Urology Case

1. Urology Case Aningalan, Arvin Antonio, Abigaile Aramburo, Jan

2. Case 1 • A 45 y/o ,male company executive presented in the emergency room with a 2 day episode of right flank pain and gross total hematuria.

3. History of Present Illness • He experienced dull aching pain radiating to the right testicle but was able to work, sleep, and generally experience no disability. 2-3 weeks PTA

4. Physical Examination • Vital signs were stable. • HEENT, heart and lungs were normal. • Abdominal findings: • (+) right CVA tenderness • absence of peritoneal irritation • bowel sounds were normal • no palpable masses • Genitalia and rectal examinations were essentially normal.

5. Laboratory findings Urinalysis: • 20-30 RBC/hpf • WBC 2-4hpf = normal

6. Salient features • Male • 45 years old • right flank pain • gross total hematuria • dull aching pain for the past 2-3 weeks radiating to the right testicle • (+) right CVA tenderness

7. Clinical Impression • Upper urinary tract obstruction (kidney,ureter) • It is characterised by pain in the flank, often radiating to either the abdomen or the groin. • (+) CVA tenderness • Total hematuria • has its source at or above the level of the bladder (eg,stone, tumor, tuberculosis, nephritis).

8. Guide questions • How would you explain the testicular pain? • Differentiate the two types of pain which originates from the GU system. • Differentiate renal from radicular pain. • How would you explain the vomiting?

9. Two types of pain have their origins in the genitourinary organs: • Local • Referred- more common • Local pain • is felt in or near the involved organ. • the pain from a diseased kidney (T10–12, L1) is felt in the costovertebralangle and in the flank in the region of and below the 12th rib. • Referred pain • originates in a diseased organ but is felt at some distance from that organ. • The ureteralcolic caused by a stone in the upper uretermay be associated with severe pain in the ipsilateraltesticle

11. Ureteral pain • Ureteral pain is typically stimulated by acute obstruction (passage of a stone or a blood clot) • The physician may be able to judge the position of a ureteral stone by the history of pain and the site of referral. • If the stone is lodged in the upper ureter, the pain radiates to the testicle, since the nerve supply of this organ is similar to that of the kidney and upper ureter (T11–12).

12. Ureteral pain • With stones in the midportion of the ureter on the right side, the pain is referred to McBurney’s point and may therefore simulate appendicitis • On the left side, it may resemble diverticulitis or other diseases of the descending or sigmoid colon (T12, L1).

13. Kidney Pain • Typical renal pain is felt as a dull and constant ache in the costovertebral angle just lateral to the sacrospinalis muscle and just below the 12th rib. • This pain often spreads along the subcostal area toward the umbilicus or lower abdominal quadrant. • It may be expected in the renal diseases that cause sudden distention of the renal capsule. • Acute pyelonephritis (with its sudden edema) • acute ureteral obstruction (with its sudden renal back pressure) • both cause this typical pain.

14. Kidney Pain • It should be pointed out, however, that many urologic renal diseases are painless because their progression is so slow that sudden capsular distention does not occur. • Such diseases include : • cancer • chronic pyelonephritis • staghorn calculus • tuberculosis • polycystic kidney • hydronephrosis due to chronic ureteral obstruction.

15. Radicular pain • Radicular Pain, or Radiculitis, is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation of the nerve root at its connection to the spinal column. • Radicular pain is commonly felt in the costovertebral and subcostal areas. • It may also spread along the course of the ureter and is the most common cause of so-called “kidney pain.”

16. Radicular pain • Every patient who complains of flank pain should be examined for evidence of nerve root irritation. • Frequent causes are: • poor posture (scoliosis, kyphosis) • arthritic changes in the costovertebral or costotransverse joints • impingement of a rib spur on a subcostal nerve • hypertrophy of costovertebral ligaments pressing on a nerve • intervertebral disk disease

17. Radicular pain • Pain experienced during the preeruptive phase of herpes zoster involving any of the segments between T11 and L2 may simulate pain of renal origin. • Radiculitis usually causes hyperesthesia of the area of skin served by the irritated peripheral nerve. • This hypersensitivity can be elicited by means of the pinwheel or grasping and pinching both skin and fat of the abdomen and flanks. • Pressure exerted by the thumb over the costovertebral joints reveals local tenderness at the point of emergence of the involved nerve.

18. Urinary obstruction • Normally, urine is formed in the kidneys, flows through the ureters to the bladder, and is released through the urethra. • A urinary obstruction blocks the normal flow of urine, causing it to back up toward the kidneys. • Urine flowing the wrong way in the urinary tract can cause infections and kidney damage. • Obstruction can occur anywhere in the urinary tract:

19. Urinary obstruction • Because of their damaging effect on renal function, obstruction and stasis of urinary flow are among the most important urologic disorders. • Either leads eventually to hydronephrosis, a peculiar type of atrophy of the kidney that may terminate in renal insufficiency or, if unilateral, complete destruction of the organ. • Furthermore, obstruction leads to infection, which causes additional damage to the organs involved.

20. Etiology A. CONGENITAL • The common sites of congenital narrowing: • externalmeatus in boys (meatal stenosis) • external urinary meatus in girls • the distal urethra (stenosis) • posterior urethral valves • ectopic ureters • ureteroceles • ureterovesical and ureteropelvic junctions. • Another congenital cause of urinary stasis is damage to sacral roots 2–4 as seen in spina bifida and myelomeningocele.

21. Etiology B. ACQUIRED • Acquired obstructions are numerous and may be primary in the urinary tract or secondary to retroperitoneal lesions that invade or compress the urinary passages. Among the common causes are: (1) urethral stricture secondary to infection or injury (2) benign prostatic hyperplasia or cancer of the prostate (3) vesical tumor involving the bladder neck or ureteral orifices (4) local extension of cancer of the prostate or cervix into the base of the bladder (5) compression of the ureters at the pelvic brim by metastatic nodes from cancer of the prostate or cervix (6) ureteral stone (7) retroperitoneal fibrosis or malignant tumor (8) pregnancy

22. Classification • Obstruction may be classified according to: • cause (congenital or acquired) • duration (acute or chronic) • degree (partial or complete) • level (upper or lower urinary tract)

23. Clinical manifestations Upper tract (ureter and kidney)— • Symptoms of obstruction of the upper tract are typified by the symptoms of ureteral stricture or ureteral /renal stone. The principal complaints are : • pain in the flank radiating along the course of the ureter • gross total hematuria (from stone) • gastrointestinal symptoms • chills • fever • burning on urination • cloudy urine with onset of infection • Nausea, vomiting, loss of weight and strength, and pallor are due to uremia secondary to bilateral hydronephrosis.

24. Clinical manifestations • Lower urinary tract obstruction (bladder, urethra) • can manifest as voiding dysfunction such as • urgency • frequency • nocturia • incontinence • decreased stream • hesitancy • postvoid dribbling • sensation of inadequate emptying • Suprapubic pain or a palpable bladder indicates urinary retention. • Infection may be present, and patients may experience dysuria. • Hematuria may be present with or without infection.

25. Clinical manifestaions Signs of obstruction in the upper urinary tract: • An enlarged kidney may be discovered by palpation or percussion. • Renal tenderness may be elicited if infection is present. • A large pelvic mass (tumor, pregnancy) can displace and compress the ureters. • Children with advanced urinary tract obstruction may develop ascites. • Rupture of the renal fornices allows leakage of urine retroperitoneally;with rupture of the bladder, urine may pass into the peritoneal cavity through a tear in the peritoneum.

26. Pathogenesis • The hallmark of urinary tract obstruction is dilation of the collecting system of the kidney which is known as hydronephrosis.  This swelling typically causes pain in the flank or upper abdomen on the affected side. 

27. Pathogenesis • Progressive back pressure on the ureters and kidneys can occur and can cause hydroureter and hydronephrosis. The ureter can then become dilated and tortuous, with the inability to adequately propel urine forward. • Chronic urinary tract obstruction can lead to permanent damage to the urinary tract. • Infravesical obstruction can lead to changes in the bladder, such as • trabeculation, • cellule formation • diverticula • bladder wall thickening • detrusor muscle decompensation

28. Pathogenesis • Hydronephrosis can cause permanent nephron damage and renal failure. • Urinary stasis along any portion of the urinary tract increases the risk of stone formation and infection, and, ultimately, upper urinary tract injury. • Urinary tract obstruction can cause long-lasting effects to the physiology of the kidney, including its ability to concentrate urine.

29. Abigaile Antonio Differential Diagnosis

31. Most likely diagnosis

32. UROLITHIASIS • The most common cause of persistent flank pain of sudden onset • The male-to-female ratio is 2:1. • peak incidence is in the third to fifth decades of life. • Patients classically present with sudden-onset flank pain, often radiating to the ipsilateral abdomen and groin.

33. Men may complain of testicular pain and women of labial discomfort. • The pain is caused by distension of the renal pelvis and upper ureter as well as by peristalsis of the ureter. • Flank tenderness can be elicited • abdominal and genital examinations are generally normal. • One-third of patients have gross hematuria.

34. PROGNOSIS • Most kidney stones pass out of the body without any intervention by a physician. • Cases that cause lasting symptoms or other complications may be treated by various techniques, most of which do not involve major surgery.

35. Guide Questions: • What are the laboratory examinations that you would request? • What imaging studies would you request? • Interpret the Imaging Examination. • What are the treatment options?

36. Arvin M. Aningalan Laboratory Examinations

37. Laboratory Examinations • Urinalysis • Blood Urea Nitrogen (BUN) • Creatinine • Blood Uric Acid (BUA) • Complete Blood Count (CBC) • Urine Culture • Stone Analysis

38. Urinalysis • Determines the Chemical and Microscopic properties of the urine. • Microscopic • RBC • WBC • Casts • Bacteria • Crystals • Chemical • Protein • pH • Specific Gravity • Sugar

39. Urinalysis • pH – determines the type of crystals and kidney disorders present. • Crystals – helpful in knowing the origin of the stone. • WBC – manifest as “pus cells” which may indicate presence of infection. • RBC - hematuria

40. BUN and Creatinine – evaluates kidney function. • BUA – determines if there are metabolic disorders that might predispose the patient to stone formation. • CBC and Urine Culture – test for the presence of infection. • Stone Analysis – analyzes composition of stone for treatment and preventive measures.

41. Imaging studies

42. Imaging Studies • Computed Tomography (CT) • Intravenous Pyelography • Tomography • KUB films and directed ultrasonography • Retrograde pyelography • Magnetic Resonance Imaging (MRI) • Nuclear Scintigraphy

43. Noncontrast Spiral CT Scan • Imaging modality of choice in patients presenting with renal colic. • Does not depend on experienced radiologic technician to obtain oblique views when there is confusion with overlying bowel gas in a nonprepped abdomen. • No need for intravenous contrast.

44. Intravenous Pyelography • Documents simultaneously nephrolithiasis and upper-tract anatomy. • Oblique views easily differentiate gallstones from right renal calculi

45. Renal Tomography • Useful to identify calculi in the kidney when oblique views are not helful. • May help identify poorly opacified calculi, especially when interfering abdominal gas or morbid obesity make KUB films suboptimal.

46. KUB Films and Directed Ultrasonography • Ultrasound examination should be directed by notation of suspicious areas seen on a KUB film. • Distal ureter is easily visualized through the acoustic window of a full bladder • Edema and small calculi missed on an IVP can be better appreciated

47. Retrograde Pyelography • Occasionally required to delineate upper tract anatomy, and localize small or radiolucent offending calculi.

48. Magnetic Resonance Imaging • Poor study to document urinary stone disease because urinary stones produces no signal.

49. Nuclear Scintigraphy • Bisphosphonate markers can identify even small calculi that are difficult to appreciate on a conventional KUB film. • However, it cannot delineate upper tract anatomy in sufficient detail to help direct a therapeutic plan.

50. Interpret