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Urological Problems Every Surgeon Should Know

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Title: 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

6
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

7
Hematuria
  • Cause of Gross Hematuria
  • Man gt50 years old
  • 1) Bladder cancer
  • 2) BPH
  • Woman gt 50 years old
  • 1 )Bladder cancer
  • 2) UTI

8
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

9
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

10
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

11
Urinalysis
  • Colour
  • Colourless - diluted urine
  • Cloudy - phosphaturia, pyuria and chyluria
  • Red - Hematuria, hemoglobinuria/myoglobinuria
  • Orange - pyridium
  • Brown - porphyria, Urobilinogen

12
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

14
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)

15
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

16
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

17
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

18
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

19
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

21
Oncology
  • Bladder Cancer - suprapubic mass, hematuria
  • history of smoking
  • obstruction (hydronephrosis)
  • irritative voiding symptoms
  • on ASA or anticoagulants
  • cystoscopy and imaging studies needed

22
Oncology
  • Renal Cancer - flank pain, palpable mass,
    hematuria
  • imaging studies needed
  • can be confused with TCC of renal pelvis

23
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)

24
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)

25
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

26
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)

27
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)

28
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

29
Trauma
  • Indications for surgery in renal trauma
  • uncontrolled bleeding
  • renovascular injury
  • nonviable parenchyma .
  • major urinary extravasation

30
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

31
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

32
Scrotum and Contents
33
Scrotum and Contents
34
Must-not-miss masses
  • Testicular torsion
  • Epididymitis
  • Acute orchitis
  • Strangulated hernia
  • Testicular cancer
  • Refer to a urologist

Junnila and Lassen Am Fam Phys, 1998
35
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

36
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

37
Torsion
38
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

39
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

40
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

41
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

42
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

43
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)

44
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

45
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

46
Orchitis
  • Signs and symptoms
  • fever
  • / hydrocele
  • Diagnosis
  • red, swollen scrotum
  • blue testis
  • no urinary symptoms

47
Orchitis
  • Treatment
  • mumps hyperimmune globulin
  • analgesics, antipyretics
  • steroids
  • ice, bed rest, scrotal elevation
  • Complications
  • if severe, testicular atrophy
  • 30 have persistent infertility problems

48
Strangulated hernia
  • Clinical diagnosis
  • Refer to emergency or general surgery

49
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)

50
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)

51
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)

52
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

53
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)

54
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

55
Hematocele
  • trauma with bleed into tunica vaginalis
  • ultrasound helpful to exclude fracture of testis
    which requires surgical repair
  • Treatment ice packs, analgesics, surgical repair

56
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)

57
Hydrocele
  • Treatment
  • nothing if tolerated and no complications
  • surgical

58
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

59
(No Transcript)
60
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)

61
Varicocele
62
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

63
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

64
Conclusions
  • Common
  • Painless and painful
  • Important and not important
  • Key Physical exam and ultrasound

65
References
  • Campbells Urology
  • Smiths Urology
  • Gillenwater
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