Back To Basics - Urology - Dr. James Watterson 2009 - Compressed

Urology Back to Basics
The “Nuts” and Bolts
James Watterson, MD FRCSC

Assistant Professor, University of Ottawa
Director, Ottawa Lithotripsy and Stone Program

Endourology and Laparoscopic Urological Surgery
Division of Urology, The Ottawa Hospital
References
• The Medical Council of Canada

– www.mcc.ca
– Objectives for the Qualifying Examination
• MCC Objectives.doc
• University of Toronto Notes
• Campbell’s Urology
Objectives
– Abdominal Mass
– Adrenal Mass
– Blood in Urine (Hematuria)
– Gynecomastia
– Ambiguous Genitalia
– Infertility
– Incontinence, Urine
– Incontinence, Urine, Pediatric (Enuresis)
– Impotence, Erectile Dysfunction
– Acute and Chronic Renal Failure (Post-renal / Obstruction)
– Scrotal Mass / Scrotal Pain
– Urinary Tract Injuries
– Dysuria and / or Pyuria
– Urinary Obstruction / Hesitancy / Prostatic Cancer
Objectives
– Abdominal Mass
– Adrenal Mass
– Blood in Urine (Hematuria)
– Gynecomastia
– Ambiguous Genitalia
– Infertility
– Incontinence, Urine
– Incontinence, Urine, Pediatric (Enuresis)
– Impotence, Erectile Dysfunction
– Acute and Chronic Renal Failure (Post-renal / Obstruction)
– Scrotal Mass / Scrotal Pain
– Urinary Tract Injuries
– Dysuria and / or Pyuria (UTI)
– Urinary Obstruction / Hesitancy / Prostatic Cancer
Blood in Urine (Hematuria)
Key Objective (s):
Differentiate red or brown urine from hematuria, transient

from persistent, and glomerular from extraglomerular
hematuria
Hematuria
Objectives
Through efficient, focused, data gathering
• Determine whether the patient has true hematuria
• Diagnose the presence of urinary tract infections
• Differentiate between glomerular and extraglomerular hematuria by examination of urine sediment
List and interpret critical clinical and laboratory findings which are key in the
processes of exclusion, differentiation, and diagnosis
• Interpret reported urinalysis findings
• Outline significance of patient’s age, gender and life style on diagnostic possibilities
Conduct an effective plan of management for a patient with hematuria

• Select treatment for patients with UTI appropriate for gender, lower, and upper urinary tract
• Outline a plan for investigation of patients with recurrent nephrolithiasis
• Formulate a management plan (non-Rx) for prevention of recurrent nephrolithiasis
• Discuss possible strategies for the detection and prevention of urinary tract tumors
Hematuria
Objectives

Hematuria
Considerations
• Pseudohematuria
– Menses
– Dyes (ie. Anthrocyanin in beets, rhodamine B in drinks, candy and
juices)
– Hemoglobinuria (hemolytic anemia)
– Myoglobinuria (rhabdomyolysis)
– Drugs (rifampin, phenazopyridine)
– Porphyria (brownish urine)
– Laxatives (phenolphthalein)
1. Urine dipstick – if positive, indicates hematuria, hemoglobinuria,

or myoglobinuria
2. Microscopy distinguishes hematuria from Hgburia or Mgburia
Hematuria
Objectives

• History & P/E
UTI
– Irritative voiding symptoms (dysuria, freq, urg, suprapubic pain, hematuria)
– Fever
– Flank pain
• Inspection of urine – Turbid
– May be secondary to excessive phosphates
• Urinalysis
– Dipstick
• Leukocyte esterase
• Nitrites
– Microscopic analysis
• False-negative (low numbers bacteria), false-positive (normal vaginal flora; NB squamous epithelial cells indicate
contamination)
Limited sensitivity
• > 2 WBCs/HPF correlates with presence of bacteriuria
• RBCs lack sensitivity (40-60% cases of cystitis) but highly specific
• Urine culture
– mid-stream vs. catheterized specimen
– Traditionally, > 105 cfu/mL
• In dysuric patients, 102 cfu/mL of a known pathogen significant
Hematuria
Objectives

Hematuria
MCC
Causal Conditions
• Transient
– Urinary tract infections
– Exercise induced
– Stones/Crystals
– Trauma
– Endometriosis
– Thromboembolism
– Anticoagulants (similar incidence of hematuria in non-anticoagulated patients)
• Persistent
– Extraglomerular (Urological)
• Renal
– Tumors
– Tubulointerstitial diseases (e.g polycystic kidneys, pyelonephritis)
– Vascular (e.g. papillary necrosis, sickle cell disease)
• Collecting system
– Tumors
– Stones
• Lower urinary tract
– Glomerular
• Isolated (e.g. IgA nephropathy, thin membrane disease)
• Post-infections (e.g. post-streptococcal)
• Systemic involvement (e.g. vasculitis, SLE)
Figure 3-7 Evaluation of nonglomerular renal hematuria (circular erythrocytes, no erythrocyte casts, and proteinuria). CT, computed tomography; IgA, immunoglobulin A; IVU,
intravenous urography; PT, prothrombin time; PTT, partial thromboplastin time; R/O, rule out.
Figure 3-6 Evaluation of glomerular hematuria (dysmorphic erythrocytes, erythrocyte casts, and proteinuria). ANA, antinuclear antibody; ASO,
antistreptolysin O; Ig, immunoglobulin.
Hematuria
Diagnostic Evaluation: Is it?
1. True or False
2. Extraglomerular vs. Glomerular
1. Dysmorphic RBCs
2. Casts (RBC, WBC)
3. Proteinuria (>100-300 mg/dL or 2+ to 3+ on dipstick)
3. Gross or Microscopic
1. > 3 RBC / HPF
4. Further Urological Questions
1. Location- Renal/Ureter/Bladder/ Prostate/Urethra
2. Painful/Painless
3. Part of Stream- Initial/Terminal/Throughout ???
4. Clots – shape of clots
Investigations for Hematuria
• History and P/E

– Smoking
– Other risk factors for urothelial malignancy
• Urine
– Urinalysis / Microscopy / C & S
– Cytology
• Upper tract
– Microscopic
• Renal U/S
– Gross
• CT urogram
• Lower tract
– cystoscopy
Hematuria
DDx
• VINDICATE
• Renal/Ureter/Bladder/Prostate/Urethra
– Neoplasm.. Neoplasm.. Neoplasm
– Stone
– Trauma
– Infection
Hematuria
Objectives

UTI
Treatment
• Principles of Antimicrobial Therapy

– Effective antimicrobial therapy must eliminate bacterial growth
– Antimicrobial resistance is increasing because of excessive utilization
– Antimicrobial selection should be influenced by efficacy, safety, cost and
compliance
• Lower Tract UTI – cystitis; most occur in women; 10% incidence

• Bacteria – E.coli causative organism in 75 – 90% of acute cystitis in young women
• Drug choices
– TMP-SMX DS BID 3 days
– Nitrofurantoin 100mg BID 3 days
– Norfloxacin 400mg BID 3 days
– Ciprofloxacin 500mg BID 3 days
UTI
Treatment
• Recurrent Lower Tract UTI in Women
– Self-start Rx
– Post-coital single dose
– Low dose prophylaxis 3-6 months
• Upper Tract UTI (Acute Pyelonephritis)

– E.coli accounts for 80% of cases
– Blood cultures positive in 25%
– Consider U/S or CT if failure to respond after 72 hrs of therapy
– Rx
• Uncomplicated – Cipro 500mg BID PO, Levofloxacin 500mg QD PO x 7 – 10 days
• Complicated – Parenteral Cipro, Levo, Amp + Gent x 7 – 10 days
Hematuria
Objectives

Risk Factors for Stone Disease
• Diet, Diet, Diet

– Dehydration
– High protein intake
– High salt intake
– Certain foods high in oxalate
• Occupation
– Dehydration
• Inflammatory Bowel Disease, Gout, Hyperparathyroidism
• Genetics
– Rarely
• Recurrent nephrolithiasis
– Refer to urologist or nephrologist
– Metabolic evaluation
• Serum chemistry (Lytes, BUN, Cr, Ca, Urate, PTH)
• 24 hour urine (Lytes, Ca, Oxalate, Uric acid, citrate, Mg, cystine)
Dysuria and/or Pyuria
Key Objective (s):
Differentiate between urinary tract infections and conditions outside the

urinary tract with similar presentation; determine which infections require
treatment, and select the appropriate treatment.
In patients with recurring urinary tract infections, determine whether a

predisposing condition may be present (e.g., stasis from obstruction, reflux).
• Through efficient, focused, data gathering:
– Interpret urinalysis and clinical findings in order to diagnose problems external to urinary tract.
– Evaluate examination findings so that problems involving the urethra or prostate are identified.
– Determine whether cystitis or pyelonephritis is the more likely diagnosis.
• List and interpret critical clinical and laboratory findings which were key in the processes of
exclusion, differentiation, and diagnosis:
– Outline significance of patient's age, gender, and life style on diagnostic possibilities.
– Select findings which are best for differentiating cystitis from pyelonephritis.
– Describe the collection of samples to be sent for culture and sensitivity; interpret results.
• Conduct an effective plan of management for a patient with urinary frequency, dysuria, and/or pyuria:
– Determine which patients require additional investigation and/or referral.
– Determine which patients require hospitalization.
– Determine which patients should be on prophylactic treatment and the type of treatment.
– Select the most appropriate treatment for the underlying condition.
– List conditions which predispose to urinary tract infections.
• Outline strategies for prevention of recurrent urinary tract infections.

• Dysuria = painful urination

– Usually caused by inflammation
– Commonly referred to the urethral meatus
– Start: may indicate urethral
– End (stranguria): usually bladder origin
– Usually accompanied by frequency and urgency
• Pyuria = presence of white blood cells (WBCs) in urine

– Generally indicative of infection and an inflammatory response of the urothelium to the
bacterium
– Bacteriuria without pyuria is generally indicative of bacterial colonization without infection
– Pyuria without bacteriuria warrants evaluation for TB, stones, or cancer
DDx
Dysuria / Freq / Urgency >> Vesical vs. Extravesical
• Extravesical
– Urological
• Urethral diverticulum / CA • Vesical
• Prostatitis
• Urethritis
• Bacterial cystitis
• Lower ureteral stone
• Bladder tumor / CIS
– Gyne
• Vulvovaginitis • Bladder stone
• Herpes
• Endometriosis • TB cystitis
• Ovarian / Uterine / Cervical CA
– Bowel
• Radiation cystitis
• Diverticulosis • Nonbacterial cystitis
• Fistula
• Crohn’s • Cyclophosphamide / ASA /
• Colon CA
NSAID / Allopurinol
Evaluation
Dysuria / Freq / Urgency >> Vesical vs. Extravesical
• History
– Age, Gender, Smoking History
– LUTS
– PMHx (Gyne, IBD, divertic), PSHx (pelvic), PGUHx (UTI, STD, Tumor, Stone, Hematuria)
• Physical examination
– Suprapubic tenderness
– Genital exam
– Rectal exam (prostate, rectum)
– Pelvic exam
• Investigations
– Urine (U/A, C&S, cytology)
– Ultrasound - pelvic
– Cystoscopy
Urinary Obstruction / Hesitancy /
Prostatic Cancer
Key Objective (s):
Determine whether a patient has an acute obstruction any time the complaint
is complete anuria or unexplained renal insufficiency
Urinary Obstruction / Hesitancy / Prostatic Cancer
Objective (s):
Through efficient, focused, data gathering:

•Determine whether the obstruction is acute or chronic, duration, complete or partial, and unilateral or bilateral,
and site.
•Ask whether pain is present, site of pain (e.g., suprapubic for bladder distention, flank for renal capsule), whether
it is colicky and radiates to ipsilateral testicle or labia (renal or ureteral colic), or occurs after a fluid load that
increases urine output (e.g., beer drinking).
•Examine for tenderness, hydronephrosis, hypertension, and palpable bladder.
processes of exclusion, differentiation, and diagnosis:
•Select ultrasonography as the diagnostic imaging tool to diagnose obstruction.
•List indications for other types of diagnostic imaging.
•Select and interpret tests of renal function; outline indications for prostate cancer screening.
Conduct an effective plan of management for a patient with urinary tract obstruction:
•Perform catheterization of the bladder for both therapeutic and diagnostic reasons.
•Select patients for referral to specialized care.
Definitions
• Uremia = clinical signs and symptoms seen as a result of

renal failure
• Azotemia = elevation of blood urea (BUN)
• Obstructive Uropathy = reversible or irreversible renal

dysfunction due to the effects of impaired urine drainage
• Hydronephrosis = dilation of the renal pelvis and calyces

Urinary Tract Obstruction
Classification
• Supravesical vs. Infravesical

• Acute vs. Chronic
• Unilateral vs. Bilateral
• Anatomical site
– Intrarenal
– Ureter
– Bladder
– Prostate
– Urethra
• Extraluminal (LN, mass) vs. Intraluminal (stone, blood
clot, fungus ball) vs. Intramural (TCC, polyp)
Diagnosis
Clinical features
• Flank pain/renal colic
• Urinary retention or overflow incontinence
• Anuria or oliguria
• Uremia
• Stones
• Recurrent UTI
• Asymptomatic
Pathophysiology
Factors Influencing Severity of Renal Dysfunction
• Complete or partial obstruction
• Duration; >30 days of complete obstruction results

in irreversible loss of renal function
• Unilateral or bilateral
• Presence of infection
Major Sequelae
• Loss of renal function
• Urinary tract infection / sepsis
• Stones
Diagnosis
• Clinical features
• Laboratory investigations
• Imaging studies
Diagnosis
• Laboratory investigations
– Elevated BUN and Cr with bilateral ureteral or bladder

outlet obstruction
– Abnormal urinary indices

Diagnosis
• Imaging studies
– Renal ultrasound
– Intravenous pyelogram (IVP)
– CT Scan
– Retrograde pyelogram
– Lasix renogram
Hydronephrosis may not develop if acute obstruction or if presence of
perinephric fibrosis
Temporary Measures
• Bypass the cause of obstruction
• Bladder outlet obstruction

– Foley catheter
• Renal or ureteral obstruction

– Ureteral stent
– Nephrostomy tube
Percutaneous Nephrostomy
Ureteral Stenting
Definitive Treatment
• Remove the cause of obstruction
• BPH
– Pharmacotherapy (alpha-blockers)
– Surgical (TURP)
• Stone
– ESWL, ureteroscopy, percutaneous stone removal
Prostate Cancer
• Most common solid tumor in U.S. males
• Second leading cause of male cancer deaths
• Lifetime risk 1/6
• Lifetime risk of a 50 year old: 50%, risk of dying 3%
• Risk factors
– Family history: 1st degree relative (2x)
– blacks
– High dietary fat
• Histologic Incidence rates

– 10-30% > 50
– 50% > 80
Presentation
• Asymptomatic
– (75%)  PSA DDx Prostatic Nodule
– abN DRE • Prostate Cancer (30%)
• BPH
• Locally Advanced
– LUTS (uncommon without met) • Prostatits
– Hematuria • Prostatic Infarct
– Hematospermia
– Renal failure • Prostatic Calculus
• Tuberculous Prostatitis
• Metastatic Disease
– Bony pain (osteoblastic)
– Renal failure
PSA
• Enzyme produced by epithelial cells of prostate

gland to liquify the ejaculate
• Elevated in:
– Prostate cancer
– Prostatitis
– BPH
– Trauma
• catheterization
– Ejaculation
Screening
• DRE
– Hypothenar eminence = benign
• PSA
– CCFP - not recommended
– US FP + Urologist – recommended
– “normal” < 4 but 30% have PCa
Age 50 unless 1st degree relative or black male >>>40-45 yrs

Screen between ages 50-70/75 years
Screening
Probability of Finding Cancer on Biopsy According to a Man’s

DRE Result and PSA Level
PSA (NG/ML)
2-4 4-10 >10

DRE
N 15% 25% 50%
AbN 20% 45% >75%

• If abN DRE +/  PSA.. AND > 10 YR LIFE
EXPECTANCY…
TRUS + BIOPSY
Scrotal Mass
Key Objective (s):
Differentiate testicular tumor from a mass of inguinal origin (not possible to

get above it, may reduce), cystic lesion (trans-illuminates), and a varicocele
(easier to palpate with patient erect)
Scrotal Mass
Objective (s):

• In boys, ask about pain, trauma, change in scrotal size, difficulty voiding
• Elicit history of undescended testicle, infertility, previous testicular tumor, and breast enlargement / tenderness
• Differentiate from condition that presents primarily with pain
• Perform abdominal exam including inguinal areas, and an examination of the male genitalia (erect and supine,
testes, epididymis, cord, scrotal skin) including rectal examination to assess the prostate and seminal vesicles,
transilluminate
•Select patients requiring ultrasound, CT and explain reason; order beta human chorionic gonadotrophin and
alpha-fetoprotein
Conduct an effective plan of management for a patient with scrotal mass:

• Outline management options for masses which are not testicular tumors.
Approach to Scrotal Masses
• Painful vs. painless

• Benign vs. malignant
• Etiology varies with age of patient
– DDX differs between adults and children
• >>>Anatomical Approach
Anatomy • Scrotal Contents:
– Testes
• Tunica albuginea
• Tunica vaginalis
– Epididymis
– Spermatic Cord:
• Vas deferens
• Arteries:
– Testicular
– Cremasteric
– Artery to the Vas
• Veins:
– Pampiniform plexus
• Nerves:
– Ilioinguinal
– Genital br. Of Genitofemoral
– Sympathetics
History
• Age of patient • Risk Factors

• HPI – Recent trauma
– Onset (acute, insidious) – Infection
– Painful vs. painless
– Instrumentation of the
– Radiation
urinary tract
– Aggravating Factors
– Relieving Factors – Congenital anomalies
– LUTS – Prior history of
• PMHx neoplasm
• PSHx
Physical Examination
• Vital Signs • Scrotum
– Temp – Skin
• Skin – Testes:
• Abdominal exam • 3.5 cm
• Inguinal • Mass
– Hernia (may reduce, unable – Hydrocele
to get above) • Transillumination
– Lymph Nodes – Varicocele
– Masses • Valsalva
• Penis • DRE
– malignancy
Differential Diagnosis
• Painful • Painless
– Trauma – Tumor
• Contusion, rupture • Intratesticular
• Paratesticular
– Epididymo-orchitis
– Varicocele
– Hernia
– Hydrocele
• Incarcerated,
strangulated
– Spermatocele
– Torsion – Scrotal wall
malignancies
• Testes
• SCC, sarcomas
• Appendages
Testicular Torsion • Intravaginal (all age groups, puberty)
• Extravaginal (prenatal, neonatal)
• Hx:
– Acute Painful scrotum
– N&V
– Rx to groin / abdomen
– None or minimal trauma
• Px:
– Patient appears unwell
– Tender, swollen testicle
– High riding, transverse lie
– Scrotal erythema
– No cremasteric reflex
Testicular Torsion
• If suspected clinically,
surgical exploration
indicated
– Orchidectomy
– Orchidopexy of
contralateral side
• INV:
– Transcrotal Ultrasound
• Duplex Doppler
– Nuclear testicular blood
flow scan
Torsion of Appendix Testis / Epididymis
•Appendix Testis: 2-3 mm embryol. remnant near upper pole of

testis
•may twist on stalk --> pain
•O/E: local tenderness, blue dot sign
Epididymitis / Orchitis
• Hx:
– More insidious onset
– Fever
– Recent instrumentation
– Sexual activity
– LUTS
• Px:
– Painful epididymis +/- testis
– Testis in normal position
– Urethral discharge
– + Prehn’s sign
• INV:
– CBC
– U/A, C&S, Urethral Swab for GC /
Chlamydia
– TB
• >>May Resemble Torsion!
Epididymitis / Orchitis
• Causative • Specific Recommendations:
– <35 years: N.gonorrhea, – GC:
C.trachomatis, E.coli
• ceftriaxone 250 mg IM
– >35 years: E.coli
– Homosexual: E.coli • Cipro 500 mg PO
– Mumps orchitis: – NonGC:
• 30% of patients with mumps • Azithromycin 1 g PO
• Risk of infertility • Doxycycline 100 mg BID x 7
• Rx: days
– Antibiotics – E.coli:
– Bed rest • IV antibiotics if severe
– Analgesics / Anti-
• Fluoroquinolone x 10-14 days
inflammatories
– Scrotal elevation
Hydrocele
• A collection of serous fluid in some part of the processus
vaginalis, usually in the tunica
• More common in childhood
• 1% of adult males
• Congenital:
– Processus vaginalis does not close after testicular descent
• Acquired:
– Primary (idiopathic) vs. secondary to disease of the testis
– Defective absorption, increased production, lymphatic obstruction
Hydrocele
• Hx:
– Painless (unless large)
– Change during day (suggests
communication)
– Other symptoms (secondary
hydrocele)
• Px:
– Transilluminates
– Palpate testes
– Hernia ?
• INV:
– Transcrotal ultrasound if
testis not palpable
Hydrocele
• Rx:
– Adults:
• Symptomatic
• Cosmesis
• Underlying testicular
pathology
– Children:
• Most will resolve in 1st year
• If persists, repair of hernia
may be indicated
• Specifics:
– Surgical
– Aspiration
– Sclerotherapy
Spermatocele
• Painless mass
• Contains fluid and
spermatozoa
• 4th / 5th decades
• Region of caput
• Usually can palpate the testis
separately from spermatocele
• Obstruction of efferent duct
• Mass may transilluminate
Spermatocele
• Rx:
• Conservative
• Spermatocelectomy
• Surgery may have
negative consequences >>>
delay if reproductive age
Varicocele
• Dilation of the veins of the pampiniform plexus of the spermatic
cord due to absent competent venous valves in the spermatic vein
• 15% of males, 30% of subfertile males (multiple theories)

– Elevated intratesticular temperature widely accepted
• Most Left-sided; May be bilateral; Right-sided only>> be

suspicious!
• Rare prior to puberty

Varicocele • Hx:
– Painless vs. dull ache; pain never present
on awakening
– Discomfort increases with standing /
activity over long period of time
– Exaggerated with Valsalva
– Infertility
• Px:
– “Bag of Worms”, “vascular thrill”
– Gr.I: Palpable with valsalva
– Gr.II: Palpable without Valsalva
– Gr.III: Visible
– Abdominal mass
• Scrotal Ultrasound
Varicocele
• Rx:
– Sx’s
– Cosmesis
– Infertility
– Ipsilateral testicular atrophy
• Surgical options:
– Retroperitoneal
– Inguinal
– Subinguinal
– Laparoscopic
– Transvenous embolization
Testicular Tumors
• Testis CA most common malignancy in males 15 to 35 years
• Incidence: 3.7 / 100,000 (whites), 0.9 / 100,000 (blacks)
• R>L, 2-3% bilateral
• Risk factors:
– Age (<10, 15-35, >60)
– Race
– Cryptorchidism
– Atrophy
Testicular Tumors
• Germ Cell tumors • Paratesticular
– Seminoma
– Non-Seminomatous
• Embryonal carcinoma • Secondary
• Choriocarcinoma
• Yolk Sac tumor
– RES
• Teratoma • Leukemia
• Mixed • Lymphoma
– Metastases
• Gonadal Stromal
– Leydig-cell
– Sertoli-cell
– Gonadoblastoma
Testicular Tumors
• Hx:
– Painless intratesticular mass (pain if hemorrhage)
– May present with metastatic disease (SOB, cough, hemoptysis,
abdominal bloating, GI complaints, lower limb edema)
• Px:
– Chest (pleural effusion, wheezing, gynecomastia)
– Abdominal exam (mass)
– Genital exam
– Nodal exam (inguinal, supraclavicular)
Testicular Tumors
• INV:
– Scrotal U/S
– CXR
– Tumor markers
• BHCG
• AFP
• LDH
– CT Chest / Abdo / Pelvis
• Rx:
– Radical orchiectomy
Testicular Tumors
• Rx:
– Dependent upon:
• Clinical stage
• Pathological stage
• Histology
– Options:
• Surveillance
• XRT
• RPLND
• Chemotherapy
Urinary Tract Injuries
Key Objective (s):
Suspect trauma to bladder or posterior urethra in patients with pelvic fracture
Examine for bleeding at the external urethral meatus after trauma; urethral
injury necessitating urgent ascending urethrogram may be present.
Urinary Tract Injuries
Objective (s):

•Elicit history about the nature of the injury, difficulty voiding, and blood in urine or at
meatus; differentiate straddle injury from sexual abuse (straddle injuries typically are
unilateral and superficial and involve the anterior portion of the genitalia in both boys
and girls
• Examine for swelling, bruising, in males’ displacement of prostate on rectal
•List the most appropriate investigations used to determine the nature and severity of
urinary tract injuries (e.g. retrograde urethrogram for urethral injury, CT scan for renal
injury)
Conduct an effective plan of management for a patient with urinary tract

obstruction:
• Outline initial management of anterior urethral injury (e.g. 7 to 10 days of urethral
GU Trauma
• Accounts for 10% of ER trauma visits
• Associated with multi-system trauma
• Subtle presentations, easily overlooked
• Diseased GU organs susceptible to injury

Trauma Evaluation
• Airway with C-spine control

• Breathing
• Circulation (2 large bore IVs)
• Disability (brief neurologic exam)
• Expose (general survey)
Renal Trauma
• Most commonly injured organ GU tract

• Often in association with multi-system organ
injury
• Blunt 80%
• Penetrating <20%
Renal Trauma
Renal Trauma
Presentation
• Hematuria (gross or microscopic)

– May be absent
• Shock (hypotension, tachycardia, oliguria)
• Flank mass
• Flank pain/tenderness
Imaging
• Need both anatomic and functional information
• CT Scan (with contrast) – gold standard

• IVP
• Angiography
Indications for Imaging in Scenario of Possible
Renal Injury
• Penetrating injuries
• Blunt injuries in association with

– Gross hematuria
– Shock (SBP<90 systolic)
– Children regardless of degree of hematuria
Renal Trauma - Classification
• AAST Renal Injury Grading Scale

Renal Trauma
Management
• ABCs
• Conservative for 85% of blunt trauma

– Admission, bedrest, serial vital signs, CBC
• Indications for surgical exploration

– Hemodynamic instability
– Penetrating injuries
– Extensive urine extravasation
– “Shattered kidney”
– Pedicle injury
Bladder Trauma
Bladder Trauma
• Classified by site
– Contusion
• Hematuria and normal cystogram
– Intraperitoneal rupture 30%
– Extraperitoneal rupture 60%
– Combined 10%
– Concommitant urethral injury 10%
Bladder Trauma
• Clinical presentation
– Extra 2X > Intraperitoneal ruptures
– Suprapubic pain and tenderness
– Inability to void
– Pelvic fracture + gross hematuria
• 98% of bladder injuries have gross hematuria
• Mortality 20%, d/t associated injuries

Bladder Trauma
• Cystogram: Study of choice!
– 300 cc of contrast
– 3 films: plain, full (300cc), drainage (+/- oblique)
• IVP:
– Poor; may demonstrate only 15% of bladder ruptures
• CT:
– Bladder filled with 300cc contrast prior to CT
– Difficult to assess bladder neck competence
The severity of bladder injury cannot be determined by

the amount of extravasation seen on any Xray study
Bladder Trauma - Management
• Extraperitoneal
– Foley catheter x 10-14 days
– Selective Exploration and Repair
• Bladder neck, prostatic urethra
• Laparotomy
• Hemorrhage / clots
• Urethral catheter cannot be placed
• Penetrating
– Open repair to rule out BN injury
Bladder Trauma - Management
• Intraperitoneal
– Open surgical repair
• Lower midline incision
• Avoid dissection in perivesical areas
• Vertical anterior cystotomy to assess bladder neck
• Debridement
• Closure in 2 layers: water-tight
• Suprapubic catheter
• Drain
– Postop
• Antibiotics
• Foley x 10-14 days
• Cystogram before catheter removal
Urethral Trauma
Urethral Trauma
• Proper management crucial
• Majority caused by blunt injury
• 5% of pelvic fractures have associated posterior urethral
injury
• 90% of posterior urethral injuries have associated pelvic
fractures
• 10-29% of prostatomembranous urethral ruptures have
bladder injury
Urethral Trauma
• Common mechanisms
– Pelvic crush – membranous urethra disruption
– Straddle injury – bulbous urethra
– Penile fracture – pendulous urethra
– Iatrogenic – false passages
• Classification
– Anterior: pendulous, bulbous urethra
– Posterior: membranous, prostatic urethra
Urethral Trauma
• Haematuria
• Inability to void or difficulty with voiding
• Blood at urethral meatus
– Sensitivity 33-100%
• Perineal ecchymosis (classically in a “butterfly”
pattern)
• Full bladder
• High riding prostate on DRE (posterior), bony
fragments
• Pelvic fracture: esp. rami #’s
Urethral Trauma - Diagnosis
• Retrograde urethrogram: Gold standard

– Oblique position
– Sterile technique
– Slight penile stretch
– 8F foley in fossa navicularis, 2cc in balloon
– 10-20 cc slow continuous injection
– Fluoroscopy preferred
– Peri-catheter if foley previously
placed
Posterior Urethral Injury
Presentation
• Pelvic #
• Blood at the urethral meatus
• “High riding” prostate
• Scrotal swelling/ecchymosis
• Inability to void
If potential for urethral injury exists,

do not insert urethral catheter
Urethral Trauma - Management
Goal: control urinary drainage and minimize long-term
complications
• Anterior:
– Primary repair: penetrating injury, penile fracture
– Suprapubic cystotomy: complete, blunt
– Urethral catheter: partial, blunt
Urethral Trauma - Management
Posterior:
• Open SPT + Delayed primary repair 3 – 6 months
• Primary catheter realignment
– Open vs.Endoscopic
– BN laceration: intrinsic sphincter mechanism crucial for
continence after membranous urethra disruption (site of
external sphincteric mechanism)
– Rectal laceration: pelvic abscess or fistula
– Long separation of prostate and bulbous urethra: difficult
delayed repair
Impotence / Erectile Dysfunction
Key Objective (s):
Recognize that a psychogenic component is present in all cases.
Recognize that testosterone deficiency is an uncommon cause of erectile

dysfunction.
Objective (s):

• Determine if an organic cause for impotence is likely by a medical, sexual, and social history.
• Exclude decreased libido, ejaculatory disorders, performance anxiety, and depression.
• Identify reveersible causes (recent medications – antihypertensives, antidepressants, etc)
• Examine for signs of vascular disease and diabetic complications (BP postural change, ankle-brachial index,
pulses); examine for gynecomastia, lack of male hair distribution, small testes.
• Order screening tests for unrecognized systemic disease (e.g. diabetes)
• If hormonal cause is likely, order testosterone, LH, prolactin.
Objective (s):
Conduct an effective plan of management for a patient with urinary tract obstruction:
• Treat associated medical conditions; suggest lifestyle changes (smoking cessation, exercise, weight
loss, diet, stress reduction)
• Determine therapy for impotence based on the underlying cause (e.g. if testosterone is low and LH
is high, consider testosterone therapy / exclude prostate; if prolactin high, pituitary
imaging/referral).
• Outline the effectiveness of inhibitors of phosphodiesterase type V and contraindications.
• Describe the role of injectable, transurethral, and vacuum devices.
• Select patients in need of specialized care (e.g., failed medical therapy, penile anatomic disease,
pelvic/perineal trauma, vascular/neurologic assessment, endocrinopathies, psychiatric, etc.).
• Counsel and educate patient (+/- partner).
• Determine the therapy for impotence based on the underlying cause.
• Describe the role of specific injectable and oral medications in patients with erectile dysfunction.
KEY POINTS: PENILE COMPONENTS AND THEIR FUNCTION DURING ERECTION
• Corpora cavernosa Support corpus spongiosum and glans

• Tunica albuginea (of corpora cavernosa) Contains and protects erectile tissue
Promotes rigidity of the corpora cavernosa Participates in veno-occlusive mechan
• Smooth muscle Regulates blood flow into and out of the sinusoids
• Ischiocavernosus muscle Pumps blood distally to hasten erection
Provides additional penile rigidity during rigid erection phase
• Bulbocavernosus muscle Compresses the bulb to help expel semen
• Corpus spongiosum Pressurizes and constricts the urethra lumen to allow forceful exp
of semen
• Glans Acts as a cushion to lessen the impact of the penis on female organs
Provides sensory input to facilitate erection and enhance pleasure
Facilitates intromission because of its cone shape
• Normal Erection
– Innervation: Autonomic (SNS, PNS): cavernous nerves
Somatic (sensory, motor): sensation, contraction of
bulbocavernosus/ischiocavernous muscles
– Nitric oxide (NO) released from nonadrenergic, noncholinergic
neurotransmission and from the endothelium
• 1) Relaxation of smooth muscles
• 2) Dilation of the arterioles and arteries, increasing blood flow
• 3) Trapping of the incoming blood by the expanding sinusoids
• 4) Stretching of the tunica to its capacity, which occludes the emissary veins between
the inncer circular and outer longitudinal layers and further decreases venous outflow
to a minimum
• 5) increase in intracavernous pressure (100 mm Hg) leading to full erection
“P(arasymp) to Point, S(ymp) to Shoot”

Erection: A Neurovascular Event
• Erectile Dysfunction
– Inability to achieve or maintain an erection sufficient for satisfactory
sexual relations
– Organic (90%) vs. Psychgenic

• Vascular Disease (70%)
• Medications (10%)
• Surgical (10%)
• Neurologic (5%)
• Endocrine (3%)
• Trauma (2%)
Erectile Dysfunction
Evaluation
Evaluation – IIEF 15
Treatment
Penile Disorders
• Tx:
– Oral (phosphodiasterase type-5 inhibitors)
– Penile Injection (PGE2, papavarine, phentolamine)
– Intraurethral pellet (MUSE): PGE2
– Vacuum Erection Device
– Penile implant
Treatment
Incontinence, Urine
Key Objective (s):
Contrast between the two most common causes of

incontinence, stress incontinence and urgency incontinence.
Incontinence, Urine
Objectives
• Determine duration, characteristics, frequency, timing, and amount; elicit other lower urinary tract symptoms,
precipitants, fluid intake patterns, changes in bowel habits or sexual function.
• Differentiate between stress (small amounts of leakage with exertion), urgency (involuntary associated with urge
to urinate), reflex (associated neurologic deficit), and overflow incontinence (associated with urinary retention)
• Perform an abdominal exam, a pelvic exam, and rectal exam for prostate size
List and interpret critical clinical and laboratory findings which are key in the processes of
exclusion, differentiation, and diagnosis
• Perform urinalysis, estimate post-void residual urine.
• Select patients in need of cystoscopy and other specialized tests.

• Outline a plan of management for cystitis and urethritis.
• Counsel patients with stress incontinence about possible pelvic muscle exercises.
• For urge incontinence, discuss trial of anticholinergic medication (e.g. oxybutynin, tolterodine)
• Select patients for referral (e.g. neurologic conditions, genital prolapse, abnormal post-void)
Lower Urinary Tract
• Group of inter-related structures

– >> efficient and low pressure bladder filling
– >> low pressure urine storage with perfect continence
– >> periodic voluntary urine expulsion at low pressure
• Functional, physiologic, and pharmacologic considerations
• Many different classifications

– >> will present a functional and practical approach
Normal Lower Urinary Tract Function
• 2 phase concept of function
• Filling / Storage
• Emptying
• Bladder Filling / Storage
– Accomodation of increasing volumes of urine at low

pressures with appropriate sensation
– Bladder outlet that is closed at rest and remains so during

increases in intra-abdominal pressure
– Absence of involuntary bladder contractions

• Bladder Emptying
– Coordinated contraction of bladder smooth musculature of

adequate magnitude
– Lowering of resistance at the level of the smooth and

striated sphincter
– Absence of anatomic (as opposed to functional) obstruction

Voiding Dysfunction
• Any type of voiding dysfunction must result from an

abnormality of one or more of the previous factors
• The Functional classification

– Failure to Store
• Because of the bladder
• Because of the outlet
– Failure to Empty
• Because of the bladder
• Because of the outlet
The Functional Classification
Failure to Store
• Because of the Bladder • Because of the Outlet
– Detrusor Hyperactivity – Stress Incontinence
• Suprasacral neurologic dz (Hypermobility)
• BOO
• Idiopathic
• Inflammation – Nonfunctional bladder
• Aging neck/proximal urethra (ISD)
• Neurologic
– Decreased Compliance • Trauma
• Neurologic dz (denervation) • Surgery
• Fibrosis / inflammation • Obstetrical/Gynecologic
• Idiopathic • Aging
• BOO
– Detrusor Hypersensitivity
• Neurologic
• Infectious
• Inflammation (I.C.)
• Psychologic
• Idiopathic
The Functional Classification
Failure to Empty
• Because of the Bladder • Because of the Outlet
– Neurologic (sacral / peripheral nerves, pain,

Herpes, DM, Tabes Dorsalis, pelvic surgery) – Anatomic
• Prostatic obstruction
– Myogenic (overdistention, infection, meds, • Bladder neck contracture
fibrosis)
• Urethral stricture
• Urethral Compression
– Psychogenic
– Functional
– Idiopathic
• Smooth Sphincter Dyssynergia
(SCI above T6)
– Pharmacologic • Striated Sphincter Dyssynergia
Evaluation of Voiding Dysfunction
• History
• Physical
• Urinalysis
• Urodynamics Videourodynamics
• Radiography
• Cystoscopy
• History
– Urologic
• Lower urinary tract symptoms
– Storage vs. Emptying symptoms
– Irritative, obstructive, pain, hematuria, incontinence (stress, urge, unconscious,
continuous)
– Ob/Gyn
– Neurologic
– Medical / Surgical
– Social / Psychologic
– Radiation
– Pelvic Trauma
• Incontinence History
– “involuntary loss of urine”

• Symptom – statement of involuntary loss
• Sign – objective demonstration of urine loss
• Condition – pathophysiology underlying incontinence
– Characterization of incontinence
• Stress – loss during coughing, sneezing, physical exertion
• Urge – sudden, strong urge to void
• Unconscious – unaccompanied by stress or urge
• Continuous
• Overflow
– Length and severity of symptoms

– Impact on quality of life
– Associated bowel problems
• Physical Exam
– Systemic vaginal and pelvic exam
• Condition of mucosa
• Urethral hypermobility
• Demonstration of incontinence / SUI
• Vaginal prolapse
– Use of bottom half of small speculum
– Bimanual exam
– Standing position in females with SUI / prolapse
– Neurologic exam
• Mental status
• Mobility
• Lumbar and sacral sensory and motor
– BC reflex, anal wink, knee and ankle DTR’s, perineal / perianal sensation
• Simple Ancillary Tests
– Voiding and intake diary
• Time, input, output, types of beverages
– Incontinence Diary
• Stress, urge
– U/A – rule out hematuria, UTI
– C & S, cytology when indicated
– Post void residual
– Pad Test
• Endoscopy
– Not recommended as a routine in the evaluation of incontinence
– May be useful when clinically indicated
• Hematuria
• Refractory incontinence
• Anatomic abnormalities
• Prior surgery
• Etc.
Transient vs. Established Incontinence
• Delirium
• Infection
• Atrophic urethritis/ vaginitis
• Pharmaceuticals
• Psychological
• Endocrine
• Restricted mobility
• Stool Impaction
Transient vs. Established Incontinence
• Delirium
• Infection
• Atrophic urethritis/ vaginitis
• Pharmaceuticals
• Psychological
• Endocrine
• Restricted mobility
• Stool Impaction
Treatment of Voiding Dysfunction

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Urology Back to Basics

The “Nuts” and Bolts

James Watterson, MD FRCSC

Director, Ottawa Lithotripsy and Stone Program

• The Medical Council of Canada

• University of Toronto Notes

Key Objective (s):

Differentiate red or brown urine from hematuria, transient

Conduct an effective plan of management for a patient with hematuria

Conduct an effective plan of management for a patient with hematuria

1. Urine dipstick – if positive, indicates hematuria, hemoglobinuria,

Conduct an effective plan of management for a patient with hematuria

Conduct an effective plan of management for a patient with hematuria

• History and P/E

Conduct an effective plan of management for a patient with hematuria

• Principles of Antimicrobial Therapy

• Lower Tract UTI – cystitis; most occur in women; 10% incidence

• Upper Tract UTI (Acute Pyelonephritis)

Conduct an effective plan of management for a patient with hematuria

• Diet, Diet, Diet

Key Objective (s):

Differentiate between urinary tract infections and conditions outside the

In patients with recurring urinary tract infections, determine whether a

• Outline strategies for prevention of recurrent urinary tract infections.

• Dysuria = painful urination

• Pyuria = presence of white blood cells (WBCs) in urine

Through efficient, focused, data gathering:

• Uremia = clinical signs and symptoms seen as a result of

• Azotemia = elevation of blood urea (BUN)

• Obstructive Uropathy = reversible or irreversible renal

• Hydronephrosis = dilation of the renal pelvis and calyces

• Supravesical vs. Infravesical

• Complete or partial obstruction

• Duration; >30 days of complete obstruction results

• Loss of renal function

• Urinary tract infection / sepsis

– Elevated BUN and Cr with bilateral ureteral or bladder

– Abnormal urinary indices

• Bypass the cause of obstruction

• Bladder outlet obstruction

• Renal or ureteral obstruction

• Remove the cause of obstruction

• Second leading cause of male cancer deaths

• Lifetime risk 1/6

• Lifetime risk of a 50 year old: 50%, risk of dying 3%

• Histologic Incidence rates

• Enzyme produced by epithelial cells of prostate

Age 50 unless 1st degree relative or black male >>>40-45 yrs

Probability of Finding Cancer on Biopsy According to a Man’s

2-4 4-10 >10

AbN 20% 45% >75%

Key Objective (s):

Differentiate testicular tumor from a mass of inguinal origin (not possible to

Through efficient, focused, data gathering:

Conduct an effective plan of management for a patient with scrotal mass:

• Painful vs. painless

• Age of patient • Risk Factors