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  1. Urethral and prostatic causes - Sharat S A
  2.  Presence of red blood cells in the urine
  3.  Urethral calculi  Urethritis  Urethral tumors
  4.  Benign prostatic hyperplasia  Ca prostate  Prostatitis
  5.  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
  6.  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.
  7.  Investigations  Plain X-ray: stones can be seen  Ultrasound abdomen  Urine examination  Urethroscope
  8.  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.
  9.  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
  10.  Clinical features  Urethral discharge, dysuria(painful urination), burning micturition.  Haematuria and blood in semen  Perineal pain, tenderness over the site  Suprapubic pain and tenderness
  11.  Investigations  Urine microscopy and culture(mainly discharge)  For bacteria and RBCs  Ultrasound abdomen  PCR for identifying the organisms.
  12.  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.
  13.  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.
  14.  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.
  15.  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
  16.  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.
  17.  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.
  18.  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:
  19.  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.
  20.  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
  21.  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
  22.  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.
  23.  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.
  24.  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.
  25.  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.
  26.  Treatment  Radical prostatectomy  Radical radiotherapy
  27. Thank you