GENITO-URINARY SYSTEM

Symptoms of Urinary Tract Diseases

1. Systemic symptoms

2. Upper urinary tract symptoms

3. Lower urinary tract symptoms

4. Other genito-urinary symptoms

I.Systemic symptoms
1. Fever
• Simple acute cystitis is afebrile disease.
• Acute pyelonephritis or prostatitis cause high temperature up to 40°C, accompanied by chills.
• Infants and children who have acute pyelonephritis may have high temp. without other
localizing symptoms
2. Weight loss
Weight loss is to be expected in advanced stages of cancer, and renal insufficiency.
3. General malaise may be noted with tumors, chronic pyelonephritis, or renal failure.

II.Upper urinary tract symptoms:

1. Pain

▪ Colicky pain: (pain in a hollow tube): Ureteric pain due to hyperperistalsis or spasm in
ureteric musculature to force against obstruction. (DD. Stone - Blood clot – Debris)
▪ Dull aching pain: Renal pain due to acute distension of the renal capsule caused by:
i. Obstruction (intermittent)
ii Inflammation (steady & severe)
➢ Radiation of renal pain: -
- Around umbilicus
- Ipsilateral testis
- GIT: Anorexia & N&V and even ileus
- Radicular pain (irritation of intercostal nerves)

2. Gross Hematuria

3. Abdominal mass
 Intraperitoneal pain Renal pain
- radiate upwards (irritation of the - never radiate upwards
diaphragm) - moving around & holding the
- lie motionless (to ↓pain) back
Radicular pain Renal pain
Share in starting at costo-vertebral angle  umbilicus
- Irritation of costal nerves - Distention of renal capsule
T10,T11,T12 - May be colicky
- Not colicky - Not altered
- May be altered by changing position

III.Lower Urinary tract Symptoms (L.U.T.S.)

▪ Storage (Irritative) symptoms
▪ Voiding (Obstructive) symptoms

A) Storage (Irritative) symptoms

■Frequency
■Nocturia

■Urgency

■Dysuria

1. Frequency:
- increased diurnal frequency. When increase more than normal range at daytime (5-7 voids)
Caused either by:
1. Increase Urinary Output (polyuria) e.g D.M., D.I. Excessive fluid ingestion
2. Decrease bladder capacity e.g. Contracted bladder or increased residual urine: e.g
B.P.H., Neurogenic bladder or Pressure from outside.
3. Bladder irritation e.g cystitis.
2. Nocturia:
- Nocturnal frequency occurs if voiding is more than [2 voids] at night.
- Nocturia without frequency occurs in: Congestive heart failure, Peripheral edema, coffee
and all alcoholic beverages, senile enlarged prostate and bladder outlet obstruction (by
exclusion of other causes)

3. Urgency: Uninhibited strong sudden desire to void. Either from:

■ Inflammatory condition
■ Neurogenic bladder and Bladder overactivity

■ Marked urinary output obstruction

■ Anxiety (no urological cause)

4. Dysuria:
■ Painful urination caused by inflammation
■ Usually referred to the external urethral meatus

■ If occurs at the start of micturition: it is of urethral origin.

■ If occurs at the end of micturition (Strangury): it is of bladder origin.

B) Voiding (Obstructive) Symptoms

■Decreased force and caliber of the urinary stream.
■Hesitancy

■Intermittency

■Post-void dribbling

■Straining

1. Decreased force and caliber of the urinary stream:

■Secondary to bladder outlet obstruction as a result of: B. P. H. or Urethral Stricture or bladder

neck obstruction.

2. Hesitancy:  difficulty to start

■ Delay in the start of micturition.

■ Normally, urination begins within a second after relaxing the urinary sphincter. ■ The
urination may be delayed in men with bladder outlet obstruction or senile enlarged prostate.
3. Intermittency:  difficulty to maintain
■Involuntary starting and stopping of the urinary stream. Commonly from prostatic

obstruction

4. Post-void dribbling:  difficulty to stop

■ Terminal release of drops of urine at the end of micturition

■ Normally small amount of residual urine in the posterior urethra is (milked back) into the
bladder at the end of micturition.
■ In early obstruction related to B.P.H., this urine escapes into the bulbar urethra and leaks out
at the end of micturition.

5. Straining:
■Means the use of abdominal musculature to urinate.

■It is a symptom of bladder outlet obstruction.

C)Pain
• Suprapubic pain:
■Due to vesical or prostatic causes: e.g bladder over distention from acute retention of urine.

It usually relieved by voiding or evacuation of the bladder

■ Suprapubic discomfort is usually caused by inflammation (acute cystitis)

• Urethral pain: may be of urethral origin (scalding ‫ )حرقان‬or referred from upper urinary tract.
➢Radiation:-
❖ Mid-ureter: -rt. (McBurney’s point) -lt (as diverticulitis) – scrotum or libia
❖ Lower ureter : vesical irritation , terminal urethralgia
• Deep seated Perineal pain: Due to prostatic disorder e.g prostatitis, BPH.

IV. Other genito-urinary symptoms

1- Testicular pain:
o Primary scrotal pain
• Acute (associated with oedema and inflammatory reaction):
▪ Orchitis
▪ Epididymitis
▪ Torsion of the testis

• Chronic (Dull pain with heavy sensation):

▪ Hydrocele.
▪ Varicocele.
▪ Spermatocele.
o Referred pain: From the kidney & retroperitoneum As it is the same embryological origin
2- Penile pain :
■ In flaccid penis Secondary to inflammation in :-
- Urinary bladder or Urethra.
- With paraphymosis (uncircumcised penis).
In erect penis
■

- Pyronie’s disease.
- Priapism.
3- Prostatic pain:
- 2ry to inflammation & edema with capsule distention
- Refred to : Perineum – lower back- inguinal region – testis
- May gives irritative symptoms or even retention of urine
4. Incontinence
Definition: Involuntary loss of urine (loss of control).
Types:
■True incontinence

■Overflow incontinence

■Urge incontinence

■Stress incontinence

1. True incontinence
■ Continuous loss of urine at all times and in all positions from the urethra.

■ Commonly with: Loss of urethral sphincter mechanism , UT fistula ( mostly vesico-vaginal

fistula)

2. Overflow incontinence
■ Secondary to chronic urinary retention

3. Urge incontinence
■ Severe urgency may precipitates incontinence

4. Stress incontinence
■ As a result of weakness in urethral sphincter mechanism

■ Occurs with physical straining:(coughing – laughing – straining)

5. Nocturnal enuresis:
♦ Definition: involuntary voiding urine during sleep.

o It occurs normally in children up to three years.

o Beyond the age of five years, it should be investigated and treated.
 6. CHANGES IN THE URINE CHARACTERS &AMOUNT
♦ Hematuria
♦ Necroturia
♦ Pneumaturia
♦ Oliguria
♦ Anuria

1. Hematuria: Presence of blood in urine.

■It is either:

o Macroscopic: gross
o Microscopic: > 3 RBC's / HPF is significant.

❖ Importance: It is the most serious symptom / sign in urology. It should be regarded as a

sign of urological malignancy until proved otherwise. It is a symptom not a disease, it needs
thorough investigations.

❖ Causes:
■Pre-renal:
o Hemorrhagic tendency (Purpura, Scurvy, anti-coagulants).
o Certain hemorrhagic fevers (Malaria).
■Renal &. Post-renal:
o Nearly all urinary diseases may be accompanied with hematuria.
o Malignancy in urinary tract is responsible for one third of its causes.

❖ Nature of hematuria
■Obvious hematuria in:
o Trauma.
o BPH.
o Urinary tract tumors: the most common cause of gross hematuria in patients over 50 years
old is bladder cancer.
■Non obvious hematuria in:

o Stone disease.
o Inflammatory.
o Early malignancy.
 ❖ Relation to micturition
■ Initial: urethral origin.
■ Terminal: pathology in bladder neck.

■ Total: mostly in bladder and upper urinary tract tumors.

❖ Color of hematuria
o Dark brown: from upper urinary tract (old blood).
o Bright red: from lower urinary tract (fresh blood).

❖ Presence of clots
▪ Worm like (thready and spiral): from upper urinary tract.
▪ Discoid: from the urinary bladder.
▪ Thick thready: from the urethra.

❖ Associated symptoms
■ As pain, fever or irritative symptoms that may give a clue to the cause and site of hematuria.
■ Asymptomatic: first thinking must be to malignancy.

❖ Investigations
Laboratory
■ Urinalysis to detect (RBC's, pus cells, Bilharzial ova, etc.).

■ Blood urea and serum creatinine (renal function tests)

■ Coagulation profile.
■ PSA
Radiological
■ Plain X-ray and IVU (to detect stones and other organic causes beside renal function).

■ Ultrasonography, CT and MRI

Cystoscopy Help in localization beside any organic lesions in the bladder.

False or pseudohematuria
Not all dark urine or red urine is true hematuria.
Examples:
■Heavy concretions of urates ■Some drugs. e.g.: the antibiotic Rifampicin

■Some vegetable dyes as beetroot. ■Phenolphthaline in alkaline urine.

Urinalysis is the preliminary test that can distinguish true from false hematuria.

➢ Blood clots in urine is a sure sign of true hematuria.

2. Necroturia

■Passage of whitish necrotic tissues in urine.

■Occurs in cancer bladder (SCC and invasive TCC).

■Usually associated with irritative symptoms as dysuria.

3. Pneumaturia
■Passage of gas in urine is pathognomonic of fistula with the gastrointestinal tract

4. Oligurea

Urine output less than 400 ML /24 hours indicates circulatory insufficiency due to shock or
■

dehydration or established acute renal failure.

5. Anuria

Less than 100ml of urine in 24 hours indicates severe acute renal failure or bilateral complete
■

obstruction. Should be differentiated from urinary retention.( examination and

ultrasonography).

Andrology symptoms

A) Male sexual symptoms:- B) Femal sexual

symptoms:-

1. Hypo or loss of libido: maybe : problems in :

- Psychic - desire
- Hypoprolactinemia - lubrication
2. Erectile dysfunction ( impotence):- - orgasm
- Psychic
- Organic
3. Anejaculation / retrograde ejaculation:
- Neurogenic
- Postoperative
- D.M.
- Psychic
4. Anorgasmia: usually psychic
c) Male infertility:-
• primary or secondary
• may be due to :-
- idiopathic testicular failure
- trauma or inflammation to testes
- drugs or irradiation
- varicocele (prolonged exposure to high temperature)
- vassal or epididymal obstruction

Scrotal symptoms
A. Absence of one or both testes: undescended, ectopic, fibrosis.

B. Atrophies testis: congenital, post inflammatory, sexual infantilism (hypogonadism)

C. Scrotal swellings:-

1. Acute (é pain) 2. Chronic (é↑size)

- Orchitis - Hydrocele
- Epididymitis - Varicocele
- Testicular torsion - Spermatocele

Penile symptoms

A. Urethral discharge: STDs : Gonorrhea( yellowish or greenish), Chlamydia(scanty,

whitish)

B. Micropeins or ambiguous genetalia: variety of intersex states

C. Urethral meatus abnormalities: Epispadias, hypospadias

D. Penile nodule: idiopathic fibrosis of tunica albuginea (pyronie’s disease)

E. Penile fracture: d/t strong trauma to an erect penis

 URINARY TRACT INFECTIONS (U.T.I.)
Definitions:
Bacteriuria: presence of bacterial colonization in urine (count >100000cfu/ml).
Pyuria: presence of more than 3 fresh leucocytes in the urine by H.P.F (high power
field).
Sterile pyuria: presence of pyuria without bacteriuria as in antibiotic therapy, TB,
stones and nonbacterial infections

Classification of U.T.I.
A) Specific: caused by specific organism e.g. T.B., bilharziasis, filariasis, and
fungal infection.
B) Nonspecific: caused by o Gram –ve organism e.g. E-coli (the commonest),
protus, klebsialla and pseudomonas
o Gram +ve organism e.g. staph and strept

Routes of infection:
1. Ascending infection.
2. Hematogenous.
3. Lymphatic spread.
4. Direct extension from neighboring organs.

Protective factors:  Antimicrobial prop. Of urine: -

1- Increase renal vascularity 1- Urinary antibodies.

2- Effective urethral peristalsis (wash out) 2- Acidic urine
3- Competent uretro vesical junction # reflux 3-Increase osmolarity
4- Genetic factors 4-Surface mucin

Predisposing factors:
1- General: anemia, D.M, uremia or immunosuppression
2- local: obstruction, F.B. e.g. stone or catheter and genital infections

3- Bacterial factors : Virulence , colonization in female , chronic prostatitis.

 Diagnosis:

A) Urine collection :
*infant : suprapubic needle.
*circumcised♂ : voided urine without cleaning
*uncircumcised ♂: voided urine after retraction of foeskin and washing of glans.
*♀ : wash of introitus , separation of libia & take mid stream urine.
B) Urine analysis: best sample is the morning specimen and examined within 1 h.

1. Pus cell >3 leukocytes per H.P.F.

2. bacteruria >100000 C.F.U./ml

C) Urine culture and sensitivity

D)Anatomical localization of U.T.I.

1. Pyelonephritis
2. Perinephric abscess.
3. Cystitis
4. Prostatitis
5. Urethritis

Acute Pyelonephritis
Definition: acute inflammation of renal pelvis and renal parenchyma.
Route of infection:
1.Ascending infection from urethra by E.coli (the commonest).
2.Haematogenous by staph or strept.
3.Lymphatic spread.
Clinical picture:
Symptoms:
1. General constitutional symptoms (fever, chill, rigors).
2. Loin pain.
3. dysuria
4. Hematuria.
Signs:
1. Fever.
2. Tachycardia.
3. Tender renal angle.
Investigations:
1. Urine analysis:
A) pyuria
B) Microscopic haematuria.
C) Positive culture/ sensitivity test
2. CBC: leukocytosis.
3. U/S: Increased kidney size
Treatment
1. Bed rest.

2. I.V. Antibiotic. ( start with empirical parenteral broad spectrum

antibiotic till the results of urine culture/ sensitivity test then
shift to suitable one)

3. I.V. fluid ( more than 50% of cases required hospitalization)

4. Analgesic.

5. Antipyretic. .

Chronic Pyelonephritis
Def. process of renal scarring and atrophy with subsequent renal insufficiency.
Et:- 1- adult: Repeated attacks of acute pyelonephritis in presence of risk factors
e.g. D.M., obstructive uropathy or renal stones lead to
2- children: association btw VUR ( vesico-ureteral reflux) & UTI

Pathology: small scarred kidney.

Clinical picture:
Usually discovered by complications as hypertension or azotemia or easy
fatigability
Investigation:
A) Labaratory:
A- urine analysis: pyuria, proteinuria and casts.
B- Urine culture/ sensitivity test
C- Serum creatinine

B) Ultrasonography: U/S: small irregular kidney contour

C) Isotope Renal scan
Treatment:
1. Long term use of antimicrobial therapy
2. Treatment of hypertension.
3. Nephrectomy in unilateral atrophic kidney if causing intractable
hypertension or persistent infection
4. Dialysis or Renal transplantation in bilateral end stage renal
disease.

Pyonephrosis
Infection of a hydronephrotic kidney. The kidney is transformed into a cavity filled with
pus and lined by necrotic renal tissues

Clinical pictures:
Pain, fever, tender renal angle and pyuria.

Treatment:
1. Kidney drainage by ureteric catheter or by percutaneous nephrostomy tube. The
cause of obstruction should be corrected.
2. Nephrectomy, for advanced cases with atrophic non-functioning kidney.

Peri-nephric Abscess

Definition: accumulation of pus in the perinephric space within Gerota's fascia.

Route of infection:
1. Haematogenous spread from a distant septic focus as tonsillitis
2. Direct spread from renal infection
Clinical picture:
▪ Acute Flank pain.
▪ Fever.
▪ Anorexia, nausea and vomiting.
▪ Skin edema, loin swelling, scoliosis and symptoms of cystitis (50%).
Investigations:
Laboratory:
▪ Urine analysis and culture: positive in 50%.
▪ CBC: leukocytosis.
▪ Blood culture: positive in 50%
Radiology:
▪ KUB:
O Enlargement of soft tissue shadow of the kidney
O Obliteration of psoas shadow due to oedema.
O Scoliosis to the side of abscess
▪ U/S & C.T are diagnostic tool *CT  ( Ring sign )

Treatment:
U/S or C.T. guided percutaneous drainage with antibiotic therapy if (small)
sized, or open drainage ( large abcess ) .
 URINARY TRACT STONES Urinary Calculi
Incidence
The third most common disease of the urinary tract, exceeded by UTI and prostate
diseases. 2-4% of general population.

Epidemiology
Age: peak age incidence 20-40 years (middle age).
Sex: male: female = 3-1
Genetic:
• Family history is +ve in 25% of recurrent stone cases.
• No specific responsible gene is coded till now.
Climatic and seasonal:
• High temp results in concentrated urine and more tendencies to crystallization.
• The highest incidence of stones is 1-2 months after the achievement of
maximal mean annual temp.

Pathogenesis:
Different substances (stone constituents) are present normally in
urine in soluble form. The key step in stone formation is
precipitation of these substances into crystals (crystallization). This
is followed by growth and aggregation of these crystals which is
enhanced by nucleation and lead to stone formation.
The concentration of the substance at which saturation is reached
and crystallization begins is called solubility product (Ksp). It is
affected by temperature, pH and presence of other substances in the
solution.
Urine is not a simple solution. It contains inhibitors of
crystallization that hold substances in solution and prevent
crystallization even in concentrations higher than Ksp.

Etiology:
1.Inadequate drainage:
Normal urine flow expels crystals before they have chance to grow and aggregate.
Stasis of urine (e.g. in obstructive uropathy) allow stones to form. Also, stasis
predisposes to infection.
 2.Excess normal constituents in urine:
This may occur either:
• Due to increased urine concentration due to decreased water intake
(dehydration) which occurs in hot climates.
• Increased excretion of the substances causing stones , as follows:
Excess urinary calcium excretion:
• Idiopathic
• Hyperparathyroidism.
• Prolonged immobilization.
Excess uric acid:
• Gout
• Purine rich food e.g red meet, liver….
• Chemotherapy for leukaemia and lymphomas.
Excess urinary oxalates
• Idiopathic hyperoxaluria
• Excess intake of food rich in oxalates e.g strawberry.
3.Presence of abnormal constituents in urine :
Infection:
Infection produces epithelial desquamation which may provide nucleus for
stone formation. Infection, also, with urea splitting organisms makes the urine
alkaline which favors phosphate stones formation.
Foreign bodies:
Catheters, sutures and stents may act as a nidus for stone formation.
Vitamin A deficiency:
Causes hyperkeratosis of urothelium, with production of debris which may act
as a nucleus for stone formation.
Cystinuria : A metabolic error.

Types of Urinary Stones:

❖ NB: Most stones are mixed.
Ca oxalate: radio opaque and formed in acid urine. (most common type)
Ca phosphate: the most radiopaque stone. Formed in alkaline urine.
Urate: typically radiolucent and formed in acid urine.
Infection stone ( Struvite stone) : Partially radio opaque formed in alkaline urine,
composed of Calcium, Ammonium Magnesium, , and Phosphate (triple phosphate
stone) (CAMP) Infection by urea splitting organisms alkalinize urine and allow precipitation
of phosphates.
Cystine:
Cystinuria is an autosomal-recessive defect in reabsorptive transport of cystine and the
dibasic amino acids ornithine, arginine, and lysine from the luminal fluid of the renal
proximal tubule. It is characterized by hexagonal cystine crystals in urine.
Cysteine stone is partially(faint) radiopadue because it contains sulfur. It is formed
in acid urine.
Since cystinuria is an inherited disease, stones may begin in childhood

- Urine pH is an important factor in the production of kidney stones. Uric acid, cystine,
and calcium oxalate stones tend to form in acidic urine, whereas struvite and
calcium phosphate stones form in alkaline urine

Stone Ca containing Magnesium Uric acid& urate Cystine

stone [Oxalate or Ammonium
phosphate] Phosphate (7-9%) (1-3%)
(75%) (15%)
Shape Irregular Staghorn stone Oval or faceted Oval

Surface Spiky Smooth Smooth Smooth

Cut Amorphous Laminated Amorphous Amorphous

section

X- ray Radiopaque Radio-opaque Radiolucent Faint

[KUB] Radiopaque

Types of renal stone

Complications:
1.Infection
2.Obstruction: hydronephrosis and deterioration of kidney function.
3.Calculus anuria: Post renal acute renal failures due to complete obstruction
in a single functioning kidney or bilateral complete obstruction.
4.Malignancy: Rarely squamous cell carcinoma of the renal pelvis due to chronic
irritation by long standing stone.
 Clinical picture:
Symptoms:

1. Renal pain:
Typical renal colic has the following criteria:
a. Severe , Colicky in nature
b. Sudden onset and offset
c. Site: In the flank
d. Not related to posture (patient is restless in bed)
e. Referred to ibsilateral testis, labia majora, inner thigh
f. Associated GIT symptoms (nausea, vomiting) Associated hematuria
g. Associated lower urinary symptoms as frequency, urgency or burning micturition
especially if the stone in the lower ureter
h. Usually there is history of similar attacks or stone passage.
In some cases renal pain may be moderate in severity of stabbing nature or heaviness
due to distension of renal capsule.
2. Symptoms of complications: Hematuria, fever, uremic
symptoms.
3. Asymptomatic:
Discovered incidentally during imaging for unrelated causes.
Signs: No reliable signs.
Investigations:
Lab:
1. Urine analysis: RBCs, pus cells, PH, crystals.
2. blood:
b. Renal function tests as blood urea and serum creatinine.
c. Serum calcium, uric acid, parathormone hormone, T3 and T4 in
some cases.

Radiological:
1. KUB: Plain X-ray may show radio opaque shadow in the area of urinary
tract if the stone is radio opaque.
2. US: abdominal ultrasound
a. May show the stone as echogenic area with posterior shadow in
the kidney.
b. Intramural ureter or the urinary bladder, but it is very difficult to
show the stone in the middle ureter.
c. US may also show back pressure in the kidney due to obstruction.
 3. Spiral CT [NON-contrast CT abdomen and pelvis]: Non enhanced
spiral CT is the preferred single imaging
technique in emergency diagnosis due to:
a. Rapid procedure
b. No contrast used
c. Can show radiolucent stones
d. May show other causes of acute abdomen witch
mimic renal colic as gall stone, diverticulitis,
appendicitis or intestinal obstruction
e. May predict stone fragility and liability to
fragmentation by ESWL

4. IVU: Intravenous injection of contrast material to be concentrated by the

kidney and secreted in urine to delineate the urinary tract. It may show
filling defect of radiolucent stone, but it has the following disadvantages:
a. Hypersensitivity reactions to contrast.
b. Dye is nephrotoxic and should not be used if serum creatinine exceeds
2.3mg/dl. So estimation of renal function is mandatory before its use.
c. Time consuming in emergency conditions.
d. Kidney may not secrete the dye either because of its bad function or
due to spasm of renal arterioles induced by pain.
SO, IVU is not suitable procedure for emergency diagnosis
5. Radio Isotope Scanning: radioactive materials are injected intravenously
to be up taken and secreted by the kidneys.
• To assess function of each kidney
separately. differential function
• Predict its recoverability after relieving
obstruction.
Differential diagnosis:
1. Myalgia, radiculitis may mimic renal pain. The pain in this case is related to
movement of the body.
2. D. D of acute renal colic from other causes of acute abdominal pain as biliary
colic, diverticulitis, appendicitis and intestinal obstruction.
3. DD of Radio-opaque calculi in X ray
• Philipolithes (calcified thrombosed pelvic veins),
• Gall bladder stones,
• Calcified lymph nodes
• Calcification in dermoid cysts Tumors.
 4. DD of Filling defect in IVU
• Radiolucent stone
• Blood clots
• Sloughed renal papillae.
• Renal pelvis tumors
Treatment:
1. Medical:
Indications:
• When pain is tolerable.
• For a single stone less than 7mm in its largest diameter.
• Absence of severe infection and marked back pressure.
• With normal or near normal contra lateral kidney.
HOW? By Medical expulsive therapy [MET]
1. Analgesics [parenteral NSAID or opioids]
2. Plenty of oral fluids
3. Control of PH of urine
4. Urinary antiseptics if there is infection
5. Alpha blockers are used to aid in expulsion of lower ureteric stones.
2. Extracorporeal Shock Wave Lithotripsy (ESWL)
Concept: Shock waves generated outside the body are focused on the stone. The
stone is precisely localized by x-ray or ultrasound. Shock wave energy fragments the
stone to multiple small size stones amenable for spontaneous passage with urine flow.
Indications:
• Kidney stone less than 2cm in its largest diameter in a patent
urinary tract.
• Ureteric calculi less than 1 cm.
Complications:
• Renal colic due to passage of fragments
• Hematuria
• Subcapsular hematoma
• Steinstrasse (fragments accumulate in the ureter and may lead
to complete obstruction) may be avoided by (JJ) ureteric stent
Advantages:
• It is non-invasive procedure.
• May not need anesthesia.
• Outpatient procedure (no hospitalization).
Disadvantages:
• Not suitable for large and stage-horn stones.
• Less effective in ureteric than in renal stones.
 • Bleeding tendency and morbid obesity, skeletal abnormalites,
aortic aneurysm are relative contraindications.

3. Endoscopic:
Endoscopes (cystoscope, ureteroscope or nephroscope) equipped with a working
channel is used to approach the stone with either:
• Extracted by forceps or basket (e.g Dormia basket).
• Fragmented in situ and then extracted.
Fragmentation of the stones is done through the endoscope by:
Ultrasonic lithotripsy, Pneumatic lithotripsy, or Laser lithotripsy.
O Bladder stones Most of bladder stones can be managed endoscopically.
O Ureteric stones can be treated by ureterorenoscope (URS).
O Renal stones: can be treated by Percutaneous
nephrolithotomy (PCNL) (compilations include :
bleeding, inj. To viscera)

4. Open Surgery :
Rarely indicated in modern urologic practice because of:
o Prolonged hospitalization
o Significant blood loss.
o Occasionally wound infection and incisional hernia.
Surgical Techniques & incisions:
Bladder: cystolithotomy,
Ureter: Ureterolithotomy.
Kidney:
o Pyelolithotomy: opening of the renal pelvis to remove the stone.
o Nephrolithotomy: incision through the renal parenchyma to
remove the stone. Anatrophic Nephrolithotomy in cases of
(staghorn stone)
o Partial nephrectomy: if the stone is impacted in a dilated
nonfunctioning lower calyx.
o Nephrectomy: For non-function kidney, if the contralateral
kidney is normal.
 PROSTATE
Anatomy of the prostate:
The prostate is a gland that surrounds the bladder outlet and the beginning of the male
urethra. Its shape is like a chestnut or inverted cone, it measures 3cm in length, 4cm
width and 2cm depth. The weight of the gland is about 18 gm.

▪ It is related posteriorly to the rectum from which it is separated by the fascia of

Denonvillier.
▪ Anteriorly it is related to the back of the symphysis pubis and fixed to by the
puboprostatic ligament.
▪ The anterolateral surfaces are related to the pelvic floor muscles (levator and muscle )
▪ The base is related to the bladder base
▪ The prostatic urethra traverses the prostate and receives the
openings of both ejaculatory ducts at the top of an elevation at the
floor of the prostatic urethra called the vermontanum. The tiny
openings of the prostatic ducts open at the floor of the prostatic
urethra at either sides of the verumontanum.
The gland is divided into different zones:
• Transitional zone is the [commonest site for the
origin of BPH]
• Central zone
• Peripheral zone is the [commonest site for prostatic
carcinoma]
• Anterior fibromuscular stroma
Clinically the gland has two lateral lobes separated by
a central sulcus or median furrow and a middle lobe
which may project into the cavity of the bladder in
BPH
 Benign Prostatic Hypertrophy
"Senile enlargement of the prostate"
Is the commonest condition of the prostate affecting about two thirds of men above
the age of 50 years.

➢ the size of prostate doesn’t necessarily determine the severity of symptoms

Etiology:
The exact etiology is unknown but two major factors are necessary for the
development of BPH, these are aging and the presence of normal testosterone

Pathology:
BPH arises mainly from the transition zone or the periurethral region as
adenomatous tissue enlarges it expands to compress the normal prostatic tissue
forming a false capsule (surgical capsule) with a line of cleavage

Histology:
Hyperplastic acini, variable in size, lined with one or more layers of cells some
of acini contain corpora amaylacia (acidophilic secretion due to hyaline degeneration)
the fibromuscular sroma show hypertrophy

Pathologic Effects:
• Urethra: is compressed, stretched, elongated and may be tortuous.
• Bladder:
1- Compensated stage :- the bladder wall becomes hypertrophied to overcome
the obstruction. The pressure inside the bladder increases leading to
formation of celules and diverticulae.
2- Decompensated stage :- the bladder dilates and post-voiding residual urine
accumulates leading to retention of urine which may be chronic or retention
with overflow incontinence.
• Upper tract: in late cases bilateral hydroureter and hydronephrosis may occur
leading to renal insufficiency in some cases.
Clinical Picture:
The patient may be presented with a group of symptoms known as "lower urinary
tract symptoms" which may be either irritative or obstructive.
• Storage (irritative ) symptom: increased frequency of micturition, Nocturia ,urgency
and urge incontinence. The increased frequency starts nocturnal which is the most
early symptom , the patient has to wake up 3-4 times by night to void , then with
time ,it progress to be diurnal.
• Voiding (obstructive ) symptoms: hesitancy, weak stream ,interrupted stream and
finally urine retention.
Obstructive symptoms occurs first but with the occurrence of infection , stone
formation irritative symptoms become manifested.
• Sexual symptoms: At first there is increased libido. Later, impotence may occur.
• Haematuria: may occurs due to congestion of veins at the base of the bladder.

• Symptoms of complications: e.g stones, cystitis or renal failure.

➢ The symptoms can be categorized according to (I-PSS)

( International prostatic symptom score) AS :
-mild : 1-7
-moderate 8-19
-severe 20-35
Physical Examination:
• Abdominal mass ( hydronephrosis)
• Pelvic mass (bladder from retention )
• Digital rectal examination (DRE):
1. symmetrical or asymmetrical enlargement
2. preserved sulci
3. smooth surface
4. sliding rectal mucosa over the gland
5. rubbery firm in consistency like that of contracted thenar eminence
(fully flexed thumb).

Acute urine retention Chronic urine retention

 - A painful bladder A non-painful bladder
The patient is unable to pass The patients may be
urine incontinence

A palpable or percussible The bladder remains

bladder palpable or percussible
after the patient has passed
urine

Investigations:
A- (Basic Investigation)
1. urinalysis : to exclude infection
2. serum creatinine : normally (0.8- 1.4 mg\ml )
3. serum prostatic specific antigen (PSA): is a tumor marker that is elevated
in prostatic carcinoma
• normal level 0-4 ng\ml
• 4-10 ng\ml the is grey zone value
• more than 10 ng\ml it may indicates cancer
4. Ultrasonography
• Abdominal US
• Transrectal US (TRUS) for exact imaging of the prostate and seminal vesicles
and detection of suspicious malignant lesions.
B- (Additional Investigations)
Uroflowmetry : a maximum flow rate below 15 ml \ sec may indicates
obstruction
Estimation of post voiding residual urine by US or
by catheterization
Cystoscopy only reserved for patients presented with
hematuria to exclude bladder pathology
IVU reserved for patients with suspected upper tract
pathology and those with hematuria to exclude upper
tract tumours
Complications:
• Hematuria
• Urine retention
• Infection : leading to increased frequency and dysurea
• Stone formation due to stagnation and infection
• Uremia due to decompensation of the upper tract and bilateral hydronephrosis
Treatment:
1. watchful waiting : in patient with mild symptoms the patients are advised to :
- decrease fluid intake at night - timed voiding
- avoidance of constipation - avoid exposure to cold
- avoid diuretics and anti-cholinergics - avoid sexual excitement
2. Medical treatment :
• Indication: in patients with some bothering symptoms but with no negative
impact on quality of life (with no complications)
• Drugs
▪ alpha adrenergic blockers ( doxazocin - terazocin ,tamsulosin):
they act by decreasing the tension of the smooth muscle of the
capsule and the stroma thus relieving the symptoms usually
improvement within 2 wks.
▪ 5-alpha reductase inhibitors (finasteride):
It inhibits the 5 alpha reductase enzyme responsible for conversion
of testosterone to its active ingredient ( dihydrotestosterone ) thus
inhibiting the growth of the prostatic cells and cause shrinkage of
the prostate and reduction of the prostate size of 25% in 3m. but it
is expensive and needs long term to be effective
3. Surgical Intervention
Indications :
o Recurrent attacks of acute retention o Hematuria
o Recurrent urinary tract infection oBladder stone and diverticulum
o Renal insufficiency o Failed medical treatment
Types of intervention
o Endoscopic prostatectomy [trans-urethral resection of the prostate or TUR-P]:
Resection of obstructing prostatic adenoma using endoscope [Resectoscope] and
monopolar electrocautery .It is the gold standard.
o Open surgery : for big prostate (>80 gm)
▪ Tansvesical prostatectomy: the adenoma is enucleated through opened
bladder.
▪ Retropubic prostatectomy (Millin's): enucleation of the adenoma at a line of
cleavage between it and the false capsule through the retropubic space
without opening of the bladder.
o Minimally invasive techniques for treatment :
1. laser prostatectomy
2. Bipolar or plasmakinetic prostatectomy
3. prostatic stents
 Prostate Cancer
A common malignancy in old men (usually over 65 y.)

Etiology:
Unknown
Risk factors include family history, high fat diet and racial factors (more in African
Americans rare in Japanese)

Pathology:
Gross:
Hard nodule or multiple hard nodules that ultimately invade the prostatic
capsule and adjacent structure. The majority of neoplasm (75%) arise from the
peripheral zone.
Microscopic:
Adenocarcinoma with varying degree of differentiation. There is a grading
system for cancer prostate (Gleasons grade) based on the degree of differentiation
and growth pattern. Grade 2 is the least malignant while grade 10 is the most
malignant.
Spread:
1. Direct to the rest of the gland (capsule, seminal vesicles, bladder and
lower ureters) invasion of the rectum is late because the rectovesical fascia
(fascia of Denonvillier) acts as a barrier for invasion.
2. Lymphatic spread :to the pelvic L.N
3. Blood spread mainly to the lower vertebrae and the femur,ribs (bone
metastasis are mainly osteoblastic but rarely osteolytic)

Clinical Features:
• 1- latent tumor: asymptomatic and discovered accidentally during routine
investigations
• 2- obstructive tumor: May presents with symptoms of lower urinary tract
obstruction and irritation usually similar to BPH but are shorter in duration and
progressive course than these of BPH
• 3- occult tumor (metastatic): 5 % May present with symptoms of metastasis
without urinary tract symptoms
Staging System TNM:
• T o No clinical abnormality
• T 1 Nodule in one lobe (microscopic)
• T 2 Diffuse disease (macroscopic intracapsular tumor)
• T 3 Extension to seminal vesicles (extra capsular)
• T 4 Lesion fixed to other tissues
• No Involved LN
• N1 Involved one regional LN
• N2 Involved several regional LN
• N3 Fixed regional LN
• N4 Involved common iliac or para-aortic LN
• Mo No metastases
• M1 Distant metastases
Diagnosis:
1.Digital rectal examination (DRE):
Palpation of a hard nodule or multiple hard nodules with oblitration of the
medial sulcus, seminal vesicles may be felt indurate.
2.Elevated serum PSA:
• It is a marker for prostatic cancer, normal value is (0-4 ng\ml).
• In BPH it may arise to 10 ng\ml
• More than 10 ng\ml it may indicates malignancy
3.Prostatic biopsy:
• The surest diagnosis could be made after the biopsy. It can be taken from the
prostate by transrectal ultrasonography (TRUS biopsy).
4.Other markers include serum acid phosphatase or serum alkaline phosphatase
5.Plain radiography of the skelton to detect metastasis
6.Isotopic bone scan to detect bone metastasis
7.CT scan for the evaluation of the extent of the local spread and LN invasion
8.Cystoscopy
Treatment:
1.Watchful waiting for old patient with very early lesion that are of low grade
malignancy. Asymptomatic and if life expectancy <10 y.
2.Radical Prostatectomy for patients with tumour confined to the prostate
with no metastasis(T1,T2) .The operation is radical retropubic
prostatectomy with block dissection of the pelvic lymph nodes.
3.Radiotherapy may be an alternative to radical prostatectomy and if life
expectancy >10 y. It is either external beam radiation or brachy-therapy
(implantation of radioactive seeds or needle in the prostate to release local
radiation).
 4.Hormonal therapy (in T3,T4) it is the main stay in the treatment of
advanced cases. It is known that prostatic cancer cells depend mainly on
androgens so hormonal therapy depends on androgen ablation by:
1- Surgical castration: Bilateral orchiectomy ( testes produces 95% of male
androgens)
2- Medical castration:
A- Antiandrogens (Nutilamide), which block the testosterone receptors by
competitive inhibition .
B- LHRH antagonist (Zoladex) which causes transient elevation of
testosterone level followed by drop of the level of this hormone.
Prognosis:
• The life expectancy of a patient with incidental focal prostatic cancer is that
of the normal population.
The 10 y. Survival rate for localized tumor is 50%. And 10% for advanced
tumors.
 Bladder Cancer
An estimated 77,000 new cases of bladder cancer were diagnosed in 2017 in USA,
and approximately 16,000 deaths are expected yearly. In Egypt, bladder cancer
ranks next to liver cancer in men and breast cancer in women.
Pathologic Types:
Carcinoma of the bladder is classified histologically into:
1. Transitional cell carcinoma (90-95%): The commonest urothelial tumor.
2. Squamous cell carcinoma (2-5%):
In Western, Non-Bilharzial cases of squamous cell carcinomas are usually
associated with chronic infection, vesical stones, chronic use of indwelling
catheters, or bladder diverticula.
Bilharzial squamous cell carcinomas are predominantly found in regions
where schistosomiasis is endemic, such as in the Middle East, Southeast Asia,
and South America
Almost all squamous cell cancers are already advanced and muscle-
infiltrative at the time of diagnosis.
3. Adenocarcinoma (0.5-2%):
It is classically associated with bladder exstrophy and a persistent urachus.
Adenocarcinoma is also found in Bilharzial cases associated with cystitis
glandularis.
4. Small cell tumor( 1%) It is highly aggressive histologic type.

Etiology and predisposing factors:

I.Transitional cell carcinoma :
A) Industrial toxins e.g. beta-naphthylamines, hair dyes, and Arsenic in
drinking water are believed to increase the risk of bladder cancer.
B) Drugs: like phenacetin, cyclophosphamide, and artificial sweetener.
C) Smoking: Smoking has been reported as a major risk factor for bladder
cancer. Smokers have four times the risk of bladder cancer than nonsmoker,
as the carcinogens excreted by the kidneys contacts the bladder mucosa for
potentially long time causing tumor formations

II.Squamous cell carcinoma:

A) Bilharzial infestation: Bilharzial ova provoke an intense inflammatory
reaction, associated with the production of oxygen free radicals, which may
induce genetic mutations or promote the production of carcinogenic
compounds. Also chronic super-added bacterial infection may in itself
predispose to malignancy.
B) Long standing cystitis and bladder stones.
Pathology:
Macroscopic appearance :
f. TCC: Papillary growth (90%). Raised plaque. Nodule. Ulcer.
g. SCC: Fungating mass (85%). Ulcer (10%). Diffuse infiltrating (5%).

Staging: TNM staging system:

Non Muscle invasive :

Tis: Carcinoma in situ (flat)
Ta: Noninvasive papillary carcinoma
T1: Tumor invade sub epithelial tissue (lamina propria)
Muscle invasive:
T2: Tumor Invades muscle
T3: tumor Invades perivesical tissue
T4: Tumor invades adjacent organs: prostate, uterus.

N M
N0: No lymph node metastasis M0: No metastasis
N1: +ve Lymph node metastasis M1: +ve metastasis.
Spread:
• Local spread to adjacent organs
• Lymphatic to obturator, internal iliac, and conman iliac lymph nodes.
Lymphatic spread in Bilharzial carcinoma is rare and late due to the associated
fibrosis which obliterates the lymphatics.
• Blood metastasis to bone, liver, and lung
WHO Grades:
• Low Grade: well differentiated
• High Grade: poorly differentiated
Clinical Features:
• Hematuria: Gross painless hematuria is present in over 80% of patients with
bladder cancer.
• Bladder irritative symptoms e.g. Dysuria, frequency, and urgency.
• Necroturia: Passage of white or red pieces of necrotic tissue with urine
specially occurred with squamous cell carcinoma
• Clinical examination:
Digital Rectal Examination (DRE)/ PV Examination: The tumor is usually felt
bimanually and its size, extension, and mobility can be assessed under anesthesia
however, it is rare to feel the mass in superficial tumor.

• Investigations:
1. Urinary cytology: but it has low sensitivity in low-grade cancers

2. Imaging:

• CT scanning of the abdomen and pelvis with contrast to assess upper and
lower urinary tract.
• Ultrasonography is commonly used as an initial evaluating tool, but it may
miss urothelial tumors of the upper tract
3. Cystoscopy: cystoscopy is the primary modality for the diagnosis of
bladder tumor, It Permits biopsy and complete resection of superficial
tumors.

! !
US image of the bladder shows a large CT cystogram demonstrates a soft-tissue
urothelial carcinoma within the bladder. filling defect.
Treatment of Non muscle invasive bladder cancer:

• The treatment of Non muscle invasive bladder cancer (Ta, T1, CIS) begins with
Complete Trans-Urethral Resection of the Bladder Tumor (TUR-BT)
followed by immediate post-operative intravesical instillation chemotherapy
(Mitomycin C).
• Intravesical instillation of BCG course: BCG attracts the immune cells to the
bladder, which then attack the malignant cells. It reduces the risk of recurrence
and progression.
• Radical cystectomy should be considered for recurrent high risk cases.
Treatment of muscle invasive bladder cancer:
Operable cases:

Neo- adjuvant chemotherapy, Radical cystoprostatectomy and pelvic

lymphadenectomy and Urinary diversion.
- An alternative protocol with bladder preservation: TUR-BT, radiotherapy and
chemotherapy

Inoperable cases: palliative therapy

Radiotherapy, Chemotherapy: Methotrexate, Vinblastine, Adriamycin, and Cisplatin

(MVAC) or Gemcitabine and Cisplatin (GC).
Gene therapy and Targeted therapy are still in early stages

N.B. For Squamous Cell Carcinoma, radiotherapy and chemotherapy are not effective.
Radical cystectomy and urinary diversion is the treatment of choice.
 Urinary Diversion after cystectomy:
Types:
A) Continent Diversions:Continence depends on:
1. Urethral sphincter: e.g. Orthotopic bladder substitution
2. One-way valve: Continent reservoir with abdominal stoma for clean
intermittent self-catheterization (CIC).
3. Anal sphincter: e.g. Ureterosigmoidostomy, and modified rectal bladder
B) Non Continent Diversions:
1. Uretero-cutaneous diversion
2. Ileal conduit
Ureterocutaneous Diversion:
Rarely done nowadays because of complications:
1) Urine leakage.
2) Ascending infections.
3) Stenosis at ureterocutaneous junction.
lleal Conduit: most common type used worldwide
The conduit is constructed using a segment of ileum
18–20 cm long. The ureters are implanted into left end and
the right end of the conduit is brought through the
abdominal wall. A stoma is protruded 1–1.5 inch above
the skin surface to form a nipple. The urine can be
collected in an adhesive collecting bag.
This method of urinary diversion has an advantage
over ureterocutenous diversion as the stoma nipple help
in avoidance of urine leakage,
Complications:
(1)Stomal complications: necrosis, stenosis, hernia, retraction, and prolapse
(2)Hydronehrosis
Ureterosigmoidostomy
The ureters are implanted onto the sigmoid colon. (rarely performed)
Complications:
1. Ascending infection.
2. Hypercholoremic acidosis: because of the larger surface area of intestinal
mucosa and longer contact time with urine.
3. Adenocarcinoma at the site where the ureters have been implanted into the large
intestine. Usually it occurs after 10 years and the cause is unknown.
Continent reservoir:
- Continent reservoir (pouch) with self catheterizable abdominal stoma may be
made from small intestine, large intestine, or a combination of both and the stoma
can be fashioned using appendix or tapered terminal ileum
- Urine evacuation is carried out CIC method

!
Diagram shows orthotopic ileal bladder substitution

Orthotopic ileal neobladder substitution : excision of the bladder and

replaces it by new one.
Orthotopic bladder substitute depends on the intact urethra and sphincter to carry urine
to the urethral meatus. It is suitable for both male and female. Ileal W bladder
substitution is the most widely performed orthotopic bladder

Complications:
1. Incontinence, especially at night in some cases
2. Incomplete empting and hyper-continence
3. Stone formation due to:
A) Presence of mucous.
B) Infections
C) Mobilization of calcium from bone due to acidosis
D) Increase intestinal absorption of oxalate due to malabsorption of fat.
4. Metabolic acidosis and nutritional disorder, usually mild and normal kidney can
deal with this condition.

): ‫ بالتوفيق‬,‫❖ ياريت لو تفتكروا زميلنا عبد الرحمن عمار في دعائكم‬