Urologic Disorders

Urinary Tract Infections

Routes: Ascending (most common), hematogenous, direct spread from adjacent organs (e.g. Diverticulitis), lymphatic (rare)

Urethritis

Common in men Presentation: LUTS (Dysuria, frequency etc) o 25% asymptomatic (esp. women) In young men: cause is usually STD o Gonococcal vs. Non-gonococcal
Gonococcal (N. gonorrhea) 3-10 days Gram -ve Profuse discharge Gram stain PCR Culture Ceftriaxone + Azithromycin/doxycycline Nongonococcal (Chlamydia) 1-5 weeks Intracellular Scant Immunoassay (Chlamydia-specific ribosomal RNA) PCR Culture Azithromycin/ doxycycline

IP

Dx

Epididymitis

Hx

Acute (<6 wks): pain & swelling Chronic: long standing pain no swelling
Epididymitis Old patient Gradual onset + LUTS +/- Hematuria Inflammation: Redness, warmth, swelling Present Positive Torsion Young <25 yrs Sudden onset LUTS usually absent High-riding testis, horizontal lie Absent Negative

P/E Cremasteric reflex* Prehns sign** U/S Nuclear scan Culture

Hyperemia No blood flow Hyper-photogenic Photopenic scan Old: E. coli Negative Young: N. gonorrhea, C. trachomatis Rx Antibiotics Surgery: Detorsion, fixation * Stroking inner thigh = Cremasteric contraction = elevation of scrotum & testis ** Elevation of scrotum & testis relieves pain

Prostatitis

Classification

Category I: Acute bacterial

Category II: Chronic bacterial

Category III: Chronic Pelvic Pain Syndrome

Category IV: Asymptomatic Inflammatory Prostatitis

Rare Irritative & obstructive LUTS Fever, chills, N&V - tender, swollen prostate

Antibiotics 4-12 wks Massage Prophylaxis Surgery

Antibiotics 4 wks Massage Alpha-blockers Anti-inflammatory Physiotherapy Surgery

Analgesics Anti-inflammatory Alpha-blockers Physiotherapy Surgery

Admit + antibiotics + drainage

Inflammation +/- infection (ascending) o Dysuria, frequency o Voiding dysfunction o Perineal pain o Painful ejaculation Difficult to treat: not all drugs penetrate capsule Can lead to urosepsis

Cystitis
More common in women (short urethra + sometimes genetic dispositions: urothelium facilitates adhesion of E. coli) Presentation: Dysuria, urgency, frequency etc. +/- hematuria o Fever is rarely present (unless pyelonephritis develops) Dx: o Dip-stick: +ve for nitrites o Urinalysis o Urine culture (gold standard) needs 2 days start empirical Rx before results Rx: o Healthy young woman ~ 3 days: ciprofloxacin o Pregnant, old, DM, injury ~ 7 days: TMP-SMX or amoxicillin o Men >50 yrs ~ 7 days: TMP-SMX or fluoroquinolone

Pyelonephritis
Inflammation of kidney & renal pelvis

Presentation o Fever, chills o Costovertebral (renal) angle tenderness o Abdominal pain, diarrhea, N&V o LUTS o Gram ve bacteremia (sepsis) Dx o CBC: Leucocytosis o Urinalysis: WBCs, RBCs, bacteria (mid-stream urine; microscopy); Dipstick (rapid results) o Culture (+ve in 80%): E. coli (most common), Enterococcus species o Renal function tests: increased creatinine? o Imaging (U/S, IVP, CT): rule out obstruction Rx: If there is an abscess/obstruction > Drain

Urolithiasis
Common in Saudi Arabia Prevalence 2-3% Lifetime prevalence: Men (20%) > Women (5-10%) Recurrence rate: 50% in 10 years Risk factors o Intrinsic Genetic e.g. Cystinuria (autosomal recessive) in children Age 20-40 years Gender (male) o Extrinsic Geography (desert, high altitudes etc) Water intake Diet (purines, oxalates, sodium) Weather (July-October) Occupation/life-style (sedentary) Pathophysiology o Anatomic abnormalities of the tract e.g. hydronephrosis, obstruction etc. lead to crystal formation o Supersaturation of minerals = crystal formation = aggregation of crystals = stones o Modifiers of crystal formation Inhibitors: Citrate, magnesium, urinary protein e.g. nephrocalcin Promoters: Oxalate (coffee, chocolate, soda drinks) Types o Calcium stones (calcium oxalate) = 75% o Uric acid stones (uric acid present in animal protein), commonest cause of radiolucent kidney stones o Cystine stones; amino acid that is insoluble in water; proximal tubules cannot reabsorb it o Struvite (Calcium phosphate +/- ammonium magnesium phosphate)

Presentation: DDx: o Renal/ureteric colic Gastroenteritis o Dysuria & frequency Salpingitis o Hematuria Appendicitis o GIT: diarrhea, ileus, N&V Colitis o Flank pain Radiating to LQ or scrotum/labia o P/E: Costovertebral (renal) angle tenderness Restlessness Tachycardia, BP Fever if w/UTI Dx: o Urinalysis: crystals, RBCs, WBCs, bacteria o Imaging CT is gold standard 1st step Plain film (KUB) shows radiopaque IVP shows radiopaque & radiolucent U/S shows hyperechoic shadow & acoustic shadow Rx: o Stone <5mm: 90% spontaneous passage Conservative: hydration, analgesia, antiemetics o Admission if: Renal impairment Refractory pain (give IV analgesics) Intractable vomiting (IV antiemetics) Pyelonephritis (stone 3mm + fever & chills) o Extracorporeal Shock Wave Lithotripsy (ESWL) o Ureteroscopy (laser) o Percutaneous Nephrolithotripsy (PNL) if huge o Open surgery (not anymore)

Voiding Dysfunction
Storage Bladder wall - Over-reactivity (women, spinal cord injury, stroke to inhibitory center) - Hypersensitivity Outlet problem - Stress incontinence - Sphincter problem Combination Urgency, frequency, nocturia Emptying Bladder Wall - Neurogenic - Myogenic - Idiopathic Outlet problem - BPH - Urethral stricture - Sphincter dys-synergia Combination Hesitancy, poor stream, dribbling, double voiding

Benign Prostatic Hyperplasia

Presentation
LUTS (obstructive & irritative) Urinary retention Urinary tract infection Hematuria Renal insufficiency

Physical Examination - Digital rectal exam (DRE) o BPH: smooth surface o Cancer: nodular - Focused neurologic exam (DM, tabis dorsalis, Parkinsons can mimic BPH) o Prostate, rectal, anal tone - Abdomen: distended bladder

Diagnosis
Urinalysis (dipstick): glucose, protein, blood (hematuria, UTI?) Urine culture: UTI? Serum prostate-specific antigen (high with cancer) Serum creatinine Flow rate (& residual volume; should be zero) U/S

Treatment
Medical - Selective alpha-1-blockers e.g. Tamsulocin, Alfuzocin, Terazocin (relax prostate) - Androgen suppression: 5-alpha-reductase inhibitors e.g. Fenasteride (potent; shrinks prostate 60% in 6 months) Surgical - Endoscopic: transurethral prostate resection (TUPR), laser ablation - Open surgery