Genitourinary Tract

1. Genitourinary Tract Begashaw M (MD)

2. Urinary caliculi Incidence -prevalance of 2-3% -male:female= 3:1, peak incidence 30-50 years of age -Recurrence rates are close to 50% -90% are idiopathic

3. Urinary caliculi

4. Prevalence common in areas -hot, dehydrated Etiology of stone formation in the urinary tract is not very clear Proposed etiologies -Urinary stasis -Infections -Lack of inhibitors

5. Risk Factors Hereditarycystinuria/xanthinuria/oxaluria Dietary excess: Vitamin C, oxalate, purines, calcium Dehydrationsummer Sedentary lifestyle UTI Hypercalcemia

6. Chemical composition Calcium oxalate (40%) Calcium phosphate (15%) Mixed oxalate / phosphate (20%) Struvite(15%) Uric acid (10%)

7. Types of renal calculi

8. Clinical features • pain • Uretericcolic • severe colicky loin to groin pain • radiate into scrotum in men &labia in women • Frequency, urgency &dysuria • Microscopic haematuria

9. Investigation U/ARBC, Pus cells, calcium oxalate KUBOpacity in UT projection Ultrasound- locates stone in the kidney - detects hydronephrosis Intravenous urogram (IVU)-presence of stone CT scanning

10. Complications Complications of ureteric calculi _Obstruction _Uretericstrictures _Infection

11. Management • Small ureteric stones /non-obstructive _Conservativeanalgesics/antibiotics Expecting passage • Big stones/obstructing Open surgery -nephrolithotomy ,pyelolithotomy Percutaneousnephrolithotomy Extra corporal shock wave lithotripsy (ESWL)

12. Bladder calculi associated with urinary stasis Foreign bodies (suture)nidusfor stone formation more common in elderly men/childen

13. Clinical features asymptomatic Suprapubicpain Dysuria Haematuria

14. Diagnosis Plain abdominal x-ray Bladder ultrasound CT scan Cystoscopy acute urinary retention

15. Management Indications for surgery Recurrent UTI Acute urinary retention Frank haematuria

16. Urinary tract infection Commonest organisms Escherichia coli (80%) Proteus mirabilis Pseudomonas aeruginosa

17. Upper urinary tract infections Classification - Acute pyelonephritis - Chronic pyelonephritis - Pyonephrosis - Renal abscess - Perinephric abscess

18. Acute pyelonephritis commonly occurs in females, in reproductive age group, childhood & pregnancy Ascends from lower UTI

19. Clinical features Nonspecific-headache, lassitude & nausea Sudden onset of pain, rigors & vomiting Pain is localized in the flank &hypochondrium lower UTI - frequency & dysuria

20. Diagnosis Urine culture & sensitivity Urinalysis - few pus cells,manybacteria Blood culture

21. Treatment Antibiotic Choice-combination of amino glycoside &penicillin parenteralantibiotics Complications-Pyonephrosis -coexisting upper tract obstruction _inadequately treatedperinephricabscess

22. Perinephric abscess is an infection of the perinephric fat resulting in pus collection source -extension of cortical abscess -distant-appendix abscess

23. Clinical feature - Swinging high grade fever - Abdominal and loin tenderness - Flank mass Diagnosis -Elevated WBC count, -Low or no pus cells or bacteria in urine -Ultrasound is usually diagnostic Treatment -Drainage of abscess,IV antibiotics/fluid

24. Perinephric abscess

25. Urinary Retention Etiology • Outflow obstruction -bladder neck/urethracalculus,clot,neoplasm -prostateBPH, prostate cancer -urethrastricture • Bladder innervation -spinal cordinjury -stroke • pharmacologic -anticholinergics

26. Symptoms of urinary tract obstruction

27. DDX

28. Urinary retention • Acute retention -characterized by pain &anuria -normal bladder volume & architecture • Chronic retention -asymptomatic -increased bladder volume -detrusorhypertrophyatony

29. Acute retention Presents with inability to pass urine for several hours Usually associated with lower abdominal pain Bladder is visible and palpable Bladder is tender on palpation

30. Management urethral catheterisation 12 to 16 Fr gauge Foley catheter If unable to pass a urethral cathetesuprapubiccystostomy

31. Urethral catheterization

32. Supra pubic cystostomy

33. Chronic retention Usually relatively painless Cause hydronephrosis & renal impairment present with hypertension Symptoms of BOO

34. Investigations CBC, electrolytes, Cr, BUN Ultrasound Cystoscopy

35. Treatment Catheterization -contraindicated in trauma patient unless urethral disruption has been ruled out -acute retention: immediate catheterization to relieve retention, leave Foley in to drain -chronic retention: intermittent catheterization • suprapubiccystotomy

36. Benign Prostatic Hyperplasia (BPH) • hyperplasia of stroma&epithelium in periurethral area of prostate (transition zone) • Affects 50% men >60 yrs • Affects 90% of men >90 yrs • Presents with obstructive and irritative symptoms • Obstruction-poor stream, hesitancy, dribbling &retention • Irritation - frequency, nocturia, urgency &urge incontinence

37. Investigations Urea/electrolytesrenalfunction Ultrasoundhydronephrosis& measure post-micturition volume Serum PSAmalignancy Uroflowmetry DRE

38. Management Observation -α-adrenergic antagonists -5α- reductase inhibitors -LHRH antagonists Surgery Transurethral prostatectomy Transvesical prostatectomy Retropubic prostatectomy

39. Complications • Early Primary haemorrhage Extravasation Fluid absorption Infection Clot retention Incontinence • Intermediate Secondary haemorrhage Retrograde ejaculation Erectile dysfunction • Late Bladder neck stenosis Urethral stricture

40. Renal injuries relatively uncommon injuries Injuries to ureters are extremely rare in traumas Renal injuries -divided mild, moderate, severe first, second &third degree

41. Classification First degree -injury limited to the kidney parenchymaonlysubcapsular hematoma Second-degree injury involved the pelvicalycealsystem - hematuriais evident Third degree -renal artery or renal vein involvement

42. Clinical features Hematuria: - the most important symptom -extent &duration of hematuriadetermines severity Pain in the flank area/hypochondrium Fullness, tenderness & bruises in the flanks Hypotension/shock - third degree injuries

43. Treatment Conservative - first degree and some second degree renal injuries - replacement of fluid - blood transfusion - catheterization and follow up Surgery- severe forms of renal injury

44. Bladder injury Associated with pelvic fractures Rupture can either intraperitoneal or extraperitoneal Clinical features -lower abdominal peritonism&inability to pass urine IVU may show urine extravasation Diagnosis  cystography Intraperitonealrupture requires laparotomy, bladder repair, urethral & suprapubicdrainage Extraperitonealrupture can be treated conservatively with urethral drainage Prophylactic antibiotics should be given

45. Bulbar urethral injury Is the commonest type direct trauma causes by falling astride an object Clinical features -blood from meatus&perinealbruising Suprapubiccystostomy Diagnosis -ascending urethrogram Prophylactic antibiotics Complication-urethral stricture

46. Membranous urethral injury Often occur in multiply injured patient 10% of men with pelvic fracture have a membranous urethral injury Tear -partial or complete Partial injuries - urethral bleeding &perineal bruising Complete injuries - inability to pass urine Diagnosis - ascending urethrogram Treatment -suprapubic catheter Complications-stricture, impotence &incontinence

47. 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

48. Treatment -circumcision, proper hygiene Complications -balanoposthitis(inflammation of prepuce), paraphimosis, penile cancer

49. Balanitis Inflammation of the glans In mild cases, the only symptoms are itching and some discharge In more severe inflammation, the glans and foreskin are red-raw and pus exudes Treatment is by broad-spectrum antibiotics and local hygiene measures

50. Urethral stricture Aetiology -inflammatory – post-gonorrhoeal -congenital -traumatic -instrumental – indwelling catheter – urethral endoscopy -postoperative