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.

Haematuria

Haematuria is often a sign of malignancy in the urinary tract and requires thorough investigation. Painful haematuria is commonly due to bladder infection; painless haematuria usually signifies cancer. Common causes of haematuria are shown in Box 16.1.

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.

Intravenous urogram (IVU)

Intravenous contrast is excreted by the kidneys, outlining the anatomy of the urinary tract. Information on structure and function is obtained (Fig. 16.2). IVU is used less than in the past – ultrasound and CT are now more common (see Box 16.2).

Figure 16.2 Additional information from an IVU.

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.

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.

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.

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.

Congenital abnormalities

The most commonly encountered anatomical abnormalities of the kidneys and ureters are listed in Box 16.3.

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

Carcinoma of the renal pelvis

Ten per cent of all renal tumours arise in the renal pelvis; 90% are transitional cell carcinomas (TCCs), 10% squamous. Many TCCs are associated with tumours elsewhere in the urinary tract. Management requires surgical excision. TCCs have a good prognosis but squamous cell carcinomas have a poor outcome.

Stone disease

Urinary stones are common. Most are due to conditions causing high urinary calcium concentrations, or due to infections (e.g. Proteus spp.) which split urea to form ammonia, rendering the urine alkaline.

Symptoms depend on the size and position of the stone, and whether there is associated urinary infection. The classic presentation is of ureteric colic (Fig. 5.7, p. 94) (also commonly called renal colic) due to the passage of a stone along a ureter. Severe colicky pain (said to be as bad as labour pain) is felt in the loin, radiating to the groin and into the scrotum or labia. Vomiting is common. The loin may be tender but physical signs may be absent. Urine dipstix is usually positive for blood. Evidence of infection (dysuria, constant loin pain between colicky exacerbations, fever, loin tenderness) should be taken very seriously since an obstructed infected kidney may be irreparably damaged in less than 24 hours if not decompressed.

The differential diagnosis is important (Box 16.4). In particular, in individuals over 50, especially those who have never previously had urinary stones, ruptured aortic aneurysm must be considered and excluded.

Diagnosis is by intravenous urogram (IVU). CT or ultrasound may also be used.

Most stones pass spontaneously, and analgesia is all that is required. Large (>0.5 mm) obstructing stones in the upper ureter are more likely to need treatment (Box 16.5).

A patient who has formed one renal stone has a 20% chance of developing another. Recurrence may be reduced by ensuring a high fluid intake to ensure more dilute urine. Underlying metabolic abnormality must be excluded (check U&E, calcium, uric acid and ALP, and do 24-hour urine collection for calcium, uric acid and citrate).

Retroperitoneal fibrosis (chronic periaortitis)

This rather peculiar condition causes thick, plaque-like fibrosis in the retroperitoneum, encasing and obstructing the ureters. Onset is slow and insidious. The condition may be associated with inflammatory forms of abdominal aortic aneurysm (and endovascular aneurysm repair is often preferred as treatment to the AAA). Treatment requires relief of ureteric obstruction (usually with stents) and steroids which cause the fibrosis to regress. Surgical exploration of the ureters is sometimes required (ureterolysis).

Urinary diversion

Permanent

Permanent urinary diversion is most frequently performed by an ileal conduit, where the ureters are drained into an isolated segment of ileum (Fig. 16.3).

Figure 16.3 An ileal conduit.

Bladder cancer

Benign bladder tumours are rare. Most bladder tumours are malignant growths arising from the transitional cell epithelium lining the urinary tract. Predisposing factors are male sex (5 : 1), smoking, chemical industry (rubber/dyes/pesticides) and schistosomiasis (squamous tumours).

Urinary retention

This is described on page 93-95.

The prostate gland

Prostate cancer

This is the commonest cancer in men, with over 27 000 new diagnoses per year in the UK. The difficulty with prostate cancer is distinguishing between those that will progress and those that are harmless. Autopsy studies on men who have died of unrelated causes demonstrate that half of all men aged 70–79 years and two-thirds of those aged 80–89 have unsuspected prostate cancer. Only around 1 in 200 of men with prostate cancer will die of it. Nonetheless prostate cancer is the fourth most common cause of cancer death in males. This confusion makes screening for prostate cancer problematic, since many cases detected would never have caused any symptoms, or shortened life, if left alone.

Aetiology and pathology

The cause is unknown, age is the only predisposing factor. The tumour is an adenocarcinoma and spreads by local infiltration, lymphatic spread to iliac and paraaortic nodes, and blood-borne spread to bone, where it causes sclerotic (rather than lytic) metastases.

Clinical features

• LUTS (see p. 243)

• Perineal pain from local infiltration

• Bone pain from metastases

• Renal failure, from bilateral ureteric obstruction.

A malignant prostate feels hard, knobbly and irregular on rectal examination.

Investigation

• U&E

• PSA

• ALP (raised with bone metastases).

PSA is secreted into blood by both normal and malignant prostate tissue. An elevated PSA may be due to a large benign gland, prostate cancer, prostate inflammation and catheterisation of the bladder. Many men with a mildly raised PSA do not have cancer; equally many men with cancer do not have markedly raised PSAs. This limits the value of PSA as a screening test. However, it is useful in monitoring progression of established disease and monitoring of treatment.

Abdominal ultrasound detects hydronephrosis due to ureteric obstruction. Trans-rectal ultrasound and biopsy establishes histological diagnosis.

Bone scanning (Fig. 16.4) may show bone metastases and MRI scanning complements EUA to establish staging, which is by the TNM classification (Table 16.4).

Figure 16.4 Bone scan showing hot spots due to metastatic carcinoma of the prostate.

Table 16.4 Staging of prostate cancer

Stage	Findings
T1a	An incidental finding of tumour with low biological potential for aggressive behaviour in a prostate removed for clinically benign disease
T1b	An incidental finding of a tumour with potentially biological aggressive behaviour found in a prostate removed for clinically benign disease (high-grade or diffuse)
T1c	Tumour identified because of an elevated serum prostate-specific antigen
T2a	Tumour involving half a lobe or less
T2b	More than half a lobe but not both
T2c	Both lobes
T3	Tumour extends through capsule and may involve seminal vesicle
T4	Tumour fixed invasive of adjacent structures other than seminal vesicle

Treatment

Options include:

• conservative management (watchful waiting)

• radical prostatectomy for suspected early (‘organ-confined’) concern; may be open or laparoscopic approaches

• external beam radiotherapy

• brachytherapy (radioactive implants placed inside the prostate)

• hormone therapy (LHRH analogues and antiandrogens).

Localised prostate cancer is potentially curable with radical treatment or combinations of these treatments. Asymptomatic, localised, well-differentiated disease may require no treatment at all. Metastatic disease may remain remarkably well controlled for long periods with hormone treatment.

Prognosis

Localised disease treated radically has 55% 10-year survival, while metastatic disease at presentation has 25% 5-year survival.

Penis and male urethra

Testes and scrotum