- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
520 CHAPTER 13 Neuropathic bladder
Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
Causes of recurrent UTIs
•Incomplete bladder emptying
•Kidney stones including staghorn calculi
•Bladder stones
•Vesicourethral reflux
•Presence of an indwelling catheter (urethral or suprapubic)
History
What the spinal cord–injured patient interprets as a UTI may be different from the UTI in a noninjured patient. The neuropathic bladder is frequently colonized with bacteria and the urine often contains white blood cells (pyuria). From time to time, it becomes cloudy from precipitation of calcium, magnesium, and phosphate salts in the absence of active infection.
The presence of bacteria, pus cells, or cloudy urine in the presence of nonspecific symptoms (abdominal pain, tiredness, headaches, feeling under the weather) is often suggestive of a UTI.
Indications for treatment of UTI in the neuropathic patient
It is impossible to eradicate bacteria or pus cells from the urine in the presence of a foreign body (e.g., a catheter). In the absence of fever and cloudy, foul-smelling urine, we do not prescribe antibiotics; the indiscriminate use of these encourages growth of antibiotic-resistant organisms.
We prescribe antibiotics to the chronically catheterized patient when there is a combination of fever, cloudy, and foul-smelling urine, and when the patient feels unwell. Culture urine and immediately start empirical antibiotic therapy with a quinolone (such as ciprofloxacin based on local sensitivity patterns), changing to a more specific antibiotic if the organism is resistant to the prescribed one.
Investigations
For recurrent UTIs, such as frequent episodes of fever, cloudy, smelly urine, and feeling unwell, the following are helpful:
•KUB X-ray for kidney and bladder stones. Some consider this to be standard annual screening in patients with chronically indwelling catheters.
•Renal and bladder ultrasound to determine the presence or absence of hydronephrosis and to measure pre-void bladder volume and postvoid residual urine volume and to localize any stones.
Treatment
In the presence of fever and cloudy, foul-smelling urine, culture the urine and start antibiotics empirically (e.g., trimethoprim, amoxicillin, ciprofloxacin), changing the antibiotic if the culture result suggests resistance to
MANAGEMENT OF RECURRENT URINARY TRACT INFECTIONS 521
your empirical choice. Response to treatment is suggested by the patient feeling better and the urine clearing and becoming nonoffensive to smell.
Persistent fever, with constitutional symptoms (malaise, rigors) despite treatment with a specific oral antibiotic in an adequate dose is an indication for admission for treatment with intravenous antibiotics.
If the patient appears to have pyelonephritis or is manifesting signs of sepsis, hospitalization and empiric IV antibiotics (such as ampicillin and gentamicin or third-generation cephalosporin) is indicated with change to oral antibiotics when the patient is afebrile for 24 hours.
Management of recurrent UTIs (see Table 13.2)
If there is residual urine present, optimize bladder emptying by intermittent catheterization (males, females) or external sphincterotomy for DSD (males). Intermittent catheterization can be done by the patient (intermittent self-catheterization, ISC) if hand function is good (paraplegic), or by a caregiver if tetraplegic.
An indwelling catheter (IDC) is an option, but the presence of a foreign body in the bladder may itself cause recurrent UTIs (though in some it seems to reduce UTI frequency).
Table 13.2 Summary of treatment for recurrent UTI’s
Low bladder pressure |
High bladder pressure + DSD |
ISC |
ISC |
IDC |
IDC |
|
External sphincterotomy—surgical, botulinum |
|
toxin, sphincter stent |
|
Deafferentation/SARS |
|
|
Remove stones if present—cystolitholapaxy for bladder stones, PCNL for staghorn stones.
522 CHAPTER 13 Neuropathic bladder
Management of hydronephrosis in the neuropathic patient
An overactive bladder (detrusor hyperreflexia) or poorly compliant bladder is frequently combined with a high-pressure sphincter (detrusorsphincter dyssynergia [DSD]). Bladder pressures during both filling and voiding are high.
At times the bladder pressure may overcome the sphincter pressure and the patient leaks small quantities of urine. For much of the time, however, the sphincter pressures are higher than the bladder pressures and the kidneys are chronically exposed to these high pressures. They are hydronephrotic on ultrasound, and renal function slowly, but inexorably, deteriorates.
Treatment options for hydronephrosis
Bypass the external sphincter
•IDC (indwelling catheter)
•ISC (intermittent self-catheterization) + anticholinergics
Treat the external sphincter
•Sphincterotomy: surgical incision via a cystoscope inserted down the urethra (electrically heated knife or laser), botulinum toxin injections into sphincter, urethral stent
•Deafferentation* + ISC or SARS
Treat the bladder
•Intravesical botulinum toxin + ISC
•Augmentation + ISC
•Deafferentation* + ISC or SARS
* Deafferentation converts the high-pressure sphincter into a low-pressure sphincter and the highpressure bladder into low-pressure bladder.
MANAGEMENT OF AUTONOMIC DYSREFLEXIA 523
Management of autonomic dysreflexia in the neuropathic patient
Autonomic dysreflexia (AD) is a unique and potentially life-threatening condition in spinal cord–injured patients. AD can cause rapid, extreme blood pressure elevation, headache, diaphoresis, bradycardia, sweating, nausea, and piloerection in patients with spinal cord lesions at and above the sixth thoracic level (T6).
Approximately 85% of quadriplegic and high paraplegic individuals are prone to AD in response to noxious stimuli. AD is more common in men than in women because of increased bladder outlet resistance. Stimuli, such as bladder distention, bowel distention, or pain, activate sympathetic neurons in the lateral horn of the spinal cord, causing unopposed reflex sympathetic activity.
Primary therapy should always be to remove the triggering stimulus (i.e., empty distended bladder or clear obstruction in Foley catheter). Rarely, acute episodes must be managed with intravenous nitrates or arterial dilators under closely monitored conditions. Chronic treatment with A-blockers may improve some symptoms of AD.
1 Vaidyanathan S, Soni BM, Sett P, et al. (1998). Pathophysiology of autonomic dysreflexia: longterm treatment with terazosin in adult and pediatric spinal cord injury patients manifesting recurrent dysreflexic episodes. Spinal Cord 36:761–770.