An introductory lecture for Medical Students. To stimulate their interest in Urology.

1. Symptoms and signs of
Genitourinary diseases
Prof J E Mensah

2. Objective
• To stimulate your interest in Urology

3. What's urology
The study of surgical and medical
diseases of the male and female
urinary tract organs (kidneys,
adrenals,ureters, urinary bladder,
and urethra), and the male
reproductive system(testes,
epididymis, vas deferens, seminal
vesicles, prostate and penis).

4. Renal functions
1. Maintenance of fluid and electrolyte homeostasis
2. Excretion of drugs and the waste products of metabolism
3. Endocrine function
4. Acid–base balance

5. Maintenance of fluid and electrolyte homeostasis
• Renal blood flow is high,1.2
litres/min,
• 22–25% of cardiac output
• produces over 175 litres/day
of ultrafiltrate(1)
• Normal urine volume is only
about 1.5 litres/day
• glomerular filtration, tubular
re-absorption(2) and tubular
secretion(3) modulate the
final composition and
volume of urine(4) to
maintain normal body fluid
and electrolyte homeostasis.

6. Excretion of drugs and the waste products of
metabolism
• Urea - protein
• Creatinine - muscle
• Bilirubin - haemoglobin
• Uric acid-nucleic acid
• Water soluble drugs

7. Endocrine function
• Erythropoietin-
regulation of RBC production
• Renin-essential for the
regulation of blood pressure via
renin–angiotensin pathway
• 1,25 dihydroxicholecalciferol-for
calcium homeostasis

8. Symptoms and signs of renal failure
Renal Function
1. Maintenance of fluid and
electrolyte homeostasis
2. Excretion of waste products
of metabolism
3. Endocrine function-
4. Acid–base balance
Renal failure
• ↑abdominal girth
• Pedal edema/Puffy face
• Malaise
• Anorexia
• Headaches
• Weight gain
• Fatigue
• Anaemia
• ETC

9. Upper and lower urinary tract
• Upper urinary tract(transportation)
Kidney→ ureteric orifice
• Lower urinary tract(storage & voiding)
Bladder neck→external urethral
meatus

10. Urine Production and transportation for
storage-Upper Urinary tract
• Urine production is a continuous
process
• Transport from
kidney→ureter→bladder is by
peristaltic contraction
• The vesico-ureteric junction(VUJ) acts
as a one way valve(under normal
conditions) allowing urine transport
into bladder and preventing reflux
back into the ureter

11. Acute upper tract obstruction
Acute obstruction
• flank pain that may radiate into the
groin or the ipsilateral thigh or both
• Nausea and vomiting.
• high fever (Obstruction coexisting
with infection is a true urologic
emergency )
• Anuria in bilateral ureteric obstruction

12. Physiology of urine storage and voiding
1. bladder filling and urine storage
• Relaxation of the detrusor muscles to
accommodate increasing volumes of
urine at a low intravesical pressure
• Concomitant contraction of the
sphincters to close the bladder
outlet(S2-S4)
2. bladder emptying
• coordinated contraction of the
detrusor muscles
• Concomitant relaxation the smooth
and striated sphincter
• Absence of anatomic obstruction

13. Patient presentation (lower urinary tract obstruction)
VOIDING (obstructive)
• INTERMITENCY
• POOR STREAM
• STRAINING
• FEELING OF INCOMPLETE EMPTYING OF BLADDER
• HESITANCY
STORAGE (storage)
• FREQUENCY
• URGENCY
• NOCTURIA
RETENTION
• ACUTE
• CHRONIC

14. Frequency-Analysis of Freq/volume chart
• Increased urine production-
Polyuria- diabetes, water therapy
• Decreased bladder
capacity(impaired storage)-Cystitis
• Increased Residual urine(failure to
empty)

15. Impact of symptoms on patient's QOL
• Urgency
• Straining
• Nocturia and frequency
• Hesitancy
• Feeling of incomplete emptying
• Poor stream

16. Mechanisms of urinary retention
• Increased anatomic urethral
resistance. i.e. bladder outlet
obstruction(BOO)
• Low bladder pressure (impaired
detrusor muscle contractility)
• Failure of co-ordination of
bladder contraction with
sphincter relaxation(DSD)

17. Retention in males
• Benign Prostatic Hyperplasia (BPH)
• Carcinoma of the Prostate
• Urethral Stricture
• Trauma to urethra or bladder neck

18. Urine retention
ACUTE RETENTION
• Painful inability to void with relief of pain
following drainage of the bladder by
catheterization
• Suprapubic pain +Suprapubic distension(full
bladder350-500mls)+failure to void
CHRONIC RETENTION
• Failure to empty bladder + Gross bladder
distention(over 800mls) + No Suprapubic
pain.
Can result in Post -renal renal failure
• ACUTE ON CHRONIC
Failure to empty bladder + Gross bladder
distention(over 800mls)+Suprapubic pain

19. Retention in women
• Extrinsic compression of bladder
neck or proximal urethra eg
fibroid,cystocoel

20. PAIN

21. GENITOURINARY PAIN
• Pain within the genitourinary tract
usually arises from obstruction
or inflammation.
• Referred pain is common.
• Acute inflammation of
parenchyma produces severe pain
and fever e.g. pyelonephritis,
prostatitis and epididymo-orchitis.
• Tumours usually do not cause pain
unless they produce obstruction or
extend to adjacent nerves

22. RENAL PAIN
• Renal or flank pain is a visceral pain
that results from obstruction of urine
flow with distension of the collecting
system or the renal capsule.
• Pain due to inflammation is dull,
aching and steady.
• It is felt in the posterior renal (costo-
vertebral) angle, below the last rib
and lateral to the sacrospinalis muscle
• Pain may radiate anteriorly toward the
umbilicus. It may be associated with
gastrointestinal symptoms e.g. nausea
and vomiting

23. Ureteric colic
• A ureteral stone is the most common cause
leading to hyperperistalsis and ureteral colic.
One of the most severe pain a human-kind
can experience.
• Patients with ureteral colic are usually moving
around in agony, and holding the flank (the
rolling sign) while patients with
intraperitoneal pathology prefer to lie
motionless.
• Ureteral pain is colicky, intermittent, and
occurring in waves.
• The site of maximum intensity varies with the
site of obstruction.
• Ureteral colic is usually accompanied by renal
pain due to distension of the renal pelvis.

24. Ureteric Colic
• The nerve supply of the upper ureter is by T
10; hence pain starts at costo-vertebral angle
and radiate around the trunk into the lower
quadrant of the abdomen, or possibly into the
anterior aspect of upper thigh and
testicle(simulates torsion) or labium
• Pain in mid-ureter simulates appendicitis or
diverticulitis.
• In the distal ureter ,the Pain is felt as
suprapubic discomfort with LUTS (urgency,
frequency) and radiates along urethra to tip
of penis.(simulates cystitis)
• Often associated with restlessness, nausea,
vomiting, sweating, and collapse.
• Associated fever chills and haematuria may
exist

25. Bladder Pain
• Acute urine retention: The sudden
inability to urinate in spite of the
desire to do so. Pain is severe,
bursting, felt in the suprapubic area.
The bladder is full and over-distended
due to complete obstruction.
• Chronic retention is painless and
dribbling is noted as overflow
incontinence.
• Cystitis: Suprapubic burning pain is
severe when the bladder is full and is
relieved partially by voiding. It is
associated with frequency,urgency
and dysuria.

26. Prostate Pain
• It is due to acute inflammation.
• Localized in the perineum and
referred to lower back and
rectum.
• Acute prostatitis is associated
with fever, frequency, dysuria or
acute retention and tenesmus.

27. Penile Pain
• Pain in the flaccid penis is
usually due to bladder or
urethral inflammation or a
stone.
• Paraphimosis: The
uncircumcised foreskin is
trapped behind the glans penis
• Priapism: Painful, persistent,
purposeless penile erection

28. Testicular/Scrotal pain
• Primary pain is due to acute
epididymo-orchitis, torsion of the
testis or trauma.
• In patients with testicular discomfort
and a normal scrotal
examination, renal or retroperitoneal
disease should be considered.
• Referred pain in renal or ureteric
colic.
• Hydrocele, varicocele and testicular
tumour may be associated with
scrotal discomfort

29. Urethral Pain
• Burning or scalding during
micturition is usually due to
inflammation(gonococcal
urethritis) or a stone.
• Dysuria is pain or burning
sensation during micturition
usually caused by
inflammation.

30. Haematuria-Blood in Urine
• 5-25% of patients with
haematuria have urologic
malignancies

31. Urine incontinence
• A symptom (complaint of
involuntary leakage )
• A sign (leakage of urine on
examination)
terrible social implication

32. Types of incontinence
Continuous
Fistula
Bladder exstrophy
Failure of lower urinary tract
Function

33. Male Genital system
• The purpose of the male
reproductive system is to create
a mechanism by which the
male's chromosomal material
may be combined with that of
the female partner to propagate
life.

34. Path to the egg
a. Emission-Muscle contractions
in the vas deferens from
propel the sperm along past
the seminal vesicles.
b. Ejaculation-the final stage of
orgasm when the sperm is
literally shot out of the penis.

35. Priapism
• Prolonged erection (>6hrs) in the
absence of sexual stimulation and
not relieved by orgasm.
• Priapism is an emergency
• Hypoxia leading to erectile
dysfunction

36. Erectile dysfunction
Definition
• consistent inability to achieve
and maintain a penile erection
sufficient to permit satisfactory
sexual intercourse.
Requirements for a GOOD erection
• Good mood(libido)
• Good nerves
• Good vessels
• Good penis

37. An Erection Requires a Coordinated Interaction of
Multiple Organ Systems
• Psychological
• Endocrine-DM
• Vascular-Cardiovascular System
• Neurologic-

38. Ejaculatory disorders
• Premature ejaculation is
persistent occurrence of
ejaculation with minimal sexual
stimulation before or shortly(LESS
THAN 1 min) after penetration.
• Retrograde ejaculation is backflow
of semen into the bladder due to
Anatomic causes e.g. incompetent
bladder neck e.g. after bladder
neck and prostatic surgery,
neurological e.g. spinal cord
injuries

39. Take Home Message
• Always try to understand the anatomical and physiological basis of
every symptom and sign
• Read Your Books-BAJA
• Google