Urological Problems Every Surgeon Should Know

1
Urological Problems Every Surgeon Should Know

• Sidney B. Radomski, MD, FRCSC
• Associate Professor of Surgery
• Division of Urology
• Toronto Western Hospital (UHN)

University of Toronto
2
Pain

• - usually due to either urinary tract
  obstruction or inflammation
• tumors usually do not cause pain unless advanced
  due to invasion of other structures or cause
  obstruction
• of renal origin may be associated with GI
  symptoms
• patients with intraperitoneal pathology prefer to
  lie motionless to minimize pain
• however renal pain (i.e..colic) are usually more
  comfortable moving around

3
Pain

• renal pain may be confused with pain resulting
  from irritation of the costal nerves mostly T10-
  T12, pain from obstruction is due to renal
  capsule or ureteral distention or spasms of the
  ureter
• location of the pain is generally reflective of
  the location of the pathology
• urinary retention (acute) produces S/P pain -
  chronic retention rarely causes pain

4
Pain

• pain in prostate is generally referred to the
  perineum (i.e. acute prostatitis) and has
  associated irritative voiding symptoms
• pain in scrotum/testicles often related to
  epididymitis, torsion or hernia if acute (chronic
  pain can be from a hydrocele or varicocele)
• always be aware of the possibility of Fournier's
  gangrene

5
Hematuria

• gt3 RBC/hpf
• Is it gross or microscopic?
• Initial, terminal, throughout?
• Painless or painful?
• 6 steps in the investigation

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Hematuria

• (1) History
• (2) Physical
• (3) Urinalysis and urine cs and cytology
• (4) Imaging studies
• (5) Cystoscopy
• (6) Anything else that is needed (i.e..
  angiogram, retrograde pyelogram)
• urine dipstick myoglobinuria or hemoglobinuria

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Hematuria

• Cause of Gross Hematuria
• Man gt50 years old
• 1) Bladder cancer
• 2) BPH
• Woman gt 50 years old
• 1 )Bladder cancer
• 2) UTI

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Hematuria

• Micro and Gross Hematuria lt 50 years of age
• less likely a malignancy
• can be UTI, stone, cancer, idiopathic
• Irritative Voiding Symptoms - keep in mind they
  may represent bladder cancer

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Other GU Problems

• Obstructing Urinary Symptoms Usually due to BPH
  or a weak detrusor
• Incontinence - be aware of a fistula or urinary
  retention
• Hematospermia - usually almost always benign-
  blood in semen
• Pneumaturia - passage of gas in the urine
• due to a fistula between the intestine and
  bladder
• often due to diverticulitis, ca of sigmoid colon
  or Crohn' s disease
• rare causes are gas forming urinary tract
  infection

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Other GU Problems

• Paraphimosis- failure of the foreskin to be
  placed in its normal position - usually
  iatrogenic
• Phimosis - inability to retract the foreskin
• can cause balanitis, retention, UTI
• look out for penile cancer

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Urinalysis

• Colour
• Colourless - diluted urine
• Cloudy - phosphaturia, pyuria and chyluria
• Red - Hematuria, hemoglobinuria/myoglobinuria
• Orange - pyridium
• Brown - porphyria, Urobilinogen

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Urinalysis

• positive dipstick - can be hematuria,
  hemoglobinuria or myoglobinuria
• this can be distinguished by microscopic
  examination of spun urine (RBChematuria)
• in hemoglobinuria the supernatant will be pink,
  in myoblobinuria the serum remains clear
• false positive hematuria - exercise, large
  amounts of vit. C
• if hematuria associated with proteinuria -
  usually renal in origin
• ASA and anticoagulants may induce hematuria (30
  have pathology)

13
Urinalysis

• Normal urine contains no bilirubin and only a
  small amount of urobilinogen
• Conjugated bilirubin only appears in urine in
  pathologic conditions such as intrinsic hepatic
  disease or obstruction of the bile ducts
• Indirect bilirubin never appears in urine
• Urobilinogen is the end product of conjugated
  bilirubin metabolism
• Hemolysis and hepatocellular diseases that result
  in increased bile pigments can result in
  increased urinary urobilinogen

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Ureteric Obstruction (Chronic)

• extrinsic compression
• usually painless
• imaging studies, U/S, IVP, CT scan
• options to relieve obstruction nephrostomy tube
  or retrograde stent insertion
• benign conditions - pregnancy, BPH/retention
• AAA (Inflammatory), Vascular reconstruction
  (iliac)

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Ureteric Obstruction (Chronic)

• Ureteric injury/ligation during surgery
  (Hysterectomy 0.5 - 3 routine, 10-15 radical)
  Less often during general sx, orthopedics and
  vascular surgery
• Crohn's disease 5-20 (usually right distal
  ureter)
• Retroperitoneal Fibrosis (can be confused with
  lymphoma) (medial deviation of ureter)
  Retroperitoneal hemorrhage, retroperitoneal
  tumors
• Tumors of the cervix, endometrium, bladder,
  prostate, sigmoid colon and rectum

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Infections

• Acute Pyelonephritis - chills, fever, flank pain,
  bacteriuria and pyuria and WBC count elevated,
  UIS or CT - swollen kidney or patchy appearance
• Cause blood borne, obstruction ,stones, reflux
• Treatment IV and or oral antibiotics x14 days for
  gram negative bacteria
• Cystitis (bacterial) - dysuria, frequency,
  urgency, hematuria, bacteriuria and pyuria-
  usually no fever and no or a low WBC

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Infections

• oral antibiotics x 5-7 days usually for gram
  negative bacteria
• Indwelling catheters- 100 bacteriuria after 7
  days
• reduced infection on CIC
• do not need to give antibiotics in these
  instances unless symptomatic

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Infections

• Perinephric abscess - similar presentation to
  acute pyelo but fevers may persist despite
  antibiotics
• may need drainage
• U/S or CT scan very helpful
• Acute prostatitis - high fever, chills, low back
  pain and perineal pain, urinary symptoms,
  arthralgia very tender prostate and swollen
• serum WBC elevated, bacteriuria and WBC in urine
• Treatment IV antibiotics

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Retention

• pain, dribbling, suprapubic mass, incontinence
  due to BPH or stricture, neurogenic, musculogenic
• start with an indwelling catheter
• watch for a post obstructive diuresis
• post op due to narcotics, IV fluids,
  anticholinergic drugs

20
Urolithiasis

• calcium stones most common
• visible on KUB
• CT scan spiral non-contrast x-ray of choice
• Findings flank pain, CVA tenderness and lower
  abdominal pain, vomiting, urinary frequency
• Low grade temp and WBC count, ileus
• 90 hematuria, hydronephrosis and stones seen on
  x-ray
• pain sudden in onset, severe, cannot be still

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Oncology

• Bladder Cancer - suprapubic mass, hematuria
• history of smoking
• obstruction (hydronephrosis)
• irritative voiding symptoms
• on ASA or anticoagulants
• cystoscopy and imaging studies needed

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Oncology

• Renal Cancer - flank pain, palpable mass,
  hematuria
• imaging studies needed
• can be confused with TCC of renal pelvis

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Oncology

• Testicular Cancer - palpable mass, painless,
  non-tender
• lt age 40 years
• gt 50 years lymphoma
• spreads to periaortic nodes and chest
• needs U/S scrotum and abdomen, CXR, tumor markers
  AFP and Beta HCG, seminoma and non-seminoma
• most common cancer in this age group (lt 40)

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Oncology

• Prostate cancer - most common cancer in elderly
  men, 2nd or 3 most common cause of death in these
  men
• PSA (abnormal ifgt4), rectal exam
• TRUS and bx
• If cancer confined to prostate with a low PSA
  Radical Prostatectomy or Radiotherapy are best
  options of treatments
• Can spread locally or to iliac nodes
• Usually spreads to bone (osteoblastic or
  osteolytic)

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Oncology

• Higher the PSA greater the chance of spread
• If spread outside prostate then hormonal therapy
  is best option but not curative (LHRH agonist or
  orchiectomy and antiandrogens)
• Life span with bone mets once diagnosed generally
  lt 2 - 3 yrs
• Controversial if PSA screening should be done
  yearly, but a rectal exam should be definitely
  done

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Trauma

• Kidney- Blunt- MVA, falls (sudden deceleration
  90)
• Penetrating - knife, gunshot (10)
• Clinical hx very important
• Urinalysis - hematuria (gross or micro) (95)
  (may be absent in some cases)

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Trauma

• Classification Minor Injuries - small
  lacerations or subcapsular hematomas and
  contusions. Major renal trauma - deep lacerations
  (majority are penetrating), pedicle injuries,
  shattered kidneys 70 of renal injuries are minor
  and can be treated conservatively
• 10-15 are renal pedicle injuries or shattered
  kidneys and require surgery
• in the other 15-20 treatment is controversial
• in most significant renal injuries other organs
  are involved (rarely renal alone)

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Trauma

• Evaluation Imaging studies very important - need
  2 kidneys. CT scan spiral with contrast - gold
  standard. IVP (high dose) - 1,5,15 and 30 min.
  can be done in emergency and OR but not as good
  as CT. U/S- not generally as accurate as CT and
  IVP
• Urinalysis - micro vs gross hematuria
• No hematuria?
• Renal Imaging is indicated in all patients with
  penetrating trauma but only in adult blunt trauma
  patients with gross hematuria or microhematuria
  plus shock

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Trauma

• Indications for surgery in renal trauma
• uncontrolled bleeding
• renovascular injury
• nonviable parenchyma .
• major urinary extravasation

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Trauma

• Bladder Trauma - usually blunt
• extraperitoneal vs intraperitoneal
• 95 hematuria
• cystogram - fill bladder with dye (gt250 - 300cc)
  - pre and post pictures
• intraperitoneal needs repair
• extraperitoneal can be managed with a large Foley
• extraperitonea1 more common, gt90 associated with
  a pelvic fracture
• make sure no urethral trauma

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Trauma

• Urethral Injury - usually posterior urethra more
  severe
• gt90 pelvic fracture
• partial or complete tear
• blood at meatus or if suspicious then do a
  retrograde urethrogram
• if rupture classic treatment is S/P tube
  insertion
• should always do a cystogram also

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Scrotum and Contents
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Scrotum and Contents
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Must-not-miss masses

• Testicular torsion
• Epididymitis
• Acute orchitis
• Strangulated hernia
• Testicular cancer
• Refer to a urologist

Junnila and Lassen Am Fam Phys, 1998
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Torsion

• Two types torsion of appendices or testicles
• I. Torsion of the Appendices
• Twisting of testicular/epididymal appendix
• Often lt 16 years of age
• Signs and symptoms
• clinically similar to testicular torsion
• "blue dot sign" - blue infarcted appendage seen
  through scrotal skin (can usually be palpated as
  small, tender lump)
• point tenderness over the superior-posterior
  portion of testicle
• Treatment
• analgesia - most will subside over 5-7 days
• surgical exploration and excision if diagnosis
  uncertain or refractory pain

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Torsion

• II. Testicular Torsion (spermatic cord torsion)
• 1/4000, males lt 25 years
• predisposing factors
• cryptorchid testis
• trauma (although 50 occur during sleep)
• bell clapper congenital deformity
• narrow mesenteric attachment from cord on to
  testis/epididymis gt testis falls forward and is
  free to rotate within tunica vaginalis
• anomalous development of tunica vaginalis or
  spermatic cord

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Torsion
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Torsion

• Signs and symptoms
• acute onset of severe scrotal pain, swelling /-
  nausea/vomiting
• retracted and transverse testicle (horizontal
  lie)
• no pain relief with testicle elevation (negative
  Prehns sign)
• epididymis may be palpated anteriorly in the
  early stages

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Torsion

• Diagnosis
• ultrasound with colour-flow Doppler probe over
  testicular artery (if torsion, no blood flow)
• decrease uptake on 99M Tc-pertechnetate
  scintillation scan
• examination under anesthesia and surgical
  exploration

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Torsion

• Treatment
• emergency detorsion (rotate "outward") /
  elective bilateral orchiopexy
• failure of manual detorsion requires surgical
  detorsion and bilateral orchiopexy (fixation)
• lt 12 hours - good prognosis
• 12-24 hours - uncertain prognosis, testicular
  atrophy
• gt 24 hours - poor prognosis, orchiectomy is
  advised

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Epididymitis

• Etiology
• Infection
• lt 35 years - gonorrhea or Chlamydia (STDs)
• gt 35 years - coliforms (from GI tract)
• Prior instrumentation
• Reflux
• increased pressure in prostatic urethra
  (straining, voiding, heavy lifting) causes reflux
  of urine along vas deferens gt sterile
  epididymitis

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Epididymitis

• Signs and symptoms
• sudden onset scrotal pain and swelling /
  radiation along cord to flank
• scrotal erythema and tenderness
• fever
• irritative voiding symptoms
• reactive hydrocele, epididymo-orchitis

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Epididymitis

• Diagnosis
• urinalysis (pyuria), urine CS
• / urethral discharge Gram stain for
  gram-negative cocci or rods
• Pain may be relieved with elevation of testicles
  (Prehns sign), absent in testicular torsion
• if diagnosis uncertain,
• colour-flow Doppler ultrasound
• nuclear medicine scan
• (examination under anesthesia)

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Epididymitis

• Treatment
• Antibiotics
• GC or Chlamydia - ceftriaxone 250 mg IM once
  followed by doxycycline 100 mg BID x 21 days
• Coliforms broad spectrum antibiotics x 2 weeks
• Scrotal support, ice, analgesia

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Orchitis

• Etiology
• Usually a result of bacterial infection
  (epididymo-orchitis)
• 30 of post-pubertal males with mumps get
  orchitis
• Mumps orchitis usually follows parotitis by 3-4
  days
• Other rare causes
• tuberculosis (TB)
• syphilis
• granulomatous (autoimmune) in elderly men

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Orchitis

• Signs and symptoms
• fever
• / hydrocele
• Diagnosis
• red, swollen scrotum
• blue testis
• no urinary symptoms

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Orchitis

• Treatment
• mumps hyperimmune globulin
• analgesics, antipyretics
• steroids
• ice, bed rest, scrotal elevation
• Complications
• if severe, testicular atrophy
• 30 have persistent infertility problems

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Strangulated hernia

• Clinical diagnosis
• Refer to emergency or general surgery

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Testicular Tumours

• any solid testicular mass in young patient must
  rule out malignancy
• slightly more common in right testis (corresponds
  with slightly higher incidence of right-sided
  cryptorchidism)
• 2-3 bilateral (simultaneously or successively)

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Testicular Tumours

• Primary
• 1 of all malignancies in males
• most common solid malignancy in males aged 15-34
  years
• undescended testicle has increased risk (10-40x)
  of malignancy
• 95 are germ cell tumours (all are malignant)
• seminoma (35)
• nonseminomatous germ cell tumours (NSGCT)
• embryonal cell carcinoma (20)
• teratoma (5)
• choriocarcinoma (lt1)
• yolk sac (ltlt1)
• mixed cell type (40)

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Testicular Tumours

• Primary
• 5 are non-germinal cell tumours (usually benign)
• Leydig (testosterone, precocious puberty)
• Sertoli (gynecomastia, decreased libido)
• Secondary
• male gt 50 years of age
• usually a lymphoma
• metastases (e.g. lung, prostate, GI)

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Testicular Tumours

• Etiologic factors
• congenital cryptorchidism
• acquired trauma, atrophy, sex hormones
• Signs and symptoms
• painless testicular enlargement
• painful if intratesticular hemorrhage or
  infarction
• firm, non-tender mass
• dull, heavy ache in lower abdomen, anal area or
  scrotum
• associated hydrocele in 10

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Testicular Tumours

• Signs and symptoms
• coincidental trauma in 10
• gynecomastia due to secretory tumour effects
• metastatic disease related back pain
• supraclavicular and inguinal nodes
• abdominal mass (retroperitoneal lymph node
  metastases)

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Testicular Tumours

• Investigations
• testicular ultrasound (hypoechoic area within
  tunica albuginea high suspicion of testicular
  cancer)
• Chest x-ray (lung metastases)
• markers for staging (ßhCG, AFP, LDH)
• CT abdomen/pelvis (retroperitoneal nodes
  enlarged)
• needle aspiration contraindicated

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Hematocele

• trauma with bleed into tunica vaginalis
• ultrasound helpful to exclude fracture of testis
  which requires surgical repair
• Treatment ice packs, analgesics, surgical repair

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Hydrocele

• Types
• communicating hydrocele patent processus
  vaginalis (a form of indirect inguinal hernia)
• non-communicating hydrocele processus vaginalis
  is not patent
• Diagnosis
• usually a non-tender cystic intrascrotal mass
  which transilluminates
• ultrasound (definitive), especially if lt 40 years
  of age (rule out tumour)

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Hydrocele

• Treatment
• nothing if tolerated and no complications
• surgical

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Spermatocele/Epidydimal Cyst

• Definition
• collection of sperm in the appendix epididymis
• located at superior pole of testicle
• Diagnosis
• aspirate contains sperm
• transilluminates
• Treatment
• usually no treatment
• excise only if symptomatic

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Varicocele

• Etiology
• dilated veins in the pampiniform plexus (90 on
  left side) incompetent valves in testicular
  veins
• left internal spermatic vein is longer and joins
  the left renal vein (on the right it empties into
  the vena cava)
• rarely from retroperitoneal tumour
• 10 incidence in young men
• 30 of men with infertility have it (associated
  with testicular atrophy)

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Varicocele
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Varicocele

• Diagnosis
• usually asymptomatic, but may be painful
• upright - mass of dilated, tortuous veins, bag
  of worms
• heavy sensation after walking or standing
• supine - venous distention abates
• pulsates with Valsalva or cough

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Varicocele

• Treatment
• surgical ligation of testicular vein above
  inguinal ligament
• percutaneous vein occlusion (balloon catheter,
  sclerosing agents)
• in the presence of oligospermia, surgically
  correcting the varicocele may improve sperm count
  and motility in 50-75 of patients

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Conclusions

• Common
• Painless and painful
• Important and not important
• Key Physical exam and ultrasound

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References

• Campbells Urology
• Smiths Urology
• Gillenwater