Urology

1. Disorders of Micturition
Natangwe Shimhanda
MBChB V, UNAM SOM
07/08/16

2. Anatomy

3. Innervation

4. Blood Supply

5. Disorders of micturition
• LUTs
• Incontinence
• UTIs
• Pelvic organ prolapse
• Fistulae
Some of them overlap

6. Lower Urinary Tract Symptoms
• LUTS is a term used to describe a range of
symptoms related to problems of the lower
urinary tract (bladder and urethra).
• LUTS are broadly grouped into voiding
(obstructive) symptoms or storage (irritative)
symptoms.

7. LUTs

8. Urinary Incontinence
Definition
• involuntary leakage of urine
Etiology
 Urgency incontinence
 detrusor overactivity
– ŠCNS lesion, inflammation/infection (cystitis,
stone, tumour), bladder neck obstruction
(tumour, stone), idiopathic
 decreased compliance of bladder wall (inability to
store urine)
– ŠCNS lesion, fibrosis
– Šsphincter/urethral problem

9.  Stress urinary incontinence (SUI)
ƒcommon in women; seen after pelvic operations
o ƒurethral hypermobility
• Šweakened pelvic floor and musculofascial urethral and vaginal supporting mechanisms
allows bladder neck and urethra to descend with increased intra-abdominal pressure
• ŠŠassociated with childbirth, pelvic surgery, aging, levator muscle weakness, obesity
o ƒintrinsic sphincter deficiency (ISD): weakness of the urethra and associated smooth and
striated muscle elements pelvic surgery, neurologic problem, aging and hypoestrogen state.
ISD and urethral hypermobility can co-exist
 Mixed incontinence
ƒcombination of stress and urgency incontinence
 Overflow incontinence
– ƒis a term sometimes used to describe urinary incontinence as a complication of urinary
retentionƒ
– use of the term should be accompanied by the associated pathophysiology (e.g. BPH
with overflow incontinence)

10. URGE INCONTINENCE
Definition
• urine loss associated with an abrupt, sudden urge to void
• “overactive bladder”
• diagnosed based on symptoms
Etiology
• idiopathic (90%)
• detrusor muscle overactivity (“detrusor instability”)
Associated Symptoms
• frequency, urgency, nocturia, leakage
Treatment
• behaviour modification (reduce caffeine/liquid, smoking cessation, regular
voiding schedule)
• Kegel exercises
• medications anticholinergics: oxybutinin (Ditropan®), tolterodine (Detrol®),
solifenacin (VESIcare®) tricyclic antidepressants: imipramine

11. STRESS INCONTINENCE
Definition
• involuntary loss of urine with increased intra-abdominal pressure (coughing,
laughing, sneezing, walking, running)
Risk Factors for Stress Incontinence in Women
• pelvic prolapse
• pelvic surgery
• vaginal delivery
• hypoestrogenic state (post-menopause)
• age
• smoking
• neurological/pulmonary disease
Treatment
• General Conservative Treatment
• surgical tension-free vaginal tape (TVT), tension-free obturator tape (TOT),
prosthetic/fascial slings or retropubic bladder suspension (Burch or Marshall-
Marchetti-Krantz procedures

12. URINARY TRACT INFECTIONS
• Very common, and much more common in women
• 25-30% of women aged 20-40 yrs have had a UTI
• 40% of patients with a UTI will have a recurrence
within a year
• At least 50% of UTIs do not come under attention
• Patients older than 65, the incidence of UTI
continues to increase in both sexes

13. Risk factors
 Females
 Age
 Diabetes mellitus: glucose in urine a good culture medium for
organisms
 May cause LMN neuropathic bladder with poor emptying
 Impaired function of WBCs
 Immunocompromised patients
 Analgesic abuse: causes papillary necrosis

14. Local risk Factors:
• Obstruction of Upper Tract
• Calculi
• PUJ Obstruction
• Sloughed Papillae
• Bladder outlet obstruction
• Urethral strictures
• Neuropathic Bladder = failure to empty
• Foreign bodies = catheters and double JJ stents
• Iatrogenic = cystoscopy, urodynamic studies
• Pregnancy
• Vesico-colic fistula
• Vaginal Infections
• Sexual intercourse

15. Pathogenesis:
• Urinary tract is sterile above distal urethra
• Majority of organism reach UT via ascending
route
• Female urethra is short and close to the faecal
reservoir = increase incidence of UTIs in females
• Main defense mechanism against infections is the
hydrokinetic effect of regular effective voiding
• Bacterial/pathogen entry and adherence to
urothelium and multiplication of organism after it
defeated normal host defences

16. Causative Pathogens:
 (KEEPS)
 Escherichia coli85% of community acquired UTIs
 50% of hospital acquired UTIs
 Gram negative organisms Klebsiella
 Proteus
 Pseudomonas
 Gram positive organisms
 Streptococcus faecalis
 Staphylococcus aureus
 Staphylococcus epidermidis
 Staphylococcus saphrophyticus
 Others:
 Tuberculosis
 Schistosomiasis

17. ACUTE PYELONEPHRITIS
Defined as the inflammation of the kidney and renal pelvis.
E. coli is the most common causative organism
Clinical Presentation:
 Hx of fever, chills, loin or back pain
 Nausea and vomiting is common
 LUTS is often absent but can occur
 Renal angle tenderness, pyrexia
 Sepsis may occur

18. Investigations
 Urine
 Dipstick: WBCs++ and Nitrite Positive
 MCS: pus cells ++ ; organisms
 Culture for specific organisms before starting antibiotics
 Investigations
 Urine analysis
 FBC, U & E
 Blood cultures
 Imaging = only needed when patient is:
 Diabetic, immunocompromised
 Hx of stone disease
 No response to antibiotics within 72 hours
 CT scans, and renal US

19. Management:
 Admit to hospital if toxic, vomiting
 IV fluids if needed
 Resuscitation if in septic shock
 Blood culture if temperature is high and there is evidence of septic
shock
 Antibiotics:
 Should have high penetration and concentration in urine and renal
tissue
 Bactericidal and broad spectrum
 Should target specific organism
 Parental therapy for 14 days, then switch to oral therapy for 7-10 days
 Antibiotics most commonly used
 Aminoglycosides ( Gentamicin, Amikacin)
 Fluoroguinolones (Ciprofloxacin)
 2nd generation cephalosporins ( Cefotaxime, Ceftazidime)
 Co-amoxiclavulanic acid

20.  Prophylaxis:
 Women with recurrent acute pyelonephritis in absence of urinary tract
abnormality
 Long term continuous low dose antimicrobial prophylaxis
 Ciprofloxacin, Cephalexin, Nitrofurantoin
 Complications:
 Septicaemia and septic shock
 Abscess
 Intra-renal
 Perinephric
 Chronic pyelonephritis
 Renal failure
 Bilateral chronic pyelonephritis occurs

21. CHRONIC PYELONEPHRITIS:
Results from repeated renal infection, which leads to scarring, atrophy of
the kidney and subsequent renal insufficiency. Diagnosis is made by
radiological or pathological examination.
Clinical Presentation:
 Usually asymptomatic
 History of recurrent UTIs
 Renal scarring is an incidental finding on radiologic investigation
 Radiologic investigation should be initiated when there are
complications of renal insufficiency such as:
 Hypertension
 Visual impairment
 Headaches
 Fatigue
 Proteinuria
 polyuria

22.  Investigations:
 Urine analysis
 U & E for renal functioning
 Renal US or CT Scan
 Management
 Eliminate recurrent UTIs
 If necessary, correct any obstructions, calculi to avoid
further renal damage
 Long-term prophylactic antibiotics to prevent/limit UTIs
 Removal of kidney is rare
 May be necessary if there are complications in a non-
functioning kidney eg. Infections, hypertension, recurrent
stone formation

23. CYSTITIS:
ACUTE CYSTITIS:
 Urinary infection of the lower urinary tract, principally the bladder.
 Most common in women, and due to ascending infection
 Diagnosis is clinical
 E. coli most common cause, followed by Klebsiella, Proteus and S.
saprophyticus
 Clinical Presentation
 Irritative voiding symptoms
 Dysuria, frequency and urgency
 Lower back pain, suprapubic pain, hematuria, cloudy/foul smelling
urine
 Fever and systemic symptoms are rare
 Elderly may present with sudden onset of incontinence

24.  Urinalysis
 WBCs in urine, hematuria might be present
 Investigations:
 Urinalysis
 Urine culture
 FBC
 Radiographic imaging not necessary
 Management:
 Short course of oral antibiotics for 3-5 days
 Single dose therapy only 70% effective
 Fluoroquinolones (Ciprofloxacin)
 Co-amoxiclavulanic acid
 2nd generation cephalosporins (Cefotaxime)
 Nitrofurantoin

25. RECURRENT CYSTITIS:
 Very common in females
 Bacterial persistence or reinfections with another organism
 Identification of the cause of recurrent infection is very important
as management of bacterial persistence and reinfection is different
 Radiographic Imaging and Other investigations
 FBC, Urine analysis, Urine MCS, Urine Culture
 US of Bladder for sources of infection
 IVP – Creatinine should be normal
 Retrograde urethrograms to localise source of infection
 If bacterial reinfection is suspected in females, pt should be
evaluated for evidence of vesico-vaginal or vesico-ureteric fistula

26.  Management
 General Measures:
 High fluid intake
 Local hygiene
 Sexual intercourse
 Complete voiding after intercourse, plus single dose of antibiotic therapy
 Avoid spermicidal creams and diaphragm contraceptives
 Topical estrogen for atrophic vaginitis
 Yoghurt and cranberry juice
 Treat constipation or any GIT problems
 Specific Measures:
 Continuous low dose chemoprophylaxis
 Nitrofurantoin, 2nd generation cephalosporin
 Nocturnal doses for 6-9 months
 Post-intercourse singe dose therapy antibiotics
 Self start therapy
 Pt has supply of treatment ( fluoroquinolones)
 When symptoms begin, pt sends a urine specimen for culture
 and start treatment followed by consultation

27. URETHRITIS:
 Infection/inflammation of the urethra. Mostly acquired during
unprotected sexual intercourse with an infected partner.
 Two types:
 Gonococcal Urethritis
 Non-gonococcal Urethritis
 Gonococcal Urethritis(GU):
 Neisseria gonorrhoeae
 Non-Gonococcal Urethritis (NGU):
 Chlamydia trachomatis
 Ureaplasma urealyticum
 Trichomonas vaginalis
 Herpes Simplex Virus

28. Clinical Presentation:
 Gonococcal Urethritis:
 Dysuria, profuse to scant amounts of yellow discharge from urethral
meatus.
 Itching in women
 Obstructive voiding symptoms if an urethral stricture developed
 40% of patients are asymptomatic
 30% of men have a concomitant infection with C. trachomatis
 Non-Gonococcal Urethritis
 Up to 75% of women with Chlamydia infections are asymptomatic
 Watery, clear urethral discharge
 Dysuria, itching during voids or irritation between voids
 Obstructive voiding symptoms if stricture developed

29.  Diagnosis and Investigations:
 FBC, Urine analysis and MCS, Specimen swab and culture
 RUG is indicated only for patients with recurrent infections
and obstructive voiding symptoms.
 Management
 Should be treated to prevent complications such as strictures,
orchitis
 Sexual education and partner treatment
 Specific Antibiotic therapy awaits urethral culture results
 NGU:
 Tetracycline or Erythromycin or Doxycycline
 GU:
 Ceftriaxone IM injection or Fluoroquinolones (Ciprofloxacin or
Norfloxacin)
 Also Ciprofloxacin plus doxycycline as oral therapy

30. SCHISTOSOMIASIS:
 Endemic in most parts of Africa and Middle East
 Caused by Schistosoma haematobium
 Life Cycle
1. Excreted ova die rapidly unless they are in contact with water
2. Eggs hatch in water and form miracida
3. They enter the Bulinus snail host and form sporocysts in the
snail’s liver
4. Sporocysts release cercariae into the water, which penetrate the
skin of the human host
5. Reach hepatic portal veins via venous circulation and worms
mature and mate
6. Gravid female worm reaches pelvic veins ova are deposited in the
mucosa of bladder and lower ureters

31. Pathology:
 Acute changes
 Occur with viable ova and form papule and pseudotubercles that disappear on
medical treatment
 Chronic changes
 Dead ova causes fibrosis and calcification
 Cause cystoscopic lesions know as sandy patches , these are permanent and do
not disappear on medical treatment
 Pathological complications
 Bladder
 Secondary bacterial infection
 Bladder wall calcification
 Bladder calculi
 Small bladder capacity
 Squamous metaplasia = squamous carcinoma
 Ureter
 Atony and vesico-ureteral reflux
 Ureteric stricture can develop, but they’re less common
 Renail failure to the bilateral ureteric obstruction and hydronephrosis
(uncommon)

32. Clinical presentation:
 Swimmer’s itch (Cercarial dermatitis)
 Katayama fever
 Occurs in unexposed populations
 Allergic reaction to schistosomes in the liver
 Present with fever, jaundice and hepatosplenomegaly
 Urinary schistosomiasis
 Terminal slightly painful hematuria
 Frequency and dysuria
 Suprapubic pain
 Urethralgia, pyuria
 Complications eg. Bladder carcinoma
 Renal pain due to ureteral strictures
 Secondary stone formation
 Renal involvement characterized by: fever, rigor, toxemia and
uremia

33. Diagnosis:
 High index of suspicion in endemic areas
 Urine
 Collect terminal urine during middle of the day and post-exercise because of
increased ova excretion
 Urine MCS – look for terminal spike of Schistosoma haematobium ova
 FBC – eosinophilia in acute phase
 Serology
 Schistosoma ELISA test
 IVP/EUG
 Calcifications (bladder wall, distal ureters and seminal vesicles)
 Dilated ureters (usually atonic, erect Post Micturition film show good drainage)
 Filling defects (bilharzial papule, blood clots, squamous ca)
 Small bladder capacity
 Cystoscopy
 Done if unsure of diagnosis or complications suspected
 For typical lesions above
 Diagnosis confirmed on bladder wall biopsy

34. Treatment:
 Prophylaxis:
 Improved housing and sanitations
 Snail eradication
 Prophylactic treatment
 Medical treatment:
 Praziquantel 40 mg/kg single dose or two divided doses
 600 mg tablets
 Treat acute infections
 Repeat urine MCS one month post-treatment to confirm
eradication of ova
 Surgical treatment:
 For complications
 Cystectomy for Bladder Carcinoma
 Ureteric reimplantation for ureteric strictures

35. Read on:
• GENITOURINARY TUBERCULOSIS:

36. Pelvic Relaxation/Prolapse
Etiology
• relaxation, weakness, or defect in the cardinal and uterosacral ligaments
which normally maintain the uterus in an anteflexed position and prevent it
from descending through the urogenital diaphragm (i.e. levator ani muscles)
• related to
– vaginal childbirth
– ƒaging
– ƒdecreased estrogen (post-menopause)
– ƒfollowing pelvic surgery
– ƒincreased intra-abdominal pressure (obesity, chronic cough, constipation,
ascites, heavy lifting)
– ƒcongenital (rarely)
– ƒethnicity (Caucasian women > Asian or African women)
– ƒcollagen disorders

38. Organ prolapse

39. GENERAL CONSERVATIVE TREATMENT
• (for pelvic relaxation/prolapse
and urinary incontinence)
• Kegel exercises
• local vaginal estrogen therapy
• vaginal pessary (intravaginal
suspension disc)

40. Management

41. Vesicovaginal fistula (VVF)
• It’s a subtype of female urogenital fistula (UGF). VVF is an
abnormal fistulous tract extending between the bladder and
the vagina that allows the continuous involuntary discharge of
urine into the vaginal vault.

42. Risk factors
• Where the culture encourages marriage and conception at a young age, often
before full pelvic growth has been achieved.
• Chronic malnutrition further limits pelvic dimensions, increasing the risk of
cephalopelvic disproportion and malpresentation.
• Obstructed labour
• Female circumcision
• Insertion of caustic substances into the vagina with the intent to treat a
gynecologic condition or to help the vagina to return to its nulliparous state.
• It can also be associated with hysterectomy,[3] cancer operations, radiation
therapy and cone biopsy.
Pathophysiology
• The effect of prolonged impaction of the fetal presenting part in the pelvis is one
of widespread tissue edema, hypoxia, necrosis, and sloughing resulting from
prolonged pressure on the soft tissues of the vagina, bladder base, and urethra.
Typically the UGF is large and involves the bladder, urethra, bladder trigone, and
the anterior cervix.
• Complex neuropathic bladder dysfunction and urethral sphincteric incompetency
often result, even if the fistula can be repaired successfully.

43. Surgical management
Vesicovaginal fistulae are
typically repaired either
transvaginally or
laparoscopically, although
patients who have had multiple
transvaginal procedures
sometimes attempt a final
repair through a large
abdominal incision, or
laparotomy.
The laparoscopic (minimally
invasive) approach to VVF
repair has become more
prevalent due to its greater
visualization, higher success
rate, and lower rate of
complications

44. References
• Lange, Smith & Tanagho’s General Urology. 17th edition.
• Alan H. Decherney et al, 2013. Current diagnosis and
treatment: Obstetrics and Gynecology. 11th edition. The
McGraw-Hill companies Inc
• Sandip P Vasavada et al. Medscape: Vesicovaginal and
Ureterovaginal Fistula published Dec 01,
2015.http://emedicine.medscape.com/article/452934-
overview