Urology

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chapter 46 Urology

INTRODUCTION AND OVERVIEW

Symptoms suggesting urological pathology are common presentations in primary care. These include recurrent urinary tract infections, frequency and urgency of micturition, nocturia and urinary incontinence.

Acute presentations to general practitioners or hospital emergency departments often involve pain: acute loin pain, testicular pain and the pain of urinary retention. Some signs may be suspicious for malignancy (e.g. haematuria). In addition, lumps in the scrotum and testes are a frequent cause for patient concern. A systematic approach to these presentations is easily followed, and history and examination will provide the diagnosis in the majority of cases.

HISTORY AND EXAMINATION

History and examination of genitourinary presentations will necessarily differ between male and female patients.

ADULT MALE

History

History taking should include the presenting complaint and any associated symptoms that may not be volunteered (e.g. haematuria, haematospermia, urethral discharge). Enquire about erectile function and recent sexual activity.

Smoking and occupational history (increase risk of bladder cancer) should be obtained. It is important to obtain an assessment of both chronicity and severity as this will guide management, particularly in bladder outlet obstruction. Nocturia is a common symptom in middle age, in both men and women.

Current medications and allergies should be noted, as well as past surgical procedures.

Family history of prostate cancer will be potentially relevant to diagnosis and screening.

Various symptoms scores have been defined for assessing the severity of lower urinary tract symptoms (LUTS), the most notable being the International Prostate Symptom Score (IPSS). This can easily be remembered by the acronym FUNWISE: Frequency, Urgency, Nocturia, Weak stream, Intermittency, Straining, incomplete Emptying. It is scored from 0 to 5 based on the number of times the symptom has occurred in the past month, and the score is then totalled from 0 to 35. A score of 0–7 is defined as mildly symptomatic, 8–19 moderately symptomatic and 20–35 severely symptomatic. In addition there is a quality of life score from 0 (delighted) to 6 (terrible). These scores are useful for assessing severity and response to treatment, and are widely used.

Examination

Examination of a male presenting with a genitourinary problem will incorporate a general physical examination including an abdominal examination and examination of the penis, scrotum, testes and hernial orifices. Percuss for a palpable bladder and ballot for a palpable kidney. The examination of the prostate is regarded by some men as invasive and avoided by many doctors, but it is invaluable in the diagnosis and management of prostate diseases. Historical descriptions of the characteristics of benign and malignant prostate glands are largely erroneous (e.g. obliteration of the median sulcus); they are usually soft or hard, large or small. Nodules may be felt, and these are often suspicious for malignancy but may also represent intra-prostatic stones.

ADULT FEMALE

History

History will begin with the presenting complaint. Ask about frequency and urgency of micturition, nocturia and urinary incontinence, haematuria, loin pain and vaginal discharge. Ask about a history of past urinary tract infections, gynaecological conditions and procedures, menstruation pattern and bowel function. If appropriate, enquire about recent sexual activity.

Ask about current medications and allergies.

Examination

Examination of a female presenting with a genitourinary problem will incorporate a general physical examination including an abdominal and gynaecological examination. Specific gynaecological conditions should be sought, such as prolapse, fibroids or vaginal atrophy. Asking the woman to cough with a full bladder can give an indication as to the severity of stress incontinence.

BEDSIDE UROLOGICAL TESTS

Dipstick and/or microbiological examination of the urine is valuable for the diagnosis of urinary tract infection and microscopic haematuria. The collection of urine samples for microbiology should be done aseptically. The GP should instruct the patient in how to collect the sample. The patient should wash their hands and the urethra should be swabbed (from front to back in females) with saline-soaked gauze. In females, the labia should be parted and the initial part of the void should be then made into the toilet, the midstream should be voided into the specimen container and the remainder in the toilet. The specimen should then be labelled and note made of whether the patient is menstruating. The specimen should be placed in a specimen bag for transportation to the laboratory.

Urine examination is carried out at the bedside, usually using urine dipstick analysis or similar cellulose strips. These contain reagents sensitive to various substances in urine such as blood, leucocytes, protein, glucose, nitrite, bilirubin and urobilinogen. A diagnosis of urinary tract infection (UTI) can be made confidently in the presence of leucocytes, nitrites and protein. It is possible to treat on this basis alone but a midstream sample for culture should also be sent, to ensure that the correct antibiotic is used.

Urinary catheters

Urinary catheterisation is usually straightforward in the anatomically normal lower urinary tract. Adult urinary catheters used in urological surgery are sized from 12 French (Charriere or Ch) to 24 French and above. The gauge equates to the circumference in mm and is approximately three times the diameter in mm. Other catheters such as the Coudé tip catheter and the Tiemann’s are used to negotiate the prostatic urethra but these are uncommonly used and inhabit the realms of the specialist. For patients with acute retention of urine, a 12 Ch catheter is usually sufficient. Although these were traditionally made of rubber, silicone is now widely used. Silicone catheters have the advantage of softness without the risk of perishing and can be left in the bladder for up to 12 weeks.

Technique

Catheterisation should be carried out using aseptic technique, and consideration given to antibiotic prophylaxis in immunocompromised or unwell patients. Prepare with antiseptic and drape the area. Fenestrated drapes are usually included in catheterisation packs for this purpose. Use 1% lignocaine gel (e.g. Instillagel®) to anaesthetise and lubricate the urethra, and allow 5 minutes to achieve maximum effect. Use the smallest catheter to effect drainage (usually 12 or 14 Ch) and insert until urine is seen to drain. Only then can the balloon be inflated. Usually 10 mL of either normal saline or sterile water is used to fill the balloon. Connect the tubing to a proprietary urinary drainage bag.

If it not possible to perform urethral drainage, suprapubic drainage is sometimes required. A palpable bladder is a prerequisite for this. Seldinger kits are now available to aid avoidance of adjacent organs (bowel and large vessels), but the standard proprietary kits such as Add-a-Cath® are still commonly available. Fine-bore tubes designed for the draining of ascites are best avoided.

UROLITHIASIS

INCIDENCE

Stones are extremely common and have a significant economic impact on a largely working population. The lifetime risk of stone formation has been reported in the range of 12% for men and 5% for women. Approximately 50% of these patients will have a second episode in their lifetime. The peak incidence is 30–45 years of age and men are three times more likely to suffer than women.

AETIOLOGY

Theories of stone formation are by no means complete, partly due to the difficulties of mimicking in vivo disease with an in vitro model. What is clear, however, is that supersaturated urine is a prerequisite to stone formation. The nucleation theory suggests that stones originate from crystals in supersaturated urine, whereas the crystal inhibition theory suggests that it is an absence of urinary inhibitors that differentiates the stone former from the non-stone former. Some work has gone into examination of potential inhibitors, particularly magnesium and citrate. Types of stones are listed in Table 46.1.

TABLE 46.1 Types of stones

Type of stone	Incidence (%)
Calcium oxalate/calcium phosphate	80–85
Urate	5–10
Struvite (magnesium, ammonium, phosphate)	5–10
Cystine	≈1–2
Xanthine	≈1–2

Risk factors for stone disease

• Genetic—there is a strong association between family history and incidence of stone disease, more than doubling the risk compared with the general population.

• Medications—certain drugs have been implicated in renal stone formation, particularly indinavir, an anti-retroviral drug now very uncommonly used.

• Chemotherapeutic drugs can cause hyperuricaemia as a side effect of protein breakdown of tumours.

• Soft drink consumption has been examined as a cause but the evidence is poor (relative risk for sucrose is 1.5).

• High protein/purine diet—high intake of animal proteins has been shown to change urinary pH, increase uric acid excretion, reduce urinary citrate and increase urinary calcium. Significant levels of purines are found in anchovies, asparagus, cauliflower, legumes, mushrooms, organ meats, poultry, sardines, spinach. By extension, a vegetarian diet appears to have a protective effect, although the effect is small.

• High sodium/salt intake—this causes increased urinary calcium excretion and has been shown to increase the risk of stones by approximately 1.3.

• Low fluid intake.

SIGNS AND SYMPTOMS

Urinary stone disease presents either acutely as renal colic or more insidiously with renal angle pain, haematuria or recurrent infections. Renal colic is a common emergency presentation, with very severe pain in the loin. The pain has been described as being more severe than labour, by patients who have endured both. Pain relief should be a priority for these patients when seen in an emergency setting. The pain is often described as a ‘colic’ but can be relentless. It often radiates to the groin or testicle, and testicular pain may be the predominant symptom. The differential diagnosis includes musculoskeletal pain and incipient herpes zoster. In the elderly, ruptured abdominal aortic aneurysm may mimic renal colic. In situations where immediate imaging is not available, this is a diagnosis to consider.

INVESTIGATIONS

Non-contrast CT of the kidneys (CTKUB) is the imaging of choice for kidney stone disease. It has largely replaced the classic intravenous pyelogram (IVP) because it gives better anatomical detail with similar radiation exposure. Measurement of serum creatinine and testing of urine for infection should be carried out.

THERAPEUTICS

Renal colic

The immediate priority is to relieve pain. Non-steroidal anti-inflammatory agents such as indomethacin or diclofenac are often used in this situation. Opiates such as morphine may be required in addition. Pethidine should be avoided as there is no evidence for superior efficacy and it has more potential as a drug of abuse. Many patients will be able to be discharged after a period of observation once a firm diagnosis has been made, as many small stones pass spontaneously.

Management of renal stones

Management of renal stones depends on many factors, including size and position, coexistent infection, renal failure and so on. Mandatory indications for immediate treatment include:

• obstructed infected kidney

• stone unlikely to pass spontaneously (e.g. > 1 cm in size)

• single kidney

• persistent pain.

In addition, social factors sometimes supervene (e.g. incipient long-haul flight). People working in certain professions, such as pilots, are forbidden from working with a renal stone, and that may influence the timing of intervention.

There is good evidence that the use of alpha-blocking drugs and calcium antagonists can assist in the passage of small stones in the lower ureter, and these are often prescribed initially in combination with pain relief.

Methods of stone removal

Ureteric stones can be removed with the assistance of ureteroscopes, which can be either rigid (rod-lens), semi-rigid or flexible (fibre-optic). There have been considerable improvements in the technology of these techniques in recent years. A wide array of baskets is available and these can be used in combination with energy sources such as pneumatic lithotripsy or (holmium) laser. External shock wave lithotripsy (ESWL) is also commonly used, particularly for small stones in the kidney, and these techniques may need to be used in combination.

For larger stones in the kidney, staghorn calculi and so on, percutaneous access may be required to carry out stone surgery. It is unusual for open renal ureteric or renal surgery to be required.

PREVENTION

In order to identify risk of further stone formation, certain investigations are carried out in patients after their first episode of colic. Some authors suggest that metabolic evaluation should be carried out only on those patients with multiple or recurrent stones.

Measurement of serum calcium and urate will identify hypercalcaemic and hyperuricosuric patients. Identification of metabolic abnormalities associated with recurrent stone disease is usually carried out by analysis of 24-hour urine excretion (volume, pH, levels of calcium, phosphate and uric acid, oxalate, citrate, creatinine). Stone analysis may also assist following operative procedure or spontaneous passage.

The most common abnormality found is idiopathic hypercalciuria (with normal serum calcium). This is most easily treated with an increased fluid intake of 1.5–2 L per day.

Chemoprevention is a holy grail for stone disease. Urinary inhibitors such as potassium citrate, alone or in combination with a thiazide diuretic, can be used. Thiazide diuretics decrease hypercalciuria by increasing reabsorption of calcium from the distal tubule. Citric acid (as lemon juice) can be taken but large amounts (100–150 mL of pure lemon juice) are required to produce enough citrate in the urine.

Where possible, avoid medications likely to increase stone risk.

Diet

Dietary fact sheets containing sensible advice are invaluable in reducing further episodes of stone disease. The following points should be included:

• Increase water intake (1.5–2 L of water per day).

• Reduce consumption of soft drinks.

• Reduce high-purine foods in urate stone formers (alcohol, anchovy, asparagus, cauliflower, legumes, mushrooms, organ meats, poultry, sardines, spinach).

• Reduce salt intake.

Dietary restriction of calcium has a counterintuitive effect on the risk of subsequent stones, and is to be discouraged.

Supplements

• Calcium citrate is preferred for postmenopausal women with stone disease. The increase in urinary calcium is counteracted by the concomitant increase in urinary citrate.

• Magnesium reduces calcium oxalate risk.

• Vitamin B₆ decreases oxalate production (foods rich in vitamin B₆ include oily fish, whole grains, poultry, soybean, avocado, bananas, nuts). Dose: 50 mg/day.¹

URINARY TRACT INFECTION

INCIDENCE

Urinary tract infection (UTI) is a common condition of young women, with an estimate of 10% of women aged between 16 and 65 years suffering from one UTI per year. It is predominantly a condition of women, but prostatic hypertrophy causes the incidence to increase in men over the age of 65 years. UTIs are classified as:

• uncomplicated lower UTI (cystitis)

• uncomplicated pyelonephritis

• complicated pyelonephritis

AETIOLOGY

UTIs can be acquired haematogenously but the vast majority arrive through ascending infection via the urethra. Bacteria vary in their virulence and this may vary depending on host factors such as obstruction, immunocompromise and so on. Most UTIs are caused by a single bacterial species. Escherichia coli is responsible for the vast majority, mostly of the O serotype. Less common pathogens include Proteus, Pseudomonas, Klebsiella and, rarely, Staphylococcus. The finding of persistent less common bacteria such as Proteus should prompt investigation for underlying pathology such as stone disease.

SIGNS AND SYMPTOMS

Simple cystitis in women usually gives a classic combination of symptoms: pain on micturition (dysuria), frequency, malaise and occasionally haematuria. In addition, patients may notice an odour associated with the urine. Pyelonephritis can cause significant morbidity, and patients may be pyrexial, with fevers, loin pain and potential sepsis. They frequently, but not always, have a preceding or coincident cystitis. Urinalysis will commonly demonstrate evidence of UTI (leucocytes, erythrocytes and nitrites), and culture of blood and urine will confirm infection with the same bacteria that lead to uncomplicated UTI.

INVESTIGATIONS

• Urinalysis—simple dipstick analysis of urine in the presence of symptoms will give the diagnosis in the majority of cases. In simple UTI, this may be sufficient, but a significant number of UTIs will not respond to empirical antibiotics, because of either resistance or lack of sensitivity. For this reason, urine culture is recommended. A culture result is usually available within a few days, such that prescribed antibiotics can be amended.

• Urine culture—the gold standard for identification of UTI is culture. Add a urine Chlamydia PCR if appropriate. Patients with dysuria and frequency may have false negative urine culture if organisms are fastidious or anaerobic.

• Upper tract investigation is not required for uncomplicated UTI. In patients with pyelonephritis, some upper tract imaging is required to rule out hydronephrosis and stone. An ultrasound of kidneys is usually sufficient. If there is evidence of complicated pyelonephritis (failure to settle, persistent pain), a contrast-enhanced CT scan may be required. It must be borne in mind that an abdominal CT carries a significant radiation dosage, with its attendant risk of malignancy.

• Cystoscopy is reserved for patients with recurrent UTI in whom no cause can be found. In young women, this is almost invariably normal. It is more common to find bladder outlet obstruction in elderly men, and a similar work-up to lower urinary tract symptoms is indicated.

THERAPEUTICS

• Antibiotics—the choice and duration of antibiotics is guided by local guidelines and antibiotic sensitivities. Trimethoprim or cephalexin have the advantage of being inexpensive and well tolerated, and are commonly used to treat uncomplicated UTI, although trimethoprim has limited sensitivity in Enterococcus and Pseudomonas species.

• Complicated UTIs are more commonly treated with quinolones (e.g. ciprofloxacin) or intravenous aminoglycosides. These are highly effective against gram-negative bacteria.

• Encourage fluid intake.

• Alkalinising urine (sodium citrotartrate) may help symptomatic dysuria.

PREVENTION

• Hygiene measures—many women will already be familiar with strategies to avoid UTI and these need to be taught to young girls from the age of toilet training. They include wiping from front to back after voiding, and avoidance of bath products, lubricants and synthetic underwear. In sexually active women, there may be a strong association between intercourse and UTI. Various measures such as voiding prior to, and after, intercourse or showering prior to intercourse can reduce the risk. Some authors advocate pre-coital antibiotics if the association is strong. (Often a single dose 4–6 hours beforehand is sufficient, or afterwards if not done so.)

• Cranberry juice—as either pure juice or as tablets, has been shown to reduce the incidence of UTI in women with recurrent cystitis by as much as half. Compliance with pure juice can be low but this is overcome by taking one tablet twice daily.

• Encourage fluids.

• Long-term low-dose antibiotics—this is rarely necessary and has been implicated in the emergence of resistant bacterial strains. Nevertheless, it is sometimes used, if only for a limited period (3–6 months). A prophylactic dose of trimethoprim or cephalexin can reduce the recurrence rate by as much as 95%. Self-start antibiotics can also be used in this way in patients with recurrent UTI, and the duration of antibiotic use may be less if employed in this way. For motivated patients, this is preferable. If antibiotics are used, they should be accompanied by a probiotic such as Lactobacillus acidophilus.

UTI IN CHILDREN

Incidence

UTI is a common bacterial infection causing illness in infants and children. It may lead to non-specific illness and the diagnosis is often more difficult to make than in adults. In this age group, a definitive microbiological diagnosis may not always be possible.

Aetiology

UTI in children may have no underlying cause, but the possibility of underlying congenital abnormality must be considered. This is discussed below.

SIGNS AND SYMPTOMS

In infants aged 3 months or less, fever and lethargy may predominate, with offensive urine and specific urinary symptoms being less common. In older infants, abdominal pain and tenderness may be more apparent, but failure to thrive and vague abdominal pain may predominate. In children above toddler age, dysuria and frequency may be more apparent than constitutional symptoms.

Investigations

Clean-catch urine is recommended. This takes patience and persistence. Urine collection pads may be used if this is not possible. Suprapubic aspiration may be required in the unwell infant prior to initiation of antibiotic treatment.

Therapeutics

Young children with UTI are mostly managed in hospital. Older children may be managed in the community but should be referred to a paediatrician. A 7–10 day course of antibiotics may be required.

Prevention and management

The investigation and management of UTI in children is a matter of debate and there has been criticism of over-investigation with invasive testing in the past. In general, the younger the infant, the greater the likelihood of underlying anatomical abnormality such as severe vesicoureteric reflux. For this reason, ultrasound is recommended as a first investigation, followed by micturating cyst-urethrography (MCUG). DMSA renography may be carried out under the care of a paediatrician in secondary care.

A diagnosis of reflux nephropathy is usually treated by prophylactic antibiotics, as most reflux will improve spontaneously over time. Circumcision has been shown to reduce the incidence of UTI in young boys with a congenital anomaly and should be considered. Severe reflux may need to be managed surgically with either endoscopic or open anti-reflux surgery.

INCONTINENCE

Urinary incontinence is the involuntary loss of urine. It is both a clinical sign and a symptom. The prevalence of incontinence increases with age and it is more common in women than men. Estimates are that 7–19% of adult women suffer from some form of urinary incontinence, with wide differences seen between different cultures and races.

Incontinence is not only a hygienic issue but it can negatively affect a patient’s quality of life, with social, psychological and sexual impairment.

Urinary incontinence may be classified as:

• stress incontinence (SUI)—loss of urine associated with abdominal effort, e.g. coughing, laughing, sneezing or straining

• urge incontinence (UUI)—urine loss that is preceded by the sudden uncontrollable desire to void

• mixed incontinence—a combination of both stress and urge incontinence

• continuous (total) incontinence—persistent loss of urine

• overflow incontinence—uncontrolled urine loss due to urinary retention

• nocturnal enuresis—loss of urine during sleep.

AETIOLOGY

(See Fig 46.1) Stress incontinence is more commonly seen with multiple vaginal deliveries and increasing age. Female continence is dependent on the supports of the bladder neck and urethra as well as the external sphincter located at the mid-urethral level. Tissue laxity and atrophy allow hypermobility with incomplete urethral closure. Male SUI is much less common and is usually due to traumatic sphincteric injury (e.g. prostatectomy for benign or malignant disease or pelvic fracture with urethral rupture).

FIGURE 46.1 Main types/causes of incontinence, and their management

Patients with UUI have increased urinary frequency and difficulty postponing voiding. They may report large-volume losses on the way to the toilet. Conditions that result in bladder irritation, such as infections, stones and tumours, may be causative and should be excluded. Detrusor overactivity is a common cause of UUI that is diagnosed with urodynamic studies. Detrusor overactivity is frequently idiopathic (overactive bladder) or it may be associated with longstanding bladder outlet obstruction or neurological disease (e.g. diabetic neuropathy, multiple sclerosis and spina bifida).

Continuous incontinence may be non-urethral and can occur with urinary fistulas and ectopic ureteric orifices.

Overflow incontinence is defined by urine leakage from a distended bladder. It results from bladder outlet obstruction or poor bladder contractility.

Signs and symptoms

A careful history should document the type, onset and severity of the incontinence. Associated urinary symptoms should be assessed as well as background fluid intake and voiding habits. The completion of a bladder diary may be beneficial in this regard. The presence of pain, haematuria or voiding difficulty may indicate complicated cases. Physical examination should include a neurological assessment including perineal sensation, anal sphincter tone and control of pelvic floor muscles.

Elderly patients may develop incontinence secondary to reversible conditions, which should be actively sought. These include: delirium, excess urine output, limited mobility, stool impaction and medications.

INVESTIGATIONS

Urinalysis and urine culture are routine. Imaging, such as with an ultrasound, is commonly done to assess the post-void residual and rule out pathology. Cystourethroscopy may be performed when indicated to evaluate the lower urinary tract anatomy.

Urodynamic studies with cystometry involve pressure/volume monitoring during artificial bladder filling. This is combined with fluoroscopy to define leakage. Information on bladder sensation, capacity, compliance and detrusor overactivity is provided. Urodynamics are indicated for patients with complicated or refractory incontinence, all those with neurological disease and prior to surgical therapy.

THERAPEUTICS

Stress incontinence

Conservative treatment involves fluid management, timed voiding and pelvic floor muscle exercises. Smoking cessation, elimination of constipation, oestrogen replacement and correction of obesity are also appropriate. Surgical therapy for female SUI involves bolstering the mid-urethral complex or bladder neck suspension. Colposuspension surgery involves elevation of the tissues surrounding the bladder neck behind the pubis, thus preventing mobility. Colposuspension has been largely replaced by urethral sling procedures. Autologous or synthetic slings are placed via the obturator foramen or retropubic space around the middle or proximal urethra to form a hammock for urethral support. The outcome data for synthetic slings (trans-vaginal tape, transobturator tape, etc) are now quite mature and they seem to remain effective at long-term follow-up.

Urge incontinence

Elimination of obvious bladder irritants, outlet obstruction and neurological disease will define overactive bladder (OAB). Anticholinergic medications (oxybutinin, toltoredine, solifenacin and darifenacin) are beneficial, along with bladder training. Anticholinergics may have significant side effects and should be used with caution in patients with glaucoma, obstructed voiding or cognitive impairment. Intravesical botulinum toxin injections are useful, but expensive, for refractory cases.

Complicated cases

Complicated cases may require more invasive therapy. Severe sphincteric deficiency such as that seen post prostatectomy or with lower motor neuron disease may be treated with an artificial urinary sphincter. An artificial sphincter involves the placement of a silicone cuff around the urethra, which is connected to a reservoir buried in the retropubic space. Fluid is cycled in and out of the cuff by a pump that is placed in the scrotum or labia. Debilitating UUI may require bladder augmentation surgery or a urinary diversion such as with an ileal conduit.

PREVENTION

Avoidance of exacerbating factors such as constipation, obesity, smoking and the treatment of asthma may prevent or reduce stress incontinence.

BENIGN PROSTATIC HYPERPLASIA

INCIDENCE

Benign prostatic hyperplasia (BPH) is a common clinical condition of the ageing man. Studies suggest that about 30% of men older than 65 years will suffer from clinical BPH. The definition of BPH is not standardised, and it may be used to refer to:

• histological features of stromoglandular proliferation

• benign prostatic enlargement

• clinical BPH—the most commonly used definition indicating the presence of lower urinary tract symptoms (LUTS) from bladder outlet obstruction by a non-cancerous prostate gland.

AETIOLOGY

BPH is an age-related process that is androgen dependent. Histological changes, prostate size and LUTS are all more prevalent with increasing age. BPH does have an inheritable component and severe forms may be hereditary.

SIGNS AND SYMPTOMS

The most common presentation of BPH is with LUTS due to bladder outlet obstruction. These symptoms can be assessed with validated scoring systems (e.g. IPSS, see above) and with a voiding diary. Occasionally, BPH-related complications such as recurrent urinary tract infections, recurrent haematuria, bladder calculi, bladder diverticula or urinary retention may lead to presentation.

History and physical examination aim to determine the impact of BPH and exclude differential diagnoses. Digital rectal examination is important to evaluate prostatic size and for possible cancer.

INVESTIGATIONS

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