Genitourinary II

Question 1

Renal tumours

Answer 1

Benign renal tumours are rare.

A benign developmental tumour of the kidney, known as an angiomyolipoma, has a characteristic CT scan appearance, due to the high fat content within the tumour, which can be used diagnostically, but in the absence of this appearance any solid lesion within the kidney should be considered as an indication for partial or total nephrectomy.

Routine biopsy of solid masses within the kidney is
not carried out, because the histology can be difficult to interpret and a benign appearance on biopsy does not exclude a malignant tumour.

Question 2

Hypernephroma (renal adenocarcinoma)

Answer 2

The commonest renal tumour is the hypernephroma or renal cell carcinoma (renal adenocarcinoma, Grawitz tumour). The incidence of renal adenocarcinoma increases steadily above the age of 40, reaching a peak in the sixth and seventh decades of life. It is more common in men than women and may occur bilaterally.

Can cause polycythaemia and HTN

Question 3

Aetiological factors of hypernephroma (renal adenocarcinoma)

Answer 3

Aetiological factors include:

• Smokers
• Coffee drinkers
• Industrial exposure to cadmium, lead, asbestos,
aromatic hydrocarbons
• Development in renal cysts in end stage kidneys in dialysis patients
• Von Hippel-Lindau disease (this suggests a genetic predisposition).

Question 4

Common presenting clinical features of renal adenocarcinoma:

Answer 4

• Haematuria;
• Loin pain
• A palpable mass

Renal adenocarcinoma is also associated with a
number of paraneoplastic syndromes:

• Hypertension (due to renin secretion)
• Polycythaemia (due to erythropoietin secretion)
• Hypercalcaemia (due to ectopic parathyroid
hormone production).

Question 5

Spread of hypernephroma occurs as follows

Answer 5

• Direct extension into perinephric tissues and
adjacent organs; direct extension may occur into
the renal vein and IVC; direct extension into
the left renal vein may obstruct the entry of the
testicular vein and result in rapid onset of a left
varicocele

• Lymphatic spread to the para-aortic nodes; and

• Blood spread to liver, brain, bone and lung
(cannon ball metastases).

Question 6

Prognosis

Answer 6

In patients with no evidence of metastasis at presentation the five-year survival may be as high as 70% but falls to 20% when the renal vein is involved or there is extension into the perinephric fat.

Rarely metastases from renal adenocarcinoma can regress spontaneously after removal of the primary tumour, but this occurs in less than 1% of cases, with a limited duration for regression of those metastases in the majority of cases.

Question 7

Wilms’ tumour

Answer 7

This is the commonest intra-abdominal malignancy in children under the age of ten years. The majority occur in the first three years of life. Less than 5% are bilateral.

The most common presentation is with an abdominal mass, but haematuria, abdominal pain, hypertension and intestinal obstruction may occur.

Metastases occur to the liver, lungs and regional nodes. Treatment is by surgical excision with aggressive chemotherapy and radiotherapy. There is an 80–90% chance of cure.

Question 8

Carcinoma of the renal pelvis

Answer 8

These are relatively rare and are usually transitional
cell tumours, although squamous cell carcinomas
have been reported in areas of squamous metaplasia.

Transitional cell carcinomas frequently infiltrate the
wall of the pelvis and may involve the renal vein. With poorly differentiated tumours the prognosis is not good and multiple tumours may occur in the ureters and bladder.

Aetiological factors include:
• analgesic abuse
• exposure to aniline used in the dye, rubber, plastics and gas industries.

Squamous metaplasia of the urothelium may occur due to chronic irritation. This may be associated with calculi and chronic infection. Occasionally, squamous cell carcinomas arise de novo from transitional epithelium.

Squamous cell carcinomas carry a poor prognosis.

Question 9

Urothelial tumours

Answer 9

Urothelial tumours arise in the transitional epithelium, which extends from the tips of the renal papillae to the navicular fossa in men and half way down the urethra in women, and represent an important pathological entity within urological practice.

Urothelial tumours may occur at any level within the urinary tract and are often multifocal. The majority, however, occur in the
1) Uinary bladder (90%)
2) Renal pelvic transitional cell carcinomas (9%)
3) Transitional cell carcinomas of the ureter (1%) are uncommon.

In patients with bladder transitional cell carcinoma there is a higher prevalence of coincidental upper tract tumours.

The commonest presenting feature of transitional
cell carcinoma of the bladder is painless macroscopic haematuria. A number of other lesions are identifi ed on the basis of investigation of either sterile pyuria or microscopic haematuria.

Question 10

Transitional cell carcinomas

Answer 10

Transitional cell carcinomas of the bladder occur
primarily on the posterior and lateral walls of the
bladder in over two-thirds of cases. One-fifth of cases present with a tumour at the trigone or bladder neck and the remainder over the vault of the bladder.

Whilst diverticula are a well-recognised predisposing factor for the development of tumours, less than 5% develop in a diverticulum.

The prognosis for transitional cell carcinoma of the bladder is defi ned by its underlying histological grade, which refl ects the predilection of the tumour to aggressive behaviour. Tumours are usually
graded as well differentiated, moderately differentiated, or poorly differentiated. Carcinoma in situ, which elsewhere in the body is usually a premalignant and relatively benign condition, is quite the reverse in the bladder.

Certainly it is premalignant, but such patients have a tendency, in at least 50% of cases, to develop a poorly differentiated aggressive tumour.

Therefore, in the urinary tract, carcinoma in situ is
treated in a very proactive fashion.

Question 11

Treatment of TCC

Answer 11

Whilst the mainstay of treatment in the UK has tended, traditionally, to be radical radiotherapy, there is an increasing trend towards radical surgery at an early stage.

Carcinoma in situ of the bladder, as mentioned above, is an indication for early intervention. Many of these patients will respond favourably to the use of intravesical BCG which acts as immunotherapy to promote the activation of T-cell mediated killing of abnormal urothelial cells.

If carcinoma in situ is widespread and does not respond to BCG, or is poorly differentiated, then most clinicians would proceed to radical treatment at an early stage.

Question 12

Adenocarcinomas

Answer 12

Other tumours of the bladder include adenocarcinomas and squamous carcinomas. Adenocarcinomas in the UK are relatively uncommon and are usually associated with a urachal remnant on the anterior wall of the bladder, although the presence of adenocarcinoma
on histology should always raise the possibility
of the direct extension of an adenocarcinoma of the
bowel.

Question 13

Squamous carcinomas

Answer 13

Squamous cell carcinoma is uncommon in the
UK but is most commonly associated with situations where there has been chronic stasis or irritation within the bladder and in this context is seen in patients with a previous history of tuberculosis or paraplegics.

In areas of the world where schistosomiasis is endemic, squamous cell carcinoma represents the commonest histological type and usually presents in patients from the second or third decade of life onwards. The tumour arises as a consequence of a chronic irritation within the bladder, leading on to squamous metaplasia and the subsequent development of a squamous carcinoma. This is precipitated by the parasite laying its eggs in a submucosal position.

Question 14

Prostate cancer

Answer 14

Carcinoma of the prostate is one of the commonest
malignant tumours in the male. The majority of cases present clinically in the sixth or seventh decade of life, but it must be recognised that, if a male lives long enough, there is a high chance of him developing carcinoma of the prostate, although it may not be manifest clinically.

Indeed, postmortem series have reported a prevalence of carcinoma of the prostate in up to 80% of 80-year-old patients.

Prostate carcinomas traditionally develop in the peripheral zone of the prostate and are adenocarcinomas. Unfortunately the majority of patients presenting with carcinoma of the prostate (two-thirds) do so with either locally advanced disease or metastatic disease already present.

Question 15

Spread of prostate cancer

Answer 15

• direct – by local extension through the prostatic
capsule to the urethra, bladder base, or seminal
vesicle;

• lymphatic – to the pelvic and para-aortic nodes

• blood-borne – via the prostatic venous plexus
to the vertebral venous plexus and to the bones
of the lumbar spine and pelvis; and to the lungs
and liver.

Question 16

Clinical presentations of prostate cancer

Answer 16

Clinical presentations include:
• lower urinary tract symptoms – features of bladder
outflow obstruction

• routine rectal examination may reveal a hard
craggy prostate

• bony metastases – bone pain, pathological fracture
anaemia due to extensive neoplastic infi ltration of
marrow-containing bones

• lymph node metastases.

Question 17

PSA

Answer 17

The advent of testing for prostate specifi c antigen
(PSA) has allowed the earlier diagnosis of many cases, although it must be recognised that the PSA test has a relatively low sensitivity and specifi city and a normal PSA does not exclude the presence of a coexisting prostate carcinoma, although conversely a markedly raised PSA level makes the diagnosis very likely.

Elevation of the PSA occurs following instrumentation of the prostate or can occur in association with a urinary tract infection. There is no evidence that digital rectal examination signifi cantly raises the PSA.

Question 18

Diagnosing prostate cancer

Answer 18

The diagnosis of prostate carcinoma rests on the histological identification of prostatic adenocarcinoma on fine needle biopsy, which is usually carried out transrectally – either under digital guidance if there is a palpable abnormality or using ultrasound guidance. This technique should be carried out with full antibiotic cover because of the risk of bacteraemia

Question 19

Treatment of prostate cancer I

Answer 19

Following the diagnosis of prostate cancer, in
addition to routine blood investigations, including a
baseline serum PSA, a bone scan is carried out, and if the tumour is considered possibly to be localised then baseline imaging with a transrectal ultrasound scan and an MRI scan to exclude local disease progression are usually the preferred staging modalities.

Question 20

Treatment of prostate cancer II

Answer 20

The radical treatment for prostate carcinoma involves either radical radiotherapy (brachytherapy or external beam radiotherapy) or radical prostatectomy.

The latter has become increasingly popular in recent years, and recent years have also seen interest in newer therapies including cryotherapy and high-intensity focused ultrasound, although these are as yet unproven.

Radical prostatectomy should be confi ned to patients where biologically a life span of at least ten years is to be expected or where the tumour is locally confined; in support of this, results would suggest that PSA level in excess of 20 ng/mL is a relative contraindication.

Question 21

Treatment of prostate cancer III

Answer 21

In patients where the tumour is locally advanced
or metastatic, then hormonal therapy is instituted.
The mainstay of treatment is to remove testosterone production either by surgical orchidectomy or chemical measures designed to achieve the same aim (anti-androgens and LHRH analogues).

There is no evidence that surgical orchidectomy is superior to chemical measures. The prognosis of patients with carcinoma of the prostate depends upon the stage of the tumour at presentation, and it is likely that in those where the tumour is detected at an early stage with a low tumour bulk, if a curative option such as radical surgery is carried out at an early stage then they can be cured. As a rule of thumb, patients presenting clinically with prostatic carcinoma before the sixth decade of life tend to have a more aggressive tumour which is reflected in a poorer prognosis.

Question 22

Carcinoma of the testis

Answer 22

Tumours of the testis are relatively uncommon,
accounting for 1–2% of malignant tumours in men;
nevertheless they predominantly affect young men.

There is a well-established link between undescended testes and testicular tumour, and it has been estimated that adults with maldescent of the testes have a 20–30 fold greater incidence of developing a testicular tumour than men with a normally descended testis.

Testicular tumours may be derived from germ cells or non-germ cells. The majority (90%) are of germ cell origin. Germ
cell tumours include seminomas and teratomas.

Nongerm cell tumours include those arising from the Sertoli cells and Leydig cells.

Question 23

Testicular tumour classification

Answer 23

Testicular tumours may be
classifi ed as follows:
• seminoma;
• teratoma;
• combined germ cell tumours (seminoma and
teratoma);
• malignant lymphoma;
• interstitial (Leydig) cell tumour; and
• Sertoli cell tumour.

The two most common types of tumour are seminoma and teratoma. Metastatic tumours are rare and include bowel, bronchus and prostate.

Question 24

Clinical features of testicular tumours

Answer 24

Clinical features of testicular tumours include:
• unilateral painless enlargement of a testis;
• secondary hydrocele;
• retroperitoneal mass;
• lymph node metastases (occasionally in the
cervical nodes);
• symptoms from other metastases; and
• gynaecomastia from hormone-secreting interstitial
tumours.

Question 25

Testicular tumour investigation

Answer 25

Serological tumour markers such as !FP,
beta-HCG and LDH should be estimated prior to orchidectomy. Ultrasound scanning is a non-invasive and very accurate way of defining primary testicular abnormalities.

Question 26

Staging in testicular tumours

Answer 26

Staging of patients with a primary testicular tumour
is principally carried out on the basis of the serological tests mentioned above and also CT scanning of the abdomen and pelvis to look for lymph node extension and retroperitoneal tumour mass. With a combination of radiotherapy and chemotherapy the cure rate for the majority of patients with testicular tumours approaches 100%.

Question 27

Testicular tumour treatment

Answer 27

The treatment of choice is radical orchidectomy via
an inguinal route, with preclamping of the inguinal
cord prior to orchidectomy to prevent manipulation
of the testis from disseminating tumour cells into the circulation.

Question 28

Carcinoma of the scrotum

Answer 28

Carcinoma of the scrotum is rare. At the present
time carcinoma of the scrotum is uncommon and is
usually seen in elderly patients. It is of the squamous type and may spread to the inguinal lymph nodes.

Treatment is by wide excision.

Question 29

Carcinoma of the urethra

Answer 29

This is a rare tumour classically associated with
chronic irritation within the urethra, often in association with a urethral stricture. Treatment involves radical excision.

Question 30

Carcinoma of the penis

Answer 30

Carcinoma of the penis is rare. It occurs between 60 and 80 years and is almost unknown in circumcised males.

Poor hygiene and accumulation of smegma may be
aetiological factors. Histologically the tumour is a
squamous cell carcinoma. It frequently starts in the
sulcus between the glans and the foreskin.

Spread is usually to the inguinal nodes. Intraepidermal carcinoma may occur on the glans penis, presenting as a red velvety lesion termed erythroplasia of Queyrat.

Question 31

Benign disorders of the penis: Balanoposthitis

Answer 31

Balanitis is inflammation of the glans penis. Posthitis is infl ammation of the foreskin. They usually occur together as balanoposthitis. It is often associated with phimosis. Smegma accumulates beneath the prepuce, which may become infected with staphylococci, coliforms, or gonococci. In patients with balanoposthitis the possibility of diabetes should always be excluded. In the case of diabetes, candida is the most likely infecting organism.

Question 32

Benign disorders of the penis: Phimosis

Answer 32

Phimosis is a tightness of the foreskin, which prevents it retracting back over the glans penis. The foreskin is adherent until the age of three years and then gradually separates by the age of six years. If the foreskin is not retractable by the age of seven years and is causing problems then circumcision is justifiable. Phimosis occurring in the adult and causing interference with voiding or sexual activity is an indication for circumcision.

Question 33

Benign disorders of the penis: Paraphimosis

Answer 33

This occurs as a consequence of pulling a tight foreskin back over the glans penis and failing to reduce it. Venous return from the glans and prepuce is obstructed, and results in oedematous swelling of the glans and prepuce. Principles of treatment are to compress the oedematous foreskin to reduce the oedema and then attempt to reduce the foreskin. Appropriate analgesia, including a local anaesthetic block and
occasionally injection of hyaluronidase into the oedematous tissue, may be helpful.

Question 34

Balanitis xerotica obliterans

Answer 34

This is a condition of the foreskin characterised by loss of skin elasticity, and fi brosis, resulting in phimosis. The condition occurs mainly between 30 and 50 years of age. The aetiology is unknown and treatment is by circumcision. In some cases it also affects the glans and the urethra, and may progress to stricture disease.

Question 35

Priapisim

Answer 35

Priapisim is rare and represents a persistent painful
erection unassociated with sexual desire.

Aetiological factors include:
• idiopathic
• leukaemia
• sickle-cell disease
• disseminated and pelvic malignancy
• neurological conditions, especially spinal cord
injury
• patients on haemodialysis
• iatrogenic due to injection of vasoactive agents
into the penis as treatment for impotence.

Therapy includes aspiration of the penis and injection of alpha-adrenergic agonists. In recalcitrant cases surgery can be used, but the success rate is limited.

Priapisim associated with sickle-cell disease is often resistant to any of these measures, and many of the cases are managed conservatively.

Question 36

Peyronie’s disease

Answer 36

This is a fibrotic condition of the corpora cavernosa. It occurs between 40 and 60 years and the aetiology is unknown. Fibrotic plaques in the corpora cavernosa result in discomfort, pain and deformity on erection.

The fibrous plaques are palpable along the shaft of
the penis. They may become calcified. Spontaneous resolution may occasionally occur. The exact cause of the lesion is unclear. Some cases are associated with Dupuytren’s contracture and others with retroperitoneal fibrosis. It may require surgical treatment to correct penile curvature, and there is an association with
erectile dysfunction.

Question 37

Impotence

Answer 37

This is a common problem in the population, occurring with an increasing incidence with age. It is defined as the inability to initiate or sustain an erection sufficient to allow satisfactory sexual intercourse to occur.

Whilst the precise neural mechanisms underlying erectile function are as yet not fully understood, it is clear that certain aetiological factors are of importance:

• Psychogenic problems;
• Diabetes;
• Alcohol;
• Liver dysfunction (resulting in endocrine
dysfunction)
• Primary disorders of endocrine function
• Atherosclerosis
• Neurological disorders
• Miscellaneous, e.g. Peyronies disease.

Question 38

Scrotal swellings

Answer 38

The cardinal features of a scrotal swelling are the ability to get above it, whether it is solid or cystic in nature as defined by transillumination, and whether it is painful and/or associated with signs of inflammation or infection. Any patient presenting with a solid testicular swelling should be considered to have a tumour unless proven otherwise and should undergo an urgent ultrasound scan.

Likewise any man presenting with a hydrocele, particularly a young adult or if there is an atypical history, should have further investigation of the testis to exclude tumour (e.g. drainage of the
hydrocele and examination, or ultrasound scan).

Question 39

The following are scrotal swellings encountered in surgical practice:

Answer 39

The following are scrotal swellings encountered in surgical practice:

• indirect inguinal hernia
• hydrocele
• epididymal cyst
• epididymo-orchitis
• testicular tumour
• torsion of the testis
• varicocele
• hematocele
• sperm granuloma
• torsion of testicular appendage

Indirect inguinal hernia and testicular tumour are dealt with elsewhere in this book.

Question 40

Hydrocele

Answer 40

A hydrocele is a collection of fl uid in the tunica vaginalis.

A primary or idiopathic hydrocele develops slowly
and becomes large and tense. It usually occurs in
patients over the age of 40.

Question 41

Secondary hydrocele

Answer 41

A secondary hydrocele may be small and lax and occurs secondary to infl ammation or tumour of the underlying testis. They tend to occur in a younger age group.

Question 42

Congenital hydrocele

Answer 42

A congenital hydrocele is associated with a hernial
sac and connects with the peritoneal cavity.
A hydrocele of the cord lies along the cord anywhere from the deep inguinal ring to the upper part of the scrotum. It does not connect with either the peritoneal cavity or the tunica vaginalis. A similar swelling may develop in the female and is known as a hydrocele of the canal of Nuck.

Question 43

Epididymal cyst

Answer 43

These may be small, large, multiple, unilateral, or
bilateral. Acquired cysts of the epididymis are usually caused by the obstruction of passage of sperm along the narrow lumen of the vas or obstruction of an epididymal tubule, resulting in a cystic dilatation of the duct system in the epididymis and efferent ductules of the testis.

The majority of these contain clear straw coloured
fluid. However, if they contain opalescent
milky fluid, containing sperm, which may be demonstrated on aspiration, they are known as spermatoceles.

It is important to realise that surgical excision of
an epididymal cyst may damage the epididymis on
that side and may result in impairment of fertility.

Question 44

Epididymo-orchitis

Answer 44

Acute infl ammation of the body of the testis is known as orchitis. However, this most frequently develops in association with infl ammation of the epididymis, and the combined condition is known as epididymoorchitis.

The commonest underlying cause is a urinary
tract infection with coliform organisms, and it is
important to exclude sexually transmitted infections,
especially in young sexually active patients. It may follow prostatitis or urethritis. The infection is thought to spread along the vas deferens or the lymphatics in the perivasal tissues. The condition may be unilateral or bilateral. It may be associated with a secondary hydrocele. Suppuration is unusual.

Orchitis may occur as a complication of mumps.
Chronic epididymo-orchitis may develop as a result
of tuberculous infection. The inflamed epididymis may become adherent to the scrotal skin, with the formation of sinuses. Tuberculous epididymo-orchitis is usually secondary to tuberculosis elsewhere in the urinary tract. Microscopy often shows ‘sterile’ pyuria with the presence of acid fast bacilli.

Question 45

Torsion of the testis

Answer 45

In the majority of cases this should be termed torsion of the spermatic cord rather than torsion of the testis.

Torsion of the spermatic cord involves twisting of the testis and epididymis together on their axis. In other cases the testis may twist on a long mesorchium.

Torsion of the spermatic cord is often precipitated by exertion which causes contraction of the cremaster muscle. Torsion represents a surgical emergency and should be treated by surgical exploration as soon as possible whenever the diagnosis is suspected.

Question 46

Anatomical abnormalities often predispose to testicular torsion.

Answer 46

These include:
• an abnormally long spermatic cord;
• the presence of a long mesorchium; and
• maldescent of the testis. This is often identifi ed
by the horizontal lie of the testis on clinical
examination.

Question 47

Anatomical abnormalities of testes: Consequences

Answer 47

These conditions are often bilateral and, if torsion
occurs on one side, once that has been dealt with, it is appropriate to fi x the other testis in the scrotum so that it cannot undergo torsion.

If treatment of torsion is delayed, infarction of the testis occurs, resulting subsequently in a small, shrunken, fibrotic testis and epididymis. Absorption of the products of dead spermatozoa
may result in the development of antisperm
antibodies, leading to sympathetic orchidopathia with consequent reduction in fertility.

Question 48

Varicocele

Answer 48

A varicocele is a varicosity of the pampiniform
plexus of veins in the spermatic cord. Varicoceles are extremely common in the population, with a reported incidence of up to 12%. The majority are left sided.

Although they are widely considered to be associated with subfertility, a causal link between the two has not been clearly established. A primary varicocele is one that arises with no obvious underlying cause.

A secondary varicocele is the result of venous obstruction.
The commonest cause of this rare type of varicocele is obstruction of the renal vein due to carcinoma of the kidney growing down and obstructing the renal vein.

Question 49

Varicocele

Answer 49

As the testicular vein on the left side drains directly
into the renal vein, back pressure may occur on the
testicular vein, resulting in the development of a varicocele.

Any patient over the age of 40 with rapid development of a varicocele on the left hand side should have an ultrasound scan of the kidney.

The main indication for treatment of varicoceles is
if they are symptomatic.

Contemporary management of a varicocele depends on local resources, but it may be very successfully managed in a minimally invasive fashion by percutaneous embolisation.

Question 50

Haematocele

Answer 50

This is a result of testicular trauma either due to
sports injuries or violence. Trauma results in bleeding into the layers of the tunica vaginalis resulting in a haematocele.

Question 51

Sperm granuloma

Answer 51

This is an uncommon chronic inflammatory lesion
resulting from extravasation of sperm from the tubules into the interstitium. The commonest cause of this is extravasated sperm, either from the site of transection of the vas, or within the epididymis, following vasectomy. A localised nodule forms which may require excision if it is symptomatic – often presenting as a painful lump.

Question 52

Torsion of testicular appendage

Answer 52

There are several small testicular appendages, the
most common of which is the appendix testis. This
is attached to the front of the upper pole of the testis.

Torsion results in sudden pain in the testis, with
oedema and congestion of the cord, testis and epididymis.

The condition is rare and usually mistaken for
torsion of the testis. The diagnosis becomes apparent on exploration. Treatment is by excision of the appendix testis.

Question 53

Acute scrotal pain

Answer 53

Acute scrotal pain is a urological emergency. Conditions include:

• Torsion of the testis
• Acute epididymo-orchitis
• Torsion of testicular appendage
• Fournier’s gangrene.

As a general rule any patient presenting with acute
scrotal pain should be considered for urgent scrotal
exploration because of the possibility that it may be
due to testicular torsion.

Question 54

Incontinence: Detrusor overactivity

Answer 54

Detrusor overactivity is one of the commonest causes of urinary incontinence. It arises idiopathically in 10–15% of the normal population or secondarily in up to 80% of males with bladder outlet obstruction; the prevalence of bladder overactivity also increases with increasing age. It also occurs frequently in patients with central neurological lesions such as strokes, Parkinsonism, or multiple sclerosis and in spinal reflex
bladders. Frequency, nocturia, urgency, and urge
incontinence are the common symptoms encountered.

These can occur on their own or more commonly in
combination with the presenting symptoms of the
underlying medical problem causing the incontinence.

Detrusor overactivity is a urodynamic diagnosis. If it is secondary to an identifi able central neurological lesion, the term neurogenic detrusor overactivity is used. In cases where no upper motor neuron lesion is present, it is termed idiopathic detrusor overactivity. The principal management of all incontinence is the provision of advice to the patient, the use of devices, catheters, pads, etc. In the context of detrusor overactivity, a combination of judicious fluid restriction to 1500 mL per day, bladder retraining and the use of anticholinergic
agents is appropriate as fi rst line management.

Question 55

Incontinence: Detrusor underactivity

Answer 55

Detrusor underactivity is another cause of urinary
incontinence. Many cases are idiopathic in origin,
but neurological pathology must be excluded. In particular, it may result from a mechanical injury to the nerves supplying the bladder, such as in patients with prolapsed intervertebral discs or tumours involving the spine, or from pelvic plexus injury as a result of pelvic surgery, or autonomic neuropathy seen in diabetes, alcoholism, tabes dorsalis, Parkinsonism, or pernicious anemia. Alternatively, it can also result from the loss of detrusor muscle in patients with decompensated
bladder outlet obstruction. Although the relationship
between outlet obstruction and detrusor underactivity is accepted by many urologists, the fact that chronic outlet obstruction leads on to detrusor underactivity has still to be proven. This condition must always be considered in any elderly male presenting with incontinence.

Many of these patients will be found to have
a palpable bladder and a third will have signifi cant
renal impairment at the time of presentation.
Female patients may present with idiopathic urinary retention at two characteristic age groups: either young patients with a history of lifelong voiding dysfunction, who are subsequently found to have poorly relaxing urethral sphincters (of unknown aetiology), or in the fifth decade of life, where in some cases a long term history of infrequent voiding can be obtained.

Question 56

Incontinence: Sphincteric causes

Answer 56

Sphincteric causes of urinary incontinence are of particular importance in the female patient and result in the majority of cases from postobstetric sphincteric weakness.

This is usually a combination of a weakness of the pelvic floor and denervation of the urethral sphincter mechanism as a consequence of damage to the somatic nerve supply mediated via the pudendal nerve.

Therapy for this is based on initial treatment with pelvic floor exercises which will benefit up to 40% of patients. In the remaining patients surgery represents the mainstay of treatment and aims to correct prolapse and increase the bladder outflow resistance by resuspension or compression of the urethra.

In the male patient sphincteric weakness can occur following lower urinary tract trauma but is usually iatrogenic in origin; the mainstay of treatment is the implantation of an artificial urinary sphincter.

Question 57

Functional urinary incontinence

Answer 57

Functional urinary incontinence refers to urinary incontinence that is not related to an objectively demonstrable lower urinary tract dysfunction but rather to loss of cognition, mobility, manual dexterity, motivation and the effect of environmental demands.

These factors are commonly involved in the development of urinary incontinence in the mentally handicapped and the elderly.

However, functional incontinence is a diagnosis of exclusion, and one must not automatically assume that all urinary incontinence in the elderly or mentally handicapped is functional in nature, as a large number have urodynamic abnormalities that are amenable to treatment.

Question 58

Incontinence: extra-urethral

Answer 58

Extra-urethral incontinence as a consequence of an ectopic ureter(s) presents early in life; fistulae are usually either as a consequence of obstetric mishaps (particularly in the developing world) or are iatrogenic in origin. These conditions will usually require surgical intervention.

Question 59

BPH

Answer 59

Benign prostatic hyperplasia (BPH) is the most common disease to affect men of middle age and beyond.

Histological BPH is present in up to 50% of men above the age of 60 years and nearly 90% by age of 80.

It is estimated that 25% of men in their sixth decade have urinary symptoms and objectively measureable bladder outflow obstruction.

Question 60

Lower urinary tract symptoms (LUTS)

Answer 60

Lower urinary tract symptoms (LUTS) are not disease specific since only 60–70% of patients with typi- cal LUTS suggestive of bladder outflow obstruction (BOO) have proven obstruction on urodynamic studies.

Symptoms related to lower urinary tract outflow obstruction can be divided into three groups:
• voiding;
• storage; and
• post-micturition symptoms.

Question 61

Voiding

Answer 61

Voiding symptoms are:

• hesitancy
• intermittency
• poor stream
• straining
• prolonged micturition
• feeling of incomplete emptying

Question 62

Storage symptoms

Answer 62

Storage symptoms are:
• nocturia;
• daytime frequency;
• urgency;
• urge incontinence
• overflow incontinence

Question 63

Post-micturition

Answer 63

Post-micturition symptoms:
• post-micturition dribbling of urine;

Question 64

Complications of the LUT: Acute retention

Answer 64

Acute retention of urine occurs in a small proportion of men presenting with a history of bladder outflow obstruction, the incidence of this complication having been estimated to be approximately 2.5% of this group of men per year.

Acute retention of urine is characterised by painful inability to void, and the residual obtained is around 1L.

Question 65

Complications of the LUT: Chronic retention

Answer 65

Insidious onset, characteristically painless, associated with renal dysfunction in 30% of cases and where the residual obtained may well exceed 2L; whilst it is presumed that chronic retention follows longstanding obstruction, it has been suggested that it may originate as a consequence of pathology other than chronic bladder outflow obstruction.

Other serious complications of symptomatic BPH are relatively uncommon in contemporary practice, but include bladder stone formation, stasis (residuals, diverticula) leading to urinary infection and recurrent haematuria.