Several symptoms indicate bladder outflow obstruction (for example, due to ... incision because of loss of the normal bladder neck mechanism, which ensures ...
ABC of Urology UROLOGICAL EVALUATION Chris Dawson, Hugh Whitfield
Common complaints and symptoms A concise but thorough history should be taken detailing the onset of the problem, the severity and duration of the complaint, and any relevant medical history and family history.
Common reasons for referral to urologist Obstructive symptoms Irritative bladder symptoms Incontinence Renal colic Haematuria Sexual dysfunction
Obstructive symptoms Several symptoms indicate bladder outflow obstruction (for example, due to benign prostatic hyperplasia): a delay before the flow of urine begins (hesitancy); a poor flow when passing urine; an inability to maintain flow throughout the prolonged act of voiding (intermittency) owing to the bladder being unable to maintain a high enough detrusor pressure; if a residual volume is left, a desire to pass urine shortly after finishing voiding (pis-en-deux).
Obstructive symptoms Hesitancy Poor flow
Intermittency Pis-en-deux Post micturition dribble A
Irritative symptoms Dysuria Urgency Nocturia
Types of incontinence Stress incontinence Urge incontinence Continuous incontinence
Left: Plain x ray film showing calcified stone (arrow) in right ureter. Right: Intravenous urogram showing obstructed right ureter with dilated calices, pelvis, and upper ureter. BMJ
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Irritative symptoms Patients may feel a burning sensation in the urethra during voiding (dysuria) or a sudden desire to void (urgency). Most adults void no more than once at night, and more than this can be considered to be nocturia. Urine production at night is increased in elderly people, patients with congestive heart failure, and those who habitually consume night time drinks. Cystitis and other inflammatory conditions may give rise to the symptoms above, but the symptoms may also be present in patients with bladder outflow obstruction or carcinoma in situ of the bladder (malignant cystitis). Incontinence Incontinence that is precipitated by physical activity is termed stress incontinence. Urge incontinence occurs when a leakage of urine follows an urgent desire to urinate and is pathognomonic of an unstable bladder. This commonly develops de novo in women (in whom it is termed idiopathic bladder instability) but may be present in men secondary to bladder outflow obstruction or in patients with a
neuropathic bladder. Some women may have both stress incontinence and urge incontinence. Continuous incontinence is typically seen in patients with a urinary fistula. It is important to ascertain how wet the patient is. Patients who need several changes of incontinence pads a day will need more urgent treatment than those who can last all day with one change of underwear. Renal and ureteric colic Renal pain is usually felt in the loin, between the 12th rib and the lateral edge of the lumbar muscles. Pain from irritation of the intercostal nerves may feel similar to the patient, but it is not colicky, may alter with the patient's position, and may be provoked by pressure on a trigger spot. Obstruction of the mid-ureter may mimic appendicitis on the right and diverticulitis on the left. Obstruction of the lower ureter may lead to symptoms of bladder irritability and pain in the scrotum, penile tip, or labia majora. A recurrent painful desire to micturate with only a small quantity of urine passed each time is called strangury. 695
Male sexual dysfunction Impotence Inability to ejaculate Premature ejaculation
Premature ejaculation is best treated by a psychosexual counsellor
Male sexual dysfunction Impotence is the inability of a male to achieve and maintain an erection. In such patients it is important to ascertain whether erections are ever achieved, especially at night or first thing in the morning. The presence of nocturnal or early morning erections makes an organic cause for impotence less likely. Retrograde ejaculation is usual in men after transurethral resection of the prostate and may be present in 40% of men after a bladder neck incision because of loss of the normal bladder neck mechanism, which ensures antegrade emission. Failure of ejaculation may also occur after sympathectomy or after retroperitoneal surgery if either of these procedures interrupts the sympathetic pathways to the prostate and seminal vesicles. a Adrenoceptor blockers prescribed for hypertension or bladder neck obstruction may impair ejaculation, but this effect is reversible when the drug is stopped.
Examination of patient
Penile cancer affecting the glans.
Examination of the external genitalia and a digital rectal examination are possible, but the rest of the urinary system is hidden from view. The kidneys are usually impalpable unless enlarged, and the bladder not percussible until it contains at least 400 ml of urine. For this reason most urological decisions cannot be made during the patient's first visit; the results of investigations must be awaited. To examine the penis, firstly, the prepuce should be retracted to exclude a penile cancer. Secondly, the position of the urethral meatus should be confirmed (normal, hypospadias, epispadias) and meatal narrowing should be excluded. Thirdly, evidence of sexually transmitted disease should be looked for. Finally, the shaft of the penis should be palpated for fibrotic plaques suggestive of Peyronie's disease.
Examination of scrotum * Confirm that both testes are present in scrotum. The normal testis is oval and smooth * Palpate the epididymis and vas on each side * If a mass is present, determine whether it originates from the testis itself or from the spermatic cord (as a general rule most testicular masses are malignant and most masses arising from the spermatic cord structures are
benign) * Ask the patient to stand up and then exclude inguinal herniae and
varicoceles
The importance of the rectal examination, particularly in male patients, cannot be overstated. Rectal examination should be performed regularly (to exclude prostate cancer) in all men aged over 40 years, whatever the presenting complaint, and in any man younger than this who presents with a urological problem. A normal prostate is about 4 cm long with the consistency of rubber. In benign hyperplasia the gland is normally uniformly enlarged with a smooth surface. The lateral sulci may deepen, and the median groove may disappear. In advanced cancer of the prostate the gland may feel stony hard, or a nodule may be palpable. Alternatively, no abnormality may be palpable.
Initial investigations A urine sample should be taken and examined by dipstick analysis for sugar, protein, and blood. The presence of microscopic haematuria should be confirmed by microscopy of a fresh, midstream specimen of urine, which in any event should be sent for bacteriological culture to exclude infection. The presence of protein on dipstick testing should be quantified by a 24 hour collection of urine for protein, and patients excreting abnormally large amounts of protein should be referred for a nephrological opinion. Urine may be sent for cytological analysis to look for abnormal or malignant transitional epithelial cells. Baseline renal function should be assessed for sending a blood sample for concentrations of urea and creatinine and for electrolyte estimation. Urine analysis to confirm microscopic haematuria.
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Radiology
Radiological investigation * Ultrasonography * x Ray examination of kidneys, ureter, and
An ultrasound scan is quick, easy to perform, and non-invasive and is particularly useful for investigating renal masses and for identifying hydronephrosis. Many radiology units now use ultrasonography in the diagnosis of bladder tumours, and it is also the examination of choice for evaluating scrotal disease. Cases of scrotal trauma needing immediate attention may be differentiated quickly by ultrasound examination, allowing other cases to be managed conservatively.
bladder * Intravenous urography * Transrectal ultrasonography
* Magnetic resonance imaging * Computed tomography
Intravenous urography Intravenous urography remains the examination of choice for
* Urodynamics
visualising the upper urinary tracts, particularly in patients with macroscopic haematuria. Patients with microscopic haematuria (determined by dipstick testing) may be adequately investigated in the first instance with an x ray examination of the kidneys, ureter, and bladder and with renal ultrasonography, but consideration should then be given to performing intravenous urography if no cause for the haematuria is discovered. The risk of allergic reactions to contrast media with intravenous urography are well known but uncommon. Recent evidence suggests that the incidence of moderate and severe allergic reactions with traditional high osmolar contrast media is 1 2% and 0 4% respectively. The use of newer, low osmolar contrast media has reduced the incidence of severe allergic reactions to approximately O-02%. Most severe reactions occur within 5-10 minutes of injection. Known atopy is a risk factor, as is asthma. Patients who are at risk should be given corticosteroids before injection of contrast to minimise the risk of allergic reactions. Other effects of contrast media include .nephrotoxicity (0-1%), which may be precipitated in patients with preexisting renal problems, diabetes, or heart failure.
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Transrectal ultrasonography Transrectal ultrasonography has added considerably to our understanding of the anatomy of the prostate. Many carcinomas appear as hypoechoic areas in transrectal ultrasound scans, but, paradoxically, most hypoechoic areas seen in such scans are benign. Current guidelines suggest that transrectal ultrasonography with a prostate biopsy should be performed either when the digital rectal examination shows an abnormality or when the serum prostate specific antigen concentration is raised. There are no indications for transrectal ultrasonography without biopsy in the diagnosis of carcinoma of the prostate, but it may be helpful on its own in patients with suspected
prostatitis. Magnetic resonance imaging v computed tomography Most renal lesions seen in magnetic resonance images are nonalternative to computed tomography only when the patient is _ , ~~~~~~~an t000 to have an allergy to contrast. In the staging of patients with _ > ~~~~~~~~nown t _ w magnetic resonance imaging seems to be more carcinoma s > T; i| ~~~renal S8 >0 t tomography for identifying involvement of the than computed ! s i,: g * $ vein. cava or renal vena w+t+* ij *000 s v ^v -~~~~~~~~Magnetic resonance imaging iS more useful in staging advanced n ~~~~~~bladder cancer as it allows the muscle layer of the bladder wall to be ~~~
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tumour invasion to be identified. The role of magnetic resonance imaging in the investigation of patients with prostate cancer is less clear. Currently such imaging is S aenswtprsaecne1Slscla.Crnlyuh mg too inaccurate with regard to staging of this cancer to allow a proper decision on treatment to be made. Notable advances are expected with the coils for rectal magnetic resonance imaging which may allow spread of the cancer outside the prostatic capsule to be identified.
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Key references McAninch JW. Symptoms of disorders of the genitourinary tract. In: Tanagh o EA, McAninch JW, eds. Smith's general urology. London: Prentice Hall International, 1995 Tanagho EA. Physical examination of the genitourinary tract. In: Tanagho EA, McAninch JW, eds. Smith's general urology. London: Prentice Hall International, 1995 Williams RD, Kreder KJ Jr. Urologic examination. In: Tanagho EA, McAninch JW, eds. Smith's general urology. London: Prentice Hall International, 1995 Patel MD, Hricak H. Current role of magnetic resonance imaging in urology. Current Opinion in Urology 1995;5:67-74 Michell MJ, Evans SA. Current role of scrotal ultrasound. Current Opinion in Urology 1995;5:79-81
Urodynamics The term urodynamics covers a wide variety oftechniques that allow assessment of bladder function. The most simple is uroflometry, which can often be combined with ultrasonography to determine the presence of residual urine in the bladder. Although this is a useful investigation in men with outflow obstruction, it cannot distinguish between true obstruction and detrusor failure. Video urodynamics offers a more complete assessment of bladder function but is undoubtedly more invasive. Pressure lines are inserted into the bladder and rectum, and the bladder is filled with a mixture of saline and contrast medium. An unstable bladder contraction is detected by a rise in pressure of more than 15 cm water during filling when the patient is not attempting to pass urine. The final phase of the examination determines the pressure generated during voiding and the flow rate that results allowing detrusor failure to be distinguished from outflow obstruction. Fluoroscopic screening during the test may also show vesicoureteric reflux, bladder diverticula, and evidence of stress incontinence. The illustration of penile cancer was provided by Mr A G Turner, of the normal testis by Mr N H Blackford, and of the renal tumour by Dr Jean Marshall, all from the Edith Cavell Hospital, Peterborough.
The ABC of Urology is edited by Chris Dawson, a senior registrar in urology at the Edith Cavell Hospital, Peterborough, and Hugh Whitfield, a consultant urologist at the Central Middlesex Hospital and the Institute of Urology and Nephrology, London.
Letterfrom Bosnia-Hercegovina signs of hope Lynne Jones
Institute of Family Psychiatry, Ipswich IPI 3TF Lynne Jones, senior registrar BMY 1996;312:698-700
"Welcome to Sarajevo," Semir said. "You see that everything is exactly the same-no gas, no water, no electricity, shelling, and sniping." Three hours earlier I had arrived back in Bosnia to work with children with special needs and was startled to find myselfin a city with brightly lit shops, including a Benetton in the main street, and full cafes. One hour later the city's fragile power supply had given in to the heaviest December snowfall in 10 years, and Sarajevo was plunged into foggy gloom. So now I sat huddled under blankets in the flat of Dr Narcisa Pojskic and her husband, Dr Semir Beslija, two physicians who had stayed in
Sarajevo throughout the war. Dr Beslija had divided his time between clinical duties in the city and the front line. Dr Pojskic had helped to set up and run the mental health project of one of the larger nongovernmental organisations. Both viewed the peace plan with a mixture of cautious optimism and ambivalence. They were all too aware of the flaws. They could not, for example, imagine how the unprecedented creation of a supposedly unified state with three separate armies was supposed to work. Nor did they believe that Bosnians expelled from cities remaining under Serb control would exercise their right to return. "So the Serbs will have their ethnically pure state, at least in the immediate future," said Semir. And the reality of an undivided Sarajevo had yet to be brought about. On the day the Dayton agreement was signed in Paris there had been some 300 sniping incidents and four shells lobbed into the city. The following day demonstrating Serbs had blocked convoys through the Karazic controlled suburbs of Iliza. "We do not feel it is peace yet," Narcisa explained. "We can smell it, but until we can go through Ilidza and do not have to travel over Mount Igman it is not peace."
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Growing health needs Professor Nedzad Mulabegovic, former dean of the medical school and now rector of Sarajevo University, is also cautious. "The situation in the city is not much better than six months ago, except that there is more food. In the hospital we are short of specific drugs, new equipment, and parts for repairs, and we are still unable to pay adequate staff salaries." Meanwhile the needs grow. There are more than 4000 amputees and 698
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