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• 11/12 (intermediate or high-risk )

• defin itive therapy over active surveillance

• watchful waiting in elderly or infirm

• T3.T4

• ADT (with calcium, vitamin D, bisphosphonates) + tBRT/docetaxel/abiraterone

• enzalutamide, apalutamide

radiation therapy for oligometastatic disease (case-by-case basis)

• N >0 or M >0

requires hormonal therapy/palliative radiotherapy for metastases; may consider combined

androgen blockade

bilateral orchiectomy - decreases testosterone production by 90%

GnRH agonists (e.g. leuprolide, goserelin),see Table 28, U47, GnRH antagonist (e.g.degarelix)

• antiandrogens (e.g. bicalutamide)

• local irradiation of painful secondaries or half-body irradiation

" CRPC

• ADT should be maintained

• non-metastatic CRPC:observation vs. apalutamide, enzalutamide, or darolutamide

• metastatic CRPC: abiraterone, enzalutamide, docetaxel-based chemotherapy

post-docetaxel: second-line chemotherapy cabazitaxel

if symptomatic without visceral metastases:radium-223

HRR mutation:olaparib

bone metastases: denosumab and /or zoledronic acid is recommended ± palliative radiation

Table 20. Treatment Options for Localized Prostate Cancer

Modality Population Considered Limitations

Watchful Waiting Short life expectancy («5-10 yr); will likely Disease progression

only receive non-curative hormonal therapy if

disease progresses

Low grade disease, good follow up:is still Disease progression:decrease in 00t

considering more curative treatment if disease associated with serial testing:risks associated

with biopsies: no optimal monitoring schedule

has been defined lo date

ED (50%). long-term effectiveness not well

-

established

locally advanced disease, older patients Radiation proctitis(5%), ED (25 50%), risk of

rectal and bladder cancer

Young patients(<75 yr). high- risk disease Incontinence (10%).E0 ( 30 50% )

Active Surveillance (serial PSA. DRE, and

biopsies)

progresses

Brachytherapy low volume, low PSA (*10). low giadc

EBRI

RP

'Other options include cryosurgery. HIFU, hormonal ablation

Prognosis

• T1-T2:comparable to normal life expectancy

• T3-T4:40-70% 10 yr survival

• N 'and/or M + :4% 5 yr survival

• prognostic factors: tumour stage, tumour grade, PSA value, PSA doubling time

PSA Screening

Digital Rectal Exam

• should be included as part of initial screening

• suspicious findings: abnormal feeling, nodularity,focal lesion, discrete change in texture/fullness/

symmetry

Prostate Specific Antigen

• glycoprotein produced by epithelial cells of prostate gland

• leaks into circulation in setting of disrupted glandular architecture

• value of <4 ng/mL traditionally considered as cut-off to differentiate normal from pathologic value,

but no single justifiable cut-off point

• measured serum PSA is a combination of free (15%) and bound PSA (85%)

• decreased free:total PSA, elevated PSA velocity and elevated PSA density associated with increased

CaP rates

Causes of Increased PSA

BPH. prostatitis, prostatic ischemia/

infarction, prostate biopsy/surgery,

prostatlc massage, acute urinary

retention, urethral catheterization,

cystoscopy, TRUS, strenuous exercise,

perineal trauma, ejaculation, acute renal

failure,coronary bypass graft radiation

therapy

PSA

m

is specific to the PROSTATE,but NOT

to prostate cancer

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Screening Recommendations

( PSA Screening J Long-Term Follow-Up on PSA Screening

Lancet 2014;384:2021-2035

Summary: At 13 yr follow up. PSA scieerrg is

favourable, showing a significant 21% relative

prostate cancel mortality reduction. live number

needed to screen and to treat from thistrial were

lower than those observed m breast cancer Inals.

However, the risks associated with screening need

to be considered when considering population-level

screening programs.

Methods: Multi-centre RCI with predefined central

database, analysis, ard cote age group (55-69 yr|

evaluating PSA in 8 European countries. Incidenceand

mortality truncated at 9.11.and13 yr follow- up in the

intervention arm wascom pa red tocontrolarm.

Results: MR of PCw incidence between intervention

and control arms was1.91after 9 yr follow- up,1.66

at 11 yr follow- up, and 1.6? at 13 yr follow-up.lilt of

PCa mortality was 0.85, 0.78.and 0.29.at 9.11.13

yr fol low- up, respectively.At13yr follow-up in PSA

screening group, relative ltd is2T%.and absolute HR

from death is1.28 per1000 men.

*

nr 1

Age 40 50 c J ( Age 50 70 ] Ago 70

*

I I

(>10 yr Mo expectancy)

Scroon it:

(<10 yr life oxpoctancyj- Don'

t Scroon

• FHx of prostate cancer

(1st 2nd degreBl

•

Afnt Screen & shared decision making with patient

Advise on: overdiagnosis,overtreatment morbidity

can American

nr c PSA>3 PSA 1-3 PSA<1

W I T

( More frequent PSA J

t f

f Rupu.it PSA q 2 yr j ( Mopo.it PSA |t 4 yr j f Ago CO, PSA- I j

I

(Consider prostate MRl)

Elevated PSA

or Abnormal DRE

Biopsy

Figure 18. Canadian Urological Association guidelines on PSA screening (2017)

Testicular Tumours

Etiology/Risk Factors

• cryptorchidism, atrophy,sex hormones, HIV infection, infertility, FMHx, PMHx of testicular cancer

Epidemiology

• rare, but most common solid malignancy in young males 15-35 yr

• any solid testicular mass or acute hvdrocoele in young patient - must rule out malignancy

• slightly more common in right testis (corresponds with slightly higher incidence of right-sided

cryptorchidism)

• 2-3% bilateral (simultaneously or successively)

Pathology

• primary

» 1% of all malignancies in males

cryptorchidism has increased risk (10-40x) of malignancy

95% are germ cell tumours (all are malignant)

seminoma (35%) -> classic, anaplastic,spermatocytic

« NSGCT > embryonal cell carcinoma (20%), teratoma (5%), choriocarcinoma (<1%), yolk sac

(«1%), mixed cell type (40%)

5% are non-germ cell tumours (usually benign ) > Leydig (testosterone, precocious puberty),

Sertoli (gynecomastia, decreased libido)

• secondary

male >50 yr

usually lymphoma or metastases (e.g.lung, prostate,Gl)

Clinical Features

• painless testicular enlargement (painful if intratesticular hemorrhage or infarction )

• dull, heavy ache in lower abdomen, anal area, or scrotum

• associated hydrocele (10%)

• coincidental trauma (10%)

• infertility (rarely presenting complaint)

« gynecomastia due to secretory tumour effects

• supraclavicular and inguinal lymphadenopathv

• abdominal mass (retroperitoneal lymph node metastases)

Methods of Spread

• local spread follows lymphatics

• right > medial, paracava), anterior, and lateral nodes

left > left lateral and anterior paraaortic nodes

“cross-over” metastases from right to left are fairly common, but no reports from left to right

• hematogenous most commonly to lung,liver, bones, and kidney

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Investigations

• diagnosis is established by pathological evaluation of specimen obtained by radical inguinal

orchidectomy

• tumour markers (

f

$-h(Xi,1.DH,AFP)

• p-h(Xi and AFP are positive in 85% of non-seminomatous tumours

• elevated marker levels return to normal postoperatively if no metastasis

• p-hCX;positive in 7% of pure seminomas, AFP never elevated with seminoma

• testicular U/S (hypoechoic area within tunica albuginea = high suspicion of testicular cancer)

• evidence of testicular microlithiasis is not a risk factor for testicular cancer

• needle aspiration contraindicated

Staging

• clinical: CXR (lung metastases),markers for staging (p-h(Xi, AFP, LDH), CF abdomen/pelvis

(retroperitoneal lymphadenopathy)

• stage I: disease limited to testis,epididymis,or spermatic cord

• stage II: disease limited to the retroperitoneal nodes

• stage III: disease metastatic to supradiaphragmatic nodal or visceral sites

Testes and scrotum have different

lymphatic drainage,therefore

trans scrotal approach for biopsy or

orchiectomy should be avoided

Table 21. 2018 TNM Classification of Testicular Carcinoma (AJCC 8th edition)

T N M

TX:primary tumour cannot be assessed NX:regional lymph nodes were not assessed MO: nodistant metaslases

TO:no evidence of primary tumour NO:no regional lymph node metastasis cM1:distant metastases

cM1a:non-relroperitoneal nodal or

pulmonary metastases

cM1b:iron-pulmonary visceral metastases

Tis:intratubular germ cell neoplasia N1:metastasis with a lymph node mass 2

cm or less in greatest dimension:or multiple

lymph nodes,none more than 2 cm in greatest

dimension

T1:limited to testisand epididymis without

lymphovascular invasion

T1a:tumour <3 cm

T1b:tumour >3 cm

pM1:distant metastases.microscopically

confirmed

pM1a:non- retroperitoneal nodal or

pulmonary metastases,microscopically

confirmed

pM1b: non-pulmonary visceralmetastases.

miCTOscopicallyconfirmed

N2:metastasis with a lymph node mass more

than 2 cm but not more than 5 cm ingreatest

T2:limited to testis and epididymis with dimension

lymphovascular invasion or invadinghilar soft

tissue or epididymis,or penetrating visceral

mesolhelial layer covering the external

surface of tunica albuginea with or without

lymphovascular Invasion

N3:metastasis with a lymph node mass more

than 5 cm ingreatest dimension

N Prefix

(c):clinical N

T 3:invasion of the spermatic cord i (p): pathological N

lymphovascular invasion

N Suffix

(sn):regional lymph node metastasis

identified by SIN biopsy only

(f):regional lymph node metastasis identified

by f NA or coie needle biopsy only

T4: invasion of the scrotumiinvasion

T Prefix

(c):clinical T.except for Tis confirmed by

biopsy an T4,the extent of primary tumour is

classified by radical orchiectomy

(p|: pathological T.subdassification of pll

applies only to pure seminoma

T Suffix

(m):synchronous primary tumours are found

in single organ

Orchiopexy

Surgical descent (orchiopexy) of

undescended testis does not eliminate

the risk of malignancy. but allows for

earlier detection by self-examination and

reduces the risk of infertility

Management

• radical orchiectomy through inguinal incision for all stages - ligate spermatic cord inside inguinal

canal

• consider sperm banking, testicular prosthesis

• adjuvant therapies (see I igurc 19. U3I )

Prognosis

• 99% cured with stage I and 11 disease

• 70-80% complete remission with advanced disease

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U31 Urology Toronto Notes 2023

— Teratoma

— Embryonal CA

— Mixed cell type

— Yolk sac CA

- ChorioCA

Gann Cell Testis Tumour

Layers of the Scrotum

Germinal cell :

SDECITT

Skin

Dartos muscle and fascia

External spermatic fascia

Cremasteric fascia

Internal spermatic fascia

Tunica vaginalis

Tunica albuginea

50% 50%

Seminoma Non Seminoma Epithelium 4-

I

f T 1

90% 10% 40% 20% 20%

Stage I Stage ll+lll Stage I Stage II Stage III

Surveillance

Radiation

/

''

' RPLND ± (residual mass)

« ? ? I

Figure 19. Adjuvant management of testicular cancer post-orchiectomy

Adapted from Dr. MAS Jewett

Penile Tumours

Epidemiology

• rare (<1% of cancer in males in U.S.)

• most common in ages 50-39

Benign

• cyst, hemangioma, nevus, papilloma

Pre-Malignant

• balanitis xerotica obliterans, leukoplakia, Buschke- Lowenstein tumour ( large condyloma)

Pre-invasive Cancer

• carcinoma in situ

Bowens disease -> crusted, red plaques on the shaft

erythroplasia of Queyrat > velvet red, ulcerated plaques on the glans

• treatment options:local excision, laser, radiation, topical 5-fluorouracil

Malignant

• risk factors

chronic inflammatory disease

ST1

phimosis

uncircumcised penis

• 2% of all urogenital cancers

• SUC (>95%), basal cell, melanoma, Paget'

s disease of the penis (extremely rare)

• definitive diagnosis requires full thickness biopsy of lesion

• lymphatic spread (superficial/deep inguinal nodes -> iliac nodes)»hematogenous

Treatment

• wide surgical excision with tumour-free margins (dependent on extent and area of penile

involvement) ± lymphadenectomy

• consider less aggressive treatment modalities in CIS (cryotherapy, laser therapy, etc.), if available

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U32 Urology Toronto Notes 2023

Scrotal Masses

Varicocele Grading

Grade 1:palpable only with V alsalva

manoeuvre

Grade 2:palpable without Valsalva

Grade 3:visible through scrotal skin

Table 22. Differentiating between Scrotal Masses

Condition Pain Palpation Additional Findings

Torsion Diffuse tenderness

Horizontal lie of testicle

Absent cremaster reflex,negative

Prehn's sign

Epididymitis Epididymal tenderness Present cremaster reflex, positive

Prehn's sign

Present cremaster reflex,positive

Prehn’s sign

Nolransillumination

transillumination.Hx of trauma

Suspect a Retroperitoneal Mass/

Process in a Patient with a Varicocele

Orchitis Diffuse tenderness if;

Acute onset

Right sided (isolated)

Palpable abdominal mass

Does not reduce while supine

Diffuse tenderness

testis not separable from

hydrocele,cord palpable

testis separable from

spermatocele.cord palpable

Bag of worms

Hematocele

Hydrocele

Spermatocele Transillumination

Varicocele Ho liansilluminalion.increases

in sice with valsalva.decrease in

size if supine

Indirect Inguinal -( if strangulated) Testis separable from hernia, cord No transillumination

not palpable,cough impulse may

transmit,may be reducible

Hard lump/nodule

Diffuse swelling

Tumour -( if hemorrhagic)

Generalized/Dependenl Edema Often postoperative or

immobilized,checkfor liver

dysfunction

Idiopathic

Table 23. Benign Scrotal Masses

Type Varicocele Spermatocele Hydrocele Testicular Torsion Inguinal Hernia

A benign, sperm- filled Collection of serous fluid that Twisting ol the testicle causing venous

epididymalretention cyst results from a defect or irritation occlusion and engorgement aswell as

in the tunica vaginalis

Usually idiopathic

Found in 5-10% testicular

tumours

Associated with trauma/

infection

Communicating:patent

processus vaginalis,changes

size during day {paediatric)

Non - communicallng: non-patent

processus vaginalis (adult)

Non-tender,intrascrotal mass

Cystic

Transilluminates

Definition Dilatation and tortuosity of

pampiniform plexus

Protrusion of abdominal contents

through the inguinal canal into the

scrotum

Indirect (through internal ting,

often intoscrotum):congenital

Direct (through external ting.rarely

into scrotum):abdominal muscle

weakness

arterial ischemia and infarction

Etiology 15% of men

Due to incompetent valves in the

testicular veins

90% left-sided

Trauma

Cryptorchidism

"Bell clapper deformity'

Many occur in sleep|50%)

Necrosis of glands in 5-6 h

Multiple theories,

including:

Distal obstruction

Aneurysmal dilations of

the epididymis

Agglutinated germ cells

"Bag of worms"

Often painless

Pulsates with Valsalva

Non-tender,cystic mass

Transilluminates

Acute onsetsevere scrotal pain.swelling Asmall bulge in the groin thatmay

increase in size with Valsalva and

disappear when lying down

Canpiesentasaswollenor

enlarged scrotum

Discomfort or sharp pain -

especially when straining,lifting,

or exercising

Hx and P/E

Invagination of the scrotum

Valsalva

Hx/P/E

Glupsets cases

Retractedand transverse testicle

(horizontal lie)

Negative Phren's sign

Absent cremasteric reHex

Investigations P/E P/E U/S torule oul tumour U/S Doppler with probe over testicular

artery

Decrease uptake on 99mlcpertechnetate scintillation scan

[doughnut sign)

Emergency surgical exploration and

bilateral orchiopexy

Definitive diagnosis NOT necessary to

take to OR

Orchiectomy if absentrestoration of

flow to testicle

Valsava U/S torule out tumour

Conservative

Surgical ligationof testicular veins Excise if symptomatic

Percutaneous vein occlusion (coils)

Repair mayimprove sperm count/

motility

Conservative Conservative

Needle drainage (high rate of

surgical recurrence)

Surgical

Treatment Surgical repair

r n

TORSION OF TESTICULAR APPENDIX

• twisting of testicular/epididymal vestigial appendix

LJ

Signs and Symptoms

• clinically similar to testicular torsion, but vertical lie and cremaster rellex preserved

•

“blue dot sign"

blue infarcted appendage seen through scrotal skin in children (can usually be palpated as small,

tender lump)

Indications for Treatment of Varicocele

• Impaired sperm quality or quantity

• Pain or dull ache affecting OOL

. Affected testis fails to grow in

adolescents

• Cosmetic indications (especially in

adolescents)

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Treatment

« analgesia - most will subside over 5-7 d

• surgical exploration and excision if refractory pain Acute scrotal swelling/pain in young

boys is torsion until proven otherwise

HEMATOCELE

• trauma with bleed into tunica vaginalis

• U/S helpful to exclude fracture of testis which requires surgical repair Transilluminatlon refers to light being

transmitted through tissue (l.e. due to

Treatment access fluid)

• ice packs, analgesics,surgical drainage, and hydrocele repair

Penile Complaints Differential of a Benign Scrotal Mass

HIS BITS

Hydrocele

Infection (epididymitis/orchitis)

Sperm (spermatocele)

Blood (hematocele)

Intestines (hernia)

Torsion

Some veins (varicocele)

Table 24. Penile Complaints

Type Peyronie's Disease Priapism Paraphimosis Phimosis Premature

Ejaculation

Definition Acquired curvature of Prolonged erection

penile shaft secondary to lasting >4 h in the

fibrous thickening of tunica absence of sexual

excitement/desire

Retracted foreskin Inability to retract

(behind glans penis) foreskin over glans

that cannot be

reduced

Ejaculation prior to

when one or both

partners desire it.

either before or soon

after intimacy

Psychological factors

Primary: no period of

acceptable control

Secondary:

symptoms after a

period of control,

not associated with

general medical

condition

penis

albuginea

Etiology Etiology unknown

Irauma/repealed

inflammation

Familial predisposition

Associated with DM.

vascular disease,

autoimmunity.Dupuytrcn's Medicalions

conliacturc.erectile Neurogenic

dysfunction,urethral

instrumentation

Penile curvature/

shortening

Pain with erection

Poor erection distal to

plaque

50% idiopathic

Ischemic (common):

Thromboembolic

(sickle cell)

Non-lschemic:

Trauma

Congenital (90%

natural separation by

age 3)

Balanitis

Iatrogenic

(post cleaning/

instrumentation)

Irauma

Infectious (balanitis. Poor hygiene

balanoposthitis).

sexual activity

Hx/P/E Painful erections Painful,swollen glans limitation and pain

signs olnecrosis penis,foreskin

Note:non ischemic Constricting band

{high flow) priapism proximal to corona Balanoposthitis

may present without Dysuria,decreased (infection of prepuce)

urinary stream in

children

Hx and P/E

Ejaculatory latency

elmin

Inability to controlor

delay ejaculation

Psychological distress

when attempting to

retract foreskin

pain

Investigations Hx and P/E Hx and P/E

Cavernosal blood gas

analysis

Doppler U/S of the

penis

Hx andP/E Hx and P/E

Testosteronelevels

if in conjunction with

impotence

Supportive measures:

PDE5 inhibitor for ED

NSAID for pain

Medical management:

Traction device

Intralesional verapamil

Intralesional collagenase

Surgical management:

Incision/excision ofplaque decompression

Phenylephrine

Inlracorporcal

injection q3-5 min

Surgical shunt no

response within1h

Treatment Treat reversible

causes

Manual pressure (with Proper hygiene

analgesia)

Dorsal slit

Circumcision (urgent Dorsal slit

or elective to prevent Circumcision

recurrence)

Rule out medical

condition

Address psychiatric

concerns,counselling

Medication:

SSRI or clomipramine

Topical lidocaineprilocaine

Topical

High-flow:

Self-limited

Consider arterial

embolication

Low-flow:

Needle aspirated

corticosteroids

mm'

wS&

Plication surgery

Penile prosthesis

1. Fibrous plaque

2. Tunica albuginea

3.Corpus cavernosum

4. Buck's fascia

5. Corpus spongiosum

6. Urethra

Erectile Dysfunction

Definition

• consistent (>3 mo duration ) or recurrent inability to obtain or maintain an adequate erection for

satisfactory sexual performance

dbjuno Li

Figure 20. Peyronie’s disease

r n

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Physiology

• erection involves the coordination of psychologic, neurologic, hemodynamic, mechanical, and

endocrine components

• nerves:sympathetic (TU-L2),parasympathetic (S2-4), somatic (dorsal penile/pudendal nerves (S2-4)) +

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U34 Urology Toronto Notes 2023

. erection (“POINT")

parasympathetics > NO release > increased cGMP within corpora cavernosa leading to:

1. arteriolar dilatation Erections POINT AND SHOOT

parasympathetics ~

point

sympathctics/somatics- shoot

2. sinusoidal smooth muscle relaxation -> increased arterial inflow and compression of penile

venous drainage (decreased venous outflow)

. emission ("SHOOT")

• #

sensory afferents from glans

secretionsfrom prostate,seminal vesicles, and ejaculatory ducts enter prostatic urethra

(sympathetics)

• ejaculation (“SHOOT”)

bladder neck closure (sympathetic)

spasmodic contraction of bulbocavernosus and pelvic floor musculature (somatic)

• detumescence

Etiology ("IMPOTENCE’ )

Iatrogenic:pelvic surgery, pelvic

radiation

Mechanical: Peyronie's, post-priapism

Psychological:depression,stress,

anxiety, PTSD.widower syndrome

Occlusive: arterial HTN,DM,smoking,

hyperlipidemia. PVD, impaired venooedusion

Trauma: pcnile/pclvic. bicycling

Extra factors:renal failure, cirrhosis.

COPD. sleep apnea,malnutrition

Neurogenic CNS (e.g.Parkinson's. MS,

spinal cord injury, Guillain-Barre, spina

bifida, stroke), PNS (e.g. DM. peripheral

neuropathy)

Chemical: antihypertensives,

sedatives, antidepressants,

antipsychotics. anxiolytics,

anticholinergics,antihistamines,

antiandrogens (including 5-a reductase

inhibitors),statins. GnRH agonists,

illicit drugs

Endocrine: DM. hypogonadism,

hyperprolactinemia,hypo/hyperthyroid

sympathetic nerves, norepinephrine, endothelin-1 -> arteriolar and sinusoidal constriction ->

penile flaccidity

Classification

Table 25. Classification of Erectile Dysfunction

Psychogenic- OrganicPrevalence

Onset

Frequency

Variation

less common

Sudden

Sporadic

With partner and circumstance

Younger

No organic risk factors

More common

Gradual

All circumstances

No

Older

Risk factors present

Age

Organic Risk Fadors (HTN,DM.

dyslipidemia)

Nocturnal Morning Erection Present Absent

'Combination can co-cxist

Diagnosis

• complete Hx (include sexual, medical, and psychosocial aspects)

• self-administered questionnaires (e.g. International Index of Erectile function, Sexual Health

Inventory for Men Questionnaire, ED Intensity Scale, ED Impact Scale)

• focused P/E, including vascular and neurologic examinations,secondary sexual characteristics

• lab investigations, dependent on clinical picture

• risk factor evaluation:fasting blood glucose or HbAlc, cholesterol profile

optional:T

'

SH,CBC,VIA,testosterone (free and total), prolactin, LH

• specialized testing including nocturnal penile tumescence monitoring usually unnecessary

• evaluation of penile vasculature only relevant with past history of trauma (e.g.pelvic fracture)

Testosterone deficiency is an uncommon

cause of ED

<8>

Treatment

• can often be managed by family physician,see sidebar for when to refer

• consider early sexual counselling referral

• must fully inform patient/partner of options, benefits and complications

• non-invasive

• lifestyle changes (alcohol,smoking, physical activity), psychological (sexual counselling and

education)

change precipitating medications

treat underlying causes ( DM, CVD, HTN, endocrinopathies)

• minimally invasive

• oral medication (see Common Medications, V47 )

sildenafil, tadalafil, vardenafil, avanafil (not available in Canada):inhibits PDE5 to increase

intracavernosal cGMP levels

- all four have similar effectiveness, difference in onset of action is not clinically significant

- tadalafil has longer half-life, no cyanopsia, and can be taken on empty or full stomach

- tadalafil should be taken when needed instead of a set daily dose

• vacuum devices:draw blood into penis via negative pressure,then put ring at base of penis

MUSE: male urethral suppository- for erection - vasoactive substance (PGE1) capsule inserted

into urethra

insufficient evidence supporting low-intensity shockwave therapy

• in patients with hypogonal testosterone, treat with dual testosterone and PDE5 inhibitor

• invasive

intracavernous vasodilator injection/self-injection

triple therapy (papaverine, phentolamine, PGEI), bimix (papaverine and phentolamine) or PGE1

alone

PDE5 inhibitors are contraindicated in

patients on nitrates/nitroglyccrin due to

severe hypotension

Initial trial of MUSE:

or intracavernosal

injection should be done under medical

supervision

Penile vascular abnormalities may be

a marker of risk for CV disease. Young

men with vascular ED have 50x higher

risk of having a CV event

u J

complications: priapism (overdose), fibrosis of tunica albuginea at site of repeated injections +

(Peyronie’s plaque), and injection site injuries (pain, hematoma, etc.)

• surgical

penile implant (last resort): malleable or inflatable

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U35 Urology Toronto Notes 2023

Trauma

• see Emergency Medicine. Elt7

Renal Trauma

Classification According to Severity

• minor

• contusions and superficial lacerations/hematomas:90% of all blunt traumas,surgical exploration

seldom necessary

• major

• laceration that extends into medulla and collecting system, major renal vascular injury,shattered

kidney

Etiology

• 80% blunt (MVC, assaults,falls) vs.20% penetrating (stab wounds and gunshots)

Clinical Features

• mechanism of injury raisessuspicion

• can be hemodynamically unstable secondary to renal vascular injury and/or other sustained injuries:

ABC*

• upper abdominal tenderness, flank tenderness, flank contusions,lower rib/vertebral transverse

processfracture

Investigations

. VIA

hematuria: requires workup but degree does not correlate with the severity of injury

• imaging

• CT (contrast, triphasic) if patient stable: look for renal laceration, extravasation of contrast,

retroperitoneal hematoma, and associated intra-abdominal organ injury

Staging (does not necessarily correlate well with clinical status)

• 1: contusion/hematoma

• 11: <1 cm laceration without urinary extravasation

• III: >1 cm laceration without urinary extravasation

• IV: laceration causing urinary extravasation and /or main arterial or vein injury with contained

hematoma

• V:shattered kidney or avulsion of pedicle

Treatment

• microscopic hematuria + isolated well-staged minor injuries -> no hospitalization

• gross hematuria + contusion/minorlacerations -> hospitalize, bedrest, repeat CT if bleeding persists

• surgical intervention/minimally Invasive angiography and embolization (majority now managed

conservatively, nonoperatively)

absolute indications

hemorrhage and hemodynamic instability

relative indications

non-viable tissue and majorlaceration

urinary extravasation

vascular injury

» expanding or pulsating perirenal mass

» laparotomy for associated injury

• follow-up with U/S or CT before discharge, and at 6 wk

Complications

• HTN in 5% of renal trauma

Bladder Trauma

Classification

• contusions: no urinary extravasation,damage to mucosa or muscularis

• intraperitoneal ruptures:often involve the bladder dome

• extraperitoneal ruptures:involve anterior or lateral bladder wall in full bladder

Etiology

• blunt (MVC,falls, and crush injury) vs. penetrating trauma to lower abdomen, pelvis, or perineum

• blunt trauma is associated with pelvic fracture in 97% of cases

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U36 Urology Toronto Notes 2023

Clinical Features

• abdominal tenderness, distention, peritonitis, and inability to void

• can be hemodynamically unstable secondary to pelvic fracture, othersustained injuries:ABCs

• suprapubic pain

Investigations

• U/A:gross hematuria in 90% of cases

• imaging (including CT cystogram and post-drainage filmsfor extravasation)

Treatment

• penetrating trauma -> surgical exploration

• contusion > urethral catheter until hematuria completely resolves

• extraperitoneal bladder perforations -> typically non-operative with foley insertion, and follow with

cystograms

surgery if: infected urine, rectal/vaginal perforation, bony spike into bladder, laparotomy for

concurrent injury, bladder neck involvement, persistent urine leak, and failed conservative

management

• intraperitoneal rupture usually requiressurgical repair and suprapubic catheterization

Complications

• complications of bladder injury itself are rare

• mortality is around 20%, and is usually due to associated injuries rather than bladder rupture

Urethral Injuries

Etiology

• posterior urethra

common site of injury is junction of membranous and prostatic urethra due to blunt trauma,

MVCs, pelvic fracture

shearing force on fixed membranous and mobile prostatic urethra

• anterior urethra

straddle injury can crush bulbar urethra against pubic rami

• other causes

iatrogenic (instrumentation, prosthesis insertion), penile fracture, masturbation with urethral

manipulation

• alwayslook for associated bladder rupture

Clinical Features

• blood at urethral meatus

• high-riding prostate on DRE

• swelling and butterfly perineal hematoma

• penile and/orscrotal hematoma

• sensation of voiding without U/O

• distended bladder

Investigations

• generally will perform RUG or cystoscopy prior to attempt at catheterization All patients with suspected urethral

injury should undergo RUG

Treatment

• simple contusions

no treatment

• partial urethral disruption

very gentle attempt at catheterization by urologist

with no resistance to catheterization > l oley x 2-3 wk

with resistance to catheterization -> suprapubic cystostomy or urethral catheter alignment

• periodic flow rates/urethrograms to evaluate for stricture formation

• complete disruption

immediate repair if patient stable, delayed repair if unstable (suprapubic tube in interim)

Complications

• stricture

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U37 Urology Toronto Notes 2023

Infertility and Andrology

Definition

• failure to conceive after 1 yr of unprotected and properly timed intercourse

• incidence

15% of all couples (35-40% female, 20% male, 25-30% combined)

Female Factors

Majority of antenatal hydronephroses

resolve during pregnancy or within the

first year of life

• see Gynaecology.GY23

Male Factors

ft Male Reproduction

. HPTA

pulsatile GnRH from hypothalamus acts on anterior pituitary'stimulating release of LH and FSH

LH acts on Leydig (interstitial) cells -> testosterone synthesis and secretion

• I SH acts on Sertoli cells -> structural and metabolic support to developing spermatogenic cells

FSH and testosterone support germ cells(responsible for spermatogenesis)

sperm route:epididymis -> vas deferens-> ejaculatory ducts-> prostatic urethra

Common Terminology on SA

Teratospermia: Abnormal morphology

Asthenospcrmia: Abnormal motility

Oligospermia: Decreased sperm count

Azoospermia:Absent sperm in semen

Mixed types:e.g.oligoasthenospermia

Etiology

• idiopathic (40-50% infertile males)

• testicular

varicocele (35-40% infertile males)

tumour

congenital (Klinefelter’s triad:small,firm testes,gynecomastia,and azoospermia)

post-infectious (epididymo-orchitis,STls, mumps)

uncorrected torsion

cryptorchidism (<5% of cases)

• obstructive

iatrogenic (surgery:see below)

infectious (gonorrhea, chlamydia)

trauma

congenital (absence of vas deferens,CF)

bilateral ejaculatory duct obstruction, epididymal obstructions

Kartagener’

ssyndrome (autosomal recessive disorder causing defect in action of cilia)

• endocrine (see Endocrinology. E51)

• HPTA (2-3%) e.g. Kallmann'

ssyndrome (congenital hypothalamic hypogonadism), excess prolactin,

excess androgens, excess estrogens

• other

Mutation of cystic fibrosis

transmembrane conductance regulator

(CFTR) gene is associated with

congenital bilateral absence of vas

deferens and epididymal cysts,even if

patient manifests no symptoms of CF

WHO Guidelines

Male Infertility Factors

SPERM COUNT

Systemic factor/Smoking

Psychological illness

Endocrinopathy

Retrograde ejaculation

Medications

Chronic disease

Obstructive

Unexplained

Narcotics

• Testicular retrograde ejaculation secondary to surgery

medications

prior exposure to chemotherapy or pelvic radiation

• drugs: cannabis, cocaine, tobacco,alcohol

• increased testicular temperature (sauna, hot baths, tight pants,or underwear)

chronic disease:e.g. liver, renal

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