GENITOURINARY

DrAfnan Abdirahman Mohamed

• Urinary symptoms
• Haematuria:
• Presence of blood in the urine (haematuria) may be the only indication of
pathology in the urinary tract.
• A sustantial haemorrhage into the urinary tract will give the urine a red or
brownish tinge (macroscpic haematuraia) and the patient may pass blood
clots, false-positive stick test and discoloured urine caused by beetroot and
some drugs.
• Haematuria may be intermittent or persistent. Blood appearing at the
beginning of the urinary stream indicates a lower urinary tract cause,
whereas uniform staining throughout the stream points to cause higher up.
• Terminal heamturia is typical of severe bladder irritation caused stone
or infection.
• If the patient experience pain with heamturia, the characteristic of
the pain may help to identify the source
• Pain:
• Inflammation and acute obstruction to the flow of urine from the
renal pelvis are liable to cause pain that is typically felt as a deep-
seated, sickening ache in the loin.
• It is probably the result of stretching of the capsule of the kidney
• However, calculi in the kidney can also be painful in the absence of
infection
• Slow-growing masses such as tumours or cysts are not usually painful
unless they are very large
• Ureteric colic
• This is an acute pain felt in the loin and radiating to the ipsilateral iliac
fossa and genitalia.
• The patient often rolls around in agony as waves of excruciating sharp
pain are imposed upon a continuing background of discomfort
• Ureteric colic is usually caused by the passage of a stone, but blood
clot or sloughed renal papilla may give identical pain.
• The site of the pain is a partial guide to the progress of a stone: the
more the pain radiates into the groin, the more distal the stone
• Bladder pain
• Bladder pain is felt as a suprapubic discomfort made worse by bladder
filling.
• In men, a sharp pain misleadingly referred to the tip of the penis may
be the result of irritation of the trigone of the bladder.
• Severe inflammation of the bladder can cause an extreme wrenching
discomfort at the end of micturition. This symptom of bladder stone
• Urethral pain
• Urethral pain is a scalding or burning felt in the vulva or penis,
especially during voiding.
• Altered bladder function
• The normal bladder has two distinct phases of function. During the
filling phase the bladder acts as a reservoir to collect urine until it is
emptied in the voiding phase.
• Inappropriate contraction of the bladder detrusor muscle during
filling (instability) is perceived as a sensation of urgency to pass urine.
• When detrusor instability has a demonstrable neurological cause, it is
known as hyperreflexia.
INVESTIGATION OF THE URINARY TRACT

• Urine

• Dipsticks impregnated with chemicals that change color in the

presence of blood, protein or nitrites
• Tests of renal function
• More than 70% of kidney function must be lost before renal failure
becomes evident: there is a large functional reserve.
• It follows that renal damage must be extensive before changes occur
in blood constituents whose level is controlled by renal excretion.
• Such damage is of three main types:
• A. reduction of renal plasma flow,
• B. destruction of glomeruli and
• C. impairment of tubular function.
• Imaging
• A plain abdominal radiograph showing the kidneys, ureters and
bladder (the KUB)
• Most urinary calculi absorb X-rays and should be sought in the region
of the renal shadows and along the course of each ureter.
• These normally follow the tips of the transverse processes of the
vertebrae, cross the sacroiliac joints and head for the ischial spine
before hooking medially towards the bladder base
• Stones with a low calcium content and those overlying bony
structures may be difficult to see on the plain film.
• Pelvic phleboliths are very common and can look like lower ureteric
calculi.
• Uric acid stones are the most common radiolucent calculi
• Intravenous urography (urography)
• Excretion renography has been a mainstay of urological investigation
since the introduction of intravenous contrast media in the 1930s
• When such a chemical is injected, usually into a vein in the
antecubital fossa, it is filtered from the blood by the glomeruli and
does not undergo tubular absorption. As a result, it rapidly passes
through the renal parenchyma into the urine, which it renders radio-
opaque
• Although intravenous urography (IVU) gives excellent images of the
urinary tract, its use should be restricted because in a few patients
the iodine in the contrast medium may provoke a potentially life-
threatening anaphylactic reaction
• Retrograde ureteropyelography (synonym: retrograde ureterogram)
• A fine ureteric catheter can be passed into the ureteric orifice through
a cystoscope. Contrast medium injected through the catheter will
demonstrate the anatomy of the upper urinary tract
• Ultrasonography
• High-resolution ultrasonography is perhaps the imaging technique
most widely used in urology.
• The size of the kidney, the thickness of its cortex and the presence
and degree of hydronephrosis can be measured with great accuracy.
• Intrarenal masses can be diagnosed as smooth walled and fluid filled
(simple cysts) or solid and complex (possible tumours)
• Transrectal ultrasonography
• This has become a routine component of the investigation of sus-
pected carcinoma of the prostate
• Computerised tomography
• CT is particularly useful to assess structures in the retroperitoneum .
• In renal carcinoma it will show:
• the size and site of the tumour and the degree of invasion of adjacent
tissue;
• the presence of enlarged lymphnodes at the renal hilum;
• Invasion of the renal vein and venacava.
ANURIA
• Anuria is defined as the complete absence of urine production. Oliguria
is present when less than 300 ml of urine is excreted in a day
• The maintenance of renal function and urine production depends upon
perfusion of the kidneys with oxygenated blood.
• Reduced renal blood flow or hypoxia impairs renal function. When both
are present, the danger of acute renal failure is even greater.
• Renal failure is traditionally divided into:
• • prerenal;
• renal;
• postrenal(obstructive).
• Prerenal
• Prerenal causes of acute renal failure include:
• Hypovolaemia
• Blood loss
• Sepsis
• cardiogenicshock
• anaesthesia;
• hypoxia.
• Renal
• Renal causes of acute renal failure include:
• drugs; Aminoglycosides, cephalosporins and diuretics can be nephro-
toxic, particularly if used in combination
• poisons;
• contrast media;
• eclampsia;
• myoglobinuria;
• incompatible blood transfusion;
• disseminated intravascular coagulation.
• Obstructive
• Obstructive causes of acute renal failure include:
• • calculi;
• pelvic malignancy;
• surgery;
• retroperitoneal fibrosis;
• bilharzia;
• crystalluria.
• Management and treatment
• Renal failure caused by acute tubular necrosis may progress through
three recognisable phases:
• oliguria;
• Thediuretic phase;
• recovery.
• The initial management is aimed at prompt restoration of the cir-
culating volume deficit and correction of tissue hypoxia
• For patients with hypovolaemia or sepsis, inotropic support with
dopamine may improve cardiac efficiency and increase renal blood
flow.
• If urine production is not promptly restored, frusemide (furosemide)
can be given but this is not always successful and the drug itself may
be nephrotoxic
• Mannitol may be used as a plasma expander and osmotic diure- tic,
but care must be taken not to overload the circulation.
• if these measures fail, acute tubular necrosis has supervened.
• Excess fluid loads must be avoided and fluid input restricted to match
the reduced output plus insensible losses (500–800 ml per 24 hours
depending on ambient conditions)
• Abnormal losses due to vomiting, nasogastric aspiration, diarrhea or
fistulae will be monitored and replaced.
• A hyperkalaemic acidosis is the characteristic metabolic abnormality
of the oliguric phase of renal failure.
• Correction of the metabolic acidosis with intravenous bicarbonate is
tempting but not always advisable.
• Rising serum potassium is life- threatening and requires effective
intervention. A calcium resonium enema is the simplest remedy
• Peritoneal dialysis
• Provided that the patient has not had recent abdominal surgery,
peritoneal dialysis can be performed by insertion of a fenestrated
catheter under local anaesthesic

• Haemodialysis
• A few sessions of haemodialysis may be life saving. A double- lumen
catheter is placed over a guidewire into one of the great veins
(jugular, subclavian or femoral)
• Haemofiltration
• This, like haemodialysis, requires the use of an extracorporeal
machine but causes much less haemodynamic upset. This may be of
critical importance for the acutely ill patient.
• Obstructive renal failure
• When the patient is too ill for surgery to remove the cause of
obstruction to the upper urinary tract,
• the treatment of obstructive renal impairment is drainage, either
externally using a nephrostomy or internally using an indwelling stent
•The kidney and ureter
Surgical anatomy
• The parenchyma of each kidney usually drains into seven calyces,
three upper, two middle and two lower calyces
• Each of the three segments represents an anatomical and physiologic-
ally distinct unit with its own blood supply.
CONGENITAL ABNORMALITIES OF THE KIDNEY

• Absence of one kidney

• The prevalence of unilateral renal agenesis is about 1:1400 and it is
usually discovered incidentally.
• If the mesonephric duct has failed to bud, the ureter will be absent.
Alternatively, the ureter and renal pelvis are present but the kidney is
absent.
• Renal ectopia
• In approximately 1:1000 people the kidney does not ascend. Ectopic
kidneys are usually found near the pelvic brim and are usually left
sided.
• The contralateral kidney is generally in its normal position.
• Disease in an ectopic kidney may present diagnostic problems and an
unwary surgeon may be tempted to remove it as an unexplained
pelvic mass.
• Horseshoe kidney
• When the medial subdivisions of the mesonephric bud meet and fuse,
the normal ascent of the kidneys is impeded by midline structures.
The result is a pair of ectopic kidneys, usually fused at their lower
poles, lying in front of the fourth lumbar vertebra and great vessels.
• Clinical features
• Horseshoe kidneys are liable to disease, possibly because the ureters
angulate as they pass over the fused isthmus
• This may lead to urinary stasis with consequent infection and
nephrolithiasis.
• Sometimes there is a true pelvi-ureteric junction obstruction
• Division of the isthmus between the kidneys is usually only indicated
in the course of surgery for abdominal aortic aneurysm.
• Congenital cystic kidneys
• Congenital cystic kidneys (synonym: polycystic kidneys) are hereditary
and potentially lethal, and can be transmitted by either parent as an
autosomal dominant trait
• Pathology
• The kidneys are huge: the cysts distort the renal capsule. The renal
parenchyma is riddled with cysts of varying size containing clear fluid,
thick brown material or coagulated blood. There may be a congenital
cystic disease of the liver
• Clinical features in the adult
• The condition is slightly more common in women than men. There are
six clinical features:
• An irregular upper quadrant abdominal mass;
• Loin pain;
• haematuria;
• infection;
• hypertension;
• uraemia
• Imaging
• Renal imaging shows multiple cysts in both kidneys and some-times
cysts in the liver and other organs.
• Polycystic kidneys have a typical appearance on urography: the renal
shadows are enlarged in all directions; the renal pelvis is compressed
and elongated; and the calyces are stretched over the cysts (‘big,
bizarre and bilateral’)
• Treatment
• As kidney failure develops, a low-protein diet will help to post- pone
the inevitability of renal replacement therapy.
• Infection, anemia, hypertension and disturbances of calcium
metabolism also need appropriate treatment by a nephrologist.
• Surgery to uncap the cysts (Rovsing’s operation) is rarely indicated
because few now accept that this can preserve renal function by
relieving pressure on the parenchyma
CONGENITAL ABNORMALITIES OF THE RENAL PELVIS AND URETER

• Duplication of a renal pelvis

• Duplication of a renal pelvis is found in about 4% of patients. It is
usually unilateral and left sided.
• The small upper renal pelvis drains the upper group of calyces; the
larger lower renal pelvis drains the middle and lower groups of
calyces
• Duplication of a ureter
• Duplication of a ureter is found in about 3% of urograms. The ureters
often join in the lower third of their course and have a common
ureteric orifice. When the ureters open independently into the
bladder the ureter from the upper pelvis opens distal and medial to
its fellow
• Clinical features
• Duplication of the renal pelvis or ureter is often a chance finding on
renal imaging, but infection, calculus formation and pelviureteric
junction obstruction are more common than in normal kidneys
• INJURIES TO THE KIDNEY
• injuries to the kidney result most often from either blows or falls on
the loin or crushing injury to the abdomen, typically in a road traffic
accident.
• Haematuria after trivial injury to the kidney should suggest the
possibility of a pre-existing disease, e.g. calculus, hydronephrosis or
tuberculosis.
• The degree of injury varies considerably from a small sub- capsular
haematoma to a complete tear through the kidney
• The kidney may be partially or wholly avulsed from its vascular
pedicle; one pole may be completely detached.
• Closed renal injury is usually extraperitoneal.
• In young children who have very little extraperitoneal fat, the
peritoneum, which is closely applied to the kidney, can tear with the
renal capsule, leaking blood and urine into the peritoneum
• Clinical features of closed renal trauma
• Superficial soft-tissue bruising can be absent but there is local pain
and tenderness.
Types of closed renal trauma: (a) subscapular haematoma; (b)
laceration; (c) avulsion of one pole; (d) avulsion of the renal pedicle.
• Management and treatment
• Conservative watchful treatment of closed renal trauma is usually
successful. The possibility of injury to other organs must be
considered at an early stage.
• Blood should be cross-matched for transfusion if there is evidence of
hypovolaemic shock or continuing haemorrhage. Intravenous access
should be established.
• The patient should stay in bed while there is macroscopic haematuria
and activity must be curtailed for a week after the urine clears.
• Morphine analgesia may be appropriate.
• Hourly pulse and blood pressure charts must be kept.
• Antibiotics should be given to prevent infection of the haematoma.
• Each sample of urine passed should be checked for haematuria and
the result charted.
• Intravenous urography (IVU) or contrast-enhanced CT should be
performed urgently to assess the damage to the kidney and to show
that the other kidney is normal.
• Blood should be sent for grouping and serum saved forcross-
matching.
• Surgical exploration
• Surgical exploration is necessary in less that 10% of closed injuries;
• it is indicated if there are signs of progressive blood loss or there is an
expanding mass in the loin.
• The aim is to stop bleeding while conserving as much renal tissue as
possible; a renal arteriogram performed preoperatively can be helpful
in framing a strategy for doing this
• Complication:
• Heavy heamatoma may lead to clot reention requiring bladder
washout
• Pararenal pseudohydronephrosis
• Hypertension resulting from renal fibrosis may occur long after injury.
It is often refractory to medical treatment and nephrec- tomy may be
necessary.
• Post-traumatic aneurysm of the renal artery
•RENAL CALCULI
• DEF: nephrolithiasis is refer to renal stone disease, urilithiasis refer to
the presence of stone in the urinary sysstem

• ETIOLOGY:
• Metabolic
• Lifestyle
• Genetic factors
• Drugs
• Others
• Risk factors increase:
• Immobility
• sedentary lifestyle
• dehydration
• metabolic distrubance: hyperparathyrodism
• history of renal calculi
TYPES OF RENAL STONES
• Oxalate calculus (calcium oxalate)
• Oxalate stones are irregular in shape and covered with sharp
projections, which tend to cause bleeding. The surface of the cal-
culus is discoloured by altered blood. A calcium oxalate mono-
hydrate stone is hard and radiodense.
• Phosphate calculus
• A phosphate calculus [calcium phosphate often with ammonium
magnesium phosphate (struvite)] is smooth and dirty white. It tends
to grow in alkaline urine, especially when urea-splitting Proteus
organisms are present
• Uric acid and urate calculi
• These are hard, smooth and often multiple.
• They vary from yellow to reddish brown and sometimes have an
attractive, multi- faceted appearance.
• Pure uric acid stones are radiolucent and appear on an excretion
urogram as a filling defect, which can be mistaken for a transitional
tumour of the upper urinary tract.
• The presence of uric acid stones is confirmed by CT
• in children, mixed stones of ammonium and sodium urate are
sometimes found. They are yellow, soft and friable. They are
radiolucent unless they are contaminated with calcium salts.
• Cystine calculus
• These uncommon stones appear in the urinary tract of patients with a
congenital error of metabolism that leads to cystinuria.
• Hexagonal, translucent, white crystals of cystine appear only in acid urine.
• They are often multiple and may grow to form a cast of the collecting
system.
• Pink or yellow when first removed, they change to a greenish colour when
exposed to air.
• Cystine stones are radio- opaque because they contain sulphur, and they
are very hard.
• Xanthine calculus
• These are extremely rare. They are smooth and round, brick-red in
colour, and show lamellation on cross-section
• Clinical features
• Renal calculi are common. Approximately 50% of patients present
between the ages of 30 and 50 years. The male–female ratio is 4:3.
• Symptoms are variable and the diagnosis sometimes remains
• obscure until the stone is discovered on a radiograph
• Silent calculus
• Even large staghorn calculi may cause no symptoms for long periods,
during which time there is progressive destruction of the renal
parenchyma.
• Uraemia may be the first indication of bilateral calculi, although
secondary infection usually produces symptoms first
• Pain
• Pain is the leading symptom in 75% of people with urinary stones.
Fixed renal pain is located posteriorly in the renal angle
• anteriorly in the hypochondrium, or in both. It may be worse on
movement, particularly on climbing stairs.
• Ureteric colic is an agonising pain passing from the loin to the groin.
Typically, it starts suddenly causing the patient to writhe to find
comfort. Pain resulting from renal stones rarely lasts more than 8
hours in the absence of infection
Investigation of suspected urinary stone disease

• Radiography
• The ‘KUB’ film shows the kidney, ureters and bladder. When a renal
calculus is branched, there is no doubt about the diagnosis An opacity
that maintains its position relative to the urinary tract during
respiration is likely to be a calculus.
• Surgical treatment of urinary calculi
• Conservative management
• Calculi smaller than 0.5 cm pass spontaneously unless they are
impacted.
• Any surgical intervention carries the risk of complications and
needless intervention should be avoided.
• Small renal calculi may cause symptoms by obstructing a calyx or
acting as a focus for secondary infection.
• However, most can be safely observed until they pass
• Modern methods of stone removal
• Kidney stones
• Percutaneous nephrolithotomy
• Complications of percutaneous nephrolithotomy include
• (1) haemorrhage from the punctured renal parenchyma this may be profuse
and difficult to control;
• (2) perforation of the collecting system with extravasation of saline irrigant;
(
• 3) perforation of the colon or pleural cavity during placement of the
percutaneous track.
• Extracorporeal shock wave lithotripsy
• A urinary calculus has a crystalline structure. Bombarded with shock
waves of sufficient energy it disintegrates into fragments.
• Open surgery for renal calculi
• Pyelolithotomy Pyelolithotomy is indicated for stones in the renal
pelvis. When the wall of the renal pelvis has been dissected free from
its surrounding fat, an incision is made in its long axis direct- ly on to
the stone. The stone is removed with gallstone forceps

• Nephrolithotomy If there is a complex calculus branching into the

most peripheral calyces, it may be necessary to make incisions into
the renal parenchyma to clear the kidney.
• Ureteric stone
• Pain
• Non-steroidal anti-inflammatory drugs such as diclofenac and
indomethacin have replaced opiates as the first line of treatment for
renal colic.
• Indications for surgical removal of a ureteric calculus
• Repeated attacks of pain and the stone is not moving
• Stone is enlarging
• Complete obstruction of the kidney
• Urine is infected
• Stone is too large to pass
• Stone is obstructing solitary kidney or there is bilateral
• obstruction
• Endoscopic stone removal
• Dormia basket The use of wire baskets under image intensifier
control has been replaced by ureteroscopic techniques but they may
be useful when the necessary instruments and expertise are not
available
• Ureteric meatotomy Stones often lodge in the intramural part of the
ureter. Endoscopic incision using a diathermy knife can enlarge the
opening and free the stone.
• Open surgery
• Ureterolithotomy
• A radiograph confirms the position of the stone immediately before
surgery.
• The incision must be appropriate for the position of the stone.
• Calculi in the upper third of the ureter are approached through a loin
or upper quadrant transverse incision as used for a stone in the renal
pelvis.
• Access to midureteric stones is through a muscle-cutting iliac fossa
incision;
• lower ureteric stones are best reached through a Pfannenstiel incision.
•NEOPLASMS OF THE KIDNEY
Benign renal tumors
• Are non-cancerous growths of the kidney that do not metastasize to
other sites in the body.
• They are not life- threatening but they can Couse complains if they
exert pressure effects on adjacent structures.
• As there is universal increase in the use of radiological imaging,
benign renal masses are being detected more frequently.
• Adenoma
• Pea-like cortical adenomas are occasionally discovered at post-
mortem examination or incidentally during radiological imaging. They
are asymptomatic and defined as benign.

• Angioma
• Angioma may cause profuse haematuria, often in young adults. The
source of the bleeding may be difficult to diagnose without renal
angiography
• Angiomyolipoma
• Angiomyolipoma is an unusual tumour of the kidney that is often but
not always associated with tuberous sclerosis. Its high fat content
gives it a typical appearance on CT. Malignant elements are present in
about one-quarter of them and may lead to metastasis.
Malignant neoplasms

• Renal neoplasm in children:

• Wilms’ tumour (synonym: nephroblastoma)
• This is a mixed tumour containing blastemal, stromal and epithelial
elements arising from embryonic nephrogenic tissue.
• The tumours are usually discovered during the first 5 years of life,
usually in one pole of one kidney. Bilateral tumours pose a difficult
clinical problem.
• Clinical features
• An abdominal tumour grows rapidly while the general well-being of
the child deteriorates.
• The mass may be enormous compared with the tiny patient.
• Some patients are hypertensive.
• Haematuria denotes extension of the tumour into the renal pelvis
and the prognosis is less good.
• Imaging by ultrasonography, CT or magnetic resonance imaging (MRI)
confirms a solid space-occupying lesion in the kidney, with or without
venous invasion, contralateral disease and distant spread
• Metastasis to the lungs occurs early. Liver, bone and brain metastases
are rare.
• Lymphatic spread is uncommon.
• Treatment These children are best treated in specialist paediatric
oncology units.
• Most unilateral tumours are treated by chemotherapy followed by
nephrectomy.
• Partial nephrectomy may be possible in patients with bilateral disease
• Renal neoplasm in adults
• Hypernephroma (synonym: Grawitz’s tumour)
• This adenocarcinoma, the most common neoplasm of the kidney
(75% incidence), arises from renal tubular cells. Whether carcinoma
arises in pre-existing adenomas is uncertain.
• Spread The tumour is prone to grow into the renal vein. Cells are
swept into the circulation and end up in the lungs, where they grow
to form cannonball secondary deposits
• Clinical features Adenocarcinoma of the kidney is twice as common in
men as in women.
• Haematuria is usually the presenting symptom, sometimes with clot
colic.
• There may be a dragging discomfort in the loin or the patient may
detect a mass
• In men, a rapidly developing varicocele is a rare but impressive sign,
occurring most often on the left side because the left gonadal vein is
obstructed where it joins the left renal vein.
• Atypical presentations In 25% of cases there are no local symptoms.
The patient presents with symptomatic secondary deposits in bone or
the lung
• Occasionally, persistent pyrexia (37.8–38.9°C) with no evidence of
infection is the only symptom.
• Pyrexia after nephrectomy suggests metastases
• A few patients present with constitutional symptoms and anaemia.
• Polycythaemia occurs in 4% of cases as a result of the production of
erythropoietin by tumour cells
• Other hormones, such as renin and calcitonin, may be
produced by the tumour. Hypercalcaemia is common.
• Investigation
• Intravenous urography is still an important component of
the investigation of haematuria.
• The plain radiograph may show abnormal calcification in the
tumour and distortion of the renal outline, which will be
confirmed on the nephrographic film.
• A chest radiograph is essential to detect lung secondaries. An
isotope bone scan will reveal deposits in bone.
• Treatment If the tumour is confined to the kidney, treatment is
nephrectomy with removal of the perinephric fat.
• Papillary transitional cell tumours of the renal pelvis
• These resemble those of the bladder but are much less common.
They may invade the renal parenchyma and have a tendency to be
multifocal and to distant spread.
• Multiple ureteric tumours are thought to arise from a field change
that renders the whole urothelium liable to metaplasia rather than
seeding down the ureter.
• Whether the carcinogen is chemical or viral is uncertain.
• Clinical features Haematuria is the most common symptom and
usually causes the patient to seek help before the tumour mass
becomes palpable.
• The presence of malignant cells in the urine may indicate whether the
tumour is well or poorly differentiated. There is some evidence that
those with poorly differentiated tumours do better if they have a
short course of radiotherapy before surgery. It is therefore useful to
obtain cells from the tumour by sampling using a brush or catheter
passed up the ureter under radiological control
• Intravenous urography usually demonstrates the tumour
• Treatment Conventional surgical treatment is by nephroureterec-
tomy. The ureter must be disconnected with a cuff of bladder wall. If
this is done by open surgery a second incision is needed to remove
the kidney.
• Squamous cell carcinoma of the renal pelvis
• This is rare and often associated with chronic inflammation and
leucoplakia resulting from stone. The tumours are radiosensitive but
metastasise early and the prognosis is poor.
•Urinary bladder
SURGICAL ANATOMY OF THE BLADDER

• It is lined by transitional epithelium covering the connective tissue

lamina propria, which contains a rich plexus of vessels and lymphatics
• When the detrusor muscle hypertrophies, the inner layer, covered by
urothelium, stands out, resulting in the appearance of trabeculation.
• Around the male bladder neck is the smooth muscle internal
sphincter innervated by adrenergic fibres, which prevents retrograde
ejaculation.
• The distal urethral sphincter is a horseshoe-shaped mass of striated
muscle that lies anterior and distal to the prostate, or in the proximal
two-thirds of the female urethra.
• At the posterolateral bladder neck, condensations of fascia pass
forward medially and laterally to the ureter to join with the prostatic
fascia; this fascia needs to be divided during cystectomy.
• The puboprostatic ligaments are well-defined condensations of the
anterior endopelvic fascia; they stretch from the front of the prostate
to the periosteum of the pubis and lie lateral to the dorsal vein
complex.
• The superior and inferior vesical arteries are derived from the
anterior trunk of the internal iliac artery.
• The veins form a plexus on the lateral and inferior surfaces of the
bladder. In the male the prostatic plexus is continuous with the vesical
plexus, which drains into the internal iliac vein. In the female similar
large veins are continuous with the vaginal plexus.
• These accompany the veins and drain to nodes along the internal iliac
vessels
CONGENITAL DEFECTS OF THE BLADDER

• Bladder exstrophy
• Bladder exstrophy occurs in 1:50 000 births (male–female ratio 4:1).
In the male, the penis is broad and short, and bilateral inguinal
herniae may be present.
• There is separation of the pubic bones
• In epispadias alone, the pubes are united and external genitalia are
almost normal, although in the female the clitoris is bifid
• Treatment
• The bladder is closed in the first year of life, usually following
osteotomy of both iliac bones just lateral to the sacroiliac joints.
• Later, reconstruction of the bladder neck and sphincters is required.
• Less satisfactorily, urinary diversion can be carried out by means of
ureterosigmoid anastomosis, an ileal or colonic conduit, or continent
urinary diversion
• Long-term complications include:
• (1) stricture at the site of anastomosis with bilateral hydronephrosis
and infection;
• (2) hyperchloraemic acidosis; and
• (3) an increased (20-fold) risk of tumour formation (adenoma and
adenocarcinoma) at the site of a ureterocolic anastomosis.
BLADDER TRAUMA

• Bladder rupture
• This can be intraperitoneal (20%) or extraperitoneal (80%).
• Intraperitoneal rupture is usually secondary to a blow or fall on a
distended bladder, more rarely to surgical damage.
• Extraperitoneal rupture is caused by blunt trauma or surgical
damage. Gross haematuria can be absent. It may be difficult to
distinguish extraperitoneal rupture from rupture of the membranous
urethra.
• Intraperitoneal rupture is associated with sudden severe pain in the
hypogastrium, often accompanied by syncope.
• The shock sub- sides and the abdomen distends and there is no desire
to micturate.
• Peritonitis does not follow immediately if the urine is sterile; varying
degrees of rigidity are present on examination.
• Investigation
• Computerized tomography (CT) is ideal. Plain erect radiographs may
show a ground-glass appearance (fluid)
• Intravenous urography (IVU) may confirm a leak
• It is important to image the patient after drainage of contrast as the
full bladder may mask extravasation
Treatment of intraperitoneal rupture

• A lower midline laparotomy should be performed;

• the edges of the rent are trimmed and sutured with a single-layer 2/0
absorbable suture. A suprapubic and a urethral catheter are placed.
• Injury to the bladder during operation
• The bladder may be injured in:
• (1) inguinal or femoral herniotomy;
• (2) hysterectomy; and
• (3) excision of the rectum.
• If the injury is recognized, the bladder must be repaired and catheter
drainage maintained for 7 days.
• If it is not recognized, the treatment is similar to that of rupture of the
bladder.
• When accidental extraperitoneal perforation of the bladder occurs
during endoscopic resection, drainage of the bladder with a urethral
catheter and the administration of antibiotics usually suffice.
 RETENTION OF URINE
• Both
• Acute retention • Blood clot
• There are many possible causes of acute • Urethral calculus
retention of urine • Rupture of the urethra
• Male • Neurogenic (injury or disease of the
• Bladder outlet obstruction (the spinal cord)
commonest cause) • Smooth muscle cell dysfunction
• Urethral stricture associated with ageing
• Acute urethritis or prostatitis • Faecal impaction
• Phimosis • Anal pain (haemorrhoidectomy)
• Intensive postoperative analgesic
• Female
treatment
• Retroverted gravid uterus • Some drugs
• Bladder neck obstruction (rare) • Spinal anaesthesia
• Clinical features
• No urine is passed for several hours.
• Pain is present.
• The bladder is visible, palpable, tender and dull to percussion.
• Potential neurological causes should be excluded by checking reflexes
in the lower limbs and perianal sensation.
• Treatment
• Treatment is to pass a fine urethral catheter (14F – French gauge is
defined as the circumference in millimetres) and arrange urological
management.
• Occasionally, in postoperative retention a warm bath can help
• If catheterization cannot be passed following can be considered
• A. supra pubic catheterization,
• B. uretheral instrumentation
INCONTINENCE OF URINE

• Overall, urinary incontinence occurs in 5% of men and 20% of women.

• Up to 40% of women over the age of 60 years and 50% of
institutionalised elderly patients experience regular episodes of uri-
nary incontinence.
• Health problems include skin breakdown and depression, and loss of
esteem and sexual activity.
Causes of incontinence

• Problems in social control: pateints with dementia often have incontinence

becouse of uninhibited detrusor hyperreflexia and imparied social
perception.
• Storage problems: patient with a small bladder capacity owing fibrosis
(tuberculosis, radiotherapy or interstitial cystitis) can develop incontinence
• Impairment of emptying: Patient with chronic retention or neurogenic
bladder dysfunction
• Weak sphincter
• Post prostectomy : due to injury to the external sphincter
• Stress in continence
• Diagnosis of urinary incontinence
• The following investigations are required:
• A careful history and physical examination and completion of
frequency voiding charts
• Urodynamic testing in most patients and in all patients in whom
surgical intervention is proposed
• Urine culture to exclude infection and measurement of serum
creatinine
Treatments for incontinence

• Management of the underlying cause

• Problems of social functioning : Patients with dementia may respond
to regular toileting.
• Storage problems : Patients with a small bladder capacity because of
fibrosis may require augmentation cystoplasty.
Bladder calculi
• Primary: develop in sterile urine
• Secondary: occurs in the presence of
• Infection, outflow obstruction
• Impaired bladder emptying or foreing body.
• Types:
• Mixed- most common
• calcium oxalate stones : Primary stones, Moderate size, solitary,
uneven surface, dark brown
• Uric acid stones: round oval smooth yellow to brown, occur in
patients with gout
• Triple phosphate: composed of ammonium, magnesium and calcium
phosphate
• Clinical features:
• Frequency: sensation of incomplete bladder emptying
• Pain occur at the end of micturitaion refered to tip of penis
• Haematuria at the end of mictuaration
• Interruption of the urinary stream
• Uti
• Treatment;
• Treat the cause
• Lithotripsy either ultrasounic lithotripsy, percutanous lithotripsy
• Contraindictions of lithotripsy:
• Urethral stricture that cannot be dilated sufficiently
• In patients aged below 10years
• Contracted bladder
• A very large stone
NEOPLASMS OF THE BLADDER
• In total, 95% of primary bladder tumours originate in transitional
epithelium;
• the remainder arise from connective tissue (angioma, myoma,
fibroma and sarcoma) or are extra-adrenal phaeochromocytomas.
• Secondary tumours of the bladder are common and most frequently
arise from the sigmoid and rectum, the prostate, the uterus or the
ovaries
• Histological types of bladder cancer include
• A. urothelial (90%)
• B. squamous and
• C. adenocarcinoma [or mixed, as a result of metaplasia in a
transitional cell carcinoma (TCC)].
Benign tumor of the bladder
• There are numerous benign tumor of bladder
• Common ones:
• 1. epithelial metaplasia
• 2. leukoplakia
• 3. inverted papilloma
• 4. nephrogenic adenoma
• 5. leiomyoma
• 6. cystitis cystica
• 7. cystitis glandularis
epithelial metaplasia

• Focal areas of transformend urothelium with normal nuclear and

cellular architecture
• Located in trigone either squamous or glandular metaplasia
• As white flaky knobby appearance in case of squamaous metaplasia
and raised red area in case of glandular ones
• Approxiametly 40% of women and 5% of men had squamous
metaplasia
• Usually related to trauma, infection and surgery
• No treatment necessary
Leukoplakia
• Similar to squamous metaplasia but addition to keratin deposition
• Appear as a white flaky substance floating in the bladder
• Benign lesion, and no treatment is necessary
Inverted papilloma
• Associated with chronic inflammation or bladder outlet obstruction
and can be located throughout the bladder but most commonly on
the trigone
• Inverted papilloma behave in a benign fashion with only a 1%
incidence of tumor recurrence
• TURO treatment of choice
 Bladder cancer
• Bladder cancer is the 9th most common cancer world wide
• And 13th most common cause of death
• Risk factors:
• Genetics: N-acetyl transferase detoxifies nitrosoamines, a known bladder
carcinogen
• Industrial products like dye and rubber workers
• Smoking
• Nutritional factors: cofffe and tea drinkers
• Alcohol
• Drugs e.g. acetaminophen
• Infection: 1. schistasoma hematobium (squamous cell ca of bladder)
• 2. HPV 3. chronic bacterial infection esp e.coli and psudomonas
Urothelial cell carcinoma

• The urothelium of the bladder is traditionally considered to be lined

by transitional cells, can transform into a variety of bening and
malignant tumors
• Therefore the list of bladder tumors is long and includes those derived
from the urothelium and mesenchyme
• There strong relation between enviromental toxin and urothelial
cancer formation
• Clinical features:
• Often vague
• Gross and microscopic hematuria
• Increased urinary frequency due to irritation of bladder
• Pelvic pain
• Palpable mass on physical examination
• Treatment protocol:
• 1. surgery
• 2. chemotherapy
• 3. immunotherapy
• 4.systemic neoadjuvant
• 5. adjuvant therapy
• Non-muscle invasive bladder cancer are managed with complete
transuretheral resection of the bladder tumor
• Intravesicle chemotherapy is generally used as prophylactic or
adjuvant therapy after complete endoscopic resection
• Mucle invasive bladder cancer
• Radical cystoprostectomy in men and anterior pelvic exentration in
women with bilateral pelvic lymphadenectomy
• Prognosis
• The significant prognostic factor for bladder cancer are grade, depth
of invasion.
• To be contin…………………
•The prostate gland
• The contemporary classification of the prostate into different zones
was based on the work of McNeal.
• He showed that it is divided into the peripheral zone (PZ), which lies
mainly posteriorly and from which most carcinomas arise, and a
central zone (CZ), which lies posterior to the urethral lumen and
above the ejaculatory ducts as they pass through the prostate;
• the two zones are rather like an egg in an eggcup. There is also a peri-
urethral transitional zone (TZ), from which most benign prostatic
hyperplasia (BPH) arises
• Smooth muscle cells are found throughout the prostate but, in the
upper part of the prostate and bladder neck, there is a separate
sphincter muscle that subserves a sexual function, closing during
ejaculation
• Resection of this tissue during prostatectomy is responsible for
retrograde ejaculation.
• The distal striated urethral sphincter muscle is found at the junction
of the prostate and the membranous urethra; it is horse- shoe shaped
with the bulk lying anteriorly
• Between the anatomical capsule and the prostatic sheath lies the
abundant prostatic venous plexus.
• The prostatic sheath is contiguous with the fascia of Denonvilliers,
which separates the prostate and its coverings from the rectum
• The growth of the prostate is governed by many local and systemic
hormones whose exact functions are not yet known.
• The main hormone acting on the prostate is testosterone, which is
secreted by the Leydig cells of the testes under the control of
luteinising hormone (LH),
• Testosterone is converted to 1,5- dihydrotestosterone (DHT) by the
enzyme 5α-reductase,
• Other androgens are secreted by the adrenal cortex, but their effects
are minimal in the normal male.
• Oestrogenic steroids are also secreted by the adrenal cortex and, in
the ageing male, may play a part in disrupting the delicate balance
between DHT and local peptide growth factor hence increase the risk
of BPH.
• prostate-specific antigen (PSA) is a glycoprotein that is a serine
protease.
• Its function may be to facilitate liquefaction of semen, but it is a
marker for prostatic disease.
• The levels increase with age, with prostate cancer and with BPH.
• There are age-related values but, in general, in men aged 50–69 years,
a level of about 3–4 ng ml–1
• Its level in men with metastatic prostate cancer is usually increased to
> 30 ng ml–1
• Men with locally confined prostate cancer usually have serum PSA
levels < 10–15 ng ml–1.
• Although PSA is a reliable marker for the progression of advanced
disease, it is neither specific nor sensitive in the differential diagnosis
of early prostate cancer and BPH
BENIGN PROSTATIC HYPERPLASIA

• Aetiology of benign prostatic hyperplasia

• Hormones
• Serum testosterone levels slowly but significantly decrease with
advancing age; however, levels of oestrogenic steroids are not
decreased equally.
• According to this theory, the prostate enlarges because of increased
oestrogenic effects
• Pathology
• BPH affects both glandular epithelium and connective tissue stroma
to variable degrees.
• These changes are similar to those occurring in breast dysplasia
• BPH typically affects the submucous group of glands in the
transitional zone, forming a nodular enlargement.
• Eventually, this overgrowth compresses the PZ glands into a false
capsule and causes the appearance of the typical ‘lateral’ lobes.