Disorder of the Bladder Prostate Urethra Seminal Vesicle

Disorder of the Bladder, Prostate, Urethra, Seminal Vesicle, Penis, & Genitalia u Anatomy and Histology (LOW URINARY TRACT) u Physiology and Pharmacology u Disorder u Diagnosis and Treatment u Prognosis H. I. Chen 2

Anatomy H. I. Chen 3

Prostate: blood supply H. I. Chen 4

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Bladder : Disorders, Diagnosis & Treatment, Prognosis (interstitial cystitis) Acquired diseases of the bladder: A. Interstitial cystitis (Hunner’s ulcer, submucous fibrosis): a. fibrosis of the vesical wall, middle aged woman, loss of bladder capacity. b. frequency, urgency, nocturia and pelvic pain with bladder distention, urine is usually normal. c. small ulcers or cracks in the mucous membrane. d. microscopic hematuria may be noted. u H. I. Chen 11

Bladder : Disorders, Diagnosis & Treatment, Prognosis (interstitial cystitis) e. ureterovesical junctions is destroyed, leading to vesicalureteral reflux, hydroureteronephrosis and pyelonephritis may then ensue. f. cystoscopy is usually diagnostic, as the bladder fills, increasing suprapubic pain is experienced. g. Treatment: There appears to be no definitive treatment for interstitial cystitis. H. I. Chen 12

Bladder : Disorders, Diagnosis & Treatment, Prognosis (interstitial cystitis) @ hydraulic overdistention with or without anesthesia. @ vesical ravage (instillation, irrigation) with silver nitrate (1: 5000 -1: 100), or 50 ml of 50% dimethyl sulfoxide (DMSO), or 0. 4% oxychlorosene sodium (Clorpactin WCS-90). @ orally, sodium pentosanpolysulfate (Elmiron), or cortisone acetate, or prednisone, or antihistamines. Heparin sodium 20, 000 u. (i. v. ) H. I. Chen 13

Bladder : Disorders, Diagnosis & Treatment, Prognosis (stress incontinence) B. Stress incontinence: a. the loss of urine with physical strain (eg. coughing, sneezing). b. common in older women of childbirth. c. the basic lesion is loss of normal midurethral resistance caused by a severe sagging of the vesical base and urethra due to poor support of these structures. d. urethral pressure studies show little closure pressure in the proximal half of the urethra. H. I. Chen 14

Bladder : Disorders, Diagnosis & Treatment, Prognosis (stress incontinence) e. the posterior urethra and bladder neck has fallen out of true pelvis, so that increased intravesical pressure & associated with decreased resistance in the proximal & mid urethra. f. the diagnosis of true stress incontinence is the lateral cystogram taken both with and without straining, in normal female, the base of bladder lies about 2 cm above a line drawn from the inferior margin of the pubis to the sacrococcygeal joint (SCIPP line), with straining, the vesical base should descend no more than 1. 5 cm. H. I. Chen 15

Bladder : Disorders, Diagnosis & Treatment, Prognosis (stress incontinence) g. Treatment: @ estrogens locally or orally if the degree of incontinence is mild. @ retropubic urethrovesical suspension (Marshall. Marchetti operation) @ endoscopic urethrovesical suspension (Stamey procedure). h. Prognosis: the cure rate approaches 85 -90%. Reoperation for recurrence case is necessary. H. I. Chen 16

Seminal vesicles: Anatomy & Histology The seminal vesicles lie just cephalad to the prostate under the base of bladder. u About 6 cm long and quite soft, each vesicale joints its corresponding vas deferens to form the ejaculatory duct. u The mucous membrane is pseudostratified, blood supply is similar to prostate: inferior vesical a. , internal pudendal & middle rectal (hemorrhoidal) a. nerve supply is mainly from sympathetic plexus. u H. I. Chen 17

Prostate & Seminal Vesicle H. I. Chen 18

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis A. Congenital disorder: rare. B. Blood ejaculation (hemospermia) : a. it is a not uncommon complaint of middle-aged men, some caused by hyperplasia of mucosa of seminal vesicles. b. diethylstilbestrol 5 mg/day for one week has been suggested. c. infection of seminal vesicles is not possible to obtain diagnostic methods. C. Acute bacterial prostatitis: a. mainly caused by aerobic gram(-)--E. Coli and Pseudomonas. H. I. Chen 19

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis b. possible route: 1. Ascent from urethra, 2. Reflux of infected urine into prostatic ducts that empty into posterior urethra, 3. Direct extension or lymphatogenous spread of bacteria from rectum, 4. Hemoatognous spread. c. acute prostatitis is usually associated with acute cystitis & results in acute urinary retention, may resolve completely in response to appropriate therapy or may progress to abscess formation. H. I. Chen 20

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis d. symptoms: chill and fever, low back and perineal pain, urinary urgency and frequency, nocturia, dysuria and varying degrees of bladder outlet obstruction, both myalgia and arthralgia are common. e. signs: rectal palpation typically discloses an tender, swollen prostate gland is firm indurated and warm, urine may be cloudy. f. laboratory finding: leukocytosis, pyuria, microhematuria, bacilluria, urine culture may be positive. Prostatic massage is contraindicated. H. I. Chen 21

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis g. Treatment: transurethral instrumentation is contraindicated during acute infection. Antibiotics usually gram-negative rods( gentamycin or tobramycin plus ampicillin. h. Prognosis: unless septicemia and septic shock, prognosis usually is good with appropriate therapy. Complication: marked swelling of prostate with acute prostatitis lead to acute urinary retention, requiring bladder drainage is best managed by the insertion of a punch suprapubic tube until inflammation subsides and patient can void by himself. H. I. Chen 22

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis D. Chronic bacterial prostatitis: a. caused by one or more specific bacteria, typical causative agents are gram-negative aerobes: E. Coli, or Pseudomonas. b. the possible routes of infection are the same in acute and usual from acute bacterial prostatitis. c. symptoms: varying degrees of irritative voiding dysfunction(urgency, frequency, nocturia, dysuria) and lower back or perineal pain; myalgia or arthralgia. H. I. Chen 23

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis d. sign: on rectal examination, the prostate may feel normal, boggy, or focally indurated, initial or terminal hematuria, hemospermia and urethral discharge are unusual findings, secondary epididymitis sometimes is associated with chronic bacterial prostatitis. e. laboratory finding: WBC usually normal, prostatic secretions obtained by prostatic massage typically show excessive numbers of inflammatory cells. H. I. Chen 24

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis f. Treatment: 1. General measures: hot sitz baths. Discomfort and painful urination may response to antiinflammatory agents (indomethacin, ibuprofen) and anti -cholinergic drugs(oxbutynin chloride, propantheline bromide). 2. Medical measures: antimicrobial agents (trimethoprim, minocycline, erythromycin). 3. Surgical measure: Transurethral resection of prostate (TURP). g. Prognosis: difficult to cure permanent, but recurrent urinary tract infections generally can be controlled by suppressive antimicrobial therapy. H. I. Chen 25

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis E. Prostatic abscess: a. in recent years, the incidence of prostatic abscess has decreased and the type of infecting organism has changed. b. 50 years ago, 75% of prostatic abscesses were caused by gonococci. More recently, about 70% caused by E. Coli. c. most cases occur in the fifth or sixth decade of life, the pathogenesis remains unclear, are probably complications of acute bacterial prostatitis. e. symptoms & signs are mimic acute bacterial prostatitis. H. I. Chen 26

Prostate & Seminal vesicles: Disorders, Diagnosis & Treatment, Prognosis f. Treatment: 1. The abscess can rupture spontaneously into urethra, preferred treatment consists of surgical drainage combined with appropriate antimicrobial therapy. 2. Drainage by transperineal insertion of a large-bore needle or perineal incision often is necessary for adequate drainage. With proper diagnosis and therapy, the prognosis is good, recurrent abscesses are rare. H. I. Chen 27

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Hypospadias: a. urethral meatus opens on the ventral side of the penis proximal to the tip of the glans penis. b. occurs in one in every 300 male children, estrogrens and progestins given during pregnancy are known to increase the incidence. c. classification: (1) glandular, ie, opening on the proximal glans penis; (2) corona, ie, opening at the coronal sulcus; (3) penile shaft; (4) penoscrotal; (5) perineal. About 70% of all cases of hypospadias are distal penile or coronal. d. hypospadias is evidence of feminization (intersex problem). H. I. Chen 28

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis e. symptoms: 1. difficulty directing the urinary stream and stream spraying, 2. Chordee (curvature of the penis) will cause ventral bending and bowing of the penile shaft, which can prevent sexual intercourse, 3. perineal or penoscrotal hypospadias needs voiding in the sitting position, and in the adult can be the cause of infertility. f. Increased incidence of undescended testicles in children, and hooded penis appearance usually caused by deficient or absent ventral foreskin. g. a buccal smear and karytyping establish the genetic sex. H. I. Chen 29

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis h. excretory urography, urethroscopy and cystoscopy are indicated to detect additional congenital anomalies of kidneys and ureters. i. Treatment: 1. Psychologic treatment: before patient reaches school age (age 2); 2. More than 150 methods of corrective surgery for hypospadias have been described: one-stage repairs using island flap and free skin grafts are performed by more and more urologists; two- stage repairs have produced excellent results over the years and are the safest method for the surgeon who does occasional hypospadias repairs, complication: fistula formation. H. I. Chen 30

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Chordee without Hypospadias: congenital, occasionally, short urethra, fibrous tissues surrounding the corpus spongiosum does, bow-penis during erection, thus preventing satisfactory vaginal penetration. Erection can be induced by injecting saline solution into the corpus cavernosum after placing a tourniquet at the base of the penis, this technique should also be used during corrective surgery to be certain that the penis will be straight after operation. Fibrous tissue found in corpus spongiosum or urethra should be totally excised. H. I. Chen 31

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Epispadias: a. the incidence of complete epispadias is approximately 1 in 120, 000 males and 1 in 450, 000 females. , the urethra is displaced dorsally. b. female with epispadias have a bifid clitoris and separation of the labia, most are incontinent, dorsal curvature of the penis (dorsal chordee) is also present in male patient. c. surgery is required to correct the incontinence, remove the chordee to straighten the penis, and extend the urethra out onto the glans penis, repair of the urinary sphincter has not been very successful. H. I. Chen 32

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis B. Acquired disorder: priapism: a. an uncommon condition of prolonged erection, usually painful and no excitement or desire. b. idiopathic in 60% of cases the remaining 40% of cases are associated with disease (eg, leukemia, sickle cell disease, pelvic tumors, pelvic infections), penile trauma, spinal cord trauma, or use of medications. c. patient usually presents with a history of several hours of painful erection, currently, intracavernous injection therapy for impotence may be the most common cause. H. I. Chen 33

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis d. the glans penis and corpus spongiosum are soft and uninvolved in the process, the corpora cavernosa are tense with congested blood and tender to palpation, the mechanism to be physiologic obstruction of the venous drainage, this obstruction causes build up of highly viscous, poorly oxygenated blood within the corpora cavernosa. H. I. Chen 34

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis e. Treatment: priapism must be considered a urologic emergency, (1) sedation followed by enemas of icecold saline solution may induce subsidence of the erection. (2) Ketamine HCl I. v. or I. m. may be effective in 50% of patients, (3) epidural or spinal anesthesia can also be used, (4) the sludged blood can then be evacuated from the corpora cavernosa through a large needle placed through the glans, other effective shunting methods are used. f. Prognosis: impotence is the worst sequel of priapism. H. I. Chen 35

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Peyronie’s disease: a. plastic induration of the penis, was first described in 1742 and is a wellrecognized clinical problem affecting middle-aged and older men. b. painful erection, curvature of penis, and poor erection distal to the involved area, the penile deformity may prevent satisfactory vaginal penetration, no pain when penis is in the nonerect state. c. penile shaft reveals a palpable dense, fibrous plaque of varying size involving tunica albuginea, the cause remains obscure. H. I. Chen 36

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis d. Treatment: (1) 50% spontaneous remission, (2) vitamin E or p-aminobenzoic acid powder for several months, (3) surgical methods: excision of plaque and replacement with a dermal graft, window suture or plication at the opposite position. H. I. Chen 37

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Phimosis: a. it is a condition in which the contracted foreskin cannot be retracted over the glans, diabetic older men chronic balanoposthitis may lead to phimosis. b. chronic infection from poor local hygiene is its most common cause, paraphimosis, calculi and squemous cell carcinoma may develop under the foreskin. c. edema, erythema and tenderness of the prepuce and presence of purulent discharge usually need medication. d. circumcision under local anesthesia should be done after the infection is controlled. H. I. Chen 38

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis Urethral stricture: a. acquired urethral stricture is common in men but rare in women, most stricture are due to infection (gonococcal urethritis or longterm use of indwelling urethral catheter) or trauma. b. strictures are fibrotic narrows, composed of dense collagen and fibroblasts, prostatitis is a common complication of urethral stricture, bladder muscle may become hypertrophic and increased residual urine. c. ureterovesical reflex, hydronephrosis, urethral fistula and periurethral abscess common develop in chronic and severe strictures. H. I. Chen 39

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis d. symptoms and signs: decrease in urinary stream, spraying double stream or postvoiding dribbling is often noted, frequency, chronic urethral discharge, acute cystitis and induration in the area of stricture may be palpable. e. diagnosis: urethrogram or voiding cystourethrogram will demonstrate the location and extent of the stricture, urethroscopy allows visualization of the stricture, the stricture can be calibrated by passage of bougies à boule. f. complications: chronic prostatitis, cystitis, diverticula, fistulas, periurethral abscesses and vesical calculi. H. I. Chen 40

Penis and Male Urethra: Disorders, Diagnosis & Treatment, Prognosis g. Treatment : 1. Dilatation, is not usually curative but it fractures the scar tissue and temporarily enlarges the lumen, the scar usually reforms. 2. Urethroscopic urethrotomy, using a sharp knife attached cutting, advantages: minimal anesthesia, easily repeated if recurs and very safe with few complication. 3. Surgical reconstruction, if urethrotomy under direct vision fails, strictures more than 2 cm in length cane be managed by patch graft urethroplasty. Stricture should not be considered “cured” until observed for at least 1 year. H. I. Chen 41

Genitalia: Disorders, Diagnosis & Treatment, Prognosis Ectopy & cryptorchidism: a. in ectopy, the testis has strayed from the path of normal descent, in cryptorchidism, it is arrested in the normal path of descent. b. ectopy may : (1) superficial inguinal (most common) (2) perineal (rare) (3) femoral or crural (rare) (4) penile (rare) (5) transverse or paradoxic descent (rare) (6) pelvic (rare) H. I. Chen 42

Genitalia: Disorders, Diagnosis & Treatment, Prognosis c. cryptorchidism is a condition in which a testicle is arrested at some point in its normal descent anywhere between the renal and scrotal areas, 25% with inguinal hernia. d. unilateral arrest is more common than bilateral arrest, incidence at birth about 3. 4%, in adults is 0. 70. 8%. e. the cause of maldescent of testicles: abnormality of gubernaculum testis, intrinsic testicular defect, deficient gonadotropic hormonal stimulation. f. Hormone therapy may be effect before 3 years age, surgical treatment includes orchiopexy & hernioplasty. H. I. Chen 43

Genitalia: Disorders, Diagnosis & Treatment, Prognosis Varicocele: a. approximately 10% of young men, dilatation of pampiniform plexus above the testis, left side is most common affected. b. veins drain into internal spermatic vein in the region of internal inguinal ring, drain into the left renal vein, on right side it drains into vena cava, incompetent valves are more common in left spermatic vein, combined with effect of gravity may lead to poor drainage. c. testicular atrophy may be present, sperm concentration and motility are significantly decreased in 65 H. I. Chen 75%. 44

Genitalia: Disorders, Diagnosis & Treatment, Prognosis d. infertility is often observed and can be reversed in a high percentage of patients by correction of the varicocele. e. the most useful surgical procedure is ligation of the internal spermatic veins at or above the internal inguinal ring. f. recently, percutaneous methods, eg, ballon catheter, sclerosing fluids have been used to occlude the veins. Spermatocele is a painless cystic mass containing sperms in vas efferentia, the cause is not clear, no therapy unless it is large enough to annoy patient, should be excised. H. I. Chen 45

Genitalia: Disorders, Diagnosis & Treatment, Prognosis Hydrocele: a. collection of fluid within the tunica or processus vaginalis, it may occur within spermatic cord, most often seen surrounding the testis. b. chronic hydrocele is more common, cause is usually unknown, and usually afflicts men past age 40 years, fluid is clear and yellow; local injury, radiotherapy, acute nonspecific or T. B. epididymitis or orchitis may develop. c. young boys with hydrocele commonly have a history of a cystic mass and hernia, usually painless, transillumination. d. surgical treatment with hydrocelectomy is necessary. H. I. Chen 46

Genitalia: Disorders, Diagnosis & Treatment, Prognosis Torsion of spermatic cord (torsion of testicle): a. it is an uncommon, most commonly seen in adolescent males, a significant number of patients with torsion who were over age 21. b. it causes strangulation of blood supply to the testis, emergency treatment within 3 -4 hours is necessary, the cryptorchid testis is prone to undergo torsion, trauma may be an initiating factor. c. torsion can be differentiated from epididymitis by Doppler sonography, absence of arterial flow is typical torsion. H. I. Chen 47

Genitalia: Disorders, Diagnosis & Treatment, Prognosis d. the most definitive test appears to be the scintillation scan using 99 m. Tc-pertechnetate, it is accurate in 90 -100% of cases. e. Treatment: if the patient is seen within a few hours of onset, manual detorsion may be attempted by local anesthesia with 10 -20 ml of 1% Xylocaine HCl at external inguinal ring, even if this is successful, surgical fixation of both testes should be done within few days. f. If manual detorsion fails, immediate surgical detorsion must be performed, although after 4 -6 hrs infarction. g. Because the opposite testicle usually is affected by the same abnormal attachments, prophylactic fixation of that organ is imperative. h. Prognosis: usually treatment instituted to late, atrophy is to be expected, if detorsion is delayed beyond 48 hours, orchiectomy is advised. H. I. Chen 48