Urology

Published on 11/04/2015 by admin

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16 Urology

Urological symptoms

Pain

Renal pain is typically a dull ache felt in the flank.

Ureteric pain due to a stone or clot passing down the ureter is a severe colicky pain starting in the loin radiating to the iliac fossa and into the testis/vulva.

Bladder inflammation causes suprapubic pain.

Lower urinary tract symptoms (LUTS)

These symptoms are often divided into irritative and obstructive urinary symptoms. Obstructive symptoms due to bladder outflow obstruction include urinary frequency, incomplete voiding, nocturia, poor stream and terminal dribbling. These are often associated with irritative symptoms of urgency and urge incontinence.

Dysuria

Dysuria (painful voiding) is usually due to urinary infection.

Urological signs

Renal masses may be palpable in the flank. A distended bladder is palpable and dull to percussion. The external genitalia are easily examined. The prostate gland is palpable via digital rectal examination. The normal prostate is soft to firm, has a well-defined median sulcus and is non-tender. A malignant prostate is enlarged, hard and irregular.

Investigations

• Urine examination by microscopy, culture, sensitivities, cytology

• Blood tests – urea, electrolytes, creatinine, calcium, alkaline phosphatase (ALP), prostate specific antigen (PSA)

• Plain X-ray – shows abnormal calcification in the urinary tract (Fig. 16.1). 90% of stones are visible.

Figure 16.1 Plain film of the abdomen with bilateral stag-horn calculi.

Urinary tract infections

Pyelonephritis

The commonest cause is ascending Gram-negative bacterial infection from the bladder. Clinical features include symptoms of high fever, rigors, vomiting, loin pain, and urinary frequency, dysuria and haematuria. The loin is tender but other signs are minimal.

Investigation

Urinalysis and culture (urine contains blood, leucocytes and organisms) are essential to achieve diagnosis. Imaging is necessary to look for renal stones and to exclude ureteric obstruction. Ultrasound and IVU are usually adequate. An obstructed infected kidney may be permanently damaged in under 24 hours and therefore needs emergency treatment.

Treatment

Antibiotics should be started as soon as urine and blood samples have been obtained for culture. Severe cases require IV treatment, e.g. cefuroxime ± gentamicin, converting to oral therapy when the infection is controlled. If the kidney is obstructed it must be decompressed immediately (by ureteric stenting or percutaneous nephrostomy).

Acute cystitis

Bacteria easily ascend the female urethra, which is only 5 cm long. In men, bacterial cystitis is usually associated with bladder outflow obstruction, stones or tumours. Symptoms include urinary frequency, dysuria, suprapubic pain and haematuria. The suprapubic area may be tender and pyrexia is common.

Investigation

Urinalysis and culture as above. Males with cystitis and females with recurrent attacks require cystoscopy to exclude an underlying bladder abnormality, as does any patient with haematuria.

Treatment

Treatment is by rest, hydration and antibiotics with follow-up urine culture after treatment. In females Candida often follows antibiotic treatment and should be checked for (with high vaginal swab) and treated if detected.

Interstitial cystitis

This condition is characterised by recurrent irritative urinary symptoms (frequency, dysuria, urgency) but sterile urine cultures. Severe forms may require surgery.

Tuberculosis of the bladder

Recurrent and chronic lower urinary tract symptoms may be due to TB infection of the bladder, which is not detected with routine urine culture. Early morning urine specimens are required, which must be examined specifically for acid and alcohol fast bacilli (AAFB).

Schistosomiasis (bilharziasis)

The parasite Schistosoma haematobium is endemic in Africa and the Middle East and causes severe chronic bladder inflammation and fibrosis which may lead to malignant change.

Prostatitis

Acute bacterial prostatitis is most commonly caused by E. coli, S. aureus, N. gonorrhoeae or Chlamydia, and diabetics are more frequently affected. Symptoms include malaise, fever, rigors with dysuria and frequency. Pain is felt in the lower abdomen and perineum. On examination the prostate is very tender. Chronic prostatitis is often difficult to eradicate.

Investigation and treatment

This involves urine microscopy, culture and sensitivity (MC&S) followed by appropriate antibiotics. Tetracycline, erythromycin and ciprofloxacin are useful if Chlamydia is suspected.

Epididymo-orchitis (see also Ch. 5)

In boys, viral infection may be the cause. The main difficulty in this age group is distinguishing infection from testicular torsion. In young males a sexually transmitted infection (e.g. Chlamydia) is usually responsible. In older men the infection is a consequence of urinary infection resulting from chronic bladder outflow obstruction. Symptoms include rapid onset of testicular pain, fevers and sometimes vomiting. The testicle becomes very swollen and exquisitely tender.

Investigation

Midstream urine (MSU) should be examined and cultured. In boys, scrotal exploration may be indicated as it is the only completely reliable way to exclude torsion. In younger men the main differential diagnosis is testicular cancer and scrotal ultrasound is required after treatment of the acute episode, to exclude an underlying tumour.

Treatment

Treatment is by rest, analgesics and antibiotics. Abscess formation may require surgical drainage.

Urinary infection in children

Urinary tract infection (UTI) in children is important since it may indicate an underlying congenital abnormality, for example vesicoureteric reflux, which may cause longterm renal damage if untreated. The clinical features of UTI in young children may be very non-specific and include vomiting, distress, weight loss and fever. Any child with a proven UTI should be thoroughly investigated to exclude a significant anatomical abnormality.

Urological trauma

This is discussed in Chapter 4.

Upper urinary tract – kidneys and ureters

Nephroblastoma (Wilms tumour)

This is the second commonest cause of death in infants. Peak incidence is 2 years. It is a highly malignant undifferentiated embryonic tumour which metastasises throughout the body. Presentation is non-specific with failure to thrive, sometimes with an abdominal mass and haematuria. Treatment requires radical nephrectomy and adjuvant chemotherapy. Small localised tumours have an 80% 5-year survival but this falls to zero if there are metastases in solid organs.

Adenocarcinoma

Aetiology and pathology

This tumour is commonest in men in late middle age and often causes paraneoplastic syndromes (Table 16.1). These cancers are usually well encapsulated and contain areas of haemorrhage and necrosis. Spread is by local infiltration and blood-borne metastases. The tumour may grow into the renal veins and vena cava.

Table 16.1 Paraneoplastic syndromes in renal cell adenocarcinoma

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Event	Cause
Raised ESR	Changes in plasma proteins
Anaemia	Depressed erythropoiesis and haemolysis
Polycythaemia	Erythropoietin secretion

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