Genitourinary Tract Begashaw M (MD)
Dec 22, 2015
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 ,pyelolithotomy
Percutaneous nephrolithotomy
Extra 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 mirabilis
Pseudomonas 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 mass
Diagnosis
-Elevated WBC count,
-Low or no pus cells or bacteria in urine
-Ultrasound is usually diagnostic
Treatment
-Drainage of abscess,IV antibiotics/fluid
Perinephric abscess
Urinary Retention
Etiology 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 antagonists
Surgery
Transurethral prostatectomy
Transvesical prostatectomy
Retropubic prostatectomy
Complications
Early
Primary haemorrhage
Extravasation
Fluid absorption
Infection
Clot retention
Incontinence
Intermediate
Secondary haemorrhage
Retrograde ejaculation
Erectile dysfunction Late
Bladder neck stenosis
Urethral 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 hygiene
Complications
-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 vaginalis
Hydrocele 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 complete
Treatment
-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