History

Urinary disease presents with a relatively small number of defined symptoms as presenting problems. Patients may present with lower urinary tract symptoms (LUTS) that are subcategorised as storage or irritative symptoms (urinary frequency, urgency, nocturia, dysuria), voiding or obstructive symptoms (change in strength of the urinary stream) and incontinence. Ongoing obstructive LUTS may eventually present as retention of urine. Haematuria may be due to benign or malignant disease; renal pain (colic) results from obstruction, most often with ureteric calculi. Occasionally there may be recognition of a renal mass. However, the majority of renal masses are now detected as incidental findings on abdominal imaging performed for investigation of often unrelated symptoms. Prostate cancer is increasingly detected in the context of overall health assessments or as a case finding during assessment of LUTS. A careful assessment of the history often suggests the diagnosis, which is usually supported by an imaging modality.

Common pathologies are congenital anomalies, functional disorders and specific malignancies, including those affecting children. Other malignancies of the urinary tract and prostate increase in frequency with age. Urinary tract trauma and infections are common to all ages. Bladder neck obstruction from prostatic disease is the most common problem in the elderly male.

Patients should be assessed for evidence of renal failure (Ch 10.7). Symptoms of chronic renal failure include nocturnal polyuria and a constellation of nonspecific symptoms: anorexia, nausea and vomiting, headache, visual disturbances, lethargy, sallow skin, oedema and general malaise.

Physical examination

Physical examination is often normal in patients with urinary tract disease. Detection of abnormalities involves identification of renal or bladder masses, together with examination of the lower urinary tract in both sexes. Imaging is often then required.

Renal masses are usually found to be due to simple renal cysts, tumours or obstruction causing hydronephrosis. Abdominal examination may reveal a unilateral renal mass or the bilateral masses of polycystic kidneys.

A renal swelling has the following characteristics:

Figure 9.1 Palpation of right kidney

Digital rectal examination (DRE) may reveal the changes of benign prostatic hypertrophy, prostatitis or carcinoma of the prostate. The external genitalia should also be examined. As with all physical examination, appropriate consent is obtained and privacy should be provided.

Diagnostic tests

Several special investigations are of critical importance. They range from simple examination of the urine (which must never be omitted) to sophisticated functional and imaging tests. Those most commonly employed are:

Figure 9.2a Cystoscopy and ureteric catheterisation

A: tip of cystoscope with elevating bridge; B: trigone of bladder; C: ureteric oriface; D: interureteric bar

Figure 9.2b Normal right ureteric orifice as seen on cystoscopy

Figure 9.2c Right ureteric orifice with guidewire in situ

Causes

Clinical assessment

Diagnostic plan

On presentation to hospital, the diagnosis is usually made after clinical history, examination and then urine dipstick with a commercial kit with positive for red blood cells is demonstrated and infection largely excluded by the absence of nitrites. The imaging modality to confirm the diagnosis will then usually be a non-contrast spiral computed tomography (CT) scan of the abdomen and pelvis. An accompanying plain abdominal X-ray is helpful in planning treatment and elucidating if the stone is radio-opaque or radiolucent. The X-ray may demonstrate an opaque calculus (85% of urinary calculi are radio-opaque — Box 9.1), which needs to be distinguished from phleboliths and other opacities. The CT findings consistent with an obstructing stone include perinephric fat stranding, dilatation of the renal pelvis and/or ureter and identification of the stone itself. The presence of the contralateral kidney should be sought and the size and position of other calculi that appear bright white should be noted. Urine should then be sent for formal microscopy and culture to definitively exclude infection and quantitate the haematuria, and to look for crystals (oxalate). At the time of presentation, blood should be drawn for full examination, creatinine, urea and electrolytes to ascertain renal function and screen for metabolic abnormalities and serum uric acid; calcium and phosphate estimations are also useful screening tests for major metabolic abnormalities. Stone analysis is done if the stone is recovered. The patient is instructed to strain the urine to check for stone passage and obtain the stone for analysis.

Box 9.1

Types of urinary calculi

70% are calcium oxalate and phosphate in acid urine (radio-opaque)

15% are urate calculi in acid urine (radiolucent)

10% are magnesium ammonium phosphate in alkaline, usually infected urine (radio-opaque)

1% are cystine (partly radio-opaque)

Prior to the popularity of CT for diagnosis, which has the advantages of high sensitivity, speed, lack of contrast administration and ability to detect other intra-abdominal pathologies, intravenous urography (IVP) was used to confirm the diagnosis of urinary obstruction, with demonstration of the causative calculus, either as a radio-opaque shadow in line with the ureter or as a radiolucent filling defect (Figs 9.4a–c), or showing a dilated upper urinary tract as the aftermath of a stone that has passed. IVP is now rarely performed in most emergency departments but is a useful adjunct if the diagnosis is equivocal. Ultrasound can be helpful in excluding other intra-abdominal and pelvic lesions or to demonstrate and serially monitor upper urinary tract dilatation due to obstruction. Ultrasound is thus of particular value in children, in whom repeated X-rays should be avoided. Renal colic with symptoms and signs of pyelonephritis (fever, systemic toxicity) always requires urgent imaging. An obstructed and infected kidney requires urgent relief, whereas obstruction in the absence of infection can be observed over the course of a week or more without likelihood of renal parenchymal damage.

Figure 9.4a Ureteric stone

Right-sided obstruction from stone causing hydronephrosis.

Figure 9.4b CT stone coronal view of VUJ stone

Reproduced with permission from John Kourambas

Figure 9.4c IVP demonstrating proximal ureteric stone

Reproduced with permission from John Kourambas

Treatment plan

Management of urinary calculi

Most urinary calculi pass spontaneously, especially if they are small or less than 5 mm. Treatment is therefore initially expectant. The patient is treated with euvolemia, as pushing fluids will exacerbate pain, and observed at regular intervals by repeat imaging; a plain film if the stone was initially visualised this way will suffice. Additional CT, ultrasound or IVP may be necessary to confirm if the stone has passed. If the stone enters the bladder its spontaneous passage is usually assured; occasionally a stone subsequently impacts in the urethra causing acute stoppage of the urinary stream. Conservative management may be supported by agents that aid stone passage by ureteric relaxation such as an alpha-blocker (e.g. tamsulosin) or calcium channel antagonists (verapamil) alone or in combination.

Indications for stone removal (Box 9.2). Removal is indicated only when parenchymal damage is a concern, for example, with unresolved urinary infection or the stone seems very unlikely to pass spontaneously, as with large calculi (>1 cm diameter) or persisting pain without progress. It is also mandatory in the case of a solitary kidney, where anuria may ensue.

Box 9.2

Indications for removal/disruption of symptomatic renal or ureteric stone

Solitary kidney

Persistent symptomatic obstruction with urinary infection and danger of renal parenchymal damage

Large calculus (>1 cm) that is unlikely to pass spontaneously

Persistent symptomatic obstruction without improvement or onward passage over one or two weeks

Methods of stone removal. Stone removal is largely an endoscopic procedure via the upper or lower urinary tract depending on the site of the stone, with or without the use of an energy source to shatter the stone prior to removal (Fig 9.4d). The other key method of removal is extracorporeal shock wave lithotripsy (ESWL, Fig 9.4e). Rarely is open stone removal required (open ureterolithotomy, pyelolithotomy or anatrophic nephrolithotomy). Laparoscopic surgery may now be used for difficult, large, impacted ureteric stones that cannot be manipulated up or down. The following methods are most frequently used in the operative management of urinary tract calculi.

Figure 9.4d URS/ureteroscopic view of stone

Reproduced with permission from John Kourambas

Figure 9.4e Extracorporeal shock wave lithotripsy (ESWL)

Photo courtesy of Dornier MedTech GmbH

Cystoscopy and ureteroscopy with stone basket extraction is suitable for small calculi in the lower or intramural ureter that fail to pass despite persisting pain. Energy sources commonly used to fragment the calculi may include pneumatic lithotripsy or laser (holmium). The patient may require temporary stenting with a flexible, double J pigtail stent to guard against recurrence of colic from the oedema left by the stone itself or the procedure to remove it, which can be removed under local anaesthetic at a later date. Stent symptoms include frequency, urgency and loin pain, especially with voiding (stents cause reflux) and haematuria. Patients should be assessed for infection, bearing in mind a degree of red and white cell loss in the urine is consistent with the stent itself.

Extracorporeal shock wave lithotripsy (ESWL). A semi-ellipsoid reflector is used and shock waves are generated from the near focal point and directed to the distant focal point to converge on the calculus in the kidney or upper ureter to fragment it. Many shock waves are required (2500 to 3000) and patients are maintained under anaesthesia or with an epidural block to maintain constant position. Stones can usually be adequately fragmented at one sitting. Most fragmented stones will then be passed spontaneously and subsequently most patients remain stone-free. About 10% of patients require additional percutaneous, ureteroscopic or open surgery to remove residual renal or ureteric fragments. Stones in the middle or lower ureter are shielded by the bony pelvis and need to be manipulated into the pelvis or upper ureter if ESWL is to be used.

Percutaneous nephrolithotomy. A percutaneous nephrostomy tract is first established and a nephroscope introduced along the track. Small stones are removed with grasping forceps; larger stones are initially fragmented with an ultrasonic lithotriptor.

Percutaneous stone surgery and, more recently, ESWL have revolutionised management of renal stones. Most upper tract stones can now be removed by ESWL or percutaneous and endoscopic means. If all modalities are available, ESWL is successful for most stones and percutaneous techniques can deal with almost all the remainder.

Causes

Painless haematuria has a number of common and less common causes (Fig 9.5).

Figure 9.5 Common causes of painless haematuria

A: renal tumour; B: tuberculosis; C: transitional cell tumour; D: engorged prostatic veins

Clinical assessment and urine microscopy

In localising the most likely source of bleeding, help may be obtained from the history and by urine microscopy. Macroscopic haematuria arising from kidney or ureter is usually dark or smoky and evenly mixed with the urine. Blood entering from the bladder, prostate or urethra is usually brighter red. Bleeding from the bladder may be evenly mixed or terminal. From the prostate, bleeding may be heaviest initially or terminally; urethral bleeding is usually heaviest initially. Bleeding from the urethra or prostate may appear at the external urethral meatus apart from micturition and cause bloodstaining of underpants or pyjamas. It should be noted if clots are present; threadlike clots may signify upper tract bleeding. These characteristics are, however, only rough guides to the source of bleeding. The history taken must also check for other evidence of a bleeding tendency, drug intake including analgesics, recent streptococcal sore throat, oedema of face or limbs, family history and evidence of renal injury. Examination will concentrate on identifying renal masses or evidence of diseases associated with haematuria and should include taking the patient’s blood pressure, which may be elevated with glomerulonephritis. Commonly, a physical examination is unrewarding in finding a cause for haematuria.

Normal urine shows fewer than four erythrocytes per high power field in microscopy of fresh centrifuged specimens. Microscopy of a fresh specimen can distinguish between glomerular and urothelial erythrocytes. The former are irregular in outline and haemoglobin content (dysmorphic). The latter are usually undamaged circular cells with normal haemoglobin content or ghost cells of normal shape lacking haemoglobin. Dysmorphic cells are most easily recognised under phase-contrast microscopy. The presence of red cell casts or heavy proteinuria is also indicative of glomerular disease.

Diagnostic and treatment plan

Cases of haematuria require full investigation and the following are suggested.

Macroscopic haematuria must be considered as being caused by a urinary tract malignancy until proven otherwise. If macroscopic haematuria remains unexplained after full investigation, the urine should be examined frequently for malignant cytology and investigations repeated in a month.

Treatment depends on the cause. Haematuria rarely causes shock requiring transfusion or iron deficiency anaemia, except after trauma.

Microscopic haematuria is investigated along similar lines, but often percutaneous renal biopsy will be necessary to identify glomerular lesions.

Bleeding due to prostatic hypertrophy, acute glomerulonephritis, bleeding disorders and less common causes, such as renal papillary necrosis, hydronephrosis, congenital renal anomalies and renal tuberculosis, will usually be associated with other diagnostic features on clinical assessment and investigations.

Urothelial tumours. Urothelial tumours are usually transitional cell tumours. The rare, squamous cell carcinoma follows chronic infection and urolithiasis.

Transitional cell tumours result from diffuse and multicentric epithelial dysplasia, often secondary to urinary carcinogens. Cigarette smoking and heavy analgesic consumption are the common risk factors. Exposure to organic solvents in the dye and paint industries is a further risk, as is chronic bilharzial (schistosomiasis) infection in endemic areas. Tumours occur after middle age and are more common in men.

The bladder is the most frequent site but all urothelium is at risk. Tumour malignancy and prognosis exhibit a spectrum from fronded papillary tumours of low grade or medium malignancy that do not invade the lamina propria, to those that are sessile, ulcerated and invasive from the onset. These latter tumours spread by direct invasion, via lymphatics and at a later stage by the bloodstream. Simple staging into superficial disease and muscle-invasive disease is helpful in determining treatment and prognosis (Figs 9.6a and b).

Figure 9.6a Staging of bladder tumour

T1: confined to lamina propria; T2: invading the muscle wall of the bladder; T3: extending through the bladder wall; T4: involving other organs or nodal spread

Figure 9.6b Endoscopic photo of TCC

More precise staging is from Ta/T1 to T4, namely:

Endoscopic and surgical ablations are the preferred treatments for superficial disease (i.e. Ta and some T1 and Tis). These patients require permanent, repeated urinary cytology and endoscopic review to monitor progress.

Deeper tumours extending into the detrusor muscle need surgical resection with radical cystectomy and diversion of ureters to an ileal conduit or in some circumstances to a neobladder created from a bowel segment. Radiotherapy and endoscopic removal may be used as primary therapy in muscle-invasive disease with or without chemotherapy but is more often reserved for those unfit for radical surgery.

Radiotherapy is particularly helpful for palliation of advanced disease. Intravesical immunotherapy (BCG) or chemotherapy can control superficial and multiple bladder tumours and is usually indicated for Tis, recurrent Ta and some cases of T1 disease.

The BCG is given as an instillation after the insertion of a catheter with an aseptic, and in particular an atraumatic, technique. A six-week course of once weekly instillation is usually undertaken; in some cases a maintenance schedule is given beyond this. BCG is usually well tolerated but has some significant side effects including sepsis (usually in association with concurrent bacterial UTI and/or traumatic catherisation), common local side effects such as dysuria, frequency, macroscopic haematuria or less commonly granulomatous prostatitis, epididymo-orchitis and rarely in the long term, a small contracted bladder. Uncommon systemic side effects, such as pneumonitis, arthritis and hepatitis, are fortunately rare. For the prevention of potentially life-threatening sepsis all patients undergo urinalysis to check for infection prior to treatment each week and treatment is delayed if infection is detected.

Renal transitional cell carcinoma is most common in association with analgesic abuse and presents as haematuria or colic. Treatment is by nephroureterectomy with excision of a cuff of adjacent bladder. This is now more frequently laparoscopically assisted.

Renal cell carcinoma (RCC). RCC is an adenocarcinoma that is more common in men and in smokers, occurs usually after middle age, and spreads by direct extension into perinephric fat, the renal vein and vena cava and via lymphatic spread to locoregional nodes. Metastases to lung, adrenal or bone are the most common sites of advanced disease and may be solitary in nature.

RCC used to present with a classic triad of haematuria, pain and a renal mass. All are features of relatively advanced disease. However, the most common presentation now is occult disease found on imaging initiated for investigation of an unrelated problem such as upper abdominal discomfort, back pain or voiding symptoms. Rarely will a patient present with one of the paraneoplastic syndromes associated with RCC such as pyrexia of unknown origin (PUO), anaemia, hypercalcaemia or symptoms due to synthesis of hormones by the tumour (e.g. erythropoietin, renin, parathyroid hormone). As a result of the plethora of paraneoplastic syndromes associated with RCC, it is sometimes termed ‘the physician’s tumour’.

Investigation needs accurate imaging by triple-phase CT of the abdomen and pelvis to delineate the lesion and any locoregional invasion of nodes or veins or to identify adrenal or liver metastases and assess the contralateral renal unit for presence, size, stones, synchronous cancer or other pathology. Occasionally an ultrasound is also required if there is difficulty differentiating between a solid tumour and a solitary renal cyst (the most common mass lesion in the kidney). Rarely, percutaneous needle biopsy or cyst aspiration is required. Plain chest X-ray or chest CT is used to detect metastases.

The usual treatment is radical nephrectomy if the tumour is locally confined. Small RCCs are often now managed with laparoscopic radical nephrectomy. Where there is a requirement for nephron-sparing surgery, for example, in a single kidney, a partial nephrectomy can be performed. Cancer-specific survival figures for the management of small RCCs of less than or equal to 4 cm with partial nephrectomy are now equivalent to those for radical nephrectomy, making partial removal an alternative. Occasionally, radical nephrectomy can be combined with removal of a locally resectable single-lung metastasis.

Prognosis is good for small tumours, especially those less than 4 cm and even those up to 7 cm. If, however, there is extensive, histologically poorly differentiated (especially sarcomatoid) or metastatic disease, the prognosis is poor. About one-third of patients have metastases on initial diagnosis. Other poor prognostic parameters are lymph node spread and spread beyond the renal capsule. Renal vein extension at the time of nephrectomy has less prognostic significance and removal of intravenous extension of tumour is worthwhile. The tumour is resistant to radiotherapy and traditionally has been highly chemoresistant, though newer immunotherapy and tyrosine kinase inhibitors (sorafenib and sunitinib) based therapies are showing some promise with regard to small improvements in survival time for those with metastatic disease.

Wilms’ tumour (nephroblastoma). This is the second most common abdominal neoplasm of childhood and occurs in children under six years of age (mean age at presentation 3.5 years). Presentation is most frequently because of increased abdominal girth, abdominal mass or serendipitous finding on ultrasound performed for other indications. Children may have microscopic haematuria (25%) but macroscopic haematuria is uncommon.

Imaging by ultrasound usually enables the differentiation to be made from a hydronephrotic or cystic kidney and gives information on renal vein or caval involvement. CT or MRI scan of the abdomen and chest will confirm the diagnosis and provide staging information about retroperitoneal and lung involvement. Wilms’ tumours may be hereditary or sporadic and may be bilateral.

These tumours may be classified as having either favourable or unfavourable histology. They are sensitive to radiotherapy and chemotherapy and usually managed with a combination of surgery and chemotherapy. (In the US, most will have surgery followed by chemotherapy. In Europe and Australia, most will have induction chemotherapy to shrink the tumour, followed by surgery. Radiotherapy is reserved for chemoresistant tumours.) Prognosis has improved with multimodal therapy and high cure rates are possible.

Neuroblastoma is a common tumour in infants and children. It is a malignant tumour of the autonomic nervous system, particularly the adrenal gland. It usually presents younger than Wilms’ (mean age at presentation 1.5 years) and often occurs in neonates. It can be confused with Wilms’ tumour initially, with a rather similar clinical picture. However, these children are usually more unwell, with anaemia, weight loss, irritability, fever and pain. They have high levels of urinary vanillylmandelic acid (VMA) and the mass can extend across the midline and around major vessels. A neuroblastoma displaces the normal kidney and is often calcified. Surgical biopsy and complex chemotherapy is required; however, delayed definitive surgical resection in advanced disease rarely improves the poor outcome for this tumour.

Common causes

Clinical features and diagnostic plan

The evaluation of LUTS requires a careful history, and of primary importance in formulating a differential diagnosis will be the patient’s age, sex and associated conditions (such as diabetes or neurological disease) and assessment of whether the symptoms are predominantly obstructive or irritative or both. This can be done in a quantitative way with the use of validated questionnaires such as the international prostate symptom score (IPSS). All patients should complete a voiding diary. Initial immediate evaluation to exclude urinary infection should be performed.

Pneumaturia and faecaluria are striking symptoms that usually cause an early attendance to seek medical help. Foul-smelling urine interpreted as faeculent by the patient may be merely the result of severe anaerobic infection. Other irritant symptoms include urethral discharge or haemospermia — these symptoms usually also cause early presentation.

The management of LUTS after exclusion of infection will depend on the predominant symptoms, the patient’s other medical conditions and their treatment, the presence of any complications such as haematuria or renal impairment and most importantly, the degree of bother caused by the LUTS. Many patients will derive benefit from simple measures such as fluid manipulation, regular bowel actions, medication timing and assistance with mobility or proximity to the toilet. Beyond this the management of some of the most common scenarios is dealt with in the next sections.

Common causes

Symptoms and signs

In patients with decreased urinary stream the stream is slow to start (hesitancy), lacks power and pressure, may stop and start (intermittency) and dribbles terminally. This may progress to acute or chronic retention of urine. The storage symptom of painless frequency is a common associated symptom. This is often more troublesome at night, is of small volume and often associated with urgency. Urge incontinence or in longstanding obstruction, overflow incontinence, may occur. Symptoms of the complications of obstruction may also be present (Fig 9.7a). These include: urinary tract infection with frequency, dysuria and haematuria; bladder diverticula predisposing to cystitis and stone formation; prostatitis and epididymo-orchitis; vesical calculus causing haematuria, dysuria and frequency; and, eventually, renal injury.

Figure 9.7a Effect of urinary obstruction

A: obstruction effect; 1: prostatic hyperplasia, submucosal venular bleeding; 2: muscle trabeculation, detrusor muscle hypertrophy, bladder diverticula and stone; 3: hydronephrosis and renal failure. B: transurethral resection. The resectoscope is in position. The diathermy cutting loop is drawn back to remove hypertrophied prostate tissue in layers.

Poor urinary stream is most commonly due to outflow obstruction at the bladder neck due to prostatic obstruction in men aged over 60 years, a problem increasing in frequency with the rising proportion of elderly men in the population. Poor flow can also result from urethral stricture or a hypocontractile bladder or a small capacity bladder. The history usually serves to differentiate these less common causes.

On examination the signs of upper urinary tract distension, and of renal injury, are sought.

Benign prostatic obstruction

On DRE, the prostate is enlarged, smooth, regular, mobile and soft. Benign prostatic hyperplasia (BPH) is normally present in most males aged over 60 years. A variant is a small muscular prostate, which gives similar symptoms of bladder neck obstruction but the prostate feels of normal size and consistency. Hence the size of the prostate on rectal examination will not always correlate with the degree of symptoms reported (Fig 9.7b).

Figure 9.7b The prostate on rectal examination

A: the normal prostate; B: benign prostatic hypertrophy; C: carcinoma of the prostate

Diagnostic plan

Patients with poor urinary stream are considered to belong to the group of patients who have LUTS. Hence their investigation is the same as any patient with LUTS. A full history, examination and urine culture are mandatory. The recording of a voiding diary over three days, documenting the volumes passed and those taken orally, is also extremely helpful, particularly in patients with irritative symptoms. Symptom scores (e.g. IPSS) allow quantification of the patient’s symptoms and a comparison over time of any changes that occur. Further investigation will depend on the result of the clinical assessment and urine culture. A patient with a normal urine culture and non-malignant DRE who is minimally bothered may require minimal intervention.

The following series of investigations are indicated in appropriate patients with poor urinary stream or LUTS:

Urodynamic assessment. Urodynamics is the study of pressure and flow relationships during the storage and transport of urne within the urinary tract. Urodynamic assessment aims to investiagte bladder filling and voiding function, accurately define bladder storage disorders and assess the severity of voiding dysfunction. This will be required in those suspected of having bladder dysfunction due to a hypocontractible bladder or with symptoms potentially unrelated to obstruction. This applies particularly to young patients and to those with predominantly storage/irritative symptoms of dysuria, frequency and urgency; these latter symptoms are less likely to respond well to prostatectomy than obstructive symptoms. Patients with a major neurological diagnosis, such as stroke, spinal cord injury or multiple sclerosis, are likely to require urodynamics.

Prostate-specific antigen (PSA). PSA is a serine protease produced by prostate cells and involved in the liquefaction of semen. It is a prostate-specific test that is elevated in conditions that affect the prostate, such as infection, hypertrophy, infarction and malignancy. As a result it is an imperfect test as a screening tool for prostate malignancy. The current recommendations by the Urological Society of Australia and New Zealand as to who should receive a PSA test reads ‘PSA based testing, and subsequent treatment where appropriate, has been shown to reduce prostate cancer mortality in large randomised studies and therefore should be offered to men after informing them of the risks and benefits of such testing. Valuable predictive information can be obtained through even a single PSA test and prognostic information can be obtained by biopsy where indicated. Where possible, over-treatment should be avoided and surveillance with early intervention discussed with carefully selected patients’.^[1] Hence the test can be offered to fit men with a good life expectancy, with or without LUTS if they are adequately informed prior to the test of its limitations and the likely ramifications of the test returning positive. As this is an area of controversy the reader is urged to refer to the latest literature on the topic and the guidelines produced and updated by their local professional bodies. The upper-most value of the PSA test as normal is also a point of contention but for most purposes, normal is less than 4 ng/ml. However, in a younger male with a small prostate, lower values may be considered abnormal. If concern exists, the patient should be referred to a urologist.

PSA values may be very high in metastatic disease. In the lower ranges of PSA, different ancillary tests may be done to further enhance the specificity of the test. An estimation of the free:total PSA ratio may be helpful in men with a PSA between 4 and 10 ng/mL to further assess their risk of prostate cancer. PSA is usually circulating complexed to binding proteins, with less than 30% found free in serum. In cancer, there is more complexed PSA and less free PSA, leading to a lower ratio than, for example, in BPH. Each laboratory will refer to a particular reference range but a free:total ratio that is low (less than 10%) has up to a 50% risk of cancer being detected. Further manipulations of PSA to increase the positive predictive value of the test include estimations of PSA density (a density greater than 0.15 ng/mL per cc volume of prostate on TRUS estimation confers and increased risk of cancer) and tracking PSA over time to assess the velocity of the PSA rise. A velocity of more than 0.75 ng/mL/year or a doubling time of less than two years is significant for increased risk of cancer.

Bone scan is done as a staging procedure if prostatic cancer is diagnosed. Technetium phosphate complexes have greater uptake in areas of bone formation stimulated by tumour, inflammation or repair. Scans cannot distinguish the various causes of increased uptake, so X-rays of ‘hot’ areas are performed to differentiate Paget’s disease, arthritis and fractures from malignancies. In about one-fifth of bone scans positive for metastases no radiographic abnormality is seen — X-ray changes of metastases are not visible until about half the bone has been destroyed.

Transrectal ultrasound and biopsy (TRUS biopsy). Prostate biopsy is performed for investigation of an elevated PSA or abnormal DRE to detect if prostate cancer is present. It is done with a transrectal ultrasound probe under antibiotic cover, usually with some form of anaesthesia, and usually 8–12 samples or cores of tissue are taken. The Gleason pattern, which describes the histological degree of differentiation in the cancer, is decided from the biopsy and gives prognostic information used in the planning of treatment.

CT scanning of the pelvis and abdomen helps stage malignant disease in some cases.

Treatment plan

1 Prostatic obstruction

Prostatic obstruction due to BPH. Only a proportion of those with symptoms come to surgery. Prostatectomy is indicated if:

• complications of obstruction have occurred — acute retention or overflow incontinence, urinary infections, stones, renal failure or ongoing haematuria

• significant obstructive symptoms exist — hesitancy, poor stream, postmicturition dribbling, and they are bothersome

• significant obstruction exists on investigations — trabeculation of bladder, diverticula, residual urine, upper tract dilatation

Conservative treatment is appropriate for many men with poor urinary stream due to BPH. Some men will require no intervention and a policy of observation may be adopted. Alternative medicines such as saw palmetto, for which there is some published data to support its use, might be used. For men with more bothersome symptoms wishing to avoid surgery, alpha-blockers such as prazosin or the more selective, tamsulosin, may be prescribed. 5HT reductase inhibitors such as finasteride lead to gland shrinkage by blocking the peripheral conversion of testosterone to dihydrotestosterone and can be used in conjunction with an alpha-blocker. They are not widely used in Australia due to side effect profile and cost. For men who are poor operative candidates, intra-prostatic stents can also be used but these carry the risk of encrustation and migration.

The operative procedure is now almost invariably transurethral resection of the prostate (TURP) using a resectoscope (endoscopic). The method is suitable for BPH, fibrous prostates or malignant prostates causing obstruction (Fig 9.8a and b).

Figure 9.8a Endoscopic view of prostate pre-TURP

Figure 9.8b Endoscopic view of prostatic fossa post resection with verum montanum in foreground

Complications of TURP include haemorrhage and clot retention, urinary infection and septic shock, stress incontinence and stricture. All patients should be aware that due to the resection of the bladder neck, retrograde ejaculation will result in nearly all cases. Patients may also experience erectile dysfunction after a TURP, though this is thought to be more in keeping with the age-related decline in erections than the surgery specifically and occurs in only around 5% of men. TUR syndrome occurs where there is absorption of the irrigation solution into the bloodstream. This risk is reduced by using isosmolar nonelectrolyte bladder washout solutions. Ablation of tissue can also be achieved using a holmium laser, which has the advantage of using the saline as the irrigant and therefore can treat larger prostates due to a lessened restriction on time of resection.

Alternatives to the traditional TURP with electrocautery include minimally invasive techniques such as microwave therapy or transurethral needle ablation (TUNA) of the prostate. These treatments have less overall impact on symptoms but possibly also less side effects and can be done as a day case. However, they have had a relatively low uptake and have not always proved to be as expeditious as anticipated. Day-case prostatic removal techniques are in constant evolution with lasers (e.g. photoselective potassium titanyl phosphate (KTP) ‘green light’ laser vaporisation) being performed in increasing numbers.

Carcinoma of the prostate. Treatment depends on the stage of disease and the complications caused by local or metastatic disease. Treatment is often undertaken in the multidisciplinary environment and patients may require input from urologists, radiation oncologists, medical oncologists, specialist urological and oncological nurses and palliative care depending on the stage of their disease and the treatment required. Specific complications of advanced disease include acute or chronic retention, painful metastases, pathological fractures and obstructive renal injury.

Prostatic cancer is staged using the TNM system. This is quite complex and for purposes of simplicity, treatment is predicated on whether the cancer is ‘organ confined’ within the prostate or has spread and become advanced and on the patient’s overall health status.

Men who present with early or organ-confined disease, and who are medically fit, will usually be offered treatment with intent to cure. This treatment may be radical surgery with removal of the prostate and re-anastomosis of the bladder to the urethra. Alternatively they may undergo radiotherapy. Both surgery and radiotherapy can take different forms. Surgical removal is commonly open surgery in the extraperitoneal retropubic space with a lower abdominal incision. A perineal approach can be used. The increasing use of laparoscopy and robotics has facilitated surgical removal, with potential improvements in the rate of recovery.

Radiotherapy can be external beam or by placement of low-dose radioactive seeds into the prostate (brachytherapy). High-dose brachytherapy with iridium wires can be administered, usually in conjunction with external beam radiotherapy, in men with higher risk disease.

All radical treatments for prostate cancer carry varying risks to future potency, continence and surrounding structures; for example, rectal toxicity associated with radiotherapy. For this reason, extensive pre-treatment counseling takes place to discuss the various risks and benefits of each approach.

A subset of men with low volume and histological low-grade disease may be offered active surveillance for their disease. This is because the biology of these tumours is such that they may not progress and the patient’s eventual death might be due to other causes. This is of particular importance in the older patient or one who is unfit for medical reasons. The decision to undertake active surveillance with regular PSA monitoring, DRE and possibly biopsy is done after careful urological consultation. There is an expectation that in some men, deferred radical treatment will be offered if their disease parameters change during the period of observation. Unexpected malignancy found on TUR is usually well differentiated and of low biological activity and can be followed by active surveillance.

In the case of advanced disease, where the aim of treatment is quality of life, the mainstay of treatment is androgen deprivation. Most prostate cancer begins as a hormone-dependant cancer and the removal of androgens, chiefly testosterone, results in a measurable decline in PSA and a clinical regression of the cancer both locally and distantly. This has not been conclusively demonstrated to prolong cancer-specific survival; however, there is emerging indirect evidence that it might and there are benefits in terms of symptomatic relief and quality of life. Historically, endocrine treatment with androgen deprivation was achieved by orchidectomy but the development of luteinising hormone, releasing hormone agonists that therefore block testicular testosterone production via a feedback loop, have lessened the requirement for orchidectomy, though the two approaches are equally efficacious, but the side effect profile differs marginally. Any form of androgen deprivation is associated with side effects related to the loss of circulating testosterone, in particular, loss of libido and potency, osteoporosis, alteration in haematological and biochemical parameters including anaemia and lipid metabolism changes, altered body fat distribution, hot flushes and changes in executive mental functioning. Patients require ongoing monitoring of these metabolic parameters, which often requires assessment by an endocrinologist.

During the ongoing management of advanced disease patients may require a variety of treatments aimed at improvement of quality of life. These might include TURP for patients with acute retention or those with persisting obstructive symptoms and can control persisting haematuria. Palliative radiotherapy is indicated for painful skeletal metastases uncontrolled by hormones. Intravenous radioisotopes are helpful for more widespread bony metastases but have significant haematologic toxicity.

Newer treatments for advanced disease that may in the future improve longevity include bisphophonates and taxane-based chemotherapy. These agents have some toxicity and are currently under further investigation.

Causes

Clinical assessment

Retention may be acute or chronic. Acute retention is associated with a painfully distended bladder that can be palpated above the pubis on physical examination as a tense, dull, pear-shaped midline swelling arising out of the pelvis. Suprapubic compression causes an urge to urinate with lesser degrees of distension. By far the most common cause of acute retention in the elderly male is benign or malignant prostatic obstruction; occasionally a lower tract stricture is responsible. It is notable that the obstruction caused by benign prostatic enlargement is dynamic; the prostate can be easily traversed by a large instrument or catheter, it is just that the pressure flow dynamics between the bladder and outlet have progressed to the point where no urine will pass. Drugs often contribute to precipitating an episode of acute retention, particularly in elderly males. Alcohol, anticholinergic agents, sympathomimetic agents, beta-blockers and tricyclic antidepressants are the most common. Acute retention may also be due to neurologic disorders such as multiple sclerosis or spinal injury or may be of psychogenic origin. In women, apart from neurogenic and psychogenic causes, the gravid uterus or fibroids or an ovarian cyst may cause retention by pressing on and obstructing the bladder. Postoperative retention is usually acute and follows operations on the abdomen, pelvis, perineum, anorectum, genitalia and inguinal region and is due to pain inhibiting relaxation of the external sphincter and contraction of abdominal muscles.

Chronic painless retention in elderly males, due to longstanding prostatic obstruction, may be associated with overflow incontinence and with renal injury.

Diagnostic plan

The assessment of acute retention is similar to that of the patient with LUTS. All patients should have their urine checked for infection (urine microscopy, culture and sensitivity) and this will often be done with placement of a catheter. Any urinary infection is treated. Tests of renal function with serum electrolytes and creatinine and urea should be done at initial assessment. PSA is not routinely performed, as the retention event will artificially elevate the result. It should be used only if there is an obvious extensive palpable cancer or suspicion of metastatic disease, which would usually markedly elevate the result.

Treatment plan

Conservative treatment should be tried first. The patient should be encouraged to void in privacy and in a warm environment and, if possible, is allowed to stand out of bed or use a toilet or a commode. Pain is relieved by opiate injection; running taps are also helpful. If these measures are unsuccessful, an anxiolytic agent, such as diazepam, and a warm bath may prevail. The addition of alpha-blockers, such as tamsulosin, in those patients with suspected bladder outflow obstruction due to BPH may be of use, especially in the setting of a trial of voiding (see below).

Conservative measures are of greatest help for those without a preceding history of bladder neck obstruction. In patients with a preceding history of poor stream, they are less likely to be successful, but still should be tried.

Catheterisation will be necessary for unrelieved retention. The catheter is left indwelling in those with a significant preceding obstructive history while their investigations proceed. In those without preceding problems, the catheter is removed after emptying the bladder (trial of voiding). If catheterisation is again required, the catheter is left indwelling pending investigation.

Technique. The technique of urethral catheterisation must minimise the risk of introducing infection in both sexes. Bacteria may come from the urethra and its environs and from the catheter contacting other unsterile objects. Breaches of asepsis are particularly liable to occur if the first attempt does not succeed and the catheter is inserted and removed several times with increasing frustration, impatience and discomfort affecting both operator and patient. Damage to the urethral mucous membrane is more likely in the male and other risk factors are a brusque and intemperate technique and the presence of urethral or prostatic pathology. Ensuring the catheter is in the bladder (flow of urine sited) prior to balloon inflation will prevent urethral injury.

Catheterisation is facilitated by adequate opiate analgesia and by initial lubrication of the urethra by an anaesthetic gel (1% lignocaine).

Using presterilised single-use catheters made of plastic, latex rubber or silicone rubber is now routine. Catheters, bougies and sounds are calibrated on the French (or Charrière) scale, which indicates external circumference in millimetres (so dividing by three gives the approximate external catheter diameter in millimetres).

The simplest catheter (Nélaton) is straight with a smooth round tip and subterminal side holes. The Tiemann catheter has a less flexible, curved olivary tip to aid in negotiating a urethra distorted by prostatic enlargement or stricture. These simple catheters are only used if the catheter is to be removed after relief of the retention (an ‘in/out’ catheter). For simple bladder evacuation a small (12F) Nélaton catheter is thus adequate as a first choice.

Further specialised types of catheters increase the range (e.g. the more exaggerated curves of the coudé and bicoudé catheters) but are infrequently used. The curved introducer of the Foley catheter also mimics the curve of the posterior urethra and adds a degree of rigidity to the otherwise flexible catheter. Use of an introducer increases the risk of urethral damage and inadvertent false passage and should be restricted to those who have had the required training in their use. Finesse and gentleness must never give way to forceful impatience. If blood clots or other debris require drainage or aspiration, a wide-bore catheter (22 or 24F) that will tolerate suction without collapsing is required; for example, a whistle-tip catheter (with end and side holes) is suitable.

For patients with acute retention requiring continuing drainage, a balloon catheter, preferably made of silicone rubber, is desirable. The catheter should not be so large as to hinder free drainage of urethral secretions and a 12F Foley catheter is satisfactory in an adult in most cases. If a Foley catheter cannot be passed, a thinner (6–8F) plastic Gibbon catheter may succeed in navigating a stricture, but often if stricture is present direct visualisation will be needed or suprapubic drainage. In the instance of a large prostate, it is often easier to pass a larger size 16 or 18F catheter with a little more inherent rigidity than a smaller catheter. It will more easily pass through the curve of the bulbar urethra without coiling up than might a smaller bore catheter. If urethral catheterisation for urinary retention is unsuccessful, the distended bladder can be drained suprapubically by percutaneous insertion of a balloon suprapubic catheter. Again, an experienced operator is required and kits based on Seldinger techniques now exist to ensure safe suprapubic puncture without traversing other organs or vessels. Any patient who has had a prior laparotomy or has a lower midline abdominal incision should have a preplacement ultrasound to mark the site of safe puncture (Fig 9.9).

Figure 9.9 Catheterisation of a distended bladder by percutaneous puncture

Acute retention due to prostatic obstruction and with pre-existing symptoms of bladder outlet obstruction is an indication for prostatectomy. After passage of a silicone-rubber urethral catheter and connection to a closed drainage system, preoperative tests and preparation are performed.

Types of urinary incontinence

Clinical features

These vary with the cause and may also commonly overlap.

Treatment plan

Irritative conditions (especially infections) must be diagnosed and treated and anatomic abnormalities causing extra-urethral incontinence identified.

Treatment is then primarily aimed at correcting urethral hypermobility or intrinsic sphincter deficiency causing stress incontinence or the OAB. Overlap of the two conditions is common and characterisation of the cause can be helped in difficult instances by urodynamic studies, which are used to demonstrate objective abnormalities. Bladder pressures and flow rate recordings can be combined with radiographic imaging (video or fluoroscopic urodynamics). Parameters measured include flow rate, residual urine, bladder volume, compliance, and voiding pressures and imaging during voiding.

1 Stress incontinence

Conservative treatment includes pelvic floor exercises, perhaps with biofeedback, correction of obesity and constipation, cessation of aggravating medications, fluid management and oestrogen replacement.

Over 100 operations have been described to correct stress incontinence. Most aim to buttress and support the tissues surrounding the bladder neck and to draw the urethra upwards behind the pubis. Abdominal or vaginal approaches can be used to achieve these aims. The most common procedures now rely on the passage of synthetic, autologous or biomaterial slings or tapes around the mid or proximal urethra and into either the retropubic space or via the obturator canal (Figs 9.10a and b). Retropubic (Burch) colposuspension is another option that can be performed either open or laparoscopically for the treatment of incontinence.

Figure 9.10a Fascial sling for stress incontinence

Based on Cardozo & Staskin, 2006

Figure 9.10b A retropubic tape such as a TVT and a transobturator tape through the same pelvic bones

From Reiffenstuhl, 1996

Common causes

Clinical assessment and diagnostic tests

4 Disorders affecting the shaft

Sebaceous (epidermoid) cysts are most common in the scrotal skin but may occur on the penis.

Subcutaneous induration of the shaft with a firm, nontender plaque of fibrous tissue in the fascia surrounding the corpus cavernosum on one or both sides is due to Peyronie’s disease, a condition of unknown cause akin to Dupuytren’s disease and which results in irreversible damage of the tunica albuginea of the corpora cavernosa. Peyronie’s disease is one of the causes of chordee during erection (Fig 9.11). The natural history of the disease is an active and painful phase of plaque development and then a quiescent phase. The active phase is treated symptomatically and no further treatment of the quiescent phase is required unless chordee that limits voiding in the upright position or sexual penetration results from the plaque.

Figure 9.11 Peyronie’s disease

From Andrology Australia

Treatment plan

Phimosis and chronic balanitis are treated by circumcision. Paraphimosis should be reduced with the aid of analgesia and sedation, if possible; if necessary, a dorsal slit is made in the constricting band. Circumcision is usually necessary for permanent relief.

The treatment of carcinoma is by amputation or local excision with a 2 cm margin. Inguinal gland management is usually delayed because of the frequency of infection within the nodes. In many cases the nodes disappear with control of infection. Later excision of inguinal nodes is essential if they are involved. The decision to explore and excise impalpable lymph nodes is based on the assessment of the overall risk of the disease as determined by the clinical stage, histological grade and the presence of vascular invasion on histology.

Management of impotence has been revolutionised by the development of phosphodiesterase type 5 (PDE5) enzyme inhibitors. These drugs act in the breakdown of cyclic guanosine monophosphate (cGMP), which causes smooth muscle relaxation in the arterioles of the corpora cavernosa, hence increasing intracavernosal blood flow and invoking erection. These drugs (sildenafil, tadalafil and vardenafil)can be taken by most patients, except where there is concomitant nitrate use for the management of angina. There is a small incidence of minor side effects such as headache and facial flushing.

Initial management of impotence therefore should take place in the general practice or primary care setting where, after careful history and examination to exclude organic pathologies that should be otherwise treated, a trial of PDE5 inhibitors may take place.

Local intracavernosal injections of a vasodilator, such as alprostadil or a papaverine-based mixture, can be used in patients who do not respond to PDE5 drugs. Long-term compliance with this treatment is poor.

Implanting an inflatable penile prosthetic device, which have high satisfaction and efficacy rates, are suitable for men who want a long-term ‘cure’ of their erectile dysfunction.

In about a quarter of cases of priapism there is an associated malignancy. If initial treatment with cold showers and oral pseudoephedrine fails then intracavernosal washout with saline followed by a dilute solution of phenylephrine with cardiac monitoring should be attempted. If these measures fail, then a shunt between one of the corpora cavernosa and the corpus spongiosum or between corpus cavernosum and saphenous vein should be carried out within six hours. Impotence is a common sequel of persistent priapism.

Sexually transmitted infections usually respond to antibiotics. Syphilis and gonorrhoea are treated with penicillin. Azithromycin 1 g orally in a single dose or doxycycline 100 mg orally two times a day for seven days is the treatment of choice for nongonococcal urethritis in men or other infection with Chlamydia trachomatis. Uncomplicated gonococcal infections are treated with ceftriaxone. Herpes genitalis is treated with acyclovir and the modern antiretroviral medications have greatly improved the prognosis of HIV infection, but this should not impact on the judicious use of condoms and needle exchange to prevent spread of the disease. Chancroid is treated with sulfonamides, granuloma venereum and inguinale with tetracycline and venereal warts are treated by local diathermy excision. Treatment of the patient’s partner is important in preventing recurrence.

The authors wish to thank Mr Chris Kimber, Dr Nathalie Webb and Mr Chris Love for their contributions to this chapter and to Mr John Kourambas for the illustrations.