Genitourinary Tract

Begashaw M (MD)

Urinary caliculi

Incidence-prevalance of 2-3%-male:female = 3:1, peak incidence 30-50

years of age-Recurrence rates are close to 50%-90% are idiopathic

Urinary caliculi

Prevalence

common in areas -hot, dehydratedEtiology of stone formation in the urinary

tract is not very clearProposed etiologies -Urinary stasis -Infections -Lack of inhibitors

Risk Factors

Hereditarycystinuria/xanthinuria/oxaluriaDietary excess: Vitamin C, oxalate, purines,

calciumDehydrationsummer Sedentary lifestyleUTIHypercalcemia

Chemical composition

Calcium oxalate (40%)Calcium phosphate (15%)Mixed oxalate / phosphate (20%)Struvite (15%)Uric acid (10%)

Types of renal calculi

Clinical features

painUreteric colic - severe colicky loin to groin pain - radiate into scrotum in men & labia in

womenFrequency, urgency & dysuriaMicroscopic haematuria

Investigation

U/ARBC, Pus cells, calcium oxalate KUBOpacity in UT projection Ultrasound- locates stone in the kidney - detects hydronephrosisIntravenous urogram (IVU)-presence of

stoneCT scanning

Complications

Complications of ureteric calculi _Obstruction_Ureteric strictures_Infection

Management

Small ureteric stones /non-obstructive _Conservativeanalgesics/antibiotics Expecting passage

Big stones/obstructing Open surgery -nephrolithotomy ,pyelolithotomyPercutaneous nephrolithotomyExtra corporal shock wave lithotripsy (ESWL)

Bladder calculi

associated with urinary stasisForeign bodies (suture)nidus for stone

formationmore common in elderly men/childen

Clinical features

asymptomaticSuprapubic painDysuriaHaematuria

Diagnosis

Plain abdominal x-rayBladder ultrasoundCT scanCystoscopyacute urinary retention

Management

Indications for surgery Recurrent UTI Acute urinary retention Frank haematuria

Urinary tract infection

Commonest organisms Escherichia coli (80%)Proteus mirabilisPseudomonas aeruginosa

Upper urinary tract infections

Classification- Acute pyelonephritis- Chronic pyelonephritis- Pyonephrosis- Renal abscess- Perinephric abscess

Acute pyelonephritis

commonly occurs in females, in reproductive age group, childhood & pregnancy

Ascends from lower UTI

Clinical features

Nonspecific-headache, lassitude & nausea Sudden onset of pain, rigors & vomitingPain is localized in the flank &

hypochondriumlower UTI - frequency & dysuria

Diagnosis

Urine culture & sensitivityUrinalysis - few pus cells,many bacteriaBlood culture

Treatment

Antibiotic Choice-combination of amino glycoside &

penicillin parenteral antibioticsComplications-Pyonephrosis -coexisting upper tract obstruction_inadequately treatedperinephric abscess

Perinephric abscess

is an infection of the perinephric fat resulting in pus collection

source -extension of cortical abscess -distant-appendix abscess

Clinical feature

- Swinging high grade fever- Abdominal and loin tenderness- Flank massDiagnosis-Elevated WBC count,-Low or no pus cells or bacteria in urine-Ultrasound is usually diagnosticTreatment -Drainage of abscess,IV antibiotics/fluid

Perinephric abscess

Urinary RetentionEtiology Outflow obstruction -bladder neck/urethracalculus,clot,neoplasm -prostateBPH, prostate cancer -urethrastricture Bladder innervation -spinal cordinjury -stroke pharmacologic -anticholinergics

Symptoms of urinary tract obstruction

DDX

Urinary retention

Acute retention -characterized by pain & anuria -normal bladder volume & architecture Chronic retention -asymptomatic-increased bladder volume -detrusor hypertrophyatony

Acute retention

Presents with inability to pass urine for several hours

Usually associated with lower abdominal pain

Bladder is visible and palpableBladder is tender on palpation

Management

urethral catheterisation12 to 16 Fr gauge Foley catheterIf unable to pass a urethral cathete

suprapubic cystostomy

Urethral catheterization

Supra pubic cystostomy

Chronic retention

Usually relatively painlessCause hydronephrosis & renal impairment present with hypertensionSymptoms of BOO

Investigations

CBC, electrolytes, Cr, BUNUltrasoundCystoscopy

Treatment

Catheterization -contraindicated in trauma patient unless

urethral disruption has been ruled out -acute retention: immediate catheterization to

relieve retention, leave Foley in to drain -chronic retention: intermittent catheterization• suprapubic cystotomy

Benign Prostatic Hyperplasia (BPH)

hyperplasia of stroma & epithelium in periurethral area of prostate (transition zone)

Affects 50% men > 60 yrs Affects 90% of men > 90 yrs Presents with obstructive and irritative symptoms Obstruction-poor stream, hesitancy, dribbling &

retention Irritation - frequency, nocturia, urgency & urge

incontinence

Investigations

Urea/electrolytesrenal functionUltrasoundhydronephrosis & measure

post-micturition volumeSerum PSAmalignancyUroflowmetryDRE

Management

Observation -α-adrenergic antagonists -5α- reductase inhibitors -LHRH antagonistsSurgeryTransurethral prostatectomyTransvesical prostatectomyRetropubic prostatectomy

Complications

EarlyPrimary haemorrhageExtravasationFluid absorptionInfectionClot retentionIncontinence

IntermediateSecondary haemorrhageRetrograde ejaculationErectile dysfunction LateBladder neck stenosisUrethral stricture

Renal injuries

relatively uncommon injuries Injuries to ureters are extremely rare in

traumasRenal injuries -divided mild, moderate, severe first, second & third degree

Classification

First degree -injury limited to the kidney parenchymaonly subcapsular hematoma

Second-degree injury involved the pelvicalyceal system - hematuria is evident

Third degree -renal artery or renal vein involvement

Clinical features

Hematuria: - the most important symptom -extent & duration of hematuria determines

severity Pain in the flank area/hypochondriumFullness, tenderness & bruises in the flanksHypotension/shock - third degree injuries

Treatment

Conservative - first degree and some second degree renal

injuries - replacement of fluid - blood transfusion - catheterization and follow upSurgery - severe forms of renal injury

Bladder injury Associated with pelvic fractures Rupture can either intraperitoneal or extraperitoneal Clinical features -lower abdominal peritonism & inability to pass

urine IVU may show urine extravasation Diagnosis cystography Intraperitoneal rupture requires laparotomy, bladder repair,

urethral & suprapubic drainage Extraperitoneal rupture can be treated conservatively with urethral

drainage Prophylactic antibiotics should be given

Bulbar urethral injury

Is the commonest typedirect trauma causes by falling astride an objectClinical features -blood from meatus & perineal

bruisingSuprapubic cystostomyDiagnosis -ascending urethrogramProphylactic antibioticsComplication-urethral stricture

Membranous urethral injury Often occur in multiply injured patient 10% of men with pelvic fracture have a membranous

urethral injury Tear -partial or complete Partial injuries - urethral bleeding & perineal bruising Complete injuries - inability to pass urine Diagnosis - ascending urethrogram Treatment -suprapubic catheter Complications-stricture, impotence & incontinence

Phimosis

Definition - inability to retract foreskin over glans penis - may be caused by balanitis (infection of

glans), often due to poor hygeine or congenital

- normal congenital adhesions separate naturally by 1-2 years of age

Treatment -circumcision, proper hygieneComplications -balanoposthitis (inflammation of prepuce),

paraphimosis, penile cancer

Balanitis

Inflammation of the glansIn mild cases, the only symptoms are

itching and some dischargeIn more severe inflammation, the glans and

foreskin are red-raw and pus exudesTreatment is by broad-spectrum antibiotics

and local hygiene measures

Urethral stricture

Aetiology -inflammatory – post-gonorrhoeal -congenital -traumatic -instrumental – indwelling catheter – urethral endoscopy -postoperative

Post-gonorrhoeal stricture

The stricture is most commonly in the bulbar urethra

Pathology Infection in the periurethral glands periurethritis, which heals by fibrosis Most strictures appear within 1 year of

infection but may not cause difficulty in micturition for 10–15 years

Complications

retention of urineurethral diverticulumperiurethral abscessurethral fistulahernia, haemorrhoids & rectal prolapse

Treatment

Dilatation- Gum-elastic bougie,metal soundUrethrotomy-Internal or externalUrethroplasty

Urethral stricture

Hydrocele

is an abnormal collection of serous fluid in a part of processus vaginalis, usually the tunica

Acquired hydroceles are primary or idiopathic, or secondary to testicular disease

Aetiology

Four different ways -by excessive production of fluid within the sac -by defective absorption of fluid -by interference with lymphatic drainage of

scrotal structures -by connection with the peritoneal cavity via a

patent processus vaginalisHydrocele fluid contains albumin & fibrinogen

Clinical features

typically translucent –transillumination possible to ‘get above the swelling’Painless swellingTestis palpable in lax fluid Complications -Rupture -haematocele occurs after trauma -may calcify

Treatment

Congenital hydroceles - herniotomy if they do not resolve spontaneously

Acquired hydroceles – hydrocelectomyLord’s operation Jaboulay’s procedure

Hydrocelectomy

Lords Jaboulay’s

EPIDIDYMO-ORCHITIS

Inflammation confined to the epididymis is epididymitis; infection spreading to the testis is epididymo-orchitis

Etiology Chlamydia trachomatis gonococcal Rare -Escherichia coli, streptococcal,

staphylococcal or Proteus

Clinical features

initial symptoms are those of urinary infectionGroin pain, fever ,swelling –painfulScrotal wall-red, oedematous & shiny Resolution may take 6–8 weeks to completeTreatment-Doxycycline -for 2 weeks-Drink plenty of fluid-Scrotal elevation

Paraphimosis

_Tight foreskin once retracted may be difficult to return

_Glans & distal foreskin-swell, obstructing ring of prepuce

_Icebags, gentle manual compression_Treatment-circumcision

Paraphimosis