Kidney	Glomerular disease
	Polycystic kidneys
	Carcinoma
	Stone
	Trauma (including renal biopsy)
	Tuberculosis
	Embolism
	Renal vein thrombosis
	Vascular malformation
Ureter	Stone
Ureter	Neoplasm
Bladder	Carcinoma
	Stone
	Trauma
	Inflammatory – cystitis, tuberculosis, bilharzia
Prostate	Benign prostatic hypertrophy
Prostate	Neoplasm
Urethra	Trauma
	Stone
	Urethritis
	Neoplasm
General	Anticoagulants
	Thrombocytopenia
	Haemophilia
	Sickle cell disease
	Malaria

Symptoms and signs

Family history, e.g. polycystic kidney. Painless haematuria is suggestive of neoplasia. Loin pain or ureteric colic suggests stone or clot colic associated with tumour. Suprapubic discomfort suggests bladder stone. Terminal bleeding with pain suggests bladder calculus. Urethral bleeding independent of micturition suggests a urethral lesion. Check the drug history. Spontaneous bruising. Palpable kidney. Palpable bladder. Enlarged prostate on examination PR.

Treatment

Appropriate to the underlying condition.

Obstructive uropathy

Hydronephrosis is the distension of the calyces and pelvis of the kidney owing to obstruction to the outflow of urine. It may be bilateral or unilateral. (For causes of hydronephrosis → Table 16.2.)

TABLE 16.2 Causes of hydronephrosis

Unilateral

Pelviureteric junction obstruction

• congenital pelviureteric junction obstruction

• aberrant renal vessels

• calculus

• tumours of the renal pelvis

Ureteric obstruction

• calculus

• ureteric invasion, e.g. cervical, rectal or colonic tumours

• iatrogenic – damage at surgery

Bilateral Urethral valves Urethral or meatal stenosis Prostatic enlargement Extensive bladder tumours Retroperitoneal fibrosis

Symptoms and signs

Loin pain. Upper abdominal pain. Fever. Rigors – if infection. Ureteric colic. Hesitancy, poor stream, frequency, distended bladder with suprapubic discomfort. Uraemia may be presenting complaint. Palpable kidney. Palpable prostate.

Investigations

• KUB: enlarged renal outline, opaque calculi

• USS: confirms diagnosis and may demonstrate lesion

• IVU (→ Fig. 16.1): early stages show pelvic dilatation with clubbing of the calyces, site of obstruction, function of kidney, trabeculation of bladder, residual urine (if bilateral hydronephrosis and uraemia, no further information would be obtained from an IVU)

• CT scan

• Cystoscopy: cause of bladder outlet obstruction or bladder tumour

• Retrograde pyelogram defines exact site of obstruction.

Figure 16.1 Intravenous urogram. There is a right-sided hydronephrosis and hydroureter. Note the dilatation of the pelvis with clubbing of the calyces and also dilatation of the ureter down to its entry into the bladder.

Treatment

Directed at the underlying cause. With a small ureteric stone the obstruction may be relieved with the passage of the stone. The presence of acute infection or marked renal impairment requires urgent decompression of the urinary tract under antibiotic cover. This may be done by percutaneous nephrostomy, suprapubic cystostomy, ureteric catheter drainage or urethral catheter drainage. A non-functioning kidney, especially if infected, should be removed.

Complications

Infection: pyonephrosis. Stone formation in stagnant urine. Hypertension due to renal ischaemia. Traumatic rupture of a hydronephrotic kidney. Uraemia.

Calculous disease

Urinary calculi are often idiopathic. They also arise secondary to stasis and infection and also in association with metabolic disorders, e.g. cystinuria. Stones may form in the kidney or bladder. Ureteric calculi are in transit from the kidney to bladder. Stones occur in about 1% of the population. The majority is composed of calcium, magnesium ammonium phosphate, or urate.

Types of calculi

Calcium oxalate (75%)

‘Mulberry’ stones covered with sharp projections. They cause bleeding and are often black owing to altered blood on their surface. Because of their sharp surface they give symptoms when comparatively small. Occur in alkaline urine.

Phosphate (15%)

Usually compound of calcium, magnesium and ammonium phosphate. Smooth and dirty white. They may enlarge rapidly and fill the calyces taking on their shape, i.e. staghorn calculus. Occur in strongly alkaline urine.

Urate (5%)

Arise in acid urine. Hard, smooth, faceted and light brown in colour.

Cystine (2%)

Usually multiple. Arise in acid urine and are of metabolic origin owing to decreased reabsorption of cystine from the renal tubules. White and translucent.

Xanthine and pyruvate stones

Rare. Due to inborn error of metabolism.

About 90% of calculi are radio-opaque. Usually only urates are radiolucent, cystine stones being radio-opaque because of their sulphur content. Precipitating factors include: diet, dehydration, stasis, infection, hyperparathyroidism, idiopathic hypercalciuria, milk-alkali syndrome, hypervitaminosis D, cystinuria, inborn errors of purine metabolism, gout, and chemotherapy (excess uric acid following treatment of leukaemia or polycythaemia).

Symptoms and signs

Renal calculi

May be asymptomatic even with large stone. Loin pain. Haematuria. Dysuria. Signs of uraemia. Colic if stone impacts in pelviureteric junction.

Ureteric calculi

Severe colicky pain radiating from loin to groin. Sweating. Nausea. Vomiting.

Bladder calculi

Dull suprapubic discomfort, terminal haematuria, dysuria, strangury. Patient may have loin tenderness, pyrexia if infection, kidney may be palpable with gross hydronephrosis or pyonephrosis.

Treatment

Acute symptoms – ureteric colic:

• Relieve pain – diclofenac sodium i.m. or p.r.; or pethidine.

• Admit to hospital

• Bed rest

• Intravenous fluids or increased oral fluids

• Collect and sieve all urine to retrieve calculus for analysis

• Check radiographs to assess progress of stone

• Stones <4 mm will usually pass spontaneously; 50% of stones between 4 mm and 6 mm will pass spontaneously. Stones >6 mm usually require removal

• Obstruction and infection require removal of stone

• Stone removal may be carried out by: ureteroscopy and fragmentation of the stone; pushing the stone back into the renal pelvis followed by fragmentation with extracorporeal shock wave lithotriptor.

Routine treatment of established urinary calculus

Removal of renal or bladder calculus by open surgical technique is now rare. Minimal invasive surgery using endoscopic techniques or extracorporeal shockwave lithotripsy is now the treatment of choice.

Percutaneous nephrolithotomy

A nephroscope is inserted into the kidney under radiographic control via a previously dilated track. The stone is then removed by grasping forceps (if small), ultrasonically disintegrated and removed by suction or disrupted into small fragments by electrohydraulic or laser lithotriptors.

Extracorporeal shockwave lithotripsy

This consists of an external energy source focused to provide a high-pressure zone that is directed to fragment the calculus. The calculus is fragmented into small particles, which pass in the urine.

Open surgery

This is used less often. A stone may be removed through the kidney substance (nephrolithotomy), or through the renal pelvis (pyelolithotomy). Surgery may be needed to correct hydronephrosis associated with a stone. If the kidney is irreparably damaged, nephrectomy is required.

Bladder calculi

Small stones may be removed cystoscopically after crushing with a lithotrite or disintegration using an electrohydraulic lithotriptor. Large stones >5 cm are removed by suprapubic cystostomy.

The stone must be analysed. The underlying cause must be treated if possible, e.g. parathyroidectomy or correction of an obstructive lesion. Attempts should be made to prevent recurrence.

Prevention of recurrence

Up to 50% of patients may have recurrence within 5 years. Prevention involves: (1) high fluid intake, especially in hot weather; (2) reduce milk intake; (3) prompt treatment of urinary tract infections; (4) calcium stones: low-calcium diet, thiazide diuretics, acidify urine; (5) oxalate stones: reduce oxalate intake – exclude rhubarb, spinach, tomatoes, strawberries, tea and chocolate; (6) urate stones: allopurinol, urinary alkalinization.

Tumours of the renal tract

Kidney

Benign tumours are rare. Adenocarcinoma accounts for 80% of renal tumours. Transitional cell tumours occur in the renal pelvis. Squamous cell carcinomas may occur in the renal pelvis and are associated with squamous metaplasia due to chronic irritation caused by stone or infection.

Renal cell carcinoma

This arises from renal tubular epithelium. Males are affected twice as commonly as females. It usually occurs over the age of 40. There is increased incidence in smokers, coffee drinkers, industrial exposure to cadmium, lead, asbestos, aromatic hydrocarbons; renal cysts in dialysis patients; von Hippel–Lindau disease. Spread is by direct extension into perinephric tissues, by lymphatics to the para-aortic nodes, by the blood, along the renal vein (which may contain tumour), to bone, liver, brain and lung (cannon ball metastases).

Symptoms and signs

The most common presentation of renal cell carcinoma is now an incidental finding on an ultrasound scan performed for unrelated conditions. Haematuria, loin pain, PUO. Palpable mass, anaemia, polycythaemia. Symptoms and signs due to secondaries – hepatomegaly, breathlessness, pathological fractures.

Investigations

• Urinalysis

• Hb, FBC, ESR: anaemia, ESR raised, occasionally polycythaemia

• USS

• CT scan (→ Fig. 16.2) – now standard investigation – diagnosis of primary, lung metastases

• CXR: metastases.

Figure 16.2 Abdominal CT scan. There is a renal cell carcinoma of the right kidney.

Treatment

Nephrectomy. The majority of smaller tumours may be removed by the laparoscopic approach. Occasionally solitary metastases may be treated by surgery. Radiotherapy is palliative for pain due to metastases. Biological modifiers such as interferon, interleukins and tyrosine kinase inhibitors for metastatic disease.

Prognosis

If the tumour is localized to the kidney, nephrectomy offers a 5-year survival of 70%.

Bladder

Some 95% of tumours in the bladder are transitional cell carcinomas but chronic irritation from stones or infection may result in squamous cell metaplasia, giving rise to squamous cell carcinoma. Adenocarcinomas are rare. Aetiological factors include smoking, aromatic hydrocarbons (rubber and dye industry), bladder diverticulae, bilharzia. What were formally regarded as transitional cell papillomas are recognized as well-differentiated transitional cell carcinomas. True transitional cell papillomas are now considered to be extremely rare. Tumours are more frequent in the middle-aged and elderly and occur more frequently in males. Spread occurs by direct invasion into the prostate, urethra, sigmoid colon, rectum or, in the female, to the uterus and vagina. The ureteric orifices may be occluded giving rise to hydronephrosis and renal failure. Lymphatic spread is to the iliac and para-aortic nodes and blood spread occurs late to the liver and lungs.

Symptoms and signs

Painless haematuria. Dysuria, frequency, and urgency. Hydronephrosis. CRF. Pain from pelvic invasion. Examination is usually negative in the early stages. The tumour may be palpable by bimanual examination under anaesthesia.

• T1: Confined to mucosa or submucosa – impalpable

• T2: Superficial muscle involved – localized rubbery thickening

• T3: Deep muscle involved – mobile mass

• T4: Invasion beyond bladder to adjacent structures – fixed mass.

Treatment of transitional cell carcinoma

• T1: Transurethral resection or cystodiathermy. For multiple small tumours, intravesical chemotherapy with mitomycin or epirubicin. Intravesical BCG therapy is reserved for poorly differentiated superficial bladder cancer or carcinoma in situ.

• T2: T2 tumours and above invade the detrusor muscle by definition and should not be managed by transurethral resection alone. A radical cystectomy is the ‘Gold Standard’ treatment but radiotherapy may be effective in those not fit for surgery.

For T1 tumours there is a 70% chance of recurrence at 5 years and a 10% chance of developing invasive disease. Check cystoscopy should be carried out at regular intervals (6 months to a year) for life.

• T3: This may be treated by radiotherapy, cystectomy or a combination of both. Cystectomy requires urinary diversion by implantation of the ureters into an ileal loop or reconstruction using bowel to fashion a ‘neobladder’. The latter can be drained by self-catheterization through a ‘continent’ stoma, or anastomosed to the urethra to allow normal voiding per urethram.

• T4: Palliative radiotherapy, systemic chemotherapy with cisplatin and gemcitabine may produce remissions.

Prognosis

Early tumours are curable. T1 tumours have an 85% 5-year survival rate, falling to 60% with T2. Approximately 40% of patients with T3 tumours are alive at 5 years. Patients with T4 tumours rarely survive for more than 1 year.

Urinary tract infections (UTIs)

These may be divided into those affecting the kidney (pyelonephritis) and those affecting the bladder (cystitis). UTIs are more common in women – the majority of women will have a UTI some time during their life. Risk factors include pregnancy, urinary tract malformations, urinary tract obstruction, calculus, prostatic obstruction, bladder diverticulum, spinal injury, trauma, urinary tract tumour, diabetes mellitus, immunosuppression.

Symptoms and signs

Acute pyelonephritis

This includes loin pain, dysuria, frequency, fever, rigors, cloudy or blood-stained urine. Tender in loin and flank.

Cystitis

Frequency, urgency, dysuria, haematuria, often no fever. Tenderness suprapubically or on examination PR or PV.

Investigations

May be haematuria and proteinuria. Colony count of >100 000 organisms/mL of a fresh MSU is significant. Microscopy shows pus cells and organisms (usually Gram-negative rods). Common organisms include Escherichia coli, Proteus, Klebsiella, Pseudomonas, and faecal Streptococci.

Treatment

Drink plenty. Antibiotics – amoxicillin 250 mg t.d.s. or trimethoprim 200 mg b.d. are appropriate initial treatments. Change antibiotic according to organism and sensitivities. Avoid sexual intercourse while infected. If the infection fails to settle on appropriate antibiotics or recurs rapidly after stopping antibiotics, further investigation is required. Two or more UTIs in a female appropriately treated require further investigation. Failure to respond to treatment suggests inappropriate antibiotics, failure to complete the course of antibiotics, resistant organisms, underlying obstruction, calculus, tumour, urinary retention, or specific infection, e.g. TB. Further investigation of recurrent attacks includes ultrasound and cystoscopy.

Sterile pyuria

Pus cells are apparent on microscopy but there is no growth on culture. Causes include inadequately treated UTI, TB, tumour, stone, prostatitis, polycystic kidneys, appendicitis, diverticulitis or analgesic abuse.

Urinary tract tuberculosis

This has shown a decline in the past 30 years but it remains a problem in the Third World and the immigrant population in the UK. Genitourinary tuberculosis is always secondary to TB elsewhere. The urinary tract is involved by haematogenous spread. The kidney is affected most frequently, the lower urinary tract being secondarily infected by descending infection, giving rise to cystitis or infection of the epididymis or seminal vesicles.

Symptoms and signs

The renal lesion is often silent. Repeated UTIs with frequency, dysuria, haematuria. Occasionally dull loin pain. Weight loss, fever, night sweats. Symptoms of uraemia may occur. Epididymitis. Scrotal sinuses.

Treatment

Antituberculous drugs. Surgery may be needed to remove a totally destroyed kidney or to deal with complications, e.g. repair of ureteric stricture or enlargement of small fibrotic bladder (ileocystoplasty, i.e. enlargement of the bladder with a cuff of ileum).

Prostate

The three commonest conditions of the prostate are: bladder outflow obstruction due to benign prostatic hypertrophy (over 50s), prostatic cancer (over 65s) and prostatitis in young adults.

Bladder outflow obstruction

Benign prostatic hypertrophy

This affects most men over the age of 50 but only 10% present with symptoms. The size of the prostate does not correlate with the degree of obstruction. The severity of symptoms depends on the degree of encroachment on the prostatic urethra. Obstruction to outflow occurs and the bladder hypertrophies. Diverticulae of the bladder, urinary infection, hydronephrosis and renal failure may ensue.

Prostatic carcinoma

This is the commonest cancer in men – over 60% of tumours at presentation are localized to the prostate gland. It is rare below the age of 50. Of patients with prostatic cancer in the UK, 25% present with advanced disease, when potentially curative treatment is not possible. Early asymptomatic disease can be detected by prostate-specific antigen (PSA) testing; transrectal ultrasound scanning with guided biopsy. Foci of carcinoma may be found incidentally in specimens resected for bladder outflow obstruction. Spread occurs to adjacent organs, e.g. bladder, urethra and seminal vesicles. Spread to the rectum is rare. Lymphatic spread is to iliac and para-aortic nodes. Blood spread occurs early, especially to the pelvis, spine and skull (osteosclerotic lesions).

Symptoms and signs

Asymptomatic. Incontinence, dysuria, haematuria, hesitancy, dribbling, retention. Bone pain, pathological fractures, sciatica, anaemia, weight loss. Rectal examination may reveal nodule in prostate or hard craggy mass involving whole prostate. The median sulcus between the lobes may be obliterated. Palpable bladder. Tenderness over bones. Hepatomegaly.

Treatment

TURP for obstruction. Treatment for prostatic cancer depends on the staging of the disease. For patients with cancer localized to the prostate gland, the options would include observation with routine monitoring of PSA, external beam radiotherapy, interstitial brachytherapy or radical prostatectomy, which may be carried out as an open procedure, laparoscopically, or robot-assisted. External beam radiotherapy and hormones would conventionally treat locally advanced prostatic cancer. Androgen deprivation therapy for metastatic disease. Subcapsular orchidectomy slows tumour growth. Other techniques of hormonal manipulation include luteinizing hormone releasing hormone (LHRH) agonists, which produce a fall of luteinizing hormone (LH) from the anterior pituitary with consequent reduction of testicular secretion of testosterone, e.g. cyproterone acetate or bicalutamide. Stilboestrol is rarely used nowadays as it causes gynaecomastia, fluid retention and possible thromboembolic complications. Local radiotherapy, especially for bony metastatic pain. Systemic taxane-based chemotherapy for hormone resistant prostatic cancer.

Prognosis

Variable. Dependent on stage at presentation. Patients with clinically localized tumours treated radically may expect a normal life expectancy. Those with metastatic disease at presentation have a median 3-year survival.

Prostatitis

This occurs most commonly in young adults. Acute bacterial prostatitis usually presents as an acute febrile illness. Chronic prostatitis presents with recurrent UTIs. If there is a past history of TB anywhere in the body, suspect tuberculous prostatitis.

Symptoms and signs

Acute bacterial prostatitis

Fever, low back pain, perineal pain, bladder irritation, outflow obstruction. Enlarged tender prostate.

Chronic prostatitis

Symptoms of UTI. Dull perineal ache. Normal or indurated irregular prostate.

Investigations

In acute prostatitis:

• WBC raised

• MSU usually shows growth

• Blood culture may be positive.

In chronic prostatitis:

• Prostatic massage may yield secretions containing white cells and occasionally organisms

• Culture for TB in chronic prostatitis.

Treatment

Acute prostatitis is treated with bed rest, antibiotics (often i.v.) and analgesia. Prostatic abscess or chronic prostatitis may occur as a complication. Chronic prostatitis is treated with long-term antibiotics, e.g. ciprofloxacin for 4–8 weeks. Prostatic massage may be effective. Tuberculous prostatitis is treated with antituberculous therapy.

Urinary retention

The retention of urine may be acute, chronic or acute-on-chronic. Patients with acute retention present as surgical emergencies. (For causes of urinary retention → Table 16.3.)

TABLE 16.3 Causes of urinary retention

Local
Urethral lumen or bladder neck	Urethral valves
	Tumours
	Stones
	Blood clot
	Meatal ulcer or stenosis
Urethral or bladder wall	Urethral trauma
	Urethral stricture
	Urethral tumour
Outside the wall	Prostatic enlargement
	Faecal impaction
	Pelvic tumour
	Pregnant uterus
	Phimosis
General
Postoperative
Neurogenic	Spinal cord injuries
Neurogenic	Spinal cord disease, e.g. tabes dorsalis, spinal tumour, multiple sclerosis, diabetic autonomic neuropathy
Drugs	Anticholinergics, antidepressants, alcohol