urogenital system

Dr. Mazen Allouche

Professor Assistant in Urology
Pain syndrome
 Kidney pain
• Pathophysiology
 capsule dilatation: in ureteral obstruction
 capsule irritation : infection , tumor, cyst .
• Localized in: Lumbar region
• Irradiation
towards subcostal region , umbilicus, and
hypogastric region.
• referred pain
• in the scrotum : embryological origin .
• there may be reflex spasm of the psoas muscle,
leading to involuntary flexion of the hip joint.
• Differential diagnosis
• radiculitis ( T10-T12) : profile, effort,
 Ureter pain
• Pathophysiology
 renal capsule dilatation: obstruction
 muscular spasm : irritation : infection , stone, tumor
• Type and physical exam
 Upper ureter: renal : upper ureteral point : +
 Middle ureter :appendicitis : middle ureteral point: +
 Lower ureter: lower urinary symptoms (LUTs): +
lower ureteral point :+
pelvic examination : +
 Bladder pain
• Pathophysiology
• dilatation : acute urinary retention (AUR)
• ulceration: infection, TB, Bilharsiosis,
interstitial cystitis
• Type
 discomfort in hypogastric region
 dysuria
 burning in the tip of urethra (referred )
• Physical exam
hypogastric region : painful
 Prostate pain
• Pathophysiology: infection, tumors
• Type
discomfort in (perinea, rectum)
scrotal-lumbar pain (referred)
LUTs .
• digital rectal examination(DRE): painful
 Testis pain
• Pathophysiology
infection ,trauma, ischemia
• Causes
orchitis , hernia, torsion , varicocele, tumors, ureteral stones
• Type
 localized : in the scrotum
 irradiate: to the spermatic cord and lower abdominal
quadrant
 referred: to lumbar region
• Physical exam :
testis : painful , hydrocele
anat. deformated : torsion
pain in lifted testis: infection torsion
 Epididyme pain

• Pathophysiology : infection, tumor

• Type
localized: scrotal pain
transmitted: to the testis
irradiate: to the spermatic cord and lower abd.
Quadrant.
referred: to the lumbar region
Physical examination
• Inspection:
Kidney exam
Renal mass in the upper anterior quad.abd. or lumbar R:
 Neuroblastoma
 Nephroblastoma
 Renal abscess
 Renal dilatation
• Palpation: in thin patient, child : right lower pole
• Technique:
 dorsal lithotomy
 one hand in the costo-vertebral angle and the other in
the sub- costal
 during inspiration.
• pain points :
 costo-vertebral point
 musculo-costal point
• Percussion :
lumbar shaking : positive in : pyelonephritis,
hematoma
 Ureter Exam
Points pain exam

• Upper ureteral point :

2 cm beside umbilicus
• Middle ureteral point :
midline between the upper anterior
iliac spine and umbilicus.
• Lower ureteral point : examined by
pelvic exam.
 Bladder exam

• Percussion :
upon filling 150 ml at least
• Technique :
 dorsal lithotomy
 above the symphysis even
umbilicus on the midline
 Conversion tympanism
into dullness
 Digital rectal exam
 Sphincter tonicity
 Rectal polyps
 Hemorrhoids
 Fistulas
 Prostate :
 morphology:
• 2 lobes and sulcus, like chestnut(4 .cm)
• soft likes cluneal muscle
 prostatic nodule :
 cancer,
 chronic prostatitis
 granulomatis ,TB
 stone
 Vaginal exam
• Girls :
hymen , clitoris, labia
• Women:
 Uterus: ptosis
 Cervix : tumor
 Salpinx :salpingitis
 discharges :
 Bartolan gland : infection
 Anterior wall :cystocele
 Posterior wall :Rectocele
 Anal Levators : tonicity
 Meatus : mucosa, mobility
 Incontinence test :
 External genital Organs exam
• Inspection :
 meatus, volume of uroflow
 ulceration
 curvature
 penis volume
• Palpitation
 penis
fibrosis : Peyrony disease
penis tumors
 Scrotum :
wall : edema , cysts
hydrocele ,hernia ( transillumination test)
 Epididyme (pain. thickness)
 testis (anatomical position. Tumor )
 Spermatic cord :
spermatocele, hernia, varicocele
 Neurological exam
• Sensation
Regions belonging : S2-S3-S4 in perineum
• Tonicity
anal sphincter
• Bulbo-cavernous reflex
neurological spinal arcus
 Lymph nodes exam

• Inguinal nodes
penis and scrotum lesions
• Per-aortal nodes
testis
• Internal hypogastric nodes
prostate , bladder
• over clavicle nodes
subsequent other nodes
Investigations
 Urine
• chemicals Dipsticks : change colour in the
presence of blood, protein or nitrites.
• The presence of protein and nitrites indicates
the likelihood of infection.
• The significance of microscopic haematuria.
• indication of the pH and specific gravity.
 Urine

• Microscopy confirm the presence of white and

red blood cells, and bacteria.
• The presence of protein casts suggests disease
affecting the renal parenchyma.
• Schistosoma ova have a typical appearance.
• vegetable or meat fibers may be present if
there is a fistula connecting the bowel
 Urine

• Cytological examination of the urinary sediment

is sensitive and specific for poorly differentiated
transitional cell tumors
 Urine

• Bacteriological culture of a clean-catch

midstream specimen of the urine is the standard
means of identifying urinary pathogens.
• The presence of organisms at a level of > 105ml
indicates the presence of infection rather than
contamination of
 Urine
• If there are pus cells in the urine but there is
no growth on the routine culture media
(sterile pyuria).
• The centrifuged sediment of multiple early-
morning urine specimens must be cultured on
Lowenstein–Jensen medium to detect urinary
tract tuberculosis.
• Chlamydia is another common urinary
pathogen that will not be detected on routine
culture.
 Urine
• Biochemical examination for electrolytes,
glucose, bilirubin, hemoglobin and myoglobin
is essential to detect abnormal amounts of
these substances in the urine.
• Analysis of a 24-hour specimen of urine will
quantify the rate of loss, and is especially
useful in the investigation of calculus disease
caused by abnormal excretion of calcium,
oxalate, uric acid and other products of
metabolism.
 Tests of renal function
• Levels of blood urea and serum creatinine can
serve as a useful clinical guide to overall renal
function.
• A creatinine clearance test will give an
approximate value for glomerular filtration rate.
• The specific gravity of the urine is fixed at a low
level when the kidney loses the power to
concentrate because of renal tubular
dysfunction.
 Intravenous urography
• iodine atoms are attached to absorb X-rays. it
is filtered to the glomeruli and does not
undergo tubular absorption.
• IVU can cause a dangerous hypersensitivity
reaction.
• Preparation: It is usual to give a laxative.
modest fluid restriction is permissible.
 Intravenous urography
• the nephrogram phase : show the renal
parenchyma opacified by contrast medium
• A delayed nephrogram on one side indicates
unilateral functional impairment.
• Distortion of the renal outline or failure of
part of the kidney to function suggests space-
occupying lesion.
 Intravenous urography
• The excretory phase : After a few minutes, the
contrast is excreted into the collecting system,
opacifying the calyces and the renal pelvis
• Later films show the ureters
• the patient is asked to pass urine and a final film
is taken to show detail of the bladder area.
• IVU is demonstrate tumors and calculi within the
urinary tract. It may also be useful to show details
of abnormal anatomy.
 Retrograde ureteropyelography
• A fine ureteric catheter can be passed into the
ureteric orifice through a cystoscope.
• demonstrate the anatomy of the upper urinary
tract.
• The procedure is particularly useful if there is
doubt about an intraluminal lesion if renal
function is deficient .
 Antegrade pyelography
• Antegrade pyelography – in which contrast
medium is introduced through the
nephrostomy – can be helpful when
retrograde studies are prevented by
obstruction at the extreme lower end of the
ureter.
 Cystography
• Cystography is now most commonly
component of video-urodynamic assessment.
• Its role in assessing ureteric reflux in children
has been largely superseded by radioisotope
scanning and dynamic ultrasonography.
 Urethrography
• Ascending urethrography is valuable to
demonstrate the extent of a urethral stricture
and the presence of false passages and
diverticula associated with it.
 Ultrasonography
• the imaging technique most widely used in urology.
• The size of the kidney, the thickness of its cortex
and the presence and degree of hydronephrosis .
• Intrarenal masses can be diagnosed as smooth
walled and fluid filled (simple cysts) or solid and
complex (possible tumors).
• Stones produce a bright ultrasonic reflection and
cast an acoustic shadow
• The volume of urine in the bladder before and after
micturition can be calculated. filling defects within it
detected.
• Scrotal contents can be displayed in great detail.
 Computerized tomography
• CT is particularly useful to assess structures in the
retroperitoneum.
• In renal carcinoma it will show:
 the size and site of the tumor and the degree of
invasion of adjacent tissue.
 the presence of enlarged lymph nodes at the
renal hilum
 invasion of the renal vein and vena cava.
• It has also been used to stage bladder and
prostate cancer.
• Non-contrast CT is also used routinely in the
diagnosis of urinary calculi.
 Radioisotope scanning
• is used in particular to obtain information
about function in individual renal units.
• Using a gamma camera, DTPA labelled with
technetium-99m can be followed during its
transit through individual kidneys to give a
dynamic representation of renal function.
• A 99mTc-DTPA and MAG-3scan is particularly
useful to prove that collecting system
dilatation is caused by obstruction.
 Endoscopy

• allow the urologist to visualise the upper and

lower urinary tracts for diagnosis and therapy.
• This allows simple diagnostic cystourethroscopy
• bladder biopsy and retrograde ureterography to
be performed under topical urethra anesthesia
with minimal discomfort to the patient.
 Urodynamic studies

• Flowmetry
• Cystometry
• Urethral profile
• Videouradynamics
 Flowmetry

• Study the urinary outlet

• Normal values :
man : 20-25 ml/sec
Women: 25-30 ml/sec
 Cystometry
• Register of pressure during
progressive filling of bladder
• Vesical capacity : 400-500 ml
• Vesical sensibility: first
sensation : 100-150 ml
• Compliance : adaptation of
the wall during filling
• Vesical contractibility : per
micturition pressure : 30-40
cm /water
Lower Urinary Tract symptoms
LUTs
 Bladder dysfunction
• Bladder has 2 functions :
• Filling phase : characterized by :
• Frequency
• Nocturia
• Urgency
• incontinence
• Voiding phase: characterized by :
• hesitancy
• Dysuria
• Abdominal straining
• urine remains in the bladder (pis-en-deux)
 Frequency
• defined by Increase of the number of the
micturition (every 2 hours) . Which must by
distinguished by :
• Polyuria defined by increase of the number and
the volume of micturition . More than 30-50 ml/h.
• Oliguria : defined by decrease of the volume of
micturition. Less than 30-50 ml/h.
• Anuria : expression of acute renal failure : less
than 450-600 ml/24 h.
• Classification : diurnal , nocturnal
 Frequency
Etiology :
polyuria : diabetes, chronic renal failure (CRF),
diuretics
Decreased capacity : TB, irradiation, surgery
Bladder Mucosal irritation : infection , stone,
tumor
Outflow obstruction : prostate hypertrophy (BPH)
Neurogenic bladder : instability
Neighbor lesions : pregnancy, appendicitis,
sigmoiditis, pelvic masses
Chronic urinary retention
 Urgency

• defined as the sudden compelling desire to

urinate, a sensation that is difficult to defer.
• It may associated with incontinence
• etiology :
all irritant factors to the wall of bladder :
infection
foreign body
tumor
neurogenic spastic bladder
 Dysuria
• Definition :
difficulty of micturition and decreased of urinary outflow .
• Etiology :
 Organic :
stenosis
BPH
 Functional :
bladder acontractility
detrusor sphincter dyssenergia (DSD)
• Results :
residual of urines
renal dilatation
renal failure
 Hematuria
• Definition :
presence of blood in the urines . It is divided to:
microscopic : above of 5 RBC/ml3
macroscopic : above of 3.105
• Pseudo hematuria :
urethral bleeding
gyneco –bleeding
drugs (Rifampicine)
food (Beetrave)
myoglobinuria
 Hematuria
investigations
• examination of midstream specimen for
infection
• cytological examination of a urine specimen
• intravenous urogram and/or urinary tract
ultrasound scan
• flexible or rigid cystoscopy
Hematuria
 Urinary retention

• Acute urinary retention :

 acute impossibility to make micturition
Clinic :
pain
impossibility to urine
urgent desire to urine
vesical globe
 Urinary retention

• Chronic urinary retention :

impossibility de complete discharge of urines
Clinic :
frequency
overflow incontinence
no pain
vesical globe
 Urinary retention

Etiology :
• extra obstacle: pelvic tumor, uterus ptosis
• Intra obstacle : prostate ,
• Neurogenic bladder
• Foreign body : urethral stone
• drugs : anticholinergics
Treatment :
• drainage
• management of etiology
 Urinary incontinence
• Involuntary emission of urines by natural tracts
• In men :
overflow incontinence :
consequent to chronic retention
stress incontinence :
over intra abdominal effort :
 Urinary incontinence
• In women :
stress inc.:
sphincter insufficiency or urethral hyper
mobility consequent to pelvic-perineal weakness
Treatment :
drugs : anti- cholinergics
Rehabilitation
Surgery
 Urinary incontinence
Urgent incontinence : in 2 sex
brutal desire that we can not resist resulting to
urinary leakage
Etiology :
irritant cause : stone, infection,
Neurologic origin : instability, dyssenergia
 Urethral discharge

• blood
• gonorrhea : yellowish brown secretions
• nongonorrhea : non thick mucosal secretion