Medical Archive

Anatomy

Kidney and Adrenal

Ureter

Bladder and Prostate

Penis

Scrotum and Testes

Urologic Malignancies

Bladder Cancer

Testicular Cancer

Kidney Cancer

Prostate Cancer

Penile cancer

Risk factors
High risk HPV (2/3 of cases)
Lack of circumcision – Foreskin acts as a nidus for inflammation and irritation if not properly maintained.

Precursor in situ lesions

• Bowen disease
  • In situ carcinoma of the penile shaft or scrotum that presents as leukoplakia
• Erythroplasia of Queyrat
  • In situ carcinoma on the glans that presents as erythroplakia
• Bowenoid papulosis
  • In situ carcinoma that presents as multiple reddish papules
  • Seen in younger patients (40s) relative to Bowen disease and erythroplasia of Queyrat
  • Does not progress to invasive carcinoma
• Lichen sclerosus
  • A biopsy of the lesion should be performed to rule out dysplastic changes or squamous cell carcinoma.
  • Once ruled out, the lesions can be treated with highly potent topical steroids such as clobetasol. Patients who have not been circumcised should be advised to undergo circumcision.
  • If lichen sclerosus causes scarring of the urethral meatus that is severe enough to affect urine outflow, a meatoplasty should be performed.

Differential diagnosis

Lesion	Characteristics
Penile cancer	Single chronic painless nodule or ulcer ± Inguinal lymphadenopathy
Behcet disease	Recurrent, painful aphthous ulcer Most occur on the scrotum and heal spontaneously within 1-3 weeks.
Candida infection	Painful or pruritic erythematous rash with foul-smelling, thick discharge Balantitis or phimosis
Herpes infection	Painful vesicular eruption that resolve spontaneously within 1-3 weeks.
Primary syphilis	Painless papule that ulcerates over time (chancre). Resolve spontaneously within 3-6 weeks

Trauma

Catheterization & assessment of injury
CT? ????

Kidney

m/c ???? ??. Blunt trauma? 80-85%
Pain, hematuria, ??? bleeding, shock, N/V, ecchymosis ?
Hct? ?? ????. CT? ?? ??
Manage
Shock manage??.
Blunt trauma? ?? (85%) bed rest & hydration? ???
??? rupture: ?? ??
?? ? rupture: ??? ?? ? ????

??? ??? Ix : Persistent ??? ?? (hemodynamically unstable)
Hematoma? ?? ?? ??? anti?????. Abscess?? PCD + DJ
Malig.HTN, ??? ?? Cx? ? ?? ??.

Ureter

Etiology
??? pelvic op. ? ??? (e.g. Uterine a. ?? ? ureter ???)
??? ???? ?? ?.

Fistula? ?? ? ?? (1-2wk POD) ? APN, sepsis ??

Clinical findings
??? ??? ?? with N/V
Associated Ileus
?? ? JP drain ?? ??? ??

?? ??? IVP? ???. ??? ????? ??? RGP
Uretero-vaginal fistula ?? – DJ catheter? ??? ?? ??? ??
5? ?? ??? emergency op., ??? ?? ?? ?? ??? stent 6? ??, ????

Bladder

Distension? ???? ?????? ? ?? ? unable to urinate
?? ?? ??? ???? Retrograde cystography

Bladder rupture

• ?? ??? ??? ?? ??? ??? ??? ?
  • Abdominal distension from urinary ascites
  • ?BUN, Cr from peritoneal reabsorption.
  • -> ?? ??
• Extraperitoneal rupture? cath. ?? ? ????

Urethra

• ?? ?? sign
  • Blood at the urethral meatus, perineal~scrotal hematoma
  • High-riding prostate on DRE
• Anterior urethral injury
  • Bulbous urethra – straddle injury
• Posterior urethral injury
  • Membranous urethra – pelvic bone fracture

Evaluation & management

• In all cases of urethral injury, urethrography or urethroscopy is recommended prior to surgery to both confirm the diagnosis and aid operative planning.
• Retrograde urethrography
  • X-ray using radiopaque contrast. Extravasation of contrast from the urethra is diagnostic of urethral injury.
  • If urethral injury has been ruled out
    • Cystogram? ??? urethral catheterization.
    • Oral analgesics and outpatient f/u.
  • If not ruled out
    • IVP? bladder? assess, ?? foley? ?? ???.
    • ?? suprapubic percutaneous cystostomy ???? ?? ??.
• ??? supra-pubic cystostomy? immediate manage
• Anterior urethral injury AUI
  • ?? ????. ?? ??? ?????.
  • Typically repaired urgently (eg, within 24 hours)
• Posterior urethral injury PUI
  • Temporary urinary diversion via suprapubic catheter, followed by delayed repair.
  • 3?? ???? ???

Testes

Sono? ??? ? ??.

Penis

• Disruption of the tunica albuginea
• Clinical presentation
  • At the moment of rupture, patients often hear a snapping sound and experience sudden-onset papin
  • After wards, as blood exits the engorged corpus cavernosum, patients experience rapid penile detumescence and formation of a penile shaft (eg, swelling, ecchymosis)
• Management
  • Urgent surgical reapir
  • Investigation with retrograde urethrography
    • b/c concomitant urethral injury occurs in ~20% of PF cases
• Complications with nonoperative management
  • Erectile dysfunction
  • Painful erection

Emergencies

Acute Urinary Retention

Testicular Torsion ????

Usually due to congenital failure of testes to attach to the inner lining of the scrotum (via the processus vaginalis).
??????, but it can present in any age group.

Clinical presentation

Testicular, inguinal, abdominal pain, N/V
Swollen, erythematous scrotum
Horizontal testicular lie with elevated testicle

Diagnosis

• Absent cremasteric reflex
• Prehn’s sign (-) (?? ????? ?? ??)
• Doppler ultrasound of the scrotum
  • Twisting of the spermatic cord or reduced blood flow
  • Reactive hydrocele may be present
  • Heterogenous echotexture
    • Late finding indicating testicular necrosis.
    • Develops after >12 hours of ischemia and can result in nonviability.

Management

?????? ? ? ??. ??? ?? ???? ?? ?? ??? ????!

Torsion of appendix testis ??? ??
??? ??? ????? ???? ?? ??? ??. ??? ?? 1-2?

Fournier’s Gangrene

• Pathophysiology
  • Cutaneous breakdown in the perianal and genital region allows for entry of genital and colonic organism.
  • Infections spreads, causing microthrombi of cutaneous vessels, causing gangrene.
  • Life-threatening necrotizing fasciitis of the perineum/scrotum 
  • Most commonly seen in patients with obesity or diabetes mellitus
• Clinical manifestations
  • Fever and confusion
  • Scrotum
    • Pain at the base
    • Edematous and tender
    • Several bullae
  • Crepitus of the perineum
• Management
  • Require urgent surgical intervention (should NOT be delayed for imaging)

Priapism

Painful sustained erection lasting >4 hrs.

Pathogenesis

• Impaired venous outflow from corpora cavernosa
• Increased cavernosal pressure
• Ischemia, hypoxia, acidosis

Causes/risk factors

• Autonomic dysfunction: spinal cord injury
• Altered blood viscosity: sickle cell disease, blood dyscrasias
• Medications/drugs: PDEi, trazodone, stimulants

Treatment

• Aspiration, irrigation
  • Blood gas analysis shows an ischemic pattern with acidosis, hypoxemia, and hypercarbia.
• Intracorporal alpha-1 adrenergic agonist
  • eg, phenylephrine
  • To stimulate contraction of cavernous smooth muscle and facilitate venous emptying.

Paraphimosis

Phimosis ??
?? ??? ??? ??? ?? ???? ?? ??.
??? ???? ? po ??? ???.
?????(balanoposthitis)? ? ??

Paraphimosis ????
Phimosis? ???, ??? ?? ??? ? ????? ???? ?? ??. (??!)
??? ??? 5? ?? ???? ?? ???, ??? reduction ?????. ??? ??? ????.

Emphysematous Pyelonephritis

Infections

Cystitis

Pyelonephritis

Prostatitis

Epididymo-orchitis

Acute epididymitis ????
35? ??? C.trachomatis(STD)
35? ??? E.coli(prostitis)? m/c cause.
• Diagnosis
? Prehn’s sign (+) (?? ????? ?? ??)
? NAAT, urinalysis/culture
3-4?? ???? conservative?? ??. (???, lidocaine, ??? ?)

??? orchitis
??
Chlamydia trachomatis (serotypes D-K) or Neisseria gonorrhoea
? Seen in young adults
? Increased risk of sterility, but libido is not affected because Leydig cells are spared.
Escherichia coli and Pseudomona
? Seen in older adults; urinary tract infection pathogens spread into the reproductive tract.
Mumps virus
? Teenage males, mumps? 20%?? ??.
? increased risk for infertility; testicular inflammation is usually not seen in children< 10 years old.
Autoimmune orchitis
? Characterized by granulomas involving the seminiferous tubules
????? ?? ?? ??

Balanoposthitis ?????

Posthitis(???)? ????? ??? ???. ??? balanitis(???)? ??
??? ??? ?? ?? 2-3? ???
?? ??? ?? topical anti ~ po anti ~ parenteral anti

Lower Urinary Tract Obstruction

Benign Prostatic Hyperplasia

Urethral Stricture

• Etiology
  • M > F. Urethral trauma (eg, catheterization), urethritis, radiotherapy
  • Fibrotic narrowing of the urethra
• Symptoms
  • Weak or spraying stream
  • incomplete emptying
  • Irritative voiding (eg, dysuria, frequency)
• Complications
  • Acute urine retention
  • Recurrent UTI
  • Bladder stones
• Diagnosis
  • Postvoid residual, uroflowmetry
  • Urethrography
  • Cystourethroscopy
• Management
  • Mild: may be observed cautiously
  • Significant: require correction with either urethral dilation or surgical urethroplasty.

Upper Urinary Tract Obstruction

Urolithiasis

Retroperitoneal Fibrosis

Pediatric Urology

Ureteropelvic Junction Obstruction

Vesicoureteral Reflux

Ureteroceles

Posterior Urethral Valve