16 The Urinary System and the Male Genital Tract

Question 1

Aims

Answer 1

Anatomy

Basic physiology

Introduction to the main diseases affecting the renal system and male genital tract

Question 2

Overview

Answer 2

Urinary tract infections

Kidneys

Bladder

Prostate

Testis

Question 3

Urinary Tract Infections

Answer 3

Very common disorder of the urinary tract

Risk factors include:
Females>males
Sexual intercourse
Pregnancy
Diabetes
Urinary tract obstructions e.g. stones or catheters

Question 4

Urinary Tract Infections

Answer 4

Bacteruria: bacteria in the urine, may be asymptomatic or symptomatic.

Urinary Tract Infection (UTI): the presence of pure growth of >10^5 organisms in fresh urine.

in urethra :
	Urethritis
in bladder : 
	Cystitis
in prostate: 
	Prostatitis
in kidney :  
	Pyelonephritis

E.coli is the most common causative organism (>70% of community UTIs).

Other organisms include: Staphylococcus, Proteus and Klebsiella

Question 5

Urinary Tract Infections

Answer 5

cystitis:
frequency, dysuria, urgency, haematuria and suprapubic pain

pylonephritis:
high fever, rigors, vomiting, loin pain and tenderness

prostatitis:
flu like symptoms, few urinary symptoms and a swollen tender prostate on PR

Question 6

Management

Answer 6

Drink plenty of fluids.

Urinate often (double voiding).

Antibiotics (trimethoprim usually first line treatment in uncomplicated UTIs).

Imaging – US in non-resolving UTIs, children, men and pyelonephritis.

Severe cases may require hospital admission specially pyelonephritis and in the elderly

Question 7

Kidney Function

Answer 7

Maintinance of water, electrolyte and acid-base homeostasis.

Excretion of many toxic metabolic waste products (urea and creatinine).

Hormonal function
Renin – help control blood pressure
Erythropoietin- stimulates production of RBCs in the bone marrow and helps in the production of vitamin D.

Question 8

Kidney Function

Answer 8

The functional unit is the nephron (consisting of a glomerulus and a renal tubule).

Filtration of most small molecules from the blood in the glomerulus.

Selective reabsorption in the renal tubule of most of the water and some molecules.

Maintenance of the acid-base balance.

Question 9

Acute Renal Failure

Answer 9

A significant deterioration in renal function occurring over hours or days

There is a low urine volume (

Question 10

Causes

Answer 10

Pre-renal
Hypoperfusion, sepsis

Renal
ATN damage to tubules due to ischaemia or nephrotoxins

Post-renal
Renal tract obstruction (eg stones, tumours)

Question 11

Management

Answer 11

Find and treat the cause

Treat exacerbating factors ( hypovolaemia, sepsis.. etc).

Stop nephrotoxic drugs ( NSAIDs, ACE-I, gentamycin and Vancomycin)

May need renal replacement therapy (haemofiltration/dialysis)

Question 12

Chronic Renal Failure

Answer 12

Classified into 5 stages depending on the glomerular filtration rate (GFR)

GFR is the volume of fluid filtered from the glomerular capillaries into the Bowman’s capsule per unit time

Symptoms usually occur by stage 4

Stage 1   =   >90
Stage 2   =   60-89
Stage 3   =  30-59
Stage 4   =   15-29
Stage 5   =

Question 13

Chronic Renal Failure Common Causes

Answer 13

Glomerulonephritis
Diabetes 
Renovascular disease 
Hypertension
Polycystic disease

Managed under nephrology team. Treat reversible causes. Avoid exacerbating factors, avoid nephrotoxic drugs.

May progress to renal replacement therapy

Question 14

Glomerulonephritis

Answer 14

A group of disorders where there is damage to the glomerular filtration apparatus. This may cause a leak of protein or blood into the urine.

Usually there is a deposition of immune complexes in one part of the nephron

Question 15

Stones

Answer 15

Crystal aggregates that form in the collecting ducts of the kidneys and can deposit anywhere in the renal tract.

Life time incidence 15%

Peak age 20-40 years.

Male: female = 3:1

Question 16

Risk Factors

Answer 16

Dehydration
Dietary factors ( increase chocolates, tea and rhubarb)
Drugs ( loop diuretics, antacids, corticosteroids, theophylline and aspirin)
Renal tract abnormalities
Recurrent UTIs
Metabolic abnormalities (hyperparathyroidism, hyperthyroidism and cancer)

Question 17

Stones

Answer 17

Patient may be asymptomatic (found accidently on x-ray or blood on dipstick ).

Pain. Kidney stones causes loin pain. Ureteric stones case renal colic (from loin to groin). Bladder and urethral stones cause pain on micturition with interrupted flow. Patients often can’t lie still from the pain.

Question 18

Management

Answer 18

Imaging options: KUB-xray (80% of stones are visible). CT scan (99% of stones visible).

Prompt pain relief

Stones 5mm or causing obstruction may need intervention

Question 19

Renal Cancer

Answer 19

Renal cell carcinoma

85% of all renal cancers.

Usually presents between the ages of 50 and 70 years.

2:1 male predominance .

Smoking an important risk factor along with obesity, hypertension, exposure to asbestos and certain hereditary conditions.

Question 20

Presentation

Answer 20

50% incidental findings on abdominal imaging.

Haematuria.

Loin pain.

Abdominal mass.

Para neoplastic syndromes: e.g. polycythaemia, hypercalcaemia and hypertension.

Question 21

Treatment

Answer 21

Radical nephrectomy +/- chemotherapy

Question 22

Bladder

Answer 22

Cystitis is the commonest benign condition

Transitional cell carcinomas are the most common malignant condition in the bladder

Question 23

Transitional Cell Carcinoma

Answer 23

Presentation:
Classically – painless haematuria
Frequency, urgency and dysuria can occur.

Tests:
Urine for cytology
Cystoscopy and biopsy

Question 24

Treatment

Answer 24

Depends on stage of disease and spread

Small lesions at early stage can be managed with diathermy on cystoscopy.

Later stages – radical cystectomy or palliative chemo/radiotherapy

Question 25

Prostate

Answer 25

Prostate is a gland that is located at the base of the bladder and around the first part of the urethra.

In normal adults weighs around 20gm.

Helps in the secretion and maintenance of semen and spermatozoa.

Question 26

Benign Prostatic Hyperplasia

Answer 26

Common

Hyperplasia: increase in the number of cells.

BPH: increase in number of cell resulting in the formation of nodules. Prostate weighs 60-100gm

Question 27

Signs and symptoms

Answer 27

Usually those of lower urinary tract obstruction: increased frequency, hesitancy, nocturia, terminal dribbling.

Can lead to an increased risk of infection.

Enlarged prostate on PR

If small and not symptomatic then conservative, reduce fluid intake (specially at night), reduce alcohol and caffeine, scheduled voiding.

Medical treatment: Alpha-blockers, reduces the smooth muscle tone in the prostate.
TURP (Transurethral Resection of the Prostate)

Question 28

Prostate Cancer

Answer 28

Age
Race (more common in black people and very uncommon in Asian people)
Family history
Hormone levels
Diet – increased risk with increased fat consumption

Question 29

Prostate Cancer

Answer 29

Signs and symptoms:

May be asymptomatic (has a slow course)

Nocturia, hesitancy, poor stream and terminal dribbling

Examination shows a hard irregular prostate

Diagnosis:

Raised PSA (prostate specific antigen) but may be normal in 30% of cases

Biopsy

Question 30

Treatment

Answer 30

Depends on stage of disease, age of patient and comorbidities

In elderly men with many comorbidities – watchful waiting may be an option

Local disease can be treated with radical prostatectomy

Hormonal therapy and radiotherapy for more advanced cases

Question 31

Testicular torsion

Answer 31

Sudden onset of pain in 1 testis.

Pain in abdomen, nausea and vomiting.

Testis is hot, swollen and tender.

The testis may lie high and transversely.

Most common 11-30 years old

Tests: USS with Doppler but may need exploratory surgery

Treatment: Surgery, URGENT, if still viable bilateral fixation (orchidopexy) if abnormal then orchidectomy

Question 32

Testicular Tumours

Answer 32

Most common malignancy in males aged 15-44 years old.

Risk factors include: undescended testis, infant hernia and infertility.

Presentation: painless testicular lump often noted after trauma or infection

Germ cell tumours

Different categories
Most common is seminoma

Treatment depends on type of tumour and stage

Usually involves an orchidectomy and a combination of radiotherapy and chemotherapy

Question 33

Summary

Answer 33

Urinary tract infections
Kidneys- acute and chronic renal failure, renal stones, renal cancer
Bladder-infection, TCC
Prostate-BPH, prostate cancer
Testis- torsion, germ cell tumours