Urology: Genitourinary System Diseases

Urology: Diseases of the Genitourinary System - Cheatsheet

Urology focuses on the surgical and medical treatment of diseases affecting the male and female genitourinary systems and male reproductive systems.

PROSTATE

Anatomy & Physiology

• Location: Distal to bladder neck, surrounds urethra (2-3 cm).

• Key Zones:

  • Transition Zone: Enlarges significantly in Benign Prostatic Hyperplasia (BPH).

  • Peripheral Zone: Origin of ~90% of prostatic cancers.

• Blood Supply: Primarily branches of the hypogastric artery. A large dorsal vein complex (draining the penis) is anterior.

• Microscopic: Glandular epithelium within fibromuscular stroma.

• Function: Secretions (20% of ejaculate) provide nutrients for sperm motility.

Prostatitis (Inflammation of the Prostate)

• Symptoms: Perineal discomfort (prostatodynia), urinary frequency, urgency, dysuria, obstructive symptoms (hesitancy, dribbling).

• Types:

  • Acute Bacterial Prostatitis:

    • Characteristics: Rapid onset, fever, back/perineal pain, chills, dysuria. Prostate is swollen, tender.

    • Cause: Usually Gram-negative bacteria (e.g., E. coli).

    • Treatment: Broad-spectrum antibiotics (several weeks).

    • Urinary Retention: Require suprapubic catheterization (transurethral risks exacerbation).

    • Abscess: May form; treat with transurethral unroofing or needle aspiration.

  • Chronic Prostatitis:

    • Characteristics: Indolent course, perineal/back/pelvis discomfort with urinary frequency, hesitancy, dysuria.

    • Diagnosis: Prostatic fluid >10 WBCs/HPF after massage, positive bacterial cultures.

    • Treatment: Oral broad-spectrum antibiotics (e.g., trimethoprim-sulfamethoxazole, quinolone) for ~6 weeks.

  • Nonbacterial Prostatitis:

    • Characteristics: Symptoms similar to chronic bacterial, but no consistent bacterial agent identified (sometimes Chlamydia trachomatis).

    • Treatment: May include antibiotics (empirical), prostatic massage, sitz baths, NSAIDs.

Benign Prostatic Hyperplasia (BPH)

• Epidemiology:

  • Hyperplasia/hypertrophy of prostate, primarily in the transition zone.

  • Symptomatic BPH uncommon before age 50.

  • No causal link to prostatitis or cancer.

• Clinical Presentation & Evaluation:

  • Obstructive Symptoms: Hesitancy, decreased stream force, terminal dribbling, intermittence, incomplete emptying.

  • Irritating Symptoms: Frequency, urgency, nocturia (due to bladder compensation).

  • DRE: Palpable enlargement, smooth contour, soft consistency.

  • Diagnosis: Urinalysis (normal w/o infection), urine flow rate (<15 mL/sec), postvoid residual (PVR), cystoscopy (trilobar hyperplasia/median lobe).

  • Complications: Can lead to acute urinary retention, hydronephrosis, renal failure (rare).

• Treatment:

  • Indications: Renal failure, poor bladder emptying (recurrent infection/stones), significant symptomatic bother.

  • Medical Therapy (First-Line):

    • α₁-adrenergic blockers (terazosin, doxazosin, tamsulosin, silodosin): Relax bladder neck/prostatic urethra, rapid response.

    • 5α-reductase inhibitors (finasteride, dutasteride): Block androgenic activity, modest decrease in prostatic size (20-30%), slow response (months). Often for larger prostates.

    • Combination therapy (α-blocker + 5α-reductase inhibitor) often best.

  • Surgical Therapy:

    • Open/Robotic (for >100g prostate): Suprapubic prostatectomy (through bladder) or simple retropubic prostatectomy (through prostate capsule). Entire prostate capsule not removed, urethra intact.

    • Transurethral Resection of Prostate (TURP): Most common. Electrocautery loop removes tissue under direct visualization. Low risk of incontinence (1-2%), impotence (<5%). No effect on future prostate cancer risk (removes transitional, not peripheral zone tissue).

    • Transurethral Incision of the Prostate: For small glands.

  • Minimally Invasive Techniques:

    • Laser treatment (Greenlight laser): Vaporizes tissue, reduced bleeding.

    • Less commonly used: Transurethral microwave thermotherapy, transurethral needle ablation (modest symptom improvement).

Malignant Diseases (Prostate Cancer)

• Epidemiology:

  • Most common cancers in men (US). >95% are adenocarcinoma.

  • Incidence increases with age, more common in African Americans, familial pattern.

  • High-fat diet implicated.

  • Histologic prevalence much higher than clinical disease.

• Clinical Presentation & Evaluation:

  • Early Stage: Asymptomatic.

  • Advanced: Weight loss, pelvic pain, ureteral obstruction, gross hematuria, bone pain (distant metastasis).

  • Digital Rectal Examination (DRE): Important for early detection. Induration or nodularity in peripheral zone (80% of cancers).

  • Prostate-Specific Antigen (PSA) Testing:

    • Cornerstone of screening. Deaths decreased ~40% since early '90s.

    • Screening age 40 for high-risk (African Americans, family history); age 55 for others. Shared decision.

    • PSA is Pro-state specific, not Cancer-specific: Elevated in prostatitis, BPH, cancer.

    • Normal Range: <4.0 ng/mL, but 20-25% cancers occur with "normal" PSA.

    • Age-adjusted PSA: Levels increase with age.

    • Free PSA: Higher % free PSA in BPH vs. cancer. <20-25% free PSA linked to cancer.

  • Transrectal Ultrasonography (TRUS): Best imaging for suspected cancer. Distinguishes zones, measures size. Cancers often hypoechoic in peripheral zone. Not a screening test. Used to guide biopsy.

  • Magnetic Resonance Imaging (MRI): Emerging screening tool, interpret with PI-RAD system.

  • Prostate Biopsy:

    • Via transrectal route (TRUS guidance).

    • Usually 10-14 cores. Premedication with broad-spectrum antibiotics needed.

  • Tumor Grade (Gleason System): Numbers (1-5) for dominant & secondary grades.

    • 2-4: Well differentiated.

    • 5-7: Moderately differentiated.

    • 8-10: Poorly differentiated.

    • Prognosis strongly linked to grade.

  • Staging (TNM System):

    • Local: DRE.

    • Distant: Bone scan (most sensitive for bone mets, especially for PSA >20 ng/mL). CT scan for lymph nodes.

    • Metastasis often affects axial skeleton (osteoblastic).

    • Lymph node dissection performed with radical prostatectomy.

• Treatment:

  • Localized Disease:

    • Watchful Waiting: For life expectancy <10 years.

    • Active Surveillance: For low-risk cancer (Gleason ≤6) with longer life expectancy; monitoring with PSA, DRE, biopsy.

    • Curative (longer life expectancy/aggressive tumors):

      • Radical Prostatectomy (surgical removal): Open, laparoscopic, or robotic (90% of cases, less transfusion, faster recovery, earlier continence). Removes prostate, seminal vesicles, vas deferens. PSA should be undetectable post-op.

      • Radiation Therapy: External beam or Brachytherapy (interstitial implants-iodine-125/palladium-103). PSA <1.0 ng/mL post-op for superior results.

      • Cryotherapy (freezing): Less effective than established treatments for intracapsular tumors.

  • Metastatic Disease:

    • Androgen Deprivation (Primary Treatment):

      • Bilateral orchiectomy (surgical) or medical castration (LHRH analogs).

      • LHRH analogs: Suppress testosterone, few serious side effects (hot flashes, decreased libido, impotence).

      • Antiandrogens: May prolong response, but conflicting results.

    • Castration-Resistant Prostate Cancer: Second-line antiandrogens (abiraterone, enzalutamide, apalutamide) and taxol-based chemotherapy.

    • Radiation: For isolated bone metastases.

KIDNEYS

Anatomy

• Location: Paired retroperitoneal organs, T12-L3 (right kidney lower).

• Coverings:

  • Renal Capsule: Fibrous, covers cortex.

  • Perirenal Fat: Adipose tissue.

  • Renal Fascia (Gerota's): Fibroareolar, encloses perirenal fat and adrenals superiorly. Limits extravasation.

Physiology

• Essential for managing urologic disorders (e.g., TURP syndrome, renal tubular acidosis).

Blood Supply

• 20% of cardiac output.

• Usually a single renal artery supplies each kidney, dividing into segmental branches. Aberrant vessels are common (65% of kidneys).

• Interruption of end arteries can lead to ischemia, infarction, hypertension.

Trauma

• Cause: Blunt trauma (70-80%) from motor vehicle accidents, falls, sports.

• Signs: Hematuria, rib/vertebral fractures, flank contusions. Retroperitoneal hematoma with shock.

• Evaluation:

  • Adults with microhematuria, no major deceleration/hypotension may not need imaging.

  • Children, gross hematuria, hypotension, major deceleration injury require evaluation.

  • Stable Patient: CT scan (classifies injury, Figure 29-11). Minor contusions most common.

  • Unstable Patient: Emergency laparotomy. Renal imaging during surgery with "one-shot" IVP.

• Treatment:

  • Blunt Trauma (stable): Observation unless major injury on CT.

  • Unstable (surgery): Renal exploration for expanding hematoma or major IVP abnormality.

  • Penetrating Trauma: Higher likelihood of exploration.

Congenital Disorders

• Horseshoe Kidney: Most common renal fusion anomaly (1:400-1:1,800 births), usually lower pole.

  • Symptoms: Obstruction/infection, hematuria, abdominal discomfort.

  • Diagnosis: CT/ultrasound.

  • Treatment: Surgical division of renal isthmus (symphysiotomy) if symptomatic.

• Congenital Ureteropelvic Junction (UPJ) Obstruction: Obstruction between ureter and renal pelvis.

  • Etiology: Intrinsic maldevelopment or aberrant vessels. Leads to hydronephrosis.

  • Symptoms: Palpable mass, intermittent pain, hematuria, infection, hypertension, stones.

  • Diagnosis: Antenatal ultrasound, Lasix renography.

  • Treatment: Surgical repair to prevent renal function loss/recurrent UTIs.

Inflammatory Diseases

• Pyelonephritis:

  • Clinical Diagnosis: Fever, flank pain, UTI, costovertebral angle tenderness.

  • Cause: E. coli (80%).

  • Treatment: Outpatient oral antibiotics (uncomplicated); IV antibiotics (sepsis).

  • Persistent Symptoms: Consider CT/ultrasound for abscess.

  • Obstructive Pyelonephritis: Urologic emergency (infected urine under pressure). Requires emergency relief of obstruction (ureteral stent or percutaneous nephrostomy); stone removal contraindicated initially.

  • Renal Abscess: Requires percutaneous drainage + antibiotics.

• Emphysematous Pyelonephritis:

  • Life-threatening infection: Bacteria form gas in renal parenchyma.

  • Association: Poorly controlled diabetes.

  • Diagnosis: CT scan.

  • Treatment: IV antibiotics, supportive care, emergent nephrectomy (standard).

• Xanthogranulomatous Pyelonephritis (XGP):

  • Prevalence: Females > males, 5th-7th decades.

  • Symptoms: Nonspecific, failure to thrive, chronic UTI.

  • Cause: E. coli, Proteus species.

  • Diagnosis: CT scan (diffuse enlargement, central nephrolithiasis, hydronephrotic pattern).

  • Treatment: Nephrectomy (often challenging due to adhesions).

• Genitourinary Tuberculosis (TB):

  • Symptoms: Painless frequency (especially night), sterile pyuria.

  • Diagnosis: PPD, urine culture (Mycobacterium tuberculosis).

  • Imaging: CT/IVP for calcifications, ureteral obstruction.

  • Treatment: Antituberculosis drugs. Nephrectomy for non-functioning kidney. Ureteral stricture management (stent, corticosteroids, reimplantation).

Neoplasms

• Renal Mass Classification: Benign/malignant, primary/metastatic.

• Most Common: Simple cyst (70%).

• Most Common Primary Malignancy: Renal Cell Carcinoma (RCC) (>85% of primary renal cancers).

• Clinical Presentation & Evaluation:

  • Symptoms: Painless hematuria (most common), but often incidental finding on CT/ultrasound.

  • Classic Triad (Flank pain, abdominal mass, hematuria): Rarely all three.

  • CT: Prominent role for solid masses, atypical cysts.

  • MRI: If IVC invasion suspected.

• Benign Neoplasms:

  • Simple Cysts: Asymptomatic, benign. Observation.

  • Complex Cysts: Septations, wall thickening, calcifications. Considered cancerous until proven otherwise. Partial/radical nephrectomy.

  • Angiomyolipoma: Diagnosed by characteristic fat appearance on CT (black on CT).

• Malignant Neoplasms:

  • Renal Cell Carcinoma (RCC):

    • Origin: Proximal convoluted tubules.

    • Etiology: Nitrosamines, cigarette smoking implicated. Male 2:1.

    • Characteristics: Spherical, pseudocapsule. 5% bilateral.

    • Symptoms: Hematuria (29-60%), flank pain, palpable mass (classic triad only 4-17%). Nonspecific (weight loss, fever, weakness).

    • Tumor Markers: No reliable markers.

    • Metastasis: Invades renal vein/vena cava. Most often lungs, bone, brain.

    • Staging: TNM system.

    • Treatment:

      • Localized: Radical or partial nephrectomy (partial preferred for small tumors). Laparoscopic/robotic approaches reduce morbidity.

      • Radical Nephrectomy: Removes kidney, perinephric fat, Gerota's fascia, adrenal gland, lymph nodes. Control renal vessels early.

  • Transitional Cell Carcinoma:

    • Presentation: Renal mass or filling defect on CT. Urine cytology may be positive.

    • Diagnosis: Ureteroscopy for visualization/biopsy.

    • Treatment: Nephroureterectomy with bladder cuff removal (high risk of lower tract seeding).

Urinary Stone Disease

• Prevalence: Significant morbidity (>500,000/year in US), men > women, ages 30-50.

• Composition: Majority are calcium oxalate.

• Risk Factors:

  • Calcium Stones: Metabolic disorders (renal tubular acidosis, hyperparathyroidism), poor hydration, immobilization, family history.

  • Uric Acid Stones: High purine intake, gout, poor hydration, hyperuricosuria.

  • Cystine Stones: Inherited disorder, affects renal reabsorption of 4 amino acids (cysteine, ornithine, lysine, arginine). Present early in life.

  • Struvite (Magnesium Ammonium Phosphate) Stones: Infection stones, chronic UTIs (e.g., indwelling catheters). Can form staghorn calculi.

• Mechanism: Urine supersaturation with calcium oxalate. Inadequate inhibitors of crystallization, or high calcium concentration. Crystal lodging and growth.

• Clinical Presentation & Evaluation:

  • Renal Colic: Most common presenting symptom. Intermittent flank pain radiating to groin, nausea, vomiting. Cause is obstruction, not stone itself.

  • Emergency Room Evaluation: Urinalysis (microhematuria common).

  • Imaging: Noncontrast CT (optimal). Uric acid stones are lucent on plain film, bright white on CT. Ultrasound less accurate.

  • Metabolic Workup: For children/recurrent stones. After stone passage, on regular diet. Includes serum calcium, PTH, electrolytes, urine pH, 24-hr urine collection.

• Treatment:

  • Obstructive Pyelonephritis: Urologic emergency ("pus under pressure"). Requires emergency relief of obstruction (internal stent or percutaneous nephrostomy). NO initial stone manipulation.

  • Ureteral Stones:

    • <5 mm: usually pass spontaneously.

    • Larger stones: Stent placement (passive dilation, eventual passage) or ureteroscopy with stone fragmentation (Holmium laser) and extraction.

  • Extracorporeal Shock Wave Lithotripsy (ESWL): Fragments stones (ureteral or collecting system) into passable pieces.

  • Uric Acid Stones: Medical treatment (dissolve with urinary alkalization and increased fluid intake).

  • Open Surgery: Rarely indicated today.

THE URETERS

Anatomy

• Function: Conduits for urine (kidneys to bladder).

• Entry to Bladder: Postero-laterally, oblique course (1.5 cm) through bladder wall.

• Wald-eyer's Sheath: Anchors lower ureter.

• Peristalsis: Propels urine.

• Anti-Reflux Mechanism: Complex relation of ureteral muscle, bladder base, and intramural ureteral lumen compression.

Ureteral Obstruction

• Causes: Stones, extrinsic masses (colon tumors, gynecologic malignancy, vascular aneurysm, inflammatory disease, retroperitoneal fibrosis).

• Diagnosis: CT, IVP (anatomic and functional info).

• Treatment: Depends on etiology. Initial: stenting.

• Bladder Outlet Obstruction (e.g., BPH): Effects transmitted to upper tracts (bilateral hydronephrosis/hydroureter). Initial management: bladder catheterization.

Iatrogenic Injuries to the Ureters

• Occurs During: General, vascular, gynecologic surgery (e.g., diverticulitis, aortic aneurysm, pelvic mass).

• Prevention: Temporary ureteral stents for high-risk cases.

• Repair: Primary end-to-end anastomosis with stenting, or ureteral reimplantation for distal injuries.

• Contaminated Field: Proximal urinary diversion (percutaneous nephrostomy/open nephrostomy).

• Aortic Aneurysm Repair: Primary repair + omentum wrap.

THE BLADDER

Anatomy

• Function: Store and evacuate urine.

• Location: Behind pubic symphysis (empty), protrudes into peritoneal cavity (full).

• Lining: Transitional epithelium.

• Detrusor: Interlacing smooth muscle bundles (main bladder muscle).

• Trigone: Triangular area between ureteral orifices and urethral opening, two distinct muscle layers.

• Ligaments: Puboprostatic (males), pubovesical (females), median umbilical ligament (urachus remnant).

• Blood Supply: Superior, middle, inferior vesical arteries (hypogastric branches). Also vaginal/uterine (females).

• Lymphatics: External iliac, hypogastric, common iliac, sacral nodes.

Evaluation

• Endoscopic Evaluation (Cystourethroscopy):

  • Visualizes bladder/urethra with flexible or rigid cystoscopes.

  • Examines mucosa (irregularities, tumors, lesions, vascularity), trabeculations, cellules, diverticula.

  • Checks ureteral orifices (position, configuration, urine efflux color).

  • Evaluates bladder neck, prostatic fossa, urethra (stricture, lesions, tumors).

  • Retrograde pyelography possible via cystoscope.

• Urodynamic Evaluation:

  • Evaluates reservoir and micturition function.

  • Postvoid Residual (PVR): Volume remaining after voiding. Measured by catheterization or ultrasound. (Normal = void to completion).

  • Cystometrogram (CMG): Evaluates intravesical pressures during filling/voiding. Measures sensation, capacity, compliance, voiding pressures, detrusor contractions. (Normal: fills to 350-500mL without significant pressure increase/contraction).

  • Urinary Flow Rate (Uroflow): Rate of urine flow from urethra. (Normal: Men 20-25 mL/sec, Women 20-30 mL/sec). Low rates indicate outlet obstruction or poor detrusor function.

  • Urethral Pressure Profile: Measures intraluminal urethral pressures.

  • Sphincter Electromyography (EMG): Evaluates sphincter activity.

  • Fluoroscopic Cystography: Visualizes bladder neck/sphincter, detects cystocele, descensus, reflux.

Congenital Anomalies

• Vesicoureteral Reflux (VUR):

  • Primary VUR: Abnormally short intramural ureteral tunnel (laterally placed ureteral bud). Allows infected urine to reflux into ureter, causing kidney damage.

  • Grading (Figure 29-15):

    • Grades I & II: Often resolve spontaneously with growth.

    • Higher Grades: Less likely to resolve, increased renal damage risk, may require surgical correction.

  • Clinical Evaluation:

    • Most often discovered during UTI investigation (29-50% of children with UTI).

    • Voiding Cystourethrogram (VCUG): Primary diagnostic test.

    • Radionuclide Cystogram: Lower radiation, detects smaller reflux, but inferior anatomic detail.

    • Renal ultrasound/IVP detect dilatation but not reflux. Cystoscopy not routine.

  • Treatment:

    • Goal: Prevent UTIs and renal damage.

    • Mild VUR (Grades I/II): Continuous low-dose antibacterial prophylaxis (benefit on renal function debated). Careful follow-up, yearly VCUG/renal ultrasound.

    • Severe/Failed Medical Management: Surgical repair (ureteral reimplantation). Lengthens intramural ureter, immobilizes meatus, supports ureter. Techniques: Glenn-Anderson, Cohen, Politano-Leadbetter.

    • Endoscopic Therapy: Transurethral injection of dextranomer/hyaluronic acid copolymer (Deflux) into bladder wall near orifice. Effective for grades 2-4, but long-term data limited.

• Exstrophy of the Bladder: Improper development of anterior abdominal wall, pelvic girdle, bladder wall.

  • Result: Exposure of bladder posterior wall, pubic symphysis separation.

  • Prevalence: 1:30,000 births, 3:1 male predominance.

  • Complications: Disfigurement, total incontinence, bacterial colonization, UTIs.

  • Treatment: Total urinary tract reconstruction (bladder augmentation, bladder neck reconstruction). Lifelong urologic follow-up due to increased adenocarcinoma risk.

• Urachal Persistence: Umbilical sinus, abdominal wall cyst, diverticulum at bladder dome, or fistula.

  • Treatment: Simple excision. Associated with adenocarcinomatous changes.

• Congenital Diverticula: Difficult to differentiate from acquired. Excision for symptomatic ones.

Trauma

• Causes: Penetrating (gunshot, stab, instrumentation), blunt trauma (pelvic fractures, sudden increase in intravesical pressure).

• Signs: Hematuria (contusions), intraperitoneal/extraperitoneal extravasation (tears). Often associated with other pelvic/abdominal injuries.

• Evaluation:

  • Symptoms: Suprapubic/pelvic pain, inability to void.

  • Urethral Disruption: Suspected with blood at meatus (perform retrograde urethrogram FIRST before catheterization).

  • Cystogram: Most dependable diagnostic study for bladder rupture. Instill contrast, take films, post-drainage film crucial.

• Treatment:

  • Small, Extraperitoneal Ruptures: Foley catheter drainage (1-2 weeks).

  • Intraperitoneal & Large/Complicated Extraperitoneal: Surgical repair (midline incision, bladder closure with absorbable suture, catheter drainage).

Inflammatory Diseases

• Bacterial Cystitis:

  • Symptoms: Irritable voiding (dysuria, frequency, urgency, nocturia), gross hematuria. Fever uncommon (suggests upper tract infection).

  • Prevalence: Much more common in women (shorter urethra). Men: usually incomplete emptying.

  • Bacteria: Gram-negative rods, especially E. coli (>80%).

  • Evaluation: Urinalysis (bacteria, WBCs, RBCs), urine culture and sensitivity (clean catch).

  • Treatment: Empirical broad-spectrum antibiotics, adjusted by culture. Symptoms resolve in 3-5 days.

  • Further Evaluation (children, men, non-responders, recurrent infections): Cystoscopy, CT urogram/renal ultrasound, urine cytology. Goal: detect correctable causes.

• Interstitial Cystitis (IC):

  • Unknown etiology. Syndrome of lower abdominal pain and irritative voiding symptoms.

  • Predominantly affects women, difficult to manage.

  • Urinalysis: Occasionally microhematuria. Urine cultures negative for bacteria/fungi/viruses.

  • Cystoscopy: Submucosal petechiae (glomerulations), rarely Hunner's ulcer.

  • Diagnosis: Exclusion.

  • Histology: Chronic inflammation, mast cell infiltration, fibrosis.

  • Treatment: Bladder dilatations (under general anesthesia), instillation of substances (dimethyl sulfoxide, heparin, amitriptyline). May require subtotal cystectomy/augmentation or diversion for severely contracted bladder.

• Bladder Fistulae: Abnormal connection between bowel and bladder.

  • Causes: Sigmoid diverticulitis (most common), neoplasm, Crohn's, penetrating injury.

  • Symptoms: UTI, hematuria, pneumaturia, fecaluria.

  • Diagnosis: Water-based contrast enemas, cystogram, cystoscopy, CT (air in bladder confirms).

  • Treatment: Resection of involved bowel, debridement/closure of bladder fistula.

  • Vesicovaginal Fistula: From prolonged labor pressure necrosis or surgical injury. Continuous incontinence. Diagnosis: cystogram, cystoscopy, methylene blue test. Repair (vaginal approach for simple).

Urinary Incontinence

• Definition: Involuntary loss of urine.

• Classification:

  • Stress Incontinence: Leakage with increased intra-abdominal pressure (cough, sneeze, laugh). Low resistance at bladder neck/urethra.

  • Urge Incontinence: Leakage preceded by urgency, inability to "make it in time." Bladder instability/involuntary contraction.

  • Overflow Incontinence: Bladder overfills (from retention) and uncontrollably empties. Obstruction or bladder inability to contract.

  • Total Incontinence: Continuous leakage. Characteristic of fistula.

• Evaluation:

  • History: Amount, associated activities, voiding diary, pad usage. Medical history (meds, trauma, surgery, deliveries, neurological disorders, diabetes, UTIs).

  • Physical Exam: Abdomen, back, pelvis, rectum (perianal sensation, anal sphincter tone, lower extremity function). Lithotomy position for women (stress incontinence).

  • Labs: Urinalysis, urine culture, cytology.

  • Other: PVR, cystoscopy, urodynamics.

• Treatment:

  • Detrusor Instability (Urge Incontinence): Anticholinergic medications (oxybutynin) for detrusor relaxation.

  • Stress Incontinence: Restore bladder neck/urethra to proper anatomic position.

    • Marshall-Marchetti-Krantz procedure: Anterior abdominal approach, sutures anchor vaginal fascia to pubic symphysis.

    • Suspension procedures (Stamey, Raz): Combined vaginal/suprapubic approach, nonabsorbable sutures to bladder neck.

    • Transvaginal "sling" procedure: Most common for women. Uses fascia or commercial tapes (transvaginal tape) to support urethra.

    • Artificial Urinary Sphincter (men): Prosthetic device (cuff, reservoir, pump).

Neurogenic Bladder Dysfunction

• Definition: Disruption of neural pathways controlling micturition.

• Micturition: Complex coordination of CNS, somatic/autonomic systems, detrusor/sphincter muscles.

• Fill Phase: Bladder relaxation (compliance), increased sphincter tone.

• Void Phase: Voluntary relaxation of external sphincter, bladder neck, detrusor contraction.

• Innervation: Parasympathetic (S3, S4), sympathetic (T11-L2), somatic (S2 via pudendal).

• Classification (Lapides):

  • Uninhibited Neurogenic Bladder: Uncontrolled detrusor contractions. Decreased capacity, normal sensation, appropriate sphincter. Causes: CVA, tumors, cerebral palsy, MS.

  • Reflex Uninhibited Bladder: Suprasacral spinal cord lesions. Phasic uninhibited detrusor contractions. Detrusor sphincter dyssynergia common. No sensation of filling, but autonomic reflexes.

  • Autonomic Neurogenic Bladder: No efficient detrusor contractions. Large residual volume. Reduced/absent sensation. Causes: Sacral cord, conus medullaris, cauda equina damage.

  • Sensory Neurogenic Bladder: Diminished/absent sensation, no detrusor hyperreflexia, large capacity. Interruptions to sensory pathways. Causes: Tabes dorsalis, diabetes, syringomyelia.

  • Motor Paralytic Bladder: Rare. No detrusor function, normal sensation, normal/increased capacity. Causes: Poliomyelitis, trauma.

• Evaluation:

  • Urodynamics: CMG (detrusor function), urethral pressure/EMG (sphincter), PVR (emptying efficiency), fluoroscopic voiding studies (anatomy, reflux), sensation assessment.

  • Other: Renal ultrasound (hydronephrosis, stones), serum creatinine (renal function).

• Treatment:

  • Goals: Preserve renal function, normalize urinary tract (continence, emptying, infection prevention).

  • Medications: Anticholinergics (tolterodine, oxybutynin) to suppress contractions, improve compliance.

  • Bladder Emptying: Clean intermittent catheterization (CIC) (preferred over chronic catheters due to lower infection rate).

  • High Pressures/Reflux:

    • Intervention mandatory to prevent renal damage.

    • Anticholinergics, CIC. If fails, bladder augmentation with bowel.

    • Alternatively, sphincterotomy (endoscopic, causes incontinence managed by condom catheter).

  • Follow-up: Annual renal function, upper tract anatomy, cystoscopy, urodynamics.

Malignant Diseases (Bladder Carcinoma)

• Prevalence: 5th most common malignancy in US, 2.5x more common in men.

• Risk Factors: Cigarette smoking (5x more prevalent), industrial carcinogens (rubber, oil).

• Histology:

  • Transitional Cell Carcinoma (TCC): 85-90%.

  • Adenocarcinomas: Associated with patent urachus, bladder dome tumors.

  • Squamous Cell Carcinoma: Chronic bladder inflammation (indwelling catheters, schistosomiasis).

• Evaluation:

  • Symptoms: Gross, painless hematuria (common), microscopic hematuria (20%), irritative voiding.

  • Diagnosis: Imaging of upper tracts (IVP/CT urogram), cystoscopy, urine cytology.

  • Staging: Depth of tumor invasion (Tis-T4).

• Treatment:

  • Ta & T1 Carcinoma (Non-muscle invasive): Transurethral resection of tumor (TURBT).

  • Recurrent/High-Risk: Intravesical chemotherapy/immunotherapy (thiotepa, BCG, mitomycin-C). BCG effective for Tis, reduces recurrence by up to 50%.

  • Close surveillance mandatory (cystoscopy, cytology q3-4 months initially).

  • Muscle-Invasive (T2+): Radical Cystectomy.

    • Men: Remove bladder, prostate, perivesical fat, pelvic lymph nodes.

    • Women: Remove bladder, ant. vaginal wall, uterus, lymph nodes.

  • Urinary Reconstruction Post-Cystectomy:

    • Ileal conduit diversion: To skin (requires collection appliance).

    • Continent cutaneous diversion: Uses right colon, catheterizable efferent limb.

    • Orthotopic neobladder: Uses detubularized bowel, anastomosed to urethra (no external appliance/catheterization).

THE PENIS

Anatomy

• Structure: Two corpora cavernosa, one corpus spongiosum. Bound by Buck's fascia, covered by skin.

• Tunica Albuginea: Thick fibrous capsule around corpora cavernosa.

• Corpus Spongiosum: Ventral, encloses urethra, forms glans penis distally.

• Blood Supply: Branches of internal pudendal artery (from internal iliac artery).

• Venous Drainage: Iliac veins via deep and superficial dorsal veins.

• Lymphatics: Glans/corpus spongiosum/distal corpora cavernosa to external iliac, superficial/deep inguinal nodes. Proximal corpora/post. urethra to internal iliac nodes.

Trauma

• Types: Blunt, penetrating, avulsion, strangulation, burns, fracture.

• Suspected Urethral Injury: Retrograde urethrogram mandatory.

• Penetrating Injuries: Repair depends on extent/location of urethral/corporal injury. Superficial lacerations can be closed. Urethral injuries may need immediate or delayed repair.

• Penile Amputations: Microsurgical reattachment if preserved (cold saline).

• Avulsion Injury (Skin): Usually superficial to Buck's fascia. Primary closure if sufficient skin. Circumferential avulsions: split-thickness skin graft (removes skin up to coronal sulcus).

• Penile Burns: Managed like other burns. Avoid prolonged urethral catheterization; use suprapubic tube for >72 hrs.

• Penile Fracture: Rupture of tunica albuginea of corpus cavernosum (during intercourse). Pain, detumescence, rapid swelling. Immediate surgical exploration, hematoma evacuation, tunica albuginea repair.

Malignant Diseases

• Premalignant Lesions (Table 29-3):

  • Leukoplakia: White plaque, acanthosis. Local excision.

  • Bowen's Disease: Solitary, erythematous plaque. Carcinoma in situ.

  • Erythroplasia of Queyrat: Raised, red, velvety areas. Carcinoma in situ.

  • Treatment for above: Nd:YAG laser, local excision, topical 5-FU.

  • Giant Condyloma Acuminatum (Buschke-Löwenstein): Large, exophytic. Similar to condyloma but extends into tissue. Local excision (may need partial/total penectomy).

  • Balanitis Xerotica Obliterans (BXO): White, atrophic lesions (glans/prepuce). Can cause urethral stricture. Topical steroids, urethral reconstruction.

• Squamous Cell Carcinoma (Penile Cancer):

  • Rare in US, common in hot/humid regions. Risk factors: poor hygiene, phimosis. Rare in men circumcised at birth.

  • Symptoms: Ulceration, necrosis, suppuration, hemorrhage of lesion.

  • Evaluation: Physical exam (inguinal region), LFTs, CXR, CT abd/pelvis, bone scan. TNM staging.

  • Treatment:

    • Small (<2cm) limited to prepuce: Circumcision alone.

    • Small (2-5cm) distal: Partial penectomy (>2cm margin, allows standing voiding). 70-80% 5-yr cure.

    • Larger distal/proximal: Total penectomy + perineal urethrostomy.

    • Inguinal Lymphadenopathy: Assess after 4-6 weeks of antibiotics (to rule out infection). If persists/develops, ilioinguinal lymphadenectomy.

    • Radiation: Alternative for small, low-stage tumors (preserves penis), but slightly lower control rates.

Acquired Disorders

• Priapism: Pathologic prolongation of penile erection. Only corpora cavernosa turgid.

  • Low-Flow Priapism (Ischemic): Venous outflow obstruction, sludging/thrombosis. Untreated: fibrosis, impotence. Causes: sickle cell, leukemia, metastatic disease, vasoactive injections.

    • Treatment:

      • Sickle cell: hydration, alkalinization, analgesics, exchange transfusion.

      • Vasoactive injections: Intracorporeal phenylephrine (<6 hrs).

      • Otherwise: Aspiration of corporal blood, corporal irrigation.

      • Winter procedure: Creates communication between corpora cavernosa/corpus spongiosum.

      • Open surgery if other measures fail.

    • High-Flow Priapism (Non-Ischemic): Increased arterial inflow. Causes: pelvic trauma (vascular fistula).

      • Diagnosis: Corporal blood gas (high PO₂).

      • Treatment: Pudendal arteriography with selective embolization.

  • Phimosis: Fibrotic contracture of foreskin, prevents retraction over glans.

    • Etiology: Poor hygiene, infection, diabetes.

    • Treatment: Improved hygiene, elective circumcision.

  • Paraphimosis: Retracted foreskin forms constricting band proximal to coronal sulcus, causing edema. Inability to reduce foreskin. Urologic emergency.

    • Treatment: Manual compression of glans to reduce edema, then reduction. If fails, incision of constricting band. Circumcision after inflammation resolves.

  • Peyronie’s Disease: Scarring of tunica albuginea (plaques), causing penile curvature (may be incapacitating).

    • Immature Phase: Painful erections, progressive curvature. Surgery contraindicated. Conservative management (collagenase, vitamin E). Spontaneous resolution possible.

    • Mature Disease: Unchanged curvature for 6+ months, pain resolved. If satisfactory intercourse inhibited:

      • Good erectile function: Plication opposite plaque or incision/excision with grafting.

      • Erectile dysfunction: Treat ED. Last resort: penile prosthesis.

  • Circumcision & Dorsal Slit:

    • Most common male operation in US.

    • Indications: Parental decision, phimosis, cosmesis, malignancy.

    • Contraindications: Myelodysplasia, hypospadias (foreskin needed for repair).

    • Procedure: Dorsal slit involves cutting foreskin proximally. Circumcision involves further excision and approximating mucosal/cutaneous edges. Avoid cautery with metal clamps.

  ---

  THE URETHRA

  Anatomy

  • Male Urethra:

    • Posterior: Prostatic urethra (transitional epithelium), membranous urethra (external striated sphincter).

    • Anterior: Meatus, fossa navicularis, penile urethra, bulbar urethra (pseudostratified/stratified columnar epithelum, except meatus = squamous).

    • Glands: Bulbourethral (Cowper's) glands (membranous), Glands of Littre (penile urethra).

    • Lymphatics: Posterior urethra to obturator/iliac nodes; anterior urethra to deep inguinal/iliac nodes.

  • Female Urethra: ~4 cm long.

    • Proximal third: Transitional epithelium. Distal two-thirds: Stratified squamous epithelium.

    • Periurethral glands of Skene.

    • Lymphatics: Proximal to iliac nodes; distal to inguinal nodes.

  Trauma

  • Anterior Urethral Injuries: Blunt trauma (straddle injuries) to bulbous urethra.

  • Prostatomembranous Urethral Injuries: Pelvic fractures (~10% cases).

  • Suspect if: Blood at urethral meatus, inability to void, penile/perineal edema/ecchymosis.

  • Evaluation: Retrograde urethrography.

    • Partial rupture: urethral extravasation + contrast in bladder.

    • Complete rupture: extravasation without contrast in bladder.

  • Treatment:

    • Small, Incomplete Anterior Ruptures: Urethral catheter or suprapubic cystostomy.

    • Posterior Urethral Injury (Pelvic Fracture): Suprapubic tube. Delayed urethral reconstruction (at least 3 months suprapubic diversion).

  Malignant Diseases

  • Male Urethral Carcinoma: Rare, >60 years old. ~80% squamous cell.

    • Distal Urethra: Partial or total penectomy.

    • Proximal Urethra: Urethrectomy and cystoprostatectomy.

  • Female Urethral Carcinoma: Only GU malignancy more common in women.

    • Symptoms: Papillary/fungating urethral mass, urethral/vaginal bleeding.

    • Spread: Distal lesions to inguinal nodes; proximal to iliac nodes.

    • Treatment:

      • Noninvasive distal: Distal urethrectomy (often squamous cell).

      • Proximal/panurethral: Chemotherapy/radiation followed by radical excision.

  Urethral Strictures

  • Causes: Straddle injury (most common), urethral instrumentation, gonococcal urethritis (less common now).

  • Symptoms: Obstructive voiding (like prostatism). UTI, inability to pass catheter.

  • Evaluation:

    • Cystoscopy (visualizes up to stricture).

    • Retrograde urethrogram + VCUG: Defines location, caliber, length.

  • Treatment:

    • Discrete (<1cm) mucosal strictures: Dilation or endoscopic incision (urethrotomy). High recurrence for longer/recurrent strictures.

    • Longer/Recurrent Strictures: Open urethral reconstruction for highest success.

      • Short bulbar stricture: Excision and primary anastomotic repair (>98% cure).

      • Long/distal strictures: Tissue transfer (preputial skin, buccal mucosa graft).

  Congenital Disorders

  • Posterior Urethral Valves (Type I Most Common): Folds of mucous membranes from verumontanum to membranous urethra.

    • Effect: Urethral obstruction, bladder distention, VUR, hydroureteronephrosis, renal damage.

    • Diagnosis: Antenatal ultrasound, poor urinary stream/inability to void in newborns. VCUG: dilated posterior urethra.

    • Initial Treatment: Infant feeding tube/suprapubic tube. Optimize fluid/electrolyte/acid-base.

    • Definitive: Endoscopic valve ablation or cutaneous vesicostomy.

  • Hypospadias: Most common congenital anomaly (1:300 male births). Urethral meatus on ventral penile surface, proximal to normal tip.

    • Classification: Perineal, penoscrotal, shaft, coronal, glanular.

    • Associated: Dorsal hood prepuce, chordee (ventral penile curvature).

    • Severe (perineal): Bifid scrotum, undescended testes, small penis (gender assignment difficult).

    • Goals of Repair:

      • Correct penile curvature (release chordee, dorsal plication sutures).

      • Create new urethra (Snodgrass repair, penile skin flaps, buccal/skin grafts).

      • Perform before age 1 to minimize psychological effects.

  Infectious Diseases

  • Gonococcal Urethritis: Caused by Neisseria gonorrhoeae (Gram-negative diplococcus).

    • Symptoms: Yellowish urethral discharge, dysuria, itching, frequency. 25% asymptomatic.

    • Diagnosis: Urethral swab culture (Thayer-Martin medium).

    • Treatment: Ceftriaxone 250mg IM single dose (for patient and sexual contacts).

  • Nongonococcal Urethritis:

    • Symptoms: Dysuria, frequency, periurethral itching, clear/white mucoid discharge.

    • Cause: C. trachomatis (most common), Ureaplasma urealyticum.

    • Diagnosis: Urethral swab cultures.

    • Treatment: Azithromycin (1g orally single dose) or Doxycycline (100mg BID x7 days). Often treated for both gonorrhea/chlamydia empirically.

  ---

  THE TESTES, MALE INFERTILITY, AND IMPOTENCY

  The Testes

  Embryology & Anatomy

  • Development: From genital ridge (retroperitoneum). Descends into scrotum by 8th month gestation.

  • Coverings: Tunica vaginalis (from peritoneum), cremasteric fibers (from internal oblique fascia).

  • Arterial Supply: Internal spermatic artery (from aorta), deferential artery, external spermatic artery.

  • Venous Drainage: Internal spermatic vein (right-vena cava, left-renal vein), deferential vein, external spermatic vein.

  • Lymphatic Drainage: Preaortic and precaval region (important for testicular malignancy spread).

  Congenital Disorders

  • Testicular Abnormalities (Cryptorchidism - nonpalpable testicle):

    • Incidence decreases with age (prematurity = higher incidence).

    • If empty scrotum: anorchia, nondescent, or retractile testis.

    • Anorchia: Absence of testis. Unilateral less concern. Bilateral requires hormone replacement.

    • Retractile Testes: Overactive cremasteric musculature. Usually descend at puberty.

    • Undescended Testicles: Lie along usual path.

      • HCG stimulatory test to assess presence (testosterone surge).

      • Laparoscopy to locate intra-abdominal testes.

      • Undescended testis has 48x greater malignancy risk. Surgical orchidopexy (movement to normal position) does not reduce risk but allows earlier diagnosis.

  • Patent Processus Vaginalis: Processus vaginalis (peritoneal tube) fails to close.

    • Complete Open: Inguinal hernia (abdominal viscera herniation), possible strangulation.

    • Partial Close: Hydrocele (increases with upright position/crying).

    • Diagnosis: "Silk glove" sign on palpation.

    • Treatment: High ligation of patent processus vaginalis if hydrocele persists >1 year or is symptomatic.

  • Testicular Cord Torsion:

    • Neonatal (Extravaginal): Testicle, epididymis, tunica all twist within fascia. Leads to infarction.

    • Adolescent (Intravaginal): Tunica surrounds testicle, allowing it to twist ("bell clapper" deformity). Acutely swollen, tender testicle, retracted high.

    • Signs: Loss of cremasteric reflex (95%).

    • Diagnosis: Color Doppler ultrasonography (evaluate blood flow).

    • Treatment: Surgical exploration is mandatory (emergency). Prolonged torsion (>6 hrs) = irreversible damage. If bell clapper, bilateral testicular fixation to prevent contralateral torsion.

  • Trauma: Direct blow to testis.

    • Evaluation: Assess tunica albuginea integrity. Ultrasound helpful.

    • Treatment:

      • Intact testicle + scrotal hematoma: Conservative management.

      • Torn tunica albuginea: Scrotal exploration, remove defunctionalized elements, close tear.

  • Scrotal Infections:

    • Cellulitis: Gram-positive bacteria. Antibiotics (cefazolin, cephalexin).

    • Candidal Fungal Infection: Topical antifungal.

    • Necrotizing Fasciitis (Fournier's Gangrene): Rare, dreaded, life-threatening mixed infection. Associated with diabetes, obesity, stricture. Scrotum erythematous, tense, moist. Spreads rapidly with crepitus.

      • Treatment: Wide debridement, drainage, broad-spectrum antibiotics (immediate aggressive management essential to prevent death).

  • Malignant Diseases (Testicular Cancer): Most common solid malignancy in men aged 18-35.

    • Evaluation (Scrotal Mass):

      • History: Duration, growth, pain, infection, trauma.

      • Transillumination: Fluid-filled (hydrocele, spermatocele) transilluminate. Solid masses do not.

      • Hydrocele: Testes float in mass.

      • Spermatocele: Mass above or below testes.

      • Varicocele: Adjacent to cord, tubular, "bag of worms" sensation (dilated internal spermatic vein). Correct if pain, atrophy, subfertility.

      • Epididymal Mass (non-transilluminating): Sperm granuloma, epididymal cyst.

      • Mass involving testicle: HIGH PROBABILITY OF MALIGNANCY.

      • Ultrasound: Differentiates causes.

      • Surgical Exploration: Usually necessary for diagnosis/treatment. Inguinal incision (NOT scrotal) to prevent altered lymphatic drainage.

    • Treatment:

      • Germ Cell Tumors: Most common.

        • Seminomas: Do not undergo further neoplastic transformation. Diffuse enlargement, glistening white.

        • Nonseminomas: Differentiate into extraembryonic (choriocarcinoma, yolk-sac) or intraembryonic (teratoma).

        • Tumor Markers (pre-orchiectomy):

          • AFP (alpha-fetoprotein): Elevated in nonseminomas only.

          • β-hCG (beta-human chorionic gonadotropin): Elevated in seminomas (30-40%) and nonseminomas.

        • Staging (Table 29-4): Retroperitoneal CT, chest X-ray, post-op tumor markers.

        • Seminoma Treatment: Radiosensitive. Stage I/IIa: retroperitoneal radiation. Bulky/metastatic: platinum-based chemotherapy.

        • Nonseminoma Treatment: Stage I: retroperitoneal lymph node dissection (preserves ejaculatory function). Advanced/metastatic: platinum-based chemotherapy.

  Male Infertility

  • Male factor causative in 40% of infertile couples, partially responsible in 20%.

  • Evaluation:

    • History: Childhood illnesses (mumps), surgeries (groin, scrotal, bladder), puberty issues, viral illnesses (spermatogenesis ~90 days), meds, toxins, smoking, intercourse timing, lubricants.

    • Physical Exam: Genitalia, body habitus (Klinefelter's), visual fields/olfactory (pituitary/hypothalamic), gynecomastia, penis lesions, urethral meatus, vas deferens/epididymis, testicles (size with orchidometer). Varicocele noted.

    • Semen Analysis: Mainstay of evaluation. 3 samples, 24 hr abstinence, within 1 hr collection. (Table 29-5)

      • Low volume: low serum testosterone, retrograde ejaculation, ejaculatory duct obstruction.

  • Treatment:

    • Retrograde Ejaculation: Diagnose by postejaculatory urine for sperm. Treat with sympathomimetic meds (pseudoephedrine). If fails, sperm harvest/IUI.

    • Ejaculatory Duct Obstruction: Diagnose with fructose analysis, TRUS. Treat with transurethral resection.

    • Azoospermia:

      • Without obstruction/low volume: vasal agenesis (rule out cystic fibrosis). May need microsurgical epididymal sperm aspiration.

      • With atrophic testicles & high FSH: Intrinsic testicular failure. Generally infertile.

      • Normal biopsy & azoospermia: Obstruction at vas deferens/epididymis. May need scrotal exploration, vasovasostomy, vasoepididymostomy.

    • Varicocele: Repair if low sperm count or abnormal parameters.

  Impotency (Erectile Dysfunction)

  • Mechanism: Erections involve neurologic, endocrine, vascular events (arterial inflow, smooth muscle relaxation, blood storage). Nitric oxide release -> cGMP -> smooth muscle relaxation.

  • Etiology: Organic pathology in >85%. Classified into:

    • Vasculogenic: Most common. Arterial insufficiency (hypertension, hyperlipidemia, diabetes, smoking). Venous leak (inability to store blood).

    • Endocrinologic: Low serum testosterone, decreased libido. Hypogonadotropic hypogonadism, pituitary adenoma.

      • First hormonal test: Serum testosterone. If low, check gonadotrophins, prolactin. Brain MRI for hyperprolactinemia.

    • Psychogenic: Component or sole cause. Nocturnal penile tumescence (NPT) test: absence of erections during REM sleep implies organic.

    • Neurogenic: Spinal cord injury, MS, alcoholism, diabetes. Surgical injury (radical prostatectomy to neurovascular bundles).

  • Evaluation:

    • NPT, duplex ultrasound, cavernosometry/cavernosography, pudendal arteriography. Not routinely performed unless for specific indications (e.g., young patient with pelvic trauma for revascularization).

  • Treatment:

    • PDE-5 inhibitors (sildenafil, vardenafil, tadalafil): FIRST-LINE. Inhibit phosphodiesterase, increase cGMP, promote smooth muscle relaxation.

    • Other options: Vacuum erection device (with constriction band), urethral suppository (alprostadil), intracavernous injections (vasoactive meds).

    • Last resort: Penile prosthesis.

  ---

  SKILLS

  Bladder Catheterization (Male)

  1. Gather all sterile materials first (catheter, drainage bag, lubricant, cleansing agent, syringe with water, drapes, gloves).

  2. Drape, grasp penis with upward traction (retract foreskin if uncircumcised). Clean meatus/glans.

  3. Coat catheter tip with lubricant, inject 10mL lubricant into urethra (Uro-jet).

  4. Slowly pass catheter until only balloon port visible (2-3 inches). DO NOT STOP at first urine.

  5. Look for urine return, then inflate balloon (7-10 mL water).

  6. Connect to drainage bag, tape to thigh.

  Bladder Catheterization (Female)

  1. Position (frog-leg or lithotomy).

  2. Spread labia (one hand or assistant).

  3. Advance catheter only half its length before inflating balloon.

  Difficulties (Catheterization)

  • Resistance (Male): Common at prostate, where urethra courses upward. Do not force, may cause trauma/false passages.

    • Action: Inject more lubricant, use larger (18-20 Fr) coude catheter (curved tip). Keep balloon port upward.

    • NEVER force catheter. NEVER inflate balloon unless fully inserted and urine seen.

  • No Urine Return: Catheter lumen blocked by lubricant (dissolves in ~1 min).

    • If still no urine: Irrigate with 60 mL saline (Toomey syringe) without inflating balloon. Confirm appropriate position.

  • Urethral Stricture: Causes resistance. Smaller catheter (12-14 Fr) might pass. If lumen too narrow, urologic consultation mandatory.

This note provides an exhaustive overview of urology, covering the anatomy, diseases, and treatments of the male and female genitourinary systems. It is intended for detailed educational study, exploring each concept with in-depth explanations, examples, and clinical context.

PROSTATE

The prostate is a gland in the male reproductive system located just below the bladder, surrounding the proximal urethra. It plays a crucial role in reproduction and is subject to several common pathologies, especially with aging.

Anatomy and Physiology

• Location: The prostate sits distal to the bladder neck, encircling the first 2-3 cm of the urethra (the prostatic urethra). The external urinary sphincter is located just distal to this, around the membranous urethra.

• Key Structures: The verumontanum is a small protrusion in the prostatic urethra where the ejaculatory ducts empty.

• Zonal Anatomy: The prostate is divided into distinct zones:

  • Transition Zone: This zone surrounds the urethra and enlarges in men with Benign Prostatic Hyperplasia (BPH).

  • Peripheral Zone: The outermost zone, where nearly 90% of prostatic cancers originate. It is the area palpated during a digital rectal examination (DRE).

  • Central Zone: A cone-shaped zone surrounding the ejaculatory ducts.

  • Anterior Fibromuscular Stroma: Composed of muscle and fibrous tissue, not glandular tissue.

• Blood Supply and Support: Blood is primarily supplied by branches of the hypogastric artery. The dorsal vein complex lies anteriorly. The prostate is anchored to the pubic bone by the puboprostatic ligaments.

• Function: The prostate is an exocrine gland whose secretions constitute about 20% of the ejaculate volume. This fluid provides essential nutrients for sperm motility and function. It remains dormant until puberty and often begins to enlarge in the fourth decade of life.

Prostatitis

Prostatitis is an inflammatory condition of the prostate. It often presents with a symptom complex called prostatodynia, which includes aching perineal discomfort, urinary frequency, urgency, and dysuria, alongside obstructive symptoms like hesitancy and dribbling.

Acute Prostatitis

An uncommon but severe bacterial infection of the prostate, typically seen after the second decade of life.

• Symptoms: Rapid onset of fever, chills, back and perineal pain, and dysuria. The prostate is swollen, boggy, warm, and exquisitely tender on DRE.

• Diagnosis: Urine sediment shows white blood cells (pyuria), and serum white blood cell count may be elevated.

• Infectious Agent: Usually a Gram-negative bacterium, most commonly Escherichia coli.

• Treatment: Requires a prolonged course (several weeks) of broad-spectrum antibiotics due to poor penetration into the prostate. If urinary retention occurs, a suprapubic catheter is preferred over a transurethral catheter to avoid worsening the infection.

• Complications: A prostatic abscess can form, diagnosed by fluctuance on DRE or imaging (CT scan). Treatment for an abscess involves drainage, typically by transurethral unroofing or transrectal ultrasound-guided needle aspiration, in addition to antibiotics.

Chronic Prostatitis

A more indolent condition than acute prostatitis, it may result from recurring infections or inadequate treatment of an initial infection.

• Symptoms: Discomfort in the perineum, back, or pelvis, along with urinary frequency, hesitancy, and dysuria.

• Diagnosis: Prostatic fluid obtained via prostatic massage characteristically has more than 10 white blood cells per high-power field. A diagnosis of chronic bacterial prostatitis requires a positive culture of this fluid.

• Treatment: A long course (e.g., 6 weeks) of broad-spectrum oral antibiotics like trimethoprim-sulfamethoxazole or a quinolone. Symptoms may recur after treatment.

Nonbacterial Prostatitis

A common and frustrating condition with symptoms indistinguishable from chronic prostatitis but without a consistently identified bacterial cause.

• Etiology: No defined agent is usually found, although Chlamydia trachomatis is sometimes isolated. Prostatic fluid examination is often normal.

• Treatment: Largely symptomatic and may include antibiotics (empirically), prostatic massage, sitz baths, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Benign Prostatic Hyperplasia (BPH)

Benign Prostatic Hyperplasia (BPH) is a non-cancerous enlargement of the prostate gland, involving both hyperplasia (more cells) and hypertrophy (larger cells), primarily in the transition zone.

Epidemiology

• BPH is a near-universal histologic finding in aging men, though not all develop symptoms.

• Symptomatic BPH is uncommon before age 50.

• There is no causal link between BPH and prostate cancer.

• The natural history is variable; not all patients experience progressive symptoms.

• Prostate size does not directly correlate with symptom severity.

Clinical Presentation and Evaluation

• Symptoms:

  • Obstructive Symptoms: Hesitancy, weak stream, terminal dribbling, intermittence, feeling of incomplete emptying.

  • Irritative Symptoms: Frequency, urgency, nocturia (due to compensatory bladder changes).

• Evaluation:

  • Digital Rectal Examination (DRE): Often reveals a symmetrically enlarged, smooth, soft prostate.

  • Urinalysis: Usually normal in the absence of infection.

  • Urine Flow Rate Test: Measures the force of the stream, typically <15 mL/second in symptomatic patients.

  • Postvoid Residual (PVR): Measures urine left in the bladder after voiding, assessed by catheterization or ultrasound.

  • Cystoscopy: May reveal trilobar hyperplasia or an obstructing median lobe.

  • Symptom Quantification: The American Urological Association (AUA) symptom score is used to quantify symptoms and measure treatment response.

• Complications: Long-standing BPH can lead to a decompensated bladder, hydronephrosis, and renal failure, though this is relatively unusual. Recurrent infections or bladder stones can also occur.

Treatment

Treatment is primarily pursued for symptomatic relief. The degree of patient bother is the most common reason to initiate therapy.

• Medical Therapy: First-line treatment for most patients.

  • -Adrenergic Blockers: Relax smooth muscle in the bladder neck and prostate. Examples include terazosin, doxazosin, tamsulosin, and silodosin. They provide rapid symptom relief but may cause weakness or postural hypotension.

  • 5-Reductase Inhibitors: Block the conversion of testosterone to dihydrotestosterone (DHT), shrinking the prostate. Examples are finasteride and dutasteride. They work best in men with larger prostates (>50 g) but may take months to show effect. These drugs lower serum PSA levels; the measured value should be doubled for accurate cancer screening assessment.

  • Combination Therapy: An -blocker plus a 5-reductase inhibitor is often considered the most effective medical treatment.

• Surgical Therapy: Reserved for patients unresponsive to or intolerant of medical therapy, or those with objective indications (e.g., renal failure, recurrent stones).

  • Transurethral Resection of the Prostate (TURP): The most common surgical procedure. An electrocautery loop is used to remove obstructing adenomatous tissue down to the prostatic capsule.

  • Open/Robotic Prostatectomy: Used for very large prostates (>100 g). The adenoma is enucleated, leaving the prostatic capsule intact.

  • Minimally Invasive Techniques: Procedures like GreenLight laser vaporization offer fewer bleeding complications than TURP. Other techniques like microwave thermotherapy are less common due to modest results.

Malignant Diseases: Prostate Cancer

Prostate Cancer is one of the most common cancers in men, with over 95% being adenocarcinomas arising from the prostatic acini. A major challenge is distinguishing clinically insignificant disease from aggressive cancer.

Epidemiology

• Incidence increases with age.

• Higher prevalence in African American men.

• A familial pattern and high-fat diet are identified risk factors.

• A large discrepancy exists between histologic cancer found at autopsy and clinically significant disease requiring treatment.

Clinical Presentation and Evaluation

• Symptoms: Most men with early-stage disease are asymptomatic. Advanced disease may cause pelvic pain, hematuria, bone pain, or obstructive voiding symptoms.

• Digital Rectal Examination (DRE): An important screening tool. Cancer typically feels like an area of induration or a hard nodule in the peripheral zone.

• Prostate-Specific Antigen (PSA) Testing: The cornerstone of screening. PSA is a protein produced by both benign and malignant prostate cells, so it is prostate-specific but not cancer-specific.

  • PSA Levels: A level < 4.0 ng/mL is generally considered normal, but cancer can exist at lower levels. Levels can be elevated in BPH, prostatitis, or after ejaculation.

  • PSA derivatives:

    • Age-Adjusted PSA: Accounts for the natural rise in PSA with age.

    • Free PSA: The proportion of unbound PSA in the serum. A lower percentage of free PSA (<20-25%) is more suggestive of cancer.

  • Screening Guidelines: The decision to screen should be a shared one between the patient and doctor. Screening may be considered from age 40 for high-risk men and from age 55 for others. It is generally not recommended for men with a life expectancy of <10 years.

• Transrectal Ultrasonography (TRUS): Not a screening test, but used to guide prostate biopsies. Cancers often appear as hypoechoic areas in the peripheral zone.

• Magnetic Resonance Imaging (MRI): Increasingly used before biopsy. The PI-RADS scoring system standardizes interpretation to identify suspicious lesions.

• Prostate Biopsy: The definitive diagnostic test. 10-14 tissue cores are systematically taken via a transrectal approach under TRUS guidance.

Tumor Grade and Staging

• Gleason Grading System: Assigns a score based on tumor differentiation. A primary and secondary grade (1-5) are summed to a Gleason score (2-10). Scores of 2-4 are well-differentiated, 5-7 are moderately-differentiated, and 8-10 are poorly-differentiated. Prognosis is strongly linked to this score.

• Staging (TNM System): Defines the extent of disease.

  • Local Staging: Primarily done by DRE.

  • Metastatic Evaluation: Radionuclide bone scan is the most sensitive test for bone metastases, which are typically osteoblastic. A CT scan can identify enlarged pelvic lymph nodes. Bone metastases are uncommon if PSA is < 20 ng/mL.

Treatment

• Localized Disease: Treatment choice is complex and depends on life expectancy, tumor aggressiveness, and patient preference.

  • Active Surveillance: Preferred for low-risk disease (Gleason 6). Involves periodic PSA, DRE, and repeat biopsies to monitor the cancer for progression, with the intent to cure if it becomes more aggressive. This differs from "watchful waiting," which is observation without curative intent, typically for men with short life expectancy.

  • Radical Prostatectomy: Surgical removal of the entire prostate, seminal vesicles, and ampullary portion of the vas deferens. Can be performed open, laparoscopically, or robotically. Robotic surgery is now the most common approach, offering reduced blood loss and shorter recovery. Potency may be preserved via a nerve-sparing technique. After surgery, PSA should become undetectable.

  • Radiation Therapy: Includes external beam radiation or brachytherapy (implanted radioactive seeds). Ten-year survival is similar to surgery.

• Metastatic Disease: Prostate cancer is initially androgen-dependent.

  • Androgen Deprivation Therapy (ADT): The primary treatment for metastatic disease. This can be achieved by surgical orchiectomy (removal of testes) or medical castration with Luteinizing Hormone-Releasing Hormone (LHRH) analogs. Side effects include hot flashes, loss of libido, and impotence.

  • Castration-Resistant Prostate Cancer: After an average of 18-24 months, the cancer often progresses despite low testosterone levels. Second-line treatments include newer antiandrogens (abiraterone, enzalutamide) and chemotherapy (taxol-based).

KIDNEYS

The kidneys are paired retroperitoneal organs vital for filtering waste from the blood, regulating electrolytes, and producing hormones.

Anatomy

• Location: Retroperitoneal, on either side of the vertebral column (T12-L3). The right kidney is slightly lower than the left due to the liver.

• Coverings: Surrounded by a fibrous renal capsule, a layer of perirenal fat, and finally enclosed by the renal fascia (Gerota's fascia).

• Blood Supply: Receives 20% of cardiac output. Typically supplied by a single renal artery from the aorta. Aberrant or multiple renal arteries are common. Renal arteries are "end arteries," meaning their blockage results in infarction of the kidney segment they supply. Aberrant lower pole arteries can cause ureteropelvic junction (UPJ) obstruction.

Trauma

Blunt trauma (e.g., motor vehicle accidents) accounts for 70-80% of renal injuries. Bleeding is a major concern, presenting as hematuria or retroperitoneal hematoma.

Evaluation and Treatment

• Imaging Indications:

  • Required for: Children, patients with gross hematuria, hypotension, or major deceleration injuries (e.g., high-speed crash, fall from height). In children, a deceleration injury can cause ureteropelvic junction avulsion, which may not present with hematuria.

  • Not necessary for: Adults with microscopic hematuria after minor blunt trauma without hypotension.

• Imaging Modality: CT scan is the gold standard for stable patients. An unstable patient going to the OR may get a "one-shot" intravenous pyelogram (IVP).

• Treatment: Most blunt renal injuries are managed non-operatively. Exploration is indicated for an expanding or pulsatile retroperitoneal hematoma or major injury on CT in a stable patient. Penetrating trauma has a lower threshold for exploration.

Renal Trauma Grading (Abbreviated)
Grade I-II (Minor): Contusion or small, non-expanding hematoma without deep laceration.
Grade III-V (Major): Deep lacerations, collecting system injury, vascular injury (thrombosis or avulsion), or a shattered kidney.

Congenital Disorders

• Horseshoe Kidney: The most common renal fusion anomaly, where the lower poles of the kidneys are typically joined by an isthmus. It occurs in 1 in 400-1,800 births and can be associated with obstruction or infection. Treatment, if needed, involves dividing the isthmus (symphysiotomy).

• Ureteropelvic Junction (UPJ) Obstruction: A blockage at the junction of the renal pelvis and the ureter, leading to hydronephrosis. It can be intrinsic (maldevelopment) or extrinsic (e.g., caused by an aberrant crossing vessel). Many cases are now diagnosed by antenatal ultrasound. Surgical repair (pyeloplasty) is performed to prevent loss of renal function.

Inflammatory Diseases

• Pyelonephritis: A bacterial infection of the kidney, usually caused by E. coli. Patients present with fever, flank pain, and UTI symptoms. Uncomplicated cases are treated with oral antibiotics.

  Obstructive Pyelonephritis: A Urologic Emergency
  When pyelonephritis occurs with an obstructing stone, it creates "pus under pressure." This condition can rapidly lead to sepsis. Antibiotics alone are insufficient. Emergency drainage of the kidney is required, either with a ureteral stent or a percutaneous nephrostomy tube.

• Emphysematous Pyelonephritis: A life-threatening, gas-forming infection of the renal parenchyma, often seen in patients with poorly controlled diabetes. CT scan is diagnostic. Treatment is emergent nephrectomy.

• Xanthogranulomatous Pyelonephritis (XGP): A chronic, destructive inflammatory process that can mimic a renal tumor. It is associated with chronic UTIs (often with Proteus) and kidney stones. The affected kidney is usually nonfunctional, and treatment is nephrectomy.

• Genitourinary Tuberculosis (TB): Can cause painless frequency and sterile pyuria (white cells in urine without bacteria on standard culture). Diagnosis is by urine culture for M. tuberculosis. It can lead to calcifications and ureteral strictures. Treatment is with anti-TB drugs, with surgery for complications.

Neoplasms

• Benign Neoplasms:

  • Simple Renal Cyst: The most common renal mass (70% of cases). They are asymptomatic, benign, and require no intervention.

  • - Complex Cyst: Cysts with septations, wall thickening, or calcifications are considered potentially malignant and may require surgical removal.

  • Angiomyolipoma: A benign tumor containing fat, smooth muscle, and blood vessels. The presence of macroscopic fat on a CT scan is virtually diagnostic.

• Malignant Neoplasms:

  • Renal Cell Carcinoma (RCC): The most common primary kidney cancer in adults, arising from proximal convoluted tubules. Risk factors include smoking.

    • Presentation: Most are now found incidentally on imaging. The classic triad of flank pain, palpable mass, and hematuria is seen in only a small minority of cases.

    • Staging: TNM system is used. RCC can invade the renal vein and vena cava. It most commonly metastasizes to the lungs, bone, and brain.

    • Treatment: Localized RCC is treated with radical nephrectomy (removal of kidney, adrenal gland, and surrounding fat/fascia) or partial nephrectomy (nephron-sparing surgery), which is preferred for smaller tumors. Laparoscopic/robotic approaches are now standard. RCC is resistant to traditional chemotherapy and radiation.

  • Transitional Cell Carcinoma (TCC): Cancer of the renal pelvis lining. Because of the risk of tumor seeding down the urinary tract, treatment is nephroureterectomy, which includes removal of the kidney, the entire ureter, and a cuff of the bladder.

Urinary Stone Disease (Nephrolithiasis)

A common condition affecting over 500,000 people annually in the US, with a higher incidence in men aged 30-50.

Stone Types and Risk Factors

Clinical Presentation and Evaluation

• Presentation: The hallmark is renal colic—severe, intermittent flank pain that often radiates to the groin, accompanied by nausea and vomiting. Microscopic hematuria is common.

• Evaluation: The gold standard for diagnosis is a non-contrast CT scan of the abdomen and pelvis.

Treatment

• As mentioned, obstructive pyelonephritis is a urologic emergency requiring immediate drainage.

• Spontaneous Passage: Stones < 5 mm often pass on their own.

• Medical Therapy: Uric acid stones can be dissolved by increasing urine pH (alkalization).

• Interventional Treatment: For stones that are large, symptomatic, or fail to pass.

  • Ureteroscopy: A small scope is passed up the ureter to visualize the stone, which can then be fragmented with a laser (e.g., Holmium laser) and removed.

  • Extracorporeal Shock Wave Lithotripsy (ESWL): Uses focused shock waves from outside the body to break the stone into passable fragments.

  • Percutaneous Nephrolithotomy (PCNL): For large kidney stones (e.g., staghorn calculi). A tract is created from the back directly into the kidney to remove the stone.

THE URETERS

The ureters are muscular tubes that transport urine from the kidneys to the bladder, featuring a crucial one-way valve mechanism.

Anatomy and Function

The ureters enter the bladder wall obliquely. This path, combined with peristaltic contractions, creates a functional one-way valve that prevents vesicoureteral reflux (VUR)—the backflow of urine from the bladder to the kidneys. Increasing bladder pressure compresses the intramural portion of the ureter, closing it off.

Ureteral Obstruction

Blockage of a ureter can be caused by intrinsic factors (e.g., stones) or extrinsic compression (e.g., tumors from the colon or cervix, retroperitoneal fibrosis). This leads to hydronephrosis (swelling of the kidney). Diagnosis is made with CT or IVP. Initial management often involves placing a ureteral stent to relieve the obstruction.

Iatrogenic Injuries

The ureters are at risk of injury during pelvic surgeries (e.g., hysterectomy, colectomy). If an injury is recognized, it can often be repaired with a primary end-to-end anastomosis. If the distal ureter is injured, a ureteral reimplantation into the bladder is performed. Prophylactic stenting before high-risk surgery can aid in intraoperative identification.

THE BLADDER

The bladder is a hollow, muscular organ that functions as a reservoir for urine.

Anatomy

• The bladder wall is composed of interlacing smooth muscle bundles called the detrusor muscle.

• It is lined by transitional epithelium (urothelium).

• The trigone is a triangular area at the bladder base between the two ureteral orifices and the urethral opening.

• The bladder is attached to the pubic bone by the pubovesical/puboprostatic ligaments.

Evaluation

• Cystourethroscopy: Endoscopic visualization of the bladder and urethra to inspect for tumors, stones, strictures, or signs of obstruction (e.g., trabeculation).

• Urodynamic Evaluation: A set of tests to assess bladder function.

  • Cystometrogram (CMG): Measures bladder pressure during filling to assess capacity, compliance (stretchiness), sensation, and detect involuntary detrusor contractions.

  • Uroflow Test: Measures the rate of urine flow.

  • Postvoid Residual (PVR): Measures urine remaining after voiding.

Congenital Anomalies

• Vesicoureteral Reflux (VUR): The backflow of urine from the bladder into the ureters, usually due to an abnormally short intramural ureteral tunnel. It is a common cause of UTIs in children and can lead to kidney scarring and damage.

  • Grading: Reflux is graded I (mild) to V (severe). Lower grades often resolve spontaneously with age.

  • Treatment: Goals are to prevent kidney damage. Options include long-term prophylactic antibiotics, endoscopic injection of bulking agents (e.g., Deflux) near the ureteral orifice, or surgical ureteral reimplantation to lengthen the submucosal tunnel.

• Bladder Exstrophy: A rare, severe anomaly where the bladder and anterior abdominal wall fail to close, leaving the inner bladder wall exposed. This requires complex surgical reconstruction and carries an increased risk of bladder adenocarcinoma.

Trauma

Bladder rupture can result from blunt trauma (e.g., a car accident with a full bladder) or penetrating injury, and is often associated with pelvic fractures.

• Types:

  • Extraperitoneal Rupture: Urine leaks into the space around the bladder. Small ruptures can be managed with catheter drainage alone.

  • Intraperitoneal Rupture: Urine leaks into the abdominal cavity. This type requires surgical repair.

• Diagnosis: A cystogram is the definitive test. A catheter is placed, the bladder is filled with contrast, and X-rays are taken to look for extravasation.

Inflammatory and Other Non-Malignant Conditions

• Bacterial Cystitis (UTI): An infection of the bladder, far more common in women. Symptoms include frequency, urgency, and dysuria. Diagnosis is by urinalysis and culture. Treatment is with antibiotics.

• Interstitial Cystitis / Bladder Pain Syndrome (IC/BPS): A chronic condition of unknown etiology characterized by pelvic pain and irritative voiding symptoms with sterile urine. It is a diagnosis of exclusion. Cystoscopy may show glomerulations (petechial hemorrhages) or a Hunner's ulcer. Treatment is difficult and focuses on symptom management.

• Bladder Fistulae: Abnormal connections between the bladder and another organ.

  • Vesicoenteric Fistula (to bowel): Commonly caused by diverticulitis. Presents with pneumaturia (air in urine) or fecaluria (feces in urine).

  • Vesicovaginal Fistula (to vagina): Often caused by prolonged labor or surgical injury. Presents with continuous leakage of urine.

Urinary Incontinence

The involuntary loss of urine, classified by symptoms:

• Stress Incontinence: Leakage with increased intra-abdominal pressure (coughing, sneezing). Caused by urethral hypermobility or sphincter weakness.

• Urge Incontinence: Leakage preceded by a sudden, strong desire to void. Caused by involuntary bladder contractions (detrusor overactivity).

• Overflow Incontinence: Leakage from an overfull bladder, usually due to outlet obstruction (like BPH) or a weak detrusor muscle.

• Total Incontinence: Continuous leakage, characteristic of a fistula.

Treatment

• Urge Incontinence: Often treated with anticholinergic medications (e.g., oxybutynin) to relax the bladder muscle.

• Stress Incontinence: Treated with procedures to support the bladder neck and urethra. The most common is a mid-urethral sling procedure, where a strip of synthetic mesh or fascia is placed under the urethra to provide support. An artificial urinary sphincter may be used in men, particularly after prostatectomy.

Neurogenic Bladder Dysfunction

A bladder that does not function properly due to neurologic disease or injury (e.g., spinal cord injury, multiple sclerosis, diabetes).

Classification (Lapides)

• Uninhibited Neurogenic Bladder: Loss of cerebral inhibition leads to uncontrolled contractions (urgency, frequency). Seen in stroke, dementia.

• Reflex Uninhibited Bladder: Bladder contracts reflexively without sensation due to a spinal cord lesion above the sacral level. Often associated with detrusor-sphincter dyssynergia (sphincter contracts instead of relaxes during voiding), leading to high pressures and inefficient emptying.

• Autonomic Neurogenic Bladder: Damage to sacral nerves causes a flaccid, areflexic bladder that cannot contract. Leads to overflow incontinence.

Treatment Goals

The primary goals are to preserve renal function by maintaining low bladder storage pressures, ensure adequate emptying, and achieve continence.

• Management Strategies:

  • Anticholinergic medications to suppress overactive contractions and improve bladder compliance.

  • Clean Intermittent Catheterization (CIC) is the preferred method for emptying a bladder that retains urine.

  • Bladder Augmentation: Surgical enlargement of the bladder using a segment of bowel to create a large-capacity, low-pressure reservoir.

Malignant Diseases: Bladder Cancer

The fifth most common malignancy, strongly associated with cigarette smoking and certain industrial chemical exposures. Most are transitional cell carcinomas (TCC).

Evaluation and Staging

• Presentation: The most common sign is gross, painless hematuria.

• Evaluation: Includes urine cytology, cystoscopy (to visualize and biopsy the tumor), and upper tract imaging (CT urogram).

• Staging: Based on the depth of tumor invasion into the bladder wall.

  • Non-Muscle Invasive (Ta, T1, Tis): Confined to the mucosa or lamina propria.

  • Muscle Invasive (T2 and higher): Invades the detrusor muscle.

Treatment

• Non-Muscle Invasive Bladder Cancer (NMIBC):

  • Transurethral Resection of Bladder Tumor (TURBT): For diagnosis, staging, and initial treatment.

  • Intravesical Therapy: Drugs instilled directly into the bladder to reduce recurrence. Bacillus Calmette-Guérin (BCG) is an immunotherapy and the most effective agent for high-risk NMIBC and carcinoma in situ (Tis).

• Muscle Invasive Bladder Cancer (MIBC):

  • Radical Cystectomy: The standard treatment. Involves removal of the bladder, prostate (in men), or uterus/anterior vaginal wall (in women), along with pelvic lymph nodes.

  • Urinary Diversion: After cystectomy, a new way for urine to exit the body must be created. Options include an ileal conduit (urine drains into a stoma bag on the abdomen) or an orthotopic neobladder (a new bladder is created from bowel and connected to the urethra, allowing for more natural voiding).

THE PENIS

The penis is composed of three erectile bodies: two corpora cavernosa and one corpus spongiosum, which contains the urethra.

Trauma

• Penile Fracture: A rupture of the tunica albuginea of a corpus cavernosum, typically occurring during intercourse. It presents with a "cracking" sound, immediate pain, and detumescence. This is a surgical emergency requiring exploration and repair to prevent erectile dysfunction and curvature.

• Avulsion Injury: Skin is torn from the shaft, often in industrial accidents. Requires skin grafting for repair.

Malignant and Premalignant Diseases

Premalignant Lesions

These lesions have the potential to develop into squamous cell carcinoma and require treatment such as local excision or topical therapy.

Squamous Cell Carcinoma

Rare in the US, but more common in regions with poor hygiene. It is extremely rare in men circumcised at birth. Treatment for localized disease involves partial or total penectomy. Metastasis occurs first to the inguinal lymph nodes.

Acquired Disorders

• Priapism: A prolonged erection lasting more than 4 hours, not associated with sexual desire. Only the corpora cavernosa are turgid.

  • Low-Flow (Ischemic) Priapism: A urologic emergency caused by blocked venous outflow. Blood in the corpora becomes sludgy and ischemic, leading to fibrosis and permanent impotence if not treated. Treatment involves aspiration of blood and injection of a vasoconstrictor (e.g., phenylephrine).

  • High-Flow (Non-Ischemic) Priapism: Caused by unregulated arterial inflow, usually from trauma creating a fistula. This type is not an emergency.

• Phimosis: The inability to retract the foreskin over the glans penis, usually due to scarring from chronic inflammation. Managed with hygiene and elective circumcision.

• Paraphimosis: The inability to pull a retracted foreskin back over the glans. The tight band of foreskin causes swelling and can cut off blood supply to the glans. This is a urologic emergency requiring manual reduction or incision of the constricting band.

• Peyronie’s Disease: Scarring (plaque formation) of the tunica albuginea, leading to penile curvature, pain with erections, and potential erectile dysfunction. Treatment is considered for stable, mature disease that prevents intercourse and can include plaque incision/grafting or placement of a penile prosthesis.

THE URETHRA

The urethra is the tube that carries urine from the bladder out of the body.

Anatomy

• Male Urethra: Long (~20 cm) and divided into posterior (prostatic, membranous) and anterior (bulbar, penile) portions.

• Female Urethra: Short (~4 cm), making women more susceptible to ascending UTIs.

Trauma

• Anterior Urethral Injury: Often from a "straddle injury" (e.g., falling on a bicycle bar), affecting the bulbar urethra.

• Posterior Urethral Injury: Often associated with severe pelvic fractures, causing disruption at the prostatomembranous junction.

• Evaluation: A retrograde urethrogram (RUG) is essential for diagnosis. A catheter should not be blindly inserted if urethral injury is suspected (e.g., blood at the meatus, high-riding prostate on DRE).

• Treatment: Initial management is urinary diversion with a suprapubic tube. Definitive repair is often delayed.

Urethral Strictures

A scarring and narrowing of the urethral lumen, often caused by prior trauma, instrumentation, or infection (historically, gonorrhea). Patients present with obstructive voiding symptoms.

• Evaluation: Diagnosed with cystoscopy and a retrograde urethrogram (RUG) to define the length and location.

• Treatment:

  • Endoscopic Management: Dilation or direct visual internal urethrotomy (DVIU). These are less invasive but have high recurrence rates for complex strictures.

  • Open Urethroplasty: The definitive cure, with success rates >90%. For short strictures, the scar tissue is excised and a primary anastomosis is performed. For long strictures, tissue transfer (buccal mucosa graft or skin flap) is required.

Congenital Disorders

• Posterior Urethral Valves (PUV): The most common cause of congenital bladder outlet obstruction in males. Membranous folds in the posterior urethra obstruct urine flow, causing bladder distention, VUR, and potential kidney damage. Often diagnosed via antenatal ultrasound. Initial treatment is catheter drainage, followed by endoscopic ablation of the valves.

• Hypospadias: A common anomaly (1 in 300 births) where the urethral meatus opens on the ventral (underside) surface of the penis. It is often associated with a dorsal hooded foreskin and ventral curvature (chordee). Surgical repair is typically performed before 1 year of age to correct the curvature and create a neourethra to the tip of the glans.

THE TESTES, MALE INFERTILITY, AND IMPOTENCY

The Testes

Embryology and Anatomy

The testes develop in the retroperitoneum and descend into the scrotum, guided by the gubernaculum. Their lymphatic drainage is to the retroperitoneal (preaortic and precaval) lymph nodes, a critical fact for testicular cancer staging and treatment.

Key Scrotal and Testicular Conditions

• Cryptorchidism (Undescended Testis): A testis that has not descended into the scrotum. It is associated with a 48-fold increased risk of testicular cancer and infertility. Surgical correction (orchiopexy) does not eliminate the cancer risk but allows for easier surveillance.

• Hydrocele/Hernia: A hydrocele is a fluid collection around the testis due to a patent processus vaginalis. An inguinal hernia involves abdominal contents passing through this opening.

• Testicular Torsion: Twisting of the spermatic cord, which cuts off blood supply to the testis. It presents with acute scrotal pain and swelling.

  Testicular Torsion is a Surgical Emergency
  Irreversible ischemic damage can occur within 6 hours. Diagnosis can be supported by color Doppler ultrasound showing absent blood flow, but surgical exploration should not be delayed if suspicion is high. Treatment involves surgical detorsion and fixation (orchiopexy) of both testes to prevent recurrence.

• Fournier's Gangrene: A life-threatening necrotizing fasciitis of the perineum and scrotum. It requires emergent, aggressive surgical debridement and broad-spectrum antibiotics.

Malignant Diseases: Testicular Cancer

The most common solid malignancy in men aged 18-35. It presents as a painless, solid mass in the testicle.

• Evaluation: A scrotal mass that does not transilluminate is concerning. Ultrasound is the primary imaging modality. Surgical exploration is performed via an inguinal incision to control the spermatic cord before manipulating the testis. A scrotal incision is contraindicated due to altered lymphatic drainage.

• Tumor Markers:

  • Alpha-fetoprotein (AFP): Elevated only in nonseminomatous germ cell tumors (NSGCT).

  • Beta-human chorionic gonadotropin (-hCG): Can be elevated in both seminomas and NSGCTs.

• Treatment: Is based on histology (seminoma vs. nonseminoma) and stage.

  • Seminoma: Very radiosensitive. Early-stage disease is treated with surveillance or retroperitoneal radiation. Advanced disease is treated with chemotherapy.

  • Nonseminoma (NSGCT): Early-stage disease can be treated with surveillance or retroperitoneal lymph node dissection (RPLND). Advanced disease requires platinum-based chemotherapy. Testicular cancer is highly curable, even with metastatic disease.

Male Infertility

A male factor is responsible or partially responsible in up to 60% of infertile couples. Evaluation is warranted after one year of unprotected intercourse without conception.

Evaluation and Treatment

• Semen Analysis: The cornerstone of evaluation, assessing sperm count, motility, and morphology. Azoospermia (no sperm) or oligozoospermia (low sperm count) requires further investigation.

• Varicocele: A dilation of the veins in the spermatic cord ("bag of worms" feel). It is the most common correctable cause of male infertility. Repair is an option for men with a varicocele and abnormal semen parameters.

• Obstruction: Blockage of the vas deferens or ejaculatory ducts can cause azoospermia. This may be correctable with microsurgery (vasovasostomy or vasoepididymostomy).

Impotency (Erectile Dysfunction - ED)

The inability to achieve or maintain an erection sufficient for sexual performance. Over 85% of cases have an organic cause.

Causes

• Vasculogenic: Most common cause. Includes arterial insufficiency (from atherosclerosis, diabetes, hypertension) or venous leak.

• Neurogenic: From spinal cord injury, diabetes, or nerve damage during pelvic surgery (e.g., radical prostatectomy).

• Endocrinologic: Low testosterone can decrease libido and contribute to ED.

• Psychogenic: Can be primary or secondary to an organic cause.

Treatment

• First-Line Therapy: Oral PDE-5 inhibitors (sildenafil, tadalafil, vardenafil). They work by increasing blood flow to the penis but require sexual stimulation to be effective.

• Second-Line Therapies:

  • Vacuum Erection Device: A pump that creates a vacuum to draw blood into the penis.

  • Intracavernosal Injections or Urethral Suppositories: Vasoactive drugs (e.g., alprostadil) administered directly to cause an erection.

• Third-Line Therapy: Penile Prosthesis. A surgically implanted device that provides a permanent solution for ED when other treatments fail.

SKILLS: BLADDER CATHETERIZATION

A common procedure to drain urine from the bladder. Aseptic technique is crucial.

Male Catheterization

1. Gather all materials: catheter kit (16 Fr Foley is standard), sterile gloves, antiseptic solution, lubricant, and a 10 mL syringe with water.

2. Position the patient supine and drape appropriately.

3. Grasp the penis with your non-dominant hand, holding it with upward traction. If uncircumcised, retract the foreskin. This hand is now non-sterile.

4. Clean the glans and meatus with antiseptic solution using your dominant hand.

5. Liberally lubricate the catheter tip. Injecting 10 mL of lubricant directly into the urethra is highly recommended to facilitate passage.

6. Slowly and gently insert the catheter into the meatus. Advance the catheter all the way to the bifurcation (Y-port), even after urine returns. This ensures the balloon is fully inside the bladder and not in the urethra.

7. Once urine is seen and the catheter is fully inserted, inflate the balloon with 7-10 mL of sterile water.

8. Gently pull back until resistance is felt, connect to a drainage bag, and secure the catheter to the thigh. Remember to reduce the foreskin if it was retracted.

Female Catheterization

1. Position the patient in a frog-leg or lithotomy position.

2. With your non-dominant hand, spread the labia to expose the urethral meatus, which is located below the clitoris and above the vaginal opening.

3. Clean the meatus with antiseptic solution.

4. Insert the lubricated catheter until urine returns, then advance it another 2-3 inches to ensure it is well within the bladder.

5. Inflate the balloon, attach the drainage bag, and secure to the thigh.

Difficulties During Male Catheterization

Resistance is commonly encountered at the level of the external sphincter or the prostate.

Important Precaution:
Never force a catheter. Doing so can create a false passage or urethral injury. Never inflate the balloon unless you are certain it is in the bladder (confirmed by full insertion and urine return).

• Troubleshooting Resistance:

  • Inject more lubricant into the urethra.

  • Try a coude-tip catheter (size 18-20 Fr). The curved tip is designed to navigate the curve at the prostate. Keep the tip pointing upward (12 o'clock position) during insertion.

  • If a urethral stricture is suspected, a smaller catheter might work, but urologic consultation is often necessary.