Notes on urinary disorders 2

Management of Clients with
Urinary Disorders
Mrs. Babitha K Devu,
Asst. Professor, SMVDCoN
1

Urinary Tract Calculi
Urinary Strictures
Nephrosis
Urinary Tumors
2

URINARY TRACT CALCULI
• In India, urolithiasis is more common in the
northern part, also called as the “stone belt.” The
risk of developing nephrolithiasis in normal
adults is lower in Asia (1-5%) as compared to
developed countries. UT stones are more
common in men except for struvite (magnesium
ammonium phosphate) stones. The incidence is
also higher in persons with family history and
stones can recur up to 50% of patients. Stone
formation is more often in summer months.
3

4
• A urinary tract stone, is a solid concretion
or crystal aggregation formed in any part of the
urinary tract from dietary minerals in the urine.
• DEFINITION
▫ Urolithiasis refers to the presence of stones in the
urinary system. Stones, or calculi, are formed in
the urinary tract from the kidney to bladder by the
crystallization of substances excreted in the urine.

• ETIOLOGY
5
METABOLIC – Abnormality result in
increased urine levels of Ca, uric acid etc.
LIFESTYLE
GENETIC FACTORS
DRUGS & OTHERS

• RISK FACTORS
▫ Sedentary life style & immobility
▫ Dehydration
▫ Metabolic disturbances
▫ History of renal calculi
▫ Climate
▫ Dietary pattern like large protein intake,
excessive tea or fruit juices, high mineral
content in drinking water
▫ H/o UTI
▫ Prolonged catheterization
▫ Male sex & Age
6

• PATHOGENESIS
Although many theories have been proposed, no
single theory can account for stone formation in all
cases.
▫ An organic mucoprotein matrix, making up 1%
to 5% of the stone by weight, is present in all
calculi.
▫ Supersaturation: The most important
determinant(Renal stones) is an increased
urinary concentration of the stones'
constituents, such that it exceeds their
solubility (supersaturation). A low urine
volume in some metabolically normal patients
may also favor supersaturation.
7

• PATHOGENESIS
▫ Crystals, when in a supersaturated
concentration, can precipitate and unite to
form a stone.
▫ Urinary pH, solute load, and inhibitors in
the urine affect the formation of stones.
 The higher the pH (alkaline), < soluble are
calcium & phosphate. The lower the pH
(acidic), < soluble are uric acid & cystine.
 When a substance is not very soluble in fluid,
it is more likely to precipitate out of solution.
 Many organic and inorganic substances are
known to inhibit stone formation.
8

• PATHOGENESIS
▫ Absence of these substance that inhibit the
formation of stones.
 The in organic inhibitors are citrate,
magnesium and organic substances are
macromolecules like glycoprotein,
glycosaminoglycans; inhibitory protein in
urine like nephrocalcin, uropontin, F1
prothrombin fragment etc.
▫ Obstruction with urine flow & UTI with
urea splitting bacteria like proteus,
Klebsiella, pseudomonas. (Cause alkaline)
9

• PATHOGENESIS
10
Urinary Supersaturation
Crystallization –
Nucleation, Growth &
Aggregation
Crystal – cell interaction
R
e
n
a
l
T
u
b
u
l
a
r
I
n
j
u
r
y
Crystal Growth & Crystal
Aggregation

• PATHOGENESIS
11
Stone Formation
Complete or Partial
Obstruction in the flow
of urine
Significant changes occurs to
the systems above the level of
obstruction depending on the
location, duration, pressure
and urinary stasis

• TYPES OF URINARY CALCULI
▫ By location
 Kidney (nephrolithiasis),
 Ureter (ureterolithiasis),
 Bladder (cystolithiasis),
▫ By type of stone
 Calcium oxalate (35 – 40 %)
 Calcium phosphate (8 – 10%)
 Uric acid (5 – 8%)
 Cystine (1 – 2%)
 Struvite (Magnesium ammonium phosphate)
(10 – 15%)
12

• Clinical Manifestations
▫ Severe pain is called renal colic. You may have
pain on the flank area, back, or lower
abdomen.
▫ In men, pain may radiate to the testicular area
and females labia; both will have groin pain.
The pain of renal colic comes and goes, but can
be intense. People with renal colic tend to be
restless.
▫ blood in the urine (red, pink, or brown urine)
▫ Vomiting & nausea
▫ discolored or foul-smelling urine
▫ Chills & fever
▫ frequent need to urinate
▫ urinating small amounts of urine
13

• Diagnostic Study
▫ A complete health history assessment and
a physical examination.
▫ Blood tests for calcium, phosphorus, uric acid, and
electrolytes
▫ Blood urea nitrogen (BUN) and creatinine to
assess kidney functioning
▫ Urinalysis to check for crystals, bacteria, blood,
and white cells
▫ Examination of passed stones to determine their
type & diagnose the underlying problem
contributing to stone formation
14

• Diagnostic Study
▫ The following tests can rule out obstruction:
 abdominal X-rays
 intravenous pyelogram (IVP)
 retrograde pyelogram
 ultrasound of the kidney (the preferred
study)/KUB
 MRI scan of the abdomen and kidneys
 abdominal CT scan
 Cystoscopy
15

• Complications
▫ Urinary obstructions
▫ Kidney infections
▫ Chronic kidney damage
16

• Management
▫ DRUG THERAPY
 Opioid agents
 NSAIDS
 Spasmolytic agents like oxybutynin
chloride
 Allopurinol (zyloprim) for uric acid
stones
 Diuretics like thiazide for Ca
reabsortion, add potassium citrate
 Treatment of infection with antibiotics
 Treatment for correction of pH
 Antiemetics
17

• Management
▫ DRUG THERAPY
 Aplha adrenergic blockers
eg: Terazosin, tamsulosin
They can relax the smooth muscles
in the ureter to facilitate stone
passage.
 If citrate level – K & Na citrate
18

• Management
▫ Comprehensive Management
 Teaching – Adequate hydration,
dietary sodium restrictions,
dietary changes, and drugs.
Most stones are 4 mm or less in
size and will be probably pass
spontaneously, but may take
weeks for it.
19

20
SPECIFIC APPROACHES
URINARY
STONE
CHARAC
TERIS
TICS
PREDISPOSING
FACTORS
THERAPEUTIC MEASURES
Calcium
oxalate
(35-40%)
Small
often
possible
to
Get
trapped
in
Ureter,m
ore
frequent
in
men
Idiopathic
hypercalciuria
hyperoxaluria,
Independent of
urinary pH,
family history
Increase hydration
Reduce dietary oxalate
Give thiazide diuretics
cellulose phosphate,(chelate
calcium and prevent GI
absorption), potassium
citrate(alkaline urine),
cholestyramine(bind
oxalate), calcium
lactate(precipitate oxalate in
GI tract) Reduce daily
sodium intake

21
SPECIFIC APPROACHES
URINARY
STONE
CHARAC
TERIS
TICS
PREDISPOSING
FACTORS
Calcium
phosphate
(8-10%)
Mixed
stones
with
struvite
or
oxalate
stones
Alkaline urine,
primary
hyperthyroidis
m
Treat underlying
cause and other
stones

22
SPECIFIC APPROACHES
URINARY
STONE
CHARAC
TERIS
TICS
PREDISPOSING
FACTORS
Struvite
(10-15 %)
3 to 4
times
common
in
women ≥
men,
always in
associatio
n
with
urinary
tract
infection
urinary tract
infections
Antimicrobial agents
acetohydroxamic acid
Surgical interventions
Measures to acidify urine

23
SPECIFIC APPROACHES
URINARY
STONE
CHARAC
TERIS
TICS
PREDISPOSING
FACTORS
Uric
acid
(5-8 %)
Predomi
nant in
men high
incidence
in jewish
men
Gout, acid
urine
,inherited
conditions
Reduce urinary
concentration of uric acid
Alkanize urine with
potassium citrate
Administer allopurinol
Reduce dietary purines

24
SPECIFIC APPROACHES
URINA
RY
STONE
CHARACTERIS
TICS
PREDISP
OSING
FACTOR
S
Cystine
(1-2 %)
Genetic
autosomal
recessive
defect, defective
absorption of GI
Cystine and
kidney
excess
concentrations
causing stone
formation
Acidic
urine
Increase hydration
Give α pencillamine and
tiopronin to prevent cystine
crystallization
Potassium citrate to
alkaline urine

• Management
▫ Surgical Management
 Indications foe endourologic, lithotripsy,
or open surgical stone removal include:-
 Stone too large (>7mm)
 Stone associated with bacteriuria or
infection
 Stones causing renal imapirement
 Stone causing severe renal colic & S/s
 Inability of the patient to be treated
medically
 Patient with only one kidney
25

• Management
 Stone too large (>7mm)
 Stone associated with bacteriuria or
infection
 Stones causing renal imapirement
 Stone causing severe renal colic & S/s
 Inability of the patient to be treated
medically
 Patient with only one kidney
26

• Management
 Endourologic Procedures: If the stone is located in
the bladder, a cystoscopy is done to remove small
stones. For large stones, a cystolitholapaxy is done.
In this procedure, a large stone is broken down with
an instrument called lithotrite. Here it uses an
ultrasonic lithotrite to pulverize stones.
 Flexible ureteroscopes, inserted via a cystoscope
can be used to remove stones from renal pelvis and
upper UT. Ultrasonic, laser or electrohydraulic
lithotripsy may be used in conjunction to pulverize
the stone or can be encaged.
27

• Management
 Endourologic Procedures: In percutaneous
nephrolitotomy, a nephroscope is inserted into
the kidney pelvis through a track (using a sheath)
in the skin. The track is created in the patient
back. The kidney stones can be fragmented using
Ultrasonic, laser or electrohydraulic lithotripsy.
The fragemnted stones are removed by irrigation.
A percutaneous nephrostomy tube is usually left
in place to make sure that the ureter is not
obstructed.
29

• Management
 Lithotripsy: This technique include
▫ Laser lithotripsy
▫ Extracorporeal shock-wave lithotripsy (ESWL)
▫ Percutaneous ultrasonic lithotripsy
▫ Electrohydraulic lithotripsy
All the techniques require spinal or general
anesthesia.
31

• Management
 Surgical therapy: A small group pf patients
require open surgeries.
▫ Nephrolithotomy
▫ Pyelolithotomy
▫ Ureterolithotomy
▫ Cystotomy
These surgeries choice depends upon the location of
the stone and may or may not be included with a
placement of stent to save the kidney which are at a risk
of acute renal failure.
35

▫ Prevention
• Avoid protein intake; usually protein is restricted to
60g/day to decrease urinary excretion of calcium and
uric acid.
• A sodium intake of 3 to 4 g/day is recommended. Table
salt and high-sodium foods should be reduced, because
sodium competes with calcium for reabsorption in the
kidneys.
• Low-calcium diets are not generally recommended,
except for true absorptive hypercalciuria. Evidence
shows that limiting calcium, especially in women, can
lead to osteoporosis and does not prevent renal stones.
• Avoid intake of oxalate-containing foods (eg, pinach,
strawberries, rhubarb, tea, peanuts, wheat bran).
36

▫ Prevention
• During the day, drink fluids (ideally water) every1
to 2 hours.
• Drink two glasses of water at bedtime and an
additional glass at each night time awakening to
prevent urine from becoming too concentrated
during the night.
• Avoid activities leading to sudden increases in
environmental temperatures that may cause
excessive sweating and dehydration.
• Contact your primary health care provider at the
first sign of a urinary tract infection
37

URINARY STRICTURES
A urinary stricture is a narrowing of the tubular
lumen of the urinary tract.
There are two common strictures in the urinary tract,
namely – Ureteral Strictures
– Urethral Strictures
38

URINARY STRICTURES
Ureteral Strictures
A Ureteral stricture is
characterized by a narrowing of
the Ureteral lumen, causing
functional obstruction. It can
affect the entire length of the
ureter, from the UPJ to the UVJ.
The most common form of ureteral
stricture is ureteropelvic junction
(UPJ) obstruction, which is
characterized by a congenital or
acquired narrowing at the level of
the UPJ
39

URINARY STRICTURES
Ureteral Strictures
Causes:
▫ Congenital or idiopathic
▫ Unintended result of surgical intervention or
previous renal stone
▫ Secondary to adhesions or scar formation
▫ Extrinsic factors such as large tumors in the
peritoneal cavity.
▫ Infections
40

URINARY STRICTURES
Ureteral Strictures
Pathophysiology:
• Pathologic analysis of the strictures reveals
disordered collagen deposition, fibrosis, and
varying levels of inflammation, depending on
factors such as etiology and interval since the
causative insult.
• The resulting ureteral obstruction may vary widely
from mild, causing only asymptomatic proximal
ureteral dilation and hydronephrosis, to severe,
causing complete obstruction and subsequent loss
of renal function.
41

URINARY STRICTURES
Ureteral Strictures
Clinical Manifestations:
• Mild to moderate colic
• The pain become severe if the patient consumes a
large volume of fluids (alcohol) over a brief period
• Infection is rare unless a calculus or foreign objects
such as stent or nephrostomy tube is present.
• Flank fullness, or abdominal fullness
Diagnostic study:
▫ History collection & Physical examination
▫ Ureteroscopy
▫ Usg, IV urography, CT
42

URINARY STRICTURES
Ureteral Strictures
Management:
No accepted medical
treatment of ureteral
stricture currently exists.
▫ Temporary care:-
Placing a stent using
endoscopy
Diverting urinary flow via
nephrostomy tube inserted
into the renal pelvis of the
affected kidney.
43

URINARY STRICTURES
Ureteral Strictures
Management:
▫ Definitive Correction:-
 Dilation of the narrowed lumen with a catheter or balloon
 If the stricture is severe or recurs after initial balloon or
catheter dilation, it is surgically incised using an
endoscopic procedure – Endoureterotomy.
 Ureteroureterostomy – an open surgical approach to excise
the stenotic area and reanastomose the ureter to the
contralateral ureter
 Ureteroneocystostomy – Distal strictures are treaed by
reimplantation of the ureter into the bladder wall.
44

46
Ureteroureterostomy Endoureterotomy

URINARY STRICTURES
Urethral Strictures
It is the result of fibrosis or
inflammation of the urethral
lumen leading to the narrowing.
More common in men.
Causes:-
▫ Trauma
▫ Urethritis (gonococcal infection,
STDs)
▫ Surgical intervention
▫ Repeated catheterization
▫ Congenital defect of the urethra
▫ BPH
▫ Cancer
48

URINARY STRICTURES
Urethral Strictures
Pathogenesis:-
Due to the etiological factors
Process of inflammation & Fibrosis begins
The lumen of the urethra narrows
Urethral compliance is compromised & sometimes
leads to meatal stenosis also.
49

URINARY STRICTURES
Urethral Strictures
Signs & Symptoms:-
Some are asymptomatic & some shows mild
discomfort, to complete urinary retention.
▫ Diminished force of the urinary stream
▫ Straining to void/dysuria
▫ Sprayed stream
▫ Postvoid dribbling or a split urine stream
▫ Incomplete bladder emptying with urinary
frequency & nocturia
▫ Hematuria/ hematospermia
▫ Pelvic pain
50

URINARY STRICTURES
Urethral Strictures
Diagnostic study :-
History collection & physical examination
Urinalysis
Urine & urethral culture
Imaging and endoscopic studies – RUG & VCUG
51

URINARY STRICTURES
Urethral Strictures
Management:-
There is no medication in the primary management
of strictures. The common procedures include:
▫ Urethral dilation
▫ Direct vision internal urethrotomy (DVIU)
▫ Urethral stent placement
▫ Open urethral reconstruction – urethroplasty
52

53
BARD HEYMAN Followers
Urethral Dilators, Size 10 to 24
Fr.
Urethral Dilation

54
Direct vision internal urethrotomy
(DVIU)

URINARY TRACT TUMORS
Cancer is when cells in the body grow out of control,
often forming a mass or tumor. In upper urinary
tract cancer, abnormal cells are found in the:
• Renal pelvis (where urine collects in the kidneys
before it travels to the ureters and bladder)
• Renal calyces (spaces deep in the kidneys)
• Ureters (thin tubes, made of muscle, which move
urine from the kidney to the bladder)
Cancers of the upper urinary tract are relatively rare.
The most common of all upper urinary tract cancers
are those found in the renal pelvis and renal calyces.
Cancer in the ureters makes up about a quarter of all
upper urinary tract cancers.
56

In lower urinary tract cancer can affect both bladder
& urethra. Bladder cancer is one of the most
common cancers, and its incidence continues to rise.
It accounts for 3% of new cancers and is the second
most common urological cancer.
Prostate cancer, is the most common cancer in
American men. One out of every 10 men will develop
the disease at some time in his life — most often
after age 50.
Other types are testicular & penile cancer.
57

Cancer that can occur in either gender
• Bladder cancer is cancer that affects the bladder. It
most often occurs in older adults, but anyone can get
bladder cancer. The most common place for bladder
cancer to develop is in the cells that line the bladder.
Fortunately, most bladder cancer is found early because
it tends to cause blood in the urine. When it is found
early, it is highly treatable.
• Kidney cancer is cancer of the kidneys. Renal cell
carcinoma is the most common type of kidney cancer in
adults.
• Adrenal cancer , also known as adrenal gland cancer, is
cancer of the adrenal glands. The adrenal glands rest on
top of the kidneys. There is one adrenal gland on each
kidney.
58

Kidney Cancer:
• What Is Kidney Cancer?
• Kidney cancer-- also called renal cancer-- is a
disease in which kidney cells become malignant
(cancerous) and grow out of control, forming a
tumor. Almost all kidney cancers first appear in the
lining of tiny tubes (tubules) in the kidney. This
type of kidney cancer is called renal cell carcinoma.
• These tumors can be benign or malignant but
malignant is more common. Incidence in India is
0.9% and mortality 0.6%.
59

Kidney Cancer:
• Cause?
▫ Idiopathic. But certain factors appear to increase the
risk of getting kidney cancer.
▫ Smoking . If you smoke cigarettes, your risk for
kidney cancer is twice that of non-smokers.
▫ Being male. Men are about twice as likely as women
to get kidney cancer.
▫ Being obese. Extra weight may cause changes to
hormones that increase your risk.
▫ Using certain pain medications for a long
time. This includes over-the-counter drugs in addition
to prescription drugs.
▫ Having advanced kidney disease or being on long-
term dialysis, a treatment for people with kidneys that
have stopped working.
60

Kidney Cancer:
• Cause?
▫ Having certain genetic conditions
▫ Having a family history of kidney cancer.
▫ Being exposed to certain chemicals, such
as asbestos, cadmium, benzene, organic solvents, or
certain herbicides
▫ Having high blood pressure. Doctors don't know
whether high blood pressure or medication used to treat it
is the source of the increased risk.
▫ Being black. The risk in blacks is slightly higher than in
whites. No one knows why.
▫ Having lymphoma. For an unknown reason, there is an
increased risk of kidney cancer in patients with
lymphoma.
61

Kidney Cancer:
• Symptoms of Kidney Cancer?
In many cases, people may have no early symptoms of kidney
cancer. As the tumor grows larger, symptoms may appear.
▫ Blood in your urine
▫ A lump in your side or abdomen
▫ A loss of appetite
▫ A pain in your side that doesn't go away
▫ Weight loss that occurs for no known reason
▫ Fever that lasts for weeks and isn't caused by a cold
or other infection
▫ Extreme fatigue
▫ Anemia
▫ Swelling in your ankles or legs
62

Kidney Cancer:
• Symptoms of Kidney Cancer?
Kidney cancer that spreads to other parts of your
body may cause other symptoms, such as:
▫ Shortness of breath
▫ Coughing up blood
▫ Bone pain
63

Kidney Cancer:
• Investigations of Kidney Cancer?
▫ History collection
▫ Physical examination
▫ Urinalysis
▫ Ultrasound
▫ CT scan
▫ MRI
▫ Renal biopsy
▫ Renal scan
▫ Angiography
64

Kidney Cancer:
• Staging of Kidney Cancer?
Stage – I: The tumour can be up to 7 cm diameter but
is confined to kidney.
Stage – II: The tumour is larger than stage – I, but
confined to kidney.
Stage – III: The tumour extends beyond the kidney to
the surrounding tissue and may also have spread to a
nearby lymph node.
Stage – IV: Cancer spread outside the kidney to
multiple lymph nodes or to distant parts of the body
such as bones, brain, lung.
65

Kidney Cancer:
• Prevention of Kidney Cancer?
Quitting smoking
Maintaining a healthy weight
Controlling BP
Reducing or avoiding exposure to toxins
High-risk group should be identified and make them
aware.
Teach them the early s/s as a cure is possible when it
is detected early and treated.
67

Kidney Cancer:
• Collaborative Therapy
Surgical Treatment
Partial Nephrectomy
Radical Nephrectomy
Ablation
Cryoablation
Radiofrequency ablation
Radiation Therapy
Chemotherapy
Biologic Therapy
Targeted Therapy
68

Kidney Cancer:
Surgical Treatment: In kidney cancer the treatment
of choice is surgery.
Partial Nephrectomy: It is also called kidney – sparing
or nephron – sparing surgery done when the tumour
size is small. Here the surgeon removes the tumor and a
small margin of healthy tissue that surrounds it rather
than the entire kidney.
Radical Nephrectomy: A complete (radical)
nephrectomy involves removing the entire kidney, a
border of healthy tissue and occasionally additional
tissues like adrenal gland, part of the ureter and
draining lymph nodes.
69

70
Partial Nephrectomy Radical Nephrectomy

Kidney Cancer:
Ablation: Destroying the tumors.
Cryoablation: A special hollow needle is inserted
through the skin and into kidney tumor using USG
or other imaging guidance. Cold gas is used to
freeze the cancer cells.
Radiofrequency ablation: A special probe delivers
electric current into the cancer cells causing the
cells to heat up or burn.
71

72
Cryoablation Radiofrequency
ablation

Kidney Cancer:
Radiation Therapy: Used palliatively in inoperable
cases and when there is metastasis to bone or lungs
occur.
Chemotherapy: 5-flurouracil, floxuridine and
gemcitabine. Renal cell carcinoma are refractory to
most chemotherapy drugs.
Biologic Therapy: this is use of drugs that boost the
immune system. Eg. α – interferon, interleukin – 2,
aldesleukin, nivolumab.
73

Kidney Cancer:
Targeted Therapy: this is the preferred treatment in
metastatic cancer as it blocks specific abnormal
signals present in kidney cancer cells that allow them
to multiply.
▫ Eg. Cabozantinib, axitinib, bevacizumab,
pazopanib are drugs which blocks signals that
play in the growth of blood vessels tha nourish
cancer cells.
▫ Temsirolimus, afinitor blocks a signal that allows
cancer cells to grow and survive.
74

Bladder Cancer:
Bladder cancer is an uncontrolled abnormal growth
and multiplication of cells in the urinary bladder,
which have broken free from the normal
mechanisms that keep uncontrolled cell growth in
check.
Bladder cancer invariably starts from the innermost
layer of the bladder (for example, the mucosa) and
may invade into the deeper layers as it grows.
Alternately, it may remain confined to the mucosa
for a prolonged period.
75

Bladder Cancer:
Incidence:
The most frequent malignant tumor of the urinary
tract is bladder cancer.
It is 3 times higher in men than in women.
Also it is 2 times more in white men than in others.
Most common age group is 60 – 70 years.
76

Bladder Cancer:
Causes:
▫ Idiopathic but the risk factors are –
 Genetic makeup, race, and family history.
 Chronic bladder inflammation.
 Smoking .
 Chemical exposures at work.
 Taking certain diabetes medications. If you’ve
taken pioglitazone more years.
 Prior chemo or radiation treatment.
 Diet.
77

Bladder Cancer:
Types: The more common types of bladder cancer are as
follows:
• Urothelial carcinoma (previously known as
"transitional cell carcinoma") is the most common
type and comprises 90%-95% of all bladder
cancers. This type of cancer has two subtypes:
papillary carcinoma (growing finger-like
projections into the bladder lumen) and flat
carcinomas that do not produce fingerlike
projections.
78

Bladder Cancer:
Types:
Adenocarcinoma of the bladder comprises about 1%-
2% of all bladder cancers and is associated with
prolonged inflammation and irritation. These
cancers form from cells that make up glands.
Squamous cell carcinoma comprises 1%-2% of
bladder cancers and is also associated with
prolonged infection, inflammation, and irritation
such as that associated with longstanding stones in
the bladder. These cells grow in flat masses of
interconnected cells.
79

Bladder Cancer:
Symptoms and Signs:
Bleeding in the urine (hematuria) - often the
bleeding is "gross" (visible to the naked eye),
episodic (occurs in episodes), and is not associated
with pain. However, sometimes the bleeding may
only be visible under a microscope (microscopic
hematuria) or may be associated with pain.
Increased urinary frequency, urgency, or a burning
sensation while passing urine (dysuria).
80

Bladder Cancer:
Symptoms and Signs:
Rarely, patients may have signs and symptoms of more
advanced disease such as
• A distended bladder (due to obstruction by a tumor at
the bladder neck),
• An inability to pass any urine,
• Pain in the flanks (due to obstruction of urine flow from
kidney to the bladder by the growing tumor mass in the
bladder),
• Bone pains,
• Foot and/or ankle swelling, or
• Cough/blood in the phlegm (due to spread to cancer
cells to bones or lungs).
81

Bladder Cancer:
Diagnostic Study:
• History collection
• Physical examination including pelvic examination
and DRE
• Urine Tests
▫ Urinalysis.
▫ Urine cytology.
▫ Urine culture.
▫ Urine tumor marker tests.
82

Bladder Cancer:
Diagnostic Study:
• Cystoscopy & biopsy
• Imaging Tests
▫ Intravenous pyelogram (IVP).
▫ Retrograde pyelogram.
▫ CT scan.
▫ MRI.
▫ Ultrasound.
▫ Chest X-ray.
▫ Bone scan.
83

Bladder Cancer:
Staging:
• Stage 0: The cancer has only grown into the center
of your bladder. It hasn’t spread into the tissues or
muscle of your bladder wall itself. It hasn’t spread
to your lymph nodes or other organs, either.
• Stage I: The cancer has grown into the lining of
your bladder, but not the muscle of your bladder
wall. Nor has it spread to your lymph nodes or
distant organs.
• Stage II: The cancer has grown through the
connective tissue in your bladder and into your
muscle.
84

Bladder Cancer:
Staging:
• Stage III: Cancer is now in the layer of fatty tissue that
surrounds your bladder. It may also be in your prostate,
uterus, or vagina. But it hasn’t spread to nearby lymph
nodes or to distant organs.
• Stage IV: This may include any of the following:
▫ The cancer has spread from your bladder into your
pelvic or abdominal wall. But it hasn’t spread to
lymph nodes or distant organs.
▫ The cancer has spread to nearby lymph nodes. But it
hasn’t reached distant organs.
▫ Cancer is now in your lymph nodes or distant sites
like your bones, liver, or lungs.
85

86
Tumor staging in bladder cancer

Bladder Cancer:
Surgical Treatment
TURBT with fulguration
Laser photocoagulation
Cystectomy (Segmental, partial or radical)
Radiation Therapy
Intravesical Chemotherapy
Systemic Chemotherapy
Intravesical Immunotherapy
87

Bladder Cancer:
Surgical Treatment
TURBT with fulguration: Transurethral resection
of bladder tumor (TURBT) is the most common
surgery for bladder cancer that’s in the early
stages.
• Fulguration: The destruction of small growths or
areas of tissue using diathermy.
88

89
Transurethral resection of bladder tumor
(TURBT)

Bladder Cancer:
Surgical Treatment
Laser photocoagulation: A laser heating of tissues above
50 degree and below 100 degree induces disordering of
proteins and other bio-molecules.
Cystectomy (Segmental, partial or radical): In this type
of surgery, your doctor removes part of your bladder (a
partial cystectomy) or all of it (a radical cystectomy).
90

Bladder Cancer:
Radiation Therapy
Intravesical Chemotherapy: Valrubicin, thiotepa.
Systemic Chemotherapy: cisplatin, Vinblastine,
Doxorubicin, methotrexate
Intravesical Immunotherapy: BCG – a weakened
strain can boost immune system, alpha interferon.
92

Notes on urinary disorders 2

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Notes on urinary disorders 2