- •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
452 CHAPTER 10 Trauma to the urinary tract
Anterior urethral injuries
History and examination
Anterior urethral injuries typically occur as a result of straddle injury to the perineum. Other causes include iatrogenic (e.g., traumatic catheterization), penile fracture, or penetrating trauma. Gunshot wounds affecting the anterior urethra also typically involve the thigh, groin, or buttock.
The patient usually presents with blood at the meatus, difficulty in passing urine, and/or gross hematuria. If Buck fascia (the deep layer of fascia surrounding the penis) has been ruptured, urine and blood coalesce in the scrotum and perineum in a classic “butterfly” pattern of bruising, reflecting the lateral attachments of Colle fascia—the superficial fascia of the groin and perineum (see Fig. 10.14 and Box 10.6).
Confirming the diagnosis and subsequent management
Retrograde urethrography delineates the presence and extent of urethral injury. Extravasation of contrast around the urethra indicates the need for urinary diversion via either urethral or suprapubic catheter to prevent further extravasation of urine and infectious complications. It is helpful to determine whether the injury is partial or complete.
Partial rupture of anterior urethra
There is contrast leak from the urethra with retrograde flow into the bladder preserved. Most cases (70%) heal without stricture formation when managed by a period of urinary diversion alone. Flexible cystoscopy may be used to place a guide wire into the bladder under direct vision, followed by placement of a Councill tip catheter. Alternatively, passage of a 16 Fr Coude tip catheter may be performed to stent the injury.
Broad-spectrum antibiotics are given to prevent infection of extravasated urine and blood. If a voiding cystogram 2 weeks later confirms urethral healing, remove the catheter. If contrast still extravasates, leave it in place a little longer. Suprapubic catheterization (percutaneously) should be performed if urethral catheterization is not easily accomplished.
Complete rupture of anterior urethra
Leak of contrast from the urethra on retrograde urethrogram without filling of the posterior urethra or bladder indicates a greater magnitude of injury. Suprapubic urinary diversion should be performed promptly to prevent complications. A short, dense urethral stricture will likely result, which is easily repaired with a high degree of success at most referral centers.
Several recent studies have shown that realignment of such injuries acutely, followed by repeated instrumentation to maintain patency, actually leads to longer strictures and more complex repairs.
Penetrating anterior urethral injuries
Urethral injuries due to gunshot or knife wounds should be treated via immediate primary suture repair using optical magnification and fine absorbable suture over a 16 Fr catheter. Voiding cystourethrography should be done in 2 weeks to confirm healing.
Immediate surgical repair of anterior urethral injuries is also done in the context of penile fracture or where there is an open wound.
ANTERIOR URETHRAL INJURIES 453
Figure 10.14 Butterfly bruising following rupture of Buck fascia.
Box 10.6 Anatomical explanation for “butterfly” pattern of bruising in anterior urethral rupture
Fascial layers of penis from superficial to deep:
•Penile skin
•Superficial fascia of the penis (Dartos fascia)—continuous with the superficial fascia of the groin and perineum (Colles fascia) and abdomen (Scarpa fascia)
•Buck fascia (deep layer of superficial fascia that envelopes penis)
•Deep fascia of the penis (tunica albuginea)—dense tissue lining containing the erectile tissue within the corpora cavernosa and the corpus spongiosum
If Buck fascia is intact, bruising from a urethral rupture is confined in a sleeve-like configuration, along the length of the penis. If Buck fascia has ruptured, the extravasation of blood, and thus the subsequent bruising, extends to the lateral attachments of Colles fascia, which forms a butterfly-like pattern in the perineum.
How to perform a retrograde urethrogram
•Use aseptic technique.
•Position patient with the pelvis at an oblique angle (bottom leg flexed at the hip and knee).
•A 16 Fr unlubricated catheter is placed in the fossa navicularis of the penis 1–2 cm from the external meatus, with the catheter balloon filled with 3 mL of water to hold the catheter in place.
•Slowly inject 30 cc of dilute contrast.
•Continuous screening (fluoroscopy) is done as contrast is instilled until the entire length of the urethra is demonstrated. Remember, as the urethra passes through the pelvic floor and membranous urethra (located at the lower portion of the obturator foramen), there is a normal narrowing, and similarly, the prostatic urethra is narrower than the bulbar urethra.
•Take film during contrast injection.
454 CHAPTER 10 Trauma to the urinary tract
Testicular injuries
Mechanisms
These can be blunt or penetrating. Most testicular injuries in civilian practice are blunt, a blow forcing the testicle against the pubis or the thigh.
Bleeding occurs into the parenchyma of the testis, and if sufficient force is applied, the tunica albuginea of the testis (the tough fibrous coat surrounding the parenchyma) ruptures, allowing extrusion of seminiferous tubules.
Penetrating injuries occur as a consequence of gunshot or knife wounds and from explosive blasts; associated limb (e.g., femoral vessel), perineal (penis, urethra, rectum), pelvic, abdominal, and chest wounds often occur.
Usually, the force is sufficient to rupture the tunica albuginea and the tunica vaginalis, and seminiferous tubules and blood extrude into the layers of the scrotum. This is a hematoma.
Where bleeding is confined by the tunica vaginalis, a hematocele is said to exist. Intraparenchymal (intratesticular) hemorrhage and bleeding beneath the parietal layer of tunica vaginalis will cause the testis to enlarge slightly. The testis may be under great pressure as a consequence of the intratesticular hemorrhage confined by the tunica vaginalis. This can lead to ischemia, pain, necrosis, and atrophy of the testis.
History and examination
Severe pain is common, as are nausea and vomiting. As a result, bimanual physical exam is notoriously difficult. If the testis is surrounded by a hematoma it will not be palpable. If it is possible to palpate the testis, it is usually very tender.
The resulting scrotal hematoma can be very large and the bruising and swelling caused may spread into the inguinal region and lower abdomen.
Testicular ultrasound in cases of blunt trauma
Scrotal ultrasound is the imaging test of choice for evaluating suspected testicular rupture. A normal, homogenous intratesticular parenchymal echo pattern suggests there is no significant testicular injury (i.e., no testicular rupture).
Hypoechoic areas within the testis (indicating intraparenchymal hemorrhage) suggest testicular rupture (Fig. 10.15).
Indications for exploration in scrotal trauma
•Testicular rupture. Exploration allows evacuation of the hematoma, excision of extruded seminiferous tubules, and repair of the tear in the tunica albuginea.
•Penetrating trauma. Exploration allows repair to damaged structures (e.g., the vas deferens or spermatic cord vessels may have been severed and can be repaired).
•In roughly 75% of cases, testicular injuries can and should be repaired primarily in lieu of orchiectomy.
TESTICULAR INJURIES 455
A
B
Figure 10.15 Scrotal ultrasound after blunt trauma shows A) multiple intraparenchymal hypoechoic areas consistent with rupture, and B) normal contralateral testis.