u Urology

Samir Bidnur, Yooah Krakowsky and Debonh Sasgea, chapter editors

Alaina Garbens and Modupe Oyeumt. associate editors
Adam Gladwish, EBM editor
Dr. Armando Lorenzo, Dr. Keith Jarvi and Dr. Sender Henchom, staff editors

Basic Anatomy Review ................... 2 Scrotal Mass........................... 27

Abdominal Wall Varicocele
Anatomy of Scrotum Spermatocele
Genito-Urinary Tract Anatomy Hydrocele
Penis Anatomy Testicular Torsion
Inguinal Hernia
Common Presenting Problems ............. 3 Hematocele
Hematuria
Scrotal Complaints Penile Complaints ...................... 29
Urinary Retention Peyronie's Disease
Dysuria Priapism
Paraphimosis
Voiding Dysfunction ..................... 5 Phimosis
Voiding Erectile Dysfunction (ED)
Failure to Store: Urinary Incontinence Premature Ejaculation
Failure to Void: Urinary Retention
Benign Prostatic Hyperplasia (BPH) Trauma ............................... 32
Urethral Stricture Renal Trauma
Neurogenic Bladder Bladder Trauma
Post Obstructive Diuresis (POD) Urethral Injuries

Infectious and Inflammatory Diseases...... 10 Infertility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Urinary Tract Infections (UTI) Female Factors
Recurrent/Chronic Cystitis Male Factors
Interstitial Cystitis (Painful Bladder Syndrome)
Acute Pyelonephritis Pediatric Urology ....................... 36
Prostatitis/Prostatodynia Congenital Abnormalities
Epididymitis and Orchitis Nephroblastoma (Wilm's Tumour)
Urethritis Cryptorchidism/Ectopic Testes
Urethral Syndrome Disorders of Sexual Differentiation
Circumcision
Stone Disease ......................... 15 Enuresis
Approach to Renal Stones
Calcium Stones Selected Urological Procedures ........... 40
Uric Acid Stones Bladder Catheterization
Struvite Stones Cystoscopy
Cystine Stones Radical Prostatectomy
Transurethral Resection of the Prostate (TURP)
Urological Neoplasms ................... 18 Extracorporeal Shock Wave Lithotripsy (ESWL)
Approach to Renal Mass
Benign Renal Neoplasms Common Medications ................... 43
Malignant Renal Neoplasms Antibiotics
Carcinoma of the Renal Pelvis and Ureter Erectile Dysfunction
Bladder Carcinoma Benign Prostatic Hyperplasia
Prostatic Carcinoma (CaP) Prostatic Carcinoma
Prostate Specific Antigen (PSA) Continence Agents
Testicular Tumours
Penile Tumours References . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Toronto Notes 2011 Urology Ul

U2 Urology Basic Anatomy Review Toronto Notes 2011

Basic Anatomy Review

Above Arcuate Line _ Fascia

r 11!::.!2::! ,..-----External Oblique
"!i='i'-
Abdominus
L - Fascia
, ' }; ' ,..----- Extra peritoneal Fat
. . ,..------ Peritoneum

Below Arcuate Lin e)--Inferior Epigastric Artery External

--- .._____Skin spermatic fascia
\..__ Superficial Fascia Pampiniform Cremaster
\..__ External Oblique plexus muscle
- ----"="="";._ '--Internal Oblique Internal
--Transversus Abdominus spermatic fascia
.._____Transversalis Fascia Tunica vaginalis
'------ Extraperitoneal Fat
'------ Peritoneum Dartos fascia

Figure 1. Midline Cross-Section of Abdominal Wall Figure 2. Anatomy of Scrotum

Minor
Renal vein Major calyx
Renal artery Pararenal fat Renal papilla
Renal sinus Renal column
Abdominal aorta Renal pelvis
IVC Renal pyramid
Ureter Ureter Renal capsule
Gonadal artery and vein (Gerota's fascia)

Internal iliac artery and vein

External iliac artery and vein
Internal pudenal artery
Common penile artery Detrusor Uretero-vesicular junction
Trigone
Base detrusor
Prostate
Prostatic urethra
Periurethral striated muscle-"2!rn.:.;...-Membranous urethra Posterior urethra
Krista Shapton 2010
Rhabdosphincter (external Bulbar urethra : }
Male Pelvic Vasculature sphincter, striated muscle) ' Anterior urethra
Spongy (penile) urethra

Sandra Tavares 2007

Figure 3. Essential Genito-Urinary

Tract Anatomy

June Li 2010

Figure 4. Cross Section of the Penis

Toronto Notes 2011 Common Presenting Problems Urology U3

Common Presenting Problems

Hematuria
Classification (see Nephrology. NP6)

Tabla , . Etiology of Hematuria by Aga Group

B-20 Glomerulonephritis, llTI, cong..ital anomalies

2()..40 un, stones, bladder tumour
4[)..60 Male: bladder tumour, stones, UTI Female: lJTI, stones, bladder tumour
>60 Male: BPH, bladder tumour, un Female: bladder tumour, un

Etiology

Tabla 2. Etiology of Hamaturia by Typa

bleeding AnticoiiiJII!nts Stone Stone

Dyes (beets. rhodemine B in candy and juicesl Coagulation defects Trauma Tumour
Hemoglobin (hemolytic anemial Sickle cell dsease Renal cell carcinoma Cammon urologic CIIUUS of h111111lwi1
Myoglobin (rhebdomyolysis) Neoplasms cell carcinoma Uretlritis c., be grossly classified 115:
TIBUIIIII
Drugs (rifaiJ'1lin. phenazopyridine. pyridium. phenytoin) Leukemia Wilm's tumour Polyps Infection
Porphyria Ttmnboembolism Foreign body Tumoun;
Ston11
Laxatives (phenolphthalein) Glomerulonephritis Uretlnl sbicture

Tuberculosis
Infarct
Polycystic kidneys
Arteriovenous malloiTIIiltion

History
full history, inquire about timing of macroscopic hematuria in urinary stream
initial: anterior urethra
terminal: bladder neck and prostatic urethra
total: bladder and/or above

Investigations
gross hematuria and symptomatic hematuria require full workup
CBC (rule out anemia, leukocytosis), electrolytes, creatinine, BUN
urine studies:
urinalysis (casts, crystals, cells)
culture and sensitivity
cytology
imaging:
CT/IVP to investigate upper tracts (ultrasound alone is not sufficient)
cystoscopy to investigate lower tract (possible retrograde pyelogram)
microscopic hematuria defined as more than two red blood cells (RBC) per high-power field
(HPF) (see Figure 5)

Acute Management of Severe Bladder HemoiThage

manual irrigation via catheter with normal saline to remove clots
continuous bladder irrigation (CBI) using large (22-26 Fr) 3-way Foley to help prevent clot
formation
cystoscopy if bleeding quite active:
identify resectable tumours
coagulate obvious sites ofbleeding
refractory bleeding:
continuous intravesical irrigation with 1% alum (aluminum potassium sulfate) solution as
needed
intravesical instillation of 1% silver nitrate solution
intravesical instillation of 1-4% formalin (need general anesthesia)
embolization or ligation ofiliac arteries
cystectomy and diversion rarely
U4 Urology Common Presenting Problems Toronto Notes 2011

,, , I I

>Z RBC,IHPF

The CUA guidelines advise: Repeat
initial urine microacopy if history of I I

Urinalysis and urine C&S
llflllhral tnurna. IXlln:isa, or me11181.
lmmedim rllhi!Tal to nephrology if 1111y
of: proteinuria, -1' craatinine, rad cell 1. Rule out and treat benign causes {i.e. Ull)
casts or clysmorphic RBCs 2. If accompanied by d1J1111orphic RBC, or 1' Cr,
evalum for primary renal disease

,, ,
If neither 1 or 2, urologic evaluation required

Uppllf Tr-ct I-Fni Opt-
l'yela!Jam- Traditional

Urothtllial Cell Carcinoma {UCCI Riak Stratification

option and widely available, but use i$

decreasing. Reasollllble sensitivity for +
HIGH RISK LOW RISK
+
UCC, but poor sensitivity for RCC.
Smoking hi&lory 1. Urine cytology
Ultrunnd - Superior to IVP for Occupational chamictlllCPosura 2. Uppar tract imaging
8VIIIuation of renal piUllllChyma and Gross hematuria
renal cysts. Urnillld sensitivity for UCC
and small renal masses. UIS alone is not
sullicilllt for uppar tract imaging.
>4Dyn old
Hx of &!Drage voiding &ymptoms
Hx of recurrent lJTI's
+1
CT - Optimallllst for renal parenchyma,
calculi ll1d infections, but less
and mora expentiv& thllll lltruound.
Involves elqiDIUre to l'lldiation and

...
Complsta &valuation
I

TreatUCC
+ve

I
3. Cysto.copy

.....
I .,.

inlnMIIIDUS CDIIII'IIl
1. Urine cytology +1111 i Follow up
2. Upper tract imaging
3. Cysto.copy
.... .. Urinalysis, cytology, and BP at
6, 12, 24, 36 months

Figure 5. Workup of Asymptomatic Microscopic Hematuria Based on AUA Guidelines

Scrotal Complaints
see Scrotal Mass, U27

Urinary Retention ------------------------------------------

see Failure to Void, U6

Dysuria
Differential Diagnosis

Tabla 3. Differential Diagnosis of Dysuria

Infectious urstllilis, 11'05f81itis, epididymitis, cervicitis, wlvovaginitis, perineal inllanmatiorilnfaelion, TB,
vestibulitis
Naaplum Renal cell, bladder, prostate, penis, vagiiiiWulva, BPH
C.lcul Bladder stone, ureteral stone, kidney stone
lnlll11mltory Seronegilliw arthropathie& (Riileliw arthritis: arthritis, uwitis, u181hritisl, drug &ide llf!ect&, autoimmune
disorders, chronic pelvic pain synctome (CPPSI. in1elslitial cystitis
Hormllllll Endometriosis, hypoeslnlgenism
TraUIIII Catheter insertion. post-coillll cyslitis (honaymoon cystitisI
Plychagenic Somalimlion disorder, MOD, stress/anxiety disorder
Othar Conteel sensitivity, foreign body

Approach
focused history and physical to determine cause (fever, discharge, CVA tenderness,
conjunctivitis, back/joint pain)
urine dip, C&S, R&M
any discharge {urethral, vaginal, cervical) should be sent for gonococcus/chlamydia testing; wet
mount if vaginal discharge
if suspect infection, may start empiric antibiotic treatment
imaging of urinary tract (tumour, stones)
Toronto Notes 2011 Voiding Dysfunction Urology US

Voiding Dysfunction
see GY36 for relevant female topics

Voiding
two phases oflower urinary tract function:
1. Storage phase - bladder filling and urine storage
accommodation and compliance
no involuntary contraction
2. Voiding phase - bladder emptying
coordinated detrusor contraction
synchronous relaxation of outlet sphincters
no anatomic obstruction
voiding dysfunction can therefore be classified as:
failure to store - due to bladder or outlet
failure to void - due to bladder or outlet
three types of symptoms: storage (formerly known as irritative), voiding (formerly known as
obstructive), post-void

Failure to Store: Urinary Incontinence

------
Definition
involuntary leakage of urine

Etiology
urgency incontinence:
detrusor overactivity:
FiluN to Store
CNS lesion, inflammation/infection (cystitis, stone, tumour), bladder neck obstruction Urinlry Tract Sr.-1111
(tumour, stone), BPH (WTSJ (irritlltift)
decreased compliance of bladder wall:
CNS lesion, fibrosis Urgancy
Nocturia
sphincter/urethral problem OV.uria
stress urinary incontinence (SUI):
urethral hypermobility Thilit
Frequent Urgant Ni{#rtlime Di8Comfort
weakened pelvic floor allows bladder neck and urethra to descend with increased
intra-abdominal pressure
urethra is pulled open by greater motion of posterior wall of outlet relative to anterior
wall
associated with childbirth, pelvic surgery, aging, levator muscle weakness 't'

intrinsic sphincter deficiency (ISD) C.usn of 11enn1 Urinary

pelvic surgery, neurologic problem, aging and hypoestrogen state
DIAPERS
intrinsic sphincter deficiency and urethral hypennobility can co-exist Delirium
lnflammatiorVInfection
Epidemiology A1rophic
variable prevalence in women: 25-45% Phllllllllcautic:lllr,/Psyc:hologiclll
Excns uriu output
F:M=2:1
Resbicted mobiity/Retention
more frequent in the elderly, affecting 5-15% of those living in the community and 50% of Stool impaction
nursing home residents

Table 4. Urinary Incontinence: Types and Treatments

Type Urga Stress Ovarllaw Mixed
Dalililio1 Involuntary leakage of urile Involuntary leakage of IJ'ine Involuntary leakage of Urinary leakage associated
preceded by a strong, suddan increases in urine whan inti'IIV8Sical with Ul'llencv and increased
sudden Ullle to void inlnHibdominal pressure pressure axceads inlnHibdominal pressure
urethral pressure

Etialagy Bladder Urethrs/Sphilcter weakness, Obslruction, neuropathy Combination of bladder and

{detrusor overactivity) post1)artum pelvic {diabetes, MS. sphilcter issues
musculature W8ilkn8Ss antic:holinal'llic drugs)
Dilgnollis Hisloly History History History
Urudynamics Stras1 Test (hBw patient Urodymmics Urodynamics
bear downfcough) Stress Test
U6 Urology Voiding Dysfunction Toronto Notes 2011

Table 4. Urinary Incontinence: Types and Treatments (continued)

...... ,
}-----------------,
Type
Traatmlllt
Urge
Lifestyle
Sims
Weight loss,
Owlflow
LWestyle
Miud
Combination of
Bladder habit training Kegel's exercises Clllheterillllion tD IIVDid management of urge and
Urge Incant!- Traidnnlnt Batox Bulking agents organ damage stress incontinence
8ewanl of lllticholinerqic side effects
including delirium and urinary retention. Medications: Surgary (slings, lVOT, Traat Wlderlying cause
Anticholin&rgics (1Diterodine artificial sphinctn)
oxybutynin
(Ditropan"J. trospium
(Trosec1111. soiW&nacin
TCAs
Neuromodulation

Failure to Void: Urinary Retention ------------------

.._,,
,}-----------------,
Acute vs. Chronic llatlntlon
Acute retention is 1 medical emergency
chlllllllimd by pain and 11111ril with
nonnal bladder volume and bladder innervation:
Acuta ovardillantion lead Ill bllddar
rupture.
Chi'Oilic retention can be asymptomlllic
grwdy incnaud bladder voUnl
1nd detrusor hypertrophy foUowed by
atony (IIIII).
Etiology
outflow obstruction:
bladder neck or urethra - calculus, clot, foreign body, or neoplasm
prostate - BPH, prostate cancer, prostatitis
urethra - stricture. phimosis, traumatic disruption
spinal cord - injury, disc herniation, multiple sclerosis
stroke
DM
post-pelvic surgery
pharmacologic:
anticholinergics
narcotics
antihypertensives (ganglionic blockers, methyldopa)
over-the-counter cold medications containing ephedrine or pseudoephedrine (e.g. Sudafed)
antihistamines (e.g. Benadryl, Nytol, Sominex)
psychosomatic substances (e.g. ecstasy)

Clinical Features
palpable and/or percussible bladder (suprapubic)
possible purulent/bloody meatal discharge
DRE - size of prostate, anal sphincter tone
neurological- presence of abnormal deep tendon reflexes, saddle sensation, etc.

Investigations
CBC, electrolytes, Cr, BUN, urine R&M, C&S, ultrasound, cystoscopy, urodynamic studies, post
void residual (PVR) scan

Treatment
guiding principles are to treat underlying cause of retention and use least invasive treatment
possible
catheterization:
contraindicated in trauma patient unless urethral disruption has been ruled out
acute retention: immediate catheterization to relieve retention, leave Foley in to drain
bladder, follow up to determine cause
chronic retention: intermittent catheterization by patient is commonly used; definitive
treatment depends on etiology
suprapubic cystotomy
for post-operative patients with retention:
encourage ambulation
alpha-blockers to relax bladder neck
may need catheterization
definitive treatment will depend on etiology
Toronto Nota 2011 Voicling Dyafunction UroiOBf U7

Benign Prostatic Hyperplasia (BPH) _ _ _ _ _ _ __ J

Definition
hyperplasia ofstroma and epithelium in periurethral area ofprostate (transition zone) - Anterior lillll"'"""n
see Pigure6 ---=
11r1111 "'""
ZIJfl8

tone ofprolltlrtic smooth muscle cells plays a role in addltlon to hyperplasla. /

Etiology
etiology unknown
androgen dihydrotestosteront: (DHT) required (converted from testosterone by
5-alpha reductase)
possible role ofimpaired apoptosis, estrogens, ather growth factors
Centnllzxn l'llripherlllzxn
Epidemiology EjiiCUIIIlny zona
age-related. extremely common (SO% of50 year olds, 80% of80 year olds) C Meog'-' Brilllley
2596 of men will require treatment
Figure I. Cr.....Saellon af
Clinical Features ProsbdB
result from outlet obstruction and compensatory changes In detrusor functl.on
voiding symptoms:
hesitancy, straining. weak/interrupted stres.m. incomplete bladder emptying lt'
decreased flow rates may be seen on uroflowmetry AIIAPrDitllli Syqmn Scllre
FUIIIWJIE
due to outflow obstruction and/or impaired detrusor contractility
storage symptoms: Urgency
urgency, frequency, nocturia, urgency incontinence NDC!uria
thought to be due to detrusor overactivity and deaeased compliance WMkelrelm
lnterm-cy
prostate Is llllOOth, rubbery and symmetrically enlarged on DRE llnlining
complications: ineo.,.-811 ._..g of
retention
overflow incontinence
Each '"fll1piGm graded
D-7 - Milcly wymp!DmllliG
out"' 5.
hydronephrosis and renal compromise B-19- Modlrmly aymp!CIIIIIIic
infection 20.J5-SIIVIfllly
gross hematuria Nata; Dy.ril. nut ilcludad in 1100111 but
bladderstones ia cammanly._illlcl with BPH

Investigations
history
a&&ess LUTS and effect on quality ofUfe, may include self-administered questionnaires (AUA
symptom and impact score)
physical exam: DRE
urinalysis to exclude UTI
c.reatinine to assess renal function renal ultrasound to assess for hydronephrosis ..... ,
prostate-specific antigen (PSA) trJ rule out malignancy (iflife apectancy >10 years)
umflowmetryto measure flow rate (optional) llpprmdllltlll'roltlta 1181
bladder ultrasowtd to determme post-void residual urine (optional) 20 4:C - ct.ltnut
25t:e-pUn
cystoscopy prior trJ potential surgical management 50 t:e -lem111
biopsy ifsuspicious for malignancy 75 t:e - oranga
I 00 cc - grapefnjt
Treatment
conservative for those with mild symptoms:
watcltful waiting - 5096 of patients improve spontaneously
..... ,,
includes Ufestyle changes (e.g. evening fluid restriction, planned voiding)
medical treatment Alllalm INIAiill11 fur IPH S...ry
Rafnlctoty urilll'f rellntion
a-adrenergl.c antagunlsts - reduce stromal smooth muscle tone [e.g. terazosln (Hytrln-}, Rac..,.n UTI1
doxazosin (cardura), tamsulosin (Plomax"), alfuzosin (Xatral-)1 Rac....-.d hamaturlll Nfrll:lory111
5-a reductase inhibitor- blocks conversion of testosterone to DHT; acts on the epithelial mediDII trlltmlnt
component of the prostate- reduces prostate size [e.g. finasteride (Proscar"), dutasteride ._,.. !IIIIa out Cllhar
CIUIM)
(Avodart")] 8lu11M
combination shown to be synergistic (see sidebar)
transurethral resection ofprostate (TURP):
see Seleded UrolDgical Procedures, U40
open prostatectomy:
for large prostates or associated problems (e.g. bladder stones)
suprapubic (transvesically to deal with bladder pathology)
retropubic (through the prostatic capsule)
om.inimallylnvasivetherapy:
prostatic stents, microwave therapy, laser ablation, water-induced thermotherapy,
cryotherapy, intensity focuaed ultrasound (HIFU) and transurethral neeclli: ablation
(TUNA)
US Urology Voiding Dysfunction Toronto Notes 2011

Urethral Stricture

.
,.... ., .........,.....
Lilt-Tim E1lld rlllmllmlil. hlllridl,
.. c.n-....n..., ...... aii:ll
,....... .,.,..,..s,.,...
IIIIUPSI Trill}
NfJM2003; 349:2387-2398
Definition
decrease in urethral calibre due to scar formation in urethra (may also involve corpus
spongiosum)
M>F

lllwly:lllnlt:lnilld, daubla-bmdad, cantralllld trill Etiology

witllllll!l of 4.5 YIIIJ. congenital- failure of normal canalization
Pllilnll: 3047 plliiiD Nth BPH
may cause bilateral hydronephrosis

IAignld Ill pil1:abo 7371. doxlzalin 7561 trauma:
fillllllride (n 768), conDilali:ln 1lllrapy instrumentation (most common)
(n= 786). Melli age 62.6. external trauma (e.g. burns, straddle injury)
CIII'IIIIMIM 11811mant-... dllllllllil
other: foreign body, removal ofinflated Foley catheter, etc.
\15. finulaide Vi. cantinllillll111arapy.
Main D*-: Clnical J1R9111ion dainad 11: infection:
fim ocamnce ol111 inl:niue IMI'bae lile of 111 long-term indwelling catheter
IIIII fiu pcin1s in 1lla AUA sympiDm ara, ICUIII balanitis xerotica obliterans (lichen sclerosis or chronic progressive sclerosing dermatosis of
LriiBy lllention.llllli nmrert
the male genitalia) causes meatal stenosis
lrinlly111ct irluclim, ar llirwy imlli1R:a.
.... The &-r l!ldLEtion il CINTII81ie
incidence rlclinicll Clinical Features
1Dpllc:lllofar daomlin- voiding symptoms (obstructive symptoms)
lft(P<0.001L fillllllride- 34!1 urinary retention
llld combinetioolMrlpy- &8'11IP<0.001).
Comnltion thenill- lillie IAIIiclive thui eitller related infections: recurrent UTI, secondary prostatitis/epididymitis
daaain [P<O.OOII artilllstwidl (P<O.OOII
IIane. 111111-na sV!bltdifnl:e Investigations
daaain llld fillllllridaalln. laboratory findings
l:.l:luiJn: longterm cantinlliJn 1herapywilh
daaain llld fillllllrida ofll8111 flow rates <10 ml/s (normal-20 ml/s) on uroflowmetry
clinicaiii'UQIIIIion othlrigl jRitllic hPerpln urine culture usually negative, but may show pyuria
&igniic:antlt ll1llll thui diltr811mint witb li1llar radiologic findings

retrograde urethrogram, voiding cystourethrogram (VCUG) will demonstrate location
urethroscopy

Treatment
urethral dilatation:
temporarily increases lumen size by breaking up scar tissue
healing will often reform scar tissue and recreate stricture
visual internal urethrotomy (VIU):
endoscopically incise stricture without skin incision
cure rate 50-8096 with single treatment, <50% with repeated courses
open surgical reconstruction:
complete stricture excision anastomosis, urethroplasty depending on location and size of
stricture

Neurogenic Bladder
Definition
a malfunctioning urinary bladder due to a deficiency in some aspect of its innervation
4C. Gf Bllldder
Capacity (35()-500 cc; Neurophysiology
J'ed$: (Agtj + 2) X 30)
ComplillnCI[minimal A Pmsur..tA Table 5. Efferent Syrnpatlnmc, Parasympathetic, and Somatic Nerve Supply
Volume)
Conlraclility (vDiuniBry and &u&lllinad) Nam Fibrn S1111ma11: Nllll'lllrllllmittlr T11111t Kay Recaplara
Cooperation of bladder and sphincter Sympathetic Trigone, internal sphincter, proximal LR!hra Adrenergic {all
T10-LZ Noradrenuline
Somlllic SZ-S4 Acetylcholile External s!ilincter Nicotinic
Parasympathetic SZ-S4 Acetylcholile Detrusor Muscarinic (MZ. M31
Narve rucrt& in micluritiDII:
"123-4 Dlpe tile inl orr t,.lloor. receptors in the bladder wall and mucosa relay information to pontine micturition centre
(PMC) and activate micturition reflex
the PMC sends excitatory/inhibitory signals to regulate micturition reflex (normally inhibited
by cortical input)
micturition: stimulation of sacral parasympathetic neurons (bladder contraction); inhibition
of sympathetic (IS relaxation) and sacral somatic neurons (ES relaxation)
urine storage: inhibition of sacral parasympathetic neurons (bladder relaxation) aided by
sympathetic activation (bladder relaxation, IS contraction); stimulation of sacral somatic
neurons (ES contraction )
voluntary action of external sphincter (pudendal n. S2-S4) can inhibit urge to urinate
cerebellum, basal ganglia, thalamus, and hypothalamus all have input at PMC
Toronto Notes 2011 Voiding Dysfunction Urology U9

Classification of Neurologic Voiding Dysfunction

lesion above PMC [e.g. stroke, tumour, multiple sclerosis (MS)]: neurogenic detrusor over
activity (detrusor hyperreflexia)
...... ''

"Spillll hack" earty phase foUowing

loss of voluntary inhibition of voiding cord injury m111ilesl$ qlllonic bladder.
intact pathway inferior to PMC maintains coordination ofvoiding episodes
lesion of spinal cord [e.g. MS, arteriovenous malformation (AVM)]: detrusor sphincter
dyssynergia (DSD)
loss of coordination between detrusor and sphincter (ie. detrusor contracts on closed
sphincter and vice versa)
component of detrusor overactivity as well
lesion of sacral cord or peripheral efferents (e.g. trauma, diabetes, disc herniation): detrusor
atony/areflexia
flaccid bladder which fails to contract
may progress to poorly compliant bladder with high pressures
peripheral autonomic neuropathy: deficient bladder sensation -+ increasing residual urine -+
decompensation (e.g. DM, neurosyphilis, herpes zoster)
muscular lesion: can involve detrusor, smooth/striated sphincter

Neuro-Urologic Evaluation
history and physical exam (urologic and general neurologic)
urinalysis, renal profile
imaging: intravenous pyelogram (IVP), U/S to rule out hydronephrosis and stones
cystoscopy
urodynamic studies:
uroflowmetry - assess flow rate, pattern
filling cystometrogram (CMG) - assess capacity, compliance, detrusor overactivity
voiding cystometrogram - pressure-flow study, assess bladder contractility and extent of
bladder outflow obstruction
EMG - helps ascertain presence of coordinated or uncoordinated voiding, allows accurate
diagnosis of DSD
video study- x-ray contrast to visualize bladder/bladder nec.k/urethra during CMG

Treatment
goals of treatment:
maintenance oflow pressure storage and emptying system with minimal tubes and collecting
devices is necessary to
prevent renal failure
prevent infections
prevent incontinence or achieve social continence
treatment options: depends on status of bladder and urethra
bladder hyperactivity-+ medications to relax bladder (see Incontinence, US)
if refractory:
- botulinum toxin injections into bladder wall
- occasionally augmentation cystoplasty
flaccid bladder-+ clean intermittent catheterization (CIC)

Autonomic Dysreflexia
exaggerated sympathetic nervous system response to visceral stimulation below the lesion in
spinal cord injury patients
lesion is usually above T6/T7
stimulation includes instrumentation, distention or stimulation of bladder, urethra or
rectum
symptoms include: hypertension, headache, reflex bradycardia, sweating, anxiety, piloerection
vasoconstriction below lesion, vasodilation above lesion
treatment: remove noxious stimulus (e.g. insert catheter), parenteral ganglionic or a-blockers,
nifedipine (prophylaxis during cystoscopy)

Post Obstructive Diuresis (POD)

--------------------------
Definition
polyuria resulting from relief of severe chronic obstruction
>3 U24 hrs or >200 cclhr over each of two COlllleCutive hours

Pathophysiology
ranges in severity: physiologic to pathologic process
physiologic POD occurs secondary to excretion of retained urea, sodium, and water (high
osmotic load) after relief of obstruction
self-limiting, usually resolves in 48 hrs with PO fluids but sometimes can continue even
after having reached euvolemic status (i.e. pathologic POD)
UIO Urology Voiding Dysfunction/Infectious and In11ammatory Diaeaaes Toronto Notes 2011

pathologic POD is a sodium-wasting nephropathy that occurs secondary to an impaired

concentrating ability ofthe renal tubules due to:
decreased reabsorption of sodium chloride in the thick ascending limb and urea in the
collecting tubule
increased medullary blood flow (solute washout)
increased flow and solute concentration in the distal nephron

Management
admit patient and closely monitor hemodynamic status and electrolytes
monitor urine output (U/0) q2h and ensure total fluid intake <U/0 by replacing every
1 cc U/0 with 0.5 cc 1/2 NS IV (PO fluids if physiologic POD)
avoid glucose-containing fluid replacement (can cause iatrogenic diuresis)
check Na and K q6-12h and replace prn
follow creatinine and BUN to baseline

Infectious and Inflammatory Diseases

Urinary Tract Infections (UTI)
----------------------------
for UTis during pregnancy, see Obstetrics, OB18

Definition
greater than 100,000 bacterialml- midstream urine
if symptomatic, 100 bacterialml may be significant

Classification
uncomplicated: lower urinary tract infection in a setting of functionally and structurally
normal urinary tract
complicated: pyelonephritis and/or structural/functional abnormality
unresolved bacteriuria = urinary tract is not sterilized during therapy (most commonly due to
resistant organisms or noncompliance)
recurrent UTI
bacterial persistence = urine cultures become sterile during therapy but resultant reinfection
of the urine by the same organisms
reinfection= new infection with new pathogen (80% of recurrent UTls)

Source
ascending (most common) - GI organisms
hematogenous (TB, perinephric abscess)
lymphatic
direct (inflammatory bowel disease, diverticulitis)

Risk Factors
stasis and obstruction:
residual urine in poorly flushing system, e.g. posterior urethral valves, reflux, medication
(anticholinergics), BPH, urethral stricture, cystocele
foreign body:
introduce pathogen or act as nidus of infection
e.g. catheter, instrumentation
decreased resistance to organisms:
diabetes, malignancy, immunosuppression
other factors:
trauma, anatomic variance (congenital), female (short urethra)

Clinical Features
storage symptoms (frequency, urgency, dysuria)
voiding symptoms (hesitancy, post-void dribbling, dysuria)
hematuria
pyelonephritis: more severe symptoms (including constitutional symptoms, CVA tenderness)
Cystitis: c....-
IEEPS Organisms
IIJeiJsrelle sp. routine cultures (see sidebar)
E. coli (90%), o1her G1111m-negalives
Enterococci non-routine cultures:
Proteus minlbilis. tuberculosis (TB)
s. aprophytiw., s. Chlamydia trachomatis
Mycoplasma (Ureaplasma urealyticum)
fungi (Candida)
Toronto Notes 2011 Infectious anclln1lammatory Diaeaaes Urology Ull

Indications for Investigations

persistence of pyuria/symptoms after adequate therapy
severe infection with an increase in creatinine
recurrent/persistent infections
atypical pathogens (urea splitting organisms)

Investigations
midstream urine R&M, C&S
dipstick: leukocytes nitrites hematuria
microscopy: >5 WBC/HPF in un-spun urine or >10 WBC/HPF in spun urine, bacteria,
WBCcasts
Gram stain: GN bacilli, GP cocci,> 1 bacterium/oil immersion field
culture and sensitivity: midstream, catheterized or suprapubic aspirate
hematuria workup - urine cytology; ultrasound, cystoscopy
CT scan if indicated

Treatment
confirm diagnosis
identify organism and treat (TMP/SMX, fluoroquinolones, nitrofurantoin, cephalosporins)
for mild infections 3 day course is sufficient (for treatment details see Common
Medications, U43)
establish predisposing cause (if any) and correct
if febrile, consider admission with IV therapy and rule out obstruction

Recurrent/Chronic Cystitis
incidence of bacteriuria in females:
pre-teens: 1 %; late teens: 4%; 30-50 years: 6%
assess predisposing factors as described above
possible relation to intercourse (postcoital antibiotics), perineal colonization
investigations may include cystoscopy, ultrasound, CT
antibiotic prophylaxis if >3 or 4 episodes per year in females

Etiology
unknown:
theories: increased epithelial permeability, autoimmune, neurogenic
associations: severe allergies, irritable bowel syndrome (IBS), fibromyalgi.a

Treatment
daily low-dose prophylaxis (nitrofurantoin, TMP/SMX)
lifestyle changes (limit caffeine intake, increase fluid/water intake, smoking cessation)
post-menopausal women: consider topical or systemic estrogen therapy
no treatment for asymptomatic UTI except in pregnant women or patients undergoing urinary
tract instrumentation

Interstitial Cystitis (Painful Bladder Syndrome)

Definition
chronic urgency, frequency pain without other reasonable causation

Etiology
unknown:
theories: increased epithelial permeability, autoimmune, neurogenic, defective
glycosaminoglycan (GAG) layer overlying mucosa
associations: severe allergies, irritable bowel syndrome (IBS), fibromyalgi.a

Epidemiology
prevalence: -20/100,000
90% of cases are in females
mean age at onset is 40 years

Classification
non-ulcerative (more common) -younger to middle-aged
ulcerative - middle-aged to older
Ul2 Urology Infedioua and ln1lammatory Diseases Toronto Notes 2011

Diagnosis
required criteria:
glomerulations (submucosal petechiae) or Hunner's ulcers on C}'!l:oscopic examination
pain associated with the bladder or urinary urgency
negative urinalysis, C&S

Differential Diagnosis
UTI, vaginitis, bladder tumour
radiation/chemical cystitis
eosin.ophilic:/TB cystitis
bladder calculi

Treatment
patient empowerment (diet, lifestyle)
pentosan polysulfate (Elmiron)
low dose amitriptyline
bladder hydrodistention (also diagnostic) under general anesthesia
intravesical dimethylsulfoxide (DMSO) or Cystistat
surgery (augmentation cystoplasty and urinary diversion cystectomy)

Acute Pyelonephritis
------------------------------------
see Infectious Diseases, ID21

Definition
infection of the renal parenchyma with local and systemic manifestations

Etiology
ascending (usually GN bacilli) or hematogenous route (usually GP cocci)
causative microorganisms: E. coli (most common), Klebsiella, Proteus, Pseudomonas,
Enterococcus jaecalis, Enterobacter, S. Aureus, S. saphrophyticus
common underlying causes of pyelonephritis: stones, strictures, prostatic obstruction,
vesicoureteric reflux, neurogenic bladder, catheters, DM, sickle-cell disease, PCKD,
immunosuppression, post-renal transplant, instrumentation, pregnancy

Clinical Features
rapid onset (hours - day)
LUTS including frequency, urgency, hematuria
fever, chills, nausea, vomiting, myalgia, malaise
CVA tenderness or exquisite flank pain
dysuria is not a symptom of pyelonephritis without concurrent cystitis

Investigations
urine R&:M, C&S (see Urinary Tract InfoctWns, UIO)
blood
CBC + differential: leukocytosis, left shift
imaging - indicated if suspect complicated pyelonephritis or symptoms do not improve with
72 hours oftreatment
Abdo/pelvic U/S
IVP
Cystoscopy

,,

CT

Treatment
may treat as outpatient if hemodynamically stable, ciprofloxacin PO x 7-14 days or
MacroBID has poor tissue penetration cotrimoxazole (TMP/SMX) POx 14 days
and 1h818fm is not usad to treat
pyelonephritis (raquil'lll post-renal severe or non-resolving: admit, hydrate and treat with ampicillin IV and gentamycin IV
emphysematous pyelonephritis: emergency nephrectomy
stone obstruction: admit and emergency stenting or percutaneous nephrostomy tube
Toronto Notes 2011 Infectious anclln1lammatory Diaeaaes Urology U13

Prostatitis/Prostatodynia .... ',

Prostlllic masuga may cMJse IIXIrllme
most common urologic diagnosis in men <50 years 18ndem81Ri and incraaed risk af
incidence 10-30% inducing sepsis, abscess or apididymo-
acute bacterial, chronic bacterial, abacterial subtypes

Tabla &. Comparison of tlla Thraa Types of Prostatilil

Type 1: Acute Bill:tlriill Pramtitis Type II: Chronic Bill:tBrill Prwliltitis Type Ill: Chronic Pelvic Pail Syndrome {AHc:IBriil]
E1ialagy KEEPS (see U10 sidebar]: 811% E. coli Recurrent e.xacerblllions of acute Divided into inflammlllory and non-inflammlllory
Ascending urethral infection and reiiUK into prostatic prostatitis signs and symptoms subtypes
ducts Recurrent UTI with same organism lntraprostatic reflux of urine urethral hypertonia
01tan associated with autlst abmuctian {BPHJ, Multilactorial (immunologicaL neuropathic,
recent cystascapy, prostatic biopsy neuroendocrine, psychosocial)
Most ilfections occur in 1he peripheral mne
(see Figure 61
AcLIIe onset fiNer, chills, malaise asymptomlllic with normal Pelvic pain, storage LUTS, ejaculatory pain, post-
Rectal, lower back and perineal pain prostate on DRE ejaculatory pain
Storagellld voiding WTS
Hematuria
lnmtigllions RectaiiiDUIIl Urine C&S: 4 specimens DREwriabla
Enlarged, tender, warm prostate Colony counts in EPS and VB3 Urine C&S negative on serial specimens
Urine C&S: 4specimens should exceed those of initial and Prostate biopsy (rarely performed) shows histological
VB1 [voided bladder urine): ilitial (urethra] midstream by 10times (suggests inflammation
VB2: midstraern (bladder) prostate as bacterial source]
EPS (eJC!li!!SSed prosta1ic secretions): {prostate] not
usually performed
VB3: post-massageiDRE (prostate)
UrineR&M
Blood CBC, C&S
Tl'1lltmllnt Supportive measures (an!Viretics, analgesics, Extended course of antibiotics Trial of antibiotic therapy fluoroquinolone or doxycycline if
stool softeners) (3-4 months) Chlamydia fnlchomtltis is suspected
PO llllibiotics Ruoracp.linolones, TMP/SMX or a -blocker to relieve sphincter spasms, NSAIDs llld
1raat for wks 1D prevent doxycydina; addition of an a-blockar supportive measuras for symptomatic llllillf
Admission criteria: sepsis, urimry retention, may reduce symptoms
immunodeficiency
IV antibiotics {ampicillin and gentamicin) asevere
Mid-stream urine C&S at 1and 3 months post
antibiotic therapy
Avoid clllheterillllion due to risk of bacteremia llld
systemic infection
Small drainage calhBtar may be inserted a
obstruction suspected

Epididymitis and Orchitis

Etiology
infection:
<35 years - gonorrhea or Chlamydia tradwmatis .... ' ,I

>35 years+ penetrative anal intercourse- GI organisms {esp. E. coli)
mumps infection may involve orchitis after parotiditis If unsura b81w8an diagnosas of
epididymitis and torsion: vo to OR.
other rare causes:
TB Ramambar: torsion >6 tn has poor
prognosil.
syphilis
granulomatous (autoimmune) in elderly men
amiodarone (non-infectious cause, involves only head of epididymis)
note: epididymitis is much more common than orchitis

Risk Factors
UTI, unprotected sexual contact
instrumentation/catheter
reflux
increased pressure in prostatic urethra (straining. voiding. heavy lifting) may cause reflux of
urine along vas deferens -+ sterile epididymitis
U14 Urology Infedioua and ln1lammatory Diseases Toronto Notes 2011

...... ,
t-----------------,
Clinical Features
sudden onset scrotal pain and swelling radiation along cord to flank
Prehn' 1ign: pain may be relieved with scrotal erythema and tenderness
elevation oftesticlel i1 epididymitis but fever
not in testicular 1Drsion. Poor sii1Sitivity, storage symptoms, purulent discharge
e5p&ciaUy in children.
reactive hydrocele

Investigations
urinalysis (pyuria), urine C&S
urethral. discharge: Gialil stain/culture
if diagnosis uncertain, must do:
colour-flow Doppler ultrasound
nuclear medicine scan
examination under anesthesia

Treatment
rule out toraion
antibiotics:
N. gono"heae or C. trachomatis - cefixime 400 mg PO once followed by azithromycin 1 g
single dose or doxycycline 100 mg bid x 10 days
coliforms- broad spectrum antibiotics (Septra, Cipro) x 14 days
scrotal support, ice, analgesia

Complications
if severe -+ testicular atrophy
30% have persistent infertility problems

Urethritis
common causes: infectious, inflammatory (e.g. reactive arthritis)

Tabla 7. lnfactious Urethritis: Gonococcal vs. Non-Gonococcal

Gunococc;al
Clusatiw= DI'Qinillm Neisseria gononheae Usually Chlamydia tr.Jchomatis
Diagn111il History of sexual conlact, yellow purulent Hirtory of sexual contact. mucoid whitish purulent
discharge, irritcrtiva L.l1TS discharge, initaliva UJTS
Gram slain (GN diplococci}, urine PCR allll/or Gram slain demonstrates >4 PMN/oil immersion field,
culture from urethral specimen no evidence of N. gonon11eae, urine PCR ami/or culture
Reactin Artllriti1 (furmly llnawn
Wer" Synclroml from urethral specimen
Urethritis, Uveitis ll1d Arthritis Cllfildme 400 mg PO DDCI orCeftrixune 125 mg Azithrumydn 1 gPO DDCI or doxycycline 100 mg
(Cin"t pee, 188, clln"t climb a 1nlll} IM once AND treat for Chlamydia trachomatis PO bid x 7 days

Urethral Syndrome
dysuria in females with consistently sterile urine cultures or low bacterial counts
some have bacterial urethrocystitis (C. trachomatis or other organisms) and require
antimicrobial treatment
treat: tetracycline or erythromycin
rule out: vaginitis, cancer, interstitial cystitis, psychological etiologies
Toronto Notes 2011 Stone Disease Urology U15

Stone Disease
Incidence
prevalanceof2-3%
male:female = 3:1, peak incidence 30-50 years of age
recurrence rate: 10% at one year, 50% at 5 years, 60-80% lifetime

Clinical Features
urinary obstruction -+ upstream distention -+ pain
flank pain from renal capsular distention (non-colicky)
severe waxing and waning pain radiating from flank to groin, testis, or tip of penis due to
stretching of collecting system or ureter (ureteral colic)
writhing, never comfortable, nausea, vomiting, hematuria (90% microscopic), diaphoresis,
tachycardia, tachypnea
occasionally symptoms oftrigonal irritation (frequency, urgency)
bladder stones result in: storage and voiding LUTS, terminal hematuria, suprapubic pain
ff fever, rule out concurrent pyelonephritis or obstruction

Differential Diagnosis of Renal Colic

acute ureteral obstruction (other causes):
UPJ obstruction
sloughed papillae
clot colic from gross hematuria
acute abdominal crisis - biliary, bowel, pancreas, abdominal aortic aneurysm (AAA)
gynecological- ectopic pregnancy, torsion/rupture of ovarian cyst, pelvic inflammatory disease
(PID)
pyelonephritis (fever, chills, pyuria)
radiculitis (Ll) -herpes zoster, nerve root compression

Location of Stones
calyx
may cause flank discomfort, recurrent infection or persistent hematuria
..... ,,

may remain asymptomatic for years and not require treatment
pelvis Ttle four narrowest passaae pointJ for
upper tract IIIDnn ara:
tend to cause obstruction at ureteropelvic junction (UPJ) 1. UPJ
staghom calculi (renal pelvis and one or more calyces) z. Palvic brim
often associated with infection that will not resolve until stone is cleared 3. Under vas dafarantlbroad Hgamant
ureter 4.lNJ
<5 mm diameter will pass spontaneously in 75% of patients

Stone Pathogenesis
supersaturation of stone constituents (at appropriate temperature and pH)
stasis, low flow and low volume of urine (dehydration)
crystal formation and stone nidus
loss of inhibitory factors:
citrate (forms soluble complex with calcium)
magnesium (forms soluble complex with oxalate)
pyrophosphate
Tamm-Horsfall glycoprotein

Risk Factors
hereditary: RTA, G6PD, cystinuria, :xanthinuria, oxaluria, etc.
dietary excess: Vitamin C, oxalate, purines, calcium
dehydration (especially in summer months)
sedentary lifestyle
medications: thiazide
UTI (with urea-splitting organisms)
myeloproliferative disorders
GI disorders: IBD
hypercalcemia disorders: hyperparathyroidism, sarcoidosis, histoplasmosis, etc.
Ul6 Urology Stone Disease Toronto Notes 2011

Approach to Renal Stone

--------------------------------

Urvent Intervention requirad if:

1. Solilllry kidney
2. Bilateral stones
3. lnllllctable pain or
4. Acuta renal faiure

Figura "1. Approach to Ranll Stone

,,_._, ________________
Investigations
screening labs
CBC -+ elevated WBC in presence of fever suggests infection
electrolytes, Cr, BUN -+ to assess renal function
Rdiollllllll ladiolluclllt urinalysis: R&M (WBCs, RBCs, crystals), C&S
IWB Calcium Uric Acid imaging
Struvita lndinavir kidneys, ureters, bladders (KUB) x-ray
Cystine to differentiate opaque from non-opaque stones (e.g. uric acid, indinavir)
CT Calcium lndinavir 90% of stones are radiopaque
Struvita crscan
Cystine
Uric Acid no contrast; good to distinguish radiolucent stone from soft tissue filling defect
abdominal ultrasound

.... ,, .
lndiemon for dndsahln bl huspibll:
may demonstrate stone (difficult in ureter)
may demonstrate hydronephrosis
IVP (not usually done)
anatomy of urine collecting system, degree of obstruction, extravasation
l.lntractBIH pain cystoscopy for suspected bladder stone
2.1nlrBctllble vomiting strain all urine -+ stone analysis
3. Fever (sugglllll infection) if recurrent stone formers, conduct metabolic studies
4. Compromised renal function
5. Singla kidney with UI&!Billl serum electrolytes, Ca, P04> uric acid, creatinine and urea
obstructionlbilatellll obstructing PTH ifhypercalcemic
stones 24 hour urine x 2 for creatinine, Ca. P04> uric acid, Mg, oxalate, citrate

.... ,..,
Treatment -Acute
medical
analgesic (Tylenol #3, DemeroJ, morphine) antiemetic

NSAIDs help lower intra-ureteral pressure (e.g. Ketoralac)
If aptic, IJilllnl uramric mnt or
percutaneous neplns1Dmy should be
alpha-blockers: increase rate of spontaneous passage in distal ureteral stones
considerad. antibiotics for UTI
IV fluids if vomiting (note: IV fluids do NOT promote stone passage)
..._,,
_._________________ interventional: if obstruction endangers patient (i.e. sepsis, renal failure)
ureteric stent (via cystoscopy)

percutaneous nephrostomy (image-guided)

lndicatiana far Pwcut.Moua

admit if necessary - see sidebar
Size >2.5 em
Staghom Treatment - Elective
UPJ obstruction medical
Caiyl;1111l diverticulum
Cystine stonas (poor1y friQIIIIIIlld conservative if stone <5 mm and no complications
wilt1 ESWLJ fluids to increase urine volume to >2 Uday (3-4 L if cystine)
specific to stone type (Table 8)
Toronto Notes 2011 Stone Disease Urology U17

interventional Bliclcyll o-IIDiian a till Tlllllnt II

kidney UnllniS..
stent if stone is 1.5-2.5 em J. !im 2007; 1119:1183-117
extraoorporeal shockwave lithotripsy {ESWL} if stone <2.5 crn
a-blockln lilellpy.
percutaneous nephrolithotomy if stone >2.5 em (see sidebar Ul6) liDs.- MBIJNE (JiruaJV 1966111 DctuiJer
ureter 2005),111e C4clillll8 Carmi SMh lilnry, Er.tiASE
ESWL is the primary modality oftreatment U1110 1111111u aladnlric diiiiJIIe of
llbllrldl pwmd 111111u Anrul Mallilu a1111u
ureteroscopy (extraction or fragmentation) if An.- Aaiacillliall (2002., 21Xl5)
- failed ESWL Wife ..medfll'lillnm idlhlled in
- ureteric stricture l'llillll: 11 studin 11'1! llill:tian crD!i1
(n=l11). Ttatmllrt rqad from Bdlys ID 6Willis.
- reasonable alternative for distall/3 of ureter ..... Giani: lnc:idlncl al dillll Lnlllll Rlnl
open ureterolithotomy (very rare)

bladder 1IIIUII: J.lminillrltian 11111 a-ilb:brwM!I

CGISIMiiw1llltmlli inmued incidence oftiDnl
transurethral cystolitholapaxy - QIIIS8Miiw blltnwlt Ilana bv 4411
remove outflow obstruction (TURP or stricture dilatation} (M 1:11.31-1.51, p<0.001).
Cabiar. a-blac:lil!lhlnpr isiiDIICilled v.rith
igJilll:lnltf incmud lllH al clllll uretnl slllne
Prevention
dietary modification:
increase tluid (>2 L/day}, potassium intake
reduce animal protein, oxalate, sodium, sucrose, and fructose intake
.... ,'
avoid high-dose vitamin C supplements
Al1hough hypercalciuria i5 a risk fac!Dr
medications: for stone formation. dacraasing diallry
thiazide diuretics for hypercalciuria calcium is NOT recommended 1o prevent
allopurinol for hyperuricosuria stone formlllion. Low dista!y calcium
potassium citrate for hypodtraturia IIIIIs 1o incnaasad lllCBID absorption and
higher Lilla levels of calcium OJIIIIII!I.

Table B. Stone Classification

Type of Slana Cllci1111 [7..15%) Uric Acil [5-10%) StruYita [5-1 0%) Cystine [1 %)
Efiolagy Hypercalciuria Uric acid in low volume, Infection with urea-splitting Autosomal recessive defect in small
Hyparuricosuria [25% of pati8111s acidi: urine with ahigh uric acid organisms [Proteus, Pseudomonas. bowel mucosal absorption and ranal
with Ca stones) concentnrtion: Provid8nciB, KJebsialle. tubular absorption of dilasic amino
Hyperoxaluria (<5% of patients) o Hyperuricosuria alone Mycoplasme, Satratia, S. autBUS) acids results in "COLA" in urine
Hypocitraturia [12% of patients) o Low urimry pH, low ume volume results in alkaline urinary pH and [cystine, omithine,lysine, .-giline)
Other causes: (e.g. Gl water loss) precipitation of struvit8
Hypomagn8S8111ia - associlll8d Drugs (ASA, thiazides) ammonium jhlsphata)
with hyperoxama and Diet [pume rich red meats)
hypocitraturia o Hyperuricosuria with hyperuricemia
High dietary sodium o Gout
Decreased uril'lll'f proteins o High rate of cell tumover or cal daldh
gdemia, cytDtaxic drugs)
Kay faatulll Radiopa!J!e on KUB Radiolucent on KUB Perpetuates UTI because stone Aggressive stone disease seen in
Rerllcing dietary calcium is NOT Radiopaque on CT harbours organism children and young allllts
an effective method of preventiol\"' Acidic urine S1one and all forei!J1 bodies roost Recurrent stone formation, family
tr8irtrnent be clecnd to avoid racurrenca hi&tory
Associated with staghom calculi Often staghom calculi
Positive urine dip and cultures Faintly radiopaque on KUB
Note: E. coli infection does nat Positive urine sodium nitroprusside
cause stnrvite stones test. urine clr'Dnnatogrephy for
cystine

Trennent Fluids to incn!llse urine volume lncreesed fluid intake Complete stone clearance Increased fluid intake (3-4L of
to >2Uday Alkalinillltion of urine to pH 6.5 to 7 Antibiotics for 6weeks urimt/davl
Matica/ if slons <5 mm For stones: celulose (bicarbonate. potassium drate) Regular follow up urine Alkalinize urine (bicarbonate,
and no complications pha&phate, orthoph05phate for allopurinol pota&&ium citratu), Penicillaminl1/
absorptive causes Shockwave lithotripsy not effective a-MPG or Captopril (form compktx
ProcadJrai/Sutg For calcium oxalate stones: thiazides, with cystine)
tTNtmant ifstons potassium citnlte, alopurinol Shockwave lithotripsy not effective
>5 mm orpresence of Calcium struvite- antibiotics (stone
complications (see U76) must be removed to treat infection)
Ul8 Urology Urological Neoplamu Toronto Notes 2011

Urological Neoplasms
Approach to Renal Mass

IUllnlso1.11d I
..
Cystic I
..
Solid

Hypoechoic
..
Dense

CT
No calcification Calcified (exclude
Thin wall Septated angiomvolipoma)

... ...
Sbip CT*
Angiography
Possible
I la!'llemass
(>1.5cm)
I I
Small mass
(<1.5cm)
I
aspiration or biopJY

I
SUI'lllrf I I
Surveillance I I SUI'lllrf I I Possible
surveillance I
Figure I. Workup of a Renal Mass
MRI DCCISionally pe!fonned I conlnlll corrnindit*d

Benign Renal Neoplasms

RENAL CYSTS
..
._----------------,

simple cysts
very common - up to 50% at age 50
Tabllra Scl11n1U.
AuiD&omal dominant JYndrume usually incidental finding on abdominal imaging
chnellrized by mantel retardation, classification of cysts (i.e. simple and complex)
epilePJY, adenoma sebaceum nd other Bosniak classification is used to stratify for risk of malignancy based on cyst features, see
hllmar111111a.
Table 9
polycystic kidney disease
autosomal recessive - massive kidneys with early renal failure in children
associated with hepatic disease
autosomal dominant - progressive bilateral disease leading to hypertension and renal failure
ea- Gf Enlllrpd ICIIInep
associated with hepatic cysts and cerebral aneurysms
SIIAPE
medullary sponge kidney
Sclerodanna
HIV nephropalhy dilatations of the collecting ducts
Amyloidosis usually benign course, but predispose to calcium phosphate stones
Polycvstic kidniiY diuas von Hippel-Lindau syndrome
Endocrinopllthy' (diabeles)
renal cysts, cerebellar and retinal hemangioblastomas, pancreatic and epididymal cysts
30-40% incidence of renal cell carcinoma

Table 9. B01niak Classification of Renal Cysts

Cl11s
Simple cyst
2 Minimally complex cyst
3 Con1llex cyst
4 Clearly malignanl
Features Risk of Malig111ncy
Round, no septalions, no calcifiCiltions, N99rzero
no solid component
Thin septillion, calcifications, hyperdense on CT Minimal
ThickEr septatians, thicker and mere irregular Moderate. surgical intervention usually
walls, measurable enhancement necessaiY
Class 3plus enhancing sllft-tissue components Near certain
Toronto Notes 2011 Urological Neoplasms Urology U19

Table 10. Bign Renal Masses

Renal Oncocylllm1 llen1l Ad1110m1
Epidlllliolagy Less than 1'!1. of alkllt renal tumours 3-7% of renal tumours. More common in males Incidence increases with age
F>M Found in 7-23% of all autopies
211% associill8d with tuberous sclerosis M:F=3:1
(especially multiple, recurrent)
Clonal neoplasm consisting of fat. smooth Spherical, capsLJIIllld with possible cenlnll scar Small cortical lesions <1 em
musde and blood vessels HistDiogically organized aggregates of Majority are solitary but can be multifocal
May extend into 11!1181 vein and become eosinophilic cells originating from intercalated Histologically organized cells with no atypia which may
symptomatic calls uf collecting diet exhibit bisornv of chromosomes 7 and 11

Dilgnasis R:idml diagnosis lncidml finding on CT although difficult to lncidml finding on CT

Negative attenuation {-ZO HU) on CT is distinguish from RCC Rarely syrl1llomatic
pathognomonic Biopsy may be performed to rule out malignancy Controversy as tD whelher this represents benign or
Rare presentation of hematuria, flank pain preofllalignant neoplasm
and palpable mass (same as RCC)
Benign course although excision warranted if PartiaVradical nephrectomy for large masses PartiaVradical nephrectornv if mass >3cm lkla tD
inCillllsad risk uf rupture and retroperitoneal High intensity focused ultrasound (HIFU) or increased risk of mlll8stllsis
bleed (large size, pregnancy, previous bleed) radiufrequency ablation (RFA) for smeller
Follow with serial UIS masses

Malignant Renal Neoplasms

RENAL ADENOCARCINOMA [Renal Cell Carcinoma (RCC)]
Etiology
cause unknown
originates from proximal convoluted tubule epithelial cells
risk factors: smoking (results in 2x increased relative risk), cadmium exposure, employment in
leather industry
familial incidence seen with von Hippel-Lindau syndrome
Epidemiology
eighth most common malignancy (accounts for 3% of all newly diagnosed cancers)
85% ofprimary malignant tumours in kidney
male:female = 3:1
peak incidence at 50-60 years of age
Pathology
histological subtypes: clear, granular, spindle cell, papillary, chromophobe

Clinical Features
usually asymptomatic- frequently diagnosed incidentally by U/S or CT
poor prognostic indicators: weight loss, weakness, anemia, bone pain
local effects: classic "too late triad" found in 10-15%:
gross hematuria 50%
flank pain <50%
palpable mass <30%
was called the "internist's tumour" because of paraneoplastic symptomatology, now called the
radiologist's tumour because of incidental diagnosis imaging
systemic effects: paraneoplastic syndromes (10-40% ofpatients)
hematopoietic disturbances: anemia, polycythemia, raised ESR
endocrinopathies: hypercalcemia (increased vitamin D hydroxylation), erythrocytosis ... , ,
(increased erythropoietin), hypertension (increased renin), production of other hormones

(prolactin, gonadotropins, TSH, insulin and cortisol) rumour may invade ranal vaint and
hepatic cell dysfunction - "Stauffer's syndrome": abnormal liver function tests, decreased inferior vana (may mull in
WBC count, fever, areas ofhepatic necrosis; no evidence of metastases; reversible following IICiiBI, hllpetic dysfunction, right lllrilll
tumour, and pulmonary .-nbolil.
removal ofprimary tumour
hemodynamic alterations: systolic hypertension (due to AV shunting), peripheral edema
(due to caval obstruction)
metastases: seen in 15% of new cases
bone, brain, lung and liver most common sites
Investigations
routine labs fur paraneoplastic syndromes (CBC, ESR, LFTs)
urinalysis (60-75% have hematuria)
renal ultrasound (solid vs. cystic lesion)
CT scan (to distinguish solid vs. cystic lesion and to determine extent and operability)
IVP (mass lesion): no longer routinely done
angiography: no longer routinely done
U20 Urology Urological Neoplamu 1'oroDio 2011

Methods of Spread
direct. venous, lymphatic
Staging
Involves cr, cheat .x-ray.liver euzymes and functions, bone &can

Table 11. 111M Clllllflcatlon of Renal Adellocarclnoma

T N M
Tl ; tllnOW' <1 em. cedined to P8l1ll pnnchyma NO: na regional nadas Ml: na evidence af IIIBIIIIalis
l1s; <4em
T1b: 4-7 em
N1: IIIBIIIIalii1D 8 node, M1: pra8IIIC8 af liltlm 11181881111il
<Zem
TZ: limDUr >7 em. cadinad to ranal p111111chyma
NZ: IIIBIIIIalii1D 8 node
T3: tllnOW' axl8nds no Dlljor vails or achnal. bll\W8tll Zand 5em cr miAtipla
but nat bawand GIJDilis fla:ia nadas <Zem
T3a: itto arRI1fll cr sills fat
T3b: irto rellllll VIii or infnllillphlli!JIIIIic IVC
Nl: nada >5 em
13c: illo supradillphl'llfllllic IVC
Figure 9. RCC Stegi1g T4: limDUr 8ld8ndl ba'jOIII Gllllla's fiiiCil

Treatment
surgical:
radical nephrectomy: en bloc removal of kidney, tumour, .ipsilateral adrenal gland (in upper
pole tumours) and intact Gerota's capsule md paraaortic lymphadenectomy
partial nephrectomy: <4 em tumour or solitary kidney/bilateral tumours
surgical removal ofsolitary metastasjs may be considered
radiation for palliation - painful bony lesiona
chemotherapy: NOT effi:ctive
advanced stage:
anti-angiogenesis (anti-VEGF)
anti-tyrosine kinase: sunit:inib
anti-ll.2: dacllzwnab (Zenapu-)
Prognosis
stage at diagnosis is the most important predictor of survival:
T 1 - 5-yeauurvival is 90-10096
T2-T3 - 5-year survival is approximately 6096
5-year survival of patients presenting with metastasis is 0-2096

Carcinoma of the Renal Pelvis and Ureter

Epidemiology
rare. a.ccounb for 496 ofall urothclial cancers
frequently multifocal, 2-596 are bilateral
M:F=3:1
relative lncldence- bladder:renal:ureter = 100:10:1
RJ:CII-...-d Pathology
&rgery is 1ha only lllflctivl inlllwnti111 papillary urothelial cell carcinoma (UCC); 8596 (othen include squamous cell. adenocarcinoma)
fur RCC; chllmDihlrapy i1 NOT uRIU.
UCC of kidney md ureter are histologically similar to bladder UCC
Risk Factors
smoking
chemical exposure (industrial dyes and solvents)
ll!lalgesic abuse (acetaminophen, ASA, and phenacetin)
Balkan nephropathy (chronic interstitial nephropathy in countries such as Serbia, Montenegro.
Romania. Bulgaria)
.... , Clinical Features
gross pe.inle&s hemeturila (70-9096 of patients)
lliffllltlllilll DillgHIIIil of Aling Dafllct microsoopic hematuria
lkD1halial ctll cninal'lll (diffa1111i118 flank pain
and CT an)
Uric acid lllllnl (dlfallll'llilllll viii dysuria
cytology and CT sctn) flank mass caused by tumour or associated hydronephrosis (10-2096 of patients)
Blaod clat
Investigations
l'lpll.., niCilllil cystoscopy and retrograde pyelogram: CT scan, radiolucent filling defect on IVP/CT urogram

GBJ Wlbl1 from 1111 pruduc;ing
orgllli11111 Treatment
radical ureteronephrectomy with cuff of bladder
dlstal ureterectomy for dlstal ureteral tumours
Toronto Notes 2011 Urological Neoplasms Urology U21

Bladder Carcinoma
Etiology
unknown, but exposure to environmental and occupational carcinogens plays a role
risk factors:
smoking (main factor- implicated in 60% of new cases)
chemicals: naphthylamines, benzidine, tryptophan, phenacetin metabolites
cyclophosphamide
prior history of radiation treatment to the pelvis
Schistosoma hematobium infection (associated with SCC)
chronic irritation: cystitis, chronic catheterization, bladder stones, (associated with SCC)

Epidemiology
2nd most common urological malignancy
male:female = 3:1, white:black = 4:1
mean age at diagnosis is 65 years

Pathology
classification:
urothelial cell carcinoma (UCC) >90%
',,
squamous cell carcinoma (SCC) 5-7% The "field d81act"tlleory helps to explain
adenocarcinoma I% why UCC has multiple lesions and
others <I% has I high rec1J111111Ce rata. The antira
stages of urothelial cell carcinoma at diagnosis: uruthalium [ptlvis to bladder) il bath8d
in can:inogens.
superficial papillary (75%) -+ >80% overall survival
15% ofthese will progress to invasive UCC
the majority of these patients will have recurrence
invasive (25%} -+ 50-60% 5-year survival
85% have no prior history of superficial UCC (i.e. de novo)
15% have occult metastases at diagnosis -lymph nodes, lung, peritoneum, liver
carcinoma in situ-+ flat, non-papillary erythematous lesion characterized by d)'liplasia confined
to urothelium
more aggressive, poorer prognosis
usually multifocal
may progress to invasive UCC

Clinical Features
hematuria (key symptom: 85-90% at the time of diagnosis)
pain (50%)
clot retention (17%)
asymptomatic (20%)
storage urinary symptoms - consider carcinoma in situ
palpable mass on bimanual exam -+ likely muscle invasion
obstruction of ureters -+ hydronephrosis and uremia (nausea, vomiting and diarrhea)
metastases
hepatomegaly, lymphadenopathy, bone lesions
lower extremity lymphedema if local advancement or lymphatic spread

Investigations
urinalysis, urine C&S, urine cytology
ultrasound
CT scan with contrast or intravenous pyelogram (IVP) -+ look for filling defect
C}'litoscopy with bladder washings (gold standard)
biopsy to establish diagnosis and to determine depth of penetration (although cold punch
biopsy can be transurethral. resection is standard)
new advances with specific bladder tumour markers (e.g. NMP-22, BTA, Immunocyt, FDP)

Grading
Grade 1: well-differentiated (10% invasive)
Grade 2: moderately differentiated (50% invasive)
Grade 3: poorly differentiated (80% invasive)

Staging
for invasive disease: CT or MRI, chest x-ray, liver function tests (metastatic work-up)
U22 Urology Urological Neoplamu 1'oroDio 2011

Tebl11112. DIM Clestificmun uf Bladd

T N M
Tt: mnirrvasive papililwy Cll'tftlma N slalus: as fllr 11!11111 cell carcdlma M status: ulur renal eel carciloma
T11: caciloma ilsitu !CIS); flatlllnull'
Tl: 1111111111' iiMidas &Ubmucau,/IIIID prapria
'121: 111rncu iiMidas superficial mu&dll
T2b: 111mu inwdes deep IIIIIIZ
T3: 1111111111' iiMidBS ptrivesical fal
T41: q.cent 11g111 ilwlv1lnant; prasteta,
Ullnls arVIIIJinll
T4b: lldjlced argan invalvamant; pelvic Will
II' Bbdlri& wall

PalvicWIIIor
Abdominal Will I
Fnltlat8 I
..
]

0
F"1111r 10. Urutllaill Call Clln:inoma Gf Bladdar

Treatment
superfida.l (non muscle invas1ve) disease: Tis, Ta, Tl
transurethral resection ofbladder tumour (TURBT) &lDgle dose or maintenance
intnwesical chemo/immuno-therapy (e.g. BCG, mitomycin C) to decrease recurrence rate
high grade disease - TURBT + lilllinlx:nance BCG OR cystectomy in select patients
invasive disease: T2a, T2b, T3
radical cystectomy + pelvic lymphadenectomy with urinary divezsion (e.g. lleoconduit
Figure II) or irradiation for small tumours
advanced/metastatic disease: T4a, T4b, N+, M+
initial combmatlon systemlc chemotherapy Irradiation surgery

Prognosis
depends on size, number oflesions, recurrence and presence of CIS:
stage Tl- 90% at 5 years
stage T2 - 55%
stage T3 - 2096
f"llglr& 11.1JeGCOndUit stage T41N+IM+ - <5%

Prostatic Carcinoma (CaP)

Etiology
notknown
risk factors
increased inddence in persons of African descent
famlly history
1st degree relative = 2xrisk
1st and 2nd degree relatives = 9x risk
high dietary fat increases risk by 2x
cJgarette smoking

Epidemiology
most prevalent cancer in males
third leading cause of mole cancer deaths (following lung and colon)
lifetime risk of a SO y.o. man for CaP is 5096, and risk of death from CaP is 3%
75% diagnosed between ages of 60 and 85 and mean age at diagnosis is 72
Toronto Notes 2011 Urological Neoplasms Urology U23

Pathology
adenocarcinoma
',
.... t-----------------,
>95% DHJ.rentill DilgJMil of 1 Proltltic
often multifocal Nodule
urothelial cell carcinoma (4.5%) l'nlstm cane {30%)
associated with UCC of bladder Benign prostatic hypurplaia
l'nlstatitis
not hormone-responsive l'nlstatic infarct
endometrial (rare) l'nllllllic: calculus
carcinoma of the utricle Tuben:ulous prostatitis

Anatomy (see Figure 6)

60-70% ofnodules arise in the peripheral zone Efllct rl Sllftun IIIII Villlllil E lilt
all'lallllllc-ud .... c-n.
10-20% arise in the transition zone
S.lnm IIIII Vlllmil ECa.-l'llldln Trill
5-10% arise in the central zone (SBCT)
lippnwl SM, Kltil EA et al..IA.WI2009;
Clinical Features 301(1):39-51
llllllldr. Rlndomilld, pB:.bo canlrallid 1rillwitll
usually asymptomatic 35,5331TIIII \'Onin E.l8ilrliL111
most commonly detected by DRE, elevated PSA, or as an incidental finding on transurethral +villmin E, or pllcebo.
resection of the prostate (TURP) c.tian: Sllaniln Dlvillmin E, IIana Ill in
DRE: hard irregular nodule or diffuse dense induration involving one or both lobes combinltian lithe dalllllld f1lnriMDns lllld.
PSA: see Prostate Specific Antigl!n, U24 cill nat pmant pniSIIt8 elncl' in lllis pilldltion al
Nlltiwly haallhy 111811.
locally advanced disease:
storage and voiding LUTS (uncommon without spread)
suspect with LUTS, incontinence back pain
n.l'rlllllll c-l'nlnnllllll 1111 tiV1l
metastatic disease: NUf 21103; 349:21&-224
bony metastasis to axial skeleton is very common (osteoblastic) S1llly: Alll'lllanimd, plabo
visceral metastasis is less common with liver, lung and adrenal metastases occurring most caolraled IM!dy designed Ill del2mine l'lllelber
tJultmart witli mllllarida Cldd IIIla lila
frequently ]R'IIIIence II prostm CA during 1711111 period.
leg pain and edema with nodal metastasis obstructing lymphatic and venous drainage ,..._ 11.882lTII!Iv.illl . . . . rilkalpniSIItl
CA (55 YIIJIIIIIQI 11 oldlt AtriCIII-Anwican,
Methods of Spread or 11st d'fBI relllive hlwi1Q pniSIIt8 CAl witli
11'1111TT111 ORE and 1 PSA IMI rl g 111tniWIN
local invasion Qlled. t2'J.v.lli1e.
lymphatic spread to regional nodes Finllllrid1 (51TO"dly) vs. piiCiba
obturator > iliac > presacrallpara-aortic lhin ,.._I'IMience GIJNUSI* CA

hematogenous dissemination occurs early 17-,..r period.

blulll: Study MS cloeed emtv as olijectiues were
nwt. lb&ra-1 MAIIIIMI TldL1ian (P<0.001)
Investigations in prM1111:1 rl pnllllll CA in 1111 filu1lrill gnllf
DRE [18\ incidallctl COITptlld 1D pllcllllo p t [24ll.
PSA elevated in the majority of patients with CaP inciclanca], but 1r1 ilcrnsa i11111 proporb al
transrectal ultrasound (TRUS) -+ size and local staging Glide tuncus !Gleason score 1-101 lhose

TRUS-guidedneedle biopsy plecebol. The njorityal11mlurs in bath graups
bone scan may be omitted in untreated CaP with PSA < 10 ng/ml 118\lwera bcdz8d di181M(T1 11 T2).
CT scanning to assess metastases The firasleride group lso lad a sigliicdy higher
inciclanca ai1111UII
swmpiDms 'dlll11111 pliabo graup.
Tabla 13. Staging of PrDitate Cancer (TNM 2002) Cancbioll: MIIIIIMII 55 who took filllllaride for
T N M 7\'IIIIW8nl 25\lals lblv1D dMop pniSIIt8
CA 1otbu plaeebotJQUP. h_.'dla
T1: dinically undetectable normal ORE and TilUS N: spread ID 11!1jianal M: distant metastasis t:IIIC8IS ilthlfinllllridl grDUpWINaf I higi.-
T1a: tumour incidiiiTIBI histologic findilg in < 5% of tissue res!!Cted lymph nodes M1a: nonregionallymph nodes Qlllll.
T1 b: tumour incidental histologic findilg in > 5% of tissue resected M1b: bone(s]
nc: tumour identified by neelle biopsy (because of elevated PSA M1c: lither site(sl with or
IMII; tumours found in 1or bath lobes by needle biopsy but nat
palpable or l'llliably visible by imaging
without bona disease
..... ,t-----------------,
,
T2: palpable, confined ID prostate
T2a: tumour involving less than alobe Coidtntiona In lnt.rprdn1
T2b: tumour involving less than or equal to 1 lobe Prostata Biopsy Renlts
T2c: tumour involving bath lobes GI8QOn ISCOI'll6 for two moe!:
prN!minant patmms ar. l"'ported
T3: tumour extEnds through prostate Cl!pSule {e.g. 3+4 = Gleason sum
T31: IIX!nlcapsular IIXIIInsion (unilateral or bilatel'lll] Nota: 4+2 not equal to 3+3 despite
T3b: tumour invadng sami1111l vesicle(s] equivalent Gleason sum)
Billlbnl "' . ..... itvolvement
T4: tumour invades adjacent structures (besides seminal vesicles] %of core and number of cores
involved
Table 14. Prostate Cancer MDrtality Risk
Low Rilk Madlll'lllt lhk High Rilk
[if any of fallowing) [if any of fuiiDWi1g)
PSA <10 10-20 >20
GIBuon Score <7 7 8-10
Stage pT1-2a pT2b-T2c pT3/4
U24 Urology Urological Neoplamu Toronto Notes 2011

Wi:ll ,......,_WIIr:WWiiliq Treatment

il Early,....... c.. Tl (small well-differentiated CaP are associated with slow growth rate)
NEJM m; 352:1 m-84. if young consider radical prostatectomy, brachytherapy or radiation
.....: To dellnnina whether aut, lldical follow in older population {cancer death rate up to 10%)
praslllldDmy improved 1118 llniwl in lTIIII with
11011-invlliw pnllllta CIIICir II compnd ID T2
......,....lliln:
.
695 lllmWIIIPI1JIIIeeM.
111rolld iam 14 CIJ'ils lll1lllld Swldlll.linllad
radical prostatectomy or radiation (70-85% survival at 10 years) or brachytherapy
T3, T4
bllwlln 1989ltld 199!.1ncmian staging lymphadenectomy and radiation or hormonal treatment
criteri incUd8d being undlr lila of 75, n!JMt N >0 or M >0 (see Common Medications, U43)
diiQIIOMd pn1111ta requires hormonal therapy/palliative radiotherapy for metastases
CIIIC8t sllg8 T2 or lels.l'ltholagr hiiiiiD show
Ilk allllldnlltt or llmlur.
bilateral orchiectomy- removes 90% of testosterone
l'ltialb W8A1 rlnllolriy lllignad 011811:1 bail ID GnRH agonists [e.g.leuprolide (Lupron or Eligard), goserelin (Zolada-)]
llillltr en iiiiiiMnlion grnup {TIIicll proslllaCIDmy) estrogens [e.g. diethylstilbestrol (DES)]
or r:an1RA Wliling). The PriniiV llllpoint antiandrogens [bicalutamide (Casodcx)]
rl1he study was IMmll lTIGitJity u ID p!IJIIIts
C111C8t with IICDIIdlty 1ndpaia lllkln ID be local local irradiation of painful secondaries or half-body irradiation
prl9lllian and dilllnt 1111111111111. ADiiyliiWIS chemotherapy regimens that include docetaxel may improve survival in advanced prostate
perflmnld on 111 inllniiiHD-trllt belil. cancer that is no longer responsive to hormone therapy
The
lelltNe risk IRR) rllocll protpeSiion nd dislllnl
llllllslllsll for 1118 inlllvmion 0.33 Table 15. Treatment Options for Localized Prostate Cancer
{p<O.OOllltld D.OO {p<O.DliiiiPiclivlly, II
compnd 1D 1118 COIIIJol Qroup. The Nlllivl risk II
derrtll d11111D poe11t1 CII1C8r in lila irrbrMnliorr

Wlll:hful Waiting Low grade cisease or short life expecllllcy Disease pragression
c:..:u-llrldicel ptOSIIIIcbrmy retb:el1he (Active Surveillance) ( <5-10 y); good follow-(Jp
risk rl dlltlr clJ11Dprillllll Cllll*' in 111111 with
11011-invlliw, WIIIID rnodllllaly dilllnrnlilfld 81'1ChythM'IpJ Low volume, low PSA (< 10), low grade Erectile dyshr.ction (5D%),? long term effectiveness
Ullourt, compll8d ID Wlldrlul Wliq. The ExtamaiB_. Locally advanced disease, older patients Radiation practitis (S'lf.), erectile dysfunction (51l%), risk
lelltNe risk rl bodllocll iiiVISiorr 111d 1he spread
rldillld111111S1111s-dsolianificarrlti Tharapy of rectal cancer
decnued with lilly lldicll prostaiiCtDrTiy
Young patients (<65 y), hilt! grade disease Incontinence (11l%), erectile dysfunction (3D-51l%)

Otlrar options includl high irt1n1ity foms11 '*n!IOUnd {HIFll), hormonlllllllltion

Prognosis
stage T 1-T2: excellent, comparable with normal life expectancy
stage T3-T4: 40-70% survival at 10 years
stage N+ and/or M+: 40% survival at 5 years
prognostic factors: tumour stage, tumour grade, PSA value, PSA doubling time

Prostate Specific Antigen (PSA)

enzyme produced by epithelial cells of prostate gland to liquify the ejaculate
leaks into circulation and is present at <4 ng/mL
measured total serum PSA is a combination of free (unbound) PSA ( 15%) and compl.exed PSA (85%)
Screening Prostate Cancer: PSA and ORE
AUA Best Practice Statement, 2009 Update
PSA may be elevated in prostate cancer and many other conditions; it is not specific to prostate
It'
In PSA testing, tlink "free and auy":
cancer
increased free/total nrtio suggeslli currently mixed evidence concerning effect of PSA screening on mortality (ERSPC and PLCO
b111ign cauu of high PSA. trials - see sidebar)
population-based, routine screening not recommended
,,.,
must discuss risk factors, test characteristics, risk of over-detection and over-treatment,
treatment and active surveillance options
well-informed patients can elect to undergo PSA test and DRE
c - ot lnt:r11uad PSA the decision to proceed to prostate biopsy should be based primarily on PSA and DRE results,
BPH, pnnibditis, i&ehsmirl/ but should take into account multiple factors (free and total PSA, patient age, PSA velocity, PSA
infarction. acute urinary retention,
Pf1)5lllhl biopsy/allgflfY, prolllrtic;
density, family history, ethnicity, prior biopsy history and comorbidities)
masua-. urllh111l c:am...rimtion, TRUS,
Strategies to Increase Specificity of PSA
111nal faiiU111, bypass Ql1lft.. age-related cut-off values
radia1ion therapy; a normal DRE does
NOT significantly llrnll1 PSA.
Table 16. Nonnal PSA Value by Aga Group
Serum PSA Concentndian {IIJ'l)
411-49 <2.5
50-59 <3.5
60-li9 <4.5
70-79 <6.5
JE st al..li1AM 1193; 270{71:86()..4.
Toronto Notes 2011 Urological Neoplasms Urology U25

free-to-total PSA ratio:

.......
complexed PSA increases in prostate cancer, decreasing the percentage of the free fraction lullllllizlll bnpunlludy
<10% free PSA suggestive of cancer, >20% free suggests benign cause NEJM2001; 3611:13211-8
PSA velocity: .....: To detamina 1111 lfficlcy of prolllla-
spdic dg8n ll'SAiscraaq ill impi'Mig
change of>0.75 nglmUyear associated with increased risk of cancer
PSA density: ........,..!dan:
Mllllllftivll in prDIIltS CIIICIIr.
1821611 IIQI!d SG-74
were remilldbltwelll1994- Z!l04 m
patients

PSA divided by prostate volume as found on TRUS E!JropB counlrin 111d p!IIIIICtiwly mild and
>0.15 nglmUg associated with increased risk of cancer IIIMimniltd llllilhlr 1 ar cantral group.
Scr.ning conlind of a PSA 1M talren MY 4
Other Uses for PSA (AUA Bast Practice Statement, 2009 Update) Y8ll1 {i llld cut-dlfor bicl!liY was at
3ri;Pri TllliMnt rl conlimld i)RIIIIII
therapeutic decision making: patients with serum PSA levels <10.0 nglmL are most likely to was laft1o the guidlines rlaldi courty. The
respond to local therapy prin'llry anll-poirt was IMII1111101111ity. 11111(zad on
Ill iniiOOon-1o-SCRIIn IIIIis.
work-up: bone scans are generally not necessary in patients with newly diagnosed prostate
11116: Median fliiMo\QJ time WIS 9yem, and
cancer who have a PSA <20.0 nglmL unless the history or clinical examination suggests bony 1lle incidence rl prostate Clf1Cel ill the sa-eerilq
involvement Pf was8.2\n. l8'l. in ill canlrDI
disease monitoring: serum PSA should fall to a low level following radiation therapy, high ThalliiiiM risk al dllth il llfliUP
n. canlrDiwu 0.80 IP<D.15I. The lllltiiiD ria
intensity focused ultrasound and cryotherapy and should not rise on successive occasions. PSA IVClJclionwas0.71
should remain undetectable following radical prostatectomy group, trnslB; lila needed to
outcome prediction: in patients with metastatic disease receiving androgen suppression sa.n r/1410 IIIII a rurlie! 11l8dld 1o 11111 r/48.
c:.I1111Dnl: T1'11111of PSAsa.ningwullill
therapy, failure to achieve a PSA nadir of <4.0 nglmL seven months after initiation of therapy is
associated with a very poor prognosis (median survival: one year) .._n
1D !Xdarallillive riskllllb:tion aiM1ollllll
rl50 at 74 {MbthiiTlljority
rl benefit se111 in m111 aged SG-611.
1lle increaled rill ridilgllllil was spcdf
iiCflllld in group, ltld clii1D the
Testicular Tumours ildolad CUll afmany prDIIltS Clnalll, !hill flct
nut be lliren irQ considlndion. Fur1her Wjy
is Wlll3llled 11 examine 1lle aptimll
Etiology (Risk Facton) llml ofPSA Uldttnsholds
cryptorchidism, atrophy, sex hormones, HIV infection, infertility 1D 1*11fon!ll1111 the optimall1llfllff 1D IHIICI
family history; personal history of testis cancer thlrisbri!MIIdilgnlllilandllllJCIIdprDIIltll
c:m:ur nutD!y.
Epidemiology
rare, but most common in young adults (17-37 years of age)
high cure rate
', ,
any solid testicular mass in young patient - must rule out malignancy On:ltiapoy
slightly more common in right testis (corresponds with slightly higher incidence of right-sided SurgiCIII dNC:unt (orchiopexy) of
cryptorchidism) undescended testis does nat reduce
the rill!: of mlllignlllncy. It can however,
2-3% bilateral (simultaneously or successively) r.duc1 the rilk of infertility lllld
physical axarn.
Pathology
primary:
1% of all malignancies in males
most common solid malignancy in males aged 15-34 years
undescended testicle has increased risk (10-40:x) of malignancy
95% are germ cell tumours (all are malignant)
seminoma (35%) classic, anaplastic, spermatocytic
nonseminomatous germ cell tumours (NSGCT) embryonal cell carcinoma (20%),
teratoma (5%), choriocarcinoma (<1 %), yolk sac (1%), mixed cell type (40%)
5% are non-germ cell tumours (usually benign) (testosterone, precocious
puberty), Sertoli (gynecomastia, decreased libido)
secondary:
male >50 years of age
usually a lymphoma
metastases (e.g. lung. prostate, GI)

Clinical Features
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%
coincidental trauma in 10%
infertility (rarely presenting complaint)
gynecomastia due to secretory tumour effects
metastatic disease related back pain
supraclavicular and inguinal nodes
abdominal mass (retroperitoneal lymph node metastases)
U26 Urology Urological Neoplamu Toronto Notes 2011

.
..,., ,
.-----------------,
Testlll nl acroblm hlva
lymphlllic drain11Q8, lllenlfore

Methods of Spread
local spread follows lymphatics:
right -+ medial, paracaval, anterior and lateral nodes
left -+ left lateral and anterior paraaortic nodes
1rans-scrotalllppi'08ch for biopsy or "cross-over" metastases from right to left are fairly common, but they have not been reported
orchieciDmy shoolei be avoided. from left to right

..,., , hematogenous most commonly to lung, liver, bones and kidney

..-----------------
AorU is 11111 Left: Lsft testicle drains
Investigations
diagnosis is established by railical inguinal orchidectomy
iniD the pr. and pnaortic nodes. tumour markers:
IVC ie on thlllight: Right testicle beta-hCG and AFP are positive in 85% of non-seminomatous tumours
draits in to the IJII111CIMIII nod11. pre-orchidectomy elevated marker levels return to normal post-operatively if no secondaries
beta-hCG positive in 7% of seminomas, AFP never elevated with seminoma
..,., ,
.
testicular ultrasound {hypoechok area within tunica albuginea =high suspicion oftesticular cancer)
evidence of testicular microlithiasis is not a risk factor fur testicular cancer
.-----------------, needle aspiration contraindicated
SUging
Clinical- CXR metatases), Management
mllbrs for staging AFP. LDH), orchiectomy for all stages
CT abdomenfpelvis
lymphadenoplllhy) adjuvant therapies as per Figure 12
Stage 1: disease limited to testis,
epididymis or lji&ITTIIIlic cord
Tentoma
Stage II: diseasa limited to the
rvtroperitoneld nodn Embryonal CA
Stage Ill: diuase m.tutlltic to Germinal cell
supradiaptngmatic: nodal or visceral Mixed cell type

Yolk sac CA
l'lthologic {Ill orchiectomy) Epithulium
T1 :tumour confined to tosli$ and Chorio CA
epididymis, no vascui.-Jlymphl.tic:
illllll$ion 90% 10% 40% 20% 20%
T2: tumour extends beyond tunica
albuginea or vascular/lymphatic Staga I Staga 11+111 Staga I Stage II Staga II
illllll$ion ./ ./
Surveillance
T3: tumour involves spermatic cord
T4: blmour invadll scrorum Ralialion ./
T4a: tumour invlldes spermatic cord
RPI.JIID ./ ./(residual mass)
T4b: tumour invedes acrollll WilD
Chemothlnpy ? ./ ./ ./

.
... , ,
.-----------------,
RPLIIIP can ba perform ad in a niiVI
sparing fashion, preserving niMII of
Figura 12. Management of Tll'licular Cancer
1
APLND = retruperilmeai-IIXIe dillectiln Adapted from Dr. MAS Jewett

Prognosis
the hypogestric plaxus to maintain 99% cured with stage I, stage ll disease
antegl"lde ejaculation. 70-80% complete remission with advanced disease

Penile Tumours
rare (<1% of cancer in males in U.S.), most common in 6th decade

Benign
cyst, hemangioma, nevus, papilloma

Pre-malignant
balanitis xerotica obliterans, leukoplakia, Buschke-Lowenstein tumour (large condyloma)

Pre-invasive Cancer
carcinoma in situ (CIS):
Bowen's disease -+ crusted, red plaques on the shaft
erythroplasia of Queyrat -+ velvet red, ulcerated plaques on the glans
treatment options: local excis.ion, laser, radiation, topical5-fluorouracil

Malignant
risk factors:
chronic inflammatory disease
STI
phimosis
uncircumcised penis
2% of all urogenital cancers
squamous cell (>95%), basal cell, melanoma, Paget's disease ofthe penis (extremely rare)
definitive diagnosis requires full thickness biopsy oflesion
Toronto Notes 2011 Urological Neoplasms/Scrotal Mlllll Urology U27

Table 17. TNM Staging for Penile Carcinoma

T N M
Tx: prinary 1ll1l0ur can nat be assessed N1: metastasis in a single superficial, M: presence {+I or absence (01 of
node distant metastasis (lung. liver, bone,
TO: no evidence of primary tumour
brainI
T.: CIS N2: melil&lil5is in or bilahral
superficial lymph nodes
Ta: non-iiMISive carciloma
N3: metastasis in deep inguinal or pelvic
T1: tumour invades subspithelial coniiiCiive lymph noda(sl unilateral
tissue (Buck's and lla1Ds fascial
T2: tumour invades carpus or
cavemosurn (throu!ll tunica albugineaI
T3: tumour invades urethra or prostate
T4: tumour invades D1her adjacent structures

lymphatic spread (superficial/deep inguinal nodes-+ iliac nodes) hematogenous

Treatment
wide surgical excision with tumour-free margins (dependent on extent and area of penile
involvement) lymphadenectomy

Scrotal Mass
see Common Presenting Problems, U3

Tabla 1B. Differentiating batwaan Scrotal Mauas Di&renti.. gf a Benign krvtal MIIR
Condition Pain Pllpalian Additional Findnp HIS IllS
llydrucale
Tol'lion + Diffuse tenderness Absent cremaster reflex. negative Prehn's siiJI, Infection
EMERGENCY! Sperm {spermatocele I
Epididymitia + Epididymal tenderness Present cremaster reflex, positive Prehn's sign llaod {hlmlltaclll
lnlllslirm (hamial
On:hitis + Diffuse tenderness PrasiJTI: cremaster reflex. positive Prehn's sign TDI'Iion
lome veins lvaricocelel
H1111atocllla + Diffuse tenderness No transillumillltion
HydiiiCIII Testis not separable from Transilumination
hydrocele, cord palpable
SparmlltDcela Testis separable from Transilumination
spermatocele, cord palpable
lllricoclll Bagofwonns No transillumillltion
lndn=ct lnguilal - (+ htnmgulatedl Testis separable from hernia, cord No transillummon
nat palpable, cou!ll impulse may
transmit, may be reducible
Tumaur - (+ hemorrhagicI Hard lump/nodule
Idiopathic:
.... ,}-----------------,
,
Vuic:ec:ale Gl'lldilg
Grade 1: l'lllpeblti only with valsalva
manaevre
Grade 2: Palpable without VIIIIIIIVII
Grade 3: Visible through scrotal skin

.... ,}-----------------,
,
lndicllions for Tl'8ltnlent vf
Vuic:ec:ale
Impaired sparm or qullllity
Pail or dulache llffectinv of
life
Affected testis fails to grow in
lldalascants
Cosm.tic indications (especially in
lldalascantsl
U28 Urology Scrotal Mass Toronto Notes 2011

Table 19. Benign Scrotal Masses

Type Vlricocele SpIIIIIDc:lla Hv*acell TIISiicullr To11i1111 l1111uinll Hamil
Dllilitian Diatatian and toltuosity A benign, sperm filled Collection of serous fluid Twisting of the testicle Protrusion of abdominal
of piiiXU& epididymal rBtention cyst that resulbi tom a dsf8ct or causilg wnous occlusion contenlli through the inguinal
irritation in the tunica vaginalis and engorgement as well as canal into the scrotum
artaial ischemia and irllrction
Etiolagy 10%ofmen Wtiple theories, ncluding: Usually idioplllhic TlllUIIlll, Indirect (through internal
Due to incorJ1)elent valves Distal obstruction Found in 5-111% testicular Cryptarchidism, ring, oftEn into scrotum)-
in the testicular vains Aranysmal dilations of the tumOUIS "Ball dapper dafonnity" congenillll
90% left sided epididymis Associated with traLIIII!/ Many occur in sleep (50%) Direct (through IIXtemal
Agglutinal!d genn cells infection Necrosis of in 5-6 ring. rarely into scrotum)-
Communicatilg: patent hoUIS abdominal muscle weakness
processus vaginalis,
changas size during day
(peds)
Non-communicating: non-
patent processus vaginal is
(adlltl
Hislllry/ "Bag of wonns", Non-tender, cystic mJISS Non-tender, inlrascn!lal Acute onset severe scrotsl A small bulge in the groin
Phylical Eum Oftan painless Transilluminates mass pail, swelling that may increase in size and
Pulsatas with valsalva Cystic Gl upsets cases disappear when lying down
Transilluminates Retracted and transverse Can present as aswollen or
testicle (horizontal lie) enlarged scrotum
Negative Phren's sign Discomfurt or shlrp pain -
Absent cramastaric reflex espacially when straining.
lilting. or exercising
IIYelligati- Physical exam Physical exam U/S to r/o tumour U/S colour ftow History 111d physical
vasava U/S to r/o tumour Doppler probe over Invagination of the scrotum
testicular artery Valsalva
Decrease uptake on 99m Tc-
pertechnetate scintillation
scan (doughnut sign)
T1111tment CanseJVBtive Consentalive Conservative Emergency manual Surgical repair
Surgical ligation of testicular Avoid needle aspiration Needle drainage detorsion (rotate outward)
wins as it Cllllead to infection, Surgical with electiva bilateral
Perculllleous vein occlusion reaccumulation and spilling orchiopexy
(balloon, sclerosing agents) of irrilllting spenn within Falure of manual delllrsion:
Repair may improve sperm scrotum surgical delllrsion with
count/motility 5075%. Excisa symptomatic orchiopexy
Orchiectomy if poor
prognosis

TORSION OF TESTICULAR APPENDIX

twisting of testicular/epididymal vestigial appendix
often <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

HEMATOCELE
trauma with bleed into tunica vaginalis
ultrasound helpful to exclude fracture of testis which requires surgical repair

Treatment
ice packs, analgesics, surgical repair
'IbroDlo Nota 2011 Peaile Com.plainb Urology U29

Penile Complaints
Payronia's Disease
Definition
benign curvature of penile shaft secondary to fibrous thickening of tumca albuginea
commonly on donal surface resulting in upward curvature of erect penis - may occur at any site

Etiology
exact etiology unknown
trauma/repeated mk:rotrauma -+ inflammation -+ fibrosis
familial predisposition
relllted to diabetes mellitus, vascular disease, autoimmunity, Dupuytren's contracture
role of vitamin E deficiency. beta-blockade, elevated serotonin

Clinical Features
penile curvature andlor pain with erection
penile shortening and poor erection distal to plaque

Tralltment
depends on pain and interference with intercourse
watchful waiting (spontaneous resolution in up to SO%)
vitamin E, potassium paraaminabenzoate (potaba) -limited efficacy
intralesional verapamll
surgery if stable disease, slgnlftcant deformity AND failed medl.cal. therapy
exdsion ofplaque prosthesis

Priapism 1. Fillraus plaqua

Z. Tmic:a lllbuailel
UROLOGICAL EMERGENCY 3. CG!pus I:IW8I'IIOIUm
4.Budt'fQc;ia
Definition 5. CGfpus _,.angiost.m
prolonged unwanted erection lasting >4 hours &. Uralhr1 c J ... Li 201 a
tumescence (swelling) of corpora cavernosa (often painful) with flaccid glans penis (no corpora
spongioswn involvement) Figura 13. Payronia'a .
.

Classlnc:atlon
low-flow (most common): reducedlabsent cavemosal blood flow-+ hypoxia. acidosis
-+ischemia
high-How: unregulated a.rtJ:rial flow with normal tissue oxygenation

Etiology
primary - 60% idiopathic
secondary:
thromboembolic - including sickle cell, thalassemia, total parenteral nutrition, dlalf!lll,
leukemia, solid tumours
neurogenic- spinal cord injury, autonomic neuropathy
traumatic - cavemosal artery laceration, arterio-venous fistula
medication- intracavernosal drug injection (e.g. triple lllix), alpha-blockers, anticoagulants.
antidepressant&. antipsychotics, anxiolytia,
reaeational drugs - cocaine, marijuana. alcohol

Treatment
treat reversible causes (e.g.leukophorms ifleukemia, treat sickle cell crisis)
high flow often self-limited - observation vs. a.rtJ:rial embolization
lowflow:
1. urgent via needle aspiration of blood
2. phenylephrine injection into the corpora cavernosa ql0-15min
3. ahunt creation between cavemosum and spongiosum ifno response within I hour

Complications
erect:lle dysfunction due to corporal fibrosis iftreatment delayed (50%)
9096 risk if>24 hours
U30 Urology Penile Complaints Toronto Notes 2011

Paraphimosis
UROWGICAL EMERGENCY
Definition
foreskin caught behind glans leading to edema -+ unable to reduce foreskin
Treatment
squeeze edema out ofthe glans with manual pressure (analgesia required)
pull on foreskin with fingers while pushing on glans with thumbs
if fails, perform dorsal slit or circumcision
elective circumcision for definitive treatment (paraphimosis tends to recur)
Complications
infection, glans ischemia, gangrene

Phimosis
Definition
inability to retract foreskin over glans penis
may be caused by balanitis (infection of glans), often due to poor hygeine or congenital
normal congenital adhesions separate naturally by 1-2 years of age
Treatment
circumcision, dorsal slit, proper hygiene (trial of topical corticosteroids in children)
Complications
balanoposthitis (inflammation of prepuce), paraphimosis, penile cancer

Erectile Dysfunction (ED)

-------------------------------------
Definition
consistent (>3 months duration) or recurrent inability to obtain or maintain an adequate
erection for sexual performance

Physiology
erection involves the coordination of psychologic, neurologic, hemodynamic, mechanical and
endocrine components
nerves: sympathetic (Tll-12), parasympathetic (52-4), somatic [dorsal penile/pudendal nerves
(S2-4)]
erection ("POINT")
parasympathetics -+ release ofnitric oxide (NO) -+ increased cGMP levels within corpora
Erections POINT AND SHOOT
parasympa1hetics = point; and
cavernosa leading to:
sympathlllict/lomatiCI = sboat 1. arteriolar dilatation
2. sinusoidal smooth muscle relaxation -+ increased arterial inflow and compression of
penile venous drainage (decreased venous outflow)
emission ("SHOOT")
sensory afferents from glans
secretions from prostate, seminal vesicles, and ejaculatory ducts enter prostatic urethra
(sympathetics)
ejaculation ("SHOOT")
bladder neck closure (sympathetic)
spasmodic contraction of bulbo-cavernosus and pelvic floor musculature (somatic)
detumescence
sympathetic nerves, norepinephrine, endothelin-1 -+ arteriolar and sinusoidal constriction
-+ penile flaccidity

Classification

Table 28. Classification of Erectile Dysfunction

Fsyt:hoganic: Organic:
Proportion 111% 90%
011141t Sudden Gradual
Fn=quenc:y Sporadic All circumstances
Variation 'IIIith partner 111d circumstance No
Age Younger Old
Organic Risk Fac:tDrs No organic risk fac!Drs Risk fac!Drs present
fHTN, DM, Dyslipidemia]
Nocbi'111VAM aractian Present Absent
Toronto Notes 2011 Penile Complaints Urology U31

Etiology (.. IMPOTENCE'")

Iatrogenic: pelvic surgery/pelvic radiation
Mechanical: Peyronie's, post-priapism
Psychological: depression, stress, anxiety, PTSD, widower syndrome
Occlusive vascular: arterial (hypertension, diabetes, smoking, hyperlipidemia, peripheral
vascular disease, smoking), venous (impaired vena-occlusion)
Trauma: penile/pelvic
Extra factors: renal failure, cirrhosis, COPD, sleep apnea, malnutrition
Neurogenic: CNS (e.g. Parkinson's, multiple sclerosis, spinal cord injury, spina
bifida, stroke), PNS (e.g. diabetes, peripheral neuropathy)
Chemical: antihypertensives, sedatives, antidepressants, antipsychotics, anxiolytics,
anti-androgens (including 5-alpha reductase inhibitors), statins, GnRH agonists, illicit drugs
Endocrine: diabetes, hypogonadism, hyperprolactinemi.a, hypo/hyperthyroid

Diagnosis
complete history (sexual, medical, and psychosocial)
self-administered questionnaires (International Index of Erectile Function, Sexual Health ... , ,
Inventory for Men Questionnaire, ED Intensity Scale, ED Impact Scale)
focused physical exam, including vascular and neurologic examinations THiolilanme deficiem:y ia an
lab investigations - based on clinical picture uncommon cause of ED.
risk factor evaluation: fasting blood glucose or HbAlc, cholesterol profile
other: TSH, CBC, urinalysis
hypothalamic-pituitary-gonadal axis evaluation: testosterone (free and total), prolactin, lli,
FSH
usually unnecessary to do further testing except in certain situations
specialized testing
non-invasive:
nocturnal penile tumescence monitor
invasive (rarely done):
intracavemous injection of papaverine or PGE1 - rule out significant arterial or venous
impairment
Doppler studies pre- and post-papaverine injection - cavernosal anatomy and arterial
flow evaluation (penile-brachial index <0.6 suggestive ofvascular cause}
angiography of pudendal artery post papaverine injection -post-traumatic ED
evaluation only fur possible vascular reconstruction
dynamic cavernosometry and cavemosography- to evaluate leakage from penile veins

Treatment
must fully inform patient/partner of options, benefits and complications
non-invasive:
lifestyle changes (alcohol, smoking), psychological (sexual counseling and education)
change precipitating medications
minimally invasive:
oral medication (see Common Medications, U43)
sildenafil (V!agra), tadalafil (Cialis), vardenafil (Levitra): inhibits phosphodiesterase
type 5
PDE-5 inhibitoR are contn.indica1ed in
rarely used patienlli on nitnrtllf/nitravlyl;erin due to
- yohimbine: a-blocker that is best fur psychogenic ED savere hypotension.
- trazodone: serotonin antagonist and reuptake inhibitor
androgen replacement therapy: if hypogonadism
vacuum devices: draw blood into penis via negative pressure, then put ring at base of penis
once erect
MUSE: Male Urethral Suppository for Erection - vasoactive substance (PGE1) capsule into
urethra
invasive:
intracorporal vasodilator injection/self-injection
triple therapy (papaverine, phentolamine, PGE1) or PGE1 alone
complications include priapism (overdose}, thickening of tunica albuginea at site of
repeated injections (Peyronie's plaque) and hematoma
implants (last resort): malleable or inflatable
vascular surgery: microvascular arterial bypass and venous ligation (investigational}
U32 Urology Penile Complaint:a!I'rauma Toronto Notes 2011

Premature Ejaculation
----------------------------------
Definition
occurrence of ejaculation prior to when one or both partners desire it
primary premature ejaculation
never experienced sexual activity without the presence of premature ejaculation
secondary premature ejaculation
the individual once had acceptable ejaculatory control, but now experiences premature
ejaculation, not associated with a general medical condition

Epidemiology
30-70% prevalence
most common sexual dysfunction reported in men 18-30 years old, associated with secondary
impotence in men 45-65 years old

Investigations
indicated by history and physical
testosterone levels if in conjunction with impotence

Treatment
must rule out and treat any associated general medical conditions (ie. fear of angina)
often thought to be due to psychological factors; identify and address specific stressors
referral to psychiatry, couples counseling or sex therapy
SSRis have been found to be effective in some cases
clomipramine (daily or PRN 4-6 hours before intercourse)

Trauma
see Emergency Medicine. ER14

Renal Trauma
Etiology
blunt (80%, motor vehicle collision (MVC), assaults, falls) vs. penetrating (20%, stab wounds
and gunshots)

History
mechanism of injury

Physical Exam
ABCs, renal vascular injury -+ shock mandating resuscitation
upper abdominal/flank tenderness, flank contusions, lower rib/vertebral transverse process
fracture suggests blunt trauma

Investigations
urinalysis: hematuria- requires workup but degree does not correlate with the severity of injury
imaging: cr (contrast triphasic) if patient stable -look for renal laceration, extravasation of
contrast, retroperitoneal hematoma. and associated intra-abdominal organ injury

Staging
I: contusion/hematoma
II: <1 em laceration without urinary extravasation
III: >1 em laceration without urinary extravasation
IV: urinary extravasation
V: shattered kidney or avulsion of pedicle

Classification According to Severity

minor: contusions and superficial lacerations/hematomas - 90% of all blunt traumas, surgical
exploration seldom necessary
major: laceration that extends into medulla and collecting system, major renal vascular injury,
shattered kidney

Management
microscopic hematuria + isolated well-staged minor injuries -+ no hospitalization
gross hematuria + contusion/minor lacerations -+ hospitalize, bedrest, repeat CT ifbleeding
persists
Toronto Notes 2011 Trauma Urology U33

surgical intervention:
absolute indications: hemorrhage and hemodynamic instability
relative indications
non-viable tissue and major laceration
urinary extravasation
vascular injury
expanding or pulsating peri-renal mass
laparotomy for associated injury

Outcome
follow up with ultrasound or CT before discharge, and at 6 weeks
hypertension in 5% of renal trauma

Bladder Trauma
blunt (MVC, falls, and crush injury) vs. penetrating trauma to lower abdomen, pelvis, or perineum
blunt trauma is associated with pelvic fracture in 97% of cases

Clinical Features
abdominal tenderness, distention, and inability to void
may be peritoneal signs or symptoms
associated injuries including pelvic and long bone fractures are common
hemodynamic instability due to extensive blood loss in the pelvis
suprapubic discomfort and/or tenderness

Investigations
urinalysis - gross hematuria in 90%
imaging
cystogram and post-drainage film for extravasation

Claulflcatlon
contusions: no urinary extravasation, damage to mucosa or muscularis
intraperitoneal ruptures: often involve the bladder dome
extraperitoneal ruptures: involve anterior or lateral bladder wall in full bladder

Treatment
penetrating trauma: surgical exploration
contusion: urethral catheter until hematuria completely resolves
extraperitoneal bladder perforations: typically non-operative with foley insertion
surgery if. infected urine, rectallvaginal perforation, bony spike into bladder or iflaparatomy
for concurrent injury
intraperitoneal rupture usually requires surgical repair and suprapubic catheteri2ation

Complications
complications of bladder injury itself are rare
mortality is around 20%, and is usually due to associated injuries rather than bladder rupture

Urethral InJuries
Etiology
posterior urethra: common site of injury is junction ofmembranous and prostatic urethra due
to blunt trauma, MVCs, peMc fracture
shearing force on fixed membranous and mobile prostatic urethra
',.._---------------,
,
anterior urethra: straddle injury can crush bulbar urethra against pubic rami AUpatients with suspected urethral
other causes: iatrogenic (instrumentation, prosthesis insertion), penile fracture, masturbation injury should undergo retrograde
Ul'llhragram {RUG).
with urethral manipulation
always look for associated bladder rupture

Clinical Features
blood at urethral meatus
high riding prostate on digital exam
sensation of voiding without urine output
swelling and butterfly perineal hematoma
distended bladder
penil and/or scrotal hematoma

Investigations
do not perform cystoscopy or catheteri2ation before retrograde urethrography if urethral
trauma suspected
retrograde urethrography- demonstrates extravasation and location of injury
U34 Urology Trauma/Infertility Toronto Notes 2011

..,., , Treatment
t----------------. simple contusions - no treatment
Do not csthmrim if IIISPIC! umh111l partial urethral disruption:
injury. very gentle attempt at catheterization by urology staff or urology resident
with no resistance to catheterization- Foley x 2-3 weeks
with resistance to cathetemation - suprapubic cystostomy or urethral catheter alignment in OR
periodic flow rates/urethrograms to evaluate fur stricture formation
complete disruption:
immediate repair if patient stable, delayed repair if unstable (suprapubic tube in interim)

Infertility
Definition
failure to conceive after one year of unprotected, properly timed intercourse
incidence:
15% of all couples - investigate both partners
1/3 female, 1/3 male, 1/3 combined problem
primary (has never conceived before) vs. secondary (has conceived before)

Female Factors
see Gptecology, GY21

Male Factors
Male Reproduction
hypothalamic-pituitary-testicular axis (HPTA): GnRH from hypothalamus acts on anterior
pituitary stimulating release of LH and FSH
LH acts on Leydig (interstitial) cells -+ testosterone synthesis/secretion
FSH acts on Sertoli cells -+ structural and metabolic support to developing spermatogenic
cells
FSH and testosterone support germ cells (responsible for spermatogenesis)
sperm route: epididymis -+ vas deferens -+ ejaculatory ducts -+ prostatic urethra

Etiology
idiopathic (25% infertile males)
endocrine (see Endocrinology, E48)
hypothalamic-pituitary-testicular axis (2-3%)
e.g. Kallmann's syndrome, excess prolactin, excess androgens, excess estrogens
testicular
varicocele (35-40% infertile males)
tumour
congenital (Klinefelter's triad: small, firm testes, gynecomastia and azoospermia)
post-infectious (epididymo-orchitis, STis, mumps)
uncorrected torsion
cryptorchidism ( <5% of cases)
obstructive
iatrogenic (vasectomy, hernia repair, hydrocelectomy, orchidopexy)
infectious (gonorrhea, chlamydia)
trauma
congenital (absence of vas deferens, cystic fibrosis)
bilateral ejaculatory duct obstruction, epididymal obstructions
Kartagener's syndrome
retrograde ejaculation secondary to bladder/prostate surgery
medications (chemotherepeutics, GnRH agonists, anabolic steroids)
drugs (marijuana. cocaine, tobacco, alcohol}
increased testicular temperature (sauna. hot baths, tight pants or underwear)
chronic disease: liver, renal

History
medical history (past illness, diabetes, trauma, CF, genetic syndromes)
surgical history (orchidopexy, cryptorchidism, prostate)
fertility history (pubertal onset, previous pregnancies, duration of infertility, treatments)
sexual history (erection/ejaculation, timing, frequency, STis)
family history
medications (e.g. nitrofurantoin, cimetidine, sulfasalazine, spironolactone, alpha-blockers)
social history (alcohol, tobacco, cocaine, anabolic steroids)
occupational exposures
Toronto Notes 2011 Infertility Urology U35

Physical Exam
general appearance (sexual development. gynecomastia)
scrotal exam (size, consistency and nodularity of testicles; palpation of cord; DRE)

Investigations
semen analysis (SA) at least 2 specimens over several weeks ..... , !
hormonal evaluation - indicated with abnormal semen analysis (rare to be abnormal with
normal SA) WHO Guidlli-
testosterone for evaluation ofHPA Narmll 11111111 V.I-
FSH measures state of sperm production Volum1: 25 ml
Concenlnltion: > 20 million sperm/ml
serum LH and prolactin are measured iftestosterone or FSH are abnormal Morphology: 30'lla nonmlll forms
genetic evaluation Motility: >SO'lla adeqlll!e forward
chromosomal studies (Klinefelter's Syndrome - XXY) J11V11111$$ion
genetic studies (Y-chromosome microdeletion, CF gene mutation) complltl in 20 minutn
pH: 7.27.8
immunologic studies (antisperm antibodies in ejaculate and blood) WBC: < 1oper high p - field or
testicular biopsy <10' WBCfml. semen
scrotal U/S (varicocele, testicular size)

.
vasography (assess patency of vas deferens)
..... , !

Treatment
lifestyle Mutation of Cystic Fibrosis
regular exercise, healthy diet Transmembrane Conductance Regulator
{CFTR) gene associated with congenilll
eliminate lifestyle habits described above bilabnllabunc1 of vas dlf1r1ns
medical {CBAVD)Ind epididymal cysts, aven if
endocrine therapy (see E48) patient manif8sts no symptoms of CF.
treat retrograde ejaculation
discontinue anti-sympathomimetic agents, may start a-adrenergic stimulation
..... , !
(phenylpropanolamine, pseudoephedrine, or ephedrine)
treat underlying infections
surgical Common Ter.....lour on Sem1111lylil:
varicocelectomy (if indicated) Teratospemnia: Abnormal morphology
AsthlnDSpiiTTlil: Abnormal motility
vasovasostomy (vasectomy reversal) Oligospermia: Demased sperm count
epididymovasostomy Amospermia: Ablant Jpann in wman
transurethral resection of blocked ejaculatory ducts Mixed types, i.e. oligoiSihenospermill
assisted reproductive technologies (ART) - refer to infertility spectalist
sperm washing + intrauterine insemination (niT)
in vitro fertilization (IVF)
intracytoplasmic sperm injection (ICSI)

Figure 14. Infertility Workup

U36 Urology Pediatric Urology Toronto Notes 2011

Pediatric Urology
Congenital Abnormalities
not uncommon; 1/200 have congenital abnormalities of the GU tract
UTI is the most common presentation postnatally
hydronephrosis is the most common finding antenatally
six common presentations of congenital urological abnormalities:

,, ,
1. ANTENATAL HYDRONEPHROSIS
Majority of antenatal hydronaphrosas
resolve during pregnancy or wilhin the
first yaar of lifa.
1 in 500 fetal U/S -detectable on U/S as early as :first trimester
most common urological consultation in perinatal period
can be unilateral or bilateral
important to examine the rest of the GU system for anomalies
differential diagnosis
UPJ or UVJ obstruction
multi-cystic kidney
reflux
posterior urethral valves
duplication anomalies
antenatal in utero intervention rarely indicated unless posterior urethral valves

2. POSTERIOR URETHRAL VALVES (PUV)

the most common obstructive urethral lesion in male infants
abnormal mucosal folds at the distal prostatic urethra causing varying degrees of obstruction
most commonly recognized on prenatal ultrasound examination -+ bilateral hydronephrosis,
thickened bladder, oligohydramnios

Clinical Presentation -depends on age and severity

antenatal: bilateral hydronephrosis, distended bladder, oligohydramnios
neonatal (recognized at birth): palpable abdominal mass (distended bladder, hydronephrosis),
ascites (transudation of retroperitoneal urine), respiratory distress (pulmonary hypoplasia
resulting from oligohydramnios) and features of oligohydramnios
neonatal (not recognized at birth): within weeks present with urosepsis, dehydration, electrolyte
abnormalities, failure to thrive
toddlers: presents with urinary infections or voiding dysfunction
school-aged boys: voiding dysfunction -+ urinary incontinence

Associated Findings
oligohydramnios - due to low intrauterine production of urine
renal dysplasia - due to high pressure reflux
pulmonary hypoplasia secondary to oligohydramnios

Diagnosis
VCUG -+ dilated and elongated posterior urethra, reflux

Treatment
immediate catheterization to relieve obstruction, followed by cystoscopic resection of PUV

3. UPJ OBSTRUCTION
the most common congenital defect of the ureter (but can be secondary to tumour, stone, etc.)
M:F=2:1
40% bilateral
unclear etiology: adynamic segment of ureter, stenosis, strictures, aberrant blood vessels -+
extrinsic compression

Clinical Presentation
symptoms depend on severity and age at diagnosis (mostly asymptomatic :finding on antenatal
UIS)
infants: abdominal mass, urinary infection
children: pain, vomiting. failure to thrive
some cases are diagnosed after puberty and into adulthood

Diagnosis
antenatal U/S most common, Doppler U/S, IVP, and renal scan furosemide
'IbroDlo Nota 2011 Urology U37

Treatment
surgical correction (pyeloplasty), consider nephrectomy if< 1596 renal function

Prognosis
good since usually unilateral di&ease

4. VESICOURETERAL RER.UX (WR)

common condition wherein urine p111111es retrograde from the bladder through the UVJ into the
ureter
incidence ranges from 1-18.5% in normal children
present in up to 70% ofchildren with UTI
85% ofVUR occurs in females but a male presenting with UTI has a hlgher lilaillhood ofhavmg
VUR
common cause ofantenatal hydronephrosis
30-5096 of children with reflux will have renal scarring
common causes: trigonal weakness, lateral insertion ofthe uretErs, short submucosal segment
(all part of"primary refluxj
many other causes including secondary reflux, infravesical obstruction, iatrogenic, secondary to
ureteric abnormalities (e.g. ureterocele, ectopic ureter. or duplication), and secondary to cystitis

Presentation
UTI, urosepsl.s
pyelonephritis
pain on voiding
symptoms ofrenal fiillure (uremia, hypertension)
diagnosis and staging lB done wing VCUG U/S

Complications
pyelonephritis
..... '.'

hydroureter/hydronephrosis VUR Gredlna IMted an C\'lflllnlll

lirwul: ureters GDv fil
lirwull: unrbn and pt11vislil
Treatment (sea sidebar for grading) lraulll: uratJn and pcilvis fill with
many cbildren outgrow" reflux (60% of primary reflux) SGIIII dilltatian
annual renal UIS and VCUGIRNC to monitor; renal scan ifswspect new renal scar (episode of Gm.. IV: lnblrs, Pllvil and
pyelonephritis) with S. .cant dllllldiDII
lrau V: Inters, Pllvis and cllycas Iii
treatment Is dependent on the grade: with major dilatalion and 1Qr1uosily
medical (grade I-III) - goal is to keep urine free ofinfection to prevent renal damage wbile
waiting for cbild to outgrow" their reflux
long term antibiotic propbylms at half the treatment dose for half the treatment time (TMP/
SMX, amoxicillin, or nitrofurantoin) Gla!Ur
surgical (ureteroneocystostomy ureteroplasty) or subureteral injection of Dc:Hux- or Coronal"
Macroplastique Sl.koronal
indications: Dilllll Penile
- failure of medical management
- new renal scars
- breakthrough infections
- high grade reflux (grade IV or V - not an absolute indication)
prognosis depends on degree of damage at the time of diagnosis

5. HYPOSPADIAS

SQ'IJIII
a condition in which the urethral meatus opens on the ventral side ofthe penis. promnal. to the J --..- '
glans penis - .
very common; 1/300 live male births . .. . Perileal
multifa.ctorial genetic mode ofinheritance
white black
may be associated with chordee, intersex states, undescended t2sticles or inguinal hernia
depending on the severity, there may be difficulty directing the urinary stream or infertility
Oong-term)
treatment Is surgical correction - optimal repair before 2 years old
circumcision should be deferred because the foreskin may be utllized in the correction
Figura 15. Clluilicetio af
(*ccam far 75%)

..... ''
r::l-cRIJ-m_cisa_pdl
_ _ nm_with_.- - - - ,

U38 Urology
..._,,
0.7%-0.8% at 1 year old
Normal Tntlcullr Develop..lllt ond
Deeclllt in Uloro
Znd Mlllllb- Tnticle begins to form
4th Month - Begins to take Dl1 its
normal and mi{J'It86 from
its origin at the kidney to the internal
inguinal ring
7th Month - The tntis, surroundld in
peritoneal caverinv. begins to descend
through the intimal ring, inguinal conal
and external ring to terminate in the
scrotum
Pediatric Urology Toronto Notes 2011
6. EPISPADIAS-EXSTROPHY COMPLEX
rare: incidence 1/30,000, 3:1 male to female predominance
epispadias-exstrophy complex: a spectrum of defects - depends on the timing of the rupture of
the cloacal membrane
bladder exstrophy (congenital absence of a portion oflower abdominal and anterior vesical
wall, with eversion of bladder)
several variants
cloacal exstrophy (vesicointestinal fissure)
most severe
exposed bladder, bowel and colon with imperforate anus
associated with spina bifida in >50%
epispadias
least severe
urethra opens on dorsal penis
high morbidity -+ incontinence, infertility, reflux
Etiology
represents failure of closure of the cloacal membrane, resulting in the bladder and urethra
opening directly through the abdominal wall
Treatment
surgical correction at birth, later corrections for incontinence, increasing bladder capacity and
vesicoureteral reflux may be needed
Naphroblastoma (Wilm's Tumour) ---------------------
arises from abnormal proliferation of metanephric blastoma
5% of all childhood cancers, 5% bilateral
average age of incidence is 3 years
1/3 hereditary (autosomal dominant) and 2/3 sporadic
familial form associated with other congenital abnormalities and gene defects
Clinical Features
abdominal mass: large, firm, unilateral (most common presentation- 80%)
hypertension (60%)
flank tenderness
microscopic hematuria
nausea/vomiting
Treatment
always investigate contralateral kidney
treatment of choice is radical nephrectomy radiation chemotherapy
Prognosis
generally good; overallS-year survival about 80%
metastatic disease may respond well
Cryptorchidism/Ectopic Tastes
definition: testes located abnormally somewhere along the normal path of descent
(prepubic > external inguinal ring > inguinal canal > abdominal)
ectopic testis (testis found outside its normal path of descent} is rare
incidence:
2.7% of full term newborns
differential diagnosis:
retractile testes
atrophic testes
intersex state (bilateral impalpable testes)
Treatment
undescended testes should be brought down to monitor for malignancy and preserve
fertility (better in less than 1 year of age)
hormonal therapy (hCG or LH may facilitate their descent -+ not proven)
surgical -+ orchiopexy
Toronto Notes 2011 Pediatric Urology Urology U39

Prognosis
untreated bilateral cryptorchidism -100% infertility
treated bilateral: 60-70% fertility rate (dependent on the age at the time of surgery)
treated/untreated unilateral: fertility is still less than the general population
risk of malignancy is 10-40x increased in undescended testes; this risk does not decrease with
surgical descent, but monitoring is made easier
increased risk of testicular torsion (always perfonn bilateral orchiopexy for prevention if doing
orchiopexy for torsion)

Disorders of Sexual Differentiation

Definition and Classification
genitalia that do not have a normal appearance based on the chromosomal sex ofthe child due
to the undermasculinization of genetic males or the virilization ofgenetic females
considered a social emergency
four major categories
1. 46XY DSD
defect in testicular synthesis of androgens
androgen resistance in target tissues
palpable gonad
2.46XXDSD
most due to congenital adrenal hyperplasia (21-hydroxylase deficiency most common
enzymatic defect) -+ shunt in steroid biosynthetic pathway leading to excess androgens
3. ovotesticular DSD
4. mixed gonadal dysgenesis (46 XY/45 XO most common karyotype)
presence ofY chromosome -+ partial testis determination to varying degrees

Diagnosis and Treatment

thorough maternal and family history needed
other fonns of abnormal sexual development:
maternal medication or drug use in pregnancy -+ maternal hyperandrogenemia
parental consanguinity
physical exam: palpable gonad(= chromosomal male), hyperpigmentation, evidence of
dehydration, hypertension, stretched phallus length, position of urethral meatus
chromosomal evaluation - sex karyotype
laboratory test:s:
plasma 17-OH-progesterone (after 36 hours of life) -+ increased in 21-hydroxylase . . Chailillflll' l'mdllll
deficiency (CAH) !Willi...
Codnne lhllllllse .\)sf /lev 21m; {21:!m336Z
plasma 11-d.eoxycortisol-+ increased in deficiency lie.._.: 11Msl'8'.iiaw llVIUIIalllle
basal adrenal steroid levels llac:tiwllla ll'lllllflly 11'111 cirann:ililn
serum testosterone and DHT pre- and post-hCG stimulation (2,000 IU/day for 4 days) fur p!IIVIOOng aapitian llf HN in h..._.
serum electrolytes nwl. Thlylld dill ilfllllnlfnllllldomilld
canllaled trBls ID assess tile elicacy rJ 1111le
ultrasound of adrenals, gonads, uterus, and fallopian tubes citlm:ilion far HIV aaPiition in IMI1
endoscopy and genitography of urogenital sinus in Alric:a \Wiich begin il2002.
sex assignment (with extensive family consultation) Clncbinl: Thill'lllli&w lwld lti'Dng INidance
must consider capacity for sexually functioning genitalia in adulthood and psychologic tt11t ITIIIIIcll mae circlm:iliill rab:ls 111e
ICqUilililn ti HN by mllllblllwlen
impact
reconstruction of external genitalia - between 6-12 months
m 11'111 24
long term psychological guidance and support for both patient and family
11111-.tof HIVIIII
.......
Circumcision whl h111 So with 1111: AMIINIIIpill
JW4 21108; 300(141:1674-84.
lie.._.: TIMslnlllll-nlylis mminad 15
Definition IU!ia (u= 53 561) tt1lt qiJIIItitDI\' ..rinld
removal of some or all of the foreskin from the penis the 1110eiltion bllval1111le liluncilion lll1d
HNJS11111101111 men who hive ret willl men
(MSMI.
Epidemiology llulll: n. Dddll ti baing HlV-plllitM Will IIIII
30% worldwide lignificlntlv 1owar in c:irwmcilad MSM.
frequency varies depending on geographic location, religious affiliation, socioeconomic Thlocidion ciMicliollll'lll
HN but notllllistic:att sigriCIIII.

classification Mill ciriJlmcilion hid I paiiClivl UlllCillion
l'liGI HN in lllldes II MSM Clllllucfld before 1he
Medical Indications ti hijllf IICtiva lnliulrMII1falpy.
phimosis Clncbinl: This lllliylis fOII'Id insl&ient
INid..:elllll male ciMiclioll
definitive treatment of paraphimosis llglinst HN inllctiDn or Dtlm Slll. llcMMt the
pndlctiwellwct ti ll'lle circn:iiorl
Contraindication& in MSM Wli11 aJnduclld Wore 11!1 n of
unstable or sick infant lil#t active antirelnMnlllhen!rt supports
f1llfw imllqltion rl male cin:oou:ilian fur HlV
congenital genital anomalies (hypospadias) preverOin III'DIIg MSM.
family history of bleeding disorders warrants laboratory investigation prior to circumcision
U40 Urology Pediatric Urology/Selected Urological Procedures Toronto Notes 2011

Complications
bleeding
infection
phimosis, skin bridges
fistula
glans injury
penile sensation deficits

Enuresis
see Pediatrics. Pl2

Selected Urological Procedures

Bladder Catheterization
catheter size measured by the French {Fr) scale- circumference in mm
SbipiiiiMIIIiq 11111r in IIIII Sldl each 1 mm increase in diameter = approximately 3 Fr increase {standard size 16-18 Fr)
111111r CaiMIIrialion (-... VIII in Cb:ll
lledcilts.il
1. Ellpllin pnx:adura 1D lhll pllilnt and on1.111 Continuous Catheterization
na cantnilllicltianl (blood IIIIIWIU, indications:
ICIOIII hlmltDml, pelvic frlcbn, !Mgll-ridng accurate monitoring of urine output
proelatll
2. Ensur8 you hlv8 cdllltr nd tit, idoclile jllly relief of urinary retention due to medication, neurogenic bladder or intravesical obstruction
tllll:1111811r 1Dpa wilhiiiiiiiCh Ill till bldlill temporary therapy for urinary incontinence
3. wpatiant don 11011-s!Brile perineal wounds
glowlllld fiiiiCt foralkil clot removal {24-28 Fr) for continuous bladder irrigation {CBI)
4. Insert 1015ml of ldocU!e ielll' iiiD LRIInl
post-operative
meQJI tnd Pnc:fl p8lils for
mindls
5. Open kllnd piiQJ patilllt'&legl Intermittent Catheterization
6. lbi . . giMs indications:
7. w coHua ball in IIQeplic
post-void residual volume measurement
9. Ab:ll.,..
B. Open lubricllltand dispel ontol:llilllllr1nly

!Dcttflltlr
ofwllar lnd callacling ..,nm
10. l'lllc:efenestJDd dnipe Mr pubic regiorund
pro*lll11iQ111
11.1imp]JIIIile lllllftv.ntlumdominlnl hind.
hold llld purpaticUir to IIIII
pltielts body (this bind is now nan-lleriel
12. C. glms ponil in ciwlurrl)lion
13. LJJbriCIII tip of clllllltr, irlllrl iiiD lllllnl
meQis tnd IIMrlce to 1lle IMI of111e IIIIIIDIIII
inllltion port
14. Wd fGI rebln of llile ido colecling
praalll w
15. !Moe urine is bling, ilftllle llllllaan l'litiiCIUt
lowilu Cl1ilullrlrnulrlel
16. pul Clllletlll bac:t lnd llpe ID patient's
111igh f1lpG the cltfllter, not 1ht callacling
$'jSIImUing)
17.11aduceforllkintop!MIIIplla;Mmolis
to obtain sterile diagnostic specimens for urinalysis/cultures
management of neurogenic bladder or chronic urinary retention
Causes of Difficult Catheterizations and Treatment
patient discomfort - use sufficient lubrication { xylocaine)
collapsing catheter -lubrication as above firmer catheter (silastic catheter)
meatal/urethral stricture - dilate with progressively larger catheters/balloon catheter
BPH - use catheter as angled tip can help navigate around prostate
urethral disruption/obstruction -filiform catheter or suprapubic catheterization
anxious patient - anxiolytic medication
Complications of Catheterization
infection - UTI
meatal/urethral trauma
Contraindications
urethral trauma: blood at the meatus of the urethra, scrotal hematoma, pelvic fracture, and/or
high riding prostate

Cystoscopy
Objective
endoscopic inspection of the lower urinary tract {urethra, prostate, bladder neck, walls and
dome, and ureteral orifices) using irrigation, illumination, and optics
scopes can be flexible or rigid

Indications
hematuria
LUTS (irritative or obstructive)
urethral and bladder neck strictures
stones
bladder tumour surveillance
evaluation of upper tracts with retrograde pyelography (ureteric:: stents, catheters)
Toronto Notes 2011 Selected Urological Procedures Urology U41

Complications
during procedure
infection, bleeding, anesthetic-related
perforation (rare)
post-procedure (short-tenn)
epididymo-orchitis (rare)
urinary retention
post-procedure (long-term)
stricture

Radical Prostatectomy
Objective
the removal of the entire prostate and prostatic capsule via a lower midline abdominal incision,
laparoscopically or robotically
internal iliac and obturator vessel lymph nodes may also be dissected and sent for pathology
(dependent on risk: clinical stage, grade, PSA)
seminal vesicle vessels are also ligated

Indications
treatment for localized prostate cancer

Complications
immediate (intraoperative)
blood loss
rectal injury
ureteral injury (extremely rare}
perioperative
lymphocele fonnation
late
moderate to severe urinary incontinence (3-10%)
mild urinary incontinence (20%)
erectile dysfunction (-50%, depending on whether one, both, or neither of the neurovascular
bundles are involved in extracapsular extension of tumour)

Transurethral Resection of the Prostate (TURP)

Objective
to partially resect the periurethral area ofthe prostate (transition zone) to decrease symptoms of
urinary tract obstruction
accomplished via a cystoscopic approach using an electrocautery loop, irrigation (glycine}, and
illumination

Indications
obstructive uropathy (large bladder diverticula, renal insufficiency)
refractory urinary retention
recurrent UTis
recurrent gross hematuria
bladder stones
intolerance/failure of medical therapy

Complications
acute:
intra- or ext:raperitoneal rupture ofthe bladder
rectal perforation
incontinence
incision of the ureteral orifice (with subsequent reflux or ureteral stricture)
hemorrhage
epididymitis
sepsis
transurethral resection syndrome (also called "post-TURP syndrome)
caused by absorption of a large volume of the hypotonic irrigation solution used, usually
through perforated venous sinusoids, leading to a hypervolemic hyponatremic state
characterized by dilutional hyponatremia, confusion, nausea, vomiting, hypertension,
bradycardia, visual disturbances, CHF, and pulmonary edema
treat with diuresis and (if severe) hypertonic saline administration
U42 Urology Selected Urological Procedures Toronto Notes 2011

chronic:
retrograde (>75%}
erectile dysfunction (5-1 0% risk increases with increasing use of cautery)
incontinence (<1%)
urethral stricture
bladder neck contracture

Extracorporeal Shock Wave Lithotripsy (ESWL)

Objective
to treat renal calculi, proximal calculi, and midureteral calculi which cannot pass through the
urinary tract naturally
shockwaves are generated and focused onto stone -+ fragmentation, allowing stone fragments to
pass spontaneously and less painfully

Indications
potential first-line therapy for renal and ureteral calculi less than 2.5 em in size
individuals with calculi in solitary kidney
individuals with hypertension, diabetes or renal insufficiency

Contraindication&
acute urinary tract infection or urosepsis
bleeding disorder or coagulopathy
pregnancy
obstruction clistal to stone

Complications
bacteriuria
bacteremia
post-procedure hematuria
ureteric obstruction (by stone fragments)
peri-nephric hematoma
Toronto Notes 2011 Common Medications Urology U43

Common Medications
Tabla 21. Antibiotics
Dnlg Duration of TNIIImant Umililti-ID Uu
TMP/SMX Simple uncomplicated cystitis 3 days Stevens.Jolrlson syndrome
Recunent cystitis LDI'(lll!rm as prophylaxis ?Salety in last 2 weeks of pregnancy
Pyelonephritis 14 days Resistalce 20% in the community
Prostatitis 4-awusb
Epididynitiil/architis (Gremilegative organism) Zweeks
nilrufunrrtoin Simple uncomplicated cystitis 7 days Contnindicated in nmal failure
Recunent cystitis Pulmonary toxicity/fibrosis
ciproflox.acin Cystitis 3 days ?Safety in pregnancy
Pyelonephritis 7-14 days Achilles tendon rupture
genlllmicin Severely ill patients with pyelaneplritis, prostatitis Only IV
Nephllllllxic
Ototoxic

Tabla 22. Erectile Dysfunction Medications

Dnlg Cia Machlnilm lndi:ltion
sildenalil (V'IIgraat) Phosphodiastarase 5 Selectiva irtlibition of PDE5 ED when some erection Sevara hypotansion
tadalafil (Cialisllt) inhibiiDr (enzyme which degrades cGMP) present Contraindicated if Hx of priapism. or in
vardenalil (l..evitra"l Leads to sinusoidal smooth muscle conditions predisposing to priapism (leukemia,
relaxation and erection myelofibrosis, polycythemia, sickle cell disease)
Contlllindicatad with nilllltas
alprostadi (MUSE: Prostaglandin E1 Activation of cAMP. relaxing ED Penilepan
Male Unrtlnl Suppository sinusoidlll smooth muscle Presyncope
fur Erection) Local release (capsule inserted
intD urethra)
alprostadi See above See above ED Thickening of tunica albuginea at site of
(intracavemosal iljection) repeated injections (Peyronie's plaque)
triple therapy also used: Painful erection
papaverine, phentolamine, Hematoma
PGE1 Contrainrlcated if Hx of priapism, or in conditions
predisposing to priapism

Tabla 23. Bign Prostatic Hyperplasia Medications

Dnlg Clus Machanism lndiCition
tei8ZOSin (llytrin"l Alpha 1blockers Alpha-adrenergic anlllgonists reduce stromlll BPH Presyncope
dDXIIZOSin (Callba"l smooth muscle tone Leg edema
tamsulosin (Aornax) Alpha 1a selactiva Reduce dynamic component of bladder outlat obstruction Ratrograde ejaculation
Alpha 1a selactiva Headache
Asthenia
Nasal congestion
finasteride 5 alpha-reductase Blocks convarsion of tastosterone to DHT BPH Saxual dysfunction
dutasteride (Avodartilt) inhibiiDr Reduces static corqlOilent of bladder outlet obstruction PSA decreases
Reduces prostatic volume
Naill: AI alpt.-IIIDCbrs diMllopad far 81'11 hiVIlsimillr afli:lcy. '-a(.llph1sala:IMI11Q811!1 hM 111 impnMld sida lllact pmfila.

Tabla 24. Prostatic Carcinoma Medications

Drug Class Machanilm lldic:ation Advasa Elfacts
leuprolide (Luprnnllt, 8igard"), GnRH agonist ntially stimulates LH. increasing testosterone and CaP (N>D, M>D) Hot flashes
goserelin (Zolad!lt8 ) causing "flare" {clinically: i'lcreased bone pain), Headache
later causes low testosterone Decreased libido
*diethylstilbestrol (DES) Estrogens Hlibit LH and cytotoxic effect on tumour cells As above Increased risk of cardiovascular events
*cyproterone acetate Steroidel antiandrogen DHT for iltracellular receptors:
with As above
1. Prevent flare produced by GnRH agonist
2. Use for compiBIB androgen blockade
3. May preserve patency
ftutamide Nort-steroidal antiandrogen As above As above Hepatotoxic: AST/ALT monitoring
bicalutamide (CasoEx)
*ketoconazole, spironolactone Steroidogenesis inhibiiDrs Blocks multiple enzymes in steroid pathway, As above Gl syrl1IIDrns
including adrenal androgens Hyperkalemia
Gynecomastia
U44 Urology Common MedicationsJR.eferenc:es Toronto Notes 2011

Tabla 25. Continanca Agents

Drug Clus lndl:lllion
oxybutynin AntispiiSIIlDiic lmibillactian Df ACh an lkge incontinence + Dry mouth
smaD1h muscle urgency + frequency Blurred visim
llecreeses frequency of Canstipatian
unirllibited detrusor Supraventricular
contraction tachycardia
lliminishes initial urge to void
oxybutynin {Ditropan<) Anticholilergic Muscarinic receptor antagonist lkge incontinence + As above
tolterodine {Detro18 ) Selective for bladder urgency + frequency
trospium [Trosec18) Increases bladder vo.,me
(Vesicaraa) llecraases detrusor pressure
dlllilenacin {Enablat')
imipramine Tricyclic Sympathomimetic sff8cts: Stress and urge As abDW
llllidelftSSBnt urinary sphincter conlnlction incontinence Weight gain
Anticholinergic elfects: Orthostatic hypotension
detrusor relaxation Prolonged PR interval
Nlllt: AIIIIIIH:IMJiilwgics 11111J11ily lfllctiw and liq acting fmmulllilns (llllrollA1 111d Ditropln XL8)111 balblr IDiarrllld. Nln IIIISCII'inic t.l3 rapiDr spaciic
llglds lsallenlcin. IHJIIIIIy Efficacious iiS older drugs, hllwever, ACTs bued 111 helcl-111/nml compuisan to lang acting furmulllilns n

References
G.... lnfllrnlti111
AnuriCillllrulogical Allocillli1111. http;'/wwau111111..D19'guidainlrl
Amll'iC111 Aao1:i1ticr1 of Ftmily Phy$icia11$. hllp;'/wtow.Mfp.tqiafpl2002041 W158UIIm
Ferri F. Practical Glide ID tt. Clll oftt.lllldical plliant (&thad.) ZW6. St Lllil: Mosby.
Galdmln I, Ausialo D. Cecil Tlldbook of Medicine (22nd ad.] 2004. Salnlars (EIIaviar).
MIICflrlme MI House lllicer Series: Uralogy. 13rd ad.] ZWI. UAJincotl Ylfllllllli &
TaiiiQIIo EA. McAnilch JN. Srrith's Glmllll Uralogy.(l&th ad.)2004. McGraw-Hill Companies,
Uralogy Clilnnal
Wein AJ, Kavoussi Ul, Novick AC, l'lrlin AW rnd Cl'eteTs CA. Campbelrs Urology. 19th ed.] PhilldeliJ!il: WB Saunders Co.

c-llll'rlllllllingl'n6ll
Colirn RA 111d llrailn RS. Micrascapic hamablia. Naw Englrnd Joumal II Mldicine.2003;348:2330-2338
MoriDnAR,IIilsm EAand Wil11111 JWI.. Nephrology: l.lnwlligltion lndtnlllrrWit!IIICIUIIIII kilhlyiiDIIBL CMAJ 166(2):213-218,Jan 2002
Teichnan JMH. Acute -.nal colic ln1m clcuiJs. New England Joumalcl Madicile. 2004;350:684693

Uralagi:ll Ern.Jn:ia
Galejs LE. Dilgnolis and treatmrnt ol the IICUII scra11rn. Americ:lln Ftmily l'hyan. 1991;51(41:817-24

Medialions
Bii-Axelson A, Holmberg I, llwtu M, et. al. Radical Proslnc:tomyversus Waiting il Early l'rosllte Cancer. NEJM. ZW5; 352: 197784.
Common Medications: Gray J (Edi1mj. Therapeutic Choicas (4th ld). Canadiln Phlrmacirls Allocilltion, Dttawa. 2003.
Micramadax heellh catlll8rias. v.ww.micnlmedax.com
Rini B. HIIIIIi S.llale*l!l J. et.al Bevaciarmab Pl.ile Cornplllll with Interferon Alta MDII!Ihmpy in l'ltientJ with Metn111ic Renal Cell Can:incml:
CALGB !11206. J. Cln. One. 2008; 26: 5422-28.