Genitourinary Tract Begashaw M (MD). Urinary caliculi Incidence -prevalance of 2-3% -male:female =...
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Transcript of Genitourinary Tract Begashaw M (MD). Urinary caliculi Incidence -prevalance of 2-3% -male:female =...
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Genitourinary Tract
Begashaw M (MD)
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Urinary caliculi
Incidence
-prevalance of 2-3%
-male:female = 3:1, peak incidence 30-50 years of age
-Recurrence rates are close to 50%
-90% are idiopathic
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Urinary caliculi
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Prevalence
common in areas -hot, dehydratedEtiology of stone formation in the urinary
tract is not very clearProposed etiologies
-Urinary stasis
-Infections
-Lack of inhibitors
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Risk Factors
Hereditarycystinuria/xanthinuria/oxaluriaDietary excess: Vitamin C, oxalate, purines,
calciumDehydrationsummer Sedentary lifestyleUTIHypercalcemia
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Chemical composition
Calcium oxalate (40%)Calcium phosphate (15%)Mixed oxalate / phosphate (20%)Struvite (15%)Uric acid (10%)
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Types of renal calculi
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Clinical features
painUreteric colic - severe colicky loin to groin pain - radiate into scrotum in men & labia in
womenFrequency, urgency & dysuriaMicroscopic haematuria
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Investigation
U/ARBC, Pus cells, calcium oxalate KUBOpacity in UT projection Ultrasound- locates stone in the kidney
- detects hydronephrosisIntravenous urogram (IVU)-presence of
stoneCT scanning
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Complications
Complications of ureteric calculi
_Obstruction
_Ureteric strictures
_Infection
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Management
Small ureteric stones /non-obstructive _Conservativeanalgesics/antibiotics Expecting passage
Big stones/obstructing
Open surgery -nephrolithotomy ,pyelolithotomy
Percutaneous nephrolithotomy
Extra corporal shock wave lithotripsy (ESWL)
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Bladder calculi
associated with urinary stasisForeign bodies (suture)nidus for stone
formationmore common in elderly men/childen
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Clinical features
asymptomaticSuprapubic painDysuriaHaematuria
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Diagnosis
Plain abdominal x-rayBladder ultrasoundCT scanCystoscopyacute urinary retention
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Management
Indications for surgery
Recurrent UTI
Acute urinary retention
Frank haematuria
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Urinary tract infection
Commonest organisms
Escherichia coli (80%)
Proteus mirabilis
Pseudomonas aeruginosa
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Upper urinary tract infections
Classification
- Acute pyelonephritis
- Chronic pyelonephritis
- Pyonephrosis
- Renal abscess
- Perinephric abscess
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Acute pyelonephritis
commonly occurs in females, in reproductive age group, childhood & pregnancy
Ascends from lower UTI
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Clinical features
Nonspecific-headache, lassitude & nausea Sudden onset of pain, rigors & vomitingPain is localized in the flank &
hypochondriumlower UTI - frequency & dysuria
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Diagnosis
Urine culture & sensitivityUrinalysis - few pus cells,many bacteriaBlood culture
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Treatment
Antibiotic
Choice-combination of amino glycoside & penicillin
parenteral antibioticsComplications-Pyonephrosis
-coexisting upper tract obstruction
_inadequately treatedperinephric abscess
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Perinephric abscess
is an infection of the perinephric fat resulting in pus collection
source -extension of cortical abscess
-distant-appendix abscess
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Clinical feature
- Swinging high grade fever
- Abdominal and loin tenderness
- Flank mass
Diagnosis
-Elevated WBC count,
-Low or no pus cells or bacteria in urine
-Ultrasound is usually diagnostic
Treatment
-Drainage of abscess,IV antibiotics/fluid
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Perinephric abscess
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Urinary Retention
Etiology Outflow obstruction
-bladder neck/urethracalculus,clot,neoplasm
-prostateBPH, prostate cancer
-urethrastricture Bladder innervation
-spinal cordinjury
-stroke pharmacologic
-anticholinergics
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Symptoms of urinary tract obstruction
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DDX
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Urinary retention
Acute retention
-characterized by pain & anuria
-normal bladder volume & architecture Chronic retention
-asymptomatic
-increased bladder volume
-detrusor hypertrophyatony
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Acute retention
Presents with inability to pass urine for several hours
Usually associated with lower abdominal pain
Bladder is visible and palpableBladder is tender on palpation
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Management
urethral catheterisation12 to 16 Fr gauge Foley catheterIf unable to pass a urethral cathete
suprapubic cystostomy
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Urethral catheterization
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Supra pubic cystostomy
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Chronic retention
Usually relatively painlessCause hydronephrosis & renal impairment present with hypertensionSymptoms of BOO
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Investigations
CBC, electrolytes, Cr, BUNUltrasoundCystoscopy
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Treatment
Catheterization
-contraindicated in trauma patient unless urethral disruption has been ruled out
-acute retention: immediate catheterization to relieve retention, leave Foley in to drain
-chronic retention: intermittent catheterization
• suprapubic cystotomy
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Benign Prostatic Hyperplasia (BPH)
hyperplasia of stroma & epithelium in periurethral area of prostate (transition zone)
Affects 50% men > 60 yrs Affects 90% of men > 90 yrs Presents with obstructive and irritative symptoms Obstruction-poor stream, hesitancy, dribbling &
retention Irritation - frequency, nocturia, urgency & urge
incontinence
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Investigations
Urea/electrolytesrenal functionUltrasoundhydronephrosis & measure
post-micturition volumeSerum PSAmalignancyUroflowmetryDRE
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Management
Observation
-α-adrenergic antagonists
-5α- reductase inhibitors
-LHRH antagonists
Surgery
Transurethral prostatectomy
Transvesical prostatectomy
Retropubic prostatectomy
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Complications
Early
Primary haemorrhage
Extravasation
Fluid absorption
Infection
Clot retention
Incontinence
Intermediate
Secondary haemorrhage
Retrograde ejaculation
Erectile dysfunction Late
Bladder neck stenosis
Urethral stricture
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Renal injuries
relatively uncommon injuries Injuries to ureters are extremely rare in
traumasRenal injuries -divided
mild, moderate, severe
first, second & third degree
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Classification
First degree -injury limited to the kidney parenchymaonly subcapsular hematoma
Second-degree injury involved the pelvicalyceal system - hematuria is evident
Third degree -renal artery or renal vein involvement
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Clinical features
Hematuria: - the most important symptom
-extent & duration of hematuria determines severity
Pain in the flank area/hypochondriumFullness, tenderness & bruises in the flanksHypotension/shock - third degree injuries
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Treatment
Conservative
- first degree and some second degree renal injuries
- replacement of fluid
- blood transfusion
- catheterization and follow upSurgery - severe forms of renal injury
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Bladder injury
Associated with pelvic fractures Rupture can either intraperitoneal or extraperitoneal Clinical features -lower abdominal peritonism & inability to
pass urine IVU may show urine extravasation Diagnosis cystography Intraperitoneal rupture requires laparotomy, bladder repair,
urethral & suprapubic drainage Extraperitoneal rupture can be treated conservatively with
urethral drainage Prophylactic antibiotics should be given
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Bulbar urethral injury
Is the commonest typedirect trauma causes by falling astride an objectClinical features -blood from meatus & perineal
bruisingSuprapubic cystostomyDiagnosis -ascending urethrogramProphylactic antibioticsComplication-urethral stricture
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Membranous urethral injury
Often occur in multiply injured patient 10% of men with pelvic fracture have a membranous
urethral injury Tear -partial or complete Partial injuries - urethral bleeding & perineal bruising Complete injuries - inability to pass urine Diagnosis - ascending urethrogram Treatment -suprapubic catheter Complications-stricture, impotence & incontinence
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Phimosis
Definition
- inability to retract foreskin over glans penis
- may be caused by balanitis (infection of glans), often due to poor hygeine or congenital
- normal congenital adhesions separate naturally by 1-2 years of age
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Treatment
-circumcision, proper hygiene
Complications
-balanoposthitis (inflammation of prepuce), paraphimosis, penile cancer
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Balanitis
Inflammation of the glansIn mild cases, the only symptoms are
itching and some dischargeIn more severe inflammation, the glans and
foreskin are red-raw and pus exudesTreatment is by broad-spectrum antibiotics
and local hygiene measures
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Urethral stricture
Aetiology
-inflammatory – post-gonorrhoeal
-congenital
-traumatic
-instrumental
– indwelling catheter
– urethral endoscopy
-postoperative
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Post-gonorrhoeal stricture
The stricture is most commonly in the bulbar urethra
Pathology Infection in the periurethral glands periurethritis, which heals by fibrosis Most strictures appear within 1 year of
infection but may not cause difficulty in micturition for 10–15 years
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Complications
retention of urineurethral diverticulumperiurethral abscessurethral fistulahernia, haemorrhoids & rectal prolapse
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Treatment
Dilatation- Gum-elastic bougie,metal soundUrethrotomy-Internal or externalUrethroplasty
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Urethral stricture
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Hydrocele
is an abnormal collection of serous fluid in a part of processus vaginalis, usually the tunica
Acquired hydroceles are primary or idiopathic, or secondary to testicular disease
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Aetiology
Four different ways
-by excessive production of fluid within the sac
-by defective absorption of fluid
-by interference with lymphatic drainage of scrotal structures
-by connection with the peritoneal cavity via a patent processus vaginalis
Hydrocele fluid contains albumin & fibrinogen
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Clinical features
typically translucent –transillumination possible to ‘get above the swelling’Painless swellingTestis palpable in lax fluid Complications
-Rupture
-haematocele occurs after trauma
-may calcify
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Treatment
Congenital hydroceles - herniotomy if they do not resolve spontaneously
Acquired hydroceles – hydrocelectomyLord’s operation Jaboulay’s procedure
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Hydrocelectomy
Lords Jaboulay’s
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EPIDIDYMO-ORCHITIS
Inflammation confined to the epididymis is epididymitis; infection spreading to the testis is epididymo-orchitis
Etiology Chlamydia trachomatis gonococcal Rare -Escherichia coli, streptococcal,
staphylococcal or Proteus
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Clinical features
initial symptoms are those of urinary infectionGroin pain, fever ,swelling –painfulScrotal wall-red, oedematous & shiny Resolution may take 6–8 weeks to complete
Treatment
-Doxycycline -for 2 weeks
-Drink plenty of fluid
-Scrotal elevation
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Paraphimosis
_Tight foreskin once retracted may be difficult to return
_Glans & distal foreskin-swell, obstructing ring of prepuce
_Icebags, gentle manual compression
_Treatment-circumcision
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Paraphimosis