UROLOGY

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SURGICAL  BLOCK-­‐  Sub  Spec  
Urology Ø Lower most portion- L3
v Surgical diseases and disorders of male genitourinary tract, v Adult kidney
female urinary tract, surgical diseases of adrenal glands Ø Vertically- 10-12 cm
Ø Transversely- 5-7 cm
ADRENAL GLANDS Ø AP dimension- 3cm
v On the top of both kidneys, both sides v Renal cortex extends between the medullary portion of the
v Cups the kidney kidney (renal columns of vertin)
v Adrenal gland and kidney is enveloped with fat whom, you v Pyramids is lie closely of different calacyeal system
called Gerota’s fascia (perirenal fascia) v Functions of kidney
Ø Except on one side which is not covered with perirenal Ø Maintains fluid and electrolyte balance
fatè lower part or the inferior part of the kidney Ø Maintains acid base balance and produce one
§ Patients with perirenal abscess when it liquefy it important substance you called renin
settle down on the pelvic cavity • Baroreceptor of the system
§ The abscess and liquid part will seep through at Ø Produce Erythropoietinà patients with end stage renal
the inferior portion of the kidney disease they are usually anemic they have low RBC
§ It will gravitate on the dependent portion which is and hemoglobin concentration because they lack
the pelvic cavity erythropoietin and they are given exogenous form of
v Weight 5 grams erythropoietinà so that RBC can function properly to
v Right adrenal gland is triangular in shape and left is produce oxygenation
crescent or lunar in shape Ø Affects calcium metabolismà Vit D is converted on its
v Both kidneys and adrenal gland perform certain endocrine active form (125-dihydroxy)
functions v Calyces are divided into major and minor calyces
v Adrenal gland- outer adrenal cortex and inner adrenal Ø 8 to 12 minor calycesà coalesce to form a major calyx
medulla Ø 3 major calyces- upper calyx, middle calyx and lower
Ø Adrenal cortex calyxà coalesce to form your renal pelvis
§ Zona glomerulosa- mineralocorticoids Ø Renal pelvis- funnel shape structure that collects urine
§ Zona fasciculate- Glucocorticoids then goes to the ureter and stored into the bladder
§ Zona reticularis- Androgen Ø When urine goes to the pacemaker of the bladder
Ø Adrenal Medulla sends signal that you need to start peristalsis so the
§ Cathecolamines urine will go down to the urinary bladder
v Blood supply Ø Pacemaker of kidney is located within the minor
Ø Small organ yet very vascular organ calycesà pag nakareceive na sila ng urine it will send
Ø Comes from Inferior phrenic arteryà supply the signal to the ureter to start peristalsis urine is brought
superior portion down to the bladder
Ø Direct branch coming off from your aortaà mid portion Ø Not stationary in positionà normal excursion
of the adrenal gland § During deep inspiration when the lungs is fully filled
Ø Renal arteryà supply the lower portion the kidney goes downward and during expiration
v Drainage kidney is move up and this is the normal excursion
Ø Organs of the right side drains in the Inferior Vena Cava of the kidney is 4 to 5 cm
Ø Left sideà left renal vein before it drains in the inferior Ø Located in the lumbar areaà normal position of kidney
vena cava Ø Ureter is expected to be long normally it is 25 cm in
Ø Lymphaticà lymph nodes accompanying supra renal length
veins Ø How do you nephroptosis from an ectopic ureter
v Divided into upper tract, mid tract, § Nephroptosis- poor support the kidney slides down
And lower tract from in its normal position Instead nasa lumbar
v To remember the different structures always remember that area sya pero sometimes you can find it in the
mid tract is the urinary bladder. All structures above it is pelvic cavity and you can still excpect that the
upper tract (kidneys, part of the ureter) and all below it ureter is in normal length kasi nasa normal position
belongs to lower tract (vas deferens, seminal vesicles, naman yung kidney the problem because of full
prostate in male, urethra, and testicles) support it gravitates down in pelvic area and the
ureter is normal in length but it is redundant na
umiikot na sya instead of outstretched
GENITOURINARY TRACT § Ectopic ureter/ kidney- it has something to do with
the embryology, where does the kidney originate?
Kidneys It starts as a ureteral bud in the pelvic cavity slowly
v Pair of bean shaped organ goes up and rotates as it finds it position. With
v Inside the retroperitoneal area ectopic ureter/ kidney it ascends and stop
v It is obliquely placed and follow the contour of psoas muscle developing so hindi na sya nakarating sa lumbar
v Right kidney lower than the left kidney obviously because of area so what happens sa length ng ureter? It is
the liver on top of it abnormally short
v Right kidney Ø Sometimes the kidney is abnormally fixed there are
Ø The top most portion of the right kidney is at the level of conditions like inflammation pyelonephric abcess . . . it
L1 holds the kidney and hindi sya nakakagalawa because
Ø The lower potion is at the level of L3 of inflammatory condition like edema and everything it
v Left kidney prevents the normal excursion of the kidney and it
Ø Top most portion- T12 doesn’t move freely
v Different structures that holds the kidney in place
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Ø Perirenal fascia/ Gerota’s fascia § Mid ureter- direct branch from aorta and branch
Ø Para renal fats and Perirenal fats enveloped kidney from gonadal artery
Ø General bulk of abdominal muscle or viscera § Distal portion- the most vascular part. Receives a
§ Usually the nephroptosis is seen in patient who are lot of blood supply. Internal iliac, common iliac and
abnormally thin because they have poor support vesical arteries
and they lack fats they usually have poor support Ø During transplantation when we harvest kidney and
to the kidney transplant it to the recipient you can directly
Ø Renal vascular pedicle- artery, vein and renal pelvis anastomose it to the ureter or area of the bladder.
v Kidney is protected by cartilaginous mga ribs sa side at the However you cannot cut ureter here and here and
back they are protected by vascular structures yung mga big anastomose it kasi nawala na yung blood supply
muscles we yung mga quadratus lumborum psoas muscle
supraspinalis Urinary Bladder
v Vehicular accident this structures may also be the one that v Reservoir, stores urine temporarily
injures the kidney and can puncture and lacerate the kidney v Urine is formed in the kidney it propels downward in the
v Nephron- basic functioning unit ureter and temporarily stored in the bladder
Ø Perform the function of the entire kidney v Detrussor muscle
v Outer renal cortex- secretory function v Capacity of 350-450 cc
v Renal medulla- most lies the excretory function v If you reach that amount of urine in your bladder usually you
v Blood Supply of the kidney can feel pain
Ø Comes from Renal artery and they are end arteryà v 150 cc of urine in bladder there is first sensation that you
meaning if something happen to the renal artery and it want to urinate, first sensory though you can hold your
was block the entire kidney will not receive any blood bladder
supply and will lead to ischemia and infarctedà v Autonomic nervous system the bladder contract what
Ø Renal artery it branches off as your segmental arteryà predominates? Parasympathetic when it relaxes
posterior segmental arteryà goes to the back and sympathetic
supply the entire posterior surface of the kidney v Sphincter is kabaliktaran that’s why it is predominated by
Ø Anterior segmental arteryà goes anteriorly sympathetic
Ø Lobar arteryà Interlobar artery (in between v Pag nagcontract ang bladder magrerelax ang sphincterà or
pyramids)à then it goes around your pyramids as your else di mo ma empty yung bladder
arcuate artery (ibabaw ng pyramid)à magbranch off ng v 2 ureters goes to the bladder postero-inferiorly salilikod
maliliit and it is your interlobar arteryà afferent dadaanan yan and exits to the bladder through two uretero
arterioleà papasok sa glomeruli orifices
Ø Renal arteries- end arteries v 2 ureteral orifices- the structure that holds this is your
Ø Anterior branch is more vascularà kasi more blood Mercier bar or intrauretheric ridge—bladder neck this what
supply ang narereceive nila you call trigonal area, uretheral diaphragm where your
Ø Less vascualar is posteriorà supply the mid segment sphincter is located
and entire posterior Ø 2.5 – 5 cm apart
v Broadel’s Line- when you view the kidney on its lateral Ø pag sa likod- 5cm apart
convex you go 1cm posterior draw an imaginary line and Ø pag nasa bladder neck- lumapit 2.5 cm
that is your broadel’s line.That is the avascular plane of the v Meron ding pacemaker ang urinary bladder eh kalian ba sya
kidney. When we do our kidney surgery we pass through magsesend ng signal na it will start contracting-
that plane so we don’t encounter a lot blood loss. Ø Located at the level of S2 and S4
v Drainage systemà Inferior vena cava Ø Kaya yung mga pasyente na merong pathology this
v Lymphaticsà lumbar lymph node level nawawala yung control di nila nararamdaman na
v Lymphatic channelsà flow right to the left puno na yung bladder (patient with neurological
problem: meningomyelocoele), di nila nararamadaman
na yung bladder is already full
Ureter v The blood supply of the bladder comes from the vesical
v Long cylindrical segment artery it has different branchesà the superior supplies the
v Connects kidney to the bladder superior part of the bladder and middle supply the mid
v Act as a conduità passage way portion of the bladder and inferior supplies the inferior
v Through peristalsis urine is brought down to ureter to the portion of the bladder and part of the prostate those that
bladder receive additional blood supply to inferior gluteal artery and
v Normal length is 25 to 30 cm in a normal adult superior obturator artery
v It has three anatomical constrictions. The entire length or I v Bladder is very vascular so if we do bladder resection on
mean the luminal diameter of the entire ureter is not the bladder tumor we encounter a lot blood loss because of
same all throughout very vascular
Ø Ureteropelvic junction- v Drainageà internal iliac veins
Ø When it crosses the iliac vessel- because of pulsation v Lymphatic follows the venous drainage
of the artery seemingly parang nacocompress yung
ureter because of pulsation Urethra
Ø Uterovesical junction- area bandang baba. It is the v Penis- 2 cylindrical structuresà 2 corpora cavernosa
rd
narrowest. Most stones lodge ditto (distal 3 portion) v corpus spongiosum- inferior portion and its not an erectile
Ø Very vascular. It has blood supply in different level of tissue, its function is to envelope and protect the urethra
the ureter v average of male urethra- 8cm and female urethra- 4cm
§ Upper ureter- emanate from renal artery v Internal pudendal artery- blood supply
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v Male Urethra Ø but now a days, we classify it by different zones
Ø 8cm in length § posterior lobe—peripheral zone, biggest portion,
Ø divided into two portion the demarcation is the common site of prostate CA
urogenital diaphragm § lateral lobe—transitional zone, benign lesions most
Ø distally that is your anterior urethra or penile urethra commonly arise here
Ø proximal- posterior urethra or prostatic urethra § central zone
v Female urethra Ø very vascular- receive blood supply from inferior
Ø 4cm long and 8mm diameter vesical, internal pudendal and hemorrhoidal or rectal
Ø walang demarcation arteries
Ø proximal part is lined by transitional same with other Ø drainage: prostatic plexus, hypogastirc vein
urinary tract sysmte
Ø distal- squamous epithelium
st
Ø blood supply: inferior vesical, vaginal and internal ------------------1 Lecture Dr. Reyes------------------
pudendal artery
Ø at the top of the bladder is the uterus
Ø rectosigmoid area
v One that separates the rectum/ rectosigmoid area from
prostatic area is your denoviere’s fascia

Scrotum
v Corrugated structure that envelopes or protects the testis
v Supports and envelope testis
v Thermoregulatory function- during warm temperature
scrotum is dangled (nakalawlaw) because the scrotal skin
moves away of the body to protect the testis from high
temperature
v During cold temperature- scrotum goes up
v Blood supply- internal pudendal and inferior epigastric areas
and femoral artery
v Different layers within scrotum
v Outer tunica vaginalis and the one adherent is tunica
albuginemiaà between this contains a small amount of fluid
where testis glides
v Hydrocele- abnormal accumulation of fluid
v Infant hydrocele- communication type of hydroceleà
communication between the abdominal cavity and scrotal
sac through a communication called patent processus
vaginalis (at birth dapat magclose yung patent processus
pag di nagclose fluids gravitate)
v Adultà secondary to inflammatory conditionà non
communicating type
Testis
v 4x3x2.5
v outer tunica vaginalisà visceral portion
v tunica albugenemiaà parietal portion which is adherent to
the testis
v blood supplyà internal spermatic through testicular artery

Epididymis
v head body and tail
v Vas deferens
v Immature sperm cell- nasa periphery
v Mature sperm cells
v Sperm cells produce by seminiferous tubules
v Interstitial cell of leydig- testosterone production
Ø 95 %- comes from testis
Ø 5 %- comes from adrenal gland
v Prostate- inferior to the bladder
Ø Endocrine that stimulates hypothalamus
v Prostate carcinoma
Ø Orchiectomy- as palliative treatment to lower down level
of testosterone
v Normal Prostate
Ø 20 grams
Ø it has different lobes( 5 lobes- 1 medial, 2 lateral lobes,
1 anterior lobe and 1 posterior lobe)
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SURGICAL  BLOCK-­‐  Sub  Spec  
• Acute onset- both, sometimes when you go to the gym and
GI symptoms of Urologic disease nag weights ka, sometimes you feel pain at the backà
Radiculitis
v causes of mimicry, apparently GI problem
• Hx of lifting heavy object, fall from a heightà swollen muscle
v Minsan manifestations shows like GI problems pero actually
• Injury and trauma
more on Urologic Disease sya
v Organs are beneath or retroperitoneal cavity
v Inflammatory reaction or edema can easily affects TYPES OF PAIN (GU)
retroperitoneal organs • LOCAL
Ø renointestinal refelxes o Felt in or near the involved organ
§ renal/ureteral disease may manifest GI disease o Deep pressure at right iliac area or RLQ there is
symptoms tendernessà acute appendicitis
§ ex: Nausea and vomitiing, abdominal pain, and o Tescticular painà orchitis, during physical activity or
distentionà the urinary tract share common sports nasipa yung testis then nagkaroon ng swelling,
Autonomic/Sensory innervation, the (GU/GI) there is tenderness and swelling kaya nag karoon ng local
§ sometimes patients with urolithiasis or obstructing pain
ureteral stones the kidney become swollen and o CVA tendernessà if there is swelling of the kidney
increase back pressure in the kidney because of o Acid peptic ulser disease
your obstruction the renal capsule become swollen o You elicit the pain where the pathology is
nadididstend and because of rigid sensory nerve • REFERRED
endings of renal capsule • More common
Ø organ relationship • Radiate and naglocalize
§ Right Kidney o Felt some distance from the diseased organ
• Hepatic flexure of colon o Uterolitihiasis or ureteral stone you will get a hiostory of
• Duodenum concomitant pain on the ipsilateral testis sumasakit yung
• Head of pancreas testis nung may uterolithiasis, the local pain is in the CVA
• Common Bile Duct tenderness and the referred pain is felt on the testis
• Liver and Gallbladder o The pain is felt in some distance away from the main
§ Left kidney organ
• Splenic flexure of colon
• Stomach KIDNEY PAIN
• Spleen • Dull and constant pain in the CVA (T10-12, L1)
• Pancreas • You will get (+) CVA tenderness
Ø peritoneal irritation • Distention of the renal capsuleà sudden swelling kaya
§ Posterior peritoneum that separates the abdominal nagpopositive sa CVA tenderness
cavity to retroperitoneal organ/space • Very rich to sa capsular nerve ending
§ Let’s say pag yung right kidney is swollen and you • Any inflammation can easily distend the renal capsule and it
have pyelonephritis or renal capsule swelling easily gives you pain
secondary to obstruction magkakaroon ng back • Ex. Acute pyelonephritis, acute utreteral obstruction secondary
pressure it causes back pressure and small bowel to stone
is nearby thus it can cause ileus and cause • Acute conditionsà (+) pain
manifestations of nausea and vomitting • Chronic conditions like Chronic inflammation di common sa
§ Anterior surface of kidney is covered by posterior kanila ang pain
peritoneum so any inflammation can cause • Chronic urinary distentionà patient experienced hypogastric
secondary involvement and cause anterior surface pain
pain
§ Most cases of kidney disease patient complains
URETERAL PAIN
lumbar pain and we can elicit positive kidney punch
or we can term it as (+) costovertebral angle • Acute pain
tenderness o Obstruction (ex. Stone / clot)
§ Costovertebral angle • Pain due to distention of the ureter
•
th
Superiorly: 12 rib • Increase back pressure to the kidney à renal capsle begins to
• Medially by sacrospinalis muscle dilate or distend, (+) CVA tenderness
• Demarcation of boundaries • Because may obstruction what the body is trying to do gusto
• (+)à involved ang kidney either inflammed nya ipush pababa yung stone or yung clotè Hyperperistalsis
• patient manifest lumbar pain or flank pain and spasm of the smooth muscle of the ureter contributes to
the pain
• but not all lumbar pain or flank pain is renal in
originà RADICULITIS/ PSEUDORENAL PAIN • (+) Colicky pain- hollow viscous organs (small intestine, ureter,
colon)
RADICULITIS (PSEUDORENAL PAIN)
• (+) Referred pain- ureteral obstruction
• Irritation / pressure on the Costal nerves • UPPER URETER- proximal third
• Common sites: T10 to T12 o Radiates to the testicle (ipsilateral testicle)
• Pain is POSITIONAL- sometimes when they change position o T11-12
nawawala yung pain, yung muscle pag di nadadagan di • MID-URETER
naman painful but in tue renal pain kahit magchange ng o Right = McBurney’s point- sometimes Acute Appendicitis
position di magbago painful padin sya, colicky pain and still o Kaya rule out for possiblity of ureterolithiasis
there
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SURGICAL  BLOCK-­‐  Sub  Spec  
o Request for urinalysis • Prostratitis- inflammation of the prostate
o Ultrasound- see whether there is dilatation of • Psychoneurosis- often times when you are student and may
kidneys or may hydronephrosis platings, may feeling na gusto maihi
o Left = resembles diverticulitis (T12, L1) • Torsion / rupture of ovarian cyst- anything that bleed where
• DISTAL URETER does it collect? Sa dependent portion of the cul de sac area
• Stone is near the ureteral orifice malapit na pumasok sa and you know that uterus is at back of the urinary bladder any
bladder form of collection in the back of urinary bladder can cause
• Hyperperistalsis and malapit sa bladder patient inflammation
experience frequency and urgency à kasi • Foreign body inside the urinary bladder- very common sa
nastistimulate yung bladder mental institution common sa women kasi you have very short
o Symptoms of vesical irritability urethra you can easily insert foreign objects to the urethra, or
o Cystitis- inflammation of the bladder children naglalaro can insert small things inside the urethra
• Bubble baths in young girl- soap baths
VESICAL PAIN
• Pain at the hypogastric area PROSTATIC PAIN
• Ex. Acute urinary retention • Inflammation of the prostate- congestes
• Hypogastric pain, sometimes distended din yung o Edema and distention of the prostatic capsuleà pain is
hypogastric area brought by this factors, lining is very rich in sensory
• Infection endings
o Most common cause • Vague discomfort / fullness in the perineal / rectal area (S2-4)
o Referred to distal urethra • (+) Lumbosacral backache
o Kaya nasesesnse nya na may frequency • (+) Frequency, dysuria, urgency
• “Strangury”- sharp stabbing pain felt on hypogastric area • (+) Rectal tenderness
• Chronic retention
o Little or no suprapubic discomfort TESTICULAR PAIN
o Bladder neck obstructionà urinary retention, detrussor PAINFUL NO PAIN
muscle loses elasticity kaya di na sya masaydo nagiging
• Trauma • Uninfected hydrocele
painful
• Infection- STD, urethritis • Spermatocele
o neurogenic bladderà bladder is totally distended and
and ascending infection and • Tumors
compliant
o Pain is not that prominent orchitis
• Torsion of the cord- this is
one of the emergency,
DYSURIA
vascular emergency,
• “Burning” sensation on urination contains blood vesselà
• Pain is (+) with voiding compromise and blood
• Inflammation of the bladder, urethra or prostate supply (360 degree rotation
st
• Often is the 1 symptom of UTI expect ischemia)
• Associated with frequency / urgencyà kasi nga inflammed • Torsion is common
yung bladder may hyper irritability yung bladder on prepubertal age
• Frequency- madalas nagpupunta sa CR • Doppler ultrasound to
• Urgency- need mag CR unless there will be escape of urine diagnose- it gives
you blood flow
CONDITIONS CAUSING SYMPTOMS OF “CYSTITIS” picture kaya wala ng
• Infection- common blood supply dun sa
• Chemical / X-ray radiation- patients receiving testesà
chemotherapeutic agents very common yung hypoperfusion
cyclophosphamide, yung nga metabolite or yung waste • Orchitis- increase
product ay excreted sa urinary tract, others are excreted sa blood flowà
liver but cyclophosphamide most common ay excreted sa hyperperfusion
urinary tract and yung metabolites nito most of the time mas • Golden period- 6
matagal silang nagstastay sa urinary bladder and comes in hours
contact in the bladder and can cause cystitis like symptom, • Orchiectomy- remove
cause irritation to the mucosa yung necrotic areas
o Same with cobalt- patient has malignancy on kasi it may form
pelvic cavity, and receiving radiation sa pelvic antibodies and attact
cavity this can also cause radiation cystitis the contralateral
o Chemical cystitis- pag ang nagcacause testis
chemical • Varicocele- dilatiion of the
• Intersitital cystitis- brought about by parasites or in the form of panpiniform vessels in the
tubercle bacilli, it can hide in between the muscle tissues of spermatic cord, PE: bag of
urinary bladder, Schistosoma hematobium worms
o Ova hide in between the muscle tissue and • Pain and discomfort
cancause inflammatory reactionà swelling, • P/3 stone
edema, lumiliit ang bladder, atrophic bladder -- severe tenderness others have heaviness lang

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EPIDIDYMAL PAIN o Source at or above the level of the bladder
• Inflammation or infection of the epididymis (“Epididymitis”) o Ex. Stone, tumor, TB, nephritis
• Tenderness and pain
• Common in adult- STD PNEUMATURIA
• Children- trauma or swelling • Passage of gas in the urine
• Epididymis is located at the anterolateral part of the testes • Fistula between the Urinary tract and the bowel (small
• Acute intestine and large intestine)
o Painful, begins in the scrotum • Fistula brought about by trauma or nagkaroon ng iatrogenic
during OR
HEMATURIA (BLOODY URINE) • Pag medyo mataas fistula between the ureter and renal pelvis
• Blood on the urine • Gush of air
• Maybe grossly you don’t see any blood but on urinalysis may • Commonly occurs in the bladder / urethra
blood cells o Also seen in the ureter / renal pelvis
• Seing blood in the urine is not normal • Causes
o Sigmoid cancer- grows very large and goes beyond the
• More aggressive dapat on diagnosing the problem where it is
confinement of sigmoid and urinary bladder is anterior
coming from
lang nito
• In relation to symptoms and diseases:
o Diverticulitis with abscess formation- nag rupture abscess
o Ureteral stone
and nagpunta sa posterior area of urinary bladder and na
o Clot (Tumor etc.)
erode to thus cause communication
o Infection (TB, Schistosomiasis, etc.)
o Regional enteritis
o Prostatitis
o Trauma
SILENT (PAINLESS) HEMATURIA
CLOUDY URINE
• Intermittent
• Freshly voided urine is clear, aromatic
• No pain during urination just presence of blood during
• Infected- cloudy, malodorous, spungent
urinating
• Causes
• Complacency must be condemned
o Alkaline urine (precipitation of phosphates)à gram
• Bladder / renal tumor (Primary) negative microorganism gives you alkaline urine
• Other causes o urea splitting microorganism (klebsiella,
o Adult Polycstic Kidney disease Proteus)
o Solitary renal cystà rupture o Alkalinity of urine precipitates the phosphate
o Sickle Cell disease content of urine
o Hydronephrosisà irritation of kidney because of some o Cause clody urine- infected
obstruction distally o Infection = urine is malodorous

TIME OF HEMATURIA CHYLURIA

• Note the time kasi pag di alam you are enteratining a lot of • Lymph fluid
differentials • Communication between the lymphatic channel and urinary
• PARTIAL tract
o Initial • “Milky white” urine
o Nung umihi may blood but then nawala
• Passage of lymphatic fluid or Chyle
§ Suggests anterior urethral lesions
• Lymphatic – urinary system fistula
§ Ex. Urethritis, stricture, meatal stenosis,
o Terminal • Renal lymphatic obstruction resulting in forniceal rupture and
o Initially wala then towards the end nawala leakage
o Bladder neck area hanggang posterior part of • Causes
urethra o Filariasis
§ Lesions arising from the posterior urethra, BN, o TB
trigone o Trauma
§ Ex. Post. Urethritis, polyps and tumors of the vesical o Retroperitoneal tumors
neck, prostatic enlargement, trigonal bladder neck
tumor, CLASSIFICATION OF INCONTINENCE
• Total hematuria- start to the end may blood • Loss of urine without warning
o Way above the trigonal area upper tract and • Sudden skip of urine without warning
kidney • True (Continuous) Incontinence
o Tumor at the dome, above the trigonal area, • Stress Incontinence
ureter and kidneys • Urge Incontinence
à anterior and posterior lesion dun mo lang ma appreciate yung • Paradoxic Incontinence
bright red color na urine o Obstruction (ex. Stone / clot)
à above the trigonal area and sa kidney di na bright red ang • Pain due to distention of the ureter
color nya- tea colored urine and it is brought about by the lysis of • Hyperperistalsis and spasm of the smooth muscle of the ureter
the RBC and comes in contact with urine it releases HEMATIN— • (+) Colicky pain
bwown ang color nun—tea colored urine
• (+) Referred pain
• TERMINAL

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TRUE (CONTINUOUS) INCONTINENCE incontinence and mapupuno yung bladder then pessure
• Loss of urine without warning goes up then exceeds at sphinteric pressure and
• Constant / periodic nagkakaroon ng escape of urine—bed wetting
o Posterior urethral valves in boys— may valvular leaflets
• Example
sa prostatic area and it cause obstruction and impedes
o Exstrophy of the bladder- at birth may _____ structure
the normal urine outflow—cystoscopy
coming out the hypogastric area, urinary bladder di nag
o Infection
coaptake
o Neurogenic bladder
o Exctrophy epispadias complex
o Epispadias- opening along the dorsal surface and not on
the tip, defect can go up to the urinary bladder, the OLIGURIA / ANURIA
sphincter is destroyed • Literally mean “REDUCED” urine volume
o Hypospadias- continent, sphincter is good • Impaired excretion of endogenous products of metabolism
o VVF- vesicovaginal fistula- Iatrogenic problem—mga
gynecologic operation Specific Gravity Oliguria
o Ectopic ureteral orifice- ureter enters the bladder and exist 1.035 < 400 mL/day
as urethreal orifice, sometimes it can go somewhere else 1.010 < 1 – 1.5 L/day
it did not open inside the urinary bladder, it can open at
the side of the vestibule OLOIGURIA- decrease normal urine output
o Iatrogenic ANURIA- no urine output
à kidney excrete the metabolic waste product pag di na excrete
STRESS INCONTINENCE there will be accumulation of it and pag tinake blood sample
• Weakness of the sphincteric mechanism increse BUN and creatinine
• Weakness of pelvic floor- multigravid patient because of à Specific gravity- gives the idea how well the kidney is
constant bearaing down during birth there is laxity of pelvic excreting our waste product—our kidneys is functioning well our
floor specific gravity should be high because it secrete a lot of waste
• Leaks in association with physical strain (coughing, laughing, product eh solute yan—very low specific gravity the metabloic
etc.) products are not excreted, excretory function is not very good
• Common in multiparous women (weak muscle support of • Causes
Bladder Neck, urethra) o Acute Renal Failure (ex. Shock, dehydration)
o Trauma and loss a lot of blood
o Fluid-ion imbalance
URGENCY INCONTINENCE
o Bilateral ureteral obstruction
• Involuntary loss of urine brought about by tense or o Suddenly two stones in the kidney gumalaw
urgency women and goes to the ureter and na obstruct both
• Minsan walang infection sides--Anuria
• Associated with neurological problem (Upper Motor o Unilateral ureteral obstruction with contralateral renal
Neuron Lesion) agenesis/ absence
• Strong desire to urinate
SYMPTOMS OF BLADDER OUTLET OBSTRUCTION
PARADOXIC INCONTINENCE à Bladder going distally
• “False / Overflow” Incontinence à Narrow yung passageway- decrease urine output
• long standing bladder outlet problem • Hesitancy- difficulty in initiating urination
• Bladder outlet- bladder neck to urethra • Loss of force / decrease of calibre of the stream
• Seen with Chronic Urinary Retention or 2° to a flaccid bladder • Terminal dribbling- di nauubos completely parang leaking
• Enlarged prostate, neurogenic bladder, urological problem faucet tulo ng tulo
(S2-S4 problem) • Urgency
• Myringocele- chronic distention of the bladder without pain • Acute urinary retention- emergency and convert it to elective
• Intravesical pressure – urethral resistance case by putting foley catheter
• (+) Dribbling of urine • Chronic urinary retention- Neurogenic bladder, enlarging
• when bladder is full of urine and pressure increases exceeding prostate, bladder distend then liliit
the sphinteric pressure there will be escape of urine and when • Interruption of stream- big stone inside the bladder, and the
pressure inside bladder goes down mag stop na yung escape bladder is filled with urine and stone suddenly float and then
of urine umihi yung patient yung stone suddenly nasa bladder neck –
kaya bigla napuputol yung pag urinate, pagka dislodged mag
ENURESIS uurinate na naman sya
• “Bedwetting at night” • Sense of residual urine- normal post void residual of urine—
• 1 to 3 years old = PHYSIOLOGIC 50cc or less
o 2° to functional or delayed neuromuscular maturation of • Cystitis = positive of residual urine- bladder is edematous
urethrovesical component
• Age 5 to 6 = urologic consult OTHER OBJECTIVE MANIFESTATIONS
• Organic diseases • Urethral discharge (STD)
o Distal urethral stenosis in girls— meatus maliit yung • Purulent (gonococcal), clear fluid scanty discharge
butas, common on young girls—because maliit yung (chlamydial)
butas it is very difficult for the bladder to empty completely • Hematospermia
so ang nangyayari nagkakaroon ng paradoxic urinary o Bloody ejaculate
    GGdG.RVdG  
 UROLOGY   8  
SURGICAL  BLOCK-­‐  Sub  Spec  
o Inflammation of the prostate / seminal vesicles
o Tumor of seminal vesicle but rare most common sya
secondary of an inflammation
• Size of the penis (infant/child)
o Micropenis (fetal testosterone def.)
o Megalopenis (over activity of adrenal Cortex)
• Visible or palpable masses- skin and flank area, abscesses,
sebaceous cyst, genital warts, condyloma
• Edema
o Lower extremities- obstruction sa lymphatic flow
o Genitalia- elephantiasis or secondary to surgery
• Gynecomastia
o Estrogen intake
o Testicular tumors
o Endocrinologic disease
o (Klinefelter)

------------------2nd Lecture Dr. Reyes------------------

    GGdG.RVdG  
 UROLOGY   9  
SURGICAL  BLOCK-­‐  Sub  Spec  
URINARY STONES ü You have to differentiate especially it can also present
fever if urinary tract is infected
o Risk factors for stone formation ü Urinalysis
ü Climate § (+) RBC
§ High temperature causes increase perspiration and § (+) WBC
cause dehydration thus cause concentrated ü Patients who are on the active disease of stone
urine—promotes urinary crystals formation may not showcase this at the same time but
§ High temperature increase exposure to sunlight – may creating calculus
increase vitamin D—increase calcium ü Normal value: 5.85
ü High sodium ü Uric acid crystals tend to precipitate at acidic less that
§ Increases calcium secretion 5.5
§ Decrease urinary pH ü Struvite stones tend to form at ph greater than 6
§ Decrease citrate content ü Urinalysis you can see that there is active stone
ü Diet- increase meat intake formation by seeing crystals on the urine
ü Increase fiber content- binds intestinal calcium and ü Radiologic investigation on stone disease
decreases calcium absorption § CT stonogram- most sensitive
ü Purine rich foods- important in uric acid stone formation § KB IVP
ü Milk- can cause hypercalciuria due to increase calcium § Ultrasound- Retrograde
intake ü Q: What is the most sensitive exam on localizing stone:
ü Increase fluid intake- keeping urine output to become CT stonogram
2L per day ü Advantage
ü Family history- 25% of patients with urinary stone is § Does not need preparation
increased to have also urinary stones § Does not need dye
ü Medications that cause urinary stone § It can determine if the stone is radioluscent or
§ Thiazide radiopaque
§ Cough medicines ü Plain KUB X-ray kasi need mo pa magprepare di mo
o Anatomy makikita kung radiolucent or radiopaque kasi it is all
ü 3 narrowest portion of ureter black pero
• Size: 30 cm ü Hydronephrotic kidney- may bara
§ ureteropelvic ü How would you know kung radiopaque or radiolucent
§ ureterovesical- narrowest—most common site of by CT Scan?
urinary obstruction § Kasi radioluscent and radiopaque makikita sa CT
§ Crosses over the iliac vessels stonogram
ü Trigone- border of inter ureteric ridge and bladder neck § By houndsfield unit
o Central Event in stone formation § It will determine kung ano yung density
ü Supersaturation § Pag ang houndsfield unit ay less than 500à
§ Example: glass of water ¼ lang then you add salt radiolucent meaning most probably ang stone is
tapos nag add kappa ng mas maraming salt uremic acid
ü Because of formation of crystal formationà citrate or § Pag more than 600à radiopaque, calcium
magnesium containing stone
ü Increase citrate § 500-600- gray area
ü Anatomical abnormalities § Staghorn stone- stone in the renal pelvis
o Calcium and Non calcium salts ü Symptamology
ü X-ray- calciumà radiopaque (kasi yung bone) § Upper third stone- testes
Ø Radiolucentà most common is uric § Distal third- Scrotum
acid stone ü Right flank pain radiate to the testes- upper third stone
ü QUESTION: radiolucent stone except: calcium ü IVP
ü QUESTION: radiolucent stone: uric acid § Intravenous Pyelogram
o Presenting sign and symptoms • X-ray na naglalagay ng dye para madetermine
ü Pain- renal colic, waxing and waning with varying kung may stone o wala
intensity • You have to prepare the patient
ü Flank pain radiating to the hypogastric area- midureter
• You should know the renal function kasi you
ü Testis- upper ureter
are injecting a contrast here, thus pwede
ü Scrotum- lower ureter
maconfine to and can destroy yung kidneys
ü Costovetebral angleà Kidney punch
th (yung ibang sinabi dko na nilagay kasi yun yung dinidiscuss nya
• Borders: 12 rib and lateral to sacrospinalis
yung mga result ng mga IVP and CT stonogram)
muscle yung angle nay un
ü Urinary pain and renal pain and ureteral pain can cause
ü Advent of more high-tech na gadgets bihira na nag
pain at hypogastric areas and sometimes it mimics
oopen
appendicitis
ü Distal ureteral stone- flank pain, male patient that
o Sign and Symptoms complains pain at the scrotum
ü Hematuria § May flank pain kasi barado din ureter, irritability
§ Sometimes microscopic and gross hematuria
and dysuria
ü Stones can cause GI manifestations, nausea and
§ (+) hydronephrosis
vomiting that is why patients with urinary stone can
ü cystolithiasis
confuse clinical doctorà appendicitis, suka ng suka
§ stone at the bladder
yung patient distended yung abdomen
    GGdG.RVdG  
 UROLOGY   10  
SURGICAL  BLOCK-­‐  Sub  Spec  
§ pathognomonic: sudden stoppage of urine ♦ Renal Hematoma- 2 cases pang ditto sa
• sudden stoppage of urine Philippines
• kasi pag full yung bladder naka float yung Ø Persistent pain after shock waveà
stone then pag once nag urinate mag lolodge (+) hematoma
yung stone sa orifice or bladder neck • Uteroscope
• the more water sa bladder pwedeng mawala ♦ Insert a uterescope and try to blast it and
pag puno yung bladder get it by stone basket
ü Recurent UTI- further investigation, CT stonogram ♦ Laserà create a cavity para ma open sya
ü Trigone- inter-ureteric ridge and bladder neck ♦ Few hours after this procedure can go
§ Stones are usually parang nakalodge sa trigonal home na
area and it seems like parang shape nya is triangle • PCNL
ü Stone formation with double J-stent ♦ Puncture at lumbar area and give shock
§ we usually put double J stent wave
§ just to by pass the stone and give medications to ♦ Complication: bladder perforation
hope that the stones will dissolve • Laparoscopy
§ should be place on the body of the patient for ♦ Small incision
atleast 3 to 6 months lang
♦ Minimally invasive
o Ultrasound
• Open stone surgery
ü Echogenic structure
ü Posterior acoustic shadowing ♦ Last option
o Retrograde Pyelography
ü Place a cystoscope ------------------1st Lecture Dr. Lantin------------------
ü Done without pa yung advent ng CT stonogram
o Urethra
ü Male- 8cm
ü Female- 4cm
o Urethral diverticulum with stenosis in meatus
ü Yung may 7 sides na stone
ü Tapos sobrang dami
o How do you push stone na nasa urethra?
ü Instill KY jelly
ü Push the stone back do a cystoscopy and do a laser
o TREATMENT
ü Prompt pain relief
ü When to admit?
§ Symptoms not control with pain meds
§ Anuria- absence of urine
§ Cannot void kasi may bara di yun anuricà
obstructed lang
ü Increase fluid intake
ü Diet
§ Uric acid stones due to increase alcohol intake
ü Conservative treatment
§ 4-5 mm size 40-50% passage to the calculi
§ >6mm less than 5% lang chance of passage
§ most uretheral stone pass through within 6 weeks
§ distal ureter- 60%
§ mid ureter- 25%
§ upper ureter- 5 %
ü Medical treatment and Surgical
§ Allopurinol, sodium bicarbonate, Thiazide diuretics
§ potassium citrate
• potent inhibitor of crystal formation of citrate
§ Orange juice, sambong buhok ng mais, buko juice
• Orange juiceà citrus for citrate
§ Non medical treatment
• ESWL
♦ Pulverize the stone
♦ Fluoroscopy or ultrasound guided
♦ Everytime the stone is blasted by the
shock wave na pupulverize sya
♦ Paano lalabas yung bato? Sasama na sya
sa urine
♦ 2 % of patient develop Steinstrasse
Ø colonization of pulverized stone on
the ureter
    GGdG.RVdG  
 UROLOGY   11  
SURGICAL  BLOCK-­‐  Sub  Spec  
Ureter- 30cm § 4-5-6à you have to treat the patient
Bladder volume- 350- 450cc o DRE
Kidney- 150 ü Mandatory in all patients experiencing urinary
Most common site of cancer- prostate gland (peripheral zone) symptoms regardless of age
Hypospadias- defect is seen on the ventral portion ü Insert slowly, then using pads of finger feel the prostate
gland
PROSTATE GLAND ü Slowly touching the prostate gland
o 20 grams ü Benign prostate gland
o Located inferiorly to the urinary bladder § Consistency of nose
o Anteriorly to the pubic bone and rectum ü Prostate cancer
o What causes the enlargement? § Hard nodule
ü Aging § Stony hard
ü Normal testicular function § .2 cc
o As one grows older the incidence of BPH increases § do prostate biopsy
o Testicular function § 2ng/ml
ü Testosterone by 5- alpha reductaseà increases 5 ü Prostatitis
DHTà potent androgen that stimulates the prostate § Tender
ü Testosterone by virtue of aromatization produces o PSA- prostate specific antigen
estrogen which also stimulates the prostate gland to § Organ specific but not cancer specific
enlarge § Maybe elevated on BPH, prostatitis and cancer
o Natural History § Independent variable
ü 55 % experience worsening of systems Q: best way of detecting suspicious prostate CA:
ü 15 % improve in time a. PSA
ü 30 % remains later b. DRE
o Assess BPH c. PSA and DRE
ü DRE d. AOTA
ü PSA PSA and DRE- higher chance of detecting prostate CA
ü Flow rate and urine determination o 0-4
o History o 4-9- 20% chance of cancer
ü Irritative symptoms o > 10- 50% chance of cancer
§ Frequency- normal frequency is 5 to 6 times per o PSA above 4 and DRE is negative- do a transrectal
day ultrasound of the prostate
§ Urgency- urge feeling to urinate o Objectives of treatment of BPH
§ Nocturia- urinating more than twice at night ü Improve the symptoms
ü Obstructive Symptoms ü Reduce the obstruction
§ Hesitancy ü Prevent long term complications
• Delay on starting – “ dr. bakit ang tagal bago § Stone formation
lumabas ng ihi ko?” § Obstruction
• Bladder takes a long time to generate the § Uremia
pressure to overcome resistance § Urinary incontinence (most common incontinence:
§ Decrease urinary symptom obstructed- overflow incontinence)
§ Intermittency o Treatment
ü Watchful waiting
• Paputol putol ang ihi
§ Medications
• The bladder should regain again pressure thus
• alpha blocking
mag pupump na naman sya ng ihi
♦ alpha receptor blocker—lower urinary
• The bladder should generate pressure to
tract and in the prostate
overcome kaso may obstruction
o Q: hirap umihi: obstructive symptoms ♦ it contract the bladder and it keeps the
o Q: obstructive symptoms of prostate except: frequency. tension
Intermittency. Increase urinary symptom. Hesitancy. ♦ once you block this magrerelax and
o SS4 international symptom makakaihi yung patient
ü Four obstructive type of questions and three irritative ♦ dynamic componentà it reduces the
type contraction of smooth muscles thus
ü High score is 35 decreasing the caliber of the urethra
ü The higher the score the more problem regarding • alpha reductase
urination ♦ remember one of the cause of obstruction
ü Not emptying your bladder completelyà obstructive is testosterone so 5 alpha reductase
type inhibitors decrease the size of prostateà
ü Sensation of incomplete emptyingà obstructive problem is decrease ang testosterone so
ü 0-5à the higher the score the more severe yung magdecrease ang sexual urgeà
symptom impotence and erectile dysfunction
ü to know when to treat the patient when to do surgery
♦ but good news is pwedeng tumubo yung
and manage it medically
hair)
ü Quality of life
♦ decrease yung size ng prostate thus
§ If you were to spend the rest of your life with
pinapaluwag nya
urinary problem how would you feel
• Pytotherapy- plants
    GGdG.RVdG  
 UROLOGY   12  
SURGICAL  BLOCK-­‐  Sub  Spec  
o Best management is to reduce the symptoms, reduce the
cause and improve the quality of life
ü Medical therapy
ü Interventional therapy
o Minimally invasive procedures
ü Laser coagulation
ü Prostatic stent
§ Compressing the size of the prostate thereby
Increases the outflow
§ Problem is that tissues tend to grow over the stent
§ After a few years magbabara na naman sya
ü Actual microwave treatment
§ Transurethral microwave of the prostate
§ We heat up the prostate 55 degree centigrade for 1
hour and then remove it
§ It kills the alpha receptor and produces apoptosis
ü TURP
§ Put in a scope and resect all the tissues that is
obstructing
§ Direct vision
o Medicalà microwave therapyà surgical procedures
o Watchful waiting—patient should be free of cancer
o Do a biopsy!!!
o Prostatectomy- last resort

------------------2nd Lecture Dr. Lantin------------------

    GGdG.RVdG