Urethral and prostatic
causes
- Sharat S A

 Presence of red blood cells in the urine

 Urethral calculi
 Urethritis
 Urethral tumors

 Benign prostatic hyperplasia
 Ca prostate
 Prostatitis

 Stone from bladder is commonly passed out through
urethra if it is small, but stone can get impacted due to
a stricture or urethral diverticulum.
 Sites of impaction
 Prostatic urethra
 Bulbous urethra
 External meatus

 Clinical features
 Painful urination with thin stream and forking of urine.
 Retention of urine
 Haematuria
 Pain in the penis
 Stone may be palpable sometimes as a hard lump in the
penis.

 Investigations
 Plain X-ray: stones can be seen
 Ultrasound abdomen
 Urine examination
 Urethroscope

 Treatment
 A stone lodged within the prostatic urethra should be
displaced back into the bladder and treated by
litholapaxy(The procedure of crushing of a stone in the
bladder and washing out the fragments through a
catheter) or suprapubic cystotomy as if it were a bladder
stone.
 Calculi in more distal parts of urethra are fragmented in
situ using the electrohydraulic or ultrasound lithotripter.
 It may be necessary to perform a meatotomy to deliver
the stone.

 Causes
 Gonococcal urethritis
 Nongonococcal urethritis
 Trichomonal urethritis
 Lymphogranuloma venerum
 Mycoplasma
 Candida
 Trauma, catheters, cystoscopes,stones
 Reiter’s disease: arthritis, conjunctivitis and urethritis
 Autoimmune disease, HLA-B27 associated condition
 Commonly include chlamydial urethritis

 Clinical features
 Urethral discharge, dysuria(painful urination), burning
micturition.
 Haematuria and blood in semen
 Perineal pain, tenderness over the site
 Suprapubic pain and tenderness

 Investigations
 Urine microscopy and culture(mainly discharge)
 For bacteria and RBCs
 Ultrasound abdomen
 PCR for identifying the organisms.

 Treatment
 For gonococcal urethritis
 Ceftriaxone is drug of choice these days
 Resistant to panicillin and ciprofoxacin
 Contact tracing is important in controlling the spread of the
disease.
 For nongonococcal urethritis
 Doxycycline or azithromycin(single oral dose) can be
used but relapse is common in males as prostate acts as
reservoir in males.

 Occurs twice as often in women as in men.
 Polyps are a common finding in prostatic urethra, where
they may result from a chronic infection.
 Angioma of urethra is rare cause of urethral bleeding.
 Carcinoma of the urethra is relatively rare, multifocal
transitional cell cancers of the bladder are sometimes
associated with tumors in the prostatic urethra.
 Carries a poor prognosis, radical surgery and radiotherapy
are ineffective.
 Bloody urethral discharge without infection should raise
the suspicion that the patient has a urethral tumor.

 Benign prostatic hyperplasia
 Aetiology
 Theories
 Hormonal: serum testosterone levels slowly but
significantly decrease with advancing age; however,
levels of estrogenic steroids are not decreased equally.
According to this theory the prostate enlarges because
of increased estrogenic effects.
 BPH is a a benign neoplasm, also called as
fibromyoadenoma. The neoplasm theory is old one, but
not universally accepted now.

 Pathology
 Usually involves median and lateral lobes or one of them.
 Involves submucosal glands.
 Median lobe enlarges into the bladder.
 Enlarged prostate compresses the prostatic venous plexus
causing congestion, called as vesical piles leading to
haematuria.
 Backpressure causes hydroureter and hydronephrosis.
 Secondary ascending infection can cause acute or chronic
pyelonephritis.
 Often severe obstruction can lead to obstructive uropathy
with renal failure.
 Bph causes impotence

 Clinical features
 Urgency, hesitancy and nocturia
 Overflow and terminal dribbling
 Difficulty in micturition with weak stream and dribble.
 Pain in suprapubic region and in loin due to cystitis and
hydeonephrosis respectively.
 Haematuria
 Retention of urine
 Prostatism, is a combination of symptoms like frequency
both at dat and night, poor stream, delay un starting and
difficulty in micturition.

 Clinical features (contd)
 Tenderness in suprapubic region, with palpable enlarged
bladder due to chronic retention.
 Hydronephrotic kidney may be palpable.
 Per rectal examination shows enlarged prostate. It
should be done when bladder is empty.
 Features of urinary infection like fever, chills, burning
micturition.

 Investigations
 Urine for microscopy and culture.
 Blood urea and serum creatinine(to asses kidney
functions)
 Ultrasound abdomen look for presence of residual
urine.
 Transrectal US(TRUS) is useful to find out nodules/
possibility of carcinoma prostate.
 IVU:

 Management
 Patient with acute retention of urine requires urethral
catheterisation
 If urethral catheterisation fails, then suprapubic
cystostomy is done.
 If patient presents with uraemia, then urethral
catheterisation is a must. That allows the kidney to
function adequately.

 Indications
 Prostatism(frequency, dysuria and urgency)
 Acute retention of urine.
 Chronic retention of urine with residual urine more
than 200ml.
 Complications like hydroureter, hydronephrosis, stone
formation, recurrent infection.
 Haematuria

 Transurethral resection of prostate(TURP)
 Cystoscope is used, enlarged prostate is identified and
resected using a high frequency diathermy current.
 Water intoxication with congestive cardiac failure(TURP
syndrome) is a complication.
 Freyer’s suprapubic transvesical prostatectomy.
 Millin’s retropubic prostatectomy
 Young’s perineal prostatectomy
 Laser treatment using holmium laser

 Drugs used for BPH
 Alpha I adrenaergic blocking agents-which inhibit
smooth muscle contraction of prostate. They reduce
bladder neck resistance so as to improve the urine flow.
 Short action- prazosin and indoramin
 Long acting- terazocin and doxazosin
 Tamsulosin- selective alpha 1a receptor blocking agent; 0.2-
0.4mg OD for 12 weeks
 5-alpha reductase inhibitors inhibits cinversion of
testosterone into dihydrotestosterone
 Finasteride 5mg daily for 6-8 months.

 Most common malignant tumour in men over 65
years.
 Occurs in peripheral zone in prostatic gland proper,
i.e. commonly in posterior lobe.
 Spread
 Local spread to seminal vesicles, bladder neck
 Blood spread to bones- pelvic bones, lumbar vertebrae.
 Lymphatic spread to obturator lymph nodes, then to
internal iliac lymph nodes.

 Clinical features
 Commonly asymptomatic
 Bladder outlet obstruction and so retention of urine.
 Haematuria, increased frequency
 Pelvic pain, back pain, arthritic pain in sacroiliac joint.
 On per rectal examination, prostate feels hard, nodular,
irregular often with loss of median groove.
 Features of renal failure
 Anaemia secondary to extensive bone marrow invasion
and also due to renal failure.

 Investigations
 Hb%, peripheral smear.
 Prostate specific antigen(PSA): more than 10nmol/ml is
suggestive.(normal:4nmol/ml)
 Blood urea, serum creatinine.
 Plain xray: sclerotic secodaries.
 USG abdomen to see the tumor extension into the
bladder and to see kidneys for hydronephrosis.

 Treatment
 Radical prostatectomy
 Radical radiotherapy

Thank you