry for more than 6 months) or secondary NE (re-emergence of bed
wetting after a period of being dry for at least 6 months).
 Monosymptomatic NE (no daytime voiding symptoms) or polysymptomatic NE (associated with
daytime voiding symptoms such as frequency, urgency and urge incontinence).
Etiology of monosymptomatic NE may be familial, nocturnal polyuria, disturbed sleep/arousal
mechanism, delay in functional bladder maturation or psychological.
Evaluation:
 History: family history, psychosocial history, voiding diary, frequency of enuresis episodes,
daytime symptoms, UTIs, bowel problems and any previous treatment.
 Examination: to exclude organic causes of neuropathic bladder.
 Urine analysis: UTI, low specific gravity and glucosuria.
 Abdominal U/S in polysymptomatic cases.
Management:
 Behavioral: - reassurance and motivational techniques (never blame or punish, keep it secret)
- conditioning therapy (bed-wetting alarm).
 Pharmacological: -Imipramine: a tricyclic antidepressant.
-Desmopressin: oral synthetic analogue of ADH.
NEUROPATHIC (NEUROGENIC) BLADDER

Etiology:
 Lesions above the sacral micturition center (upper motor neuron lesion) e.g. cerebrovascular stroke,
spinal cord injury and Parkinsonism.
 Lesions at or below the sacral micturition center (lower motor neuron lesion) e.g. spinal cord injury,
herniated disks and peripheral neuropathies (as diabetes mellitus and post radical pelvic surgery).
Effect: various patterns of detrusor-sphincter dysfunction can occur:
 Bladder contractility may be pathologically increased (OAB or spastic bladder with low capacity)
or decreased (underactive or atonic bladder).
 The bladder outlet may be overactive (causing functional obstruction) or become paralysed (causing
incontinence)
 The synchronized function of the bladder and its outlet may be lost (detrusor-sphincter
dyssynergia).
 Consequently; urinary incontinence, chronic retention, UTIs, stone formation, vesico-ureteral reflux
and renal impairment may occur.
Evaluation:
 History of LUTS, neuro-urological deficits and uremic manifestations.
 Abdominal examination to detect chronic retention, palpable or tender kidney.
 Neurological assessment of perineal sensation, lower limbs function, and anal sphincter tone.
 Essential investigations are urine analysis, serum creatinine, abdominal US and urodynamics.
Treatment
 Aim: to enhance urinary continence and preserve renal function.
 Strict regular follow up: to prevent, detect and treat any complication.
Treatment includes treatment of the cause if possible, antimuscurinics, clean intermittent
catheterization (CIC), intravesical botulinum injection, neuromodulation, augmentation cystoplasty
and urinary diversion.
60
GENITO-URINARY
TUMORS
- To describe the classification pathology, clinical presentation, investigations and
management strategies of renal tumors and bladder cancer.
- To list the various types of urinary diversions after radical cystectomy.
- To mention the pathology, diagnosis and treatment strategies of prostate cancer
and testicular tumors.
GENITO-URINARY TUMORS
RENAL TUMORS
A– Primary renal tumors:
1. Tumors of the mature renal parenchyma:
i- Malignant tumors e.g. renal cell carcinoma (90% of adult renal tumors).
ii- Benign tumors (rare) e.g. adenoma and angiomyolipoma.
2. Tumors of the immature renal parenchyma: Wilms’ tumor.
3. Tumors of the pelvicalyceal system mainly transitional cell carcinoma (TCC).
B- Secondary renal tumors: e.g. lymphoma and leukemia.
RENAL CELL CARCINOMA (RCC)

RCC is the most common renal tumor and represents about 3% of all adult malignancies. It occurs
commonly at the age of 50-70 years. It is bilateral in 2%.
Spread: * Local to the collecting system and renal capsule then to surrounding organs.
* Renal vein and inferior vena cava (IVC) may be permeated by tumor thrombus.
* Hematogenous to the viscera or bones.
* Lymphatic to the regional lymph nodes.
Clinical presentation of RCC:
 Accidentally detected during investigation for other medical condition.
 Urological manifestations: flank pain, hematuria and palpable renal mass. This classic triad is
now rarely found as a complete triad "too late triad."
 Non-urological manifestations:
- Metastatic manifestations: dyspnea, hemoptysis, bone pain, pathologic fractures and
manifestations of brain metastasis… etc.
- Paraneoplastic syndromes: RCC may produce various hormones and cytokines. Thus pyrexia,
hypertension, anemia, polycythemia, neuromyopathy, elevated ESR, hypercalcemia, or abnormal
liver function (without hepatic metastasis) may be found.
- Venous involvement (IVC) can cause secondary varicocele and bilateral lower limb edema.
Imaging studies:
 Abdominal ultrasonography:
- Detects and differentiates the nature of a
renal mass e.g. solid, cystic or complex
masses.
- Assesses the state of the other kidney.
- Detects metastasis of other organs e.g. liver.
 Abdominal CT (pre & post contrast) is the
gold standard for diagnosis and staging.
 MRI may replace CT especially in renal
impairment and during pregnancy.
 Chest X-Ray for chest metastasis. Abdominal CT with
Biopsy: is carried out after nephrectomy. Biopsy contrast: Left renal tumor
is not indicated preoperatively unless
benign renal lesion (benign tumor or abscess) is highly suspected.
Treatment:
 Nephron-sparing surgery (excision of the tumor and sparing the rest of the kidney) whenever
possible (especially in tumors of only functioning kidney and bilateral renal tumors).
 Radical nephrectomy for organ-confined tumor is the standard treatment.
 Debulking (cytoreductive) nephrectomy in advanced cases.
 Immunotherapy and antiangiogenic drugs (target therapy) to treat distant metastasis.
61
WILMS' TUMOR (NEPHROBLASTOMA)

It is the most common childhood renal tumor; its mean age is 3.5 years. It is bilateral in 7 % of cases.
Clinical presentations:
1- Abdominal mass in 90% of cases. 2- Abdominal pain. 3- Gross hematuria (ominous sign).
4- Atypical presentations: includes e.g. hypertension, fever and secondary varicocele
Imaging studies:
 Abdominal U/S: It detects the renal mass and assesses the other kidney.
 Abdominal CT/MRI can demonstrate tumor size, stage, bilaterality and lymph node involvement.
 Chest X-Ray: It may show metastasis.
Treatment: 1- Radical nephrectomy is the mainstay.
2- Chemotherapy is essential since the tumor is chemo-sensitive.
3- Radiotherapy may be needed.
PELVICALYCEAL SYSTEM AND URETERIC UROTHELIAL TUMORS
Predisposing factors include smoking, prolonged irritation (chronic infection and large calculi) and
analgesic abuse.
Pathology: 1- TCC is the most common type.
2- SCC may arise from squamous metaplasia.
 Gross or microscopic hematuria occurs in over 75 %.
 Flank pain occurs in up to 30 %.
 Flank mass is late and rare.
 Other symptoms of advanced stages e.g. weight loss and anorexia.
IVU: Filling defect of right
Imaging studies: renal pelvis urothelial tumor
 Abdominal ultrasonography: The lesion is seen as heterogeneous
mass in the renal pelvis or in a calyx. Hydronephrosis may be detected in cases of ureteric tumors.
 Abdominal CT with contrast is the standard tool for staging.
 MRI is indicated in renal impairment and pregnancy.
 IVU: the lesion appears as a filling defect in the renal pelvis or in a calyx.
Urine cytology: a urine sample is taken for detection of any malignant cells.
Cystoscopy: to detect any co-existing bladder tumor (13%).
Flexible uretero-renoscopy: The tumor is visualized and can be biopsied.
Treatment: Nephro-ureterectomy that entails removal of kidney, the whole ureter and a cuff of the
bladder by open surgery or laparoscopy, with or without chemotherapy.
BENIGN RENAL TUMORS
1- RENAL CORTICAL ADENOMA: It presents as a small mass less than one cm and should be
followed up as any kidney space occupying lesion is considered malignant until proved otherwise.
2- ANGIOMYOLIPOMA
 It is composed of blood vessels, smooth muscle cells and adipocytes more predominant in females
 Presentation:
- May be asymptomatic and discovered accidentally by U/S.
- Renal pain.
- Massive retroperitoneal bleeding may cause severe flank pain and sudden hypotension.
 CT provides accurate diagnosis because of the high fat content.
 Treatment of angiomyolipoma:
- Conservation and follow up for lesions less than 4 cm.
- Nephron sparing surgery or simple nephrectomy in larger tumors.
- Selective arterial embolization: indicated in cases of massive retroperitoneal hemorrhage.
62
BLADDER CANCER
Epidemiology:
 Bladder cancer is one of the most common cancers in Egypt.
 Males are more affected due to more exposure to the predisposing factors.
 TCC tends to appear at the ages above 50 years. Squamous cell carcinoma (mostly in bilharzial
bladder) occurs at younger ages (between 30-50 years).
 Risk factors:
- Occupation: > Farmers (pesticides, fertilizers and schistosomiasis).
> Painters and leather & gas-station workers (aromatic amines).
- Tobacco smoking.
- Chronic bladder irritation (by e.g. schistosomiasis, large bladder stones and indwelling
catheters) that causes the precancerous squamous metaplasia.
- Radiation exposure.
Macroscopic (cystoscopic) picture:
Papillary, nodular or flat red patches of carcinoma in situ (CIS).
Microscopic picture:
- Transitional cell carcinoma (TCC): About 60%
- Squamous cell carcinoma (SCC): About 35%
- Adenocarcinoma: Rare as the bladder is deficient in glands.
Spread:
- Direct: to peri-vesical fat, prostate, seminal vesicles, uterus, vagina,
intestine, pelvic wall and even the anterior abdominal wall. Cystoscopic view of
- Lymphatic: to the obturator, internal and external iliac then to the papillary bladder tumor
common iliac lymph glands.
- Hematogenous: rare, late and occurs mainly to the liver, lungs, brain and bones.
Staging: The TNM staging system is used. T stage indicates that the tumor is non-muscle invasive in
(CIS, Ta, T1) or muscle invasive in (T2-T4). Positive lymph nodes (N 1-3) and/or distant
metastasis (M1) indicate metastatic disease.
Symptoms:
 Hematuria: The most common presenting symptom in TCC is recurrent total painless profuse
hematuria. It may be the only symptom in early stages.
 Pain (urethral, perineal & supra-pubic) and irritative LUTS especially in SCC.
 Other symptoms (late):
- Necroturia (pieces of fleshy sloughed necrotic tissues in urine).
- Renal pain and manifestations of renal failure due to obstruction of the ureter/s.
- Manifestations of metastasis e.g. jaundice, hemoptysis, sciatic and bone pain.
- Loss of weight and generalized weakness.
Signs:
 Examination may reveal nothing especially in non-muscle invasive tumors.
 General examination: e.g. pallor, cachexia and uremic manifestations.
 Abdominal examination may reveal e.g.
- Supra-pubic tenderness and mass (in huge anterior & domal tumors).
- Renal enlargement (hydronephrosis).
- Enlarged tender liver (may be found in metastatic cases).
- DRE: 1- May reveal a firm to hard tender bladder mass in posterior wall tumors.
2- Bimanual examination is essential for detection of:
* Degree of bladder mass mobility; whether the mass is mobile (resectable) or fixed (inoperable).
* Anterior wall and domal bladder masses.
63
Investigations for bladder cancer:

 Imaging:
a) Abdominal U/S is a primary beneficial investigation:
- Urinary bladder: any sizeable bladder growth can be
easily defined.
- Presence of obstruction and degree of dilatation of the
kidneys and ureters.
- Other abdominal organs e.g. liver for (enlargement,
metastasis and cirrhosis).
b) Abdominal pre and post-contrast C.T. scanning for: Sonographic appearance of
- Detection of the mass and local staging. a bladder tumor
- Detection of enlarged lymph nodes and liver metastasis.
c) MRI is a better alternative to CT.
 Cystoscopy and biopsy: Sure diagnosis of bladder cancer is achieved by cystoscopic biopsy
through the following steps:
- Cystoscopic examination of the interior of the urinary bladder.
- TUR biopsy is mandatory for pathological type, degree of local infiltration and tumor grade.
- Bimanual examination under anesthesia to evaluate the mobility of the bladder harboring
tumor
Treatment:
A- Non-muscle invasive TCC:
Trans-urethral resection of the tumor (TURBT) is the main
line of treatment.
Other adjuvant therapies may be needed (according to the stage):
- Intravesical chemotherapy: e.g. gimcetabin and
mitomycin.
- Intravesical immunotherapy (BCG vaccine) induces a
local immune response against the tumor to prevent its
recurrence
B- Muscle invasive non-metastatic (operable) tumors:
 Radical cystectomy with appropriate urinary diversion is
the standard treatment.
Abdominal CT with
 TURBT with adjuvant chemo-radiotherapy (bladder preservation contrast: Bladder tumor
protocol) in some selected cases.
C- Inoperable:
 In fixed or metastatic tumors, systemic chemotherapy is used.
 In medically unfit patients the treatment is symptomatic and/or palliative for pain, troubling
irritative LUTS, hematuria and uremia.
Urinary diversion techniques after cystectomy:
Choice of the technique and type depends on many factors e.g. renal function, degree of ureteric
dilatation, condition of the intestine and patient’s & surgeon’s preference.
64
Types of supravesical urinary diversion (after radical cystectomy)

Shunt Type Shunt Name Remarks
Without tube/s or Orthotopic neobladder Continence by the external urethral
appliance sphincter with maintenance of
(continent) per urethral voiding
Urinary reservoir with Regular urine evacuation by the
cathterizable abdominal stoma patient using Nelaton catheter
Ureterosigmoidostomy Continence by the anal sphincter
With tube/s or Ileal loop conduit Only one stoma with ileostomy bag
appliance Bilateral ureterocutaneous shunt Two indwelling ureteric stents
(incontinent) connected to an external appliance
A. Orthotopic neobladder: Using the intestine (either small, large intestine or both) for
reconstructing a new bladder. Both ureters are reimplanted into the newly designed reservoir which
is anastmosed to the urethra depending on the external urethral sphincter to maintain continence.
B. Continent reservoir with catheterizable stoma: The reservoir is designed from the intestine with
a special stomal opening through the umbilicus or lower abdomen to be regularly evacuated by the
patient.
C. Uretero-sigmoidostomy: The ureters are reimplanted into the sigmoid colon.
Complications:
 Ascending infection of the kidneys due to reflux.
 Obstruction of the ureter/s with subsequent hydronephrosis.
 Hyperchloremic hypokalaemic acidosis with reabsorption of urine constituents from the colon.
D. Ileal conduit: An ileal loop is isolated and the ureters are reimplanted into it. The ileal loop is
connected to the abdominal wall and an ileostomy bag is applied.
E. Bilateral uretero-cutaneous shunt: It is resorted to in case of markedly dilated atonic ureters with
bilateral hydronephrosis and compromised renal function. Its disadvantages include urine leakage,
ascending infection and stenosis of the stoma/s.
PROSTATE CANCER
Prostate cancer (PCa) is the most common cancer diagnosed in men in western countries. In Egypt it is
less diagnosed. Its incidence increases with advancing age. In familial PCa, patients are affected at
younger ages.
Pathology
A. Histopathologically, over 95 % of cancers of the prostate are adenocarcinomas.
B. Grading employs the Gleason scoring system which relies upon the appearance of the glandular
architecture under the microscope and the score ranges from 2 to 10.
C. Spread:
 Local (extracapsular): to the seminal vesicles and the bladder (may result in ureteral obstruction).
 Lymphatic: to obturator, internal iliac and external iliac lymph nodes.
 Hematogenous:
- Bone metastasis is typically osteoblastic (osteosclerotic) and yet can lead to pathologic fractures.
- Mostly to the lumbar spine (can result in cord compression). Other sites are proximal femur,
pelvic bones, thoracic spine, ribs, skull and humerus.
- The rare visceral metastases may involve the lung, liver and brain.
 Asymptomatic: These cases are accidentally discovered on DRE, by raised serum prostatic
specific antigen (PSA) or histopathology of chips retrieved by TURP for BPH.
65
 Locally advanced prostate cancer:

- Obstructive and/or irritative LUTS can result from tumor extension into the urethra, bladder neck
or trigone.
- Deep perineal pain. - Hemospermia.
- Renal pain, renal impairment or obstructive anuria due to ureteral invasion.
 Metastatic disease e.g.:
- Bone pain, bone swelling and pathologic fracture.
- Symptoms of cord compression as lower limbs weakness and urinary or fecal incontinence.
- Irritative cough and hemoptysis due to pulmonary metastasis.
 DRE Signs:
- Hard nodule(s), lobe or even the whole prostate.
- Obliteration of lateral sulcus; unilateral or bilateral (frozen pelvis).
Screening: Men with family history of prostate cancer are at higher risk and should be subjected to
screening by the age of 45 years by DRE and serum PSA.
Investigations:
 Serum PSA: The normal cutoff value is 2.5 ng/ml. It may be raised in other conditions e.g. BPH,
prostatitis and after prostatic biopsy. Thus it is not PCa specific.
 TRUS guided biopsy:
- Most cancerous lesions are hypo-echoic and located in the peripheral zone.
- TRUS may aid in assessment of tumor burden and its local extension.
- Multiple needle biopsies are taken from both lobes in addition to any suspicious area/s.
 Pelvi-abdominal MRI or CT: for detection of local extension of disease and the presence of
lymph node metastases (PCa staging).
 Investigations for distant metastasis:
- Total body MRI is the current method for detection of metastasis.
- Radio-isotope bone scan in suspected bone metastasis.
- Chest X-ray and/or chest CT to detect pulmonary metastasis.
Management:
1. Localized prostate cancer. The options include:
 Watchful waiting (aims at detection of complications and dealing with them) is indicated for
asymptomatic patients with life expectancy less than 10 years.
 Active surveillance (aims at delayed intervention with the intention of cure in case of progression)
is indicated for small low grade tumors. Programmed follow up is carried out by repeated PSA
estimations, MRI and TRUS biopsy.
 Radical prostatectomy (by open, laparoscopic or robotic surgery) is indicated for fit patients with
life expectancy more than 10 years. The prostate is excised totally within its capsule together with
the seminal vesicles and the abdominal parts of the vasa deferentia. The bladder neck is
reanastomosed with the membranous urethra.
 Radiotherapy is an alternative to radical prostatectomy aiming at complete cure with nearly
comparable therapeutic outcome.
2. Locally advanced (extracapsular spread): Radiotherapy + Hormonal treatment.
3. Metastatic disease:
 Hormonal treatment (androgen deprivation) by medical therapy (LH releasing hormone
analogues) or bilateral orchiectomy.
 Symptomatic and palliative treatment for e.g. bone pain and spinal cord compression by medical
treatment (analgesics and steroids) and radiotherapy. Surgery is indicated with fractures.
4. Hormone refractory (androgen independent) prostate cancer: The patient goes through this
state after nearly two years of hormonal therapy. Radiotherapy or chemotherapy is resorted to.
66
TESTICULAR TUMORS
Risk factors: include
 the undescended testis
 testicular atrophy e.g. after mumps orchitis.
Pathological classification:
I- Primary testicular tumors:
A. Germ cell tumors:
1- Seminoma (most common testicular tumor in adults).
2. Non-seminomatous germ cell tumors (NSGCT)
a. Embryonal Cell Carcinoma (most common testicular tumor in children)
b. Teratoma (occurs in both children and adults).
c. Choriocarcinoma (rare): Characterized by early hematogenous spread.
3. Mixed Cell Type: These are mixtures of seminoma and NSGCT.
B. Non-germ cell tumors: Leydig cell tumors, Sertoli cell tumors and gonadoblastoma.
II- Secondary testicular tumors e.g.:
- Lymphoma: It is commonly bilateral.
- Leukemia: especially in children with acute lymphocytic leukemia.
Methods of spread:
 Lymphatic: (the most common). The retroperitoneal peri-aortic lymph nodes are involved. The
inguinal lymph nodes may be affected with scrotal invasion or violation.
 Hematogenous: (in late stages) visceral (lungs, liver, & brain) and osseous metastasis.
 Local: to epididymis, spermatic cord, tunica albuginea or scrotal skin.
A. Symptoms:
 Painless testicular swelling: is the most common presentation. Usually it is gradual with
sensation of heaviness in the scrotum due to the mass.
 Acute presentation: Acute testicular pain that may simulate acute epididymo-orchitis. It is due to
hemorrhage, infection, torsion, tumor infarction or local invasion.
 Symptoms of metastasis e.g.:
- Abdominal mass and swelling of the lower extremities (lymphatic spread).
- Bone pain, cough and hemoptysis (blood spread).
B. Signs:
 Testicular swelling which is firm to hard with loss of testicular sensation. Actually and as a rule,
any painless palpable solid testicular lump should be considered malignant until proved
otherwise.
 Secondary vaginal hydrocele or spontaneous hematocele.
 Signs of functioning tumors (hormone producing): e.g. virilization in pre-pubertal children and
gynecomastia in adults in Leydig and Sertoli cell tumors.
 Signs of metastasis:
- Palpable left supra-clavicular (Virchow gland) or inguinal lymph nodes.
- Abdominal mass due to retro-peritoneal lymph nodes metastasis.
- Secondary varicocele, lower limb edema, hepatomegaly etc.
67
Investigations for testicular tumors:

I. Tumor markers:
One or more of the following markers may be raised according to the histo-pathologic type of
the tumor:
- Alpha-fetoprotein (AFP)
- Beta-human chorionic gonadotrophin (β HCG)
- Lactic acid dehydrogenase (LDH)
II. Imaging:
- Scrotal ultrasonography: to detect the mass especially in the presence of secondary vaginal
hydrocele that can conceal the swelling.
- Abdominal ultrasonography: to detect enlarged retro-peritoneal lymph nodes, metastasis to the
abdominal organs and renal obstruction due to ureteric compression.
- Abdominal CT scan: for detection of retroperitoneal lymph nodes and tumor staging.
- Investigations for metastasis e.g. chest X-Ray, chest CT, bone scanning and brain CT.
III- Testicular biopsy: (by inguinal retrograde orchidectomy)
It is the cornerstone for the diagnosis of testicular tumors. Needle biopsy or scrotal exploration is
contraindicated to avoid upstaging of tumor by spread to the inguinal lymph nodes.
Differential diagnosis:
 Old neglected calcified hematocele.
 Tense vaginal hydrocele.
 Epididymo-orchitis simulating tumors presenting with acute testicular pain.
Treatment:
I- Retrograde inguinal orchidectomy for the primary testicular tumor
II- Management of the retro-peritoneal lymph nodes:
- Radiotherapy for seminomas (radio-sensitive) or retroperitoneal lymph node dissection for
NSGCTs.
- Chemotherapy for high stages of either seminomas or NSGCTs.
III- Follow up for five years includes:
- clinical assessment
- tumor markers assay
- CT scanning for the abdomen and chest.
68
RENAL
TRANSPLANTATION
- To know the advantages of renal transplantation over dialysis as a renal
replacement therapy.
- To know the contraindications, prerequisites and complications of renal
transplantation
RENAL TRANSPLANTATION
RENAL TRANSPLANTATION
Chronic renal failure (CRF) means irreversible, slow & progressive deterioration of renal
function over a period of months or years. Its treatment entails renal replacement therapy in
the form of chronic peritoneal or hemo-dialysis or renal transplantation. Renal transplantation
became the procedure of choice for managing patients with end stage renal disease because:
 It effectively replaces both the exocrine and endocrine (erythropoietin production, vitamin D
activation, etc.) function of the kidney.
 It significantly reduces the morbidity and mortality of end-stage renal disease.
 It provides a better quality of life than dialysis since it lacks the disadvantages of dialysis
e.g. permanent link to the dialysis machine, arteriovenous fistula and blood born viral
transmission).
 It is the most cost-effective treatment strategy.
However, the shortage of donors and tissue incompatibility hinder the procedure.
Absolute contraindications for renal transplantation include:
 Advanced physiological age (above 70 years).
 Incurable infection e.g. HIV and cytomegalovirus.
 Severe untreatable cardiac disease.
 Active malignancy.
Relative contraindications (if treated, transplantation can be considered):
 Urinary tract abnormalities as UTI and BOO.
 Active peptic ulcer.
 Curable infections and septic foci.
 Systemic and metabolic diseases that can potentially damage the graft after successful
transplantation e.g. oxalosis, cystinosis and immunologic diseases.
The donor:
 Types: living related, living un-related or cadaver donor.
 Prerequisites:
- Age between 21-60 years with written consent for donation.
- Perfect urinary tract and renal function of both renal units.
- Free of infectious diseases and malignancy.
- Absence of any generalized disease that could adversely affect renal vessel integrity or
perfusion e.g. DM or hypertension.
Compatibility evaluation: Once the patient and donor are accepted and accepting, ABO & Rh
blood grouping, HLA tissue typing and cross-matching are carried out.
Pre-transplant nephrectomy of the recipient kidney/s is not indicated except in:
 Uncontrolled renal hypertension.
 Nephrotic syndrome.
 Unresolved urinary tract infection.
 Extremely large kidney/s e.g. polycystic kidney disease.
Surgery: The transplanted kidney is placed at the iliac fossa. The renal vessels are anastomosed
to the iliac vessels and the ureter is implanted into the bladder.
The patient should be maintained on immunosuppressive therapy for life.
Complications:
 Surgical complications e.g. vascular or ureteral obstruction and urinary leakage.
 Graft rejection: hyper-acute (intra-operative), acute (within two months) or chronic rejection.
Actually, after 10 years more than 50 % of the grafts are rejected.
 Immuno-suppression induced complications e.g. infections and malignancy.
69
UROLOGIC CATHETERS
- To list and identify the various types of catheters used in urologic practice and
their indications and contraindications.
- To know the appropriate technique of urethral catheterization.
UROLOGIC CATHETERS
UROLOGIC CATHETERS
General principles of catheters and catheterization:
 Size of catheters: The size of a catheter is expressed in French (Fr) or Charriere (Ch). One Fr (one
Ch) corresponds to 1/3 millimeter of the outer diameter of the circular cut section of the catheter.
 Under-sized catheter use is a must and oversized catheter is condemned.
 Rules of asepsis during and after catheter insertion should be kept to minimize the possibility of
infection.
 A catheter should be well lubricated to be introduced gently with no violence.
 Catheter patency should be checked and kept all the time.
 Purpose of insertion:
1- Drainage of the bladder or kidney. 2- Stenting of the urethra or ureter.
3- Injection of contrast material for imaging.
4- Local instillation of irrigating fluid, chemotherapy or immuno-therapy.
URETHRAL CATHETERS
Types:
a) Nelaton catheter: It has a single channel and it is not self-retaining.
b) Two-way Foley catheter: It has an extra channel connected to a sub-terminal balloon which when
inflated keeps the catheter indwelling.
c) Three-way Foley catheter: The third channel for infusion of an irrigating fluid
Indications (uses) for:
I- Nelaton catheter:
 Emergency bladder drainage in:
i. Acute urine retention.
ii. Clot retention to evacuate and wash of blood clots before fixation
of three-way Foley catheter.
 Clean intermittent self catheterization (CIC) for atonic bladder. Nelaton catheters
 Intravesical instillation of BCG or chemotherapy for treatment of non-muscle invasive bladder TCC.
 As a tubal drain after open surgery.
 Diagnostic: Filling of the bladder with contrast material to get retrograde cystogram (to diagnose
bladder rupture) or VCUG (to diagnose VUR).
II- Two-way Foley catheter (for continuous bladder drainage):
 Recurrent acute urine retention.
 Chronic urinary retention with:
i. acute on top of chronic urine retention
ii. overflow incontinence.
iii. impaired renal function with bilateral hydro-ureteronephrosis. Two-way Foley catheter
 Preoperative: e.g. cesarean section, hysterectomy and colo-rectal surgeries; to keep the bladder
decompressed in order to avoid its iatrogenic injury.
 Postoperative: i. After bladder surgery e.g. litholapaxy, cystolithotomy and TVP.
ii. After urethral surgery e.g. VIU, urethroplasty and hypospadias repair.
iii. To fix an external ureteric catheter.
 In certain situations e.g. prolonged operations, comatosed patients and patients with
cerebrovascular or cardiac strokes.
70
UROLOGIC CATHETERS
III- Three-way Foley catheter (for continuous bladder irrigation):

 After evacuation of all blood clots in clot retention.
 After TURP or TURBT in order not to allow formation of blood clots.
Contraindications of urethral catheterization:
* Acute urethritis or epididymitis. * Urethral stone.
* In urethral trauma, urethral catheterization should not be attempted except by the urologist.
Complications of urethral catheterization:
Acute:
 Trauma during introduction (false passage) or with inadvertent traction of Foley catheter before
balloon deflation.
 Infection e.g. urethritis, epididymo-orchitis and bacteremia.
 Obstructed catheter by e.g. blood clots and phosphatic encrustation.
 Retained catheter due to failure of deflation of the balloon.
Chronic:
 Urethral stricture.
 Encrustation and stone formation.
 Defunctionalization of the bladder with long term drainage.
Technique of urethral catheterization:
General principles: Three-way Foley catheter
 The procedure and its complications should be discussed with the patient.
 A focused clinical history including urologic pathology, previous urologic surgery and
catheterization attempts should be taken.
 The patient should be in the supine position. Examination of the external genitalia and DRE are
mandatory to assess the whole urethra and exclude any contraindication of catheterization.
 Catheterization should be carried out in a sterile fashion with antiseptic preparation with draping of
the patient’s meatal and genital area.
Procedure: (A) In male patients:
 Hold the penis by the non-dominant hand to be perpendicular to the abdomen in order to eliminate
the peno-scrotal angle (between the penile urethra and the perineal urethra).
 Insert the lubricated tip of the catheter into the urethral meatus, continue gently & firmly to advance
the catheter for about 10 cm, then bring the penile shaft to the horizontal plane parallel to the abdomen.
 Continue to advance the catheter, while expecting to feel a slight increase in resistance as the
membranous urethra (external striated sphincter) is traversed.
 Once the catheter has been introduced up to the connector or to the two-way bifurcation, wait for
spontaneous urine passage.
(B) In female patients:
 The “frog-leg” position is most suitable. The non-dominant hand is used to spread the patient’s
labia to reveal the urethral meatus. It is the first opening identified below the clitoris. The female
urethra is approximately 4 cm long, so the catheter has not to be introduced as much as in males.
(C) After successful urethral catheter insertion:
 The retaining balloon should not be inflated unless the proper position of the catheter has been verified.
 The catheter should be attached to a sterile closed bag system.
 The drainage bag should be placed below the level of the bladder to allow flow with the tubing as
straight as possible since kinks would impair drainage.
71
UROLOGIC CATHETERS
URETERIC CATHETERS
They are slender, long, radio-opaque and scaled tubes. They are inserted under anesthesia and
fluoroscopic guidance, either endoscopically (using a cystoscope) or during open surgery. They
are usually applied being loaded on an already introduced guide wire.
Types:
 External ureteric catheter: It passes from outside the body to the urethra, into the ureteric
orifice through the whole ureter up to the renal pelvis. It is attached to a Foley catheter to be
fixed.
 Indwelling ureteric catheter (double J or JJ stent): It has two coiled ends (renal and bladder).
It is self retained and fenestrated all through.
Indications (uses):
 Diagnostic (using ureteric catheter only):
- Retrograde uretero-renogram before PNL and in cases of ureteric injury or stricture
- Selective urine sample from one uretero-renal unit for culture or cytology
 Drainage in case of:
- Obstructive anuria (most important indication)
- Obstructive pyelonephritis
- Persistent leakage after renal or ureteric surgery or trauma
 Stenting after:
- Pyeloplasty, ureteric reimplantation or resection & reanastomosis
- Ureteroscopy
 Before SWL for bilateral renal stones or stone in a solitary kidney. External ureteric catheter
Advantages of external ureteric catheter over indwelling JJ stent:
 No vesico-ureteric reflux
 Removal without anesthesia
 Suits short term (few days) purposes
 Allows injection of contrast material to perform uretero-
renography
 Being an external catheter, it cannot be neglected
 Cheaper
Advantages of JJ stent over external ureteric catheter:
 Concealed (no urethral involvement or external urine collecting
bag)
 Less chance for obstruction or slippage Indwelling (double J or JJ)
 Suits long term (weeks or few months) purposes ureteric stent
 Spares the urethra with less urethral complications e.g. stricture
Complications: (especially with indwelling ureteric JJ stents)
 Irritative LUTS and renal pain
 Ascending renal infection especially
 Hematuria: the renal end of the ureteric catheter hits the upper calyx with inspiration
 Upward or downward migration of JJ stent.
 Encrustation and stone formation on a neglected JJ stent.
72
UROLOGIC CATHETERS
PERCUTANEOUS NEPHROSTOMY(PCN) TUBE

It is a single J-tip radio-opaque catheter. It is introduced through the loin to the pelvi-calyceal
system loaded on a guide-wire under fluoroscopic or sonographic guidance.
Indications:
 Obstructive anuria
 Infected hydronephrosis
 Hydronephrosis with renal function impairment
 It can also be used as a percutaneous cystostomy (suprapubic) tube
Contraindications:
 Bleeding tendency
 Suspicion of renal tumor
Complications:
 Hematuria
 Infection
 Obstruction
 Slippage Percutaneous nephrostomy tube
 Leakage around the catheter or after its removal
PERCUTANEOUS CYSTOSTOMY TUBE
It is introduced through the suprapubic region to a full bladder. It may be inserted under
ultrasound guidance or even fluoroscopy in a contrast-opacified urinary bladder. Care must be
taken to avoid injury to the sigmoid colon. It is a simple procedure with almost 100% success
rate.
Indications:
 Acute retention of urine with any of the following conditions:
- Failure of urethral catheterization
- Bleeding per urethra or multiple urethral false passages
- Acute urethritis
- Acute epididymitis or epididymo-orchitis
 Diversion of urine in:
- Partial anterior urethral rupture
- Fourneire gangrene
Contraindications include:
- bladder rupture
- bladder tumor.
- empty bladder
GUIDE WIRES
- Guide wires are thin long radio-opaque wires with GUIDE WIRE
malleable tip that can be passed easily through any
endoscope or catheter.
- They guide the passage of endoscopes and catheters
through the urinary tract during e.g. VIU, URS, PCN
insertion and PNL
WITH OUR BEST REGARDS AND WISHES 73

Urology For Undergraduate 2021

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Urology

Revised Fifth Edition

II- Lower urinary tract symptoms (LUTS):

ACUTE URINARY (URINE) RETENTION:

E- Treatment of hematuria: entails treatment of the cause besides:

FOCUSED UROLOGIC EXAMINATION

II- Intra-abdominal swellings:

Male external genitalia examination:

II- Scrotum, testes, epididymes and spermatic cords:

III-Differential diagnosis of inguino-scrotal swellings:

Inguinoscrotal swellings include e.g.:

Different anatomical types of hydrocele

Special clinical tests for vaginal hydrocele:

 Findings by DRE (both normal and abnormal findings):

Urinary casts include:

Normal sonographic appearance of the:

KUB film can show:

D- Intravenous urography (IVU):

NON-SPECIFIC GENITO-URINARY INFECTIONS

Risk factors for UTI:

3) PYONEPHROSIS: It may result from:

GENITO-URINARY TUBERCULOSIS (TB)

Clinical presentation of genito-urinary TB:

III- Cystoscopy in case of TB may show:

SCHISTOSOMIASIS OF THE URINARY TRACT

Clinical picture includes:

Investigations for schistosomiasis and its complications:

II) Vesico-ureteric reflux = VUR (Functional obstruction):

Clinical manifestations of hydronephrosis:

Sonographic appearance of hydronephrosis:

 Radiological signs of hydronephrosis include:

BLADDER OUTLET OBSTRUCTION

BENIGN PROSTATIC HYPERPLASIA (BPH)

C. Other urodynamic studies (cystometry):

α1 adrenergic blockers 5α-reductase inhibitors

Retrograde urethrography showing

Pathologic effects of urinary stones:

Methods of detection of stones:

Modalities of treatment of urolithiasis:

Sonographic appearance KUB: KUB: Bilateral staghorn

C- Percutaneous nephrolithotripsy (PNL):

Treatment: (no medical treatment or open surgery)

URINARY TRACT TRAUMA

Mechanisms and etiology:

Grading: (by abdominal CT):

Investigations in case of renal trauma aim to:

UPPER URINARY TRACT ANOMALIES

IV. Congenital cystic kidney diseases include:

LOWER URINARY TRACT ANOMALIES

Different types of Distal penile Scrotal

B- ERECTILE DYSFUNCTION (ED)

7- Other Causes of Acute Scrotum

VOIDING DYSFUNCTION AND NEURO-UROLOGY

OVERACTIVE BLADDER (OAB)

NOCTURNAL ENURESIS (NE)

NEUROPATHIC (NEUROGENIC) BLADDER

RENAL CELL CARCINOMA (RCC)

WILMS' TUMOR (NEPHROBLASTOMA)

Investigations for bladder cancer:

Types of supravesical urinary diversion (after radical cystectomy)

 Locally advanced prostate cancer:

Investigations for testicular tumors: