This document contains lecture notes on various topics in urology from Dr. Elsayed Salih of Al-Azhar University. It includes sections on the diagnosis of urinary tract diseases through symptoms and investigations. It also covers congenital anomalies of the urinary tract including horseshoe kidney and polycystic kidney disease. Specific conditions discussed include renal cysts, vesicoureteral reflux, hydronephrosis, bladder exstrophy, and hypospadias.

1. Urology Lectures
Undergraduate students
Associate professor of urology Dr. Elsayed Salih Al-Azhar university
elsayedsalih@gmail.com

2. Urology Lectures
1Dr. Elsayed Salih
Diagnosis of urinary tract diseases 1
Congenital Anomalies of UT 6
Congenital Polycystic kidney 8
Pelviureteric junction obstruction (PUJO): 11
Vesicoureteral reflux (VUR) 12
Bladder Exstrophy (Ectopic Vesica) 13
Hypospadias 14
Posterior Urethral Value (PUV) 16
Urinary tract injuries 17
Injuries of the kidney 17
Ureteric injury 20
Bladder injury 21
Urethral injuries 22
Urinary tract inflammation 24
Non-specific Urinary tract infection 24
Urinary tract infection: general treatment guidelines 26
Acute Pyelonephritis 27
Perinephric Abscess 28
Pyonephrosis 28
Interstitial Cystitis 29
Epididymitis and Orchitis 30
Urethritis 31
Prostatitis / Prostatodynia 31
Specific infections 33
UT Bilharziasis 33
Genito-urinary tuberculosis 35
Stone Disease 37
Management of urolithiasis 41
Extra-corporeal Shock Wave Lithotripsy (ESWL) 43
Percutaneous nephrolithotomy (PCNL) 44
Open renal stone surgery 44
Management of ureteric stones 45
Management of bladder stones 46
Prevention of stone formation 47
Obstructive uropathy 48
Hydronephrosis 50
Benign Prostatic Hyperplasia (BPH) 52
Urethral stricture 58
Anuria 59
Retention of urine 61
Hematuria 63
Urological neoplasms 66
Renal neoplasms 66
Renal Cell Carcinoma 68
Nephroblastoma 71
Neuroblastoma 73
Carcinoma of the Renal Pelvis and Ureter 73
Bladder cancer 74
Urinary Diversion 78
Prostate Cancer 79
Renal Transplantation 84
Voiding Dysfunction 86
Male infertility 88
Penile Complaints 91
Peyronie's Disease 91
Priapism 91
Erectile Dysfunction (ED) 93
Premature Ejaculation (PE) 95
Diseases of Testis and scrotum 95
Imperfect descend of the testis 96
Testicular Torsion 98
Varicocele 100
Testicular Tumors 102
Index

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Diagnosis of urinary tract diseases
Symptomatology
1) Pain
▪ Analysis of pain includes:
1. Site.
2. Severity
3. Character.
4. Reference (Radiation)
5. What increase
6. what decrease.
7. Associated symptoms
▪ Site of pain:
A. Renal pain:
All types of pain can occur in kidney but the commonest are:
- Colicky pain (most common) or Dull aching pain.
1- Dull aching pain: due to distension of renal capsule. as in
• Acute inflammation of the kidney.
• Bleeding in a cyst.
• Peripheral renal tumor.
• Renal abscess.
• Acute hydronephrosis.
2- Renal colic:
▪ Most common cause is stone.
▪ Definition of colic:
spasmodic pain which occur in hollow viscous or tubular structure lined by smooth muscle due to
contraction of these muscles in an attempt to get rid of an obstructing agent.
▪ Character:
1. colicky pain in renal angle.
2. may radiate to epigastrium.
3. not related to posture
4. may be relieved by NSAlDs.
5. may be associated with nausea, vomiting & diaphoresis.
B. Ureteric pain:
1. Upper third: (T11 – L1 symp.) colicky pain similar to that of renal colic.
2. Middle third: should be differentiated from appendicitis on Rt side & diverticulitis on Lt side.
3. Lower third: (T12 - L2 symp.) (S2,3,4 parasymp.) most common causes are stones and
stricture.
Criteria: As renal colic +
✓ Referred to scrotal skin in male & labia major in female.

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✓ may be referred to tip of penis.
✓ pain usually associated with irritative voiding symptoms (frequency, urgency)
C. Urinary bladder Pain:
Common causes
1. full bladder (most important)
2. cystitis.
3. stones
4. Malignancy
Criteria:
▪ Character: dull aching or discomfort.
▪ Site: supra-pubic region.
▪ Referred to: tip of penis.
▪ Relieved by: evacuation of bladder in full bladder.
D. Prostatic Pain:
may be acute or chronic.
a) Acute pain:
• severe pain in the perineum.
• associated with: dyschasia (rectal dysentery), high grade fever and urine retention.
• e.g. acute prostatitis , prostatic abscess.
b) Chronic pain:
• pain in perineum, lower abdomen, around anus, tip of penis.
• due to chronic prostatitis.
E. Urethral Pain: Causes: stone or inflammation. Character: burning pain in urethra.
F. Testicular Pain
G. Epididymal Pain
2) Symptoms related to act of micturation
A. Obstructive voiding symptoms:
▪ Causes: - infra-vesical obstruction. - the commonest cause in elderly male is BPH.
▪ Criteria:
1) weak urinary stream.
2) difficulty
- to initiate (Hesitancy)
- to maintain (Intermittency)
- to terminate (Post-micturition dribbling)
3) sense of incomplete voiding.
4) retention of urine (acute or chronic) (see later)
B. Irritative voiding symptoms:
▪ due to bladder and urethral irritation (Malignancy, cystitis, stone)
▪ Criteria:

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1. frequency: by day (Diurnal) and by night (nocturia).
2. burning micturition.
3. urgency: strong desire to micturate which can't be postponed, can't hold urine whenever
desire develops.
4. urge incontinence: strong desire to micturate which can't be postponed and if postponed,
involuntary escape of urine drops will occur.
(C) Day and Night Incontinence:
- stress incontinence.
- urge incontinence (neurogenic, stone, cystitis, malignancy)
- Total incontinence as in → VVF (vesico-vaginal fistula)
- Paradoxical incontinence (false): retention with overflow as in BPH & urethral stricture.
3) Change in physical character of urine
A. Volume:
1. Normally — 0.5 - 1 ml / kg / h (800 - 1600 ml / day)
2. Decrease in volume
• < 400 cc / 24 h → oliguria (least volume to excrete toxic metabolite from the body)
• No urine / 12 h (with empty bladder) → anuria (see later)
3. Polyuria: Definition: urine output > 3L / day.
Causes:
a- Renal causes:
1. Nephrogenic diabetes insipidus (amyloidosis, hypokalemia, hypercalcemia)
2. Polyuric phase of ATN
3. Diuretics.
4. CRF.
b-Endocrinal causes:
1- DM.
2- Cranial diabetes insipidus.
3- Cushing disease (hypokalemia, glycosuria).
4- Conn's disease (hypokalemia).
5- Hyperparathyroidism (hypercalcemia).
Others: 1- Psychogenic (compulsive water intake).
2- Drugs as high doses of vitamin D
B. Color:
• Normally → golden or amber yellow.
• Red urine → hematuria (see later)
C. Aspect:
• Normally → clear.
• Turbid urine → pyuria, crystalluria, proteinuria, chyluria
• chyluria: The urine looks milky due to presence of lymph. The color clears on addition of ether.
• Pneumaturia (air in urine) → UTI by gas forming organism or vesico- colonic

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4) C.R.F symptoms:
• Anemia (pallor)
• Asthenia (weakness).
• Anorexia.
• Headache.
5) GIT symptoms; as
• renal colic with nausea & vomiting.
• pyelitis in newborn with gastroenteritis.
• due to: - reno-intestinal reflex. - peritoneal irritation. - organ relationship.
6) Metastasis symptoms: -Brain -Bone. -liver -lung. - others
7) Masses:
• renal mass.
• bladder mass
• scrotal mass
8) Infertility (see later)
9) Sexual dysfunction: (see later)
libido, erection, ejaculation, orgasm.
10) Other symptoms:
as urethral discharge and gynaecomastia.
Examination for Urinary tract diseases:
1) General examination:
2) Abdominal examination
3) Genital examination
4) Digital rectal examination
Investigations:
A. Laboratory investigations:
1) Biochemical blood tests for renal function
• serum urea
• serum creatinine.
• serum electrolytes.
• arterial blood gas
2) Urinalysis:
• for abnormal substances such as protein or signs of infection.
• dipstick urinalysis, involves the dipping of a biochemically active test strip into the urine
specimen to determine levels of tell-tale chemicals in the urine.
• Urinalysis can also microscopy, culture and sensitivity
3) tumor markers: as PSA and acid phosphatase

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B. Imaging
1) Ultrasound:
- Principle: It hits structure of the body then the reflected different intensities (according to
H2O content) are recorded. The same introducer receives the reflection.
- Can detect:
a) Solid from cystic mass.
b) post voided residual in the bladder
c) All types of stones, Radiolucent or Radio-opaque.
d) Trans rectal U/S (TRUS): For prostatic lesions, especially if PSA is high or abnormal
prostatic outline on DRE. can provide access for biopsies.
2) Radiology:
a) KUB
• is plain radiography of the urinary system the greatest utility of the abdominal radiograph
in urology is to evaluate for calculi (Fig. 1),
• check the presence and position of catheters and stents, and obtain a preliminary view
before performing other examinations.
• Bony abnormalities as spina bifida and sacral agenesis, fractures of the spine or pelvis,
osteoblastic metastases (typical of prostate carcinoma), osteolytic metastases (the
majority of solid tumors), or manifestations of hematologic disorders (sickle cell anemia,
myeloma) or Paget's disease
• Abnormal gas collections as Gas in the renal parenchyma or collecting system as a
result of recent instrumentation or emphysematous pyelonephritis
b) Intravenous pyelogram:
• Procedure: contrast (Urografin) is given lV kidney uptake concentration excretion.
• Value: diagnosis of:
1) Anatomical description of the urinary system
2) Stones, tumors (filling defect), diagnose renal artery stenosis
3) Differential kidney function.
4) Vesico-ureteric reflux, Congenital absence of kidney
5) Shattered kidney and Renal pedicle injury.
• Side effects
1. Anaphylactic shock.
2. Acute renal failure (contrast nephropathy).
• contraindications:
1) Renal impairment (blood urea > 50 mg %).
2) acute obstruction
• IVU infusion method: to decrease the incidence of contrast nephropathy of the dye.
• urografin (2 ml/kg) + saline infusion over 15 minutes.

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Figure 1: KUB with staghorn stone IVP IVP with stone Lt kidney
4) CT scans and MRI can also be useful in localizing urinary tract pathology.
5) voiding cystourethrogram is a functional study where contrast "dye" is injected through a
catheter into the bladder and urethra. diagnosis of VUR, stricture, PUV, Urethral injuries.
6) Renal arteriography:
• Mainly indicated to diagnose renal artery stenosis & A-V malformations.
• To differentiate between benign and malignant cysts:
a) If malignant abnormal vascularity.
b) lf benign avascular.
7) Radionuclide Imaging.
8) Surgical procedures
• Cystoscopy
• Biopsy
9) Urodynamic tests
evaluate the storage of urine in the bladder and the flow of urine from the bladder through the
urethra. It may be performed in cases of incontinence or neurological problems affecting the
urinary tract.
Congenital Anomalies of UT
A. Congenital anomalies of the kidney
1) Anomalies of Number
- unilateral renal aplasia. (renal agenesis)
- bilateral renal aplasia. (incompatible with life)
- super-numery kidney.
2) Anomalies of shape:
- Lobulated kidney (persistent fetal lobulation):
3) Anomalies due to abnormal fusion:
- S-shaped kidney
- L-shaped kidney.
- Discoid shaped kidney.
- Horse-shoe kidney (commonest)

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4) Anomalies due to failure of communication:
- solitary renal cyst.
- polycystic kidney.
5) Anomalies due to failure of migration:
- ectopic kidney
6) Anomalies in size:
- hypo-plastic kidney.
- hypertrophied kidney.
7) Anomalies of the renal pelvis:
- bifid pelvis.
- double pelvis.
- PUJO
8) Anomalies of renal vessels:
- renal artery stenosis → renal HTN
- aberrant renal artery → hydronephrosis.
B. (II) Congenital anomalies of ureter:
1) double ureter (common)
2) retro-caval ureter.
3) congenital mega-ureter.
4) ureterocele
5) vesicoureteric reflux.
C. (III) Congenital anomalies of urinary bladder:
1) Ectopia vesica (exstrophy)
2) Congenital anomalies of urachus:
- urachal diverticulum.
- urachal cyst.
- urachal sinus.
- patent urachus (fistula)
3) Congenital contracture of bladder neck (Marrion's disease).
4) Congenital diverticulum.
5) Septate, Bipartite urinary bladder.
D. Congenital anomalies of urethra:
- Phimosis.
- Paraphimosis.
- Meatal stenosis.
- Urethral values.
- Congenital urethral diverticulum
- Hypospadias.
- Epispadias

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Simple renal cyst:
Clinical picture:
1. Usually asymptomatic.
2. Dull aching pain in the loin due to stretch of renal capsule.
3. Renal mass if large.
4. Acute symptoms if complications occurred as hemorrhage infection or rupture.
Investigations:
1. Ultrasound and CT scanning most helpful to differentiate it from complicated cyst of renal tumors
2. IVU: space occupying lesion
3. Renal angiography.
Treatment:
1. No treatment in most of cases but follow up is required.
2. Aspiration of the fluid in the cyst and sclerosing by 95 % alcohol.
3. Marsupialization or excision open or laparoscopic.
Congenital Polycystic kidney
Definition: Congenital bilateral cystic changes of the kidney.
Etiology:
• It's due to lack of communication between the ureteric bud and the metanephric mass resulting
in fluid accumulation & cyst formation.
• It's a hereditary disease.
Types:
1. Autosomal dominant (adult) polycystic kidney disease.
2. Autosomal recessive (infantile) polycystic kidney disease.
Autosomal dominant (adult) polycystic kidney disease:
Pathophysiology
• due to mutations in genes coding for polycystin 1 (PKD1, chromosome 16p, most common)
and polycystin 2 (PDK2, chromosome 4q)
• Also, associated with TSC2 / PKD1 contiguous gene syndrome
• Cysts form in all regions of the nephron, enlarging and expanding throughout life
• Normal renal function is maintained until mid-adulthood in most patients.
Etiology:
Not clear whether the lesion is congenital or acquired. its
origin may be similar to polycystic kidney
Pathology:
• Thin-walled cortical cysts, measuring up to 10 cm, which
are filled with clear yellow fluid
• lined by single layer of cuboidal, flattened or atrophic
epithelium.
Figure 2: Simple renal cyst

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Gross Description: Markedly enlarged kidneys with bosselated surface composed of subcapsular
cysts. Cysts contain clear to brown fluid
Micro Description:
• Cysts are lined by cuboidal or flattened epithelium.
• Functional nephrons exist between cysts with areas of global sclerosis, tubular atrophy,
interstitial fibrosis and chronic inflammation
Clinical Features
1. Third most common cause of end-stage renal disease
2. Patients present with hematuria, abdominal pain, hypertension, urinary tract infection or
urolithiasis
3. Associated with von Meyenburg complexes in liver (97%); hepatic cysts (50%); berry
aneurysms (10-30%); mitral valve prolapse (20%); cysts in pancreas, lung, spleen, pineal gland
and seminal vesicles; aortic aneurysms; hepatic fibrosis.
4. 25% die from infection, 40% from hypertension and heart disease and 15% from berry
aneurysms or stroke.
Complications:
1. Hematuria → due to rupture of cyst.
2. Polyuria → failure of kidney to concentrate the urine.
3. Renal HTN → renal ischemia → renin.
4. Renal failure.
5. Stone formation due to stasis & recurrent infection.
6. Malignant transformation.
DD: → from other renal swellings.
1. Hydronephrosis. (Bilateral or unilateral)
2. Renal tumor. (Wilm's tumor) (Bilateral)
3. Multi-cystic kidney (Unilateral)
Investigations:
1. KFT (for renal failure).
2. Urine analysis hematuria or pyuria.
3. U/S or CT scan: most accurate detect multiple cysts in both kidneys.
4. IVP: bilateral smooth spider leg appearance with elongated renal shadow.
Treatment
A. Conservative:
1. Control of HTN by salt restriction & antihypertensive.
2. Urinary antiseptics to guard against infection.
3. Correction of anemia.
4. Dialysis → if renal failure occurs.
B. Surgical:
• Rovsing operation: By puncture of superficial cysts to minimize pressure atrophy.
• Laparoscopic nephrectomy and Renal transplantation.
Figure 3: ADPCKD

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Horse-shoe kidney:
investigations:
• IVU: the kidneys are in lower position; the lower poles are nearer to the midline and the lower
pole calyces point medially and lie medial to the ureter (Flower vase appearance).
Treatment:
• only for complications as stones or PUJO
• division of isthmus at the level of inferior mesenteric artery rarely needed.
Ectopic kidney
Aberrant and Accessory renal arteries:
• single renal artery present in 80% of population
• aberrant arteries originate from artery other than aorta or main renal artery it is very rare.
• Accessory arteries originate from aorta or main renal artery.
• these vessels may compress PUJ  PUJO
• division of these arteries may cause ischemia and infarction of the corresponding portion of
renal parenchyma (end arteries).
Figure 4: Horse-shoe kidney
Pathology:
• Fusion occurs early in embryonic life when the kidneys lie
low in the pelvis.
• Ascent of the kidney is arrested by the isthmus being
blocked by the inferior mesenteric artery.
• The renal pelvis lies on the anterior surface of the kidney.
• The ureters thus ride over the isthmus which connects the
lower poles.
Clinical picture:
1. one third of the patients remain asymptomatic.
2. The rest develop symptoms of complications as pain
hematuria and fever.
3. A hydronephrotic horseshoe kidney may be palpable
below the umbilicus.
Site: usually near the pelvic brim and usually left sided.
etiology: failure of renal ascend & rotation.
Diagnosis
• Gives mass in iliac fossa.
• Renal ectopia may present diagnostic problems when
acute disease develops in the kidney. Surgeon may
remove it by mistake as an unexplained pelvic mass.
• IVU: ureter is short & straight.
• DD: abnormal mobile kidney (ptosed - floating)
Figure 5 :Ectopic kidney

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Renal Agenesis
• complete absence of one kidney.
• failed development or arrested ureteric bud.
• Usually unilateral and associated with pulmonary hypoplasia.
• Diagnosis: - Routine pre-natal U/S.
• Renal angiography (the only diagnostic method).
Renal Hypoplasia
• small sized one kidney while the other is normal.
• unequal division of the metanephric mass.
• The only presentation is Hypertension.
• TTT: Nephrectomy.
Renal Dysplasia
• Multi-cystic changes of the kidney
• lt is the most common congenital disorder of the kidney.
• Normal sized kidney but with impaired function.
• Failed communication of the renal tubules.
Pelviureteric junction obstruction (PUJO):
• lt is the most common cause of obstructive uropathy and hydronephrosis in children.
• More common in males.
• More common on left side, but bilateral in 10 - 20%.
Pathology: (figure 6)
• Narrowing (stenosis) of pelvi-ureteric junction and failure of relaxation.
• High insertion of the ureter.
• Extrinsic obstruction by aberrant renal vessels.
Presentation:
1. Antenatal diagnosed; by ultrasound (enlarged kidney).
2. infants: loin mass is the most common finding
3. Children: intermittent loin pain (especially after water intake).
4. adolescence: recurrent loin pain and UTl.
Investigations
1. IVU: pelvi-calyceal system dilatation with arrest of contrast at the PUJ.
2. Diuretic renography to assess:
• ability of the pelvis to empty after frusemide injection (obstruction).
• split renal function
3. Ultrasonography: important if poor renal function for hydronephrosis.
4. MRU and CT (figure 7)
Treatment:
1. Pyeloplasty: open or laparoscopicaly.
Figure 6: PUJ obstruction
figure 7: MRU left PUJ
obstruction

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• To correct the obstruction surgically.
• Anderson-Hynes pyeloplasty is the most common operation performed.
2. endoscopic endopyelotomy.
3. Nephrectomy in case of hopeless kidney function.
Vesicoureteral reflux (VUR)
common condition wherein urine passes retrograde from the bladder through the UVJ into the ureter
incidence
• ranges from 1-18.5% in normal children
• prevalence of VUR is higher among children with UTIs (15-70%, depending on age).
• 85% of VUR occurs in females
• common cause of antenatal hydronephrosis
• present in 50% of patients with PUV.
• 30% of children with reflux will have renal scarring
causes:
• primary reflux trigonal weakness, lateral insertion of the ureters, short submucosal
• secondary reflux: infravesical obstruction, posterior urethral valves or a neurogenic bladder
iatrogenic, secondary to ureteric abnormalities (e.g. ureterocele, ectopic ureter. or
duplication), and secondary to cystitis
Presentation
1. UTI, urosepsis
2. pyelonephritis
3. pain on voiding
4. symptoms of renal failure (uremia, hypertension)
Investigation:
1) Urine analysis
2) US
3) Ascending voiding cyst urethrogram (AVCUG) for diagnosis and staging (figure 8)
4) Radionucleotide study
Figure 8: grades of VUR reflux

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• Grade I - Reflux into nondilated ureter
• Grade II - Reflux into renal pelvis and calyces without dilation
• Grade III - Reflux with mild-to-moderate dilation and minimal blunting of fornices
• Grade IV - Reflux with moderate ureteral tortuosity and dilation of pelvis and calyces
• Grade V - Reflux with gross dilation of ureter, pelvis, and calyces, loss of papillary
impressions, and ureteral tortuosity
Complications
• Pyelonephritis
• hydroureter/hydronephrosis
Treatment:
▪ many children •outgrow" reflux (60% of primary reflux) annual renal U/S and VCUG/RNC to
monitor; renal scan if suspect new renal scar (episode of pyelonephritis)
▪ treatment Is dependent on the grade:
A. medical (grade I-III) - goal is to keep urine free of infection to prevent renal damage while
waiting for child to ·outgrow" their reflux
B. long term antibiotic prophylaxis at half the treatment dose for half the treatment time (TMP/
SMX, amoxicillin, or nitrofurantoin).
C. surgical:
1) (ureteroneocystostomy± ureteroplasty)
2) sub ureteral injection of Deflux or Macroplastique
indications:
a) failure of medical management
b) new renal scars
c) breakthrough infections
d) high grade reflux (grade IV or V - not an absolute indication)
▪ prognosis depends on degree of damage at the time of diagnosis
Bladder Exstrophy (Ectopic Vesica):
Incidence: 1 : 50000 of births more common in males
Embryologic mechanism: thought to be in part due to
failed reinforcement of the cloacal membrane by
underlying mesoderm.
Presentation: The classic manifestations are:
1. A defect in the abdominal wall occupied by both the
exstrophied bladder as well as a portion of
the urethra
2. small sized penis
3. A flattened puborectal sling
4. Separation of the pubic symphysis
5. Shortening of the pubic ramii
6. External rotation of the pelvis. Figure 9; Bladder Exstrophy

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7. Females frequently have a displaced and narrowed vaginal orifice, a bifid clitoris, and
divergent labia
Complications:
1. Vesicoureteral reflux
2. Bladder spasm
3. Bladder calculus
4. Urinary tract infections
5. Malignant transformation.
Treatment:
- Management at birth:
1. the exposed bladder is irrigated and a non-adherent film is placed to prevent as much contact
with the external environment as possible.
2. Primary (immediate) closure is indicated only in those patients with a bladder of appropriate
size, elasticity, and contractility.
- Modern therapy: is aimed at surgical reconstruction of the bladder and genitalia.
[1] Modern Staged Repair of Exstrophy (MSRE):
− the initial step is closure of the abdominal wall, often requiring a pelvic osteotomy.
− 2–3 years of age the patient then undergoes repair of the epispadias.
− bladder neck repair usually occurs around the age of 4–5 years.
[2] Complete Primary Repair of Exstrophy (CPRE)
- the bladder closure is combined with an epispadias repair
Hypospadias
Definition: It's a common congenital anomaly
in which the urethra open on the ventral
aspect of the penis or perineum instead of
the tip of penis
Incidence: 1/300 ♂ children
Etiology:
− Glandular: due to failure of canalization of
the glans.
− Penile: due to failure of fusion of two urethral
folds.
− Perineal type: occurs due to failure of
development of whole penile urethra.
Pathology;
− Types:
1. Glandular. EUM opens on under surface of
the glans.
2. Coronal: Meatus is at the coronal sulcus
Figure 10: Types of Hypospadias.

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3. Penile: EUM opens on the under surface of the shaft of the penis may be distal, midpenile
and proximal.
4. Peno-scrotal.
5. Perineal: The scrotum is split. The urethra opens between its 2 halves
- The distal part of urethra (corpus spongiosum distal to the urethral opening) is replaced by
fibrous band (chordee).
- The ectopic meatus lies on the ventral aspect of the penis .
- The prepuce is not complete on the ventral aspect like a hood over glans (hooded prepuce)
- hypospadias is anterior (50%), middle (30%) and posterior (20%) (Figure 10).
Diagnosis:
1. Abnormal prepuce present dorsally only (hooded prepuce).
2. Urethral opening more proximal than usual.
3. abnormal stream of urine.
4. 10% of patients have inguinal hernia or undescended testis.
5. 8% of patients have upper urinary tract anomalies.
6. After puberty: Bowing of penis downwards during erection due to presence of fibrous
chordee.
Complications:
1. stenosed meatus.
2. ventral curving of the penis.
3. Infertility.
4. psychological problem.
Treatment:
• age of repair: most suitable time for repair is 6 m - 2 y
• Types of operations:
1. Glandular hypospadius: MAGPI → Meatal Advancement & Glanuloplasty Incorporated.
2. Other types: Snodgrass. - Mathieu repair
• Elements of Repair:
1. Orthoplasty (straightening) of significant curvature of penis.
2. Meatoplasty & glanuloplasty.
3. Urethroplasty.
• Complications of Repair:
1. Bleeding. 2. Haematoma.
3. Fistula (commonest) 4. Stenosis.
5. Infection. 6. Glanular breakdown.
7. Meatal retraction.

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Epispadias:
Definition:
• abnormal opening of urethra on the dorsum of the penis.
• It occurs in around 1 in 120,000 male and 1 in 500,000 female births
Types:
a) lncomplete type:
− Subdivided into: glanular, mid-penile or peno-pubic.
− The patient is continent.
.
Posterior Urethral Value (PUV):
• An obstructing membrane in the posterior male urethra as a result of abnormal in
utero development.
• It is the most common cause of bladder outlet obstruction in male newborns.
Pathology:
1. Hydronephrosis.
2. Vesico-ureteric reflux.
3. Bladder dysfunction.
4. Deterioration of renal function
Clinical picture:
− Antenatal diagnosis: bilateral hydronephrosis.
− Neonatal period: poor stream, acidosis, and raised blood urea. Urinary tract infection in the
dilated system resulting in septicemia.
− Older children: poor urinary stream, hematuria, or retention of urine
− lt shows a distended bladder and palpable kidneys.
Investigation
− Kidney function test: for complication
− Abdominal ultrasound: bilateral hydronephrosis, a thickened bladder wall with
thickened smooth muscle trabeculations, and bladder diverticula.
− Voiding cystourethrogram (VCUG) is more specific for the diagnosis. Vesicoureteral
reflux is also seen in over 50% of cases.
− Renogram
Treatment:
− Primary management by endoscopic valve ablation.
− Vesicostomy or ureterostomy followed by valve ablation in selected cases.
b) Complete type:
− The condition is associated with ectopia vesica
(exstrophy-epispadias complex).
− The patient is incontinent.
Treatment: during the first 7 years of life, reconstruction
of the urethra,
closure of the penile shaft and mobilization of the corpora
Figure 11: Epispadius

19. Urology Lectures
18Dr. Elsayed Salih
Urinary tract injuries
I. Injuries of the kidney:
Incidence: injuries of the kidney are relatively rare due to:
▪ The kidneys are well protected by the rib cage and by the heavy muscles of the back.
▪ The kidneys are mobile in their adipose fat & thus flee away from the force of trauma.
▪ The fibrous capsule does protect the parenchyma from splitting.
▪ Renal injuries are potentially serious and may be complicated by injuries of other organs.
Etiology:
1. Predisposing factors:
a. Enlarged kidney (hydronephrosis)
b. Fracture ribs / vertebrae.
c. Ptosed kidney.
2. Precipitating factors:
a. Blunt trauma: (commonest 85%) e.g. Motor vehicle accident, falling from height.
b. Penetrating renal trauma: e.g. Gunshot, stab wound.
c. Iatrogenic injuries during surgery.
d. Spontaneous rupture due to minor unnoticed trauma.
Grading of renal injury: (table 1 and figure 12).
Table 1: the American Association for the Surgery of Trauma (AAST) renal injury grade system
Grade Type of injury Description
I Contusion Microscopic or gross hematuria, urologic studies normal
Hematoma Subcapsular, non-expanding without parenchymal laceration
II Hematoma Non-expanding perirenal hematomas confined to the retroperitoneum
Laceration Superficial parenchymal lacerations less than 1 cm in depth without
urinary extravasation
III Laceration Parenchymal lacerations greater than 1 cm in depth without urinary
extravasation
IV Laceration Parenchymal lacerations extending through the renal cortex, medulla,
and collecting system
Vascular injury Injuries involving the main renal artery or vein with contained
hemorrhage
V Vascular injury Completely shattered kidney
Complete avulsion of renal hilum which devascularized kidney
Clinical picture:
▪ Symptoms:
1. History of Trauma.
2. Pain in the flanks. lt may be obscured by injury to other organs.
3. Hematuria: (degree is not proportionate to severity).
✓ lt may appear some hours after injury.
✓ lt can occur between third day and third week after the accident.
✓ May be absent in:

20. Urology Lectures
19Dr. Elsayed Salih
The degree of hematuria
does not correlate with the
degree of injury; in fact, renal
pedicle avulsion or acute
thrombosis of segmental renal
arteries can occur in the
absence of hematuria while
renal contusions can present
with gross hematuria.
a) Superficial tear.
b) Avulsed pedicle or ureter.
c) Traumatic anuria.
d) Severe hypotension.
Local Exam:
1. Marked tenderness & rigidity in the hypochondrium & lion
2. Swelling in the lion due to pseudo haemato-hydronephrosis
3. Shifting dullness in cases of internal hemorrhage.
Picture of complications.
Complications:
I- General: 1-shock. 2- injury to other organ.
II-Local:
✓ Pseudo haemato-hydronephrosis.
✓ Secondary hemorrhage.
✓ Infection and peri-nephric abscess.
✓ Renal failure
✓ Hypertension.
✓ Renal atrophy
✓ Renal artery stenosis.
✓ Renal calculi
Investigations:
1) urine analysis.
2) Plain X-ray: show →
a. Fracture lower ribs or spine, and Foreign body.
b. Blurring of psoas shadow by the perinephric haematoma
3) U/S: It can detect injury, its type & extent.
4) I.V.P: to visualize the upper urinary tract as soon as the shock is controlled. lt may show:
✓ Normal function & configuration of kidney if the injury is minimal.
✓ Deformed renal pelvis or calyces if there is laceration or blood clots.
4. Nausea vomiting and abdominal distension,
due to retroperitoneal hematoma involving
splanchnic nerves (resembling paralytic ileus).
5. Oliguria due to hypovolemia and hypotension.
6. Retention of urine due to clots in the bladder.
▪ Signs:
General Examination:
1. Shock (hemorrhagic or neurogenic)
2. Hematuria (95%)
3. Anuria. (in severe cases)
4. Associated injuries as fracture rib with or
without pneumothorax. Figure 12: grading of renal injury

21. Urology Lectures
20Dr. Elsayed Salih
✓ Extravasation of contrast within the renal shadow or into perirenal space.
✓ Non-visualization of kidney due to total pedicle avulsion, arterial thrombosis or severe
contusion causing vascular spasm.
✓ Confirms the presence of a functioning kidney on the opposite side, as nephrectomy of
the injured kidney may be needed.
5) C.T scanning: (the best), show:
✓ Parenchymal lesion.
✓ Urine extravasation,
✓ Lack of contrast uptake suggests renal artery injury.
✓ Associated injury of other organs.
6) Arteriography: can detect any renal vessel injury & localize the arterial bleeding which can
be controlled by embolization.
7) Renal isotope scanning in selected cases.
Treatment:
1. Renal trauma is an acute emergency.
2. Most renal injuries will be cured by conservative management, as most injuries (85%) are minor.
3. The principles of trauma victims care should be followed.
I. Conservative management:
1) Hospitalization with bed rest until hematuria has stopped & local signs of injury have subsided.
2) Analgesics for pain.
3) Large fluid intake to guard against clot retention & for hypovolemia.
4) Broad spectrum antibiotics to guard against secondary infection.
5) Follow up parameters:
a. Pulse, blood pressure and size of any peri-renal mass.
b. Repeated samples of urine are examined and compared grossly for red color.
c. Hemoglobin & hematocrit estimations.
d. Repeated urine analysis for RBCs.
II. surgical management:
❖ Indications:
1) Persistent progressive hematuria or failure to stabilize vital signs.
2) Presence of a progressively enlarging peri-renal mass.
3) Evidence of peri-renal infection.
4) Penetrating injuries.
5) Renal pedicle injury (5% of all injuries).
6) Presence of an associated intraperitoneal injury.
7) indications for delayed surgery:
• lf hydronephrosis develops; it is treated by relief of obstruction.
• lf hypertension develops; vascular repair or nephrectomy is performed.
❖ Technique;
1) Trans peritoneal approach.

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21Dr. Elsayed Salih
2) traumatized devascularized renal tissue is debrided.
3) Small defects of cortical tissue are sutured. Large defects are filled by omental or perirenal
fat to obliterate dead space.
4) Water-tight closure of the pelvi-calyceal system.
5) Partial nephrectomy is done if one pole of the kidney is avulsed.
6) Nephrectomy is done if the kidney is shattered or with complete avulsion of vascular pedicle,
if the other kidney is functioning well.
II. Ureteric injury:
Etiology:
1) External penetrating trauma. (Rare)
2) Surgical (operative) trauma (iatrogenic) "Commonest" as in hysterectomy, CS, colorectal injury.
3) Instrumental injury → Endoscopic stone extraction.
4) Radiation injury.
Clinical picture:
✓ Anuria if bilateral.
✓ Urinary leakage and fistula
✓ Renal mass (hydronephrosis)
✓ History of trauma.
✓ Renal pain and fever.
✓ Hematuria.
Investigations:
1) U/S.
2) Excretion urography or ascending retrograde urography may reveal obstruction or
extravasation.
3) CT scan with contrast showing extravasation of the dye.
Management
A. lf immediate diagnosis:
✓ Fair patient condition: uretero-vesical continuity should be restored by 1ry anastomosis.
✓ Poor patient condition: deliberate ligation of the proximal end of the ureter and nephrostomy
for drainage of urine then delayed repair.
B. If delayed diagnosis: Temporary nephrostomy, then delayed repair.
C. Types of repair:
1) lf no loss of length: primary end-to-end anastomosis over a double pigtail catheter.
2) If there is little loss of length
✓ Psoas hitch of bladder: re-implantation of the ureter into the bladder.
✓ Boari's operation: a flap of bladder wall is fashioned into a tube to replace the lower ureter.
3) lf there is marked loss of length:
✓ Uretero-ureterostomy: end-to-side implantation of the ureter into the contralateral ureter.
✓ Replacement of the damaged ureter by a segment of ileum or mobilized appendix.
✓ Nephrectomy in selected cases when the outcome is poor and the other kidney is normal.

23. Urology Lectures
22Dr. Elsayed Salih
III. Bladder injury
Etiology:
1. Blunt trauma:
a. Direct: blow or kicks in the suprapubic region.
b. Indirect: fracture pelvis, (most common in extra-peritoneal type)
2. Penetrating trauma: stab, gun shots and instrumentation as cystoscopy or during TURP or
TURT.
3. Spontaneous rupture of diseased U.B.
Pathology:
There are 3 types of rupture ( figure 13):
1. Extra-peritoneal rupture (65%) → urine leakage to inferior & lateral side to UB
2. Intra-peritoneal rupture (25%) → urine leakage above bladder.
3. Combined. (10%)
Clinical picture: table 2
Intra-peritoneal typeExtra-peritoneal type
• 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
1) History of
trauma.
Mild.Marked.2) Shock.
Suprapubic pain &tenderness
which soon become generalized in
the abdomen (peritonitis)
Pain and tenderness is suprapubic
which remain localized for long time
then spreads up to the abd. wall.
3) Pain and
tenderness
No desire for micturitionThere's intense desire for
micturition but the patient can't void
urine.
4) Desire of
micturition.
Feel extra-vasated urine as fullness
in the recto-vesical pouch.
Soft swelling around the prostate
and bladder.
5) PR
Show small amount of urine and
blood.
Show small amount of urine and
blood.
6) Catheterization
Complications-
1) Shock and Hemorrhage.
2) Peritonitis in the intra-peritoneal type.
3) Pelvic abscess in extra-peritoneal type.
4) Associated injuries e.g. rupture urethra.
Figure 13

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23Dr. Elsayed Salih
investigations:
1. Plain X-ray show fracture pelvis.
2. Abdominal U/S.
3. IVU → show leakage of dye from the bladder.
4. ascending cystourethrography.
5. C.T cystography.
Management:
I) Emergency: correct hemorrhage & shock.
II) Extra-peritoneal rupture:
(1) Urethral catheter drainage →Tear will close within 10 - 14 days.
(2) Open surgery & Injury repair:
Indications:
1- failed conservative treatment (no healing > 10 days)
2- Bone fragment projecting in the bladder.
3- Extension of tear to bladder neck (Incontinence)
4- Rectal perforation.
Technique: Trans-vesical approach.
III) Intra-peritoneal & combined injury:
- No conservative treatment because the urine in peritoneal cavity can lead to peritonitis
- line of ttt → Exploration & Repair.
IV) Fracture pelvis: External fixation.
V) Post-injury management:
1- Prophylactic antibiotic. 2- Follow up by cystography.
IV. Urethral injuries:
1. Posterior Urethral injury
Etiology:
• 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
• other causes: iatrogenic (instrumentation)
Types:
a) Contusion.
b) Laceration that does not involve the whole circumference.
c) Laceration that involves the whole circumference.
d) Complete circumferential laceration with torn of puboprostatic ligament.
Clinical Features
▪ Blood at urethral meatus
▪ High riding prostate on digital exam
▪ Sensation of voiding without urine output
▪ Swelling and butterfly perineal hematoma
▪ Distended bladder

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24Dr. Elsayed Salih
Do not catheterize if
suspect urethral injury.
complications:
▪ Blood loss and hemorrhagic shock are common.
▪ Deep extravasation of urine to extraperitoneal space
▪ Injury of external sphincter (sphincter urethrae).
▪ Urethral stricture.
▪ Impotence may result due to injury of the nerves to the corpora cavernosa that pass adjacent
to the membranous urethra.
2. Anterior urethral injury
Etiology:
• straddle injury can crush bulbar urethra against pubic rami
• other causes: iatrogenic (instrumentation, prosthesis insertion), penile fracture,
masturbation with urethral manipulation
Types:
a) Contusion.
b) Laceration that does not involve the whole circumference.
c) Laceration that involves the whole circumference.
Clinical picture
• History of trauma
• Blood at meatus
• Perineal hematoma
Complications:
▪ Urinary extravasation: if the patient try to void urine extravasates to superficial perineal pouch.
▪ Urethral fistula.
▪ Infection and sloughing of the perineal skin in neglected cases.
▪ Peri urethral abscess.
▪ Stricture of urethra.
Investigations of urethral injury:
▪ Ascending urethrogram: Shows site of extravasation and type of injury.
▪ Urgent IVU to detect associated urinary.
Treatment of urethral injury:
a) Simple contusions - no treatment
b) Partial urethral disruption:
• Very gentle attempt at catheterization by urology staff
• With no resistance to catheterization- foley x 2-3 weeks
• With resistance to catheterization - suprapubic cystostomy or urethral catheter alignment in or
periodic flow rates/urethrograms to evaluate for stricture formation
c) Complete disruption:
• Immediate repair if patient stable,
• Delayed repair if unstable (suprapubic tube in interim)
Figure 14: Ascending
urethrogram with posterior
urethral injury

26. Urology Lectures
25Dr. Elsayed Salih
Urinary tract inflammation
Non-specific Urinary tract infection
Definitions:
▪ UTI is a broad term used to describe microbial colonization of the urine. It includes infection
of the structures of the urinary tract from the kidney down to the urethral meatus. Infection
of organs such as the prostate and epididymis are also included in the definition.
▪ Bacteriuria denotes the presence of bacteria in the urine, which is usually free of bacteria.
It can be symptomatic or asymptomatic.
▪ Pyuria is the presence of white blood cells (WBCs) in the urine and is generally accepted
as an indication of infection and as an inflammatory response of the urothelium to the
bacteria.
▪ Bacteriuria without pyuria is an indication of bacterial colonization without infection.
▪ Sterile pyuria occurs with tuberculosis, stone disease or cancer.
Types:
1. Uncomplicated UTI is a term describing infection in healthy patients who have a structurally
and functionally normal urinary tract.
2. Complicated UTI is usually associated with elements which increase the chances of
acquiring bacteria and decreasing treatment efficacy. Incidence increases if alterations to
host defensive mechanisms. These include obstruction, prostate enlargement in men,
urethral stenosis in women, vesicoureteric reflux, diabetes mellitus, human
immunodeficiency virus and spinal cord injuries with high-pressure bladders.
UTIs may be isolated, recurrent, or unresolved:
• Isolated UTI: an interval of at least 6 months between infections.
• Recurrent UTI: >2 infections in 6 months or 3 within 12 months. Recurrent UTI may be
due to re-infection (i.e. infection by different bacteria) or bacterial persistence (infection by
the same organism originating from a focus within the urinary tract). Bacterial persistence
is caused by the presence of bacteria within calculi (e.g. struvite stone,) within a
chronically infected prostate (chronic bacterial prostatitis,) within an obstructed or atrophic
infected kidney, or occurs because of a bladder fistula (with bowel or vagina) or UD.
• Unresolved infection: implies inadequate therapy and is caused by natural or acquired
bacterial resistance to treatment, infection by different organisms, or rapid re-infection.
Pathogenesis
Causative organism:
▪ Gram-negative bacteria: Escherichia coli (the most common), Proteus, and Klebsiella.
▪ Gram-positive bacteria include E. faecalis and S. saprophyticus.
▪ Chlamydia trachomatis
▪ Mycoplasma (Ureaplasma urealyticum)
▪ fungi (Candida)
Predisposing factor
1. Bacterial virulence factors.
2. Bacterial adherence to vaginal and urothelial epithelial cells.

27. Urology Lectures
26Dr. Elsayed Salih
3. Anatomical and functional urinary tract abnormalities,
4. Pregnancy
5. Stones
6. Old age
7. Diabetes
8. Immunosuppression
9. Urinary tract instrumentation
10. Indwelling catheters.
11. UTI in women is common and the incidence increases with age. Sexually active women are
at the highest. It has been noted that some women have recurrent UTI/cystitis at regular
intervals possibly linked to oestrogen levels.
Rout of spread:
▪ Ascending infection → the commonest.
▪ Hematogenous spread.
▪ Lymphatic spread from colon.
Diagnosis: Depends upon
1. Site of UTI
2. Acute or chronic
3. Complicated or un complicated UTI
4. Predisposing factor present
5. Age of the patient
Clinical Features
▪ Storage symptoms (frequency, urgency, dysuria)
▪ Voiding symptoms (hesitancy, post-void dribbling, dysuria)
▪ Hematuria
▪ Pyelonephritis: more severe symptoms (including constitutional symptoms, CVA
tenderness)
General investigation of UTI
Midstream urine (MSU) examination C&S:
▪ Dipstick: leukocytes ± nitrites ± hematuria
▪ Microscopy: >5 WBC/HPF in un-spun urine or >10 WBC/HPF in spun urine, bacteria, ±
WBC casts
▪ Gram stain: GN bacilli, GP cocci,> 1 bacterium/oil immersion field
▪ Culture and sensitivity: midstream, catheterized or suprapubic aspirate
Further investigation:
required if:
• Acute pyelonephritis, a pyonephrosis or perinephric abscess is suspected.
• Recurrent UTIs develop.
• The patient is pregnant.
• Unusual infecting organism (e.g. Proteus), suggesting the possibility of an infection stone.

28. Urology Lectures
27Dr. Elsayed Salih
These further investigations will include
1. KUB X-ray.
2. IVU (looking for infection stones in the kidney; avoid in pregnant women).
3. renal USS.
4. CT scanning.
5. cystoscopy.
Urinary tract infection: general treatment guidelines
1. Antimicrobial drug therapy:
Empirical treatment involves the administration of antibiotics (table 3) according to the
clinical presentation and most likely causative organism before culture sensitivities are
available.
Table 3: Antibiotics
Drug indication Duration Limitation of use
TMP/SMX Simple uncomplicated cystitis
Recurrent cystitis
Pyelonephritis
Prostatitis
Epididymitis/orchitis (Gram
negative organism)
3 days
Long term as
prophylaxis
14 days
4-6 weeks
2 weeks
Stevens Johnson
syndrome
? Safety in last 2 weeks of
pregnancy
Resistance = 20% in the
community
nitrofurantoin Simple uncomplicated cystitis
Recurrent cystitis
7 days Contraindicated in renal
failure
Pulmonary toxicity/fibrosis
ciprofloxacin Cystitis
Pyelonephritis
3 days
7-14 days
? Safety in pregnancy
Achilles tendon rupture
gentamicin Severely ill patients with
pyelonephritis, prostatitis
Nephrotoxic
Ototoxic
2. Definitive treatment:
✓ Once urine or blood culture results are available, antimicrobial therapy should be adjusted
according to bacterial sensitivities.
✓ Underlying abnormality should be corrected if feasible (i.e. extraction of infected calculus;
removal of catheter; nephrostomy drainage of an infected, obstructed kidney).
3. General preventative advice
▪ Encourage a good fluid intake, cranberry juice, double voiding, avoid constipation.
▪ In women: voiding before and after intercourse; wiping perineum from ‘front to back’ after
voiding.

29. Urology Lectures
28Dr. Elsayed Salih
Acute Pyelonephritis
Definition: infection of the renal parenchyma with local and systemic manifestations
Etiology
1. ascending (usually GN bacilli) or hematogenous route (usually GP cocci)
2. causative microorganisms: E. coli (most common), Klebsiella, Proteus, Pseudomonas,
Enterococcus jaecalis, Enterobacter, S. Aureus, S. saphrophyticus
3. 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
1. rapid onset (hours - day)
2. LUTS including frequency, urgency, hematuria
3. fever, chills, nausea, vomiting, myalgia, malaise
4. CVA tenderness or exquisite flank pain
5. dysuria is not a symptom of pyelonephritis without concurrent cystitis
Complications
1. Septicemia and septic shock.
2. Pyonephrosis.
3. Perinephric abscess.
4. Chronic pyelonephritis & renal hypertension.
5. Chronic renal failure if the disease affects both kidneys.
D.D:
1. Acute cholecystitis. Ultrasound can differentiate.
2. Acute appendicitis.
3. Perinephric abscess.
4. Basal pneumonia and pleurisy.
Investigations
1. urine examination, C&S
2. blood: CBC with differential: leukocytosis, left shift
3. imaging - indicated if suspect complicated pyelonephritis or symptoms do not improve with
72 hours of treatment
• IVP
• Abdo/pelvic U/S
• CT
4. Cystoscopy
Treatment
• may treat as outpatient if hemodynamically stable, ciprofloxacin PO for 7-14 days or
cotrimoxazole (TMP/SMX) PO for 14 days
• severe or non-resolving: admit, hydrate and treat with ampicillin IV and gentamycin IV
• emphysematous pyelonephritis: emergency nephrectomy
• stone obstruction: admit and emergency stenting or percutaneous nephrostomy tube

30. Urology Lectures
29Dr. Elsayed Salih
Perinephric Abscess
Routs of infection:
1. Hematogenous: From distant focus (tonsils, osteomyelitis).
2. Extension from neighboring suppurative focus:
3. Such as pyelonephritis, appendicitis, cholecystitis.
4. Infection of a peri-nephric hematoma.
Clinical picture:
1. Hectic fever, anorexia, headache and rigors.
2. Acute onset with pain in the loin associated with nausea and vomiting.
3. The loin is tender and rigid and, as the infection progresses, swelling can be detected.
4. valuable sign is flattening of the normal concavity of loin
D.D: (As acute pyelonephritis).
Treatment:
Under antibiotic cover, immediate drainage is done through:
• Lumbar incision in large abscess.
• Percutaneous drainage in selected cases.
Pyonephrosis
Retention of infected urine and pus in the kidney due to obstructing agent.
Etiology:
• Primary, when infection and obstruction occurs simultaneously
• Secondary, when infection occurs on top of previously hydronephrotic kidney
Clinical picture: (Pain -Fever -Swelling -Pyuria)
1. Closed type (complete obstruction)
(No pus comes out with urine due to the obstructing agent, toxemia is severe)
• General: hectic fever, rigors, anorexia, headache, malaise...etc.
• Local:
a. Loin pain (throbbing) and tenderness (pus under tension).
b. Renal swelling: usually small (large in secondary type).
2. Open type (partial obstruction)
Figure 15: Ct of perinephric
abscess
investigations:
1. High leukocytosis.
2. Ultrasonography or CT scan: most diagnostic
3. Plain X-Ray: Raised indented copula of the
diaphragm, obliteration of psoas shadow and
scoliosis.
4. IVP a "Mathe's sign". X-Ray in erect and lying
posture: Loss of normal mobility of the kidney.

31. Urology Lectures
30Dr. Elsayed Salih
(The pus comes out in large amount so toxemia is less severe).
• Presents with triad of anemia, fever & renal swelling (large).
• With or without secondary cystitis (pyuria, frequency, burning micturition).
Complications:
1. Septicemia and septic shock.
2. Pyemia.
3. Permanent renal scarring.
4. Peri-nephric abscess.
Investigations:
1. Urine analysis
2. High leukocytosis.
3. Ultrasonography or CT scan:
4. Plain X-Ray and IVP: stone and delayed execration
D.D: as acute pyelonephritis.
Treatment:
1. Drainage by ureteral stent placement or nephrostomy tube with antibiotics.
2. Management of the cause as stones and stricture.
3. Nephrectomy in nonfunctioning kidney
Acute cystitis: see previously in general principals
Recurrent/Chronic Cystitis
▪ predisposing factors as described above
▪ possible relation to intercourse (postcoital antibiotics), perineal colonization
▪ investigations may include cystoscopy, ultrasound, CT
▪ antibiotic prophylaxis if >3 or 4 episodes per year in females
Etiology: unknown but theories:
a. increased epithelial permeability, autoimmune, neurogenic
b. associations: severe allergies, irritable bowel syndrome (IBS), fibromyalgia
Treatment
1. low-dose prophylaxis (nitrofurantoin, TMP/SMX)
2. lifestyle changes (limit caffeine intake, increase fluid/water intake, smoking cessation)
3. post-menopausal women: consider topical or systemic estrogen therapy
4. no treatment for asymptomatic UTI except in pregnant women or patients undergoing urinary
tract instrumentation
Interstitial Cystitis (Painful Bladder Syndrome)
Definition
Chronic urgency, frequency ± pain without other reasonable causation
Etiology: unknown but theories
a. increased epithelial permeability, autoimmune, neurogenic, defective glycosaminoglycan
(GAG) layer overlying mucosa

32. Urology Lectures
31Dr. Elsayed Salih
If unsure between
diagnosis of epididymitis and
torsion: go to OR.
Remember: torsion  6 has poor
prognosis.
b. associations: severe allergies, irritable bowel syndrome (IBS), fibromyalgia
Classification
a. non-ulcerative (more common) -younger to middle-aged
b. ulcerative - middle-aged to older
Diagnosis: required criteria:
1. glomerulations (submucosal petechiae) or Hunner's ulcers on cystoscopy.
2. pain associated with the bladder or urinary urgency
3. negative urinalysis, C&S
Differential Diagnosis
1. UTI, vaginitis, bladder tumor
2. Radiation/ chemical cystitis
3. Eosinophilic and tb cystitis
4. Bladder calculi
Treatment
1. Patient empowerment (diet, lifestyle)
2. Pentosan polysulfate (elmiron)
3. Low dose amitriptyline
4. Bladder hydrodistention (also diagnostic) under general anesthesia
5. Intravesical dimethylsulfoxide (dmso) or cystistat
6. Surgery (augmentation cystoplasty and urinary diversion ± cystectomy)
Epididymitis and Orchitis
Etiology
1. infection: gonorrhea or Chlamydia trachomatis
2. mumps infection may involve orchitis after parotiditis
3. rare causes:
• TB
• syphilis
• granulomatous (autoimmune) in elderly men
• amiodarone (non-infectious cause, involves only head of epididymis)
 note: epididymitis is much more common than orchitis
Risk Factors
1. UTI
2. instrumentation/ catheter
3. reflux
4. increased pressure in prostatic urethra (straining. voiding. heavy lifting) may cause reflux of
urine along vas deferens → sterile epididymitis
Clinical picture:
1. Sudden onset scrotal pain and swelling ± radiation along cord to flank

33. Urology Lectures
32Dr. Elsayed Salih
Prehn sign: pain may be
relieved with elevation of testis in
epididymitis but not in testicular
torsion. Poor sensitivity
specially in children.
2. Scrotal erythema and tenderness
3. Fever
4. Storage symptoms, purulent discharge
5. Reactive hydrocele
Investigations
1. Urinalysis (pyuria), urine C&S
2. Urethral discharge: Gram stain/culture
3. Colour-flow Doppler ultrasound
4. Nuclear medicine scan
Treatment
1. Rule out torsion
2. Antibiotics:
• N. gonorrhea or C. trachomatis - cefixime 400 mg PO once followed by azithromycin 1 g
single dose or doxycycline 100 mg bid x 10 days
• Coliforms- broad spectrum antibiotics (quinolone) x 14 days
3. Scrotal support, ice, analgesia
Complications
• Testicular atrophy
• Infertility problems
Urethritis
Common causes: infectious, inflammatory (e.g. reactive arthritis)
Table 4: infectious Urethritis: Gonococcal vs. Non-Gonococcal
Prostatitis / Prostatodynia
▪ Most common urologic diagnosis in men <50 years
▪ Incidence 10-30%
▪ Acute bacterial, chronic bacterial, abacterial subtypes

34. Urology Lectures
33Dr. Elsayed Salih
Table 5: Comparison of three Types of Prostatitis
Type 1: Acute bacterial Prostatitis Type II: Chronic
bacterial Prostatitis
Type Ill: Chronic Pelvic
Pain Syndrome
(Abacterial)
Etiology •coli most common (see previously)
•Ascending urethral infection and
reflux into prostatic Ducts
•Often associated with outlet
obstruction (BPH) recent
cystoscopy, prostatic biopsy
•Most infections occur in the
peripheral zone
• Recurrent
exacerbations of
acute prostatitis
signs and
symptoms
• Recurrent UTI with
same organism
• Divided into
inflammatory and non-
inflammatory subtypes
• lntraprostatic reflux of
urine ± urethral
hypertonia
• Multifactorial
(immunological
neuropathic,
neuroendocrine,
psychosocial)
Clinical
picture
•Acute onset fever, chills, malaise
•Rectal, lower back and perineal pain
Storage and voiding LUTS
•Hematuria
• Frequently
asymptomatic with
normal prostate on
DRE
• Pelvic pain, storage
LUTS, ejaculatory pain,
postejaculatory pain
Investigations • Rectal exam
• Enlarged, tender, warm prostate
• Urine C&S: 4 specimens
✓ VB1 (voided bladder urine): initial
(urethra)
✓ VB2: midstream (bladder)
✓ EPS (expressed prostatic
secretion (prostate).
✓ VB3: post-massage DRE
(prostate)
• Urine R&M
• Blood CBC, C&S
• Urine C&S: 4
specimens
Colony counts in
EPS and VB3 should
exceed those of initial
and midstream by 10
times (suggests
prostate as bacterial
source)
• DRE variable
• Urine C&S negative on
serial specimens
• Prostate biopsy shows
histological inflammation
Treatment • Supportive measures (antipyretics,
analgesics, stool softeners)
• PO antibiotics for 4 weeks to prevent
complications.
• Admission criteria: sepsis, urinary
retention, immunodeficiency
• IV antibiotics {ampicillin and
gentamicin) if severe
• Mid-stream urine C&S at 1 and 3
months post antibiotic therapy
• Avoid catheterization due to risk of
bacteremia and systemic infection
• Small drainage catheter may be
inserted if obstruction suspected
• Extended course of
antibiotics (3-4
months)
• fluoroquinolones,
TMP/SMX or
doxycycline;
addition of an ɑ-
blocker may reduce
symptoms
• Trial of antibiotic therapy
fluoroquinolone or
doxycycline if Chlamydia
trachomatis is suspected
ɑ-blocker to relieve
sphincter spasms,
NSAIDs and supportive
measures for
symptomatic relief

35. Urology Lectures
34Dr. Elsayed Salih
Specific infections
UT Bilharziasis:
Etiology: It is due to Schistosoma haematobium mainly in 94% and by S. mansoni in 4%.
Life cycle of Schistosoma in figure 16
Figure16: Life cycle of Schistosoma haematobium.
Pathological changes in the bladder:
A. Gross appearance;
1. Redness of mucosa due to granulation tissue.
2. Granularity of mucosa.
3. Bilharzial nodule.
4. B. tubercle
5. B. Polyp (projection above surface):
▪ The polyp may be single or multiple but few.
▪ The size varies but does not exceed 2 cm in diameter,
▪ Small polyps are sessile but as they increase in size they acquire a pedicle and take a
mulberry shape.
4. Ulcers: Minute ulcers produced by the extrusion of the ova may fuse and form a large
saucer shaped or excavating ulcer. Phosphatic encrustation of the floor of the ulcer may
occur.
5. Sandy patches: Due to atrophied mucosa overlying calcified ova in the submucosa which
appear like sand under water.
6. Bilharzial fibrosis
7. Leukoplakia due to squamous metaplasia.
8. Carcinoma

36. Urology Lectures
35Dr. Elsayed Salih
B. Microscopic picture
1. Hyperplasia.
2. Brunn nests: Are buds of hyperplastic epithelium which are later separated from the surface
to form subepithelial nests.
3. Cystitis cystica: Results from degeneration and vacuolization of the central cells of Brunn
nests.
4. Cystitis Glandularis: The Brunn nests undergo metaplasia into columnar epithelium.
5. Squamous metaplasia.
Clinical picture:
1. Terminal hematuria is the symptom of early infestation.
2. Frequent and painful micturition.
3. Clinical picture of complications.
Complications:
1) secondary infection.
2) Stone formation.
3) Bladder neck obstruction (BNO).
4) Stricture ureter.
5) Squamous cell carcinoma of the bladder.
6) Hypochromic microcytic anemia and weakness.
7) Contracted bladder.
8) Vesico-ureteric reflux.
9) Hydronephrosis.
Investigations:
▪ Urine analysis.
▪ Immunological tests: ELISA & CFT.
▪ Plain X-Ray: Calcification or stones.
▪ IVU; stricture ureter and contractrde bladder
▪ Cystoscopy: pathological lesion as cystitis, polyp or ulcer.
Treatment:
▪ Anti - Bilharzial drugs as Praziquantel
▪ Treatment of associated lesions:
1. Secondary infection: Antibiotics.
2. Ulcers Small superficial. Anti-Bilharzial drugs + Antibiotics.
3. Chronic deep ulcer: Surgical excision or diathermy coagulation.
4. Polyps: Cystoscopic fulguration.
5. Ureteric stricture endoscopic dilatation
6. BNO: endoscopic incision or Wedge excision.
7. Contracted bladder: augmentation cystoplasty.
8. Malignancy by radical cystectomy

37. Urology Lectures
36Dr. Elsayed Salih
Genito-urinary tuberculosis
Etiology:
▪ Causative organism: Mycobacterium T.B human type (75%)
▪ Route of infection:
o Hematogenous (mainly): from T.B focus (mediastinal or mesenteric)
o Ascending infection (sometimes): from T.B prostatitis, seminal vesiculitis or
cystitis
▪ Precipitating factor: low resistance of the patient
Pathology:
A. The kidneys:
▪ Tuberculous bacilluria may occur without naked eye lesions in the kidneys.
▪ The initial naked eye lesion is a minute cortical focus.
▪ The microscopic foci may heal or progress to chronic T.B. lesion.
▪ Infection spreads through the tubules and lymphatics to reach the papillae of the
pyramids.
▪ Tuberculous follicles in a papilla coalesce and later on burst into the related calyx.
▪ Tuberculous material enters the renal pelvis which becomes involved, Ulceocavernous
type.
▪ The lesion in the cortex coalesces and caseates to form cavities in the renal substance,
caseocavernous type.
B. The Ureter:
▪ Becomes involved, the wall becomes thickened, fibrotic and later shortened
▪ the golf hole appearance of the ureteric orifice as seen on cystscopy.
▪ Stricture lower third.
C. the bladder:
Affection of the bladder results in a thickened fibrosed and contracted bladder with decreased
capacity.
✓ The other kidney & Genital organs (seminal vesicles, prostate & epididymis) become
affected by ascending infection from the bladder or Haematogenous.
Clinical picture:
1. Frequency the earliest & main symptoms due to:
• irritation by tuberculous debris.
• Polyuria of the failing kidney.
• Tuberculous cystitis,
• Contracted bladder at which stage the frequency becomes very severe.
2. Pyuria, haematuria & painful micturation.
3. T.B toxaemia.
4. It is unusual for a T.B kidney to be palpable.
5. The prostate, seminal vesicles, vas, and epididymis should be examined by P/R for
nodules

38. Urology Lectures
37Dr. Elsayed Salih
Complications:
1- Kidney:
• T.B pyonephrosis
• T.B hydronephrosis
• Stones
• T.B perinephric abscess
• Military T.B
• Renal failure
2- Ureter: stricture ureter
3- Urinary bladder: Hematuria and Contracted bladder
4- Genital organs: - infertility
Investigations:
1. Bacteriological examination of the urine:
✓ Ziehl Neelsen method and examined for the acid-fast bacilli.
✓ Culture on Lowenstein medium (98% accuracy).
2. Plain X-Ray may reveal calcified areas.
3. IVP:
✓ Hydronephrosis
✓ Moth eaten appearance
✓ Small contracted bladder
✓ Stricture ureter
4. Cystoscopy:
✓ TB lesions as tubercle or ulcer
✓ Thimble bladder
✓ Golf hole ureteric orifice.
5. Retrograde uretropyelography.
6. Chest X-ray, Tuberculin test & PCR.
Treatment:
▪ Medical treatment:
1. Sanatorium admission
2. Diet: good diet, vitamins & minerals
3. (anti tubercular drugs)
✓ Rifampicin (600 mg daily) orally together with
✓ INH (300 mg daily) orally.
✓ Ethambutol and pyrazinamide
▪ Open surgical treatment: Under cover with anti- T.B. therapy:
1. Nephro-ureterectomy: Indicated in unilateral nonfunctioning kidney.
2. augmentation cystoplasty: contracted bladder.

39. Urology Lectures
38Dr. Elsayed Salih
Stone Disease
Incidence
▪ Prevalence of 2-3%
▪ Male: female = 3:1, peak incidence 30-50 years of age
▪ Recurrence rate: 10% at one year, 50% at 5 years, 60-80% life time
Stone Pathogenesis
Mechanism of formation: Unknown but theories:
1) Saturation of urine by salts:
• It depends on:
1. type of solute (concentration).
2. PH of urine.
3. Temperature.
• It's important to decrease recurrence of stone by control of PH and solute.
2) Super-saturation:
• Above saturation level.
• due to absence of:
a) Inhibitors → inhibit stone formation (organic nephrocalcin, inorganic → Mg citrate)
b) Complexing agents e.g. ca citrate
c) Without nucleus formation.
3) Nucleation: e.g. epithelial cells, urinary crystals, RBCs, WBCs, ….
4) Crystal formation:
5) Crystal aggregation.
6) Crystal retention: factor that increase retention.
a) Pelvi-ureteric junction obstruction (PUJO)
b) Medullary sponge kidney
c) UT obstruction.
d) Crystals & epithelial adhesion.
Etiology: (Predisposing factors)
(I) Pre-renal Causes:
1) Hypercalcemia due to:
A. Idiopathic hypercalciuria (60%):
1. Excess absorption of Ca from GIT (commonest)
2. Excess excretion of Ca in urine
B. Hypercalciuric state (40%) e.g.
1. Hyper-parathyroidism
2. Hyperthyroidism (↑ bone catabolism)
3. Cushing syndrome
4. Paraneoplastic syndrome (PTH like) (Bronchogenic carcinoma, Renal cell carcinoma)
5. Multiple Myeloma → ↑Adrenalin (pheochromocytoma)

40. Urology Lectures
39Dr. Elsayed Salih
• Character of stone in hyper-parathyroidism:
1-Radio-opaque. 2-Multiple. 3-Bilateral.
• E-coli is the commonest organism of UTI but
not form stone.
• Most common stone is Ca oxalate.
• Most opaque stone is Ca phosphate (as
composition of bone)
6. Vit. D toxicity.
2) Hyper-oxaluria: due to:
a) 1ry
hyper-oxaluria (oxalosis): due to enzyme deficiency in liver → ↑ oxalate formation.
b) 2ry
hyper-oxaluria (dietary): - ↑ intake ↑ absorption (in short bowel syndrome)
3) Hyperphosphaturia: - ↑ intake of proteins.
4) Hyper-uricosuria: in
a) Gout & during ttt of leukemia.
b) ↑ purine intake → Red meat liver (adenine & guanine → xanthine oxidase → uric acid)
c) lead to uric acid nucleus upon which oxalate will ppt.
5) Cystinuria: due to ↑ absorption.
6) Low citrate level: acidosis → ↓ serum citrate → hypocitraturia as citrate → precipitation of
calcium as ca oxalate.
(II) Renal Causes:
due to renal tubular necrosis → kidney fails to excrete H+ ions → alkalosis of urine (ppt of Ca
phosphate) & acidosis of blood.
(III) Post-renal Causes:
a) Infection.
b) Stasis of urine.
Classifications of urinary stones: according to
1. Stone size
2. Stone location: Stones can be classified according to anatomical position: upper, middle or
lower calyx; renal pelvis; upper, middle or distal ureter; and urinary bladder.
3. X-ray characteristics
Types of Stones
(1) Ca Oxalate stone (60 %):
• Commonest type
• Oxalate stone is hereditary.
(2) Ca Phosphate stone (10%):
• Usually in association with Ca oxalate. (10%)
• Pure phosphate stone are rare (5%)→ due to renal tubular acidosis.
(3) Struvite stone (5-10%)
• Triple phosphate stone = Ammonium, Mg, Phosphate, Carbonate "CO3"
• Infection stone (Mg, PO4, NH4 + CO3)
• Formed by urea splitting organism: Proteus Mirabilis, Pseudomonas, Klebsiella.
• Mechanism: Urea → organism by urease enzyme in bacteria → ammonium (NH4) + H2O →
alkaline urine → ppt of Mg, NH4 & PO4.
(4) Uric acid stone. (5-10%) Metabolic stone
(5) Cystine stone. (1%) Metabolic stone
(6) Xanthine stone → Radiolucent
(7) Matrix stone → soft gelatinous material in urine

41. Urology Lectures
40Dr. Elsayed Salih
Pathology of stones:
Table 6: Composition of stone:
Cystine
stone
Uric acid stoneCalcium
phosphate
calcium
oxalate
- Multiple- Multiple- Single or Multiple.- Single1-No.:
- small- Small- large- Moderate2- Size:
-Oval- Oval facetted- Oval or
stagehorn
- Irregular3- Shape:
- Smooth-Smooth- Smooth- Spiky4- Surface:
- Cystine
(sulphur
containing)
- Pure uric acid
- Ca++ urate
- Ca phosphate
-Triple PO4→ PO4,
Mg, NH4, HCO3
- Ca oxalate5-
Composition:
-Yellow- Yellow- Dirty white- White6- Colour:
-Hard-Hard- Chaky friable- Hard7-
consistency:
-Amorphous- Amorphous- Laminated- Amorphous8- Cross
section:
-Radio
opaque due
to sulphur
- Pure → radio-lucent.
- Ca urate →
Radio-opaque.
- Radioopaque.- Radio-
opaque
9- X-ray
Clinical Features
1. Urinary obstruction ± upstream distention ± pain
▪ Flank pain from renal capsular distention (non-colicky).
▪ Severe waxing and waning pain radiating from flank to groin, testis, or tip of penis due to
stretching of collecting system or ureter (ureteral colic)
2. Writhing, never comfortable, nausea, vomiting, hematuria (90% microscopic), diaphoresis,
tachycardia, tachypnea
3. Occasionally symptoms of trigonal irritation (frequency, urgency).
4. Bladder stones result in: storage and voiding luts, terminal hematuria, suprapubic pain.
5. If fever, rule out concurrent pyelonephritis or obstruction.
Differential Diagnosis of Renal Colic
1. Acute ureteral obstruction (other causes):
a) UPJ obstruction
b) sloughed papillae
c) clot colic from gross hematuria
2. acute abdominal crisis: biliary, bowel, pancreas, abdominal aortic aneurysm.
3. Gynecological: ectopic pregnancy, torsion/rupture of ovarian cyst, pelvic inflammatory disease
(PID)
4. pyelonephritis (fever, chills, pyuria)
5. radiculitis (L1): herpes zoster, nerve root compression

42. Urology Lectures
41Dr. Elsayed Salih
RadiolucentRadiopaque
Uric Acid
indinavir
Calcium
Struvite
Cysteine
KUB
indinavirCalcium
Struvite
Cysteine
Uric Acid
CT
Location of Stones
A. Kidney
▪ Calyx
- May cause flank discomfort, recurrent infection or persistent hematuria
- May remain asymptomatic for years and not require treatment
▪ Pelvis
- Tend to cause obstruction at ureteropelvic junction (upj)
- Staghorn calculi (renal pelvis and one or more calyces)
- Often associated with infection that will not resolve until stone is cleared
▪ Ureter: <5 mm diameter will pass spontaneously in 75% of patients
C. Bladder
D. Urethra
Complications:
1- Haematuria: due to injury to mucosa.
2- Infection: pyonephrosis, pyelonephritis, pyelitis, cystitis.
3- Migration, repeated attack of colic.
4- Obstruction: hydronephrosis, retention or anuria.
5- Malignancy: due to chronic irritation.
6- Renal Failure.
Investigations
2. screening labs
i. CBC  elevated WBC in presence of fever suggests infection
ii. Electrolytes, Cr, BUN ± to assess renal function
iii. Urinalysis: R&M (WBCs, RBCs, crystals), C&S
i.
ii.
iii. abdominal ultrasound
• May demonstrate stone (difficult in ureter)
• May demonstrate hydronephrosis
iv. IVP:
• Anatomy of urine collecting system, degree of obstruction, extravasation
3. cystoscopy for suspected bladder stone
2. imaging
i. (KUB) kidneys, ureters, bladders x-ray
• to differentiate opaque from non-opaque stones
(e.g. uric acid, indinavir)
• 90% of stones are radiopaque (figure 17).
ii. CT scan: accurate method of diagnosing renal and
ureteric stones (except) indinavir stones. Allows
accurate determination of stone size and location and
good definition of pelvicalyceal anatomy (figure 18).

43. Urology Lectures
42Dr. Elsayed Salih
indication hospitalization:
1. intractable pain
2. intractable vomiting
3. Fever ( infection)
4. Compromised renal function
5. Single kidney with ureteral
obstruction
6. bilateral obstructing stones
4. stone analysis
5. metabolic studies: if recurrent stone formers:
✓ serum electrolytes, Ca, PO4, uric acid, creatinine and urea
✓ PTH if hypercalcemic
✓ 24 hour urine: for creatinine, Ca, PO4 , uric acid, Mg, oxalate, citrate
Management of urolithiasis:
Acute
1. medical
▪ analgesic (NSAID and morphine) ± antiemetic
▪ alpha-blockers: increase rate of spontaneous passage in distal ureteral stones
▪ antibiotics for UTI
▪ IV fluids if vomiting (note: IV fluids do NOT promote stone passage)
2. interventional: if obstruction endangers patient
(i.e. sepsis, renal failure)
▪ ureteric stent (via cystoscopy)
▪ percutaneous nephrostomy (image-guided or US guided)
Elective managment
▪ Medical (conservative)
▪ ESWL.
▪ Endoscopy.
▪ Open Surgery.
Figure 18: Non- contrast CT scanning with Large
(11 mm) stone in the left ureter at the L5 level. left
hydroureteronephrosis with reduced parenchyma.
Figure 17: Radiograph of the right
kidney showing a complete
staghorn calculus.

44. Urology Lectures
43Dr. Elsayed Salih
Indication of interference:
1. Pain
2. Obstruction.
3. Infection.
4. Functional loss.
Management of Renal stones
1) Medical.
2) Extra-corporeal Shock Wave Lithotripsy (ESWL)
3) Percutaneous nephrolithotomy (PCNL)
4) Combined PCNL and ESWL
5) Open renal stone surgery
a) Pyelolithotomy.
b) Extended pyelolithotomy
c) Nephrolithotomy.
d) Pyelonephrolithotomy
e) Partial nephrectomy.
f) Simple nephrectomy.
6) Laparoscopic stone extraction.
Medical (conservative):
Aim:
• Spontaneous passage.
• ↓ metabolic activity →↓stone recurrence.
Indications:
• Small stone < 5 mm
• No infection
• No distal obstruction
Include:
1) Antispasmodic: e.g. buscopan.
2) Analgesic: up to morphia.
3) Antiseptic: to guard against infection.
4) ↑fluid intake: esp. water (3-4 litre / day)
5) Diet:
• Ca containing stone → ↓use of milk & milk products.
• Oxalate stone → ↓ Tomato, Spanish, Mango, Strawberry, Coffee
• Uric acid →↓ Red meat, Liver, Coffee, Tea, Coca, Soup.
6) Drugs:
• Ca oxalate stone → Vit. B6 (pyridoxine)
• Phosphate stone → Aceto hydroxamic acid (urease inhibitor)
• Uric acid stone → Xanthine oxidase inhibitors (Allopurinol)
• Cystine stone → D-penicillamine, Mercapto-propionyl glycine (Best), Acetyl cystein.
7) PH of urine:
• Dilution of urine: slight alkalinization of urine.
• Alkalinization of urine: in uric acid & cystein stone by potassium citrate
• Acidification of urine: in Ca & PO4 stone by vit.C.

45. Urology Lectures
44Dr. Elsayed Salih
Orange & Lemon (Citric acid) → produce alkalanization and not
acidification as citric acid enters Kreb's cycle → HCO3
8) Chemolysis of stone:
i. Irrigation of the cavity for repeated time by drugs:
1. Uric acid stone → - alkalinization of Urine. - Allopurinol.
2. Cystine stone → - alkalinization. - MPG.
3. Sturvite stone → -acidification, -antibiotic, -urease inhibitor (acetohydroxamic acid)
ii. Only used to ↓ size & so spontaneous passage.
iii. Not used in Ca oxalate.
Extra-corporeal Shock Wave Lithotripsy (ESWL)
Objective
• To treat renal calculi, proximal calculi, and mid ureteral calculi which cannot pass through the
urinary tract naturally
• Shockwaves are generated and focused onto stone  fragmentation, allowing stone
fragments to pass spontaneously and less painfully (figure 19)
Methods:
A. Ultrasonic lithotripsy:
▪ Explosion of the stone using ultrasonic waves.
▪ The micro-fragments will pass spontaneously in the urine.
B. Electro-hydraulic lithotripsy:
▪ Explosion of the stone by shock waves, directly at the calculus.
▪ Micro-fragments will pass spontaneously in the urine.
Indication: potential first-line therapy for renal and ureteral calculi less than 2 cm in size
Contraindication:
1) Acute urinary tract infection or urosepsis
2) Bleeding disorder or coagulopathy
3) Pregnancy
4) Obstruction distal to stone
5) Impaired renal function.
Complications
1) bacteriuria and bacteremia
2) post-procedure hematuria
3) ureteric obstruction (by stone fragments)
4) peri-nephric hematoma Figure 19: stone fragmentation by ESWL. The stone is
centered in the machine following which the stone is
broken up with soundwaves.

46. Urology Lectures
45Dr. Elsayed Salih
PCNL
Indications:
1. Stone > 2 cm (especially hard
2. Urinary obstruction.
3. Cystine stones
4. ESWL failure.
Advantages:
1. small incision
2. Short hospital stay.
3. minimal operative and postoperative complications.
Complications
1. Hemorrhage.
2. Extravasations of irrigation used fluid.
3. Residual stones.
4. injury of Renal or other organs injury e.g. colon, pleura.
Open renal stone surgery
It becomes 3rd
choice method for renal stone management.
Indications:
▪ Failure of previous lines of treatment.
▪ Complex renal stones
▪ Presence of congenital anomalies as horse shoe kidney
Incision: flank incision (mainly)
Technique:( figure 21)
Pyelolithotomy.
▪ Always tried first especially with extra-renal pelvis.
▪ lt can to be done in intra-renal pelvis using Gil Vernet retractor.
▪ incision in the posterior aspect of the renal pelvis then the stone is removed.
Figure 20: PCNL
Method;
1. Establish a track for percutaneous
endoscopy,
2. A nephroscope is introduced at
the location of the stone.
3. Small stone extracted with
forceps.
4. Large stone fragmented by
lithotripsy (either laser ultrasonic
or pneumatic)
5. lnsertion of a nephrostomy tube
for 48 hours for drainage.

47. Urology Lectures
46Dr. Elsayed Salih
the ureteric stone
management depend on site, size
and effect of the stone
Advantages:
a) Minimal bleeding.
b) No damage for renal parenchyma.
c) Rapid healing
Nephrolithotomy.
Indicated when pyelolithotomy cannot be done:
▪ Stone in a calyx with narrow neck.
▪ lntra-renal pelvis.
▪ Dense adhesions around the pelvis.
Disadvantages: The reverse of advantages of pyelolithotomy.
▪ The incision is in the substance of the kidney may be through
ln Brodel's line (in the posterior aspect of the kidney
between lateral 1/3 and medial 2/3).
▪ Radial incision directly on the stone.
Partial nephrectomy. if multiple stones impacted in nonfunction part of the kidney.
Simple nephrectomy. lf the kidney is non-functioning provided that the other kidney is normal.
Management of ureteric stones
Conservative management: see previous
Active management:
Indications:
1. Stone large than 5mm
2. Distal obstruction
3. Persistent pain
4. Failure of medical treatment
5. Evidence of infection
Figure 22: Ureteroscopy
Figure 21: Open renal stone surgery
by
▪ Nephrolithotomy
▪ Pyelolithotomy
Type of management: depend on site size and effect of
the stone
1. ESWL
2. Push bang technique: pushed to kidney then
PCNL
3. Ureteroscopy (URS):
Aim: Stone extraction or fragmentation.
Technique;
▪ Cystoscope and insertion of guide wire to ureteric
orifice
▪ dilatation of distal ureter and introduction of URS
▪ visualization of stone then extraction by forceps or
Dormia basket.
▪ Fragmentation may be needed

48. Urology Lectures
47Dr. Elsayed Salih
Types of lithotripsy
c. U/S waves.
d. Electro-hydrolytic.
a. Laser.
b. Pneumatic, (lithoclast)
Complications
▪ Infection
▪ Perforation
▪ Avulsion
▪ Stricture ureter
▪ Migration of stone
▪ Difficulty to introduce guide wire
1. Open ureterolithotomy
Incision :
▪ Stone upper 1/3 → flank incision (stone is best extracted by pyelolithotomy)
▪ Stone middle 1/3 → abernathy incision 2 inches above the asis and passes
downwards and medially to mid-inguinal point (muscle cutting).
▪ Stone lower 1/3 → midline supra-pubic incision.
2. Laparoscopic ureterolithotomy
Management of bladder stones
Instrumental: lf < 2 cm
▪ Cystolitholapaxy (Trans-urethral): mechanical compression of the stone using lithotrate then
removal of the fragments by Ellik's evacuator.
▪ Cystolithotripsy: fragmentation by lithotripsy U/S waves, Electro-hydrolytic, Laser or
Pneumatic (lithoclast)
Surgical: suprapubic cystotolithotomy,
Indications
a. Larger and harder stones
b. Cases where open prostatectomy or bladder diverticulectomy is indicated.
c. Failure of stone fragmentation
d. In children
Management of urethral stones:
▪ Posterior urethra: Supra-pubic cystolithotomy for stone firmly impacted supported by
urethral dilator & removed trans-vesical.
▪ Penile urethra: trial of removal by forceps if failed, External urethrotomy will be done
▪ Glandular urethra: External meatotomy.

49. Urology Lectures
48Dr. Elsayed Salih
Although hypercalciuria is a risk factor
for stone formation. decreasing dietary calcium
is NOT recommended to prevent stone
formation. Low dietary calcium lead to
increased oxalate absorption and higher
urinary levels of calcium oxalate.
- Ca oxalate stone is ppt in neutral PH.
- Ca phosphate & Struvite stones are ppt in
alkaline PH.
- Cystine & Uric acid stones are ppt in acidic
PH.
- Citrate inhibit ppt of Ca.
- Mg inhibit ppt of oxalate.
- Pyrophosphate inhibit ppt of phosphate.
- Hyper-oxaluria is an inborn error of
metabolism of glycine.
- Hard stones:
▪ Ca oxalate monohydrate stone.
▪ Cystine stone.
▪ Some types of uric acid stone.
✓ Calcium oxalate stones:
1. Avoid diet rich in oxalates.
2. Hydrochlorothiazide 50 mg/d aids in the
dissolution of Ca oxalate stones.
3. Citrates 5 mg bid inhibits crystallization of
oxalates.
✓ Uric acid stones
1. Avoid diet rich in purines.
2. Rule out myeloproliferative or neoplastic
diseases.
3. Urine should be kept alkaline, e.g. by NaHCO3 1
gm tds.
4. Allopurinol 30 mg/day is indicated in patients with
hyperuricemia.
✓ Struvite stones
1. Aluminum hydroxide orally restricts phosphate
absorption.
2. Long term antibiotics to eradicate UTl.
3. Avoid indwelling catheters.
4. Increase urine acidity by vitamin c
Prevention of stone formation
1. dietary modification:
▪ Increase fluid (>2 L/day), potassium intake
▪ Reduce animal protein, oxalate, sodium, sucrose, and fructose intake
▪ Avoid high-dose vitamin C supplements
2. The stone should be chemically analyzed.
3. Treating infection and other causes of stone formation.
4. Follow up of stone formers to detect early recurrence.
5. Metabolic work-up to know etiology of the stone.
▪ Serum Ca and phosphorus to exclude hyperparathyroidism.
▪ 24-hour urine collection for the following whose normal values are:
a. Ca <300 mg.
b. Uric acid <800 mg.
c. Oxalates <40 mg.
d. Citrates 300-900 mg.
6. medications:
i. Thiazide diuretics for hypercalciuria
ii. Allopurinol for hyperuricosuria
iii. Potassium citrate for hypocitraturia

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49Dr. Elsayed Salih
Obstructive uropathy
Obstruction anywhere in the urinary tract associated with changes in the urinary system proximal
to the obstruction.
Classifications
1. Acute or chronic obstruction.
2. Partial or complete obstruction.
3. Unilateral or bilateral obstruction.
4. Congenital or acquired obstruction.
5. Extrinsic or intrinsic obstruction.
Etiology
I. Unilateral
A. Kidney and pelvis:
• Congenital:
1. Horse-shoe kidney.
2. Aberrant renal vessels crossing the pelvis.
3. PUJ obstruction.
• Acquired
1. Stones.
2. Tumors of the kidney or pelvis.
3. Renal TB.
B. Ureteric obstruction:
• From outside:
1. Pressure from adjacent structures e.g.
▪ Gartner duct cyst, pregnancy,
▪ Tubo-ovarian abscess
▪ Diverticular abscess, cancer cervix, rectum...etc.
2. Aberrant blood vessels and Aneurysm
3. Idiopathic retro-peritoneal fibrosis.
4. Retro-caval ureter.
5. Retroperitoneum:
▪ Fibrosis, Hematoma,Lymphocele,Lymphoma
▪ Metastatic tumor (eg, breast, prostate, testicular).
▪ Pelvic lipomatosis,Sarcoidosis,TB
• ln the wall
1. Congenital stenosis.
2. Ureterocele.
3. inflammatory stricture after repair of damaged ureter, calculus or ureteric TB.
4. Neoplasm of ureter or bladder cancer involving the ureteric orifice.
• ln the lumen:
1. Stone (commonest).

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most common
causes differ by age:
• Children: Anatomic
abnormalities as PUJO and PUV
• Young adults: Calculi
• Older adults: BPH or prostate
cancer,
2. Blood clot
3. Fungus ball
4. Urothelial carcinoma
5. Sloughed renal papillae
II. Bilateral (lower urinary tract obstruction)
A. Congenital:
1. Posterior urethral valve (PUV).
2. Phimosis.
B. Acquired
1. prostatic hyperplasia (BPH) (commonest).
2. Cancer prostate.
3. Post-operative bladder neck scarring.
4. Urethral stricture (e.g. post-traumatic).
Sequalae of obstructive uropathy
1. Hydronephrosis.
2. Retention of urine.
3. Calcular anuria.
Pathology:
1. Urethra  dilatation
2. Bladder:
✓ Early: muscle hypertrophy and trabeculation and diverticula
✓ Late: Bladder dilatation and atony chronic retention
3. Ureter: muscle hypertrophy then atony and dilatation  hydroureter.
4. Kidney:
a) Morphological:
✓ Pelvic hypertrophy  pelvic atony and dilatation
✓ Parenchymal thinning and atrophy.
b) Functional: increased intra-pelvic pressure  urine excretion stops  decrease GFR
✓ Unilateral: contralateral hypertrophy
✓ Bilateral: renal impairment
Diagnosis:
Clinical picture:
1. Pain is common, usually along T11 to T12.
2. Absolute anuria occurs with complete obstruction at the level of the bladder or urethra
or bilateral obstruction.
3. Infection complicating obstruction may cause: dysuria, pyuria, urgency and frequency,
pyelonephritis, and occasionally septicemia.
4. palpable flank mass, particularly in massive hydronephrosis of infancy and childhood.
Investigations
A. Urinalysis and serum electrolytes, BUN, and creatinine.

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Hydronephrosis
Definition:
• Dilation of the renal pelvis and calyces, usually caused by obstruction of the free flow of urine
from the kidney. Untreated, it leads to progressive atrophy of the kidney.
• One or both kidneys may be affected.
• In hydroureteronephrosis, there is distention of both the ureter and the renal pelvis and calices.
• The obstruction is acute or chronic, partial or complete, unilateral or bilateral.
Etiology: see obstructive uropathy
Diagnosis:
 Presentations of hydronephrosis
1) Mild pain or dull achinq pain in the loin:
a) lncreases by excessive fluid intake.
b) Often associated with dragging heaviness.
c) The kidney may be palpable.
2) Attacks of acute renal colic: may occur with no palpable swelling.
3) lntermittent hvdronephrosis (with Dietl's crisis)
• Acute renal pain + renal swelling→some hours later → no pain or swelling but large volume
of urine is passed.
 C/P of the cause
• Stone: colic, painful hematuria.
B. Imaging: for suspected ureteral or more proximal
obstruction:
1. Abdominal ultrasonography is the initial imaging test
of choice in most patients without urethral
abnormalities.
2. Voiding cystourethrography and cystourethroscopy
for suspected urethral obstruction.
3. IVU (figure 23)
4. Pelvi-abdominal CT.
5. Antegrade or retrograde pyelography is preferred to
studies that involve vascular administration of
contrast agents in the azotemic patient.
6. Radionuclide scans.
7. MRU (Magnetic resonance of urine).
Treatment: consists of eliminating the cause of
obstruction
a) Temporarily by: JJ stent or nephrostomy tubes.
b) Permanently by:
Surgery as pyeloplasty, ureteroplasy and urethroplasty
Instrumentation (eg, endoscopy, lithotripsy)
Figure 23: IVP with
hydroureteronephrosis

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52Dr. Elsayed Salih
• BPH: prostatism (LUTs).
• TB: constitutional symptoms, frequency.
 C/P of the complications
e.g. Hypertension, fever (in infections) and in late cases ) renal failure.
Complications:
1) Renal hypertension.
2) Renal failure (if bilateral hydronephrosis or unilateral in the only functioning kidney).
3) Infection  pyonephrosis (2ry).
4) Pressure atrophy.
5) Others: calcification - rarely hemorrhage or rupture (more liable to trauma).
D.D: polycystic kidney, hypernephroma, liver swellings and splenomegaly.
Investigations:
For diagnosis
1) U/S: detects the size of the kidney and the thickness of the renal cortex.
2) lVU:
▪ Dilatation of renal pelvis.
▪ Flattening of calyces.
▪ Clubbing.
▪ Ballooning of the calyces, widening of the waist.
▪ Later, faint nephrogram around dilated calyces (soap-bubble appearance).
3) Ascending (retrograde) pyelography indicated if IVU is contraindicated due to renal failure.
4) Renal isotope scanning detects the remaining functioning parenchyma.
5) Plan X-Ray: Abnormal psoas shadow. Stone, calcifications.
For complications
▪ KFTs: for renal failure.
▪ Urine analysis: polyuria of low specific gravity.
▪ CBC & ESR: to exclude infection.
For the cause
▪ Trans-rectal U/S for BPH.
▪ Cystoscopy  bladder lesions (bilharziasis or tumor).
Management of the cause: As
1) Stones → Pyelolithotomy, Ureterolithotomy
2) Stricture → excision and end to end anastomosis
3) Aberrant Vessel → Transection of the ureter and anastomosis in front of the vessel
4) Benign Prostatic Hyperplasia → Transurthral resection of Prostate (TURP)
5) Carcinoma of Prostate → TURP+ Hormonal Therapy
6) Urethral Stricture → Urethroplasty
7) Meatal Stenosis → Meatoplasty
8) Phimosis → Circumcision

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53Dr. Elsayed Salih
Benign Prostatic Hyperplasia (BPH)
Definition: Benign condition associated with symptom complex (syndrome) of what's called LUTS
(lower urinary tract symptoms)
hyperplasia of stroma and epithelium in periurethral area of prostate (transition zone)
zonal anatomy of prostate:
Epidemiology
• age-related. Extremely common (50% of 50 year olds, 80% of 80 year olds)
• 25% of men will require treatment
Etiology: Unknown but theories:
1) Hormonal dependent theory: (Role of Androgen)
a) Testosterone → 5 α-reductase enzyme → dihydrotestosteront (DHT)→ ↑ growth factors
→ enlargement.
b) Role of estrogen: (Hormonal imbalance) there's associated ↑ of serum estrogen. (↑ E / T
Ratio)
a) Secretion of intermediate peptide growth factors may play role in development of BPH.
2) Programmed cell death regulation (Apoptosis): impaired apoptosis (↑ cell growth )
3) Neoplastic theory: BPH is considered as Benign tumor.
4) Inflammatory theory: (not accepted): based on appearance of chronic infl. cells e.g.
lymphocytes in stroma.
Pathology: figure 25
Figure 25: of BPH
Site.
Most commonly arises from
submucous group of glands in
▪ Transitional zone (peri-urethral)
 lateral lobes.
▪ lf arising from CZ sub-cervical
glands  middle lobe.
Figure 24: Zonal anatomy of the prostate

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54Dr. Elsayed Salih
 AUA prostatic
symptom score (IPSS)
(FUNWISE)
1. Frequency
2. Urgency
3. Nocturia
4. Weak Stream
5. Intermittency
6. Straining
7. Emptying, feeling of
incomplete
 Each symptom take score
of 5:
✓ 1-7 = MILD symptom
✓ 8-19 = MODERATE
symptom
✓ 20-35 = SEVERE symptom
 Dysuria not included in the
score
Macroscopic
Changes ln the prostate:
1. No gritty sensation during cutting it.
2. Fibrous trabeculae divide the adenoma into lobules.
3. Yellowish in color.
Changes ln the urethra:
1. Urethral narrowing as it is stretched and compressed from side to side.
2. This narrowing interferes with bladder emptying.
3. Exaggeration of the normal posterior curve of the urethra.
The urinary bladder, ureters and kidney show changes as in obstructive uropathy.
Microscopic
a) Hyperplasia of acini (fibro-myo-adenoma),
b) Dried prostatic secretion  corpora amylacia.
Clinical picture:
symptoms
1) voiding symptoms:
a) Hesitancy,
b) Straining.
c) Weak/interrupted stream
d) incomplete bladder emptying
▪ Decreased flow rates may be seen on uroflowmetry
▪ Due to outflow obstruction and/or impaired detrusor contractility
2) storage symptoms:
a) urgency,
b) frequency,
c) nocturia,
d) urgency incontinence
▪ thought to be due to
1. Detrusor over activity
2. Deceased compliance
3. Congestion of the bladder mucosa.
4. Increased residual urine.
5. Complications: cystitis, stones & trigonal irritation.
3) Sexual symptoms: increased libido at the start, later impotence occur.
4) Symptoms of complications.
Signs
▪ General:
a) Exclude complications (uremia, fever).
b) Exclude DD (cystitis, cancer prostate with metastasis, neurological examination for DM and
Parkinsonism).

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55Dr. Elsayed Salih
prostate size doesn't
correlate with either symptom
or mode of management
▪ Local:
a) Mass or tenderness in the renal angle (hydronephrosis).
b) Supra-pubic palpable bladder (retention).
c) DRE: prostate is
✓ Smooth,
✓ Rubbery
✓ Symmetrically enlarged
✓ Median sulcus preserved.
✓ Notch between it & seminal vesicle is preserved.
✓ Mucosa of rectum mobile over prostate
Complications:
1. Retention of urine:
a) Acute retention of urine is sometimes the 1st
presentation of BPH. Retention is precipitated
by excess fluid intake, alcohol, wintry weather, cystitis, diuresis, constipation, unrelieved
sexual excitement. Acute retention is very painful and needs urgent intervention.
b) Chronic retention with overflow incontinence. The condition is painless and the actual
complaint of the patient is incontinence.
2. Overflow incontinence
3. Hydronephrosis and renal compromise
4. Infection
5. Hematuria
6. Bladder stones
 Assess LUTS and effect on quality of life, may include self-administered questionnaires (AUA
symptom and impact score)
D.D :
1. Cancer prostate.
2. Chronic prostatitis
3. Bladder tumors.
4. Bladder calculi.
5. Detrusor muscle weakness or instability.
Investigations:
Laboratory:
1. Urine analysis.
2. liver & kidney function.
3. Urine culture.
4. PSA (prostate specific Ag) (see later)
Uroflowmetry
▪ Q max (peak) = normal > 15 ml / sec.
▪ Less than 10 ml / sec means
obstruction to bladder outflow (figure 26). Figure 26: uroflowmetry of man with BPH Qmax
is 7 ml/sec.

57. Urology Lectures
56Dr. Elsayed Salih
Imaging:
▪ Abdominopelvic US:
a) visualize kidney changes,
b) measure amount of post-voiding residual urine in the bladder
c) diagnose any bladder pathology.
▪ TRUS. (Trans-rectal ultrasound)
a) asses size of prostate,
b) exclude presence of focal lesion
c) U/S guided biopsy can be taken.
▪ IVU: to show (figure 27)
a) back pressure on the kidney.
b) the bladder floor can be elevated
c) distal ureters lifted medially
(J-shaped ureters or fishhook ureters).
d) Chronic bladder outlet obstruction can lead to detrusor
hypertrophy, trabeculation and formation of bladder diverticula.
Urodynamic study in selected cases
Treatment:
I. Conservative for those with mild symptoms:
• watchful waiting - of patients improve spontaneously
• includes life style changes (e.g. evening fluid restriction, planned voiding)
• avoid ppt factor e.g. Excess work, worry, weather (cold), wine, women, withholding urine in
bladder, spices, constipation.
II. Medical therapy:
1. α-blockers: reduce stromal smooth muscle tone e.g. terazosin (Hytrin) doxazosin
(Cardura), tamsulosin, alfuzosin (Xatral), silodosin
2. 5α-reductase inhibitors: blocks conversion of testosterone to DHT; acts on the epithelial
component of the prostate reduces prostate size e.g. finasteride (Proscar), dutasteride
(Avodart)
3. combination shown to be synergistic
4. Phytotherapy.
III. Minimal Invasive therapy:
1- Intra-prostatic stent.
2- Trans-urethral needle ablation.
3- Balloon dilatation.
4- Thermotherapy. Microwave heat therapy.
5- Endoscopic transurethral cryo-ablation of the prostate.
IV. Surgical
A. Endoscopic
Figure 27: IVU of BPH

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57Dr. Elsayed Salih
1. TURP (Trans-Urethral Resection of Prostate)
Objective
 To partially resect the periurethral area of the prostate (transition zone) to decrease
symptoms of urinary tract obstruction (figure 28)
 Accomplished via a cystoscopic approach using an electrocautery loop, irrigation (glycine},
and illumination
Complications
• Acute:
1) Intra- or extraperitoneal rupture of the bladder
2) Rectal perforation
3) Incontinence
4) Incision of the ureteral orifice (with subsequent reflux or ureteral stricture)
5) Hemorrhage
6) Epididymitis
7) Sepsis
8) Transurethral resection syndrome (also called "post-TURP syndrome·)
✓ Caused by absorption of a large volume of the hypotonic irrigation solution used, usually
through perforated venous sinusoids, leading to a hypervolemic hyponatremic state
✓ Characterized by dilutional hyponatremia, confusion, nausea, vomiting, hypertension,
bradycardia, visual disturbances, CHF. and pulmonary edema
✓ Treat with diuresis and (if severe) hypertonic saline administration
• Chronic:
1) Retrograde ejaculation (>75%}
2) Erectile dysfunction (5-1 0% risk increases with increasing use of cautery)
3) Incontinence (<1%)
4) Urethral stricture
5) Bladder neck contracture
2. Trans-urethral vaporization.
3. Trans-urethral Incision.
4. Laser:
▪ Lasers use concentrated light to generate precise and intense heat.
Figure 28: TURP
Indications
1) Obstructive uropathy (large bladder
diverticula, renal insufficiency)
2) Refractory urinary retention
3) Recurrent UTIs
4) Recurrent gross hematuria
5) Bladder stones
6) Intolerance/failure of medical therapy

59. Urology Lectures
58Dr. Elsayed Salih
▪ There are several different types of prostate laser surgery, including:
a) Photo selective vaporization of the prostate (PVP).
b) Holmium laser ablation of the prostate (HoLAP).
c) Holmium laser enucleation of the prostate (HoLEP).
B. Open prostatectomy
Indications
1. Very large prostate.
2. Bladder diverticula
3. Bladder stones.
4. TURP is not possible for another reason.
Types
 Trans vesical prostatectomy
 Retropubic (Millin's) prostatectomy
Bladder diverticulum
Definition A diverticulum is an outpouching in the bladder. It can be either congenital or acquired.
Types:
a) Congenital diverticula are usually diagnosed in childhood or on prenatal ultrasound.
b) Acquired bladder diverticula are often due to bladder outlet obstruction from
• BPH
• Urethral stricture
• Neurologic disease.
Acquired diverticula are most typically seen in
elderly men and often associated with BPH.
Clinically
1) Bladder diverticula are often asymptomatic
2) urinary retention
3) urinary tract infection,
4) blood in the urine.
5) Stone bladder
6) Tumor
Diagnosis
1. imaging studies
• CT scan
• Ultrasound incidentally.
• Cystogram
2. Cystoscopy
treatment:
▪ Treatment of the cause.
▪ Congenital or acquired diverticula do not always require treatment
▪ Open and laparoscopic diverticulectomy. If there is complication
Figure 29: bladder diverticulum

60. Urology Lectures
59Dr. Elsayed Salih
Urethral stricture
Definition
• decrease in urethral caliber due to scar formation in urethra (may involve corpus spongiosum)
• M>F
Etiology
1) Congenital: failure of normal canalization may cause bilateral hydronephrosis
2) Trauma:
a) Instrumentation (most common)
b) External trauma (e.g. Burns, straddle injury)
c) Other: foreign body, removal of inflated Foley catheter, etc.
3) inflammation:
a) Long-term indwelling catheter
b) Balanitis xerotica obliterans (lichen sclerosis or chronic progressive sclerosing
dermatosis of the male genitalia) causes meatal stenosis
4) Neoplastic;
a) Urethral polyps
b) Venereal warts
c) Carcinoma of the urethra.
Clinical Features:
1) voiding symptoms (obstructive symptoms)
2) urinary retention
3) related infections: recurrent UTI, secondary prostatitis/epididymitis
Complications
1. Retention of urine.
2. Urethral diverticulum.
3. Extravasation of urine with peri-urethral fistula.
4. Stone formation.
5. Infertility.
6. Infection e.g. urethritis, cystitis...etc.
7. Squamous cell carcinoma.
8. Renal insufficiency.
9. Straining  precipitating hernia, hemorrhoids...etc.
Investigations
1) laboratory findings
• Flow rates <10 ml/s (normal-20 ml/s) on uroflowmetry
• Urine culture usually negative, but may show pyuria
2) radiologic findings
• Voiding cystourethrogram (VCUG): will demonstrate location (figure 30)
• Urethral ultrasonography.

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60Dr. Elsayed Salih
3) Uroflowmetry: reveals obstructed flow
4) Urethroscopy.
• Complete stricture excision ± anastomosis, ± urethroplasty depending on location and size
of stricture
• Types of urethroplasty
a) Anastomotic,
b) Buccal mucosal onlay graft,
c) Scrotal or penile island flap.
d) Johansen's urethroplasty
Anuria
Definition.: No urine excretion for 12 h.
OR excretion of < 400 cc / 24 h (with empty bladder) = oliguria.
Types: (Etiology)
(1) Pre-renal causes:
▪ Shock (hypovolemic, septicemic, cardiogenic, neurogenic)
▪ Heart failure.
▪ Hemorrhage
(2) renal causes: - due to bilateral renal disease.
a. Diseases:
1. Acute glomerulonephritis.
2. Systemic Lupus Erythematosus.
3. polycystic kidney
b. Toxic:
1. endogenous, (bile)
2. exogenous: NSAIDs, aminoglycosides (streptomycin), anti. TB (INH)
Figure 30: AVCUG
Treatment
1) Urethral dilatation:
• Temporarily increases lumen size by breaking
up scar tissue
• Healing will often reform scar tissue and recreate
stricture
2) Visual internal urethrotomy (viu):
• Through the urethroscope and under direct
vision, the stricture is incised with sharp knife
blade usually at the 12 O'clock position.
3) Open surgical reconstruction: