r) 3-way Toley to help prevent clot formation

should be done after manual irrigation of all clots

• cystoscopy

identify tumours or other source(s)

• coagulate obvious sites of bleeding or transurethral resection of tumours (under general or

regional anesthesia)

Microscopic Hematuria

Definition

• blood in the urine that is not visible to the naked eye

• >2 RBCs/HPT on urinalysis of at least two separate samples

f 2 RBCs/HPfJ

i

Retost after undorlying

^

YES

couso resolved

*

Identify bonign rovorsiblo cousos (o.g. infection,

urethral trauma,hoavy exercise, monsos,medication, etc )

NO

Referral to YES

nephrology

Evidenco of glomerular disease

(t Cr.proteinuria, dysmorphic RBC, RBC casts)?

NO

Negative results AND

LOW RISK patient

*

1) Renal U/S

2) Urine cytology

I

f f

Urinalysis, urine cytology,

and BP at 6.12. 24,

and 36 months

Positive result HIGH RISK patient:

Ago >40 yr old

Smoking history

Occupational chomical oxposuro

Gross homaturia

Hx of storngo or voiding symptoms

Hx of recurrent UTIs,urological disorders

Polvic radiation exposure

r n

iJ

Urological roforral

for cystoscopy

+

Figure 8. Workup of asymptomatic microscopic hematuria

Based on CUA Guidelines.Alternatively.Uie AUA recommends cystoscopy andCT urogram lor all patients with confirmed microscopic hematuria;

follow-up for negativeworkup is urinalysis yearly for two yr. with repeat anatomic evaluation if microscopic hematuria persists

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U6 Urology Toronto Notes 2023

Lower Urinary Tract Dysfunction

• two phases oflower urinary tract function

1.storage phase (bladder tilling and urine storage) requires:

• accommodation and compliance

• no involuntary contraction(s)

2. voiding phase (bladder emptying) requires:

• coordinated detrusor contraction

synchronous relaxation ofoutlet sphincters

• no anatomic obstruction

• lower urinary tract dysfunction can thereforebe classified as:

• failure to store: due to bladder or outlet

• failure to void: due to bladder or outlet

• three types of symptoms

• storage (formerly known as irritative)

voiding (formerly known as obstructive)

post-voiding

Transient Causes of Reversible Urinary

Incontinence in the Elderly

DIAPERS

Delirium

Inflammation/Infection

Aroplik vaginitis/urclhritis

Plratmacculicals/Psychological

Excess U/O

Restricted mobility/Rctcntion

Stool impaction

Urinary Incontinence

Definition

• involuntary leakage ofurine

Epidemiology

• variable prevalence in women:25-45%

. F:M=2:1

• more frequent in the elderly, affecting5-15% ofthose livingin the community and 50% ofnursing

home residents

Urgency is the complaint of a sudden

compelling desire to void that is difficult

to defer it is not necessarily associated

with incontinence

Table 3.Urinary Incontinence:Types and Treatments

Type Stress Urgency Mixed Overflow

Definition Leakage preceded by Leakage withurgency and Leakage associated with

strong,sudden urgeto void increased intra-abdominal urinary retention

pressure

Leakage v/ilhsudden

increasesininlraabdominal pressure

(cough,sneeze,exertion)

Sphincter incompetence Detrusor overactivity

Urethral hypermobility Bladder hypersensitivity

Common inmiddle aged

and older women,and

men following prostate

cancer treatment,or rarely

surgical treatment ol BPH

Hi:when leakage occurs,number ol pads,LUIS,history of neurologic disease,pelvic

suigeryJradiothcrapy.obstetrical history,bowel and sexual function, medications,

impact on quality of tile

P/E:geneial(edema,neurologic abnormalities,mobility, cognition, dexterity),

abdomen (distended bladder).CU (prolapse in women,DRE in men), cough lest

U/A,urine CtS.voiding diary (type of incontinence,how often, volume ol leakage)

Urodynamics

Same as stress and

urgency incontinence

Etiology BPH with overflow

incontinence

From weak bladder that

does not empty (e.g.

diabetic cystopathy)

Investigations SeeUrinary Uelenlion.U1

Risk reduction:weight Conservative:fluid

loss,smoking cessation management, bladder management of stress and Treat underlying cause

Kegel exercisespelvic lloor training.Kegel exercises urgency incontinence

muscle therapy (PfMl) Medication:

Surgciy:urethral slings,or anticholinergics,p-3

artificial sphinctei inmen agonist

Management Combination of Cathcterication

Botulinum toxin A bladder

injection

Hcuromodulation

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Lower Urinary Tract Symptoms

Urinary Retention

• storage symptoms: frequency, urgency (strong need to void ), nocturia (TUN)

• voiding symptoms:stream changes/straining, hesitancy, incomplete emptying, post-void dribbling

(SHHD)

Table 4. Etiology of Urinary Retention

Outflow Obstruction Bladder Innervation Pharmacologic Infection

If a trauma patient is unable to void,

has blood at urethral meatus, a

scrotal hematoma, or a high riding

prostate, there is urethral injury until

proven otherwise so catheterization is

CONTRAINDICATED unless performed by

urology staff or resident

Bladder neck or urethra: calculus, Intracranial: CVA, tumour.

Parkinson's, cerebral palsy

Spinalcord: injury,disc

herniation. MS

Anticholinergics

Narcoltcs

Antihypertcnsives (ganglionic

blockers, melhyldopa)

OTC cold medicationscontaining

Post- abdominal or pelvic surgery ephedrine or pseudoephedrine

Antihistamines

Psychosomatic substances (e.g.

MDMA (ecstasy))

GU: Dll. prostatitis, abscess,

genital herpes

Inlccted foreign body

Varicella toslet

clot, foreign body, neoplasm,

neurological (DSD)

Prostate:8PH. prostate cancer

Urethra:stricture, phimosis,

traumatic disruption

Miscellaneous:constipation,

pelvic mass,severe prolapse in

DM

vromen

Clinical Features

• suprapubic pain (with acute retention), incomplete emptying, weak stream

• palpable and/or percussible bladder (suprapubic)

• possible purulent/bloody meatal discharge (with UTI)

• increased size of prostate or reduced anal sphincter tone (with neurological disease) on 1)R1:

• neurological: presence of abnormal or absent deep tendon reflexes, reduced “anal wink," saddle

anesthesia

Acute vs. Chronic Retention

Acute retention is a medical emergency

characterized by suprapubic pain and

inability to void

Oironic retention can be painless with

greatly increased bladder volume and

detrusor hypertrophy followed by atony

(late)

Investigations

• CBC, electrolytes,Cr, BUN, U/A and urine C&S, U/S, cystoscopy, urodynamic studies, PVR

Treatment

• treat underlying cause

• catheterization

• acute retention

immediate catheterization to relieve retention; leave Tolev in to drain bladder;follow-up to

determine cause; closely monitor fluid status and electrolytes (risk of POD)

chronic retention

intermittent catheterization by patient may be used;definitive treatment depends on etiology

• suprapubic catheter if obstruction precludes urethral catheter

• for postoperative patients with retention:

• encourage ambulation

• a-blockers to relax bladder neck /outlet ( men only)

may need catheterization

definitive treatment will depend on etiology

• minimize narcotic use

Patients with ascites may have a falsely

elevated PVR measured by bladder scan

r

Anterior Benign Prostatic Hyperplasia libromuscular area Transition

zone

Definition

• proliferation of epithelial tissue, connective tissue, and smooth muscle in the prostatic transition zone

Etiology

• unknown

DHT required (converted from testosterone by 5-a reductase)

« possible role of impaired apoptosis, estrogens, other growth factors

Urethra Urethral

zone

Peripheral zone

Central zone

Epidemiology

• age- related, extremely common (50% of 50 y/o, 80% of 80 y/o)

• 25% of men will require treatment

Ejaculatory zone

Maaghan Briailoy j

Figure 9. Cross-section of prostate

r n Clinical Features

• result from outlet obstruction and compensatory and/or age-related changes in detrusor function

• voiding and storage symptoms

. DRfi

L J

Prostate size does not correlate well

• with symptoms in BPH prostate is smooth, rubbery, and may be symmetrically enlarged +

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U8 Urology Toronto Notes 2023

• complications

retention

overflow incontinence

hydronephrosis

• renal insufficiency

• infection

• gross hematuria

• bladder stones

Approximate Prostate Sizes

20 cc - chestnut

25 cc - plum

50 cc -lemon

75 cc - orange

300 cc - grapefruit

Investigations

• mandatory: Hx including LUTS,surgery, trauma, medications (OTC and phytotherapeutic agents),

impact of QOL, P/E including DRE,VIA to exclude UTT

• recommended:symptom inventory (IPSS or AUA-Symptom Index (SI)), PSA if >10 yr life expectancy

or if it changes management of LUTS

AUA BPH Symptom Score

FUNWISE

Frequency

Urgency

Nocturia

Weak stream

Intermittency

Straining

Emptying,incomplete feeling of

• optional: Ur, urine cytology, uroflowmetry, PV R, voiding diary, sexual function questionnaire

• renal U/S to assess for hydronephrosis

• consider cystoscopy or bladder ultrasound prior to potential surgical management to evaluate outlet

and prostate volume

• biopsy if suspicious for malignancy, i.e.elevated PSA or abnormal DRE

Each symptom graded out of 5

0-7:Mildly symptomatic

8-19: Moderately symptomatic

20-35: Severely symptomatic

Note: dysuria not included in score but Is

commonly associated with BPH

Treatment

Table 5. Treatment of BPH (see Table 28, U47, Figure 6, U3, and Figure 7, U4)

Conservative Medical Surgical Minimally Invasive

Surgical Therapies

When to use Asymptomatic or mildly

symptomatic,minimal

bother

Watchful waiting:50“

of patients improve

spontaneously

lifestyle modifications

|e.g. evening lluid

restriction, planned

voiding)

Moderately to severely Absolute or relative

symptomatic,bothersome indications,significant

bother

o-adrenergic antagonists: TURP (see U45)

reduce smooth muscle tone BPK VP (< 60 cc)

(neck of bladder,prostate, laser prostatectomy

urethra)

5- a reductase inhibitor:

block conversion ol

testosterone to DM;ad to (»100 cc)

reduce proslate sice

Combination of

u-adrenergic antagonists

and 5-a reductase inhibitor

is synergistic

Antimuscarinics or p- 3

agonist (for storage IUIS.

without elevated PVR)

P0E5 inhibitors|E0 and for

storage and voiding IUIS)

Desmopressin (IUIS

with nocturia);risk of

hyponatremia in »65 yr

Patients who wish to avoid

or maynot tolerate surgery

Initial a-adrenergic antagonist

monotherapy for score <20,combination

therapy for score >20 (type of

medication is sice-dependent;5-a

reductase inhibitor beneficial with larger

prostates)

Options TUMI

UroLift (<80 cc)

Convective water vapour

energy ablation (Return'

)

Proslalic stent (for those

Open simple prostatectomy unlit for surgery)

IUIP(<30 cc|

Aquablation (<80 cc)

Men with planned cataract surgery

should avoid starting a-adrenergic

antagonists until after their surgery due

to the risk of intraoperative floppy iris

syndrome

Urethral Stricture

Definition

• decrease in urethral caliber due to scar formation in urethra

. M>l

;

BPH Surgery

Absolute Indication

• Renal failure with obstructive

uropathy

• Refractory urinary retention Etiology

• congenital

failure of normal canalization (e.g. posterior urethral valves)

• trauma

• instrumentation/catheterization (most common)

• external trauma (e.g. burns,straddle injury)

• foreign body

• infection

long-term indwelling catheter

STT (gonococcal or chlamydial disease)

• inflammation

balanitis xerotica obliterans (BXO;lichen sclerosus or chronic progressive sclerosing dermatosis

of the male genitalia) causing meatal and urethral stenosis

• radiation

• malignancy (urothelial carcinoma)

• most urethral cancers in men are squamous ( vs. prostate,bladder, or upper tract that are mostly

transitional cell in origin)

Relative Indications

• Recurrent UTIs

• Recurrent hematuria refractory to

medical treatment

• Renal insufficiency (rule out other

causes)

• Bladder stones

• Severe symptoms unresponsive to

medical therapies ri

u J

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Clinical Features

• voiding and storage symptoms +/- gross hematuria

• urinary retention

• hydronephrosis

• related infections: recurrent UTI,secondary prostatitis/epididymitis

(§>

Combination Therapy is. a- Blocker or SARI

BJUInl 2l)I1;10|J $):946-54

Rriposo to tomparnst inidenteolacute urinary

retertm. benign prmtatic hyptrplasu (BPH)-

related surgery and overall clinical progression in

patients treated mill tamsolosin.dutasteride. and

combination tlierapy.

Methods: 4 yr com bination of dutasteride and

tamsulosin study was a multicentre double-blind RCT

ot outcomes in men >50 yr with symptomatic BPH.

with PSA >1.5 nglmland <10 ng /ml, and prostate

volume <30 ml Patients received tamsulosin,

dutasteride or combination therapy. Primary

endpoint was time to hist acute urmary retention or

BPH-related surgery:secondary endpoint was clinical

progression of BPk'symptoms.

Results:Combination therapy resulted insignihcantly

greater improvementsin symptoms compared to

dutasteride from 3mo.and tamsulosin from 9 mo.

and in BPH -related health statusfrom 3 and 12 mo.

respectively.There was a significant increase ut

Adverse Orug (vents|A0t ) with combination therapy

vs. monotherapies.However,withdrawal rates due to

drug-related adverse events weie similar across the

treatment groups.

Conclusions: Men with baseline prostate volume

>40 mL and basehne PSA ^VS ng /mLhad greater

reductions in relative risk (RR) of BPH -related surgery

and RR of clinical progression on combmed therapy

oi dutasteride monotherapy thanon tamsulosin

monotherapy.

Investigations

• laboratory findings

flow rates <10 mL/s(normal >15 mL/s) on uroflowmetry

urine culture usually negative, but V I A may show pyuria

• radiologic findings

• RUG and VCUG will demonstrate location

• cystoscopy

Treatment

• urethral dilatation

• temporarily increases lumen size by breaking up scar tissue

healing will often reform scar tissue, recurrence ofstricture

• visual internal urethrotomy (V1U )

• endoscopically incise stricture

• equal success rates to dilation with mid bulbar strictures <2 cm

• high rate of recurrence (30-80%), avoid in younger patients

• open surgical reconstruction (urethroplasty)

complete stricture excision with anastomosis depending on location and size of stricture

may require graft to reconstruct (e.g.buccal mucosa)

higher success rate than urethral dilatation or visual internal urethrotomy

Neurogenic Bladder

Definition

• dysfunction of the urinary bladder due to deficiency in some aspect of its innervation, often presents

with overflow incontinence and urgency incontinence

Neurophysiology

• see Figure 6, U3 and Figure 7, U4

• stretch receptors in the bladder wall relay information to PMC and activate micturition reflex

(normally inhibited by cortical input)

• micturition (voiding)

• stimulation of parasympathetic neurons (bladder contraction)

inhibition of sympathetic and somatic neurons (internal and externalsphincter relaxation,

respectively)

voluntary relaxation of the pelvic floor and striated urethral sphincter

• urine storage

• opposite of micturition

• voluntary action of external sphincter ( pudendal nerve roots S2-S4) can inhibit urge to urinate

• cerebellum, basal ganglia, thalamus, and hypothalamus all have input at PMC in the brainstem to

inhibit the detrusor reflex

Finasteride forBenign Prostatic Hyperplasia

Cochrane DB Syst Rev 20IO;10:CD006015

Rirpose: to eienn ne the effectmenessard safety of

finasteride vs. placeboot other active controlsfor Ibe

treatment oi unitary tract symptoms.

Summery of findings:

t. Finasteride improved unoaiy symptoms more than

placebo nr trials >1yr duration and significantly

lowered the risk of BFH progress on.

2.Compared with o-bfockers.finasteride was less

effective than either doisiosin or terazosin,but

equally as effective astamsulosin.

3.5ymptom improvement with finasteride dotamsm

is equal todoraiosin alone.

4.Furasleride treatment resulted in an increased risk

ol ejaculation disorder,impotence, and lowered

libido compared with placebo.

5.Compared with doraiosm and teraiosin, finasteride

had a lower rsk of asthenia, doziness, and postural

hypotension.

Examples of Neurogenic Lower Urinary Tract Dysfunction

• neurogenic detrusor overactivity (NDO;formerly termed detrusor hyperreflexia)

» lesion above PMC (e.g. stroke, tumour, MS, Parkinson’

s disease)

• loss of voluntary inhibition of voiding

• intact pathway inferior to PMC maintains coordination of bladder and sphincter Nerve

m

roots in micturition:

"S2-3-4 keeps the urine off the floor"

. DSD

• suprasacral lesion of spinal cord (e.g. trauma, MS, arteriovenous malformation, transverse

myelitis)

loss of coordination between detrusor and sphincter (detrusor contracts on closed sphincter and

vice versa)

component of detrusor overactivity as well

• detrusor atony/arellexia

• lesion of sacral cord or peripheral nerves (e.g. trauma, DM, disc herniation, MS, congenital spinal

cord abnormality, post abdominoperineal resection)

flaccid bladder which fails to contract

» may progress to poorly compliant bladder with high pressures

• peripheral autonomic neuropathy

deficient bladder sensation -> increasing residual urine -> decompensation (e.g. DM,

neurosyphilis, herpes zoster)

• muscular lesion

• can Involve detrusor,smooth/striated sphincter

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Neuro-Urologic Evaluation

• Hx and P/E (urologic and general neurologic)

• voiding diary, assess for incontinence, urinary symptoms, and UT1 risk (hydration status,

catheterization, voiding frequency)

• catheterization volumes in patients with CIC

• all patients: U/A, PVR, renal profile

moderate/high-risk (spinal cord injury,spina bifida, MS): urodynamics, renal U/S, renal profile

• imaging

• U/S to rule out hydronephrosis and stones;occasionallyCl'

scanning with or without contrast

• cystoscopy (if suspicion of bladder tumour, hematuria)

• urodynantic studies

• uroflowmetry to assess flow rate, pattern

• filling CMG to assess capacity, compliance, detrusor overactivity

• voiding CMG (pressure-flow study) to assess bladder contractility and extent of bladder outflow

obstruction

» video study to visualize bladder/bladder neck/urethra during CMG using x-ray contrast

EMG and video ascertains presence of coordinated or uncoordinated voiding,allows accurate

diagnosis of DSD

“Spinal shock”initially manifests as

atonic bladder

Treatment

• goals of treatment

• prevent renal deterioration

• prevent infections (UTI)

achieve social continence

• CIC (if there is associated inability to void)

• treatment options depend on status of bladder and urethra

bladder hyperactivity -> antimuscarinic medicationsto relax bladder (see Urinary Incontinence,

U6 )

if refractory

- botulinum toxin injections into bladder wall (detrusor muscle)

- occasionally augmentation cystoplasty (enlarging bladder volume and improving

compliance by grafting section of detubularized bowel onto the bladder)

- occasionally urinary diversion (ileal conduit or continent diversion) in severe cases if

bladder management unsuccessful

flaccid bladder > CIC

Dysuria

Definition

• painful urination

Etiology

Table 6. Differential Diagnosis of Dysuria

infectious Cystitis,urelhrilis.prostatitis, epididymilis/orchitis (if associated withlower trad inflammation),cervicitis,

vulvovaginitis,perineal Inflammalion/infeclion.tuberculosis, vestibulitis

Kidney,bladder,prostate,penis,vagina/vutva. BPH

Bladder stone,urethral stone,ureteral stone

Seronegative arthropathies (reactive arthritis:arthritis,uveitis,urethritis),drug sideeffects,autoimmune

disorders,chronic pelvic painsyndrome (CPPS),interstitial cystitis

Endometriosis,hypoestrogenism

Catheter insertion,post-coital cystitis (honeymoon cystitis)

Somatiiation disorder,depression, stress/amiely disorder

Contact sensitivity,foreign body,radialion/chcmical cystitis,diverticulum

Hcoplasm

Calculi

Inflammatory

Hormonal

Trauma

Psychogenic

Other

Investigations

• focused Hx and P/E to determine cause (fever, d/c, conjunctivitis, CVA tenderness, back/joint pain)

• any d/c (urethral, vaginal, cervical) should be sent for gonococcus/chlamydia testing; wet mount

if vaginal d/c

U/A and urine C&S

ifsuspect infection,may start empiric ABx treatment (see Table 9, U16 )

± imaging of urinary tract (tumour,stones)

n

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Hydronephrosis

Definition

• the upper urinary tract consists of the kidneys and ureters

• dilation of the renal pelvis, calyces,and ureters,generally caused hy obstruction of antegrade urine

flow (i.e. pelvicaliectasis)

Etiology

• mechanical

« congenital:see Congenital Abnormalities, U39

acquired

intrinsic:trauma, inflammation and bleeding, calculi, urologic neoplasms, BPH, urethral

stricture, phimosis, previous urological surgery

extrinsic:trauma, neoplasms (uterine fibroid; colorectal, uterine, and cervical malignancies;

lymphoma), aortic aneurysm, pregnancy (gravid uterus)

• functional

neuropathic: neurogenic bladder, diabetic neuropathy,spinal cord disease

hormonal: pregnancy (progesterone decreases ureteral tone)

Investigations

• focused Hx, inquiring about pain (flank, lower abdomen, testes, labia), U/O, medication use,

pregnancy, trauma, fever, Hx ofUTls, calculi, FID, and urologicalsurgery

. CBC, electrolytes,Cr, BUN,VIA, urine C&S

• imaging studies ( U/S is >90% sensitive and specific)

CT:helps delineate anatomy and potential causes (e.g.obstructing stone),but does not provide

much functional information

mercaptoacetyltriglycine (M A(i3) diuretic renogram: provideslittle anatomic structural

information but evaluates differential renal function and demonstrates if functional obstruction

exists

retrograde pvelogram:helps to delineate anatomy and can allow for stent insertion to decompress

if obstruction is present

Treatment

• hydronephrosis can be physiologic (e.g. pregnancy)

• treatmentshould be guided at improving symptoms, treating infections, or improving renal function

• urgent treatment may require percutaneous nephrostomy tube or ureteralstenting to relieve pressure

• treatment can include pyeloplasty to repair an obstructed UP) in congenital or acquired UP)

obstruction

Post-Obstructive Diuresis

Definition

• polyuria resulting from relief of obstructive uropathy (i.e. elevated creatinine)

• >3 L/24 h or >200 cc/h for two consecutive hours

Pathophysiology

• physiologic POD secondary to excretion of retained urea, Na and H2O (high osmotic load) after relief

of obstruction

self-limiting; usually resolves in 48 h with PO fluids but may persist to pathologic POD

• pathologic POD is a Nan -wasting nephropathy secondary to impaired concentrating ability of the

renal tubules due to:

decreased reabsorption of NaCl in the thick ascending limb and urea in the collecting tubule

increased medullary blood flow (solute washout)

increased flow and solute concentration in the distal nephrons

Management

• admit patient and closely monitor hemodynamic status and electrolytes(Na ' and K+q6-l2 h and

replace pm; follow Cr and BUN to baseline)

• monitor U/O q2 h and ensure total fluid intake <U/0 by replacing every I ml. U/O with 0.5 mL 1 /2

normal saline (NS) IV (PO fluids if physiologic POD)

• avoid glucose-containing fluid replacement (iatrogenic diuresis)

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Overactive Bladder

Definition

• a symptom complex that includes urinary urgency with or without incontinence, urinary frequency

(voiding >8 timesin a 24 h period),and nocturia (awakening ONE or more times at night to void)

Etiology

• multiple etiologies proposed (neurogenic, myogenic, idiopathic)

• symptoms thought to be from involuntary contractions of the detrusor muscle

• may be associated with other conditionssuch as SU1 in women and BPH in men (see Table 5, U8)

Epidemiology

• l

'

:M =l:l

• prevalence increases with age. 42% in males £75 y/o; 31% in females £75 y/o

• women experience incontinence more commonly than men

Diagnosis

• the diagnostic processshould documentsymptoms that define overactive bladder and exclude other

disorders that could cause the patient'

ssymptoms

• minimal requirements for the process consist of:

• focused history including past genitourinary disorders and conditions outlined in Table 7,

questionnaires of LUTS and diaries of urination frequency, volume and pattern (3d micturition

diary)

P/E including genitourinary, pelvic,and rectal examination

U/A to rule out hematuria and infection

• in some patients, the following investigations could be considered

post

-void residual

cystoscopy to rule out recurrent infections, carcinoma in situ and other intravesical abnormalities

• urodynamics to rule out obstruction in older men

Treatment

• non-pharmacological:behaviour therapies such as bladder training, bladder control strategies, pelvic

floor muscle training, fluid management, weight reduction (if overweight), and avoidance of caffeine

and alcohol

• pharmacological (see Table 29, U48)

antimuscarinics:oxybutynin hydrochloride, tolterodine,solifenacin, fesoterodine,darifenadn,

propiverine, or trospium

(53-adrenoceptor agonist: mirabegron

• refractory patients may be treated with:

neuromuscular-junction inhibition: botulinum toxin bladder injection

• others

percutaneous tibial nerve stimulation (not used commonly in Canada)

sacral neuromodulation

Table 7. Conditions that Could Contribute to Symptoms of Overactive Bladder

Lower Urinary Tract Conditions

Neurological Conditions

Systemic Diseases

Functional and Behavioural

Medication

UII. obstruction, impaired bladder contractility

Stroke, MS, dementia,diabetic neuropathy

CNF,sleep disorders[primarily nocturia)

Excessive caffeine andaicohol, constipation, impaired mobility

diuretics, anticholinergic agents, narcotics, calcium - channel blocker, cholinesterase inhibitors

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Infectious and Inflammatory Diseases

Table 8. Antibiotic Treatment of Urological Infections

Condition Drug Ouration

Urethritis Non Gonococcal

aiithromycin (1g PO) ild

Antibiotic therapy should always be

based on local resistance patterns

and adjusted according to culture and

sensitivity results

J ! !

doxycydine (100 mg PO BID)

Gonococcal

ceftriaxone (250 mgIM) AND treat for Chlamydia liachamolis

7 d

xl

Simple,Uncomplicated UTI TMP/SMX (160 mg/800 mg P0 BID) 3 d

:J H

nilrofuranloin (100 mg PO BIO)

ciprofloxacin (1g PO once daily OR 400 mg IV q12 h)

Sd

Complicated UTI up to 2-3 wk

OR

ampicillin (1g IV q6 h)* gentamicin (1mg/kg IV q8 h) (used for relatively up lo 2-3 wk

short courses because of loxicily)

OR

ceftriaxone (1-2 g IV q24h)

Prophylactic Treatment

Continuous:IMP SMX (40 mg/200 mg POOHSOR 3x/wk)

up to 2-3 wk

Recurrent/Chronic Cystitis

6-12 mo

: n:

nitrofurantoin (50-100 mg PO OHS)

Post-Coital:TMP-SMX (40mg/200 mg-80 mg!400 mg)

6-12 mo

within 2h of coitus

OR

nitrofurantoin (50-100 mgP0 once daily)

ciprofloxacin (500- 750 mgP0 BID)

within 2 h olcoitus

Acute Prostatitis 2-4 wk

OR

TMP-SMX (160 mg/800 mg PO BID) 4 wk

OR

IV therapy with gentamicin and ampicillin. penicillin with (Maclaniase 4 wk|IV and oral step- down)

inhibitor,3rdgen cephalosporin. OR a fluoroquinolone

ciprofloxacin (S00 mg PO BID)

in-blockers.anti-inflammatories

<35 yr (presumed S1I) celtiiaxone (200 mg IM)

Chronic Prostatitis 4-6 wk

Epididymitis/Orchitis xl

AND

doxycydine (100 mg P0 BID)

>35 yr (presumed urinary source)

ofloxacin (300 mg P0BID)

ciprofloxacin (500 mg PO BID)

± ceftriaxone (1g IV) OR ciprofloxacin (400 mg IV)

10 d

10 d

Acute Uncomplicated

Pyelonephritis

7 d

x1

Acute uncomplicated pyelonephritis:

suspected or confirmed Enterococcus

infection requires treatment with

ampicillin

OR

IV therapy with a fluoroquinolone, gentamicin and ampicillin,

extended spectrum cephalosporin, extended spectrum penicillin.OR a

carbapenem

14 d total IV and oral slop - down

Urinary Tract Infection

•for UTls during pregnancy, see Obstetrics, OB31

Definition

•symptoms suggestive of UTI + evidence of pyuria and bacteriuria on U/A or urine C&S

if asymptomatic + 100000 Cl-

'

U/mL = asymptomatic bacteriuria; only requires treatment in

certain patients (e.g. pregnancy, immunosuppressed, prior to urologic surgery)

Classification

•uncomplicated: lower UTI in a setting of functionally and structurally normal urinary tract

•complicated: structural and/or functional abnormality, male patients, immunocompromised,

diabetic, iatrogenic complication, pregnancy, pyelonephritis, catheter-associated

•recurrent:see Recurrent/Clironic Cystitis, U14

Risk Factors

•stasis and obstruction

• residual urine due to impaired urine flow (e.g. PUVs, reflux, medication, BPH, urethral stricture,

cystocele, neurogenic bladder)

•foreign body

• introduce pathogen or act as nidus of infection (e.g. catheter, instrumentation)

•decreased resistance to organisms

DM, malignancy, immunosuppression, spermicide use, estrogen depletion, antimicrobial use

•other factors

• trauma, anatomic abnormalities, female, sexual activity, menopause, fecal incontinence

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UM Urology Toronto Notes 2023

Clinical Features

• storage symptoms:frequency, urgency

• voiding symptoms:hesitancy, post-void dribbling, dvsuria

• other:suprapubic pain, hematuria,foul-smelling urine

• pyelonephritis-if present:typically presents with more severe symptoms (e.g.fever/chills, CVA

tenderness,flank pain)

Indications for Investigations

• pyelonephritis

• persistence of pyuria/symptoms following adequate antibiotic therapy

• severe infection with an increase in Cr

• recurrent/persistent infections

• atypical pathogens (urea splitting organisms)

• Hx ofstructural abnormalities/decreased flow

Prevention of UTIs

• Maintain good hydration (try

cranberry preparations or

D-mannose)

• Avoid feminine hygiene sprays and

scenlcd douches

• Empty bladder immediately before

and aflcr intercourse

• Vaginal estrogen therapy for periand post menopausal women with

recurrent UTIs

Investigations

• U/A, urine C&S (only ifsymptomatic)

U/A:leukocytes ± nitrites ± hematuria

C&S: midstream, catheterized, or suprapubic aspirate

• if hematuria present, retest post-treatment, if persistent need hematuria workup (see Microscopic

Hematuria, US )

• U/S,CT scan if recurrent or treatment-resistant UTIs,suspected anatomic abnormalities, history

indicates complicated cystitis

• pelvic examination for women if recurrent UTI

Treatment

• see Table 8, Antibiotic Treatment of Urological Infections,U13

• asymptomatic bacteriuria should not be treated (exceptions:pregnancy, before urological procedure)

• if febrile, consider admission with IV therapy and rule out obstruction

Prevention of UTIs

• maintain good hydration (emerging evidence re: cranberry preparations and D-mannose)

• void regularly (do not hold urine for prolonged periods of time)

• avoid feminine hygiene sprays and scented douches

• empty bladder immediately before and after intercourse

Organisms

• typical organisms:SEEK PP (£. coli 75-95%)

• atypical organisms

tuberculosis (TB)

Chlamydia trachomatis

Mycoplasma (Ureaplasma urealyticum)

fungi (Candida)

Recurrent/Chronic Cystitis

Definition

• >3 UTls/yr

Etiology

* bacterial reinfection (80%) vs.bacterial persistence (relapse)

• bacterial reinfection

recurrence of infection with either 1) a different organism, 2) the same organism if cultured

>2 wk following therapy, or 3) with any organism with an intermittent sterile culture

• bacterial persistence

same organism cultured within 2 wk of sensitivity-based therapy

Investigations

• assess predisposing factors

• investigations may include cystoscopy, U/S,CT

Treatment

• lifestyle changes(limit caffeine intake, increase fluid/H’

0intake)

• ABx (variousstrategies):continuouslow-dose daily suppression vs. post-coital only vs.self-start

therapy

• post-menopausal women: consider topical estrogen therapy

• no treatment for asymptomatic bacteriuria except in pregnant women or patients undergoing urinary

tract instrumentation

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U15 Urology Toronto Notes 2023

Interstitial Cystitis (Painful Bladder or Bladder Pain

Syndrome)

Definition

• bladder pain, chronic urgency, and frequency without other identifiable causation

Classification

• non-ulcerative (more common) and ulcerative (Hunner’s lesions)

Etiology

• unknown

Epidemiology

• prevalence: 20 in 100000

• 90% of cases are in females, 94% are white

• median age is 40 yr (non-ulcerative seen in younger to middle-aged, while ulcerative seen in middleaged to older)

Clinical Features

• pelvic pain (typically supra-pubic tenderness)

• storage symptoms (frequency > urgency > nocturia)

• negative U/A, urine C&S, urine cytology

• cystoscopy: glomerulations(submucosal petechiae), Hunner’slesions

Differential Diagnosis

• urology: non-infectious cystitis (radiation, chemical, eosinophilic, TB), OAB, bladder calculi, prostaterelated pain

• gynaecology: endometriosis, vulvar disorders

• neurology: pudendal nerve entrapment

• MSK:pelvic floor disorders

• drugs:ketamine, tiaprofenic acid

Cystoscopic evaluation is not necessary

to make a diagnosis

Investigations

• Hx,P/E,frequency volume chart

• symptom scoresto establish baseline and response to treatment

• U/A, urine C&S, urine cytology

• cystoscopy

Treatment

• first line: patient education, dietary modifications, bladder retraining,stress management

• pelvic floor physiotherapy can be added for patients with pelvic floor dysfunction or pelvic pain

• second line:guided by symptom phenotype

» oral: amitriptyline, cimetidine, hydroxyzine, pentosan polysulfate (PPS),gabapentin, quercetin

intravesical:dimethylsulfoxide, heparin, lidocaine, PPS,oxybutynin

• third line: hydrodistension, botulinum toxin A,sacral neuromodulation

endoscopic treatment if Hunner'

slesions(cauterization, resection, triamcinolone injection)

• fourth line:radical surgery (substitution cystoplasty or urinary diversion ± cystectomy)

Acute Pyelonephritis

Definition

• infection of the renal parenchyma with local and systemic manifestations

• clinical diagnosis of flank pain,fever, and elevated WBC

Etiology

• ascending from lower UT1(usually Gram-negative bacilli) or hematogenous route (usually Grampositive cocci)

• causative microorganisms

Gram positives:Enterococcus faecalis,S.aureus, S.saphrophyticus

Gram negatives: E. coli, Klebsiella, Proteus, Pseudomonas, Enterobacter

• common underlying causes of pyelonephritis

• stones, strictures, prostatic obstruction, vesicoureteric reflux, neurogenic bladder, catheters,

DM,sickle-cell disease,PCKD, immunosuppression, post-renal transplant, instrumentation,

pregnancy

Clinical Features

• rapid onset (<24 h)

• LUTS including frequency, urgency, hematuria; NOT dysuria unless concurrent cystitis

• fever, chills, nausea, vomiting, myalgia, malaise

• CVA tenderness and/or exquisite flank pain

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U16 Urology Toronto Notes 2023

Investigations

• U/A, urine C&S

• CBC and differential:leukocytosis, left shift

• imaging if complicated pyelonephritis orsymptoms do not improve with 48-72 h of treatment

abdominal/pelvic U/S

• CT

• nuclear medicine: DMSA scan can be used to help secure the diagnosis

• a photopenic defect indicates active infection or scar; if normal alternative diagnoses should be

considered

Treatment

• hemodynamically stable

outpatient oral ABx treatment ± single initial IV dose (see Tabic 8. U I3)

• severe or non-resolving

admit, hydrate, and treat with IV ABx (see Table 8,UB)

• emphysematous pyelonephritis

• most patients receive nephrectomy after IV ABx started and patient stabilized

consider temporization with nephrostomy tubes

• renal obstruction

• admit for emergent stenting or percutaneous nephrostomy tube

Prostatitis/Prostatodynia

Epidemiology

• prevalence:9% of rnen/yr, 6% with bothersome symptoms

• most common urologic diagnosis in men <50 v/o, 3rd most common in men >50 y/o

Classification

Table 9. Comparison of the Four Types of Prostatitis

Acute Bacterial

Prostatitis (Category Prostatitis (Category Syndrome (Category Prostatitis (Category

Chronic Bacterial Chronic Pelvic Pain Asymptomatic

I) ID III) IV)

Etiology Acute infection

SEEK PP|80% f. co/r)

Chronic inlection t

prostatitis symptoms

Symptoms without

evidence ol inlection

IIIA:inflammatory

DIB: noninflammatory

LUIS, pelvic pain

IIIA:leukocytosis in

prostatic fluid

1116: no leukocytosis in

prostatic fluid

Incidental inflammation

Clinical Features LUTS, pelvic pain

Systemic signs:fever,

chills, malaise

leukocytosis in prostatic

LUTS, pelvic pain

No systemic signs

Recurrent UIIs

Leukocytosis in prostatic

No symptoms

leukocytosis in prostatic

fluid

Hud fluid

Positive bacterial cultures Posilivc bacterial cultures

Hx. P/ E (abdominal,

external genitalia,

perineum, prostale)

U/A. urine CSS

1RUS if suspect abscess

Investigations Hx.P/E (same asCategory I Hx, P/E (same as

pelvic floor)

4 glass test for culture:

V61 (urethra)

V82 (bladder)

EPS (post

- massage)

V83 (post-massage)

A8x (see Table 8.1113)

- blocker if obstruction

No investigations unless

considering ABx for

Symptom score (NIH -CPSI’) elevated PSA or infertility

4- glasslest

Consider psychological

assessment

Category II)

ABx (see Table 3. U13)

Catheterization if severe

obstructive

Drainage if abscessis

present

Supportive measures

ABx if ABx naive

Multimodal therapy

(UP0IN1). including:

o- btockers

Anti- inflammatories

Phytotherapy (quercetin,

cernilton)

Treatment ABx if elevated PSA.

infertility,or planned

prostate biopsy

'NIH-CPSI:National Institute of Health Chronic Prostatitis Symptom Index

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Epididymitis and Orchitis

Etiology

• common infectious causes

<35 yr: Neisseria gonorrhoeae or Chlamydia trachomatis

£35 yr or penetrative anal intercourse:Cil organisms(especially E. coli)

• other causes

mumps infection may involve orchitis, post-parotitis

TB

syphilis

• granulomatous (autoimmune) in elderly men

amiodaronc (involves only head of epididymis)

chemical:rellux of urine into ejaculatory ducts

Risk Factors

. UTI

• unprotected sexual contact

• instrumentation/catheterization

• increased pressure in prostatic urethra (straining, voiding, heavy lifting) may cause reflux of urine

along vas deferens -> sterile epididymitis

• immunocompromised

It unsure between diagnoses of

epididymitis and torsion, always go

to OR

Remember:torsion >6 h has poor

prognosis

Clinical Features

• sudden onset scrotal pain and swelling ± radiation along cord to flank

• scrotal erythema and tenderness

• Prehn’s Sign (relief of pain with lifting of testicle)

• fever

• storage symptoms, purulent d/c

• reactive hydrocele

Investigations

• U/A, urine C&S

• ± urethral d/c:Gram stain/culture

• if diagnosis uncertain, MUST rule out testicular torsion ( U/S Doppler)

• U/S can confirm diagnosis with increased vascularity

Treatment

• rule out torsion (see Table 23, Investigations, U32)

• see Table H , UI 3 for Mix therapy

• scrotal support, bed rest, ice, analgesia

Complications

• if severe -> testicular atrophy

• 30% have persistent infertility problems

• inadequately treated acute epididymitis may lead to chronic epididymitis or epididymo-orchitis

Urethritis

Etiology

• infectious or inflammatory (e.g. reactive arthritis) Reactive Arthritis (formerly known as

Reiter'ssyndrome)

Urethritis, uveitis (or conjunctivitis), and

arthritis

(can’t pee, can’tsee, can’t climb a tree)

Table 10.Infectious Urethritis:Gonococcal vs. Non-Gonococcal

Gonococcal Non-Gonococcal

Causative Organism

Diagnosis

Usually Chlamydia twcliomatis

Hr of seiual contact,mucoidwhitish purulent

die,

'

Storage LUTS

Gram stain demonstrates >4 PMN/

oil immersion field,no evidence of H.

gonorrhoeae,urine PCR and/or culture Irom

urethral specimen

See Table 8. U13

Heissetiogonorrhoeae

Hx ol sexual contact,thick, profuse, yellowgrey purulent d/c. LUTS

Gram stain |GN diplococci),urine PCR and/or

culture from urethral specimen

If culture negative or unresponsive

to treatment consider:Ureaptasma

urealyticum, Mycoplasma genitalium.

Trichimonas vaginalis. HSV, or

adenovirus Trcalmenl See Table 8. U13

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U18 Urology Toronto Notes 2023

Stone Disease

Epidemiology

• prevalence: ~8% and increasing

• M:l

;

*2:l

• peak incidence 30-50 yr of age

• recurrence rate:10% at 1 yr, 50% at 5 yr, 60-80% lifetime

• calcium oxalate most common stone type;othersinclude uric acid,struvite, calcium phosphate,

cystine, etc.

Risk Factors

• hereditary: RTA,glucose-6-phosphate dehydrogenase deficiency, cystinuria (defect in the proximal

renal tubular reabsorption of cystine), COLA syndrome (defect in resorption of cystine,ornithine,

lysine and arginine), xanthinuria, hyperoxaluria, etc.

• lifestyle:minimal fluid intake (most common risk factor); excess vitamin C, oxalate, purines, calcium;

living or working in extreme heat

• medications:loop diuretics (furosemide, bumetanide), acetazolamide, topiramate, zonisamide,

indinavir, acyclovir,sulfadiazine, triamterene

• medical conditions: UTT (with urea-splitting organisms: Proteus, Pseudomonas, Providencia,

Klebsiella, Mycoplasma,Serratia, S. aureus), myeloproliferative disorders, inflammatory bowel

disease, gout, DM, hypercalcemia disorders (hyperparathyroidism, tumour lysissyndrome,

sarcoidosis, histoplasmosis), obesity (BM1 >30)

• bladder stones: bladder outlet obstruction, catheters, neurologic disease, DM (requires different

management)

Key Points in Stone Hx

- Diet (especially FLUID INTAKE)

• Predisposing medical conditions

• Predisposing medications

• Previous episodes/investigations/

treatments

• FMHx (1st degree relative)

The Four Narrowest Passage Points for

Upper Tract Stones

• UPJ

. Pelvic brim

• Under vas deferens/broad ligament

. UVJ

Clinical Features

• urinary obstruction -> upstream distention -> pain

flank pain from renal capsular distention (non-colicky)

« severe waxing and waning pain that can radiate from flank to groin, testis, or tip of penisfrom

distended collecting system or ureter (ureteral colic)

• writhing, persistent discomfort, nausea, vomiting, hematuria (90% microscopic), diaphoresis,

tachycardia, tachypnea

• occasionally symptoms of trigonal irritation (frequency, urgency), if the stone is in the lower ureter

• bladder stones result in:storage and voiding LUTS, terminal hematuria,suprapubic pain

• if fever,rule out concurrent pyelonephritis and/or obstruction

• can also present incidentally, without any pain or symptoms

Table 11. Differential Diagnosis of Renal Colic

GU Abdominal Neurological

Pyelonephritis

Ureteral obstruction from other cause: UPJ

obstruction, dot colic secondary to gross

hematuria,sloughed papillae

Gynaecological:ectopic pregnancy,torsion/

rupture of marian cyst, PID

Radiculitis(11):herpes zoster, nerve root

compression

Neuromuscular (MSK) back pain

Abdominal aortic aneurysm (AAA)

Bowel ischemia

Pancreatitis

Other acute abdominal crisis(appendicitis,

cholecystitis, diverticulitis)

Radiopaque Radiolucenl Location of Stones

• calyx; may cause flank discomfort, persistent infection, persistent hematuria, but if non-obstructive,

likely remains asymptomatic

- pelvis:tend to cause obstruction at UPJ, may cause persistent infection

• ureter: <5 mm diametersvill passspontaneously in 75% of patients but can do so with varying degrees

of pain

KUB Calcium

Struvite

Cystine

Uric acid

Indinavir

Alazanavir

CT Calcium Indinavir

Struvite

Cystine

Uric add

Alazanavir

Stone Pathogenesis

• supersaturation ofstone constituents (at appropriate temperature and pH)

• stasis,low flow, and low volume of urine (dehydration)

• crystal formation and stone nidus

• loss of inhibitory factors

citrate (formssoluble complex with calcium)

magnesium (formssoluble complex with oxalate)

pyrophosphate

Tamm-Horsfall glycoprotein

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