- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
172 CHAPTER 5 Infections and inflammatory conditions
Interstitial cystitis
Interstitial cystitis (IC) is a refractory bladder disorder of unknown etiology. Also known as painful bladder syndrome, IC is characterized by daytime and nighttime urinary frequency, urgency, suprapubic and pelvic pain of unknown etiology, and no identifiable pathological cause.
The presence of glomerulations on cystoscopic examination (petechiae seen after bladder wall distention) or Hunner’s ulcers may help confirm clinical suspicion. Only 5% of cases are associated with Hunner’s ulcers (focal regions of panmural inflammation).
The symptom complex is similar to that of prostatitis type IIIB noninflammatory CPPS (prostatodynia).
IC is a diagnosis of exclusion (see Table 5.5). It is diagnosed once other causes for these symptoms have been excluded (e.g., TB, radiation cystitis, bladder tumor, overactive bladder). The presence of uninhibited bladder contractions on urodynamics excludes a diagnosis of IC.
In 1988, the National Institute of Diabetes, Digestive, and Kidney Diseases (NIDDK) described criteria for IC. However, originally developed for research purposes, it identifies patients with more severe disease and some experts do not recommended it for use in clinical practice.
Epidemiology
IC predominantly affects females (~90%). Estimated female prevalence is 18.1 cases per 100,000 from European studies. American data suggest higher rates of 52–67 per 100,000.
Associated disorders
A higher prevalence of allergies, irritable bowel syndrome, fibromyalgia, focal vulvitis, lupus, and Sjögren syndrome has been reported in IC. Anxiety, depression, and adjustment reactions are also found.
Pathogenesis
IC appears to be a multifactorial syndrome. Possible contributing factors include the following:
•Increased mast cells. Studies have demonstrated increased mast cells in bladder smooth muscle (detrusor). Activated mast cells release histamine, which can cause pain, hyperemia, and fibrosis in tissues.
•Defective bladder epithelium. An abnormal glycosaminoglycan (GAG) layer may allow urine to leak past the luminal surface, causing inflammation in muscle layers.
•Neurogenic mechanisms. Abnormal activation of sensory nerves causes release of neuropeptides, resulting in neurogenic inflammation.
•Reflex sympathetic dystrophy of the bladder. Excessive sympathetic activity
•Urinary toxins or allergens
•Bladder autoimmune response
Evaluation
Exclude other causes for symptoms (see Table 5.5). History, examination (including pelvic in women and DRE in men), urinalysis, and culture are
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INTERSTITIAL CYSTITIS |
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Table 5.5 NIDDK* diagnostic criteria for interstitial cystitis |
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Diagnosis criteria |
1. |
Cystoscopic evidence of Hunner’s ulcer |
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or petechiae (glomerulations) |
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2. |
Bladder/pelvic pain or urinary urgency |
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Exclusion criteria |
1. |
Bladder capacity >350 mL, measured by awake |
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cystometry |
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2.Lack of urgency with a 150mL injection in cystometry
3.Uninhibited contractions during cystometry
4.<9 months from onset
5.Absence of nocturia
6.Symptoms improved by antibiotics, anticholinergics, or antispasmodics
7.Daytime voids <8
8.Bacterial cystitis or prostatitis within 3 months
9.Bladder or ureteral calculi
10.Genital herpes
11.Uterine, cervical, vaginal, or urethral cancer
12.Urethral diverticulum
13.Cyclophosphamideor drug-induced cystitis
14.Tuberculous cystitis
15.Radiation cystitis
16.Bladder tumor
17.Vaginitis
18.<18 years old
* National Institute of Diabetes and Digestive and Kidney Diseases.
mandatory. The IC symptom index questionnaire and voiding diaries are useful. Urodynamics has limited role. Diagnostic studies are as follows.
Cystoscopy
Ten percent of patients will have pink ulceration of bladder mucosa (Hunner’s ulcer). Under anesthesia, the bladder should be distended twice (to 80–100 cmH2O for 1–2 min) and then inspected for diffuse glomerulations (>10 per quadrant in ¾ bladder quadrants).
Bladder biopsy is only indicated to rule out other pathologies such as carcinoma in situ. In conscious patients, bladder filling causes pain and reproduces symptoms.
174 CHAPTER 5 Infections and inflammatory conditions
Intravesical KCl challenge
In 75% of IC patients, installation of 0.4 M KCl into the bladder will provoke pain and symptoms.
Treatment
Patients should understand that there is no known cure, and treatment is for symptom control. The Interstitial Cystitis Association, at www.ichelp. org, is a useful patient resource. Stress reduction, exercise, and diet modification may be helpful.
There are only two FDA-approved medications:
•Pentosan polysulfate sodium: 100 mg PO tid; augments protective GAG layer of bladder to minimize irritative effects
•50% Dimethylsulfoxide (DMSO), weekly intravesical instillation x6 weeks; often used as cocktail with triamcinolone, heparin sodium, NaHCO3
All other medications are off-label.
Oral medications
Tricyclics (amitriptyline) have anticholinergic, antihistamine, and sedative effects. Narcotics are to be avoided.
Nerve stimulation
Transcutaneous electrical nerve stimulation (TENS) or sacral neuromodulation can be used.
Surgery
Transurethral resection, laser coagulation or diathermy of Hunner’s ulcers, and bladder hydrodistention under anesthesia may be beneficial, otherwise surgery should only be considered after failed conservative treatments. Rarely, urinary diversion cystectomy or enterocystoplasty may be required.
Further reading
Moldwin RM, Evans RJ, Stanford EJ, et al. (2007). Rational approaches to the treatment of patients with interstitial cystitis. Urology 69(Suppl 4A):73.
Payne CK, Joyce GF, Wise M, et al. (2007). Interstitial cystitis and painful bladder syndrome. J Urol 177:2042.
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