Ureteric stones

A stone that originated from the kidney Peak age: 30-50 Presenting symptoms: Emergency (acute) management: Surgical management:
st
and is located in the ureter. M:F = 3:1 1. Pain due to urinary obstruction 1 line:
Recurrence:  Flank pain, non-colic, due to 1. Resuscitate patient according Cystoscopy & JJ stent
IVP – showing obstruction of ureter and  50% after 5 years expanding of the renal to the ATLS principles ESWL for stone < 2cm &
kidney. Pre & post voiding.  60-80% life long capsule 2. Analgesics & Antiemetic’s uretaroscopy for stone at any
 Flank pain extending to 3. NSAIDs to lower the intra- locations of the ureter.
groin, testis or penis due to ureteral pressure
nd
Risk factors: expanding of the collecting 4. Medical Expulsion Therapy 2 line:
 Hereditary system of the ureter, ureteric (MET): Image guided percutaneous
 Lifestyle colic.  Alpha-blocker increase nephrostomy (PCNL)
o Not enough H2O 2. Nausea & Vomiting rate of spontaneous  Stones > 2cm
o  Ca 3. Haematuria (mostly microscopic) passage of distal ureteral  Staghorn
o Vit C 4. Diaphoresis, tachycardia & stones.  Ureteropelvic
o  Oxalate tachypnea due to pain  CBB junction
 Medication: 5. Occasional frequency & urgency 5. AB if bacteriuria  Anatomical
o Loop diuretics due trigonal irritation 6. IV fluids if vomiting – DOES abnormalities
o Acetazolamide 6. IF: fever present, consider NOT promote passage of  Failure of other
 Medical conditions concurrent pyelonephritis and/or stone. modalities
rd
o DM obstruction. 3 line:
Shows dilation of o Gout Bladder stones; Prevention: Laparoscopic or open stone
proximal ureter as o Hypocalcaemia  Suprapubic pain  Dietary modification: removal.
stone progresses
o Urinary oxalate  Storage & voiding LUTS o  fluid & K RARE
down towards
o UTI  Terminal haematuria o  animal protein, Na,
bladder.
o Obesity (BMI > 30) oxalate, sucrose, fructose
o Urinary stasis Diagnosis: o Avoid high dose Vit C
o Uric acid 1. Blood & Urine supplements
 Immobility  FBC, U&E, uric acid,  Medication prophylaxis:
Dilation of complete L oxalate, serum Ca o Thiazide diuretic for
ureter after passing a  Urine MC&S hypocalcaemia
stone. 2. KUB X-ray / ultrasound o Allopurinol for
3. IVP hyperuricosuria
4. CT scan o Potassium citrate for
5. Cystoscopy (Bladder stone) hypocitraturia &
hyperuricosuria

1
 Vesicoureteral reflux
Vesicoureteral Reflux (VUR): Fluoroscopic voiding cystourethrogram (VCUG):
A VCUG allows us to evaluate a child's urethra and bladder size,
Retrograde passage of urine from the bladder, through shape, and capacity. This procedure uses x-rays and a contrasting
the ureterovesicular junction (UVJ), into ureter. agent that is administered by catheter into the child’s bladder.

Grade 1 VUR Grade 2 VUR

Grade 1 – Ureters only fill

Grade 2 – Ureters and pelvis fill
Grade 3 - Ureters and pelvis fill with some dilation
Grade 4 – Ureters, pelvis and calyces fill with significant Grade 3 VUR Grade 4 VUR
dilatation
Grade 5 – Ureters, pelvis and calyces fill with major
dilatation and tortuosity.

Grade 5 VUR

2
 Ectopic Kidneys

Ectopic Kidney: Intravenous Pyelogram (IVP) : Retrograde Pyelogram:

An intravenous pyelogram (IVP) is an x-ray examination of the kidneys,
An ectopic kidney is a birth defect in which a kidney ureters and urinary bladder that uses iodinated contrast material
is located in an abnormal position. In most cases, injected into veins.
people with an ectopic kidney have no complaints. In
other cases, the ectopic kidney may create urinary Ectopic kidney on the left
problems, such as urine blockage, infection, or
urinary stones.

During foetal development, a

baby’s kidneys first appear as
buds inside the pelvis, near the
bladder. As the foetal kidneys
develop, they climb gradually
toward their normal position
near the rib cage in the back.
Sometimes, one of the kidneys
fails to make the climb. It may
stop after making part of the
climb. Or it may remain in the
pelvis.
Crossed fused renal ectopia: Crossed fused renal ectopia
An ectopic kidney
may cross over and
become fused with
the other kidney.
Some kidneys climb
toward the rib cage,
but one may cross
over so that both
kidneys are on the
same side of the
body. When a
crossover occurs, the
two kidneys may grow
together and become fused.

3
 Bladder rupture

Bladder rupture: Investigations: VCUG & CT cystogram:

 Lab: Voiding cystourethrography preferred contrast enhanced study for
Five types of rupture o Serum Creatinine diagnosis of bladder rupture.
Type I: Bladder contusion o U&E
 Most common form  Imaging: Intra-peritoneal bladder rupture
 Results from incomplete tear of o Pelvic X-ray
bladder mucosa o VCUG
 Cystography is normal o CT
Type II: Intra-peritoneal rupture  Other:
 Results from trauma to lower o KUB ultrasound
abdomen when bladder is distended
 Because bladder dome is weakest Associated injuries:
portion, it ruptures most easily  Renal injury
 Contrast is then seen in the  Urethral injury
paracolic gutters and between loops
of small bowel Treatment: Extra-peritoneal bladder rupture
Type III: Interstitial injury-rare  Transurethral or Suprapubic catheter
 Caused by a tear of the serosal o Drain 10- 14 days, monitoring
surface cystogram
 Mural defect without extravasation o Most heal in 7-10 days, remove
will be seen catheter and complete trail of voiding
Type IV: Extra-peritoneal o Almost all extra-peritoneal bladder
 Almost always associated with pelvic injuries heal like this in 3 weeks. If
fractures not, surgery.
 Usually close to base of bladder  Surgical closure of bladder defect
anterolaterally o Most intra-peritoneal ruptures
 Subdivided into o Extra-peritoneal ruptures with
o Simple - with extravasation extravasation of urine
limited to peri-vesical space o Bladder leaks so also requires
o Complex - with catheter for 10-14 days
extravasation extending to o Follow with successful trail of voiding
thigh, scrotum or perineum
Type V: Combined extra- and intra-peritoneal
rupture

4

Varicocele:
An abnormal enlargement of the pampiniform venous
plexus in the scrotum. Defective valves, or compression
of the vein by a nearby structure, can cause dilatation
of the testicular veins near the testis, leading to the
formation of a varicocele.
Varicoceles vary in size and can be classified into the
following 3 groups:
 Large - Easily identified by inspection alone
 Moderate - Identified by palpation without
bearing down (Valsalva manoeuvre)
 Small - Identified only by bearing down, which
increases intra-abdominal pressure, thus
impeding drainage and increasing varicocele
size
Varicocele
Symptoms:
 Visible or palpable enlarged vein,
“Bag of worm”
 Dragging-like or aching pain within
scrotum
 Feeling of heaviness in the
testicle(s)
 Atrophy (shrinking) of the
testicle(s)
 Alteration of testosterone levels
 Benign prostatic hyperplasia (BPH)
and related urinary problems
Causes:
1. Idiopathic (primary) varicocele:
Occurs when the valves within the
veins along the spermatic cord do not
work properly. This is essentially the
same process as varicose veins, which
are common in the legs. This results in
backflow of blood into the
pampiniform plexus and causes
increased pressures, which on rare
occasion can lead to permanent
damage to the testicular tissue due to
disruption of normal supply of
oxygenated blood via the testicular
artery.
Majority of idiopathic varicoceles
occur on the left side, because the left
testicular vein travels superiorly and
connects to the left renal vein (at a
90-degree angle), while the right
testicular vein drains directly into the
inferior vena cava. Isolated right sided
varicoceles are rare.
2. Secondary varicocele:
Due to compression of the venous drainage
of the testicle. A pelvic or abdominal
malignancy is a definite concern when a
unilateral right-sided varicocele is newly
diagnosed in a patient older than 40 years
of age. One non-malignant cause of a
secondary varicocele is the so-called
"Nutcracker syndrome", a condition in
which the superior mesenteric artery
compresses the left renal vein, causing
increased pressures there to be transmitted
retrograde into the left pampiniform
plexus.[14] The most common cause is
renal cell carcinoma followed by
retroperitoneal fibrosis or adhesions.
Testicular venogram:
Venography is the most reliable modality
for the detection of subclinical
varicoceles because the findings
demonstrate abnormal retrograde flow
into the spermatic veins or pampiniform
plexus. However, the procedure remains
invasive and is usually reserved for
patients undergoing sclerotherapy.
Left testicular venogram. This image
shows a left testicular varicocele before
embolization. Note: radiographs of
varicoceles should be avoided to restrict
radiation exposure.
Ultrasound:
Ultrasonography is the examination of
choice for investigating varicoceles, and it
remains the most practical and most
accurate non-invasive technique
5

Benign Prostatic Hyperplasia (BPH)
Benign prostatic hyperplasia (BPH) is a condition
in which the prostate gland becomes enlarged.
However, the actual size of the gland does not
necessarily predict symptom severity. Some men
with minimally enlarged prostate glands may
experience symptoms while other men with
much larger glands may have few symptoms. BPH
is very common among older men, affecting
about 60% of men over age 60 and 80% of men
over age 80.
BPH
BPH Symptoms:
The symptoms associated with BPH are
collectively called lower urinary tract
symptoms (LUTS).
Voiding (Obstructive) Symptoms:
 A hesitation before urine flow starts
despite the urgency to urinate
 Straining when urinating
 Weak or intermittent urinary stream
 A sense that the bladder has not
emptied completely
 Dribbling at the end of urination or
leakage afterward
Storage (Irritative) Symptoms:
 An increased frequency of urination
(every few hours)
 An urgent need to urinate and
difficulty postponing urination
 Painful or burning sensation when
urinating
Serious Complications:
Urinary retention is a serious complication of
severe BPH that requires immediate medical
attention. Urinary retention can be a sign of
obstruction in the bladder. Bladder
obstruction can cause kidney damage, bladder
stones, urinary tract infections, blood in the
urine, and incontinence as urine dribbles out
in small amounts.
Special investigations:
 PSA
 Urine analysis
 Uroflowmetry
 Ultrasound
 Cystoscopy
Management:
Watchful Waiting - involves lifestyle
changes and an annual examination.
The primary goals of treatment for BPH are
to improve urinary flow and to reduce
symptoms.
1. Medications
 Are the best choices for men with
mild-to-moderate symptoms who
want treatment. Choices include
alpha-blockers, anti-androgens, or a
combination of the two. Specific
factors indicate the best choice,
although most men take an alpha-
blocker.
 Men with moderate-to-severe
symptoms often respond to the
same medications as men with mild
symptoms. Recent developments in
drug therapy have reduced or
delayed the need for surgery.
2. Surgery – Obstructive symptoms
 Transurethral resection of the
prostate (TURP)
 Heat or lasers to destroy
prostate tissue
Immediate management (with obstructive
symptoms):
 Rapid and complete emptying of
the bladder by catheterization.
Transurethral catheter is effective.
 Alpha-blocker
Complications:
 Heavy bleeding.
 Low sodium in the blood. This
rare complication is called TURP
syndrome or transurethral
resection (TUR) syndrome. It
occurs when the body absorbs
too much of the fluid used to
wash (irrigate) the surgical area
during the procedure.
 Temporary difficulty urinating.
 Urinary tract infection
 Difficulty holding urine.
 Dry orgasm. TURP can cause
retrograde ejaculation
 Erectile dysfunction. The
inability to keep or maintain an
erection is a possible long-term
side effect of TURP.
 Need for re-treatment. Some
men require follow-up
treatment after TURP, either
because symptoms return over
time or because they never
adequately improve.
6

Urethral injuries can be classified into 2
broad categories based on the anatomical
site of the trauma.
 Posterior urethral injuries are
located in the membranous and
prostatic urethra. These injuries
are most commonly related to
major blunt trauma such as motor
vehicle collisions and major falls,
and most of such cases are
accompanied by pelvic fractures.
 Anterior urethra injuries are
located distal to the membranous
urethra. Most anterior urethral
injuries are caused by blunt
trauma to the perineum (straddle
injuries), and many have delayed
manifestation, appearing years
later as a urethral stricture.
 External penetrating trauma to the
urethra is rare, but iatrogenic
injuries are quite common in both
segments of the urethra. Most are
related to difficult urethral
catheterizations.
Posterior Urethral Injury
Clinical signs:
 Blood at urethral meatus
 Perineal / Butterfly hematoma
 High riding prostate
 Leakage of urine into surrounding tissues
and result in swelling, inflammation,
infection and abdominal pain.
 Inability to urinate
 Retention of urine in the bladder
 Haematuria
 For males, the most common sign of a
problem is blood - even a drop - at the
tip of the penis.
 Swelling and bruising of the penis, scrotum
and perineum may also occur, along
with pain in the affected area.
Urethrogram:
Images from ascending urethrography (a) and
descending urethrography performed with a
suprapubic catheter (b) in a male patient with
pelvic trauma show a complete transection of
the posterior urethra with contrast material
extravasation into the perineal soft tissues
(arrow in a), as well as bladder neck disruption
with further extra-peritoneal contrast material
extravasation (arrow in b).
Immediate management:
1. Resuscitate according to ATLS
principles
2. Suprapubic catheter – May be
left in place for -6 months for
bleeding from associated
injuries as well as swelling to
subside before definitive
management.
3. Stabilize pelvic fracture if
present, manage other injuries.
Definitive Management:
Ultimate repair of the posterior urethral injury can
be performed 6-12 weeks after the event, after
the pelvic hematoma has resolved and the
patient's orthopaedic injuries have stabilized.
It is often carried out via a perineal approach, and
repair consists of mobilizing the urethra distally to
allow a direct anastomosis after excision of the
stricture. To prevent tension on the anastomosis,
the distal urethra can be mobilized to the
penoscrotal junction. Further length can be
achieved with division of the septum between the
corpora cavernosa and with inferior pubectomy. A
urethral catheter is left indwelling to stent the
repair, and the suprapubic catheter may be
removed. Transpubic approaches for this repair
have also been described and may be useful in
men with fistulous tracts complicating a
membranous urethral injury. Combining a
perineal and abdominal approach with
pubectomy provides maximum exposure of the
prostatic apex.
Early realignment of posterior urethral injuries is
also a treatment option. This has been performed
at the time of injury, using interlocking sounds or
by passage of catheters from both retrograde and
antegrade approaches. Also, direct suture repair
has been attempted in the immediate post injury
period. Another approach could be careful
insertion of a urethral catheter under fluoroscopic
guidance by a urologist experienced in that
approach. These approaches have the
disadvantage of possible entrance into and
contamination of the pelvic hematoma with
ensuing haemorrhage and sepsis.
7

Cannon ball lesions:
Cannonball metastases refer to large well
circumscribed, round pulmonary metastases that
appear like cannonballs.
Metastatic disease in young patient
Differential diagnosis: Signs & Symptoms: Treatment:
Tumour cells reach the lungs via the  cough Palliative & Supportive
pulmonary circulation, where they o The cough usually worsens or
lodge in small distal vessels. doesn’t go away. Treatment options for lung metastases are
o The cough may be dry (no based on:
Lung metastases only develop if a phlegm) or productive (with  Where the cancer first started (primary
person already has cancer. Almost any phlegm). The person may cough cancer)
type of cancer can spread to the lung. up blood-stained phlegm.  The size and location of the lung metastases
Cancers that typically spread to the  shortness of breath  The number of lung metastases – single or
lung include: o Shortness of breath can be multiple
 lung – metastases occur in caused by the lung metastases or  The person's symptoms and lung function
the other (contralateral) lung a build-up of fluid in the space if there is cancer in other areas of the body
 breast between the lung and chest wall  Previous treatment, if any
 skin (melanoma) (pleural effusion).  The person's age and overall health
 pancreas  chest pain  Chemotherapy is used most often to treat
 kidney  unexplained weight loss lung metastases. Surgery is sometimes an
 colorectal option. Radiation therapy, laser surgery or
 head and neck – such as oral, Sometimes lung metastases do not cause stents may be used, but these treatments
pharyngeal, Laryngeal any signs or symptoms when they first are used less often than chemotherapy and
 thyroid develop or while still very small. surgery.
 testicular  Depending on the type of primary cancer,
 bladder Serology: other treatments may also be used to treat
 oesophageal  PSA lung metastases, including hormonal
 stomach  Serum Testosterone therapy, biological therapy or targeted
 liver  Tumour markers: therapies.
 bone o Alpha-fetoprotein (AFP)
 soft tissue sarcoma o Beta-HCG
 ovarian o Prostatic acid phosphatase (PAP)
 cervical
 prostate
 lymphoma
8
 RCC
Renal Cell Carcinoma: Signs and symptoms:
Renal cell carcinoma is a kidney cancer that originates in the Classic triad:
lining of the proximal convoluted tubule.  Haematuria
 Flank pain
 A palpable mass in the flank
or abdomen
Other signs and symptoms include
the following:
 Weight loss (33%)
 Fever (20%)
 Hypertension (20%)
 Hypercalcaemia
manifestations (5%)
 Night sweats
 Malaise
 Varicocele (2% of males) -
Usually left sided, due to
obstruction of the
testicular vein.
Special investigations:
Lab studies used for diagnosis of
renal cell carcinoma include the
following:
 Urinalysis (UA)
 Complete blood cell (CBC)
count with differential
 Electrolytes
 Renal profile
 Liver function tests (LFTs;
aspartate aminotransferase
[AST] and alanine
aminotransferase [ALT])
 Serum calcium
Imaging studies used to evaluate and
stage renal masses include the
following:
 Excretory urography
 CT scanning
 PET scanning
 Ultrasonography
 Arteriography
 Venography
 MRI
Management:
The principal treatment options for renal
cell cancer are as follows:
 Surgery
 Radiation therapy
 Immunotherapy
 Molecular-targeted therapy
Surgical resection remains the only known
effective treatment for localized renal cell
carcinoma, and it is also used for palliation
in metastatic disease. Targeted therapy and
immunomodulatory agents are considered
standard of care in patients with metastatic
disease. Chemotherapy is used only
occasionally, in certain tumour types.
Experimental treatment approaches include
vaccines and nonmyeloablative allogeneic
peripheral blood stem cell transplantation.
9

Urethral stricture is an abnormal narrowing of
the tube that carries urine out of the body
from the bladder (urethra).
Urethra stricture
Causes: Treatment: Optical Urethrotomy:
 Inflammation or scar tissue from  Urethral dilation Direct vision internal urethrotomy (DVIU) is a
surgery, disease, or injury. Rarely, it  Urethrotomy surgery to repair a narrowed section of the
may be caused by pressure from a  Urethral stent placement, urethra by cutting through it.
growing tumour near the urethra.  Open urethral reconstruction
 Sexually transmitted infection (STI)
 Procedures that place a tube into
the urethra (such as a catheter or
cystoscopy) Optical Urethrotomy.wmv.mp4
 Benign prostatic hyperplasia (BPH)
 Injury to the pelvic area
 Repeated urethritis
Symptoms include:
 Blood in the semen
 Discharge from the urethra
 Bloody or dark urine
 Strong urge to urinate and frequent
urination
 Decreased urine output inability
(urinary retention)
 Painful urination or difficulty
urinating
 Loss of bladder control
 Pain in the lower abdomen and
pelvic area
 Slow urine stream (may develop
suddenly or gradually) or spraying
of urine
 Swelling of the penis
10

BCG is a vaccine used to prevent tuberculosis (TB),
but it's also an effective treatment for some non-
invasive bladder cancers. It's given directly into the
bladder (intravesical). BCG is a type of
immunotherapy drug and doctors aren't sure exactly
how it works in bladder cancer.
Benefits of intravesical BCG :
Intravesical BCG, in combination with TURBT, is the
most effective treatment for non-muscle invasive
bladder cancer. BCG therapy has been shown to
delay (although not necessarily prevent) tumour
growth to a more advanced stage, decrease the
need for surgical removal of the bladder at a later
time, and improve overall survival.
BCG for Bladder Ca
Urological uses:
Transitional cell carcinoma of the
bladder
It is a common treatment for non-
muscle invasive bladder cancer,
particularly for cancers that have a risk
of worsening over time. BCG is believed
to work by triggering the body's
immune system to destroy any cancer
cells that remain in the bladder after
TURBT.
BCG is in a liquid solution that is put
into the bladder with a catheter. The
person then holds the solution in the
bladder for two hours before they
urinate. The treatment is usually given
once per week for six weeks, starting
approximately two to three weeks after
the last TURBT. Further booster
(maintenance) treatments can extend
the benefit of BCG.
Risk factors for bladder TCC:
 Smoking
 Increasing age
 Being white
 Being a man
 Exposure to certain chemicals
 Previous cancer treatment.
 Taking a certain diabetes
medication
 Chronic bladder inflammation
 Family history
Treatment Non-Muscle invasive:
 Transurethral resection of
bladder tumour (TURBT)
Followed by:
 Intravesical chemotherapy
 Intravesical BCG
Treatment Muscle invasive:
 Radical cystoscopy
Side effects of BCG:
Most people who are treated with intravesical
BCG have some side effects; the most common
of these include the need to urinate frequently,
pain with urination, fever, blood in the urine,
and body aches. These symptoms usually begin
within two to four hours of treatment and
resolve within 48 hours.
Anyone who develops a fever (temperature
greater than 100.4ºF or 38ºC) and drenching
night sweats 48 hours or more after treatment
with BCG should contact their healthcare
provider. These may be signs of less common
but more serious side effects, including body
wide infection.
11
 Testicular torsion
Testicular torsion refers to the torsion of the Differential diagnosis:
spermatic cord structures and subsequent loss of  Epididymitis, orchitis, epididymo-
the blood supply to the ipsilateral testicle. This is a orchitis (often mistaken)
urological emergency; early diagnosis and  Hydrocele
treatment are vital to saving the testicle and  Testis tumour
preserving future fertility.  Idiopathic scrotal oedema
 Idiopathic testicular infarction
 Traumatic rupture
 Traumatic hematoma
 Appendicitis
 Fournier Gangrene
 Scrotal Trauma
 Spermatocele
 Testicular Choriocarcinoma
 Testicular Seminoma
 Testicular Trauma
 Varicocele
Classification:
A- Intra-vaginal torsion
 abnormally high attachment of the
tunica vaginalis to the spermatic
cord, which allows rotation of the
testicle within the sac
B- Extra-vaginal torsion
 It occurs during the perinatal period
as the testicle descends and twists
around the spermatic cord prior to
attachment to the posterior scrotal
wall.
C - Long mesorchium
 The mesorchium is a
dense band of connective
tissue that attaches the
efferent ductules of the
epididymis to the
postero-lateral wall of the
testes. If elongated, this
may allow the testicles to
twist and the epididymis
to remain fixed.
Prehn’s sign:
Physical lifting of the testicles
relieves the pain of epididymitis
but not pain caused by testicular
torsion.
Negative Prehn's sign:
No pain relief with lifting the
affected testicle, which points
towards testicular torsion.
Positive Prehn's sign:
There is pain relief with lifting the
affected testicle, which points
towards epididymitis.
Special investigations:
 Doppler
 Radio-nuclear isotope
study
Treatment:
1. Reduce if able
2. Urgent scrotal exploration
Intraoperative Considerations:
Either a midline raphe incision or bilateral transverse
scrotal incisions can be made. Enter the ipsilateral
scrotal compartment, incise the tunica vaginalis, and
then deliver the testicle for examination. The
spermatic cord is then untwisted. Evaluate the testis
for viability. If viability is in question, place the
testicle in warm sponges and re-evaluate after
several minutes.
If the testis is necrotic, perform an orchiectomy to
avoid prolonged, debilitating pain and tenderness. In
addition, retention of a necrotic testis may
exacerbate the potential for subfertility, presumably
because of development of an autoimmune
phenomenon.
To prevent subsequent torsion, fix viable gonads to
the scrotal wall with 3-4 nonabsorbable sutures. A
dartos pouch can be made, into which the testicle is
placed. Contralateral orchiopexy is always performed
when testicular torsion is confirmed intra-
operatively, in order to prevent future torsion of that
testicle.
Signs of a viable
testis after
detorsion include
a return of
colour, return of
Doppler flow, and
arterial bleeding
after incision of
the tunica
albuginea.
12
 Hypospadias
It is characterized by the abnormal position of urethral Classification: Risk Factors:
meatus on the ventral penile shaft. Structures affected Classified according to the location of the meatus.  Father with hypospadias
in varying degrees are the anterior urethral portion,  The anterior form: glandular, coronal and distal penile.  Low birth weight
the glans, the prepuce, and the corpus spongiosum  The middle form: "mid-shaft” and proximal penile.  Twin or triplet births
and corpora cavernosa.  The posterior form: penoskrotal, scrotal and perineal.  Maternal iron supplements
 Smoking mothers
Hypospadias is defined as the combination of three  Fathers with pesticide contact
anatomical abnormalities of the penis:  Pregnancy through artificial insemination
1. Proximal urethra, with or without ectopic stenotic or medical support
meatus, which may be located on the ventral side Treatment:
at any position between the tip of the glans and Surgery is the treatment of choice for most
the perineum. hypospadias. The severity of the
2. Ventral penile shaft deviation malformation determines the procedure.

The goals of surgical treatment of

hypospadias are as follows:

 To create a straight penis by repairing

any curvature (orthoplasty)
 To create a urethra with its meatus at the
3. A typical dorsal winged prepuce, by a lack of tip of the penis (urethroplasty)
circular ventral union of the prepuce
 To re-form the glans into a more natural
conical configuration (glansplasty)
 To achieve cosmetically acceptable penile
skin coverage
 To create a normal-appearing scrotum
 The resulting penis should be suitable for
future sexual intercourse, should enable
the patient to void while standing, and
The 2nd and 3rd characteristics may not necessarily be
should present an acceptable cosmetic
present. In contrast, the first feature is an
appearance.
unconditional part of the definition.
NEVER circumcision!!!

13
 Schistosomiasis Haematobium
Schistosomiasis (also known as bilharzia, snail Lifecycle: Blood:
fever, and Katayama fever) is a disease caused  FBC
by parasitic worms of the Schistosoma type. It  CRP
may infect the urinary tract or the intestines.  LFT

Signs & Symptoms: Treatment:

 Abdominal pain Praztiquantel 40mg/kg STAT in divided dose
 Cough
 Diarrhoea
 Eosinophilia
 Fever
 Fatigue
 Hepatosplenomegaly
 Genital sores
 Papular dermatitis
 Cystitis and ureteritis
 Glomularnephritis
 Bladder cancer due to chronic
irritation

Schistosoma Haematobium:
Found in the Venous plexuses around the
urinary bladder and the released eggs travels
Diagnosis:
to the wall of the urine bladder causing
Examine urine for eggs – Microscopy & Dipstick for blood
haematuria and fibrosis of the bladder. The
Can be identified in the bladder wall, associated with SCC bladder.
bladder becomes calcified, and there is
increased pressure on ureters and kidneys
otherwise known as hydronephrosis.
Inflammation of the genitals due to S.
haematobium may contribute to the
propagation of HIV. Studies have shown the
relationship between S. haematobium
infection and the development of squamous
cell carcinoma of the bladder.

14

Fournier's gangrene is a rare and often fulminant
necrotizing fasciitis of the perineum and genital
region frequently due to a synergistic
polymicrobial infection. Sparing the testicles,
bladder and rectum due to their separate blood
supply which is directly from the aorta.
The clinical course usually progresses through
the following phases:
 Prodromal symptoms of fever and
lethargy, which may be present for 2-7
days
 Intense genital pain and tenderness that
is usually associated with oedema of the
overlying skin; pruritus may also be
present
 Increasing genital pain and tenderness
with progressive erythema of the
overlying skin
 Dusky appearance of the overlying skin;
subcutaneous crepitation
 Obvious gangrene of a portion of the
genitalia; purulent drainage from
wounds
Early in the course of the disease, pain may be
out of proportion to physical findings. As
gangrene develops, pain may actually subside as
nerve tissue becomes necrotic.
Systemic effects of this process vary from local
tenderness with no toxicity to florid septic shock.
In general, the greater the degree of necrosis, the
more profound the systemic effects.
Fournier’s Gangrene
Pathophysiology:
Localized infection adjacent to a portal of
entry is the inciting event in the
development of Fournier gangrene.
Ultimately, an obliterative endarteritis
develops, and the ensuing cutaneous and
subcutaneous vascular necrosis leads to
localized ischemia and further bacterial
proliferation. Rates of fascial destruction as
high as 2-3 cm/h have been described.
Infection of superficial perineal fascia
(Colles fascia) may spread to the penis and
scrotum via Buck and dartos fascia, or to
the anterior abdominal wall via Scarpa
fascia, or vice versa. Colles fascia is
attached to the perineal body and
urogenital diaphragm posteriorly and to
the pubic rami laterally, thus limiting
progression in these directions. Testicular
involvement is rare, as the testicular
arteries originate directly from the aorta
and thus have a blood supply separate
from the affected region.
The following are pathognomonic findings
of Fournier gangrene upon pathologic
evaluation of involved tissue:
 Necrosis of the superficial and
deep fascial planes
 Fibrinoid coagulation of the
nutrient arterioles
 Polymorpho-nuclear cell
infiltration
 Microorganisms identified within
the involved tissues
Diagnosis:
Diagnosis of Fournier gangrene is based
primarily on clinical findings, and
treatment is based on these clinical
findings. Incisional biopsy may ultimately
confirm the diagnosis.
 FBC
 Arterial blood gas (ABG) sampling
 Blood and urine cultures
 Disseminated intravascular
coagulation (DIC) panel
 Cultures of any open wound or
abscess
Imaging:
 X-ray
 Ultrasound
 CT
Predisposing factors:
 diabetes mellitus
 local trauma
 urine leakage
 perirectal or perineal surgery
 extension of peri-urethral
 anal infection
 anorectal abscess
 genitourinary infection
 alcoholism
 Immunosuppression
 renal or hepatic disease
Treatment:
1. Resuscitate according to ATLS principles
2. IV access with Crystalloid
3. Broad spectrum AB
 The antibiotic spectrum should
cover staphylococci, streptococci,
the Enterobacteriaceae family of
organisms, and anaerobes.
 Ciprofloxacin and Clindamycin.
 Vancomycin can be used to provide
coverage for methicillin-resistant
Staphylococcus aureus (MRSA)
4. Surgical debridement of the area and
tissue biopsy
The testicles are often spared in the
necrotizing process. If it is uninvolved,
place the exposed testicle in a
subcutaneous pocket to prevent
desiccation. If a testicle is involved in the
necrotic process or its viability is
questioned, perform orchiectomy.
15

A hydrocele testis is the accumulation of fluids around a
testicle, and is fairly common. It is often caused by fluid
secreted from a remnant piece of peritoneum wrapped
around the testicle, called the tunica vaginalis. Provided
there is no hernia present, hydroceles below the age of 1
year usually resolve spontaneously.
Hydrocele can be produced in four ways:
1. By excessive production of fluid within the sac,
e.g. secondary hydrocele.
2. through defective absorption of fluid
3. By interference with lymphatic drainage of
scrotal structures as in case of elephantiasis.
4. By connection with a hernia of the peritoneal
cavity in the congenital variety, this presents as
hydrocele of the cord.
Hydrocele
Primary hydroceles:
The swelling is soft and non-tender,
large in size on examination and the
testis cannot usually be felt. The
presence of fluid is demonstrated by
trans illumination. These hydroceles
can reach a huge size, containing
large amount of fluid, as these are
painless and are often ignored.
Secondary hydrocele:
Due to testicular diseases, can be the
result of, cancer, trauma (such as a
hernia), or orchitis (inflammation of
testis), and can also occur in infants
undergoing peritoneal dialysis. A
hydrocele is not a cancer but it
should be excluded clinically if a
presence of a testicular tumour is
suspected, necessary in case of acute
hydrocele in a young man as it may
be due testicular tumour. Secondary
hydrocele is most frequently
associated with acute or chronic
epididymo-orchitis. It is also seen
with torsion of the testis and with
some testicular tumours. A
secondary hydrocele is usually lax
and of moderate size: the underlying
testis is palpable. A secondary
hydrocele subsides when the primary
lesion resolves.
Causes: Versus Indirect Inguinal hernia:
During embryogenesis, the testis
descends through the inguinal canal,
drawing a diverticulum of
peritoneum into the scrotum as it
descends. This peritoneal tissue is
known as the processus vaginalis.
Normally, the communication
between the processus vaginalis and
the peritoneum is obliterated, and
the tunica vaginalis is the tissue that
remains overlying the testis and the
epididymis. Congenital hydrocele
results when the processus vaginalis
remains patent, allowing fluid from
Treatment:
the peritoneum to accumulate in the
There are two surgical techniques available for
scrotum.
hydrocelectomy:
Hydroceles that appear later in life
Hydrocelectomy with Excision of the Hydrocele Sac
may be caused by an injury or
Incision of the hydrocele sac after complete
surgery to the scrotum or groin area.
mobilization of the hydrocele. Partial resection of the
Or they can be caused by
hydrocele sac, leaving a margin of 1–2 cm. Care is
inflammation or infection of the
taken not to injure testicular vessels, epididymis or
epididymis or testicles. In rare cases,
ductus deferens.
hydroceles may occur with cancer of
Hydrocele Surgery with Plication of the Hydrocele Sac
the testicle or the left kidney. This
The hydrocele is opened with a small skin incision
type of hydrocele can occur at any
without further preparation. The hydrocele sac is
age but is most common in men
reduced (plicated).
older than 40.
The hydrocele fluid can be aspirated. This procedure is
less invasive but, recurrence rates are high.
Sclerotherapy, the injection of a solution following
aspiration of the hydrocele fluid may increase success
rates. In many patients, the procedure of aspiration
and sclerotherapy is repeated as the hydrocele recurs.
16

Azoospermia is the medical condition of a man not
having any measurable level of sperm in his semen. It
is associated with very low levels of fertility or even
sterility.
Causes:
Obstructive azoospermia:
 Genetic conditions, such as congenital
bilateral absence of the vas deferens, may
affect sperm transport.
 Infections of the male reproductive system,
such as in the testicles or prostate, may affect
male fertility.
 Trauma may cause azoospermia. Previous
injury or surgery to the spine, pelvis, lower
abdomen, or male sex organs may cause
damage to the male reproductive system.
This may include surgery on an inguinal
hernia. Trauma may affect sperm production
or cause an obstruction in the flow or
transport of sperm.
 A varicocele is a condition that causes the
veins in the scrotum to become enlarged and
dilated.
 Vasectomy
Non-obstructive azoospermia:
 Medicines, such as steroids, antibiotics, and
medicines used to treat inflammation or
cancer may affect male fertility.
 Smoking, drinking alcohol, and using illegal
drugs may also cause problems with sperm
production.
Azoospermia
 Genetic conditions may affect sperm production or
development of reproductive organs. These
include Klinefelter syndrome and Kallmann
syndrome.
 Abnormal hormone levels may be caused by
disorders of the testicles. This may affect the
production of sperm.
 Radiation used to treat cancer may affect sperm
production.
 Retrograde ejaculation is a condition that causes
semen to travel into the bladder instead of outside
the body. It is usually caused by a problem with
the neck of the bladder and may be due to spinal
cord injuries, medicines, or diabetes.
 Other causes include pesticides, heavy metals,
heat, and undescended testes.
Signs and Symptoms:
 Inability to get your partner pregnant
 Increased body fat, body hair, and breast tissue
 Clear, watery, or whitish discharge from the penis
 Presence of a mass or swelling on the scrotum that
feels like a bag of worms (varicocele)
 Stress or emotional pressure from not being able
to conceive a child
 Testicles that are small, soft, or cannot be felt
 Veins that are enlarged, twisted, and may be seen
in the scrotum (varicocele)
Semen markers:
Fructose
Treatment:
The treatment will depend on the cause of your
azoospermia. You may need any of the
following:
 Medicines may be given to treat an
infection of the reproductive system.
Hormones may be used to treat a
hormonal imbalance.
 Percutaneous embolization is a
procedure that may be used to treat a
varicocele. An obstruction (blockage)
is made in the enlarged veins. This
stops the flow of blood within the
vein.
 A sperm extraction is a procedure to
remove sperm from the testicles or
epididymis if there is an obstruction.
The sperm that is taken out may be
saved or used to fertilize a woman's
egg.
 Surgery may need to be done to
remove a varicocele or repair a
blocked vas deferens.
17
 Erectile dysfunction
Erectile dysfunction (ED) or impotence is sexual dysfunction Treatment:  Pumps:
characterized by the inability to develop or maintain an erection  Oral medication: o A vacuum erection device helps draw blood
of the penis during sexual activity. o Phosphodiesterase type 5 inhibitors into the penis by applying negative pressure.

Causes:
 Drugs (anti-depressants (SSRIs) and nicotine are most
common)
 Neurogenic disorders
 Cavernosal disorders (Peyronie's disease)
 Psychological causes: performance anxiety, stress, and
mental disorders
 Surgery
 Surgery o Prosthetic implants which involves the
 Aging. It is four times more common in men aged in their 60s insertion of artificial rods into the penis.
than those in their 40s.  Topical medication:
 Kidney failure o Topical cream combining alprostadil with the
 Diseases such as diabetes mellitus and multiple sclerosis permeation enhancer DDAIP
(MS). While these two causes have not been proven they
are likely suspects as they cause issues with both the blood
flow and nervous systems.
 Lifestyle - smoking is a key cause of erectile dysfunction.
Smoking causes impotence because it promotes arterial
narrowing.  Injectable medication:
 Surgical intervention for a number of conditions may remove o papaverine, phentolamine, and prostaglandin E1
anatomical structures necessary to erection, damage
nerves, or impair blood supply

18
 Suprapubic catheterization
A suprapubic cystostomy or suprapubic catheter is a Indications: Procedure:
surgically created connection between the urinary  Failed urethral catheter
bladder and the skin which is used to drain urine from  Urethral injuries
the bladder in individuals with obstruction of normal  Long term usage (if left in urethral long
urinary flow. terms catheters can lead to acquired
hypospadias and recurrent/chronic UTIs,
Trocar urinary tract infections).

Contraindications:
 Need to rule out bladder cancer in cases of
clot retention
 Lower abdominal incisions with likelihood
of adhesions
 Pelvic fracture

Complications:
 UTIs
 Blockage
 Bladder stones
 Bladder cancer
 Bypass track by urine
 Fistula

Suprapubic Catheterization#showall#showall.mp4

19
 Circumcision
Male circumcision is the surgical removal of the foreskin Medical indications: Dorsal slit procedure preferred
(prepuce) from the human penis.  Phimosis
 Paraphimosis
 Balanoposthitis
 Treated penile cancer
 Treated condylomata
 Religion
 Trauma
 Penile fracture
 Hygiene in the mentally handicapped
 HIV prevention
 Uroshealth application (old people)

Contraindications:
 Hypospadias
 Request for fashion etc.
 Penis chordee
 Ambiguous genitalia

Complications:
 Amputation
 Necrosis
 Bleeding
 Infection
 Scaring / bad wound healing
 Too much skin removed
 Too little skin removed
 Fistula
 Meatel stenosis
 Skin bridging

20
 SCC of the Penis

Around 95% of penile cancers are squamous cell Causes: Treatment:

carcinomas. Other types of penile cancer such as  Male Depends on the stage of the cancer
Merkel cell carcinoma, small cell carcinoma,  Infections
melanoma and other are generally rare ca. o HIV  Surgery
o HPV o Wide local excision—the tumour and some
o Genital warts surrounding healthy tissue are removed
 Hygiene o Microsurgery—surgery performed with a
o Poor hygiene microscope is used to remove the tumour and
o Smegma as little healthy tissue as possible
 Injury o Laser surgery—laser light is used to burn or cut
o Balanitis away cancerous cells
o Phimosis o Circumcision—cancerous foreskin is removed
o Paraphimosis o Amputation (penectomy)—a partial or total
o Circumcision removal of the penis, and possibly the
 Other associated lymph nodes.
o Age  Radiotherapy
o Lichen sclerosis o adjuvant with surgery to reduce the risk of
o Tobacco recurrence
o UV light  Chemotherapy
 Biological therapy
Associated with HPV, with the main subtype being
HPV-16 (involved in 60% of cases). HPV-18 is Advanced – Radical surgery + Chemotherapy + Radiotherapy
involved in 13% of cases.

21
 Enuresis
Causes in children:
1. Nocturnal enuresis (bedwetting)
 Slow physical development
 Anxiety
 Excessive urine production
during sleep
 Genetic
 OSA
 Urinary structural problems
2. Diurnal enuresis
Used in the treatment of enuresis
 Overactive bladder
 Inadequate voiding
Enuresis refers to a repeated inability to control
 Small bladder capacity
urination.
 Constipation
3. Mixed enuresis - Includes a
Classification:
combination of nocturnal and
Primary enuresis:
diurnal type. Therefore, urine is
Refers to children who have never been
passed during both waking and
successfully trained to control urination. This
represents a fixation. sleeping hours.
Secondary enuresis:
Refers to children who have been successfully
trained (are for at least 6 months dry) but revert to
wetting in a response to some sort of stressful
situation. This represents a regression.
Causes in adults:
 Bladder cancer
 Diabetes
 Medication side effect
 Neurological disorders
 Obstructive sleep apnoea
 Prostate cancer
 Prostate enlargement
 Urinary tract infection
 Urinary tract stones
Rarely, acute anxiety or other
emotional disorders may be the cause
of adult bed-wetting.
Treatment in children:
Many children overcome incontinence naturally
(without treatment) as they grow older.
1. Behavioural modification
 Moisture alarms
 Dry-bed training
 Bladder training
i. Urinating on a schedule,
such as every 2 hours (this
is called timed voiding)
ii. Avoiding caffeine or other
foods or drinks that may
contribute to a child's
incontinence
iii. Healthy urination, such as
relaxing muscles and
taking your time
2. Medication
 Synthetic ADH – Desmopressin
22

The spinal patient:
Patient requires long term catheter,
decreases risk of sensitivity to latex.
100% silicone F catheter
Adults with gross haematuria
Foley catheter (20-24F) or 3-way
irrigation catheter (20-30F)
Post Laparotomy (man):
Post-operative, short term
Foley (straight tip) catheter (16-18F)
Obstruction by prostate:
Adult males with obstruction at the
prostate - Coudé tip (18 F)
Urinary Catheters
2 Year old child:
Foley; to determine size, divide
child's age by 2 and then add 8
The neonate:
Infants younger than 6 months -
Feeding tube (5F) with tape
Four basic models exist
including:
• 2-way catheters (inflation and
drainage)
• 3-way catheters (inflation,
drainage and irrigation)
• 4-way catheters (inflation,
drainage, irrigation and prostatic
surgical irrigation)
• Diagnostic catheters (used to
diagnose such medical
conditions as urethral diverticula)
Can’t get a catheter out?
 Further deflate the
balloon
 Change patient position
to relax muscles
 Surgical removal
23
 Prostate Ca
Prostate cancer is one of the most common Staging: Factors that can increase your risk of prostate Treatment:
types of cancer in men. Prostate cancer  Stage I - This stage signifies very early cancer include: 1. Early
usually grows slowly and initially remains cancer that's confined to a small area of  Active surveillance
confined to the prostate gland, where it the prostate. When viewed under a  Older age. Your risk of prostate cancer 2. Radiotherapy
may not cause serious harm. While some microscope, the cancer cells aren't increases as you age.  Radiation
types of prostate cancer grow slowly and considered aggressive.  Being black. Black men have a greater risk of  Brachytherapy
may need minimal or no treatment, other  Stage II - Cancer at this stage may still be prostate cancer than do men of other races. In 3. Hormone therapy
black men, prostate cancer is also more likely
types are aggressive and can spread small but may be considered aggressive  Luteinizing hormone-
quickly. to be aggressive or advanced. It's not clear
when cancer cells are viewed under the releasing hormone
why this is.
microscope. Or cancer that is stage II may (LH-RH) agonists - 
 Family history of prostate or breast
be larger and may have grown to involve testosterone
Prostate cancer that is more advanced cancer. If men in your family have had
both sides of the prostate gland.
prostate cancer, your risk may be increased.  Testosterone
may cause signs and symptoms such as:  Stage III - The cancer has spread beyond Also, if you have a family history of genes that blockers
 Trouble urinating the prostate to the seminal vesicles or increase the risk of breast cancer (BRCA1 or  Orchiectomy
 Decreased force in the stream of other nearby tissues. BRCA2) or a very strong family history of 4. Surgery
urine  Stage IV - The cancer has grown to invade breast cancer, your risk of prostate cancer  Robot surgery
 Blood in the semen nearby organs, such as the bladder, or may be higher.  Laparoscopic
 Discomfort in the pelvic area spread to lymph nodes, bones, lungs or  Obesity. Obese men diagnosed with prostate prostatectomy
 Bone pain other organs. cancer may be more likely to have advanced
 Radical
disease that's more difficult to treat.
 Erectile dysfunction prostatectomy
5. Chemotherapy
Diagnosis:
6. Freezing prostate
 DRE
7. Biological therapy
 PSA
 Imaging
o Ultrasound
o Bone scan
 Biopsy

24

Peyronie’s disease is the development of fibrous scar
tissue inside the penis that causes curved, painful
erections.
Signs and Symptoms:
 Scar tissue. The scar tissue (plaques) associated
with Peyronie's disease can be felt under the skin
of the penis as flat lumps or a band of hard
tissue.
 A significant bend to the penis. The penis might
be curved upward, downward or bent to one
side. In some cases, the erect penis might have
narrowing, indentations or an hourglass
appearance, with a tight, narrow band around
the shaft.
 Erection problems. Peyronie's disease might
cause problems getting or maintaining an
erection (erectile dysfunction).
 Shortening of the penis. The penis might
become shorter as a result of Peyronie's disease.
 Pain. You might have penile pain, with or without
an erection.
Peyronie’s disease
Causes: Treatment:
 Repeated injury to the penis 1. Wait-and-see approach
 The curvature of your penis isn't severe and
Risk factors: is no longer worsening
 Hereditary  You can still have sex without pain
 Connective tissue disorders  Pain during erections is mild
 Increases with age  You have good erectile function
 Smoking 2. Medication
 Prostate surgery  To reduce plaque and pain
 Collagenase Clostridium histolyticum
Complications of Peyronie's disease might (Xiaflex)
include: 3. Surgery
 Inability to have sexual intercourse  Suturing (placating) the unaffected side
 Difficulty achieving or maintaining an  Incision, excision and grafting
erection (erectile dysfunction)  Penile implants
 Anxiety or stress about sexual abilities 4. Other
or the appearance of your penis  Iontophoresis - uses a weak electrical
 Stresses on the relationship with your current to deliver a combination of
sexual partner verapamil and dexamethasone
 Difficulty fathering a child, because noninvasively through the skin.
intercourse is difficult or impossible
Diagnosis:
 Physical exam
 Ultrasound
25